Streamlining the oxytocin supply chain to ensure increased access to high quality oxytocin and improved maternal health outcomes in Ghana - Jhpiego
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Streamlining the oxytocin supply chain to ensure
increased access to high quality oxytocin and improved
maternal health outcomes in Ghana.
Name of Presenters: Afua Aggrey; Claudette Diogo; Deogratius Kimera; Beth Yeager & Megan
Rauscher
PPH Community of Practice Annual Meeting
July 21–23, 2020
PPH COP 2020
Overview
This presentation summarizes the steps taken to improve the quality of
oxytocin in Ghana. Findings and recommendations cover the following
areas as they relate to oxytocin quality:
• Procurement and sourcing practices
• Current policy and regulatory environment
• Finance and reimbursement schemes
• Inventory management and logistics with a focus on cold chain
capacity
2 PPH COP 2020
Maternal Health in Ghana
• In Ghana, maternal health has improved over the past
years, although at a snail’s pace
• Some efforts made by government to improve maternal
health include increase in proportion of births attended
by skilled health personnel (currently above 70%),
capacity building of health professionals, increase in
nurse-to-population ratio and improvement in access to
reproductive health services.
• National resource allocation to the health sector has also
been increased with the introduction of free maternal
care.
• However, the MMR has remained stagnant (310 per
100,000 live births*) with postpartum hemorrhage being
one of the leading direct causes of deaths amongst
mothers.
• Oxytocin which is available in Ghana is the WHO
recommended drug that could potentially reduce PPH,
save the life of mothers and flatten the mortality curve.
Oxytocin saves lives!!!!
*Ghana Statistical Service (GSS), Ghana Health Service (GHS), and ICF. 2018. Ghana Maternal
Health Survey 2017: Key Findings. Rockville, Maryland, USA: GSS, GHS, and ICF.
3 PPH COP 2020
So what’s the
problem?
OXYTOCIN
QUALITY!
In Ghana, there were high reported
oxytocin assay failure rates of 56%
and 62% (2103, 2014).*
PPH COP 2020
Whatthreatens oxytocin quality?
Summary of oxytocin
quality threats:
• At the point of
manufacture: use of
poor quality active
pharmaceutical
ingredients and/or
presence of impurities
• Exposure to excessive
heat: cumulative
exposure to high
temperatures –
particularly during
transport – increases
oxytocin’s rate of
degradation
5 PPH COP 2020Oxytocin in Ghana Decentralized procurement. Prior to
Overview of Current Model
INTERNATIONAL
2017, oxytocin was principally
procured centrally through UNFPA.
INDIVIDUAL CONTRACTS Since 2017/18, procurement of
SUPPLIERS
oxytocin has been decentralized and
RMSs are the primary procurement
and distribution units for oxytocin.
REGIONAL HEALTH FACILITY
WHOLESALER MEDICAL
WAREHOUSE
Authorized wholesalers can deliver directly
to health facilities if RMS is stocked out
6 PPH COP 2020Oxytocin Volume at Facility Level
Needed Flow of Oxytocin based on Registered Births (2018) vs Actual Flow through RMS in 2018 in Cubic Meters
6.0 The difference indicates that oxytocin is likely
being supplied by other sources than RMS.
5.0
4.0
Cubic Metres
3.0
2.0
1.0
0.0
Ashanti Brong Central Eastern Greater Northern Upper East Upper Volta Western
Ahafo Accra West
Needed Volume Actual Volume
NOTE: Volta RMS not included as it did not provide any oxytocin in 2018. Assumptions - One ampoule of
oxytocin per birth, 9% PPH cases rate (4 ampoules), did not include induction or augmentation. Both
inventory and births data was aggregated to a region level.
7 PPH COP 2020Cold Chain Capacity
Availability of Functional Fridges at Health Facilities and Gap
• Over 90% of health centers, polyclinics and Health facilities supporting MCH with working
hospitals have a fridge storing oxytocin cold storage used to store oxytocin based on EUV
survey *
• Estimated Gap 45
• 40 Hospitals 40
• 120 Health Centers 35
• 40% of CHPS that reported deliveries have 30
a fridge storing oxytocin 25
• Estimated Gap 20
• 700 CHPS 15
10
• Estimated cost of fridges $58,000 – 5
$100,000 to fill the gaps. 0
• $65 for a 45 L fridge CHPS Health Center Polyclinic Hospital
With Fridge No Fridge
• $120 for a 120 L fridge
*GHSC-PSM EUV September 2019 Report
8 PPH COP 2020Regulation and Oxytocin Labelling
Oxytocin labelling and storage conditions
• In Ghana, if oxytocin is to be stored
outside of the refrigerator, the product
must demonstrate stability for the
duration of its shelf-life (usually a
minimum of 2 years) at 30° C
• Oxytocin injection products are NOT
stable for two years at 30° C and should
NOT be stored outside of the
refrigerator.
Photo of oxytocin observed during data collection, 2019.
• As a zone 4 country, storage conditions
on oxytocin injection labelling should Inspection and enforcement. Ensuring pharmaceutical
indicate storage at 2-8° C; however, not quality—including the inspection and enforcements of
all oxytocin products imported were quality assurance policies falls under the purview of the
labelled as such. This could have resulted Ghana FDA. At the time of the assessment, there were
in improper storage and degraded high fees associated with the importation, sale and
oxytocin in the market. distribution of unauthorized products but enforcement
was challenging.
9 PPH COP 2020Finance
Insurance reimbursement vs. actual prices and costs
*Data are from a
domestic wholesaler that NHIS reimbursement
supplied over 400,000 price: Oxytocin and all
ampoules of oxytocin in essential medicines
Average
2019 and is a large Wholesaler including the medicines
supplier for RMSs. Mark-Up to
RMSs* benefits package were
reimbursed directly using a
Additional CURRENT
Wholesaler GAP
fee-for-service model. The
Mark-Up to NHIS reimbursement price
Domestic RMSs for $0.52 PER
Warehousing Extended AMPOULE for oxytocin at the time of
Cost of Payment Terms*
International Costs assessment was lower than
International Transport what oxytocin costs
Supplier Price
domestically and
internationally.
2019 NHIS REIMBURSEMENT PRICE ($0.04)
10 PPH COP 2020Recommendations/Progress to date :
5 Registration and procurement of appropriate labelled oxytocin.
6 Revision of NHIS reimbursement price for oxytocin
7 Strengthening of inventory management and cold chain processes at all
levels
5 Filling of cold chain gaps at health facilities for oxytocin
IN PROGRESS
6 Ensuring central framework contracting for oxytocin
11 PPH COP 2020THANK YOU
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