Supply-chain strategies for essential medicines in rural western Kenya during COVID-19

Abstract Problem The coronavirus disease 2019 (COVID-19) pandemic has disrupted health systems worldwide and threatened the supply of essential medicines. Especially affected are vulnerable patients in low- and middle-income countries who can only afford access to public health systems. Approach Soon after physical distancing and curfew orders began on 15 March 2020 in Kenya, we rapidly implemented three supply-chain strategies to ensure a continuous supply of essential medicines while minimizing patients’ COVID-19 exposure risks. We redistributed central stocks of medicines to peripheral health facilities to ensure local availability for several months. We equipped smaller, remote health facilities with medicine tackle boxes. We also made deliveries of medicines to patients with difficulty reaching facilities. Local setting Τo implement these strategies we leveraged our 30-year partnership with local health authorities in rural western Kenya and the existing revolving fund pharmacy scheme serving 85 peripheral health centres. Relevant changes In April 2020, stocks of essential chronic and non-chronic disease medicines redistributed to peripheral health facilities increased to 835 140 units, as compared with 316 330 units in April 2019. We provided medicine tackle boxes to an additional 46 health facilities. Our team successfully delivered medications to 264 out of 311 patients (84.9%) with noncommunicable diseases whom we were able to reach. Lessons learnt Our revolving fund pharmacy model has ensured that patients’ access to essential medicines has not been interrupted during the pandemic. Success was built on a community approach to extend pharmaceutical services, adapting our current supply-chain infrastructure and working quickly in partnership with local health authorities.


Introduction
The coronavirus disease 2019 (COVID-19) pandemic has challenged health systems worldwide as they cope with the demands of infection control and management of the disease while maintaining the delivery of other ongoing essential care services to patients. 1,2 Low-and middle-income countries such as Kenya face new threats to an already overburdened health system. 1 One important challenge of the pandemic is the threat to the availability of essential medicines. Containment and mitigation strategies, central to the COVID-19 response, have the potential to disrupt medication supplies for vulnerable patients who can only afford access to the public-sector health system. 1,2 This supply-chain disruption is caused by government-mandated lockdowns, limitation of essential clinical services, lack of personal protective equipment for health-care providers, and stock-outs of essential medicines. 1,3,4 Addressing these challenges is essential to ensuring a robust response for patients with COVID-19-related needs, while preserving care for patients with other acute and chronic illnesses. In this paper, we describe strategies used to respond to these challenges, to implement proactive and patient-centric solutions, and to secure a continuous supply of essential medicines to patients in rural western Kenya.

Local setting
The Academic Model Providing Access to Healthcare partnership in western Kenya has developed care, education and research infrastructure to respond to the needs of patients living with human immunodeficiency virus infection. 5 The partnership has subsequently leveraged this infrastructure for the management of a comprehensive set of noncommunicable diseases. 6,7 A key component of the chronic disease management programme has been the creation, implementation and scale-up of the revolving fund pharmacy scheme, in partnership with the appropriate local health authorities and local community leadership. Over the past decade the revolving fund pharmacy model has successfully addressed many supply-chain needs for essential medicines in alignment with the Kenya essential medicines list. [8][9][10] The scheme operates within the catchment area of the Academic Model Providing Access to Healthcare partnership, spanning across seven counties and serving a population of 8 million people in western Kenya.
After the first case of COVID-19 was identified in Kenya on 13 March 2020, the government immediately implemented physical distancing and sheltering-in-place orders beginning 15 March 2020. Before this time, the revolving fund pharmacy scheme used a pull-based supply system whereby medicines were supplied to 85 peripheral health facilities Lessons from the field Supply of medicines during COVID-19, Kenya Dan N Tran et al.
throughout western Kenya based on drug order requests from those health facilities. However, after the Kenyan government enacted physical distancing guidelines and curfew requirements, we switched to a push-based supply system to support more rapid availability of medicines during this health crisis. We developed three context-specific strategies to ensure a continuous, timely and secure supply of essential medicines to patients throughout western Kenya. We present the available data on 33 essential medicines in 14 therapeutic categories.

Approach
The first strategy was the creation of decentralized warehouses in peripheral health facilities. In response to the physical distancing directives, staff of the revolving fund pharmacy scheme worked in partnership with appropriate county health authorities to determine the types and quantities of medications, as well as a delivery plan for essential medicines. Before the COVID-19 pandemic, the majority of the revolving fund pharmacy scheme's medications were stored in a central pharmacy warehouse. After March 2020, we decentralized the medication supply by redistributing the central stock of essential medications for chronic disease management (such as hypertension, diabetes and epilepsy) and acute ailments (such as infectious diseases) to 11 health facilities throughout western Kenya.
The second strategy was to provide patients with safer access to essential medicines. As of 15 March 2020, patients with chronic disease needs were encouraged to limit visits to hospitals. In response, staff of the chronic disease management programme increased the time between follow-up clinical visits. The change in follow-up interval was communicated by the clinicians to patients and the staff of the revolving fund pharmacy, who then modified the quantity of medications provided to each patient. Thus, we could easily refill patients' long-term medications without unnecessarily exposing patients or clinicians to the risk of COVID-19. We converted many of the health facilities in the chronic disease management network into sites where medicine tackle boxes containing a full complement of chronic disease medications were provided to assist staff with dispensing. These facilities were the smallest ones, located in very rural areas, where chronic disease medications have traditionally not been available. Medicine tackle boxes were stationed at these facilities even on days when there was no chronic disease management clinic, so that patients could come and obtain medication refills at their convenience. The clinicians in our network informed patients about the new system so that patients could correctly refill their medications at facilities equipped with medicine tackle boxes. Patients were reminded to follow all safety measures as per the health ministry guidelines, including wearing of masks and handhygiene. By enabling access to chronic disease medicines at the nearest health facility, we avoided the need for patients to travel long distances via public transport to reach higher-level facilities.
The third strategy was community delivery of medications. For patients who faced extra problems in reaching even their nearby health facilities (such as informal sector labourers, full-time caregivers or patients with disabilities), we developed a system of direct deliveries of medication to patients. Using our point-of-care electronic medical record system, 11,12 we identified patients who were due for medication refills. A member of the pharmacy staff called each patient to verify demographic, clinical and medication information, and invited the patient to come to a conveniently located medication drop-off point in the community. Drop-off points could be a patient's home, a local church, the community chief 's office, a local dispensary or any other agreed upon location that a patient could conveniently visit while adhering to social distancing recommendations. To maintain confidentiality, medications were pre-packed in opaque brown bags to conceal the contents. A 90-day supply of medication was dispensed to reduce the frequency of contact the patients were required to have with health-care staff. On distribution days, patients were given time-slots for attendance so that there were no more than six patients at any time. Patients observed hand-hygiene (washing hands when they reached the drop-off point) and physical distancing (maintaining at least 2 m of space from others) while receiving their medicines from the pharmacist who used personal protective equipment. The pharmacy staff verified the medication and gave each patient appropriate counselling to ensure therapeutic safety. We encouraged patients to pay via the local cashless mobile phone-based payment service. Patients were also advised to purchase national health insurance to take advantage of the benefits package including outpatient medication coverage. For patients who could not afford a 90-day supply of medications, we loaned them the cost of the medications using our revolving drug fund and designed a repayment plan over the course of 90 days. Patients with acute complications were evaluated by a clinician via synchronous telephone consultation, thus streamlining the referral process and avoiding unnecessary visits to the health facility.

Relevant changes
The supply of these medications to facilities surged in April 2020, 1 month after Kenya's first COVID-19 case was identified ( Table 1). The quantity of medicines for chronic diseases supplied increased about 2.5-fold in April 2020 relative to April 2019 (from 308 760 to 787 200 units) and the quantity supplied for non-chronic diseases increased 6.3fold (from 7570 to 47 940 units). These increases ensured that medications were available in the selected peripheral health facilities for several months. We were able to be proactive and responsive by adapting our responses to the local context during this health crisis.
Before March 2020, we had 11 peripheral health facilities equipped with tackle boxes. In less than 1 month after the first case of COVID-19 in Kenya, we had converted and equipped an additional 46 peripheral and rural health facilities with tackle boxes, so that more patients could easily receive their medications while minimizing COVID-19 exposure risks.
As of 19 June 2020, our team has delivered medications to 264 out of 311 patients (84.9%) whom we were able to reach. All patients received a 90-day supply of medicines at each encounter, followed by a follow-up telephone call to ensure the medications were being used correctly. Currently, our team is working closely with health authorities, local COVID-19 rapid-response teams and community strategy focal personnel. The plan is for continuous drug delivery efforts, community-based portable care delivery and communityhealth volunteer engagement to ensure patients do not miss any treatments for hypertension, diabetes and other noncommunicable diseases.
Lessons from the field Supply of medicines during COVID-19, Kenya Dan N Tran et al.

Lessons learnt
Preserving the supply of essential medicines in low-resource settings is essential to protect patients with and without COVID-19-related complications during this pandemic. Our paper describes a proactive approach to ensuring the continuous, timely and secure supply of essential medicines for public-sector patient populations throughout western

Box 1. Summary of main lessons learnt
• Community-centric and proactive strategies ensured the continuous, timely and secure supply and availability of essential medicines for public-sector patient populations during the coronavirus disease 2019 pandemic. • Adaptability, flexibility and forward thinking allowed us to leverage and convert the current pharmacy network to more local medicine distribution points so that patients continued to have safe access to essential medicines. • Local partnership was required to ensure an important pillar of the health system was not interrupted during this health crisis.
Lessons from the field