Strengthening public health supply chains in many low- and middle-income countries (LMICs) is essential to achieving universal health coverage (UHC) by 2030. But for communities to receive quality health care, they must have consistent and affordable access to quality health products. Therefore, when LMIC governments and their partners strive to get products to people, they must use all available in-country resources and expertise.
There are several ways to leverage the private sector in order to strengthen public health supply chains. At VillageReach we believe private sector integration is critical for building high-performing public health supply chains that are equitable, people-centered, resilient and sustainable. Integrating private sector capacity creates efficiencies and makes the public health supply chain more resilient to shocks.
And we are not alone in this belief. The World Health Organization developed the country connector during COVID-19 to provide countries with practical guidance for engaging the private sector, and more and more donors are investing in public-private collaborations. In many LMICs, private sector companies already offer health service provision through hospitals, clinics and pharmacies, as well as enable public health supply chains with services such as transport and warehousing.
Leveraging private distributors
Another area of opportunity for LMIC governments to leverage private sector capacity is through increased collaboration with private pharmaceutical distributors, companies that procure and supply medicines to hospitals, pharmacies and health facilities. The overall challenges of engaging private distribution channels are not a new topic. In their 2019 article, authors Prashant Yadav and Amanda Glassman explore why the private pharmacy channel (i.e., distributor, wholesaler, retailer) is mostly ignored by LMIC governments and global health funders as a strategy to support UHC and expand access to health products.
No longer ignoring this opportunity is not only strategically important for Africa but also urgent.
The African Union is developing the African Medicines Agency (AMA) to regulate medicines being manufactured and distributed among its member states. Countries that work now to integrate private distributors will be better prepared to meet the AMA regulations for health products as well as to contribute to the development of those regulations. And with the launch of the African Continental Free Trade Area, private distributors can expand on their national markets to access new customers across the continent.
For governments and their partners interested in capitalizing on this current opportunity we are sharing lessons learned from our first year of implementation in the Democratic Republic of Congo (DRC).
Lessons learned from DRC
In September 2021, we began working with the DRC government and partners to remove barriers hindering private sector for-profit pharmaceutical distributors from participating in the public health supply chain (see Figure 1 below).
Figure 1: Roadmap: Increasing for-profit private distributors supply to public health facilities in the DRC
Here are three important lessons for partners to consider before they fund or engage in this work.
1. Governments should engage with all qualified distributors
Building high-performing public health supply chains requires the government to look holistically at the various strengths of all distributors providing quality medicines. This means both for-profit and not-for-profit distributors. Previously in DRC private for-profit distributors were mostly excluded as suppliers to public health facilities. Even though some for-profit distributors have more capacity to invest and expand than their not-for-profit peers, they were limited to being suppliers to private sector hospitals and health facilities.
In the DRC private not-for-profit distributors primarily store and distribute health products for specific diseases (such as Malaria, HIV/AIDS, Tuberculosis) or specific programs (family planning) through contracts with international donors. Essential medicines, those that are the basis of primary health care, are often a lower priority for these not-for-profit distributors because their funding is tied to delivering specific health products. By highlighting this gap, and the existing resource constraints of public distributors, we were able to help the government, its technical partners and private companies see the value of integrating for-profit private distributors to improve the availability and accessibility of essential medicines across all hospitals and health facilities (both public and private).
Because at the end of the day engaging all qualified distributors means more health products reaching more people.
2. Integration needs a legal framework and regulations
In the DRC the public health supply chain was managed almost exclusively by the government through a public distribution system until it dissolved due to financing problems in 2003. Since then, a system primarily made up of private not-for-profit distributors, called the FEDECAM, has been the primary source of supply to public health facilities. Despite the robust use of private not-for-profit distributors in DRC, public health laws did not sufficiently address for-profit distributors, inhibiting their participation.
To resolve this issue, we worked closely with the DRC Ministry of Health (MoH) to develop language for a Decree to be added to the 2018 Framework Law on Public Health. This Decree, which will go into effect at the end of 2022, regulates the participation of all distributors, both for-profit and not-for-profit, as suppliers to public health facilities. But to get here required us to build a coalition of stakeholders, including the MoH and private distributors, as well as key supply chain partners such as the National Order of Pharmacists, to support a legal framework.
Through workshops at both the national and provincial levels, and amplifying the successful integration of private for-profit distributors in several DRC provinces as part of a World Bank funded project, we obtained alignment from these stakeholders, establishing a legal framework to guide and grow for-profit private distributors participation in the public health supply chain.
Additionally, we are working to strengthen the Congolese Pharmaceutical Regulatory Authority (ACOREP), with Bill and Melinda Gates Foundation funding, to increase its maturity on the WHO Global Benchmarking Tool scaling system. By implementing the WHO Listed Authority framework we intend to promote increased access to safe, effective and quality health products. According to the new Decree, all for-profit private distributors that want to deliver health products to public facilities will need to be certified through ACOREP (to date 17 private companies have received this certification: 14 distributors and 3 manufacturers).
3. On-going strategic collaboration between government and private distributors
In the DRC, there are few MoH employees with experience managing on-going relationships with private sector for-profit distributors. The COVID-19 pandemic increased these interactions, as for-profit distributors were often the only source of supply for some health products during the pandemic., collaboration through circumstance alone will not enable sustainable relations. This is why we are advocating for government and these private companies to have on-going intentional collaboration, that includes longer-term objectives and clear processes for engagement. We have learned that this is essential to motivate for-profit distributors to invest the necessary personnel and resources and develop business plans that align with government priorities.
Building supply chains for the future
Universal health coverage in LMICs is not possible without strong public health systems – without strong public health supply chains. Lessons from our work in DRC can help other countries leverage private distribution participation in public health supply chains. Engaging all distributors is the best way to get products to people, because only when the hardest to reach communities have reliable and consistent access to health products can we truly say that everyone, everywhere has the health care needed to thrive.
For more information about VillageReach’s private sector engagement contact Joseph Roussel, Director of Private Sector Engagement, firstname.lastname@example.org. For specific questions on our work in the DRC, please contact email@example.com and firstname.lastname@example.org.
About the Authors
Martin Mahombisa is Private Sector Engagement Specialist at VillageReach based in our DRC office. A pharmacist, he has worked for private pharmaceutical distributors and for a leading private health facility in Kinshasa.
Patrick Cizungu is Government Engagement Specialist at VillageReach based in our DRC office. A pharmacist, he has over 20 years of experience in the DRC public health system, primarily as a provincial pharmaceutical inspector.