MEDICINES PROCUREMENT FRAMEWORK FOR PUBLIC HOSPITALS UNDER MINISTRY OF HEALTH- GHANA
MEDICINES PROCUREMENT FRAMEWORK FOR PUBLIC HOSPITALS UNDER MINISTRY OF HEALTH- GHANA
Author: Domie Godswill (BSc, MBA, MPH, PhD Student- PCU, Manila Philippine
Abstract
The Medicines Procurement Framework Agreement of the Ministry of Health, Ghana was introduced in 2017 as part of strategies to ensure an all-time availability of essential medicines to improve the quality of healthcare delivery. After almost five years of implementation, not much is known and documented on the perceptions, opinions, and views of health care providers as key stakeholders of the policy. This study explored the opinions, views, and experiences of health care professionals on the implementation and sustainability of the Medicines Procurement Framework Agreement. As a qualitative study, it used in-depth interviews and documentary review as the main methods of data collection twenty-five healthcare professionals in six government health facilities in the Western Region were purposely selected and interviewed and Data was analyzed using the Nvivo 7 software any content analysis. The study revealed that most other healthcare professionals are not fully aware of the content of the policy. The study also found that technical considerations of improving equity, efficiency, and, quality of healthcare delivery and also to reduce administrative bottlenecks provided the contexts for the policy. The study further revealed that actors in the MPFA at the Regional, District, and sub-District levels were also not adequately engaged in the policy-making process. The study noted further that the sustainability of the policy is threatened by non-stakeholder involvement in the policy process, restrictions on purchases outside the MPFA as well as the non-responsiveness of suppliers to call-offs. The study, therefore, recommends the need for regular engagements of key stakeholders to ensure ownership, interest, and motivation. There should be regular education on the policy to explain the goals and objectives to actors. These stakeholder engagements should consider a possible policy review to inculcate the views, perceptions, and opinions of actors to ensure sustainability
Keywords: Medicines Procurement Framework Agreement, Essential Medicines, Public Procurement, Quality Healthcare Delivery, Policy Sustainability
Introduction
Medicines are vital elements of healthcare, and access to medicines is a fundamental human right and forms one of the basic building blocks of all functioning health systems (Hogerzeil, 1986, 2006; United Nations 2015; WHO, 2018). Essential medicines availability is key to ensuring quality healthcare delivery. In Ghana, available records show that essential medicines availability in almost all public health facilities fall below the WHO recommended threshold of 80% (Osei-Assibey and Akweongo, 2017, GHS Holistic Assessment Report, 2019, 2020). It is also evident that health facilities are struggling to meet their medicines requirements for the treatment of patients. (GHS Holistic Assessment Report, 2020). Anvuur, Kumaraswamy, and Male, (2006) reported that health facilities in developing countries are unable to ensure value-for-money procurement due to a lack of capacity resulting in equity, efficiency, and quality issues
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Background to the Study
United Nations, (2015) indicated that the availability of medicines will a play critical role in the attainment of goals four, five and, six of the Millennium Development Goals (MDGs) and goal three of the Sustainable Development Goals (SDGs). Ritchie et al, (2018) and UNDP (2007) also respectively noted that medicines are fundamental to quality healthcare delivery and that achieving the MDGs and SDGs and Universal Health Coverage (UHC) would need strong structures that ensure ready availability of drugs that would assist to provide integrated services and improve the quality lives of people. In its report outlining draft road map for access to medicines, vaccines and other health products. Expressing concern about the proliferation of sub-standard medicines and their effect on quality healthcare delivery, WHO, (2018) stated that strong regulatory frameworks, assessment of the quality, safety and efficacy or performance of health products through prequalification market surveillance and assessment of quality, safety and performance are the surest ways to achieve and maintain medicines and other health related supplies for effective healthcare delivery.
Ghana’s health sector’s objectives seek inter alia to improve health status of the citizenry. These health-sector strategic objectives namely to Ensure sustainable, affordable, equitable, easily accessible healthcare services (Universal Health Coverage); to reduce morbidity, disability, mortality and intensify prevention and control of non-communicable diseases; to enhance efficiency in governance and management of the health system and to intensify the prevention and control of communicable diseases and reduction of new HIV/AIDS and other STIs especially among vulnerable groups require the availability and supply of essential medicines as a key component of Primary Health Care (PHC) (GHS strategic Plan, 2016-2021). As a sector, a number of interventions and activities have been initiated and being implemented to ensure the regular availability of drugs. Among them are the review of the Public Procurement Act, the development of sector specific procurement manual, improvement in planning and budgeting, renovation of various Regional Medical Stores (RMSs), training of Supply Chain Practitioners (SCPs), and the introduction of the Medicines Procurement Framework Agreement (MPFA). (GHS, 2019)
However, Studies by Osei-Assibey & Akweongo (2017) and Anvuur, Kumaraswamy and Male, (2006) show that less developed countries including Ghana faced enormous difficulties with their decentralized procurement systems due to lack of general capacity accounting for poor value for money transactions in both government and donor financed projects. It cited issues such as insufficient procurement planning, wasteful expenditures, lack of capacity to pay suppliers, funding inadequacies, general low supplier delivery problems and lack of qualified procurement staff in the execution of health policy reforms difficult and maintained that problems of the procurement system of the health sector should be comprehensively addressed. A study by Osei-Assibey & Akweongo, (2017) concluded that GHS accounted for only 17-18% availability of essential medicines as against the WHO standard of 80% and the GHS Holistic Assessment, (2020) also indicate that only 64% of total medicines requirement was available at RMSs
To address these technical gaps, the government of Ghana through the MOH/GHS introduced the Medicines Procurement Framework Agreement in 2017 aimed at ensuring the constant availability of essential medicines in all public health facilities across the country for quality healthcare delivery. Medicine Procurement Framework Agreement or Contract otherwise known as “Blanket Purchase Agreement” is a long-term agreement that provides terms and conditions specifically price and quantities under which smaller repeat purchasing orders may be issued for a defined period of time (MOH, 2021). Ahead of the roll out of the MPFA, Kanyoma Kizito et al. (2013) opined that, though framework agreements have some great benefits, there are thorny issues such as non-supplier adherence to the framework contracts resulting from shipment schedules and other financial difficulties as challenges for its successful implementation. Miller and Taylor, (2014) and (Ameyaw et al, (2012) also confirmed that inadequate stakeholder engagement on any policy is a key factor responsible for the lack of understanding of the policy and its eventual successful implementation. Against these backdrops, the study sets to explore the views and opinions of key stakeholders on the Medicines Procurement Framework Agreement of the Ministry of Health- Ghana in the Western Region of Ghana and to bring lessons learnt to the attention of policy makers.
Review of Related Literature
According to Arney et al, ( 2014) “Framework agreements are long-term memorandum of understanding that provide the terms and conditions under which smaller repeat purchasing orders known as call offs may be issued for a defined period of time” and in the Ghanaian context, the Medicine Procurement Framework Agreement or Contract is also called “Blanket Purchase Agreement” an arrangement that specifies the general terms and conditions (price and quantities) under which the MOH as a lead party will order smaller repeated purchasing orders from suppliers over period of time specifically one year though renewable but not guaranteed (MOH, 2017).
Before this agreement came into force, Public Procurement in Ghana had gone through series of transformations since independence transgressing from state dominance through to private participation, decentralization and finally with the promulgation of the Public Procurement Act (Act 663 as amended 914) (Verhage et al,2002; Nathan, 2012; PPA, 2006, MOH, 2004). Public procurement in Ghana’s health sector suffered from a number of challenges including lack of general capacity, poor value for money, insufficient procurement planning, wasteful expenditures, lack of funds to pay suppliers, and low supplier delivery which resulted in almost non-availability of essential medicines to deliver healthcare in many state healthcare facilities (Osei-Assibey & Akweongo 2017).
A number of studies conducted locally had concluded that medicines availability prior to and even after the enforcement of the agreement is way below the WHO standard resulting from implementation challenges such as poor response to call offs by framework contract suppliers, non-payment or delay in payment to framework contract suppliers from health facilities, and general lack of understanding of the policy goals and objectives by health professionals as key actors (Ameyaw et al, 2012; Miller and Taylor, 2014; Osei-Assibey & Akweongo, 2017; GHS Holistic Assessment Report, 2020). To address the gap and ensure all time availability of medicines for healthcare delivery the medicine procurement framework agreement was instituted with a centralized power by the Ministry of Health to be the lead (sole negotiator and purchaser) in the contract execution which is similar to that of South Africa where all procurement for essential medicines was done by a national tendering unit on behalf of the provinces but in cases of supplier failures the provinces were allowed to do ‘buyouts’ with approval from provincial authorities contrary to what pertains in the Ghanaian version (Medicines Sans Frontiers, 2013; Zuma, S.M. 2017; Zuma, S.M. & Modiba, L.M., 2020) and also in the USA where Arney L. & Yadav P, (2014) reported that although the framework for the procurement of medicines is usually characterized by centralized negotiation and contract management, the agreement allows for decentralized procurement authority with the key elements being federal (regional) pricing arrangements, direct negotiation of flexible contracts with manufacturers and a direct purchase and distribution approach facilitated by prime vendor programs. Arney L. & Yadav P. (2014) further noted that the USA framework, also allows for all indefinite-delivery contracts to be directly shipped to facilities (users) with suppliers permitted to determine the realistic minimum and maximum quantities for each delivery order which makes their system more decentralized and acceptable by all stakeholders. Indeed, the South African and the USA medicine frameworks are hybrids of centralized negotiation (where framework contracts are first negotiated between the federal government agencies and multiple manufacturers under the framework agreements) and decentralized ordering ( where facilities engage in direct ordering through decentralized procuring entities from private distributors/wholesalers operating under these service contracts. Studies show that the South African Framework for medicine procurement is too cumbersome and is not working perfectly due to long contract process, non-payment of suppliers, poor supplier performance, and lengthy buy-out process and non-inclusivity of stakeholders resulting in unnecessary stock-outs (Barraclough A & Clark M 2012; Modisakeng et al, 2020). Similar sentiments were expressed with regards to the Ghanaian context (Osei-Assibey & Akweongo, 2017; Anvuur, Kumaraswamy and Male, 2006) which might have alarmed the Ministry of Health (MOH) as part of its overall health supply chain management review introduced the Medicine Procurement Framework which objectives are to improve medicines availability, ensure uniformity in product pricing, reduce administrative cost in acquisition process involving bulk buying to enjoy economies of scale (MOH, 2017). That notwithstanding, there is low level of awareness among some health professionals of the content, context and the processes of the policy. Also, the views and opinions of health professionals with regards to the formulation, implementation and sustainability of the policy and its effect on the access, quality, and efficiency in service delivery have not been explored and documented. Only few studies on Procurement Framework Agreements in Ghana, have focused on the health sector and their scope was limited to either one category of professionals or one facility and there seem to be paucity of views and opinions of health care providers on the policy implementation and its sustainability.
Against this background, this study sort to explore a wider stakeholder views and opinions on the Medicines Procurement Framework Agreement of the Ministry of Health, Ghana and to specifically answer whether health professionals understand the content of Procurement Framework Agreement, and also to find out which contextual factors influenced the adoption of the policy. The study also wanted to explore further on the implementation status of the policy and find out what are the roles actors in the framework played and are still playing and to also ascertain if the policy had met its objectives and will be sustainable in the future. To address these concerns, the study relied on the following research questions.
1 To what extent do health professionals understand the content of Procurement Framework Agreement?
2 Which contextual factors influenced the adoption of the Procurement Framework Agreement?
3 What has been the implementation status in the Procurement Framework Agreement in the Western Region?
4 What are the roles of actors in the sustainability of the Procurement Framework Agreement in the Western Region?
5 Is the policy sustainable? How does it affect quality of care?
Policy Framework that Guided the Study
The study was guided by Walt and Gilson’s Policy Triangle (1994) as basis for its conceptual framework. Writing extensively on the policy triangle Buse, (2008), Rajkotia, (2011), Addai et al, (2006) and Columbini et al, (2011) all noted that any policy has four elements namely the content, context, process, and actors and strongly recommended the Walt and Gilson’s Policy Triangle (1994) as a guide to policy study frameworks. Consequently, the Walt and Gilson’s Policy Triangle (1994) was relied on to derived the conceptual framework for the study
Source: Walt and Gilson (1994)
Conceptual Framework for the study
Independent variable ( ) Independent variable ( )
Procurement Framework Agreement (PFA)
· Negotiation and Selection of suppliers
· Medicines availability to Regional Medical Stores
· Uniformity in product pricing
· Bulk purchase and economies of scale.
· Access to substitutes outside Framework agreement
· Access to New brand or quality
Implementation of Procurement Framework
· Meeting Delivery Timelines
· Delivery based on Specified Quantities or brand
· Continuous flow of medicinal commodity
· Delivery of substandard medicinal commodity
· Adherence to specified packaging standards
· Acquisition of medicinal commodities under emergency situations and supplier delays
Availability of Essential Medicines
Quality Health Care Delivery
· Attendance Rate
· Health Complications
· Fatality Rates
· Patient Self-Medication
· Frustration of patients and staff
Dependent variable ( ) Dependent variable ( )
Figure 1. Conceptual Framework. (Authors Construct, 2022)
The conceptual framework demonstrates the assumed relationship between four fundamental variables; Procurement Framework Agreement, the implementation of Procurement Framework, availability of essential medicines, and the Quality of Healthcare Delivery and these are grouped under two main variables, the independent and dependent variables. The independent variables are Procurement Framework Agreement and the implementation of Procurement Framework and the dependent variables are the availability of Essential Medicines and Quality Health Care Delivery. The framework assumed that the availability of medicines for quality healthcare delivery depends on the interplay between the content of the Framework, its implementation process and the roles of stakeholders within the context of the policy.
Methods
The study was conducted in the Western Region of Ghana and adopted Cross sectional study design with qualitative approach: Phenomelogical and Historical. The study population included Health Professionals with procurement and drug usage responsibilities and sample of 25 respondents were drawn from 6 facilities across the region. Data Collection tools Techniques used for the study were In-depth interviews, Documentary review, and focus group discussions. The data collection instruments were tested/piloted for reliability and validity in the Bono Region where seven respondents comprising a Regional Medical Stores staff, a Doctor, a Nurse, an Accountant, an Administrator, a Procurement Manager and a Pharmacist were involved. Data for the study was collected between January and April 2022. Data collected include Demographic, Content, context, and processes of the medicine procurement framework agreement, views, opinions and perceptions of healthcare professionals on the implementation of the policy, and views, opinions and perceptions of healthcare professionals on the sustainability of the policy. Qualitative content analysis was used for data analysis and filed data was methodically organized and coded into themes using Nvivo 7 statistical software and inductive content analysis was used to analyse the data and bio data was quantitatively and other results descriptively presented. Ethical clearance was obtained from the GHS Ethical Review Committee for the conduct of the study (GHS-ERC /21/57C). Permission was granted and informed consent obtained from respondents who voluntarily participated in the study. Covid-19 protocols were adhered to during the study. There was no conflict of interest in this study.
Results
Bio data
Table 1. Demographic profile of Respondents
Demographic(s)
Age (n= 25)
No
30-39
5
40-49
13
50-59
7
Sex (n= 25)
Male
18
Female
7
Working Experience (n=25)
6-10 years
10
More than 10 years
15
Licensing/Registration status (n=25)
Yes
25
No
0
Educational Background (n=25)
Graduate/University
17
Higher National Diploma
4
Advanced Diploma ( Nursing)
4
Grade/Role (n- 25)
Lower Level Management
Middle Level Management
Senior Level Management
6
9
10
Profession Category (n = 27)
Accountant
Health Services Administrator
Procurement Staff
Supply Chain Staff
Doctor
Nurse Managers
Pharmacist
Physician Assistant
3
3
4
4
3
2
4
2
Profession Category (n = 7)
Regional Health Directorate 1
Regional Medical Stores 1
Regional Hospital 1
District Health Directorate 1
District Hospital 1
Health Centre 1
CHPS Compound 1
Source: (Field Data, 2022)
A cross section of Twenty five (25) health professionals between the ages of 30-59 were interviewed. They have between Diplomas and Master’s Degrees in their relevant fields. No respondent holds a PhD. All respondents are registered professionals and belong to various regulatory and professional associations
Stakeholders take on the Policy
Policy Content
Out of the three categories identified from the 25 respondents, Fifthteen (15) respondents constituting 60% were not aware of the policy, six respondents, accounting for 24% were aware of the policy but had no idea about its content and 4 respondents making up 16% were both aware of and have knowledge of the content of the policy. However, while some were aware of the policy, they were unable to state the goals, objectives and the elements of the policy. Some also indicated they had not sighted the policy document because they were unable to say anything factual about it. More interesting is that, even those who were directly involved in the implementation at the regional level were not able to effectively relate to content of the policy. This confirms the position of Ameyaw et al, (2012) on the introduction and implementation of framework agreement in the educational sector where they found out that most stakeholders in the sector were unaware of the framework because they were not fully engaged and involved. It is clear that some health professionals at the regional, district and sub-district levels are not fully aware of the policy and supported by a respondent: “No am not aware of any policy. Usually such things when they are done at the National and Regional levels, they always organize training on them for us but……..I mean this one nothing like that was done” (District Director, 47 years)
Policy Context
The results of the study indicate that a number of factors necessitated the roll-out and the implementation of the Medicines Procurement Framework Agreement. Notable among them are minimization of administrative bottlenecks, improving equity, efficiency and quality of care. Others included technical issues such as to reduce corruption in procurement, address the problems of lack of funds at the lower levels to engage in large volumes of procurement to enjoy economies of scale, low staff capacity and lack of qualified procurement staffs especially at the regional and district levels. These contextual factors are supported by literature (Grindle and Merilee S, 2017,) in their studies into policy analysis where they enumerated factors such as sector reforms, technical and administrative bottlenecks, economic factors, traditional and socio-cultural factors and environmental factors and demographic changes as key determinants of policies. It is also evident that technical and administrative bottlenecks necessitated the roll out of the policy and this was underscored by a respondent as “I think the first consideration was purely to address some technical issues and that informed the policy; I mean it was to improve equity, efficiency and quality of healthcare delivery” (Procurement manager, 47 years)
Policy Process
The results of the study confirmed that the initiation and formulation of the Medicines Procurement Framework Agreement was done at the highest level and the regional, district and sub-district levels are expected to ensure the implementation of the policy. This was in agreement with Anderson (2011) and this was supported by a respondent: “Sincerely I don’t know how the medicine procurement policy was formulated. I was not involved. I don’t think I remember any stakeholder engagement to roll out the policy in the health sector” (District Director, 45 years)
Policy Implementation
Although policy actors generically play very essential roles in any policy implantation, the results of the study indicate that health professionals at the Regional and District levels were not involve in the negotiation, award and management of the framework contracts and are unable to perform their roles effectively in the implementation of the policy. This is against the position of Sutcliffe & Court, (2005) where he maintained that policy actors at the implementation level should be allowed to provide technical skills, expert knowledge and practical experience and also develop monitoring mechanisms that will reveal discrepancies between the policy’s expected and actual results as means of policy evaluation. This was echoed by respondents “I was not involved in the formulation of the policy…….even as a group, I don’t remember our group AHSAG was even involved in any of the process” (Administrator, 59 years) and in a rather long statement, another respondent noted:-“We were not adequately engaged in the policy process such as its initiation and formulation making us not to play our roles effectively. This has denied inputs from the lower levels into the policy process. Also, there is no implementation guidelines and role definitions for regional, district and sub-district level actors except that they send their medicine requirements in the case of regional level to the national level and the districts and sub-districts to the RMS and all these can affect sustainability. In fact, actors at the regional, district and sub-district levels are not allowed to take part in the selection of suppliers and award of contracts under the MPFA thereby rendering us unable to monitor and supervise supplier performance a situation that can affect the implementation of the policy”. (Medical officer 47 years)
The study also revealed that implementation is associated with non-availability of and access to medicines as expressed by a participant: - “If you asked me, I’ll say that the policy is not making drugs available at the RMS, how much more would the District get it not to talk of the facilities. The policy just need a review to relax its rigid clauses. Districts and regions should deal with their suppliers. National cannot understand local needs better than the locals themselves. Simplicita” (Pharmacist, 45 years) which contradicts the position of Ministry of Finance (2019) and MOH, (2021) when they maintained that the Medicine Procurement Framework Agreement will ensure all time availability of essential medicines to all health facilities across the country.
Sustainability of the policy
The results of the study also indicate that low level of involvement of key stakeholders in the policy process is a potential to affect its ownership, proprietorship, acceptability, legitimacy, and eventual sustainability. The study further revealed that lack of or inadequate financial resources to enable facilities pay for medicine supplies to ensure constant supplier response to call offs is another factor that will strongly militate against the policies sustainability. These facts supports what Bennet et al, (2004), Shiagayeya et al (2010), Bates et al, (2011), and Anderson (2011), concluded about policy sustainability and also a direct opposite of the USA and the South African version of the Medicine Procurement Frameworks. These positions were supported by respondents as indicated. “They need to fully involve us. I think the whole thing was too centralized and rushed” (Health Services Administrator, 57 years). “The authorities should allow us at the district level to engage the suppliers. The current arrangement is not helping because we even don’t know the suppliers we are dealing with” (DDHS, 43 years). In adequate provision of financial resources to enable facilities pay for medicine supplies and “The policy is not bad, but we cannot sustain it with the current level of erratic NHIS claims payment” (Accountant, 44 years; Administrator, 45 years)
Discussions, Conclusion, and Recommendations
Inferring from the results, it is important to indicate that; the Medicine Procurement Framework Agreement (Policy) generally is good. The policy goals, objectives, scope and relevance are adequate in ensuring equity, efficiency and quality of healthcare delivery in the country as a whole. The content, context, process and actors of the policy are well structured to deal with technical and administrative bottlenecks to essential medicines procurement and has potentials of assisting the health sector to achieve the Sustainable Development Goals on health and the health sector objectives and can also address technical and administrative holdups to essential medicines procurement and supplies
However, the policy advocacy and engagement processes were not all-inclusive. Health professionals were not fully engaged on the content, context and process of the policy with regards to their inclusion of views, opinions and perceptions on the policy process and how these elements can be factored into the implementation of the policy. The implementation of the policy is also fraught with shortages of medicines resulting from non-response to call-offs. There is still some equity, quality and efficiency gaps that need to be addressed. It may be concluded that the policy for now had not met its full objectives of ensuring all time availability and access to essential medicines and that to sustain the policy, implementation challenges must be addressed
On the basis the findings and the conclusions of the study, the following recommendations are made. That there is the need for broader and an all-inclusive stakeholder engagement to ensure all implementation challenges of the policy must be addressed including financial resource availability. There should also be the formation of Technical Working Groups or Committees across all regions and districts to oversee implementation of the policy. There is also the need for continuous capacity building of health professionals for their full understanding of the policy and as a long term measure there should be a possible review of the policy implementation guidelines to include full stakeholder participation, involvement, and acceptability.
Limitations of the Study
The Sampling technique (Non-probability-purposive) used for the study presents to some extent the inability to evaluate if the population is well represented (inability to calculate intervals and the margin of error) as well as External validity- Generalization of findings to a larger population. There is also the possibility of respondents to manipulate the data which may result in some inaccuracies in the research outcomes.
Nevertheless, the study will assist policy makers to review the MPFA and also provide basis for engagement with Development partners and other actors and help in deepening the understanding of public health and government institutions, healthcare professionals, managers, practioners and other stakeholders in the implementation of the policy to improve efficiency and to ensure quality service delivery. It will also inform well-planned interventions to benefit the suppliers and the pharmaceutical companies under the agreement because, understanding the implementation process would mean that all parties would play their roles properly to improve quality care. Implementing the recommendations of the study will benefit the patient to access quality care as ensuring all time availability of essential medicines for quality healthcare service delivery will be given a priority. It will also contribute to the existing body of knowledge on procurement framework and supply chain management by serving as a resource material for both practioners and academia and setting the tone for further research
Acknowledgment
The Author acknowledged the immense contributions, advice, support and mentorship of the following entities and personalities who made this study a reality: - Nana Kwame Owusu Boampong (PhD), my academic advisor at the MPH level, Dr Vitalis Bawontuo (PhD), former Dean and Dr Lydia Asante- the Dean and Lecturer of the Faculty of Health and Allied Science of the Catholic University of Ghana, Dr Francis Takyi, Mr Noah Paul Quarm, Mr Samuel Dodzi, and Mr Iddrisu Kunamsi my colleagues and Nana Kofi Koomson my office staff, the GHS Ethics Review Committee, the Western Regional Health Directorate, and all the participating health institutions.
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