THE UNITED REPUBLIC OF TANZANIA

MINISTRY OF HEALTH

TANGANYIKA MEDICAL TRAINING BOARD

TABORA (EA) POLYTECHNIC COLLEGE

SCHOOL OF HEALTH AND ALLIED SCIENCE

DEPERTMENT OF PHARMACY

ORDINARY DIPLOMA RESEARCH PROJECT PROPOSAL

ASSESSMENT OF AVAILABILITY OF ESSENTIAL MEDICINES AMONG HEALTH

FACILITIES IN TABORA MUNICIPAL

Research Project Report Submitted in Partial Fulfillment of the Requirements for the
Ordinary Diploma of Pharmaceutical Sciences

RESEARCHER NAME EXAVIERY S. YUDA

REGISTRATION NUMBER NS.0104/0037/2015
SUPERVISOR NAME PHARM ERASTO MURUNGU
MODULE INSTRUCTOR NAME PHARM ISMAIL B.SAID

1
 CERTIFICATION
I Exaviery S Yuda I certify that I am the writer of this individual research report recommend for
acceptance Tabora (Ea) Polytechnic College by the report entitled: “Assessment Of Availability
Of Essential Medicines Among Health Facilities In Tabora Municipal” in partial fulfillment of
the requirements for the award of ordinary diploma of pharmaceutical sciences of Tabora (EA)
Polytechnic College.

NAME OF SUPERVISOR SIGNATURE DATE

……………….……………. ……………… ………………..

2
DECLARATION AND COPYRIGHT
I Exaviery S Yuda , declare that this project is my original work and that it has not been
presented and will not be presented to any college for a similar or any other ordinary diploma
award

Signature: _____________________ Date: ___________________________

This dissertation is a copyright materials protected under the Berne convention, the copyright act
1999 and other international and national enactments, in that behalf, on intellectual property. It
may not be reproduced by any means, in full or in part, except for short extracts in fair dealing
for research or private study. Critical scholarly review or discourse with an acknowledgement,
without the written permission of the directorate of postgraduate studies, on behalf of both the
author and Tabora (E.A) Polytechnic College.

3
 ACKNOWLEDGEMENT
My gratitude goes to the Almighty God, for His blessings. I am also grateful to my family and
accolades, for their cooperation and support which had a positive impact during whole research
period.

My sincerely thanks go to my lecturer Pharm. Ismail Said, Pharm. Erasto Murungu and other
different individuals for their synergic directional support and contributions in many ways in
making this project complete and successful.

4
 ABSTRACT
Background: The 2018 edition of the National Essential drugs List came into effect in
September 2018. Relevant policies require that all primary medical and health institutions
should supply national essential drugs, while secondary and tertiary medical and health
institutions should supply a certain percentage of essential drugs.
Methods: Our research used the standard methods of WHO, selected basic drugs, combined
with the actual situation of Tabora municipal, selected medical institutions, conducted drug
availability and affordability studies.

Results: The availability of the lowest-price generics (LPGs) of essential drug in health
facilities is much higher than that of the Originator brands (OBs); the overall affordability is
better, but there is a large gap between the affordability levels of OBs and LPGs. OBs are
relatively poorly affordable.

Conclusion: The implementation of the national essential drug system in Tabora municipal has
achieved certain results, but there is still a gap from the expected target. It is recommended to
update and adjust the list of essential drugs in accordance with the demand for clinical
medicines, ensure that medical and health institutions at all levels supply essential drugs,
popularize knowledge of essential drugs, and moderately adjust the price of OBs to reduce the
medication burden.

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LIST OF TABLES

Table 1: Showing Medicines Available In 5 Dispensaries from January to march

Table 2: Showing Medicines Available In 4 Hospitals from January to march
Table 3: Availability of some essential medicines in Magereza hospital from Jan to Sept
Table 4: Descriptive statistics of projected quarterly demands compared to last ordered quantites
and actual medicines received

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LIST OF FIGURE
FIGURE 1: Line graph showing Trend on Availability of medicines in magereza dispensary each
month

Figure 2: Bar chart showing Order Waiting Time In 5 Health Facilities

Figure 3: Pie chart showing Descriptive statistics of projected quarterly demands compared to
last ordered quantities and actual medicines received
Figure 4: Histogram showing comparison between received and ordered amounts of medicines

Figure 5: Sources of funds used to purchase medicines and medical supplies from private
suppliers

Figure 6: % Respondents answering questions on the kind of complications/impacts due to the

shortage of medicines

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 TABLE OF CONTENTS
CERTIFICATION........................................................................................................................................- 2 -
DECLARATION AND COPYRIGHT..............................................................................................................- 3 -
ACKNOWLEDGEMENT.......................................................................................................................- 4 -
ABSTRACT................................................................................................................................................- 5 -
LIST OF TABLES........................................................................................................................................- 6 -
LIST OF FIGURE........................................................................................................................................- 7 -
TABLE OF CONTENTS........................................................................................................................- 8 -
ABBREVIATIONS...............................................................................................................................- 10 -
CHAPTER ONE........................................................................................................................................- 11 -
1.1 Background.................................................................................................................................- 11 -
1.2 LITERATURE REVIEW....................................................................................................................- 12 -
1.3 Research Problem Statement.......................................................................................................- 13 -
1.4 Research Rationale......................................................................................................................- 13 -
1.5 Research objectives.....................................................................................................................- 14 -
1.5.1 Main Objectives.......................................................................................................................- 14 -
1.5.2 Specific Objectives...................................................................................................................- 14 -
1.6 Research Questions.....................................................................................................................- 14 -
1.7 Research Variables......................................................................................................................- 14 -
1.8 Research Hypothesis...................................................................................................................- 14 -
CHAPTER 2.........................................................................................................................................- 15 -
METHODOLOGY............................................................................................................................- 15 -
2.1 Study Design...............................................................................................................................- 15 -
2.2 Study Area...................................................................................................................................- 15 -
2.3 Study Population.........................................................................................................................- 15 -
2.4 Sampling Technique and Size.....................................................................................................- 15 -
2.5 CRITERIA FOR INCLUSION............................................................................................................- 16 -
Exclusion criteria...........................................................................................................................- 16 -
2.6 Ethical Clearance And Permission..............................................................................................- 16 -
2.7 Data Collection Tools And Collection Techniques......................................................................- 16 -

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 2.8 Data Collection Procedures.........................................................................................................- 16 -
2.9 Data Analysis..............................................................................................................................- 16 -
2.10 Study limitation.........................................................................................................................- 17 -
2.10.1 Study limitation..................................................................................................................- 17 -
3.0 RESULTS AND FINDINGS...........................................................................................................- 18 -
4.0 DISCUSSION.....................................................................................................................................- 25 -
5.0 CONCLUSION...................................................................................................................................- 28 -
6.0 RECOMMENDATION........................................................................................................................- 29 -
7.0 REFERENCES....................................................................................................................................- 31 -
8.0 APPENDICIES...................................................................................................................................- 33 -
Appendix I: Ethical approval letter...............................................................................................- 33 -
1.1 Ethical approval letter by TABORA (E.A) POLYTECHNIC COLLEGE...............................- 33 -

9
 ABBREVIATIONS

STGs Standard treatment guidelines

EML Essential medicines list

UHC Universal health coverage

WHO/HAI World Health Organization/Health Action International

OTC Over the counter

TFDA Tanzania food and drug authority

NEMLT National essential medicine list

WHO World health organization

EM Essential medicine

INN International non-proprietary name

CME Continue in – service medical education

RA Regulatory authority

DIC Drug information center

LPGs Lowest-price generics

OBs Originator brands

DTC Drug therapeutic committee

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 CHAPTER ONE

INTRODUCTION

1.1 Background
Health is a fundamental human right while access to health care is a way of ensuring the
fulfillment of this right Universal health coverage (UHC) as the main target of sustainable
development goal strives to achieve access to quality health services according to the need, while
ensuring imposition of less financial hardship on the users of the services. The realization of
UHC have the access of essential medicines (EMs) at its core as they are an indispensable
element for delivery of services and a requirement for high-quality care.
Availability and affordability are dimensions of measures of access to medicines in health
systems. Access to affordable, quality-assured EMs is crucial to reducing the financial burden of
care, preventing greater pain and suffering, shortening the duration of illness, and averting
needless disabilities and deaths worldwide. However, one third of the world’s population lacks
regular access to EMs, resulting a cascade of preventable misery and suffering. This estimate
rises to over 40% in low income countries and over 50% in poorest countries of Asia and Africa
despite the issuance of legislations supporting the implementation of UHC by the countries. EMs
satisfy the priority health care needs of the population. They are intended to be available within
the context of functioning health systems at all times in adequate amounts, in the appropriate
dosage forms, with assured quality, and at a price, the individual and the community can afford .
In many developing countries, lack of financial resources or information can create barriers to
accessing essential medicines and contributing for the increased rate of morbidity and mortality.
On top of unavailability of EMs, high price of medicines is posing a problem in the provision of
health services. Price of medicines is a concern in low- and middle-income countries where up to
90% of the population purchases medicines through out-of-pocket payments. This has a huge
impact on the affordability of medicines and treatment outcome of diseases.
In the mid-1990s, civil society organizations in developed and developing countries started
drawing attention to the need for increased access to essential medicines as part of the fight
against poverty. Later, the World Health Organization/Health Action International (WHO/HAI)
project was established in 2001 to deal with medicine prices and availability. The main focus of
this project was to develop a reliable methodology for collecting and analyzing availability,
affordability and medicine price component data across healthcare sectors and regions; to publish
survey data to improve price transparency; and to advocate for appropriate national policies and
strategies. Through series of improvements, this guideline has been used to measure medicine
prices, availability, and affordability throughout the globe . Tanzania is one of the developing
nations facing the dire consequences of unavailability and unaffordability of medicines. To this
end, studies conducted in the country are limited in the provision of region-specific price,
availability and affordability data on EMs. Therefore, this study was designed to availability of
EMs in Tanzania by using WHO survey methodology.

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1.2 LITERATURE REVIEW
In Tanzania during the early 1990s, medicines and other supplies were still centrally provided
(‘push’) as standard, pre-packed EDP ‘kits’to all health facilities (excluding hospitals) from the
Medical Stores Department (MSD).The MSD is the national semi-autonomous, non-profit
department under the Ministry of Health and Social Wel-fare (MoHSW), responsible for the
procurement and delivery of medicines to public and Non-Governmental Organization health
facilities. Kits and the MSD were established with help from the Danish International
Development Agency, DANIDA, together with UNICEF and the Government of Tanzania. Kits
were colored either blue or yellow depending on the level of health facility (dispensary or health
center, respectively) and delivered six times a year (two kits per delivery) (Amenyah et al,2005).
Each kit was designed to last a month, and as they were procured pre-packed from both
international and national suppliers (Euro Health Group, 2007a) the MSD only had to manage up
to four variants (Center for Pharmaceutical Management, 2003). The kits contained 35
medicines, 17 medical supply items and 5 stationary items (United Republic of Tanzania, 1998).
Medicines were selected based on a combination of the National Essential Drug List of Tanzania
(first created in 1991 and updated in 2006) together with national morbidity data. The MSD
delivered kits to the district capital, which had 2 weeks to distribute the kits to health facilities
ensuring their arrival on the first day of the month (Euro Health Group, 2007a).

A study in 1998 found that nearly all (99%) of the kits distributed arrived at their destination,
suggesting few were being lost during delivery (Price Waterhouse Coopers Tanzania, 1999).
Nevertheless, the standardized nature of the kits meant that in some areas certain medicines were
depleted at a faster rate, causing stock-outs or accumulated surpluses due to differences in
catchment areas and disease burdens (Center for Pharmaceutical Management, 2003; Amenyah
et al, 2005; COWI et al,
2007). To mitigate stock-outs and expired medicines, the District Medical Officer (DMO) was
authorized to reallocate medicines between facilities; however, because of lack of funds for
transport and significant political pressure by communities not to move medicines away from
their local facilities, redistribution of medicines seldom occurred (Gilson et al, 1994).
Indent/integrated logistics system (ILS) (‘pull’ system) 2004–present
.
In early 2000, with support from DANIDA, the Pharmaceutical Supply Section (PSS) within the
MoHSW designed a new ‘pull ’system (indent), which included 70 essential medicines and
allowed health facilities (excluding hospitals) to specifically order individual medicines. Vertical
programs such as family planning and specific disease control programs including sexually
transmitted infections, malaria and HIV remained independent and devel-oped their own
individual supply chains. Under the indent system, facilities had individual accounts at MSD and
received a standard credit roughly equivalent to
monthly kits worth every quarter (Boex & Msemo, 2007).Health facilities were required to
estimate quarterly consumption (current ‘stock on hand’subtracted from quarterly monthly
consumption) for the 70 items and place quarterly medicines orders through the district office.
The DMO was responsible for examining the orders against the available fund credit and then
distributing the packages upon receipt from MSD. The indent system meant that MSD moved
away from supplying four stock items to

12
individually packing 70 products in the orders for over 3000 health facilities every month
(Center for
Pharmaceutical Management, 2003). As with the kit sys-tem, health facilities were almost
entirely dependent on the MSD for medicine supplies; a study carried out in
2005/2006 found little difference in medicines availability between the two systems (Euro Health
Group, 2007a).

In 2005, the MoHSW in collaboration with John Snow Inc’s DELIVER Project expanded the
indent ‘pull’system to include all vertical programs under the umbrella of the
ILS and rolled it out nationally in 2009. The Expanded Program of Immunization and the
National Tuberculosis and Leprosy Programs were excluded, however, as they
Essential medicines in Tanzania Inez Mikkelsen-Lopez et al 75 Health Systems were deemed to
perform well under their own vertical programs (Amenyah et al, 2005). The ILS introduced a
new ordering system of 12 forms to be completed by health facilities. The Request and Report
(R&R) form (Figure 1) is used for quarterly ordering of around 100 pre-determined priority
medicines (all items in the kit were included in this list). The R&R form contains a fixed
algorithm that requires data from stock ledgers together with physical counts of inventory to
estimate presumed quarterly consumption that is subsequently used to estimate the quan-
tity needed.

1.3 Research Problem Statement

The problem of unknown and lack of medicines in health facilities results to many dangers to the
community. Treatment failure and development of drug resistance may result to prolonged
sickness, increased drug costs and death.

Awareness of essential medicines reduces usage of substandard medicines in the community.

These drugs do not meet quality standards and specifications to be used in management of
various health problems.

1.4 Research Rationale

Effective health care of patients in health facilities is associated with presence of medicines used
in management of various health problems. This study aim was to determine factors undermining
presence of essential medicines in selected health facilities in Tabora. Within a certain course of
treatment, we was also approach to the total medicine cost for the treatment of a disease with
standard doses According to the National Essential Drug Formulary (2018 Edition) to influence
safety of essential medicines.

A literature review reveals that there are a number of published reports on medicines’ availability
surveys in Tanzania, conducted over the years (URT2007, URT 2008a and URT 2008b).
Medicines availability surveys, by nature, act as a monitoring tool for the functioning of the
pharmaceutical procurement and distribution system, and hence need to be done periodically and
systematically. In general, most of the previous surveys highlight the poor availability of
essential medicines and medical supplies in public health facilities, and some try to highlight

13
some of the causes. This report adds to this body of continuous periodic surveys trying to
monitor the improvement in availability of essential medicines and medical supplies. The report
highlights problems in the procurement, ordering and distribution of essential medicines by
looking at the availability of the essential medical supply “absorbent medicines” which service
providers and users complained of being lacking in many public facilities. It is important to note
that absorbent medicines is used here as an entry point for discussing the problems facing the
public pharmaceutical procurement and distribution system in Tanzania. At the same ti me, the
shortage or stock-out of medicines is a serious problem that has immediate consequences for the
patients who need it. As a researcher i will use the findings of this report and other future
researches to advocate for improvements in the medicines procurement and distribution system.

1.5 Research objectives

1.5.1 Main Objectives
The main objective is to asses availability of essential medicines among health facilities in
Tabora municipal.

1.5.2 Specific Objectives

i. To investigate common medicines used to manage main health problems
ii. How long the availability problem had persisted prior to survey
iii. To asses affordability of these medicines to patient
iv. To asses safety and efficiency of these medicines

1.6 Research Questions

i. Does the personnel recognize the common medicines used in management of common
health problems?
ii. What are factors affecting availability of essential medicines in the health facility?
iii. Is the price of essential medicines affordable to patients?
iv. Do these medicines have effective response in therapeutic problems?

1.7 Research Variables

The availability of essential medicines were considered as the outcome variables. Type of sector,
source of drugs (local or imported), the nature of facilities, duration of therapy, monthly income
of lowest paid government worker (to be converted to daily wage), the type of medicines (OBs
and LPGs) were treated as independent variables.

1.8 Research Hypothesis

The availability of medicines at health facilities is a critical element of service delivery quality,
without which the health facilities was be seriously limited in their ability to provide adequate
health care.

14
 CHAPTER 2
METHODOLOGY
The study mainly focused on two target groups: (i) District Medical Officers, and (ii) health
facility in-charges (responsible for ordering medicines and medical supplies for their districts)
and health facilities, respectively. The survey was done through telephone interviews. The
survey tools consisted of two slightly different questionnaires for two groups. The
questionnaires comprised mainly open ended questions, which were later coded for analysis. For
each target group, the questionnaire addressed issues of medicines supply management around
ordering, stock availability, distribution, projected average demand, sources of alternative funds,
and how availability issues impact health service delivery. These provided valuable information
on the situation faced by their patients and facilities.

2.1 Study Design

This study employed a cross sectional design. This design was preferred for this study because it
was quick and cost effective in terms of resources and time.

2.2 Study Area

The study was be conducted in specific health facilities in Tabora

2.3 Study Population

The study population consisted of various public and private healthcare providers and health
facility in charges and patients attending health services.

2.4 Sampling Technique and Size

The sampling method is simple random sampling method, the method used to select the
Pharmacist, Pharmaceutical Technicians, Pharmaceutical Dispensers and any other health care
providers, questionnaires provided to all respondents engaged.

Sampling technique is the way of sampling (obtaining sample), there are many sampling
technique but in this research, simple random sampling was be used, whereby any
Pharmaceutical Personnel working in health facilities was be picked to participate in the research
if he or she is wishing.

The formula developed by Krejci et al., 1970 for sample size determination was be used to
calculate study sample.

N = Z2PQ.
d2
Where
N= Minimum sample size
Z= Constant, Standard normal deviate(1.96 for 95% confidence level)
P= Population proportion with characteristics of interest (7500=75%)
Q= 1-P

15
d= Acceptable Margin of error (5%)
From the formula above,
N= (1.96)2 * 0.75*(1-0.75)
(0.05)2
N=288
Therefore, the minimum sample size of respondents was be 288
For the case of data error 5% of the sample size was be added hence;
288*25% = 216
The 5% is added to the minimum sample size;
216+288= 504. Therefore, the sample size was 504 health personnels.

2.5 CRITERIA FOR INCLUSION

All health personnel who accepted to participate in the research.

Exclusion criteria
This study excluded those who refused to sign the concert form.

2.6 Ethical Clearance And Permission

Approval to conduct the study was sought from the pharmacy department and permission to
conduct the study was obtained from the health facilities in which the research was conducted .
Consent to participate in the study was be requested from participants and confidentiality of
information clearly explained.

2.7 Data Collection Tools And Collection Techniques

Data was collected by using self-administered structured questioner with close ended items.

2.8 Data Collection Procedures

The data collection procedures followed a previously developed plan which details the task
which was carried out and who was involved.

The questioner was pretested among 10 personels to establish its validity before the study was
conducted.

2.9 Data Analysis

The data was entered and analyzed using the Statistical Software for Social Sciences (SPSS),
where all calculations were automatically done and are presented in the report in the form of
tables or graphs.

2.10 Study limitation

2.10.1 Study limitation
The findings of the study are limited to the questionnaires and interviews used to collect the
information. Our target sample is not completely randomly selected, as we were restricted to our

16
initial contact list and additional contacts given by respondents. The way the contact list was
developed could have created a geographical bias, as most respondents provided contact
information for nearby colleagues.

17
3.0 RESULTS AND FINDINGS
AVAILABILITY

Health Facility Level

Here the findings show that 87% received the last delivery of medicines between January and
March 2022; 80% between October and December 2021; and a significant percentage of
facilities had received medicines supplies for the previous four quarters

Table 1: Showing Medicines Available In 5 Dispensaries from January to march

HEALTH LEVEL QUANTITY QUANTITY QUANTITY WAITING
FACILITY ORDERED RECEIVED AVAILABLE % TIME
(unit)
MAGEREZA DISPENSARY 8600 6400 74 3
BUKAMA DISPENSARY 7550 6210 82 5
KILOLENI DISPENSARY 7640 6500 85 3
KALIUA DISPENSARY 6550 5150 78 3
KANYENYE DISPENSARY 7365 6170 83 4

The table shows above shows data collected from 5 dispensaries regarding specific selected
essential medicines ordered and received from MSD. Requesitions differ depending on amount
of medicines needed to meet community needs in health provision.

Table 2: Showing Medicines Available In 4 Hospitals from January to march

HEALTH LEVEL QUANTITY QUANTITY AVAILABLE % WAITING
FACILITY ORDERED RECEIVED TIME
(unit)
IGUNGA HOSPITAL 45980 41300 91 3
KITETE HOSPITAL 67855 61030 91 2
URAMBO HOSPITAL 35070 31090 88 2
NKIGA HOSPITAL 34090 29300 85 4
The table shows above shows data collected from 4 hospital facilities regarding specific selected
essential medicines ordered and received from MSD. Requesitions differ depending on amount
of medicines needed to meet population needs in health provision.

Table 3: Showing availability of some essential medicines in Magereza hospital from Jan to Sept
Medicines Medicines available in Magereza Dispensary
Jan Feb Mar Apr May Jun Jul Aug Sep
ALU tabs 450 232 10 555 480 310 230 170 470
Co-trimoxazole 700 420 180 600 310 190 40 700 350

18
 tabs
ORS Osmol
(pack) 290 232 149 289 222 188 82 312 264
Parasetamol
tabs 1080 740 310 1200 880 450 110 900 540
Amoxycillin
caps 980 420 55 900 510 90 0 700 420

The table above indicates amount of selected medicines each month before and after receiving
ordered medicines from MSD (quarterly)

FIGURE 1: Line graph showing Trend on Availability of medicines in magereza

dispensary each month

Availability of medicines in magereza dispensary each month

1400
1200
1000
800
600
400
200
0
Jan Feb Mar Apr May Jun Jul Aug Sep

ALU tabs Co-trimoxazole tabs ORS Osmol (pack)

Parasetamol tabs Amoxycillin caps

The graph above indicates amount of selected medicines each month before and after receiving
ordered medicines from MSD (quarterly)

ORDER WAITING TIME

When health facilities were asked how long they had to wait from the time they placed an order
to the ti me they received the supplies, about 70% said that they had to wait for two or more
months, and only 10% had their orders delivered in less than a month (See Figure 4 below).
DMOs receive supplies from the MSD and are responsible for distributing them to the health
facilities, so there would be a time difference (delay) between the order reaching the DMO and
reaching the facility. This weakness is being addressed, as evidenced by a pilot study conducted
by the MSD in Tabora Region. In Tabora medicines were delivered directly to health centres,
reducing the time facilities had to wait for their orders. The study does not indicate, however,

19
how much time was reduced. The plan is to scale up the operation to the rest of the country this
year, depending on the availability of funds (MSD, 2011). The study also uncovered non-
operational health facilities, which were allegedly ordering medicines, highlighting an important
problem in the system: leakage. Although it is beyond the scope of this study, recommendation
for further studies is to try to quantify the level of leakage and investigate the causes of leakage.

Figure 2: Bar chart showing Order Waiting Time In 5 Health Facilities

WAITING TIME(months)
MAGEREZA 3

NKIGA 4

URAMBO 2

KITETE 2

IGUNGA 3

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5

Data indicates delivery of medicines in some health facilities took a long time. Medicines where
delivered after 4 months in Nkinga hospital, 3 months in Magereza dispensary and Igunga
hospital and 2 months in Urambo and Kitete hospital.

DEMAND AND SUPPLY

Here we analyze the difference between what is actually needed per quarter and what was
actually received, in order to demonstrate the demand gap.

From Table 4 below it can be seen that there is a big gap between projected quarterly demands
and the actual quantities of medicines received most recently, at both levels. The gap certainly
contributes and in part explains some of the causes of shortages/stock-outs.

Table 4: Descriptive statistics of projected quarterly demands compared to last ordered

quantites and actual medicines received
Facility
level
Std.
Mean Deviation

20
 Quantity of medicines last ordered 103.03 40.9
Average quarterly demand of medicines 137.8 54.2
Quantity of medicines received most
recently 70.7 20.8
Difference between demand and quantity
received 67 22.2

Findings show that 93% of health facilities habitually receive less medicines they order. This
could indeed be another factor that contributes to the perpetual shortages or stock-outs.

Figure 3: Pie chart showing Descriptive statistics of projected quarterly demands

compared to last ordered quantities and actual medicines received

Mean

18% Quantity of medicines last ordered

27% Average quarterly demand of
medicines
Quantity of medicines received most
recently
19% Difference between demand and
quantity received

36%

DISTRIBUTION OF MEDICINES IN 9 HEALTH FACILITIES

Figure 4: Histogram showing comparison between received and ordered amounts of

medicines

21
 Comparison of quantity ordered and received
80000
70000
60000
50000
40000 QUANTITY ORDERED (unit)
30000 QUANTITY RECEIVED

20000
10000
0
I E
EZ
A A N A
NY GA TE BO A
AM LE LIU UN TE IG
GE
R
U K ILO KA NY
E KI A M NK
A B K IG R
M KA U

The histogram above gives further information on the relationship between the distribution of
medicines demand in 9 health facilities facility levels against the ordered amounts. In a rational
ordering system all orders would fall on the unity line.

Steps Taken by DMOs and Health Facilities

On answering1 the question on exploring the steps taken to deal with a shortage or stockout, most
DMOs (87%) said that they bought stocks directly from private suppliers, 54% borrowed from
other facilities, and 44% put “emergency orders to MSD.2” Only district, regional and referral
hospitals are able to order directly from the MSD as and when they need to.

At the health facility level, the most common ways to reduce the problem are to borrow from
other facilities (83%), and closely related to that, to send patients to other facilities (67%). 57%
put “emergency orders to MSDs” via DMOs, whereas 30% bought from private suppliers.

The Importance of Alternative Funding

The money allocated by the central government to each facility and held in the MSD account
cannot be withdrawn to purchase medicines from private pharmaceutical suppliers in the event
that the MSD is out stock . The availability of alternative funds that are controlled by a facility
can play a significant role in mitigating any shortages occurring at the MSD.

Those DMOs who said that they bought from private suppliers were asked where they got the
funds to do this. Figure5 shows the sources of these funds. The funds most commonly used by
the DMOs are from cost sharing methods (55%) and the Health Basket Fund (48%).

1
2

22
At the facility level, 20% of respondents reported that they mostly used cost sharing and another
20% the Community Health Fund. These funds can play a significant role in cushioning the
effect of stock-outs as a result of MSD inefficiencies. However, there are problems in the
collection of and access to these funds.
Figure 5: Sources of funds used to purchase medicines and medical supplies from private
suppliers

The ability to buy from other suppliers depends on the availability of alternative funds. That is,
those facilities that have a good user fee collection system and active health facility committees
that can request funds from the district accounts are better placed to mitigate any shortfalls in the
usual ordering system. In order to determine whether the ability to purchase had an effect on the
availability of absorbent medicines, we compared those DMOs and facilities that said they
purchased from private suppliers with those who did not.

Consequences Of Medicines Shortages

Due to its functions and importance, as discussed in the introduction of this report, gauze and
medicines availability problems are likely to impact service delivery at facilities. The survey
asked health facility in-charges to list these complications or impacts on service delivery. Around
49% said that they had reduced or stopped elective surgeries and were only attending to
emergency cases; and 20% said that there was a possibility of increased levels of medical
complications such as cross infections.

At the facility level, 80% thought that the likelihood of cross infections would increase, and 17%
cancelled or reduced the number of elective surgeries.

Figure below gives a list of complications/impacts as reported by DMOs and health facilities.

23
Figure 6: % Respondents answering questions on the kind of complications/impacts due to
the shortage of medicines

About half of the DMOs who reported that they had all essential medicines in stock also reported
that the stock levels were not sufficient. About 32% of DMOs reported being out of at least one
type of ALU (they are usually three types), and 28% reported stock-outs of surgical gloves.
Surgical gloves were reported to be in short supply in 58% of the cases at the DMO level. The
majority (68.85%) of the DMOs had sufficient stocks of ALU.

24
4.0 DISCUSSION
The availability and accessibility of medicines and medical supplies are huge challenges facing
most nations’ health systems, but the challenge is even greater for developing nations such as
Tanzania. These are faced with multiple priorities with limited financial resources. The limited
resources are oft en plundered or mismanaged, and thus serve the interests of a few individuals.
A specific and apt example here is the recent case uncovered by the CAG where 8 billion
Tanzanian shillings worth of drugs were found to have expired at the MSD, while at the same ti
me health facilities continue to have perennial shortages of essential medicines.

In short, the survey confirmed that DMOs and health facilities faced serious shortages and
sometimes stock-outs of absorbent medicines, mainly due to the unavailability of the item at the
central medical store. Nevertheless, there were other factors that played a role and still play one
in the poor availability of medicines and medical supplies at the facilities. These are discussed in
more detail in this section. Specific and general recommendations on what interventions are
required to improve the availability of medicines and medical supplies are also presented .

The Ordering Cycle

One of the factors that affect the availability of essential medicines in the districts’ health centres
and dispensaries is the order cycle. Facilities order once every three months, which means that if
facilities miss any items in their orders, they would have to wait for three months before they can
reorder those items. This restriction/cycle program is run by the MSD and is designed to reduce
the workload at the MSD central and zonal stores. Shortening the order cycle would have the eff
ect of reducing the number of out of stock days for some items, which may be out of stock at the
health facility but in stock at the MSD. This may come at an increased cost to the MSD, but if
executed well the costs could be off set by the benefit associated with regular/high turnover of
stock (e.g., improved stock holding levels leading to fewer drugs that expire at MSD stores).

Ordering and Delivery

Another factor contributing to the problem is the way the orders are compiled and sent to the
MSD, and how the MSD acts on the orders and sends them to the DMOs and health facilities. As
already discussed, health facilities compile their orders on a quarterly basis, and thus they have
the challenge of forecasting demand for three months. Most facilities knowingly ordered less
than their projected demands, then when their orders were sent to the DMOs, it was possible that
orders were further revised, mostly downwards. So by the ti me the MSD got the orders they
would send less than what was requested. In the end, health facilities can never have stocks that
are aligned with their demands. This particular observation raises three questions that need to be
addressed: (1) Why do facilities order less (or sometimes more) than what they need? (2) Why do
DMOs revise the orders? and (3), Why does the MSD send less than what is ordered? In a
perfect/logical system, health facilities would compile their orders so that they reflect their
quarterly projected demand, and then forward them to DMOs who would confirm that the

25
calculations were sound and then send them to the MSD, who would fulfill the order as it is.
DMOs are meant to act as a check for health facilities’ orders, so it is in their mandate to revise
the orders. For the system to work, however, this needs to be done in consultation with the health
facilities. The extent to which this happens is unclear. With regard to the MSD sending less than
what is ordered, the main reason could be that they ration out supplies that they think they are
low on so that everyone gets some (URT, 2007a, p. 32). Another possibility could be that they
revise all orders downwards, working on the assumption that all orders are inflated.

Essential Medicines and medical supplies

The survey assistants probed some of the respondents as to why there were anomalies in the
ordering process. From the answers that were recorded, we could see that the main contributory
factor was the unavailability of funds. On closer analysis the issue of problems associated with
funds can be divided into four groups: (i) insufficient funds, (ii) inequitable allocation, (iii) errati
c and/or less than satisfactory disbursement by the MoFEA, and (iv) difficulties in accessing
alternative sources of funds - where alternative sources of funds means funds other than those
disbursed by the MoFEA into MSD accounts.

Health Facility Funding

Health facilities order from the MSD based on their financial capabilities. According to one
DMO, dispensaries in his district are allocated Tsh.1,170,000 each, and health centres about Tsh.
2,430,000 each per quarter, from which they have to buy all of their essential medicines and
medical supplies. The facilities have to balance their needs with what they can afford, and this
explains why sometimes they order less than what they need. Some ordered more than their
projected quarterly demand, and the assumption here is that they had sufficient funds to afford
the costs of the extra goods. This gives a mixed picture in which some facilities have excess
whereas others have insufficient funds. The allocation of funds seems to be based on the type of
facility only and not on the usage of the facility by the population. This may explain the
difference in ordering behavior, where facilities attending to a comparatively lower number of
patients may have excess funds while ones with high patient attendance have insufficient funds.
Indeed this unequal allocation of resources for drugs was highlighted in the 2008 CAG Audit
Report (URT 2008c, pg.20), and as usual, no corrective measures have been taken.

Alternative Sources of Funds

DMOs and facility in-charges faced with the critical shortage of medicines have been responding
to the crisis in a number of ways. In our survey the majority of DMOs said that they were buying
supplies directly from private suppliers using alternative sources of funds, namely CHFs and
cost-sharing funds. At the facility level, only 30% reported that they were doing the same.
Facilities primarily referred patients to other facilities where they thought they had the item in
stock or borrowed from such facilities. It is not clear how successful they were. The availability
of funds that are under the direct control of DMOs and health facilities can play a great role in

26
improving the availability of essential medicines and medical supplies. Health basket funds,
community health funds, and national health insurance funds are innovative ways through which
Tanzanian health services are financed. These funds have the potential to improve health services
at the facility level. However, there are currently problems in the collection and administration
of, as well as access to, these funds (URT 2007a, pp. 21-26). The situation is particularly worse
at the lower health facility level, and perhaps this explains why only 30% of the health facilities
said that they bought from private suppliers using these funds.

Problems at the Central Medical Store

A drug tracking study done in 2007 (URT 2007a, pp. xii-xiii) identified three main weaknesses
of the drug supply system in Tanzania: (1) essential medicines were consistently insufficient or
out of stock at the MSD, encouraging a system of rationing; (2) insufficient attention was being
paid to the procurement and distribution of essential medicines compared to specific vertical
program supplies (vertical program refers to supplies for family planning, AIDS, immunization,
malaria, TB, leprosy, nutrition and eye programs); and (3) vertical program distribution was not
being invoiced at the level that covers costs, and in effect the vertical programs were being
subsidized by the sale of essential medicines and medical supplies. Based on a recent interview
had with an MSD official, the third weakness seems to have been addressed, and in fact the offi
cial claims that they mainly depend on income from these programs to run the MSD. The
improvement is mainly due to: (1) the introduction of the ILS, where all ordering and delivery is
done using the same platform (soft ware, forms and transport trucks), and (2) improved funding
arrangements for the program through which donors deposit monies on ti me directly into MSD
accounts. The markup to cover MSD costs also seems to have been revised. There is no evidence
that the other two weaknesses have been addressed, and we suspect they may be a factor in this
particular case of the poor availability of medicines.
A senior MSD staff highlighted this problem during an unofficial interview. Poor procurement
planning is to a large extent the result of the poor demand data received from facilities, poor
inventory management at the central and the zonal medical stores, and the lack of accountability
and/or lack of necessary skills of inventory managers.

It would have been interesting to know the quantity of medicines procured for 2010/2011,
assuming this was done under the competitive tendering system previously used. Unfortunately,
our eff orts to get this information from the MSD were unsuccessful. It is worth noting that in
2007/08, the MSD advertised a tender for 180,000 medicines rolls (an average of 3 rolls per
health facility per month), but in 2008/2009 it advertised for only 68,000 rolls - an average of
1.13 rolls per health facility per month. Our survey found that the average medicines demand per
facility was around 11.8 per quarter (i.e., about 3 rolls per month), hence 180,000 rolls would be
about right for the MSD to procure for the year.

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5.0 CONCLUSION
One of the weaknesses of drug supply in Tanzania still lies at the level of the Medical Stores Department.
Essential medicines are often out-of-stock at MSD Central Office, but Districts and health facilities are
not notified of this during the lengthy waiting period between the order being made and the actual supply
(or non-supply) of medicines. Thus, Districts and health facilities are not able to pursue alternative
sources of procurement. In the selected Regions where MSD fulfilment rates could be), MSD had an
average order fulfilment rate around 65% (with a range from 44% to 93%). Since a major percentage of
drugs is unavailable at MSD, out-of-stock situations “downstream” in public health facilities inevitably
occur due both to late notification and to insufficient funds and capacity to purchase the missing items
from alternative suppliers. The assessment’s analysis was constrained by the fact that several forms of
information could not be collected from MSD by the assessment team. For example, MSD Central
Medical Stores in Dar es Salaam was only able to provide information on order fulfilment rates for
Mbeya Region, where the Central Store is also in charge of the packing of items for the Zonal Office. In
other Regions, MSD Zonal Offices were not keeping records consistently and were unable to provide an
overview of such important data. This is consistent with findings from other studies such as the Drug
Tracking Study (URT, 2007).

Other factors in medicine shortages were found at District level as well at the health facility level itself.
District Pharmacists are overburdened by their supervisory and oversight role, and health facility officials
are challenged by low capacity to carry out correct drug ordering. Although Districts are able to procure
medicines from alternative suppliers in case of medicine stock-outs at MSD level, they face practical
challenges stemming from procurement processes, lack of funding at District level, and inadequate
communication with MSD Zonal Stores, which prevents make timely procurements from alternative
suppliers.

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6.0 RECOMMENDATION
Shortages or stock-outs of essentials medicines and medical supplies are common occurrences in
Tanzania. The survey has shown that apart from medicines, there were a number of other
essentials medicines and medical supplies that were in short supply, including gloves, syringes
and quinine injections. This perennial problem needs to be addressed by the respective
responsible organs – MoFEA, MoHSW (through the PSU), the MSD and the PMO-RALG. All
recommendations made by previous studies on this issue need to be revisited and evaluated with
regard to whether or not they have been implemented. This study makes the following
recommendations, each of which is annotated with the relative duration of time required for
implementation: Short Term (S/T) refers to immediate to 6 months, Medium Term (M/T) refers
to 6 months to 1year, and Long Term (L/T) refers to a period of 1 to 2years.
1. Ordering cycle: The MSD, in conjunction with the MoHSW, should review the three-
month order cycle. Cutting down the ti me spent on order preparation and delivery will have the
immediate effect of reducing the number of days a facility is out of stock of a particular item that
is available at MSD stores.
2. Ordering and order revision/fulfillment process: There is an urgent need to revise and
bolster the way orders are created, taking into consideration the qualifications and workloads of
the responsible personnel. The key informant interviews revealed that the workload of DMOs oft
en leaves them with limited ti me to scrutinize the orders. Not all districts have pharmacists who
are suitably qualified to help with the orders; and dispensary and health centre staff are oft en
few and poorly trained.
• The MoHSW/ PSU should translate HSSP III goals of increasing the numbers of trained
health care workers into specific objectives, e.g., the number of pharmacy staff to be trained and
by when. (L/T)
• The MoHSW/ PSU should ensure that all health facility workers are sufficiently trained
for making orders using the appropriate MSD forms. (S/T)
• MoHSW/MSD should use computers or other electronic means (mobile phone
technology/SMS) in the ordering process at least at the district/DMO level, in line with the HSSP
III (2009-2015) strategic objective for ICT, to “expand country-wide information network at the
regional and district level.” This will serve to improve the timely and accurate processing of
orders, as well as the capturing of accurate demand data. (L/T)
3. Access to centrally allocated and locally available funds:
• The MoFEA, in conjunction with the MoHSW /PSU, should ensure the ti mely and
regular disbursement of funds as agreed. The MoHSW should monitor and report on the
disbursements and aggressively pursue the MoFEA for compliance with the agreed schedule.
(S/T)

29
• The MoHSW/PSU should use the essential medicines funds allocation formula, which
takes into account population, disease burden and under five mortality rate for facilities, and
monitor it for effectiveness. That is, the MoHSW/PSU should measure the availability of
medicines before and after application of the formula, particularly where there is a resulting
funding increase. (S/T)
• The PMO-LGA and the MoHSW should investigate and find solutions to the obstacles
faced by health care facilities when trying to access user fees, in many cases held in district
accounts, which could go a long way in helping to procure medicines from alternative suppliers
when the MSD is out of stock. Districts should monitor the effectiveness of the use of these
funds in improving the availability ie medicines and medical supplies. (M/T)
4. Stock-out at central medical store:
• The MSD should regularly review contingency plans for all es medicines and medical
supplies vulnerable to global availability and price fluctuations. Tanzania is particularly exposed
to this risk due to the fact that more than 70% of its pharmaceuticals are imported, and even the
30% produced locally depend on imported raw materials (GTZ, 2007, pg. 30). (S/T)
• The MSD should have mechanisms to order alternatives to out-of-stock items,
particularly from the local market. If there are no provisions for such actions within the
Procurement Act 2004, then a case should be made for inclusion of the option. In this case we
found that Salama Pharmaceuticals Ltd, a local wholesaler, had available supplies of medicines
that were suitable for use, the only difference with the out-of-stock item being the size and price.
(M/T to L/T)
• The MSD should become more customer oriented, use regional benchmarks to establish
good performance in terms of service delivery and customer satisfaction. The MSD should
monitor order delivery times, accuracy, out– of-stock items, and most importantly, customer sati
sfaction on each order delivered. (S/T)
• Stock-outs due to poor procurement planning should be reviewed. Directors who have
authority over managers/employees should hold to account incompetent or negligent staff ,
particularly where performance problems are attributed to an individual. The MSD management
should ensure that all employees have clear contracts, showing roles and responsibilities against
which their work can be evaluated and accountability enforced. (M/T)
• The PSU should actively monitor and report on the performance of the MSD. Where
appropriate, particularly with regard to accountability at the director level, the PSU should report
to the Minister of Health for appropriate actions to be taken. (S/T)
Improving the availability of and accessibility to essential medicines may add extra costs to the
procurement and distribution system. However, poor availability also carries a high cost, which
is oft en not quantified.

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7.0 REFERENCES

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8.0 APPENDICIES
Appendix I: Ethical approval letter
1.1 Ethical approval letter by TABORA (E.A) POLYTECHNIC COLLEGE

TABORA(E.A) POLYTECHNIC COLLEGE,

P.O.BOX 1764,
TABORA.

TO
THE PRINCIPAL
TABORA (E.A) POLYTECHNIC COLLEGE
P.O. BOX 1764
TABORA.

U.S.F

THE MODULE TUTOR OPERATION RESEARCH,

TABORA (E.A) POLYTECHNIC COLLEGE
P.O. BOX 1764
TABORA.

REF: A REQUEST FOR PERMISSION TO CONDUCT A RESEARCH STUDY

IN TABORA HEALTH FACILITIES.

Refer the heading above

I am a 3rd year student studying a Diploma in pharmaceutical sciences at Tabora(E.A)
Polytechnic College.
I hereby requesting for an opportunity to conduct a research study on assessment of
availability of medicines in various health facilities from may 2022 to June 2022.

It’s my gratitude as my request will be taken in to action by your office,

Yours sincerely
………….
EXAVIERY S YUDA

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