Impact of NHIF-CSDS scheme on availability & financing of essential medicines: A case study of Webuye District Hospital,

1. Financing and Availability of Essential Medicines Before and After Introduction of the National Hospital Insurance Fund Civil Servants and Disciplined Services Medical Scheme: A case study of Webuye District Hospital, Kenya Lucy Winkie Mecca, Bpharm U51/63523/2013

2. Introduction • About 30% of the world’s population does not to have access to essential medicines. • Kenyan public facilities experience high stock-outs of essential medicines • Financing is an important determinant of access to essential medicines • NHIF Medical Scheme contributes to financing of essential medicines in public hospitals

3. Justification • Effect of introduction of the NHIF-CSDS Medical Scheme on availability of essential medicines not studied. • Introduction of the scheme may paradoxically compromise availability of essential medicines.

4. Research Questions • Has the funding for essential medicines increased since the introduction of the NHIF-CSDS Medical Scheme? • Did stock-outs of essential medicines reduce after the introduction of NHIF-CSDS Medical Scheme? • What factors affect availability of essential medicines at Webuye District Hospital?

5. Main Objective To compare availability and funding of essential medicines before and after implementation of NHIF-CSDS Medical Scheme.

6. Specific Objectives • To compare the proportion of FIF allocated for procurement of medicines before and after implementation of the scheme. • To determine and compare the contribution of the FIF, KEMSA and others to the essential medicines budget before and after implementation of the scheme.

7. Specific Objectives……… • To determine the frequency and duration of stock-outs of essential medicines before and after implementation of the scheme • To explore factors that could affect the stock-out rate of essential medicines.

8. METHODS

9. A retrospective longitudinal before-after study of four years; the latter two of which the NHIF-CSDS Medical Scheme was in operation. • Study period: 1 Jan. 2010 – 31 Dec. 2013 • Study site: Webuye District Hospital, Kenya. • 145 essential medicines were selected for study • antiretroviral, anti-tuberculosis and contraceptives not included

10. Data sources • Authority to Incur Expenditure records • KEMSA Orders Forms and Invoices • Local Purchase Orders and invoices from suppliers • S3 cards on which all hospital receipts are recorded • Pharmacy summary budgets and stock control cards (electronic and manual)

11. RESULTS

12. Allocation of FIF • The median of the quarterly FIF allocation for purchase of medicines was significantly greater after introduction of the new NHIF scheme • Kshs 1.04 million vs. 0.70million, p=0.008 • The mean proportion of FIF allocated quarterly for purchase of medicines was also higher • this increase was not statistically significant • 9.12 % vs. 7.55%, p=0.0502

13. Contributors to essential medicines budget Three sources: • KEMSA • FIF • Other Facility Comparisons were made for • Proportion of essential medicine contributed • Expenditure on essential medicines

14. Mean proportion (%) of essential medicines procured and source

15. Within-source comparisons (proportions)

16. Mean expenditure on essential medicines by source

17. Within-source comparison (expenditure)

19. Stocked-out time • The average monthly stocked-out time reduced in 2012/13 • this reduction was not statistically significant • 21.75% to 19.47%, p= 0.099 • The first months of the quarter were characterized by a high stock-out rate

20. Stock-out rates of individual medicines • Some antibiotics such were never stocked out • amoxicillin capsules and co-trimoxazole tablets • Theatre medicines had low stock-out rates (<2.5%) • Neostigmine, Thiopentone, Suxamethonium injections • Some pediatric preparations and topical preparations had high stock-out rates (>50%). • Co-amoxiclav, Erythromycin, Ibuprofen suspension

21. Determinants of stock-out rates • FIF expenditure was a significant determinant of monthly stock-out rates (p = 0.025) • Supply from KEMSA was a significant determinant of stock-out rates of individual medicines. • Absence from the KEMSA list or non-supply of orders to KEMSA predicted a higher stock-out rate of individual medicines (p < 0.0001)

22. DISCUSSION

23. The increase in FIF allocation can be attributed to additional funding • NHIF and free maternity reimbursements • Decline in KEMSA supply could be attributed to: • reduction in number of essential medicines included in the KEMSA Standard Order Form • challenges from devolution of health services

24. Financing through FIF and availability in KEMSA were found to be significant predictors of stock-out rates. • No significant change in stock-out rates most likely due to inadequate financing. • The first months of the quarter had the highest stock-out rates due to winding procurement procedures.

25. Conclusion & Recommendation • No significant change in stock-out rates of essential medicines after implementation of the NHIF-CSDS medical scheme • The NHIF was implemented into a system that was inadequately funded. • Contextual factors should be taken into account when implementing insurance schemes. • Studies on availability of essential medicines after devolution of health should be done

26. Thank you