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The Efficiency of Inefficiency: Medicine Distribution in Sudan

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The Efficiency of Inefficiency: Medicine Distribution in Sudan

  • Abdeen M. Omer *

*Corresponding Author: Abdeen M. Omer, Occupational Health Administration, Ministry of Health, Khartoum, Sudan.

Citation: Abdeen M. Omer, (2024), The Efficiency of Inefficiency: Medicine Distribution in Sudan, J. Pharmaceutics and Pharmacology Research, 7(4); DOI:10.31579/2688-7517/169

Copyright: © 2024, Abdeen M. Omer. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Received: 22 January 2024 | Accepted: 05 February 2024 | Published: 04 March 2024

Keywords: sudan; healthcare; medicines; regulatory authorities; pharmacy management

Abstract

The strategy of price liberalisation and privatisation had been implemented in Sudan over the last decade, and has had a positive result on government deficit. The investment law approved recently has good statements and rules on the above strategy in particular to pharmacy regulations. Under the pressure of the new privatisation policy, the government introduced radical changes in the pharmacy regulations. To improve the effectiveness of the public pharmacy, resources should be switched towards areas of need, reducing inequalities and promoting better health conditions. Medicines are financed either through cost sharing or full private. The role of the private services is significant. A review of reform of financing medicines in Sudan is given in this article. Also, it highlights the current drug supply system in the public sector, which is currently responsibility of the Central Medical Supplies Public Corporation (CMS). In Sudan, the researchers did not identify any rigorous evaluations or quantitative studies about the impact of drug regulations on the quality of medicines and how to protect public health against counterfeit or low-quality medicines, although it is practically possible. However, the regulations must be continually evaluated to ensure the public health is protected against by marketing high quality medicines rather than commercial interests, and the drug companies are held accountable for their conducts.

The CMS reform is stronger today than it was in the early 1990s when the reforms were started. There are many highly committed and able individuals throughout the public sector in the absence of the single-minded pursuit of commercial success. Also, in the long-term interest of employment growth and the public at large, narrower concerns have prevailed. Managements and boards are less able and less willing to impose accountability for results on themselves and their employees. Stock-out of life saving items is common, and sanctions for non-performance are often absent altogether. To overcome those common symptoms of all public owned enterprise, and achieve the strategic objectives of the FMOH by increasing the access of population to the essential medicines. The privatisation of the CMS’s ownership is the best solution of choice. By resurrecting competition, which could be achieved mainly through privatisation of the CMS ownership, many of the mentioned pitfalls can be avoided. The new business should be responsible (of course without any kind of monopoly) for drug supply and distribution to the public health facilities on competition basis. The initial capital of the drug stocks for the different health facilities should be given by this new business by signing a clear agreement with interested states’ ministries of health. 

Introduction

The CMS reform is stronger today than it was in the early 1990s when the reforms were started. There are many highly committed and able individuals throughout the public sector in the absence of the single-minded pursuit of commercial success. Also, in the long-term interest of employment growth and the public at large, narrower concerns have prevailed. Managements and boards are less able and less willing to impose accountability for results on themselves and their employees. Stock-out of life saving items is common, and sanctions for non-performance are often absent altogether. To overcome those common symptoms of all public owned enterprise, and achieve the strategic objectives of the FMOH by increasing the access of population to the essential medicines. The privatisation of the CMS’s ownership is the best solution of choice. By resurrecting competition, which could be achieved mainly through privatisation of the CMS ownership, many of the mentioned pitfalls can be avoided. The new business should be responsible (of course without any kind of monopoly) for drug supply and distribution to the public health facilities on competition basis. The initial capital of the drug stocks for the different health facilities should be given by this new business by signing a clear agreement with interested states’ ministries of health. 

1.1 Recommendation

The study reveals the need for further research to find out how efficient the regulatory authorities at both federal and state levels are. The research also needed to discover whether or not counterfeit medicines are sold on the Sudanese market. From the data obtained in this article some general inferences could be made:

  1. The brad outlines remain intact, but preventing drug smuggling across national boarders (Sudan shares frontiers with 9 countries) is hard to police.
  2. The enforcement of the Act and its regulation governing the manufacture, importation, sale, distribution and exportation of medicines are not adequate enough to control the illegal importation and sale of medicines in Sudan.
  3. The splitting of the drug regulatory authority between two ministries and the marketing of unregistered medicines by public drug suppliers (namely the CMSPO, and RDFs), and NGOs undermine the quality of medicines and ultimately jeopardise the health of the people taking medication. 

In the light of the findings the following recommendations could be useful at various levels:

  1. There is an urgent need for government to implement the provisions of existing Act.
  2. The government should adequately equip and fund the National drug Analysis laboratories to start active post-marketing surveillance.
  3. A more spirited effort need to be made by the FGDOP and the States’ Departments of Pharmacy to ensure all the medicines on the pharmacies’ shelves are registered and come from legal sources.
  4. The states’ departments of pharmacies are not in existence should be re-established and invigorated. They should be adequately funded to be able to acquire the necessary facilities for their operations.
  5. The CMSPO should stop importation, manufacture and distribution of unregistered medicines. It should also cease selling the tenders’ product to the private pharmacies. The latter practice undermines the inspection outcomes, because it makes inspectors task too difficult (i.e., cannot identify the source of medicine whether it is CMSPO or not).

The public sector is rigid, bureaucratic personnel-management practices, low incentives, poor job satisfaction and unsupportive work environment compared to the private sector. Such situation demoralised pharmacists and encourages them to join the private sector. Many (65%) of surveyed private-sector pharmacists claimed they were public sector pharmacists migrated to the private sector. Although information on migration is sparse, anecdotal evidence persuasively underscores the problem. An internal flow of pharmacists plagues all states, since pharmacists move from poorer states to wealthier ones and from the public sector to the private. Strategies to meet current and future challenges in pharmacy human resources are urgently needed. Approaches that focus on the training of individuals, which do not take into account the job satisfaction (i.e. the nature of the work itself) and pharmacists' mobility, can enjoy only limited success. Increased production alone cannot compensate for weak motivation, high attrition and increasing mobility. To reverse decades of neglect, policy-makers in both (state and federal level) should begin now, first by recognising the problem and secondly by fixing it through the immediate implementation of potentially effective strategies. Although, we do not advocate the creation of new barriers to the movement of pharmacists between private and public sectors, steps should be taken to redress the unbalanced situation. Ten immediate steps are recommended:

  • Large-scale advocacy is needed to achieve heightened political awareness within states and at federal level. One potential outcome of large-scale movement would be the beginnings of introduction of pharmacy care concept, which reshapes the pharmacy services around the patients in hospitals and community pharmacies. This concept will benefit the health care system users and motivate pharmacists to do a good job to their clients and employers. The employers need to foster an organisational culture that recognises and values staff contribution. Central to the delivery of effective recognition are employees' immediate bosses, where a participative and considerate management style is shown as a major predictive factor of retention.
  • The Federal Ministry of Health (FMOH) needs to learn from the past experience of Khartoum, Red Sea, Northern, and Algadarif States and current Gezira State then, identify success stories. Pharmacists and their organisations, and Ministries of Health have not remained passive in confronting the crisis in pharmacy workforces. The goodwill and commitment of public sector pharmacists to provide quality care despite low wages (30% of the average private salary) and medicines supply shortages at times of appalling conditions should not be overlooked.
  • Pharmacist job satisfaction: Job satisfaction is how people feel about their jobs. Experiencing job dissatisfaction leads to withdrawal cognition and employee turnover. Job dissatisfaction can be caused in many ways, including high centralisation, routinisation, low integration, low communication and policy knowledge. Pharmacy education has a key role to prepare pharmacy student for practice and must anticipate the changing professional role. New strategies need to be developed with the participation of pharmacy professionals’ associations, unions, universities and ministries of health and higher education representatives to meet both; the short-term and long-term needs of pharmacists as pharmacy care providers. Technology will, no doubt give opportunity to join postgraduate studies (e.g., P.G. diploma or M.Sc. courses) from overseas via e-learning or continuing pharmacy professional development programmes. 
  • Salaries and incentive’s structure: This includes the process of creating new jobs, addressing low wages, as well as developing incentive’s structure that supports pharmacists over the course of their working lives. In order to stem the flow of pharmacists to the private sector and increase their performance, the Ministry of Health needs to pay incentives to its pharmacy staff on a semi-private basis. Introduction of the employment contract and the application of the incentive budget line opposite performance proved to be effective in Khartoum State experience. The obligations of each part (employer and employee) should be written in non-ambiguous language and transparent reward system should be in place. When transparency of reward system is poor, its credibility will be questioned and pharmacists might not respond to the explicit incentive system at all. IDS, 2000 pointed the lack of training and potential career development is a particularly important contributor to voluntary resignations. Uncompetitive pay is often debated as a reason for employee turnover. The perception of receiving a fair salary is a determinant of retention. It seems to be important both at the recruitment stage and subsequently as a determinant of retention rates is the perception that employees are receiving a fair salary. It is important to note this doesn’t necessarily equate to a large salary, since people often compare themselves with peers in the same occupations or with friends and family rather than with better paid or higher skilled workers. Also, when promises are broken and expectations are perceived (haven’t been met), employees take actions to withdraw from the organisation, which may include actually quitting jobs.
  • Pharmacy staff motivation: In addition to financial incentives, Ministry of Health should continue to invest in improving the working conditions to ensure the suitable qualified and skilled pharmacists are retained for longer periods. Recruitment of qualified pharmacists (which may include looking outside the public services). A clear definition of job assignments (staff at hospitals` level enter into written contracts to perform according to MOH guidelines) and regular supervision will assist MOH to achieve a good staff performance. MOH should provide transport to pharmacists (senior and specialised pharmacists could be offered private vehicles) from their residence to the place of work to increase their motivation. Company-paid private medical insurance, and a company car for senior staff, child day care facilities, pension and retirement plans are the most desired and lead to employee retention.
  • Redistribution of Pharmacy workforces: To address the problems of pharmacy profession in Sudan, an increase in access to essential medicines is insufficient. Far more important is the need to strengthen the pharmacy workforce in localities, states and federal health institutions to address the challenges and to use the resources and interventions for provision of effective pharmaceutical services. 
  • Small staff and efficient teamwork: The pharmacy workforces are divided into two levels (1) Department of pharmacies at Ministry of Health, and (2) Hospitals. The Department of pharmacy at state level should consist of 6 pharmacists at maximum and 25 at federal department of pharmacy including drug analysis laboratory. The hospitals` department of pharmacies classified as follows:

(i) Group A includes big hospitals (e.g., Khartoum and Omdurman hospitals). The numbers of pharmacists in Group A hospitals are 15 pharmacists in addition to pharmacy assistants and other supportive staff to cover all shifts. One manager, 3 pharmacist work in Drug Information Centre, three for internal hospital pharmacy, two in outpatient pharmacy, three in people pharmacy and one in clinical pharmacist;

(ii) Group B includes medium hospitals and capital cities hospitals (e.g., Ibrahim Malik, and Medani Hospitals). The Hospital Pharmacy Department (HPD) this group managed by 4 to 6 pharmacists; 

(iii) Group C includes small and rural hospitals. Two pharmacists could run the HPD in these hospitals. Paying attention to create more flexible and efficient system for PHRs management in the government institutions might help improve the condition of shortages of pharmacists in the public sector. The advantages of small staff can be easily managed, trained and financed, and teamwork could be developed. This also improves the performance and productivity of the public sector pharmacists thereby reduces the number of PHRs needed to provide satisfactory pharmaceutical services in the public sector institutions. The best indicators of staff retention are the fostering of friendships at work, and managers in health cares should take time to get knowing people and foster opportunities for friendship and socialising. 

  • National leadership at the highest level is essential and will only come to heighten the awareness of the fundamental importance of pharmacists in health care in general and in the pharmaceutical care in particular, and the development of new methods and strategies.
  • Continuing pharmacy professional development: The most important element of National Drug Policy (NDP) and 25 years pharmacy strategy has yet to be tackled. MOH should fully recognise its 25 years pharmacy strategy goals could be achieved through people's (especially pharmacists) expertise. Appropriate training and development is the key to reach those goals and make strategy visions become reality. A wide variety of external (e.g., distance or e-learning in the developed world) and internal training and development programmes for pharmacists should be introduced. A pharmacist's career or pathway should be developed. A policy for active selection of training fields should be formulated according to the priorities of health care needs. The career development relies on individual training and development to enable employees to move into more challenging roles and can provide enhanced rewards for those who are promoted.
  • Pharmacy staff discipline and accountability system: Disciplinary procedures, which provide a range of possible responses (from warnings through dismissal, depending on the severity and frequency of the offence should be clearly stated in the new work contracts). Pharmacy managers and team leaders in different settings (administration or care providing, at both state and federal levels) should be trained to invoke disciplinary procedures and to bring criminal charges when necessary.

Improving effectiveness of the public pharmacy is by switching resources towards areas of need, reducing inequalities and promoting better health. Unless there are clear incentives for pharmacists, they can move away from public sector.

Findings innovative approaches to stop brain drain of the pharmacists from the public sector and to increase their productivity and performance might be more appropriate strategies to solve the problem in Sudan. These strategies comprise, for instance, monitory incentives, continuing professional development, working condition and job satisfaction of civil service PHRs. 

The study may help the Ministry of Health to better look at the real issues of PHRs in the public sector and formulate more relevant and useful policies and plans to retain qualified and skilled pharmacists in the public sector on a solid evidence base. Monitoring and evaluation of information provided to MOH.

The data must be accurate and up to date. The study revealed low salaries, job dissatisfaction in relation to the pharmacy practice and bureaucracy, working conditions, lack of recognition for contribution at work, and lack of professional development training programmes are the main factors influencing the brain drain of the PHRs. 

These factors affect PHRs immigration and retention concurrently rather than in insolation.

Given the time constraints required to get the new contracting arrangements in place, there is a risk that good practice developments in options for change for change field sites may not be used effectively (continue to evaluate and disseminate the lessons that emerge from these sites). 


 

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