How Ethiopia Can Develop a More Sustainable Health Supply Chain

Ethiopia is a complex and heterogeneous nation home to five official languages, numerous ethnic and religious groups, and some of the world’s most fascinating geography—two mountain ranges, a desert, giant lakes, and the formidable Great Rift Valley at its center.

Its geography and diversity pose unique challenges to public health services, especially its health supply chain system. The country contains more than 4,000 state-run hospitals and health centers, and more than 17,000 health posts, many of which lack continuous power, internet connectivity, or consistent drug and medical supplies.

The government’s medical procurement system is disjointed, the lines of responsibility between departments are unclear. Despite the best efforts of the Ethiopia Pharmaceutical Supply Services (EPSS)—the parastatal entity responsible for sourcing drugs—long lead times and last-mile delivery complications mean that medicines continually run out of stock or pass their expiry dates. Only 60 percent of the country’s health facilities are supplied with drugs from EPSS.

The remaining facilities collect drugs from a district health office, which results in compromised drug safety and quality due to limited warehousing and inadequate staffing. The Pharmaceutical and Medical Equipment Directorate (PMED), part of the Ministry of Health, also sources drugs for health facilities and has a mandate to manage supply chain initiatives and monitor and improve efficiency, roles that often overlap with the EPSS. These agencies also work with the Ethiopian Food and Drug Administration to define the country’s essential drug list. Overlapping responsibilities and functions between these three agencies lead to duplication, complication, and a range of related challenges.

Another major obstacle to efficiency in the health supply chain is the lack of data and digitization. Reporting in many rural health facilities remains paper-based, which is not conducive to a demand-driven supply system. Plus, the absence of centralized patient and morbidity data makes basic supply forecasting and planning a challenge. Although the health system is undergoing a digital transformation, digitizing records and centralizing reporting into a single software system (DHSI2), progress has slowed considerably in recent years.

To meaningfully reform the healthy supply chain system, the government should continue to seek opportunities to engage the private sector, practice drug stewardship, align with common supply chain frameworks, and improve the interoperability and use of digital tools.

Embrace the Private Sector

Private businesses have a unique incentive to innovate supply chain operations and eliminate inefficiencies to get their products to market. Accountability to shareholders and the lure of greater profits pushes private companies to deliver products faster and better, but often to “convenient” locations. For example, there are limited incentives for a company to spend thousands on delivering a few products to rural villages when it could focus its logistics operations in a large city with millions of potential customers. For governments tasked with reaching the most remote and vulnerable, harnessing innovation and learning from the private sector can significantly improve their logistics capabilities. The government’s challenge is creating the right partnerships and incentives to ensure that goods reach the last mile, even when potential revenue for businesses is limited.

The Ethiopian government has demonstrated success in piloting public-private partnerships. EPSS recently entered a partnership to improve transportation and fleet management. Using EPSS’s own vehicles, a private company was put in charge of delivering medicines to 285 health facilities. Within months, supplies were reaching 94 percent of facilities, up from 47 percent. The Ministry of Health and the EPPS believe the private sector can help the supply chain to overcome stockouts and better assure the quality of health commodities.

This concept aligns with the U.S. Agency for International Development’s goal of helping governments transition from directly operating their health supply chains to purely overseeing them. PMED’s role would shift to managing the work being done by private companies under contract. Currently, PMED is piloting new public-private partnership models to operate and maintain diagnostic equipment and health technology in major hospitals. For example, St. Peter’s Hospital in Addis Ababa leases its medical imaging facility and equipment from a private firm.

Photo: Zambia MAMaZ Against Malaria

Practice Drug Stewardship

To ensure better drug availability and safe and accurate prescription of over-used medicines such as antibiotics, clinicians across the country need to practice good drug stewardship. Drug stewardship reduces overprescribing and supports rational drug use in health facilities to prevent medicines, especially antimicrobials, from becoming ineffectual from overuse. According to the World Health Organization, Ethiopia is a high-burden country for tuberculosis (TB) and previously for multidrug-resistant TB; to address this challenge, health providers will need access to digitally networked diagnostic equipment and a consistent stock of alternative drugs.

Lessons from the United Kingdom’s international Fleming Fund program could inform Ethiopia’s approach to rational drug use and improve clinical awareness around antibiotic overuse. In Indonesia, the Fleming Fund has supported antimicrobial use surveys in hospitals and at chicken and aquaculture farms, leading hospitals to develop regular, automated report templates for their drug stewardship committees, in turn allowing these committees to identify poor prescribing practices and push for greater laboratory diagnostic use. Clinical education, behavior change programs, strong clinical and laboratory communication, and rapid diagnostics are needed to change over-prescribing practices and improve rational drug use.

Photo: Zambia MAMaZ Against Malaria

Align with Common Frameworks and Digital Systems

In many parts of the country, pharmacists have become de facto supply chain experts. Limited supply chain training opportunities mean pharmacists or health professionals are taking on multiple jobs, often outside of their skillsets. Previous aid programs have sought to fill this gap, but too often paired their capacity-building initiatives with per diem incentives. This approach tends to spur participation but not real learning, and often encourages the wrong individuals to attend.

A separate issue is that supply chain performance is measured against different standards and metrics across government suppliers and aid implementing partners, muddying a clear understanding of supply chain performance and maturity. To increase efficiency and supply chain development, aid partners need to work in tandem with the government to standardize performance measurement with a common set of key performance indicators (KPIs), equip and train the right staff, and define supply chain maturity with common metrics.

Common KPIs and performance measurement systems should accompany common data systems and clear lines of responsibility. A recent assessment of Ethiopia’s health information system maturity showed significant gaps, with interoperability and governance policies scoring particularly low. Continued efforts to roll out the DHIS2 platform will support supply chain forecasting and planning and improve health system planning. PMED and EPSS will also benefit from upcoming investments in an enterprise-level digital platform that tracks and manages the performance of private sector vendors.

Affording the most vulnerable citizens access to medicines and medical supplies is complex. It requires constant innovation, dedicated capacity building, continuous performance improvement, and comprehensive drug stewardship. By partnering with the private sector, investing in rational drug use, and using common systems and KPIs, Ethiopia can get medicines to patients on time and save lives.

Kim Shelsby is the Principal Global Health Practice Specialist for supply chains. Yodit Admasu Birhane is a health supply chain consultant in Ethiopia.