With low- and middle-income countries (LMICs) increasingly and disproportionately affected by noncommunicable diseases (NCDs), equitable access to essential medicines and products is critical. However, medicine availability remains a challenge in many countries. In a WHO survey of 40 countries, NCD medicine availability in the public sector was only 36%.
PATH, the founding member and Secretariat of the Coalition for Access to NCD Medicines and Products (“Coalition”), has conducted numerous assessments documenting the low availability of hypertension and diabetes medicines and products in the public sector. No Empty Shelves assessments in Senegal (2015) and Kenya (2016) and later Journey of the Pill Assessments in Kenya (2019) and Ghana (2020), linked the paucity of quality supply chain data for forecasting to many of the availability and affordability constraints faced by people living with NCDs in many LMICs.
A country that responds to the needs of people living with NCDs requires a public health supply chain that reliably supplies quality medicines and products for management of hypertension, diabetes, and other NCDs. Given the unique challenges contributing to the low availability of NCD medicines, building the capacity of health and supply chain systems to forecast NCD medicine and product needs is a critical first step in improving the performance of NCD supply chains in LMICs.
In response to this need, the Coalition developed an NCD Forecasting Tool for Essential Medicines and Products and accompanying toolkit, in partnership with the ministries of health in Kenya and Uganda. The NCD Forecasting Tool was piloted in four counties in Kenya beginning in September 2020. In March 2021, learnings from the pilot period were incorporated into five-year costed county forecasts for hypertension and diabetes medicines. The results of the forecasting exercise is informing the four counties’ supply planning as well as the national NCD strategic plan. The experience gained through this partnership using the NCD Forecasting Tool is relevant to other countries seeking improved NCD forecasting within their supply chains.
With the knowledge of demand for medicines and products, program managers, financing stakeholders, and supply chain decision makers can make informed strategic decisions that will lead to more realistic financing, increasingly strategic procurement, and result in greater availability of NCD products throughout public health supply chains for the benefit of people living with NCDs.
UNRELIABLE SUPPLY OF NCD MEDICINES AND PRODUCTS
The ability of public health supply chains in LMICs to meet the demand for quality, affordable essential NCD medicines becomes increasingly urgent as countries grapple to respond to an escalating burden of NCDs against the backdrop of COVID-19. The NCD response in most LMICs is complicated by the unreliable availability of essential NCD medicines and products within public health supply chains. Based on previous assessments conducted by PATH, at the root is insufficient financial resources, weak demand forecasting, and poor downstream distribution. When public health supply chains do not deliver, people living with NCDs must resort to retail pharmacies, often incurring high out-of-pocket costs to access the daily medicine they need from the private sector.
In response to the unreliable availability of essential NCD medicines at the country level, the WHO Global NCD Action Plan set a goal of “80% availability of the affordable basic technologies and essential medicines, including generics, required to treat major noncommunicable diseases in both public and private facilities by 2025.” Various systemic factors contribute to stockouts of NCD medicines at health facilities. The Coalition identified a paucity of quality program and supply chain data in health and logistics information systems to support demand forecasting. Too often, planning for medicines is based on available funds, data from the central warehouse rather than quality consumption data from health facilities and is rarely informed by current or planned service delivery data, leading to perpetual cycles of stockouts and distribution imbalances. With no well-defined methodology for using available data to forecast demand for NCD medicines and products, unreliable (or lack of) forecasting throughout public health supply chains often becomes the norm.
Budget limitations and the lack of demand forecasts contribute to a vicious circle of insufficient financing, uninformed procurement leading to supply chain imbalances, and frequent stockouts at health facilities. Instead, countries must disrupt the norm of budget constrained forecasts with the best practice of thoughtfully prepared long-term demand forecasts that inform procurement budgets and health sector NCD medicine financing needs. Information from reliable forecasts also informs strategic planning and routine supply chain management decisions throughout the system.
THE COALITION TAKES ACTION
In October 2019, the Coalition convened a technical working group (TWG) of supply chain experts, clinicians, and Ministry of Health representatives from Kenya and Uganda along with representatives from WHO. The group developed an NCD forecasting algorithm, tool, and initiative that would support the development of a forecasting tool, incorporating elements such as local disease prevalence, health-seeking behavior, prescribing patterns, and clinical guidelines into the tool’s algorithm. For several months, the TWG worked in collaboration with Ministry of Health teams to develop the NCD Forecasting Tool along with an accompanying user guide, workshop facilitator guide, and key debriefing materials to assist users with next steps and future capacity building needs.
The goal of the Coalition’s forecasting initiative is to provide stakeholders with strategic information on the actual demand for, and cost of, delivering a reliable supply of quality medicines and products to those living with NCDs. With more realistic demand and cost information, ministries of health will be equipped with the data they need to improve financing and procurement, and in turn adequately meet the needs of people living with NCDs.
KENYA PILOTS THE TOOL TO IMPROVE NCD FORECASTING
Like many LMICs, Kenya’s high burden of NCDs significantly challenges the healthcare system, testing the government’s responsiveness to meeting the needs of the population. The IHME/GBD study estimates that in 2019 NCDs accounted for 39% of all deaths in Kenya. COVID-19 has exacerbated the risk of living with NCDs for the estimated 700,000 adults (2.4%) living with diabetes mellitus and 7 million (24%) with hypertension. In addition, the Kenyan Health Policy 2014–2030 projects that mortality due to NCDs will increase by 55% between 2011–2030. To attain the goal of universal health coverage, an important policy objective is to halt and reverse the rising burden of NCDs. Improving access to essential diabetes and hypertension medicines in the public health supply chain is a critical part of meeting this objective.
Building on the 2016 Kenya No Empty Shelves Assessment, in the 2019 Journey of the Pill report, PATH documented the frequency and duration of stockouts of four essential diabetes and hypertension tracer drugs (including biguanide and hormone hypoglycemics and calcium channel blocker and diuretic anti-hypertensives) on the day of assessment visit and during the previous 12 months. Only 43% of health facilities had all tracer drugs available on the day of visit. Furthermore, the cumulative duration of stockouts over 12 months were recorded at 22 secondary and tertiary health facilities. In a 12-month period, the duration of stockouts extended up to 297 days for specific NCD medicines.
In late 2020, the Coalition partnered with four Kenyan counties and a Kenya MOH technical advisory group, that included representation from the Department of NCDs (DNCD) and the Division of Health Products and Technologies (DHPT), and Kenyatta National Hospital to pilot the NFT methodology and tools. With the support of the Coalition and Access Accelerated in Kenya, the four counties of Makueni, Nakuru, Kilifi, and Nyeri leveraged their demographic, morbidity, and services data from surveys and the health information system to determine the demand for hypertension and diabetes treatment services within the network of public health facilities. Given unreliable NCD supply chain data, a representative sample of patient records from Kenyatta National Referral Hospital (KNH) and each county’s referral hospital was consulted to provide prescription data needed by the forecasting algorithm to estimate each county’s annual need for the hypertension and diabetes medicines in the Kenya Essential Medicines List (2019).
In March 2021, following COVID-19 precautions in place throughout Kenya at that time, a joint Coalition and Kenya Ministry of Health team of facilitators led four county forecasting teams through the process of using their available data and the NFT to prepare an NCD demand forecast. The multidisciplinary county forecasting teams included respective county pharmacists, directors of health, health information officers, and hospital clinicians. Each of the four county teams prepared a five-year, costed, demand forecast for hypertension and diabetes medicines and products. Leveraging the prescription data from the four counties and KNH, the team prepared a national demand forecast for hypertension and diabetes medicines and products. The forecast results were presented to stakeholders representing the Kenya Medical Supplies Authority, the DNCD, the DHPT, NCD Alliance Kenya, and local implementing partners.
LEVERAGING THE RESULTS OF KENYA’S NCD FORECAST
Kenya adopted the WHO GAP goal and set a target of 80% mean availability of NCD commodities in the national NCD Strategy 2021/22–2025/26. Equipped with information from the NFT on the true demand for hypertension and diabetes medicines in specific counties and estimates for the national level, NCD stakeholders in Kenya are using these data when developing their upcoming strategic plans and corresponding budgets, to improve availability of these medicines and products at county and national levels.
For the first time, Kenya budgeted for the cost of NCD commodities over the next five years in their national NCD strategy, with costing of hypertension and diabetes medicines being supported by the NFT. As Dr. Maree, Head of Department of NCDs, MOH Kenya said “We just developed our NCD Strategic Plan (2021–2026) and for the first time were able to estimate our requirements of medicines over the next five years. Before, we had no means to quantify or prove what we as a ministry required for hypertension and diabetes. Our forecast is evidence based and we can support our argument. Now we will be able to use the strategy document to lobby with the counties, the national treasury, and the parliament to appropriate funds.” Additionally, NCD leaders in the advocacy community plan to use the NFT forecasts for evidence-based advocacy with relevant stakeholders within the country. Meanwhile, the national NCD supply chain TWG (PATH is Secretariat) will continue to work towards addressing the other barriers impacting access to NCD medicines and products as captured in the roadmap of recommendations developed from the Journey of the Pill assessment and adopted by the NCD supply chain TWG.
The four counties that completed NCD forecasts with the help of the NFT committed to use the results to inform their periodic supply planning. The forecast included all oral and injectable medicines for the treatment of hypertension and diabetes medicines on the Kenya Essential Medicines List as well as statins and consumable products needed for blood sugar self-monitoring. Scaling up NCD forecasting to all counties is a priority for Kenya’s devolved health system. With the support of the Coalition and other health partners, Kenya aims to scale the NFT to 10 counties in 2021, 25 counties in 2022, and all 47 counties in 2023.
To respond to the growing burden of NCDs in LMICs, county health leadership and advocacy stakeholders need reliable forecasts of unconstrained demand. This essential information will help inform policy decisions aimed at creating a more realistic budgetary environment to support procurement and NCD medicines financing throughout a country’s supply chain. With better NCD forecasting supporting the political will to improve access to quality NCD services in LMICs, countries will be able to progressively reduce their NCD medicines financing gap and strengthen their supply chains to meet and even surpass the WHO GAP goal of 80% availability of quality, affordable, NCD medicines and products in the public health supply chains and make progress toward the proposed WHO targets that 60% of PLWD receive statins along with 80% achieving good control of blood pressure and glycaemia.
SCALING THE USE OF THE NFT BEYOND KENYA
At the end of September 2021, Uganda began their utilization of the NFT to prepare a five-year forecast of hypertension and diabetes medicines. As Dr. Gerald Mutungi, Department of NCDs, Uganda Ministry of Health noted “For the first time in Uganda we have NCDs drugs and supplies estimates that will inform our planning and resource mobilization strategies. The estimates are believable because they are informed by our own prevalence studies, Essential Medicines lists, Uganda Clinical Guidelines, Referral Hospital prescription practices and our own local studies. Bravo! Thank you to the Coalition for this great innovation and partnership with Uganda government” The Coalition’s vision when developing the NCD forecasting algorithm was to create a tool that could become a global good. The experience gained through piloting the NFT in Kenya laid the groundwork for the NFT forecasting effort in Uganda. The Coalition’s close collaboration with NCD leadership in both the Kenyan and Ugandan Ministries of Health is leading to an NFT implementation model, paving the way for other LMICs with high NCD burdens and forecasting challenges to be able to partner with the Coalition to strengthen their NCD forecasting capabilities. As the work in Uganda continues, the Coalition is preparing to finalize the tool and implementation process, to allow for broader geographic scale. Recognizing that forecasting is just a first step, the Coalition’s comprehensive support will include developing country financing strategies, advocacy, and capacity-building aimed at ultimately achieving equitable access to affordable NCD medicines and products.
ABOUT THE COALITION FOR ACCESS TO NCD MEDICINES AND PRODUCTS
Launched in 2017, the Coalition for Access to NCD Medicines and Products is a global, multisectoral group dedicated to increasing access to and availability of medicines and health products for NCDs. Through technical support, advocacy, and resource mobilization at the global, regional, and national level, the Coalition works in partnership with global leaders and national Ministries of Health to 1) strengthen supply chain and health systems as needed to increase access to safe, affordable, essential quality-assured NCD medicines and products in low- and middle-income countries (LMICs); 2) influence policy change at global and national levels to establish an enabling environment for NCD supply security; and; 3) foster cross-sectoral collaboration to improve access to affordable NCD medicines and products.
 2015 STEPS survey and 2014 KDHS estimates.
 PATH. Journey of the Pill: Findings of the NCD Commodity Supply Chain Assessment in Kenya. Seattle: PATH; 2020.