COMMENTARY Open Access

Pharmaceutical system strengtheningin Uganda: implementing a holistic,evidence-informed, long-term strategyMartin Oteba1, Anita Katharina Wagner2, Morries Seru3, Martha Embrey4 and Birna Trap1*

Abstract

A strong pharmaceutical sector is a precondition for effective and efficient health care and financing systems, andthus for achieving the best possible health of a population. Supported by visionary, long-term donor funds, in conjunctionwith mutual trust, the USAID-funded Securing Ugandans Rights to Essential Medicines (SURE) and Uganda Health SupplyChain (UHSC) program engaged in a close, more than 10 year-long (in 2018) collaboration with the Ministry of Health ofUganda. Over time, the partnership implemented numerous multi-pronged comprehensive changes in thepharmaceutical sector and conducted research to document successes and failures. We describe the evolutionand key characteristics of the SURE/UHSC interventions.

Keywords: Pharmaceutical system strengthening, Pharmaceutical sector development, Logistic system development,Supply chain

BackgroundThis paper introduces the Journal of Pharmaceutical Pol-icy and Practice theme series on medicines managementin Uganda. Together, the series publications to date [1, 6]summarize the results of the implementation and evalu-ation of a long-term, visionary pharmaceutical system de-velopment strategy in Uganda. The strategy was led by theMinistry of Health’s (MOH) Pharmacy Department in col-laboration with two US Agency for International Develop-ment (USAID) supported programs—Securing UgandansRights to Essential Medicines (SURE) (2009–2014) [7] andits successor, Uganda Health Supply Chain (UHSC)(2014–2019). Here, unique aspects of SURE/UHSCare highlighted, system strengthening interventionsare documented, including lessons learned, and a visionfor the future is shared.

What is unique about the health systemstrengthening program in Uganda?The Uganda SURE/UHSC programs designed a compre-hensive set of interconnected interventions to strengthen

the country’s pharmaceutical sector. The planned inter-ventions were piloted and evaluated to understand whatworks and what does not and changes were integratedinto the country’s health system.An options analysis in 2010 conducted jointly by the

MOH and USAID [8] identified long-standing subopti-mal areas in Uganda’s essential medicines supply chain.In response, USAID funded the SURE and UHSC pro-grams to develop and implement a comprehensive andsustainable intervention strategy to improve medicinesmanagement. The strategy is based on the understand-ing that a supply chain cannot function withoutadequate human resources, information systems, finan-cing, and evidence-informed regulations and policies,and that interventions need to consider the vertical andhorizontal interconnectivity between these elements(Fig. 1).SURE/UHSC interventions focus on strengthening

existing human resource capacity, building lasting infor-mation systems that also generate routine monitoring &evaluation (M&E) data, managing medicines andfinances, and supporting national health policy develop-ment to ensure that new interventions are anchored inthe system through routine procedures and practices.

* Correspondence: birna.trap@gmail.com1Management Sciences for Health, Plot 15, Princess Anne Drive, Bugolobi,P.O. Box 71419, Kampala, UgandaFull list of author information is available at the end of the article

© The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Oteba et al. Journal of Pharmaceutical Policy and Practice (2018) 11:23 https://doi.org/10.1186/s40545-018-0150-1

Human resource capacity was strengthened by improv-ing the skills of individual health facility staff membersin medicines management including stock and storagemanagement, ordering and reporting, and rational druguse and by building the capacity of training institutionsto teach medicines management. Initially, health staffresponsible for pharmaceuticals in about half (n = 1499)of all government and private not-for-profit (PNFP)health facilities covering about half of all the districtswere targeted for in-service supervision by trained medi-cines management supervisors (MMS) [1]. A new multi-pronged approach, Supportive Supervision, PerformanceAssessment, and Recognition Strategy (SPARS), was im-plemented by training existing local district governmentand PNFP staff members as MMS [1].Makerere University was tasked with institutionalizing

the training and testing of the MMS. The MMS takepersonal responsibility, are accountable, and receive in-centives for implementing SPARS under the leadershipof the district health officer.MMS motivate and support front-line health workers

to improve how they manage medicines along all supplychain functions [1]. The health workers as well as theMMS are encouraged and motivated by the performanceassessment carried out during each supervisory visit andwhich is linked to a recognition scheme tailored to boththe health worker and the MMS.

A robust and sustainable information system is neededto identify problems, assess the impact of pilot interven-tions, and routinely monitor and evaluate systemperformance.SURE developed the Pharmaceutical Information

Portal (PIP) in 2013, now residing in the MOH, as adatabase for SPARS facility performance data and othersector-related data to be used by managers at all levelsto manage pharmaceuticals and facility performance [1].Existing pharmaceutical system performance mea-sures were used or new ones developed as appropriateto design the SPARS performance measures. Govern-ment staff can query PIP in real time about medicinesmanagement performance in each of about 3000 govern-ment and PNFP health care facilities and they can aggre-gate information across facility, district, regional, andnational levels. For example, a recent PIP query revealeda serious problem with suspected malaria cases thattested negative, yet received artemisinin-based combin-ation therapy. As a result, policy makers restricted theuse of such medicines to cases that test positive and in-stituted the use of rapid diagnostic tests at all levels ofcare.The financing skills of individual health facility staff

members in government and PNFP facilities werestrengthened by providing supervision in budgeting andexpenditure management for health commodities, by

Fig. 1 Action-oriented pharmaceutical sector strengthening cycle depicting priority action areas, levels, and goals for Uganda

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developing standard operating procedures, and by build-ing the capacity of training institutions to teach pharma-ceutical and health commodity financial management aspart of their pre-service curricula.A new financial and commodity tracking system

(FACTS) was designed to be implemented at national med-ical stores and central ministerial levels. The existing supplychain systems were harmonized, standardized and opti-mized to more accurately quantify needs, and introduceorder and delivery schedules, and a national quantificationand procurement planning unit (QPPU) was established.The supply system was also streamlined from nationalstores to facility level by introducing the concept of “onesupplier - one facility” and by rationalizing supply manage-ment at facility level to have only one stock card for eachitem per facility.To sustain successful interventions and ensure they could

be adapted to changing needs, interventions needed to beintegrated into existing policies, regulations, procedures,and practices. Although, like other donor-driven programs,much SURE/UHSC support takes place at the districtlevel, however, SURE/UHSC was designed from the begin-ning to connect closely to the central-level MOH, throughstrategies including staff secondments to the Pharmacy De-partment, Planning Department, and several priority dis-ease programs. This assured that from the start, the MOHwould own the interventions and transform them into na-tional policies and practices. Examples include the following:

� SPARS was made a national strategy, rolled outnationwide, and expanded from focusing onessential medicines to include antituberculosis andantiretroviral treatment, laboratory services, andpharmaceutical financial management;

� RxSolution, an electronic logistics managementinformation tool, was piloted and chosen for rolloutat all higher-level facilities [7];

� the inspection of public sector facilities for GoodPharmacy Practices (GPP) became a legal requirementthat links to SPARS performance to GPP accreditation;

� the National Medicines Policy and pharmaceuticalsector M&E system were updated to integrate thenew initiatives and;

� the curricula to train health workers such aspharmacists and pharmacy technicians, nurses andnurse aids, laboratory technicians, physicians, andclinical officers, were revised to include training inmedicines management components (stock andstorage management, ordering and reporting, rationalmedicines use); moreover, the MMS trainingcomponents including supportive supervision,RxSolution, and pharmaceutical financialmanagement became part of the curriculum forpharmacy students at Makerere University.

The Ministry of Health, SURE/UHSC program leader-ship, and USAID have been committed to designingchange, piloting change, assessing impact of change, andscaling up change if the interventions were documentedas feasible and effective. In those cases, the Ministry ofHealth translated the successful interventions into newpolicies that were implemented nationwide and by all do-nors. Interventions were rigorously evaluated to share les-sons learned and avoid replication of unsuccessfulapproaches [9]. Health system research played an import-ant part of the planning and the funding. Following eightyears of program implementation, program staff con-ducted more than 20 evaluations of new interventions,which were designed and carried out through close collab-oration between program staff, MOH and district staff,and with assistance from academic colleagues at MakerereUniversity and Harvard Medical School [1–6, 10, 11]. Thecontinuous evaluation approach has prompted additionalchanges; for example, operational research revealed thatMMS training needed more focus on supportive supervi-sion [10]. Furthermore, an evidence-focused mindset hasbeen instilled among MOH staff at all levels and has sup-ported the professional development of several programand MOH staff members and future managers.Interventions to strengthen pharmaceutical sector in

Uganda are summarized in Table 1.

What made this unique program happen?A confluence of several factors enabled the SURE/UHSCprogram. The HIV/AIDS pandemic prompted largedonor investments in global health and the need to rad-ically rethink how pharmaceutical systems function tosupport antiretroviral therapy. Different from manycountries that targeted antiretroviral therapy supply sys-tems through largely vertical, donor-driven programs,the Ugandan government and USAID embarked on abroad pharmaceutical system-strengthening focus char-acterized by: 1) More than 10 years of donor commit-ment to holistically strengthen interconnected aspects ofthe pharmaceutical sector, 2) change orientation withinnovation and no more business as usual, 3) adherenceto USAID’s Collaborating, Learning, and Adapting con-cept with research support from Harvard University andMakerere University, and 4) the MOH’s vision coupledwith trust among the key implementing stakeholders.

What are lessons learned?Among the many lessons learned in implementing theSURE/UHSC program, a few stand out:

� The great need for trusting collaborations andcoordination among multiple players withingovernment ministries including the MOH atcentral, district, and facility levels, religious medical

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bureaus that oversee the PNFP sector, donors, andtheir implementing partners.

� The need to maximize use of limited resourcesby strengthening and harmonizing nation-wideprocedures and practices and by making systemperformance information widely and easilyavailable.

� The need for quality information to enhancemanagement decision making and the importanceof building the capacity of health workers andmanagers at all levels in data use and resource

management using standardized procedures andpractices.

� The need to design, implement, and monitorperformance.

� The need for multi-pronged intervention strategiesthat target different levels of the system simultan-eously, such that operational process changes arebacked by policy changes and

� implemention of the program at central level as wellas district level to be able to test new interventionsand incorporate them into policy.

Table 1 Interventions to strengthen the pharmaceutical sector in Uganda

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� The need to assess how well interventions areimplemented, how they are perceived, and how wellthey are working by using the soundest yet feasiblelongitudinal evaluation methods possible, and to useresults to continually adapt and improve systeminterventions and to pause and modify unsuccessfulinterventions.

In addition, several of the positive lessons learnedcame from initially negative experiences that throughevaluation and analysis were modified and made suc-cessful by applying multipronged strategies to addresseducational, managerial, regulatory, and financial issues.In an under-resourced, fragmented health care delivery

and financing system such as Uganda’s, a synergy of ef-forts is needed to optimize health gains from govern-ment and donor investments in human and financialresources. This harmonized rather than competitive ap-proach to development aid requires government leader-ship, time, and a paradigm shift among donors andimplementing partners. Building on the impacts of theMOH-SURE/UHSC interventions, the program hasevolved as a center of excellence for supporting the sup-ply chain management needs of different implementingpartners, and SURE/UHSC staff have supported otherpartner health programs in their logistic activities. Forexample, under MOH leadership, the SPARS tool thatforms the basis of information in PIP has become thestandardized supply management tool for all essentialmedicines and all managers including donors to theHIV/AIDS programs. SURE/UHSC staff have supportedother partner health programs in their logistic activities.USAID’s continuous funding to support the PharmacyDepartment’s coordination activities and the commit-ment of USAID, MOH, and SURE/UHSC staff to fostercoordination among implementing have resulted indonor funds used to build on rather than duplicate ef-forts. In addition, readily available information in thePIP on facility performance (e.g., stock outs, expiredmedicines) has been crucial for all parties to jointly en-gage in priority-setting discussions.

What are visions for the future?A strong health system is recognized as a prerequisitefor reaching several of the United Nations’ sustainabledevelopment goals by 2030. Uganda is well-placed totranslate continued donor support for health systemstrengthening into measurable population health andeconomic benefits; however, the government and donorswill need to make critical decisions to maximize limitedresources. Moreover, health care and financing needs arecontinuously changing. What will it take to keepstrengthening the Ugandan system while adapting it toaddress emerging demands?

The SURE/UHSC program has successfully put in placea pharmaceutical system infrastructure on which to buildan evolving, learning health system [9]. However, the in-terconnected components of the pharmaceutical sectorstrengthening cycle—human resources, information sys-tems, financing and policies and regulations—will requirecontinued, coordinated advances. This will demand polit-ical will, deliberate policy and program actions, and inno-vations to operate increasingly complex pharmaceuticalcare and financing systems.

Epidemiological shift to chronic conditionsThe rising prevalence of chronic and non-communicablediseases needs both prevention strategies and ap-proaches to making often lifelong treatments accessible,appropriately used, and affordable for the health systemand households—progress toward universal healthcoverage is required to limit unaffordable out-of-pocketexpenditures.If the pharmaceutical and financial systems can adapt to

this new epidemiological reality, it will be possible to makeinnovative and effective yet highly priced treatments forcancers and other chronic diseases available [3].

Addressing equityPoverty and income inequality had been on a downwardtrend until 2012. However, the percentage of Ugandansliving under the poverty line increased from 19.7% in2012/13 to 27.0% in 2016/17 [12–15]. If focused ad-equately on the poor, moving universal health coverageforward can improve equity in access to quality healthcare, but major efforts will also be needed to strengthensystems outside of the health sector such as taxation.Without a functioning pharmaceutical system that givesdecision makers access to real-time information on whouses medicines, which medicines are used, and howmuch money households and the government spend onmedicines, supplies, and services, universal health cover-age efforts in general, and coverage of the poor in par-ticular, will likely fail.

Community engagementTo make the most of investments in health systemstrengthening, individuals and households must beempowered to take ownership of the process and tounderstand their rights to quality health care and accessto medicines; in addition, such empowerment can helpimprove system governance, along with transparency,equity, and accountability. Uganda offers many oppor-tunities to promote stronger linkages between the healthsystem and communities, such as through facilitatinguptake of primary prevention, screening, testing (usingrapid diagnostics), and early diagnosis and treatment ofdiverse diseases. Moreover, community feedback can

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inform health system planning to meet changing popula-tion needs. In partnership with United Nations Chil-dren’s Fund, United Nations Population Fund, andPATH, Uganda is exploring the feasibility of using stan-dardized tools to enable community feedback on theavailability of essential medicines and on health systemgaps. Creating a health system that is more responsive tocommunity needs will strengthen national health com-modity planning and foster grassroots demand foraccountability.

SummaryTo improve Uganda’s health system equitably and sustain-ably, the country will need to make the most of current re-sources and it will need more resources. Increased healthsystem investments—from the government or donors—can produce better health only when interconnectedpharmaceutical and health care delivery and financing sys-tems function well. The SURE/UHSC program has built asolid foundation on which to base continued holisticpharmaceutical and health system development.

AbbreviationsEMHS: Essential medicines and health supplies; EMHSLU: Essential Medicinesand Health Supplies List of Uganda; FACTS: Financial and commoditytracking system; GDP: Good dispensing practices; GPP: Good pharmaceuticalpractices; M&E: Monitoring and evaluation; MMS: Medicines managementsupervisor; MOH: Ministry of Health; PFM: Pharmaceutical financialmanagement; PIP: Pharmaceutical information portal; PNFP: Private not-for-profit; QPPU: Quantification Procurement and Planning Unit;SPARS: Supervision Performance Assessment Recognition Strategy;SURE: Securing Ugandans’ Rights to Essential Medicines [program];TB: Tuberculosis; TWOS: TB web-based ordering and reporting system;UCG: Uganda Clinical Guidelines; UHSC: Uganda Health Supply Chain[program]; USAID: United States Agency for International Development;VEN: Vital, essential, and necessary; WAOS: Web-based ARV ordering andreporting system

AcknowledgementsWe thank all colleagues who over the years have made SURE/UHSC and thetransformation of the pharmaceutical sector in Uganda possible. These include,but are not limited to, the staff in the US Government and the Government ofUganda, and all individuals who provided care, taught, conducted research, andserved in multiple other ways to improve affordable, equitable access toappropriately used, effective medicines for the people of Uganda.

FundingThe studies in the thematic series were funded by the United States Agencyfor International Development (USAID). USAID did not have any role in thedesign, data analysis, or writing of papers for the thematic series studies.

Authors’ contributionsMO, AW and BT conceived and drafted the commentary based on theirknowledge and experiences of implementation of the SURE/UHSC program.All authors took part in the writing and editing of this commentary. Allauthors read and approved the final version.

Ethics approval and consent to participateAs a summary of interventions, no personal identifiable health or personaldata, human tissue, or animals were involved, nor was there any datacollection. All authors of the manuscript have read and agreed to its contentand are accountable for all aspects of the accuracy and integrity of themanuscript in accordance with ICMJE criteria.

Consent for publicationThe commentary is original, has not already been published in a journal, andis not currently under consideration by another journal. Consent forpublication from the Ministry of Health has been obtained.

Competing interestsThe authors declare that they have no competing interests.

Publisher’s NoteSpringer Nature remains neutral with regard to jurisdictional claims inpublished maps and institutional affiliations.

Author details1Management Sciences for Health, Plot 15, Princess Anne Drive, Bugolobi,P.O. Box 71419, Kampala, Uganda. 2Harvard Pilgrim Health Care Institute, 133Brookline Avenue, 6th Floor, Boston, MA 02215, USA. 3Ministry of Health,Pharmacy Department, Lourdel Road, Wandegeya, Kampala, Uganda.4Management Sciences for Health, 4301 N. Fairfax Drive, Suite 400, Arlington,VA 22203, USA.

Received: 30 April 2018 Accepted: 19 August 2018

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