Commodity Security: The Role of Drug Revolving Fund Scheme in Low- and Middle-Income Countries

Abstract

The purpose of the study is to establish the role of Drug Revolving Fund (DRF) Scheme in achieving commodity security in LMICs. DRF scheme is a self-sustaining health financing strategy that charges “user fees” just enough to recover the cost of health commodities and aims to ensure that quality lifesaving health commodities are available, affordable, and accessible to all irrespective of one’s financial status, thereby contributing to achieving universal health coverage, especially through the primary health care system. The study, using a literature review approach, aimed to establish that commodity security can be realized through functional DRF scheme as a component of a sustainable health financing strategy in the face of foreign aid donor fatigue and dwindling government investment in public health care due to other competing demands. The study finds that a functional DRF scheme requires a strong political and financial commitment, robust management, and technical systems, and involves stakeholder and community participation, and use of operational guidelines and that going to scale are best achieved when done in a phased, and incremental manner. The contribution to knowledge of the study is that the DRF scheme is a feasible pathway to attaining commodity security without exerting enormous demands on already scarce resources of LMICs.

1. Introduction

Universal health coverage (UHC) means that all people have access to the full range of quality health services they need, when and where they need them, without financial hardship [1]. Therefore, access to affordable and acceptable quality medicines is perhaps the most crucial element in achieving UHC among citizens as indicated by target 3.8 of the UNSDGs, which specifically states to “Achieve UHC, including financial risk protection, access to quality essential health care services and access to safe, effective, quality and affordable essential medicines and vaccines for all,” [1] making commodity security, therefore, a critical component of achieving UHC.

The ability of every person to obtain and use quality lifesaving medicines whenever and wherever he or she needs them is known as commodity security [2, 3]. Several governments in developing countries, especially in sub-Saharan Africa, provide drugs free of charge to certain segments of the population that are considered most vulnerable, for example, pregnant, and lactating women and children under the age of five, mostly for the treatment of malaria and diarrhea and other related childhood diseases. Furthermore, most of the free drug interventions in low- and-middle-income countries (LMICs) are financed by foreign aid donors, and therefore, may not be sustainable in the long run, for reasons that include scarce resources and many competing demands and global aid donor fatigue among other issues [4].

Therefore, there is an urgent need for LMICs, where health care services for the majority of citizens are through the public health facilities, to develop a sustainable approach to achieving commodity security, and UHC thereby, for their citizens, especially the most vulnerable that can be further affected and impoverished by huge out-of-pocket expenditure to access health care services, including affordable and quality lifesaving medicines [5]. A sustainable pathway for LMICs to achieve quality health commodity availability, accessibility, and affordability, thereby gaining commodity security for citizens, is arguably the drug revolving fund (DRF) scheme.

The DRF scheme within Bamako initiative was adopted as the initial approach for sustainable financing of drug supply, especially at the primary health care level [6]. The DRF scheme is a concept that should promote access and ensure the availability and affordability of drugs in public health facilities. It guarantees the sustainability of drug supplies and services. The focus of the scheme is to ensure the sustainability and continuity of the essential drugs program [7, 8].

After the launch of Bamako Initiative in the 1980s, there were several failed attempts to establish drug-revolving schemes in the country from the 1980s to 1990s [7, 8]. The drug-revolving scheme still exists in most states in Nigeria but only in principle with no substance on the ground. In 2008, Partnership for Transforming Health Systems Phase 2 (PATH2) establishes sustainable drug supply system (SDSS), which incorporated the principles of Bamako Initiative-DRF system. Pilot states in this intervention include Enugu, Jigawa, Kaduna, Kano, and Lagos. Other states that received “light touch” were Bauchi, Borno, Nasarawa, and Zamfara states.

Challenges included inadequate or lack of capitalization, ambiguous management structures, lack of financial sustainability plan, inadequate human resources for health in quantity and training, lack of responsible procurement practice, and poor accountability among others. In the two states that were considered successful, some of the reasons attributed to that include responsible procurement, establishment of framework agreements between the drug management agencies and suppliers, “ring-fencing” of funds for health commodity, financial sustainability plans, including diversification of income, and operating in line with established guidelines [9, 10, 11, 12].

Recently, donors like TGF, USAID, and BMGF have launched fresh efforts to help sub-national entities in Nigeria revitalize their DRF scheme, though with differing approaches. BMGF had between 2016 and 2021 supported the supply chain transformation program in Niger and Kaduna states through its technical partner, Pamela Steel Associates. The intervention focused on supporting drug management agencies to revitalize the DRF scheme. Currently, BMGF through African Resource Centre (ARC) as a technical partner is supporting some states to establish a public private partnership (PPP) with Pharma industries (“Suppliers”) with the aim to create market for the manufacturers and availed states with a dependable source of health commodities through establishment of MoU. In addition, the Pharma industries are encouraged, as part of their Corporate Social Responsibility (CSR), to embark on some interventions like upgrading warehouses, etc., for the states. Lastly, TGF is investing in building resilient and sustainable systems for health (RSSH) across Nigeria through National Agency for the Control of Aids (NACA) as Principal Recipient (PR) with the National Product and Supply Chain Management Programme (NPSCMP) as Sub-Recipient (SR) focusing on strengthening the Logistics Management Coordinating Units (LMCU) and proposed infrastructural projects especially upgrading of state central medical stores to pharma grade. It is yet to be seen what these renewed interventions will be.

Lastly, the study is organized under the following major sections:

1. Commodity security-Drivers of commodity security (supply chain and related functions), commodity security as a component of global health security.

2. Universal health coverage-Concept and principles, primary health care as the road to UHC, commodity security as a critical component of UHC.

3. Foreign aid donor fatigue-Potential drivers, impact of foreign aid donor fatigue on the ability of LMICs to achieve UHC.

4. Health financing strategies-Types of health financing strategies, sustainable health financing options for LMICs.

5. DRF scheme-Concepts and principles, the history of DRF scheme, how DRF scheme can achieve commodity security, examples of successful implementation of DRF scheme in Kano-Nigeria and Khartoum-Sudan.

6. Results and discussions-Lessons learnt from successful implementation of DRF scheme in LMICs.

7. Conclusion

2. Methodology

This study, using a literature review approach, aims to establish the role of DRF scheme in LMICs toward achieving commodity security. An assessment of specific DRF scheme, its design, or implementation is beyond the scope of this study. Nonetheless, some cases of a functional DRF scheme were mentioned. Furthermore, this study also establishes connections between commodity security and DRF scheme with themes like UHC, global aid donor fatigue, and sustainable health financing for LMICs. A literature review is a piece of academic writing demonstrating knowledge and understanding of the academic literature on a specific topic placed in context. It includes a critical evaluation of the material with the aim to build an argument. In conducting a review of related literature, electronic search of peer-reviewed journal articles, edited academic books, articles in professional journals, statistical data from government websites, and technical reports were carried out for specific keywords either alone or in combination, including commodity security, universal health coverage, foreign aid donor fatigue, health financing strategies, and drug revolving fund. The criteria for the selection of materials or studies to be reviewed was based on if the materials were published in English language, if the study population are in LMICs, and whether the studies have defined inclusion criteria and/or ethical clearance. The study was conducted between March 2023 and June 2023. The information generated was analyzed qualitatively leading to findings and conclusions.

3. Commodity security

Commodity security is defined as the ability of every person to obtain and use quality lifesaving health commodities whenever and wherever he or she may need them [2, 3]. In other words, the ultimate goal of commodity security from a customer perspective is the satisfaction of clients or customers seeking health care services by ensuring that lifesaving health commodities are available when needed. Therefore, commodity security will remain a mirage without a functional supply chain system.

3.1 Drivers of commodity security: logistics and supply chain management

“A supply chain is a set of 3 or more organisations linked directly by one or more of the upstream or downstream flows of products, services, funds and information from a source to a customer” [13]. The three basic or minimum organizations linked in a supply chain are manufacturers, transportation companies, and the buyer. Logistics which is the operational component of a supply chain is defined as “the flow of material, information and funds between consumers and suppliers” [14].

Positive health outcomes are highly dependent on how well the health delivery system, including information, financing, personnel, and supply chain (including supplies)—is performing. From a logistics perspective, we can say that the success of any health intervention program depends on a strong, functional, and resilient logistics system. The importance of having lifesaving health commodities at health facilities whenever and wherever they are needed cannot be overemphasized. However, the availability of these health commodities will not be possible without a well-functioning supply chain system. The supply chain system and logistics system both need to be managed systematically for effectiveness and efficiency in order to achieve the ultimate goal of the logistics system, which is to satisfy its “six rights + 1” and that is ensuring that the right goods, in the right quantities, in the right condition, are delivered to the right place, at the right time, for the right cost, and to the right customer. Therefore, “Supply chain management is defined as management of the 2-way linkages and coordination of activities and flows (of goods, services, information and funds) from raw materials through to the end user both within and outside the organisation” [13].

A functional logistics and supply chain system depends on the availability of trained and well-motivated health personnel that ultimately drive such a system. Human beings are at the heart of every successful logistics system. Supply chain management of lifesaving health commodities, including high-value medicines like antiretroviral (ARV) drugs, vaccines, and cancer drugs, involves a series of activities to guarantee their continuous flow from the point of manufacture to the point where they are used by consumers.

3.2 Supply chain and related functions

The supply chain or its functions operate within a management system that provides decision-makers with relevant information to help determine what types of products are needed, where and when they are needed, and in what quantities. Commodity security can only be guaranteed if the supply chain and related functions are functioning at optimal levels. The supply chain and related functions are broadly classified into core supply chain functions, which include product selection and rational use, quantification, procurement, warehousing and distribution, and data management, while the supply chain-related functions otherwise known as institutional enabling environment enabling areas include governance and leadership, staffing and training, financial management, and quality management system. The institutional enabling environment areas create a conducive operating landscape for the core supply chain to thrive.

3.2.1 Core supply chain functions

Core supply chain functions are critical to achieving commodity security as these are activities that directly influence the identification of lifesaving health commodities to their ultimate use by clients. Put differently, core supply chain functions, or activities are at the heart of fulfilling the six “rights” of the logistics system and thereby achieving commodity security as demonstrated below:

• The RIGHT product is possible through product selection.

• In the RIGHT quantity is possible through quantification.

• And the RIGHT condition is possible through warehousing.

• To the RIGHT place is possible through warehousing and distribution.

• At the RIGHT time is possible through distribution.

• For the RIGHT cost is possible through procurement.

The purpose of the logistics system is to provide the six “rights” as earlier explained; and by doing so it ensures that the customer, for which the whole system exists to satisfy, achieves commodity security. Therefore, it can be concluded that the purpose of the logistics system is to achieve commodity security. Hence, commodity security is not possible without a functional supply chain system and its core functions, which include product selection, data management, quantification, procurement, warehousing, and distribution as illustrated in Figure 1.

Figure 1.

Schematic diagram showing a relationship between supply chain functions and the six “rights”.

3.2.2 Institutional enabling environment functions

The institutional enabling environment functions or areas make it possible for effective and efficient implementation of core supply chain functions. Every functional system, including the logistics and supply chain system, needs well-qualified and trained personnel to be successful because systems are manned by humans. Also, to establish and sustain any system requires funding and efficient management of those funds. Lastly, without sound governance and leadership, the right vision and support to make a success of the logistics and supply chain system will be lacking. Lastly, there must be a system of quality assurance and control which together establishes a quality management system to ensure the supply chain system and its core functions are functioning properly and progressing toward achieving its desired goal. The quality management system also incorporates continuous improvement elements to ensure resilience in a dynamic operating environment.

3.3 Commodity security as a component of global health security

“Global health security is the existence of strong and resilient public health systems that can prevent, detect, and respond to infectious disease threats, wherever they occur in the world” [15, 16]. The strategic vision of the global health security agenda focuses on three basic priority areas namely to prevent avoidable outbreaks, to detect threats to global health early, and to respond rapidly and effectively [15, 16]. In these three focus areas, lifesaving health commodities are a critical component. For instance, vaccines play a critical and central role in preventing deadly disease outbreaks in children and adults alike. Equally true is the role of laboratory commodities in detecting and diagnosing strange diseases early, thereby limiting the spread of such diseases to a pandemic level. Lastly, if and when these diseases are detected and diagnosed, drugs against them are needed to treat those affected and thereby improving their quality of life and reducing morbidity. Therefore, commodity security is critical to achieving the global health security agenda.

4. Universal health coverage: concepts and principles

Universal health coverage means that all people and communities receive health services, including access to treatment with quality and affordable lifesaving health commodities, whenever and wherever they need it without constituting undue financial burden to citizens [1]. The principle of universality forms a core component of UHC. Simply put, the mandate of the UHC is to reach everyone with quality health care irrespective of their social status. True universality means that some interventions or practices in LMICs where some segments of the population are considered most vulnerable, for instance, children and pregnant women, and therefore qualify for free health care are discriminatory and do not ensure equity for all citizens. Unfortunately, such discriminatory practices are being funded by the global aid donors by their choice for which segment of the population they want to focus upon; and arguably, it could be as a result of scarce resources or global aid donor fatigue. This again is one reason why the LMICs must find a sustainable way to achieve commodity security for their citizens rather than relying on global aid to meet the health care needs of their citizens, and worst, only some segments for that matter, thereby making it difficult to realize the mandate of UHC.

4.1 Primary health care as the road to universal health coverage

Primary health care (PHC) is fundamental to achieving UHC and represents a pathway to move toward UHC, especially in LMICs. It is a critical milestone along the road to achieving UHC targets. It enables universal, integrated access to quality health care services and products people need for health and well-being, thereby improving universal coverage and financial protection. According to WHO projections, about 75% of the projected health gains from the SDGs could be achieved through PHC and 90% of essential UHC interventions can be delivered through PHC with significant cost efficiencies, especially when an integrative PHC approach is used [17, 18].

PHC remains the most cost-effective way to address comprehensive health needs close to people’s homes and communities [18]. In low- and middle-income countries, more than half the 15.6 million excess deaths are amenable to health care and 42% of them are due to not using health services [19]. Geographic access—the distance people must travel to access health services—is a common barrier, and PHC is the most viable solution to removing that barrier to accessing health care in most if not all LMICs.

PHC is the most efficient way of using available resources to deliver services. It ensures that effective interventions are delivered at the place with the lowest cost within the service delivery system [18]. This critical role that the PHC plays is closely augmented by the DRF scheme’s core principle of ensuring that the most effective interventions allocated a lower mark-up to protect the poor from undue financial hardship […]. Therefore, PHC contributes to financial protection for individuals and households, which can be caused by both rare events of expensive treatments and cumulated expenditure of more frequently needed services. Through PHC, people can avoid unnecessary expensive treatments and deteriorations in health conditions that require more expensive treatment from a lack of early intervention. PHC is also the most equitable way for delivering needed services. It is the most frequently used service by everyone, and with the service being closer to the people and community, it improves service coverage and quality [18].

4.2 Commodity security as a critical component of universal health coverage

Universal health coverage (UHC) mandate seeks to accomplish three related objectives: equity in access—where everyone who needs health services should get them, including those who cannot pay for them; quality of health services—good enough to improve the health of those receiving the services; and financial-risk protection—ensuring that the cost of health care, including the cost of lifesaving health commodities, does not put people at risk of financial hardship [20, 21]. Commodity security equally entails that lifesaving health commodities are available everywhere they may be needed by those who need to use them. This, however, does not guarantee usage but only that it assures seekers of health care services that if need arises, the health commodities that will save their lives will be available at every health facility. This is very important, especially for LMICs, where the majority of the populace resides in rural and in some cases hard-to-reach locations. Therefore, commodity security helps to build confidence among citizens that when they go to health facilities to seek care, which in most cases will require the need for lifesaving health commodities, they are assured that those commodities will be available. Also, commodity security promotes health-seeking behavior among citizens because of the confidence in the health care system to be able to make available health commodities that will restore their health again. Hence, commodity security has in these ways contributed to access to UHC among the most vulnerable populace in the society. Secondly, commodity security envisages that lifesaving health commodities will be available to those who need them at an affordable price, without having to put health care services seekers under financial hardship. Therefore, knowing that there will be health commodities a client needs at the health facility and that they are not out of reach financially becomes a motivation to seek health care at the nearest health facility. Until those who seek health care services can afford the cost of their medications, then one cannot say that commodity security exists. However, because majority of the population in LMICs is poor, the issue of affordability seems to hinder the pace at which the quest for UHC is being achieved and the more reason for LMICs to find a sustainable health financing strategy of option [22].

5. Foreign aid donor fatigue

Foreign aid is defined as “the international transfer of capital, goods, or services from a country or international organization for the benefit of the recipient country or its population. Aid can be economic, military, or emergency humanitarian” [23]. Foreign aid may be given for different purposes both as a diplomatic tool or in pursuance of foreign policy. Whatever the purpose is, the aid is given more to serve the interest of the donor country or institution first and second to benefit the recipient country.

Foreign aid donor fatigue or simply “donor fatigue” is defined as “a phenomenon in which people no longer donate to charities, although they have in the past” [24]. Expressed differently, it can also mean the hesitancy of the international community (either nations, private organizations, or individuals) to respond to a call for action toward a humanitarian crisis, be it a natural disaster (earthquakes, tsunamis/floods, wildfires, etc.) or man-made (e.g., wars, conflicts, terrorism). On a larger scale, it can also refer to a slowness to act on the part of the international community or any other donor base in response to a humanitarian crisis or call-to-action. Foreign aid seems to be at a crossroads when it is needed the most in LMICs. Since the early 1990s, there has been a pronounced fall in the real amount of foreign aid provided by donors for developing countries [25, 26, 27].

The term “donor fatigue” was espoused by donors and development aid agencies in the late 70s to convey their frustration at the slow pace of change in their recipient countries and communities, despite their huge investments. They were frustrated with the slow progress and impact of their technical and financial investments. Many donors described this phenomenon as the “leaking basket” which dissipates invested resources [25]. It is also true, especially in Africa, which has relied heavily on aid flows, and has witnessed little, if any reduction in poverty. Indeed, the number of people living in poverty worldwide is likely to rise in the remaining years of the twentieth century [24, 25, 26, 27]. On the face of it aid is being withdrawn when it is still desperately needed [25]. However, the question is: why should not it? Is foreign aid effective in alleviating poverty? If not, reducing it may be the sensible thing to do. If there are no developmental returns, why incur the cost? [25, 26, 27].

5.1 Potential drivers of foreign aid donor fatigue

There are several reasons why foreign aid donors are showing signs of fatigue or reducing the amount of aid they give to LMICs. The debate on potential drivers of foreign aid donor fatigue is as varied as the individuals or institutions you are dealing with. Simply put, differing reasons exist based on individual perspectives and may be a result of social constructs, rather than reality. The following potential drivers of donor fatigue are examined, though briefly:

5.1.1 Policy shift

What seems to be like “donor fatigue” may actually be a shift in the policy of the donor country for strategic reasons. And because policies are most times aligned with political leadership at the helm of affairs, there may be changes with every incoming administration that can have negative or positive effects on the country’s foreign aid policy. This change will either manifest as an increase in the volume of foreign aid or as a decrease to it. For instance, the Trump administration in pursuance of its “America First” agenda pursued changes to foreign aid funding, desiring to reduce federal spending, including ending the need for foreign assistance. Some initiatives built on the work of previous administrations, while others conflicted with, and in some instances sought to dismantle, long-standing U.S. programs and policies [28].

5.1.2 Negative perception

There are some many opinions out there in the public about how foreign aid is administered in beneficiary countries. True or not, this negative publicity tends to raise internal tension and heat up the polity in donor countries with the resultant effect being more scrutiny about the volume of aid leaving donor countries to LMICs. National budgets are a trade-off between many competing demands, hence public support or otherwise by taxpayers and voters is considered critical to the sustenance, decline, or total removal of foreign aid programs. In addition, the legitimacy of any aid program as expressed by citizens can determine the quality of foreign aid. Therefore, public opinion is a critical factor in the continued flow of foreign aid from donor countries [29, 30, 31]. Some of these negative perceptions are related to corruption associated with aid administration in recipient countries, with little progress recorded despite a huge volume of aid flowing into those countries for specific interventions, etc.

5.1.3 Corruption

The perception of corruption in aid-recipient countries has been shown to cause donor fatigue. However, it is also true that corrupt countries are the ones with the highest need for foreign aid [25]. This is contradictory, yet true and represents a dilemma to donor countries and their citizens in that the reason for donor fatigue is the same reason why more aid is channeled into those countries either because it is a moral burden to support the vulnerable poor, or in the hope of bringing good governance and development or simply because it serves a strategic national interest of the donor country [25].

5.1.4 Economic recession

“Economic crises generally lead to reductions in foreign aid. However, the widely held view that budgetary constraints caused by economic crises reduce aid is inaccurate because donor government outlays actually tend to increase” [32]. When recession hit donor countries especially in such a way that it takes a huge toll on the banking sector, then it becomes difficult for foreign aid to flow out of those countries because of the fiscal cost associated with the banking sector.

Economic recession that hit hard on financial institutions of donor countries makes it less likely for politicians to show willingness or have the ability to provide foreign aid in this situation. It is common practice for banks to provide credit facilities to offset the cost and effect of economic recession in LMICs through development and economic recovery funds, but when the toll is heavy on financial institutions in donor countries, it results in donor fatigue and less flow of aid to help development agenda of LMICs. Also, voters place a lower priority on aid during economic downturns and politicians respond by cutting aid. Therefore, economic downturns lead to reduced public support for helping the poor abroad [32].

5.1.5 Increased demand for aid

Before now, there were problems in just a few places in the world, however, these days there seem to be many problems in many countries at the same time, including countries where foreign aid flow out from. Today, the whole of Europe is engulfed in a proxy war with Russia over the invasion of Ukraine. This is the case of your house on fire, likewise your neighbor’s house; which are you supposed to focus on first? Therefore, it may not literally mean that foreign aid has been reduced, but that there are so many demands placed on the available budget which consequently reduces the volume of aid to LMICs. Hence, when foreign aid is not flowing toward countries that need it as expected, it is tagged as foreign aid donor fatigue without considering the enormous pressure on donor countries. And the fact that nontraditional recipients are beginning to require aid.

5.1.6 Internal crisis

As quoted somewhere above, the fact that there are so many problems in so many places all at the same seems to be weighing heavily on the ability of developed nations to keep up with their commitment to foreign aid. Most recently, the world was plagued with the Covid-19 pandemic of 2020, which hit the hardest developed, traditional donor nations. As if that was not enough, the Russia war on Ukraine erupted, which has involved almost all of Europe and the USA. And multiplied regional antagonism among friendly nations. Lastly, the effect of climate change and its consequence on energy has all gotten the “plate” of the developed nations full. The resultant effect is that LMICs are receiving less attention and foreign aid from developed nations to help deal with their developmental problems.

5.2 Impact of foreign aid donor fatigue on the ability of LMICs to achieve UHC

In summary, the issue of foreign aid donor fatigue which is causing a decrease in the volume of funds donor countries are prepared to commit to tackle developmental issues in LMICs is no longer in doubt while LMICs are more desperately in need of more aid to be able to meet their obligations to their citizens. There is the foreign debt servicing burden, low internally generated revenues, constant budgetary deficits, and increasing demand for scarce resources due to population growth. Therefore, if foreign aid continues to dwindle, it will constitute a risk to meeting the target of UHC by 2030, as envisioned by the UNSDGs. Therefore, there is a need for careful transitioning from foreign aid so as not to reverse the gains achieved in public health programs, such as HIV/AIDS, immunization, malaria, tuberculosis, nutrition, maternal and child health. Already, aid flows for HIV programs have stagnated in recent years, likely as a result of foreign aid donor fatigue. Estimates of future funding requirements needed to sustain present gains and to achieve universal treatment coverage to sustain existing programs and achieve universal treatment coverage suggest indicates that the current funding is less than sufficient, and more is being required [32, 33, 34]. Inferentially, there is almost a 100% chance that if the current trend in foreign aid donor fatigue should continue, LMICs will not be able to close the funding gap, and the vision for UHC will be compromised. For instance, when donor commitment toward malaria and childhood vaccination programs decreased due to foreign donor aid fatigue, there was a reversal of the gains already recorded in those public health programs [35, 36]. Therefore, if LMICs are not to be caught napping, there is an urgent need to search for a sustainable health financing strategy that can sustain the present gains being recorded through foreign aid inflows into the health sector. It is obvious that foreign withdrawal is a matter of when and not if.

6. Health financing strategies

Health commodities can save lives and have the ability to improve health outcomes and reduce mortality and morbidity due to diseases. It is also true that these lifesaving health commodities come at a cost and this cost is sometimes beyond the reach of the poor in the society. Simply put, health commodities are needed to save lives and improve health, but at what cost?

Health financing is a strategy to make health care services, including lifesaving health commodities, accessible to citizens whenever and wherever they may need it without unnecessary financial burden. According to the Ref. [37], health financing is a core function of health systems that can enable progress to attain UHC through ensuring there is commodity security and effective health care service as envisioned by SDG 3.8. Sadly, there are still many people in society that cannot afford the cost of health care, including the cost of obtaining lifesaving health commodities. There are also situations where people pay out-of-pocket but do not get quality and therefore value for their money.

6.1 Types of health financing strategies

There are five functional health care financing strategies identified and practiced globally. These strategies are listed and represented by a schematic diagram in Figure 2.

1. General tax revenues,

2. Social insurance,

3. Private/voluntary insurance,

4. Financial aid (by donors, NGOs),

5. Community-based insurance and

6. “User Fees” or individual out-of-pocket payment.

Figure 2.

Types of health financing strategies.

6.1.1 General tax revenues

Health financing with general tax revenues is a common practice in the developed nations of the West and is feasible because of their economic stability; however, that is not the case in LMICs as revenues so generated through general taxes are small and inadequate in light of other competing demands. There are three ways revenues can be generated through general taxes—direct, indirect, or excise taxes [38, 39].

6.1.2 Social insurance

Here, health care services are paid for through contributions by the employee and their employer. The health fund is usually independent of the government but works within a tight framework of regulations. Premiums are linked to the average cost of treatment for the group as a whole, as against an individual, which results in cross-subsidies from the healthy to the less healthy [38, 39].

6.1.3 Private insurance

This is also referred to as voluntary insurance. People pay premiums related to the expected cost of providing services to them. This occurs when employers and/or individuals choose to purchase insurance from private firms so as to mitigate the potential loss of income associated with illness or the costs of health care consumption. Thus, people who are in high health risk groups pay more, and those at low risk pay less. Cross-subsidy between people with different risks of ill health is limited. Membership of a private insurance scheme is usually voluntary. The insurance fund is held by a private (frequently for-profit) company [38, 39].

6.1.4 Financial aid

Financial aid, also known as charitable donations, comes from the developed nations and private organizations channeled through NGOs. The work of non-profit organizations in the development and financing of public health cannot be understated. The activities of the organizations are mostly for specific interventions, such as the treatment of HIV/AIDS, tuberculosis, malaria, immunization against targeted childhood illnesses, maternal neonatal, and child health. Financial aid has become a major source of health financing in LMICs. Furthermore, financial aid goes beyond intervention in health and comprises several technical assistances, including in areas of democracy, food sufficiency, and humanitarian interventions during natural or man-made disasters, for example, during internal or external conflicts [39].

6.1.5 User fees

User fees, also known as individual, out-of-pocket payments, is another form of health financing where individuals seeking health care services pay for those services out of their personal funds. Even in the developed countries with universal health coverage, individual out-of-pocket payments represent an important mechanism of health care financing. These payments, at times, are made as payment-in-full for a particular service received, or as cost-sharing instituted by insurance or government plans in the form of deductibles, co-payments, and coinsurance [38, 39].

6.1.6 Community-based health insurance

Community-based health insurance is a form of private health insurance where individuals, families, or community groups finance or cofinance the costs of their health care services. It is intended for people living in the rural area as well as for people in the informal sector who cannot get adequate public, private, or employer-sponsored insurance. Here, premiums are commonly set according to the risk faced by the average member of the community; that is, there is no distinction in premiums between high and low-risk groups. However, unlike social health insurance schemes, enrolment is generally voluntary and not linked to employment status. Funds are held by a private nonprofit entity [38, 39].

6.2 Sustainable health financing option for LMICs

Recently, there have been more discussions on ways for nations to achieve sustainable health financing toward realizing the goals of UHC, including ensuring commodity security to citizens. According to the Ref. [37], “experience demonstrates that real progress is possible in countries at all income levels. However, each country’s pathway will differ depending on the local context.” The WHO is of the opinion that health financing reforms should not simply be imported from one country to another, but the unique context of each country and its starting point in terms of health financing arrangements must be considered. It goes on to state that the underlying causes of performance problems differ in each country, and it is these causes that the reforms proposed in a health financing strategy must address. It is also true that there may not be just one way or health financing strategy for countries to achieve UHC; however, some strategies may be more feasible, based on the context and level of development of a country. This is true for LMICs, where almost all the health-financing strategies discussed above play a part.

But the question to ask is—are all these strategies sustainable? And if the answer is no, then what is the most sustainable strategy for LMICs to achieve commodity security, which is a critical component of UHC? According to Ref. [37], country experience should be looked at through the lens of the health financing functions, rather than labels, and can provide valuable lessons. Labels such as “social health insurance,” “community insurance,” or “tax-funded systems” mean little by themselves and hide the complex choices and options available to countries as they raise, pool, and use funds to ensure the availability and use of quality services. Three core health-financing functions as identified by the WHO are:

• Revenue raising (sources of funds, including government budgets, compulsory or voluntary prepaid insurance schemes, direct out-of-pocket payments by users, and external aid)

• Pooling of funds (the accumulation of prepaid funds on behalf of some or all of the population)

• Purchasing of services (the payment or allocation of resources to health service providers)

For LMICs, whose majority of the population resides in rural settings far away from urban health centers where revenues from the tax are mostly invested; and other forms of health financing make more sense. For those people in rural settings, available, quality, and affordable lifesaving health commodities to treat their basic illnesses are most important to them. The DRF scheme, as we shall see later, guarantees quality and affordable lifesaving health commodities to the poorest of the poor through design that incorporates “exemption and deferral.” Secondly, because the DRF scheme is expected to be financed once, thereafter, it is self-sustaining through the principle of user fees for cost recovery and sustainability. Therefore, it is not designed for profit, but to bring health care services closer and more accessible to the people.

7. Drug revolving fund scheme: concepts and principles

The provision of access to quality and affordable essential medicines is a critical element of the UHC; however, most people, especially the most vulnerable in society, lack access to these commodities that their lives depend upon most of the leading causes of mortality and morbidity in LMICs are preventable or treatable with lifesaving health commodities [40, 41]. Drug Revolving Fund (DRF) is a scheme where medicines are sold at a light mark-up on the cost-price, and the revenue generated is used to replenish stocks, with the aim to provide safe and quality drugs at affordable prices and is usually part of the wider user fee model of sustainable health financing [41, 42].

The core concepts and principles of the DRF scheme as derived from the Bamako Initiative include but are not limited to:

• Promote additional investment and attract resources that citizens spent on accessing health care services in the private and informal sectors back to the public system.

• Increase in access to primary health care by raising effectiveness, efficiency, financial viability, and equity to health services.

• Meet basic community health needs through increased access to quality lifesaving health commodities and technologies.

• Improve regular contact between health care providers and the communities they serve.

• That communities should participate directly in the management and funding of lifesaving health commodities and technologies.

• Capture a fraction of the funds’ households were already spending in the informal sector and combine them with government and donor funding to revitalize health services and improve their quality through community participation.

• Community participation in the management and control of resources at the health facility will ensure ownership and accountability of public health services to users.

• The pricing mechanism guarantees that basic services are priced below what is obtainable in the private sector and cross-subsidized with higher mark-ups on lower priority interventions.

• Develop local criteria for exemption and deferral for the poor so that no one is denied access to care because of their financial status.

• Autonomy from central administrative interference, and in the use of revenue accruing from the sales of health commodities and ensuring that procurement funds are “ring fenced” from access and use other than as outlined in the guidelines for the scheme.

In summary, the DRF scheme is designed to be self-sustaining and to ensure the availability, affordability, and accessibility of quality health commodities and technologies at facilities after initial investment either by the government or donors thereby reducing the burden of regular or annual budgetary allocations.

7.1 The history of drug revolving fund scheme

The DRF has its origin in the Bamako Initiative, which was adopted to tackle the poor availability of medicines in sub-Saharan Africa, especially at the primary health care level. The Bamako Initiative was the brainchild of UNICEF and WHO and was adopted by African ministers of health in 1987. The initiative was based on the realization that many of the LMICs especially those of sub-Saharan Africa faced issues of resources and the practicality to implement successfully comprehensive primary health care (PHC) which is critical to achieving UHC. Most of the PHC centers, including public hospitals in urban settings, were merely consulting clinics where clients come to get a diagnosis and prescription and then go the private drug outlets, which are mostly unlicensed and unsupervised, to fill their prescriptions at an exorbitant price. This situation has resulted in loss of confidence in the public health care system in LMICs. Africa’s ministers of health believed that the Bamako Initiative can reverse this ugly trend. The Initiative proposed the use of an essential drug list and the development of realistic national drug policies to support the provision of essential drugs. Among other provisions that included community participation in the implementation of the scheme to promote accountability and ownership [6].

7.2 How drug revolving fund scheme can achieve commodity security

It has been established in Sections 3.2 and 3.3, respectively, that achieving UHC is only possible through functional primary health care and that when commodity security exists at primary health care, it restores confidence in public health care and encourages health-seeking behavior among citizens especially the vulnerable masses in rural settings which form the majority of the population in LMICs. Furthermore, the concepts and principles of the DRF scheme enumerated above, if implemented carefully will lead to commodity security for citizens. In this section, it will be further discussed as to how DRF scheme through some of its concepts and principles can bring about commodity security.

7.2.1 Ownership through community participation

The concept of community participation not only promotes ownership of the DRF scheme internally (for the staff that runs the scheme in the health facilities) and externally (for the clients from the catchment area of the health facility and beyond), but it also helps to enlighten community members about the existence of the scheme and mobilize community patronage. As quoted earlier, the impression about public health facilities to the ordinary citizen is that they are just “mere consulting clinics,” which further worsens the poor health-seeking behavior of average community members. Therefore, the concept of community participation in the DRF scheme ensures that citizens have regular contact with their health care providers, where quality health commodities can be accessed whenever and wherever the need may arise.

7.2.2 Autonomy and ring: Fencing of procurement funds

The DRF scheme principles envisaged that funds for procurement of health commodities are “ring-fenced” from interference by authorities not involved with the operation of the scheme in any health facility. Simply put, the funds for procurement cannot and should not be used for any other purpose other than for the purpose of procurement of health commodities for the health facility where they are domiciled. Secondly, autonomy in the discretionary of revenue accruing from sales of health commodities is the sole prerogative of the members of the DRF committee; therefore, it is expected that such funds should be used to ensure the availability of health commodities at the health facility, which is one of the components of commodity security is therefore guaranteed under a functional DRF scheme.

7.2.3 Differential pricing mechanism

In the DRF scheme, the most effective interventions were priced below private sector charges and cross-subsidized through higher markup and higher co-payments on lower priority interventions [6]. Simply put, health conditions that are considered to be of high impact on citizens, such as malaria and common infections, and may be associated with the poorest of the poor are applied a lower “mark-up” so that community members within that social bracket are not exposed to unnecessary financial hardship while accessing health care services. Equally, interventions that are sought by community members in the upper social class are priced higher in a bit to offset the subsidy for the most effective interventions. This concept ensures that those with life-threatening conditions are not prevented from accessing acre because of their financial status, thereby making sure every person is able to obtain and use quality, affordable lifesaving health commodities whenever and wherever the need arises.

7.2.4 Use of “mark-up” for sustainability purposes

The DRF scheme was designed to be self-sustaining through the application of “user fees” not for profit but as a strategy for “cost recovery” to ensure the sustainability of the scheme such that the revenue from sales of health commodities is reinvested to procure and make them available and affordable. The concept of “cost recovery” and “user fees” in DRF scheme has attracted a lot of debate for and against. Those argue that “user fees” promotes responsible use of health care services as people tend to abuse and not value anything tagged as free. On the other hand, the opponents of “user fees” insist that charging the poor fees to access health care services will only drive them away from visiting health care centers even when they are very sick [5, 6, 7, 8]. However, those who oppose “user fees” do not yet understand that the unbearable out-of-pocket expenditure, which they fear will further impoverish the poor is a result of the fact that those purchases are made from for-profit, private drug stores and private clinics occasioned by lack of availability of health commodities at the public health facilities ab initio.

7.2.5 Exemptions and deferrals

The DRF scheme in its provision envisaged that even at “cost recovery” mark-up, still there may be people in the communities that due to one reason or the other may not be able to afford the cost of the health commodities they need to save their lives and has provided an escape route or solace for such individuals so that no one is denied access to treatment because of their financial status. The DRF scheme has two ways to ensure everyone is able to obtain and use quality health commodities whenever and wherever the need arises. The first is known as “exemption”-which means individuals are exempted from paying ‘user fees’ because they have been assessed to be poor and cannot afford the cost of their treatment. The second is known as “deferral” which means that some individuals may not afford the cost of their treatment at the moment that they need it because of a temporal bad financial situation but could be able to pay in the future when their situation improves. In such a case, the payment for the cost of their treatment is deferred to a future date. Therefore, the DRF scheme is able to guarantee that every person is able to obtain and use quality health commodities whenever and wherever he or she needs it—this is called commodity security.

7.3 Example of successful implementation of drug revolving fund scheme

The DRF scheme is not without challenges, yet there are examples of successful implementation in several LMICs, which serve as best practices to other countries or sub-national entities within a country to borrow a leaf from. Some of the challenges experienced and are being experienced include but are not limited to weak political and financial commitment, poor leadership and managerial competence, resistance to change, and poor management of receivables, in the operations of the scheme [2, 6, 41]. Below are selected examples of successfully managed DRF schemes.

7.3.1 Drugs and medical consumables supply agency, Kano, Nigeria

Kano state is the most populous state in Nigeria with a population of 940,128 according to the census data of 2006 and was projected to be 14,253,549 in 2019 by the National Bureau of Statistics of the Federal Republic of Nigeria.

Before the support by Department for International Development (DFID), UK, in 2008, through the Partnership for Transforming Health Systems Phase 2 (PATHS 2), health facilities in Kano have lost patronage of the citizens and health workers were not working in the best environment because of lack of needed basic structures and systems [43]. As part of the key objective of the intervention, the focus was to improve the sustainable availability of health commodities at the health facilities, at the same time looking into other health system strengthening objectives [43]. Prior to the DFID-PATHS2 intervention, the total amount used for procurement of health commodities by the Kano state government was a meager N32million, as a result, most public health facilities resorted to self-help to source their supplies from the open market, which inculcated the prevalence of “parallel DRF” (a situation where health workers exploit clients by selling health commodities, usually brought in by them and hidden in their drawers and under their consulting tables, to them at exorbitant prices) [9]. The support by the UK government under PATHS2 will later continue with the Maternal, Newborn and Child health Program (MNCH2).

Between 2008 and 2013, procurement increased exponentially from N133 million in 2008 to N1 billion in 2013 with an increased number of sales transactions from a mere 402 to 2081 in the same period and with just 183 health facilities being supported by the DRF scheme to a whooping 699 [9]. This is an indication of an increased confidence in public health facilities and their patronage as well. Furthermore, the availability of health commodities rose from 6.5% to 84.95% in 657 primary health centers (PHC) while it rose at the secondary health centers (SHC) from 36% to 92.31% between 2008 and 2013 [41] and cumulatively, availability of health commodities on request rose from 25% in 2007 to 93% in 2015 [44]. Therefore, there was increased availability of health commodities, which is one of the core tenets of the DRF scheme.

On affordability, three successive annual drug price surveys carried out between 2008 and 2013 revealed that prices of health commodities in public health facilities are lower by about 63% than what they cost at private pharmacies and drug stores. In addition, in an attempt not to deny any person health care because of their financial status, Kano State DRF also incorporated a “deferral and exemption” policy, whereby the poor can access health care services free of charge or with deferred payment [9].

On accessibility, the increase in revenue from a mere N133 million to about N1 billion, representing a percentage increase of about 800%, from 2008 to 2013 showed that more people are having access to health commodities than when the DRF scheme came in place [9]. This is further confirmed under the MNCH2 when it reported that the Agency went from supplying 20 PHC facilities, and 10 SHC facilities across the state as of November 2015, to supplying over 700 health facilities across Kano (661 PHCs, and 39 SHCs) from two central medical stores and four zonal stores [44].

To conclude, a look at success factors toward the successful implementation of DRF scheme by the DMCSA, Kano, is worth highlighting here. Firstly, there is strong political buy-in in the scheme, which ensured that vested personal interests in the procurement process and contracting for supplies of health commodities, and operation of parallel DRF in health facility workers does not derail the scheme. Political buy-in also ensured that enabling policy guidelines are in place to regulate the conduct of bureaucrats and power play between different departments and units within the Ministry of Health and other relevant stakeholders [43]. Secondly, clarity in the implementation model has been identified as one of the success factors for the successful implementation of DRF by the DMCSA, Kano-Nigeria. Whereas others approach the implementation of the DRF scheme either as free, partial subsidy or full cost recovery or a mixture of all; DMCSA Kano-Nigeria chose a full cost recovery (for the cost of health commodities) approach excluding personnel overhead cost, infrastructure, cost of equipment [43]. Thirdly, the DMCSA Kano-Nigeria implemented a competitive pricing approach for determining the mark-up on the cost of health commodities which makes the selling price of the items affordable to clients. Also, DMCSA-supported facilities do not charge consultation fees to clients, which in other facilities account for a substantial part of the out-of-pocket expenses born by clients. Furthermore, the mark-up elements adopted in DMCSA are just for sustainability to cover the cost of potential expiries, inflation, monitoring and evaluation, exemptions, and deferrals all of which is not more than 20% added to the cost of health commodities [43]. Fourthly, capacity development and system strengthening are one of the success factors observed in the successful implementation of DRF scheme by the DMCSA. Activities being implemented include training for various staff involved in the running of the scheme at state, local government, facility, and community levels. These trainings are segmented to match the knowledge need and role of the staff being trained such as forecasting and quantification and procurement at the state level, monitoring and supportive supervision, and reporting [43, 44]. Lastly, community engagement and participation have been critical to the successful implementation of DRF scheme by the DMCSA by ensuring that there is local ownership, which leads to community members canvassing for support for the development of infrastructure, funding by political leadership, accountability of the scheme to the community it serves among other roles [43].

7.3.2 National medical supplies fund, Khartoum, Sudan

The National Medical Supplies Fund (NMSF), created by an act in 2015, is the government’s main store responsible for securing medicines, consumables, and medical equipment for the public sector. Before this time, it was called the Central Stores for Sudan Medical Supplies since 1935. It became a public corporation in 1991 with the adoption of “user fees” and “cost recovery” system policy to finance health services. In 2002, NMSF established states revolving drug funds aiming to expand the coverage for safe, effective, and acceptable quality medicines [45].

The impact of DRF through the NMSF, Khartoum-Sudan has been reported in two separate studies indicating that the availability of key items on average was greater than 93% in DRF-supported health facilities compared to 86% in those not supported by the DRF scheme [46]; however, these studies revealed that availability of essential medicines in DRF-supported health facilities ranged from 95 to 100% [46, 47]. Consequently, increased attendance and utilization of health services at public health facilities saw a steady rise with only a small number of the public attributing their lack of visit to lack of availability or affordability of essential medicines [46, 47]. Hence, sustained availability of low-cost medicines at primary health care centers closer to the people who are most vulnerable and disadvantaged can be achieved through the DRF scheme [46].

Success factors to the DRF scheme of the NMSF, Khartoum-Sudan was first, identified as due to substantial initial financial investment through capital seed stock of medicines that was provided by Save the Children International to the scheme to kick off at the onset [47]. Secondly, political commitment, in providing a legal framework for NMSF to operate, and allowing it to maintain a separate account so that its managers have a free hand in keeping generated revenues out of public treasury regulation, was instrumental to its success to this day [47]. Therefore, it is important that DRF scheme be provided with initial capital to set out and be allowed freedom to manage proceeds of sales of health commodities for the purpose of the scheme and excluded from the Ministry of Finance. Thirdly, the NMSF Khartoum-Sudan was given a free hand to apply private sector management style in running its business affairs and focusing on performance and results within the public sector [47]. The private sector approach entrenched the culture of accountability and transparency in financial management and allows measures that recruit staff based on competency and reduce risk to the operations of the organization. Fourthly, applying the principle of pooled procurement helped to price discounts due to economies of scale and keep the cost of health commodities as low as possible and contributed to responsiveness to stock-out situations in DRF-supported health facilities by not restricting purchase by health facilities to a cash-and-carry basis at the time of purchase [47]. Fifthly, the NMSF Khartoum-Sudan ensured that expensive drugs remain continuously available, subsidized, and affordable through the sale of cheaper essential medicines at low cost with a focus on high turnover instead [47]. This principle ensures that potential losses from the sale of expensive medicines are covered through the expected high turnover from sales of cheaper essential medicines and guarantees continued funding and subsidy for others. Lastly, monitoring, evaluation, and reporting of DRF activities at the health facilities by the supervision teams helped to ensure visibility, financial accountability, transfer of skills, and redistribution of health commodities from overstocked facilities to where they may be most needed, thereby leading to prevention of loses through potential expiry and damage [47].

8. Results and discussions

The results and discussions are structured as lessons learnt from implementation of successful Drug Revolving Fund Scheme in LMICs as synthesized from the review of the literature and from specific examples of successful implementation of DRF schemes in LMICs as mentioned above under Section 7.3 and are presented below. Indeed, very useful lessons have been learned from implementation of DRF scheme at national and sub-national levels that can provide good guidance for intending implementers. Below are some of the most critical lessons learned.

8.1 Political commitment

This is the most crucial and rate-determining step in establishing a successful DRF scheme. First, a DRF scheme must need to be empowered by a legal framework in order to succeed and as well as not to be easily affected when there is a change in political leadership. The act establishing the DRF scheme must envisage likely challenges and tackle them. For instance, the procurement funds and revenue from the sales of health commodities must be “ring-fenced” and shielded from external interference. It is equally important that revenue from the DRF scheme should not be subjected to any form of tax and import duties so as to avoid passing the burden on clients.

8.2 Initial capital investment

“Medicines safe lives and improve health, but they are costly” [40]. Following next to political commitment is a financial commitment from the government or donors to help supply the initial capital investment necessary to kick start the DRF scheme without which the concept of a DRF scheme will just be a mere wish. The failure of many DRF schemes in LMICs is due to a lack of financial commitment and the release of the needed initial capital investment. This initial capital investment could be in the provision of “seed stock” or funds to procure “seed stock” that will then be sold and revolve to generate more revenue and the circle continues leading asset growth of the DRF scheme. It is important that this initial capital investment be adequate and done once, as the idea of DRF scheme is to be self-sustaining and free the government from making recurrent annual budgets and releases. If this is happening, then the DRF scheme is not being run professionally.

8.3 Stakeholder engagement and buy-in

The health care sector is multidisciplinary with varied interests that differ one from another. Secondly, there are different revenue generation points or service delivery points such as the laboratory unit, theater unit, maternity unit, radiology unit, nursing unit, and pharmacy unit, within any health facility especially if it is a secondary of tertiary health facility. These different units or departments are being supervised by their parent professional bodies or departments in the Ministry of Health. It is therefore natural for different sections of the health facility to be apprehensive about what the concept of the DRF scheme entails for them. Thirdly, there is also the fact that health workers in LMICs are known to bring private business dealings into public health facilities because of lack of adequate funding by the government to provide all the necessary support for a conducive working environment. For instance, when there is no funding for procurement, it is easy for the pharmacist to buy their personal drugs and sale to clients. Likewise, when doctors and nurses realize that there are no health commodities at the pharmacy, they too are known to sale medicines to their patients in the consulting rooms. The same goes for the laboratory scientist who runs diagnostic tests who also buy all the necessary reagents and run the laboratory as their personal business premises. However, the concept of the DRF scheme will change all these unethical practices that seem to be a “new normal” and are bound to be resisted for personal interest. Therefore, all these stakeholders must be carried along in the initial consultation and design of the DRF scheme, otherwise, it will be frustrated.

8.4 Phased implementation approach

Establishing a DRF scheme, just like any other change program, requires an incremental approach so that successes or milestones can be reached and celebrated at intervals, which serve to build trust and provide the basis for motivation and more effort. The incremental approach also enables the system to monitor and evaluate progress and develop lessons learned for continuous improvement. For instance, the scheme can kick off with a number of limited health facilities onboarded and thereafter they can be increased when the system has fully stabilized in terms of adequately meeting the expectations of stakeholders, for example, in meeting the health commodity requirements of health facilities since the DRF scheme envisaged that all health facilities must source their commodities centrally. If “going to scale” was done too quickly the system may not be able to withstand the shock in increased demand from health facilities and this can create the impression that the scheme is not able to meet their health commodity requirements, which may result in health facilities “seeking self-help.” Similarly, some concepts like “exemption and deferral” can be delayed until the scheme has matured and accumulated reasonable revenue to absorb such costs.

8.5 Robust management and technical systems

There are three critical systems that have contributed to the success of DRF schemes in places the scheme has been launched-these are financial management and accountability system, functional supply chain system, and strong monitoring evaluation. For any DRF scheme to succeed, these three different but complementary systems must work in harmony. A strong financial and accountability system is required to ensure that there are no revenue leakages in the system that will starve it of needed funds.

Equally critical is the need for a functional supply chain system especially in the use of data for demand and supply planning such that procurement is guided by the use of data to avoid stuffing the supply chain pipeline that could lead to potential expiry and waste. Also, procurement should be “pooled” to maximize economies of scale and drive prices lower. However, even more critical is the need for a transparent and responsible procurement devoid of corruption, otherwise, the final prices to the consumers will be high, which will defeat the concept of affordability and access. Finally, on functional supply chain systems, most successful DRF schemes incorporate last-mile distribution to deliver health commodities to the doorsteps of the health facilities. This is a good practice that allows health care workers to focus on providing health care services to their clients rather than being engulfed in logistics matters.

Lastly, monitoring and evaluation is another system that must be in place to ensure that the scheme does not derail from its set goals and targets. Hence, there should be periodic supportive supervision of supported health facilities as well as regular performance review meetings to review the operation of the scheme and to proffer solutions to issues and to encourage continuous improvement.

8.6 Availability of, and compliance to operational guidelines

Strict compliance with operational guidelines of the DRF scheme is very critical to the success of the scheme. Systems like the DRF scheme must have operational guidelines or standard operating procedures (SOPs) that define roles and responsibilities, processes, procedures, list forms of records and job aids describing how tasks should be completed successfully. The lack of robust operational guidelines or lack of strict compliance with it is probably the major reason for failed DRF schemes.

8.7 Stakeholder participation and collaboration

Earlier we have seen the role of stakeholder engagement, and buy-in, which is very critical from the onset to bring key opinion leaders (KOLs) to the table to accept the new changes in administration and control with respect to running the DRF scheme and this need to continue all through the life of the scheme. This is different from stakeholder participation and collaboration, which comes to bear during the actual implementation of the scheme. This applies to the front-line staff of different departments and units in the health facility or sector and the community it serves. Every person should be seen to be participating in the running of the DRF scheme, including the members of the communities it serves. This fosters ownership and local support that is needed for the successful implementation of the scheme.

9. Conclusion

Commodity security guarantees a situation where every person is able to obtain and use quality lifesaving health commodities whenever and wherever he or she may need them, which is a critical component to achieving universal health coverage. The need to achieve universal health coverage through building and strengthening primary health care closer to the people is needed now than ever before. But even more critical is to ensure that the primary health care system is equipped with necessary tools, including lifesaving health commodities and technologies that are qualitative, available, affordable, and accessible to all irrespective of their financial status. The increased demand for foreign aid donors among other reasons has led to a situation where donors who hitherto responded to call to assist LMICs are either not forthcoming or the volume of such donations have drastically reduced, a situation that has now come to be known as foreign aid donor fatigue. Therefore, there is a need for LMICs to fashion out a sustainable health financing strategy that will recognize the competition on the already scarce resources available to LMICs governments so that the gains obtained by donor-supported public health interventions, such as HIV/AIDS, malaria, tuberculosis, and childhood vaccinations programs, are not reversed when foreign aid becomes unavailable or too little to make any reasonable difference to the myriad of existing and new public health challenges bedeviling LMICs. The DRF scheme is one of the recognized strategies for health financing that is self-sustaining, where “user fees” are charged to clients just enough to cover the cost of health commodities through individual out-of-pocket payments and community co-payments. Therefore, political leaders and stakeholders in the health sector need to show renewed commitment to supporting the establishment and reengineering of DRF scheme to ensure commodity security to their citizens, thereby contributing to realizing the UNSDGs of achieving UHC for all.

Conflict of interest

The author declares no conflict of interest.