The effects of Jazia prime vendor system in complementing the existing pharmaceutical supply chain across public healthcare facilities in Tanzania

Background: The availability of quality medicines in the provision of healthcare services is an integral part of universal health coverage (UHC). In low and middle-income countries (LMIC) the accessibility to essential medicines is often limited especially in peripheral healthcare facilities. The reasons for this situation include: - limited resources, weak transparency and poor accountability mechanisms in the pharmaceutical supply chain. These challenges have received substantial attention by health system researchers and health system strengthening initiatives. The focus has often been on interventions to establish public-private partnerships (PPP). The United Republic of Tanzania in 2014 started implementing a unique PPP, the Jazia prime vendor system (Jazia PVS), as a contracted private wholesaler supplier to complement the existing medicines supply chains in public facilities. The aim of this doctoral thesis was to analyse the Jazia prime vendor system. Methods: A mixed-method research design was used to analyse the effect of the prime vendor system, in improving access to healthcare commodities in public healthcare facilities in Tanzania. The research combined household and health facility quantitative surveys with the qualitative research methods. Specifically, the thesis first assessed the effects of medicines availability and stock-outs on household’s utilisation of health care services. Second, it examined the role of accountability in the performance of the Jazia PVS. Third, it analysed how acceptability factors of the Jazia PVS affected shortages of essential medicines. Lastly, it estimated the costs and costs drivers of setting up a prime vendor system in the pilot regions and the predicted costs of national scale-up. A cross-sectional study that combined information from 1,237 households along a survey covering 89 public healthcare facilities was used for assessing the effects of medicines availability and stock-outs on household’s utilisation of health care services in Dodoma region. The household survey captured information on healthcare access and utilization, ownership of different assets, insurance and health promotion activities. On the other hand, the facility survey included observation of actual healthcare commodities available, record review over a three-month period before survey date, and interviews with key staff. Descriptive analysis and multivariate logistic regressions models were estimated to assess the effects of medicine availability and stock-outs on utilization patterns and to identify additional household-level factors associated with health service utilization. Framework analysis was adopted to summarise the results of accountability and acceptability experiences of Jazia PVS implementers using a deductive and inductive approaches. Data were drawn from, 14 focus group discussions (FGDs), 7 group discussion (GD) and 30 in-depth interviews (IDIs) with a range of persons involved in Jazia PVS. Lastly, a micro-costing approach was used to estimate costs and costs drivers for setting up a prime vendor system in the regions and model the national scale-up costs of the Jazia PVS in other regions. Results: The results showed that household’s healthcare utilization was positively and significantly associated with continuous availability of essential medicines (odds ratio (OR): 3.49; 95% CI: 1.02-12.04; p~0.047). Healthcare utilization was positively associated with household membership in the community health insurance funds (OR, 1.97; 95% CI: 1.23-3.17; p~0.005) and exposure to health promotion (OR: 2.75; 95% CI: 1.84-4.08; p~0.000). Qualitative findings revealed that some accountability mechanisms implemented in conjunction with Jazia PVS contributed to the performance of Jazia PVS. These include inventory and financial auditing conducted by district pharmacists and the internal auditors, close monitoring of standard operating procedures by the prime vendor regional coordinating office and peer cascade coaching. Besides, the auditing activities allowed identifying challenges of delayed payment to the vendor and possible approaches for mitigation while peer cascade coaching played a crucial role in enabling staff at the primary facilities to improve skills to oversee and manage the medicines supply chain. The most critical factor contributing to the acceptability of the Jazia PVS was the perceived effectiveness of the system in achieving its intended purpose. Participants’ acceptability of Jazia PVS was influenced by the increased availability of essential medicines at the facilities, higher-order fulfilment rates, and timely delivery of the consignment. Furthermore, acceptability was also influenced by the good reputation of the prime vendor, close collaborations with district managers and participants’ understanding that prime vendor was meant to complement the existing supply chain. The estimated Jazia PVS start-up financial costs amounted to US$ 2,170,989.74. Training of the staff and healthcare workers accounted for 27.9% (US$ 605,060.13) while the health facility baseline assessment and the official launch of the Jazia PVS amounted to 5.4% (US$ 117,406.86) and 3.7% (US$ 79,951.42) respectively. The economic start-up costs accounted for about 52.2% (US$ 1,209,573.47) of the total economic costs and the largest share 32.0% (US$ 741,836.55) was for staff and healthcare workers training. The Jazia PVS national roll-out costs amount to US$ 8,031,335.3 with the largest share going to the training of the staff and healthcare workers 45.8% (US$ 3,618,682.96). The current study provides evidence on the potentiality of the Jazia PVS in complementing existing pharmaceutical supply chain, indicating that such a model can be used to increase efficiency in the provision of services. LMICs interested in establishing PPP within the intension of improving healthcare delivery may adopt good lessons from the Jazia PVS in Tanzania. Nonetheless, strong capacity of various bodies to exercise oversight and sanctions in the implementation of the PPP is important in ensuring accountability linkages for the public and private entities. In conclusion, these results highlight the importance of medicine availability in promoting access to health services in low-income settings. Effective planning and medicine supply management from national to health facility level is an important component of quality health services. In terms of accountability, it revealed that there is a need for capacity building linked to financial and supply management at lower-level health facilities, including health facility governing committees, which are responsible for priority-setting and decision-making at the facility level. PPP has the potential to improve service delivery; however, it is crucial to select a reputable and competent vendor, together with being loyal to the contractual agreement. Short-term experts, staff and health workers training comprised the largest component of Jazia PVS start-up costs. Integration of Jazia PVS into the existing regional and district administrative structures result in decreased implementation costs as no new structures were established and new staff deployed