Introduction

Efficient and effective health systems are critical for managing healthcare costs. In low and middle income countries (LMICs) of Africa, Asia, and the Middle East, increasing the efficiency of health spending could increase health-adjusted life expectancy by 1-2 years.¹ Effective management of human resources and competent procurement and supply chain management of medicines, which together account for the largest costs in any health system, are critical for improving health systems efficiency.

Task shifting enables more efficient use of the human resources² and can produce equivalent or superior outcomes for many diseases and health interventions including non-communicable diseases,³ HIV/AIDS,^4,5 contraceptive distribution,⁶ and others.⁷ Community health workers can accelerate task shifting and to close the gap in healthcare access in LMICs.⁸ Improved procurement and supply chain management can reduce costs and diminish drug shortages,⁹ which adversely affect health outcomes especially in LMICs with weak procurement and supply chain management systems.¹⁰

Task shifting

Evidence strongly points to benefits of task shifting, which can reduce health costs to the health system or the patient with 6.9% to 98% reduction in costs per patient treated or overall programmatic costs. The benefits of task shifting to CHWs are demonstrated when managing general health system activities¹¹ or specific conditions. Management of tuberculosis, which leads to 1.5 million new cases worldwide each year¹² and requires medication under supportive observation for many months,¹³ has been shifted to health workers in the community with 57–74% reduction in the cost per patient treated in Ethiopia, South Africa and Uganda, and by 32–44% in Bangladesh and Pakistan.^14–19 In Brazil supervision of medication has been shifted to close relatives with reduced program costs,²⁰ or in Bangladesh entrusted to patients.²¹

For HIV/AIDS where around 15 million people receive life-long antiretroviral treatment (ART) and require regular follow up to monitor response,²² task shifting has produced cost savings without adverse effect on care. In China, community based detection of HIV in high-risk groups led to a 97% reduction in cost per case detected.²³ In Ethiopia treatment initiation and monitoring of ART was shifted from physicians to nurses with cost savings.²⁴ In Nigeria shifting ART care to less expensive cadres of health workers lowered costs,²⁵ and in South Africa and Uganda moving dispensing of ART from pharmacists to pharmacy assistants reduced human resource costs.^26–28

Task shifting has also produced cost savings while maintaining service quality for surveillance and treatment of malaria,^29,30 controlling blood pressure,³¹ management of acute malnutrition,³² detection of sleeping sickness,³³ treatment of mental illness,³⁴ management of major obstetric procedures,³⁵ treatment of severe pneumonia in Pakistan with 81% reduction in costs,³⁶ surveillance to reduce transmission of Chagas disease,³⁷ and diagnosis and treatment of schistosomiasis.³⁸

Supply chain management and procurement

Improved procurement and supply chain management has enabled different countries to reduce drug prices by 7.7% – 79.4%, increase drug availability and to reduce drug stock outs. Brazil has introduced national policies to promote multiple sources for procured drugs, develop national pharmaceutical industry, and improve procurement. Between 1997 and 2003 Brazil achieved an 80% reduction in the annual cost of antiretroviral drugs.³⁹ In India, development of an essential drugs list, centralized procurement, and promotion of rational drug use among physicians resulted in around 30% cost savings and increased drug availability.⁴⁰ The National Essential Medicines Scheme in China created an essential medicines list, improved public procurement of drugs, and achieved cost savings of up to 40% for patients in rural districts.⁴¹

Centralized or pooled procurement of drugs has produced significant cost savings, as shown by group purchasing by neighboring countries in the Middle East,⁴² by different government agencies in Jordan,⁴³ by different municipalities in Brazil,⁴⁴ or by hospital networks in Serbia and Brazil.^45,46 Centralized procurement by Mexican government has lowered drug prices for ART by 38%, but not as much as benchmark prices obtained by other upper middle-income countries.^47,48 Centralised procurement can have unintended consequences. In Kenya, centralised procurement for anti-malarial medicines resulted in increased stock outs, as the sole supplier selected could not meet demand.⁴⁹ Procurement of locally procured drugs can also lower costs, but not always as monopolies emerge.⁵⁰

In LMIC, better supply chain management improves drug availability and reduces stock outs, including in disaster settings,⁵¹ for primary care drugs,^52–54 for contraceptives,⁵⁵ for drugs related to HIV care other than antiretroviral medicines,⁵⁶ and reduces energy costs associated with the supply,⁵⁷ though minor increase in procurement costs could occur.⁵⁸

Revolving drug funds, where users make an initial financial contribution for procuring drugs and regular re-stocking of supplies, which users then pay to purchase,⁵⁹ can produce cost savings when introduced with enhanced procurement or supply chain management, as shown in Sudan,⁶⁰ or improve drug availability, as shown in Guinea⁶¹ and Nigeria.⁶²

Innovations in financing and supply chain management, such as the Affordable Medicines Facility-malaria, where the Global Fund negotiated bulk discounts from manufacturers and used both public and private sector for distribution,⁶³ resulted in reduced manufacturer and end-user prices⁶⁴ and rapidly increased the availability of artemisinin based combination treatments.^64,65

Discussion

Countries have used different approaches to introduce task shifting when managing different diseases with notable improvements in efficiency and no adverse effects on patient care or outcomes. Similarly, investing in improved procurement and supply chain management have led to substantial efficiency gains and improved availability of medicines.

The evidence points to substantial opportunities for policymakers to promote better management of human resources and to strengthen procurement and supply chain management in order to improve health system efficiency and enhance health outcomes.

References

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