Factors affecting implementation of the medicine redistribution guidelines in Western Uganda

Abstract

Background

Medicine redistribution involves the movement of medicine commodities from facilities with surplus stock to areas with deficit to reduce medicine waste. Recognizing the immense potential of medicine redistribution, the Uganda Ministry of Health launched the “Uganda National Redistribution Strategy for the Prevention of Expiry and Management of Expired Medicines and Health Supplies” in 2012, revised in 2018. Despite this strategy, effective implementation of redistribution remains a challenge and information on factors affecting implementation of the guidelines is limited. Therefore, this research was conducted to bridge this gap.

Methods

A cross-sectional study was conducted in 69 primary healthcare facilities in Hoima and Kabarole Districts in Western Uganda. Two data collection tools were utilized including a compliance checklist used to assess the compliance of primary healthcare facilities to the medicine redistribution guidelines. A semi-structured questionnaire was used to determine the factors affecting implementation of the guidelines as reported by the healthcare workers in the selected primary healthcare facilities. The compliance assessment focused on key procedural domains, including the triggers for redistribution, the roles and responsibilities players involved in the process, and the documentation required. Additionally, knowledge of the redistribution process was evaluated through aspects such as routine inventory checks, coordination within and across districts, and the formal authorization steps required for the process. Data were analysed using IBM SPSS version-29. Facilities that achieved a compliance score of 75% or higher were deemed compliant. Logistic regression analysis was used to determine the associated factors at 0.05 level of significance.

Results

Compliance of primary healthcare facilities to the medicine redistribution guidelines in Western Uganda was low, with only 29.5% of the facilities meeting the 75% compliance threshold. The main factors statistically associated with compliance to the redistribution guidelines included facility level of care (p = 0.002), awareness of the existence of guidelines (p = 0.003), knowledge of the triggers and steps of redistribution (p = 0.001), and availability of updated guideline documents (p = 0.018). In addition, respondents highlighted operational and logistical barriers faced during implementation including poor means of transportation of medicines 54 (51.4%), delays in authorization of redistribution 10 (9.5%) and presence of surplus stock in the receiving facilities 8 (7.6%).

Conclusion

Less than a third of the facilities complied with the medicine redistribution guidelines. The facility’s level, knowledge and awareness of the guidelines, and access to updated guidelines were key factors associated with compliance to the medicine redistribution guidelines. The Ministry of Health should intensify efforts to raise awareness and ensure easy access and dissemination of the latest guidelines.

Introduction

Pharmaceutical supply chain systems are essential in ensuring the availability and equitable supply of health commodities [1]. They are essential for managing the flow of medicines from manufacturers to end-users, including hospitals, clinics, and pharmacies [2, 3] and are also a vital component of the health system in achieving Universal Health Coverage [4]. Globally, these supply chain systems face challenges such as logistical inefficiencies, regulatory hurdles, and economic constraints [5,6,7]. A key weakness in the supply chain systems of many developing countries is the standardized budgeting and commodity stock allocation for healthcare facilities of the same classification level. This one-size-fits-all approach overlooks critical differences such as patient load and catchment population size. As a result, one facility may face a shortage of a particular medicine, while a nearby facility experiences an oversupply of the same drug [8, 9] which leads to significant wastage of medicines through expiration [8, 10]. For instance, in 2016, essential medicines worth US$550,000 expired [8]. These supply chain inefficiencies cause financial losses and pose an environmental risk due to improper disposal of medicines [11].

Recognizing the immense potential of medicine redistribution, the Ministry of Health launched the “Uganda National Redistribution Strategy for the Prevention of Expiry and Management of Expired Medicines and Health Supplies” in 2012, with a revision in 2018 [8, 12]. Despite this strategy, effective implementation of redistribution remains challenging. For example, 67% of healthcare facilities in Eastern Uganda were reported not to comply with the medicine redistribution guidelines [13]. Building upon Kyalisiima et al.‘s research in Mbale, Eastern Uganda, our study aims to identify more insights into the factors affecting compliance with medicine redistribution guidelines. While Kyalisiima et al. interviewed 55 healthcare professionals from 33 facilities, our study engaged a larger sample size (105 respondents from 69 healthcare facilities) across two districts—Kabarole and Hoima. This enhances the statistical power and reliability of our findings. Furthermore, collecting data from two districts in the region allowed for a deeper understanding of regional variations, capturing a range of practices and challenges. It also facilitated comparative analyses that revealed unique factors which may not be apparent in single-district studies.

This study aimed to investigate the factors affecting the implementation of medicine redistribution guidelines in western Uganda. By uncovering these factors, the study sought to generate actionable insights to strengthen policy adherence and inform targeted strategies for more effective redistribution practices in the region.

Methodology

Study design, area and period

This was a cross-sectional study. The data was collected from February 2024 to March 2024 from Hoima and Kabarole Districts located in Western Uganda. Hoima District has a total of 40 (19 Health Center II, 19 Health Center III and 2 Health Center IV) public primary healthcare facilities while Kabarole district has a total of 48 (27 Health Center II, 19 Health Center III and 2 Health Center IV) public primary healthcare facilities [14]. The two districts therefore have a total of 88 (46 Health Center II, 38 Health Center III and 4 Health Center IV) primary healthcare facilities. There are no secondary and tertiary public health care facilities in these districts. The secondary and tertiary healthcare facilities are administratively located in Hoima and Kabarole cities. In primary healthcare facilities, service delivery is stratified by Health Center level and population size [14]. Health Centre II serves around 5,000 people, offering preventive, promotive, and outpatient curative services. Health Centre III caters to about 20,000 people, adding maternity care, inpatient services, and laboratory services. Health Centre IV serves approximately 100,000 people and includes emergency surgical procedures and blood transfusions, along with all services provided at lower levels [14].

Study population and sampling

In this study, all the 88 primary health facilities in Hoima and Kabarole districts were targeted. However, only 69 facilities, representing a response rate of 78%, participated in the study. According to Draugalis et al., this response rate is considered acceptable as it exceeds the commonly recommended threshold of 75% for survey-based research [15]. The study engaged with two key roles within each facility, as outlined in the medical redistribution guidelines: the facility In-charge and the stores personnel. These healthcare professionals are directly responsible for implementing and managing the medicine redistribution strategy at their respective facilities [12].

One respondent was selected from Health Center II’s because the facility in-charge also acts as the medicine store personnel. For Health Center III’s and Health Center IV’s, two respondents were selected, including the Facility In-charge and the medicine stores person.

Data collection tools and instruments

Two data collection tools were utilized in the survey: a semi-structured questionnaire and an observational compliance checklist. The questionnaire included open-ended questions about the guidelines, reasons for redistribution, steps followed, tools required, and factors affecting implementation. The observational compliance checklist was used to assess compliance of the facilities with the Uganda National Redistribution Guidelines for Prevention of Expiry and Handling of Expired Medicines and Health Supplies. This assessment focused on variables drawn from both the procedural and administrative aspects of the redistribution process, including triggers for redistribution, the redistribution process itself, financial principles, institutional roles, and documentation practices. The checklist aimed to evaluate whether health facilities’ practices were aligned with the prescribed guidelines, particularly in terms of identifying redistribution needs in a timely manner, executing the necessary steps correctly, and ensuring stakeholders fulfilled their designated roles and responsibilities. Key variables included the identification of redistribution triggers such as excess stock, impending expiry, erroneous deliveries, and stock that could not be consumed due to a short shelf life. Compliance was assessed through regular inventory monitoring, trigger systems, and procedural adherence such as conducting monthly physical stock assessments, ensuring effective communication between storekeepers, Health Facility In-Charges (HF I/Cs), and District Health Officers (DHOs), and the correct initiation and completion of redistribution using designated forms. These forms included the Redistribution Notification Form (Annex A), Requisition and Issue Voucher (HMIS 017), EMHS Redistribution Form (Annex E), and Stock Card (HMIS 015) [15]. Compliance also involved verifying that required authorizations were obtained and that roles at both the facility and district levels were fulfilled, particularly during inter-district redistributions. Facilities that scored 75% or higher on the compliance checklist were deemed compliant, indicating a satisfactory level of adherence to the guidelines.

Data collection procedure

A data collection plan was developed, and six research assistants were trained on the data collection procedure. The training covered ethical considerations, obtaining consent, and proper data collection and management. During the data collection, the research assistants obtained permission from the District Health Office and healthcare facility administration to conduct the study. The research assistants visited the healthcare facilities to meet potential respondents. During these visits, the research assistants explained the study’s purpose, requested participation, and obtained informed consent from all the respondents that participated in the survey. After consenting, respondents were guided through the questionnaire. To assess respondents’ knowledge of the redistribution process, participants were asked to identify the steps involved in redistribution together with the tools used at each step. Medicine store personnel provided data on facility compliance with medicine redistribution guidelines. The collected data was subsequently uploaded to the Open Data Kit for analysis.

Data management analysis and quality assurance

The quantitative data collected via Open Data Kit (ODK) was standardized and analysed using IBM SPSS version 29. Descriptive statistics were used to summarize demographic characteristics, knowledge, and compliance with the Uganda National Redistribution Strategy. Compliance was evaluated across seven main domains, with facilities achieving a compliance score of 75% or higher deemed compliant and the overall mean compliance of all facilities in the studied areas was calculated. The respondents’ knowledge of the redistribution process was assessed based on the redistribution steps, with a cutoff of 80%, aligning with job-related expectations using the modified Angoff’s method [16]. Logistic regression analysis was employed to examine factors influencing the implementation of the strategy. Crude odds ratios were presented at the initial analysis stage, while forward selection was used for adjusted analysis to obtain adjusted odds ratios. Independent variables with p-values less than 0.05 at 95% confidence interval were considered statistically significant.

Results

Social demographic characteristics

Out of the 88 healthcare facilities targeted, data were collected from 69 (78.4%) facilities. Most respondents were from HC III facilities 62(59.0%). Of the 105 healthcare professionals interviewed, the majority 64 (61.0%) were from Kabarole District. Nurses 41 (39.0%) comprised the largest group of participants. Most of the respondents 51 (48.5%) had 6–10 years of working experience. Majority of respondents were certificate holders in nursing, midwifery or nursing assistance 53 (50.5%) as shown in Table 1.

Table 1 Social demographic characteristics

Compliance to the medicine redistribution guidelines

Results showed that 70.5% of the primary healthcare facilities surveyed were non-compliant with the medicine redistribution guidelines. Compliance rates were particularly low in Hoima, with only 13 (31.7%) facilities adhering to the guidelines, while in Kabarole, only 18 (28.1%) facilities adhered with the medicine redistribution guidelines as shown in Table 2.

Table 2 Comparison of compliance levels between districts and health facility level

Factors affecting implementation of medicine redistribution guidelines

Knowledge of the redistribution process

Sixty-four (61%) healthcare professionals interviewed demonstrated adequate knowledge about the medicine redistribution process (Table 3).

Table 3 Knowledge of steps in the redistribution process

Awareness and availability of updated guidelines among health facility respondents

Regarding the availability of updated guidelines at health facilities, only 26 (24.8%) respondents reported having the updated guidelines at their facility. While 66 (62.9%) respondents were aware of the Uganda National Redistribution guidelines, only 26 (24.8%) had access to the updated guidelines at their facilities. Most respondents 45 (42.9%) indicated that their primary source of information was word of mouth or advice from peers. Official communications and meetings with the Ministry of Health were also crucial, with 25 (23.8%) respondents relying on them, and another 25 (23.8%) depending on formal training provided in healthcare facilities (Table 4).

Table 4 Awareness and availability of guidelines among respondents

Challenges in the implementation of the redistribution process

The major challenge reported by most respondents was poor transport means and the associated costs at 54 (51.4%), followed by Delays in the authorization process 10 (9.5%) as shown in Table 5.

Table 5 Challenges in the implementation of the redistribution process

Factors associated with compliance to the medicine redistribution guidelines

The factors are shown in Table 6. Facilities where respondents showed adequate knowledge about the redistribution process steps were 3.7 times more likely to comply with the implementation (AOR = 3.7, 95% CI: 1.6–8.2, p = 0.001). Facilities with updated guidelines were 3.2 times more likely to comply with the Uganda National Redistribution Strategy (AOR = 3.2, 95% CI: 1.4–12.6, p = 0.018). Health Center IVs had the highest compliance rate, with 62.5% of them in compliance, and were 19.4 times more likely to comply compared to Health Center IIs (AOR = 19.4, 95% CI: 2.8–172.2, p = 0.002). Additionally, facilities where respondents were aware of the guidelines were 5.2 times more likely to comply (AOR = 5.2, 95% CI: 2.5–17.9, p = 0.003).

Table 6 Factors affecting compliance to implementation of the redistribution guidelines

Discussion

Results from this study revealed that most primary healthcare facilities in the districts surveyed did not comply with the medicine redistribution guidelines. These results concur with Kyalisiima et al. who found that only one-third of facilities in Eastern Uganda complied with guidelines [13]. This means that healthcare workers are not using the medicine redistribution guidelines as part of their stock management tools. The main reason given by the respondents regarding the failure to adhere to the distribution guidelines was poor transport and high associated costs. This finding is similar to findings by Kefale and Shebo in Ethiopia where transportation challenges led to stockouts [17]. The transport challenges could be due to the lack of funds allocated for the redistribution at the district and facility levels.

Facilities where respondents showed adequate knowledge about the redistribution process steps were three times more likely to comply with implementation compared to those who were not knowledgeable. These findings contradict a previous study which shows that physicians’ knowledge of guidelines does not necessarily lead to better implementation in primary care [18]. These results suggests that, in the context of medicine redistribution, understanding the process steps is crucial for compliance. The discrepancy may be due to differences in guidelines, and setting, or challenges faced by healthcare workers.

Only about a quarter of health facilities had access to updated guidelines. This shows a gap in the dissemination of crucial health information necessary for optimal healthcare delivery. These results align with another study which shows that limited access to updated guidelines, either through restricted internet access or lack of paper-based guidelines, is a barrier to implementing maternal health evidence products [19]. This limited access can lead to inconsistencies in applying best practices. Additionally, the reliance on word of mouth and peer advice as primary source of information by most respondents further complicates the issue, as it increases the risk of disseminating outdated guideline information. Peer pressure has been shown to be an important incentive for adherence to guidelines among healthcare workers [20]. In order to take advantage of the existing informal networks within health settings, the Ministry of Health should leverage these networks to disseminate updated guidelines, ensuring timely access and broader reach of information among health workers [21].

Although most respondents were aware of the redistribution guidelines, only about a quarter reported having the updated version available at their facilities. This significant gap between awareness and access suggests that while healthcare providers are generally aware of the guidelines, their ability to implement them is hindered by the unavailability of the updated version. Proper dissemination of service delivery guidelines can significantly enhance service delivery such as family planning practices in sub-Saharan Africa [22]. The disconnect between awareness and availability of the guidelines can lead to inconsistent application of best practices.

Furthermore, only a quarter of respondents relied on formal training and official communications from the Ministry of Health as a source of health information. The underutilization of these channels suggests a need for more frequent and accessible training programs. Although respondents may peruse the guidelines, they need to be educated about them through continuing education or professional meetings [20]. In addition, the ministry of health can take advantage of the resources, structured systems and higher cadre professionals in Health Center IVs (HC IVs) to conduct the formal trainings to improve awareness and compliance with redistribution guidelines in Health Centers. These can serve as mentorship centres to build capacity by sharing resources, conducting hands-on training, and utilizing digital platforms for continuous learning. Regular on-site visits and feedback systems can further support this initiative.

Limitations

The study limitations relate to generalizability, reliance on self-reported data, and limited scope of data collection. The study was confined to two districts, which may not represent other regions, and focused on primary healthcare facilities, affecting generalizability. The reliance on self-reported data from healthcare professionals introduced the potential for information bias, as responses may not accurately reflect actual practices.

Conclusion

Compliance with the medicine redistribution guidelines in primary healthcare facilities was low, with key factors such as the facility’s level of care, knowledge and awareness of the guidelines, and access to updated versions influencing adherence. The ministry of Health could leverage the resources and structured systems in Health Center IVs (HC IVs), along with their higher cadre professionals, in conducting formal training to improve awareness and compliance with redistribution guidelines in Health Center III’s and II’s. HC IVs can also serve as mentorship centers, building capacity by sharing resources, conducting hands-on training for healthcare workers in the lower health centers. Lastly, the Ministry of Health can consider utilising online platforms and peer platforms to dissemination of the latest guidelines to ensure easy access by health professionals.