Countries working to provide quality health care often face bottlenecks in keeping remote health clinics stocked with essential medicines. This isn’t necessarily because they can’t afford sufficient drugs and supplies. Delivery may be stymied by bad roads and poor communications systems. Or the distribution process may have been established for a centralized system and can no longer keep pace with the growth in clinics in faraway settlements.
Zambian officials faced these problems first-hand a few years ago, when they realized that lifesaving malaria medicines weren't getting to remote, rural clinics. As a result, deaths from malaria were not dropping, despite the availability of treatments.
Working with the World Bank, Zambia sought to test new modes of distribution in a pilot program that included an impact evaluation . The evaluation  helped the government understand how to restructure distribution to improve the supply chain to get drugs to clinics, which meant more lives saved. Now, more than one-third of the country’s original 74 districts operate under the new distribution system. As the rollout continues, many of the vital lessons learned have been incorporated. One example includes a system that ensures equitable access to life-saving commodities to all health clinics—regardless of how remote they may be. This and other measures are being incorporated in the next phase of the roll-out with the help of the World Bank and other cooperating partners.
John Bosco Makumba, an Operations Officer in the World Bank’s Zambia office who focuses on the health sector, talks about the program, what it's meant for rural Zambia, and why supply chain challenges help him get out of bed in the morning.
Q: How did you get interested in development and what are some of the passions you bring to your work?
A: I grew up in rural area in Zambia, where I saw people struggling daily, and I knew early on that I wanted to help improve people’s lives. Both my parents were teachers; my father was a headmaster while my mother taught domestic science (cookery). I was brought up by my mother as my father died in a road crash when I was just two. I was always struck by the inequality between urban and rural areas in terms of access to education, health, water and sanitation and a whole range of services. Where I grew up, the nearest health clinic was 10 kilometers away, and people walked long distances to access health services. As a consequence, people resorted to traditional remedies or indeed arrived too late to receive effective treatment.
I’m passionate about focusing on results and making a difference in people’s lives, especially those in the most disadvantaged areas. Zambia is a vast country and it’s more expensive to deliver services to rural areas—which results in the need to deliberately focus our interventions in these areas. The project I’m working on now focuses on improving availability and access to essential health commodities to underserved areas. We are helping improve health outcomes and it’s gratifying to visit a rural health clinic and see it is stocked with life-saving medicines. Contributing in this way gets me up in the morning to report for work; while there have been improvements generally, much more still needs to be done.
Q: What was the situation in health clinics before the project got started?
A: For many years, we made headway in terms of prevention interventions: The Zambian government distributed insecticide-treated nets and increased its spray coverage for killing mosquitos [which transmit malaria]. The outputs were quite good, but we weren’t getting positive outcomes, and malaria cases were actually increasing in some regions. We started to look at why people were not accessing effective treatments and discovered that while the government invested a lot in moving medicines to the districts, there were problems getting the drugs to the individual health centers. People could go to a clinic, get tested, and be told they have malaria, but then there wouldn’t be any drugs available. In many rural districts, patients were given a prescription to a pharmacy so that they could potentially turn to the private sector, but there was no local pharmacy they could go to. The result was many fatalities. We needed to undertake a study looking at various distribution models to ensure that life-saving drugs were available where they were needed most.
Q: What are some of the biggest challenges you face in supply chain issues in Zambia?
A: Zambia uses a push system. The government supplies identical health center kits to all the health centers regardless of the epidemiological profile, which means that an area that is malaria-endemic gets the same amount as areas with fewer cases—or even none at all. This approach is not demand-driven, which leads to shortages in some areas and overstocks in other areas. Other challenges include poor road infrastructure and insufficient storage facilities. Medicines need to be kept under certain conditions in terms of temperature and aeration, but they aren’t, in practice. Insufficient human resources is another obstacle: The government doesn’t have sufficient staff to run supply chain management, and so pharmacists—and as it is, there aren’t enough of them— are left to handle health logistics for their districts.
Q: What is it like to travel on some of these roads?
A: Trucks with medicines can travel up to 1,000 km on bad roads— which can take up to 2 days—just to deliver drugs from a central storage area to rural health clinics. Many of the clinics aren’t located on main roads, and so, in addition to the difficult and poor state of the roads, some areas get flooded in the rainy season. Some clinics, meanwhile, are accessible only by an inadequate bridge and when that bridge is washed away during the rainy season, it means having to get a boat and then from there, continuing on a bicycle or motorcycle. These are obviously not ideal conditions for transporting drugs.
Q: How did the impact evaluation on the Zambia supply chain affect the government’s decision to implement new policies? Do you find that policymakers are interested in impact evaluations and hearing about what works—and what doesn’t—in development?
A: There was quality engagement with the government from the start, and you can’t go wrong if you produce numbers proving that specific changes will get you better results. The numbers spoke for themselves, so it wasn’t difficult for the government to make a decision to scale up. The impact evaluation also showed the government that they were underinvesting in the supply chain system.
Implementing a new system meant an increase in uptake of drugs causing a central-level stock-out of certain vital drugs, as well as a general increase in relevant costs related to storage and distribution. But these costs were worth it because this translated into reduced malaria deaths. The government is now making adjustments to adopt a hybrid system that will bring together the benefits of both the pull and push systems.
I’ve found that policymakers are interested in evidence, but because most are politicians, they feel uncomfortable with the concept of control districts and the idea of denying access to life-saving drugs for a particular group of people. Having a control with an impact evaluation is critical to determine the effects of the intervention. This is a major challenge, but we are continuing to improve the quality of our dialogue with policymakers.
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Strategic Impact Evaluation Fund 
Brief: Challenge of Ensuring Adequate Stocks of Essential Drugs in Rural Health Clinics