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Background: Strengthened national health systems are necessary for effective and sustained expansion of antiretroviral therapy (ART). ART and its supply chain management in Uganda are largely based on parallel and externally supported efforts. The question arises whether systems are being strengthened to sustain access to ART. This study applies systems thinking to assess supply chain management, the role of external support and whether investments create the needed synergies to strengthen health systems.Methods: This study uses the WHO health systems framework and examines the issues of governance, financing, information, human resources and service delivery in relation to supply chain management of medicines and the technologies. It looks at links and causal chains between supply chain management for ART and the national supply system for essential drugs. It combines data from the literature and key informant interviews with observations at health service delivery level in a study district.Results: Current drug supply chain management in Uganda is characterized by parallel processes and information systems that result in poor quality and inefficiencies. Less than expected health system performance, stock outs and other shortages affect ART and primary care in general. Poor performance of supply chain management is amplified by weak conditions at all levels of the health system, including the areas of financing, governance, human resources and information. Governance issues include the lack to follow up initial policy intentions and a focus on narrow, short-term approaches.Conclusion: The opportunity and need to use ART investments for an essential supply chain management and strengthened health system has not been exploited. By applying a systems perspective this work indicates the seriousness of missing system prerequisites. The findings suggest that root causes and capacities across the system have to be addressed synergistically to enable systems that can match and accommodate investments in disease-specific interventions. The multiplicity and complexity of existing challenges require a long-term and systems perspective essentially in contrast to the current short term and program-specific nature of external assistance. © 2011 Windisch et al; licensee BioMed Central Ltd.
This work uses findings from document and literature review, health facility surveys, and key-informant interviews at district and national levels. A literature review was conducted covering both peer-reviewed and grey literature, including the media. Sources included PubMed, Web of Science, Eldis, Google and Google Scholar. Grey literature such as audit reports, evaluations and tracking studies were a main source of information. National level assessments were based on principles of Grounded Theory implying that the process of data collection and emerging findings continuously shape research approaches [25-27]. A first question guide focused on information gaps which resulted from the review. National partners performed key-informant interviews, based on a few guiding questions which allowed respondents to flexibly raise new issues and hypotheses. To ensure consistency of interpretation, interviews were conducted by the investigators themselves. Responses were validated in subsequent interviews with other stakeholders. We triangulated the different sources for validation by following up findings from the literature review and within interviews and relating findings at district and facility level with views from national stakeholders. Observations at health service delivery level took place in Iganga District in the Eastern Region of Uganda. The study site Iganga was chosen as it is also the study site of a larger research project studying the effects of antiretroviral treatment on maternal and child health. Iganga is one of 95 districts in Uganda and it covers a mainly rural area with a population of around 650,000 out of the national population of 32.4 million [28]. Four health centres (HCs) at level IV and III and one district hospital provide ART services. HC-IVs are structurally small clinics with 1-2 clinicians, an obstetric theatre and laboratories. HC-IIIs also provide some laboratory services. The district hospital started to provide ART in 2005 followed by gradual provision through HCs in 2006 and 2007. By September 2009 a total of 1,171 people in the district had been started on antiretroviral drugs (ARVs). To evaluate the performance of ART at the service-delivery level in Iganga District, two onsite surveys were conducted at all ART-providing HCs in June 2008 and September 2009. They included a complete document review of registers, logbooks, drug stocks, patient files and observed practices, and staff and patient interviews in 72 health facilities. Semi-structured interviews were conducted with 17 health staff and 273 patients. The detailed results will be published in a separate paper currently in process.
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