Mrs Chiagozie Mgbemena is the Assistant Director of Health Product Management at the Institute of Human Virology, Nigeria (IHVN). In this interview, she spoke about the state of warehousing of medicines and other health products in the country, reasons for expired pharmaceutical products flooding the markets and how to ensure effective arehousing of healthcare products, among others.
Can you briefly tell us what warehousing of health products is about?
Warehousing is storing physical inventory, in this case, health products though it can be anything. It can be health or consumer products - just storing them until they are ready to be used or distributed to the consumers or people who require them.
Can you describe the state of warehousing of health products in public health facilities in Nigeria? Are they following laid-down protocols or at par with international best practices?
I will start by giving you an insight into the warehousing layout in the country. We have different levels of warehouses; there is mfederal or national warehouses, and the state warehouses. We don't have a strong structure when it comes to warehousing at the lower levels.
At the national level, we have federal medical stores in Abuja and Lagos, which are the central warehouses, and the state warehouses.
Because donors support the central warehouses, they meet international standards for warehouses. There are the premier warehouses in Abuja and Lagos as I mentioned. All that you expect to see in state-of-the-art international warehouses would be found there; all the equipment and the personnel required.
At the state level, it is different being that the state warehouses are not as equipped as the national ones and do not enjoy the same donor support as the national warehouses.
However, the Global Fund is currently supporting the states through the Federal Ministry of Health to upgrade 21 warehouses including the Federal Central Medical Stores Oshodi up to pharma-grade standard. This means that the quality of medicines stored in such facilities will be preserved or maintained.
Some medicines require ambient or room temperature to maintain their quality/integrity. While others require lower temperatures and therefore should be kept in refrigerators or cold rooms. Cooling systems are available in pharma-grade warehouses, where such medicines and other health commodities should be stored.
In the coming months, 21 state pharmagrade warehouses, including the Federal Central Medical stores in Oshodi, will be fully operational and available for use in-country.
This means that there are 16 warehouses left to be upgraded, hopefully, the process will commence, as soon as the Global Fund and the federal and state ministries agree and finalise the terms of engagement and implementation.
How can the country tackle the menace of expired medicines and other healthcare products?
Damaged products usually arise as a result of mishandling, therefore, when products are not handled the way they should when they are being moved or transported, from one location to another, they get damaged.
Expired products are a different case - some factors result in expiry. One of them is inaccurate quantification, especially when you over-quantify. Over-quantification happens when you are making plans to buy medicines, and you plan for more than what you can consume.
The second reason is when your inventory management is not done appropriately, it can result in expiry. I would say that the first thing to do to avoid expiry is to be sure that you quantify what you can consume. For us in the health product management space/supply chain, we ensure that we use assumptions.
This means that you come up with what you need based on the current realities of the programme. For inventory management, it is important that whoever is the custodian of the medicines tracks all the commodities received and issued.
There is also a need to incorporate an early warning system (EWS) or ensure that the commodities that are first to expire are dispensed or issued out of the stores. The EWS would prompt the user when products are at risk of expiry.
This would enable the manager to make prompt decisions about what steps to deploy to mitigate expiry.
In the HIV programme, for example, a change in the regimen (this is when a more effective medicine for treatment is discovered, and the ones used previously are discontinued) can result in wastage and expiry of the discontinued treatment.
Therefore, the way out of this is by ensuring that accurate systems for quantification and inventory management are in place. However, expiry due to regimen change is inevitable and is being managed by the disease programmes and the donors.
Despite laid-down protocols, we cannot rule out the fact that there will still be unethical practices such as changing expiry dates in these warehouses. For example, in an open drug market, though coordinated wholesale centres have been put in place now, we cannot rule out the fact that there will still be unethical practices.
Are there regulatory mechanisms that come with warehousing of health products in the country?
We know that expired products are dangerous to the health of the populace. NAFDAC has a system to check this, but some people thrive in engaging in these criminal activities. We can only continue to make efforts to avoid this, especially within the public health space, by leveraging the integrated national waste drive exercise.
Waste drives ensure the inventory of all expired health products is taken and documented across all facilities in the 36+1 states of the country. They are then transported to an incineration site where they are destroyed safely.
This is usually supported by donors for HIV, tuberculosis, and malaria commodities. This is not the case for other medicines outside the earlier mentioned category; therefore, recycling or reintroduction of expired health products remains a major public health issue to be given adequate attention by responsible government entities.
I am aware that various health facilities have their incinerators and, in the states, NAFDAC has incinerator sites for the destruction of expired medicines and other health products, however, there is no structure or protocol that regulates reverse logistics of expired health products from the private sector or essential medicines.
It is not robust; there is no organisation around that system, so I agree there is an issue with this in the country. There is a strong need to raise awareness and educate the public on the impending health hazards of expired medicines and how to identify them by physical verification.
Warehousing of health products requires cold chain equipment; considering the epileptic power supply in the country, how can the challenge be mitigated?
There are warehouses supported for upgrades, and for those the states have committed to counterpart funding to address the power supply issue. When these medicines move from the states to facilities that don't have power supply at all, then this becomes an issue.
In the public health supply chain, as a rule, cold chain items should never be kept in locations with epileptic or non-existent power
supply.
Health products that require refrigeration or cold chain systems are kept in storage facilities that are equipped to house them. In
standard warehouses, the appropriate temperature and humidity must be
maintained for ambient (room temperature) and cold chain commodities.
For stores where there is no power supply and you need to store medicines at room temperature, the best you can do is to make sure that those products or medicines are stored in a cupboard away from
direct sun rays.
Ensure that there are curtains on the windows, the storage space, and the environment is clean, free of rodents and insects, moisture, and direct contact with rain and other environmental elements.
What are the major challenges in the country's storage of health products?
One of the challenges with warehousing in the country is storage capacity. Sometimes, the products that are ordered are more than the
storage spaces available. I believe that the ongoing warehouse upgrade with support from the Global Fund will improve the capacity and conditions of the storage.
That way, we are confident that quality
medicines are being made available for use to Nigerians.
The national and the state warehouses are not the only places we store
medicines. Health commodities are stored at facilities, hospitals, primary health care centres, and private warehouses. Government's support is required to improve the storage conditions in the facilities at the lower levels - hospitals and primary healthcare centres. If quality products at national and state warehouses are compromised when distributed to facilities due to sub-optimal storage conditions, the investment at the national and state levels is wasted.
There is a need for more support and awareness to improve the storage conditions of health facility stores. Minimal upgrades can be deployed to ensure that the products stored at the facilities retain their quality before being issued or dispensed to the user. Storage of medicines in the homes of the clients is another area of concern.
For rural areas in need of health care products, what should be put in place for priority diseases like HIV, tuberculosis, and malaria?
For rural areas, a focal person trained in basic principles of store and inventory management should manage the store. The store may be a room, but the key thing is that the person in charge should ensure
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that the store is clean, well-ventilated, and has no direct access to
the sun, moisture, rain, and other environmental conditions.
Secondly, the focal person must possess basic logistics skills - the ability to update the inventory control cards to monitor what is received and issued out, or dispensed. This enables him to monitor and prevent expiries, as well as stock-outs. Stock outs are as bad as expiry - if you have no medicines to serve your clients then you have not done your job. Basic inventory control management knowledge and skills are necessary. Store managers should also be able to make quick decisions, it is important to have them trained in key management skills to manage the products and the store.
How is IHVN helping to improve the warehousing of health products in Nigeria?
IHVN does not have active roles in warehousing and distribution; however, in the past we warehoused TB medicines and commodities on behalf of the National TB, Leprosy, and Buruli Ulcer Programme.
Currently, in collaboration with government entities and other partners, we engage in the quantification and supply planning of HIV commodities. After quantification and procurement of these commodities are completed, we work with other partners to distribute these items to where they are needed.
Utilisation reports from the facilities or service delivery points are received and reviewed by the team, discrepancies are queried and addressed. IHVN has been in the public health space in Nigeria for 20 years, implementing prevention, care, and treatment programmes across various disease areas.
Apart from programme implementation, IHVN is also big on research and development. IHVN has set up state-of-the-art laboratories across the country in collaboration with other stakeholders and have built and managed robust data systems for health.
A huge capacity for various health programmes implementation resides within the Institute, therefore the skills for public health implementation with IHVN is an asset to the national health programmes and Nigeria.
In my core area, which is Health Product Management/Pharmacy, IHVN is known for her contribution to the body knowledge in pharmacovigilance.
Thousands of health professionals have been trained in logistics management and pharmaceutical care of HIV and tuberculosis clients.
