E-DRUG: History of Central Medical Stores (8)
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[Thanks Andy for this fascinating and detailed story of 'CMS's in South Africa. BS]
Dear E-druggers
While there is little formal record of the events and developments in South Africa, there is some institutional memory. Here are some personal recollections and opinions:
1. South Africa's health system has a long history of fragmentation. After the creation of the Union of South Africa in 1910, which brought together the British colonies of the Cape and Natal with the former Boer Republics of the Transvaal and Free State, the health systems in the 4 provinces remained fairly separate. I am not sure what impact WWI had on medicines supply. While the country was largely dependent on imported products (mostly from the UK), this was also an era of pharmacy compounding from raw ingredients. There was a limited local production capacity, mostly for patent medicines.
2. Much changed with WWII, when access to imported materials from the UK was extremely difficult. Supply to the government health services was apparently taken over by the military for the duration of the war. Medical Base Depot at the Pretoria Head Quarters of the Union Defence Force (then called Roberts Heights) became an important first centralised supply point.
3. After the war, and with the first National Party government established in 1948, a new form of fragmentation was introduced. The 4 provinces were responsible for "curative" services, whereas the Department of National Health and Population Development was responsible for "preventive and promotive" services. One of the wrinkles here is that psychiatric services and family planning services were regarded as "preventive and promotive". The 4 provinces resumed supply medicines for curative services, using their depots in Cape Town, Durban, Johannesburg and Bloemfontein. Over time, a number of sub-depots were created in the Cape Province. However, the Department of National Health and Population Development continued to rely on the Medical Base Depot in Pretoria.
4. During the apartheid era (1948-1994), a series of "bantustans" or "homelands" were created for different African language groups (referred to as "tribes"). Each of these structures created a separate department of health. By 1994, 4 of the "bantustans" had supposedly become independent of South Africa, and therefore independent of the medicines supply system in the Republic. However, the rest were supplied from the military Medical Base Depot and its sub-depots located in a number of South African cities.
5. This arrangement was abruptly stopped in 1987.
Apparently, the anti-apartheid movement had obtained invoices showing that a very large number of doses of depot medroxyprogesterone acetate injections (DMPA) were being procured by the South African Defence Force. There had been rumours for some time that DMPA was being used inappropriately to "sterilise" African women.
Richard Laing will recall the decision in early post-independence Zimbabwe to ban DMPA, and the subsequent decision to return it to the market.
As the military was still supplying all of the family planning services in the South African public sector, as well as all of the non-independent "bantustans", it was effectively procuring almost all DMPA for the entire country. Use in the private sector was probably minimal, as is the situation today.
In order to manage the political fall-out from this disclosure, it was decided to move all medicines supply for the Department of National Health and Population Development's family planning and psychiatric services to the depots operated by the provinces. [As a conscripted "national serviceman", I was Acting Commanding Officer of 12 Medical Sub-Depot in Durban at the time, so managed the handover to the Provincial Medical Supply Centre in the city].
6. South Africa has therefore only briefly - during WWII - had anything resembling a "Central Medical Stores", in the form of Medical Base Depot (MBD). MBD still exists, but is only responsible for supplying military establishments, some of which also cater for military veterans and their families. The SA National Defence Force participates in the state tender, so can procure medicines from the Essential Medicines List. However, it also buys outside of that system, on quotation.
The 4 provincial depots have been complemented by new structures created in the additional 5 provinces created after 1994. Initially, a contracted-out primary distributor system was introduced (see Rob Summers and colleagues piece in EDM in 1998 and the HST report from the same year), but most provinces now operate their own depots. There are currently 10 provincial depots operating in the 9 provinces (the Eastern Cape has 2). However, there is a lot of discussion at present about reducing the reliance on even these decentralised depots, and of using more direct deliveries to health facilities or a "cross-docking" system of distribution points at district level.
Here are some sources that may be useful:
* Summers RS, Möller H, Meyer D, Botha R. "Contracting-out" drug procurement and distribution: experience with a primary distributor system in South Africa. Essential Drugs Monitor 1998; 25/26: 10-11. (http://apps.who.int/medicinedocs/pdf/whozip10e/whozip10e.pdf)
* Summers R, Conry I, et al. The impact of rationalised pharmaceutical procurement and distribution and of the essential drugs programme implementation. Northern Province Report: Evaluation 2. Health Systems Trust, Durban, 1998. (http://www.healthlink.org.za/uploads/files/drgmx_np.pdf)
* Coovadia H, Jewkes R, Barron P, Sanders D, McIntyre D. The health and health system of South Africa: historical roots of current public health challenges. Lancet. 2009; 374: 817-34.
* Van Rensburg HCJ (ed). Health and health care in South Africa (2nd edition). Van Schaik, Pretoria, 2012 (ISBN: 9780627030130)
Regards
Andy
Andy Gray BPharm MSc(Pharm) FPS FFIP
Senior Lecturer
Division of Pharmacology
Discipline of Pharmaceutical Sciences
School of Health Sciences
Consultant Pharmacist (Research Associate)
Centre for the AIDS Programme of Research in South Africa (CAPRISA)
University of KwaZulu-Natal
Visiting Fellow, Faculty of Pharmacy, Rhodes University, Grahamstown
South Africa
email: graya1@ukzn.ac.za
or andy@gray.za.net