Procurement process and shortages of essential medicines in public health facilities: A qualitative study from Nepal
Basant Adhikari, Kamal Ranabhat, Pratik Khanal, Manju Poudel, Sujan Babu Marahatta, Saval Khanal, Vibhu Paudyal, Sunil Shrestha
PLOS Global Public Health · 2024 · DOI: 10.1371/journal.pgph.0003128
Countries: Nepal
What Was Studied
This qualitative study examined why essential medicines run short in public health facilities during Nepal's transition to federalism. Researchers conducted 59 semi-structured in-depth interviews (of 61 planned) between June and July 2021 with health post in-charges, health coordinators, store managers, and logistics officers across six randomly selected districts of Bagmati Province — Chitwan, Nuwakot, Lalitpur, Sindhupalchowk, Makwanpur, and Sindhuli — covering 12 local governments (one municipality/metro and one rural municipality per district), plus the provincial Health Logistics Management Center (HLMC). Interviews, mostly conducted remotely by Zoom or phone because of COVID-19 restrictions, were audio-recorded, transcribed, translated to English, and analysed using inductive thematic analysis, with codes independently cross-checked by two researchers. Findings were organised into four domains: purchasing/procurement, inventory management, demand and supply, and shortage of essential medicines.
What They Found
Of 59 participants, most (57.6%, 34/59) were health post in-charges. The study identified delays in the procurement process as the primary driver of shortages: the administrative process typically starts in the first quarter of the fiscal year but medicines reach service-delivery points only in the third quarter. Quality-monitoring gaps compounded this — while the province enforced a minimum shelf-life of 18 months, tender documents at the local level specified no shelf-life requirement at all, with one logistics officer describing medicines received with only 12 to 14 months' shelf life remaining. The medicines most frequently reported out of stock were family-planning commodities (condoms, Depo-Provera injectables, oral contraceptive pills), zinc tablets, amoxicillin, ciprofloxacin, and albendazole, alongside salbutamol, ranitidine, chlorpheniramine, vitamin B complex, amlodipine, and metformin. Health workers reported that shortages measurably reduced patient flow — one health assistant in Makwanpur reported that daily patient visits fell from 50-60 to just 10-20 once medicine supply became unreliable — and pushed low-income patients toward costlier private clinics.
What This Means for Nepal
This study's local-level tender gap is a direct, checkable governance failure: Schedule 8 of Nepal's 2015 Constitution assigns 'basic health and sanitation' — including local procurement for health posts and primary health centres — to the country's 753 local governments, but this research shows local tenders had no shelf-life clause even though the province enforced an 18-month minimum. The family-planning and essential commodities found most often out of stock (condoms, Depo-Provera, oral contraceptives, zinc) are exactly what Nepal's roughly 50,400 Female Community Health Volunteers depend on for household-level distribution, so local procurement failures cascade directly into a flagship community health programme. MoHP/DoHS and provincial Health Logistics Management Centres should mandate a minimum shelf-life clause in all local-government tender documents (mirroring the standard already used at province level) and ring-fence a dedicated local-level procurement budget line for family-planning and other frequently-stocked-out essential medicines, rather than leaving 753 local governments to estimate demand and negotiate supplier quotations independently with no minimum quality floor.
Contextualisation
Nepal's 2015 federal restructuring assigned 'basic health and sanitation' — including health posts, primary health centres, and local procurement — to the country's 753 local governments under Schedule 8 of the Constitution, while provinces and the centre retain concurrent authority under Schedule 9; this study's finding that local-level procurement tenders lacked even a basic shelf-life clause, unlike the 18-month minimum enforced at the province level, is exactly the kind of tier-coordination gap researchers have documented since federalism began. The medicines found most frequently out of stock — condoms, Depo-Provera injectables, oral contraceptive pills, and zinc — are the same family-planning and child-health commodities that Nepal's roughly 50,400 Female Community Health Volunteers (FCHVs) rely on for household-level delivery, so procurement delays at the local tier cascade directly into a flagship community health programme.