Synopsis of the Literature Review for WG 5:

Supply Chains and Distribution


Mapping supply and distribution chains for tracer pharmaceuticals in India, Uganda and South Africa.

Effective supply/distribution chains for medicines depend heavily on systems that are operational in each country. These systems may be well structured and functioning efficiently or may be complex and often less effective.

During the literature review, the task of WG5 was to map out the supply/distribution chains for the selected tracer medicines in India, Uganda and South Africa, and  to study how these chains contribute to accessing essential medicines in these countries. The review identified the main up-stream and down-stream players in the distribution chains, and how medicines become available to the consumer.

Focus of this review:

The review focused on the overall structure of supply/distribution chains looking at both urban and rural settings in India, South Africa, and Uganda. The aim was to provide insight into public, private, and alternative mechanisms of the supply/distribution chains generally, but more specifically for the seven tracer medicines (Artemisinin, lamivudine, rifampicin, oxytocin, fluoxetine, metformin and fentanyl). The other important focus was to map the players in the supply/distribution chains (including the international and local producers, importer../css/s__storage_facilities__distribution_operations_and_providers__as_well_as_information_on_provider__ndash.css; consumer relations) and to review the criteria for performance of supply/ distribution chains (commercial interests and costs; national-, regional- and local-level policies; community level needs). Following an analysis of existing literature, the group identified a framework for assessing the actual performance of supply/distribution chains for use in data collection. This includes identification of facilitators and barriers of supply and distribution to ascertain whether tracers drugs are getting to destination points in appropriate quantities and within the required time frame. Key contributing factors include: Costs and profit incentives; supply/distribution chain forecasting, planning and regulation; warehousing, geographic distance; and quality control.

The literature review identified a major gap in literature specific to the tracer medicines. Generally most reviewed literature was not explicit on supply or distribution chains, nor did they provide specific information on the selected tracer medicines. The few studies focusing on drug supply and management are either based on essential drugs in general, general supply overviews for programme medicines or on tracer drugs which are not of interest to the working group.


India has a well established pharmaceutical industry and produces all the tracer medicines selected in this study.  The country however has a complex intra-state and inter-state supply/ distribution chain structure making understanding the functionality of the supply/distribution chain confusing. The distribution set-up in the Indian pharmaceutical industry is a highly fragmented system that has evolved on the basis of a two-tier sales tax structure (the Central Sales tax (CST) and local sales taxes). Most medium and big local pharmaceutical industries avoid the CST by conducting distribution through their own carrying and forwarding agencies that transfer goods across states as interstate stock transfers. While the selected tracer medicines are locally manufactured, their supply/distribution chains can easily be traced, and so clear supply chains can be followed. However, tracing the supply chain between key players is more complex as they include multi-directional relationships between large scale producers, small producers, super-stockists, clearing and forwarding agents, central stores, wholesalers, hospital, retailers or pharmacists, public and NGO agencies, practitioner and the end user/patients.

South Africa

South Africa, has a medium-sized pharmaceutical industry. The supply/distribution chain for essential medicines involves both public and private players and often the supply/distribution chains for the selected tracer medicines were not easy to follow. The exact role of the pharmaceutical industry in the supply/distribution of the tracer medicines is unclear. For example, literature describes a context for ARV drug supply chains in South Africa’s public sector but does not explicitly deal with the key players in the supply/distribution chain for the tracer medicines. The ARV supply chain is not entirely vertical, and there are certain elements which are separate from the overall national distribution systems. For ARVs and anti-TB medicines, the key players (identified through a ministry of health official) include a quality assurance pharmacist from a large local manufacturer, senior management pharmacists within trade associations, the director of the wholesale sector (pharmacist), the national quality assurance mangers from distribution agencies, private retail sector senior representatives from doctors’ conventions and pharmaceutical societies and public sector pharmacists at managerial level (national and provincial DOH levels). For oxytocin, fluoxetine, metformin and fentanyl, so far there is no literature available for South Africa to identify the key players in the supply/distribution chains of these selected medicines.


Uganda has a pharmaceutical industry that is still in its infancy with only one firm pre-qualified to manufacture ARVs. In Uganda, public sector procurement is limited to medicines on the national essential medicines list (EML), on which the selected tracer medicines are listed. Regulations for public sector procurement of drugs stipulate that 90% of tenders must be ‘national competitive tender’ and 10% ‘international competitive tender’. Of the 90% of nationally competitive tenders, 94% is imported goods, and 6% is produced locally within Uganda. Upstream, the main players are the international and local manufacturers, and the importers. Centrally, the Uganda Ministry of Health procures the medicines which are then stored centrally at the National Medical Stores (NMS). Medicines are also procured by the church funded Joint Medical Stores (JMS) for non-profit organizations, or private sourcing/importer and storage by wholesalers. Downstream, the main players are the public and NGO hospitals, pharmacies, clinics and drug-shops. However, the exact relationships and factors affecting the supply/distribution chains are not well documented, and the interaction between international and national players needs further exploration.


This synopsis is a result of the collaboration within WG5, under the coordination of the WG5 coordinators: Celestino Obua and Simon Mutauza.

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