Hospital drug supply chain consists of four major phases in patient management: prescription, dispensing, administration and monitoring of the treatment. However, as a product, medicine has traditionally logistic supply chain including selection, procurement and stock management. Each of these steps of drug supply chain involves different actors but hospital pharmacy remains their focal point in hospital. Drug supply chain performance and safety are essential parts of an effective health care system and had become priorities for public health.Madagascar is a very poor country whereas 40% of health expenditures in charge of households. In this context, making operational the hospital pharmacy is essential in public hospitals whose main users are especially the middle class and the poor. Yet, hospital pharmacy is only on a structuring phase for two reasons: the lack of available pharmacists for this sector and the unclear national pharmaceutical policy for hospitals.The objective of this thesis is to contribute to the improvement of accessibility and quality of public health care in public hospitals of Madagascar by providing a proposal of an optimal and justified model of drug supply chain taking account the human, material and financial resources.First, description and analysis of hospital pharmacies and the drug supply chain in public hospitals were done from qualitative research. For that purpose, semi-structured interviews have been conducted with health actors of the supply chain. The principal issue perceived by interviewees was the heterogeneity of the system in terms of technical and financing management. The drug supply chain is not under control: no internal procedure has been established for the selection of pharmaceutical products, the quantification of needs is complex, the stock management is difficult to supervise, a standard prescription protocol is lacking, the dispensing is performed by unqualified staff, no pharmaceutical preparation is manufactured in the hospitals and the administration occurs without pharmaceutical support. Then, we focused on procurement, the essential of current activities of Malagasy hospital pharmacies in drug supply chain. Our retrospective and evaluative study was conducted in a university hospital and utilized indicators for assessing the procurement management of medicines and preventing stock-outs and overstocking. The calculations of these indicators show a suboptimal drug supply chain. The drug supply chain needs some improvements. In order to define some strategic priorities of the implementation of these improvements, a survey on health actors was conducted in line with the international recommendations for hospital pharmacy. 32/75 (42,7%) of these recommendation could be conducted according to the participants. An optimal organizational model of drug supply chain is proposed and will be made available to the Ministry of health to be tested in public hospitals. This model aims at implementing the « pharmaceutization » of the resources and the different steps of the drug supply chain.

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   |texte=   Proposal of a model of drug supply chain at public hospitals in Madagascar
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