Presentation on theme: "Overview of Ethiopia ARVs and other Medicines Supply Management Issues WHO Meeting October 2005."— Presentation transcript:
Overview of Ethiopia ARVs and other Medicines Supply Management Issues WHO Meeting October 2005
MSH/RPM Plus in Ethiopia Started operation in September 2003 Funded by USAID/E under PEPFAR Registered by Ministry of Justice as US-PVO in June 2004 Set up a modest office in Addis Current staff of 17 (all Ethiopian)
Qualitative and Quantitative Assessment Human resources – staffing levels & training needs Infrastructure – structural & equipment System/Procedure – components of the pharmaceutical management system Availability
LEVELS PRIVATE SECTOR PUBLIC SECTORPARTNERS International EPI/TBL FP/PMTCT GF National PASS/MOH/MOD Local Importers/Wholesalers Distributors (70) Regional Regional Stores (14) Local Community District Stores Target Population Local Manufacturers (12) Multinational Suppliers Private Pharmacies, Druggist Shops, RDVs(2450) NGOs, CBOs, FBOs, Special Pharmacies WB Other Donors (USAID, JICA, etc) & Procurement Agencies HAPCO The Pharmaceutical Supply System: ETHIOPIA PHARMID Parastatal PHARMID Branches (8) Hospitals, Health Centers
Drug Import/Distribution: Public Sector Major Players: Pharmacy Administration and Supply Service – PASS/MoH Pharmaceuticals and Medical Supplies Import and Wholesale Share Company - PHARMID Armed Forces and Ethiopian Red Cross NGOs, Donors including the UN Private Commercial Sector – There are 51 importers and wholesale distributors
Public & Private Sector Pharmacies (i) Public/NGO Non-profit Pharmacies: Special Pharmacies (USAID/Irish supported pharmacies managed by public health facilities) - 260 KENEMA Pharmacies (City Council) - 35 Red Cross Pharmacies/Drug Shops/RDVs - 41 Hospital/HC Pharmacies (DRF/IPP/OPP) (ii) Private for-profit Pharmacies: Pharmacies/Drug Shops/Rural Drug Vendors
SECTOR Ownership Drug Outlets Private Red Cross PHARMID Private Donation Drug Outlets in Ethiopia Public Health Facilities PHARMID Red Cross Private PHARMID Private Public / Quasi-Private (Non-Profit) Private Supply Source City Council KENEMA Pharmacy 304 Drug Shop 270 Rural Drug Vendor Special Pharmacy 260 Out -Patient Pharmacy In-Patient Pharmacy Pharmacy 24 Druggist Shop 7 Rural drug Vendor 4 Pharmacy 25 Drug Shop/RDV 16 Service OTC, RxHosp Rx, otc OTC, Rx ARVs OTC, Rx ARVs RPM Plus/MSH 2003
Drug Supply Management Cycle Approach Selection & Quantification Management Support Distribution Procurement Use Policy and Legal Framework M&E
Main areas of investigation for site assessments Information management ~What record keeping and reporting procedures are in place to build upon? ~What transaction forms are used between facilities and suppliers (RHBs, PHARMID etc.)? ~What methods of communication and information exchange are used? ~What basic MIS system can be put in place to improve accountability and stock status and patient tracking?
Main areas of investigation for site assessments Human resources ~What is the current status of pharmacy and lab man power in the target facilities? ~How can the number of pharmaceutical personnel be increased to cope with increasing workload? ~What other methods are there to tackle the manpower problem? Infrastructure ~How adequate and appropriate are the infrastructure and storage conditions of pharmaceutical and laboratory facilities in the target sites? ~What infrastructure improvements can be initiated and at which target facilities (working space, shelving, security, privacy, record keeping, etc)?
Findings - Staffing & Training Shortage and high attrition rate of professional staff (There are 26 pharmacists -46% in HF, 36 Druggists -75% in HF, 30 Pharm Technicians - 83% in HF, 14 Pharmacy Assistants -100% in HF, and 4 clerks) Limited management capacity at regional, district and health facility levels Inadequate training on rational drug use and drug supply management Lack of standard operating procedures, current reference materials or manuals
M&E and Inventory Control Inventory control systems (bin cards, stock cards etc.) not adequate [only 64% of PMTCT facilities have bin/stock card] Weak monitoring and evaluation system Limited quality assurance of drugs due to shortage of human resources, weak information system, and lack of quality assurance management system.
Preliminary Findings from 15 ART Sites IndicatorPercentage (n=15) Pharmacist available and trained Two pharm. personnel available (not pharmacists) 47% 87% Monthly collection of ARV drugs feasible53% Stock record cards used SOP available for ARV management 80% 0% Stock status regularly recorded Stock status regularly reported 53% 47% Space for confidential patient counseling7% Lockable storage space (cabinets) available Lockable filing cabinet suitable for ART Sufficient cold storage space available 43% 29% 79% Kardex filing Computer Patient registration book for out-patients 0% 22% 29%
Additional Findings from the Assessment of 15 ART Target Sites 80% of the sites receive supplies from PHARMID 80% of sites use stock cards but only 53% of sites regularly update and 47% report stock status Only 60% use bin cards but only 40% update them 33% of the facilities realized that there is loss due to damage, expiry and pilferage but only 1 facility had a system of recording such losses Only 67% reported some kind of supervisory visits 88% of the sites had stock of essential drugs on the day of the visit 67% use past consumption data for quantification
Appropriate Tools Patient profile card Daily drug dispensing register Monthly activity reports Periodic supervisory tools and feedback mechanism Expiry date tracking chart Adherence follow-up chart Temperature monitoring chart for commodities Facility supervisory checklists Inventory management stock cards, bin cards, requisition slips, ADR reporting formats etc. Simple locally sustainable computer software where applicable
Sample Monitoring Indicators ~% patients who could correctly describe how the prescribed medication should be used ~% ART sites that had ARV drug by type was out of stock for more than 5 days during the last quarter ~% of ARV drugs expired during the last quarter ~Cost of loss due to expiry of ARV drugs ~% of defaulters of ART program
Demonstration of Computer System in the Making…… PHARMID / PASS LEVEL PHARMID BRANCHES/RHB LEVEL HEALTH FACILITY LEVEL Drug supply management Drug stock management, client care and dispensing
Collaborative Vision for HIV/AIDS Patient Monitoring System Clinical System Pharmacy System Diagnostic System (Laboratory, Rad. etc.) Care & Support System Patient Profile HMIS Management System
PASS / PHARMID HQ/ DACA / HMIS ART Service Centers ART Patients Supply Chain of ARV Drugs PASS/ PHARMID BRANCHES / DACA/ HMIS Information Flow Consolidated information based on data from the health facilities Report on the supervisory visits and directives to the ART centers Information based on periodic surveys of ART centers or Patients New patient enrollment (by gender and age) in different programs (ART, PEP, PMTCT), revisiting patients, defaulters, change in regimen, drug substitution, and total drug consumption, current stock position, drug requirements, patient satisfaction and quality of care information Information for International Community and National Publications Consolidated information for ARV quantification and scaling up Report on the supervisory visits and directives to the branches Information based on periodic surveys of ART centers or Patients
ARV Drug Inventory Management at the Facility Level Drug Main Store Stock cards, Bin cards, Temperature recording chart, Expiry date tracking charts Drug Dispensing Pharmacy Individual patients cards Drug dispensing register Bin cards Stock status and daily drug consumption report Temperature recording chart for commodities Expiry and adherence tracking charts Requisition slips Stock and consumption report ARV drugs
PASS/ PHARMID HQ HEALTH FACILITIES ART Patients Supply Chain of ARV Drugs PHARMID BRANCHES/ RHBs RPM Plus MIS Support Areas Strengthen Procurement Storage, inventory and distribution system Simple MS Access based computer system* + training on the use of information + Supervisory tools and procedures Strengthen Storage, inventory and distribution system Simple MS Access based computer system* + training on the use of information+ Supervisory tools and procedures S trengthen Quantification, storage, Inventory,expiry tracking, adherence tracking and follow-up system ADR monitoring and reporting system Individual patient counseling and drug history recording system (computerized or manual)**
Current Challenges I. Difficulty in meeting minimum requirements by the new sites: ~GF money earmarked for site renovation has not been put to use ~Pharmacies at new sites have no confidential counseling rooms and/or booths ~Many sites have no lockable cupboards, filing cabinets, shelves
Challenges (contd …) II. Integration of ETAEP and GF ART drugs and services - the technical details of the integration need to be worked out urgently (eg. Distribution outlets, flow of information) lll. Need to revise Regimen and Dosage Forms List of ARV drugs permitted for importation – list does not include: > Tenofovir > Triple combinations > Pediatric solid and liquid formulations are limited > 2 nd line regimen is incomplete
Challenges (contd …) IV.Unreliability of suppliers due to manufacturing constraints (e.g. Stavudine; new orders for GSKs AZT-containing drugs now need > 5 months to be processed) Good news: many generic manufacturers are coming on the market (partial shipment within 3 weeks!) V. Significant difference in the pattern of ARV prescribing by clinicians (next slide)
Challenges (contd …) VI. Acute Shortage of Pharmacy Staff – one pharmacist serving > 1200 patients at Zewditu ~The need for training mid-level pharmacy personnel to handle ARVs and fully participate in ART ~Unavailability of data clerks
There is a need for pharmacy data clerks to record drug movement, track expiry and monitor patient profile.
Computerized ARV Drug Use and Stock Management Tool at Zewditu Hospital – data is being maintained by RPM Plus staff, because the facility could not assign a data clerk. Data clerks are urgently required at all facilities!