Transcript Assessment survey of TB drug management

Assessment Survey of TB Drug
Management in Cambodia
Uchiyama Y, Chay S, Kousoum M, Leng C, Kien S, Nou C, Chhom C
(CENAT/JICA National TB Control Project, Cambodia)
Background
 In 2003, the National Tuberculosis Programme of
Cambodia (NTP) faced serious stock shortage of TB
drugs for the first time in its history due to the
occurrence of unpredictable events related to drug
management (DM). Although the crisis was come
through, it became the trigger for the NTP to
recognize the significance of DM and to review the
current practices. To that end, the National Center for
Tu b e r c u l o s i s a n d L e p r o s y C o n t r o l / J a p a n
International Cooperation Agency (CENAT/JICA)
National TB Control Project, in collaboration with
the Ministry of Health (MOH), initiated and
organized the National Workshop on TB Drug
Management in September 2003 to identify
weaknesses and the causes in TBDM.
 As the next step, the Project implemented the
assessment survey to:
- verify the findings obtained from the Workshop
- provide data on the availability & use practices of
TB drugs, which will help develop action plans
for the improvement of TBDM.
Drug supply management
system in Cambodia
Selection/Procurement
 National Essential Drug List
 Public procurement (centralized system)
- Yearly drug requests from ODs/NHs to MOH
- Quantity adjustment, pricing & open tender by MOH
Distribution
 Flow of drug delivery & requests
- CMS ⇔ ODs/NHs: quarterly
- ODs ⇔ RHs/HCs: monthly
 Inventory & store management, following MOH
guidelines
Use
 Management is various among national programmes
OD: Operational district
NH: National hospital
CMS: Central Medical Stores
RH: Referral hospital
HC: Health center
NTP TBDM
Selection
 Criteria: National/WHO Model List & authorized
TB guides
Procurement (source other than national budget)
 Donation of GDF-standard TB drugs from Japan
through the JICA’s Grant Aid Program (2004-2006)
Distribution
 Safety stocks (ODs/NHs: 3M, RHs/HCs: 1M)
Use
 8M treatment regimen
(C1: 2RHZE/6EH, C2: 2RHZES/1RHZE/5RHE,
C3: 2RHZ/6EH)
 DOTS approach: hospitalization, ambulatory &
home delivery
 DOTS expansion to HCs: 780/942 HCs
(March 2004)
 Two TB staff in each health facility with TB service
Examples of findings from the
National Workshop on TBDM
Selection/Procurement
 Quantity of TB drugs per bottle delivered ≠
quantity indicated on the label
 Shelf life of TB drugs delivered is not long
enough to use up
Distribution
 Stock records ≠ physical counts
 Poor quality of loose tablets (color change,
moisture)
 No measure to verify the validity of TB drug
consumption
Use
 Poor patients’ adherence to TB treatment
 Poor knowledge of TB/TB treatment among TB
staff
Management support
 DM has not been a priority for NTP supervision
Policy and legal framework
 Private practitioners do not follow the TB
treatment guidelines
 TB drugs are available in private pharmacies
without prescription
Survey methods
 Design/Setting
- Treatment record review, structured interview &
inventory check
- 107 public TB health facilities (cover 40% of all the
TB cases) in 14 TB high-burden ODs (14 provinces)
out of 75 ODs (24 provinces), including a problematic
OD in TBDM reported, and 66 private pharmacies
 Intervention (7 investigators)
- Preparation (Oct-Nov 03), data collection (Nov 03Feb 04) & data analysis (Feb-Mar 04)
 Outcome measures
- % of new ss+ TB patients who received correct TB
drugs in correct dosage
- % of TB staff/new ss+ TB outpatients who had correct
knowledge of TB/TB treatment
- % of drug stores where stock records corresponded
with physical counts for TB drugs
- % of expired stocks for TB drugs
- % of drug stores where stock-out for TB drugs was
observed
- % of treatment cost per new ss+ TB patient
(Design & outcome measures were referred to in the Drug Management for
Tuberculosis Manual, MSH)
Survey results 1
% of new ss+ TB patients who received correct TB drugs
in correct dosage
TB facilities surveyed: 107
TB facilities with TB standard treatment regimen:
107 (100%)
TB treatment records CENAT (141), RHs (328),
reviewed: 2,146
(1,677)
Dosage of TB drugs
given
Breakdown of
incorrect medication
(n=232)
Correct
HCs
1,911
89.1%
Incorrect
232
10.8%
Unknown
3
0.1%
<25 Kg
2
0.9%
25 - 34
43
18.5%
35 - 49
38
16.4%
50 – 59
125
53.9%
24
10.3%
60+
Survey results 2
% of TB service providers who had correct knowledge
of TB/TB treatment
Interviewees: 92
Q1-Q4
Four definitions of a new ss+ TB case
Q5-Q9
Five types of TB drugs provided to a new ss+
case (50Kg), with dosage & duration of
treatment
Q10
Experience in receiving DOTS training in the
last 6M
Answer All of Q1-Q4
correct All of Q5-Q9
30
32.6%
61
66.3%
All of Q1-Q9
26
28.3%
Q10 (answer “Yes”)
14
15.2%
Survey results 3
% of new ss+ TB outpatients who had correct knowledge
of TB treatment
Interviewees: 799
IF: 339 (42.4%)
CF: 460 (57.6%)
Q1 What TB drugs must you take? (name, color)
Q2 How many tablets of each drug must you swallow
per day?
Q3 How many times a week/when must you swallow
TB drugs?
Q4 How long does your treatment last?
Q5 What will happen if TB drugs are not taken
properly?
Q6 When must you (CF) return to TB facility to take
TB drugs?
Q7 Did the TB staff tell you to return to the health
facility in case of ADR signs?
Q8 Does anybody look at you when you swallow TB
drugs?
Answer correct (Q1-Q7)
Answer “Yes” (Q8)
504 (63.1%)
535 (67.0%)
IF
315 (92.9%)
CF
189 (41.1%)
Survey results 4
- % of drug stores where stock records corresponded
with physical counts for TB drugs
- % of expired stocks for TB drugs
- % of drug stores where stock-out for TB drugs was
observed
Drug stores surveyed: 51 (OD: 13, RH: 13, HC: 23, CENAT: 2)
Drug stores (stock records=physical counts)
All TB drugs
Individual
TB drug
Exp. stock /
total stock
Drug stores
(stock-out)**
5 (9.8%)
RH
Z 500
E 400
150/100
EH
S 1000
400/150
13
(25.5%)
23
(45.1%
)
16
(31.4%
)
15
(29.4%
)
21*
(77.8%
)
8.2%
13.8%
0
0
20.0%
2
(3.9%)
5
(9.8%)
1
(2.0%)
1
(2.0%)
3*
(11.1%
)
* S 1000 vials were stored in 27 out of 51 facilities
** [Physical counts=expired stocks] is regarded as stock-out
Survey results 5
Treatment cost per new ss+ TB patient (8M, 35-49Kg)
Product/unit price
(US$) of loose
tablets
RH 150/100
Med. Pvt.
pharmacy
(03)
0.0500
Public
procure.
(MOH
03)
0.0187
Med. Intl.
(02)*
0.0188
RH 150/75
Z 500
GDF
(03)
0.0117
0.0500
0.0379
0.0328
Z 400
0.0126
E 400
0.0375
0.0172
0.0150
0.0110
EH 400/150
0.0500
0.0205
0.0137
0.0118
Cost
37.5
17.4
14.1
9.2
Adjusted cost**
37.5
17.4
16.2
10.6
353.8%
164.2%
152.8%
% GDF cost
*
Quoted from the International Drug Price Indicator Guide, MSH.
**
Added 15% for shipping and insurance costs to FOB prices
Conclusions & recommendations






Further attention should be paid to treatment for
TB patients weighing >50Kg.
Periodic training on DOTS is needed for
peripheral TB staff.
TB patients’ answers are affected by interviewers’
position & character (central NTP staff in charge
of IEC/supervision activities are eligible).
DOT rate among CF patients can be increased
with expansion of community DOT.
Periodic training on stock management is needed
for pharmacists & store keepers.
More pharmacists are needed to reduce workload,
or incentives should be considered for them.
Conclusions & recommendations
(contd.)



TB drugs procured should be of high quality & the
cheapest price. GDF-standard TB drugs are
preferable.
An indicator-based TBDM assessment survey can
be utilized for:
identifying both strengths & weaknesses in TBDM
monitoring changes in TBDM practices & quality
of DOTS
developing specific action plans for the
improvement of TBDM
providing health education to TB patients
Close cooperation with the MOH is important to
address DM issues that are beyond the NTP scope.