Transcript Ethiopia

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
The Pharmaceutical Supply System: ETHIOPIA
PUBLIC SECTOR
International WB
GF
EPI/TBL
FP/PMTCT
PARTNERS
Other Donors (USAID, JICA, etc)
& Procurement
Agencies
PRIVATE SECTOR
Multinational Suppliers
National
Local
Manufacturers
(12)
HAPCO
PASS/MOH/MOD
PHARMID
Parastatal
Regional
Local
Regional Stores (14)
Community
PHARMID Branches (8)
District
Stores
Hospitals, Health
Centers
Local
Importers/Wholesalers
Distributors (70)
Private
Pharmacies, Druggist
Shops, RDVs(2450)
NGOs, CBOs,
FBOs, Special
Pharmacies
Target Population
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
Drug Outlets in Ethiopia
SECTOR
Ownership Public Health Facilities
Drug Outlets
Supply Source
Service
Private
Public / Quasi-Private (Non-Profit)
Special Pharmacy 260
Out -Patient Pharmacy
In-Patient Pharmacy
PHARMID
Private
Donation
Hosp Rx, otc
Red Cross
Pharmacy 25
Drug Shop/RDV 16
City Council
KENEMA
Pharmacy 24
Druggist Shop 7
Rural drug Vendor 4
PHARMID
Red Cross
PHARMID
Private
OTC, Rx
ARVs
OTC, Rx
Private
Pharmacy 304
Drug Shop 270
Rural Drug Vendor
Private
PHARMID
OTC, Rx
ARVs
RPM Plus/MSH
2003
Drug Supply Management Cycle Approach
M&E
Selection &
Quantification
Use
Management
Support
M&E
Procurement
M&E
M&E
Distribution
Policy and Legal Framework
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
PMTCT/ART Program Assessment
RPM Plus Nov/Dec 2003
Pharmacy Personnel in Health Centers
2
1
Druggist
Pharm Tech
Pharm Asst
Adet
Woreta
Wukro
Marai
Axum
Mojo
Bole
Tekle
Haymanot
Addis
ketema
Lideta
0
Clerk
PMTCT/ART Program Assessment
RPM Plus Nov/Dec 2003
5
4.5
4
3.5
3
2.5
2
1.5
1
0.5
0
Z
ditu
w
e
ur
Tik
Pharmacist
A
ss a
n ba
Druggist
am
Ad
a
um
Ax
e
Fel
Pharm Tech
ge
o
Hiw
t
Pharm Asst
K
ma
ar a
ra
Clerk
PMTCT/ART Program Assessment
RPM Plus Nov/Dec 2003
Pharmacy Personnel in Hospitals
25
24
23
22
21
20
19
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
0
Zewdit u
T ikur Anbassa
Lab Technologist
Adama
Axum
Lab Technician
Felege Hiwot
Lab Asst
Karamara
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
Indicator
Percentage (n=15)
Pharmacist available and trained
Two pharm. personnel available (not pharmacists)
47%
87%
Monthly collection of ARV drugs feasible
53%
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 counseling
7%
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……
Drug supply
management
PHARMID / PASS LEVEL
PHARMID BRANCHES/RHB LEVEL
Drug stock management,
client care and dispensing
HEALTH FACILITY LEVEL
Collaborative Vision for HIV/AIDS Patient
Monitoring System
HMIS
Clinical System
Pharmacy System
Patient
Profile
Diagnostic System
(Laboratory, Rad. etc.)
Care & Support System
Management System
Supply Chain of
ARV Drugs
PASS / PHARMID HQ/ DACA
/ HMIS
Information Flow
•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
PASS/ PHARMID
BRANCHES / DACA/ HMIS
•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
ART Service Centers
ART 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
ARV Drug Inventory Management
at the Facility Level
Drug Main Store
•Stock cards, Bin cards, Temperature recording chart, Expiry date tracking
charts
Requisition slips
ARV drugs
Stock and consumption report
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
Supply Chain of
ARV Drugs
PASS/ PHARMID HQ
RPM Plus MIS
Support Areas
Strengthen
•Procurement
•Storage, inventory and distribution system
PHARMID
BRANCHES/ RHBs
•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
HEALTH FACILITIES
Strengthen
•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)**
ART Patients
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
> 2nd line regimen is incomplete
Challenges (contd …)
IV. Unreliability of suppliers due to manufacturing
constraints (e.g. Stavudine; new orders for GSK’s
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)
Number of Doses Dispensed
Comparison of the use of Efavirenz &
Neverapine at Zewditu Hospital
25000
20000
15000
Efavirenz 600mg
Neverapine 200mg
10000
5000
0
March
April
May
June
Number of doses Dispensed
Comparison of the Use of EFV & NVP
at Black Lion Hospital
70
60
50
40
EFV
30
NVP
20
10
0
March
April
May
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!
Thank You !