Current Status of HIV Pharmaceutical Management in Guangxi Province, China

Helena Walkowiak, Management Sciences for Health /SPS

Sharri Hollist, MSH/Strengthening Pharmaceutical Systems

Beth Yeager, MSH/SPS

Dr Connie Osborne, WHO

Dr Zhang Lan, WHO

December 9, 2008

Outline of Presentation

Overview of the WHO, MSH, Guangxi province ARV management Program

Objectives of the Assessment Key findings Options/strategy for strengthening ARV

pharmaceutical management in Guangxi Province

ARV Management in Guangxi Province - Strengthening Pharmaceutical Systems (SPS) Program – An Overview

Funded by U.S. Agency for International Development

Implemented by Management Sciences for Health and supported by WHO

5 year award June 29, 2007 – June 28, 2012

In collaboration with NCAIDS and WHO Workshop in Guangxi

Province to introduce a tool for assessing the management of ARVs (July 2008)

Key Objectives of the Assessment

Map the flow of ARV medicines through the supply system including the processes of procurement, quantification, distribution and dispensing

Understand the roles and responsibilities of staff at each level in managing medicines for the ART Program

Identify forms, tools and procedures used for procuring ARV medicines, managing inventories, recording medicines transfers, dispensing, and reporting data

Solicit feedback on which procedures and tools currently being used are effective in managing ARV medicines and which may need to be strengthened to support program scale up

Site Visits: December 3 to 7, 2008

Unit UnitLevel

Guangxi Autonomy

Provincial CDC The Fourth People's Hospital Provincial/City

Guilin CDC Guilin The Third People's Hospital City

Luzai County CDC Luzai County People’s Hospital County

Liuzhou CDC Guangxi Autonomy Longtan

HospitalCity/Provincial

Heng County CDC Heng County People's Hospital County

Status of the ART Program

The number of patients on ART is increasing rapidly From approximately 3,500 at end of 2007 to 5,217

including 144 children at end September 2008 7,000 projected at end of 2008 and 15,000 at end

2009 Increase of patients from 2007 to 2008 averaged

106% at sites visited (range 21% to 194%) 2nd line – 25 plus several patients waiting for VL results 37 treatment sites in 21 counties

3 sites provide treatment for children ARVs are procured primarily by the MOH, with additional

donations from the Clinton Foundation and Glaxo

ARV Supply System in Guangxi Province

ARVs are dispensed at 3 levels of health care system – provincial, prefecture/city and county levels

At each level, CDC orders for the sites from the level above usually quarterly using a pull system Longtan Hospital orders directly from Provincial CDC Some stores and sites have been ordering monthly

due to shortages at provincial store Lead time: between 1 day and 1 week Supplies are collected and transportation is reported

to be a significant cost Some sites requisition medicines from CDC store

monthly or quarterly, and others as needed

Key Findings: Strengths

In general, many ART pharmaceutical management operations are reported to be working well Standard procedures for ordering, receiving and

dispensing medicines and reporting are followed across sites

Communication and coordination between provincial level and stores/sites is generally good and sites can return short dated stock for exchange

Guangxi ARV drug management protocol available Storage space is generally adequate and secure;

pallets, shelving and A/C available in most sites Dispensing supplies – envelopes and labels available

Key Issues (1)

Inadequate stocks of ARVs at Provincial Store No ARVs purchased through national procurement in

2008 ARVs are procured through bidding process at provincial

level as necessary to fill the gap No stockouts have occurred for patients but the

provincial level staff are on constant alert to manage shortages

Orders from lower levels often cannot be filled in full increasing order frequency, management and transport costs

To avoid stockouts, sites issue smaller quantities to patients who must return more frequently to collect refills increasing their transportation and in some cases accommodation costs

Key Issues (2)

Record keeping and reporting needs to be strengthened No standard forms to record inventory

transactions (receipts, issues, running balance) Other gaps – expiry date monitoring and

temperature monitoring tools “Too many forms” – some forms and reports are

reported to be duplicative; tools need to be streamlined and consolidated where possible

In long term, sites request a database linked to the patient information system

Key Issues (3)

Written standard operating procedures for managing medicines and controlling inventories at each level are not in place Many staff managing ARVs are part time so sites want

standardized procedures and simple tools to streamline activities to ensure efficient use of staff

No formal methods for forecasting needs Methods used for annual planning and quarterly or

monthly procurement are diverse e.g. buffer stocks Developing assumptions about future use reported to

be especially problematic as guideline changes are implemented and numbers of patients and regimens used increase

Sites request “simple tools” and procedures to analyze data and quantify needs supplemented by training

On-going and proposed support under the SPS program

Review of existing manual forms and tools to identify options to streamline, consolidate and fill gaps

Draft SOPs and related tools have been developed First training on SOP implementation – June 2009 Develop procedures and a supervision tool for

monitoring Provide follow up support

Site visit findings were discussed with national and provincial stakeholders and partners to prioritize needs, identify options and develop an action plan to strengthen existing ARV management systems in Guangxi Province eg., Strengthening quantification procedures suggested by other partners