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TB MEDICINE SUPPLY CHAIN MANAGEMENT: THE SOUTH AFRICAN PERSPECTIVE

Dr Lindiwe Mvusi Africa TB Regional Conference on

Management of TB Medicines 06 December 2012

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BACKGROUND

• Population: 50, 586 757 • Provinces - 9 • Districts - 53 • Sub districts - 253 • Health facilities – 4000 • District -unit service

delivery • Budgets determined

provincial level 2

NC 2.2%

WC 10.5%

EC 13.5%

KZN 21.4% FS 5.5%

NW 6.4%

LP 11%

MP 7.2%

GP 22.4%

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THE EPIDEMIC IN SOUTH AFRICA 1990-2010

ART for TB co-infected patients

TB Prevalence (per 100 000)

TB Mortality rate (per 100 000)

Incidence vs Notification rate (per 100 000)

Global Report on TB Control 2011

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TRENDS IN TB NOTIFICATIONS BY PROVINCE: 2007-2011

0

20000

40000

60000

80000

100000

120000

140000

EC FS GP KZN LP MP NC NW WC

2007

2008

2009

2010

2011

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6.9% 6.3% 6.4% 6.7% 6.9%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

EC (N=8 648)

2.7%

5.8% 4.0%

7.6% 7.1%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

FS (N= 1 561)

3.8% 5.0% 4.6% 3.7%

6.5%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

LP (N= 953)

8.7%

3.2%

6.0% 7.7%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

MP (N= 3 076)

5.6% 3.9%

5.3%

2.8%

6.5%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

NW (N= 1 701)

3.1% 3.3% 4.6% 3.8%

6.5%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

NC (N= 1 579)

5.6% 6.0% 4.4% 4.1%

6.3%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

WC (N= 8 376)

3.2% 2.6% 3.4% 3.0% 4.7%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

GA (N= 6 117)

MDR Trends (2007-11)

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XDR Trends (2007-11)

10.1% 12.4% 12.0% 11.7%

10.1%

0.0%

5.0%

10.0%

15.0%

20.0%

2007 2008 2009 2010 2011

EC (N=973)

2.8% 2.6% 3.8%

1.9%

6.6%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

FS (N=58)

3.8% 3.8% 4.7%

5.7% 5.2%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

GA (N=289)

2.8% 1.7%

4.6%

1.1%

4.8%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

LP (N=31)

2.4% 1.9% 3.8% 4.6%

3.2%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

MP (N=95)

0.8%

3.3% 3.1% 1.4%

4.4%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

NW (N=47) 7.4%

11.9% 10.2% 10.8%

18.4%

0.0%

5.0%

10.0%

15.0%

20.0%

2007 2008 2009 2010 2011

NC (N=201)

3.3% 3.4% 5.0% 5.9%

6.9%

0.0%

5.0%

10.0%

2007 2008 2009 2010 2011

WC (N=413)

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PROBLEM STATEMENT • Incorrect completion of

BIN cards • Poor follow up of

outstanding stock • Overstocking of TB

medicines at facility level

• Hoarding of stock by facilities

• Wastage – due to inappropriate storage and expiry

• Most clinics do not have pharmacists but pharmacy assistants (PA)

• Poor supervision of clinics • Inaccurate estimates of TB

medicines • Ordering of medicines not

informed by the disease burden and profile of patients seen at facilities

• Increase in reports of stock out of medicines

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INTERVENTIONS (1) • Training of health care workers responsible for managing

TB medicines in clinics, pharmacists and TB coordinators – 3 day training workshops – Methodology

• Didactic, exercises, group discussions – Sessions

• Management and policies • Principles of quantification • Procurement • Distribution • Supervision and monitoring • Quality improvement plans

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INTERVENTIONS (2)

• Involvement of TB programme managers in the quantification process

• Strengthened collaboration between programme and pharmacists at national and provincial levels

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POST INTERVENTIONS

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FINDINGS Achievements • Variations in levels of

implementation at facility level • Improved collaboration between

programme managers and Access to Affordable Medicines Unit, EDL Committee at national level

• Improved collaboration at provincial level between programme managers Pharmaceutical Services Unit and Medical depot managers

Challenges • No post training evaluation

was included as part of this training programme

• Lack of a system to accurately monitor stock levels in clinics

• Continued reports of medicine stock out • Depot/ health facility levels • Supplier problems • Incorrect estimates

• Poor supervision of facilities by district/ hospital pharmacist – TB coordinators/ PHC supervisors

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Comprehensive Assessment of the Problem • Assessment of the TB medicines supply chain and

management • Objectives:

– Assess the status of the TB medicines supply chain – Document best practises in the TB pharmaceutical management – Describe the current practises in the budgeting and resource planning

for TB supply management at all levels – Describe the quantification process for TB medicines at all levels – Make recommendations for strengthening the TB pharmaceutical

management

• Conducted in seven of the nine provinces in priority districts

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FOCUS AREAS

• Strategic areas – selection and procurement procedures, financing and budgeting for TB

drugs and payment of suppliers, ordering system from suppliers, stock management, storage of TB drugs and distribution to healthcare facilities.

• Operational areas – storage, stock management, availability of tracer drugs and supplies,

ordering systems, prescription practises, patient counselling/ education, availability of necessary human resources

• Methodology − Interviews (managers at all levels, HCW, patients), record review, site

visits and physical stock count

FINDINGS

•TB treatment protocol development •EDL process for TB •Availability at different levels of healthcare system

Selection (Strategic NDOH)

•Determining quantities needed •Tender for suppliers •Creation of standard drugs

& suppliers list for depots •Bidding and negotiation

Procurement (strategic – NDOH): •Payments

•Logistics and distribution •Review consumption information and product selection

Distribution (strategic, operational – provincial):

• Stock management • Prescribing (STG’S) • Dispensing to patients

– labeling, packaging, advise

Use (operational – facility):

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• Good governance over selection of national EDL drugs list

• Involved PTC’s in most provinces

• Provinces develop own code lists by facility type and monitor compliance

• Tenders process improving since taken over from Treasury

• Concerns with TB tender as no supplier splits for critical medicines

• prices negotiated on average 35 % lower than SEP (priv)

• Provinces use National Supplier list. Some do own tenders or purchase off contract

• Provincial depots in all • Manual ordering

processes with financial vetting which delays process

• Old IT system so no stock visibility of facility pharmacy and poor stock management in WH

• Mixture of In house distribution & Outsourced

FINDINGS

•TB treatment protocol development •EDL process for TB •Availability at different levels of healthcare system

Selection (Strategic NDOH)

•Determining quantities needed •Tender for suppliers •Creation of standard drugs

& suppliers list for depots •Bidding and negotiation

Procurement (strategic – NDOH): •Payments

•Logistics and distribution •Review consumption information and product selection

Distribution (strategic, operational – provincial):

• Stock management • Prescribing (STG’S) • Dispensing to patients

– labeling, packaging, advise

Use (operational – facility):

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USE • Stock management in smaller facilities poor as nurse driven and no pharmacy support or

supervision • stock unavailability is minimal and varies between TB and ARV’s depending on which province • less than 70% compliance with treatment protocols for non drug resistant TB and even worse

compliance for MDR • Main reasons for non compliance is

• poor recordkeeping: • no weights monitored, • Treatment changes due to side effects not documented

• In correct dose for weight and phase – either too high or too low • No correction of dose on continuation phase

• Patients well educated in taking their medication, side effects and nutrition support • Minimal use of community DOT supporters or CHW in treatment

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WAY FORWARD

• Dissemination of findings • Development and implementation of a work plan to

address the weaknesses • Monitoring and evaluation framework

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Thank you for your attention