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
 The Pharmaceutical Supply System: ETHIOPIA
LEVELS PUBLIC SECTOR PARTNERS PRIVATE SECTOR
International WB EPI/TBL Other Donors (USAID, JICA, etc)
GF FP/PMTCT & Procurement Multinational Suppliers
Agencies
National
HAPCO Local
Manufacturers
(12)
PASS/MOH/MOD

Local
PHARMID
Importers/Wholesalers
Parastatal
Distributors (70)

Regional Regional Stores (14) PHARMID Branches (8)

District Private
Local
Stores Pharmacies, Druggist
Shops, RDVs(2450)
Hospitals, Health NGOs, CBOs,
Centers FBOs, Special
Pharmacies

Community
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 Private
Public / Quasi-Private (Non-Profit)

City Council Private

Red Cross
Ownership Public Health Facilities KENEMA

Special Pharmacy 260 Pharmacy 25 Pharmacy 304

Pharmacy 24
Out -Patient Pharmacy Drug Shop/RDV 16 Drug Shop 270
Drug Outlets Druggist Shop 7
In-Patient Pharmacy Rural Drug Vendor
Rural drug Vendor 4

PHARMID PHARMID PHARMID Private

Supply Source Private Red Cross Private PHARMID
Donation

OTC, Rx
Service Hosp Rx, otc OTC, Rx OTC, Rx
ARVs
ARVs
RPM Plus/MSH
2003
Drug Supply Management Cycle Approach

M&E Selection & M&E

Quantification

Use Management Procurement

Support

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

0
H aym anot
ketem a

W oreta
W uk ro
Lideta

Adet
M arai
Axum
Bole

M ojo
Add is

Tekle

Druggist Pharm Tech Pharm Asst 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

Pharmacist Druggist Pharm Tech Pharm Asst Clerk

 PM T CT /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 Adama Axum Felege Hiwot Karamara

Lab Technologist Lab Technician Lab Asst

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 47%
Two pharm. personnel available (not pharmacists) 87%
Monthly collection of ARV drugs feasible 53%
Stock record cards used 80%
SOP available for ARV management 0%
Stock status regularly recorded 53%
Stock status regularly reported 47%
Space for confidential patient counseling 7%
Lockable storage space (cabinets) available 43%
Lockable filing cabinet suitable for ART 29%
Sufficient cold storage space available 79%
Kardex filing 0%
Computer 22%
Patient registration book for out-patients 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
Drug supply
management

PHARMID BRANCHES/RHB LEVEL

Drug stock management, HEALTH FACILITY LEVEL

client care and dispensing
Collaborative Vision for HIV/AIDS Patient
Monitoring System
HMIS

Clinical System

Pharmacy System
Patient Diagnostic System
Profile (Laboratory, Rad. etc.)

Care & Support System

Management System
Supply Chain of
ARV Drugs Information Flow
•Information for International Community and National Publications
PASS / PHARMID HQ/ DACA
•Consolidated information for ARV quantification and scaling up
/ HMIS
• Report on the supervisory visits and directives to the branches
•Information based on periodic surveys of ART centers or Patients

PASS/ PHARMID •Consolidated information based on data from the health facilities
BRANCHES / DACA/ HMIS •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,
ART Service Centers drug substitution, and total drug consumption, current stock position,
drug requirements, patient satisfaction and quality of care information

ART Patients
 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 RPM Plus MIS
ARV Drugs
Support Areas
PASS/ PHARMID HQ Strengthen
•Procurement
•Storage, inventory and distribution system
•Simple MS Access based computer system* + training on
the use of information + Supervisory tools and procedures
PHARMID
BRANCHES/ RHBs
Strengthen
•Storage, inventory and distribution system
•Simple MS Access based computer system* + training on the
use of information+ Supervisory tools and procedures
Strengthen
HEALTH •Quantification, storage, Inventory ,expiry tracking, adherence
FACILITIES 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)
 Com parison of the use of Efavirenz &
Neverapine at Zewditu Hospital

Number of Doses Dispensed

25000

20000

15000
Efavirenz 600mg
10000 Neverapine 200mg

5000

0
March April May June

Com parison of the Use of EFV & NVP

at Black Lion Hospital
N umber of doses D ispensed

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 !