THE VALUE CHAIN SURE/MOH-Pharmacy Division Newsletter

Issue 1, September 2011

SURE staff facilitators at the pharmaceutical sector policy options analysis (POA) conference

Increasing Access to Essential Medicines By Birna Trap With the aim to strengthen the pharmaceutical supply systems and improve access to quality essential medicines in Uganda, the US Agency for International Development (USAID) funded SURE program was established in July 2009. To coordinate the program’s implementation, SURE and the PD meet weekly to jointly coordinate and develop the program’s activities. Much has been done during SURE’s first year—there are now four regional offices, staff are working in 29 out of 45 districts, and the program has installed computers at three district hospitals to help with logistics. Regular stock status reports are produced bimonthly and assistance is given to National Medical Store and the Joint Medical Store to increase efficiency and effectiveness. With help from health staff from all over the country, SURE has implemented several surveys and studies, including a policy options analysis (POA) to review supply chain performance and give recommendations on how the supply chain could be strengthened. Through this newsletter The Value Chain, we hope to bring SURE/PD and the many activities closer to you and keep you updated on our future achievements.

Welcome to the first issue of the Value Chain Newsletter produced by the Securing Ugandans’ Right to Essential Medicines (SURE) Program and the Uganda Ministry of Health (MOH) –Pharmacy Division (PD). This publication will help you follow collaborative activities toward improving access to essential medicines and health supplies in Uganda

IN THIS ISSUE

Essential medicines 1

Medicines’ supervisors 2

ART reporting 3

Appropriate use of medicines 3

Counterfeit medicines 4

The kit system assessment 4

Hospital computerization 5

The policy options analysis 5

The Joint medical store 6

Online ARV ordering 6

End user verification survey 7

Key profiles 8

IN THE NEXT Value Chain Newsletter

Field stories

Uganda Medicines Therapeu-tics Advisory Committee

Pharmaceutical data ware-

house

Bi-annual pharmacists’ meeting

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storage practices, rational medicine use, communication, mentoring skills and how to assess performance. Florence Senfuma, a dispenser at Luwero Health Center IV attended the medicines management supervisory course in the central region. She is now a certified medicines management supervisor. During the training, Florence said, “I have learned how to assess drugs and avoid drugs expiring in my store. I look forward to implement what I have learned once I get back to the facility.”

These supervisors are now prepared to provide on-the-job training of health workers and routinely monitor health facility performance using a standard supervisory tool. Very soon, the District health teams will begin to receive monthly reports on district performance for action, prepared by the supervisors. By end of 2011, MMSs in all the 45 SURE-supported districts will have received the training and initiated supervisory visits to strengthen regular supply chain management at facility level. The plan is to have MMSs in all districts in Uganda through a collaborative effort with implementing partners like the World Bank, Department for International Development [UK], and USAID’s implementing partner programs-a roll out to be coordinated by the Pharmacy Division.

The laboratory technician Bugiri hospital, Dan Musobya (centre) takes the supervision team through a file of stocks for laboratory equipment. (Right) Emmanuel Umirambe, SURE’s eastern pharmaceutical field coordinator; (left) Godfrey Wafula, Bukoolo North medicines management supervisor for eastern region.

Using Trained Medicines Management Supervisors to Improve Medicines’ Man-agement By Khalid Mohammed In collaboration with the Pharmacy Division, SURE has adopted a performance monitoring and rewards-based strategy that aims to strengthen supply system for health commodities at district level. The strategy is implemented by trained medicines’ management su-pervisors (MMSs). Between September 2010 and March 2011, 81 super-visors from 29 district health offices in the central and eastern regions were trained. During the training, MMSs acquire knowledge and skills in the essential medicines’ concept, inventory management, good

Message from the Pharmacy Division By Oteba O. Martin In this era of demand for good governance, transpar-ency, and accountability, regular information sharing becomes more relevant than ever. Given the central role supply chain management plays in the functioning of a health care system and the resources deployed to enable the system to function smoothly and effi-ciently, this newsletter is handy and timely as an infor-mation sharing medium for all the stakeholders. The Value Chain, as indicated by its name, will pro-vide insight on the developments in the Ugandan Medicines and Health Supplies supply chain arena including investments made therein. It is hoped that all the stakeholders will find this publi-cation extremely useful; stakeholders are strongly en-couraged to contribute to future editions. Therefore, I ask everyone with interest in health commodity secu-rity to find time to read The Value Chain and to also contribute to its improvement. Given that this is the first edition of the newsletter, allow me on behalf of the team to sincerely apologize for any inadequacies that you may identify as a reader and request you to give us feedback. I thank you all for your interest in the newsletter.

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Ministry of Health Takes Action to Address Inappropriate Use of Medicines By Lawrence Were According to the World Health Organization (WHO), more than half of medicines worldwide are prescribed, dispensed, or sold inappropriately, and half of all patients fail to take medicines correctly. This results in waste of scarce resources, increased medical care costs, and poor treatment outcomes. Studies have shown increased resistance to commonly used antibiotics, and today Uganda is among the countries facing multidrug-resistant Mycobacterium tuberculosis strains. In the first quarter of 2011, the MOH launched the National Communications Strategy for promoting rational use of medicines in all regions of Uganda. The strategy targets both public and private health units, and

ral medicines, Uganda, like many developing countries has changed its treatment policy for malaria from the affordable chloroquine and sulfadoxine/ pyrimethamine combination, to the more expensive artemisinin-based combination therapy (ACT). The problem is partly attributed to inadequate information on medicine use, poor prescribing and dispensing practices, wide spread self-medication, slow implementation of regulations, and limited involvement of communities and leaders in educational programs on rational use of medicines. The strategy aims at creating awareness for individuals, policy makers, and implementing partners who are responsible for allocating

“...Now, they can order and even teach others within their facilities.”

HIV/AIDS logistics health workers attending the ART workshop in Mbale district, Eastern Uganda. Photo by: Julian Natukunda

Health Workers Receive Training in Antiretroviral Reporting By Loi Gwoyita & Julian Natukunda An assessment done by the AIDS Control Program (ACP) and SURE between January - June 2010 found that facility ordering and reporting quality for antiret-roviral) was poorly done, and that availability of ARVS in these facilities was as low as 55 percent. Between August and October 2010, ACP and SURE selected and trained a total of 554 HIV/AIDS logistics health workers in ordering and reporting to improve on ARV reporting quality.

According to participants, the order forms were diffi-cult to fill out and the process always took a long time. Many staff members had left this exercise to be done by their seniors. But now, they can order and even teach others within their facilities. District ARV ordering is now coordinated by district logistics people who send reminders to facilities, review orders, and provide feedback before orders are sent. At least seventy SURE-supported district and health sub-district supervisors underwent the one day training and final examination about ARV ordering and reporting.

provides a framework to guide stakeholders in developing infor-mation, education, and communication interventions in addi-tion to behavioral change communica-tion interventions to promote rational use of medicines. Because of the in-creased resistance to antimalarials, antibac-terial and antiretrovi-

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SURE’s program operations associate, Peter Mugagga (right) hands over one of the minilab test kits to the head of national drug quality control laboratory, Sr. Dr. Antonia Nakamya. Photo by: Julian Natukunda.

The kit supply system, however, is never a fit for all. All facilities receive one kit according to health facility level regardless of patient load. Therefore, facilities with low patient numbers receive more supplies than needed, and these extra supplies are at risk of expiry or will be wasted if not redistributed. The survey showed that 63 percent of items are oversup-plied for some items, with more than a year’s supply de-livered bimonthly. If allowed to expire, government will lose more than 1.5 million US dollars just for these items. The kit system has increased availability and widened the range of medicines, but lifesaving medicines are still not available all the time and redistribution is necessary to reduce costs. Therefore, the kit system may not be a long-term, cost-effective solution but for now, it has increased availability of essential medicines.

How Effective is the Kit System for Health Facilities?

resources and enforcing regulations. What can you do if you are a prescriber or dispenser? Follow treatment regimens outlined in standard

treatment guidelines Give patients the full prescribed amount of medi-

cine, and Instruct patients to take all their medication even

if they feel better.

Supporting National Drug Authority in Combating Counterfeit Medicines By Julian Natukunda A counterfeit medicine is a fake or substandard medi-cine. For some time, National Drug Authority (NDA) has used Minilabs (small mobile laboratories) to detect poor quality medicines in Uganda. Up to February 2011, NDA survived on seven minilabs and more was needed to effectively cover the whole country. On March 1 2011, the SURE Program supplied two minilab test kits to the National Drug Quality Control Laboratory to be used in regions where test kits were lacking to strengthen the fight against counterfeit medicines on the market.

By Dorthe Konradsen In June 2010, National Medical Store (NMS) in col-laboration with the MOH, introduced the kit system, where supplies and quantities to be used in health fa-cilities are determined centrally and not by health care (HC) workers. The kit system is aimed at increasing availability of essential medicines and health supplies at primary HC-level facilities (HC II and HC III). In December 2010, SURE program on behalf of Phar-macy Division, designed and implemented a study to assess the impact of the kit system. It was found out that introduction of the new kit system made a 38 per-cent increase in allocation for medicines and availabil-ity of heath supplies. About 67 percent of district and health facility staff preferred the kit system over the order-based system, since the kit had increased medi-cines’ availability.

This timely contribution came at a critical period when NDA had recognized the great role minilab test kits play in reducing the number of counterfeit pharmaceutical drugs. Minilab kits can test up to 41 different medicines including antimalarials, ARVs, at border entry points and if medicines are found to be counterfeit, they are quaran-tined. New samples are collected and re-tested at the na-tional laboratory with more sophiscated equipments and methods.

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Fifteen participants successfully completed the RxSolution training in November 2010 and the software is currently being piloted at Butabika, Kayunga, and Masaka hospitals. William Olumu, a senior pharmacist at Masaka Regional Referral Hospital and a user of RxSolution said, “RxSolution has helped to minimize unauthorized stock transactions and improved stock management, ordering, pharmaceutical financial management as well as report generation.” Feedback from other RxSolution pilot users at Butabika (a national mental health referral hospital) indicates that the software has improved drug accountability and stores arrangement where medicines are stored according to batch numbers and expiry dates. The software will be rolled out to hospitals and facilities throughout the country after completion of the pilot phase.

The Policy Options Analysis Conference By Birna Trap In April 2010, the SURE program collaborated with the MOH to conduct a supply system policy options analysis (POA) conference, attended by close to 200 policy makers and stakeholders from the pharmaceutical sector. The goal was to analyze Uganda’s pharmaceutical supply system and, from a cost-effective point of view, identify challenges, constraints, and propose alternatives to reduce inefficiencies, based on data obtained from various stakeholders including National Medical Store, Joint Medical Store, health facilities, National Drug Authority, MOH, and Ministry of Finance. Continues on page 6.

Hospitals in Uganda to Have Computerized Logistics Management System By Michael Kavuma and Petra Schaefer Aiming at improving logistics management at hospi-tals, MOH has embarked on a strategy to computerize all hospitals in Uganda. The MOH Resource Centre and Pharmacy Division conducted an extensive and thorough review process where over 15 open source and vendor pharmaceutical software tools were evalu-ated, and RxSolution selected as Uganda’s future lo-gistics management system. The software supports best practices for quantifica-tion, supply chain-management and storage. It also has features to support dispensing practices.

RxSolution is an open source software, meaning it is free of charge so licensing costs are eliminated. To roll out RxSolution, two specialists from the Strengthening Pharmaceutical Systems South Africa Program undertook to train system administrators, super users, and trainers in the software. Among the trainees who received training in using the RxSolution were regional pharmacists, stores personnel from se-lected pilot hospitals, MOH technical staff, and SURE staff members.

William Olumu (centre), senior pharmacist at Masaka Regional Referral Hospital demonstrates how RxSolution software operates. (Left) Assistant Commissioner health services Pharmacy Division- Martin Oteba, and (right) SURE’s district information management coordinator, Kim Hoppenworth.

Some of the dignitaries that attended the POA conference.

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Integrating ARV Medicines Reporting into Mainstream Health Care Reporting By Petra Schaefer and Michael Kavuma To order the correct amount of antiretroviral (ARV) medicines and have them on hand at all times requires health facilities to regularly report on ARV drug consumption and patient numbers. In the last three years, reporting rates for MoH facilities have been at 40-50 percent compared to PEPFAR implementing partner (IP) supported facilities whose rates have been between 80- 90 percent.

More SURE support to JMS comes to improve its procurement processes, management of third party logistics distributors, and development of a monitoring and evaluation function. With implementation of recommendations resulting from various on-going assessments, there is hope that JMS will have the ability to more effectively and efficiently supplement National Medical Store as a central supply agency.

Support to Joint Medical Store (JMS)

Overview of Joint Medical Store storage area

Many recommendations resulted from the conference: Establishing a national quantification and procure-

ment planning unit Streamlining supply chain information and functions Outsourcing distribution to third-party agents Recognizing and addressing the large funding gap for essential medicines and health supplies Establishing a financial and commodity tracking

system and, Prioritizing procurement of essential medicines

and health supplies (EMHS) according to vital, essential, and necessary concept. Only time will show how many of these recommendations will be possible to implement. But, it is beyond any doubt that if successfully implemented, Uganda will be-come a different country with much improved ac-cess to EMHS and better Health care provision.

By Saul Kidde Having been in business for over 30 years, Joint Medi-cal Store (JMS), a private not-for-profit (PNFP) organization has played an increasingly important role as a central agency for essential medicines and health supplies (EMHS) in Uganda. JMS has for long sup-plied medicines and other health supplies including equipment, primarily to PNFPs which contribute 40 percent of all health care facilities. When support from DANIDA ended and the kit sup-ply system was introduced for public sector primary health care facilities, PNFPS started experiencing months-long stock-outs of EMHS, including antima-larials. In response to this situation, USAID has strengthened its collaboration with JMS and is work-ing to help expand its services. The plan is for JMS to supply and distribute all EMHS to all PNFP facilities. Also the SURE program, following recommendations from the pharmaceutical sector policy options analysis is supporting JMS with additional assessments on dis-tribution, warehousing, and management information system functions to improve efficiency. For example, SURE together with the Supply Chain Management System project supported a post implementation re-view of JMS’s MACS and SAGE software function where an agreement was reached to identify an alter-nate resource planning system to handle JMS’s current and future needs.

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In December 2010, the SURE program working with MOH Resource Centre facilitated two consultants from Health Information Systems Program in Tanzania to setup and train a technical team comprising of MoH and development partners to support implementation and roll out of a central-ized reporting and ordering system.

This was aimed at improving and harmonizing reporting rates for both IP supported and government facilities. The centralized system was successfully integrated into the ex-isting open source health information reporting software and a server purchased to host the web-based health man-agement information system at the Resource Centre. The server was provided by the SURE program to the Ministry of Health Resource Centre. Once complete, the web based system will enable facilities to: Report on ARV stock and patient numbers Order for ARV drugs from medical stores and, Generate ARV drug quantities required at facilities This will also enable the Ministry of Health to easily access ARV patient regimen statistics in each reporting cycle. It is aimed at building sustainable solutions and strengthening institutional information systems for medicines and other health care information.

MoH Pharmacist for Hoima Regional Referral Hospital Abigaba Margaret (Left), and SURE’s Monitoring and Evaluation /Information Systems coordinator Belinda Blick (middle), carryout a stock count of malaria medicines at Rushooka Health centre IV in Ntungamo district during the EUV survey . Photo by: Julian Natukunda

End User Verification Survey to Curb Malaria Mortality and Morbidity By Belinda Blick With support from MSH’s Strengthening Pharma-ceutical Systems Program, MOH Pharmacy Divi-sion together with the SURE program started col-lecting data on availability of malaria medicines and malaria case management in June 2010. The data collection exercise known as the “end user verification (EUV) survey” collects data on behalf of Ministry of Health (MOH), National Malaria Control Program (NMCP) and Presidential Malaria Initiative (PMI) to inform policy makers and planners on the effectiveness of the health sys-tem in making malaria commodities available to those who need them. A total of fifty facilities from all levels of health care in ten districts have so far been visited, and data on supply chain and ma-laria case management collected. According to the September 2010 EUV report, 31 percent of adult patients and 36 percent patients be-low age of five had been diagnosed with malaria. This calls for the need to ensure appropriate malaria treatment is administered to patients. However, less than half of all health workers are trained in malaria case management. The EUV survey is a biannual exercise and data collection is done by use of both mobile telephones and paper based systems.

Assistant Commissioner MOH Resource Centre, Dr. Eddie Mukooyo (Left) and SURE program Chief of Party Dr. Birna Trap( Right) sign equipment agreements for the ARV reporting system. Photo by: Petra Schaefer

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The Pharmacy Division and SURE program acknowledge support from— MOH Resource Centre, MOH Programs (AIDS Control Program, National

Tuberculosis and Leprosy program, Central Public health laboratories, Na-tional Malaria Control program, and Reproductive Health program )

Makerere University and the Infectious Disease Institute National Drug Authority Joint Medical Store National Medical Store Uganda Medicines Therapeutics Advisory Committee Euro Health Group Pharmaceutical Healthcare Distributors (RTT) Management Sciences for Health US Agency for International Development US Centers for Disease Control President’s Malaria Initiative District Health Officers /Chief Administrative Officers Medicines Management Supervisors Implementing Partners

From the Managing Director position at the Euro Health Group, Dr. Trap is now Chief of Party for SURE program. She brings 25 years of expertise in pharmaceutical sector to the program. Birna has worked with essential medicines and health projects in over 30 countries.

As Assistant Commissioner in charge of Pharmacy Division, Martin has over 20 years experience in pharmacy management including supply chain, international and global health diplomacy. Martin has been with Ministry of Health since 1990 and was part of the team formulating the SURE program.

Profiles

About the SURE /MoH Collaboration SURE is a five-year program ending in 2014, funded by the United States Gov-ernment through the United States Agency for International Development (USAID). It is implemented by Management Sciences for Health (MSH), and works closely with Pharmacy Division to improve availability and accessibility to quality essential medicines and health supplies in Uganda. SURE and Phar-macy Division among other activities support commodity management, human resource capacity at central and district levels, improved management informa-tion and reporting systems, monitoring and evaluation, and strengthening man-agement and planning to optimize resource utilization.

Securing Ugandans’ Right to Essential Medicines (SURE) Management Sciences for Health (MSH) Uganda office Plot 15, Princess Anne Drive, Bugolobi P.O BOX 71419. Kampala, Uganda. Tel: 256 414 235 038 Fax: 256 414 235 035 Email: sureinfo@sure.ug | www.sure.ug Ministry of Health (MOH) Republic of Uganda Plot 6 Lourdel Rd, Wandegeya P.O. Box 7272 .Kampala Uganda Tel: 256-41-340884 Fax: 256-41-340887 Email: info@health.go.ug | www.health.go.ug

The Value Chain Newsletter Editor in Chief: Julian Natukunda Contributors: MOH and SURE staff. For More information and to contribute to the next issue; Please write to Julian Natukunda at jnatukunda@sure.ug or jnatukunda@msh.org or Call +256 (0) 759 800 155 This Newsletter is made possible by the generous support of the American people through the US Agency for International Development (USAID), under the terms of cooperative agreement number AID-617-A-00-09-00003. The contents are the responsibility of Management Sciences for Health and do not necessarily reflect the views of USAID or the United States Government.

Martin Olowo Oteba Assistant Commissioner, Health services, Pharmacy Division

Dr. Birna Trap Chief of Party, SURE Program