Report Brief of civil society health users Monitoring of Access to Medicines in 5 Districts Tanzania 20122013 PRAXISCOFMEDSARPAM Mtetezi Project Initiative 1 Methodology Districts Monitors ID: 749618
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Civil Society Health Access Forum
Report Brief of civil society health users Monitoring of Access to Medicines in 5 Districts, Tanzania -2012-2013PRAXIS|COFMED|SARPAMMtetezi Project Initiative
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Methodology
DistrictsMonitors
Facilities
Months (2012)
Months (2013)5154555
District coveredDodoma:KondoaMpwapwaDar-es-Salaam:IlalaKinondoniTemeke
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Types of medicines monitored
#
Type of medicines
Ailments protected
Cluster of diseases protected1Artemether + lumefantrine 20 + 120mgMalaria
Malaria2Paracetamol 120mg/5mlFever, painMalaria/palliative3Paracetamol 500mgFever, pain4
Lamivudine/Stavudine/ Nevirapine 30+6+50mg dispersible
HIV infection
Chronic infections (HIV/TB), Immune deficiency5Rifampicin/isoniazid (150 + 75)mgTuberculosis 6Acyclovir 200mgHerpes Zoster, Chicken Pox-VZV (in immune comprised), 7Fluconazole 50mgFungal infections(eg.Cryptococcal meningitis)8Cotrimoxazole 480mgPneumonia,UTI,Bacterial Infections (Chest, lung, STD infections9Ceftriaxone 250mg pwd for injectionG+ve, G-ve infections(eg. Pneumonia, meningococcal meningitis,septicemia(in combination)10Cotrimoxazole 240mg/5mlRTI(eg. PCP,pneumococcus pneumomnia), UTI11Misoprostal 200 ugPostpartum HaemorhageMother and child health12Oxytocin 10IU/mlLabour induction, PPH13Vitamin A capsulePrevent blindness,14Zinc Sulphate 20mg dispersibleDiarhoea in children
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Key access indicators measured
Facilities in-stock“facilities which have actually got the type of medicine monitored at the time of the monitoring visit” This indicator goes along with Stocked facilities – “Facilities which normally stock the type of medicine monitored”Average stock-levels
“The counted stock-levels (in packs)”
Average days out-of stock
“Reported no. of days that a type of medicine has been out of stock”Average days needed to replenish“No. of days used for a type of medicine to arrive after an order has been made”4Slide5
Key Findings by Cluster of Ailments
MalariaChronic infectionsBacterial infectionsMCH5Slide6
Data reported through a monthly report card
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Malaria
Artemether + lumefantrine 20 + 120mg for uncomplicated malaria was designated as a 1st line treatment for malaria by TDFA and MoHSWAlthough other anti-malarials may be in stock, lack of access means 1st-line recommended treatment is not followed
May lead to development of resistance to future treatment
May also mean patients are directed to purchase 1
st line treatment in private facilities, with income for out-of –pocket payments for the poorest serving as a barrier7Slide8
Generally, supply of stocks was widespread throughout the health system - % of facilities-in-stock compared to stocked facilities
However supplies were erratic – a reflection of budget fluctuationsErratic supplies lead to least protection through 1st-line malaria treatmentIn 2012, supplies were lowest at end of FY – indicating inadequate annual funds or/and lapses caused by transition to new FY (i.e. closing accounts of ending then waiting to open and approval of budget of new FY before medicines are ordered)
Average stock-levels decline between 2002 and 2012
Medicine bought in bulk quarterly. Tends to deplete at end of quarter – leads to least protection against 1
st-line malaria treatment8Slide9
Widespread supply of anti-malarial stocks in designated facilities
Stocks were widely available in all corners of designated facilities. Sometimes overflowing to facilities that usually do not keep this type of medicine
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Supplies were erratic
The situation deteriorated btw 2012 and 2013. Tho’ there was constant supply of stock in facilities in 2012, the proportion decline in 2013 – with certain facilities which usually stock this this anti-malarial medicine not having stock in the facility – leaving users unprotected against uncomplicated malaria – inaccessible 1
st
line malaria treatment
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Tho’ still at a high level, % of stocks in facilities is declining
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Chronic infections (HIV/TB)
Concerned medicines were well stocked and well distributed across the health systemProcurement of medicines was not done directly by facilities – indicated by a high non-response of average days for replenishmentProcurement was done directly by national programmes
Stock-out levels declined at end of quarter – indicating lack of advance planning and ordering of new stocks
Levels of stock-outs of ARVs have been unstable in 2013, indicating deteriorations of protection against HIV infection
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Reform has been done to decentralise procurement planning for ARVs
Has accounted for increase in stock-levels, stocked facilities, but slight delays in stock-levels at facilities, stock-outs and no. of days to replenishThe case of ARVs is a reform process that has seemed not to have gone right
A dispensing facility staff captured by Community Monitors at work
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ARV stock-levels have been falling, part. at quarter-end
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Average days out of stock monthly and needed to replenish ARVs dramatically rose in 2013
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Stock-outs of ARVs more common at quarter-end (April 2012, 2013, end of FY in May, June and July, 2013)
Better planning and foresight could improve the situation
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Access to medicine for TB has been an example of a well managed national programme
Month
Stocked Facilities
% Stock-levels p.m.
Days out-of-stock p.m.Days to replenish stockFeb, 2012281000
0Mar, 20122510000Mar, 20133710000Apr, 20133110000
May, 2013
45
8017.545Jun, 20132310000Jul, 20133510000Something isolated happened in May, 2013, likely associated with planning for a new FY or a procurement issue17Slide18
Chronic illnesses are associated with immune-deficiency
Users require to guard against immune deficiency and fungal infections18Slide19
Protection against immune deficiency
High stock-out days despite short time needed for replenishment Stock levels were erratic, affected by quarterly planning, financial and procurement cycleSituation has worsened in 2013Users unprotected against viral attacks in the wake of immune deficiency
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No. of days needed to replenish Acyclovir 200 mg reduced in 2013, but stock-outs remained high
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All indicators declined in the case of protection against fungal infections
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Days out-of-stock and to replenish stocks have increased in 2013 – the latter indicating crisis procurement to deal with stock-outs at quarter-end
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Protection against bacterial infections (Chest, lung, STDs)
Monitoring looked at access to medicines on bacterial infections such as Urinary Tract Infections, Pneumonia, meningitis, reproductive tract infectionsAccess (supply) worsened severely in availability of Ceftriaxone 250 mg injection and Cotrimoxazole 240mg/5ml in 2013 – leaving users severely unprotected to pneumonia/UTI and bacterial infections respectively
Access (supply and availability) was stable but erratic for Contrimoxale 240mg/5ml for respiratory infections
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Extreme fluctuations of days out-of stock
(Blue bars = rising, grey = falling)
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No. of stock-out days increased in 2013, especially around end of quarter, FY
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Mother and child health services
The medicines monitored here aim at protecting life and health rights of mothers and children – MDG 4,5&6Medicines for maternal health were fairly protected – despite isolated incidences of high stock-outs for Misoprostal 200 ug (for stopping excessive bleeding after giving birth - postpartum hemorrhage – a key cause of maternal death
An MCH inpatient being interviewed by COFMED Community monitor
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Stock-out trends for MCH supplies – 2012- 2013
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It can be seen, average days out-of-stock for Misoprostal 200 ug (to stop excessive bleeding after giving birth) was both high and increased
Although small quantities are needed in-stock, there were sharp drops in stocks at beginning of both calendar and FYData collected indicates quantities of up-to 90 packs are bought after 3-6 months – consumed btw 10-20 a monthReplenishments are not managed directly by facilities, as they wait for supplyNew orders not made in sufficient advance, leading to observed stock-outsThe level of stock-outs for oxytocin 101U/ml for inducing labour and Vitamin A for treating anemia (decrease in blood quantity) increased in 2013
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Stock-levels were erratic and generally declined in 2013
Although stock-levels for Zinc Sulphate 20 mg dispersible for treating diarrhea in children (a main cause of U5 mortality) increased from 2012-2013, stocks were very erraticProcurement was generally done quarterly in large quantities stock-outs increasing at end of quarterDespite these problems, stock-out dates and days needed to replenish stocks decreased in 2013, indicating success with decentralisation
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All the foregoing condition require paracetamol for palliative care to facilitate treatment. Paracetamol 120mg/5ml for children is particularly important to suppress fever, known to be a cause of U5 mortality
Stock-levels were erratic for both and particularly lower for paracetamol for children in 2012, putting children at risk
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Picture in 2014
2012-2013 districts + Hai district31Slide32
No.of Days Out-of-stock
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No. of days-out-of-stock
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No. of days-out-of-stock
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Conclusions
Procurement mechanism contribute to lack of accessStocks are lowest at end/beginning of new quarter
/FY
Users are least protected during these periods
Better evidence-based planning at LGA level will contribute to accessProper change management has to be implemented when changing procurement modalities e.g. from supply through national programmes to LGAs. These have led to lack of access35Slide36
Recommendations
Civil society through COFMED needs to step-up pharmacovigilance and advocacy to ensure accessSpecific focus to be placed on predictable, sustainable allocation of funds through the national budget
Transparent procurement mechanisms
Timely planning, order placement and delivery of medicines to eliminate procurement-cycle induced stock-outs
Overall Assessment:
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