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THE VALUE CHAIN Pharmacy Division-SURE Newsletter Issue 2, March 2012

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Welcome to the second issue of the Value Chain Newsletter. In this issue, we feature stand-alone stories from the field highlighting our achievements and successes. This publication will update you on our collaborative activities toward improving access to essential medicines and health supplies.

IN THIS ISSUE Field stories…………..........2, 3 Support to JMS………............4 SURE-MUK collaboration.......5 New information sharing system…………………….……...5 Breaking cultural barriers……6 The UMTAC ………….. …....7 Stock status reports…………..7 Planned/ongoing activities…...8 Upcoming publications and reports..........................................8 Partners…….………....….…..8 Distribution of the 45 intervention districts (shaded areas )

MOH and SURE trained Medicines Management supervisor explains the correct method of dispensing to a health worker in Luwero district. Photo credit: SURE Program

The USAID funded and Management Sciences for Health led Securing Ugandans’ Right to Essential Medicines (SURE) Program is working with the Uganda Ministry of Health (MOH) Pharmacy Division and partners to strengthen pharmaceutical management systems. Since our last issue, the SURE program has moved into all 45 of its designated districts and has registered everincreasing improvement in indicators measuring dispensing, ordering and reporting, storage, and stock management at public health facilities and private not-for-profit facilities. The Pharmacy Division in collaboration with other implementing partners such as STAR E, STAR EC and STRIDES and in collaboration with SURE has started the roll out of supervision and performance assessment by trained medicines management supervisors (MMS) into 42 more districts as part of achieving national coverage. As this issue describes, the presence of MMS at facility level has transformed medicines management and led to better availability of essential medicines. Please find out more about our achievements in the pages to follow and feel free to share a copy of this newsletter with colleagues. We will keep you updated on our progress!


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Stories from the Field In Uganda, districts and health sub-districts play a key role in delivering and managing health services. Although 72% of households live within five kilometers of a health facility, poor infrastructure and lack of medicines and health supplies continue to hinder access to quality services. According to the Annual Health Sector Performance Report 2009/10, only 21% of facilities had six vital medicines (artemisinin-based combination therapy, cotrimoxazole, depo provera, measles vaccine, oral rehydration solution, and sulfadoxine/pyrimethamine) available at all times.

Mentoring and Coaching at Koboko Health Center IV By Jimmy Ondoma and Denis Okidi

Over the years, Koboko HC IV, located in the West Nile region of Uganda, has experienced challenges in the management of essential medicines and health supplies (EMHS). Stock-outs of vital medicines were widespread, while huge quantities of slow-moving medicines were at risk of expiring. These problems were attributed to health workers’ poor skills in logistics management. In addition, there was no reliable information to guide staff on when and what to order, because stock cards were not regularly updated.

Lebu Akim, the Stores’ Assistant at Koboko Health Centre IV store after the intervention. Photo by: Jimmy Ondoma

has used the supervision, performance assessment, and recognition (SPARS) approach in 45 districts in Uganda. This approach involves mentoring and coaching pharmacy and stores’ staff at private not-for-profit and public health facilities in medicines management. In the last six months, Lebu Akim, a Store’s Assistant at Koboko Health Centre IV underwent two sessions of mentoring and coaching by the medicines management supervisor trained by the SURE program. “Our system for stock management has improved. We update our stock cards regularly and carry out a physical count every month, which we never used to do in the past. Our orders are based on consumption, and we keep enough stock to last up to the next delivery,” says Lebu.

Above is the appearance of part of the store with piles of medicines and supplies at Koboko HC IV before intervention. Photo by Jimmy Ondoma

In July 2011, Pharmacy Division and SURE program started capacity-building activities aimed at strengthening EMHS systems at health facilities in the region. SURE

SURE assessed the facility’s performance after the third supervisory visit in January 2012. The assessment was based on five medicines management indicators that included storage quality and use of stock cards, appropriate availability of vital and non-vital medicines; and dispensing quality. The results showed the health facility’s overall increase in performance in stock management from 30% to 63%. Storage management improved from 54% to 76% and ordering and reporting from 56% to 76%.


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Stories from the Field

Kojja Health Center IV Registers Increase in Medicine Stocks

480mg tablets were reduced to 17 from 37 days, while artemether-lumefantrine 20mg/120mg tablets were not out of stock at all.

By Samuel Omalla and Victoria Nakiganda

Kojja Health Center (HC) IV in Mukono district (central region) is one of the facilities that had previously performed poorly, with frequent stock-outs of vital medicines.

The graph below shows improvement at Kojja HC IV after the baseline and second visit conducted in April and May 2011. Scale 0–4 represents scores for each indicator, the maximum being 5.

“From October to December 2010, we didn’t have cotrimoxazole 480mg tablets for 37 days. Artemetherlumefantrine 20mg/120mg tablets (35 kg and above) also ran out of stock for 32 days,” says Sarah Namakula a nursing officer in-charge at Kojja HC IV store . Between December 2010 and April 2011, 68 medicines management supervisors (MMS) from central and eastern regions were trained. The role of these supervisors is to provide on-the-job training to health workers in stock and storage management, prescribing and dispensing, and ordering and reporting practices, while collecting data on indicators to enable them to monitor performance of health facilities.

Through regular supportive supervision, more health workers like Sarah are gaining skills on how to order medicines correctly, manage medicines stock and the store, update and fill out stock cards, and dispense properly. This will minimize medicine wastage, stock inadequacies, and overstocking in facilities. Monthly data on medicines stock and facility performance will also be available for decision making.

Bundibugyo Hospital Appreciates New Changes By Lynda Nantongo and Timothy Nuwagaba

A patient receives medicine from Sarah Namakula, a dispenser and nursing officer in-charge at Kojja Health Center IV. Photo by: Samuel Omalla

At Bundibugyo Hospital, Angole Ruben has worked as a store in-charge for 29 years. Now, as a medicines management supervisor, Angole is using the knowledge and skills he acquired during the training he attended in April 2011 to mentor and train other health workers in the district.

Kojja HC IV is one of the facilities receiving supportive supervision from MMS. Supervision visits conducted in May and June 2011 revealed an increase in stock of vital medicines. Kojja HC IV’s stock-out days for cotrimoxazole

Since then, Angole has worked hard to make his store stand out as one of the best maintained stores in Bundibugyo. His efforts have paid off; a team from the United Nations Children’s Fund that visited the store in


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September 2011 likened Angole’s well-maintained store to those operating in Australia. The district health team, too, is full of praise for the hospital’s new changes. “We used to order for medicines and supplies without prioritizing. As result, there were frequent stock outs of medicines. The shelves in the store were unlabeled, and it would take me a longer time to locate some of the medicines once an order was placed,” says Angole. The store is cleaner, essential medicines and supplies are consistently available, and shelves are labeled according to medicines’ generic names with updated stock cards on every shelf. Improvements in dispensing and prescribing practices include longer dispenser-patient interaction time and use of dispensing equipment to count medicines . Reporting and ordering is also better.

Angole Ruben (Blue coat) with the Store assistant Eratus Kamero while updating stock cards. Photo by Lynda Nantongo.

With the MMSs mentoring and training other health workers in their districts, service delivery to the population will continue to progress as medicines and health supplies are made available at facilities.

Business Process Transformation Project Improves Customer Service Delivery at JMS By Andrew Hayman and Andrew Cohen

‟order to cash‟, „forecast to replenishment‟, and „purchase to pay‟. Participants acquired skills in interviewing JMS staff to identify value-added and non-value added activities, and in designing new processes. They also used their new knowledge to create process maps indicating the sequence of activities, departments responsible, and time spent weekly on each

The Joint Medical Store (JMS) participated in a business process transformation project to strengthen the efficiency and effectiveness of its procurement, warehousing, and sales functions. Taking part in the project were senior and middle management staff at JMS who not only analyzed and redesigned current processes, but also identified and eliminated activities that did not add value. For example, as part of the analysis, at least 67% of such activities in the “forecast to replenishment” process were completely eliminated. The project also resulted in a 72% decrease in time spent on non-value added activities for all primary processes. This led to the creation of new and more customer-responsive processes. Participants at JMS during the start of the team training exercise, together with the facilitator, Andrew Hayman .

activity, and then to decide on the appropriateness and value of each activity‟s contribution to delivering customer service. The business process transformation project enabled JMS to determine ways to move forward with a detailed implementation strategy for the revised activities.

Uganda SURE facilitated the project, Photo credit. Joint Medical Store which began with a one-day workshop where participants received in-depth The workshop and process analysis were part of technical assistance protraining on three primary processes— vided to JMS between August and November 2011 by the USAID-funded SURE program and RTT, one of SURE‟s implementing partners.


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Institutionalizing Training in Supply Chain Management By Khalid Mohammed

The SURE program is working with one of its partners, Makerere University (MUK), to institutionalize the training of medicines management supervisors. The initial agreement is for MUK College of Health Sciences (MUK CHS) to train 220 MMS from all districts in the country enabling them to perform in-service training in medicines management (MM). In parallel to MMS training, as part of getting MM into preservice training, MUK will assist in changing the curriculum of all health training institutions to incorporate MM into the curricula of all health workers. In November 2011, MUK conducted its first training, where 20 participants successfully passed the two-week’s course in supply chain management. While speaking at the closing ceremony, the deputy principal at MUK CHS said, “Effective next year, the component of medicines management will be included in the college’s training curriculum.” Adome Odoi, a professor at the college who is spearheading the drive to change the curriculum, believes that having MUK conduct trainings in supply chain management will provide MMS and health workers with knowledge to carry out their jobs effectively. Odoi thanked the SURE program for sharing their tools, materials, and expertise that has

A pioneer participant receives a supervision bag and certificate after attending the MMS training conducted by Makerere . Photo credit: MUK CHS

bridged the gap between academic concepts and actual practice in the field. The Pharmacy Division led by the Assistant Commissioner Health Sciences-Martin Oteba, applauded the curriculum change and pledged on behalf of Ministry of Health to provide the technical support necessary to ensure its smooth implementation.

Netbooks Lay Foundation for Easy Information Sharing By Kim Hoppenworth and Tom Opio

Medicines management supervisor Peter Okot (left) demonstrates how he uses the electronic form installed on the netbook to the Senior Pharmacist at Masaka Regional Referral Hospital, William Olumu (right) and Tom Opio, SURE’s District Information Officer (center).

As a result of monthly data collection on facility performance by MMS in Uganda, a lot of paperbased data collection forms were generated. The number of MMS increased to 146 in October 2011. However, in the last ten months, data from at least 300 facilities was submitted for analysis, which required extra time and resources to enable data entry and analysis. In September 2011 the use of netbooks was introduced. The netbooks offer a computerized system for MMS to capture and share data electronically. The netbooks are installed with Adobe Acrobat X (pdf data collection software) that allows direct data entry into an electronic form designed in the same format as the paper form the MMS were using.


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SURE organized a two-day training where eight MMS gained hands-on experience on the use of netbooks, filling out electronic pdf forms, setting up an email account, and using online support tools such as Team Viewer and Skype. “One month after the training, half of the MMS including those who had no prior knowledge and experience in using computers submitted data using the pdf electronic form,” said Kim Hoppenworth, SURE’s District Computerization Coordinator.

The trained MMS are now using netbooks and pdf forms to collect and submit data, which are easily and quickly shared using electronic mail. Since MMS enter data directly and share it electronically, the software facilitates data collection, aggregation, and initial analysis. The SURE program has procured netbooks for all MMS working in the 45 SURE-supported districts. This will not only equip MMS with computer and communication skills, but will also improve capacity and performance of district health facilities in planning, distributing, managing, and monitoring of essential medicines and health supplies.

Women MMS Break Cultural Barriers in Central Uganda By Samuel Omalla

In a region where only a handful of women can ride motorcycles due to cultural norms and taboos, Doreen Naluggwa, a 30-year-old Clinical Officer at Seeta Nazigo Health Center III, in Mukono district, is one of the few women who have broken the norm. She had never thought of riding a motorcycle until early 2011 when she received an invitation to undergo a six-day motorcycle defensive training course. In November 2010, Doreen attended a two-week course in medicines management organized by the SURE and Pharmacy Division which she passed successfully. But to serve as a medicines management supervisor, she also had to learn how to ride a motorcycle, after which she would get

Doreen Naluggwa puts on her protective gear before starting her journey to a health facility to provide supportive supervision. Photo Credit: SURE Program

a motorcycle to ease her transport during the supervisory visits. “I never thought that I would be able to learn how to ride, but I managed. I was the only lady that passed in my group. Now, I don’t fear riding a motorcycle because I realized that no one can know I am a lady when I wear the helmet and the riding suit. Even the community has got used to seeing me riding my bike. It feels good and I make my supervision schedules without worrying about transport,” says Doreen. Despite the scar on her right leg that she got after hitting a log while riding a motorcycle, Doreen has not given up. She is responsible for supervising five facilities in her district. Four facilities are located far from Doreen’s facility, and the motorcycle has made it possible for her to plan, get to clinics, and work with staff comfortably. Other health workers are now seeing her as a contact person to pass on their needs to the District Health Officer. She has requested and delivered dispensing trays and also redistributed medicines from over-stocked to understocked facilities using the motorcycle. Today, 26 female MMS like Doreen have completed motorcycle riding training—breaking the barriers entrenched in the Central Ugandan culture.


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New Committee for Appropriate Use of Medicines By Dorthe Konradsen

Although several health sector strategic documents stress the importance of using medicines appropriately, Uganda had no organizational entity focused on medicine use and therapeutics. To address this gap, the SURE program in close collaboration with the Pharmacy Division and the Quality Assurance Departments proposed to the Ministry of Health to urgently create a national body to promote appropriate use of medicines in the public sector.

7 UMTAC has already held three meetings to review, update, and finalize the essential medicines, laboratory commodities, and health supplies lists, and also identified necessary changes to the Uganda Clinical Guidelines 2010. The new lists classify all the essential medicines and supplies into “vital,” “essential” and “necessary,” an important step to prioritize the use of scarce resources. Once complete, the lists will guide health facility staff in ordering medicines and supplies and the National Medical Stores in making procurement decisions. SURE continues to support UMTAC to update the Essential Medicines List and develop the Essential Health Supplies List; while the US Centers for Disease Control and Prevention supports the development of Essential Laboratory Commodities

MOH Makes Stock Status Report Official MOH Document By Morris Okumu

Having declared the stock status report an official government document, the Uganda Ministry of Health (MoH) requires that the report be presented every two months to all levels of management.

Some of the members that attended the Uganda Medicines Therapeutics and Advisory Committee launch. Photo credit: SURE Program

January 13, 2011 marked the launch of the first national committee in charge of appropriate use of medicines—the Uganda Medicines and Therapeutics Advisory Committee (UMTAC). The goal of UMTAC is to promote availability and appropriate use of medicines and health supplies in the public sector. Speaking at the launch, former Director General—Health Services at MOH, Dr. Kenya Nathan Mugisha said, “One of the main challenges facing medicines and health supplies management in the health sector is lack of an authoritative channel through which health workers can access information on current practices in rational medicines use, prioritization of requirements and continuous education on rational medicines use. UMTAC inauguration is a timely intervention to ensure that we have in place a structure to mitigate the challenges.”

“The MoH publishes on a bi-monthly schedule a national stock status report that is shared with all partners. This report is discussed by the Health Policy Advisory Committee and published on our website. The report is very informative and has provided basis for actions on so many issues,” said Dr Asuman Lukwago, Acting Permanent Secretary MoH while addressing the board and management of Medicines Stores Department of Tanzania. In 2010, SURE and Pharmacy Division launched the stock status report, which highlights challenges, bottlenecks, and potential solutions to mitigate stock-outs and expiries of antiretrovirals, HIV test kits, artemisinin-based combination therapies (ACTs), anti-TB medicines, reproductive health commodities, laboratory products, and other selected tracer medicines. The report was developed to respond to the need for better coordination to ensure commodity security. It quickly produced results; it triggered a donation of first-line antiretrovirals for the public sector by US government, as well as a donation of ACTs from UK’s Department for International Development—in both cases averting a looming stock-out.


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The Pharmacy Division and SURE program acknowledge support from—

Events, Ongoing and Planned Activities

            

MOH Resource Centre and technical programs (AIDS Control Program, National Tuberculosis and Leprosy Program, Central Public Health Laboratories, National Malaria Control Program, and Reproductive Health Program) Makerere University Kampala 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 and Prevention District Health Officers /Chief Administrative Officers Medicines Management Supervisors Implementing partners

About the SURE /MoH Collaboration SURE is a five-year program ending in 2014 funded by the US government through the US Agency for International Development. The program is implemented by Management Sciences for Health, and works closely with the Pharmacy Division to improve availability and accessibility to quality essential medicines and health supplies in Uganda. SURE and the Pharmacy Division support commodity management, human resource capacity at central and district levels, improved management information and reporting systems, monitoring and evaluation; and strengthening management and planning to optimize resource utilization. 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 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

Updating of the essential medicines and health supplies lists and treatment guidelines Roll out strategy for the online ARV ordering and reporting (webbased) system RxSolution pilot is finalized. Roll out to the first 10 facilities to be conducted this year National Drug Authority (NDA) and SURE will begin piloting the new inspection tool for pharmacies in public health sector. MOH-PD and SURE conducted the 3rd Regional Pharmacists‟ meeting (February 2012) Organized a meeting between DHOs and medicines management supervisors for Western and Central regions Makerere University College of Health Sciences completed 3rd MMS training in medicines management (March 2012)

New and Upcoming Publications/Reports

For more information and to contribute to the next issue please Contact Julian Natukunda at jnatukunda@sure.ug or jnatukunda@msh.org or call +256 (0) 759 800 155

The Pharmacy Division and SURE program have undertaken a number of assessments to improve pharmaceutical health delivery in Uganda. Once finalized, publications are expected on the following

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-617A-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.

Second kit system survey

Annual pharmaceutical health sector performance

Concept paper—SPARS strategy

The national TB logistic assessment

A new national essential medicines and health commodities logistic manual


The Value Chain Newsletter II