Civil Society Health Access Forum

Civil Society Health Access ForumReport Brief of civil society health users Monitoring of Access to Medicines in 5 Districts, Tanzania -2012-2013

PRAXIS|COFMED|SARPAMMtetezi Project Initiative

1MethodologyDistrictsMonitorsFacilitiesMonths (2012)Months (2013)5154555District coveredDodoma:KondoaMpwapwaDar-es-Salaam:IlalaKinondoniTemeke2

Types of medicines monitored#Type of medicinesAilments protectedCluster of diseases protected1Artemether + lumefantrine 20 + 120mgMalariaMalaria2Paracetamol 120mg/5mlFever, painMalaria/palliative3Paracetamol 500mgFever, pain4Lamivudine/Stavudine/ Nevirapine 30+6+50mg dispersibleHIV 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 children3Key access indicators measuredFacilities in-stockfacilities 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 monitoredAverage stock-levelsThe counted stock-levels (in packs)Average days out-of stockReported no. of days that a type of medicine has been out of stockAverage days needed to replenishNo. of days used for a type of medicine to arrive after an order has been made

4Key Findings by Cluster of AilmentsMalariaChronic infectionsBacterial infectionsMCH5Data reported through a monthly report card

6MalariaArtemether + 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 followedMay lead to development of resistance to future treatmentMay also mean patients are directed to purchase 1st line treatment in private facilities, with income for out-of pocket payments for the poorest serving as a barrier7Generally, supply of stocks was widespread throughout the health system - % of facilities-in-stock compared to stocked facilitiesHowever 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 2012Medicine bought in bulk quarterly. Tends to deplete at end of quarter leads to least protection against 1st-line malaria treatment

8Widespread 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 9Supplies were erraticThe 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 1st line malaria treatment

10 Tho still at a high level, % of stocks in facilities is declining11Chronic 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 programmesStock-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

12Reform has been done to decentralise procurement planning for ARVsHas 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 work13ARV stock-levels have been falling, part. at quarter-end

14Average days out of stock monthly and needed to replenish ARVs dramatically rose in 201315Stock-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 situation16Access to medicine for TB has been an example of a well managed national programmeMonthStocked Facilities% Stock-levels p.m.Days out-of-stock p.m.Days to replenish stockFeb, 20122810000Mar, 20122510000Mar, 20133710000Apr, 20133110000May, 2013458017.545Jun, 20132310000Jul, 20133510000

Something isolated happened in May, 2013, likely associated with planning for a new FY or a procurement issue17Chronic illnesses are associated with immune-deficiencyUsers require to guard against immune deficiency and fungal infections18Protection against immune deficiencyHigh 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

19No. of days needed to replenish Acyclovir 200 mg reduced in 2013, but stock-outs remained high20All indicators declined in the case of protection against fungal infections21Days out-of-stock and to replenish stocks have increased in 2013 the latter indicating crisis procurement to deal with stock-outs at quarter-end22

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 respectivelyAccess (supply and availability) was stable but erratic for Contrimoxale 240mg/5ml for respiratory infections23Extreme fluctuations of days out-of stock (Blue bars = rising, grey = falling) 24No. of stock-out days increased in 2013, especially around end of quarter, FY25Mother and child health servicesThe 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 monitor26Stock-out trends for MCH supplies 2012- 201327It 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

28Stock-levels were erratic and generally declined in 2013Although 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

29All 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 mortalityStock-levels were erratic for both and particularly lower for paracetamol for children in 2012, putting children at risk30Picture in 20142012-2013 districts + Hai district31No.of Days Out-of-stock32No. of days-out-of-stock33No. of days-out-of-stock34ConclusionsProcurement mechanism contribute to lack of accessStocks are lowest at end/beginning of new quarter/FYUsers are least protected during these periodsBetter 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 access35RecommendationsCivil 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 budgetTransparent procurement mechanismsTimely planning, order placement and delivery of medicines to eliminate procurement-cycle induced stock-outsOverall Assessment:

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