Second Africa TB Regional Conference on Management of TB Medicines

Africa TB Conference 2012, Zanzibar December 5-7, 2012

Country experience in planning, quantification and supply of MDR-

TB medicines in Kenya

Dr Richard Muthoka DLTLD

To render Kenya and its communities free of Leprosy, TB and Lung Disease

Objectives of Quantification and Procurement Planning • To quantify the country’s multidrug-resistant (MDR)

TB medicines needs • To highlight the challenges of MDR TB commodity

security experienced in Kenya • To describe the interventions laid down to address

these challenges • To share results and lessons learned

Background Information • Case Notification Rate (CNR) in 2011 for all forms of TB is

298/100,000. Total cases—103,981 (CNR 83%) • Policy on surveillance—all retreatment cases • WHO estimates (2003):

– Retreatment cases—1.7% – 0.9% among the new cases

• 2003 to 2011, cumulative MDR-TB Patients diagnosed: 692 • Treatment of MDR-TB

– Private sector in 2006 – Public sector

• From April 2008, 389 patients on treatment – 284 patients on treatment – 101 patients cured

• Drug resistant (DR)-TB treatment sites 134

Trend of TB Cases: 1987–2011

Problem Statement

• Need to have uninterrupted supplies • Need for focus on supply planning of second-line TB

medicines • Challenges in data for planning for scale-up of DR-TB • Slow enrollment of cases leading to expiry of some drugs • Changes of treatment protocols for DT-TB care and treatment • Decentralization of MDR-TB treatment • Short expiry dates of medicines • Geographical diversity of country • Different levels of understanding of needs by health care

workers

Interventions

• Conduct a comprehensive quantification • Develop a procurement plan • Advocacy for Green Light Committee (GLC) to

approve treatment of all DR-TB patients • Form a commodity supply chain monitoring team • Ensure a reliable supply of second-line medicines to

support MDR-TB treatment and decentralization plan

Process of Implementation of Interventions

Step 1 • Decide composition of the commodity security subcommittee • Identify key stakeholders (USAID, MSH, KAPTLD, World Bank, KEMSA, Kenya-

pharma/Phillips, WHO, KANCO, MSF, CDC and MOMS, IOM & NACC)

Step 2

• Bring together of all key stake holders for consensus building on key assumptions (1 day)

• Select a smaller team to then use the assumptions to generate the actual commodities requirements

• Actual F and Q and supply planning exercise (3 days)

Step 3 • Identify of key financial partners • Plan for dissemination meeting

Process of Implementation of Interventions

Step 4 • Obtain funding commitment

Step 5 • Procurement

Step 6 • Monitoring of procurement process by the

commodity security committee

Financial Gap Analysis and Commitment

13,227,210.59 (100%)

Total financial gap FY 2012-2013

11,671,546.69 (88.24%)

1,555,663.9 (11.76%)

Total commitmentsResultant Gap after commitment

Results

Immediate • Quantification draft report completed • Advocacy and identification of key partners and

dissemination of the report • Funding commitments obtained from government

and donors to meet the financial obligation • GoK officials, donors, and procurement agents

committed to adhere to procurement plan

Results

Procurement requirements

Available funds

(USD) (USD)

First Line anti-TB medicines 4,028,577.08 6,132,992.00 -2,104,414.92Second line anti-TB medicines 954,687.95 1,680,992.00 -726,304.05Total Cost for 1st&2nd Line Medicines 4,983,265.03 7,813,984.00 -2,830,718.97PW&D fees 10% 498,326.50 340,894.39 157,432.11Sub total 5,481,591.53 8,154,878.39 -2,673,286.86

AFB Microscopy & Equipments 1,559,708.49 417,042 1,142,666.49Central Reference Laboratory 1,396,784.76 330,456 1,066,328.76Gene-Xpert laboratory items 2,534,249.30 2,534,249.30 0Sub total 5,490,742.55 3,281,747.30 2,208,995.25

Stationery requirements 629,190.00 206,796.00 422,394.00IEC Materials 1,625,686.00 28,125.00 1,597,561.00Sub total 2,254,876.00 234,921.00 2,019,955.00 Grand totals 13,227,210.08 11,671,546.69 1,555,663.39

Stationery &LMIS Tools RequirementCDCGFssf

GFssf USAID, WHO

Gok

Laboratory CommoditiesGFssf

, Bank & GFssf

World Bank

FINANCIAL GAP FOR TB COMMODITIES FOR THE YEAR 2012-2013

Item Description Financial Gap

(USD) Funding Source

First and Second Line Anti-TB Medicines

Monitoring and Evaluation

• An all inclusive commodity security subcommittee in place which meets monthly to assess the stock-status situation and monitor the commodities pipelines

• The committee meets monthly to review the MDT-TB commodities stock situation and review procurement quantities or call downs from suppliers

• Feedback given to all stakeholders (2-page report detailing the stock status situation in the country)

Lessons Learned • An all inclusive process is key for support and ownership • Bringing together donors, government, and procurement

agencies ensures effective coordination of commodity supply • A comprehensive procurement plan acts as a good roadmap

for the procurement process and is a vital tool for monitoring • A well functioning mechanism for monitoring of commodity

pipeline always provides early warnings thus ensuring uninterrupted access to medicines

• Timely planning on capacity building of staff to address knowledge gaps on both commodity management and rational use/pharmacovigilance of medicines

Strengths and Weaknesses of Interventions

Strengths • Support from the partners by providing skills and insight to

the quantification and forecasting process • Government commitment • Support from the GLC for expansion of MDR-TB treatment • 2011 annual case report provided morbidity data for

quantification Weaknesses • Missing data of previous procurements from KEMSA during

quantification • Insufficient data on average monthly consumption from the

facilities to enable a consumption-based quantification method

Challenges

• Poor recording and reporting due to unavailability of hard M&E tools and treatment algorithms

• Inadequate commodity management at the facilities—ordering, storage, inventory management, prescribing of SLMs, and handling of expired medicines

• Human resources—knowledge gap on patient management in view of the decentralization

• Poor pharmacovigilance results in – Poor quality care of patients as a result of

decentralization – Increased toxicities, morbidity, and mortality

Summary

To assure uninterrupted supply of MDR-TB medicines— • Involve all relevant stakeholders in building assumptions • Determine the requirements • Develop a comprehensive procurement plan • Obtain commitments from government, donors, and

procurement agencies • Put in place a well functioning mechanism for pipeline

monitoring that provides regular and timely feedback • Act promptly on the feedback

CSC - Group photo