THE HEALTH MANAGER, Issue 7

union-imdp.org

THE HEALTH MANAGERTHE INTERNATIONAL MANAGEMENT DEVELOPMENT PROGRAMME® (IMDP)

ISSUE 7, 2014

EXECUTIVE PERSPECTIVE: MIRANDA BROUWER, MD

IMDP PARTICIPANT PROFILE: CHARITY OMENKA PROGRAM MANAGER, INSTITUTE OF HUMAN VIROLOGY, NIGERIA

CHALLENGES TO PROCUREMENT OF MEDICINES FOR DRTB

IN THIS ISSUE ON SUPPLY CHAIN MANAGEMENT

International Union Against Tuberculosis and Lung DiseaseHealth solutions for the poor

WELCOME TO

The Health ManagerISSUE 7, 2014

SUPPLY CHAIN MANAGEMENT

Dear Reader,

The recent rise of Ebola cases in Africa has once again underlined the impor-tance of robust public health logistics management. Supply chain management impacts the speed and accuracy of addressing the needs of patients with public health solutions.

In this issue of The Health Manager, Dr. Miranda Brouwer - a veteran special-ist in TB control, has worked in many low-resource countries and co-teaches IMDP’s Supply Chain Management course - shares her three cardinal rules of logistics management for clinical and programme professionals; Jessica Burry, the pharmacists at The Union North America highlights challenges to procure-ment of medicines for drug-resistant tuberculosis (DRTB); and Charity Omenka, a program manager at the Institute of Human Virology in Nigeria, reflects on the impact of the logistics training.

For further training on this subject, please visit www.union-imdp.org for The Union’s IMDP course on Supply Chain Management, November 10 -14, 2014 in Kuala Lumpur, Malaysia.

José Luis Castro Executive Director, The Union


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INSIDE THIS ISSUE

Executive Perspective: Miranda Brouwer, MD . . . . . . . 4

IMDP Participant Profile: Charity Omenka . . . . . . . . 10

The Broken Supply Chain: Challenges to Procurement of Medicines for DRTB . . . 14

The Health Manager is published by The Union’s Interna-tional Management Development Programme (IMDP). Director of Publications: José Luis Castro, Marketing and Business Development Manager: Stephan Rabimov. © 2014 The Union.

Photo credit: Courtesy of the Foundation for Innovative New Diagnostics (FIND)

4 Photo: Courtesy of Dr Miranda Brouwer

Dr Miranda Brouwer remembers the time when a diligent tuber-culosis programme field professional carefully wrote out the req-uisition for ten thousand units of a needed drug. Precise perhaps to a fault, the worker placed a decimal point and two zeroes after the numeral, and handed the form off to the procurement section.

There, a procurement specialist failed to see the decimal point – and scheduled an order for one million units.

Dr Brouwer, who observed the incident as a consultant, is happy to report that the error was caught before any harm could be done.

EXECUTIVE PERSPECTIVE:MIRANDA BROUWER, MDDR BROUWER, A VETERAN SPECIALIST IN TB CONTROL, HAS WORKED IN MANY LOW-RESOURCE COUNTRIES AND CO-TEACHES IMDP’S SUPPLY CHAIN MANAGE-MENT COURSE.

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But, she says, it was a close call that illustrates one of her three cardinal rules of supply management for clinical and programme professionals: communicate frequently, meaningfully and careful-ly with your colleagues in the procurement section.

“In many ministries and programmes,” she says, “the TB profes-sionals and the pharmacists or others in procurement are in differ-ent silos and don’t normally interact. If the pharmacists don’t have a clear and complete understanding of how care is being delivered in the field, and if the TB professionals don’t understand how the

RULE ONE OF SOUND SUPPLY PROCUREMENT AND MANAGEMENT

COMMUNICATE FREQUENTLY, MEANINGFULLY AND CAREFULLY WITH YOUR COLLEAGUES

IN THE PROCUREMENT SECTION.

Photo credit: HERD Nepal, permission to use given.

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procurement specialists do their job, the risk of a request going wrong increases.”

In addition to the decimal point error, Dr Brouwer has heard of pharmacists ordering loose tablets rather than blister pack sheets, or vice versa, because the field requisition was imprecise or incom-plete. Had the pharmacists better understood treatment protocols and procedures, she notes, such misunderstandings would diminish.

“The procurement people need a reference point so they can readily tell whether an order is in the normal range.”

For this to happen, Dr Brouwer says, a programme or ministry has to take time to bring both departments together in an exchange of information: each side has to understand how the other functions.

Dr Brouwer’s second rule of sound supply procurement and man-agement: always take the patient’s perspective. “People often say that Procurement and Supply Management is all about paper and boxes,” she notes, “but ultimately it’s about people. The end of the line is a patient who needs a drug or a health care worker needing supplies for tests.”

RULE TWO OF SOUND SUPPLY PROCUREMENT AND MANAGEMENT

ALWAYS TAKE THE PATIENT’S PERSPECTIVE.

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DATE LOCATION FACULTY LEVEL FEE LANGUAGE

November 10–14, 2014

Kuala Lumpur, Malaysia

Ron Wehrens and Miranda Brouwer

Middle- to senior-level professionals

Euro 1,500 Course fee includes accommodation, break-fast, lunch, tea breaks, and course materials

English

SUPPLY CHAIN MANAGEMENT 2014 COURSENovember 10 – 14, 2014 • Kuala Lumpur, Malaysia • Register at union-imdp.org

REGISTRATION DEADLINE: October 10th, 2014

Contact IMDP: [email protected]

Upon acceptance into course, applicants will be invoiced. Fee payment is due within 30 days of invoicing.

WHO SHOULD ATTEND

This course is designed for middle- to senior- level procurement spe-cialists, doctors, pharmacists, warehouse managers and consultants manag- ing drugs and/or laboratory supplies. Partici- pants involved in HIV/AIDS programmes or the forecasting, procurement, storage and distribution of TB-related commodities will all benefit from this training.

PROGRAMME AGENDA

The objective of this five-day course is to provide participants with the practical knowledge and skills to effectively manage the antituberculosis medicines and laboratory commodities needed in today’s TB programmes.

There is increasing collaboration and coordination with TB programmes and many of the topics covered in this course can also be applied to the management of antiretroviral drugs and HIV diagnostics.

The techniques presented in lectures will be applied during realistic case exercises and simulations related to pharmaceutical supply management (PSM).

BENEFITS OF TRAINING

1) Discover the key global actors in the production, financing and distribution of TB drugs and supplies

2) Gather technical knowledge about first- and second-line TB medicines

3) Write better PSM plans for grants

4) Become familiar with laboratory require-ments, including those needed for latest diagnostic techniques such as GenXpert

5) Strengthen procurement skills

6) Achieve better prices and supply management

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Often the professional who prepares the requisitions sits in an of-fice and does not see the patients and workers at the front lines of care delivery. This, she says, can cause the procurement process to appear as a depersonalised function. Workers in this situation

have to consciously think of the patient and the clinical profes-sionals every day, she says: “Get the patient perspective into your work,” she advises. “Think of the end user when you go through

RULE THREE OF SOUND SUPPLY PROCUREMENT AND MANAGEMENT

CHECK, RECHECK AND RECHECK.

Photo credit: HERD Nepal, permission to use given

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each procurement step. The more attention you pay to this, the better the work will be done.”

Dr Brouwer’s third rule: “Check, recheck and recheck.” With very large orders covering up to a year common in many low resource countries, the numbers can get very large. The margin between under-supplying and over-ordering with risk of expiry is thin, and the cost stakes high. So, it is important to be careful. She recom-mends that all organisations have a team of people to review each large order before it is placed.

Dr Brouwer is looking forward eagerly to the upcoming IMDP course on Supply Chain Management. As a teacher, she learns from participants as well as they learn from her. The course, she prom-ises, will be lively, rich in “real-world” examples and case studies, and keep participants engaged in group activities.

Participants will go home with three things, she says: “Practical tools they can use without reinventing the wheel, sharpened skills and new knowledge.”

Photo credit: HERD Nepal, permission to use given

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Knowing how to manage the supply chain of multidrug-resistant tuberculosis (MDR-TB) was a challenge for Charity Omenka, Pro-gramme Manager at the Institute of Human Virology in Nigeria.

But that was before she enrolled on the International Development Management Programme (IMDP) ‘Supply Chain Management’ in 2013. Today, Omenka, who has a background in pharmacy and public health, is able to take on the challenges of supply chain management and more.

“The course met all of my objectives and more,” said Omenka, whose main responsibilities include procurement, stocking and pipeline

Photo: Courtesy of Charity Omenka

PARTICIPANT PROFILE:CHARITY OMENKA PROGRAM MANAGER, INSTITUTE OF HUMAN VIROLOGY, NIGERIA

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management of pharmaceuticals. She added, “It was really very useful. The facilitators were wonderful, versatile, experienced and vastly knowledgeable.”

Omenka stressed that she had got much more out of the course than just answers to the questions that she had arrived with. “I came to the course with three major questions about supply chain management, and they were all answered. But I learned far more than this. The instructors were very experienced, knowledgeable and helpful—I took away all kinds of useful tools. For example, one key insight I gained was how to apply the Pareto principle*

I CAME TO THE COURSE WITH THREE MAJOR QUESTIONS ABOUT SUPPLY CHAIN MANAGEMENT,

AND THEY WERE ALL ANSWERED.

Photos: Courtesy of Charity Omenka

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to my work, which has made a big difference in helping us manage our pipeline efficiently and keep control of our budget.”Omenka said she enrolled on the IMDP course eager to know how others had dealt with similar challenges, and what resources might be out there to help. She was not disappointed.

Omenka had three concerns in particular which led her to seek support from The Union. The first was reconciling the costs of cer-tain laboratory commodities (equipment, tests, etc. ) within IH-VN’s budget from the program’s funder, the Global Fund to Fight AIDS, Tuberculosis and Malaria. Her other concerns were ques-tions around the availability of new treatment specifically for chil-dren with MDR-TB and about ancillary drugs.

Omenka explained, “Ancillary drugs are those used to manage the side effects of second-line TB drugs. Doctors would complain that the drugs we were supplying were not enough. They didn’t under-stand that our grant didn’t cover other diseases a patient might have, just the side effects of MDR-TB treatment.”

Kitted second line drugs

Photos: Courtesy of Charity Omenka

Updated medication charts and folders

A copy of the medication chart correctly filled

Pyrazinamide 400mg supplied by IDA.

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New-Found Knowledge

Omenka has put her new-found knowledge to good use. She has firmer control over budgeting, supply and cost containment; has instituted the per-patient allowance model for ancillary medica-tions and has applied the Pareto principle* to everything from choosing shipping routes to warehousing to purchasing decisions.

One of the facilitators was particularly helpful with the supply/cost question. Omenka was provided with numerous websites and other resources to help her with sourcing commodities and to keep the costs in check. Another facilitator opened up a discussion on the question of ancillary drugs. Omenka learned that a similar programme in the Philippines simply provided doctors with a per-patient allowance, which they can then apply to whichever drugs they think are the most appropriate.

Last but not least, Omenka learned that there are currently few pediatric-specific MDR-TB drugs available—children are generally treated with smaller doses of adult drugs. “But the Clinton Founda-tion and Global Fund are working to get drug manufacturers inter-ested in addressing this, so there is hope,” said Omenka with a smile.

* (The Pareto principle, also known as the 80 –20 rule, states that in many cases, 80% of effects arise from 20% of causes. For example, 80% of Omenka’s budget is accounted for by about 20% of the drugs that she is responsible for—so adjustments to the way these go through the pipeline will have the greatest impact on cost control.)

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DATE LOCATION FACULTY LEVEL FEE LANGUAGE

December 1–5, 2014

Kuala Lumpur, Malaysia

Golpalakrishnan Viswanath and Gayatri Sriram

Middle- to senior-level professionals

Euro 1,500 Course fee includes accommodation, break-fast, lunch, tea breaks, and course materials

English

LEADING MANAGEMENT TEAMS 2014 COURSEDecember 1 – 5, 2014 • Kuala Lumpur, Malaysia • Register at union-imdp.org

REGISTRATION DEADLINE: October 31st, 2014

Upon acceptance into course, applicants will be invoiced. Fee payment is due within 30 days of invoicing.

WHO SHOULD ATTEND

Middle- to senior- level health programme managers and directors who must execute strategy, manage and supervise other staff and work with different stakeholders across multiple levels, divisions and locations in a national health programme or organisation.

PROGRAMME AGENDA

This course explores leadership and strategy execution in high performing teams. Changing the performance and behavior of others requires that leaders first identify the changes that must occur within themselves.

This five-day course will help participants enhance their performance by building leadership competencies and strengthening their mentoring and coaching skills.

The course combines exercises, case studies from real health management situations and role-playing simulations. Participants will address specific managerial problems from their own countries and strategic issues affecting public health programmes globally.

BENEFITS OF TRAINING

1) Assess your strengths as a leader and practice various management styles

2) Create a personal map of strengths and weaknesses for self-development

3) Negotiate and manage communica-tions in multi-partner arrangements

4) Learn about the performance manage-ment process and its applications

5) Practice coaching and mentoring skills in order to obtain optimal results

6) Improve your ability to handle conflict and difficult people and conversations


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THE BROKEN SUPPLY CHAIN: CHALLENGES TO PROCUREMENT OF MEDICINES FOR DRTBJESSICA BURRY PHARMACIST, THE UNION N.A., BSC. PHARM, ACPR, MSC. INFECTIOUS DISEASES

Provision of medicines, diagnostics and medical supplies is clearly a necessity for even a basically functional health care system. Finding the right products and getting them to the people who need them at the right time is quite often a challenge, particularly in resource-limited settings. In addition to the usual logistic issues of customs clearance, shipping and providing quality-assured (QA) medicines, the supply chain for second-line drugs (SLDs) for drug-resistant tuberculosis (DRTB) is fraught with other problems that make it even more difficult to ensure patients are able to receive treatment, let alone to scale up access to diagnosis and treatment for all those who need it.

Photo: Courtesy of Jessica Burry

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In 2012, the World Health Organization (WHO) estimates that 450,000 people developed multidrug-resistant tuberculosis (MDR-TB), with approximately 9.6% of them being extensively drug-re-sistant tuberculosis (XDR-TB).1 For these patients, who require 24 months of treatment, interruption in their medicine supply can have detrimental consequences, leading to development of further resistance and thereby limiting the number of effective medications

and increasing the risk of spreading DRTB. In a disease where only 62% of patients are cured or at least finish the two years of treat-ment,2-4 a broken supply chain or receiving poor quality medicines can mean the difference between life and death.

In the pharmaceutical world, the population known to be affected by MDR-TB is relatively small and the disease is not life-long. This means that the economic incentive for pharmaceutical suppliers to engage in the expensive process of producing anti-TB medicines

IN A DRTB, WHERE ONLY 62% OF PATIENTS ARE CURED OR AT LEAST FINISH THE TWO YEARS OF TREATMENT,

A BROKEN SUPPLY CHAIN OR RECEIVING POOR QUALITY MEDICINES CAN MEAN THE DIFFERENCE

BETWEEN LIFE AND DEATH.

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is small. Production of some Active Pharmaceutical Ingredients (APIs) and final products such as the injectables require fermenta-tion, crystallization and freeze-drying, processes that are expensive and complex.5 Aside from expensive manufacturing procedures, in the current regulatory environment it takes years for new medi-cines to be approved by National Regulatory Authorities (NRAs) or quality assured by the WHO Pre-Qualification Program (PQP). Small patient populations means small orders that suppliers will need to pool together to run a production-sized batch, increasing the lead-time* and risk of stock-out* at the national level.

Despite the production challenges, additional suppliers are need-ed to improve supply and avoid monopolies that produce high prices, while currently unvalidated suppliers must engage in QA and regulatory processes.

In many countries where resources are already strained, the funds directed towards supply chain management are limited. Without specialised training and appropriate data/IT programmes for phar-macy and logistics staff, accurate forecasting and supply manage-

* Lead-time: * Stock-out:

The time from placing an order to receiving the shipment on-site. Includes administrative processing, payment pro-cessing and shipping times. If a manufacturer does not have supply on-hand, the lead-time will lengthen consider-ably to account for production time.

A temporary lack of medicine at a health facility that may be caused by many factors in the supply chain.

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ment are next to impossible. Securing funding for medicines and programmess is a necessary first step; however, staff capacity build-ing is equally essential if health systems are to improve. In many low-income countries, this may mean collaboration of the Ministry of Health with Non-Governmental Organisations (NGOs) special-ised in Supply Chain Management to make tools and trainings avail-able for local staff, with the intent to reduce stock-outs, improve in-ventory and supply management and improve overall access to care.

Resources also need to be allocated for National Regulatory Bod-ies to implement or improve their abilities to accurately evaluate manufacturers to ensure only high quality medicines are available in their country, regardless of the procurement mechanism. Alter-natively, policies can be implemented to allow faster registration of medicines already approved by the WHO PQP or Stringent Regula-tory Authorities (SRAs) and to ensure only high quality products are available nationally, across the public and private sectors. Such policies would reduce the number of DRTB cases attributed to self-

WITHOUT SPECIALISED TRAINING AND APPROPRIATE DATA/IT PROGRAMMES FOR PHARMACY AND

LOGISTICS STAFF, ACCURATE FORECASTING AND SUPPLY MANAGEMENT ARE NEXT TO IMPOSSIBLE.

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prescribing and use of poor-quality medicines. Given that many SLDs have a short shelf-life of only two years, national policies to decrease customs clearance time (which can take many months) would be a useful step in improving access to medicines.

Despite the many challenges, there have been improvements in the supply chain since the formation of the Global Drug Facility (GDF), which started supplying SLDs in 2006. They have been able to in-crease the supplier base and provide QA medicines to an increasing number of patients each year, and at a decreasing price. Recently, with the support of UNITAID, GDF announced they would expand their stockpile of SLDs, which was implemented to reduce lead-times and allow for supply of emergency orders to decrease stock-outs. However, at over US$5,000 per patient treated, with a large percentage of patients going untreated, and a shortfall of TB-allo-cated funding globally, there is still much work to be done. Patients already endure two years of treatment with toxic medicines that cause psychosis, deafness and constant nausea, and they should not need to also worry about whether or not there will be enough drugs in stock at the clinic to finish the treatment that could save their life.

References: 1. http://www.who.int/tb/en/2. http://www.theunion.org/what-we-do/publications/technical/dr-tb-drugs-under-the-microscope-the-sources-and-prices-of-medicines-3rd-

ed3. Orenstein E, Basu S et al. Treatment Outcomes Among Patients with Multidrug-Resistant Tuberculosis: Systematic Review and Meta-Analysis.

The Lancet, Vol 9, March 2009.4. Johnston J, Shahidi N, et al. Treatment Outcomes of Multidrug-Resistant Tuberculosis: A Systematic Review and Meta-Analysis. PLoS One,

Vol 4, Issue 9, Sept 2009.5. Developing and Strengthening the Global Supply Chain for Second-Line Drugs for Multidrug-Resistant Tuberculosis. Workshop Summary.

The Union, North America 61 Broadway, Suite 1720 · 10006 New York, NY, USA Tel: (+1) 212 500 5736 · Fax: (+1) 347 772 3033 email: [email protected] · www.union-imdp.org

THE HEALTH MANAGERTHE INTERNATIONAL MANAGEMENT DEVELOPMENT PROGRAMME® (IMDP)

ISSUE 7, 2014


union-imdp.orgHealth solutions for the poor

THE HEALTH MANAGER, Issue 7

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