Assessment survey of TB drug management

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Assessment survey of TB drug management in
Cambodia Uchiyama Y, Chay S, Kousoum M, Leng C,
Kien S, Nou C, Chhom C
CENAT/JICA National TB Control Project, Cambodia
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Drug supply management system in Cambodia

• Selection/Procurement
• National Essential Drug List
• Public procurement (centralized system)
• Yearly drug requests from ODs/NHs to MOH
• Quantity adjustment, pricing open tender by MOH
• Distribution
• Flow of drug delivery requests
• CMS ? ODs/NHs quarterly
• ODs ? RHs/HCs monthly
• Inventory store management, following MOH
  guidelines
• Use
• Management is various among national programmes

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NTP TBDM

• Selection
• Criteria National/WHO Model List authorized TB
  guides
• Procurement (source other than NB)
• Donation of GDF-standard TB drugs from Japan
  through the JICAs Grant Program (2004-2006)
• Distribution
• Safety stocks (ODs/NHs 3M, RHs/HCs 1M)
• Use
• 8M treatment regimen
• (C1 2RHZE/6EH, C2 2RHZES/1RHZE/5RHE, C3
  2RHZ/6EH)
• DOTS approach hospitalization, ambulatory
  home delivery
• DOTS expansion to HCs 780/942 HCs (March 2004)
• Two TB staff in each health facility with TB
  service

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Examples of findings obtained from the
National Workshop on TBDM

• Selection/Procurement
• Qty. of TB drugs per bottle delivered ? qty.
  indicated on the label
• Shelf life of TB drugs delivered is not long
  enough to use up
• Distribution
• Stock records ? physical counts
• Poor quality of loose tablets (color change,
  moisture)
• No measure to verify the validity of TB drug
  consumption
• Use
• TB patients poor adherence to TB treatment
  poor knowledge of TB/TB treatment among TB staff
• Management support
• TBDM has not been a priority for supervision
• Policy and legal framework
• Private practitioners do not follow the TB
  treatment guidelines
• TB drugs are available in pvt. pharmacies without
  prescription

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Survey methods

• Design/Setting
• Treatment record review, structured interview
  inventory check
• 107 public TB health facilities (cover 40 of all
  the TB cases) in 14 TB high-burden ODs (14
  provinces) out of 75 ODs (24 provinces),
  including a problematic OD in TBDM reported 66
  pvt. pharmacies
• Intervention (7 investigators)
• Preparation (Oct-Nov 03), data collection (Nov
  03-Feb 04) data analysis (Feb-Mar 04)
• Outcome measures ()
• New ss TB patients who received correct TB drugs
  in correct dosage
• TB staff/new ss TB outpatients who had correct
  knowledge of TB
• Drug stores where stock records corresponded with
  physical counts
• Expired stocks for TB drugs
• Drug stores where stock-out for TB drugs was
  observed
• Treatment cost per new ss TB patient
• (Design outcome measures were referred to in
  the Drug Management for Tuberculosis Manual, MSH)

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Survey results 1 of new ss TB patients who
received correct TB drugs in correct dosage

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Survey results 2 of TB service providers who
had correct knowledge of TB/TB treatment

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Survey results 3 of new ss TB outpatients
who had correct knowledge of TB treatment

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Survey results 4 of drug stores where stock
records corresponded with physical counts of
expired stocks for TB drugs of drug stores
where stock-out for TB drugs was observed

• S 1000 vials were stored in 27 out of
  51 facilities.
• Physical countsexpired stocks is
  regarded as stock-out

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Survey results 5
Treatment cost per new ss TB patient (8M,
35-49Kg)

• Quoted from the International Drug
  Price Indicator Guide, MSH.
• Added 15 for shipping and insurance
  costs to FOB prices

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Conclusions recommendations

• Further attention should be paid to treatment for
  TB patients weighing gt50Kg.
• Periodic training on DOTS is needed for
  peripheral TB staff.
• TB outpatients answers are affected by
  interviewers position character (central NTP
  staff in charge of IEC/supervision activities are
  eligible).
• DOT rate among CF patients can be increased with
  expansion of community DOT.
• Periodic training on stock management is needed
  for pharmacists store keepers.
• More pharmacists are needed to reduce workload,
  or incentives should be considered for them.

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Conclusions recommendations (contd.)

• TB drugs procured should be of high quality the
  cheapest price. GDF-standard TB drugs are
  preferable.
• An indicator-based TBDM assessment survey can be
  utilized for
• identifying both strengths weaknesses in TBDM
• monitoring changes in TBDM practices quality of
  DOTS
• developing specific action plans for the
  improvement of TBDM
• providing health education to TB patients
• Close cooperation with the MOH is important to
  address DM issues that are beyond the scope of
  NTP.