Evaluating the Effectiveness of TB Medicine Supply Management Training in Western Cape, South Africa Fathima Fyzoo 1 ; Margaret von Zeil 2 1.Management Sciences for Health, SPS 2. Department of City Health, Western Cape ICIUM November 2011, Antalya, Turkey

Background  South Africa (SA) has the second highest tuberculosis (TB) incidence in the world at 971 per 100,000 population ( WHO Global TB report, 2009 ).  The SA National TB programme targets for 2011: cure rate of 85% and treatment success rate of >85%  An effective medicine supply management (MSM) system is essential  In SA, TB is managed mainly at a primary health care (PHC) level  MSM at most PHC facilities presents a huge challenge  SPS decided to provide support for MSM with a specific focus on TB

Objectives  To determine the feasibility of using of TB medicine supply indicators for monitoring TB medicine management practices  To determine the effectiveness of TB MSM training for nurses at PHC facilities

Design  Intervention with a pre-post assessment and no control group Setting  Intervention was undertaken at primary health care facilities within the public sector in the Western Cape province

Intervention/Methods (1) A two day training workshop on TB MSM provided to 46 nurses from 28 PHC facilities

Intervention/Methods (2) TB MEDICINE LIST Tick if item is Stocked Tick if item has a stock card Stock Card balance Shelf (physical stock) balance Tot. Qty issued in 3 last months Maximu m (Re- order) level Averag e stock level Quantity expired (no. of packs) 1. Rif, INH, ETHAM & PZA 150/75/400/275 - Rifafour e-275 (28s) 2. RIF, INH, ETHAM & PZA 150/75/400/275 - Rifafour e-275 (56s) 3. RIF, INH, ETHAM & PZA 150/75/400/275 - Rifafour e-275 (84s) 4. RIF, INH, ETHAM & PZA 150/75/400/275 - Rifafour e-275 (112s) 5. RIF, INH, ETHAM & PZA 150/75/400/275 - Rifafour e-275 (140s) 6. RIF, INH, ETHAM & PZA 150/75/400/275 - Rifafour e-275 (100s) 7. Rifampicin and isoniazid 150/75 - RIFINAH (56s) 8. Rifampicin and isoniazid 150/75 - RIFINAH (84s) 9. Rifampicin and isoniazid 300/150 - RIFINAH/RIAZID (56s) TB MSM Facility Assessment Tool

Intervention/Methods (3) Facility TB MSM indicators 1. % TB medicines with a stock card 2. % of TB stock cards updated 3. % of TB medicines with correct average and re- order stock levels 4. % of TB medicines out of stock per month 5. % of TB medicines expired per month

Results (1): Baseline & post training assessment at 3months p= 0.011p=0.003p=0.001

Results (2): Baseline and post training assessment at 3 months

Results (3)  No correlation was found between facility improvement and the number of nurses per facility trained  None of the facilities showed any relapse following improvement across all indicators over the 3 month assessment period  The ‘expired TB medicines’ & ‘correct average/reorder level’ indicators are more appropriate as a quarterly indicators rather than monthly indicators

Summary  Use of TB MSM indicators was effective in measuring the outcome of training in a PHC setting.  Nurse training in TB medicine supply management resulted in improved TB stock management.  As a limitation, the evaluation did not follow-up on sustainability of good medicine management practices hence future evaluations should be designed as quarterly assessments over a longer period.

Conclusions & Policy Implications  In the absence of pharmacists/pharmacist’s assistants at PHCs, training and capacity building of PHC nurses can ensure good MSM  Implementation of simple assessment tools and indicators for routine self monitoring can be effectively used to encourage good MSM practices at a PHC level  Ongoing M & E by PHC supervisors and district coordinators is essential to ensure sustainability of interventions

Acknowledgements 1.District PHC supervisors/coordinators, Western Cape 2.Tiwonge Mkandiwire, SPS, MSH 3.P.C. Palli, Independent Research Statistician THANK YOU!