Quantification from a TB Perspective PSM Workshop to Develop GFATM PSM plans for HIV, TB and Malaria February 2006, Nairobi

Framework: Pharmaceutical Management Cycle Selection Procurement Management Support Distribution Use Policy and Legal Framework Quantification

Quantifying Medicines and Supplies Needs Purpose To estimate the quantity of medicines needed to ensure an uninterrupted supply and to fully cover estimated TB treatment requirements

Applications of Quantification (1) Prepare and justify a drug budget (e.g. for GFATM) Plan for new and expanding tuberculosis programs—e.g. DOTS expansion to other districts Optimize medicine budgets based on TB cases to be treated and the most cost- effective treatment approaches QUAN 3

Applications of Quantification (2) Calculate emergency needs for disaster relief and epidemics Replenish an existing supply network that has become depleted of products Compare current consumption of medicines with tuberculosis treatment priorities and usage in other health systems QUAN 4

Critical Issues in Quantification (1) QUAN 7 1.Developing the medicine list (selection) 2.Preparing an action plan for quantification 3.Using centralized or decentralized quantification 4.Using manual or computerized methods for quantification 5.Estimating time requirements, including procurement period, stock-outs, safety stock 6.Filling the supply pipeline

Critical Issues in Quantification (2) QUAN 8 7.Considering the impact of lead time at all levels (buffer stock: 6 months national; 3 months district) 8.Adjusting for program growth and for losses due to waste and theft 9.Cross-checking estimates produced with previous years of alternative methods 10.Estimating total procurement cost 11. Adjusting and reconciling final quantities in accordance with available funds

Quantification is difficult Must know accurate number of patients at all levels Must know number of patients in each category of treatment Must accurately calculate the quantity of each medicine and supplies needed to avoid under or over stock

Options for Quantification 1.Morbidity based: this is the WHO- recommended method that bases estimates on number of cases 2.Consumption based: An alternative method available to systems with a functioning DMIS to base estimate on past consumption—also useful for ordering or replacing stocks 3.Adjusted-consumption based: Estimates based on data from another region or health service QUAN 5

Comparison of Quantification Methods QUAN8 Consumption versus Morbidity Consumption – need good inventory records Morbidity- need patient attendance data Both methods – need data on existing stocks, lead times, costs

Morbidity Method (1) 1.Estimate number of expected cases per disease category in the projected year –e.g cases category I for 12 months 2.Identify the number of tablets of each medicine selected to treat category I TB patient –504 of isoniazid/rifampicin (RH) –168 of pyrazinamide (Z) –168 of ethambutol (E)

Morbidity Method (2) 3.Account for new cases during stock-out periods, safety stock, procurement period, and lead time –8 months total or 1000 category I cases 4.Multiply the number of tablets required by the total estimated cases –1000 category I cases x 504 units isoniazid/rifampicin = 504,000 –1000 category I cases x 168 units pyrazinamide = 168,000 –1000 category I cases x 168 units ethambutol = 168,000 Then add to these totals the number of tablets equal to an 8- month supply (504,000 x 1.67—8/12) 5.Subtract stock on hand and the result is amount to procure

Example of spreadsheet – Morbidity Method (1) *Adjusted order factor in years: equals lead time plus safety stock (e.g., 6 months + 2 month = 8months = 0.67 years) Treatmen t Category (A) Estimated Cases for Year (B)(C)(D)(E)(F) Basic Units per Case (e.g., tab, vial) Total Basic Units per Product Needed Adjusted Order Factor * Quantity in Stock Total Quantity to Procure (A x B)(0.67 x C) RH 150/75 mg tabsCat. I ,000337,68052,000789,680 Z 400 mg tabsCat. I ,000112,56015,000265,560 E 400 mg tabsCat. I ,000112,5609,800270,760

Example of spreadsheet – Morbidity Method (2) Treatment Category (G) Units per container (blister) (H)(I)(J) Number contain ers (blister) to buy Container (blister) PriceTotal Price US$ (F/G) (G x H) RH 150/75 mg tabsCat. I 2828, ,742 Z 400 mg tabsCat. I 289, ,509 E 400 mg tabsCat. I 289, ,512

Consumption Method (1) 1.Divide total annual consumption of specific medicine units by 12 to get average monthly consumption –Isoniazid/Rifampicin = 259,200 ÷ 12 = 21,600 units/month 2. Account for amount of units required monthly and taking into account stock-out periods, safety stock, procurement period, and lead time –8 months: 21,600 x 8 = 172,800 additional units

Consumption Method (2) 3.Combine total annual consumption with buffer amounts to get total number of units to be ordered –259, ,800 = 432,000 units total 4.Subtract any stock on hand

Example of spreadsheet – Consumption Method See handouts in participant’s notebooks for rest of spreadsheet

Adjusted-Consumption Method When neither consumption nor morbidity method is feasible This option extrapolates consumption data from another region or health system –population-based (medicine use x 1000 population) –service-based (medicine use per specific patient or case)

How to make TB quantification easier? Use fixed dose combination medicines with 3 or 4 medicines in one tablet Use patient kits where all medicines needed for a full course of treatment are in one product (patient pack) Both reduce the number of products to count For example: Current regimen: (RH)+ Z+ E = 3 products If use 4 FDC (RHZE) = 1 product If use patient kit = 1 product

Summary – Quantification Needed for: –Planning, budgeting, and ordering Critical issues: –Must first have good selection of drugs –Decide who will quantify – centralized (NTP) vs. decentralized activity –Tools to use - manual vs. computerized –Knowledge of lead times, stock-outs, safety stock, growth, losses, existing stocks –Reconcile quantities needed with budget