1. Current Status of HIV Pharmaceutical Management in Guangxi Province, China Helena Walkowiak, Management Sciences for Health /SPS Sharri Hollist, MSH/Strengthening Pharmaceutical Systems Beth Yeager, MSH/SPS Dr Connie Osborne, WHO Dr Zhang Lan, WHO December 9, 2008

2. Outline of Presentation  Overview of the WHO, MSH, Guangxi province ARV management Program  Objectives of the Assessment  Key findings  Options/strategy for strengthening ARV pharmaceutical management in Guangxi Province

3. ARV Management in Guangxi Province - Strengthening Pharmaceutical Systems (SPS) Program – An Overview  Funded by U.S. Agency for International Development  Implemented by Management Sciences for Health and supported by WHO  5 year award  June 29, 2007 – June 28, 2012

4. In collaboration with NCAIDS and WHO Workshop in Guangxi Province to introduce a tool for assessing the management of ARVs (July 2008)

5. Key Objectives of the Assessment  Map the flow of ARV medicines through the supply system including the processes of procurement, quantification, distribution and dispensing  Understand the roles and responsibilities of staff at each level in managing medicines for the ART Program  Identify forms, tools and procedures used for procuring ARV medicines, managing inventories, recording medicines transfers, dispensing, and reporting data  Solicit feedback on which procedures and tools currently being used are effective in managing ARV medicines and which may need to be strengthened to support program scale up

6. Site Visits: December 3 to 7, 2008 Unit Level Guangxi Autonomy Provincial CDCThe Fourth People's Hospital Provincial/City Guilin CDCGuilin The Third People's Hospital City Luzai County CDC Luzai County People’s HospitalCounty Liuzhou CDC Guangxi Autonomy Longtan Hospital City/Provincial Heng County CDC Heng County People's HospitalCounty

8. Status of the ART Program  The number of patients on ART is increasing rapidly From approximately 3,500 at end of 2007 to 5,217 including 144 children at end September 2008 7,000 projected at end of 2008 and 15,000 at end 2009 Increase of patients from 2007 to 2008 averaged 106% at sites visited (range 21% to 194%)  2 nd line – 25 plus several patients waiting for VL results  37 treatment sites in 21 counties 3 sites provide treatment for children  ARVs are procured primarily by the MOH, with additional donations from the Clinton Foundation and Glaxo

9. ARV Supply System in Guangxi Province  ARVs are dispensed at 3 levels of health care system – provincial, prefecture/city and county levels  At each level, CDC orders for the sites from the level above usually quarterly using a pull system Longtan Hospital orders directly from Provincial CDC Some stores and sites have been ordering monthly due to shortages at provincial store  Lead time: between 1 day and 1 week  Supplies are collected and transportation is reported to be a significant cost  Some sites requisition medicines from CDC store monthly or quarterly, and others as needed

10. Key Findings: Strengths  In general, many ART pharmaceutical management operations are reported to be working well Standard procedures for ordering, receiving and dispensing medicines and reporting are followed across sites Communication and coordination between provincial level and stores/sites is generally good and sites can return short dated stock for exchange Guangxi ARV drug management protocol available Storage space is generally adequate and secure; pallets, shelving and A/C available in most sites Dispensing supplies – envelopes and labels available

12. Key Issues (1)  Inadequate stocks of ARVs at Provincial Store No ARVs purchased through national procurement in 2008 ARVs are procured through bidding process at provincial level as necessary to fill the gap No stockouts have occurred for patients but the provincial level staff are on constant alert to manage shortages Orders from lower levels often cannot be filled in full increasing order frequency, management and transport costs To avoid stockouts, sites issue smaller quantities to patients who must return more frequently to collect refills increasing their transportation and in some cases accommodation costs

13. Key Issues (2)  Record keeping and reporting needs to be strengthened No standard forms to record inventory transactions (receipts, issues, running balance) Other gaps – expiry date monitoring and temperature monitoring tools “Too many forms” – some forms and reports are reported to be duplicative; tools need to be streamlined and consolidated where possible In long term, sites request a database linked to the patient information system

14. Key Issues (3)  Written standard operating procedures for managing medicines and controlling inventories at each level are not in place Many staff managing ARVs are part time so sites want standardized procedures and simple tools to streamline activities to ensure efficient use of staff  No formal methods for forecasting needs Methods used for annual planning and quarterly or monthly procurement are diverse e.g. buffer stocks Developing assumptions about future use reported to be especially problematic as guideline changes are implemented and numbers of patients and regimens used increase Sites request “simple tools” and procedures to analyze data and quantify needs supplemented by training

15. On-going and proposed support under the SPS program  Review of existing manual forms and tools to identify options to streamline, consolidate and fill gaps  Draft SOPs and related tools have been developed First training on SOP implementation – June 2009 Develop procedures and a supervision tool for monitoring Provide follow up support  Site visit findings were discussed with national and provincial stakeholders and partners to prioritize needs, identify options and develop an action plan to strengthen existing ARV management systems in Guangxi Province eg., Strengthening quantification procedures suggested by other partners