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Title: Assessment survey of TB drug management


1
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
2
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

3
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

4
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

5
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)

6
Survey results 1 of new ss TB patients who
received correct TB drugs in correct dosage

7
Survey results 2 of TB service providers who
had correct knowledge of TB/TB treatment

8
Survey results 3 of new ss TB outpatients
who had correct knowledge of TB treatment

9
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

10
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

11
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.

12
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.
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