Global Fund Regional Workshop on Learning from PSM Experiences to Improve Grant Performance

1
Global Fund Regional Workshop on Learning from
PSM Experiences to Improve Grant Performance

• Abuja, Nigeria
• December 1214, 2007

2
Findings and Lessons Learned from Selected Case
Studies
3
Objectives

• Discuss the case studies objectives of in three
  countries in West Africa
  
• Articulate the key challenges in implementing
  malaria grants in Ghana, Guinea-Bissau, and
  Nigeria
  
• Draw lessons learned from the findings

4
Outline

• Background
• Objectives and methodology
• Findings and lessons learned
• Conclusion

5
Background

• Global Fund malaria grants2,584,874,749 U.S.
  dollars (USD), including more than 264 million
  artemisinin-based combination therapy (ACT)
  treatments
• Slow procurement and implementation
• Three countries selected as case studies to
  assess procurement and supply management (PSM)
  for ACTs in context of Global Fund grants

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Case Studies Objectives

• Describe ACT implementation in the three
  countries
  
• Focus on procurement, supply, and distribution of
  ACTs
  
• Trace progress and document key events in
  implementing the Global Fund grant related to
  ACTsfrom developing the proposal and the PSM
  plans to distributing ACTs to health facilities
• Identify bottlenecks in the processes that
  contributed to delays
  
• Describe the steps taken to address those
  bottlenecks
  
• Draw lessons learned from how the three countries
  implemented their grants

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Methodology

• Document review from various sources
• Field visitsOctoberDecember 2006
• In-depth interviews with key stakeholders
• Document review
• Visits to selected storage areas and health
  facilities
  
• Mapping of delays in the procurement process

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Ghana ACT Implementation Timeline

• First-line treatmentartesunate-amodiaquine
• January 2005Treatment policy changed to ACTs
• March 2005ACT order placed
• April 2005ACTs arrive in Accra, Ghana
• October 2005Distribution begins

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Ghana General Findings (1)

• Procurement process
• ACTs arrived one month after order placed
• Process facilitated by direct disbursement to
  supplier
  
• Principal Recipient (PR)Ghana Health Service
  (GHS), which had existing relationships with
  subrecipient (SR), National Malaria Control
  Program (NMCP), and other parts of PSM chain PR
  took part in proposal development
• Country Coordinating Mechanism (CCM) recognized
  for technical strength
  
• Planning undertaken early with key stakeholders
• Human resources capacity strengthened

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Ghana General Findings (2)

• Training started late therefore, distribution
  began six months after product arrived
  
• Medicines distributed after training completed
• Procurement of locally manufactured ACTs led to
  adverse drug reactions (ADRs) and poor acceptance
  of new treatment
  
• Some early stock-outs occurred
• Quantification challenges
• Government did not procure for non-Global Fund
  districts
  

11
Guinea-Bissau ACT Implementation Timeline

• First-line treatmentartemether/lumefantrine
• June 2005Treatment policy change to ACTs
  announced
  
• October 2006Treatment policy change endorsed by
  policy makers

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Guinea-Bissau General Findings

• Experienced PR with plan to transfer PR
  responsibilities to local institution
  
• Policy change process slow
• Human resources challenges
• No existing relationships among stakeholders
• Delayed submission of implementation plan impeded
  access to additional resources
  
• ACTs had not been procured at time of assessment

13
Nigeria ACT Implementation Timeline

• First-line treatmentartemether/lumefantrine
• February 2005Treatment policy changed to ACTs
• July 2005Full payment for ACT order sent
• November 2005ACTs ready to ship
• February 2006Required documentation and
  approvals for importation received
  
• March 2006First shipment of ACTs arrived
  implementation begins
  

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Nigeria General Findings

• Procurement
• Procurement agency contracted
• Procurement took more than 15 months because of
  challenges
  
• Challenges in replenishment of stock
• Leakage to private sector
• Experienced PR with good credibility
• No existing relationships with NMCP and other key
  actors
  

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Findings PR, SRs, CCM Roles and Responsibilities

• Unclear definition of and distinction in roles
  and responsibilities for PR, SR, and CCM
  
• PR has limited experience and capacity in
  procurement and supply management
  
• Undefined mechanisms of accountability
• Undefined structures and mechanisms for
  collaboration
  

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Findings Coordination

• Existing relationships vs. building
  relationships
  
• Many key stakeholders not involved early
• PSM stakeholders
• Coordination mechanisms not used (e.g.,
  coordinating/implementation committees)
  
• Resources for implementation underestimated

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Findings Planning

• No written implementation plans
• Activities
• Roles
• Timelines
• Key stakeholders not involved in planning
  process
  
• Planning for technical assistance (TA) and
  capacity building not included in proposal or
  implementation plan

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Findings PSM Plan Development

• Technical assistance for PSM plan development
• TA not sought early
• Often, external consultants used for PSM plan
  development without involvement or understanding
  of implementers
  

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Findings PSM Implementation

• Limited understanding of procurement procedures
  and regulations
  
• Delays and resource waste through fund transfers
  and currency conversions
  
• Training often not appropriately coordinated with
  arrival of medicines and distribution
  
• Limited regulation and quality monitoring of
  substandard products
  
• Inadequate budgets

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Findings Global Fund Mechanisms

• Insufficient understanding of Global Fund
  mechanisms and procedures
  
• Insufficient awareness of existing document and
  resources

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Findings Monitoring, Evaluation, and Reporting

• Milestones and targets often not aligned with
  activities and fund disbursement
  
• Unrealistic targets
• Inadequate systems for routine monitoring
• Multiple malaria monitoring systems
• Insufficient human resources capacity building
  for collecting and analyzing data
  
• Lack of standardized reporting systems

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Lessons Learned Effective Coordination (1)

• Clearly articulated stakeholder roles and
  responsibilities may lead to smother
  implementation
  
• Memorandums of Understanding (MOUs) or other
  contractual mechanisms between PRs and SRs may
  help establish or create greater accountability
  
• Review of Global Fund guidelines on CCMs may
  assist better understanding of roles and
  responsibilities
  
• Incorporating key stakeholders, including the
  private sector, early in process promotes
  ownership and acceptance as well as adherence to
  the policy

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Lessons Learned Effective Coordination (2)

• Creating mechanisms for coordination and
  collaboration among PR, SRs, and other
  implementers assists the implementation process
  
• Delegating specific functions while maintaining
  oversight may liberate the PR for macrolevel
  activities
  
• Decentralizing resources for implementation can
  promote a more rapid implementation process
  

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Lessons Learned PR Experiences

• Selecting PRs on the basis of strict criteria
  that measure their capacity and ability may
  promote great credibility and smoother
  implementation
• Ensuring that PRs have experience and capacity in
  procurement and supplies management (or ensuring
  that capacity built rapidly) reduces bottlenecks
  in these processes

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Lessons Learned Planning for Procurement and
Distribution (1)

• Developing implementation, procurement,
  distribution, training, and monitoring and
  reporting plans soon after the proposal is
  approved and before implementation begins may
  facilitate appropriately planned implementation
• Including provisions for technical assistance and
  capacity building in key areas ensures budgets
  are available with minimal time lag for obtaining
  such assistance

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Lessons Learned Planning for Procurement and
Distribution (2)

• Clarifying country procurement procedures,
  preparing needed documents, and budgeting
  adequately for complementary activities, such as
  customs clearance and distribution, ensures
  budgets are available for these activities with
  minimal lead times
• Involving institutions already involved in the
  countrys pharmaceutical management, and using
  the existing distribution agency as a central
  information system may facilitate adequate buy-in
  and use of existing systems

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Lessons Learned Global Fund PSM Plan Development

• Ensuring that country-level implementers are
  fully involved in PSM Plan development
  facilitates implementation
  
• Ensuring that PSM Plan fully reflects country
  context facilitates implementation

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Lessons Learned Procurement

• Understanding the procedures of suppliers,
  procurement agents, and others involved in the
  procurement process, including the payment terms,
  may reduce lead times
• Direct disbursement by the Global Fund to the
  suppliers reduced procurement lead times

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Lessons Learned Supply Chain Management

• Integrating supply chain systems rather than
  creating parallel ones may simplify
  implementation
  
• Costs of distribution, including distribution to
  peripheral facilities, need to be adequately
  estimated
  
• Developing systems to track inventory assists
  subsequent monitoring

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Lessons Learned Training and Communication (1)

• Coordinating training to begin before medicines
  arrive in country and to end before distribution
  begins helps minimize time lag for distribution
  while ensuring effective recall of issues by the
  health care providers
• Training all health system cadres in key
  pharmaceutical management functions may improve
  the supply chain management of the commodities

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Lessons Learned Training and Communication (2)

• Avoiding registering products that do not comply
  with standard dosage schedules or quality
  standards may reduce the likelihood of their
  procurement and wide distribution and prevent
  ADRs
• Developing mechanisms to address the quality of
  the locally produced medicines as part of a
  broader quality assurance system may facilitate
  instilling consumer confidence in the new
  treatment, particularly if it is being
  manufactured locally

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Lessons Learned Monitoring, Evaluation, and
Reporting (1)

• Aligning milestones and targets with activities
  and fund disbursement facilitates the continuous
  availability of funds for planned activities
  
• Developing realistic targets improves the
  likelihood that targets are effectively met
  
• Coordinating the system for monitoring of malaria
  with other diseases may assist in efficient use
  of resources for similar activities and avoids
  duplicate recording

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Lessons Learned Monitoring, Evaluation, and
Reporting (2)

• Recruiting staff to collect and analyze data
  helps with efficiency and long-term
  cost-effectiveness
  
• Standardizing reporting systems avoids
  overburdening the system with multiple streams of
  data and reporting mechanisms

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Conclusion

• Successful procurement and supply management is
  key to success of implementation of Global Fund
  grants
  
• Grant management in PSM is a key challenge within
  most Global Fund grants