Background

1. Assessment Survey of TB Drug Management in CambodiaUchiyama Y, Chay S, Kousoum M, Leng C, Kien S, Nou C, Chhom C (CENAT/JICA National TB Control Project, Cambodia) Background • In 2003, the National Tuberculosis Programme of Cambodia (NTP) faced serious stock shortage of TB drugs for the first time in its history due to the occurrence of unpredictable events related to drug management (DM). Although the crisis was come through, it became the trigger for the NTP to recognize the significance of DM and to review the current practices. To that end, the National Center for Tuberculosis and Leprosy Control/Japan International Cooperation Agency (CENAT/JICA) National TB Control Project, in collaboration with the Ministry of Health (MOH), initiated and organized the National Workshop on TB Drug Management in September 2003 to identify weaknesses and the causes in TBDM. • As the next step, the Project implemented the assessment survey to: • verify the findings obtained from the Workshop • provide data on the availability & use practices of TB drugs, which will help develop action plans for the improvement of TBDM.

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 OD: Operational district NH: National hospital CMS: Central Medical Stores RH: Referral hospital HC: Health center

3. NTP TBDM Selection • Criteria: National/WHO Model List & authorized TB guides Procurement (source other than national budget) • Donation of GDF-standard TB drugs from Japan through the JICA’s Grant Aid 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 from the National Workshop on TBDM Selection/Procurement • Quantity of TB drugs per bottle delivered ≠ quantity 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 • Poor patients’ adherence to TB treatment • Poor knowledge of TB/TB treatment among TB staff Management support • DM has not been a priority for NTP supervision Policy and legal framework • Private practitioners do not follow the TB treatment guidelines • TB drugs are available in private 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, and 66 private pharmacies • Intervention (7 investigators) • Preparation (Oct-Nov 03), data collection (Nov 03-Feb 04) & data analysis (Feb-Mar 04) • Outcome measures • % of new ss+ TB patients who received correct TB drugs in correct dosage • % of TB staff/new ss+ TB outpatients who had correct knowledge of TB/TB treatment • % of drug stores where stock records corresponded with physical counts for TB drugs • % of expired stocks for TB drugs • % of drug stores where stock-out for TB drugs was observed • % of 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 for TB drugs - % 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 counts=expired 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 >50Kg. • Periodic training on DOTS is needed for peripheral TB staff. • TB patients’ 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 NTP scope.