Tlai-Tlai Sepetla, Itumeleng Tshabalala & Kekeletso Ntoi March 14, 2013

1. Capacity Needs Assessment for Pharmaceutical Services for ART Program in Lesotho:PRELIMINARY RESULTS Tlai-Tlai Sepetla, Itumeleng Tshabalala & Kekeletso Ntoi March 14, 2013

2. Outline • Background • Rationale for the assessment • ART supply chain • ARVs and OI medicines available in Lesotho • Objectives of the assessment • Methodology • Questionnaires • Sampling and data collection • Ethical considerations • Preliminary Findings & recommendations

3. Background • High HIV/AIDS pandemic in Lesotho: 23% in adults, 27% in pregnant women • According to MOH documents, there are 189 accredited ART sites • Challenges: inadequate human resources and limited funds for ART services • MOHSW needs evidence-based decisions to address human resource challenge • Disease Control Directorate (DCD), with support from the SIAPS program, initiated the capacity needs assessment for pharmaceutical services for the ART program

4. ARV Supply Chain (Pull System)

5. Objectives of the Assessment • To identify the numbers and skills of pharmaceutical personnel available in the country for provision of ART related services • To identify the gaps in the capacity of staff in the ART program in the country; • To recommend the required capacity of staff in the ART program to ensure good quality service provision • To make recommendations to policy makers on how to efficiently make use of available personnel so as to maximize their efficiency • To build local capacity in assessment process

6. Timeline

7. Methodology- Sampling and Data Collection • Descriptive, cross-sectional study • Sampling frame for health facilities: • Geographical areas: Low land/high land, Urban/Rural • Ownership: GoL, Private not-for-profit, Private • Five Districts: Leribe, ThabaTseka, Mohale’sHoek, Mafeteng, and Maseru • 95 HFs were selected from 125 HFs in 5 districts • Data collection teams: 10 teams for data collection at HFs; 2 ppl/team, 2 teams/district • Data collectors collected the data at DHMTs and HFs • The principal investigator team collected data mainly at DCD, NDSO, 1 DHMT and few HFs in Maseru

8. Methodology- Questionnaires • 1 structured questionnaire used to collect the data for numbers and cadres of workforce for pharmaceutical services for ART program in all 95 sampled ART sites • 5 Structured questionnaires with limited semi-structured questions used to collect data of workload, performance, training, self-learning, and problem solving capacities of the staff who provide pharmaceutical services for ART program in DCD, NDSO, DHMTs, and HFs. • Data collection visits at DCD, NDSO, 5 DHMTs, and 95 HFs in 5 districts • Data was entered into Microsoft (MS) Excel spreadsheet and analyzed using MS-Excel. Chi-square test was used to compare the difference between groups.

9. Study Limitations • The information collected through questionnaire 1 section A part 6 (# of patients and types of services provided) might not be as updated and reflective of the current situation due to a probable incompleteness of records. • Due to the fact that most of the private facilities are found in the urban areas, there is a possible skewness of results for the private facilities in respect of the urban areas. • Because this assessment did not include a census, the results will be limited to only indicating the skills gap in a selection of the facilities.

10. Ethical Considerations • The names and contact details of the respondents were only for clarification of any queries of the data- confidentiality maintained at all times • The data collectors signed a confidentiality agreement to ensure that they will not disclose any information about the respondents and their responses to anyone • The respondents were requested to sign the consent form when they agreed to participate in the assessment

11. Preliminary Findings

12. Preliminary Findings: Overview of ARVs logistics information system (1) • Data is collected at the health facilities: • Submitted to NDSO directly from the hospitals or via DHMTs from the primary health facilities (H/Cs). • DCD-Pharmacy unit requested the DHMTs to submit monthly consolidated reports in order to be updated about the availability of the ARVs: • to compare with the morbidity data, • to take necessary actions such as prioritized supervision or redistribution of the over-stocked ARVs. • However, only 30% of the districts are able to submit the reports timeously.

13. Preliminary Findings: Overview of ARVs logistics information system (2) • The monthly ARV logistics data is collected manually using the ART requisition form . • Form indicates the following data: • consumption, • stock on hand, • number of patients for each medicine, • order quantity, and • expiry dates

14. Preliminary Findings: Overview of ARVs supply system (1) • NDSO has a delivery schedule for four geographic groups, namely group A- highland, group B-south, group C-north, and group D-central • A detailed schedule with the advice of timely submission of the requisition is provided to each health facility • DPOs send the requisition forms to NDSO by fax as per NDSO’s schedule. • NDSO captures the monthly reports into RxSolution and supplies the ARVs according to the requisitions or the stock levels at NDSO.

15. Preliminary Findings: Overview of ARVs supply system (2) • NDSO delivers the ARVs as scheduled to the hospitals and to the DHMTs for supplies for the H/Cs. • NDSO also delivers to H/Cs along the delivery route • Upon receiving the supplies, DHMTs deliver them to the H/Cs as soon as possible. • Lack of transport at the DHMTs often delays the delivery of supplies to the H/Cs

16. Preliminary Findings: Overview of Quantification (1) • Quantification of the ARVs is performed centrally. • The Pharmacy department of DCD in collaboration with NDSO, Global Fund, Clinton Health Access Initiative (CHAI) and other stakeholders conducts the quantification and forecasting of ARVs is done annually in November and reviewed after the national budget is announced. • Supply data (provided by NDSO) and morbidity methods are applied • MS-Excel and customized software are used for quantification by DCD and CHAI, respectively. • No quantification guidelines for DCD pharmacy unit • However, Staff received training on quantification and use of the software • Unreliable data quality of the ARV monthly requisitions and morbidity reports is the main concern of DCD-Pharmacy.

17. Preliminary Findings: Overview of Quantification (2) • Quantification of ARVs is meant to estimate the budget requirement for the same fiscal year but for procurement planning purposes. the budget seems to be sufficient as there have been limited stock-outs reported. • However, sometimes the GF funding arrives late and the DCD has to seek urgent support from the MOH. • The ARVs are then procured by NDSO through restrictive tender biannually according to the results of the quantification & forecasting.

18. Preliminary Findings: Capacity Needs • The main cadres for the provision of the ART pharmaceutical services are pharmacists, pharmacy technicians, nurses/midwives, and trained nursing assistants. • Other cadres that assist in pharmaceutical services include physicians, counselors, lay health care workers and non-professional staff. • The estimated provider-patient- ratio (PPR) for ART and general pharmaceutical services for pharmaceutical and nursing professionals are at the lower margin of Hirschhorn’sestimates1 • Indicates that these HCWs are overloaded. 1 Lisa R Hirschhorn, Lulu Oguda, Andrew Fullem, et al.Estimating health workforce needs for antiretroviral therapy in resource-limited settings. s.l. : Human Resources for Health. 4:1, 2006.

19. Preliminary Findings: Capacity Gaps and Possible causes • Delayed distribution from District Health Management Teams (DHMTs) to the health facilities • due to lack of transport; • Poor pharmaceutical inventory management, in particular, at the private and primary health care facilities (H/Cs) • due to insufficient storage space and knowledge, and high workload; • Poor data quality for ARV monthly requisitions and ART monthly morbidity reports • due to inadequate knowledge and high workload including high volumes of paper work; • Insufficient adverse drug reaction (ADR) information given to patients and confirmation of patient’s understanding in medicine use during medication counseling • taking for granted that the patients are refill patients

20. Preliminary Findings: Infrastructure and system constraints • Storage space was insufficient or lacking at NDSO, health facilities, and DHMTs. • Storage conditions are poor at the H/Cs’ stores and DHMTs’ alternative stores. • The two-step pharmaceutical distribution system does not work well at the DHMT level due to lack of transport • creates the demand for storage space, • increases DPOs’ workload, and • delays distribution of pharmaceuticals to the H/Cs • DPOs’ supportive supervision activities compromised • lack of transport, and • increased workload due to handling pharmaceuticals

21. Preliminary Findings: Training • 74% of the surveyed HCWs received PSM and ART treatment trainings • In addition to the classroom-based in-service training, three most useful self-learning methods, as indicated by the HCWs, were: • on-the-job training by supervisors/guided by regular mentors, • reading guiding materials, and • attending technical meetings • Very few HCWs would initiate self-learning to improve their capacities • This provides a basis for managers to review and plan capacity building approaches accordingly

22. Preliminary Findings: Challenges • More challenges found in infrastructure, staffing level, PSM capacity, PSM and information management systems than those in ART treatment capacity. • Main challenges included: • high volumes of paper work • different reporting requirements for vertical programs • submitting the monthly reports /requisitions late • Do not have computer/software, • shortage of data clerks, • do not have daily dispensing tally sheet; not given guidance on how to use tally sheet, and • lack of or inconsistent availability of transport for report submission

23. Preliminary Findings: Addressing challenges • More efforts are taken to address the infrastructure, staffing and system issues than to address HCWs’ own capacity issues  • The most common initiative is “communication”, that is, reporting to the management or related authorities/colleagues, requesting more staff, or requesting trainings. • “communication” works best for PSM • most of the PSM issues are supply mistakes or late deliveries and can be solved by quick responses • Task-shifting was found to work well for storage and information management as these are labor intensive and can be done under supervision

24. Preliminary Recommendations

25. Preliminary Recommendations: Capacity Building (1) • Analytical skill and basic M&E for DCD pharmacy officers; • Advanced logistic management for NDSO ART logistics officer; • Coaching, M&E, and managerial skills for DPOs; • PSM (including data management and quantification) and medication counseling, and basic managerial capacity for HCWs; • Basic storage management and medication counseling skills for lay health workers; • Hygienic medicine-handling skills for non-professional staff ; and • It may be worthwhile for DCD-Pharmacy Unit to select few HCWs  to participate in quantification activities as capacity building (TOT) and improving data quality approaches

26. Preliminary Recommendations: Capacity Building (2) • Diversified training and learning methodologies are required for capacity building for health care workers. • Classroom in-service training and on-the-job trainings should incorporate adult learning approaches with practical, hands-on, and problem-solving oriented case studies and experience sharing and discussions • DCD or DPOs’ supportive supervision can be conducted in a systematic manner. • Periodic mentorship workshops with well-designed training series and post-training supervision are useful for long-term capacity building strategy

27. Preliminary Recommendations: Capacity Building (3) • In the self-learning experiences, new staff orientation and post-training briefing are not considered useful by most of the HCWs probably due to their overwhelming character • Since these are basic and routine capacity building activities at any organization, the managers should review these activities and incorporate them into most helpful learning approaches, such as • providing guiding materials and assigning a mentor to the new staff; • having post-training briefings in the staff or technical meetings.

28. Preliminary Recommendations: System Strengthening (1) • MOH should continue or initiate more infrastructure renovation to improve the working and storage space and conditions . • Improving working conditions will enhance HCWs’ moral and performance, and consequently, improve the quality of the services. • MOH should consider a direct distribution of all the pharmaceuticals from NDSO to the HFs, and if possible, cost-share with DHMTs . • It will avoid delay of distribution and reduce DPOs’ burden in distribution and allow them to provide better coaching and supervision to the HFs.

29. Preliminary Recommendations: System Strengthening (2) • To efficiently make use of the transport, DHMTs should consider joint supervision for several district supervisors or partners. • Cross-level visits (DCD-Pharmacy officer to visit any primary HFs, or DPO to visit any hospitals) could be initiated by sharing transport to gain mutual updates and learn from different experiences.  • The capacity building and system strengthening strategy through ART program will contribute to the improvement of the general system. • Since pharmaceutical supply management is a cross-cutting area, the supervisors should educate the HCWs to apply their PSM capacity across all the programs • non-financial awards to those who perform well can be provided to recognize and appreciate their performance.

30. Thank You!