Inventory Control and Good Storage Practices Training for Primary Health Care Nurses and Pharmacy Staff in Khomas, Ohangwena, and Otjozondjupa Regions, Namibia

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January 2017

Inventory Control and Good Storage Practices Training for Primary Health Care Nurses and Pharmacy Staff in Khomas, Ohangwena, and Otjozondjupa Regions, Namibia

Alemayehu Lemma Wolde

January 2017

Inventory Control and Good Storage Practices Training in Khomas, Ohangwena, and Otjozondjupa Regions

This report is made possible by the generous support of the American people through the US Agency for International Development (USAID), under the terms of cooperative agreement number AID-OAA- A-11-00021. The contents are the responsibility of Management Sciences for Health and do not necessarily reflect the views of USAID or the United States Government.

About SIAPS

The goal of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program is to assure the availability of quality pharmaceutical products and effective pharmaceutical services to achieve desired health outcomes. Toward this end, the SIAPS result areas include improving governance, building capacity for pharmaceutical management and services, addressing information needed for decision-making in the pharmaceutical sector, strengthening financing strategies and mechanisms to improve access to medicines, and increasing quality pharmaceutical services.

Recommended Citation

This report may be reproduced if credit is given to SIAPS. Please use the following citation.

Wolde, A. 2017. Inventory Control and Good Storage Practices Training for Primary Health Care Nurses and Pharmacy Staff in Khomas, Ohangwena, and Otjozondjupa Regions, Namibia. Submitted to the US Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. Arlington, VA: Management Sciences for Health.

Key Words

Inventory management, training, primary health care (PHC), Ohangwena, Khomas, Otjozondjupa, Namibia

Systems for Improved Access to Pharmaceuticals and Services Pharmaceuticals & Health Technologies Group Management Sciences for Health 4301 North Fairfax Drive, Suite 400 Arlington, VA 22203 USA Telephone: 703.524.6575 Fax: 703.524.7898 Email: [email protected] Website: www.siapsprogram.org

CONTENTS

Acronyms and Abbreviations ...... iv Executive Summary ...... v Background ...... 1 Training Objectives ...... 3 intervention ...... 4 Training Content ...... 4 Groupwork Activities...... 5 Discussion of Outputs ...... 12 Conclusions and Recommendations ...... 13 Annex A. Participant List All Regions and All Rounds ...... 14 Annex B. Training Program-Generic for all Trainings* ...... 18 Annex C. Sample Planning Exercise Sheet ...... 19 Annex D. Photos ...... 20

iii

ACRONYMS AND ABBREVIATIONS

AIDS acquired immundeficiency syndrome AMC average monthly consumption ART antiretroviral therapy ARV antiretroviral CPD continued professional development EDT Electronic Dispensing Tool FESC Facility Electronic Stock Card HIV human immundeficiency virus min–max minimum–maximum MOHSS Ministry of Health and Social Services MSH Management Sciences for Health NIMART Nurse initiated and managed ART PHC primary health care R/N registered nurse SCMS Supply Chain Management Systems SIAPS Systems for Improvement Access for Pharmaceuticals and Services SOP standard operating procedure SSV support supervision visit TB tuberculosis USAID US Agency for International Development WHO World Health Organization

EXECUTIVE SUMMARY

Although the Ministry of Health and Social Services (MOHSS) with the US Agency for International Development (USAID)–funded Systems for Improving Access to Pharmaceuticals and Services (SIAPS) Program introduced a number of automated inventory control tools, such as the Facility Electronic Stock Card (FESC) and Electronic Dispensing Tool (EDT) for district hospitals, since June 2015, at the primary health care (PHC) level, inventory control and storage practice are a major challenge and the major cause of stock-out of medicines for antiretroviral therapy (ART), tuberculosis (TB), and malaria in all regions in Namibia.

Stock card use has been a major challenge throughout the country, particularly at PHC facilities, as evidenced by low scores (44% national average per the Support Supervision Visit Report 2017). To ameliorate these challenges, the MOHSS has revised and distributed standard operating procedures (SOPs) for the management of medicines and medical supplies at PHC facilities in the period of 2015–16, and training on these SOPs has been provided to all staff at the PHC level in the Khomas, Ohangwena, and Otjozondjupa regions in the months of May, June, August, and November 2017.

The training was needed to improve inventory control and good storage practices, thereby improving access and restraining increases in the pharmaceutical budget by reducing expiries and damaged pharmaceuticals and at the same time building the training capacity of the regional pharmacists. Facilitation of these trainings was supported by the SIAPS technical advisor.

The three regions trained a total of 152 health workers from all of their districts. The professionals, mainly nurses and pharmacy technicians, were trained for two days and received eight credits from the Health Professional Council of Namibia and a certificate of participation from the MOHSS and SIAPS upon completion of training.

The training was considered comprehensive as it encompassed the entire inventory control cycle and was designed to address challenges frequently encountered by facility staff. Core concepts in inventory control and good storage practices were shared during the discussion and group work presentation. The questions raised by trainees and the experiences exchanged enabled staff to grasp the main goals and key processes of maintaining necessary inventory levels. Participants are taught how to calculate stock levels and order quantities as well as observe critical storage requirements to ensure the quality and safety of medicines.

Attendance at trainings in the Ohangwena and Otjozondjupa regions was far lower than planned. This can be attributed to several factors but the major cause may be lack of awareness of the importance of the inventory control. Effective communication with and sensitization of the pharmacy managers about the importance of inventory control in pharmaceutical management should take place at the district level, especially at PHC facilities, to ensure participation of their staff in training. The MOHSS should organize the relevant training for managers on this issue. The regional pharmacists should supervise the trainees (public facility staff managing pharmacies) regularly and continue hands-on training at the facility level to follow up on participants’ action plans, which they draw up at the end of training. It would also be appropriate for the region to organize later training for staff who did not attend the training sessions.

BACKGROUND

Namibia is situated on the Southwestern coast of Africa. It has a population of about 2.4 million, and is one of the most sparsely populated countries in the world (2.8 people/km2). Namibia is an upper-middle-income country with an estimated gross national income per capita of 5,630 US dollars (USD). Its Gender Development Index score has improved from 0.981in 2014 to 0.986 in 2015. Thirty-two percent of women and 44% of female-headed households live below the poverty line. The unemployment rate in the country sits at 27.4%.1

Namibia operates an integrated pharmaceutical supply chain whereby the Central Medical Store (CMS), a government entity, oversees the procurement, storage, and distribution of all pharmaceuticals and clinical supplies for use in public health facilities in the country. The range of product categories handled by the CMS includes: essential medicines, including antiretroviral medicines (ARVs), malaria medicines, TB medicines; contraceptives and other reproductive health supplies; vaccines; HIV test kits; clinical supplies such as gloves, needles, syringes, and bandages; surgical instruments such as scissors and blades; radiology supplies such as X-ray films and contrast media.

Country ownership of the public health supply chain in Namibia is already strong, with the government owning and driving major operational functions and contributing the bulk of funds required for procurement of essential medicines and clinical supplies. The approximate total value of health commodities procured annually through the CMS is about 950 million Namibian dollars (NAD) (USD 80 million) in the period 2016–17. There is a modest contribution for direct pharmaceutical budget from partners, mainly from the Global Fund, to procure ARVs and related supplies.

Namibia operates a classic CMS distribution system for pharmaceutical management, with a CMS warehouse at Windhoek and two Multi-Regional Medical Depots (MRMDs), located in Oshakati in the northwest and Rundu in the northeast. Rundu and Oshakati MRMDs serve the most populated part of the country, where approximately 40%–50% of the population resides. Rundu MRMD serves seven health centers, 29 clinics, and one hospital in the Kavango region and fills emergency orders from facilities from in the Caprivi region as well as Rundu Intermediate Hospital. Oshakati MRMD serves seven district hospitals, 15 health centers, 64 clinics, and one mortuary (police facility).

Essential medicines should always be available in the right amounts, so that health workers can effectively help their patients. Medicines and medical supplies play an important role in every health system if they are used correctly. Medicines and medical supplies can cure diseases, alleviate suffering, or correct and maintain body functions, preventing serious consequences; help for preventive purpose as a prophylaxis; or be used for adjuvant therapy in conjunction with a number of surgeries and diagnostics. Continuous availability of these products and maintaining them in the required storage conditions, to avert overstock, stock- out, and product deterioration is a critical function in pharmaceutical supply management. Therefore, skills in inventory control and storage practices play a critical role, requiring a trained pharmaceutical management staff. Unfortunately, in most developing and developed

1 MOHSS/Directorate: Special Programmes. 2017. National Strategic Framework for HIV/AIDS 2017/18– 2021/22. Windhoek: MOHSS.

1 Inventory Control and Good Storage Practices Training in Khomas, Ohangwena, and Otjozondjupa Regions countries the emphasis given to the inventory control of pharmaceuticals is negligible, given its affect on global development goals.

In general, inventory management for pharmaceutical supply sounds easy—all that must be done is to order, receive, store, issue, and then reorder a limited list of items. Yet, as has been observed, “we can distribute Coca-Cola all around the world, but we can’t seem to get medication to save a child from something as simple as diarrhea” (Annie Lennox, 2008).2 In reality, the task is difficult, and in many countries, including Namibia, poor inventory management in the public pharmaceutical supply system leads to waste of financial resources, shortages of some essential medicines or overages of others resulting in expiration, and a decline in the quality of patient care.

The director general of the World Health Organization (WHO) asserted that “the lack of availability of essential pediatric medicines, including antibiotics, is one reason why countries are not making adequate progress towards some Millennium Development Goals.”3 Problems in inventory control generally feature subjective, ad hoc decisions about order frequency and quantity, inaccurate stock records, and a lack of systematic performance monitoring, all of which result in more frequent interim orders. Often, these problems are directly related to lack of knowledge and appreciation of what inventory management involves, as well as to ineffective management and chronic underfunding for the management of this activity. Shortage of appropriately skilled staff is a critical challenge in Namibia, and has mainly resulted from low levels of awareness of the importance of capacity building.

Inventory control and storage practices constitute a major challenge and are the major cause of stock-out of medicines for antiretroviral therapy (ART), TB, and malaria in all regions in Namibia. The MOHSS has revised and distributed SOPs for the management of medicines and medical supplies at PHC facilities in the year 2015–16, however, training on these SOPs has not been provided to all staff at the PHC level in the Khomas, Ohangwena, and Otjozondjupa regions. Stock card use is a major challenge in the country, particularly at PHC facilities, as evidenced by the lower scores (44% national average per the SSV Report 2017).

The MOHSS is decentralizing ART services through establishing nurse initiated and managed ART (NIMART) sites, but the inventory control of ART is not being supported by Facility Electronic Stock Cards (FESC) and staff are not oriented on this tool. Revised SOPs have printed and distributed to the health facilities, which are ready for use in training. FESC is being implemented at the PHC level, which makes it necessary to introduce the tool during the training.

Since 2012/13, the Supply Chain Management Systems (SCMS) project and the SIAPS Program, implemented by Management Sciences for Health (MSH), have been supporting MOHSS and the regional management teams (RMTs) in building the capacity of PHC staff, In 2017, SIAPS supported three regions: Khomas, Ohangwena, and Otjozondjupa. This report covers the training in all three regions. These regional health departments have requested and secured support to roll out training of inventory control and good storage practices at different times. The trainings were conducted in May, June, and August and November in Khomas, Ohangwena, and Otjozondjupa, respectively. See the annexes (A, B, C, and D) of the report

2 http://www.jhsph.edu/research/centers-and-institutes/ivac/resources/IVAC-Improving-Access-to-Essential- Medicines.pdf 3http://www.who.int/dg/speeches/2007/eb120_opening/en/index.html

2 Background for participants list, the generic training program, photos and practical exercises carried out during the trainings.

Training Objectives

The trainings aimed to improve the management of ARVs, TB medicines, and related health commodities. It was necessary to improve inventory control and good storage practices, thereby improving access and further reducing the increasing pharmaceutical budget by reducing cases of expired and damaged pharmaceuticals. The specific objectives of the trainings were the following:

• Enable the health professionals working at the health facilities to manage pharmaceuticals

• Introduce inventory control and storage practices concepts

• Sensitize the participants on the importance of pharmaceuticals management to the patients

• Improve pharmaceutical ordering, receiving, storage, and distribution skills

• Motivate health workers toward recognizing the importance of inventory control and good storage practices

• Sensitize participants on the budget implications of mismanagement of pharmaceuticals

INTERVENTION

Three trainings were conducted, at different places and at different times. The content of the training in all the sessions was the same and the duration of each training iteration was two days. The training presentations are based on Managing Pharmaceutical Store: A Manual for Clinics and Health Centres (2017)4. The trainings were conducted by regional pharmacists, experienced PHC nurses, and pharmacist assistants with the technical support of the ART logistic advisor from MOHSS/NMPC and the senior technical advisor from SIAPS (table 1).

The training was carried out using the following techniques:

 Training slides—based on the PHC Medicines and Medical Supplies Management Manual  Snap questions  Group exercises  In session interactions  Case study exercises  Implementation plan

Table 1. Facilitators of all trainings S/N Facilitators Designation Regions Level 1 Wuletaw Chufo Pharmaceutical services All National 2 Alemayehu Wolde SIAPS All National 3 Alexander Anaba Senior pharmacist Ohangwena Regional 4 Julia Tshitayi Senior registered nurses Ohangwena District 5 Seija Nakamhela Pharmacist Khomas Regional 6 Sefinew Abate Pharmacist Otjozondupa District 7 Tsegaye Telila Pharmacist Otjozondupa District 7 Lynette S. Karises Pharmacist assistant Otjozondupa District

Training Content

The training covered the following focal areas/topics/practical case study exercises:

1) General logistics/supply chain management concepts in the Namibia context 2) Introduction to the essential medicines concept 3) Ordering (main and interim), receiving and issuing medicines 4) The pharmacy store: storage of medicines and cold chain management 5) Classwork: storage of medicines 6) Organizing the Store: stock arrangement 7) Inventory management session 1 and the dashboard 8) Groupwork: monthly consumption, min and max, order quantity 9) The stock card: a tool for inventory management and FESC 10) Classwork: completing the stock card 11) Assessing stock status

4 MOHSS 2017. Managing Pharmaceutical Store: A Manual for Clinics and Health Centres. Windhoek: MOHSS.

4 Intervention

12) Groupwork: assessing stock status 13) Introduction to planning for improvement of good storage practices at the facilities 14) Groupwork on planning for improvement at the facilities

Groupwork Activities

1) VEN classification 2) Storage requirement and results of poor storage 3) Completing of stock cards based on the transaction 4) Calculating average monthly consumption (AMC), min–max, order quantities, and months of stock 5) Preparation of the plan of action

Output of the Trainings

Attendance in the Khomas, Ohangwena, and Otjozondjupa Regions

A total of 152 health workers (table 2) were trained for two days each. The training in Khomas was conducted for two rounds. All the participants were from the Khomas district PHC facilities and hospitals. In Ohangwena, the region planned to train 90 staff; however, 58 participants attended a second-round training. In Otjozondjupa, the plan was to train 90 staff from four (all) districts, but only 49 participants attended the training. Participants were trained in two groups over a two-day period with two days for traveling.

Table 2. Number of health workers trained by designation and regions, 2017 Row labels Count of trainees by designation Khomas region 45 Admin officer 6 Enrolled nurse 1 Pharmacist 1 Pharmacist assistant 20 Quality assurance 1 Registered nurse 15 Senior registered nurse 1 Ohangwena region 58 Enrolled nurse 23 Health assistant 1 Pharmacist 3 Pharmacist technician 1 Pharmacist’s assistant 8 Registered nurse 22 Otjozondjupa region 49 Enrolled nurse 21 Medical officer 3 Pharmacist 1 Pharmacist assistant 7 Registered nurse 11 Senior medical officer 2 Senior registered nurse 4 Grand total 152

5 Inventory Control and Good Storage Practices Training in Khomas, Ohangwena, and Otjozondjupa Regions

Figure 1 shows participant distribution by region, district, and gender. The distributions clearly show that most of the participants, especiallly in the Ohangwena and Otjozondjupa regions, came from the district where the training was conducted. Engela district in the Ohangwena region and the Otjiwarongo district from the Otjozondjupa region accounted for more than 50% participants. The major reason for this skewed distribution may have been the proximity to the training venue as well as the skewed distribution of the health facilities in these regions.

35 34

25 22

20 19

15 13 F 11 M 10 9 7 6 6 6 5 5 3 3 3 3 2

Engela

Okongo

Khomas

Eenhana

Okakarara

Okahandja

Otjiwarongo Grootfontein Khomas Ohangwena Otjozondjupa

Figure 1. Participant distribution by region, district, and gender

The training produced positive outcomes, as seen in the post-test results. The participants were quite excited about the exposure to new/updated knowledge. Practical operational challenges were discussed and solutions offered, especially in the areas of stock card use, FESC, and ordering of medicines. The training areas were plotted for- pre and post-tests and compared for improvements made by the participant. Figures 2–5 display the pre- and post- test results for the three regions.

6 Intervention

18 16 14 12 10 8 6 pre-test 4 2 0 1 2 3 4 5 6 7 8 9 10 Figure 2. Pre-and post-test results in Khomas region, round 1 (May 2017)

Pre Vs Post test 100% 92% 88% 90% 80% 84% 84% 84% 80% 80% 84% 80% 84% 68% 80% 76%76% 70% 72% 68% 72% 72% 64% 64% 60% 64% 60% 68% 64% 56% 56% 56% 50% 56% 52% 52% 40% 40% 52% 48% 48% 36% 36% 30% 20% 10% 0% Pre-test

Figure 3. Pre- and post-test results in Khomas region, round 2 (November 2017)

7 Inventory Control and Good Storage Practices Training in Khomas, Ohangwena, and Otjozondjupa Regions

120%

100%

80%

60% pre-test post-test

40%

20%

0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23

Figure 4. Pre- and post-test results in Ohangwena region, round 1 (June 2017)

120%

100%

80%

60% Pre-test Post-test 40%

20%

0% 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35

Figure 5. Pre- and post-test results in Ohangwena region, round 2 (June 2017)

More than 90% of the trainees improved in the post-tests, as shown in the figures 6–9. For unknown reasons, some participants’ knowledge did not improve.

8 Intervention

120%

100%

80%

60%

40% Pre-test 20% Post-test

Participants test result out of100% out result test Participants 0%

1 2 3 4 5 6 7 8 9

26 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Average result Average Participants' exam code

Figure 6. Pre- and post-test results in Otjozondjupa region, round 1 (August 2017)

120%

100%

80%

60%

Pre-test 40% Post-test

20% Participantstest result out 100%of

Participants' exam code

Figure 7. Pre- and post-test results in Otjozondjupa region, round 2 (August 2017)

Most of the participants, more than 90%, improved in the post-tests, as shown in figure 7. For unknown reasons, some participants did not improve on the post-test or even had poorer results on the post-test than the pre-test.

9 Inventory Control and Good Storage Practices Training in Khomas, Ohangwena, and Otjozondjupa Regions

120%

100%

80%

60%

40% Pre-test 20% Post-test

Participants test result out of100% out result test Participants 0%

1 2 3 4 5 6 7 8 9

26 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Average result Average Participants exam code

Figure 8. Pre- and post-test results in Otjozondjupa region, round 1 (July 2017)

120%

100%

80%

60%

Pre-test 40% Post-test

20% Participantstest result out 100%of

Participants exam code

Figure 9. Pre- and post-test results in Otjozondjupa region, round 2 (July 2017)

The training was also considered for accreditation after the content was evaluated by the Health Professional Council of Namibia and considered as part of continuous professional development (CPD), with eight credits assigned to it for health care professionals who attended the training (figure 10).

10 Intervention

Figure 10. Accreditation results from Namibian Health Professional Council for first- round training for Khomas, Ohangwena participants

DISCUSSION OF OUTPUTS

The key message is that effective inventory management can provide reliable availability and assured supply of low-cost products even in remote areas, with poor infrastructure So why then are there so still so many problems with public sector inventory management of pharmaceuticals? In many cases, no systematic procedures and rules exist to guide staff, a problem compounded by lack of understanding of the basic issues of proper inventory management on the part of managers. These core concepts were reflected during the discussion and groupwork presentation. As the managers seem to have limited understanding of the importance of inventory control, they do not send their staff to relevant trainings. The main challenge experienced was non-attendance at the training by most intended critical participants (nurses from PHC clinics), especially those from Eenhana and Khomas districts. A 64% attendance rate was achieved in Ohangwena, with Eenhana PHC accounting for bulk of failed attendance. The attendence rate in the Khomas and Otjozondjupa regions was only 50%.

The issue of training duration was also a challenge, as there was little time for participants to do more hands-on practice exercises and exhaustively discuss their operational challenges. Participants were enjoined to go back to their facilities and implement their drawn-up action plan according to set implementation dates. This will be followed by increased supervisory visits by the district pharmacist and regional pharmacist to monitor implementation of the action plans and compliance with the use of stock cards at these facilities.

CONCLUSIONS AND RECOMMENDATIONS

The training objectives were mostly met, as after the training participants understood the basic skills of stock control and inventory management, identified their challenges, and were able to use skills acquired at the training to draw up action plans to start solving these problems. The trainings were successful with regard to content, even though not all target trainees participated

Most of the trainees scored above 69% in the post-test evaluation and all of them did very well on practical and skill-based assessments. All trainees who had scored below 50% on the pre-test scored above 50% on the post-test, an encouraging result.

The following recommendations were put forward, bearing in mind the challenges experienced:

 Effective communication and sensitization of the managers on the importance of inventory control for pharmaceutical management should be in place at the district level, especially for PHC, to ensure participation in training. The MOHSS should organize training for managers on this issue.

 Continuing hands-on training should be done at the facility level as a follow-up of the action plans drawn up by participants.

 It is also appropriate if the region organizes training for those who did not attend the trainings, as there were facilities that were not represented at these sessions.

ANNEX A. PARTICIPANT LIST ALL REGIONS AND ALL ROUNDS

SN Gender Names Facility District Designation Region

1 F Ruben Ilonga Grabab Khomas Registered Nurse Khomas 2 M Simon Kandjimbi Grobab Khomas Khomas 3 M Thomas Shipushu Okaryangava Clinic Khomas Khomas 4 F Doline Goreses Whimbili Khomas Khomas 5 F Helena Shangula Khomosdal HC Khomas Khomas 6 F Maria T. Penda Otjimuse Khomas Pharmacist’s Khomas 7 F Maria N. Nekongo Maxwilil Khomas Assistant Khomas Thomas 8 M Defence Clinic Khomas Khomas Shuutameka Sandra Mercy 9 F Defence Clinic Khomas Khomas Mutahane 10 F Helena S. Iyambo Robert Mugabe Khomas Registered Nurse Khomas Shanyengange 11 F Omundundu Clinic Engela Ohangwena Peneyambeko Wilhelm 12 F Edundja Clinic Eenhana Ohangwena Hamukwaya 13 M Herman Nangolo Epembe Clinic Eenhana Ohangwena 14 M Joseph Sheya Epinga Clinic Eenhana Ohangwena Lazarus 15 M Oshikunde Clinic Eenhana Ohangwena Shapange 16 F Sevelen Hangula Edundja Clinic Engela Ohangwena 17 M Junias Hambadi Ohaukelo Clinic Engela Ohangwena Itridis Naloliwa 18 F Omundundu Clinic Engela Ohangwena Iipinge 19 F Saima Eliakim Edundja Clinic Eenhana Ohangwena 20 F Sabina Hamalwa Edundja Clinic Eenhana Ohangwena 21 F Martha Indongo Omuhongo Clinic Eenhana Ohangwena Selma 22 F Omundaungilo Clinic Eenhana Enrolled Nurse Ohangwena Mweukonga Teofilus 23 M Ongula Clinic Eenhana Ohangwena Naukushu 24 F Tressia Niilungu Onangolo Clinic Eenhana Ohangwena Andreas 25 M Ohalushu Clinic Engela Ohangwena Sheehela 26 F Victoria Udina Ohangwena Clinic Engela Ohangwena Penexupifo 27 F Omungwelume Clinic Engela Ohangwena Kondjeninasho 28 F Martha Shikolalye Onekwaya Clinic Engela Ohangwena 29 F Lucia Daniel Ekoka Clinic Okongo Ohangwena 30 F Saima Itamalo Ohaukelo Clinic Okongo Ohangwena 31 F Victoria Kashile Okongo Clinic Okongo Ohangwena Beata 32 F Okongo Clinic Okongo Ohangwena Shakuyungwa 33 F Raimo Haufiku Omboloka Clinic Okongo Ohangwena 34 M Toini Ngonuhapo Okambembe clinic Engela Health Assistant Ohangwena 35 M Miller Nyanyiwa Engela Dist Hosp Engela Ohangwena 36 F Nsuami Makaya Engela Dist Hosp Engela Pharmacist Ohangwena 37 M Adebayo Ayodeyi Okongo Dist Hosp Okongo Ohangwena Pharmacist 38 F Rosalia Gotrieb Okongo Clinic Okongo Ohangwena Technician Immanuel 39 M Eenhana Dist Hosp Eenhana Ohangwena Shikesho Leonard 40 M Engela Dist Hosp Engela Ohangwena Shipanga 41 F Linda Namibinga Engela Dist Hosp Engela Pharmacist’s Ohangwena 42 F Alina Shipalanga Odibo Health Centre Engela Assistant Ohangwena 43 F Hilma Shindubu Odibo Health Centre Engela Ohangwena 44 F Priskilla Laudika Ongenga Clinic Engela Ohangwena 45 F Sylvia Mweenda Ongha healthcentre Engela Ohangwena 46 F Jona Kayofa Okongo Dist Hosp Okongo Ohangwena

14 Annex A. Participant List All Regions and All Rounds

SN Gender Names Facility District Designation Region

47 F Salome Nakwafila Epembe Clinic Engela Ohangwena 48 M Andreas Ekandjo Eenhana Dist Hosp Eenhana Ohangwena 49 F Kamati Immanuel Onekwaya Engela Ohangwena 50 M Mateus Immanuel Engela Clinic Engela Ohangwena 51 M Efraim N Lebeus Olukula Clinic Okongo Ohangwena FJosephine 52 F Eenhana Dist Hosp Eenhana Ohangwena Haimo Anna 53 F Eenhana Dist Hosp Eenhana Ohangwena Ndamanomhata 54 F Selma Abital Eenhana Dist Hosp Eenhana Ohangwena 55 F Monika Mwapota Onambutu Clinic Eenhana Ohangwena 56 F Rauna Issak Onangolo Clinic Eenhana Ohangwena 57 F Beata Johannes Oshaango Clinic Eenhana Ohangwena 58 F Monika Hedimbi Oshandi Clinic Eenhana Registered Nurse Ohangwena 59 F Ndilimeke Shifidi Endola Clinic Engela Ohangwena 60 F Ulla Nghihalwa Eudafano Clinic Engela Ohangwena Hamukoto Wakapa 61 F Liisa Haixwema Engela Ohangwena Clinic 62 F Lahya Amutenya Ohangwena Clinic Engela Ohangwena 63 F Olivia Dumeni Onamukulo Clinic Engela Ohangwena 64 F Ottilie Shailemo Ondobe Clinic Engela Ohangwena 65 F Shimau Helena Ongenga Clinic Engela Ohangwena 66 F Klaudia Nghole Okatope Clinic Engela Ohangwena Hendrina 67 F Eenhana Dist Hosp Okongo Ohangwena Shiningombwa Ndesheetelwa 68 F Okongo Clinic Okongo Ohangwena Shakuyungwa Precious Nsala 69 F Poly Clinic Grootfontein Otjozondjupa Sizuka Lubanda O 70 M Okahandja Dist Hosp Okahandja Otjozondjupa Musweu 71 F Bilhildis Gowaseb Okahandja Dist Hosp Okahandja Otjozondjupa Florence 72 F Okahandja Dist Hosp Okahandja Otjozondjupa Karamata 73 F Samanda Auxas Otjozondu Clinic Okahandja Otjozondjupa Helena P 74 F Okakarara Dist Hosp Okakarara Otjozondjupa Hangalo 75 F Daisy U Mujahere Okakarara Clinic Okakarara Otjozondjupa Theoboldina 76 F Okondjatu Clinic Okakarara Otjozondjupa Kaitjizemine Nauyele N 77 F Okakarara Dist Hosp Okakarara Otjozondjupa Kamholo 78 M Richart Zaondja Okakarara Dist Hosp Okakarara Enrolled Nurse Otjozondjupa 79 F Regina Riruako Okamatapati Clinic Okakarara Otjozondjupa 80 F Paulina Hamases Otjiwarongo Otjozondjupa Tauno P 81 F Otjiwarongo Dist Otjiwarongo Otjozondjupa Amunyela Hosp 82 F Felicity Schrader Otjiwarongo Otjozondjupa 83 F Johanna Pinehas Otjiwarongo Otjozondjupa Benhard Otjiwarongo Police 84 M Otjiwarongo Otjozondjupa Akwenye Station Norma NU 85 F Osire Clinic Otjiwarongo Otjozondjupa Kahamboe 86 M Whysley Useb Kalkfeld Clinic Otjiwarongo Otjozondjupa 87 M Joseph Ipinge Kalkfeld Clinic Otjiwarongo Otjozondjupa Otjiwarongo Police 88 F Martha Shiimi Otjiwarongo Otjozondjupa Station 89 F Laina Lukas Etunda Clinic Otjiwarongo Otjozondjupa Grootfontein Dist 90 M Dr Dick Manatsa Grootfontein Otjozondjupa Hosp Dr Laura Otjiwarongo Dist Medical Officer 91 F Otjiwarongo Otjozondjupa Muszinguani Hosp 92 M Dr Olenga J Otjiwarongo Dist Otjiwarongo Otjozondjupa

15 Inventory Control and Good Storage Practices Training in Khomas, Ohangwena, and Otjozondjupa Regions

SN Gender Names Facility District Designation Region

Olenga Hosp Onyekachi U 93 M Okakarara Dist Hosp Okakarara Pharmacist Otjozondjupa Adindu Grootfontein Dist 94 M Gerson Aib Grootfontein Otjozondjupa Hosp Grootfontein Military 95 M Wilhelm Antindi Grootfontein Otjozondjupa Hosp Erasmus T 96 M Okakarara Dist Hosp Okakarara Otjozondjupa Kamboo Pharmacist’s 97 F Kaarukire Rukata Otjiwarongo Dist Otjiwarongo Assistant Otjozondjupa 98 F Martha Aikanga Hosp Otjiwarongo Otjozondjupa Ester T Otjiwarongo Dist 99 F Otjiwarongo Otjozondjupa Nghilungilwa Hosp Johanna 100 F Otavi Health Centre Otjiwarongo Otjozondjupa Shilimela 101 F Hilde Kambonde Poly Clinic Grootfontein Otjozondjupa Festus Lavo 102 M Nau-aib Clinic Okahandja Otjozondjupa Kalongo Martha 103 F Otjozondu Clinic Okahandja Otjozondjupa Shilomboleni 104 F Elisabeth Pataka Ovitoto Clinic Okahandja Otjozondjupa 105 F Idda N Nashongo Okakarara Dist Hosp Okakarara Otjozondjupa Olichen M Otjiwarongo Dist 106 F Otjiwarongo Otjozondjupa Endjere Hosp Registered Nurse Hilma N 107 F Osire Clinic Otjiwarongo Otjozondjupa Haimbondi Kathrina A Otjiwarongo Dist 108 F Otjiwarongo Otjozondjupa Hifititeko Hosp Josefina P 109 F Orwetoveni Clinic Otjiwarongo Otjozondjupa Shitaleni Otjiwarongo Dist 110 M Michael Ucham Otjiwarongo Otjozondjupa Hosp 111 F Veronica Eigowas Poly Clinic Grootfontein Otjozondjupa Dr Steve 112 M Okahandja Dist Hosp Okahandja Otjozondjupa Kabamba Ngoy Senior Medical Justin Mukeba Otjiwarongo Dist Officer 113 M Otjiwarongo Otjozondjupa Mutombo Hosp 114 F Emilia K Tobias Okakarara Dist Hosp Okakarara Otjozondjupa 115 F Hilma N Muhenje Otjiwarongo Otjozondjupa Senior Agnes M Otjiwarongo Dist 116 F Otjiwarongo Registered Nurse Otjozondjupa Mudabeti Hosp 117 F Maria Negumbo Otjiwarongo Otjozondjupa Elizabeth Intermediate Hosp 118 F Khomas Registered Nurse Khomas Hamwaanyena Katutura Natanael 119 M Windhoek Dist Khomas Enrolled Nurse Khomas Ngeshapu 120 F Hileni Hatutale Ministry of Defence Khomas Khomas Officer 121 M Paulus Ngololo Ministry of Defence Khomas Khomas 122 M Kagiso Totwe Intermediate Hosp Khomas Khomas 123 M Brian Kaela Katutura Khomas Khomas 124 F Julia Nghuukufwa Windhoek Dist Khomas Khomas 125 F Zita Ilukena Windhoek Dist Khomas Khomas 126 F Rebekka Fotolela Windhoek Dist Khomas Khomas 127 M Michael Simataa Windhoek Dist Khomas Khomas Dhimbulukweni 128 F Windhoek Dist Khomas Pharmacist Khomas Mumbala Assistant 129 F Ivy Chika Windhoek Dist Khomas Khomas Intermediate Hosp 130 F Linea Amutenya Khomas Khomas Katutura Immanuel Windhoek Central 131 M Khomas Khomas Naukushu Hosp Natangwe Windhoek Central 132 M Khomas Khomas Itengula Hosp

16 Annex A. Participant List All Regions and All Rounds

SN Gender Names Facility District Designation Region

133 F Vivoliana Kapner Central Medical Khomas Khomas 134 F Irya Valombola Store Khomas Khomas Quality 135 F Jane Lichisa Khomas Khomas Assurance 136 F Lovisa Amoomo Khomas Khomas 137 F Nikanor Victor Intermediate Hosp Khomas Khomas 138 F Suoma Petrus Katutura Khomas Khomas 139 F Martha Ihuhwa Khomas Khomas Viangana 140 F Khomas Khomas Marenga 141 F Laili Sheetekela Windhoek Dist Khomas Khomas Angelika Registered Nurse 142 F Windhoek Dist Khomas Khomas Kemanye 143 F Mercia Uazena Khomas Khomas 144 F Selma Willbard Khomas Khomas 145 F Paulina Ilonga Windhoek Central Khomas Khomas 146 F Odette Demoura Hosp Khomas Khomas Wilhelmina 147 F Khomas Khomas Bundje 148 F Lettie Ankonga Ministry of Defence Khomas Khomas Lef Taimi 149 F Ministry of Defence Khomas Khomas Kadalwa Ndapewoshali Senior Officer 150 F Ministry of Defence Khomas Khomas Mhata Immanuel 151 M Ministry of Defence Khomas Khomas Haulyondjamba Intermediate Hosp Senior 152 F Lahya Malakia Khomas Khomas Katutura Registered Nurse

ANNEX B. TRAINING PROGRAM-GENERIC FOR ALL TRAININGS*

Inventory Management and Good Storage Practices Training, Pharmacist Assistants and Nurses in Khomas Region

Venue: Heja Game Lodge May 15–16, 2017

Time Activity Facilitator Monday, May 15, 2017 08h00 – 08h30 Registration All Opening prayer Introductions All Welcoming remarks Regional director Housekeeping Ms. Seija Objectives of the training and expectation of participants Mr. Wuletaw 08h30 – 09h00 Pre-test All 0900h – 09h45 General Logistics/Supply Chain Management Concepts Mr. Wolde/Tsegaye with Namibian Context 10h00 – 10h15 Plenary All 10h15 – 10h30 TEA BREAK All 10h30-11:00 Introduction to Essential Medicines Concept Mr. Wuletaw/Ms. Seija 11h00 – 11h30 Ordering (Main and Interim), Receiving, Issuing Medicines Ms. Seija/Wuletaw 11h30-12:30 The Pharmacy Store – Storage of Medicines Mr. Wolde/Ms. Seija 12h30 – 13h00 Plenary All 13h00 – 14h00 LUNCH 14h00 – 14h30 Class Work: Storage of Medicines All 14h30 – 15h00 Plenary 15h00 – 15h30 TEA BREAK 15h30 – 16h30 Organizing the Store – Stock Arrangement Mr. Wolde/Ms. Seija 16h00 – 17h00 Discussion All

Tuesday, May 16, 2017 08h00 – 08h30 Recap Participant 08h30 – 10h30 Inventory Management Session I and II and Intro of FESC Mr. Wolde/Ms. Seija 10h30 – 10h45 TEA BREAK 10h45 – 11h30 Group Work: Monthly consumption, Min and Max, Order All Qty. 11h30 – 12h45 The Stock Card – A Tool for Inventory Management Mr. Wuletaw/Wolde (FESC) 12h45 – 13h00 Class Work – Completing the Stock Cards All 13h00 – 14h00 LUNCH 14h00 – 14h15 Assessing Stock Status Ms. Seija/Mr. Wuletaw 14h15 – 15h00 Group Work – Assessing stock status 15h00 – 15h30 Brief Introduction – How to Plan for Improvement of Ms. Seija/Mr.Wolde Inventory Control and Good Storage Practices at the Facilities Level 15h30 – 16h30 Group Work on Planning for Improvement of Inventory Ms. Seija/Mr. Wolde Control and Good Storage Practices at the Facilities 16h30 – 17h00 Post-test and closing Ms. Seija/all *Training programs for all regions were the same except for the moderators and the dates of the training.

ANNEX C. SAMPLE PLANNING EXERCISE SHEET

Division Pharmaceutical Services – Xxx Region

Inventory Management and Good Storage Practices Training Workshop

Work plan Name:……………… Duty station:…………… Date:……………

Problem Area % Level of Activities to Target Improved % Monitoring Compliance Improve Date Compliance Strategy Level There is no stock 0% 1 Get the stock card 100% 90–95% Supervisors card in use at our at the facility acceptable support visit facility. Difficult to 2 Stock take know the stock 3 Establish a stock level at any time card without counting 4 monitor the stock movement Minimizing the Currently 6 1 Set up the stock 1 Orders 2 Orders are Orders interim order to orders b/n levels b/n acceptable monitored at the suppliers orders 2 Monitor the order intervals supplier (RMS, CMS, triggering points point. hospital) 3 Do the stock take during every order 4 Calculate order quantity for all products 1 2 3 4

ANNEX D. PHOTOS

Participants of Ohangwena Region, Ondangwa Town Lodge

Regional HealthDirector of Otjozondjupa , Mrs. M. F. Kavezembi, opening the training at Otjiwarongo, C’est Bon Hotel

20 Annex D. Photos

Participants at C’est Bon Hotel, Otjiwarongo, Otjozondupa Region

Participants at Heija Lodge, Khomas region