HIV/TB Pharmaceutical Management and Supply Chain Training Report

August 2017

Kholiwe Shongwe Wenzile Mthimkhulu Alemayehu Duga

August 2017

HIV/TB Pharmaceutical Management and Supply Chain Training Report

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.

Shongwe K, Mthimkhulu W, Duga A. 2017. HIV/TB Pharmaceutical Management and Supply Chain Training Report. 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

Systems for Improved Access to Pharmaceuticals and Services Pharmaceutical 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 E-mail: [email protected] Web: www.siapsprogram.org

ACRONYMS AND ABBREVIATIONS

AHF AIDS Healthcare Foundation AIDS acquired immunodeficiency syndrome ART antiretroviral therapy ARV antiretroviral CMS Central Medical Stores HIV human immunodeficiency virus IEC information, education, and communication MOH Ministry of Health LMIS logistics management Information system MDT multi-drug therapy MSH Management Sciences for Health PEPFAR US President’s Emergency Plan for AIDS Relief PTC Pharmacy and Therapeutics Committee QIP quality improvement plan RFM Ralegh Fitkin Memorial [Hospital] SHIMS Swaziland HIV Incidence Measurement Survey SIAPS Systems for Improved Access to Pharmaceuticals and Services TB tuberculosis UNAIDS Joint UN Programme on HIV/AIDS USAID US Agency for International Development

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CONTENTS

Acronyms and Abbreviations ...... iii Introduction ...... 1 Background ...... 1 Objectives of the Training ...... 2 Opening the Training Session ...... 3 Training Format ...... 5 Target Audience ...... 6 Pre- and Post-Test Results ...... 8 Next Steps ...... 10 Photos ...... 11 Annex A. Training Agenda ...... 13

INTRODUCTION

Background

According to the Swaziland HIV Incidence Measurement Survey (SHIMS) report, Swaziland had the most severe HIV epidemic in the world, with a measured HIV prevalence of 26% among adults aged 15–49 years in 2006–2007.1 To combat this epidemic, in 2009, the Government of the Kingdom of Swaziland initiated support for scale-up of national HIV prevention and treatment programs.2 The US President’s Emergency Plan for AIDS Relief (PEPFAR) was implemented through the US Agency for International Development (USAID) in 2003 in 50 countries, including Swaziland, to fight the epidemic. The implementation plan included the training of health professionals to reduce the transmission of HIV and also assist countries by providing health commodities to treat HIV infections and reduce transmission. Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, supports the Ministry of Health (MOH) in strengthening pharmaceutical systems to improve availability of HIV and tuberculosis (TB) medicines, from the central level to the facility level. The MOH is implementing antiretroviral therapy (ART) services through the Swaziland National Aids Program (SNAP). SNAP was established in 1987 to respond to the HIV epidemic. The core mandate of the program is to coordinate health sector interventions, as they account for more than 70% of the total HIV response. The program is responsible for implementing ART services in health facilities; it provides in-service training for HIV management to prescribers (doctors and nurses), accredits health facilities, and manages the HIV guidelines for safe prescribing and use of antiretrovirals (ARVs). Currently, the MOH has 264 health facilities (inclusive of clinics, health centers, and hospitals, both public and private) that provide TB and ART services to patients. Of these, 43 (hospitals and health centers) are “mothers” to the ministry’s clinics. The mother facilities are responsible for monitoring ART services provided by their respective baby clinics and managing their patient and stock data, and then placing orders to Central Medial Store (CMS) on their behalf.

According to the World Health Organization, many countries spend 30–40% of their health care budgets on medicines and medical commodities, and a significant amount of the funds are wasted because of irrational medicines use and inefficiencies in stock management due to lack of skills. Other serious problems that health care organizations face include the overuse of antimicrobials, which increases the risks of antimicrobial resistance, leads to increased adverse drug reactions (ADRs), and results in considerably higher costs associated with drug use. Training pharmacy personnel on proper handling of medicines can help improve the proper handling and dispensing of medicines, rational use of medicines, and adherence to treatment to improve patient health outcomes.

1 Central Statistical Office (CSO), Swaziland, and Macro International. 2008. Swaziland demographic and health survey 2006–07. Mbabane, and Calverton, MD: CSO and Macro International; c2008. Chapter 14, HIV prevalence and associated factors. 2 Government of the Kingdom of Swaziland (GKOS) and Government of the United States of America (USG). Partnership framework on HIV and AIDS, 2009–2013. Mbabane and Washington, DC: GKOS and USG; 2009.

OBJECTIVES OF THE TRAINING

The primary objective of the training was to develop the skills of the pharmacy personnel on proper management of HIV and TB medicines in health facilities.

The specific objectives of the training were to:

• Improve the skills of health workers handling pharmaceuticals in health facilities on inventory management of TB and HIV health commodities

• Ensure that pharmacy personnel are able to complete logistics management information systems (LMIS) forms for ordering and reporting of TB and HIV health commodities

• Ensure that pharmacy personnel are able to properly label medicines, and provide medicines information and proper counseling on medicines use to patients to help achieve improved adherence to treatment

• Ensure that pharmacy personnel understand the importance of reporting ADRs for TB and HIV medicines to improve patient outcomes

OPENING THE TRAINING SESSION

The training was carried out in four sessions, one for each project region, held August 7–17, 2017. Each session took place over two days. The training schedule is presented in table 1; the facilitators and scope of training are presented in table 2. The training agenda is shown in annex A.

Table 1. Training dates and number of participants trained Region Training dates Venue Number of pharmacy personnel trained Lubombo August 7–8, 2017 George Hotel 21 Manzini August 9–10, 2017 George Hotel 31 Shiselweni August 14–15, 2017 George Hotel 30 Hhohho August 16–17, 2017 Happy Valley Hotel 22 Total 104

Ms. Fortunate Bhembe, Deputy Director for Pharmaceutical Services in the MOH, opened the training and welcomed everyone who had come to participate in the two-day event. She mentioned that for the country to achieve the UNAIDS 90-90-90 goal target for HIV infection diagnosis and treatment, availability of medicines was an important component—hence the need to periodically build capacity of pharmacy personnel on pharmaceutical management and supply chain practice in order to achieve positive patient health outcomes. She further stated that the MOH was working around the clock to ensure that each health facility from the primary health care level to the national level has trained pharmacy personnel managing medicines in order to improve patient health outcomes, as currently the primary health facilities depend heavily on nurses’ support for pharmaceutical management.

Table 2. Facilitators and scope of training Name of facilitator Position Topics presented Sibongile Mabuza Pharmacist (Medicines 1. CMS processes for supplying health facilities and Regulatory Unit)–CMS Reporting timelines 2. Overview of Health Facility Pharmaceutical SOPs 3. Overview of pharmacology, drug-drug interaction and common side effects for ARVs Sihle Nhlabatsi Pharmacist (Malaria 1. Assessing Stock Status for Decision Making Program)–CMS 2. Overview of Pharmacology, Drug- Interactions and Common Side Effects for TB medicines Pholile Maphalala Pharmacist (TB and 1. Assessing Stock Status for Decision Making ART Program)–CMS 2. Overview of Pharmacology, Drug-Interactions and Common Side Effects for TB medicines Mavis Vilane Strategic Analyst–CMS– Logistics Management Information System: Theory and Data Management Unit Practical Session Alex Duga Technical Advisor 1. Reporting Adverse Drug Reactions (Pharmaceutical (Pharmacovigilance) Services)–SIAPS 2. Pharmaceutical Waste Management Wenzile Senior Technical Officer 1. Overview of Supply Chain of Medicines System:

3 HIV/TB Pharmaceutical Management and Supply Chain Training Report

Name of facilitator Position Topics presented Mthimkhulu (Supply Chain)– SIAPS Definition & Purpose 2. Components of Supply Chain and Key Terms Albert Chinhenzva Pharmaceutical Advisor– Importance of PTCs/ MDTs and Quality Improvement AIDSFree Projects (QIPs) Kholiwe Shongwe Technical Advisor 1. Good Storage Practices (Pharmaceutical 2. Rational Medicines Use Services) SIAPS 3. Good Dispensing Practice

TRAINING FORMAT

Eight facilitators conducted the regional trainings, handling presentations on different topics. The training was structured in an interactive manner, with a participatory approach. The facilitators presented the theory session, which involved explaining different concepts to participants and facilitating an interactive session involving discussion, questions, and answers. The training also involved practical sessions where the participants did group exercises designed to guide them in making informed decisions on selection and rational use of medicines at their health facilities.

TARGET AUDIENCE

Target audiences for the training workshop were pharmacists, pharmacy technicians, pharmacy assistants, and nurses working in the pharmacy from hospitals, health centers, and clinics providing ART and TB services in Swaziland. A quick view of participant characteristics is shown in table 3.

Table 3. Participants of the training by gender and profession in each region Gender Profession Region Male Female Pharmacist Pharmacy technician Nurse Hhohho 7 15 2 7 13 Lubombo 4 17 1 3 17 Manzini 13 18 2 8 21 Shiselweni 10 20 1 6 24 Total 34 70 6 24 74

A total of 104 health care workers were trained from all regions. In the Lubombo region, from August 7–8, 2017, a total of 21 health care workers were trained, of whom 17 were females and 4 were males. In the Manzini region, from August 9–10, 2017, 31 health care workers were trained, of whom 18 were females and 13 were males. In the Shiselweni region, from August 14– 15, 2017, 30 health care workers were trained, of whom 20 were females and 10 were males. In the Hhohho region, from August 16–17, 2017, 22 health care workers were trained, of whom 15 were females and 7 were males. Table 4 shows the health facilities represented at the training by region.

Table 4. List of health facilities represented by region Lubombo region Manzini region Shiselweni region Hhohho region Siphofaneni Clinic Philani Clinic Hlathikhulu Mbabane Government Hospital Government Hospital Ndzevane Clinic National Psychiatric Hospital Matsanjeni Health Baylor Center of Center Excellence Mambane Clinic Raleigh Fitkin Memorial Hospital New Haven Clinic Motshane Clinic Lomahasha Clinic Sappi-Usutu Clinic Nkwene Clinic Mahwalala Clinic Tsambokhulu Clinic The AIDS Information Support Mfishane Clinic Mkhuzweni Health Center (TASC) Clinic Center New Thulwane Family Life Association of Moti Clinic Bulembu Clinic Clinic Swaziland (FLAS) Manzini Clinic Hlane Clinic Matsapha Healthcare Clinic Lavumisa Clinic Salvation Amry Clinic Cabrini Ministries Cana Clinic Jericho Clinic Nyonyane Clinic Clinic Lubulini Clinic Lushikishikini Clinic Nhlangano TB Ward Ekuphileni Clinic Tikhuba Clinic Bethany Clinic MSF- Nhlangano Piggs Peak Government Hospital Royal Swaziland AIDS Healthcare Foundation Nhlangano Health Dvokolwako Health Sugar Corporation (AHF)—Matsapha Clinic Center Center Clinic

6 Target Audience

Lubombo region Manzini region Shiselweni region Hhohho region Manyeveni Clinic Mangcongco Clinic JCI Clinic Horo Clinic Sinceni Clinic Bhekinkosi Clinic Ntshanini Clinic Ntfonjeni Clinic Good Shepherd Mahlangatsha Clinic Mahlandle Clinic Malandzela Clinic Hospital Khuphuka Clinic King Sobhuza II Clinic Magubheleni Clinic Mbabane Public Health Unit Malindza Clinic Manzini Wellness Center Clinic Dwaleni Clinic Sigangeni Clinic Ubombo Ranches Manzini Healthcare Clinic Gege Clinic Ezulwini Satelite Hospital Clinic Sitsatsaweni Clinic Women and Children Hospital Zombodze Clinic Mangweni Clinic Shewula Clinic Sigcineni Clinic Mashobeni Clinic Mpolonjeni Clinic National TB Hospital Silele Clinic Manzini Clinic Nhlangunjani Clinic TB Program Tfokotani Clinic Lamvelase AHF—Manzini Clinic Sigombeni Clinic Luyengo Clinic Mankayane Government Hospital

PRE- AND POST-TEST RESULTS

Before the training started, participants took a test to measure their level of knowledge on specific pharmaceutical management and supply chain components. At the end of the training, they took the same test to determine the level of change made in their knowledge by the training. The results of pre- and post-tests for each region are displayed in figures 1–4.

The results showed improved skills of trained participants in pharmaceutical management and supply chain elements. For example, 72.7% of participants from Lubombo scored below 55% on the pre-test, whereas more than 70% of participants scored 55% or above on the post-test; 30% (n=7) of participants scored 100% on the post-test. Improved skills were also observed in the Manzini, Shiselweni, and Hhohho regions. Figures 1–4 depict the pre- and post-test results in all regions. The improved skills demonstrated will result in improved pharmaceutical care and inventory management of HIV and TB medicines in health facilities. This will in turn improve medcines availablity in health facilities and improve patient health outcomes.

Figure 1. Pre- and post-test results, Lubombo region

8 Pre- and Post-Test Results

Figure 2. Pre- and post-test results, Manzini region

Figure 3. Pre- post-test results, Shiselweni region

Figure 4. Pre- and post-test results, Hhohho region

NEXT STEPS

The pharmacy personnel were tasked with improving medicines inventory management and pharmaceutical care for improved patient health outcomes back in their respective health facilities.

Each health facility was specifically tasked with developing a quality improvement plan (QIP) of their choice on issues in pharmaceutical management and rational medicines use to bridge identified gaps. SIAPS in collaboration with CMS will visit the health facilties on a quarterly basis to assist and mentor pharmacy personnel in developing and implementing QIPs to address the gaps identified after the trainings.

PHOTOS

Ms. Fortunate Bhembe, Deputy Director for Pharmaceutical Services at the MOH opening the TB and HIV Pharmaceutical Management and Supply Chain Training Workshop in Manzini. She thanked USAID, through PEPFAR, for providing this support to build the capacity of pharmacy personnel on proper management of TB and HIV medicines to ensure availability and rational use of medicines to improve patient health outcomes.

11 HIV/TB Pharmaceutical Management and Supply Chain Training Report

Hhohho region training participants

Manzini region training participants, with SIAPS Country Director Mr. Matshotyana first row, left)

ANNEX A. TRAINING AGENDA

KINGDOM OF SWAZILAND MINISTRY OF HEALTH

TB/HIV Pharmaceutical Management and Supply Chain Training for Pharmacy Personnel: Agenda

TIME ITEM RESPONSIBLE DAY 1 08:00–08:15 Registration MSH Operations 08:15–08:30 Welcoming remarks Ms. Fortunate Bhembe 08:30–08:45 Introduction of participants—ice breaker, ground rules Mr. Wenzile Mthimkhulu development 08:45–09:00 Pre-test Mrs. Kholiwe Shabangu 09:00–09:30 Overview of Supply Chain of Medicines System: Mrs. Kholiwe Shabangu Definition and Purpose 09:30–10:00 Components of Supply Chain and Key Terms Mr. Wenzile Mthimkhulu 10:30–11:15 Overview of Health Facility Pharmaceutical SOPs Sibongile Mabuza 11:15–12:00 CMS Processes for Supplying Stock to Health Facilities Mrs. Sibongile Mabuza and Reporting Timelines 12:00–12:45 Assessing Stock Status for Decision Making Mr. Sihle Nhlabatsi/Ms. Pholile Maphalala 14:00–14:30 Inventory Management and Updating Stock Cards Mr. Albert Chinhenzva 14:30–15:00 Good Storage Practices Kholiwe Shabangu 15:00–16:00 Waste Management Mr. Alex Duga 16:00–16:15 IEC/poster discussion break Ms. Neliswa Bhembe 16:15–17:00 Importance of PTCs/MDTs, and QIPs Mr. Albert Chinhenzva DAY 2 08:00–08:15 Registration MSH 08:15–08:30 Recap Participants 08:30–09:30 Logistics Management Information System: Theory and Mrs. Mavis Vilane-Mgongo Practical Session 09:30–10:30 Reporting of ADRs (Pharmacovigilance) Mr. Alex Duga 11:00–12:00 Overview of Pharmacology, Drug Interactions, and Mrs. Sibongile Mabuza Common Side Effects of ARVs 12:00–13:00 Overview of Pharmacology, Drug Interactions, and Ms. Pholile Maphalala/Mr. Common Side Effects of TB Medicines Sihle Nhlabatsi 13:45–14:15 Good Dispensing Practices Mrs. Kholiwe Shabangu 14:15–14:45 Waste Management Mr. Alex Duga 14: 45–15:00 Post-Test and Evaluation Mr. Wenzile Mthimkhulu 15:00–15:15 Way Forward Mr. Mzwandile Vilakati 15:15–15:30 Closing remarks Kidwell Matshotyana