PROCURING AND DISTRIBUTING ARVs AND OTHER A.R.T COMMODITIES IN MALAWI Technical Briefing for Consultants in Procurement and Supply Management for HIV,

PROCURING AND DISTRIBUTING ARVs AND OTHER A.R.T

COMMODITIES IN MALAWI

Technical Briefing for Consultants in Procurement and Supply Management for HIV, TB and Malaria

Caesar Mudondo, Project Officer HIV/AIDSHealth and Nutrition Section

UNICEF Malawi

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Outline

1. HIV/AIDS situation in Malawi

2. Structure of the healthcare system

3. Background to ART program in Malawi

4. Guidelines for management of HIV/AIDS

5. Estimating needs (quantification)

6. Procurement system for ARVs and drugs for OIs

7. Distribution system for ARVs and other ART commodities

8. Challenges

9. Successes

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

HIV/AIDS situation in Malawi

• Population of Malawi 10.5 million• 900,000 living with HIV/AIDS• HIV prevalence 14.4% (15-49 year), 2003• New infections (15-24 year olds) 46%• New infections overall 10,000 per year• 80,000 <15 year olds estimated with HIV/AIDS• 86,000 deaths due to HIV/AIDS per annum

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Structure of the healthcare system

• Ministry of Health and Population (MOHP)- policy formulation and implementation of healthcare programs

• National AIDS Commission- coordinating HIV/AIDS activities and programs

• Central Medical Stores-storage and distribution of medicines and other medical supplies to government and CHAM facilities

• Pharmacy, Medicines and Poisons Board- medicines regulatory authority

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Background to ART program in Malawi

• National HIV/AIDS policy adopted by GOM in 2003• MOHP adopted policy to adopt ART country-wide (July

2004 launch of ART)• GFATM approved US$ 196m for HIV/AIDS• ART implemented in phases• 170,000 people estimated to need HAART• 4,000 on ART in Jan 04. 37,500+ in Dec 05 (i.e. 20% of

patients requiring ART)• 1,024 health workers trained in ART in public sector and

240 in private sector• 83 facilities (23 in private sector) implementing ART• ART free in public sector

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Guidelines for management of HIV/AIDS

• Guidelines for management of HIV/AIDS developed• Health workers trained on guidelines• First line regimen: [2 NRTI + 1 NNRTI] d4T+3TC+NVP (Fixed-dose combination)

“Triomune”Alternative first line regimens: AZT+3TC+NVP d4T+3TC+EFVSecond line regimen: AZT+3TC+TDF+LPv/RTv• OIs managed as per recognised protocols

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Estimating needs (quantification)

• No sound historical data as basis for quantification available

• Initial estimates of ARV needs based on case load of TB and clinicians’ experience

• 20 years TB experience-no o/s for first line drugs• Use of standardised first line treatment important• 54 facilities categorised as low (25 patients/ month),

medium (50 patients) and high (150+ patients) burden. • 24 low, 26 medium and 4 high burden• ARVs packaged into starter and continuation packs (kits)

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Estimating needs (contd)

• Starter pack for use during first 15 days• Continuation pack for next 30 days• Starter pack contains d4T/3TC/NVP+d4T/3TC• Continuation pack contains d4T/3TC/NVP• Kits produced containing starter and continuation packs

• Quantities of each drug per pack worked out for low, medium and high burden

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Procurement system for ARVs and drugs for OIs

• ART largely funded by GFATM• Procurement of medicines and other medical supplies generally responsibility of CMS

• Procurement responsibility for ARVs and other ART commodities contracted out to UNICEF

• Includes ARVs, diagnostic agents (HIV test kits), OI drugs and other medical supplies (lancets etc)

• UNICEF closely liaises with NAC and MOHP re-procurement of commodities

• Needs originate from MOHP and UNICEF provides TA and procures

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Distribution system for ARVs and other ART commodities

• UNICEF responsible for clearing all ARVs and other ART commodities

• Other ART commodities are delivered by UNICEF (in agreed proportions) to regional medical stores for further distribution to user facilities

• ARVs are delivered by UNICEF (in agreed proportions) direct to service delivery points

• Push for first line ARVs • 2nd line treatment for referral facilities• Based on consumption adjustments to quantities supplied to facilities can be made. Shift categories

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Challenges

• Funding limitations and lengthy procurement formalities• Lengthy lead times and effect on ability to react to urgent

needs • Estimating needs accurately in light of lack of reliable

historical data• Limited sources of supply for ARVs• Developing adequate capacity for supply management

Developing local capacity for procurement in shortest possible time

• Moving from “push” to “pull” for ARVs and other ART commodities

• M&E to ensure ability to react timely

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Successes

• Scaled up ART from 3,700 patients at 9 sites in 2003 to 35,000 patients at 83 sites Dec 2005

• Kit concept assisted in minimising problems related to quantification at facility level

• Procurement and distribution arrangement has worked satisfactorily to date (approx US$14m to date)

• No stock outs of ARVs at national or facility level• Increase in demand of ART services since launch of ART

(e.g. demand for HIV testing has increased 4-fold) • Quarterly supervisory visits to sites very useful

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

B = Starter drugs for patients weighing 60 Kg or above

AA = Starter drugs for patients weighing 59Kg or less

B

Malawi Design and Plan for ART../5

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Malawi Design and Plan for ART../6Continuation drugs: 60 tablets in a tin

Patients 60 Kg+

Patients 59 Kg-

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

Delivery and Distribution

Technical Briefing Seminar in Procurement and Supply Management for HIV, TB and Malaria. Copenhagen, 30 January – 2 February 2006

THANK YOU FOR YOUR ATTENTION