THE VALUE CHAIN Pharmacy Division-SURE Newsletter |

Issue 2, March 2012

Welcome to the second issue of the Value Chain Newsletter. In this issue, we feature stand-alone stories

from the field highlighting our achievements and successes. This publication will update you on our

collaborative activities toward improving access to essential medicines and health supplies.

MOH and SURE trained Medicines Management supervisor explains the correct method

of dispensing to a health worker in Luwero district. Photo credit: SURE

Program

The USAID funded and Management Sciences for Health led Securing Ugan-

dans’ Right to Essential Medicines (SURE) Program is working with the Uganda

Ministry of Health (MOH) Pharmacy Division and partners to strengthen

pharmaceutical management systems. Since our last issue, the SURE program

has moved into all 45 of its designated districts and has registered ever-

increasing improvement in indicators measuring dispensing, ordering and

reporting, storage, and stock management at public health facilities and private

not-for-profit facilities. The Pharmacy Division in collaboration with other

implementing partners such as STAR E, STAR EC and STRIDES and in

collaboration with SURE has started the roll out of supervision and performance

assessment by trained medicines management supervisors (MMS) into 42 more

districts as part of achieving national coverage. As this issue describes, the

presence of MMS at facility level has transformed medicines management and

led to better availability of essential medicines. Please find out more about our

achievements in the pages to follow and feel free to share a copy of this

newsletter with colleagues. We will keep you updated on our progress!

Distribution of the 45 interven-

tion districts (shaded areas )

IN THIS ISSUE

Field stories…………..........2, 3

Support to JMS………............4

SURE-MUK collaboration.......5

New information sharing sys-

tem…………………….……...5

Breaking cultural barriers……6

The UMTAC ………….. …....7

Stock status reports…………..7

Planned/ongoing activities…...8

Upcoming publications and re-

ports..........................................8

Partners…….………....….…..8

THE VALUE CHAIN NEWSLETTER 2

Stories from the Field

has used the supervision, performance assessment, and

recognition (SPARS) approach in 45 districts in Uganda.

This approach involves mentoring and coaching pharmacy

and stores’ staff at private not-for-profit and public health

facilities in medicines management.

In the last six months, Lebu Akim, a Store’s Assistant at

Koboko Health Centre IV underwent two sessions of

mentoring and coaching by the medicines management

supervisor trained by the SURE program.

“Our system for stock management has improved. We up-

date our stock cards regularly and carry out a physical

count every month, which we never used to do in the past.

Our orders are based on consumption, and we keep

enough stock to last up to the next delivery,” says Lebu.

SURE assessed the facility’s performance after the third

supervisory visit in January 2012. The assessment was

based on five medicines management indicators that

included storage quality and use of stock cards,

appropriate availability of vital and non-vital medicines;

and dispensing quality. The results showed the health

facility’s overall increase in performance in stock manage-

ment from 30% to 63%. Storage management improved

from 54% to 76% and ordering and reporting from 56% to

76%.

Above is the appearance of part of the store with piles of medi-

cines and supplies at Koboko HC IV before intervention.

Photo by Jimmy Ondoma

Lebu Akim, the Stores’ Assistant at Koboko Health Centre IV

store after the intervention. Photo by: Jimmy Ondoma

In Uganda, districts and health sub-districts play a key

role in delivering and managing health services. Although

72% of households live within five kilometers of a health

facility, poor infrastructure and lack of medicines and

health supplies continue to hinder access to quality

services. According to the Annual Health Sector Perform-

ance Report 2009/10, only 21% of facilities had six vital

medicines (artemisinin-based combination therapy,

cotrimoxazole, depo provera, measles vaccine, oral

rehydration solution, and sulfadoxine/pyrimethamine)

available at all times.

Mentoring and Coaching at

Koboko Health Center IV By Jimmy Ondoma and Denis Okidi

Over the years, Koboko HC IV, located in the West Nile

region of Uganda, has experienced challenges in the

management of essential medicines and health supplies

(EMHS). Stock-outs of vital medicines were widespread,

while huge quantities of slow-moving medicines were at

risk of expiring. These problems were attributed to health

workers’ poor skills in logistics management. In addition,

there was no reliable information to guide staff on when

and what to order, because stock cards were not regularly

updated.

In July 2011, Pharmacy Division and SURE program

started capacity-building activities aimed at strengthening

EMHS systems at health facilities in the region. SURE

THE VALUE CHAIN NEWSLETTER 3

A patient receives medicine from Sarah Namakula, a dispenser

and nursing officer in-charge at Kojja Health Center IV. Photo

by: Samuel Omalla

Stories from the Field

Kojja Health Center IV Registers

Increase in Medicine Stocks By Samuel Omalla and Victoria Nakiganda

Kojja Health Center (HC) IV in Mukono district (central

region) is one of the facilities that had previously per-

formed poorly, with frequent stock-outs of vital medicines.

“From October to December 2010, we didn’t have cotri-

moxazole 480mg tablets for 37 days. Artemether-

lumefantrine 20mg/120mg tablets (35 kg and above) also

ran out of stock for 32 days,” says Sarah Namakula a nurs-

ing officer in-charge at Kojja HC IV store .

Between December 2010 and April 2011, 68 medicines

management supervisors (MMS) from central and eastern

regions were trained. The role of these supervisors is to

provide on-the-job training to health workers in stock and

storage management, prescribing and dispensing, and

ordering and reporting practices, while collecting data on

indicators to enable them to monitor performance of health

facilities.

Kojja HC IV is one of the facilities receiving supportive

supervision from MMS. Supervision visits conducted in

May and June 2011 revealed an increase in stock of vital

medicines. Kojja HC IV’s stock-out days for cotrimoxazole

480mg tablets were reduced to 17 from 37 days, while

artemether-lumefantrine 20mg/120mg tablets were not

out of stock at all.

The graph below shows improvement at Kojja HC IV after

the baseline and second visit conducted in April and May

2011. Scale 0–4 represents scores for each indicator, the

maximum being 5.

Through regular supportive supervision, more health

workers like Sarah are gaining skills on how to order

medicines correctly, manage medicines stock and the

store, update and fill out stock cards, and dispense

properly. This will minimize medicine wastage, stock

inadequacies, and overstocking in facilities. Monthly

data on medicines stock and facility performance will

also be available for decision making.

Bundibugyo Hospital Appreci-

ates New Changes By Lynda Nantongo and Timothy Nuwagaba

At Bundibugyo Hospital, Angole Ruben has worked as a

store in-charge for 29 years. Now, as a medicines

management supervisor, Angole is using the knowledge

and skills he acquired during the training he attended in

April 2011 to mentor and train other health workers in

the district.

Since then, Angole has worked hard to make his store

stand out as one of the best maintained stores in

Bundibugyo. His efforts have paid off; a team from the

United Nations Children’s Fund that visited the store in

THE VALUE CHAIN NEWSLETTER 4

Business Process Transformation Project Improves Customer Service

Delivery at JMS

Participants at JMS during the start of the team training exercise,

together with the facilitator, Andrew Hayman .

Photo credit. Joint Medical Store

September 2011 likened Angole’s well-maintained store to

those operating in Australia. The district health team, too, is

full of praise for the hospital’s new changes.

“We used to order for medicines and supplies without priori-

tizing. As result, there were frequent stock outs of medicines.

The shelves in the store were unlabeled, and it would take me

a longer time to locate some of the medicines once an order

was placed,” says Angole.

The store is cleaner, essential medicines and supplies are

consistently available, and shelves are labeled according to

medicines’ generic names with updated stock cards on every

shelf. Improvements in dispensing and prescribing practices

include longer dispenser-patient interaction time and use of

dispensing equipment to count medicines . Reporting and

ordering is also better.

With the MMSs mentoring and training other health

workers in their districts, service delivery to the popu-

lation will continue to progress as medicines and

health supplies are made available at facilities.

Angole Ruben (Blue coat) with the Store assistant Eratus Kamero

while updating stock cards. Photo by Lynda Nantongo.

By Andrew Hayman and Andrew Cohen

The Joint Medical Store (JMS) partici-

pated in a business process transforma-

tion project to strengthen the efficiency

and effectiveness of its procurement,

warehousing, and sales functions.

Taking part in the project were senior

and middle management staff at JMS

who not only analyzed and redesigned

current processes, but also identified and

eliminated activities that did not add

value. For example, as part of the

analysis, at least 67% of such activities

in the “forecast to replenishment”

process were completely eliminated. The

project also resulted in a 72% decrease

in time spent on non-value added

activities for all primary processes. This

led to the creation of new and more

customer-responsive processes.

Uganda SURE facilitated the project,

which began with a one-day workshop

where participants received in-depth

training on three primary processes—

‟order to cash‟, „forecast to replenishment‟, and „purchase to pay‟. Partici-

pants acquired skills in interviewing JMS staff to identify value-added and

non-value added activities, and in designing new processes. They also

used their new knowledge to create process maps indicating the sequence

of activities, departments responsible, and time spent weekly on each

activity, and then

to decide on the

appropr iateness

and value of each

activity‟s contribu-

tion to delivering

customer service.

The bus iness

process transfor-

mation project

enabled JMS to

determine ways to

move forward with

a detailed imple-

mentation strategy

for the revised ac-

tivities.

The workshop and process analysis were part of technical assistance pro-

vided to JMS between August and November 2011 by the USAID-funded

SURE program and RTT, one of SURE‟s implementing partners.

THE VALUE CHAIN NEWSLETTER 5

By Khalid Mohammed

The SURE program is working with one of its partners,

Makerere University (MUK), to institutionalize the training

of medicines management supervisors. The initial agreement

is for MUK College of Health Sciences (MUK CHS) to train

220 MMS from all districts in the country enabling them to

perform in-service training in medicines management (MM).

In parallel to MMS training, as part of getting MM into pre-

service training, MUK will assist in changing the curriculum

of all health training institutions to incorporate MM into the

curricula of all health workers.

In November 2011, MUK conducted its first training, where

20 participants successfully passed the two-week’s course in

supply chain management. While speaking at the closing

ceremony, the deputy principal at MUK CHS said,

“Effective next year, the component of medicines manage-

ment will be included in the college’s training curriculum.”

Adome Odoi, a professor at the college who is spearheading

the drive to change the curriculum, believes that having

MUK conduct trainings in supply chain management will

provide MMS and health workers with knowledge to carry

out their jobs effectively. Odoi thanked the SURE program

for sharing their tools, materials, and expertise that has

bridged the gap between academic concepts and actual

practice in the field.

The Pharmacy Division led by the Assistant Commis-

sioner Health Sciences-Martin Oteba, applauded the

curriculum change and pledged on behalf of Ministry

of Health to provide the technical support necessary to

ensure its smooth implementation.

Institutionalizing Training in Supply Chain Management

A pioneer participant receives a supervision bag and certifi-

cate after attending the MMS training conducted by Maker-

ere . Photo credit: MUK CHS

By Kim Hoppenworth and Tom Opio As a result of monthly data collection on facility

performance by MMS in Uganda, a lot of paper-

based data collection forms were generated. The

number of MMS increased to 146 in October 2011.

However, in the last ten months, data from at least

300 facilities was submitted for analysis, which re-

quired extra time and resources to enable data entry

and analysis.

In September 2011 the use of netbooks was intro-

duced. The netbooks offer a computerized system

for MMS to capture and share data electronically.

The netbooks are installed with Adobe Acrobat X

(pdf data collection software) that allows direct data

entry into an electronic form designed in the same

format as the paper form the MMS were using.

Netbooks Lay Foundation for Easy Information Sharing

Medicines management supervisor Peter Okot (left) demonstrates

how he uses the electronic form installed on the netbook to the Senior

Pharmacist at Masaka Regional Referral Hospital, William Olumu

(right) and Tom Opio, SURE’s District Information Officer (center).

THE VALUE CHAIN NEWSLETTER 6

SURE organized a two-day training where eight MMS

gained hands-on experience on the use of netbooks, filling

out electronic pdf forms, setting up an email account, and

using online support tools such as Team Viewer and

Skype.

The trained MMS are now using netbooks and pdf forms

to collect and submit data, which are easily and quickly

shared using electronic mail. Since MMS enter data

directly and share it electronically, the software facilitates

data collection, aggregation, and initial analysis.

The SURE program has procured netbooks for all MMS

working in the 45 SURE-supported districts. This will not

only equip MMS with computer and communication

skills, but will also improve capacity and performance of

district health facilities in planning, distributing,

managing, and monitoring of essential medicines and

health supplies.

a motorcycle to ease her transport during the supervisory

visits.

“I never thought that I would be able to learn how to

ride, but I managed. I was the only lady that passed in my

group. Now, I don’t fear riding a motorcycle because I

realized that no one can know I am a lady when I wear

the helmet and the riding suit. Even the community has

got used to seeing me riding my bike. It feels good and I

make my supervision schedules without worrying about

transport,” says Doreen.

Despite the scar on her right leg that she got after hitting

a log while riding a motorcycle, Doreen has not given up.

She is responsible for supervising five facilities in her

district. Four facilities are located far from Doreen’s

facility, and the motorcycle has made it possible for her

to plan, get to clinics, and work with staff comfortably.

Other health workers are now seeing her as a contact

person to pass on their needs to the District Health Offi-

cer. She has requested and delivered dispensing trays and

also redistributed medicines from over-stocked to under-

stocked facilities using the motorcycle.

Today, 26 female MMS like Doreen have completed

motorcycle riding training—breaking the barriers

entrenched in the Central Ugandan culture.

“One month after the training, half of the MMS includ-

ing those who had no prior knowledge and experience

in using computers submitted data using the pdf

electronic form,” said Kim Hoppenworth, SURE’s Dis-

trict Computerization Coordinator.

Women MMS Break Cultural

Barriers in Central Uganda By Samuel Omalla

In a region where only a handful of women can ride

motorcycles due to cultural norms and taboos, Doreen

Naluggwa, a 30-year-old Clinical Officer at Seeta Nazigo

Health Center III, in Mukono district, is one of the few

women who have broken the norm. She had never thought

of riding a motorcycle until early 2011 when she received

an invitation to undergo a six-day motorcycle defensive

training course.

In November 2010, Doreen attended a two-week course in

medicines management organized by the SURE and Phar-

macy Division which she passed successfully. But to serve

as a medicines management supervisor, she also had to

learn how to ride a motorcycle, after which she would get

Doreen Naluggwa puts on her protective gear before starting

her journey to a health facility to provide supportive supervi-

sion. Photo Credit: SURE Program

THE VALUE CHAIN NEWSLETTER 7

MOH Makes Stock Status Re-

port Official MOH Document By Morris Okumu

Having declared the stock status report an official govern-

ment document, the Uganda Ministry of Health (MoH)

requires that the report be presented every two months to

all levels of management.

“The MoH publishes on a bi-monthly schedule a national

stock status report that is shared with all partners. This

report is discussed by the Health Policy Advisory Commit-

tee and published on our website. The report is very infor-

mative and has provided basis for actions on so many

issues,” said Dr Asuman Lukwago, Acting Permanent

Secretary MoH while addressing the board and manage-

ment of Medicines Stores Department of Tanzania.

In 2010, SURE and Pharmacy Division launched the stock

status report, which highlights challenges, bottlenecks, and

potential solutions to mitigate stock-outs and expiries of

antiretrovirals, HIV test kits, artemisinin-based

combination therapies (ACTs), anti-TB medicines, repro-

ductive health commodities, laboratory products, and other

selected tracer medicines. The report was developed to

respond to the need for better coordination to ensure

commodity security. It quickly produced results; it trig-

gered a donation of first-line antiretrovirals for the public

sector by US government, as well as a donation of ACTs

from UK’s Department for International Development—in

both cases averting a looming stock-out.

New Committee for Appropriate

Use of Medicines By Dorthe Konradsen

Although several health sector strategic documents stress

the importance of using medicines appropriately, Uganda

had no organizational entity focused on medicine use and

therapeutics. To address this gap, the SURE program in

close collaboration with the Pharmacy Division and the

Quality Assurance Departments proposed to the Ministry

of Health to urgently create a national body to promote

appropriate use of medicines in the public sector.

January 13, 2011 marked the launch of the first national

committee in charge of appropriate use of medicines—the

Uganda Medicines and Therapeutics Advisory Commit-

tee (UMTAC). The goal of UMTAC is to promote

availability and appropriate use of medicines and health

supplies in the public sector.

Speaking at the launch, former Director General—Health

Services at MOH, Dr. Kenya Nathan Mugisha said,

“One of the main challenges facing medicines and health

supplies management in the health sector is lack of an

authoritative channel through which health workers can

access information on current practices in rational

medicines use, prioritization of requirements and con-

tinuous education on rational medicines use. UMTAC

inauguration is a timely intervention to ensure that we

have in place a structure to mitigate the challenges.”

Some of the members that attended the Uganda Medicines

Therapeutics and Advisory Committee launch. Photo credit:

SURE Program

UMTAC has already held three meetings to review,

update, and finalize the essential medicines, laboratory

commodities, and health supplies lists, and also identified

necessary changes to the Uganda Clinical Guidelines

2010. The new lists classify all the essential medicines and

supplies into “vital,” “essential” and “necessary,” an im-

portant step to prioritize the use of scarce resources. Once

complete, the lists will guide health facility staff in

ordering medicines and supplies and the National Medical

Stores in making procurement decisions. SURE continues

to support UMTAC to update the Essential Medicines List

and develop the Essential Health Supplies List; while the

US Centers for Disease Control and Prevention supports

the development of Essential Laboratory Commodities

THE VALUE CHAIN NEWSLETTER 8

The Pharmacy Division and SURE program ac-

knowledge support from— MOH Resource Centre and technical programs (AIDS Control Program,

National Tuberculosis and Leprosy Program, Central Public Health Labo-

ratories, National Malaria Control Program, and Reproductive Health Pro-

gram)

Makerere University Kampala

National Drug Authority

Joint Medical Store

National Medical Store

Uganda Medicines Therapeutics Advisory Committee

Euro Health Group

Pharmaceutical Healthcare Distributors (RTT)

Management Sciences for Health

US Agency for International Development

US Centers for Disease Control and Prevention

District Health Officers /Chief Administrative Officers

Medicines Management Supervisors

Implementing partners

About the SURE /MoH Collaboration SURE is a five-year program ending in 2014 funded by the US government

through the US Agency for International Development. The program is imple-

mented by Management Sciences for Health, and works closely with the

Pharmacy Division to improve availability and accessibility to quality essential

medicines and health supplies in Uganda. SURE and the Pharmacy Division

support commodity management, human resource capacity at central and

district levels, improved management information and reporting systems,

monitoring and evaluation; and strengthening management and planning to

optimize resource utilization.

Ministry of Health (MOH)

Republic of Uganda

Plot 6 Lourdel Rd, Wandegeya

P.O. Box 7272. Kampala Uganda

Tel: 256-41-340884

Fax: 256-41-340887

Email: info@health.go.ug |

www.health.go.ug

Securing Ugandans’ Right to

Essential Medicines (SURE)

Management Sciences for Health

(MSH) Uganda office

Plot 15, Princess Anne Drive,

Bugolobi

P.O BOX 71419. Kampala, Uganda

Tel: 256 414 235 038

Fax: 256 414 235 035

Email: sureinfo@sure.ug |

www.sure.ug

For more information and to

contribute to the next issue please

Contact Julian Natukunda at

jnatukunda@sure.ug or

jnatukunda@msh.org

or call +256 (0) 759 800 155

This newsletter 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-617-

A-00-09-00003. The contents are the

responsibility of Management Sciences for

Health and do not necessarily reflect the

views of USAID or the United States

government.

Events, Ongoing and

Planned Activities

Updating of the essential medi-

cines and health supplies lists

and treatment guidelines

Roll out strategy for the online

ARV ordering and reporting (web-

based) system

RxSolution pilot is finalized. Roll

out to the first 10 facilities to be

conducted this year

National Drug Authority (NDA)

and SURE will begin piloting the

new inspection tool for pharma-

cies in public health sector.

MOH-PD and SURE conducted

the 3rd Regional Pharmacists‟

meeting (February 2012)

Organized a meeting between

DHOs and medicines manage-

ment supervisors for Western and

Central regions

Makerere University College of

Health Sciences completed 3rd

MMS training in medicines man-

agement (March 2012)

New and Upcoming

Publications/Reports

The Pharmacy Division and SURE

program have undertaken a number

of assessments to improve pharma-

ceutical health delivery in Uganda.

Once finalized, publications are

expected on the following

Second kit system survey

Annual pharmaceutical health

sector performance

Concept paper—SPARS strategy

The national TB logistic assess-

ment

A new national essential medi-

cines and health commodities

logistic manual