Uganda: Estimation of Commodity Requirements for 2002-2004, Drugs to Treat Sexually Transmitted Infection

Publication date: 2002

Uganda Estimation of Commodity Requirements for 2002–2004 Drugs to Treat Sexually Transmitted Infection Prepared for the Ministry of Health, Uganda Yasmin Chandani September 2002 Uganda Ministry of HealthUganda Ministry of Health Uganda: Estimation of Commodity Requirements for 2002–2004 Drugs to Treat Sexually Transmitted Infection Prepared for the Ministry of Health, Uganda Yasmin Chandani September 2002 Uganda Ministry of HealthUganda Ministry of Health DELIVER DELIVER, a five-year worldwide technical assistance support contract, is funded by the Commodity Security and Logistics Division (CSL) of the Office of Population and Reproductive Health of the Bureau for Global Health (GH) Field Support and Research of the U.S. Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI), (contract no. HRN-C-00-00-00010-00), and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], Social Sectors Development Strategies, Inc., and Synaxis, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management and analysis of USAID’s central commodity management information system (NEWVERN). This document does not necessarily represent the views or opinions of USAID. It may be reproduced if credit is given to DELIVER/John Snow, Inc. Recommended Citation Chandani, Yasmin. September 2002. Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat Sexually Transmitted Infection. Arlington, Va.: John Snow, Inc./DELIVER for the U.S. Agency for International Development. Abstract Explains the quantification methodology used for estimating the need for sexually transmitted infection (STI) drugs in the public and NGO sectors in Uganda from 2002–2004. The results of the drug assessment showed that, for STI purposes, some drugs would be oversupplied, while other drugs would be undersupplied. Short-term and long-term recommendations are included. Uganda Ministry of HealthUganda Ministry of Health DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: deliver.jsi.com Contents Acronyms.v Acknowledgments. vii Executive Summary . ix Short-term Recommendations .x Mid- to Long-term Recommendations .x Overview: Commodity Financing in the Public Sector .3 1. Essential Drugs .3 2. STI and OI Drugs .4 3. Malaria Drugs .4 4. Tuberculosis Drugs .5 5. HIV Test Kits.5 Quantification of Drugs for Syndromic Management of STIs .7 Background.7 Assumptions .7 Recommendations .13 General Recommendations .13 STI Program .13 Quantification.13 Procurement and Financing .14 Distribution .14 Information Systems.14 Appendices A. People Contacted.15 B. Treatment Algorithms for the Major STD Syndromes .19 C. Methodology for Quantifying STI Drugs for Syndromic Management .23 Tables 1. Estimate for Number of Women Treated for STIs .9 2. Estimate for Number of Men Treated for STIs .9 3. Estimates for Pregnant Women Treated for Syphillis .9 4. Quantities of STI Drugs Still Required between May 2002–April 2003 for Syndromic Management in Public and NGO Sectors .10 5. Estimated Quantities of STI Drugs Required between May 2003–April 2004 for Syndromic Management in Public and NGO Sectors .11 6. Quantifying to Order: STI Drugs, Laboratory Tests and Reagants, Expendable Medical Fixed Supplies .25 7. Quantity to Order.30 8. Summary Cost Estimate.31 9. Quantity to Order.32 10. Summary Cost Estimate.33 iii Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI iv Acronyms ACP AIC AIDS AIM CBD CDC/GAP CPR DANIDA DFID DHS ED EDP EGPAF EU GFATM GLRA GOU GTZ HC HIV HIV/AIDS HSSP JMS JSI LMIS MAP MOH MOS MTCT NBTU NGO NMS OI OJT PHC PHC-CG PMTCT and PPTCT PMTCT+ PSI RH SDP SLA SOH STI SWAp TASO AIDS control program AIDS Information Centre acquired immune deficiency syndrome USAID-funded district based AIDS project community-based distribution Centers for Disease Control and Prevention/Global AIDS Program contraceptive prevalence rate Danish International Development Agency British Department for International Development Demographic and Health Survey essential drugs essential drug program Elizabeth Glaser Paediatric AIDS Foundation European Union Global Fund for AIDS, TB and malaria German Leprosy Relief Association Government of Uganda Deutsche Gesellschaft fur Technische Zusammenarbeit (German international development agency) health center human immunodeficiency virus see HIV and AIDS DANIDA-funded Health Sector Support Project joint medical stores John Snow, Inc. logistics management information system Multi Country AIDS Program Ministry of Health months of supply mother-to-child transmission (used by researchers and funders) Nakasero blood transfusion unit nongovernmental organization National Medical Stores opportunistic infection on-the-job training primary health care primary health care conditional grants preventing MTCT or PTCT beyond preventing MTCT, considering the family Population Services International reproductive health service delivery point senior logistics advisor (FPLM) stock on hand sexually transmitted infection Sector Wide Approach The AIDS support organization v Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI UAC Uganda AIDS Commission UNAIDS United Nations Programme on HIV/AIDS UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID United States Agency for International Development VCT voluntary counseling and testing (HIV) WB World Bank WHO World Health Organization (Geneva, Switzerland) vi Acknowledgements The authors wish to acknowledge the support given to this activity by the many Uganda Ministry of Health, nongovernmental organizations (NGO) and cooperating agency personnel listed in appendix A. It will be critical to the success of the HIV/AIDS program activities in Uganda that these people and others continue to review and revise the assumptions and quantifications resulting from this preliminary report. The views stated in this report are those of the authors, and do not necessarily reflect the views of the U.S. Agency for International Development or the Uganda Ministry of Health. vii Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI viii Executive Summary Funding sources for procuring commodities for HIV/AIDS programs are increasing in Uganda and include the Ministry of Health budget, the World Bank supported Multi-Country AIDS Program (MAP), the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), and resources from donors and foundations. Without a systematic attempt to quantify commodities for all HIV/AIDS programs, and coordinated procurement and ordering, however, there is a great risk of less than optimal use of resources through duplicate and incorrect orders. As part of expanding its HIV/AIDS services, the MOH/U will channel new funds toward purchasing a wide range of commodities, including laboratory reagents (HIV test kits, syphilis RPR kits); as well as drugs for treating sexually transmitted infections (STI), tuberculosis (TB), opportunistic infections (OI), and anti­ retrovirals (ARV), either as a single dose for prevention of mother-to-child transmission or as combination therapy. This report provides details about the quantification methodology used for estimating needs of STI drugs in the public and NGO sectors in Uganda from 2002–2004. Separate reports exist or will be compiled for each of the other categories of commodities. Although estimates of STI drug requirements had already been prepared by the program, these were budget- driven rather than need-based and did not reflect actual demand or past consumption. There was a significant dearth of hard data on past consumption, partly due to prolonged stockouts after the termination of the previous World Bank STI project in 2000. Thus, the quantification process relied heavily on the expertise and knowledge of many key stakeholders, including the Uganda AIDS Commission (UAC), the Ministry of Health AIDS Control Program (MOH/ACP), the National Medical Stores, Joint Medical Stores, and the Centers for Disease Control and Prevention/Uganda (CDC). After extensive consultation with stakeholders and review of available records, the required quantities and assumptions made in arriving at these quantities were presented to program managers and STI technical staff. Because of the scarcity of hard data, the quantification is based on a series of generally liberal assumptions related to staff, training in the revised syndromic management algorithm, prevalence rates, and overlap of drug use for STIs and other purposes. If some of these positive assumptions are not met, the proportional quantities of STI drugs might have to be adjusted. Another important point to keep in mind is that, given alternative uses of these same drugs for other health problems, tracking the accuracy of the forecast will be difficult. The team found that benzathine penicillin, doxycycline, cotrimoxazole, and erythromycin ordered with MAP funds will be oversupplied for STI purposes, partly due to changes in the treatment algorithm after the order was placed. In contrast, ciprofloxacin, metronidazole, nystatin pessaries, aciclovir tablets, and RPR test kits for syphillis will be undersupplied for the period May 2002–April 2003, if the projections prove accurate. Approximately, an additional $4.1 million will be required to purchase STI drugs and consumables for 2002– 2003 and about $10.5 million for STI drugs and consumables in 2003–2004. The projections should be carefully reviewed before making final purchasing decisions. However, there is an urgent need to place the order for the 2002–2003 commodities, to reduce the chances of a stockout. Similarly, the 2003–2004 procurement process should be started soon to ensure the continuity of supply of these items. The most serious concern were the delays in receiving some of the drugs (notably metronidazole) because the manufacturer that won the tender was not able to get the products registered by the National Drug Authority (NDA) by the due date. ix Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI The team’s recommendations include the following: Short-term Recommendations • Validate projections with STD/ACP program staff. Given the liberal nature of the assumptions, thoughtful consideration should go into using the projections as a starting point from which to make future procurement decisions • Begin to identify possible funding sources for U.S.$3.8 million required to supply sufficient drugs to meet demand for STI services in 2002–2003 (table 4), in case funds from the GAFTM are not sufficient. • Liaise with the STD/ACP unit and pharmacy unit to develop a distribution plan for incoming STI drugs. • Although consumption of all STI drugs should be closely monitored to validate assumptions made for the quantification, and to help with future forecasts, particular attention should be paid to consumption of erythromycin. If prescribing practices do not change relatively soon, as stated in the assumptions, then more quantities of erythromycin may need to be ordered. • Strengthen STI sentinel site reporting to increase data availability for quantification and other program management interventions. Mid- to Long-term Recommendations • Expedite the development and maintenance of a central commodity database to keep track of all MOH and donor inputs for essential health commodity supplies. This information has been, and is likely to continue to be, crucial in alerting commodity management donors and stakeholders about impending stockouts or shortages in various product categories. • Explore the inclusion of STI drugs and financing mechanism in the MOH/pharmacy and UHSSP transition from push to pull system, beginning in January 2003, aimed at assisting districts to quantify their own needs. This could be a first step towards integrating the supply of STI drugs into the essential drug system. • Given that developing a traditional model of a centralized LMIS is not possible in the Uganda environment, work with NMS to use order quantities, stock-on-hand, and high-quality issues data that could be validated by quick surveys at the time national forecasts are conducted. • MOH, UAC, WB, and NDA staff to communicate regularly on shipment status of awarded tenders to ensure that potential delays of incoming commodities, whether through delayed registration or other causes, are identified early enough for timely resolution. x Background The Government of Uganda (GOU) estimates that the antenatal HIV prevalence is 6.1 percent and approximately 1.1 million people with HIV/AIDS are living in the country. Growing government commitment and nongovernmental organizations involvement, coupled with strong support from interna­ tional donor organizations, has contributed to both a reduction in prevalence and an increase in HIV/AIDS knowledge and program development. However, there is a need to greatly expand the range and quality of prevention, and care and support interventions to continue the progress that has been made. The availability of HIV/AIDS commodities will be central to the effort to expand the range and quality of services being offered. To ensure the consistent and reliable availability of these commodities to customers, programs must, in the medium- to long-term— • Be able to quantify their commodity needs. • Have or orchestrate resources to ensure procurement of these commodities. • Have or access skills to procure these commodities. • Deliver the commoditie s reliably to all customers along the supply chain. Recognizing this, the GOU/Ministry of Health (MOH) has requested the DELIVER/Uganda project to assist in coordinating the quantification of the range of commodities required by HIV/AIDS programs. This quantification will provide a detailed justification for all HIV/AIDS commodity requirements across both the public and civil society sectors for 2002 and 2003. Currently, there are several funding sources that are and can be used to procure commodities for HIV/AIDS programs, including the MOH budget, the World Bank supported Multi-Country AIDS Program, funds from the Global Funds for AIDS, Tuberculosis and Malaria (GFATM), and resources from donors and foundations. Without a systematic attempt to quantify commodities for all HIV/AIDS programs and a coordination of procurement and ordering, however, there is a great risk of less than optimal use of resources through duplicate and incorrect orders. Many commodities included under the umbrella of HIV/AIDS are already on the essential drugs list, which are used specifically by HIV/AIDS program components (e.g., sexually transmitted infection [STI], tuberculosis, and opportunistic infection [OI] drugs), as well as other purposes. Thus, this document will focus on HIV/AIDS program logistics and commodities while referencing other public health commodities, where appropriate, given GOU’s long-term goal to integrate supply and logistics systems for health programs. Key stakeholders involved in implementing HIV/AIDS prevention and treatment programs include the Uganda AIDS Commission (UAC), the Ministry of Health AIDS Control Program (MOH/ACP), and the Uganda Blood Transfusion Unit; nongovernmental organizations (NGOs), including the AIDS Information Center (AIC) and The AIDS Support Organization (TASO); and other cooperating agencies, such as the Centers for Disease Control and Prevention (CDC) and AIM Uganda. 1 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI 2 Overview: Commodity Financing in the Public Sector In general, financing for commodities used in public sector facilities combines MOH and donor funds. Donors can contribute in two ways: (1) through Sector Wide Approach (SWAp) funding via budget support to the Ministry of Finance; or (2) through provision of in-kind contributions, such as direct supplies of commodities to specific programs. To date, there has been no central mechanism or section of the MOH that keeps track of all the various donor inputs, in terms of commodity supplies. However, DELIVER/Uganda is currently working with the pharmacy section to establish a commodity tracking database that will maintain records of all donor commodity inputs. The following is an approximate summary of funding sources, by program, for commodities in the public sector in Uganda. The focus is on commodity inputs for lower-level health units (HC II, III, and IV) and not on district, regional, and referral hospitals. 1. Essential Drugs Health units currently obtain essential drugs and supplies in the following ways: • Pre-packed EDP kits, which are procured centrally and distributed to all public sector health facilities on a quarterly basis. Funding for the 30–40 essential drugs included in the kit has come from GOU and DANIDA, through its HSSP project. The content of the kits has recently been updated to more accurately reflect health facility needs. The supply of drugs in the kit is generally insufficient for health unit needs’ and only lasts 1–1.5 months. • Direct purchases by the district or health units using funds from the primary health care conditional grants. In theory, after the funds have been released, 50 percent are available for drug purchases to supplement supplies in the kit. In practice, delays in the release of funds and reporting requirements on use of the funds have led to limited use of PHC-CG grants for purchasing drugs. Even if the full amount allocated for drugs from the PHC-CG grants were released regularly, funding is still not sufficient for drug needs at the lower levels. A recent study conducted by MOH/pharmacy section and UHSSP demonstrated that distric ts require approximately U.S.$2.40 per capita to provide sufficient commodities for the minimum package of services that GOU has committed to providing for Ugandans. Currently, including all GOU and partner direct and in-kind contributions, only about U.S.$0.96 per capita is being spent on commodities. To address the issue of irregular and insufficient supplies, the pharmacy section is planning a phased transition to a comprehensive order-based system for essential health commodities. The transition to the new “pull” system will begin in January 2003. Key elements of the new system include— � To instill the idea of a “value” for the kit among lower level health units, DANIDA/GOU funding for essential drugs will be a budget line equal to the value of the imported kit. � During the transitional period, health units can use the budget line to purchase locally assembled kits until they have sufficient capacity to estimate their requirements and place orders for individual items. 3 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI � Eventually comprehensive orders will be placed using funds from both the essential drugs budget line and the PHC-CG budget, and each health unit will have separate accounts at NMS/JMS. � Donated products for vertical programs will be integrated onto the order form for the pull system to encourage systematic orders to be placed by each health facility for all its commodity needs. 2. STI and OI Drugs Funding for these supplies has been erratic in the last several years. Initially, the World Bank STI project (1995–2000) supplied condoms for STI/HIV prevention, drugs for STI syndromic management, TB treatment according to DOTS, and OI treatment. Other donors for these commodities during the same period included DFID and KfW. These commodities were provided to MOH, NGO, and mission sites. After the project funding ran out in 2000, a small amount of MOH funds were allocated to purchase STI drugs. This money was never used for STI drug purchases but reallocated for purchasing essential drug program (EDP) kits. Consequently, since the end of 2000, there has been no provision of STI drugs to lower levels through the national program on a consistent basis, since the EDP kits purchased do not contain all the drugs required for syndromic management of STIs. In theory, districts should have been able to obtain these drugs by ordering from NMS using their PHC-CG drug budgets. In practice, release of the PHC grants has not been timely and districts have had difficulties accessing funds after their release. Thus, it is likely that health centers have had inconsistent supplies and shortages of STI drugs. Although TB and malaria drugs were also affected by the shortages in funding, the programs have been better able to mobilize other donor resources to ensure provision of supplies. Between April–July 2002, most of an emergency shipment, valued at U.S.$1.3 million, of drugs for STI, TB, OI, and HIV test kits, syphilis test kits, and expendable medical supplies arrived, procured through the World Bank-assisted MAP project. Through standard non-emergency procedures, the project has also procured substantial amounts of HIV/AIDS commodities, which will be supplied through the Uganda AIDS Commission and the MOH, starting in early 2003. Although estimates were made of commodities required for treating STIs, TB, malaria, and specialized OIs, this was a budget-driven exercise rather than a systematic quantification of needs for both public and civil society sectors based on demand and a realistic assessment of Uganda’s capacity to deliver services and supplies. 3. Malaria Drugs The main funding source for anti-malarial drugs is the government via budget support to the treasury from donor agencies. This money, the conditional PHC grant, is, in turn, supplied to the district health departments. After district health departments are informed of their allotment, they are required to spend 50 percent of the amount on drugs, part of which is spent on anti-malarials. Districts and health units also receive anti-malarial drugs in the pre-packed EDP kit. In times of crisis, donor agencies have been known to purchase anti-malarial drugs directly on behalf of the government, and supply them to the MOH for distribution. WHO provided this support during a malaria epidemic in the late 1990s. On the whole, however, there is no coordinated approach to donor support of the malaria program. Most recently, with the change in policy of chloroquine (CQ) and sulphadoxine-pyrimethamine (SP) as first- line treatment, as of July, the MOH did not plan for additional anti-malarial drugs to be purchased under the MAP project. This has resulted in low stock levels of both first-line and second-line treatment drugs, especially sulphadoxine-pyrimethamine. The issue of an impending stockout was discussed at the joint 4 Overview: Commodity Financing in the Public Sector meeting of MOH and donors in April, and DfID and Irish AID both agreed to step in and fill the gap by purchasing a one-year supply each of SP and quinine, worth $1.2 million. As an emergency measure, a two- month supply of SP was bought locally and distributed in July and August. Another four-month supply is being air shipped in, while the remaining six–month supply will come in through a regular sea shipment. Unfortunately, the long registration process for double -scored packs of quinine has resulted in a delay in purchasing and bringing in stop-gap quinine supplies. Details on the quantification can be found in the companion report on anti-malarial drugs. 4. Tuberculosis Drugs There have been two main sources of funding for TB drugs in recent years: the MOH and the German Leprosy Relief Association (GLRA). The primary source during the later 1990s was the MOH. Between 1995 and 2000, funds from the World Bank STI Project were used to supply TB drugs. GLRA also supplied TB drugs between 1995 and 2000, especially during lapses in the MOH procurement process. More recently (2001), the TB program has been relying on a World Bank Debt Relief Facility and GLRA to supply its TB drugs. Although the TB program expects this to change in the near future through the World Bank MAP project supplies, orders of a one-year supply of drugs through that mechanism have been delayed due to the lengthy registration process for manufacturers for the TB 4 and TB 2 blister packs. Similarly, suppliers from the Global Drug Facility of the STOP TB fund are unable to step in and cover the potential shortage in TB drugs because products from their manufacturing site are also not registered in Uganda and the long registration process is hindering quick action in this area. The TB program applied for funds through the Global Fund for AIDS, TB, and malaria (GFATM), but, to date, they have not received an award of funds through this mechanism. A detailed outline of the organizational structure, management and functioning of the TB program can be found in the companion report on TB drugs. 5. HIV Test Kits In the past, HIV rapid test kits for VCT and PMCT were funded by a variety of sources, including CDC/GAP, DfID, the NORAD/UNFPA VCT Project, UNICEF, and USAID. Funding for these services and supplies is currently provided under the following sources: EGPAF, EU, Irish AID, UNICEF, USAID, and the MAP project. For the National Blood Safety program, the Nakasero Blood Transfusion Unit (NBTU) receives 40 percent of its operating budget from the European Union, and these funds are used to procure HIV ELISA test kits for testing of donated blood, hepatitis B test kits, and syphilis test kits. The remaining 60 percent of its funding is through budgetary allocations from the MOH, and this money is also used to procure supplies, such as blood bags, reagents etc. NBTU recently received support from DfID for an emergency shipment of a three-month supply of blood bags to prevent a national stockout. The certainty of continued EU funding for the program is not assured, and it is important that the unit’s supply needs are quantified along with other test kit requirements. The MOH/ACP will receive some HIV test kits through the World Bank MAP project described earlier. In addition, Uganda recently submitted a Country Proposal to the Global Fund for AIDS, Tuberculos is and Malaria (GFATM), and was awarded $53 million in August 2002. Approximately 40 percent of the total funding submission will be used for commodity purchase, but detailed quantification of HIV test kits and other supplies is needed before final commodity purchase and detailed procurement plans can be made. 5 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI The following section summarizes the initial quantification of STI drug needs for the public and civil society sectors in Uganda for 2002–2004. This report and all the information contained therein, represents the first time a needs-based quantification has been conducted for these sectors in Uganda. Given the dearth of hard data on past consumption of STI drugs, and incidence and prevalence rates of STIs, the quantification process relied heavily on the expertise and knowledge of key stakeholders, especially at STI/ACP program within the MOH. Because of the scarcity of hard data, the quantification is based on a series of generally liberal assumptions related to staff, training in the revised syndromic management algorithm, prevalence rates, and overlap of drug use for STIs and other purposes. If some of these positive assumptions are not met, the proportional quantities of STI drugs might have to be adjusted. Another important point to keep in mind is that, given alternative uses of these same drugs for other health problems, tracking the accuracy of the forecast will be difficult. 6 Quantification of Drugs for Syndromic Management of STIs Background Except in hospital settings, STIs are diagnosed and treated syndromically. A treatment algorithm for four major syndromes (urethral discharge, genital ulcer, abnormal vaginal discharge, and lower abdominal pain) was developed several years ago, and has been used by trained health workers for diagnosis. Clients are only referred for laboratory diagnosis and treatment of STIs when the first- and second-line treatment has not worked. The guidelines have undergone several rounds of revision by the MOH/STD control programme and the final version is expected to be published in September 2002 (see appendix B). This quantification was based on the draft of the recently revised guidelines. Current data on prevalence and incidence of STIs in Uganda is extremely limited. In the 2000–2001 Uganda DHS, 8 percent of women and 3 percent of men self-reported having an STI in the previous 12 months. However, the same report documented extremely low levels of knowledge about symptoms of STIs, thus the true incidence of STIs is certainly higher than the reported one. Assumptions used in the quantification relating to incidence of STIs on a national level and incidence of individual syndromes were developed in consultation with MOH/STD Control Programme Managers. Implementation of STI services was at its peak during the five years of the World Bank STI project (1995– 2000). There were relatively consistent levels of drugs available during the same period. In addition to the World Bank, drugs were also provided by DfID and KfW. However, during the period between December 2000 (when the project ended) and June 2002, when the new supply of STI drugs through the World Bank MAP project is expected to arrive, drug supply for STI treatment has been sporadic or non-existent in public sector sites. Assumptions 1. For this quantification, a consumption- and logistics-based forecast was not conducted, because there have been prolonged shortages and stockouts of STI drugs in the public sector, at the national level, since the World Bank STI project ended in 2000. Some sales/issues data exists from Joint Medical Stores, the primary supplier of the NGO sector. However, the data is not reliable enough to conduct a logistics-based forecast, because the JMS supply is highly dependent on what is available in the NMS pipeline, and JMS’ sales fluctuate accordingly. Thus, when NMS has high stock levels, JMS sales are low, and vice versa. 2. NMS stock levels of any of the STI products are almost depleted. Although JMS has some items in stock, current stock levels for the purposes of quantification were assumed to be zero, because it was impossible to determine the proportion of JMS stock that was used for STI versus other purposes. 3. JMS also has some quantities on order, but, for the same reason, these were not included in the quantities on order in the quantification. The quantities that have been included in the quantification are those expected to arrive as part of the emergency shipment in June 2002 under the World Bank MAP project, as well as quantities expected to arrive in January 2003. 4. During the course of the World Bank STI project, the STD/ACP program conducted extensive training of health workers at all levels (down to HC2) in STI syndromic management. Also, ongoing training of 7 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI health workers in STI syndromic management is included in district training plans. For the purpose of quantification, it is assumed that service capacity to treat all patients in STI syndromic management exists, and additional training is not needed before service providers can provide treatment. Dissemination and training of service providers in the new guidelines will be done through ongoing district training efforts. 5. Population data was gathered from the 2000/2001 DHS. The rate of natural increase in the population is low (2.7 percent); so no adjustment was made for 2003 population figures. 6. There is no current data on national prevalence of STIs among men or women. In women, prevalence was assumed to be 2 percent. This is believed to be a low estimate, but excludes asymptomatic infections, which will not be captured by the national policy of STI treatment by syndromic management. 7. For males, although general prevalence is believed to be low, incidence is likely much higher, with an average of five repeat visits per STI case. The 2001 HIV/AIDS surveillance report showed the incidence of urethritis ranging from 7 percent to 1 percent. For the purposes of quantification, it was assumed that 2 percent of men suffered an STI episode in a 12-month period. 8. No current data on prevalence or incidence of STI syndromes among men or women exists. The prevalence of each syndrome used in the quantification was based on results from two facility-based surveys in 1996 and 1998 and the combined experience of program managers at the MOH STD control unit and CDC. Although normal vaginal discharge (candidiasis) is not an STI, quantification of drugs for its treatment was included because, at the service level, there is little differentiation between abnormal and normal vaginal discharge. 9. Drugs to treat “other” conditions apart from the four major STI syndromes for both males and females were not included in the quantification and should be addressed in subsequent visits. Similarly, drugs to treat STIs in children were not included as part of the quantification. 10. According to the DHS, 54.4 percent of women and 64.3 percent of men who had an STI sought treatment at a clinic or hospital. For women, because they have well-established relationships with public sector health units and because, in general, they cannot afford private services, the majority were assumed to attend public sector or NGO sites. In contrast, it was assumed that only half those men went to public or NGO sites, and the rest sought care at private facilities. 11. According to the DHS, 13 percent of women were pregnant at the time of the survey. In community- based surveys carried out by the MOH, 17 percent were found to be pregnant. For the purposes of quantification, a 15 percent pregnancy rate was used. 12. Although an ideal programmatic goal is to achieve universal treatment of partners, currently it is assumed that 35 percent of all partners of clients treated for a syndrome go to either a public or NGO site to be treated. 13. Because all the drugs are being bought under WB/MAP funding, procurement will be done by the MOH, in accordance with its new procurement procedures. Only the emergency shipment and the January 2003 order will be procured under WB/MAP. Thus a lead time of nine months was assumed. Buffer stock was assigned at 4.5 months (or half the lead time). 14. For the projections for 2003–2004 no lead time was factored in, because this had already been accounted for during the 2002–2003 quantification, and the assumption was the forecasting was done with enough notice to allow for the planned procurement to arrive on time. A buffer stock of 4.5 months was built into 8 Quantification of Drugs for Syndromic Management of STIs the projection. Because of the uncertainties around consumption rates, it was assumed that the buffer stock was depleted by the time the 2003–2004 shipments arrive in country, and thus the stock on hand for most products would be zero at that time. Although this is not the norm in forecasting, it was done deliberately to account for lack of data on consumption and possible delays in procurement. However, for drugs that were over ordered in 2002–2003 (benzathine penicillin, doxycycline, and erythromycin), stock on hand was taken at the quantity that was over-supplied. The only exception was for cotrimoxazole. It was assumed there would be 50 percent leakage into other uses of the drug, and stock on hand was taken at half of the over­ supplied quantity. The following tables summarize the data used to determine prevalence or incidence of each syndrome (see appendix C for details of treatment by syndrome and logistics adjustments): Table 1: Estimates for Number of Women Treated for STIs Total population for 2001 21,563,446 A Total number of women (A x 52%) 11,212,992 B Number of women in reproductive age 15–49 (B x 40.1%) 4,496,410 C Estimated prevalence of STIs in women (C x 25%) 1,124,102 D Estimated number of STI cases treated syndromically in public sector health 562,051 E facilities (D x 25%) Percentage and number of STI cases by syndrome F Abnormal vaginal discharge syndrome (E x 48%) 269,784 F1 Abdominal pain (E x 29%) 162,995 F2 Genital ulcer (E x 18%) 101,169 F3 Others (5%) 28,102 F4 Table 2: Estimates for Number of Men Treated for STIs Total population for 2001 21,563,446 A Total number of men (A x 48%) 10,350,454 B Number of men aged 15–49 (B x 40.1%) 4,150,532 C Estimated proportion of men suffering an STI episode in 12 months (C x 830,106 D 20%) Estimated number of STI cases treated syndromically in public sector health 83,011 E facilities (D x 30%) Percentage and number of STI cases by syndrome F Genital ulcer syndrome (E x 60%) 66,409 F1 Urethral discharge syndrome (E x 30%) 16,602 F2 Other (E x 10%) 24,903 F3 Table 3: Estimates for Pregnant Women Treated for Syphilis Total population for 2001 21,563,446 A Total number of women (A x 52%) 11,212,992 B Number of women in reproductive age 15–49 (B x 40.1%) 4,496,410 C Number of women pregnant in a year (C x 15%) 674,462 D Number of women that attend at least one ANC visit (D x 95%) 640,738 E Number of women that receive screening for syphilis (50% of sites in the 320,369 F country, E x 50%) Prevalence of syphilis among pregnant women (F x 8%) 25,630 G 9 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI Based on the number of cases of men and women treated for STIs identified in tables 1–3 above, table 4 presents the quantities of drugs required for STI treatment between Ma y 2002 and April 2003 that still must be ordered after both the emergency and regular procurement shipments from MAP arrive. As mentioned previously, quantities required were estimated based on the recently revised guidelines presented in appendix B. Details on the conversion from number of cases to quantities of drugs can be found in appendix C, table 6. Table 4: Quantities of STI Drugs Still Required between May 2002–April 20031 for Syndromic Management in Public and NGO Sectors Drug Name, Dosage, Form Quantity Quantity on Quantity to Required Order§ Orderf Benzathine penicillin dry powder for injection 309,466 2,000,000 0 Ciprofloxacin 500 mg tablet 5,208,380 1,500,000 3,708,380 Doxycycline 100 mg tablet 16,222,025 18,750,000 0 Metronidazole 200 mg tablet 19,747,271 18,750,000 997,271 Cotrimoxazole 400/80 mg tablet 2,708,810 20,000,000 0 Erythromycin 250 mg tablet 8,845,715 10,000,000 0 Nystatin 100,000 I.U. pessary 20,057,199 7,200,000 12,857,199 Acyclovir 200mg tablet 16,409,069 312,500 16,096,569 Water for Injection 10 ml 309,466 0 309,466 Rapid Plasma Reagin (RPR) Syphilis Antigen Test 714,819 400,000 314,819 Total Cost of Commodities to Order U.S.$3.8 mil. § Quantities on Order include emergency shipments for May/June 2002 and planned shipments under ongoing tender, expected in early 2003. Only World Bank/MAP shipments have been included. f Quantity to Order sufficient to fulfill 12 months of projected demand plus 9 months lead time and 4.5 months buffer stock. Quantity to order is given in individual units not in pack sizes Using approximate costs provided by the World Bank, the quantities to order listed in table 4 will cost about U.S.$ 3.8 million (see appendix C, table 8). These are quantities of STI drugs required over and above the procurements already conducted under MAP. Although cefixime was included in the quantification, because the quantities to order are few and there are no clear guidelines about the level where cefixime would be used, the drug was omitted from the above summary table. It is interesting to note that—primarily due to changes in the syndromic management protocols—significant quantities of benzathine penicillin (1.7 million vials), doxycycline (2.5 million tablets), and cotrimoxazole (17.3 million tablets) will not be needed by the STI program. In practice, however, it will take time for the changes in the treatment practices to be disseminated and implemented at lower levels. Thus, changes in prescribing patterns will not be immediate, and it is likely, in fact, that many of the drugs will be used, if not by the STI program, then for OI prevention and treatment or other purposes. Table 4 does not include quantities of all the consumable supplies or equipment required for STI syndromic management and screening and treatment of pregnant women for syphilis. Including these, the cost for commodities is about U.S.$4.1 million (see appendix C, table 8). The quantities listed in table 4 should be procured immediately to reduce the possibility of a stockout of STI drugs. This is the sum of quantities required to meet the projected demand (as calculated by the methodology documented in this report) and fill the pipeline, because there are no stocks at present. 10 1 Quantification of Drugs for Syndromic Management of STIs An estimate for quantities of STI drugs required from May 2003 to April 2004 was also conducted, primarily to provide STI program managers with a ballpark estimate of their commodity needs for the following year, thus allowing for forward planning in resource allocation. The quantification was based on the same assumptions as the one for 2002–2003, and these are likely to be quite different in practice. Although the dollar figure is useful for forward budget allocations, the actual quantities of each drug required are likely to change and careful re-examination of the assumptions and figures should precede any procurement decisions. The details of quantities and costs of STI drug estimates for 2003–2004 are listed in table 5. Table 5: Estimated Quantities of STI Drugs Required between May 2003–April 2004 for Syndromic Management in Public and NGO Sectors Drug Name, Dosage, Form Quantity Required Stock on Hand§ Quantity to Orderf Benzathine Penicillin dry powder for Injection 200,244 1,690,534 0 Ciprofloxacin 500 mg tablet 3,370,125 0 3,370,125 Doxycycline 100 mg tablet 10,496,607 2,527,975 7,968,632 Metronidazole 200 mg tablet 12,777,650 0 12,777,650 Cotrimoxazole 400/80 mg tablet 1,752,762 8,645,595 0 Erythromycin 250 mg tablet 5,723,702 1,154,285 7,284,706 Nystatin 100,000 I.U. pessary 12,978,191 0 4,569,417 Acyclovir 200 mg tablet 10,617,635 0 10,617,635 Water for Injection 10 ml 200,244 0 200,244 Rapid Plasma Reagin (RPR) Syphilis Antigen Test 462,528 0 462,528 Total Cost Of Commodities To Order U.S.$10.2 mil § Stock on Hand is assumed to be zero except where quantities oversupplied previous year. No further shipments are included, because early 2003 shipments are included in previous estimate. f Quantity to Order sufficient to fulfill 12 months of projected demand plus 4.5 months buffer stock. Quantity to order is given in individual units not pack sizes. Using the same prices as for 2002–2003 and the same exchange rate, the full years estimate of STI drugs will cost about U.S.$10.2 million (see appendix C, table 10). Including consumables, the total cost is about U.S.$10.5 million. 11 12 Recommendations The following combination of short- and medium-term recommendations will ensure that time-sensitive actions and long-term strategic approaches with significant implications for commodity availability and logistics functions can be taken and/or begun. It is anticipated that the recommendations will be implemented collectively by the STD/ACP Programme and relevant partners internal and external to the MOH working in each programmatic area. General Recommendations Recommendation 1 (mid- to long-term). Continue advocating for the urgent need to recruit a senior logistics officer to work within the expanded pharmacy department. Although the DELIVER resident advisor will continue to work with the pharmacy department team in implementing logistics system improvement activities, it is important that the team include logistics management skills so capacity building within the MOH in the area of supply chain management is possible. Recommendation 2 (mid-term). Explore the possibility of developing an action plan between all the units in the MOH and NMS to concretely determine the timeframe for integrating selected logistics management functions and obtain commitments to move the plan forward. Recommendation 3 (short-term). Identify possible study tours for NMS and other appropriate commodity managers to visit neighbouring countries and to benefit from lessons learned in integration, decentralization, and reform of the national medical stores. Recommendation 4 (mid-term). Expedite the development and maintenance of a central commodity database to track all MOH and donor inputs for essential health commodity supplies. This information has been, and is likely to continue to be, crucial in alerting commodity management donors and stakeholders about impending stockouts or shortages in various product categories. STI Program Quantification Due to the lack of hard data, the quantification of STI drugs required is based on a series of generally liberal assumptions developed with ACP/STI program staff about prevalence and incidence rates of the various syndromes. By using these liberal assumptions, the quantities required are much more likely to be overstated than understated. However, because there is significant overlap between the drugs quantified for the purposes of STI syndromic management and other uses of these same drugs, tracking the accuracy of the quantification will be difficult and stockouts of some items might still be possible. Recommendation 5 (short-term). Validate projections with STD/ACP program staff. Given that projections are primarily based on assumptions rather than data, they should be used as a starting point for thoughtful discussion prior to making concrete purchasing decisions. Recommendation 6 (mid-term). During subsequent visits, ensure that quantities for “other” STI diagnoses are quantified and included in the overall needs estimates for STI drugs. 13 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI Procurement and Financing Financing sources for STI drugs are fragmented between MAP and GFATM expected funds. The procure­ ment mechanism for GFATM has not been selected. Regardless of the selected options, the product must be received promptly and steps taken to prevent delays due to awards given to unregistered product manufacturers. Recommendation 7 (short-term). Begin to identify funding sources for the U.S.$3.8 million needed to supply sufficient drugs to meet demand for STI services projected in table 4, if funds from the GAFTM are insuffi­ cient. Advocate for MAP or GFATM funds to be allocated toward continued supply of STI drugs in 2003– 2004, if possible through the HSSP budget line for essential drugs (see table 5). Recommendation 8 (short-term). Ensure that product specifications are consistent with STD/ACP program requirements and the assumptions in the methodology. Recommendation 9 (mid- to long-term). MOH, UAC, WB, and NDA staff to communicate regularly on shipment status of awarded tenders to ensure that potential delays of incoming commodities, whether through delayed registration or other causes, are identified early enough for timely resolution. Distribution Recommendation 10 (short-term). Develop a distribution plan for incoming STI drugs with the STD/ACP unit and pharmacy unit. Develop a mechanism for distributing STI drugs to ensure appropriate drug provision by health unit level and to ensure distribution that reflects the geographic treatment patterns of STIs. Recommendation 11 (mid- to long-term). As a first step toward integrating the supply, financing, and purchasing of STI drugs into the essential drug system, help districts quantify their needs, and continue to advocate for including STI drugs in the MOH/Pharmacy and UHSSP transition from a push to pull system, beginning in January 2003. Information Systems Recommendation 12 (short-term). Although consumption of all STI drugs should be closely monitored to validate assumptions made for the quantification and to help with future forecasts, particular attention should be paid to consumption of erythromycin. If prescribing practices do not change soon, as stated in the assumptions, more quantities of erythromycin may need to be ordered. Recommendation 13 (mid- to long-term). Strengthen STI sentinel site reporting to increase data availability for quantification and other program management interventions. Recommendation 14 (mid- to long-term). Begin to think about including STI drugs in the district quantifi­ cation plan for other essential drugs to ensure a long-term logistics management information system data available on the actual consumption of these products. Recommendation 15 (mid- to long-term). Ideally, development of a centralized LMIS would provide the most accurate and timely logistics data for use in subsequent forecasting excercises, as well as help in day-to­ day management of STI and other drugs. However, this system would be extremely expensive and use valuable time and resources to implement, and would not have the support of key stakeholders because it is not consistent with strategies outlined in MOH/Uganda’s Health Sector Strategic Plan. It’s possible to integrate STI drugs into the district drug financing mechanism, collect quality issues data from NMS; validate the quantities with survey teams during forecasting or quantification exercises. 14 Appendix A People Contacted 15 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI 16 People Contacted Name Organization Telephone Executive Director, AIDS Information Dr. Charles Hitimana-Lukanika Centre 077 420900 Mr. Tephy Mujurizi Laboratory Technologist, AIC 077 495547 Mrs. Josephine Kalule Program Manager, AIC 077 412373 Maurice Adams Director, AIM 077 765432 Rebekah Mkasa PMTCT Coordinator, AIC 077 495547 Dr. Paul Waibale Assistant Director, AIM 077 502243 Dr. Robert Downing CDC/UVRI 075 788222 Dr. Rebecca Bunnel CDC/Uganda 075 751019 Dr. Donna Kabatesi CDC/Uganda 075 751029 Dr. Jonathon Mermin CDC/Uganda 075 759305 Ms. Caroline Healey Crown Agents Dr. Andrew Namonyo DDHS, Pallisa District nnamonyo@yahoo.com Chris Forshaw Pharmaceutical Advisor, UHSSP 077 760176 District, Drug Management Advisor, Hanif Nazerali UHSSP 077 771772 Wim Mensink JMS 075 766400 Graham Root Malaria Resource Centre 077 744038 Dr. Kataha Nakasero Blood Transfusion Unit 077 431880 Ms Teddy Lukinda Infection Control, MOH 041 340874 Dr. Kato Malaria Program, MOH 077 415697 Martin Oteba Chief Pharmacist, MOH 077 512975 Dr. Florence Ebanyat RH, MOH 041 340874 Dr. Zainab Akol STD/ACP, MOH 077 451008 Dr. Fred Kambugu STD/ACP, MOH 077 588285 Mrs. Vastha Kibirige STD/ACP, MOH 077 565100 Dr. Wilford Kirungi STD/ACP, MOH 077 434139 Dr. Elizabeth Madraa STD/ACP, MOH 077 695109 Dr. Joshua Musinguzi STD/ACP, MOH 077 611135 Dr. Saul Onyango STD/ACP, MOH 077 508669 Charles Ssebatwale STD/ACP, MOH 077 437662 Dr. Francis Adatu TB/Leprosy, MOH 077 501988 Saul Kidde NMS 077 771337 Dr. Susan Mukasa PMTCT Advisor, PSI/CMS 077 503597 John Kokas Omiat Procurement Officer, UACP/UAC 077 377346 Suzanne McQueen USAID PHN Officer 077 200529 Elise Ayers USAID 041 235879 Dr. Benon Biryahwaho Chief Virologist, UVRI 071 200234 Mr. K. Walusaga Medical Microbiologist, UVRI 077 517197 Ms. Musarait Kashmiri Chief Operating Officer, VR Promotions 071 639904 Dr. Joseph Imoko WHO/TB Medical Officer Giuliano Gargioni WHO Advisor to TB 077 401191 WHO Health Sector Policy Planning and Dr. Humphrey Karamagi Management 077 431371 Joseph Serutoke WHO Professional Officer 077 771339 17 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI 18 Appendix B Treatment Algorithms for the Major STD Syndromes The following algorithms were reproduced from the yellow wall chart developed by the STD Control Unit, STD/ACP, and MOH, and adjusted, based on conversations with program managers. Publication of revised algorithms is expected in October 2002. This reproduction is only to facilitate understanding of the quantification methodology and does not capture all details of the revised algorithms. 19 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI 20 Appendix B Treatment Algorithms for the Major STD Syndromes Code 1: Urethral Discharge Urethral Discharge Ciprofloxacin 500 mg stat, plus Doxycycline 100 mg b.d. x 7d If discharge or dysuria persists, find out if partners were treated Repeat Doxycycline 100 mg b.d. x 7d, plus Metronidazole 2 gms stat Start the treatment again If it persists Cefixime 400 mg stat Yes No Code 2: Genital Ulcer Genital Ulcer If no blisters, vesicles If you see blisters or vesicles present Ciprofloxacin 500 mg b.d x 3d, plus Benzathine penicillin 2.4 M.U. IM stat Aciclovir 200 mg 5 hourly x 5d. Perform RPR test. If positive, treat with Benzathine penicillin 2.4 M.U. IM stat. Erythromycin 500 mg 6 hourly x 7d If ulcer persists, find out if partners were treated. If no, retreat, if yes If it persists If it persists Repeat Aciclovir 200 mg 5 hourly x 5d Refer IF PREGNANT or ALLERGIC TO PENICILLIN: Erythromycin 500 mg 6 hourly x 14d 21 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI Code 3: Abnormal Vaginal Discharge Abnormal Vaginal Discharge Lower Abdominal Tenderness?? Ciprofloxacin 500 mg stat, plus Doxycycline 100 mg b.d. x 7d, plus Metronidazole 2 gms stat If discharge or dysuria persists Treat as abdominal painYes Examine Itching, Erythema, Excoriations? . Repeat Doxycycline 100 mg b.d. x 7d, plus Ciprofloxacin 500 mg stat If discharge persists Refer IF PREGNANT: Cotrimoxazole 2.4g (5 tabs) b.d. x 3d, plus Erythromycin 500 mg 6 hourly x 7d; postpone Metronidazole till 2nd trimester; DO NOT give ciprofloxacin, chloramphenicol, doxycycline, or tetracycline No Yes No Nystatin pessaries insert 1p (100,000 I.U) o.d. x 14d plus Metronidazole 2 gms stat If discharge or dysuria persists Refer Code 4: Lower Abdominal Pain Take history and examine, bimanual if possible Period overdue/pregnant? If bleeding, recent delivery or abortion, severe pain or vomiting or rebound tenderness? Refer QuicklyCiprofloxacin 500 mg b.d x 3d, plus Doxycycline 100 mg b.d. x 10d, plus Metronidazole 400 mg b.d. x 10d. If no improvement in 7 days Refer Lower Abdominal Pain No Yes IF IUCD , remove 2-4 d after commencing treatment 22 Appendix C Methodology for Quantifying STI Drugs for Syndromic Management 23 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI 24 A p p en d ix C TA B LE 6: E stim ated R equirem ents for S TI D rugs for U ganda M ay 2002 - A pril 2003 D IA G N O S IS Y ear 2002 E stim ated N um ber E pisodes Y ear 2003 P rojected N um ber E pisodes (c ) N o. o f V isit D rug P roduct B asic U nit B asic U nit per D ose N o. D oses per D ay N o. o f D ays B asic U nits per E pisode Total B asic U nits N eeded Fem ale S TI syndrom e 562,051 562,051 1.0 V aginal D ischarge S yndrom e (V D S ) 48% 1.1 P regnant 15% Treated 269,784 40,468 269,784 40,468 1st 1. C otrim oxazole 2.4g (5 tabs 400/80m g) b.d. x 3d 2. E rythrom ycin 500 m g, (250m g tabs x 2) 6 hrly x 7d Tablet Tablet 5 2 2 4 3 7 30 56 1,214,030 2,266,190 1.2 N on- P regnant 85% Treated C andidiasis 80% 80% 50% w ith 5 incidents per year of candidiasis 229,317 183,453 183,453 91,727 458,634 229,317 183,453 183,453 91,727 458,634 1st 1. N ystatin pessary 100,000 I.U o.d x 14d 2. M etronidazole 2g stat (200m g tabs x 10) 3. N ystatin pessary 100,000 I.U o.d x 14d P essary Tablet P essary 1 10 1 1 1 1 14 1 14 14 10 14 2,568,348 1,834,534 6,420,871 15% R evisit 100% 100% 27,518 27,518 27,518 27,518 27,518 27,518 2nd 1. D oxycycline 100 m g b.d. x 7 days 2. C iprofloxacin 500m g stat Tablet Tablet 1 1 2 1 7 1 14 1 385,252 27,518 1.3 N on-P reg. 85% Treated G on/C hlam 20% 20% 20% 229,317 45,863 45,863 45,863 229,317 45,863 45,863 45,863 1st 1. C iprofloxacin 500m g stat 2. D oxycycline 100m g b.d. x 7d 3. M etronidazole 2g stat (200m g tabs x 10) Tablet Tablet Tablet 1 1 10 1 2 1 1 7 1 1 14 10 45,863 642,087 458,634 25 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI 26 Appendix C TABLE 6: Estimated Requirements for STI Drugs for Uganda May 2002 - April 2003 Year 2002 Year 2003 DIAGNOSIS Estimated Number Episodes Projected Number Episodes (c ) No. of Visit Drug Product Basic Unit Basic Unit per Dose No. Doses per Day No. of Days Basic Units per Episode Total Basic Units Needed Male STI syndrome 249,031 249,031 2.0 Urethral Discharge Syndrome (UDS) 30% males 74,709 74,709 100% Treated 74,709 74,709 1st 100% 74,709 74,709 1. Ciprofloxacin 500mg stat Tablets 1 1 1 1 74,709 100% 74,709 74,709 2. Doxycycline 100 mg b.d. x 7 days Tablet 1 2 7 14 1,045,930 5% Revisit 3,735 3,735 2nd 100% 3,735 3,735 1. Doxycycline 100 mg b.d. x 7 days Tablet 1 2 7 14 52,297 100% 3,735 3,735 2. Metronidazole 2 g stat (200mg tabs x 10) Tablet 10 1 1 10 37,355 1% Revisit 37 37 3rd 1. Cefixime 400 mg (200mg tabs x 2) stat Tablet 2 1 1 2 75 Year 2002 Year 2003 DIAGNOSIS Estimated Number Episodes Projected Number Episodes (c ) No. of Visit Drug Product Basic Unit Basic Unit per Dose No. Doses per Day No. of Days Basic Units per Episode Total Basic Units Needed Female STI syndrome 562,051 562,051 3.0 Lower Abdominal Pain (LAP) 29% 162,995 162,995 100%90% Non-Pregnant 162,995 162,995 1st 100% 162,995 162,995 1. Ciprofloxacin 500mg b.d. x 3d Tablets 1 2 3 6 977,969 100% 162,995 162,995 2. Doxycycline 100 mg b.d. x 10 days Tablet 1 2 10 20 3,259,896 100% 162,995 162,995 3. Metronidazole 400 mg (200mg x 2 tabs) b.d. x 10 d Tablet 2 2 10 40 6,519,792 27 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI TABLE 6: Estimated Requirements for STI Drugs for UGANDA May 2002 - April 2003 DIAGNOSIS Female STI syndrome 4.0 Genital Ulcer Females (GUS) 18% Year 2002 Year 2003 Estimated Projected Number Number Episodes Episodes (c ) 562,051 562,051 101,169 101,169 No. of Visit Drug Product Basic Unit Basic Unit per Dose No. Doses per Day No. of Days Basic Units per Episode Total Basic Units Needed 4.1 70% blisters(susp. Herpes) 100% 70,818 70,818 70,818 70,818 1st 1. Aciclovir 200mg 5 hourly x 5d Tablet 1 5 5 25 1,770,461 20% revisit 14,164 14,164 2nd 1. Aciclovir 200mg 5 hourly x 5d Tablet 1 5 5 25 354,092 4.2 30% ulcer (susp. Syphilis) 30,351 30,351 1st 16% allergy and pregnant 4,856 4,856 1. Erythromycin 500 mg (250mg tabs x 2) 6 hrly x 14d Tablet 2 4 14 112 543,886 85% Non Pregnant 100% 100% 25,798 25,798 25,798 25,798 25,798 25,798 1st 1. Ciprofloxacin 500 mg b.d x 3d PLUS 2. Benzathine penicillin 2.4 M.U stat 3. Water for Injection, 10 ml 4. Syringe 10 ml and 21 Gauge needle Tablet Vial Vial Syringe/Needle 1 1 1 1 2 1 1 1 3 1 1 1 6 1 1 1 154,789 25,798 25,798 25,798 20% revisit 4.2 5,160 5,160 2nd 1. Erythromycin 500 mg (250mg tabs x 2) 6 hrly x 7d Tablet 2 4 7 56 288,939 28 Appendix C TABLE 6: Estimated Requirements for STI Drugs for Uganda May 2002 - April 2003 Year 2002 Year 2003 Estimated Projected Basic No. Basic Total DIAGNOSIS Number Episodes Number Episodes (c ) No. of Visit Drug Product Basic Unit Unit per Dose Doses per Day No. of Days Units per Episode Basic Units Needed Male STI syndrome 249,031 249,031 5.0 Genital Ulcer Male (GUS) 60% 5.1 70% blisters(susp. Herpes) 174,322 174,322 100% 174,322 174,322 1st 1. Aciclovir 200mg 5 hourly x 5d Tablet 1 5 5 25 4,358,043 20% revisit 34,864 34,864 2nd 1. Aciclovir 200mg 5 hourly x 5d Tablet 1 5 5 25 871,609 5.2 30% ulcer (susp. Syphilis) 74,709 74,709 1st 100% 74,709 74,709 1. Ciprofloxacin 500 mg b.d. x 3d PLUS Tablet 1 2 3 6 448,256 100% 74,709 74,709 2. Benzathine penicillin 2.4 M.U stat 3. Water for Injection, 10 ml 4. Syringe 10 ml and 21 Gauge needle Vial Vial Syringe/Needle 1 1 1 1 1 1 1 1 1 1 1 1 74,709 74,709 74,709 836,744 20% revisit (5.2 + penicillin allergy 14,942 14,942 2nd 1. Erythromycin 500mg (250mg tabs x 2) 6 hrly x 7d Tablet 2 4 7 56 29 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI TABLE 6: Estimated Requirements for STI Drugs for Uganda May 2002 - April 2003 DIAGNOSIS Estimated Number Episodes Projected Number Episodes No. of Visit Drug Product/Item Basic Unit Basic Unit per Dose No. Doses per Day No. of Days Basic Units per Episode Total Basic Units Needed Estimated No. Pregnant Women Screened (e) 320,369 320,369 Rapid Plasma Reagin (RPR) Syphilis Antigen Test 1. Benzathine Benzylpenicillin dry powder for Injection, 2.4 MU I.M. stat 2. Water for Injection, 10 ml 3. Syringe 10 ml and 21 Gauge needle 1. Benzathine Benzylpenicillin dry powder for Injection, 2.4 MU I.M. stat 2. Water for Injection, 10 ml 3. Syringe 10 ml and 21 Gauge needle 1. Erythromycin 500mg (250mg x 2tabs) 6 hrly x 14 d Slide Vial Vial Syringe/Needle Vial Vial Syringe/Needle Tablet 1 1 1 1 1 1 1 2 1 1 1 1 1 1 1 4 1 1 1 1 1 1 1 14 1 1 1 1 1 1 1 112 320,369 25,373 25,373 25,373 12,815 12,815 12,815 28,705 Syphilis Prevalence 8% (+ Reactive RPR) 100% Treated 99% 50% Partners txted 1% Penicillin Allergy 25,630 25,630 25,630 25,630 25,373 25,373 25,373 25,373 25,373 25,373 12,815 12,815 256 256 (a) Year 2001 Estimated Number of Episodes estimated by MOH STD/ACP (b) Year 2002 = May 2002 - April 2003 (c) Year 2002 Projected Number of Episodes are Population Based estimates 30 Appendix C TABLE 7: Quantity to Order: STI Drugs, Laboratory Tests and Reagents, Expendable Medical Supplies UGANDA May 2002- April 2003 Adjusted Adjusted SoH + QR QR QR AMQR AMQR X LT 1.5 X LT Q on Order QO Total Adjust for Adjust for Average AMQR X Stock on Hand Quantity Basic Partner Losses/ Monthly Supplier Lead Time and to Order Drug Product Units TX 35% Wastage Quantity Lead Time Plus Quantity [Total No. Needed (Cipro, Dox) 5% Required in Months1,2 Buffer Stock3 on Order Basic Units] Benzathine Penicillin dry powder for Injection 138,695 138,695 145,630 12,136 109,224 163,836 2,000,000 -1,690,534 Ciprofloxacin 500 mg tablet 1,729,104 2,334,290 2,451,005 204,250 1,838,250 2,757,375 1,500,000 3,708,380 Doxycycline 100 mg tablet 5,385,462 7,270,373 7,633,892 636,158 5,725,422 8,588,133 18,750,000 -2,527,975 Metronidazole 200 mg tablet 8,850,314 8,850,314 9,292,830 774,403 6,969,627 10,454,441 18,750,000 997,271 Cefixime 200 mg tablet 75 75 78 7 63 95 0 173 Cotrimoxazole 400/80 mg tablet 1,214,030 1,214,030 1,274,732 106,228 956,052 1,434,078 20,000,000 -17,291,190 Erythromycin 250 mg tablet 3,964,464 3,964,464 4,162,687 346,891 3,122,019 4,683,029 10,000,000 -1,154,285 Nystatin 100,000 I.U. pessary 8,989,219 8,989,219 9,438,680 786,557 7,079,013 10,618,520 7,200,000 12,857,199 Aciclovir 200mg tablet 7,354,204 7,354,204 7,721,914 643,493 5,791,437 8,687,156 312,500 16,096,569 Water for Injection 10 ml 138,695 138,695 145,630 12,136 109,224 163,836 0 309,466 Laboratory Tests and Reagents Rapid Plasma Reagin (RPR) Syphilis Antigen Test 320,369 336,387 28,032 252,288 378,432 400,000 314,819 Expendable Medical Supplies Vacutainer Tubes and Needles - 10 ml (for blood draw for RPR) 320,369 336,387 28,032 252,288 378,432 200,000 514,819 10 ml Syringes and 21 Gauge Needles packed together 138,695 145,630 12,136 109,224 163,836 200,000 109,466 Gloves, Examination Latex Disposable/Non-Sterile 6/8 565,726 594,012 49,501 445,509 668,264 50,000 1,212,275 Gloves, Examination Latex Disposable/Non-Sterile 9/10 565,726 594,012 49,501 445,509 668,264 50,000 1,212,275 Cotton Wool Absorbent Swabs (7.5cm X 7.5cm, 9cm Ply) 250,000 262,500 21,875 196,875 295,313 0 557,813 Gauze hospital quality (9 X 8 mesh, 90/91cm width X 100mt length) 3,000 3,150 263 2,367 3,551 0 6,701 Equipment Speculum (stainless steel) for health facilities missed [MED] 1,000 0 0 0 0 0 1,000 Speculum (stainless steel) for health facilities missed [LG] 1,000 0 0 0 0 0 1,000 Forceps sponge-holding, straight (stainless steel) 1,000 0 0 0 0 0 300 1 Lead Time = The time from preparation of the order, to approval, procurement, shipment to or within country, customs clearance, and time in central warehouse for reception, inspection, storage and packaging until ready for distribution. 2 For the purposes of this quantification, Lead Time is assumed to be 9 months 3 For the purposes of this quantification, Buffer Stock = 0.5 Lead Time, or 4.5 months 4 Current Stock on Hand is assumed to be zero given reported shortages and stockouts. Therefore, additional quantities of product are required to cover Lead Time and Buffer Stock. 31 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI TABLE 8: Summary Cost Estimate for STI Drugs, Laboratory Tests and Reagents, Expendable Medical Supplies UGANDA May 2002 - April 2003 Quantity Quantity Basic Pack Size TOTAL to Order to Order Unit Cost Cost COST Basic [Total No. Pack [Rounded to ($ U.S.)** ($U.S.)** ($ U.S.) Strength Unit Basic Units] Size Pack Size] NMS NMS NMS No. (a) (b) ( c ) (d) (e) (f) (g) (h) 1 Benzathine Penicillin dry powder for Injection 2.4 MU. Vial 0 100 0 $21.20 $0 2 Ciprofloxacin 500 mg tablet 500mg Tablet 3,708,380 100 37,084 $3.60 $133,502 3 Doxycycline 100 mg tablet 100mg Tablet 0 1,000 0 $10.60 $0 4 Metronidazole 200 mg tablet 200mg Tablet 997,271 1,000 997 $2.55 $2,542 5 Cefixime 200 mg tablet^ 200mg Tablet 173 100 2 $4.10 $8 6 Cotrimoxazole 400/80 mg tablet 400/80mg Tablet 0 1000 0 $6.70 $0 7 Erythromycin 250 mg tablet 250mg Tablet 0 1000 0 $32.00 $0 8 Nystatin 100,000 I.U. pessary 100,000 I.U. Pessary 12,857,199 2800 4,592 $58.50 $268,632 9 Aciclovir 200mg tablet 200mg Tablet 16,096,569 100 160,966 $20.50 $3,299,803 10 Water for Injection 10 ml 10ml Ampoule 309,466 100 3,095 $3.30 $10,214 TOTAL $3,714,701 minus cefixime $3,714,693 No. Laboratory Tests and Reagents 12 Rapid Plasma Reagin (RPR) Syphilis Antigen Test (100/kit) Slide 314,819 100 3,148 $11.45 $36,045 TOTAL $3,750,738 No. Expendable Medical Supplies & Equipment 13 Vacutainer Tubes and Needles - 10 ml (for blood draw for RPR) 10 ml Tube/Needle 514,819 100 5,148 $18.00 $92,664 14 10 ml Syringes and 21 Gauge Needles packed together 10ml Syringe/Needle 109,466 100 1,095 $9.00 $9,855 15 Gloves, Examination Latex Disposable/Non-Sterile 6/8 Medium 50 pc/box 1,212,275 50 24,246 $4.50 $109,107 16 Gloves, Examination Latex Disposable/Non-Sterile 9/10 Large 50 pc/box 1,212,275 50 24,246 $4.50 $109,107 17 Cotton Wool Absorbent swabs (500g) 500g Box 557,813 100 5,578 $1.72 $9,607 18 Gauze pads sterile 10cm x 10cm 100 Box 6,701 100 67 $7.33 $491 19 Speculum (stainless steel) for health facilities missed [MED]^ ^ Medium each 1,000 1 1,000 $8.20 $8,200 20 Speculum (stainless steel) for health facilities missed [LG]^ ^ Large each 1,000 1 1,000 $8.80 $8,800 21 Forceps sponge-holding, straight (stainless steel)^ ^ each 300 1 300 $7.20 $2,160 TOTAL $349,991 GRAND TOTAL $4,064,684 Description of Item Drug Product ** Exchange Rate U.S.$ 1.00 = 1800 Ushs. 4/2002 ** Actual WB contract prices not available, so total shipment cost divided by quantity used to estimate unit price, based on letter from UAC 27 August 2002 ^Price for cefixime found in UNICEF May 2002 document on sources and prices of HIV/AIDS drugs ^^ price from JMS Catalogue February 2002 32 Appendix C TABLE 9: Quantity to Order: STI Drugs, Laboratory Tests, Reagents, Medical Supplies UGANDA May 2003- April 2004 Adjusted Adjusted Annual SoH + QR QR QR AMQR AMQR X 4.5 QR + BS Q on Order QO Total Adjust for Adjust for Average AMQR X Stock on Hand 4 Quantity Basic Partner Losses/ Monthly 4.5 to get Annual QR and to Order Drug Product Units TX 35% Wastage Quantity Buffer Plus Buffer Quantity [Total No. Needed (Cipro, Dox) 5% Required Stock 1,2 Stock on Order 3 Basic Units] Benzathine Penicillin dry powder for Injection 138,695 138,695 145,630 12,136 54,612 200,244 1,690,534 -1,490,290 Ciprofloxacin 500 mg tablet 1,729,104 2,334,290 2,451,005 204,250 919,125 3,370,125 0 3,370,125 Doxycycline 100 mg tablet 5,385,462 7,270,373 7,633,892 636,158 2,862,711 10,496,607 2,527,975 7,968,632 Metronidazole 200 mg tablet 8,850,314 8,850,314 9,292,830 774,403 3,484,814 12,777,650 0 12,777,650 Cefixime 200 mg tablet 75 75 78 7 32 116 0 116 Cotrimoxazole 400/80 mg tablet 1,214,030 1,214,030 1,274,732 106,228 478,026 1,752,762 8,645,595 -6,892,833 Erythromycin 250 mg tablet 3,964,464 3,964,464 4,162,687 346,891 1,561,010 5,723,702 1,154,285 4,569,417 Nystatin 100,000 I.U. pessary 8,989,219 8,989,219 9,438,680 786,557 3,539,507 12,978,191 0 12,978,191 Aciclovir 200mg tablet 7,354,204 7,354,204 7,721,914 643,493 2,895,719 10,617,635 0 10,617,635 Water for Injection 10 ml 138,695 138,695 145,630 12,136 54,612 200,244 0 200,244 Laboratory Tests and Reagents Rapid Plasma Reagin (RPR) Syphilis Antigen Test 320,369 336,387 28,032 126,144 462,528 0 462,528 Expendable Medical Supplies Vacutainer Tubes with Needles - 10 ml (for blood draw for RPR) 320,369 336,387 28,032 126,144 462,528 0 462,528 10 ml Syringes and 21 Gauge Needles packed together 138,695 145,630 12,136 54,612 200,244 0 200,244 Gloves, Examination Latex Disposable/Non-Sterile (LG) 565,726 594,012 49,501 222,755 816,767 0 816,767 Gloves, Examination Latex Disposable/Non-Sterile (MED) 565,726 594,012 49,501 222,755 816,767 0 816,767 Cotton Wool Absorbent Swabs (7.5cm X 7.5cm, 9cm Ply) 250,000 262,500 21,875 98,438 360,938 0 360,938 Gauze hospital quality (9 X 8 mesh, 90/91cm width X 100mt length) 3,000 3,150 263 1,184 4,340 0 4,340 Equipment Speculum (stainless steel) for health facilities missed [MED] 1,000 0 0 0 0 0 1,000 Speculum (stainless steel) for health facilities missed [LG] 1,000 0 0 0 0 0 1,000 Forceps sponge-holding, straight (stainless steel) 1,000 0 0 0 0 0 300 1 Lead Time = no lead time assumed because this was factored into 2002-3 quantification 2 For the purposes of this quantification, Buffer stock is assumed to be 4.5 months 3 For the purposes of this quantification, SOH for most products assumed to be zero, except for those oversupplied during 2002-3 (BP, Doxycycline, Cotrimoxazole, Erythromycin) for which SOH is assumed to be the oversupplied quantity from previous year. Cotri was taken at 50% to account for other uses of the drug 33 Uganda: Estimation of Commodity Requirements for 2002–2004. Drugs to Treat STI TABLE 10: Summary Cost Estimate for STI Drugs, Laboratory Tests and Reagents, Expendable Medical Supplies UGANDA May 2003 - April 2004 Quantity Quantity Basic Unit Size TOTAL to Order to Order Unit Cost Cost COST Basic [Total No. Unit [Rounded to ($ U.S.)** ($U.S.)** ($ U.S.) Strength Unit Basic Units] Size Unit Size] NMS NMS NMS No. (a) (b) ( c ) (d) (e) (f) (g) (h) 1 Benzathine Penicillin dry powder for Injection 2.4 MU. Vial 0 100 0 $21.20 $0 2 Ciprofloxacin 500 mg tablet 500mg Tablet 3,370,125 100 33,701 $3.60 $121,324 3 Doxycycline 100 mg tablet 100mg Tablet 7,968,632 1,000 7,969 $10.60 $84,471 4 Metronidazole 200 mg tablet 200mg Tablet 12,777,650 1,000 12,778 $2.55 $32,584 5 Cefixime 200 mg tablet^ 200mg Tablet 116 100 1 $4.10 $4 6 Cotrimoxazole 400/80 mg tablet 400/80mg Tablet 0 1000 0 $6.70 $0 7 Erythromycin 250 mg tablet 250mg Tablet 4,569,417 1000 4,569 $32.00 $146,208 8 Nystatin 100,000 I.U. pessary 100,000 I.U. Pessary 12,978,191 100 129,782 $58.50 $7,592,247 9 Aciclovir 200mg tablet 200mg Tablet 10,617,635 100 106,176 $20.50 $2,176,608 10 Water for Injection 10 ml 10ml Ampoule 200,244 100 2,002 $3.30 $6,607 TOTAL $10,160,053 minus cefixime $10,160,049 No. Laboratory Tests and Reagents 12 Rapid Plasma Reagin (RPR) Syphilis Antigen Test (100/kit) Slide 462,528 100 4,625 $11.45 $52,956 TOTAL $10,213,005 No. Expendable Medical Supplies & Equipment 13 Vacutainer Tubes with Needles - 10 ml (for blood draw for RPR) 10 ml Tube/Needle 462,528 100 4,625 $18.00 $83,250 14 10 ml Syringes and 21 Gauge Needles packed together 10ml Syringe/Needle 200,244 100 2,002 $9.00 $18,018 15 Gloves, Examination Latex Disposable/Non-Sterile (LG) ^^ Large Box 816,767 50 16,335 $4.50 $73,508 16 Gloves, Examination Latex Disposable/Non-Sterile (MED)^^ Medium Box 816,767 50 16,335 $4.50 $73,508 17 Cotton Wool Absorbent swabs (500g) 500g Box 360,938 100 3,609 $1.72 $6,216 18 Gauze pads sterile 10cm x 10cm 100 Box 4,340 100 43 $7.33 $315 19 Speculum (stainless steel) for health facilities missed [MED]^^ Medium each 1,000 1 1,000 $8.20 $8,200 20 Speculum (stainless steel) for health facilities missed [LG]^^ Large each 1,000 1 1,000 $8.80 $8,800 21 Forceps sponge-holding, straight (stainless steel)^^ each 300 1 300 $7.20 $2,160 TOTAL $273,974 GRAND TOTAL $10,434,022 Description of Item Drug Product ** Exchange Rate U.S.$ 1.00 = 1800 Ushs. 4/2002 ** Actual WB contract prices not available, so total shipment cost divided by quantity used to estimate unit price. Actual price estimated to be lower since it would exclude freight ^ Price for cefixime found in UNICEF May 2002 document on sources and prices of HIV/AIDS drugs ^^ price from JMS Catalogue February 2002 34

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