Abstract Currently Vietnam is receiving support from various - PDF document

SUPPLY CHAIN OF THE HIV/AIDS PROGRAM IN VIETNAM – AN ASSESSMENT OF PERFORMANCE AND SUSTAINABILITY Tran Quang Lam 1 Xavier Tomsej 2 Abstract Currently Vietnam is receiving support from various international donors (PEPFAR, Global Fund, CHAI) to ensure availability of pharmaceuticals to 130,000+ HIV/AIDS and 60,000+ methadone patients. As donor support will continue to decrease, raising the questions around ownership, capacity, sustainability, and affordability of existing supply chain systems. This assessment applies both quantitative and qualitative methodologies and provides the baseline status of existing supply systems, identify gaps, and provide recommendation for future interventions that will foster integration of multiple supply chains into one cost effective and efficient supply chain system for HIV/AIDS commodities. Eleven supply chain components were under assessment and then, relevant components were divided into two groups and determined as better reflecting either the performance or the sustainability using a scoring system. Practical recommendations include: In the first phase, procurement partners would continue for a limited interim period to provide the same services to allow the government to invest more in the pharmaceutical management system. In the second phase, technical assistance focus would shift to the central level toward advising and strengthening the operational capacity and linkages. In the last phase, both procurement and technical assistance support by the donors would phase out, leaving the new system to take control. Introduction Since the detection of its first case of HIV infection in 1990, Vietnam has formulated and implemented a number of medium-term plans for HIV/AIDS prevention and control. The National Strategy on HIV/AIDS Prevention and Control in Vietnam was formulated on the basis of multi-sector coordination with the active support of United Nations (UN), international organizations and individuals that are supporting the HIV/AIDS prevention and control program in Vietnam. The contents of the Strategy were developed on the basis of the common principles of the UN’s Declaration of Commitment on HIV/AIDS , made up at the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS), the Vietnamese Government’s commitments to, and the Vietnamese State’s line on people’s health protection and care and socio-economic development. Since 2005, Vietnam has multiple sources for pharmaceuticals and supplies which are responsible to ensure commodity availability and improve the access of general and most at risk populations to prevention and of HIV/AIDS patients to treatment at the facility level. It resulted into the creation of a number of supply chain mechanisms to respond to donor and internal needs for monitoring and accountability. Over time, support from different donors decreased and will continue to decrease further in the future, which has raised the questions 1 Independent consultant 2 USAID | Bureau for Global Health, Washington DC, USA 1

among all the stakeholders around ownership, capacity, sustainability, and affordability of existing supply chain systems. These questions helped to lead the discussion towards an assessment of the national supply chain system that can provide the baseline status of existing systems, identify gaps, and provide recommendation for future interventions that will foster integration of multiple supply chains into one cost effective and efficient supply chain system for HIV/AIDS commodities. The illustration of existing supply chain systems of HIV/AIDS-related pharmaceuticals is given below to facilitate a better understanding of the existing system. Objectives The overall objectives of this assessment is to provide VAAC with a comprehensive review of the performance of the multiple existing supply chains that deliver HIV/AIDS related pharmaceuticals and supplies; identify the strengths and weakness of these systems; and document the recommendations to establish an efficient and cost effective integrated supply chain system that will be sustainable after donor support wanes. These finding will provide a baseline of functionality of the existing systems and identify opportunities for further system revision/strengthening. Methodology This assessment primarily consisted in collecting information on the current activities of the HIV/AIDS supply chain system at all levels via the qualitative and quantitative methodologies. At the time of this assessment, no comprehensive dataset existed on the HIV/AIDS-related supply chain. A few evaluations existed, though they were commodity- or project-specific and tended to be too narrow in focus to cover all aspects of the supply chain. Consequently, very little secondary data was available for analysis and the evaluators had to resort to collecting primary data in order to meet the assessment objectives. In order to meet the objectives of this assessment, this paper reports on each component of the public supply chain used in the fight against the HIV/AIDS epidemic in Vietnam. Eleven supply chain components were under assessment including Organizational situation and readiness; Logistics management information system (LMIS) and supportive supervision; Drug list compliance; Quantification and Forecasting; Procurement; Inventory control; Warehousing and Storage; Transportation and Distribution; Organizational support for managing the supply chain; Drug use; and Financing and Transition planning. The tool set used for data collection from the sites is based on the Logistics System Assessment Tool (LSAT) funded by USAID. The LSAT collects information on all 11 components of the supply chain.  Quantitative information was collected from sites providing ARV, Methadone or CD4 testing services and Provincial AIDS Centers. Many of these sites also provide VCT (e.g. in OPCs), preventive (in co-located preventive health centers) or additional curative services (in co-located hospitals). However, we did not specifically interview drug management staff associated with these services, therefore data on their related pharmaceuticals are inconsistent.  Qualitative information on 11 components of the supply chain system was collected through a 1-day workshop at the central level (VAAC) using focus group discussion guidelines. There was participation of approximately 30 discussants from various MOH departments, VAAC departments, and other agencies involved in HIV/AIDS related 2

commodity supply chain activities. Desk review, a number of meetings with WHO 3 , and personal observations from site visits and many meetings provided additional qualitative information. In order to ensure the assessment accurately represents all the diversity of the HIV/AIDS system, a sampling frame and appropriate sample size need to be determined. First, 10 provinces were intentionally selected in function of the following criteria: 1. Geography 2. Urban/remote environments 3. Wealthy/poor provinces 4. Presence of three programs (National, Global fund, and PEPFAR) 5. Prevention, Care & Treatment, and Harm Reduction activities are represented in these provinces 4 . Developing the sampling frame of facilities : all facilities providing ARV, Lab and Methadone services in the 10 selected provinces were listed. Since ARV, Lab and Methadone are the three main services of the VAAC supply chain system, we classified the facilities on that basis. However, other related services i.e. VCT, OIs, condoms, syringes, etc. are sometimes provided at the same location (though not in the same buildings). In addition, facilities in the 10 provinces are grouped by funding source i.e. PEPFAR, Global Fund and National Target Program. For a statistically significant sample, at least 15 percent of total facilities should be selected. 5 In the case of this assessment, it requires a minimum of 59 facilities (45 ARV, 6 Methadone and 8 Lab) to be selected. The total number of facilities selected is 71 or 16% of the total facilities nationwide. The numbers are 47 (16%), 8 (19%) and 6 (12%) for ARV, MTD and Lab respectively. Quantitative Results and Discussion The questionnaire was designed to capture data associated with two different attributes of the HIV/AIDS supply chain: its Performance and its Sustainability 6 . Performance groups together the components of the system that best provide indications on how the system runs (well, average, or poorly), regardless of whether the system is externally supported, country-owned, or operated by a mix of external and national actors . Under this definition, operational components such as LMIS and Supportive Supervision, Inventory Control, Warehousing & Storage, and Product Use are criteria selected for measuring Performance . Sustainability groups together the structural components of the system seen through the lens of country ownership (i.e. whether these structural components are country-owned, funded, or operated). Organizational Situation & Readiness, Organizational Support for Managing the 3 Dr Socorro Escalante, WHO Pharmaceutical Policy Advisor 4 Though, by design, the assessment focused on ART, MMT and lab services. 5 Assessing Supply Chains for HIV/AIDS Commodities, DELIVER project, May 2006 ). 6 Scores on sections 4 (Quantification) and 5 (Procurement), and those obtained on sections 3 (Essential Drug List Compliance) and 8 (Transport & Distribution) were respectively removed from the Performance and Sustainability criteria because there were not enough statistically relevant responses (many questions were left unanswered or did not apply to the interviewed sites). However there is enough qualitative information available to submit some hypotheses and draw some tentative conclusions in the Discussion section.