IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA

Transcription

1 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA

2 Published by the Ministry of Helth nd Socil Welfre, Dr es slm, Tnzni 2008 Ministry of Helth nd Socil Welfre, Tnzni Printed by: Jmn Printers Limited, Dr es Slm, Tnzni Any prt of this document my be reproduced in ny form without the prior permission of the publisher provided tht this is not for profit nd tht due cknowledgement is given. Any reproduction for profit must be mde with the prior permission of the publisher Copies my be obtined from: The Permnent Secretry, Ministry of Helth nd Socil Welfre, PO Box 9083, Dr es Slm Tel: Fx:

3 Acknowledgements/Disclimer This document hs been produced with the finncil ssistnce of the Europen Community nd the technicl support of the World Helth Orgniztion. The views expressed herein re those of the uthors nd cn therefore in no wy be tken to reflect the officil opinion of the Europen Community or the World Helth Orgniztion

4 4 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA

5 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA i TABLE OF CONTENTS LIST OF FIGURES LIST OF TABLES ABBREVIATIONS ACKNOWLEDGEMENTS iii iv v vi 1. EXECUTIVE SUMMARY 1 2. INTRODUCTION Country Profile Structure of Ntionl Helth & Phrmceuticl System Phrmceuticl services Rtionle of the ssessment 4 3. STUDY DESIGN AND METHODOLOGY Survey purpose Methodology Smpling nd survey popultion Trining of the Survey Tems Dt collection Dt entry nd nlysis Scope nd limittion of the ssessment RESULTS AND ANALYSIS Structure of medicines supply system in Tnzni Ctegories of products mnged t vrious level of cre Key medicines mngement functions t different levels of Helth cre Customers t vrious levels of PSM Turn over t MSD Selection of Products Avilbility of EML nd STG Use of NEMLT in procurement Quntifiction / Forecsting Procurement Sources of procured products t the Centrl Store Ordering Delivery Indictors used for ssessing products delivered Storge/Stock Mngement Adequte storge cpcity Storge conditions Stock mngement techniques used Avilbility of trcer products Stock out dys Expiry of stocks Distribution Frequency of distribution for the vrious levels Types, numbers nd cpcities of vrious mens of trnsport Qulity Assurnce system The structures used for qulity control Rtionl Use Finncing Informtion Mngement Monitoring nd evlution Performnce Indictors Humn resource 35

6 ii IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 5.0 DISCUSSIONS Selection of products nd order plcement Structure Helth fcility Phrmcies Procurement of medicines Quntifiction of needs Procurement methods Products storge nd stock mngement Avilbility of medicines nd medicl supplies t Helth Fcilities Qulity Assurnce system The impct of Verticl Progrms CONCLUSION RECOMMENDATIONS RECOMMENDATIONS OF THE STAKEHOLDERS WORKSHOP REFERENCES ANNEXES 51 Annex 1: Dt Collection Points 51 Annex 2: List of nmes of Dt Collectors for the Assessment 51 Annex 3: List of Trcer Medicines 52

7 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA iii LIST OF FIGURES Figure 1 Key medicines mngement functions Figure 2 Supply functions performed by verticl progrms Figure 3 Resons for non complince with EML t fcility level Figure 4 Procurement methods nd led time Figure 5 Procurement sources nd their frequency of use Figure 6 Percentge use of indictors for ssessing products delivered Figure 7 Percentge dequcy of storge cpcity t ll levels Figure 8 Percentge medin vilbility of 20 trcer medicines Figure 9 Use of revenues collected t MSD Figure 10 Activities crried out during supervision Figure 11 Performnce indictors regulrly evluted Figure 12 Level of initil trining offered to stff in procurement Figure 13 Level of regulr trining offered to stff in procurement t helth fcilities

8 iv IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA LIST OF TABLES Tble 1 Generl Helth Indictors Tble 2 Levels of Helth Service Delivery Tble 3 Fcilities visited Tble 4 Formtion of Zonl Stores Tble 5 Ctegories of products mnged t vrious levels of cre Tble 6 Customers t vrious levels of the procurement nd supply mngement Tble 7 Totl sles in USD nd percentge mrk up of MSD Tble 8 Resons for non complince with the NEMLIT in procurement Tble 9 Informtion used in quntifiction of needs Tble 10 Responsibilities nd tools used in quntifiction Tble 11 Tendering methods, percentges of ppliction nd led times in dys Tble 12 Criteri considered when wrding contrcts Tble 13 A summry of wrd contrcts in USD for the yer 2006 Tble 14 Frequency of ordering Tble 15 Indictors used in mesuring suppliers performnce Tble 16 Volume of imports by centrl store in 2006 Tble 17 Delivery types t ll levels Tble 18 Adherence to storge conditions Tble 19 Adherence to stock mngement techniques Tble 20 Resons for stock outs t ll levels Tble 21 Cuses of expiry of stocks Tble 22 Frequency of distributions Tble 23 The number nd cpcity of vehicles for distribution Tble 24 Criteri used to ssure qulity of products procured Tble 25 Stndrd operting procedures vilble t MSD Tble 26 Medicine informtion sources Tble 27 Amount of expenditure in USD nd sources of funding Tble 28 Activities supported by donor funding Tble 29 Administrtion fees on selected ctegory of products Tble 30 Type of informtion monitored regulrly Tble 31 Processes monitored Tble 32 Professionl ctegory of stff nd their function Tble 33 Ares needing improvement identified during workshop to disseminte results of the ssessment

9 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA v ABBREVIATIONS AIDS Acquired Immunodeficiency Syndrome ARVs Anti-retrovirls C & F Cost nd Freight CIF Cost Insurnce nd Freight CPT Crrige Pid To DDP Delivered Duty Pid DDU Delivered Duty UnPid EML Essentil Medicines List FEFO First Expiry first Out FIFO First In First Out FOB Free on Bord Vessel GDP Gross Domestic Product GOT Government of Tnzni HF Helth Fcility HIV Humn Immunodeficiency Virus HTC Hospitl Therpeutic Committee ILS Integrted Logistics System MOHSW Ministry of Helth nd Socil Welfre MSD Medicl Stores Deprtment NEDLIT Ntionl Essentil Drugs List for Tnzni NEMLIT Ntionl Essentil Medicines List for Tnzni NGO Non-Governmentl Orgniztion OI Opportunistic Infection PHF Primry Helth Fcility PORALG Prime Minister s Office Regionl Administrtion nd Locl Government PT Phrmcy Technicins SOP Stndrd Operting Procedures STG Stndrd Tretment Guidelines TFDA Tnzni Food nd Drugs Authority WHO World Helth Orgniztion

10 vi IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA ACKNOWLEDGEMENTS The Ministry of Helth would like to express its grtitude to the World Helth Orgniztion (WHO) whose finncil support mde it possible to conduct this survey. The Ministry would lso like to cknowledge ll people who contributed their time nd expertise to crry out this survey. In prticulr we would like to mention the following: The Director for Hospitl Services Ministry for Helth, Dr Z. Berege; the Chief Phrmcist nd Assistnt Director of Phrmceuticl Services, Mr Joseph Muhume nd Mrs. A. Sillo for the dministrtive support they offered during the ssessment period nd while prepring this report. Specil thnks go to Ms Rose Shij, the WHO Country Office Essentil Medicines nd Medicine Policy Ntionl Professionl Officer (EDM NPO) for her technicl support throughout the whole process of the ssessment. The Ministry is lso grteful to ll helth workers in the surveyed fcilities for fcilitting the dt collection process. The Ministry is grteful for the coopertion given by the Director Generl of MSD for setting side his time during interviews. The support extended by the entire mngement tem of MSD nd the individul stff is highly pprecited. The close coopertion nd guidnce received from the Regionl Medicl Officers nd District Medicl officers, Regionl nd District Phrmcists of Dr es Slm, Moshi, Mwnz, Tbor, Mbey, nd Mtwr regions re highly pprecited. The Medicl Directors of Bugndo, K.C.MC, Mbey nd Muhimbili hospitls re cknowledged for providing ccess to useful informtion pertining to medicines supply in their hospitls. Specil grtitude is extended to stff of ll sectors who volunteered to respond to the lengthy questionnires during the whole time of the survey. The use of the dtbse nd the modules developed to cpture informtion in structured mnner posed quite chllenge. The efforts nd the enthusism experienced in using this softwre hve been overwhelming. We thnk Mr. Jmes Annn the Temporry Advisor from the Ministry of Helth Ghn for his support on the use of the dt nlysis softwre. We lso thnk Mrs Helen Tt nd Mrs Mgli Bbley from WHO Hedqurters who coordinted nd fcilitted the dt nlysts nd principl investigtors trining in Ghn. Lstly but not lest, the vluble work done by the dt collectors who devoted their time nd commitment to collect the dt for this survey is cknowledged. These include: Prof. Dr. M. Justin-Temu, Dr. M. Jnde, Dr. G. Rimoy, Mr F. Nicolus, Mr. A. Mlis, Mr. N. Mhdu, Ms. C. Muzg, Ms. C. Mgege, Mr. E. Ngimisi, Mr. W. Shngo nd Ms. R. Tumbo. Not forgetting Mr. C. Mkwy nd Mr. H. Mchung who compiled nd nlyzed the dt. We thnk the entire Tnznin Tem who hs demonstrted exceptionl skills nd bility of tem spirit nd skills. It is our hope tht this spirit of support nd coopertion will be the modus operndi for future works nd ssignments. Finlly, the Ministry of Helth nd Socil Welfre wishes to cknowledge Mr. C. Msemo for coordinting this ssessment.

11 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 1 1. EXECUTIVE SUMMARY A well functioning medicines supply mngement system is vitl in ssuring n un-interrupted supply of essentil medicines tht re efficcious nd of good qulity, physiclly nd finncilly ccessible nd used rtionlly. Crrying out n in-depth ssessment of the system provides informtion for trgeted interventions in strengthening the system. In the light of the bove, WHO supported Tnzni minlnd in August 2007 to undertke n in-depth ssessment of the supply mngement systems of essentil medicines nd medicl supplies in the public helth. The survey ws crried out using the WHO drft tool for the in-depth ssessment of the medicines supply mngement system (June 2007 version). The Medicl Store Deprtment which is the structure responsible for procurement nd distribution t the ntionl level is semi- utonomous, public, non-for-profit orgniztion creted in It opertes self sustining revolving drug fund with 8 zonl stores. Dt from the study found tht stock vilbility of twenty (20) trcer medicines ws t n verge of 79% t the dtes of evlution in the Zonl Stores. The stock out sitution mesured by the number of dys the item hs been out of stock in yer rnged between one (1) nd one hundred eighty three (183) dys. Led times for delivery by se on the verge were long tking up to 8 months. In ddition the time used to cler products from the port to the centrl wrehouse ws lso long. Stock mngement techniques lso were found to be wek except for trcebility of btches (though this hd been rted poor by the TFDA in previous qulity inspections) nd the definition of minimum stock levels. This could hve contributed highly on the number of expired medicines nd supplies which ws found to be 3.7% of sles for the yer for 2006 t the centrl store. The ssessment lso found tht, most fcilities studied hd functioning Phrmcy system (88.9%) nd kept Essentil Medicines (92.9%). However, in most of the Phrmcies, generl indequcy of storge spce, storge equipment nd fcilities for controlling tempertures were found. For exmple only 33% of Phrmcies reported to hve dequte storge cpcity, only 52% hd fcilities for cold storge nd only 22% hd dequte storge equipment. Importnt prmeters in stock mngement such s mximum nd minimum levels of stock were not determined in lmost ll fcilities. The ssessment showed the level of stock mngement in lmost ll of the Phrmcies needed to be improved. Although vilbility of trcer medicines ws high t helth fcilities, the sme fcilities lso presented considerble number of stock-out dys. Some medicines were out of stock for 4 months. Tnzni hs bout 640 registered Phrmcists, 352 Phrmcy Technicins (PT) nd 312 Phrmcy Assistnts. With more thn 5400 helth fcilities in the country, it is evident tht there re indequte phrmceuticl humn resources t helth fcilities, districts nd regions. The ssessment lso found tht there were more res in the helth fcilities mngement systems tht required improvement. This ws in comprison with how the supply chin mngement ws mnged in the regionl, centrl nd ntionl levels. The ssessment showed tht there were chllenges with regrds to the quntifiction processes nd stff interviewed did not hve unified system for determining wht to order from the Centrl Store. The forecsting bility ws still low, nd Helth fcility stff (78%) ffirmed tht very miniml inititives were in plce to provide continuous trining. Only 11% of fcilities used dt on dontion supplied by prtners. Results showed tht only 33% fcilities procured exclusively from MSD, the ntionl procurement gent while 45% procured from other sources. At the Medicl Stores Deprtment (MSD), procurement ws done predominntly through competitive tender system, nd the medicine price survey conducted in 2004 indicted tht the medicines procurement prices were below the interntionl reference prices with n overll medicines vilbility of 72 %.

12 2 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 2. INTRODUCTION 2.1 Country Profile The United Republic of Tnzni is union of between Tngnyik (Tnzni Minlnd) nd Znzibr. It hs totl Are of 945,000 squre kilometers, of which 883,000 squre kilometers re lnd; 881,000 squre kilometers in the minlnd nd 2,000 squre kilometers in Znzibr. Projections for 2009 indicte Tnzni s totl popultion of 41.9 millions, of which 44.4% (18.6 million) re children under 15 yers. The popultion of Znzibr is estimted to be 1.2 million (63 % in Unguj nd 37% in Pemb Islnd) 1. The country s economy is bsed minly on griculture nd tourism, which ccounts for 75-78% of the totl export ernings, yet meet only one third of Tnznins imports. Tble 1: Generl nd helth indictors 2 Estimted Popultion July ,990,5563 Estimted % Popultion living under the poverty line of 1 USD 57.8% Life expectncy t birth (M/F) yers, 2008 Mle 51.4 yrs Femle 53.6 yrs Under five mortlity per 1000 live births 112 Infnt mortlity per 1000 live births 68 HIV prevlence rte mong dults 5.8 Per cpit public helth spending in US$, % of the popultion within 5 km of fcility, % of popultion within 10 km of fcility, Medicines budget 2002, US$, million 18.3 Medicines budget 2007, US$, million Structure of Ntionl Helth & Phrmceuticl System The helth system in Tnzni hs two mjor components; the public nd the privte sector. The public shre is 56%; the privte shre is 44% (which includes Fith Bsed Orgniztions (NGOs) 30% nd privte for profit 14 %). The system works t four levels; the community, the wrd where there is dispensry nd helth centre t the division level. As one moves further there is the district nd regionl hospitls t district nd regionl levels respectively. At the zonl nd ntionl levels, re the consultnt/ referrl hospitls. 1 Popultion nd Housing Census Generl Report, Centrl Census Office, Ntionl Bureu of Sttistics Source UN popultion division (

13 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 3 Level Tble 2: Levels of Helth Service Delivery Type of helth Service Remrks fcility popultion Country Ntionl Hospitl, MSD, Privte wholeslers 36 million There is only one ntionl hospitl, serves 36 million becuse it offers some specilized services not generlly vilble in other consultnt hospitls Zone Consultnt Hospitl, ZMS 8 million Serve s the referrl centre for the hospitls in the surrounding regions in the zone. There re four consultnt hospitls in totl including the ntionl hospitl Region Regionl Hospitl, million 17 regionl hospitls Phrmcy District District Hospitl, Phrmcy ,000 A number of NGO hospitls function s designted district hospitls (DDH). More thn one hospitl my be vilble in ech district, usully run by NGOs (219 hospitls) Division Helth centre , helth centers Wrd/ Villge Dispensry, Medicl stores 5-10,000 More thn one dispensry my be vilble in wrd (4679) Community Helth post, ADDO 2-5,000 Currently in Tnzni there re totl of 5,379 helth fcilities geogrphiclly distributed so tht 70% of the popultion is within 5 km of fcility nd 90% is within 10 km s t the end of Administrtively, the helth system is lrgely decentrlized. The MoHSW hs direct responsibility for the referrl nd regionl hospitls, nd regultory power over ll helth fcilities. The district fcilities re independently run by the Prime Minister s Office Regionl Administrtion nd Locl Government (PORALG). 2.3 Phrmceuticl services In improving the Phrmceuticl sector, the government endorsed the first Ntionl Drug Policy, the Stndrd Tretment Guidelines (STG) nd the Ntionl Essentil Drug List for Tnzni (NEDLIT) in The STG nd NEDLIT were lter revised in These documents re crucil in medicine quntifiction, procurement nd supply to chieve therpeuticlly better outcomes to the ptients, most importnt objective of ll helth cre systems. The Ministry of Helth nd Socil Welfre is currently in the process of revising the NEDLIT, STG nd the NDP nd hs produced drfts in The overll objectives of the NDP re to mke vilble to ll Tnznins t ll times sfe, efficcious nd qulity essentil medicines t ffordble price to n individul nd the community, when these re needed to prevent, cure or reduce illness nd suffering. The NDP set up mster pln for Phrmceuticl sector to further improve the sector between 1992 nd 2000, with cler objectives, strtegies, time frme nd budget required to chieve development in key res of the phrmceuticl sector. It provides frmework to coordinte ctivities by the vrious ctors in the phrmceuticl sector: the public, privte nd mission sectors, donors nd other interested prties. 3 MOH&SW, Second Helth Sector Strtegic Pln (HSSP), July2003-June 2008, April 2003

14 4 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA Implementtion of the NDP Phrmceuticl Mster pln is coordinted by the Phrmceuticl Services Unit (PSU) t Ministry of Helth (MOH&SW). Some of the key roles of the PSU re to: Ensure tht MSD performs ccording to the MSD Act of 1993 Ensure tht dequte funds to procure drugs nd medicl supplies re provided to MSD Assist helth fcilities with cpcity to quntify drugs requirements Estblish effective strtegies for improving rtionl drugs use In collbortion with TFDA ensure the qulity of medicines Estblish effective drug mngement nd monitoring systems t helth fcility level nd reduce drug wste nd pilferge Ensure n pproprite lloction of resources to helth fcilities for drugs tht tkes into ccount equity, ptient lod, morbidity nd drug needs. Provision of medicines nd medicl supplies in Tnzni is through the public non-for-profit system (56%) nd privte-for-profit sector (44%). All public fcilities receive their supply shres by either using llocted finncil budgets or drw supplies for use ginst estblished budget ceilings. The totl medicine budget disbursed for the public sector for the yer 2000, 2001 nd 2002 nd 2007 in US$ ws 14.1million, 16.2 million, 18.3 million, 28.5million respectively. The budget for yer 2007/08 ws US$ million. Although the budget hs been incresing every yer this however is not enough to meet the ntionl medicine needs. The Tnzni Food nd Drugs Authority (TFDA) is responsible for the regultion of medicines nd conducts inspections of the privte nd public drugs outlets in Tnzni. Tnzni hs bout 640 registered Phrmcists, 352 Phrmcy Technicins (PT) nd 312 phrmcy Assistnts 4. The Phrmcy Council is responsible for regulting the phrmcy profession nd for registering the phrmceuticl personnel in the country. 2.4 Rtionle of the ssessment The increse of scope of ctivities within the pst few yers hs seen n increse in the number of prtners involved in the procurement nd supply mngement of essentil medicines, especilly those for priority diseses such s HIV/AIDS, TB nd mlri. This increse in roles nd upsurge in funding from both the government nd prtners to service the helth fcilities hve ffected the wy the centrl supply system opertes s it puts more demnds for reporting, coordintion nd ccountbility with ll stkeholders nd in prticulr funding gencies. These chllenges hve spilled over to helth fcilities where prllel reporting is lso still needed despite the indequte humn resources. It is ginst this bckground tht Tnzni decided to do n in-depth ssessment of procurement nd supply mngement system s well s mpping of the prtner s coordintion within the procurement nd supply mngement system. 4 Source Phrmcy Council

15 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 5 3. STUDY DESIGN AND METHODOLOGY 3.1 Survey purpose The objective of this ssessment ws to crry out n in-depth ssessment of the country medicine supply mngement systems nd lso the finncil flows for essentil medicines nd medicl supplies. Subsequently it ims t providing sitution nlysis of the strengths nd weknesses of existing medicines supply systems nd to propose recommendtions nd strtegies on how to improve them. Specific objectives were: To undertke n in-depth ssessment of medicines finncing nd finncil flows for the existing systems for procurement nd distribution of essentil medicines including medicines for HIV/AIDS, TB, mlri, opportunistic infections, contrceptives, vccines, condoms, HIV/AIDS test kits, medicl devices nd lbortory products. To identify nd nlyse t ech level of the medicines supply mngement cycle (selection, procurement, distribution, nd use), the ctors involved in ech ctegory of product. To determine the strengths nd weknesses of existing medicines supply systems nd to propose recommendtions nd strtegies on how to improve them. To disseminte results to stkeholders to help develop coordinted, coherent nd efficient ntionl medicines supply pln or strtegy. 3.2 Methodology The ssessment focused minly on the Public helth fcilities medicines supply system. The survey ws crried out using the WHO drft tool for the in-depth ssessment of the medicines supply mngement systems (June 2007 version). The survey tool consisted of questionnires for the following level of helth cre: Questionnire N 2 Ministry of helth Questionnire N 3 Priority disese progrms Questionnire N 4 Centrl Medicl Stores Questionnire N 5 District stores Questionnire N 6 Helth fcilities For ech level, the questionnire ddressed medicines supply mngement issues round: Structure Selection Quntifiction Procurement Ordering Storge & stock mngement Distribution Qulity ssurnce Rtionl use Resource lloction0 Informtion mngement Monitoring nd evlution, nd Humn resource

16 6 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA Smpling nd survey popultion The ssessment ssessed the procurement nd supply mngement systems in six geogrphicl res representing the Estern, Western, Centrl, Northern, nd Southern prts of Tnzni. Dr es Slm ws purposely chosen s the cpitl city of Tnzni minlnd nd the other five dministrtive regions lso purposely chosen were Mwnz, Tbor, Moshi, Mbey nd Mtwr. The criteri for selection of the sites ws bsed on the intensity of the helth service ctivities crried out, the geogrphicl nd economicl distribution nd the presence of comprehensive helth system structure, comprised of primry, secondry nd tertiry levels of helth cre. Presence of functioning medicl store nd operting distribution system ws prerequisite. The res re economiclly different with Dr es slm nd Mwnz being more economiclly vibrnt followed by Mbey nd Moshi. Tbor nd Mtwr represented the lest developed regions. Dr es Slm region is the commercil cpitl of Tnzni. Mwnz city is on the shores of Lke Victori nd is economiclly vibrnt with ctivities such s mining, fishing industries nd frming. Mbey is n griculturl town with incresing trde ctivities long its borders with Zmbi nd Mlwi. Moshi on the other hnd is n emerging tourist center. Its economy is dependent on the service industry, tourism nd griculture of csh crops for export. Tbor nd Mtwr represent the economiclly unstble regions with some ctivities of subsistent frming s their mjor source of income. The selected sites took into ccount the six Medicl Stores Zonl brnches of Mwnz, Tbor, Mbey, Mtwr, Moshi nd Dr es Slm. The Ministry of Helth nd Socil Welfre (MOHSW) provided the list of helth fcilities. Those closest to the regions/ districts nd zonl medicl stores were chosen for the survey. Since the smpling ws representtive, the results cn be generlized to the country. In ech region, the following units were surveyed: At the centrl level: The Medicl Store Deprtment s well s the following verticl progrms were surveyed: 1 Eye Cre Services 2 Ntionl TB& Leprosy 3 Ntionl Mlri Control 4 Ntionl Aids Control 5 Reproductive nd Child Helth 6 Extended Progrm on Immuniztion At the Regionl level, totl of five zonl medicl stores nd twenty seven Helth fcilities were surveyed s follows:

17 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 7 Tble 3: Fcilities visited AREA MTWARA MBEYA TABORA MOSHI MWANZA DAR ES SALAAM Type of fcility Regionl Store or Zonl Medicl Store Referrl Hospitl Regionl Hospitl District Hospitl Helth Center Dispensry Sub Totl Grnd Totl Trining of the Survey Tems The survey tem comprised of numbers 12 dt collectors, one dt nlysts nd coordintor. The dt collectors consisted of phrmceuticl stff from the public s well s the privte sectors s well s members from the cdemi. The trining of dt collectors took plce in Dr e s Slm, Tnzni from 25 th -27 th July A field test of the dt collection instrument ws crried out t the trining loction. After the trining, ech region ws ssigned tem of two dt collectors. Lter on, three dt nlysts from Tnzni prticipted t three dy workshop on dt entry nd nlysis tht ws orgnized by WHO in Accr- Ghn from 21 st 23 rd August The trining equipped the prticipnts with bsic knowledge on hndling the softwre progrms Dt collection Dt ws collected from helth fcilities in the six regions between 30 th July 2007 nd 3 rd August Fce to fce interviews using structured questionnires were used to collect dt nd informtion. The coordintor for the ssessment nd two dt collectors gthered informtion on policy issues ffecting the medicines supply mngement system t the ministry of helth level nd verticl disese progrms Dt entry nd nlysis Dt collected for ll sites surveyed ws entered into softwre nd nlysed by the dt nlysts. To ensure ccurcy of the dt, the ntionl Coordintor counterchecked ll dt entered ginst the originl filled-in questionnires. During this exercise, dt entry errors were corrected. Where there were technicl problems in correcting dt entry errors, communiction to the Softwre Engineer commissioned by WHO in Accr ws mde vi emil.

18 8 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA Scope nd limittion of the ssessment The findings of the ssessment re limited to the questionnire tool used to collect informtion nd dt. Some dt could not be obtined. For exmple, the finncing nd funding flows of the helth fcilities could not be cptured with precision, since most of the fcilities do not control ny funds nd stff interviewed hd no direct ccess to informtion nd records of the budgets for their helth fcilities. Most of the finncil informtion is kept t the Administrtion office nd in Accounts sections nd time ws not dequte to gther the informtion from those other sources. The Helth centers nd Dispensries in prticulr were not ble to provide dequte informtion on funding since they receive medicines nd medicl supplies ginst n llocted budget line which is mnged by the Medicl Stores Deprtment.

19 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA RESULTS AND ANALYSIS 4.1 Structure of medicines supply system in Tnzni The Medicl Stores Deprtment, creted in 1993, is semi-utonomous unit under the ministry of helth. It opertes self sustining revolving drug fund nd its min customers re the Zonl Medicl Stores which supply products to regionl nd districts hospitls, helth centers nd dispensries. The Centrl store nd the zonl stores together form n institution known s the Medicl Stores Deprtment, which hs governing Bord of Trustees. This Bord ppoints directors of MSD. A mngement committee comprising of ll directors meets regulrly to discuss issues pertining to the mngement of the orgniztion. The five zonl stores visited (see tble below) reported to not hving independent Bords but rther hd mngement committees comprising of stores mngers, wrehouse officers nd ccountnts nd other professionls. Ech store operted seprte Bnk Account tht serves s collection ccount for ernings on sles s well s for servicing the opertionl business. Tble 4: Formtion of Zonl Stores Nme of the store Nme of region Distnce in Km from Dte of cretion the MSD MWANZA MWANZA 1164 JULY 1994 TABORA TABORA 1023 JULY 1994 MTWARA MTWARA 580 JULY 1994 MBEYA MBEYA 850 JULY 1998 MOSHI KILIMANJARO 562 JULY 2000 All helth fcilities visited hd phrmcy sections which re under the ledership of the Medicl Officer in Chrge. 4.2 Ctegories of products mnged t vrious level of cre The tble below shows the ctegory of products mnged t ech level. It cn be seen tht not ll products re mnged by ll the fcilities. For HIV products for exmple, only 48% helth fcilities reported to mnge them.

20 10 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA Tble 5: Ctegory of products mnged t vrious levels. Ctegory of products LEVEL Centrl Medicl Store Zonl Stores H e l t h Fcilities Essentil Medicines 100% 100% 92.6% Antimlril 100% 100% 96.3% Condoms 100% 100% 55.6% Contrceptives 100% 100% 51.9% HIV/AIDS Medicines 100% 100% 48.1% Medicl Supplies 100% 100% 85.2% Medicines for OI 100% 100% 66.7% Peditric Formultions for HIV nd Mlri 100% 100% 51.9% Regents for blood sfety 100% 100% 51.9% TB medicines 100% 75% 66.7% Vccines 100% 100% 55.6% 4.3 Key medicines mngement functions t different levels of Helth cre The following key medicines supply mngement functions were observed t the different levels s follows: Figure 1: Key medicines mngement Functions The functions of the MSD include ll the ctivities in the medicines supply mngement cycle except dispensing. This rnges from the selection of list of medicines for its ctlog from the Ntionl Essentil Medicines list, to procurement, storge nd distribution to its customers. The zonl stores conduct the sme ctivities s t MSD with the exception of procurement of medicines nd medicl supplies. At the helth fcility levels, the vrious functions performed t the phrmcy re depicted in figure bove. The phrmcy deprtments t referrl nd ntionl hospitls lso hve wider roles nd some reported tht they offered trinings to lower phrmceuticl cdres nd other helth professionls nd re involved in preprtion of bsic phrmceuticls for hospitl use. Those secondry nd tertiry helth fcilities re lso responsible for the selection (of products for their fcilities from the NEMLIT), quntifiction, ordering, wrehousing of

21 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 11 medicines nd medicl supplies. Verticl progrms lso performed some of supply mngement functions s shown below: Figure 2: Supply functions performed by verticl progrms % of progrmmes tht perform function 100% 80% 60% 40% 20% 0% Product selection Responsibility of progrmmes Distribution Quntifiction of needs Wrehousing Distribution Storge The figure bove illustrtes involvement of the verticl disese progrms in the medicines supply mngement system in Tnzni. As prt of the helth sector reforms in the country, the procurement nd supply mngement ctivities of the verticl progrms re supposed to be integrted within the one system of the MOHSW used for ll medicines. 4.4 Customers t vrious levels of PSM With regrds to customers of the stores, the Centrl Store serves ll Zonl Stores s well s the ntionl hospitl nd some fcilities in Dr es Slm. The zonl stores re geogrphiclly distributed to provide medicines nd supplies closest to the popultion. The Tble below shows the customers of MSD nd its Zones. Customers Tble 6: Customers t the vrious level of the supply system LEVEL Centrl Medicl Store Zonl Stores Helth Fcilities District Fcilities 100% 100% No responses District wrehouses 100% 50% - Fith-bsed HF 100% 100% - Helth Fcilities 100% 100% - NGOs 100% 50% - Ptients 100% 0% - Privte phrmcy 0% 0% - Regionl helth fcilities 100% 75% - Schools - 25% - Armed Forces - 25% -

22 12 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA The MSD nd its zones therefore supply products to helth fcilities t the centrl level i.e. ntionl referrl hospitls, regionl helth fcilities, district helth fcilities, helth centers nd dispensries, fith bsed helth fcilities, pproved non-governmentl orgniztions, rmed forces, schools nd other trining institutions tht hve medicl services within their estblishment. However, helth fcilities do not supply to ny lower levels Turnover t MSD The figure below sttes the totl sles nd percentge mrk-up t the MSD in three consecutive yers: Tble 7: Totl sles in Us Dollr nd percentge mrk-up of MSD Yer Turnover in US$ of the MSD 38,417,481 52,000,000 86,980,000 % mrk-up of totl sle 17% 17% 15.5% The Zonl stores nd helth fcility phrmcies do not sell products but rther distribute further the products to lower levels. 4.5 Selection of Products Selection of products is done in ccordnce to the Ntionl Essentil Medicines List for Tnzni (NEMLIT). The selection of products for the Ntionl Essentil Medicines List for Tnzni (NEMLIT) is done t the level of ministry of helth. The MSD further selects list of medicines nd medicl supplies for its price ctlogue. Fcilities use MSD price ctlogue s guide to plce orders with MSD Avilbility of EML nd STG The drft 2007 revised version of NEMLT ws vilble t the MSD. There were no tretment guidelines found except those for tuberculosis the version lst reviewed in 2005/06. The drft EML ws vilble in 80% of the Zonl stores. There were no STGs found in Zonl Stores. With respect to helth fcility phrmcies, 38% only hd the EML, nd the ones in use were lst revised in 2006 nd were in drft form Use of NEMLT in procurement Results showed tht t the MSD, procurement of essentil medicines is not limited to the EML. It ws reported tht there re medicines for tertiry cre procured under request of helth institutions offering cre nd mngement. Resons for non complince with the NEMLIT re s follows: Tble 8: Resons for non-complince with the NEMLT in procurement Resons for procuring out of the EML Rnking of priority (No 1 is the most importnt nd 3 the lest). The prescribers do not gree with the STG 1 b. The EML does not ddress locl needs or demnd 2 c. The products on the EML re not vilble from the suppliers 3 (CMS, regionl wrehouse, district wrehouse )

23 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 13 Similrly t the helth fcility level, only bout 52% of fcilities procured medicines within the EML. The min resons for non complince re tht the EML does not ddress locl needs (33% of fcilities) nd tht products from EML re not vilble (22%). Other resons re shown in Figure below: Figure 3: Non complince with EML t fcility level Resons for Non complince with EML t fcility level 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Limiting is not defined in phrm.. EML does not ddress locl need.. EML not revised nd not conform... Products from EML not vilble Lst version of EML not vilble Prescribers not fmilir with STGs Prescriber do not gree with STGs % of fcilities 4.6 Quntifiction / Forecsting At the Centrl Medicl Store there is specil committee responsible for forecsting nd quntifiction of essentil medicines. Other ctegory of products such s HIV/AIDS medicines, nti-mlris etc. re forecsted nd quntified by their respective verticl progrms. At the helth fcilities it ws found tht seven helth fcilities out of twenty seven conducted quntifiction exercises on n nnul bsis; four indicted tht they do not do quntifiction while sixteen did not respond to the question.

24 14 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA The informtion used in the quntifiction t the different levels is shown in the tble below: Informtion Used Tble 9: Informtion used in the quntifiction of needs LEVEL Centrl Medicl Zonl Medicl Helth Fcilities Progrm Store Stores 1 st Consolidting Consolidting Dispenser Demogrphic dt distribution dt distribution dt to user dt (83.33%) (100%) (100%) (77.8%) 2 nd Consolidting Expiry dtes of Stock on hnd t Consolidting decentrlized stock on hnd ll level (59.3%) decentrlized forecsts (100%) (100%) forecsts (66.67%) 3 rd Dontions provided Stock out Avilble finnce Stndrd by prtners/donors durtion (75%) (51.9%) Tretment (100%) Guidelines (66.67%) 4 th Sesonl nd Avilble finnce Stndrd Dispenser to user regionl vritions (50%) Tretment dt (66.67%) (100%) guidelines (51.9%) 5 th Stndrd Tretment Consolidting Demogrphic guidelines (100%) decentrlized dt (51.9%) forecsts (50%) 6 th Stock on hnd t ll Sesonl level (100%) nd regionl vritions (50%) 7th Expiry dtes of stock Stock on hnd t on hnd (100%) ll level (50%) The following fctors were importnt in determining quntifiction needs: Consumption or distribution pttern, vilble finnces nd stock on hnd s well s expiry dtes of stock t hnd, ll of which re widely used cross ll the four levels. At the CMS, other informtion is lso used, such s dontions, Stndrd Tretment Guidelines nd Sesonl vritions. Zonl stores lso took into ccount vilble finnces nd sesonl vrition, while helth fcilities do consider vilble finnces nd stndrd tretment guidelines s well s demogrphic dt. The ltter dt re lso commonly used t progrm level. The tble below explins the vrious ctegories of stff involved in the quntifiction of different ctegories of products t different levels. The tble lso shows the tools used in quntifiction nd forecsting of medicines. With regrds to this, the Centrl Medicl Store uses n Enterprise Resource Plnning (ERP) tool (Orion) in the quntifiction of essentil medicines nd medicl supplies. Quntifiction of needs for medicines nd medicl supplies is performed once in yer. The medicl store hs procurement pln developed by the procurement mngement unit of the deprtment. The pln includes medicines nd supplies finnced by prtners.

25 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 15 As for helth fcilities, quntifiction of needs is done mnully. Use of computer progrms is much less common nd excel is the most used progrm. Tble 10: Responsibilities & tools use in quntifiction Level of Cre Ctegory of products Responsible stff Tool used MSD Essentil medicines Forecst Committee Orion Progrms HIV/AIDS Tem comprising JSI, NACP, Clinton Excel Foundtion Peditric formultions Tem comprising JSI, NACP, Clinton Excel for HIV/AIDS nd Mlri Foundtion OI Tem comprising JSI, NACP, Clinton Foundtion TB Supplies Officer MS Access Mlri Excel Vccines UNICEF None Zonl stores Regents for blood 'Tem comprising JSI, NACP, Clinton Excel sfety including HIV/ AIDS Foundtion Condoms Supplies Officer Excel, Ppiline Contrceptives Supplies Officer Ppiline Essentil medicines, Are mngers, phrmcist nd Support Mnul Antimlrils, wrehouse officers Condoms, Are mngers, phrmcist nd Support Mnul wrehouse officers, Progrm Mnger Contrceptives Phrmcist, Are mnger, nurse, Support Mnul wrehouse officer, Progrm Mnger HIV/AIDS medicines Are mngers, phrmcist nd Support Mnul wrehouse officers, Progrm Mnger Medicl supplies Are mngers, phrmcist, wrehouse Medicl officers nd nurses, Supplies OI Ntionl AIDS Control Progrmme, Support Mnul phrmcists, mnger Peditric Formultions Ntionl AIDS Control Progrmme, Support Mnul HIV nd Mlri wrehouse officers, phrmcist, mnger Regents Advnced Diplom in Medicl Lbortory Technology, Ntionl AIDS Control Progrmme, Phrmcist TB medicines TB nd Leprosy Coordintor, Medicl doctor, phrmcist Vccines Medicl doctor, environmentl helth officer, phrmcist, mnger.

26 16 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA Level of Cre Ctegory of products Responsible stff Tool used Helth Fcilities Essentil Medicines Hospitl phrmcist, Clinicl Officer, Helth Fcility in chrge, Medicl Doctor, phrmceuticl ssistnt, AMO, Supply Excel, Support Mnul, Mnul ledger book Officer. Antimlril Hospitl phrmcist, Clinicl Officer, Nurse Assistnt Excel, Support Mnul Condoms Peer eductor, Medicl doctor, Regionl Support Mnul AIDS Coordintor, Hed of generl Store, Nursing Officer, RCH Coordintor, MCH, Clinicl Officer Contrceptives Peer eductor, Medicl Doctor, MCHCO, Support Mnul Nurse, Nursing officer, RCH coordintor, MCH, Clinicl Officer HIV/AIDS Medicines Hospitl Phrmcist, Excel, Support Mnul Medicl Supplies Hospitl Phrmcist, Supplies officer, Support Mnul Phrmceuticl technicin, AMO, Hed of Fcility, Clinicl Officer OI Hospitl Phrmcist, Clinicl Officer Support Mnul Peditric Formultions Hospitl Phrmcist, Support Mnul HIV nd Mlri Regents Lbortory technologist, Hospitl therpeutic committee TB medicines Regionl TB coordintor, Medicl Doctor, Support Mnul District TB nd leprosy coordintor, Clinicl Officer Vccines Hospitl Phrmcist, Helth officer, Nursing Officer, RCH coordintor, Regionl Cold chin coordintor, District cold chin coordintor Support Mnul The ssessment lso found tht only six out of twenty seven fcilities reported to hve procurement nd supply mngement plns. Copies of the plns were provided, however in ll of them the procurement pln did not include medicines nd supplies finnced by prtners. All fcilities with the procurement pln ffirmed tht they hd committee for the development of the pln. 4.7 Procurement At the Centrl Store, procurement of essentil medicines nd ll other ctegories of products re procured by the MSD Tender Bord. The tender bord membership is comprised of people with different qulifictions including, Phrmcists, Finncil experts, Mteril Mngement stff nd Logisticins. The re mngers re responsible for procurement t the zonl levels, while t the helth fcility level, different people procure medicines. This could be the supplies officer, Nursing Officer, Hed of Fcility, Phrmcist or RCH coordintor depending on the fcility in question.

27 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 17 The most common tendering methods include the following: Tble 11: Tendering methods percentges of ppliction nd led times in dys Centrl Medicl Store Helth Fcilities Responsible for procurement Procurement Methods Tender Bord Averge led time Supplies officer, Nursing Officer, Hed of Fcility, Phrmcist, RCH coordintor Averge led time Interntionl Competitive Bidding 80% 150 0% Ntionl Competitive Bidding 100% % 75 Negotited Tender 0% % 90 Selective Bidding 10% % Direct Procurement 2% 18 22% 16.7 Shopping 3% 7 - For the centrl medicl stores, led times for the procurement re further grphiclly displyed below: Figure 4: Procurement Methods nd Led Times Led time for procurement CMS Length in dys Interntionl Competitive Bidding N tionl Competitive Bidding Negotited Tender Selective Bidding Direct Procurement Shopping As cn be seen, procurement through interntionl competitive bidding is the slowest procurement method s it hs led time of 150 dys. Selective bidding is lso slow (90 dys), while direct procurement nd shopping re the fstest methods (respectively 18 nd 7 dys).

28 18 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA The Centrl Store pplies the following Incoterms during procurement ie CIF, DDP, FOB, DDU nd CPT/ C&F. The Medicl Store Deprtment reported tht it considered ll the criteri in the questionnire when wrding contrcts. There is technicl committee responsible for nlyzing tenders; the wrd of tenders is mde by its tender bord. The results of the tender re publicly declred before prticipting bidders. Results of the tender re only red out during the opening of bids, but re not published. The frequency of procurement is once yer but there is in between emergency purchses tht follow the sme procedures. At the Helth Fcility level, the criteri in the questionnire re not widely used. The most commonly used criteri re price (19% of fcilities), performnce of supplier (15%) nd qulity of product (11%). It ws found tht SOP documents for cll of tenders were used in few fcilities (3.7%) nd the rest hd none. Preselection of suppliers ws prcticed by 11% only of the fcilities surveyed. Most procurement of medicines done by helth fcilities sources supplies from within the country s such INCOTERMS re not pplied in purchse contrcts. Tble 12: Criteri Considered when wrding contrcts Criteri Centrl Medicl Store Helth Fcilities 1 st Ntionl preference Price (18.5%) 2 nd Performnce of Supplier Performnce of supplier (14.8%) 3 rd Price Qulity of product (11.1%) 4 th Qulity of product 5 th Stted delivery time 6 th Supplier terms of pyment Sources of procured products t the Centrl Store At CMS, the gretest percentge of expenditure is for products purchsed from Interntionl Suppliers. In prticulr, interntionl suppliers ccount for ll the expenditure on ntimlril nd vccines. Locl mnufctures ccount for the lrgest shre of essentil medicines, while interntionl mnufctures provide the gretest prt of HIV medicines. Locl distributors ccount for the lrgest shres of medicl supplies, medicines for opportunistic infections nd regents.

29 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 19 Tble 13: A summry of wrd Contrcts in US $ for the yer 2006 Sources of Procurement Ctegory of Products Interntionl supplier US$ Interntionl mnufcturer US$ Locl Distributor US$ Locl Mnufcturer US$ Essentil Medicines 5,163,633 2,237,051 11,774,583 Others Specify US$ HIV/AIDS medicines 2,547,538 68,347 Antimlrils 14,865, TB medicines Medicines for opportunistic infections Peditric formultions for HIV/AIDS nd mlri Vccines 269, , Contrceptives 1,565, ,012 Condoms 967,050 Medicl supplies 5,185,089 7,680,927 1,529,303 Regents for blood sfety including HIV test kits 187,541 With regrds to helth fcilities, results show tht only 33% of them procure products exclusively from the MSD which is the ntionl procurement gent. Some helth fcilities however, procure medicines nd supplies from other sources s indicted below: Figure 5: Procurement sources nd their frequency of use Procurement sources 22% 33% Exclusively from MSD Other sources No response 45%

30 20 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 4.8. Ordering Ordering t CMS is strictly performed on n nnul bsis, while zonl stores order ccording to their needs. As for Helth Fcilities, bout hlf of them plce their orders every three months, while the rest order ccording to needs. Not mny responses were obtined from progrms, but nnul ordering nd ordering ccording to needs seem to be the most common options Tble 14: Frequency of Ordering Frequency CMS ZMS HF Progrm Qurterly 0% 0% 44.4% 0% Semi-nnul 0% 0% 0% 0% Annul 100% 0% 0% 16.7% According to the needs 0% 100% 44.4% 16.7% For the Centrl store, the verge led time for deliveries is 5-8 months by se nd dys by ir nd within 90 dys by lnd. The centrl Store is 80 km, 3 km nd 700 km from the irport, se port nd border respectively. The verge time tken to remove products from the port, irport nd border is 21 dys, 7 dys nd 3 dys respectively. The min problems encountered during the customs clernce of products re: ) From the se port - lengthy clering nd customs procedures b) From the irport - lengthy inspection time nd c) At the border points - lengthy documenttion processes. The verge time it tkes to trnsport products to the centrl Store from the se port nd irport is one hour while from the border is one dy. Performnce of the supplier is mesured using the following performnce indictors: Tble 15: Indictors used in mesuring Suppliers` performnce Performnce Indictors Rel. Freq. Products delivered conform to order 70 Respect of storge conditions 56 Qulity of service fter sles 30 Respect of greed delivery time schedule 30 Dmges nd losses 4 Volume of supplies hndled by the Centrl Store in the yer 2006 is s follows: Tble 16: Volume of Imports by Centrl Store in 2006 Volume of Imports in 2006 Number of 40 feet continers Number of 20 feet continers Volume in m3 for the mritime or surfce Volume in m3 by irfreight shipping

31 IN-DEPTH ASSESSMENT OF THE MEDICINES SUPPLY SYSTEM IN TANZANIA 21 The Zonl stores however, plce their orders with the Centrl store ccording to needs. There is n internl policy of replenishing their stocks fortnightly. All products re delivered by the Centrl Store to the zones. Averge led time to receive products ordered from higher level is fourteen (14) dys. 4.9 Delivery At zonl stores most of the deliveries re performed by the supplier, while t the helth fcilities level, it is quite common for fcilities to collect items themselves (48% of fcilities do so). Tble 17: Delivery types t ll levels CMS ZMS HF Delivery By the supplier - 100% 59.3% Collected by the store - 25% 48.1% Delivered by office of DMO 4% Indictors used for ssessing products delivered The CMS uses ll the indictors which were given in the questionnire. Zonl stores nd helth fcilities however tend to use product conformity to order nd respect of storge conditions, but they re less likely to use qulity of service fter sles nd respect of greed delivery time schedule s indictors for qulity delivery of products. In generl, Helth Fcilities re less likely to ssess products delivered thn CMS nd zonl stores. Figure 6: Percentge use of indictors for ssessing product delivered Indictors used for ssessing product delivered 120% 100% 80% 60% 40% CMS ZMS HF 20% 0% Product conforms to order Qulity of services fter sles Respect of greed delivery time schedule Respect of storge conditions