SUPPLY CHAIN GHANA - WHO · A precondition for the achievement of Millennium Development Goals 4...

Better medicines for children in Ghana

Ministry of Health

GHANA

Supply chain assessment of child-specific medicines in Ghana An in-depth assessment conducted at selected sites in Ghana

December 2011

Supply chain assessment of child-specific medicines in Ghana

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© World Health Organization 2011

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The Ghana National Drugs Programme Ministry of Health P.O. Box MB 582, Accra‐Ghana Tel +233 302 661670/1 Fax +233 302 664309 Email: [email protected] Website: www.ghndp.org Ghana Project Website: www.ghndp.org/childmedicines WHO Project Website: www.who.int/childmedicines/en/

Project team

Brian Adu Asare, Ghana National Drugs Programme, Accra

Akosua Agyeman, Pharmacy Council, Accra

Edith Andrews Annan, WHO Country Office for Ghana, Accra

Fidelicia Bakobie, Adabraka Polyclinic, Accra

Lina Bannerman‐Hyde, Faculty of Pharmacy, Kwame Nkrumah University of Science and Technology (KNUST), Kumasi

Cyril Dan Lardy, Maamobi Polyclinic, Accra

Edmund Dianbiir, Regional Health Administration, Wa

Shelta Genfior, Pharmacy Council, Accra

Martha Gyansa‐Lutterodt, Ghana National Drugs Programme, Accra

R.K.S. Hadzi, Regional Health Administration, Wa

Karen Interkudzi, Pharmacy Council, Accra

Ralph Johnson, Faculty of Pharmacy, KNUST, Kumasi

John Klu, Pharmacy Council, Accra

Wolarko Klu, Faculty of Pharmacy, KNUST, Kumasi

Augustina Koduah, Ghana National Drugs Programme, Accra

Isaac Koduah, Independent Consultant, Accra

Maame Abena Kwane Owusu Ansah, Faculty of Pharmacy, KNUST, Kumasi

Sarah Quartey, Faculty of Pharmacy, KNUST, Kumasi

Zacchi Sabogu, Regional Health Administration, Wa

Joseph Tsiase, Ridge Hospital, Pharmacy Department, Accra

Saviour Yevutsey, Pharmacy Unit, Ghana Health Service, Accra


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Table of contents

ABBREVIATIONS.......................................................................................................................................... VII ACKNOWLEDGEMENTS ...........................................................................................................................VIII CONFLICT OF INTEREST STATEMENT................................................................................................VIII EXECUTIVE SUMMARY ................................................................................................................................ IX INTRODUCTION............................................................................................................................................... 1 BACKGROUND.................................................................................................................................................. 2 METHODOLOGY .............................................................................................................................................. 2

SELECTION OF MEDICINES ................................................................................................................................. 3 SELECTION OF ASSESSMENT SITES...................................................................................................................... 3 DATA COLLECTION............................................................................................................................................ 3

FINDINGS ........................................................................................................................................................... 4 GENERAL ASSESSMENT ...................................................................................................................................... 4 SELECTION OF PRODUCTS .................................................................................................................................. 5 QUANTIFICATION AND FORECASTING .............................................................................................................. 5 PROCUREMENT .................................................................................................................................................. 5 ORDERING.......................................................................................................................................................... 6 STORAGE/STOCK MANAGEMENT....................................................................................................................... 7 DISTRIBUTION .................................................................................................................................................... 7 QUALITY ASSURANCE SYSTEM........................................................................................................................... 8 FINANCING ........................................................................................................................................................ 8 INFORMATION MANAGEMENT .......................................................................................................................... 8 MONITORING AND EVALUATION ...................................................................................................................... 9

DISCUSSIONS.................................................................................................................................................. 10 RECOMMENDATIONS AND CONCLUSION.......................................................................................... 11 REFERENCES .................................................................................................................................................... 12 ANNEX 1: LIST OF CORE AND SUPPLEMENTARY MEDICINES..................................................... 13 ANNEX 2: MEDICINE DATA COLLECTION FORM............................................................................. 15 ANNEX 3: AVAILABILITY OF INDIVIDUAL MEDICINES, PUBLIC, PRIVATE

AND MISSION SECTORS........................................................................................................ 31 ANNEX 4: TRACER MEDICINES LIST...................................................................................................... 33


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List of figures

Figure 1: Customers of the Regional Medical Stores.................................................................................. 4 Figure 2: Mean percentage availability of medicines on the day of data collection, public and

private sectors ............................................................................................................................... 10

List of tables

Table 1: Medical stores included in the assessment ................................................................................. 3 Table 2: Lead times for various procurement methods ........................................................................... 6 Table 3: Main considerations for the award of contracts ......................................................................... 6 Table 4: Distances of assessed medical stores from next level medical store, airport and seaport ......................................................................................................................... 7 Table 5. Mean percent availability of medicines on the day of data collection, public

and private sectors.......................................................................................................................... 9


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ABBREVIATIONS

BMC Better Medicines for Children

CHAG Christian Health Association of Ghana

CHPS Community‐based Health Planning and Services

CMS Central Medical Stores

CSS Commodity Security Study

EML Essential Medicines List

FDB Food and Drugs Board

GHS Ghana Health Service

GNDP Ghana National Drugs Programme

ITN Insecticide‐treated net

LMIS Logistics Management and Information System

MDGs Millennium Development Goals

MIS Management Information System

MOH Ministry of Health

NCS National Catholic Secretariat

NHIS National Health Insurance Scheme

RMS Regional Medical Stores

SOPs Standard Operating Procedures

SSDM Stores Supplies and Drug Management

STGs Standard Treatment Guidelines

WHO World Health Organization


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ACKNOWLEDGEMENTS

We are grateful to the Ministry of Health for its permission to conduct this study. We would also like to thank the directors and heads of regional health directorates who endorsed the assessment and granted access to their facilities for inclusion. We wish to extend our thanks to the Advisory Group in the Ghana Better Medicines for Children Steering Committee. We are thankful for the cooperation and participation of pharmacists and other staff at assessment sites. The World Health Organization (WHO) provided technical support for the assessment and its assistance is gratefully acknowledged. We would also like to thank the following individuals whose assistance was invaluable to the study: Dr Clive Ondari, Dr Sue Hill and Dr Herman Garden. This supply chain assessment was conducted with financial support from WHO.

CONFLICT OF INTEREST STATEMENT

None of the authors of this assessment report or anyone who had influence on the conduct, analysis, or interpretation of the results has any competing financial or other interests.


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EXECUTIVE SUMMARY

Background

A precondition for the achievement of Millennium Development Goals 4 and 61 is the availability of essential medicines for children. Infant and under‐five mortality rates are estimated at 50 and 80 respectively per 1000 births2. Most of these deaths are caused by diseases that could be prevented, treated, or managed by access to safe, essential child‐specific medicines. Child‐specific medicines are those manufactured to suit the age, physical condition, and body weight of the child taking them. Efficient medicines supply systems are crucial in ensuring access to child‐specific medicines in developing countries. The Better Medicines for Children (BMC) project takes into consideration an in‐depth assessment of the public supply system for the supply of child‐specific medicines. The main goals of the assessment are to:

• identify the extent of availability of child‐specific medicines in the public supply system;

• analyze the national supply system within the context of supply management functions; and

• identify the strengths and weaknesses of the system with respect to child‐specific medicines.

Methods

The assessment of the public supply chain for child‐specific medicines was done through structured interviews using World Health Organization (WHO) standard tools adapted to fit the child‐specific medicines context for Ghana. The country was divided into three areas. One assessment site was identified in each of the three areas. Structured, in‐depth interviews were done at each survey site. Qualitative analysis was done on data collected under 11 thematic areas, namely: general supply systems; selection of products; quantification of needs; procurement; ordering; storage/stock management; distribution; quality assurance; financing; information management; and monitoring and evaluation.

1 United Nations Development Programme, Millennium Development Goals.

2 Ghana Demographic and Health Survey Report, 2008.


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Key results

Selection of products

Selection of child‐specific medicines was based on a national selection process; however, the national essential medicines list (EML) does not clearly identify key child‐specific medicines by formulation. This is the top‐rated reason for procuring child‐specific medicines outside of the national EML.

Quantification and forecasting

There is capacity for efficient quantification based on adjusted dispensed‐to‐user data from the Logistics Management and Information System (LMIS). However, in some instances, these data are not well managed within LMIS. Quantification was mainly done using spreadsheet applications to generate six‐month forecasts.

Procurement

Child‐specific medicines are procured, along with all other essential medicines, through procurement methods with lead times ranging between 4–120 days. Suppliers are issued a contract on the basis of a purchase order with contract awards based on product quality vis‐à‐vis supplier quotations (compared to the national health insurance agenda [NHIA] prices).

Ordering

Order periods are more demand‐driven than periodic, though the two systems are run equally. Products are delivered by the supplier, but with orders from the central medical stores (CMS), regional medical stores (RMS) arrange their own means of transport. Distances from CMS range between 30–740 km.

Storage/inventory control

Inventory control for child‐specific medicines, along with other commodities, is carried out on a quarterly basis. The most common causes of stock outages were “delays in delivery” and “quantities delivered not in conformity with quantities ordered”. Prescribing patterns that fail to conform with standard treatment guidelines (STGs) are the main cause of expiration in medicine inventories.

Distribution

At the time of the assessment, transport challenges were found to be RMS‐specific; the most common challenge was a lack of vehicles. Child‐specific medicines do not have a defined distribution system.

Quality assurance system

The most common criteria used to ensure quality are: products are registered in‐country with the Food and Drugs Board (FDB) and products are chosen from pre‐selected suppliers. Product samples are not taken on a batch‐by‐batch basis for quality analysis.


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Financing

There were no special financial arrangements for child‐specific medicines. (Internally generated funds support all essential medicines).

Information management

There are no special Management Information Systems (MIS)/Logistics Management and Information Systems (LMIS) in place for child‐specific medicines. All medicines are managed on the same platform. There are reports which cover logistical information systems. These are not submitted to the central medical stores (CMS), but to the regional health administration (RHA). Products financed by partners have their own MIS.

Monitoring and evaluation

Supervision by the CMS is weak. Through the Ministry of Health’s (MOH) Ghana National Drugs Programme (GNDP), Ghana Health Service (GHS) provided supervision, but did not include training. There are no separate monitoring systems, either internally or externally, for child‐specific medicines.

Conclusions and recommendations

• There are no special/separate structures within the public supply system to explicitly ensure access to child‐specific medicines. Child‐specific medicines are grouped with other essential medicines; the lack of emphasis on these medicines is reflected by low availability patterns, as observed during this assessment. A specific policy needs to be created to ensure the supply chain is child‐sensitive.

• Education and training programmes are needed. Tools for raising awareness regarding the availability of child‐specific medicines and their use need to be created.

• From the supply perspective, child‐specific formulations need to be included in the national EML for subsequent procurement into the public supply chain.

• From the demand perspective, guidelines for prescribing need to be strengthened in accordance with the national EML and STGs.


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INTRODUCTION

The pharmaceutical sector operates a supply chain with centralized procurement and distribution of health commodities. Medicines are supplied from a national central medical store (CMS) through several regional medical stores (RMSs) to health facility medical stores. In the event of non‐availability of products within the public supply system, commodities can be procured from the open market, but through due process involving the issue and receipt of a certificate of non‐availability in the RMS or CMS. The mainstay of supply is the procurement of health commodities through public procurement arrangements into the CMS to serve the 10 regional medical stores, three teaching hospitals and private facilities. To ensure availability, more than 1000 peripheral health facilities are either supplied by the CMS, an RMS, or the private sector. In support of the public supply system, the National Catholic Secretariat (NCS) runs a pharmaceutical supply system that provides essential medicines to member institutions of the Christian Health Association of Ghana (CHAG). Furthermore, some earmarked donors provide essential medicines and health commodities (e.g. insecticide‐treated nets (ITNs)) that are often delivered to the CMS for further distribution to the regions and health facilities. The pharmaceutical private sector is well developed to complement the public systems with an extensive network of private community and hospital/clinic pharmacies and licensed medicines outlets serving patients from the pool of public, private and mission health facilities. In the management and supply of pharmaceuticals and other related health commodities, Ghana adopted a revolving fund mechanism in the early 1990s for public sector institutions. Revolving medicine funds operate throughout the health facilities and the principle underlying their creation has not changed with the inception of the National Health Insurance Scheme (NHIS). Mark‐ups over the basic unit purchase price are added at the CMS level and other tiers in the system to help generate revenue for re‐supply and to pay for distribution costs. Proper implementation of policy, rational and prudent management, and sound governance and finance management are needed in order to sustain the gains made and address emerging issues to strengthen the supply system in country. Various discussions and systemic reviews have confirmed that all is not well with health commodity security and its supply systems. The main problems have been identified as policy implementation, financing, commodity procurement and distribution, facility capitalization and revolving fund management, monitoring and evaluation, human resources, and supervision. There is a need to investigate the impact of these existing challenges on the supply of child‐specific medicines.


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The Better Medicines for Children (BMC) project design took into consideration an in‐depth assessment of the public supply system for the supply of child‐specific medicines. The main goals of the assessment were to:

• identify the level of availability of child‐specific medicines in the public supply system;

• analyze the public supply system within the contexts of supply management functions;

• identify the strengths and weaknesses of the system with respect to child‐specific medicines.

This study was conducted using the standardized tools developed by WHO (see Annexes).

BACKGROUND

The child‐specific medicines‐related aspects of the public supply system in Ghana remain undetermined. Little is known about how medicines for children move through the supply system. Thus, the BMC project design addressed the need to assess the supply system from a child‐specific medicines perspective. Public sector procurement is pooled at the national level (i.e. there is centralized procurement for the regions); procurement and distribution is the responsibility of the Ministry of Health. The following tender processes are used for public sector procurement: international competitive bidding, national competitive bidding, and negotiation/direct purchasing. Public sector procurement is limited to medicines on the Essential Medicines List (EML). There are regulations for local preference in public sector procurement.

METHODOLOGY

This assessment of the supply systems of child‐specific medicines in Ghana was conducted using a revised framework for in‐depth Assessment of Medicines Procurement and Supply Management Systems in the Public Health Sector. Data collection captured the following thematic areas:

• General supply systems

• Selection of products

• Quantification and forecasting

• Procurement


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• Ordering

• Storage and stock management

• Distribution

• Quality assurance

• Financing

• Information management

• Monitoring and evaluation

Selection of medicines

A total of 30 (representing 38 formulations) medicines were used as the focal medicines — 38 formulations from the WHO Better Medicines for Children core list (31 global medicines), and 7 supplementary medicines selected at the country level. This was representative of medicines commonly used in the treatment of a range of chronic and acute conditions. This also included the specific dosage form and strength that is to be collected for each medicine. The full list of survey medicines is provided in Annex 1.

Selection of assessment sites

The country was divided into three areas, or ‘bands’. 1. Southern band (Greater Accra Region ‐ major urban centre)

2. Middle band (Ashanti Region)

3. Northern band (Upper West Region)

In each band, the RMS was selected as the data collection point.

Table 1: Medical stores included in the assessment

Southern band - Greater Accra Region

Middle band - Ashanti Region

Northern band - Upper West Region

Medical Store Greater Accra Regional Medical Stores; and Central Medical Stores

Ashanti Regional Medical Stores

Upper West Regional Medical Stores

Data collection

In‐depth interviews were held with RMS managers in the selected areas for a period of 2 hours each.


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FINDINGS

General assessment

All the RMSs included in the assessment were found to operate with similar functional characteristics with respect to child‐specific medicines. The main common functional activities were found to be product selection, quantification of needs, placing orders with CMS, storage, stock management, and distribution of medicines to health facilities. Due to the non‐availability of distribution vans, however, some of the RMSs do not distribute medicines to the health centres; as a result health centres devise their own means of transporting medicines from the RMS to their facilities. The functions listed above are performed to serve a host of entities, including regional hospitals and teaching hospitals, district hospitals, public and mission health facilities, non‐governmental organizations (NGOs), and private practitioners.

• In the Ashanti Regional Medical Stores, patients in some instances received supply of anti‐rabies vaccines directly from the RMS. Also, private pharmacies occasionally receive supply of medicines from the RMS. This is not true for the other RMSs.

• The Upper West Regional Medical Stores (UW‐RMS) also served some health facilities in the northern region due to the proximity of the facilities to this RMS. Although the facilities preferred receiving supplies from the UW‐RMS than from the Northern Region‐RMS (NR‐RMS) the UW‐RMS gives higher priority to the health facilities within its own region.

Figure 1: Customers of the Regional Medical Stores

*Occasional and rare customers

RMS

Regional Hospitals

District Hospitals

Health Facilities

Mission Health

Facilities

NGOs Private Prac-

titioners

Educational Institutions

*

Private Pharmacies

*

Patients *


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Selection of products

The selection of child‐specific medicines was mainly based on demand but RMSs were also guided by the national EML. The clusters of reasons for procurement outside the EML included (in order of importance): 1. Products on the EML do not include child‐specific formulations

2. Prescribers are not familiar with STGs

3. The latest version of the EML is not available

4. The EML does not address local need or demand

5. Products on the EML are not available from suppliers (CMS, other RMSs), but may be found on the open market

6. Limiting procurement to the EML is not defined in the Ghana Pharmacy Act, Act 489, 1994.

The top‐rated reason for procurement outside of the EML was based on concerns about the ability of the national EML to meet the local demand for child‐specific formulations. There were also concerns about the extent of distribution of the national EML by the distant RMS.

Quantification and forecasting

Quantification of needs for child‐specific medicines was the responsibility of the RMS Manager, supported by other staff including Pharmacists or Supply Officers. The basic qualification for the RMS manager was a Bachelor of Pharmacy Degree, although some managers had secondary degrees in relevant areas such as Health Services Planning and Management. Information used for quantification was largely found to be dispensed‐to‐user data adjusted by seasonal and regional variations, particularly for child‐specific medicines. Other useful sources of data were stock‐on‐hand at all levels and consolidated distribution data (issue data at each level). The main tools for quantification were spreadsheet applications, like Microsoft Excel, guided by the SOPs for logistics management from the Ghana Health Service (GHS). Data was normally retrieved from stock management software with quantification done for a period of six months.

Procurement

Procurement planning was done to cover all medicines without any special attention to any particular therapeutic group (e.g. children). Child‐specific medicines are thus included in the plan. Plans are approved at the Regional Health Administration (RHA), though they are distributed by the regional medical stores.


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In the case of stock outs in the national system, child‐specific medicines are mainly procured from local manufacturers, local distributors, and private wholesalers. The procurement methods mainly used are selective bidding, national competitive bidding, and direct procurement. Direct procurement is only used for emergency drugs e.g. uterotonics.

Table 2: Lead times for various procurement methods

Procurement method Lead time* Selective bidding 60 days National competitive bidding 80 – 120 days Direct procurement 4 – 14 days

The type of contract issued to suppliers was contract on basis of purchase order. The process of procurement was guided by the SOPs for logistics management as outlined by GHS and the National Procurement Act. Pre‐selection of suppliers was either done at the RMS, to be reviewed and approved by the RHA, or done and approved at the RHA. The main considerations for the award of contracts were Quality of Products as confirmed by the Food and Drugs Board (FDB) certificate; Supplier Quotations; Performance of the Supplier; Expiry dates of products; and Stated Delivery Time. However, highest priority was given to Supplier Quotations and Quality of Products.

Table 3: Main considerations for the award of contracts

Included in all RMS responses Average priority ratings Quality of products Yes 4 Supplier quotations Yes 3 Stated delivery time No 4 Expiry date No 3 Performance of supplier No 2

Varied responses were observed from the RMSs assessed regarding the criteria for award of contracts. These included conformity to old contract formats (used as a guide) and conformity to standard operating procedures at Procurement unit, RHA (used as a guide). There was a well‐constituted technical committee to analyse tenders and a regional health tender committee to award contracts. All procurement prices are compared to the National Health Insurance Authority (NHIA) prices as reference prices. The results of tender processes are published on Public Procurement Authority (PPA) website and in public notices.

Ordering

Ordering of products was the responsibility of the RMS manager (a pharmacist) and is supported by either another pharmacist or a supply officer. The order periods were more demand driven than periodic, though the two systems are run at par. Product orders were delivered by the supplier in the when purchasing from the private sector; however, with orders from the CMS, the RMSs arranged their own means of transport.


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Table 4: Distances of assessed medical stores from next level medical store, airport and seaport

Assessment site Distance (km) from next level medical

store

Distance (km) from nearest airport

Distance (km) from nearest seaport

Northern band 740 5 760 Middle band 269 12 289 Southern band 30 8 30

Performance of suppliers is monitored using performance indicators such as:

• whether products were delivered and conformed with the order;

• whether the agreed delivery time schedule was met;

• level of quality of service after sales.

Storage/Stock management

Stock inventory controls were carried out with other commodities on a quarterly basis. The storage capacity for the Ashanti RMSs was not adequate. The most common causes of stock outs were delays in delivery and quantities delivered were not in conformity with quantities ordered. The most common reason medicines expired before their use was a lack of STG compliance by prescribers, followed by unidirectional prescribing patterns, modification of the STG in the course of the financial year, and lack of respect for first expires‐first out (FEFO) practices.

Distribution

At all RMSs, the number of vehicles available for transport was not enough to meet distribution needs. In the case of the northern site, its truck had broken down, as a result facilities have to arrange their own transportation. Transportation challenges were found to be RMS‐specific, however the most commonly rated challenge was simply the lack of vehicles. Some RMSs (very distant from the CMS) are faced with long distances to cover and are often far from the CMS. This, coupled with poor road networks, climatic challenges (i.e. flooded rivers blocking road access to some communities, engines overheating in hot seasons, etc.), and a lack of support staff to offload products makes distribution difficult. Child‐specific medicines do not have any specific distribution system.


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Quality assurance system

The most common criteria used to ensure quality were:

• the product is registered in the country with the Food and Drugs Board (FDB)

• the product is from a preselected supplier (with a positive public image and a good track record)

In some instances however, acceptance of the products by health facilities who are clients to the regional medical stores is considered. FDB certification (based on quality assessments done at the national quality control lab) of the product was the most important quality standards referred to by RMSs. Also for some products flowability and the fact that products are being purchased from the CMS were used, in addition to FDB certification, as guarantees for quality. Product samples were however, not assessed on a batch‐by‐batch basis for quality by the FDB to inform every order by the RMSs. The assessment noted that pharmaceutical inspections were also carried out within the last three years. The stores however, did not have any RMS‐level written procedures for processes such as selection of products, quantification of needs, procurement, training, recruitment of personnel, etc. Reference was made to the national documents by the Government of Ghana/Ministry of Health (MOH)/Ghana Health Service (GHS).

Financing

There were no special funding arrangements for child‐specific medicines. The main source of funds was the internally generated funds (IGF) of the RMS which support all essential medicines. Some RMSs clearly stated that the availability of funds was not a problem in the procurement of child‐specific medicines.

Information management

Information for quantification is available through a management information system (MIS) which is computerized for some RMSs, but not others. RMSs using relevant software expressed satisfaction in matching their needs to the abilities of the software package. Whereas such software were not universally available in all the RMSs, processes such as quantification, ordering, distribution, and so forth are managed with spreadsheet applications. The following information is monitored:

• quantities received

• average monthly consumption

• expiry

• stock on hand (inventory)


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There are reports which cover logistics information systems and the parameters above, but these reports are not submitted to the CMS. These are either kept for in‐house use and/or submitted to the District Director of Administration (DDA)/Deputy Director of Pharmaceutical Services (DDPS)/Regional Director at the Regional Health Administration (RHA). Products financed by partners come with their own Management Information Systems (MIS). In most instances, the MIS captures data on distributions schedules, quantities for distribution, and quantities distributed.

Monitoring and evaluation

The CMS had not conducted any supervisory visits to its customers at the time of this assessment. There were some visits, however from the MOH, GHS, and the Regional Health Directorate. In some cases, activities carried out during these visits included:

• review of need quantification

• review of ordering process

• checking storage conditions

• performing a physical inventory

• checking stock cards and reports

• monitoring finances

• performing needs assessments to improve performance

None of these assessments capture training of personnel. Performance is also monitored internally assessing various performance indicators. The most common indicators identified at all RMSs were:

• stock out rates

• number of stock‐out days

• percentage of medicines that were past their expiry date

There are no separate monitoring systems either internally or externally for child‐specific medicines.

Table 5. Mean percent availability of medicines on the day of data collection, public and private sectors

Public sector

(n=15 outlets) Private sector (n=30 outlets)

Mission sector (n=4 outlets)

Originator brand 2.7 % 9.0 % 4.6 %

Lowest price generic 19.3% 17.4% 21.7%


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Figure 2: Mean percentage availability of medicines on the day of data collection, public and private sectors

Source: Annan E, Gyansa-Lutterodt M, Asare B.A, et al. Child-Specific Medicine Prices, Availability, Affordability in Ghana. Accra, Ghana National Drugs Programme, 2010.

DISCUSSIONS

Data from the Price and Availability component of the BMC baseline assessment suggest that there is low availability of child‐specific medicines within the medicines supply system in Ghana. The public sector showed availability of 2.7 % and 19.3% for originator brands and lowest price generics, respectively, with the private sector showing 9.0 % and 17.4% for originator brands and lowest price generics, respectively. The mission sector also showed availability of 4.6 % and 21.7% for originator brands and lowest price generics, respectively. The lack of availability of distribution trucks or vans in the Upper West RMSs can pose a threat to the supply of medicines for children, especially for liquid preparations such as syrups. The place of the national EML in ensuring the procurement and distribution of child‐specific formulations is crucial. This is coupled with other factors, such as change of prescribing habits on the demand side and availability of child formulations at the CMS level on the supply side.


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RECOMMENDATIONS AND CONCLUSION

• There are no special/separate characteristics of the public supply systems to specifically ensure access to child‐specific medicines. Child‐specific medicines run with other essential medicines, but are loosely emphasized as reflected by low availability patterns. A specific policy to make the supply chain child sensitive is needed.

• In making child‐specific medicines available, the supply system in Ghana needs an addendum to the national EML specifying exact formulations/dosage forms and strengths of medicines for children within the existing national EML policy. This would serve as a basis for ensuring subsequent procurement into the public supply system.

• From the demand perspective, there is a need to strengthen prescribing procedures and bring them into accordance with the national EML and STGs.

• Regional medical stores require support and vehicles to strengthen the efficient distribution of child‐specific medicines. The load‐bearing capacity of the vans used is of key importance due to the weight per volume ratio of formulations such as syrups.

• Education, training and awareness creation on the availability of child‐specific medicines and the importance of using them is needed.


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REFERENCES

• Standard Treatment Guidelines, 6th Edition 2010, Ghana National Drugs Programme, Ministry of Health, Ghana.

• Essential Medicines List, 6th Edition 2010, Ghana National Drugs Programme, Ministry of Health, Ghana.


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ANNEX 1: List of core and supplementary medicines

List* No. Medicine name (Name must be unique)

Medicine strength Dosage form

G 1. Amoxicillin clavulanic acid, suspension 125 mg/5 ml /ml

G 2. Amoxicillin Dispersible tablet 250 mg /tab

G 3. Amoxicillin Suspension 250 mg+ 62.5 mg /ml

G 4. Amoxicillin/clavulanic acid, dispersible tablet 125 mg+31.25 mg/5 ml /ml

S 5. Amoxicillin/clavulanic acid, suspension 250 mg + 125 mg /tab

G 6. Artemether + lumefantrine, dispersible tablet, 20 mg + 120 mg /tab

S 7. Artesunate/amodiaquine, dispersible tablet 25 mg+ 75 mg /tab

S 8. Azithromycin, powder, 200 mg/5 ml /ml

G 9. Beclometasone, inhaler 100mcg/dose /dose

G 10. Benzylpenicillin injection, 600 mg = 1 million IU /vial

G 11. Carbamazepine chewable tablet 100 mg /tab

G 12. Carbamazepine suspension 100 mg/5 ml /ml

S 13. Carbamazepine tablet 200 mg /pack

G 14. Ceftriaxone injection 500 mg vial /vial

G 15. Chloramphenicol injection 1 gram vial /vial

G 16. Cotrimoxazole dispersible tablet 100 mg + 20 mg (also expressed as 400 mg + 80 mg)

/tab

G 17. Diazepam rectal solution 2.5 mg/ml /ml

G 18. Ferrous salt, suspension 30 mg Fe/5 ml /ml

G 19. Gentamycin injection 10 mg/ ml /ml

G 20. Ibuprofen tablet 200 mg /tab

G 21. Isoniazid, scored tablet 50 mg /tab

S 22. Mebendazole tablet 500 mg /tab

G 23. Morphine immediate release tablet 10 mg /tab

G 24. Morphine oral solution 10 mg/5 ml /ml

G 25. Oral rehydration solution (ORS) sachet 500 ml /sachet

G 26. Oral rehydration solution (ORS) sachet To make 1 litre /sachet

G 27. Paracetamol suspension 120 mg/5 ml OR 125 mg/5 ml

/ml

G 28. Phenobarbital injection 200 mg/ ml /ml

G 29. Phenobarbital oral liquid 3 mg/ ml (also expressed as 15 mg/5 ml)

/ml

G 30. Phenytoin chewable 50 mg /tab

G 31. Phenytoin suspension 25 or 30 mg/1 ml /ml

G 32. Procaine penicillin injection 1 gram = 1 million IU /vial

S 33. Quinine injection 300 mg/ ml /ml

G 34. Salbutamol inhaler 100 mcg/dose /dose

G 35. Spacer device

G 36. Vitamin A capsules 100,000IU /tab

S 37. Vitamin K1 injection (water soluble) 1 mg /ml

G 38. Zinc dispersible tablet 20 mg /tab


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ANNEX 2: Medicine data collection form

Questionnaire for in-depth assessment of medicines procurement and supply management systems including financial flows in the public

health sector

Questionnaire: REGIONAL/DISTRICT STORES Country: __________________________

Name of store: __________________________

Level: � Regional Name of the region: _____________________

� District Name of the district: _____________________

Address: ___________________________________________________

Tel/Fax/Email: ___________________________________________________

Name of Head of Regional Stores: ________________________________________

Qualification of Head Regional Stores: _____________________________________

List of assessors:

Surname/First name Structure/Function Tel/Email Comments

List of persons interviewed:

Date of interview

Surname/First name of person interviewed

Function Tel/Email


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A. Store activities and customers A.1. Is the store responsible for the following activities for medicines for children?

Activities Yes No Comments

If no, who is responsible for the activity?

Product selection

Quantification of needs

Procurement (arranging call for tenders, etc.)

Making orders

Storage

Stock management

Distribution

Dispensing

Others, specify

A.2. Which of the following are customers to the store? Please specify the number for each type of customer.

Customers for the store Yes No Number Comments

Regional health facilities (Regional teaching hospital, ..)

District warehouses

District health facilities (District hospital, ...)

Health facilities (Health center, health post...)

Private pharmacy

Mission health facilities

Non-governmental organizations

Private practitioners

Patients

Others (please specify..)

Total number of customers

B. Selection of products

B.1. How are medicines for children selected?

EML � cEML � STG � Other � ____________


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B.2. Are procurements of children’s medicines at the store limited to the EML?

� Yes � No Comments:

B.3. If no, arrange in order of priority the three main reasons for which the Medical Stores procures children’s medicines and medical supplies outside the EML.

Reasons for procuring out of the EML Yes No

Ranking of priority

(1 is the most important and 3 the

least)

Comments

a. Limiting procurement to the EML is not defined in the pharmacy law

b. The last version of the EML is not available

c. The EML has not been revised and does not conform with recent STG

d. The EML does not address local need or demand

e. The prescribers are not familiar with the STG

f. The prescribers do not agree with the STG

g. The products on the EML are not available from the suppliers (CMS, regional warehouse, district warehouse…)

h. The products on the EML are not child formulations

i. Others (Please specify)

C. Quantification/forecasting C.1. Who is responsible at the store for the quantification of needs for children’s

medicines?

Staff responsible for quantification

Qualification of staff Comments


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C.2. Which of the following information is used in needs quantification for child-specific medicines?

Information used in the quantification of needs Yes No Comments

Available finances

Consolidating decentralized forecasts or quantification

Consolidating distribution data (issue data at each level)

Demographic data or disease prevalence/morbidity

Dispensed-to-user data (consumption)

Donations provided by partners/donors

Seasonal and regional variations

Standard Treatment Guidelines (STG)

Stock on hand at all level

Stock out duration

The expiry dates of stock on hand

Others (please specify)

C.3. Are any of these tools employed in the quantification of child-specific medicines? (Quantimed, Esther software, management software, support manual…)


If yes, what specific tool is used?

C.4. Over what time period are needs for children’s medicines and medical supplies quantified?

If the period varies with the category of please specify the product accordingly.

Quantification period Yes No Comments

Yearly

Every 2 years

Every 3 years

Others (please specify)

C.5. Is there a procurement plan ?


If yes, provide a copy and answer questions C6 to C8

If no, skip to questions in section D

C.6. Is there a committee responsible for the development of the procurement plan?



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If yes, attach list of members

C.7. Does the procurement plan include children’s medicines?

� Yes � No � NA Comments:

D. Procurement D.1. If not, and in case of stock-out in the national system for any child-

specific medicines, which supplier (s) do you procure from?

a. Private wholesalers


b. Private pharmacies


c. Mission structures


d. Local manufacturers


e. Local distributors


f. International manufacturers


g. International distributors


h. Others, specify



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D.2. What is the average lead-time for each of the following tender process?

Procurement method Average lead time in days

(from the publication of tender to signing a contract with the supplier)

International competitive bidding

Selective bidding

(suppliers pre-selected)

Negotiated tender

National competitive bidding

Direct procurement

Others (specify)

D.3. What type of contract is offered to the suppliers? a. Contract on basis of purchase order


b. Instalment delivery contract


c. Others, specify


D.4. Has the store an SOP/document for call of tender specific for the procurement of medicines and medical supplies?


If yes, attach copy

D.5. Is there pre-selection of suppliers by the store?


If yes, attach a copy of document on pre-selection process


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D.6. Which of the following Incoterms are used for contracting procurement of child-specific medicines? If Incoterm varies with category of product, specify accordingly in the table.

Incoterm Yes No Comments

FOB (Free On Board)

Free carrier

CIF (Cost Insurance and Freight)

DDU (Delivered Duty Unpaid)

DDP (Delivered Duty Paid)

Others, please specify

D.7. Arrange in the order of priority the three main criteria considered in awarding contracts.

Criteria for award of contract Yes No

Order of priority

(No 1 is the most important to 3 the least)

Comments

Quality of product

Performance of supplier

Price

Stated delivery time (lead time)

National preference

Supplier terms of payment (100% in advance, 100% after delivery)

Impact on bulk procurement

Supplier quotations

Others, please specify

D.8. Are the criteria for contract award clearly defined in an SOP/tender documents?


D.9. Is there a technical committee to analyse tenders?


If yes, attach list of members

D.10. Is the award of tender done by a committee?


D.11. If yes, which of these?

a. National Commission for Public Tenders?



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b. Tender 's Board for the CMS?


c. Others (please specify) � Yes � No

Please specify the composition of the commission

D.12. Are the procurement prices compared to standard reference prices?


If yes, which standards?

D.13. Are the results of the tender published?


D.14. What is the frequency of procurement of child-specific medicines? Frequency of procurement

Yes No Comments

2 times a year

1 time a year

Every 2 years

Others, specify

D.15. State in US$ the contract award in 2009 for each category of product at the various suppliers mentioned in the table below: (Put No/NA where applicable).

Sources of Procurement

Category of products International supplier

US$

International manufacturer

US$

Local distributor

US$

Local manufacturer

US$

Others

Specify

US$

Pediatric formulations for Pneumonia & Diarrhoea

D.16. What are the purchased prices to the store in 2009 for the following 30 products?


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E. Ordering

No. Medicine name (Name must be unique)

Medicine strength Unit present-ation

Purchase price to CMS

Comments

Amoxicillin clavulanic acid, suspension 125 mg/5 ml / ml

Amoxicillin dispersible tablet 250 mg /tab

Amoxicillin suspension 250 mg+ 62.5 mg / ml

Amoxicillin/clavulanic acid, dispersible tablet

125 mg+31.25 mg/5 ml / ml

Amoxicillin/clavulanic acid, suspension 250 mg + 125 mg /tab

Artemether + lumefantrine, dispersible tablet,

20 mg + 120 mg /tab

Artesunate/amodiaquine, dispersible tablet

25 mg+ 75 mg /tab

Azithromycin, powder, 200 mg/5 ml / ml

Beclometasone, inhaler 100mcg/dose /dose

Benzylpenicillin injection, 600 mg = 1 million IU /vial

Carbamazepine chewable tablet 100 mg /tab

Carbamazepine suspension 100 mg/5 ml / ml

Carbamazepine tablet 200 mg /pack

Ceftriaxone injection 500 mg vial /vial

Chloramphenicol injection 1 gram vial /vial

Cotrimoxazole dispersible tablet 100 mg + 20 mg (also expressed as 400 mg + 80 mg)

/tab

Diazepam rectal solution 2.5 mg/ ml / ml

Ferrous salt, suspension 30 mg Fe/5 ml / ml

Gentamycin injection 10 mg/ ml / ml

Ibuprofen tablet 200 mg /tab

Isoniazid, scored tablet 50 mg /tab

Mebendazole tablet 500 mg /tab

Morphine immediate release tablet 10 mg /tab

Morphine oral solution 10 mg/5 ml / ml

Oral rehydration solution (ORS) sachet 500 ml /sachet

Oral rehydration solution (ORS) sachet To make 1 litre /sachet

Paracetamol suspension 120 mg/5 ml OR 125 mg/5 ml

/ ml

Phenobarbital injection 200 mg/ ml / ml

Phenobarbital oral liquid 3 mg/ ml (also expressed as 15 mg/5 ml)

/ ml

Phenytoin chewable 50 mg /tab

Phenytoin suspension 25 or 30 mg/1 ml / ml

Procaine penicillin injection 1 gram = 1 million IU /vial

Quinine injection 300 mg/ ml / ml

Salbutamol inhaler 100mcg/dose /dose

Spacer device

Vitamin A capsules 100,000IU /tab

Vitamin K1 injection (water soluble) 1 mg / ml

Zinc dispersible tablet 20 mg /tab


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E.1. Who is responsible for making orders for the following for paediatric products?

Staff responsible for

ordering Qualification of

staff Comments

E.2. What is the frequency of orders at the store for child-specific medicines?

Frequency of orders Yes No Comments

Quarterly � �

Semi-annual � �

Annual � �

According to the needs � �

Others, to specify � �

E.3. Are the ordered products

a. Delivered by the supplier?


b. Collected by the store’s own means?


E.4. How far is the stores (in km) from the following? a. The higher-level store __________________________

b. The airport __________________________

c. The seaport __________________________

d. Other point of delivery (border) __________________________

E.5. What is the average time (lead time) it takes to receive products from the higher-level store? a. The sea port __________________________

b. The airport __________________________

c. The border __________________________

E.6. Is the performance of the supplier monitored?


E.7. If yes, which of these performance indicators are evaluated?

a. Products delivered conforms to the order



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b. Respect of agreed delivery time schedule


c. Respect of storage conditions


d. Quality of service after sales


e. Others, please specify


E.8. In the case of a decentralized system, what was the volume of medicines and medical supplies imported in 2006 for the store?

Volume of imports in 2009

Number of 40-foot containers

Number of 20-foot containers

Volume in m3 for the maritime or surface shipping

Volume in m3 by air freight

Others, specify

F. Storage/Stock management

AS APPLICABLE TO STORAGE FACILITIES

F.1. What is the storage capacity in cubic meters at the CMS?

F.2. Is there adequate storage capacity for forecasted quantities of medicines and medical supplies?


F.3. At what intervals are inventory controls carried out for child-specific medicines?

Frequency per year Yes No Comments

Once � �

Twice � �

Thrice � �

Others, specify � �


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F.4. From the following proposals, rank the 3 main causes of stock out in the store

Causes of stock out Yes No

Ranking of priority

(No 1 is the most important and 3

the least)

Comments

Delay in delivery � �

Quantities delivered not in conformity with quantities ordered

� �

Transport means not available � �

Funds not available for the order � �

Stock cards are not up to date � �

Minimum and maximum stock levels not regularly updated

� �

Error in forecasts � �

No stock control � �

Insufficient staff � �

Unqualified staff � �


F.5. Percentage of child-specific medicines products that expired at the store in 2009?

(Value of expired products/value of stock) x 100:

F.6. From the following proposals, arrange in order of priority the main causes of expiry

Causes of expiry Yes No

Order of priority

(No 1 is the most important and 3 the least)

Comments

Non-respect of the rule “first expired, first out” � �

Error in the forecasts � �

None compliance to the STG by prescribers � �

Modification of the STG in the course of the financial year

� �

No stock control � �

Insufficient staff � �

Unqualified staff � �



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G. Distribution

G.1. Has the CMS an adequate number of vehicles to pick up and distribute medicines and medical supplies?


G.2. If no, what is the number, the type and the capacity of the vehicles

available to the store?

Number of vehicles Type of vehicle Capacity of the vehicle in m3

G.3. In general, are orders delivered to customers within the deadlines?


G.4. If no, arrange in order of priority the 3 main problems encountered

during the delivery/pick up of medicines and medical supplies.

Problems encountered Yes No

Order of priority

(No 1 is the most important and 3 the

least)

Comments

Lack vehicle � �

Poor condition vehicles � �

High cost of transport � �

No driver � �

Poor road network � �

Dangerous road network � �

Long distance to cover � �

Climatic problems � �


G.5. Is there a specific distribution system for products financed by partners?


G.6. If yes, do children’s medicines have a specific system of distribution?

Category of products Existence of

a specific system

If yes, briefly describe the system of distribution

Yes No

Paediatric formulations (Syrups)

� �


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H. Quality assurance system In case of a decentralized procurement system, answer questions H1 through H7, otherwise proceed to H8

H.1. Which of the following criteria are used to ensure the quality of medicines procured? a. Products registered in the country


b. Products from pre-selected suppliers


c. Products pre-qualified by WHO


d. Products registered in a country with high pharmaceutical regulation (ICP/ICH)


e. Others


H.2. Among the following products bought in 2009, to which quality standards did they conform?

No Availability in % Quality standards

(e.g. WHO prequalified etc.)

Comments

Amoxycillin susp 125 mg/5 ml (100 ml)

Cotrimoxazole susp 200 mg +40 mg/5 ml (100 ml)

Albendazole suspension 20 mg/5 ml (20 ml)

H.3. Are samples of each batch procured systematically taken for quality control analysis?



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H.4. If yes, what is the percentage of registered products that did not comply in 2009?

H.5. What are the main causes of non-conformity?

H.6. Which structure is used for the quality control of products procured?

a. The quality control laboratory of the CMS

� Yes � No � N/A Comments:

b. The national quality control laboratory


c. Sub-regional quality control laboratory


d. An external laboratory


H.7. Is the laboratory used for the quality control of products?

a. Pre-qualified by WHO?


b. Accredited in accordance with the ISO17025 or EN45002?


c. Accepted by a Regulatory Authority ICP/ICH


H.8. Has a pharmaceutical inspection been performed at the Stores within the last 3 years?


If yes, specify the year and 3 main positive and negative results


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H.9. Does the Store have a written procedure for the following processes?

If yes, attach a copy Processes Yes No N/A Comments

Selection of the products � � �

Quantification of needs � � �

Procurement � � �

Placing of order � � �

Reception � � �

Storage � � �

Stock management � � �

Inventory control � � �

Destruction of expired/damaged products � � �

Returned products � � �

Redistribution of products in overstock � � �

Distribution � � �

Dispensing � � �

Quality assurance � � �

Financial management � � �

Monitoring/evaluation/supervision � � �

Training � � �

Recruitment of personnel � � �

Others, specify � � �

I. Financing

I.1. Please state the various sources of financing available to the store for the procurement of each category of the following products. Give expenditures in 2009, the budget for 2010 and the type of financing:

Category of products

Sources of funds

(Government, Global Fund,

MSF…)

2009

expenditure

US$

2010

budget

US$

% budget increase

2007

Type of financing

(Drug revolving fund,

loan, subsidy…)

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

Paediatric medicines

4 4 4 4 4

Is available funding for children’s medicines adequate for procurement of forecasted quantities? If not, what are the reasons?

a. Insufficient government allocations for procurement of medicines for children

b. Delay in the release of government budget

c. Inadequate funding from partners

d. Delay in the release of funds from partners

e. Inadequate capital for the CMS

f. Others, specify


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ANNEX 3: Availability of individual medicines, public, private and mission sectors

Medicines availability in outlets

Brand Lowest price

Medicine name Medicine list National

EML status

Public (n=15)

Private (n=30)

Mission (n=4)

Public (n=15)

Private (n=30)

Mission (n=4)

1. Amoxicillin clavulanic acid, suspension

Global yes 0.0% 0.0% 0.0% 6.7% 6.7% 0.0%

2. Amoxicillin dispersible tablet

Global no 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

3. Amoxicillin suspension Global yes 0.0% 16.7% 0.0% 100.0% 100.0% 75.0%

4. Amoxicillin/clavulanic acid, dispersible tablet

Supplementary no 0.0% 3.3% 0.0% 6.7% 10.0% 0.0%

5. Amoxicillin/clavulanic acid,Suspension

Global yes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

6. Artemether + lumefantrine, dispersible tablet

Global yes 33.3% 50.0% 75.0% 6.7% 46.7% 0.0%

7. Artesunate/amodiaquine, dispersible tablet

Supplementary yes 0.0% 0.0% 0.0% 0.0% 6.7% 0.0%

8. Azithromycin, powder Supplementary yes 13.3% 36.7% 25.0% 40.0% 50.0% 75.0%

9. Beclometasone, inhaler Global yes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

10. Benzylpenicillin injection Global yes 0.0% 0.0% 0.0% 73.3% 56.7% 75.0%

11. Carbamazepine chewable tablet

Global no 0.0% 3.3% 0.0% 0.0% 0.0% 0.0%

12. Carbamazepine suspension

Global no 0.0% 16.7% 0.0% 0.0% 0.0% 0.0%

13. Carbamazepine tablet Supplementary yes 0.0% 23.3% 0.0% 6.7% 20.0% 25.0%

14. Ceftriaxone injection Global no 13.3% 16.7% 0.0% 33.3% 23.3% 50.0%

15. Chloramphenicol injection

Global yes 0.0% 0.0% 0.0% 46.7% 23.3% 25.0%

16. Cotrimoxazole dispersible tablet

Global no 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

17. Diazepam rectal solution Global yes 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

18. Ferrous salt, suspension Global yes 0.0% 0.0% 0.0% 0.0% 3.3% 0.0%

19. Gentamicin injection Global no 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

20. Ibuprofen tablet Global yes 0.0% 0.0% 0.0% 86.7% 76.7% 100.0%

21. Isoniazid, scored tablet Global no 0.0% 0.0% 0.0% 0.0% 3.3% 0.0%

22. Mebendazole tablet Supplementary yes 6.7% 53.3% 25.0% 46.7% 23.3% 50.0%

23. Morphine immediate release tablet

Global yes 0.0% 0.0% 0.0% 0.0% 3.3% 0.0%

24. Morphine oral solution Global no 0.0% 0.0% 0.0% 6.7% 0.0% 0.0%

25. Oral rehydration solution (ORS) sachet

Global yes 0.0% 0.0% 0.0% 80.0% 86.7% 75.0%


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Medicines availability in outlets

Brand Lowest price

26. Oral rehydration solution (ORS) sachet

Global yes 0.0% 0.0% 0.0% 0.0% 10.0% 25.0%

27. Paracetamol suspension Global yes 0.0% 0.0% 0.0% 0.0% 13.3% 0.0%

28. Phenobarbital injection Global yes 0.0% 0.0% 0.0% 20.0% 13.3% 25.0%

29. Phenobarbital oral liquid Global no 0.0% 0.0% 0.0% 6.7% 0.0% 0.0%

30. Phenytoin chewable Global no 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

31. Phenytoin suspension Global no 0.0% 6.7% 0.0% 0.0% 0.0% 0.0%

32. Procaine penicillin injection

Global yes 0.0% 0.0% 0.0% 0.0% 6.7% 0.0%

33. Quinine injection Supplementary yes 0.0% 0.0% 0.0% 80.0% 36.7% 100.0%

34. Salbutamol inhaler Global yes 6.7% 16.7% 0.0% 33.3% 26.7% 50.0%

35. Spacer device Global no 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

36. Vitamin A capsules Global yes 0.0% 0.0% 0.0% 0.0% 3.3% 0.0%

37. Vitamin K1 injection (water soluble)

Supplementary yes 0.0% 0.0% 0.0% 53.3% 10.0% 75.0%

38. Zinc dispersible tablet Global no 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%


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ANNEX 4: Tracer medicines list

1. Amoxicillin suspension, 125 mg/5 ml

2. Amoxicillin dispersible tablet, 250 mg

3. Amoxicillin/clavulanic acid, suspension, 250 mg+ 62.5 mg

4. Amoxicillin/clavulanic acid, suspension 125 mg+31.25 mg/5 ml

5. Amoxicillin/clavulanic acid, dispersible tablet, 250 mg + 125 mg

6. Artemether+lumefantrine, dispersible tablet, 20 mg + 120 mg

7. Artesunate/amodiaquine, dispersible tablet, 25 mg+ 75 mg

8. Azithromycin, powder, 200 mg/5 ml

9. Beclometasone, inhaler 100 mcg/dose

10. Benzylpenicillin injection, 600 mg = 1 million IU

11. Carbamazepine suspension, 100 mg/5 ml

12. Carbamazepine chewable tablet 100 mg

13. Carbamazepine tablet 200 mg

14. Ceftriaxone injection 500 mg vial

15. Chloramphenicol injection 1 gram vial

16. Cotrimoxazole dispersible tablet, 100 mg + 20 mg (also expressed as 400 mg + 80 mg)

17. Diazepam rectal solution, 2.5 mg/ ml

18. Ferrous salt, suspension 30 mg Fe/5 ml

19. Gentamicin injection 10 mg/ ml

20. Ibuprofen tablet 200 mg

21. Isoniazid, scored tablet 50 mg

22. Mebendazole tablet 500 mg

23. Morphine oral solution 10 mg/5 ml

24. Morphine immediate release tablet 10 mg

25. Oral rehydration solution (ORS) sachet to make 500 ml

26. Oral rehydration solution (ORS) sachet to make 1 litre

27. Paracetamol suspension 120 mg/5 ml OR 125 mg/5 ml

28. Phenobarbital injection 200 mg/ ml

29. Phenobarbital oral liquid 3 mg/ ml (also expressed as 15 mg/5 ml)

30. Phenytoin suspension 25 or 30 mg/5 ml

31. Phenytoin chewable tablet 50 mg

32. Procaine penicillin Injection 1 gram = 1 million IU

33. Quinine injection 300 mg/ ml

34. Salbutamol inhaler 100 mcg/dose

35. Spacer device

36. Vitamin A capsules 100,000 IU

37. Vitamin K1 injection (water soluble) 1 mg

38. Zinc dispersible tablet 20 mg

SUPPLY CHAIN GHANA - WHO · A precondition for the achievement of Millennium Development Goals 4...

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