Abstract Currently Vietnam is receiving support from various - - PDF document

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SUPPLY CHAIN OF THE HIV/AIDS PROGRAM IN VIETNAM – AN ASSESSMENT OF PERFORMANCE AND SUSTAINABILITY

Tran Quang Lam1 Xavier Tomsej2

Abstract

Currently Vietnam is receiving support from various international donors (PEPFAR, Global Fund, CHAI) to ensure availability of pharmaceuticals to 130,000+ HIV/AIDS and 60,000+ methadone patients. As donor support will continue to decrease, raising the questions around

• wnership, capacity, sustainability, and affordability of existing supply chain systems.

This assessment applies both quantitative and qualitative methodologies and provides the baseline status of existing supply systems, identify gaps, and provide recommendation for future interventions that will foster integration of multiple supply chains into one cost effective and efficient supply chain system for HIV/AIDS commodities. Eleven supply chain components were under assessment and then, relevant components were divided into two groups and determined as better reflecting either the performance or the sustainability using a scoring system. Practical recommendations include: In the first phase, procurement partners would continue for a limited interim period to provide the same services to allow the government to invest more in the pharmaceutical management system. In the second phase, technical assistance focus would shift to the central level toward advising and strengthening the operational capacity and linkages. In the last phase, both procurement and technical assistance support by the donors would phase out, leaving the new system to take control.

Introduction

Since the detection of its first case of HIV infection in 1990, Vietnam has formulated and implemented a number of medium-term plans for HIV/AIDS prevention and control. The National Strategy on HIV/AIDS Prevention and Control in Vietnam was formulated on the basis of multi-sector coordination with the active support of United Nations (UN), international

• rganizations and individuals that are supporting the HIV/AIDS prevention and control

program in Vietnam. The contents of the Strategy were developed on the basis of the common principles of the UN’s Declaration of Commitment on HIV/AIDS, made up at the 2001 United Nations General Assembly Special Session on HIV/AIDS (UNGASS), the Vietnamese Government’s commitments to, and the Vietnamese State’s line on people’s health protection and care and socio-economic development. Since 2005, Vietnam has multiple sources for pharmaceuticals and supplies which are responsible to ensure commodity availability and improve the access of general and most at risk populations to prevention and of HIV/AIDS patients to treatment at the facility level. It resulted into the creation of a number of supply chain mechanisms to respond to donor and internal needs for monitoring and accountability. Over time, support from different donors decreased and will continue to decrease further in the future, which has raised the questions

1 Independent consultant 2 USAID | Bureau for Global Health, Washington DC, USA

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

• guidelines. There was participation of approximately 30 discussants from various MOH

departments, VAAC departments, and other agencies involved in HIV/AIDS related

commodity supply chain activities. Desk review, a number of meetings with WHO3, and personal observations from site visits and many meetings provided additional qualitative information. In order to ensure the assessment accurately represents all the diversity of the HIV/AIDS system, a sampling frame and appropriate sample size need to be determined. First, 10 provinces were intentionally selected in function of the following criteria:

• 1. Geography
• 2. Urban/remote environments
• 3. Wealthy/poor provinces
• 4. Presence of three programs (National, Global fund, and PEPFAR)
• 5. Prevention, Care & Treatment, and Harm Reduction activities are represented in these

provinces4. Developing the sampling frame of facilities: all facilities providing ARV, Lab and Methadone services in the 10 selected provinces were listed. Since ARV, Lab and Methadone are the three main services of the VAAC supply chain system, we classified the facilities on that basis. However, other related services i.e. VCT, OIs, condoms, syringes, etc. are sometimes provided at the same location (though not in the same buildings). In addition, facilities in the 10 provinces are grouped by funding source i.e. PEPFAR, Global Fund and National Target

• Program. For a statistically significant sample, at least 15 percent of total facilities should be

selected.5 In the case of this assessment, it requires a minimum of 59 facilities (45 ARV, 6 Methadone and 8 Lab) to be selected. The total number of facilities selected is 71 or 16% of the total facilities nationwide. The numbers are 47 (16%), 8 (19%) and 6 (12%) for ARV, MTD and Lab respectively.

Quantitative Results and Discussion

The questionnaire was designed to capture data associated with two different attributes of the HIV/AIDS supply chain: its Performance and its Sustainability6. Performance groups together the components of the system that best provide indications on how the system runs (well, average, or poorly), regardless of whether the system is externally supported, country-owned, or operated by a mix of external and national actors. Under this definition, operational components such as LMIS and Supportive Supervision, Inventory Control, Warehousing & Storage, and Product Use are criteria selected for measuring Performance. Sustainability groups together the structural components of the system seen through the lens

• f country ownership (i.e. whether these structural components are country-owned, funded, or
• perated). Organizational Situation & Readiness, Organizational Support for Managing the

3 Dr Socorro Escalante, WHO Pharmaceutical Policy Advisor 4 Though, by design, the assessment focused on ART, MMT and lab services.

5 Assessing Supply Chains for HIV/AIDS Commodities, DELIVER project, May 2006). 6 Scores on sections 4 (Quantification) and 5 (Procurement), and those obtained on sections 3 (Essential Drug

List Compliance) and 8 (Transport & Distribution) were respectively removed from the Performance and Sustainability criteria because there were not enough statistically relevant responses (many questions were left unanswered or did not apply to the interviewed sites). However there is enough qualitative information available to submit some hypotheses and draw some tentative conclusions in the Discussion section.

4 Supply Chain and Financing & Transition Planning are selected criteria associated with Sustainability. Overall Results Each section showed the following results: Performance:

• 1. Management Information System & Supportive Supervision (62%)
• 2. Inventory Control (48%)
• 3. Warehousing & Storage (64%)
• 4. Product Use (72%)

Sustainability:

• 1. Organizational Situation & Readiness (65%)
• 2. Organizational Support for the Supply Chain (41%)
• 3. Financing and Transition Planning (42%)

The supply chain achieved its highest score on Product Use (72%) while Warehousing & Storage, another Performance criterion, shows the third highest score with 64%. In contrast, the supply chain achieved lowest on Organizational Support for Managing the Supply Chain (41%), a Sustainability criterion, while the second scoring section also belongs in the Sustainability group: Financing and Transition Planning (42%). As a result, the system performs somewhat better on Performance (62%) than on Sustainability (50%). Supply Chain Performance The performance of each donor-supported supply chain system (NTP, GF, PEPFAR) measured by their respective average score is 57%, 61% and 63%. These average results are due to decent scores (high seventies or sixties) attained in the Drug Use and LMIS components of the supply

• chain. Two “Other Donors” sites (World Bank and PACT) scored higher -65%- on account of

high performance in the same sections. When comparing the various levels in the health care system, the assessment shows that the Central, Provincial, and District levels perform equally (63-62%) due to their high performance in Drug Use (76%-71%). Mirroring the high-performing functions by all donors, the provincial level performs best in Drug Use and Warehousing & Storage (respectively 71% and 64%). By facility type, Central, Provincial, District hospitals and Preventive Health centers, and Provincial AIDS Centers all perform equally (62%) riding the Drug Use and Warehousing & Storage waves. When sites are classified as co-located or stand-alone, the stand-alone sites perform a little better (65%, N=10) on average as supply chain actors than co-located sites (60%, N=51), as evidenced by their higher performance on MIS & Supportive Supervision, Warehousing & Storage, and Drug Use. The identity of the supporting donor is no factor in these results as all donors are represented in this category. It is plausible that, without the benefit of co-location, these sites enjoy a dedicated storage room with all the required space and equipment provided by their respective donor. Similarly, donors may be paying special attention to these sites

• wing to the fact that they cannot share into the resources provided by a co-located facility. As

a result donors may have had to invest in dedicated staff and training, newer equipment, may be visiting more frequently, and generally providing more support. The possible explanations

behind the fact that Drug Use scores so much higher (80% against 70%) for stand-alone sites are more elusive. Analysis by commodity shows labs performing more poorly than ARV and methadone sites (55% against respectively 62% and 64%). All commodities face Performance challenges on Inventory Control. This is counter-intuitive because both MMT clinics and some labs (such as CD4 or confirmatory test labs) must follow strict standards of operations as defined by Circular 10 and Decision 1099 respectively. Yet on a commodity basis, all sites meet mediocre Inventory Control standards on most measures. On a system level basis, central hospitals segregate damaged and expired products from their inventory and stock records. So do a sizable minority of provincial hospitals and almost 90% of PACs (Lam Dong province being the exception). Almost 80% of district hospitals and Preventive Health centers also observe this good practice. Most sites (all central hospitals and a small majority of provincial hospitals and AIDS Centers) stated the existence of a system for tracking ARV losses and adjustments. In terms of commodity type, this translates into a large majority of labs and ARV-managing sites, and all methadone clinics tracking losses and adjustments for their commodities. However, looking deeper into the Inventory Control weakness, by and large provincial and district sites reported not being aware of the existence of an established maximum and minimum stock level policy at their respective level. Similarly, many provincial and district sites report that no written provision exists that governs the re-allocation of overstocked drugs. Both findings reflect a poor understanding of the purposes of inventory control, which in turn is a predictable consequence of the “Push” nature of the supply system. Component-by-component Analysis and Discussion: Performance

Logistics Management Information System (LMIS) and Supportive Supervision

The LMIS is maintained consistently well across the different programs (NTP, GF, and PEPFAR) of the system. However its use is limited to reporting up to the higher level. Levels below the central level do not track logistics indicators nor perform analyses on their own: they rely on the push system7 for donated drugs and manage only basic logistics information if they procure other commodities on their own. At the provincial level, one third of them (Dong Thap, Ha Giang, and Hanoi) display some

• weaknesses. Those provinces have no automated LMIS, indicators are not tracked and

therefore decisions are not evidence-based, although the data reported to the central level is sufficient in scope for ensuring re-supply8. In Ha Giang (one of the northernmost provinces) as in all other provinces, communication with other levels on drug supply and management is

• fficially conducted through paper-based reports9. Few meetings or supervisory visits take

place, and when they occur, they cover a meaningful range of drug management aspects in only a minority of sites. The same is true with the other types of commodities under this study. Hanoi Central hospitals tend not to have a logistics management system. While half of central hospitals report using a software package for drug management, these systems are patient- based and offer a basic functionality for managing prescriptions. However no indicators are tracked and little data is available for analysis and decision-making other than short-term ones. No logistics-related communication is shared with other levels. Supervisory visits occur only annually and require external technical assistance. In contrast, the supervisors of these

7 A Push system is a supply chain in which the decision on how much to distribute is based on a supply-side

“trigger” rather than actual “customer” or recipient demand. In this case, the distribution plan developed at the central level determines the demand level.

8 Whether the data is consistently of sufficient quality is another matter, as explained in the Recommendations 9 However a basic online system also exists

6 pharmacies within the hospitals use tools to review a wide range of supply chain issues with the drug management staff, including in most instances the budgeting of drug management

• activities. Except as potential training and/or supportive supervision resources, from a logistics

management perspective, central hospitals operate in isolation and cannot contribute significantly to the strengthening of the supply chain management capacity, even at central level. Half of the sampled provincial hospitals and one third of the PACs reported using software (though the software is not common to multiple sites –much less connects them together). At district level, almost half of the facilities reported using some computerized drug management

• tool. In the context of transitioning the role of quantification for distribution planning from

donor projects at the central level to the provincial or even the district level (HCMC), the presence and utilization of software presents an opportunity to automate at least part of this process, achieving efficiencies and minimizing errors from manual processing. MIS is overwhelmingly used for inventory management (89%) at all levels; less than half of the sites use it for forecasting or quantification, least of them the central level sites, of which

• nly one-third use a formal MIS for this purpose. Almost one-third of provincial level sites use

the MIS to plan the distribution of drugs, either to the district level or to themselves by scheduling deliveries. More than half of all sites reported they do not track any indicator relating to product availability or other supply chain-related practices. In a push system where re-supply decisions are made at the central level, the focus on using the LMIS for inventory control is appropriate and justified given that the lower levels do not have the authority to manage the supply of their HIV/AIDS commodities. However, the use of some basic patient- centered logistics management indicators such as drug availability and product quality at delivery are relevant for service monitoring and improvement purposes, and would be welcomed. In 61% of sites, including all PACs and central hospitals, supportive supervision visits are either provided or received with the support of technical assistance in some form or other. Of the three supply chains, the MTD program tends to receive the least external technical assistance for providing or receiving supportive supervision, although half of MTD clinics interviewed receive monthly supervising visitors and another third receive supervisors on a quarterly basis. This probably means that most supervisory visits are conducted by the Government itself. This close attention by the Government reflects hands-on regulation of the MTD program, most likely because of the nature of the drug involved. ARV-managing sites receive technical assistance for the purpose of supportive supervision in a much greater proportion than other commodity programs. Most (70%) of these visits occur on a quarterly basis; only 1 site reported never being visited for supervision. All MTD and lab sites reported being visited for supervision at least on an annual basis. An equal proportion of labs tend to be supervised quarterly and annually. Most PACs perform supervisory visits on a quarterly basis; the balance (40%) does it annually. Supportive supervisors overwhelmingly concentrate on inventory control during their visits: they study the inventory records, examine the storage room, and conduct physical inventory. In addition, they review the progress accomplished since the previous visit, discuss implementation of activities and what help might be needed, and provide on-the-job training. This is important to highlight, as the supervisors do not limit their role as “inspectors” or “auditors", but also as advisors and facilitators of discussions in a participatory process leading to sustainable solutions. As mentioned above, this emphasis on inventory management is an efficient use of resources while benefiting the patients, in that it supports product availability and accurate stock

• reporting. However, the accuracy of the logistics management information relies heavily on

the supportive supervision model, which itself is largely operated by PEPFAR (USAID/SCMS). Whether the GVN will adopt this model in a sustainable way is a fair question, the answer to which will have an impact on the long-term performance of the LMIS. Sites cited frequent monitoring and assistance with managing supply chain information as the chief strengths of the MIS. In contrast, an almost equal number of sites cited the manual reporting system as the main weakness of the MIS. One fourth of all sites recommended the installation of a drug management and reporting system –or just a computer with an Excel- based template- at their facility. While we expect most sites at all levels to be computerized within the next few years, the choice of software that will run on those computers will determine the extent of their benefits for supply chain management. With wide variations of numbers of patients and sites across programs and provinces and a low degree of supply chain management skills across all levels and types of facility, reconciling these different orders of magnitude in demands into a single national tool is a significant challenge. However, SCMS has come up with an Excel-based tool that will support the distribution planning component of the ARV and MTD supply chains, offering 2 co-existing quantification methods combined into a single tool for use depending on provincial and other characteristics. This tool will be rolled

• ut as part of a multi-province pilot in the course of the summer and fall.

Inventory Control

The HIV/AIDS supply chain in Vietnam is a push (top-down) system. Treatment and test10 sites report their past consumption and stock status, these reports are aggregated at the provincial level and then forwarded to the central level where a joint SCMS-VAAC team corrects the numbers and quantifies the requirements over approved time horizons. In short, this central-level team develops a distribution plan, which CPC1 (Tam Long for BD reagents) later executes. All HIV/AIDS drugs must be in full supply and sites at each level must close each month with a stock balance equal to a preset number of months of consumption11. The central-level team also decides (SCMS suggests and VAAC decides) on whether ARV stock must be re-allocated, from where, to where, and how much. About half of sampled sites report the existence of written provisions for re-allocation of overstocked supplies. In addition, the guidelines call for a FEFO (First Expired, First Out) inventory issue policy at all levels, which is widely observed in practice. Among exceptions are sites, whether labs or OPCs, in some big central and provincial hospitals. In short, except in some big hospitals, there is no autonomy of inventory control at site level. The absence of stock outs results from several mitigating mechanisms:

• 1. Safety stock at provincial and site levels
• 2. Re-allocations: Excess stock at site level can lead to expiry. To minimize this risk,

stock managers return their excess stock to the provincial level where it becomes available to replenish sites that are under stocked in this particular drug.

• 3. Cooperation between donor programs: At central or even provincial level, authorities

“borrow” the required amount of drugs that are in shortage in one of the programs from the stock of another program. Replenishment is done at the next distribution and records are adjusted at the next reporting cycle.

10 Only those test sites that belong to the VAAC chain of command. Some labs report to the DOH or to another

ministry, such as MOD.

11 As an illustration of the absence of inventory control autonomy, most provincial and district level sites in our

sample either responded negatively or didn’t know how to respond on the question whether such guidelines exist.

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• 4. Emergency orders at provincial level: though undesirable because of the big amount of

resources that must suddenly mobilize to achieve this non-routine task, some

• ccurrences of emergency orders are unavoidable in most supply chains. Because of

the disturbance it causes to the entire supply system and the precedent it sets, use of this mechanism should be minimized inasmuch as possible. A minority of provincial sites report the existence of written procedures for guiding the redistribution of excess or shortage drugs at the provincial level (Thanh Hoa, Quang Nam, HCMC and An Giang), and only half of PACs report the same (Thanh Hoa, Da Nang, Phu Yen, HCMC, Dong Thap). Further down the system levels, a sizable minority (40%) of district Preventive Health centers also report knowing about this mechanism. In contrast, a large majority of sites (87%) confirms the existence of a FEFO inventory control policy at all levels. This majority is distributed by donor along the following lines: more than 1/3 are PEPFAR supported sites while 59% are supported in equal measure by GF and CDC/LG. In practice, it appears almost all stock-managing sites apply FEFO.

Warehousing & Storage

About half of the central and provincial hospitals report following a procedure for recording complaints to drug suppliers about product quality, while two-thirds of PACs and district preventive health centers report having one. However, none of these facilities could produce an established procedure on paper. Most of the sites agreeing with these statements are ARV- managing sites. In terms of disposal, only half or fewer sites at each level report the existence of written guidelines, both for medical waste and for expired or damaged products. Interestingly, a relatively larger share of district preventive health centers is familiar with this procedure. A majority of central and provincial hospitals, as well as PACs and district Preventive health centers agree with the statement that written procedures exist for destroying damaged and expired products.

Product Use

Standard treatment guidelines exist for HIV/AIDS care & treatment and harm reduction drugs and are known to facilities at all levels. Written procedures exist for monitoring and supervising prescribing practices. Awareness of (or compliance with) this is much weaker in one third of provinces (in our sample, Ha Giang, Lam Dong, and Thanh Hoa). However all provinces report that prescribing practices are monitored and compared with STGs. All ARV and methadone treatment sites report doing so, as well as all sites supported by all donors according to questionnaire respondents. This practice is implemented or reinforced as part of the supportive supervision visits (at least those performed in PEPFAR-supported sites). Almost half of provinces (Da Nang, Dong Thap, Thanh Hoa and HCMC) report at least 3 kinds

• f barriers to access to drugs. These barriers are programmatic, operational and “cultural” (most
• f them referring to stigma). The cultural barrier is present across all 3 commodities (ARVs,

MTD and lab supplies) with equal severity. More than one fourth of ARV and methadone sites report cultural barriers, and as much as one third of methadone clinics report both programmatic and operational barriers to access to drugs for their patients. Price is a small barrier and only with respect to lab services as observed by some FHI-supported sites. HCMC also reported some religious barriers, though limited to ARVs and no comment was provided. In terms of donors and implementing partners, operational barriers were reported in NTP, GF, and PEPFAR sites with equal occurrence. Cultural barriers are more prevalent and involve sites supported by all donors with similar frequency.

Supply Chain Sustainability Sustainability results tend to decrease significantly when compared with Performance (50% against 62%). As with supply chain operational performance, the scores on sustainability are almost identical across donors: 48%, 50%, and 49% for NTP, GF and PEPFAR respectively, all weighed down by their low contributions on Organizational Support for the Supply Chain, and Financing & Transition Planning. “Other donors” show a little headway with 53% because these sites perform better on Organizational Situation and Readiness (71% against low sixties elsewhere). By province, Hanoi displays the highest sustainability score (64%) carried by its performance

• n Organizational Situation & Readiness, the lowest being Dong Thap with 38%, weighed

down by low contributions from all 3 components. Phu Yen (26%) and Quang Nam (45%) are to be treated with caution as provincial variables because they are each represented by a single site in the study. Ha Giang, Ho Chi Minh City and Thanh Hoa score equally with 50%-52% (52% for HCMC). While one province scores high on Organizational Situation & Readiness (Quang Ninh, 76%), no province scores high on Financing & Transition Planning (the highest, Hanoi, shows 62%, probably thanks to its proximity to the center of decision-making). The Central level barely bests the others on sustainability, though not by much (52% versus 50% and 49% for provincial and district levels respectively). Central hospitals have an insignificant lead (52%) against all other types of facility, provincial and district hospitals, PACs, district PHCs and “Others” (military and independent MMT clinics and an orphanage) –all scoring 49%-50%. For the purpose of the facility type tabulation, CPC1 is reflected separately as a non-health system entity. Unsurprisingly it is an outlier in terms of supply chain sustainability: its score is 63%, on account of a very high score (95%) on Organizational Support for Supply Chain Management and a very low one on Financing & Transition Planning (29%). With regard to Organizational Support for Supply Chain Management (OSSCM), these are rather alarming results since all the lab sites, most of the MTD clinics and 40% of the ARV sites are PEPFAR-supported sites, while the only supply chain management support project for these commodities is a PEPFAR project. SCMS trains staff, develops SOPs and tools, and conducts supportive supervision visits –all subjects of OSSCM questions- on a regular basis. The other questions pertain to the perceived importance of supply chain management, the existence of a staffing and retention strategy for this function, and how long supply chain staff remain in this role before moving to other jobs. The scores on these questions are mostly zero for Lab and ARV sites, underscoring the lack of importance the system gives to drug management in general, and drug managers in particular. When it comes to Financing & Transition Planning, the result on which essentially confirms the free status of HIV/AIDS drugs and estimates the awareness of donor and government plans by interviewees, the above scores indicate the extent to which all programs know (or care) little about the future of their activities. Component-by-component Analysis and Discussion: Sustainability

Organizational Situation and Readiness

In a majority of provinces (60%), questionnaire respondents stated they work 50% or more of their time on supply chain (designated as "full-time" staff in this report). These drug staff members are more likely to work in PEPFAR-supported sites (63% in CDC/LG, 75% in SMART-TA). They are also much more likely to work with the methadone program (83%). The rest is spread equally managing ARVs or lab supplies.

10 In almost half of provinces, the number of fulltime drug management staff surpasses that of those who work part-time on supply chain issues; two more provinces have an equal number

• f full- and part-timers. There are more full time pharmacy staff than multi-taskers within all

levels except in central hospitals. All types of sites have more supply chain full time staff than multi-taskers except in provincial hospitals, where most staff working on supply chain share their time with other duties. The vast majority of sites across all provinces and levels and in every type of sites find the current institutional structure effective to achieve their mission in the fight against the HIV/AIDS epidemic. A large majority of sites (76% across 9 out of 10 provinces, all levels and all types of sites) believe their institution has adequate managerial and technical expertise to carry out all its assigned supply chain activities, including in the future. A smaller majority (60%) across more than three fourth of all provinces, within all levels and across all site types believe their institution have enough permanent staff to carry out their responsibilities in the future without donor support. The same observations are valid within each commodity category (ARV and methadone treatment sites and labs). The ratio between dedicated supply chain staff and multi-taskers is much more balanced in the ARV “world” than with other commodities. Conversely, the organizational status of drug management staff is very low at all levels. Even among provincial hospitals, less than 40% of senior pharmacists have the same ranking as a unit head. Only at the central hospital level do most pharmacy managers have the same authority level as other heads of functional units. Very few drug management staff are government employees. Most of them are “permanent” health staff (i.e. they are employees of their respective OPC, clinic, or lab site’s co-located preventive or curative health facility), whether working in an ARV, MTD or lab setting. In methadone clinics, a noticeable number of staff are contract/project staff whose employment will end at the same time as the supporting project.

Organizational Support for Managing the Supply Chain

Supply chain management is a well-resourced activity at all levels of the system. It is considered a growing priority among a minority of sites at provincial and district levels and a “newly introduced priority” among a sizable minority of central level sites. In Da Nang and Lam Dong, as many respondents estimate supply chain management is not recognized as a priority as others estimate it is a well-established (Da Nang) or a growing priority (Lam Dong). Drilling further down, almost half of provincial hospitals consider supply chain management as a growing priority (the other half sees it as an established, well-resourced activity). Almost a third of district preventive health centers share the same opinion (against 2/3 for “well- established”). This opinion prevails at least across 3 commodities (ARVs, MTD and lab supplies) and all programs, although this perception declines relative to the other opinions in CDC/LG-supported sites and those supported further by “other donors” such as the World Bank. Supply chain-related SOPs are available and consistently implemented and adhered to in only half the sites at each level. At the national level, this situation is observed only in 1/3 of

• provinces. This indicates that in those sites, even when staff have been trained, they have no or

little materials to guide their actions, maintain quality of drug management tasks, and ensure continuity of service when staff rotate in and out of their drug management function. There is no specific staffing plan for supply chain management in any province (though HCMC site responses conflict in this area), regardless of the commodity type or donor, although the

• pinion is more nuanced among PEPFAR-supported sites, perhaps because of assumptions

created by the regular supportive supervision visits by SCMS technical advisors. In contrast, all central hospitals claim having a staffing plan. Insofar as the system’s capacity to provide supply chain input into their staff training, only the Hanoi central hospitals and CPC1 have that training function. A minority of provinces have an equal number of sites that report either having or not having that capacity, but a large majority

• f provinces do not have that capability inside their part of the system (though labs present a

more balanced picture). This lack of institutionalized capacity is reported across all donors. Two-thirds of provinces have some sites (at least ¼) who are planning to have their supply chain staff trained, one-third12 has no such plan at all. By type of facility, central hospitals and PACs are more likely to have such a plan in place. No donor or specific drug supply chain stands out either. Some staff in half of the provinces report knowing of a harmonized curriculum in supply chain management though the majority of respondents within those provinces do not know of any such ministry-organized curriculum. Those who claim to know

• f such a curriculum are more likely to work in provincial hospitals and in the methadone
• program. These sites are also more likely to be PEPFAR-supported. Yet a strong majority of

supply chain personnel in all provinces, with the exception of Phu Yen, have received formal supply chain training at some point or other. In one-third of provinces, personnel of all their sites have been formally trained in supply chain management. Among the different types of facilities, district preventive health centers are the least likely to have formally trained staff in supply chain management. All other types of site personnel are well trained. They work on all commodities, irrespective of the donor. In terms of job retention, a majority of provinces claims to implement a strategy for retaining qualified staff. According to comments gleaned from respondents, the “strategy” is often limited to the payment of salaries or supplementary hardship allowances by donor projects, which doesn’t augur well for staff retention in a post-donor era. The majority of district level sites report no organized attempt at staff retention. Among these, district preventive health centers are least likely to do so, whereas Lab and PEPFAR sites are most likely to implement such a strategy. One-third of provinces have at least ¼ of their supply chain staff rotating out

• f their supply chain duties every 2 years or less. The large majority of provinces have at least

1/3 of their supply chain staff remaining in their supply chain duties for 2 years or longer. In the provinces with the fewest sites (An Giang, Dong Thap, Ha Giang, Hanoi, and Quang Nam), all supply chain staff remain in their duties for at least 2 years.

Financing & Transition Planning

In a minority of provinces, a couple of sites charge patients for HIV/AIDS commodities, namely for ARVs and for testing. This happens in 2 PACs and 2 provincial hospitals, one of them including a lab. These 2 PACs are co-supported by the NTP and the GF. In HCMC, this revenue is used to pay for commodities or commodity-related expenses. Apart from these exceptions, no money is charged to HIV/AIDS patients for any service. The personnel of a very large majority of sites of all types, across all types of commodities and donors, and in all provinces, are aware of plans by donors to reduce or phase out their drug donations and drug-related support in the next few years. The least aware province, Ha Giang, is an NTP province with no other donor support. Except in Hanoi (central hospitals) and HCMC (PAC and a couple of district preventive health centers), the large majority of sites, mostly ARV sites and labs in all other provinces, report that no national supply chain transition plan is being implemented. PEPFAR-supported sites seem to be the most ambivalent as to whether this implementation is taking place.

12 This includes An Giang, Da Nang, and Dong Thap

12 Less than half of all sites exhibit confidence in managing their drug supply without project support in future –though a majority of them trust having enough supply chain personnel after donor withdrawal (as indicated in Organizational Situation and Readiness), indicating that the concern focuses on either the expected lack of drugs and/or equipment, or of intangibles, such as skills, training, leadership or political support, etc. The sites that are confident are most likely to be PACs and least likely to be district level sites. Of those not responding or expressing no such confidence, many cited “Quantification/Planning & Reporting” and especially “Inventory Management” as the supply chain functions they consider being capable of carrying forward after donors’ departure. Only 4 treatment sites and 1 lab reported confidence in managing Procurement. More than two times as many sites believe that they will not be eligible for health insurance reimbursement for dispensed HIV/AIDS drugs or tests than those who believe they will. More than a third of all sites did not respond (presumably do not know the answer to this question). Both optimists and pessimists tend to be equally distributed among all donors. In summary, few system-wide patterns emerge from the analysis of the collected data. In spite

• f the system’s fragmentation, many structural attributes do not matter in terms of their impact
• n the supply chain’s performance or/and sustainability. If one ignores the patient load

criterion, neither the identity of the donor or program, nor the situation or wealth of the provinces, nor the level in the system, nor the type of facility really makes a significant impact

• n supply chain sustainability scores. All these variables yield similar supply chain

sustainability ratings; the spread between the results shown on the basis of all these variables is at most 28 percentage points, though in the vast majority of measurements, it is less than 10 percentage points. On supply chain performance, it matters whether you are in a Northern province, you are a patient of a central rather than district hospital, whether the site stands alone, and whether it is a treatment rather than a lab or prevention site. If the site cumulates all these (sometimes conflicting) characteristics, the supply chain cumulatively achieves a relatively higher

• performance. However if any one or more of these conditions is missing, the remaining

variables still matter, but very little. In terms of supply chain sustainability, the co-location variable has a small positive impact on sustainability (while on the contrary stand-alone sites perform better), and that your longer- term prospects as a drug dispenser or other staff are better if you manage methadone13. Qualitative Analysis and Discussion: Performance

Quantification at Peripheral Levels

Quantification expertise –whether it is for procurement or for distribution planning- is weak

• verall and weaker still in PEPFAR-supported sites. Some voices call for the quantification for

planning the distribution of ARVs to be transitioned from donor projects at the central level to the provincial level. Ho Chi Minh City currently plans to delegate this role even further, to the district level. However this expertise at these levels does not currently exist. In most provinces,14 OPCs and methadone clinics do not carry out quantification functions as part of their regular tasks; the same applies to military clinics. Of those who report performing a

13 By commodity type, the MTD program is more sustainable (57%) than the ARV program (48%), while the

HIV/AIDS lab system’s sustainability seems really in question (43%).

14 6 of 10 provinces our sample, excluding Dong Thap, Ha Giang, Hanoi and Phu Yen)

quantification role, the vast majority of OPCs and methadone clinics only report dispensed and in-stock quantities to their respective PACs. In contrast, one third of central hospitals and one third of PACs play a bigger role in quantification as they forecast for an annual tender or consolidate district reports province-wide (PACs). However they forecast for OIs and lab supplies for their own facility’s account; this annual exercise does not amount to quantifying a wide range of ARVs to supply a whole province on a bimonthly basis. A minority of PACs (20%) do not perform even basic data quality assurance when aggregating quantification reports from their OPCs and methadone clinics. It will take time, local buy-in, monitoring, and close technical assistance to capacitate the provincial and (especially) district levels (e.g. in Ho Chi Minh City) in this special skill.

Procurement at Peripheral Levels

Sites that procure any commodity (i.e. NHTD, CPC1, a minority of provincial hospitals, and about half of all PACs) are all satisfied with the on-time delivery of drugs, whether self- procured (non-donor supported OIs) or provided free of charge by the HIV/AIDS program. Very few ARV stock outs occur, though treatment sites have reported unavailability of TB, OI and STD drugs that are not donor-supported. Following the pattern of sites that are involved in procurement (usually this involvement is limited to sending a wish list to the DOH), only some central hospitals, Da Nang Provincial Hospital, and less than half Provincial AIDS Centers follow a vendor pre-qualification process. From respondents’ comments, however, the “process” for pre-qualifying vendors appears to be informal and/or accidental (such as based

• n the history of past procurements, with previous vendors grandfathered into the pre-qualified

pool of suppliers). In terms of quality monitoring, a small minority of sites (N=14) have provided information. Of those who did, a large majority (79%) reported following written procedures to ensure product

• quality. These sites include 2 central hospitals, one-third of provincial hospitals, and less than

half the number of PACs. One-third of that majority is supported by NTP, 20% by CDC/LG, and half by PEPFAR. Insofar as the existence of a product quality complaint recording and reporting system, most of the sites that follow product quality assurance procedures also apply such a system, though one provincial hospital and one PAC do not. Sustainability

Essential Drug List Compliance

The roles of the National Essential Medicines List (EML) are to provide a basis upon which 1) physicians prescribe medicines for patients and 2) The Government procures medicines for its National Programs. Drugs on the EML are categorized as Level 1, 2, or 3 drugs, depending on the system level(s) at which they must be available. A level 1 (primary care level) drug must be available at all levels of the system while a level 3 drug such as Amphotericin B must be available in tertiary hospitals only. In Vietnam however, many essential medicines such as Zinc formulations and insulin for children are not on the National List, while the EML includes many medicines which are not truly essential, such as Radix Asparagi (asparagus). The EML is published as an appendix to a Circular as well as on the DAV website. The list is updated every 5 years and the DAV and WHO are currently working on the 8th version of the EML. All programs report fully complying with the Essential Drug List. Quang Nam and Lam Dong are the only provinces with low compliance while HCMC and Da Nang show some slight

14

• weaknesses. Weaknesses emerge in district hospitals and preventive health centers and in

military clinics. A plausible reason for this may be that, although HIV/AIDS sites showing low compliance on the EDL tend to be associated to a greater extent to facilities managing other commodities (OIs, VCTs, syringes, condoms, and TB drugs), these sites and staff are programmatically segregated from the rest of the hospital and exclusively use the HIV/AIDS Program-approved regimen list (see below). Although the rest of the hospital uses the EDL for

• ther drugs, the EDL is not used inside the OPC itself.

Indeed, two factors overshadow the importance of the EML. The first one is the existence of a separate list of approved HIV/AIDS treatment regimens. The second one is the existence of the Insurance Reimbursed Medicines List which is released by the Health Insurance unit of the MOH and is much longer than the EML. Medicines on the latter list are guaranteed (partial) reimbursement, which creates a strong incentive for dispensing sites to dedicate a majority of procurement and supply management resources towards buying and stocking these drugs, sometimes to the detriment of non-reimbursed medicines. The length and content of the Insurance-Reimbursed Medicines List are sources of concern. Vietnam Social Security (VSS), as an implementing body, has no influence over a medicine’s inclusion into or exclusion from the list. This decision is under the authority of another ministry, which doesn’t have to financially account for the consequences of its own decisions since the responsibility for reimbursing the cost of drugs falls under VSS. Over time, this moral hazard threatens the ability

• f the VSS to sustain the Health Insurance mechanism.

Most central and provincial sites reported all their drugs as included in the essential medicine list with the exception of CPC1, while almost all district level sites didn’t answer this question. This can be explained by the fact that staff interviewed in OPCs and MTD clinics at district level do not use the EDL in their work; they use the HIV/AIDS Program-approved regimen list instead.

Transportation & Distribution

Different types of commodities are delivered to sites in combined shipments in every province. At least half the sites in a minority of provinces reportedly need but do not have a sufficient number of vehicles to meet the distribution schedule. This situation happens most in connection with lab commodities but also to a lesser extent with ARVs. None of the sites pay a third party specifically for commodity transportation in any province, except some sites in HCMC, and mainly for methadone (for ARVS to a lesser extent). Unsurprisingly as a result, a very large majority of sites of all types are not aware that their HIV/AIDS commodities are supported by an external donor. Consequently none of them is contemplating alternative scenarios if donors gradually withdraw their transport and distribution support, hence the low scores on Financing and Transition Planning.

Quintessentially Central Level Functions: Quantification and Procurement

Quantification Guiding quantification for the nationwide demand from the central level makes sense for several reasons, foremost of which is the ability to align this function with two closely related

• thers: Procurement and Transport & Distribution.

The central level currently performs both the quantification for procurement and that for distribution planning (see “Mapping of the Supply System” section above). However this function is currently dependent on external partners and, in the context of the impending transition, the future institutional “home” of this function is a fair question. Quantification of ARVs and methadone is currently coordinated out of VAAC’s Care & Treatment, and Prevention & Harm Reduction divisions respectively. The quantification expertise in these

divisions is quite strong; however it is confined to a very small group of people aided by a larger group of experts spread across three outside partners. Given the ephemeral character of two of these partners over the middle term, this partnership is unsustainable and the recruitment

• f additional quantification staff within the VAAC is an urgent priority. Indeed quantification

is a specific skill that takes several years of practice to master and starting building this capacity now would dramatically increase the chances of a successful quantification transition. However such staff are hard to come by and at the time of writing there were no known plans to hire capable potential experts in this area of VAAC. Procurement Section “Procurement at peripheral levels” above describes the strengths and limitations of the HIV/AIDS system’s ability to procure at the provincial level. Procurement is limited to OI drugs and lab supplies from domestic providers or local representatives of foreign pharmaceutical companies. At the central level, the National Hospital of Tropical Diseases procures ARVs from domestic manufacturers on behalf of the National Targeted Program, but the budget is limited to about US$1million per year (about 4% of the demand by currently enrolled patients as expressed by the combined HIV/AIDS drug procurement budget of PEPFAR, the Global Fund, and the National Targeted Program) and covers only a small number of patients (2,382 patients)15. In addition, prices paid by the NTP are commonly 3 to 4 times higher than the prices paid by SCMS or VPP for the same generic drug.16 In the context of the donors’ impending transition, some of the questions raised involve the extent to which the GVN currently has the capacity to take on the responsibility for procuring from international markets on a scale far beyond what it is currently doing (a very limited extent, if any); and what is required for the GVN to build that capacity. The challenges ahead are multiple and various in nature. Following are a few of them:

• 1. Budgeting and sources of funding for commodity procurement
• 2. Legal framework in support of centralized commodity procurement
• 3. Institutional framework geared toward sustaining a centralized commodity

procurement mechanism

• 4. Technical capacity required for operating an effective and sustainable central

procurement mechanism

• 5. Technical capacity required for ensuring commodity quality assurance upstream and

downstream of the procurement phase. Conclusions The Vietnamese HIV/AIDS commodity supply chain currently exhibits average operational performance while its long-term sustainability is called into question. On the USAID|DELIVER Project’s Supply Chain Evolution Framework, it would likely place in the “Organized” stage (or “Qualified” maturity level in USAID/SCMS’ Capability Maturity Model Diagnostic Tool –CMM), where the system is formally in place and achieves its objectives, albeit inconsistently, at high cost, and with heavy external support. Overall the supply chain links involving Product Use and Essential Drug List Compliance

• perate very well: in summary, prescribing and dispensing practices are good and compliance

15 Source: VAAC, January 2012 16 Source: “Finance Mobilization in ARV Supply”, presentation by Dr. Hoang Thi Hien to the National

Assembly’s Committee 50 on AIDS, Drugs, and Prostitution, September 2012.

16 with the guidelines is high. In addition, the management system of supply chain information (LMIS) is in place -though it is squarely confined to inventory management- and is routinely used for decision-making –though this takes place only at the central level. Similarly, sites generally consider themselves well-equipped, well-staffed, and well-integrated into the broader health system. A matter of concern is the system’s ability to operate effectively. “Nuts-and-bolts” supply chain functions such as procurement, quantification, inventory control, and warehousing & storage

• perate on a basic level of domestic expertise. The main challenge resides in its capacity to

continue operating –at a meaningful performance level- over the middle term. The distribution

• f roughly 95% of ARVs and 100% of methadone to patients is currently dependent on the

local distributor contracted by foreign partners. The supply chain’s long-term planning, training and innovative and improvement capacities largely sit outside the system, residing with one donor-supported project17. It is unclear whether the decision-makers anticipate –or have a common position on addressing- the need in developing capacity within VAAC in supply chain management in order to better absorb the impact of departing donors. The sustainability of the whole supply system’s middle-term performance and longevity relies

• n the question whether a government-owned and -led plan exists or is being developed to

guarantee the continuity of supply chain operations for HIV/AIDS patients after donor

• withdrawal. Fortunately the latter has recently become a priority within the donors and some

VAAC departments. According to USAID’s Supply Chain Evolution Framework, the breakthrough for supply chain sustainability takes place at the “Integrated” level of the maturity model. At this stage the government, recognizing the strategic contribution of supply chain management in achieving its public health objectives, has raised the authority of a central logistics management unit (LMU) to coordinate the management of commodity supply chain activities across all departments, institutions and health levels of the program. The LMU is heading a clear drug management chain of command throughout the system whose objective is to save and improve patients’ lives by operating an effective, sustainable and agile supply chain. The GPD’s recent creation is a first step towards that situation, yet a critical one. RECOMMENDATIONS Among operational recommendations, formalizing some technical processes and procedures involving inventory management, safe waste disposal, a quality monitoring and complaint system, and expired product destruction into mandatory guidelines is an important one. Equally important is the introduction of an online user-friendly multi-commodity inventory management system to accomplish two main objectives. First, provide bottom-up visibility in the inventory status at every level of the system for efficient decision making. This would enable the few central level government staff in charge of supply planning to even out their work over the entire cycle and manage processes currently involving at least 10 external consultants at “crunch time” at the beginning of each month. The second main objective would be to enable drug management staff at site level to capture a couple of indicators on a regular basis to monitor and improve the site’s performance on key issues such as stock out rate, regimen-specific consumption trends and the like. This would at a minimum facilitate the

17 Five institutes have been formally mandated to provide MMT training, including MTD management, to this

program, while the 3 regional labs will assume similar national responsibilities for CD4 laboratories. However, supply chain management capacity building must be institutionalized in these bodies first. There is no similar nationally mandated institution for ARV management.

content of supervision visits. Being able to remotely monitor key indicators may even reduce their frequency over time, saving significant costs in a context of sustainability planning. The more challenging recommendations focus on ensuring long-term sustainability of a well- performing supply chain and are of a systemic nature. Supply chain management capacity building must be institutionalized within the government system. Great strides were made this year in that regard with the appointment of 2 specific institutions for strengthening the capacity

• f the methadone program and the appointment of 3 regional labs to do the same for the lab

system (though these 3 labs still need to be formally designated as “regional”). A similar mechanism must be put in place for supporting the ARV and other commodity supply chains. For ensuring supply chain sustainability, the visibility of supply chain management “activity” will have to be raised administratively to a separate department at the central level. The supply chain management function will have to consolidate all relevant commodities across the programs in order to achieve economies of scale and efficiency gains. As decisions will increasingly be made in function of affordability and feasibility -parameters that were initially secondary in a context of emergency relief plans- supply chain management personnel will have to be professionalized to perform these functions, or, if the government so chooses, to hold outsourced contractors technically, ethically and financially accountable. Ensuring the financial sustainability of HIV/AIDS prevention, care and treatment services is conditional to a central entity paying reasonable prices for costly medicines such as ARVs and

• methadone. To leverage those prices, the government will have to procure on the international

markets, most likely through a procurement agent with global reach. In order to prepare for a new environment, VAAC needs to reinforce routine operational linkages with all the government entities involved with paying for, importing and ensuring the quality of drugs, such as Drug Administration of Vietnam, Ministry of Finance, Vietnam Social Security and others. Especially the Vietnam Social Security as the co-payer for reimbursable drugs must acquire greater control over the criteria for inclusion of drugs in the reimbursable drug list. Failing this reform, bankruptcy seems inevitable over the long term. Reference 1- Anh Tuan Nguyen et al. Medicine Prices, Availability, and Affordability in Vietnam. Research Article, Southern Med Review Vol 2, Issue 2, Sep. 2009. 2- Decision No. 173/2008/QD-TTg of the Prime Minister Promulgating the Regulations

• n Applying the Necessary Measures for Meeting the ARV Demand in an Emergency,

Hanoi, December 25, 2008. 3- Decision No. 1202/QD-TTg of the Prime Minister on Approval of the National Targeted Program for HIV/AIDS Prevention and Control for 2012-2015. 4- Decision No. 1099/QD-BYT of the Minister of Health on Promulgating Regulation on Conditions for Implementation and Quality Management of the T-CD4 Cytometry Tests, Hanoi, April 4, 2013. 5- Decision No. 288/QD-BYT of the Minister of Health on Functions, Tasks, Authority, and Organizational Structure of the Vietnam Administration of HIV/AIDS Control under the Ministry of Health, Hanoi, January 25, 2013 6- Decision No. 4139/QD-BYT of the Minister of Health on the Modification and Supplement of Contents in “Guideline on HIV/AIDS Diagnosis and Treatment” Promulgated in Decision No. 3003/QD-BYT by the Minsiter of Health Dated August 19, 2009, Hanoi, November 2, 2011

18 7- Decision No 482/QD-BYT of the Minister of Health on Assigning Training Units the Task of Training on the Program of Opioid Addiction Treatment with Methadone, Hanoi, February 6, 2013. 8- Draft Decision by the Minister of Health Regarding the Issuance of Guidelines on antiretroviral (ARV) drugs supply management in HIV/AIDS prevention and control, Hanoi, May 30, 2012. 9- Health Strategy and Policy Institute, World Health Organization, and Drug Administration of Vietnam: Assessment of National Medicines Policy (1996-2010) Implementation, Draft Report, Hanoi, 2011 10- Health Insurance-covered Medicine List 11- Health Organization Office of the Representative in Vietnam. Medicine Prices: Policy Options for Vietnam. WHO Briefing with the National Assembly Committee on Social Affairs, Hanoi, Vietnam, 18 November 2010. 12- National Strategy on HIV/AIDS Prevention and Control to 2020 With a Vision to 2030. 13- National Plan of Action on Care, Support and Treatment for HIV infected People 14- Nguyen Van Thanh: Medicinal Production for HIV/AIDS Control Program, DAV PowerPoint presentation, No date. 15- Pollard, R.: An Assessment of the Total Market Approach for Condoms for HIV/AIDS, Population Services International (Vietnam) Consultancy Report, December 2010. 16- Supply Chain Management System. National Supply Assessment: Capability Maturity Model Diagnostic Tool (CMM) and National Supply Chain Key Performance Indicator

• Assessment. Submitted to the US Agency for International Development by the Supply

Chain Management System (SCMS), 2012. 17- Third Country Report on HIV/AIDS Prevention and control by UNAIDS 18- USAID|DELIVER PROJECT. Logistic System Assessment Tool (LSAT). Submitted to the US Agency for International Development by the USAID|DELIVER PROJECT, April 2009. 19- Vuong, T., et al. Drug Policy in Vietnam: A Decade of Change? International Journal

• f Drug Policy, 2011

20- Wehrens, Ron: The Provision of Harm Reduction Commodities in Vietnam, WHO Consultancy Report, March 2011 21- World Health Organization Office of the Representative in Vietnam. No date. Medicines Prices Make People Sicker and Poorer. 22- World Health Organization, Regional Office for South-East Asia: Access to Medicines, Briefing Note, January 2006.