Swaziland

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Background

The rates of TB, HIV, and AIDS in Swaziland are among the highest in the world. The HIV prevalence rate among 15 to 49 year olds in 2015 was 28.8%, and 80% of TB patients were co-infected with HIV (2014). The Government of Swaziland adopted a decentralization strategy to expand HIV treatment and care services, including the accreditation of private health facilities for the provision of antiretroviral therapy (ART). The scaled-up provision of antiretrovirals (ARVs) has put enormous pressure on the country’s pharmaceutical services, health sector budget, supply chain system, and human resources. Prior to SIAPS, stock-outs of key essential medicines, including ARVs, were common and human capacity was a serious obstacle exacerbated by the lack of training facilities for pharmacists and pharmacy technicians.

SIAPS started work in Swaziland in 2011 as a follow on to the Strengthening Pharmaceutical Systems program. Through SIAPS, USAID provided USD 5.5 million to Swaziland to support pharmaceutical system strengthening over a five-year period.

Selected Activities

SIAPS’ goal in Swaziland was to ensure the availability of quality pharmaceutical products and effective pharmaceutical services to achieve desired health outcomes for HIV/TB care and treatment. SIAPS interventions aimed to strengthen governance in the pharmaceutical sector, increase capacity for pharmaceutical supply management and services, address information for decision making, and improve pharmaceutical service delivery. In collaboration with the MOH, donors, and implementing partners, interventions were designed and implemented as guided by Government of Swaziland health sector policy and strategic documents.

Strengthening the Medicine Regulatory System: The legislation regulating medicines, pharmaceutical establishments, and the pharmacy profession in Swaziland was outdated and ineffective. SIAPS reviewed the national pharmaceutical policy and legislation to develop two bills to establish the first-ever medicines regulatory authority (MRA) and the pharmacy council. SIAPS facilitated the development of the 2012–2016 Pharmaceutical Strategic Plan to provide strategic direction for strengthening the pharmaceutical sector in Swaziland. SIAPS also supported the MOH to develop an implementation plan for the MRA and guidelines for registering importers and donating medicines.

Human and Institutional Capacity Development: The shortage of qualified pharmacy personnel was a major limitation in the country’s efforts to expand HIV/AIDS and TB treatment programs. SIAPS supported the development of pharmaceutical workforce training programs to meet the demands of HIV/AIDS and TB management. It also supported the MOH and other stakeholders to design the curriculum for the first pharmacy training program in Swaziland. Southern Africa Nazarene University (SANU) established a Department of Pharmacy and launched programs for pharmacy assistants and technicians. SIAPS also trained 1,148 service providers on pharmaceutical management.

Managing Information Systems for Better Patient Care: There was limited organizational and human resource capacity to implement a logistic management information system (LMIS) to ensure an uninterrupted supply chain for ARVs. SIAPS worked with in-country partners to revamp the LMIS and improving the use of RxSolution and other electronic tools for inventory and patient management. Paper-based LMIS tools were redesigned and harmonized and a central data management unit (DMU) was established to oversee the LMIS implementation. An electronic LMIS was developed and rolled out to central warehouses and selected laboratory facilities. Supply chain and performance monitoring decisions were made based on LMIS data from the DMU.

Increasing the Availability of Medicines: The rapid scale-up of HIV and TB treatment programs exposed weaknesses related to procurement and supply chain systems, indicated by frequent stock-outs of essential medicines. SIAPS supported the MOH to establish the Supply Chain Technical Working Group (TWG) to facilitate planning, procurement, and distribution to avoid both over- and under-stocking of key commodities. TWG members and MOH technical officers were trained on quantification principles, processes, methodologies, and key quantification tools. SIAPS also provided on-the-job mentoring and support during quantification exercises to further build the capacity of local stakeholders.

Improving Patient Safety and Treatment: To improve patient safety and promote adherence to HIV/TB treatment, SIAPS assisted the MOH to design interventions to address adverse drug reactions. SIAPS mobilized stakeholders from the Swaziland National AIDS Programme and the National Tuberculosis Control Program to implement the Sentinel Site-based Active Surveillance System for Antiretroviral and Anti-TB Treatment Program. This program was launched in 2013 at eight hospitals. SIAPS developed protocols and tools for the system, trained implementers, conducted supervision visits, and disseminated data.

Results

Figure 1. Products listed in the database (December 2016) [Click to enlarge]

Pharmaceutical Regulation Strengthened: The Medicines and Related Substances Control Bill was signed into law in October 2016. The MOH can now register medicines and medicine importers and manage a National Drug Regulatory Authority. Swaziland has developed a database of medicine importers and the more than 6,000 products they import (figure 1). The medicine database enables the MOH to compile an audit of all medicines currently available in the market place and start the registration process.

 

Celebrating the graduation of the first cohort of pharmacy technicians at SANU with the Minister of Health, Hon. Senator Sibongile Ndlela-Simelane (in mortar board). [Click to enlarge]

Increased Local Capacity to Train Pharmacy Personnel: With this new cadre of pharmacy workers entering the workforce, Swaziland has made progress in meeting its human resource needs to deliver high-quality pharmaceutical care and services. Due to increasing demand, the certificate program was upgraded to a pharmacy degree in 2014. In July 2014, SANU graduated the first cohort of students with a certificate of pharmacy. By September 2016, 145 students had entered the program.

 

Improved the Availability of Data for Decision Making: The revised tools have increased the health facility-level reporting rate from 56% in 2012 to 97% in 2014. By using LMIS data to resupply ARVs, 100% of facility orders have been fulfilled and stock-outs of tracer ARVs were eliminated. Each quarter, procurement decisions are made using LMIS data. This saved the government more than USD 6 million in unnecessary procurement. The forecasting and supply planning exercises help to inform stakeholders of imminent stock-outs, shortages, expiries, and overstock.

Fewer Stock-outs: As a result of coordination and better quantification systems and processes, the stock-out rate for tracer commodities decreased from 50% to 0% at the central warehouse and from 23% to 0% at health facilities from December 2011 to September 2014.

The Minister of Health, Hon. Benedict Xaba, and Dr. S. Dlamini-Nqeketo of the World Health Organization launch the standard treatment guidelines/essential medicines list in 2012 (photo courtesy of Swaziland country office). [Click to enlarge]

Improved Patient Safety: Data from the active surveillance system help monitor medicine safety and enabled data-driven decision making. From June 2013 to September 30, 2016, 4,210 patients were enrolled in the system and 1,224 adverse drug events (ADEs) were reported. Of the enrolled patients, 76% were taking ARVs and 24% were taking anti-TB medicines. However, 58% of the ADEs were from patients on TB medicines and 42% were from those on ARVs. The most prevalent ADEs were gastrointestinal effects and peripheral neuropathy (17%), followed by central nervous system effects (11%).

Project Legacy 

Through advocacy and technical support, SIAPS played a crucial role in establishing the MRA, which will facilitate access to safe, effective, and quality medicines for the people of Swaziland. With the new cadre of pharmacy workers entering the workforce, Swaziland has taken an important step toward meeting its human resources needs to deliver high-quality pharmaceutical care and services. SIAPS has enhanced coordination and information flow to reduce stock-outs, which has resulted in better health outcomes for ART patients and put the country on course to achieving the AIDS-Free Generation goals.

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