All of the 22 primary health clinics in Shiselweni has a dispensary and a pharmacy storeroom. The stock comes mainly from Central Medical Stores (CMS) which is part of the Ministry of Health. The MoH expects clinics to stock between two and three month supply of medications.
On my count there are seven order forms that are sent to CMS on a monthly basis from each clinic. These are hardcopy forms as there is no automated pharmacy ordering system in Swaziland. The seven forms include medication orders for ARVs [antiretrovirals], PMTCT [prevention of mother to child transmission of HIV], TB [tuberculosis], family planning, general medications, vaccines, and the last form is for lab materials. There is a new form for 2nd line TB medications that will be initiated in Shiselweni soon. MSF supplies medications to the clinics on a monthly basis as well (thankfully we only have one order form) with the goal of filling the gaps in supply available from CMS. MSF has primary responsibility for supplying second-line TB drugs (working with the Green Light Committee) in Shiselweni.
In order to complete an order, the person (often a pharmacy staff member but in some cases a nurse) needs to calculate the Average Month Consumption using the information contained on stock cards, know the current stock level, and make the calculation on what amount is needed to ensure that the clinic holds no more than a three month supply. The order form for the anti-retroviral treatments also required information on the number of patients (adults and pediatrics) seen over the month, the number of new diagnoses, and the treatment regimens that the patients are on. Completing this form takes at least two hours (depending on the accuracy of the stock cards).
Between the clinics writing the orders and arrival at the warehouse, the orders are sent to the MoH Regional Office for validation with a stamp and signature. The when you look at the sheer number of forms, times they are handled, and stops on the journey to the warehouse, you find there are numerous opportunities for the orders to be misplaced and delayed. I am working with the MoH/CMS to see if we can streamline this process.
CMS operates two warehouses in Swaziland that are located in Matsapha, about 90km from Shiselweni. The work in the warehouse is overseen by pharmacy technicians and a focused distribution team that is ultimately led by one pharmacist. CMS supplies more than 190 facilities with Essential Medications. By my math that is 7 (order forms) x 190 (clinics) x 12 (months) which is nearly 16000 orders and I have no idea the number of medications that equates to!!