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10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
Thanks to our generous sponsors
ManagingFreeSupplyofQualityMedicinesandHealthProductsinRajasthanStateinIndiawithITsupportof
e-Aushadhi Software
NirmalGurbaniProfessor(PharmaceuticalManagement)
IIHMRUniversityJAIPUR(India)
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
AccessandAffordability
• AccesstohealthstandsasfundamentaltohumanrightsunderUNcharter
• InIndia,healthspendingbytheStateisverylow(nearly1%oftheGDP)
• 79%ofPop.spendonhealthisout-of-pocketwithmajorspendingbeingcostofmedicinalproducts
• Almost30%ofthehouseholdsslideintopovertyduetohightreatmentcosts
• Itisimperativethataccessandaffordabilitytoqualityessentialmedicinesandhealthproductsdirectlyaffectsthehealth
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
INDIA’S PHARMA INDUSTRY • “Pharmacyofthedevelopingworld”• 3rd in(10%inglobalsales)termsofvolumeand14th (1.5%)
intermsofvalue• ItisamongthetopFiveproducersofbulkdrugsinthe
world• AfterUSA(169),IndiahasthehighestnumberofUSFDA
approved(>500)plantsand>1200plantsWHO/GMP• TotalSale>USD25b(nearlyhalfisexports)• CAGRover11%.Despite“PharmacyoftheGlobalSouth”,Accesstomedicinesisstillelusiveforcommonman
KeyBarrierstoAccesstoMedicines
1. Grossinadequacyofgovernmentspendingonhealthcare2. Inefficientprocurementsystems3. Inefficientmedicinedistributionmechanism4. Unaffordablemarketprices5. Poorregulatorycontrolandhugepricevariationinoff-
patentbrandedgenerics,makestheaffordabilityatthemercyofmanufacturers,prescribers,anddispensers
6. Irrationalprescriptionanduseofmedicines7. Tiltofmarketmainlytowardsbrandeddrugs
Basically,costofproducingessentialmedicinesandhealthproductsarenothigh,but,aremadeexpensivebytheindustrytoencouragepromotion
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
India:ACountryofCountries
• InIndia,33federalstates/Unionterritoriesareruledbydifferentelectedpoliticalparties- DiversityinPoliticalpartiesstands
• Healthisunderconcurrentlist(CentralaswellasStatesubject)ofIndianConstitution
• Thereby,bothCentralandStateGovts.managehealth• MajorexpectationsarefromStategovernmentsas
implementationagenciesatgrassrootlevels• Oftenlackofconsensusonmajorissuesofnationalinterest• Policyparalysisandadhocdecisionsonpolitical
considerations/favoritism,etc.10th Global Health Supply Chain Summit, Accra (Ghana); Nov
15-17, 2017
Rajasthan,aWesternStateadjoiningPakistanInitiative:ToReachUnreached
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
RajasthanLargest StatePop. > 70 m
Mumbai
New Delhi
Chennai
Bangalore
AccesstoQualityMedicinesandHealthProductsInitiativeinRajasthan
MUKHYAMANTRI NIHSHULK DAVA YOJNA (MNDY)(Chief Minister’s Free Drug Distribution)
• accessibilitytohealthservicesforall• toreduceout-of-pocketexpenditure• entitledeveryonetoreceivefreemedicinesandhealthproductsfromanygovernmenthealthfacility
• toreachunreachable(unabletoaffordtreatment)• RajasthanMedicalServiceCorporation(RMSC)wasconstitutedforfreedistributionofdrugstoallpatientsvisitinggovernmenthealthfacilitiesthough17648DrugDistributionCentres (DDCs)
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
A LEAP FORWARD 2nd October 2011 Enhancing RUM andACCESS TO MEDICINES & HEALTH PRODUCT IN RAJASTHAN
Through CHIEF MINISTER’S FREE MEDICINE SCHEME
COMPONENTS OF FREE MEDICINES SCHEMEA. TO MAKE DRUGS AVAILABLE IN
GOVT. HOSPITALS.B. TO CHANGE PRESCRIPTION
BEHAVIOUR OF DOCTORS/HP
1. Establishment of autonomous centralized procurement agency :Rajasthan Medical Services Corporation
1. Sensitization and orientation about rational use of drugs (RUD)
2. Identification of drugs for free essential drug list (EDL)
2. Write prescription on self carbonated prescription slips
3. Procurement through a two-bid transparent e-tendering process
3. Diagnosis must be written
4. Drug Warehouse at every district 4. Write Generic / Salt names5. Empanelled laboratories for quality testing 5. Use out of Essential Drug List 6. System for transportation of drugs 6. Follow Standard Treatment Guidelines
7. System for storage and distribution of drugs in all hospitals
7. Constitution of Drug and Therapeutics Committee (DTC)
8. e-Aushadhi Software for Inventory management
8. Prescription Audit
9. Transparent and prompt payment system 9. Computerized drug dispensing up to PHCs
10. Sufficient funds 10. Patient counselling
AddressingQualityApprehensionsofDoctorsonGenerics
• Thedrugsarenotequivalenttothereferentialbrandmedicationsinqualityandfunctioning
• Thedrugshavepoorefficiencyincomparisontobrandedcounterparts
• Thegenericmedicationsarecostliercomparedtobrandeddrugs
• Shiftingtogenericscanevokeundesiredconsequencesandimpairthecondition
• GenericsarelowpricedbecauseoftheirlowqualityMythswereclearedinthesensitizationprogram
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
Contract Manufacturing
(turnover 1000 cr.)is manufacturing for
TorrentZydus Cadila
IndocoIPCA
Micro Labs
MankindLupin
AbbottWockhardtPiramal Healthcare
SunCiplaRMSC
Sanofi Aventis
Intas
InstitutionsCovered(Medical&Health/MedicalEducationDepartment)
S. No. Type of Institutions No. of Institutions1 Medical College Hospitals 28
2 District hospitals 36
3 Satellite Hospitals 8
4 Sub-Divisional Hospitals 16
5 CHCs 567
6 PHCs 2133
7 Dispensaries 194
8 Sub Centers 14407
9 Aid Posts 13
10 MCWC 118
11 Mobile surgical units 7Around 17648 DDCs in total
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
EDL - Provision of Medicines/Surgical and Sutures
CategoryofHealthcareInstitutions
Based on Level of Care
Medicines SurgicalItems Sutures Total
MedicalCollegeHospitals 601 73 77 751
District/Sub-dist/SatelliteHospitals 521 69 37 627
CHCs 446 51 11 508PHCs/Dispensaries 237 34 2 273SubCenters 29 8 0 37
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
AdvantagesofGenericProcurement
SN Name of the Medicine Packsize
RMSCProcurePrice Rs.
DPCO2013CeilingPrice Rs
MRPs of Selected brands Rs
(ApproxRs65=1$)
1 Cetirizine Tablets 10 mg 10x10 10.43 153 Alerid160.60, Zyncet160.70
2 Cefixime Tablets 100 mg 10x 10 119.71 826 Zifi530, TaximO866.403 Cefixime Tabs 200 mg 10x 10 221.8 1208 Ziprax 890.40
4 Diclofenac Sod Tabs 50 mg 10x10 14.11 182 Dicloran219.5,Reactin225.7
5 Ofloxacin Tabs 200 mg 10x10 82.7 526 Oflox551.5, Zenflox412.8
7 Ceftriaxone Injection 1 g 1 Vial 11.86 47.95 Monocef 50.348 Amlodipine 5 mg Tablets 10x10 9.82 233 Amlogard244.67, Amtas
244.67, Amlopress244.679 Clopidogrel Tablets 75
mg10x10 53.84 644 Plavix676.14, Deplatt 504,
Clopivas478.810 Glibenclamide Tab 5 mg 10x10 11.52 103 Daonil 108.7
AdvantagesofGenericProcurement
SN Name of the Medicine Packsize
RMSCProcurePrice Rs.
DPCO2013CeilingPrice Rs
MRPs of Selected brands Rs
(Approx Rs 65 = 1 $)
11 Domperidone Tablets 10mg
10x10 12.97 224 Domstal235.2, DomDT235.2,Domperi 252.29,
12 Alprazolam Tabs 0.5 mg 10x10 12.94 216 Anxit 226.8, Alprax255.5
13 Losartan Tablets 50 mg 10x10 35.52 462 Losar484.2,Losacar 498.1
14 Azithromycin Tablets500 mg
10x3x3 371.79 1604.7 Azithral 1872,Aziwok1867,Zathrin1870
15 Enalapril Tablets 5 mg 10x10 16.15 297 Envas310,Enam 311
16 Atorvastatin Tabs 10 mg 10x10 25.6 509 Atorva534.5, Atorec534
17 Paclitaxel 260 mg Inj 43.4 ml 637.70 8987.27 Mitotax958818 Imatinib Tablets 400 mg 10x10 1729 21332 Imatib 30242, Veenat 20270
,Zealata 29123
19 Glimepiride 2 mg 10x10 11.67 529 Amaryl555.47
Unique Features of Scheme in RajasthanUsing Educational, Managerial and Regulatory Interventions
1. PolicyentitlementmakingitUniversalinnature2. IssuanceofGovernmentOrdersforprescriptionbygenericname3. Settingupofuniqueinfrastructureathealthcareinstitutions4. SensitizationandOrientationoftheprescribers5. ConstitutionofDTCsforPrescriptionAudits6. AppointmentandTrainingofPharmacistsandInformatics
Assistants7. EffectiveComplaintandFeedbacksystem8. DrugMonitoringthroughnotavailable(NA)drugreportingsystem9. SMSbaseddailymonitoringandfeedbacksystem10.“Nearexpiry” and“dangerzone” drugsmonitoring11.SlowmovingandExcesssupplydrugmanagement12.InventoryManagementthroughe-Aushadhiapplication
e-AushadhiAn Advanced Drug Warehouse Inventory Management Software
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
NeedofITApplication?
• It is a huge logistic exercise to order, receive, store, quarantine,send for quality check, receive quality clearance- Issue 816 Medicines and Health Products.- 17648 healthcare institutions (depending on level of care) forissuance to approximately 250,000 patients every day
• The challenges of supplying so many products to so many facilitiesfor so many patients could only be handled by “COMPUTER”
•To address this requirement an IT based online advance DrugInventory Management Application was developed by CDAC forproviding complete supply chain management solution for themedicines and health products through “e-Aushadhi” Application•URL : http://www.eaushadhi.rajasthan.gov.in
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
Resources- HR
• Resources at IT CELL, RMSC HQ1. AGM IT - 12. Software Engineers from CDAC - 43. Informatics Assistants - 4
Resources at DDWs and Healthcare institutions- 3121 Informatics Assistants- Placed at DDWs/MCDWs/Hospital stores/DDCsfor data entry in the e-Aushadhi application
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
Whatise-Aushadhi?
A web based application which deals with the following:ü Complete SCM Solution for drugs, surgical items and suturesü Provides detailed information from the stage of procurement of products to its
consumption by the end usersü Provides inventory management at all DDWs and at sub stores / DDCs of
Medical college hospitals, District Hospitals, CHCs and PHCsü The application has modules useful for day to day activities like
- Demand Generation- Purchase Order generation- Challan (Delivery note) Process- Quality Control- Inter warehouse transfer- Supplier Payment- Monitoring Reports for better tracking the stock position of supplies, providereplenishments of supplies as and when required and take strategic decisions.
ü It is a complete solution providing transparency in the process of procurement,supply and distribution of supplies
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
e-Aushadhi hasbeenimplementedat4305(includingDDCs)locationsacrossthestateofRajasthan.
e-Aushadhi
e-Aushadhi Users
39 Drug Warehouses 2255
PHCs & Disp. Inc.
DDCs
RMSCHQ
1 DDC
35 MCHs
298 DDCs
57 DH, SDH & SHs
300 DDCs
555CHCs
766 DDCs
Stakeholders
e-Aushadhi
Head Quarter• RC & PO Processes • Inter DDW Drug Transfer.• Budget Allocation & Supplier Payment
P&C, MS, CMHO, PMO
• All Report access.• Demand Approval Desk
District Drug Warehouses
• Challan Process • Sample Send to QC Cell.• Issue to Hospital store.• Drug Transfer to other DDWs
Empanelled LAB
• Sample Receiving• Sample Test Result Entering and uploading
Report
Suppliers• PO Report with consignee• Supplier Interface Desk & Drug Delivery
StatusDirector PH,PS Med. Edu.
• All Report Access & Demand Approval
Internal Auditor
• Inward and Outward value Reports ,• PO Value Reports etc.
Autonomous centralized procurement agency.ESTABLISHMENT OF RAJASTHAN MEDICAL SERVICES
CORPORATION (RMSC)Procurement Cell
Finance Cell
Logistic Cell
Quality Control Cell
Supply Cell
IT Cell
Equipment Procurement & Maintenance Cell
Sample sent to HQ for Quality assurance Approval from HQ
Laboratory
Annual demand received from M&H Dept. and ME Dept
Contract signed b/w Suppliers and HQ
A purchase order is generated for DDWH as consignee
Drug is
ready for
Issue
RMSC Work Flow ……….
Drugs distributed to patients
Work Flow……….(cont’d)
Indent for Issue
Receive after approval
DHSDHCHCPHCMedical CollegeOthers
Drugs Issued to DDC
Processes of e-Aushadhi
• BudgetProcessing• DemandProcess• RateContractDesk• Purchase Order Generation• Challan (Delivery Note) Process• Quality Control• Payment to Supplier and Penalty Check
q Expired itemsq Broken itemsq Accepted itemsq Ordered items etc. based on which automatic amount calculated willbe paid to the supplier.
• Inter Ware House Transfer• Role Based Access (unique usernames and passwords)
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
Howe-Aushadhihelps?
Abilitytodefinethedrugsintogroups,subgroups,Categories,CodificationOnlineAnnualDemandgenerationfromHospitalstore
(MC/DH/SDH/SH/CHC/PHCandDispensaries),OnlineCompilationofthatdemandfromDistrictlevelandStateLevel
ReportreadilyavailableforthestockpositionReportreadilyavailableforPreviousconsumptionrecordsTrackexpirydate/shelflifeforthedrugsReorderlevelfeaturealertsImprovedInventoryManagementEasy Access to Information
Ø storage location of drugsØ real time list of expired itemsØ status of pending purchase ordersØ inward/outward recordsØ Quality control reports on drugsØ handling of Quarantine drugs andØ maintenance of current stock positions
Users How e-Aushadhi helps ?
Head Office (Supply)
1. Generate online Purchase Order to make availability of drugs at all DDWs.2. Generate drug Transfer Orders according to the Short/Excess request
of DDWs3. Generates Alert If Quantity of an item reaches below a critical level in
DDW.(Action Taken Report to ensure availability of Drugs at all Districts)
District Drug Warehouse
1. Give the feedback of purchase Order to HQ before issue to supplier.2. Receive the Drugs from Supplier through challan Process3. Send sample to RMSC Quality Control cell for quality check.4. Issue the Drugs to Hospital stores against their indents.5. Assess the quantity to be managed before expiry date according to their
consumption (Stock available based on Ideal Consumption)6. Generate online excess and short request, and• Excess /Short (Report) Detail Report Warehouse wise• Transfer Excess /Short Request Detail Report Drug wise• Transfer Approval Detail Report by HQ & Transfer Detail Report for DDW• Approved but not Transferred & Transferred but not acknowledged.7. Physical Drug Locator (Floor & Rack Wise )and shifting of Drugs Report
Supply Management
Users How e-Aushadhi helps ?
Hospital stores
(MC,DH,SH,SDH,PHC,CHC
,Disp. Etc)
1. Generate the Indents to DDW and receive the Drugs from DDW2. Issue the Drugs to DDC Counters against their Indents3. Return the unusable Drugs to DDW4. View the Stock of DDW ,Hospital store and their DDCs at a
glance through DDW Hospital store DDC Stock Detail Reporta. View the stock of particular Drug at all the hospital stores of aDistrictb. View available Drugs at DDW but not in HospitalStore.(Hospital store Not Available Drugs)
Process for substore
Drug Distribution
Counter (DDC)
1. Generate the Indents to Hospital store and receive the Drugsfrom Hospital store.
2. Issue the Drugs to Patients
All Users can view Stock on Hand Report and Near Expiry Detail Report up to DDC Level
Supply Management
Drug Quality Status
Warehouses
Return to
Supplier
Hide batch no, company name etc.
Quality Control Laboratory
Drug Samples
Test Result
PassRelease to Hospital Stores
Fail
Quality Status
1 2
34
5
Quality Control – Work Flow
MajorActivitiesthrougheAushidhi
• QualityControlManagement• FinanceandSupplierpayments• CapturingPurchaseandIssuedetails• SupplierPerformanceDetailedReport• StateLevelMonitoringofDrug/ProductStatusatall
DDWs/DDCs/SS• Productsgoingtoexpirein180days• SystemSuggestedDistrict-wisePurchaseOrderQuantity• EnsuringAvailabilitytoeliminatestockouts• Non-availability(NA)HitsAlerts/Reports• IndentedandIssueDetails
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
GenerationofMajorRepotsØ Current Stock Reports for Warehouse, Hospital store, DDCsØ Stock Ledger ReportØ DDW, Hospital store, DDC Stock Details, including those available at DDW but
not at Hospital StoresØ Material Inward Register and Outward Register Reports (Finance)Ø Daily Activity ReportØ Near Expiry Detail ReportØ Purchase Order Register ReportØ Challan (Delivery Note)/Receipt Register ReportØ Issue Register ReportØ Budget Detail ReportØ Drug Transfer Detail ReportØ NA Hits report etc.Ø ABC and FSN Analysis and ReportØ Stock Available based on Ideal ConsumptionØ Action taken report to ensure availability of drugs
“NotAvailable(NAHit)” ProductReportingSystem
NAHitReport:- Everytransactionofdrugissuedtopatientsisrecordedine-Aushadhi,informationonprescriptionlikename,age,sex,diagnosis,name&quantityofdrugs,duration
etcarerecordedinthesoftware.Duringthisnotavailable“NA” drugsarealsorecorded
TheSupplyCellmonitortheseNAreportsdailyandcoordinatebetweenDDW,Sub-storeandDDCstomakedrugavailablefromDDWtosub-store
thantoDDCaswellassuppliertoexpeditethesuppliesifinpipelineorissueafreshpurchaseorderifrequired
“Nearexpiry” &“Dangerzone” drugsmonitoring
The tracking of near expiry medicines is one of the best outcomes ofonline inventory management system. The supply cell of corporationmonitors and intimates Medical Superintendents, PMOs, CMHOs andOIC DDWs about the near expiry and danger zone drugs by monthlyreports so that the drugs may be consumed within their shelf lifeperiod
Near expiry drugs are arbitrarily classified into two major categories:
Near expiry drugs: The drugs which are about to expire within next180 days (6 months)
Danger zone drugs: The drugs which are about to expire within next60 days (2 months)
Slowmoving/ExcesssupplyproductsandShortsupplydrug/productmanagement
Slowmoving(Excessdrugs): ThestockofthedrugatDDWexceedstherequirementforthenextoneyear.(morethanannualconsumption)
ShifttoanotherDDWor
“Sensitizedoctorsforconsumptionoftheexcess/slowmovingdrugs
Shortdrugs:Thestockwhichisnotsufficientfor4monthsatDDWkeepinginviewtheestimateddemandofthatdrugfor4months(lessthanbufferstock)
ShiftfromanotherDDWor
Sensitizedoctorsforthealternativeprescriptionor
“Notavailablecertificate” issuedbyDDWtotherespectivehospitalssothatshortdrugsmadeavailablethroughLocalPurchase(10%additionalbudget
allottedtoeachinstitutesforlocalpurchase)
EffectiveComplaint&Feedbacksystem
24x7complaintandenquirycell
•Toresolvethecomplaintrelatedtoavailabilityofdrugs
•Totakenecessaryactionaccordingtofeedbackfrompeoples
91 66 00 55 00
Regular SMS to various users for important activities
“Vivek Pharma for
PONo.F.(14)/OSD/2014/1
32 Date: 18/12/2014 ,
Ciprofloxacin Tablets only
60% has been supplied.
Provide supply schedule
with in 3 days and supply
immediately to avoid
penal action.”
Suppliers(Delaysupply)
“Dear Dr. Naval
Kishore Gupta, 1
Drug(s) are going to
Expire in 6 Months in
your District Drug
Ware House”
DPC(NearExpiry)
“PONo.F.(14)/OSD/201
4/155 Dated : 25-Dec-
2014 For Supplier :
Biogenetic Drugs Pvt
Ltd Jaipur has been
generated today.”
Supplier,DPC/DDWPharmacist
(POGenerated)
“Dear Dr. Naval
Kishore Gupta, 9
Drug(s) Samples are not
send to RMSC for QC
Check from your
District Drug Ware
House”
DPC (delay sample)
SMS based daily monitoring & feedback system
After OPD hours daily about 7500govt. doctors of the state receivethe SMS everyday which containsthe number of patient he/she hasattended and number ofavailable/not available drugs fromthe prescription. Likewise eachDPC, CMHO, PMO, MS, PrincipalMedical College receives messageregularly about number ofpatients served, NA Hits, NearExpiry drugs etc.
Teams frommanyStateGovernmentshavevisitedRMSC– HQ,Jaipurtoseetheeffectivenessandworkingofe-AushadhiApplication.
Implemented [ 13States] Under MoU Signing stage [5 States]
Not Implemented [ 11 States]
UnderNationWideRollOut
1. Maharashtra2. Punjab3. Orissa4. AndhraPradesh&Telangana5. Gujarat6. MadhyaPradesh7. CMSS(CentreMedicalSupplyServices,NewDelhi)8. Jammu&Kashmir9. Jharkhand10. Bihar11. Uttaranchal12. Manipur13. DamanandDiu14. DadraandNagarHaveli
Discussionsunderway withfollowing States–1. UttarPradesh2. Chhattisgarh3. HimachalPradesh4. Assam5. Meghalaya
e-Aushadhi- Replication
•NHSSPNationalHealthSectorSupportProgramByMinistryofHealthNepal•UNFPA• WHO&PHFITeam• USAID• Deloitte,Delhi• NorthKoreaTeamofGovt.Officials• Nepal– CentreforLabourandSocialStudies•BPPI,Gurgaon•UnitedMultipurposeClub,Assam,Guwahati• Group-B Officers of Central Secretariat Services from Institute ofSecretariat Training and Management, Department of Personnel &Training, GOI
TeamsfromvariousOrganizations/CountriesvisitedRMSCHQ
e-GovernanceAward
RMSCwasawardedthee-Governanceawardfore-Aushadhiapplicationon12th Feb2013in16th Nationale-GovernanceConference
Conclusions
Utilizationoftheavailableappropriateandaccuratepricinginformationsupportedby
• technicalexpertise• strongpoliticalwill/supportand• clearadministrativeandrobustITsupportapproachescoupledwithpropereducational,managerialandregulatoryinterventions cansuccessfullybringapositivechangetowards
ENHANCINGAFFORDABLEACCESSTOQUALITYMEDICINESTOWARDUNIVERSALACCESSTOHEALTH
10th Global Health Supply Chain Summit, Accra (Ghana); Nov 15-17, 2017
Allpeopleshouldget
Safeand
Effectivemedicines
ALONGWAYTO
GO…tofillthe
InformationGap
THANKYOUforyourinterest
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