0

MINISTRY OF HEALTH AND SOCIAL WELFARE

Mapping of the
medicines procurement
and supply management
system in Tanzania






Ministry of Health and Social Welfare in collaboration
with:



1




2

MINISTRY OF HEALTH AND SOCIAL WELFARE
TANZANIA








MAPPING OF THE MEDICINES PROCUREMENT
AND SUPPLY MANAGEMENT SYSTEM IN
TANZANIA








2008



3

Published by the Ministry of Health and Social Welfare, Dar es salaam, Tanzania

2008 Ministry of Health and Social Welfare, Tanzania



Printed by:






Any part of this document may be reproduced in any form without the prior permission of the
publisher provided that this is not for profit and that due acknowledgement is given.
Any reproduction for profit must be made with the prior permission of the publisher






Copies may be obtained from:

The Permanent Secretary,
Ministry of Health and Social Welfare,
PO Box 9083, Dar es Salaam
Tel: 255 22 2120261
Fax: 255 22 2139951


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TABLE OF CONTENTS
ABBREVIATIONS..................................................................................................................6
ACKNOWLEDGMENTS.......................................................................................................9
EXECUTIVE SUMMARY ...................................................................................................11
1.0 INTRODUCTION.....................................................................................................13
1.1 Rationale of the study................................................................................................15
2.0 OBJECTIVES............................................................................................................17
3.0 METHODOLOGY.......................................................................................................18
3.1 Sampling....................................................................................................................18
3.2 Selecting the geographic area....................................................................................19
3.3 Approvals and authority to meet with Partners.........................................................19
3.4 Collection of Data .....................................................................................................20
3.5 Data processing, analysis and reporting:...................................................................20
3.6 Limitation of the study..............................................................................................21
4.0 RESULTS....................................................................................................................22
4.1 Map of the procurement and supply management system........................................22
4.2 Financial resources....................................................................................................25
4.3 Procurement of medicines.........................................................................................28
4.4 Forecasting and quantification ..................................................................................30
4.5 Partners and programs procurement policies.................................................................31
4.6 Coordination..............................................................................................................32
4.7 Agencies responsible for procurement ......................................................................32
4.8 Placement of orders & contract management ...........................................................33
4.9 Monitoring Supplier Performance.............................................................................34
4.10 Quality assurance...................................................................................................35
4.11 Stock Management (LMIS) ...................................................................................35
4.12 Support of other supply management activities ....................................................35
4.13 Storage and distribution.........................................................................................36
5.0 DISCUSSION...........................................................................................................37
5.1 Procurement of medicines.........................................................................................38
5.2 Quality Assurance .....................................................................................................39
6.0 RECOMMENDATIONS...........................................................................................40
7.0 ANNEXES ..................................................................................................................41


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LIST OF FIGURES
Figure 1 Map of medicines supply systems in Tanzania
Figure 2 Product category Vs No. of funders
Figure 3 Percentage expenditures by source
Figure 4 Procurement agents/implementing agents
Figure 5 Procurement Agents grouping
Figure 6 Monitoring performance of suppliers
Figure 7 First point of storage


LIST OF TABLES
Table 1 Development partners
Table 2 Product category Vs financial support given
Table 3 Procurement agents/implementing partners
Table 4 Types of Support Funds amount USD 000.00
2006 2007
















6

ABBREVIATIONS
AXIOS International Philanthropic Organization Donation
Program for Nevirapine, Determine HIV test kits and
Fluconazole
ABBOTT Abbott Fund A Philanthropic wing of Abbott
Laboratories USA
CCT Christian Council of Tanzania
CDC US Centers for Disease Control and prevention
CIDA Canadian International Development Agency
CHAI Clinton HIV/AIDS Initiative - William J. Clinton
Foundation
COLUMBIA Columbia University Mailman School of Public Health -
USA
CUAMM Collegues Universitaires Aspirants et Medecins
Missionnaires - Italian non-governmental health
organization
Crown Agents Procurement agent world wide
CRS Catholic Relief Services
CSSC Christian Social Services Commission
DANIDA Danish International Development Assistance
DELIVER DELIVER PROJECT collaborate with USAID to help
developing countries improve essential health commodity
supply chains
EGPAF Elizabeth Glaser Pediatric AIDS Foundation
GAVI Global Alliance for Vaccines and Immunization - GAVI
Alliance
GLOBAL FUND Global financial assistance for the fight against AIDS,
Tuberculosis and Malaria
HAVARD Harvard University - USA
IMA Interchurch Medical Assistance
JICA Japan International Cooperation Agency
JSI John Snow Inc (USA)

7

NORAD Norwegian Agency for Development Co-operation
OMS / WHO World Health Organization
PEPFAR President Bush's Emergency Plan for AIDS Relief
PFIZER Multinational Pharmaceutical Company Donates
Diflucan (Fluconazole)
SCMS Supply Chain Management System ( USA )
SIDA Swedish International Development Cooperation Agency
TEC Tanzania Episcopal Council (Roman Catholics)
TMAP Tanzania Multisectoral HIV/AIDS Project
UNICEF The United Nations Children's Fund
UNITAID International facility for the purchase of drugs against
HIV/AIDS, Malaria and Tuberculosis (Initiative of Air
France).
USAID United States Agency for International Development
WB World Bank
AIDS Acquired Immunodeficiency Syndrome
EM Essential Medicines
EML Essential Medicines List
ARVs Anti-Retrovirals
EPI Expanded Program on Immunization
GOT Government of Tanzania
FBHF Faith Based Health Facility
HF Health Facility
HIV Human Immunodeficiency Virus
ILS Integrated Logistics System
MOHSW Ministry of Health and Social Welfare
MSD Medical Stores Department
NACP National Aids Control Program
NGO Non-Governmental Organization
NMCP National Malaria Control Program
NTLP National Tuberculosis and Leprosy Program

8

NEMLIT National Essential Medicine List for Tanzania
OI Opportunistic Infection
PHLB Private Health Laboratory Board
PSU Pharmaceuticals Supplies Unit
STG Standard Treatment Guidelines
SRA Stringent Regulatory Authority
STI Sexually Transmitted Infections
SOP Standard Operating Procedures
TFDA Tanzania Food and Drugs Authority
US FDA Unites States of America Food and Drug Administration


9

ACKNOWLEDGMENTS
The Ministry of Health wishes to thank the World Health Organization
(WHO) whose financial support enabled the conduct of this survey. The
Ministry would like to acknowledge all people who contributed their time
and expertise to carry out this survey. In particular we would like to
mention the following: The Director for Hospital Services Ministry for
Health, Dr Z. Berege; The WHO Country Office Essential Medicines and
Medicine Policy National Professional Officer (EDM NPO), Ms Rose Shija
and the Chief Pharmacist, Mr Joseph Muhume.

The Ministry is grateful to all health workers in the surveyed departments,
sections and facilities for facilitating the data collection process, these
include Program Manager for NTLP, Dr. S. Egwaga; MSDs management
team members, Director of Pharmaceuticals and Technical Services, Ms.
L. Nderimo; Procurement Officer for Vertical Programs Mr. S. Samwel,
and Vertical Programs Manager, Mr. Msoma; also Program Administrator
at EPI head office, Ms. Jean Bomani; Logistics officer at NACP, Ms. Emma
L. Msuya; Logistics officer at the National Malaria Control Program, Mr.
Wina Shango for setting aside their time during interviews.

The Ministry is also grateful to all health care delivery partners involved in
this survey for their cooperation and time for interviews. The support
extended by the various supervisors and management team members of
these partners and individual staffs is highly appreciated.

The valuable work done by the data collectors who devoted their time and
commitment to collect the data for this survey is acknowledged. These
are Dr. R. S. Malele, Senior Lecturer, Faculty of Pharmacy, Muhimbili
University Collage of Health Sciences (MUCHS) and Mr. V. Manyirizu of
Department of Pharmacy, at Muhimbili National Hospital.


10

We thank the Software Engineer Mr. James Annan from Ministry of Health
Ghana/WHO AFRO for his support on the use of the data analysis software
as well as Mrs Helen Tata WHO/HQ for her technical input particularly in
the preparation of this document.

Finally, the Ministry of Health wishes to acknowledge the study
Coordinator Mr. Heri Mchunga for his role in this study.

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EXECUTIVE SUMMARY
This report describes a field study carried out in Tanzania mainland to
map the procurement and distribution of essential medicines and medical
supplies in both public and private not for profit sectors.

The mapping identified partners, government, donors, faith based
organizations, non-governmental organisations, private organisations,
and health facilities involved in the medicines supply chain systems. The
study looked into three parameters Financing, procurement and
distribution circuits.

Data was collected using a questionnaire tool that was developed by WHO
specific for this study. The study looked into the financial flows, processes
of selection of products, quantification / forecasting procedures and how
procurement is effected. Other areas verified in this study include quality
assurance systems, warehousing and storage, inventory management,
distribution, information management and human resource aspects.

All vertical disease programs under the ministry of health and social
welfare that are directly involved in the essential medicines supply chain
management were examined for their ordering processes, storage and
distribution management functions. The same was done to partners that
are directly or indirectly supporting or complementing the delivery of
healthcare services in Tanzania.

It was found that donors have varied and diverse interests in health care
service delivery programs. Most of bilateral donors, NGO, FBO and Private
partners are mainly targeting disease programs related to HIV/AIDS, this
is evidenced by the big numbers of this group of donors who are
supporting procurement of medicines, medical supplies and laboratory
reagents and test kits to fight against HIV/AIDS and related diseases. On
the other hand multilateral donors such Global Fund, GAVI, UNICEF,

12

World Bank are targeting enhancement of interventions against all major
endemic and epidemic diseases, HIV/AIDS, TB, Malaria, Measles, DPT etc

Whereas the Multilateral and Bilateral donors largely use the public
channel to procure and distribute their targeted donor products, most of
the NGO, FBO and Private partners do not follow public channels. At the
same time there is limited information sharing among this group of
partners.

13

1.0 INTRODUCTION
Pillars for medicines access include evidence based selection and rational
use, adequate resources (human and financial), affordable prices and
adequate and reliable Supply Systems.

The major challenge of National Medicines Policy is assuring an un-
interrupted supply of essential medicines that are efficacious and of good
quality, physically and financially accessible and used rationally. To attain
this objective, many countries have set up national essential medicines
supply systems, most of which consists of a Central Medical Stores and
distribution facilities from the central to regional and district levels.
Unfortunately, in some countries these national systems are unreliable
and do not ensure regular supply of essential medicines.

In Tanzania essential medicines in the public sector are mainly procured,
stored and distributed by the Medical Stores Department (MSD) an
autonomous department within the Ministry of Health and Social Welfare.
The increase of scope of activities within the past few years has seen an
increase in the number of partners involved in the procurement and
supply management of essential medicines, especially those for priority
diseases such as HIV/AIDS, TB and malaria. This increase in roles and
number of partners to service the health facilities have affected the way
the overall medicines supply system operates.

To-date several partners are involved in the medicine supply chain of
countries, these include Multilateral and Bilateral Donors, Non
Governmental Organizations, Faith Based Organizations and Private
Sector. Most have varied and diverse interest in health programs which
results into an uncoordinated multiple vertical supply chain arrangements,
wastage of scarce resources and inefficiency in supply system
management.


14

On a positive note, within the past decade, there have been increased
funds from these partners for medicines. However, most of the funding is
targeted to a small portion of the essential medicine list as they focus
mainly on a few disease programs. Also, unfortunately few of these put
enough funds for strengthening the procurement and supply management
system.

According to the Paris Declaration on Aid Effectiveness
1
, which many
countries have signed, the need for donors to align with country`s agenda
using its systems as well as for harmonization of their procedures is a
cornerstone for increased aid effectiveness. Adherences to the five
principles of aid effectiveness do not need to be over-emphasized as
illustrated below:













Against this background and with the aim of improving access to essential
medicines WHO is assisting 11 countries in the WHO African region
(Cameroon, Ethiopia, Nigeria, Tanzania, Kenya, Zambia, Senegal,
Rwanda, Mali, Uganda and the Republic of the Congo) for the mapping

1
The Paris Declaration on Aid effectiveness; 2005

D EVELOPMENT R ESULTS






M
a
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i
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g

f
o
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R
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s










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M
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A
c
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o
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a
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Ownership

(Partner countries)

Aligning with
country
agenda

Using
country
systems

Countries
set the
agenda


Alignment



Harmonization



Establishing

com mon

arrangements

Simplifying
procedures

Sharing
information

(Donor Partner)

(Donor Donor)

1

2

3

4 &5


15

and assessment of medicines supply systems and subsequently
addressing the gaps identified for the improvement of the systems.

1.1 Rationale of the study
Mapping of procurement and supply management system of essential
medicines and medical supplies in Tanzania is one of the two areas of
study that was identified by the Ministry of Health and Social Welfare
Tanzania and got support from the WHO for funding. The objective of this
study was to map carry out in-depth assessment of all the countrys
procurement and supply management systems and also the financial
flows for essential medicines and medical supplies and to develop a
strategy for strengthening the system.

The MOHSW in Tanzania carried out this study with the aim of assessing
the current situation with respect to access to essential medicines and
medical supplies in the country. Subsequently it aims at addressing the
gaps identified in order to improve the system.

It is envisaged that the map and data obtained can be used by both
partners and the Ministry to provide factual evidence for:
Knowing all those working in the medicines supply system within
the country
Mobilizing resources for under-financed product categories within
the national framework on health needs
Targeting gaps and redefining strategies for strengthening
medicines procurement systems
Providing information for program monitoring and future projects
Sharing information among partners to support planning for a
coordinated, coherent and efficient national medicines supply
system

16

To re-schedule procurement priorities, facilitate coordinated
forecasting and maintain an un-interrupted supply chain
To ensure full supply and security for all categories of essential
medicines.

17

2.0 OBJECTIVES
The general objective is to map the procurement and distribution
as well as the financial flows for essential medicines including
medicines for HIV/AIDS, TB, malaria, opportunistic infections,
contraceptives, vaccines, condoms, HIV/AIDS test kits, medical
devices and laboratory products

Use the results from this study together with those results from
another study (the in-depth assessment of all the country's
procurement and supply management systems and also
the financial flows for essential medicines and medical
supplies) conducted at same time, to develop a strategy for
strengthening the systems.

To develop a coordinated, coherent and efficient national
medicines supply plan or strategy.

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3.0 METHODOLOGY
In this study, data were collected using a questionnaire tool that was
developed by WHO specific for this study and was used in some other 10
African countries.

The study looked into the financial flows, processes of selection of
products, quantification / forecasting procedures and how procurement is
effected by various partners. Other areas verified in this study included
quality assurance systems, warehousing and storage, inventory
management, distribution, information management and human resource
aspects.

The mapping identified partners, government, donors, faith-based
organizations, nongovernmental organizations, private organizations, and
health facilities involved in the medicines supply systems.
All vertical disease programs under the ministry of health that are directly
involved in the essential medicines supply management system were
examined for their ordering processes, storage and distribution
management functions. The same was done to partners that are directly
or indirectly supporting or complementing the delivery of healthcare
services in Tanzania.

The data collected were entered into a database. This software produced
automatically a spreadsheet data and a schematic chart, which were
analyzed and interpreted to form this report. The results are presented by
examining the spread and involvement of the various partners in the
support of various healthcare delivery programs and services.

3.1 Sampling
A list of all partners in the country involved in the procurement and
distribution of essential medicines, including medicines for priority

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diseases such as HIV/AIDS, TB, malaria etc, was established. All the
partners on the list were included in the study.
Essential products used in the study included:
1. Essential Medicines
2. HIV/AIDS medicines
3. Medicines for opportunistic infections
4. STI drugs
5. Antimalarial
6. TB medicines
7. Pediatric formulations for HIV/AIDS and malaria
8. Vaccines
9. Contraceptives
10. Condoms
11. Medical supplies
12. Reagents for blood safety including HIV test

3.2 Selecting the geographic area
Dar es salaam which is the capital city of the country was selected. This is
because most of the partners or donors and the different Disease
Programme Managers have offices or representatives in Dar Es Salaam,
therefore were easily reached.

3.3 Approvals and authority to meet with Partners
The Ministry of Health issued an introduction letter to Partners requesting
them to provide the necessary information and data related to
procurement and supply of health commodities being provided by the
partners/donors.


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3.4 Collection of Data
Questionnaire No 1 was used to collect information from partners and also
from vertical disease programs (See appendix 1).

Appointments for interviews were made before the study started in some
instances, questionnaires were hand carried to the interviewee to be
completed and later picked up. In the event of missing or inadequate
information in this latter case, face to face interviews were organized to
clarify and validate information submitted.

3.5 Data processing, analysis and reporting:
A software developed by WHO, was used to capture the mapping data for
funding, procurement and distribution or goods delivery points. The study
team was trained on the use of this analysis tool from data entry to report
generation and interpretation. This was done in Accra- Ghana from 21
st

23
rd
August 2007. Two types of reports were automatically generated by
the software. One is a schematic presentation of the procurement and
distribution pathway for essential medicines, elaborated from information
collected. The second presentation is the spread sheet (Excel format)
containing all the input data. The spread sheet report was used to prepare
various graphs and figures to illustrate the results.

Illustrative tables were drawn for those study areas that were not
captured in the software, these include the following activities; selection
of products, forecasting and quantification, procurement work groups and
policies, contract managements activities, quality assurance, stock
management and capacity building in supply chain management.

All data were counterchecked against the original filled-in questionnaires
to ensure accuracy. During this exercise data entry errors were
corrected.

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3.6 Limitation of the study
The financing figures and funding flows of many partners could not be
captured since most of the interviewed officers / partners were reluctant
in providing their budgets. Some either needed some approval from their
abroad Principals or had limited access to the respective consolidated
budgets. Most of the financial information is said to be kept by Executive
Officers. Furthermore, it was not easy to determine the actual value of
in-kind donations as many invoices declare value for customs purposes
that do not reflect the true value of the donation.


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4.0 RESULTS
The results of this study will be presented under the following sub-
sections.
The Map of the procurement and supply management in Tanzania
Financial resources / funders
Procurement of medicines
i. Procurement of Essential medicines and supplies
ii. Procurement of Vertical Programs
iii. Selection of Products
iv. Selection of medicines for Vertical Programs
Forecasting and quantification
v. Forecasting and quantification for Vertical Programs
Partners and programs procurement policies
Coordination
Agencies responsible for procurement
Placement of orders & contract management
Monitoring supplier performance
Quality assurance
Stock Management (LMIS )
Financial resources for support of supply management activities
Storage and distribution

4.1 Map of the procurement and supply management system
Data obtained from the questionnaires after compilation and analysis
provided the following schematic drawing:


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Figure 1: Map of Medicines supply systems in Tanzania

Source
Of Funds
Procurement
Agent/Body
Point of 1
st
warehousing
Point of 2
nd
warehousing
MEDICAL STORE
Medicines supply systems in TANZANIA. 2007
PRIMARY HEALTH CARE FACILITY DISTRICT STORE
ZONAL MEDICAL STORE
ESSENTIAL
MEDICINES
ARVs MALARIA TB OI
ARVs
Ped
REAGENT
Blood safety
(+ HIV test)
VACCINES CONDOMS CONTRACEPTIVES
MEDICAL
SUPPLIES
REGIONAL/DISTRICT
VACCINE STORE
HEALTH FACILITY
GOVERNMENT
MULTILATERAL
DONOR
BILATERAL
DONOR
NGO/PRIVATE
AXIOS
TEC
&CCT
CRS IMA CUAMM HOSPITAL COLUMBIA HOSPITAL
TEC
&CCT
HEALTH FACILITY
HEALTH FACILITY
HOSPITAL
TEC
&CCT
ZONAL BLOOD
SAFETY CENTRE
Point of
Distribution
GOVERNMENT
W
B GLOBAL
FUND
S
I
D
A
P
E
P
F
A
R
U
S
A
I
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HOSPITAL
TEC
&
CCT
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CROWN
AGENTS
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United Republic of Tanzania
PATIENT

45

How to read the map

1. The first row of boxes in the map corresponds to the categories of
products studied and each category of product is designated by a
specific color.
2. The next row of boxes represent various partners supporting the
different categories of products and each partner is identified by a
specific color under the four main groups of donors (government,
bilateral, multilateral and NGO or private).
3. To inform on what categories of products each partner supports,
there are arrows from each partner to a category of product bearing
the color designated to the product category
4. The third row of boxes stand for the Agents which procure products
on behalf of financing partners
5. The last three but one row of boxes represent the various levels of
warehousing after the products have been procured by the
procurement agents.
6. The last box in pink is the final beneficiary of the products, the
patient.

NOTE:

MOH, MSD, MNH, Public HF in TZ, Public HF in Zanzibar (HF-
ZB)
: Global Fund, GAVI, UNICEF, WHO, World Bank
: USG (PEPFAR), USAID, USG (CDC), NORAD, JICA, CIDA,
SIDA, UNITAID
: CHAI, CUAMM, FHI, AXIOS, EGPAF
: CSSC, CRS, IMA, Faith Based Hospitals (FBH) under TEC and
CCT
ABBOTT, HAVARD, COLUMBIA, SCMS, CROWN AGENTS,
DELIVER
Government
Bilateral
NGO
FBO
Private
Multilateral

25

4.2 Financial resources
The study looked at 21 cooperating partners operating in Tanzania. Of
these, six are multilateral, eight bilateral, three NGO and four private
partners
Table 1: Development Partners

Types of Partners Partners
Multilateral Partners GLOBAL FUND
UNICEF
WB
GAVI
WHO
UNITAID
Bilateral Partners CIDA
CLINTON HIV AIDS INITIATIVE
JICA
NORAD
SIDA
USG - PEPFAR
USG - CDC
USAID,
NGO partners AXIOS DONATION PROGRAM
CSSC
CUAMM
Private Partners ABBOTT FUND
COLUMBIA UNIVERSITY
HAVARD UNIVERSITY
PFIZER DONATION PROGRAM

At the same time, the following programs of the MOHSW provided
information.
1 Safe Blood / Blood Transfusion
2 National TB& Leprosy
3 National Malaria Control
4 National Aids Control

26

5 Reproductive and Child Health
6 Extended Program on Immunization

4.2.1 Categories of products supported
The following figure shows the categories of products supported by the
partners in Tanzania.

Figure 2: Product category Vs No of funders



As can be seen support for laboratory reagents, HIV test kits ranked
number one followed by ARVs and Opportunistic Infections medicines.

4.2.2 Sources of funds
Essential medicines account for the greatest percentage of funds (21%)
even though they are supported by only three donors. HIV/AIDS
medicines account for 18% of funds and are supported by nine partners,
while Antimalarial and Vaccines account for 17% and are supported by
three. Reagents for blood safety are the category of product with more
donors (13) and receive 12% of funds. The other categories receive less
than 6% of funds.

27

Table 2: Product Categories Vs financial support given




















NB: Actual value of the directly donated goods was not wholly captured; the percentage
contribution by partners would have been significantly higher if the actual value of all
donated goods is captured).


When looking at expenditure by source, (see annex 2 for table of funding
by category and source) overall Government funding was over USD 166.6
Million (53%), followed by Global Fund amount USD 100.6 Million (32%)
and development partners contributed over USD 46.2 Million (15%).

Figure 3: Percentage expenditures by Source





Category of Product # Donors
Total
Expenditures 2006-
2007 ($)
Total
Expenditures 2006-
2007 (%)
Essential Medicines 3 $65,869,000 20.9%
Anti-retroviral HIV/AIDS
medicines
9 $56,853,000 18.0%
Antimalarial 3 $54,201,000 17.2%
TB medicines 2 $4,700,000 1.5%
Medicines for opportunistic
infections
7 $3,722,000 1.2%
Pediatric formulations for
HIV/AIDS and malaria
4
Vaccines 3 $17,300,000 5.5%
Contraceptives 2 $17,734,000 5.6%
Condoms 3 $3,905,000 1.2%
Medical supplies 5 $53,859,000 17.1%
Reagents for blood safety
including HIV test
13 $37,027,000 11.7%
TOTAL $315,170,000 100.0%
Expenditures by Source 2006-2007
Government
53%
Global Fund
32%
Development
Partners
15%
Government
Global Fund
Development Partners

28

4.3 Procurement of medicines

4.3.1 Procurement of essential medicines and supplies
The centralized procurement system is in place whereby the whole
requirements of all levels of health facilities in Tanzania are purchased by
a single agency, The Medical Stores Department. The MSD Tender Board
is in place and is the legal entity under Tanzania Public Procurement Act
2004 and Regulations 2005 that is empowered to advertise, receive,
evaluate and awards successful bidders. Price and quality of product are
given equal consideration when determining factor for awarding tender.

Public health facilities draw their requirements from MSD either through
their respective funds deposited at MSD direct by MOHSW or by direct
purchase using their own funds from other sources including government
basket funds.

4.3.2 Procurement of Vertical program items
These are mostly non MSD catalogue items (only about 5% are on MSD
list of products) and are procured only under special request by the
respective programs. MOHSW and the programs mobilize enough funds
from the government or development partners or both and deposit the
same to MSD which in turn advertise tenders. In some incidences
development partners donate direct goods to the programs. The study
showed that 75% of Multilateral donors such as Global Fund, WHO, WB
and 40% of Bilateral donors such as CIDA, SIDA, NORAD give financial
support to the government whereas the rest such as GAVI, UNICEF,
PEPFAR, USAID, CDC, CHAI, UNITAID, JICA prefer direct donation of
goods through their own procuring section eg GAVI, UNICEF, JICA or
international procuring agents such SCMS, DELIVER, JSI and Crown
Agents or through implementing partners such as CRS, IMA, Columbia
university, Harvard University, EGPAF, AXIOS and FHI. About 90% of
NGO and Private Partners such as CUAMM, CSSC and ABBOTT FUND

29

prefer direct donation of goods to beneficiary sites, whereas the rest such
as PFIZER prefer direct donation of goods but through the government
channels.

On the other hand the MOHSW utilize the technical expertise of some
multilateral partners to procure specialized goods. For instance vaccines
for EPI are solely procured by UNICEF under special arrangements.

4.3.3 Selection of the general essential medicines
In Tanzania selection of the essential medicines is done at the national
level by the National Medicine and Therapeutic Committee which has
the overall responsibility of making appropriate selection, supervising
adequate procurement and rational management and use of essential
medicines to public health facilities within the available budge limitation.
It ensures that only efficacious, safe, cost effective and good quality
medicines are used. The committee not only develops and guides
implementation of an efficient cost effective National Medicine Formularly
and Standard Treatment Guidelines (STG) but also develops and
publishes the National Essential Medicine List for Tanzania (NEMLIT). All
these three are periodically updated in order to address new diseases or
medical challenges that require new or alternative interventions and or
treatment protocols.

4.3.5 Selection of medicines for Vertical Programs
The various Vertical programs under MOHSW such as NACP (HIV/AIDS),
NTLP (TB and Leprosy), EPI (Vaccines), RCHS (Reproductive and Child
Health), NMCP (Malaria), BTS (safe blood) keep a list of medicines,
laboratory reagents and medical supplies appropriate to their programs
plan and need. This selection is done by the MOHSW in collaboration with
the program managers. Treatment protocols are developed and
implemented by the programs. National advisory sub-committee for the

30

respective programs are in place. These committees play great roles in
monitoring the performance of the programs. Program managers maintain
and regularly update list of their respective medicines and or medical
supplies.

The Survey showed that all programs adhere to the MOHSW selection
criteria

4.4 Forecasting and quantification
At MSD, procurement plans are based on requirement estimates derived
mathematically from the following data: (i) forecasts, (ii) stock on hands
at all levels of distribution system, (iii) previous procurement quantities
ordered or deliveries expected, (iv) losses expected to occur due to
damage or expiry, (v) direct donations from development partners (vi)
desired stock at the end of each planning period (including safety stocks
and working stocks at all levels). The estimated quantity of medicine
required in a successive planning period, usually an year, is calculated as:

Quantities required = (Stock on hand + Quantities already ordered +
direct donations expected from any other source - Estimated consumption
for the period - Losses - Desired stock at the end of period).

When the net supply requirement is a negative number, the quantity
equivalent to the integer must be obtained to maintain the desired stock
level. If the number is positive, there is a possible over supply of stock
and no order is required to be placed. Order deliveries are planned in a
staggered manner to enable not only proper utilization of warehouse
space but also enabling good cash flow by not holding unnecessary excess
stocks at any time.
The VEN (vital, essential and non-essential) analysis, therapeutic
category analysis and ABC analysis techniques are utilized at MSD to

31

select priorities and reduce the quantities of less cost-effective medicines.
Items pulled by primary healthcare facilities under the newly introduced
Integrated Logistics Systems (ILS) are another priority area.

4.4.1 Forecasting and quantification for Vertical programs
This is performed by all programs. It is however, conducted once each
year as the base for determining annual needs. Programs work closely
with partners (90%) to determine the quantities and generate a
procurement plan. JSI and SCMS have played a great role in forecasting
and quantification for ARVs, Laboratory reagents and HIV test kits, Anti-
malarials, Products for RCHS, Condoms, and safety syringes. On the other
hand EPI program manager works very closely to Regional and District
vaccine cold chain coordinators together with partners at UNICEF to
generate the annual procurement plan for vaccines.

4.5 Partners and programs procurement policies
It was noted that over 95% of programs and partners follow the
applicable policies in procuring of their respective medicines. Procurement
is limited to products on the EML, treatment protocol of the program,
made on the basis of plan and according to needs. Procurement is limited
to only those manufacturers and products that are WHO pre-qualified,
registered in the country of origin and also registered in Tanzania by
TFDA in case of medicines and PHLB for Laboratory reagents, HIV test
Kits and related test kits.

Procurement of medicines, reagents and related goods under financial
assistance from Global Fund follow the laid down policy of the fund.
Procurement is limited only to those goods that are pre-qualified by WHO
or other Stringent Regulatory Authority (SRA) included in the approved
list of the GF such as US FDA. Likewise procurement of goods using USG
fund follow the applicable USG procurement policy that prescribe the

32

eligibility of products source and applicable quality assurance conditions.
For example, only USFDA approved ARVs are to be procured using USG
funds. Approval has to be previously sought from the funding partners for
any deviation that is absolutely necessary.

4.6 Coordination
It was noted with satisfaction that there exist good collaboration between
the MOHSW, Vertical Programs and development partners. Over 88% of
partners collaborate with the government and participate in many guided
decisions include product selection, forecasting and quantification,
procurement planning, monitoring and evaluation. More than 75% of
partners prefer that there should be coordination mechanisms which meet
on qurterly basis, whereas the remaining prefer semesterial meetings.
Currently the co-ordination among partners especially in generating their
respective procurement plan is relatively low (68%).

4.7 Agencies responsible for procurement
A number of procurement agents are involved in procurement of
medicines and medical supplies for public health facilities. Goods procured
under government budget (including budget support by development
partners) were either procured through MOHSW ministerial tender board
(5%) or by Medical Stores Department (90%) or by Multilateral procuring
agent UNICEF (5%) for procurement of specialized product vaccines.
As earlier on indicated 75% of Multilateral donors and 40% of Bilateral
donors procure through the government channels (MSD), whereas the
rest use international procurement agents. Only 6% of NGO and private
donors use the service of MSD, remaining 40% use appointed agents and
54% procure on their own both delivering goods direct to beneficiary
health facilities.

Figure 4: Procurement agents / implementing partners

33



When grouped together the procurement agents it can be seen that
although MSD is the largest procurement agent representing about 14
partners including the government itself, however a significant number of
partners do not use it as seen in Figure below.

Figure 5: Procurement agents grouping



4.8 Placement of orders & contract management
The MOHSW ministerial tender board and MSD award contract to
successful bidders and initiate contract management activities for each
award. Whereas most of MOHSW tenders and awards are based on Lots,
at MSD, tenders and awards are on individual item basis. The later strives

34

to get the lowest or competitive price of individual items, where as the
former benefit on managing fewer contracts at a time. This practice has
enabled MSD to get prices of medicines and supplies at low rate than the
respective international price indicators
2
.

All programs funded by the government and budget support partners
place their orders through MSD (90%), MOHSW (5%) and through
UNICEF (5%).

4.9 Monitoring Supplier Performance
Only 20% of the surveyed partners have a formal procedure to monitor
supplier performance. MSD follow the PPA 2004 and Regulations 2005
which in one way or another provided the SOP for procurement of goods
using public fund. However the study has revealed that there are no
written down simple, clear and user friendly Standard operating
procedures (SOPs) in procurenmet in most agents. Despite this, a good
number of procurement agents 95% observed that goods are in
conformity to the order, delivery dates are respected 60%, storage
conditions on transit are adhered to 92%, but only 40% rapidly address
problems identified during procurement process.

Figure 6: Monitoring Performace of suppliers


2
MOHSW/WHO; Survey of the Medicine Prices in Tanzania, 2004

35

Monitoring Supplier Performance
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Goods in conformity
with order
Delivery dates
respected
Storage conditions
respected
Problems rapidly
addressed


4.10 Quality assurance
All procurement agents except MSD do not systematically take samples
from batches procured and send for quality analysis. Only few agents
30% include MSD keep track of batch records. MSD send samples to
appropriate quality control laboratory either TFDA 90%, Government
Chemistry Agency (GCA) 5%, and sometimes Tanzania Bureau of
Standards (TBS) 5% for analysis.

4.11 Stock Management (LMIS)
The survey revealed that all programs and partners have some kind of
special tools for stock management, Ledger or stock cards for inventory
control 92%, requisition forms 76%, discrepancy report 42%, expiry
products report 77%, computerization of inventory 80%. The inventory of
all vertical programs in the MOHSW is managed at MSD by the oracle
based Orion system.

4.12 Support of other supply management activities
Many partners set aside budget allocation for support of medicines supply
management activities these include capacity building in supply chain
management (60%), computerization of inventory control (50%), quality
control of products (10%), and test results (70%), warehousing and

36

storage 60% (mainly GF), medicines and medical supply distribution
(82%).

4.13 Storage and distribution
The schematic presentation of the map of the procurement and supply
management system in Figure 1 above explains how the medicines and
supplies are handled right from procurement, warehousing, first, second
and third delivery points.
About 61% of partners use MSD as first point of warehousing, 29% use
their own storage facilities and 10% send products directly to the health
facilities.

Figure 7: First Point of storage
First Point of storage
61%
10%
29%
MSD
Health Facility
Partner Store

With regards to distribution of products, for the vertical programs this is
carried out by MSD in accordance with the schedules provided by the
programs.

Private/NGOs/FBOs and some developmental partners procure and
distribute medicines and medical supplies directly to beneficiary health
facilities. Only few partners use MSDs distribution circuit.


37

5.0 DISCUSSION
From the schematic presentation of the map of the procurement and
supply management system it is obvious that the government of Tanzania
has a number of Partners supporting the pharmaceutical sector; from
multilaterals to NGOs. These support the government in its aim of
implementing the national medicine policy goal which aims at providing
accessible, equitable and quality pharmaceutical services to all
Tanzanians. They also support the government in its quest to achieving
the millennium development goals and other disease elimination targets.

The map also shows that Partners have varied and diverse interests in
health programs. However support from the majority of the partners was
limited to a few products of the NEMLIT leaving the country to handle the
rest of the medicines for the disease problems affecting the majority of
the population. It was found that most of bilateral donors, NGO, FBO and
Private partners mainly targeted disease programs related to HIV/AIDS;
this is evidenced by the big numbers of this group of donors who are
supporting procurement of medicines, medical supplies and laboratory
reagents or test kits to fight against HIV/AIDS and related diseases. On
the other hand multilateral donors such Global Fund, GAVI, UNICEF
targeted enhancement of interventions against all major endemic and
epidemic diseases, HIV/AIDS, TB, Malaria and vaccines.

When looking at the product category versus financial support, essential
medicines constituted only 21% of the total expenditure of
pharmaceuticals compared to medicines for vertical programmes. With
such a significant share of pharmaceutical resources tied up in a few
vertical programs, this distorts the budget ceilings with under-funding for
medicines and supplies for other major health problems in the country.

The survey also showed that the Government of Tanzania provides the
largest share of funds for the procurement of medicines and other

38

supplies ie 53%. Although the government is still the biggest source of
funds for health interventions, the contribution of the development
partners is quite significant, without which the situation would have not
been the same as it is now. However a better coordination is missing.

Direct donation (in table in annex 3 indicated as in kind) is gradually
replaced by the budget support to the government, which then define the
necessary priorities and funding needs in close collaboration with the
development partners. One can recognize a wide spectrum of funding
partners with a large variation in approach, way of working, demands and
operations. Multilateral and some of Bilateral Donors prefer budget
support to the government. Many of Bilateral Donors however prefer
direct donations through international procurement agents and or
implementing partners. NGO and private partners prefer direct donation
to health facilities by themselves or through implementing partners.
5.1 Procurement of medicines
In this survey it was observed that MSD procures for almost all
Government funds, Global fund, some of bilateral donors, FBOs and
NGOs. On good technical reasons the government contracted UNICEF as a
procurement agent for all vaccines and related supplies. Few private
partners sporadically use MSD as a procurement agent. Some bilateral
donors such as USG (PEPFAR), USAID, and UNITAID, World Bank use
procurement agents of their own choice with limited information sharing
among partners. Similarly, most NGOs, FBOs and Private Partners have
their own procurement system and also in most cases there is very
limited information sharing among this group of partners and MoH.
Therefore there is a significant portion of medicines and supplies
bypassing the Medical Store department which is the body mandated to
procure and distribute medicines in Tanzania. Qualitative feedback from
survey respondents and health system workers indicate that this makes
supply management and quality control even more difficult. Also with

39

such different procurement systems in Tanzania there is no one
comprehensive procurement plan for the medicines and supplies
requirements in the country making it difficult to do proper forecasting.

On a good note, the global fund used the Government existing systems
for cash flow, procurement and distribution of medicines and medical
supplies exemplifying an excellent government-partner alignment and
harmonization according to the Paris declaration. Some partners also
allocated funds for capacity building of some health workers. However,
strengthening the medicines supply system may not be fully achieved
through capacity building alone.
5.2 Quality Assurance
The quality assurance begins with product selection; procurement policy,
and also the quality control of receivables. It has been noted with a
concern that most partners rely much on the procurement policy and give
little weight to the quality control of the received medicines. Apart from
visual inspection a regular analysis of the batch representative samples is
a good practice to ensure bioequivalence, efficacy and effectiveness of the
product. Survey results showing that all procurement agents except MSD
do not systematically take samples from batches procured and send for
quality analysis to the in-country quality control laboratories raise a
concern.

40

6.0 RECOMMENDATIONS

1. Move towards reducing Donor direct funding to budget support to the
government need to be addressed

2. Improving access to Strategic Public Health supplies is a priority,
where principle determinants in product sourcing and availability,
pricing, procurement and supply management, need to be addressed.

3. A mechanism that links technical cooperation in procurement and
supply management with broader concept of enhancing availability of
essential medicines and medical supply need to be put in place.

4. Challenges in coordinating management of financing from separate
channels, supplier participation in procurement processes, stock
management and distribution, as well as the technical support that has
been received from international donors and agencies need to be
addressed.

5. Procurement planning for HIV/AIDS commodities is a critical
component of the scale-up process in Tanzania, that requires an
intense and coordinated effort at the national level to collect and
process data, estimate needs, execute tenders and product orders,
receive and distribute product. The need to initiate planning to ensure
the sustainability of processes once the Global Fund and other
development partners financing is no longer available is mandatory.

6. Training in forecasting and quantification for HIV/AIDS related
commodities is a priority together with proper inventory management
leading to availability and accuracy of raw data.

7. Emphasis is made that there is a need to develop a coordinated,
coherent and efficient national medicines supply strategy.

41

7.0 ANNEXES
Annex 1: Questionnaire for the Mapping of the PSM
Country: __________________________________________
Name of Partner/Donor: ___________________________
Person Interviewed:
Position:
Address:
Tel:
Fax
Email:

1. Which of the following program components are being supported by this organization
in procurement and supply management of medicines and medical supplies.
For each program component, please state year when this support started and when it
is foreseen to end.

Program components Yes No Starting Year Year foreseen
to end Support
Essential Drug Program
HIV/AIDS
Malaria
TB
STI
OIs
Family Planning
EIP
Blood safety
Laboratory
Others (specify)

2. What type of support is involved?
a. Financial Yes No
b. Technical Yes No
c. Others (specify) Yes No

If the support is financial, please answer the question below:

3. Which of the following applies to the funds provided to procurement of products by
this Partner?
a. Loan Yes No

42

b. Grant Yes No
c. Donation Yes No

4. List in the table below the amount spent in 2006 and budget allocation in 2007
for the procurement of medicines and supplies in each product category
Specify the main products financed in each program component.


Program
component
Amount
Spent in 2006
Products
supported
in 2006
Amount
Spent in
2007
Products
supported in
2007
Essential Medicines
HIV/AIDS
Malaria
TB
STI
OIs
Family Planning
EIP
Blood safety
Laboratory
Other (specify)

If there are different focal persons in this organization managing different program
components please complete one questionnaire for each program component.
In this case, also provide the following information:
Name of program component supported:
Name of focal person in the organization:
Name of person interviewed:


5. The products to be procured in each program components are selected by:

a The Donor Agent Yes No
b The Ministry of Health Yes No
c The Program Manager Yes No
d Others (please specify) Yes No

6. Who is responsible for the quantification of needs

a. The Donor Agent Yes No
b The Ministry of Health Yes No
c The Program Manager Yes No
d Others (please specify) Yes No

7. Which of the following criteria is considered for procurement of medicines and
medical supplies:


43

a Procurements are limited to products on the EML Yes No
b. Procurements are made on the basis of a plan Yes No
c. Procurements are made according to needs Yes No

8. Do you belong to a working group in the country that coordinates procurement
activities? Yes No
If yes, which of the following leads this working group?
a. Ministry of Health Yes No
b. UNICEF Yes No
c. World Bank Yes No
d. WHO Yes No
e. UNDP Yes No
f. Others(Please specify)__________________________
9. How often does this working group meet?
Monthly Yes No
Quarterly Yes No
2 times a year Yes No
Yearly Yes No
Others (Please specify)__________________________________

10. Which Agency is responsible for the procurement (preparing tender and awarding
contract) of products financed by this partner?
a. Ministry of Health Yes No
b. Central Medical Store Yes No
c. Privately contracted Agent Yes No
d. The organization itself Yes No
e. Others (Please specify) Yes No

11. Does this partner have a specific policy for the procurement of essential medicines
and medical supplies? Yes No
12. If yes, Which of the following criteria are considered in procuring products?
a. WHO prequalified suppliers and products Yes No
b. Products registered in a country whose DRA is
ICB/ICP compliant Yes No
c. Products registered in the country of use Yes No
d. Others (Please specify)

13. Who is responsible in making an order for products financed by this partner?
a. Ministry of Health Yes No
b. A procurement agent (UNICEF etc) Yes No
c. World Bank Yes No
d. The Partner Yes No

44

e. The CMS Yes No
f. Others(Please specify)__________________________

14. Which are the suppliers contracted by the Partner and the total value of procurement in
US$ for each category of products from the various suppliers mentioned in the table below in
2006:

Source of Procurement
Category of Products
Internationa
l supplier
US$

International
manufacture
r
US$
Local
Distribut
or
US$
Local
Manufactur
er
US$
Others
Specify
US$
Essential Medicines
HIV/AIDS medicines
Antimalarials
TB medicines
Medicines for
opportunistic
infections

Pediatric formulations
for HIV/AIDS and
malaria

Vaccines
Contraceptives
Condoms
Medical supplies
Reagents for blood
safety including HIV
test kits


15. Which of the following criteria are used to monitor supplier performance?
a. Products received conform to what was ordered Yes No
Comments..
b . Delivery deadlines are respected Yes No
Comments
c. Storage conditions during transportation are respected Yes No
Comments.
d. Rapidly address problems identified during procurement Yes No
Comments.
e. Others (Please specify)____________________________________
If yes, provide copy of SOP for procurement


45

16. Are samples systematically taken from batches procured and sent for quality analysis?
Yes No

17. If yes, to which of the following laboratories are the samples sent?:

a. National Quality Control Laboratory (NQCL) Yes No
b. Regional Quality Control Laboratory (RQCL) Yes No
c. Laboratory in Donor country (LDC) Yes No
d. Others (please specify) (0) Yes No

18. Has the Partner provided special tools to manage the following:
a. Daily dispensing Yes No
b. Delivery/receipt of products Yes No
c. Discrepancy report Yes No
d. Expired products Yes No
e. Inventory Control Yes No
f. Issue Voucher Yes No
g. Requisition form Yes No
h. Stock card Yes No
i. Others (Please specify)

19. Which of the following structures is responsible for the distribution of products
procured by this Partner?
a. Ministry of Health Yes No
b. Central Medical Store Yes No
c. Privately contracted Agent Yes No
d. The Partner itself Yes No
e. Others (Please specify) Yes No

20. Does the procurement plan consider some budget allocation for the following activity
areas?:

No Activity area Yes No If Yes,
Budget in
(US$)
Comments
a Medicines & medical supplies
distribution

b Warehousing and storage
c Remuneration for warehousing staff
d Staff development for supply chain

46

management
e Computerization of inventory

21. First Delivery Point: Indicate against each product category in the table
below which of the following is the first point of delivery after procurement?

a Central Medical Stores
b. Regional Stores
c. District Stores
d. Health facility
e. Others (Please specify)


















22. Second Delivery Point: Indicate against each product category in the table below
which of the following is the second point of delivery after procurement?

a Central Medical Stores
b. Regional Stores
c. District Stores
d. Health facility
e. Others (Please specify)


Product category First Point of delivery
Essential
Medicines

HIV/AIDS
medicines

Malaria Medicines
TB medicines
STI Medicines
Contraceptives
Condoms
Blood safety
reagents

Laboratory
reagents

Other (Please
Specify)

Product category Second Point of delivery
Essential
Medicines

HIV/AIDS
medicines

Malaria Medicines
TB medicines
STI Medicines
Contraceptives
Condons
Blood safety
reagents

Laboratory
reagents

Other (Please

47









23 Third Delivery Point: Indicate against each product category in the table below which of
the following is the third point of delivery after procurement?

a Central Medical Stores
b. Regional Stores
c. District Stores
d. Health facility
e. Others (Please specify)









Specify)

Product category Third Point of delivery
Essential
Medicines

HIV/AIDS
medicines

Malaria Medicines
TB medicines
STI Medicines
Contraceptives
Condons
Blood safety
reagents

Laboratory
reagents

Other (Please
Specify)



45

Annex 2: Types of Support Funds amount USD 000.00 For 2006 2007
Essential
medicines
(EM)

(MSD)
Essential
medical
supplies
(MSD)
National Aids
Control Program
(NACP)
National
Blood
Transfusion
(Safe
blood)
National
Malaria
Control
Program
(NMCP)
Extended
Program
on
Immuniz
ation
(EPI)
National
TB &
Leprosy
Program
(NLTP)

Reproductive and Child
Health Section
(RCHS)

Medicines Medical
Supplies
ARVs OI STI Lab
Reagents/
HIV test
kits
Condo
ms
HIV
/Hepatitis
test kits
Anti
Malarial
(ACT)
Vaccines Anti TB
&
Leprosy

medicine
s
Contracep
tives
Condom
1
GOVERNMENT
OF TANZANIA
65,831 53,859 16,484 Include
d in EM
Include
d in EM
Included in
EM
Include
d in EM
17,300 450 12,700
2 GLOBAL FUND 22,380 3,707 12,940 3,219 54,201 4,250
3
USG PEPFAR/
JSI/SCMS

In kind
7,540
in kind

4 USG - CDC In kind In kind
5
USAID/DELIVE
R/JSI
3170 In kind 5,034
in kind
686
In kind
6
UNITAID/
CLINTON HIV
AIDS
INITIATIVE
9,450
In kind

7 JICA In kind In kind
8 SIDA 5,125 15 9,888
9 CIDA 4,045
10 NORAD 1,279

1

11 UNICEF In kind
12 WB/TMAP In kind
13 GAVI In kind
14 WHO 38
16 ABBOTT FUND In kind In kind 1,300
17 PFIZER In kind
18 AXIOS
DONATION
PROGRAM
In kind In kind 376 +
in kind

19 CSSC In kind In kind In kind
20 COLUMBIA In kind In kind
21 HAVARD In kind In kind
22 CUAMM In kind In kind In kind


TOTAL
65,869 53,859 +
in kind
56,853
+
in
kind
3,722 +
in kind
EML +
in kind
37,027+
in kind
3,219 EML +
in kind
54,201 17,300 +
in kind
4,700 17,734 686 +
in kind