STOCK LEVEL SURVEY. Prepared For: MINISTRY OF HEALTH, GOVERNMENT OF CAMBODIA. Prepared By: THE REPRODUCTIVE AND CHILD HEALTH ALLIANCE (RACHA)

STOCK LEVEL SURVEY 1998 A SURVEY OF STOCK LEVELS, DISPENSED QUANTITIES AND STORE MANAGEMENT/CONDITIONS AT HEALTH CENTERS AND REFERRAL HOSPITALS OF THE MINISTRY OF HEALTH OF CAMBODIA Prepared For: MINISTRY OF HEALTH, GOVERNMENT OF CAMBODIA Prepared By: THE REPRODUCTIVE AND CHILD HEALTH ALLIANCE (RACHA) June 1998

ACKNOWLEDGMENTS The Reproductive and Child Health Alliance (RACHA) conducted and published the results of this 1998 Stock Level Survey in collaboration with the Ministry of Health, Government of Cambodia. RACHA is a partnership of three US-based organizations selected by United States Agency for International Development (USAID), including the Association for Voluntary and Safe Contraception (AVSC), the USAID-financed Service Expansion and Technical Support (SEATS) project, and the USAID-financed Basic Support for Institutionalizing Child Survival (BASICS) project. RACHA was created in 1997 to assist the USAID in the implementation of its Maternal and Child Health (MCH) Strategy in Cambodia. Part of this strategy calls on RACHA to provide assistance to the Ministry of Health (MOH) to improve consumer access to pharmaceuticals and commodities. The 1998 stock level survey was performed in support of this activity. This report summarizes the results of the aforementioned stock level survey. The survey was undertaken during March and April 1998. Data were collected by three teams of surveyors, each consisting of one representative from RACHA and one from the Essential Drugs Bureau (EDB), Department of Drugs, Food, Medical Materials and Cosmetics of the MOH. A survey supervisor was employed to coordinate the activities of the survey teams, process the collected data, and assist in the writing of this report. The names of the survey supervisor and surveyors follow: Mr. William L. Scott (supervisor) Mr. Khieu Sochea Ly (MOH surveyor) Mr. Kim Saroeun (MOH surveyor) Mr. Tep Keila (MOH surveyor) Mr. Moob Harch (RACHA surveyor) Mr. Pel Chann Dan (RACHA surveyor) Mr. Sin Kosal (RACHA surveyor) Mr. Heng Heang (RACHA surveyor alternate) RACHA would like to express its heartfelt thanks to Mr. Scott and the surveyors for their work in making this survey a success. RACHA would also like to thank Mr. Chroeng Sokhan, Chief of EDB, for his cooperation in this activity and his review of the draft report. Finally, RACHA would like to thank the hundreds of MOH staff who gave their time and energy in assistance to the surveyors.

TABLE OF CONTENTS Page SUMMARY i SECTION ONE: INTRODUCTION 1 1.1 Background 1 1.2 Objectives 1 SECTION TWO: METHODOLOGY 2 2.1 Sample Size and Survey Methods 2 2.2 Selection of Commodities to Survey 3 2.3 Classification of Sites 4 2.4 Problems Faced During Survey 4 2.5 Notes Regarding Tables and Charts 5 SECTION THREE: FINDINGS AND ANALYSIS 7 3.1 Stock Status of Commodities by Category 7 3.1.1 Examination of Stocked-out Facilities 7 3.1.2 Examination of Nearly Stocked-out Facilities 7 3.1.3 Examination of Facilities Maintaining Excessive Stock 8 3.2 Stock Status of Commodities by Item 8 3.2.1 Examination of Stocked-out and Nearly Stocked-out Facilities 8 3.2.2 Examination of Facilities Maintaining Excessive Stock 9 3.3 Usable Versus Unusable Stock of Commodities 9 3.4 Pharmacy Storage Conditions 9 3.5 Location of Commodities 10 3.6 Contraceptive Method Mix 11 TABLES 12 CHARTS 18 APPENDIX A: APPENDIX B: APPENDIX C: LIST OF SITES SURVEYED SAMPLES OF SURVEY FORMS AND TALLY SHEETS SURVEY DATA

LIST OF ABBREVIATIONS AIDS : Acquired Immune Deficiency Syndrome CMS : Central Medical Store CYP : Couple Year Protection IUD : Intra-Uterine Device MCH : Maternal Child Health MOH : Ministry of Health MOS : Months of Stock OC : Oral Contraceptive ORS : Oral Rehydration Salts RACHA : Reproductive and Child Health Alliance UNDP : United Nations Development Programme

SUMMARY Stock-outs of nine widely-used oral medicines are low at Ministry of Health health centers and referral hospitals. On average, only 7 percent of these facilities are stockedout of one or more of the surveyed oral medicines [i.e. Amoxycilline (), Cotrimoxazole (100+20mg), Cotrimoxazole (400+80mg), Metronidazole (), Multivitamins, ORS, Paracetamol (100mg), Paracetamol (500mg), P.M. Penicilline ()]. Stock-outs of four widely-used injectable medicines/perfusions and five contraceptives are moderately high. On average, 16 percent of health centers and referral hospitals are stocked-out of one or more of the surveyed injectable medicines/perfusions [i.e. Ampicilline (500mg), Penicillin G IM/IV (1 Mui), Dextrose 10% (500ml), Dextrose 5% (500ml)], and 11 percent are stocked-out of one or more of the surveyed contraceptives [i.e. Condom, Depoprovera (150mg/ml), IUD CT380A, Progesterone (.075mg) OC, Progestrone (.15mg)+Oestradiol (.03mg) OC]. Many health centers and referral hospitals are nearly stocked-out of the eighteen surveyed essential drugs and contraceptives [i.e. are resupplied every three months but have less than 1.5 months of stock]. On average, 17 percent are nearing stock-out of one or more of the surveyed oral medicines and injectable medicines/perfusions, while 25 percent are nearing stock-out of one or more of the surveyed contraceptives. Many of these sites could experience a stock-out of these items prior to re-supply. A large percentage of health centers and referral hospitals maintain excessive stock of the eighteen surveyed essential drugs and contraceptives [i.e. the stock on hand exceeds that which can be used prior to expiration]. On average, 12 percent possess excessive amounts of one or more of the surveyed oral medicines; 17 percent have excessive amounts of one or more of the surveyed injectable medicines/perfusions; and 21 percent have excessive amounts of one or more of the surveyed contraceptives. Unless action is taken to relocate the excess stock, some or all of it could expire prior to usage. Ninety Eight percent of the stock of the eighteen surveyed essential drugs and contraceptives at health centers and referral hospitals is usable. On average, less than 2 percent of the stock of the surveyed items is unusable due to expiration, damage or other reasons. Eighty Seven percent of health centers and referral hospitals have a dedicated room for storing commodities (i.e. a pharmacy). However, in many cases the room is too small to adequately store the required commodities. Also, 100 percent possess some racks and or cabinets in which to store commodities and 97 percent have some form of ventilation in the area used for storage. Finally, the method mix for contraceptive use in the public sector birth spacing program is 71 percent Depoprovera, 18 percent oral contraceptive, 8 percent IUD, and 3 percent condom. i

SECTION ONE INTRODUCTION 1.1 Background The Cambodian Ministry of Health (MOH) operates a distribution system for delivering bulk amounts of essential drugs and contraceptives to their facilities throughout the country. Facilities include Health Centers, Former District Hospitals (scaling down to become Health Centers), and Referral Hospitals. Information regarding the actual level of stock of essential drugs and contraceptives maintained in these facilities is uncertain. Thus, the goal of this survey was to determine the actual amount of essential drugs and contraceptives located in these facilities and to determine whether these amounts meet the monthly distribution demands 1.2 Objectives The objectives of the survey were the following: To collect data at each surveyed facility on the (1) current stock of 18 essential drugs and contraceptives and (2) dispensed amounts of these items over the most recent three-month period. To obtain information on storage conditions and store management practices at the surveyed facilities. To determine the existence and type of stock transaction and reporting instruments that are in use. To report on the (1) observed stock levels of the 18 surveyed items, (2) storage conditions and store management practices, and (3) the contraceptive method mix prevailing at health centers and referral hospitals. 1

SECTION TWO METHODOLOGY 2.1 Sample Size and Survey Methods A systematic random sample of approximately 12 percent of the 270 health centers and referral hospitals thought to be operational as of 1 March 1998 (according to MOH provincial staff) were selected (n = 31). Appendix A contains a complete list of the chosen sites. After pretesting the survey instrument at two non-surveyed sites, adjustments were made and the survey was conducted between 1 March 1998 and 30 April 1998. The following sets of questionnaires/tally sheets were used at each site (see Appendix B for samples): REGISTRATION FORMS/RECORDS SURVEY SHEET STOCK BALANCE SURVEY SHEET OUTPATIENT CONSULTATION REGISTER - MONTHLY TALLY SHEET INPATIENT CONSULTATION REGISTER - MONTHLY TALLY SHEET BIRTH SPACING REGISTER - MONTHLY TALLY SHEET MATERNITY CONSULTATION REGISTER - MONTHLY TALLY SHEET GYNAECOLOGY CONSULTATION REGISTER - MONTHLY TALLY SHEET General information pertaining to the operation of the facility and storeroom management/conditions was collected on the REGISTRATION FORMS/RECORDS SURVEY SHEET. The stock count of the surveyed commodities was recorded on the STOCK BALANCE SURVEY SHEET, and the total amounts dispensed of each surveyed commodity between 1 December 1997 and 28 February 1998 were recorded on the five MONTHLY TALLY SHEETS listed above. Sites were normally visited during morning hours over a one to two day period, as most facilities shut down between 10:30 a.m. and noon. In general, one team of surveyors (consisting of one member of the MOH and one member of The Reproductive and Child Health Alliance (RACHA)) would visit each health center and two to three teams would survey the larger former district hospitals and referral hospitals. At each site, the survey team took note of the condition of the pharmacy store (if such a separate entity existed). They also observed whether (1) the storeroom contained racks/cabinets, (2) the storeroom had ventilation (storerooms were considered to be ventilated if they possessed a window that could be opened), and (3) the commodities were stored on racks/cabinets, labelled and alphabetized. At each facility, the survey team took a count of the stock of nineteen surveyed commodities. A separate count was made for each room where stock was maintained. Stock was categorized as either usable or unusable. Unusable stock was defined as any amount of a commodity that had either expired or could not be used due to damage to the contents of the item or its container. At some sites, the stock count included containers that were partially full. Where possible, the contents of these containers were actually 2

counted. In cases where this was not possible or difficult, the content of these containers was estimated. Finally, at each site the survey team reviewed the contents of any register that contained a record of amounts of the surveyed commodities actually dispensed to consumers. Data from each such register was recorded for a three month period beginning on 1 December and ending on 28 February. Three months of data was collected to obtain a reasonable monthly average of consumption. Time constraints made it impossible to collect more than three months data. 2.2 Selection of Commodities to Survey Based on an analysis of consumption trends at peripheral facilities that was conducted prior to the survey, a group of fourteen oral medicines, injectable medicines and perfusions were chosen to be surveyed. Commodities were chosen based on how often they were prescribed by health center and referral hospital staff. The items most often prescribed were chosen to be surveyed. A list of the fourteen oral medicines, injectable medicines and perfusions that were surveyed follows: Oral Medicines: Amoxycilline (250 mg) Cotrimoxazole (100+20 mg) Cotrimoxazole (400+80 mg) Erythromycin (250 mg) Metronidazole (250 mg) Multivitamins Oral Rehydration Salts Paracetamol (100 mg) Paracetamol (500 mg) P.M. Penicilline (250 mg) Injectable Medicines/Perfusions: Ampicilline (500 mg) Penicilline G IM/IV (1 Mui) Dextrose 10 % (500 ml) Dextrose 5 % (500 ml) In addition to the aforementioned medicines and perfusions, all contraceptives used in the MOH birth spacing program were surveyed. These included: Condom Depoprovera (150 mg/ml) IUD CT 380A Progestrone Oral Contraceptive (0.075 mg) Progestrone + Oestradiol Oral Contraceptive (0.03 mg + 0.15 mg) It should be noted that there were a few widely-used medicines that were not surveyed. The most notable exceptions were Ferrous Sulfate and Folic Acid, Acetyl Salicylic Acid, and Quinine. Quinine was omitted because it is distributed to MOH facilities through a special program. The nature of this distribution would have made quantifying the results difficult. The other two items were inadvertently overlooked. 3

2.3 Classification of Sites This survey focused on two types of peripheral facilities: health centers and referral hospitals. Referral hospitals were easy to classify since all had been designated as such by the MOH. Health centers were not as easy to classify. In many cases, health centers are in a state of transition from being a former district hospital. Because some of these facilities still service in-patients, it was useful in some cases to classify them as former district hospitals (in the process of becoming health centers). 2.4 Problems Faced During the Survey The surveyors experienced several problems during the survey. The biggest problem was the lack of access to MOH staff during the visits. The health facilities surveyed were often closed by 11:00 am, with some essential personnel leaving even earlier. This necessitated early morning departures by the survey teams to sites that were located in areas with poor road access. In most cases it took the survey team considerable time to record the register data, thus it was necessary to borrow registers to obtain photocopies for later transcription. This led to additional logistics problems finding photocopiers, and then finding reliable ways of returning the registers. Some of the sites were located in areas of armed conflict, in one case necessitating the selection of an alternate site. Another site was mined, but well marked, so it was surveyed. Before visiting any site, current safety conditions were checked by contacting local United Nations Development Programme (UNDP) offices which had radio contact with remote field sites. Since the survey was conducted at the height of the traditional hot, dry season, this affected the pace of work and caused delays. Because of these delays, the more remote province sites were not surveyed until last, by which time the rains had begun. An alternate site was selected on one occasion because of high water and muddy road conditions. Finally, in one case, an alternate site was selected because the original site did not have the records on the number of drugs dispensed. 4

2.5 Notes Regarding Tables and Charts For each surveyed commodity that was dispensed at a surveyed facility between 1 December 1997 and 28 February 1998, a Months of Stock (MOS) stock level figure was calculated. The MOS figures were derived using the following formula: MOS for Commodity X = Stock on Hand of Commodity X on Date of Visit Average Monthly Consumption of Commodity X Between 1 December 1997 and 28 February 1998 (aka CMM) Tables 1 and 2 (and Chart 1) of this report use the following criteria for categorizing the stock level situation of commodities at peripheral facilities: (a) Stock-out = 0 Stock (b) Potential Stock-out = > 0 to <= 1.5 MOS (c) Satisfactorily Stocked = > 1.5 to <= 5 MOS (d) Over-stocked = > 5 to <= Maximum Usable MOS (e) Excessively Stocked = > Maximum Usable MOS Facilities that maintained stock of a commodity greater than 0 but less than 1.5 MOS were considered to have the potential for eventual stock-out (hence the category name) because they (in all cases) possessed less than enough stock (i.e. 1.5 months worth) to last until the expected re-supply (i.e. on average in 1.5 months, since their review period is three months and they were surveyed at random times throughout that review period). Facilities were considered to maintain satisfactory stock for a commodity if the stock on hand was greater than 1.5 MOS but less than 5 MOS, since 5 MOS has been set as the maximum stock level for peripheral facilities receiving quarterly re-supply by the MOH. Facilities were over-stocked if the stock on hand was greater than the maximum of 5 MOS set by MOH, but was not so high that it could not all be used prior to expiration (i.e. did not exceed the maximum usable stock). In all but two cases (Cotrimoxazole (100+20 mg) and Progestrone + Oestradiol Oral Contraceptive (0.03 mg + 0.15 mg)) all the stock on hand of each commodity had a single expiration date. For these two special cases, some portion of the stock on hand at some facilities had a shorter expiration date. For the purposes of this survey, it is assumed that facilities maintaining such stock will distribute this stock to users before they distribute stock with a later expiration date, thus preventing further wastage. As can be readily observed from Table 2, each commodity has a unique sample size. Only sites that actually dispensed some amount of a commodity between 1 December 1997 and 28 February 1998 were considered in the sample for that commodity. The sample sizes for injectable medicines/perfusions were much less than for oral medicines because these items are not normally dispensed at health centers. The small sample sizes for contraceptives reflect the fact that the birth spacing program has not yet begun at all MOH facilities and that in those places where it has begun, not all contraceptives are being dispensed just yet. 5

Whereas Table 2 shows the percentage breakdown (based on the sample size) by stock level for each commodity, Table 1 represents the average percentage breakdown by stock level across all (1) oral medicines (nine), (2) injectable medicines/perfusions (four) and (3) contraceptives (five). Table 6 contains data on the average monthly amounts dispensed of contraceptives at all surveyed facilities. These monthly figures were multiplied by twelve to obtain the average yearly amounts dispensed. Couple Year Protection (CYP) factors were then divided into these yearly amounts to determine the number of couple years of protection for each contraceptive. Each calculated value for a contraceptive was divided by the total of all calculated values and multiplied by 100 to obtain contraceptive method mix percentages. The CYP conversion factors used in this analysis were: Contraceptive CYP Conversion Factor Condom 150 Depoprovera (150 mg/ml) 4 IUD CT 380A.28 (i.e. 1/3.5) Progestrone Oral Contraceptive (0.075 mg) 15 Progestrone + Oestradiol Oral Contraceptive 15 (0.03 mg + 0.15 mg) One final note: Though data were collected for Erythromycin (250 mg), this data was not considered in this report. The wildly fluctuating consumption pattern and inconsistent distribution of this commodity made it too difficult to analyze. Erythromycin's strange consumption pattern and inconsistent distribution is most likely the result of its usage in the AIDS/STD program. 6

SECTION THREE FINDINGS AND ANALYSIS The key findings of the survey along with appropriate analysis of stock level, storage, and dispensed data are presented in this section. 3.1 Stock Status of Commodities by Category 3.1.1 Examination of Stocked-out Facilities Table 1 (and Chart 1) shows the stock status of peripheral facilities by category of surveyed item. Stock-outs were reasonably low for oral medicines [i.e. Amoxycilline (), Cotrimoxazole (100+20mg), Cotrimoxazole (400+80mg), Metronidazole (), Multivitamins, Oral Rehydration Salts (ORS), Paracetamol (100mg), Paracetamol (500mg), P.M. Penicilline ()]. They were 7 percent on average. These low stock-out rates (when compared with stock-outs of injectable medicines/perfusions and contraceptives) most probably reflect the care taken by MOH health center and referral hospital staff to accurately estimate the need for these items. Stock-outs of injectable medicines and perfusions [i.e. Ampicilline (500mg), Penicillin G IM/IV (1 Mui), Dextrose 10% (500ml), Dextrose 5% (500ml)] were decidedly higher than those of oral medicines. They averaged 16 percent. It is uncertain why stock-outs of these items should be higher than those of oral medicines though it could be due to the fact that in some facilities (mostly former district hospitals) these items are no longer routinely used, and are thus not regularly requested. Another explanation could be pilferage, though the survey teams observed no evidence of this. Finally, the stock-outs could merely be the result of unreliable supply and the lengthy lead time required by the Central Medical Store (CMS). Stock-outs of contraceptives [i.e. Condom, Depoprovera (150mg/ml), Intra-Uterine Device (IUD) CT380A, Progesterone (.075mg) Oral Contraceptive (OC), Progestrone (.15mg)+Oestradiol (.03mg) OC] were also higher than those of oral medicines. They averaged 11 percent. These high values most probably reflect the current confusion within the supply system regarding the birth-spacing program. Many facilities continue to request resupply through the National Maternal Child Health (MCH) Center (despite attempts to integrate supply of contraceptives with essential drugs) and often do so only when their current stock becomes very low. 3.1.2 Examination of Nearly Stocked-out Facilities Though Stock-outs for many of the surveyed commodities were low, the percentage of health centers and referral hospitals that were nearly stocked-out of one or more of the eighteen surveyed items was quite high [a facility was considered nearly stocked-out if had less than 1.5 months of stock on hand]. On average, 17 percent of the surveyed facilities were nearing stock-out of one or more of the surveyed oral medicines and injectable medicines/perfusions, while 25 percent were nearing stock-out of one or more of the surveyed contraceptives. 7

These findings are not entirely surprising considering that the surveyed facilities only request a maximum of five months of stock when asking for resupply. Since the lead time between filing the request and receipt of commodity is currently anywhere from two weeks to two months, there is a strong likelihood that a large percent of facilities will fall below 1.5 months of stock sometime before resupply. Placing the point of supply (i.e. the operational district store) closer to the peripheral facilities should ultimately reduce the number of facilities experiencing near stock-out. Consequently, as more operational district stores become "operational" (i.e. the store is adequately staffed and the personnel appropriately trained), the number of peripheral facilities experiencing near stock-out or stock out should decline, provided the lead time is reduced to a few days (as is planned). 3.1.3 Examination of Facilities Maintaining Excessive Stock Just as there are many facilities maintaining low stock, there are numerous maintaining excessive stock. The problem is primarily related to injectable medicines/perfusions and contraceptives. On average, a full 17 percent of facilities maintained more stock of the surveyed injectable medicines/perfusions than can be used prior to expiration, and 21 percent had more contraceptives than can be used before expiring. Though it may seem contradictory that there are as many facilities that are nearly stocked-out as there are those that maintain excessive stock, it can be explained. The problem is most probably due to oversupply that took place some time in the past before the distribution system became more mature. This is clearly the case in regard to the contraceptives. Large amounts were provided to many facilities in 1997 whose initial need was not easily determined. 3.2 Stock Status of Commodities by Item 3.2.1 Examination of Stocked-out and Nearly Stocked-out Facilities Table 2 shows the stock status of peripheral facilities by individual surveyed item. Of the oral medicines, no item had more than a 33 percent combined stock-out and near stockout rate. Cotromoxazole (100+20mg) and ORS had the lowest stock-out and near stockout rates. In fact, ORS is the only item of all surveyed to have had zero stock-outs. Of the surveyed injectable medicines and perfusions, Ampicillin (500mg) and Dextrose 10% (500ml) had the highest stock-out rates (22 and 20 respectively). Most of the facilities stocked-out of Ampicillin were former district hospitals. It is possible that some of these facilities are no longer servicing in-patients and, therefore, no longer use these items. Contraceptive stock-outs and near stock-outs tended to be on the high side (except for IUD CT 380A). Forty-four percent of facilities were either stocked-out or nearly stocked-out of Depoprovera while 45 percent were either stocked-out or nearly stockedout of Progestrone+Oestradiol OC (Microgynon). The stocked-out and nearly stockedout facilities tended to have much larger than average usage of these items. It is possible 8

that usage is increasing so quickly at these facilities that the staff cannot accurately forecast the need and do not request enough during resupply. 3.2.2 Examination of Facilities Maintaining Excessive Stock Of the surveyed oral medicines, ORS had the highest percentage of facilities with more stock than could be used prior to expiration. ORS was in excess at 36 percent of facilities. This is due primarily to the short shelf-life of this product. According to information obtained from CMS, all of the current stock of this product is set to expire in November 1999. The only other oral medicine found in excess at a large number of facilities was Cotrimoxazole (100+20mg). This is, perhaps, due in part to the very low amounts dispensed of this item at some facilities. Since CMS rounds all requests to the nearest bottle, it would not be unusual for facilities that have low usage of this medicine to maintain excessive amounts. As for the injectable medicines and perfusions, the survey showed that Penicillin G IM/IV (1 Mui) and Dextrose 10 % (500 ml) were held in excessive amounts at a large number of facilities (24 and 25 percent respectively). Most of the facilities where these items were in excess were former district hospitals in the process of phasing out their inpatient services. The low usage associated with this phase out and the short shelf-life of these products (they expire in November 1999) has resulted in a large portion of this stock put in danger of expiration before usage. It is assumed that a similar situation exists for most other injectable medicines and perfusions at former district hospitals. 3.3 Usable Versus Unusable Stock of Commodities Table 3 shows the percentage of usable and unusable stock found on the date of visit. Health centers and referral hospitals had little, if any, unusable stock of oral medicines, injectable medicines/perfusions and contraceptives. In fact, less than two percent of the stock, on average, was found to be unusable. Only for Cotrimoxazole (100+20 mg) was there a significant amount of unusable product (9 percent). Health center and referral hospital staff claim this could have been caused by local commune clinics that had closed down and dumped their remaining (nearly expired) stock on them. 3.4 Pharmacy Storage Conditions Table 4 contains information pertaining to store conditions and store management. The results of the survey show that a large portion (87 %) of health centers and referral hospitals have dedicated a room to act as the pharmacy for the facility. The survey also showed that all facilities (whether they have a dedicated pharmacy store or not) possess racks and or cabinets in which to hold stock. However, the condition of the storeroom and racks varies greatly. Many of the storerooms are clearly too small to hold the existing stock and, because of this, some stock has been piled on other stock in a manner that could lead to damage and wastage. Why the storerooms should not be able to hold 9

the existing stock is not exactly clear though some facilities were holding containers of commodities destined for other sites that hadn't yet been picked up. Even those storerooms that have adequate room to store stock did not always store the items on the shelves. Sometimes this was due to inadequate number of racks and/or cabinets. In other cases, shipments had just arrived and had not yet been put in order. In only a few instances, was this the result of sloppy store practices. The lack of racks and/or cabinets and the general lack of storage space accounts partially for why only 71 % stored all items appropriately on racks/cabinets. The lack of labels for the commodities on the racks/cabinets (only 35 % had them) and the fact that few facilities kept the items on the racks organized alphabetically may be symptomatic of poor store management. In fact, in some cases the same drug could be found frequently in more than one location within the storeroom. In addition, drugs were kept in containers meant for other commodities and in some cases mixed together. Finally, nearly all facility storerooms (97%) possess some form of ventilation. In most cases this consists of a barred window that can be opened without jeopardizing security to allow the free flow of air. For reasons that were unclear to the surveyors, most facilities choose to keep these windows closed during both working and non-working hours. 3.5 Location of Commodities Table 5 shows the proportion of stock maintained in each unit of the peripheral facility. For oral medicines, injectable medicines and perfusions, nearly 84 % of the stock (on average) is held in the pharmacy storeroom with only small amounts held in the subpharmacy (11 %) and other locations (4 %). [Other locations can include, at times, the home of the storeroom manager, as was the case at one site.] This means that the stock balance reported on the quarterly or monthly request form by these facilities (for these items) is reflective of the majority of stock in the facility and no action is required to account for the stock outside the pharmacy on the request form. The case of the contraceptives is quite different. Only 61 % of the stock (on average) was held in the pharmacy storeroom and in many of the sites surveyed none of the stock was held in the pharmacy. This phenomenon is probably reflective of the autonomy currently exercised by birth spacing attendants in maintaining and dispensing contraceptives. In part this may be due to the fact that he or she needs access to these commodities during hours when the rest of the facility is not open but is probably more reflective of the current vertical nature of the birth spacing program. Because, on average, nearly 37 % of the contraceptive stock is currently kept in the birth spacing unit, a large portion of the total stock is not accounted for on the request form when facilities request re-supply. Action should be taken to move the amounts now kept in the birth spacing unit to the pharmacy storeroom or to somehow account for this stock in the request (which in most cases is not being done presently). 10

3.6 Contraceptive Method Mix Table 6 (and Chart 6) shows the contraceptive method mix derived from the average monthly amounts dispensed by health centers and referral hospitals between December 1997 and February 1998. The survey showed that an overwhelming percentage (71 %) of women prefer the Depoprovera injection at public facilities. This finding confirms what had been suspected by the National MCH Center of the MOH and donors. The survey also showed that 18 percent of the method mix in the birth spacing program is attributable to oral contraceptive usage with 17 percent using the Progestrone (.15mg)+Oestradiol (.03mg) OC (Microgynon) and only one percent using the Progesterone (.075mg) OC (Overette). Only eight percent of users utilize the IUD. Perhaps the most surprising finding was the relatively small number of women/men who come to health centers and referral hospitals to receive condoms for birth spacing. Only three percent of the method mix in the birth spacing program is attributable to condom usage. [It should be noted that the public sector also provides condoms through its Acquired Immune Deficiency Syndrome (AIDS) prevention programme. Since these condoms serve the dual purpose of preventing AIDS and pregnancy, the overall percentage of the method mix in the public sector attributable to condom usage is probably a bit higher. However, the overall percentage is probably no higher than six percent given the fact that CMS issues of condoms for the birth spacing programme are only slightly lower than CMS issues for the AIDS programme.] As expected, a larger percentage of users coming to referral hospitals utilize the IUD. This is attributed to the fact that not all health centers are equipped to insert the IUD while most referral hospitals are. One final note: no attempt was made to determine the percentage of the public sector method mix attributable to sterilization. The contribution of sterilization is thought to be very low (less than one percent). 11

TABLES

CHARTS

APPENDICIES

APPENDIX A LIST OF SITES SURVEYED Site: Date Surveyed: Province: Svay Reang Chan Trea Former District Hospital March 5 Svay Teap Former District Hospital March 6 Municipality: Phnom Penh Chmoy Changwa Health Center March 10 Toul Kork Health Center March 11 Province: Kampot Chak Krey Health Center March 17 Trapeing Reing Health Center March 18 Touk Meas Health Center March 19 Province: Takeo Ang Roka Referral Hospital March 20 Batti Referral Hospital March 23 Roveang Health Center March 23 Champar Health Center March 24 Province: Kampong Speu Treng Traying Health Center March 25 Damnak Chan Health Center March 25 Roleang Sen Health Center March 26 Province: Kampong Cham Provincial Referral Hospital April 2-3 Soung Referral Hospital April 22 Kroch Chmar Referral Hospital April 23 Province: Kandal Ksach Kandal Referral Hospital March 30 Ponhea Leu Former District Hospital April 24

Site: Date Surveyed: Province: Kampong Thom Treal Health Center March 31 Prasat Balang Former District Hospital April 1 Province: Battambang Knach Romeas Health Center March 31-April 1 Province: Siem Reap Provincial Referral Hospital April 6-7 Dan Run Health Center April 7 Prasat Bakong Former District Hospital April 9 Kra Lanh Referral Hospital April 8 Province: Kampong Chhang Provincial Referral Hospital March 26-27 Province: Ratanikirri Vouen Sai Former District Hospital April 21 Lum Phat Former District Hospital April 22 Province: Mondulkiri Keo Sima Former District Hospital April 21-22 Province: Kratie Snoul Former District Hospital April 21

APPENDIX B SAMPLES OF SURVEY FORMS AND TALLY SHEETS 1. REGISTRATION FORMS/RECORDS SURVEY SHEET 2. STOCK BALANCE SURVEY SHEET 3. OUTPATIENT CONSULTATION REGISTER - MONTHLY TALLY SHEET 4. INPATIENT CONSULTATION REGISTER - MONTHLY TALLY SHEET 5. BIRTH SPACING REGISTER - MONTHLY TALLY SHEET 6. MATERNITY CONSULTATION REGISTER - MONTHLY TALLY SHEET 7. GYNAECOLOGY CONSULTATION REGISTER - MONTHLY TALLY SHEET

REGISTRATION FORMS / RECORDS SURVEY SHEET 1. Introduce RACHA and Ministry of Health staff. Describe purpose of survey. 2. Ask that Director of Facility and Pharmacist(s) to be present. If one or neither can be present, then request that someone knowledgeable be present. 3. Write down contact names and positions: Director: Pharmacist: Other: 4. Write down name, type and location of facility: Name: Type: Location: 5. Does this facility accept inpatients (yes/no)? 6. Does this facility accept outpatients (yes/no)? 7. List all units of the facility (circle below): Birth Spacing Outpatient Maternity Immunization Inpatient Gynaecology Surgical TB Other (specify):

Register Information 8. List all registers used within facility (circle below): Birth Spacing Outpatient Maternity Immunization Inpatient Gynaecology Surgical TB Other (specify): 9. Which registers/records contain "dispensed to patient" information (circle below): Birth Spacing Register Outpatient Register Maternity Register Immunization Register Inpatient Register Inpatient Treatment Record Gynaecology Register Other (specify): 10. Review contents of each register/record to confirm which contain "dispensed to patient" information. 11. For each register/record containing "dispensed to patient" information, gather information for December 1997 through February 1998 (in the case of the Inpatient Treatment Record, gather information for November 1997 through March 1998). 12. Confirm that there is no duplication between registers. For example: be certain that the information on the Inpatient Treatment Records is not also shown in the Outpatient Register, etc. 13. For Outpatient Register, indicate the columns found on the register. Circle applicable categories: Patient Number New Patient Old Patient Name of Patient Zone Age Sex Referred From Patient Address Clinical Symptom Diagnosis Treatment Dispensed Referred To Remarks List other categories not shown above.

14. For Birth Spacing Register, indicate the columns found on the register. Circle applicable categories: Patient Number New Patient Old Patient Name of Patient Zone Patient Address Sex Age Type of Service Contraceptives Dispensed Payment Received Remarks List other categories not shown above.

Stock Information 15. List all locations where stock is kept (circle below): Pharmacy Sub-pharmacy Birth Spacing Unit Outpatient Unit Maternity Unit Immunization Unit Inpatient Unit Gynaecology Unit Surgical Unit TB Unit Other (specify):

16. For each location where stock is kept, provide following information. Provide a separate sheet for each location: Name of location (e.g. pharmacy): Are stock transactions for this location recorded (yes/no)? If yes, on what are they recorded (circle below): Fiche Card A Tally Sheet Other (specify): To whom does this facility send its request for resupply (e.g. sub-pharmacy might send request to pharmacy): Does this facility use a form to request for resupply (yes/no)? If yes, describe form: Does the form contain the following information: opening balance, amount received, amount issued, and closing balance (yes/no)? If yes, how are the numbers calculated on the following (circle below): A. Opening Stock: Carried Forward Physical Inventory Count Other (specify)? B. Received Stock: Fiche Delivery Voucher Other (specify)? C. Issued Stock: Fiche Tally Form Daily Register Other (specify): D. Closing Stock:Calculated Physical Inventory Count Other (specify)?

17. After collecting above data, perform physical inventory of all locations containing stock. 18. During the physical inventory of the main pharmacy store answer following questions related to main pharmacy store (only): Does a separate store exist for the main pharmacy (yes/no)? Is there any ventilation in this store (yes/no)? Does this store contain racks (yes/no)? Are all items of suitable size kept on racks in this store (yes/no)? Note: It is acceptable for certain items to be placed on the floor if they are too large to be placed on racks. If items are kept on racks, are the items individually labelled (yes/no)? If the items are individually labelled, are they alphabetized (yes/no)?

STOCK BALANCE SURVEY SHEET Name of Surveyors: Name of Facility: Type of Facility (Circle One): Health Center Referral Hospital Former District/HC Location of Facility: District: Province: Date of Survey Time In Time Out Signature of Pharmacist:

COMMODITIES Store/Pharmacy Sub - Pharmacy Birth Spacing Unit Out Patient Unit Maternity Unit In Patient Unit Other Total Usable Unusable - Expired Unusable - Other Total Unusalbe Amoxycilline Cotrimoxazole 100+20mg Cotrimoxazole 480+80mg Erythromycine Metronidazole Multivitamins Oral Rehydration Salts Paracetamol 100mg Paracetamol 500mg Phen. Meth. Penicilline Injectables: Ampicilline 500mg Peni.G IM/IV 1mui (Benzl Penicillin) IVs: Dextrose 10% 500ml Dextrose 5% 500ml Contraceptives: Condom (Piece) Depropovera 150 mg/ml IUD cut 380A (piece)

Progesterone (Overette) (Pill) Progesterone + Oestradiol (Pill)

OUTPATIENT CONSULTATION REGISTER MONTHLY TALLY SHEET Name of Surveyor: Date of Survey: Name of Facility: Month/Year: Patient Diagnosis Amoxycilline Cotrimoxazole 100+80mg Cotrimoxazole 480+80mg Erythromycine Metronidazole Multivitamins Oral Rehy. Salts Paracetamol 100mg Paracetamol 500mg P. M. Penicillin Ampicilline 500mg Benzl Penicillin 1mui Dextrose 10% 500ml Dextrose 5% 500ml 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Sub-total REMARKS

INPATIENT CONSULTATION REGISTER MONTHLY TALLY SHEET Name of Surveyor: Date of Survey: Name of Facility: Month/Year: Patient Diagnosis Amoxycilline Cotrimoxazole 100+80mg Cotrimoxazole 480+80mg Erythromycine Metronidazole Multivitamins Oral Rehy. Salts Paracetamol 100mg Paracetamol 500mg P. M. Penicillin Ampicilline 500mg Benzl Penicillin 1mui Dextrose 10% 500ml Dextrose 5% 500ml 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Sub-total REMARKS

BIRTH SPACING REGISTER MONTHLY TALLY SHEET Name of Surveyor: Date of Survey: Name of Facility: Month/Year: PATIENT 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Subtotal Progesterone+ Oestradiol Oral Pill (Microgynon) Depoprovera 150mg/ml Condom IUD CT 380A Progesterone Oral Pill (Overette) REMARKS

MATERNITY CONSULTATION REGISTER MONTHLY TALLY SHEET Name of Surveyor: Date of Survey: Name of Facility: Month/Year: Patient Amoxycilline Cotrimoxazole 100+80mg Cotrimoxazole 480+80mg Erythromycine Metronidazole Multivitamins Oral Rehydration Salts Paracetamol 100mg Paracetamol 500mg Phen. Meth. Penicilline Ampicilline 500mg PeniG Im/V 1mui (benzl Penicillin) Dextrose 10% 500ml Dextrose 5% 500ml 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Subtotal REMARKS

GYNAECOLOGY CONSULTATION REGISTER MONTHLY TALLY SHEET Name of Surveyor: Date of Survey: Name of Facility: Month/Year: Patient Amoxycilline Cotrimoxazole 100+80mg Cotrimoxazole 480+80mg Erythromycine Metronidazole Multivitamins Oral Rehydration Salts Paracetamol 100mg Paracetamol 500mg Phen. Meth. Penicilline Ampicilline 500mg PeniG Im/V 1mui (benzl Penicillin) Dextrose 10% 500ml Dextrose 5% 500ml 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Subtotal REMARKS

APPENDIX C SURVEY DATA 1. PHARMACY STORAGE DATA 2. STOCK COUNT 3. FACILITY TOTAL DISPENSED DATA 4. FACILITY MOS FIGURES 5. COMMODITY EXPIRATION DATES