Medication and BP measurement devices are an essential part of launching a hypertension program. The BP device model chosen for a new hypertension program should be externally validated as accurate, come with multiple cuff sizes, and be durable and affordable for the program [14]. Technical specifications outlined by WHO should be considered when procuring devices [15].
Due to environmental concerns, manual mercury BP devices are being phased out globally [15]. To replace outdated mercury devices, the WHO recommends accuracy-validated automated BP devices over the alternative of manual aneroid BP devices for measuring adult BP. This is because aneroid BP devices require frequent calibration to maintain accurate BP readings and are more prone to observer bias and terminal digit preference [14, 15]. Validated automated digital devices, which inflate automatically and use oscillometric pulses to estimate BP, can be for home or office use, require less skill to operate, eliminate risk of observer bias and terminal digit preference, do not require re-calibration, and require less maintenance [14, 15]. BP devices designed for home use should not be implemented in health care facilities, as they provide accurate readings only up to 30,000 measurements compared to devices designed for office use, which maintain accuracy for up to 100,000 measurements [14]. Automated BP devices purchased for a hypertension program should always be a validated, which means meeting rigorous accuracy standards. National standards for BP devices should be updated to meet WHO-recommended technical standards [15].
Steps 3A and 3B: Inventory current medications and BP devices
Before forecasting the quantity of medications and BP devices that will be needed for a new hypertension program, program staff should conduct an inventory survey at facility level (Table 3–Step 3A and 3B) to assess quantities of currently available products.
Steps 3C and 3D: Forecast medication and BP device needs for start up
The Resolve to Save Lives medication forecasting tool can be used to estimate antihypertensive medication requirements for a new hypertension control program (Table 3–Step 3C). The tool is based on the best available program growth and medication consumption assumptions derived from hypertension control program experiences in India and should be adapted to local contexts. Possible modifications include the estimated program drop-out rate, expected patient enrollment, percent of patients requiring treatment escalation at each step or desired coverage in the public sector.
BP measurement device requirements can be calculated based on average daily number of adult patients visiting the facility, the average duration of time to screen one patient, and the number of hours the facility is open each day. Human resource availability also needs to be considered to estimate how many devices are needed for opportunistic screening (Table 3–Step 3D).
Steps 3E and 3F: Procure medications and BP devices
Program staff should work with national or subnational procurement entities to plan and implement a procurement and distribution strategy for quality-assured medications and BP devices. National procurement entities can source products according to individual national practices, including instituting competitive tendering. Considerations to plan sourcing and procurement include selecting suppliers based on their ability to deliver on-time and in-full, product shelf life at delivery, national registration status, and quality assurance.
The majority of generic manufacturers supply high-quality and affordable antihypertensive medications. Unfortunately, in some cases, antihypertensive medicines have been found to be of poor quality [16] and national programs may want to limit procurement to products with strict regulatory authority approval (for example, United States Food and Drug Administration or European Medicines Agency certification) or manufacturing sites with Good Manufacturing Practice certification by a trusted regulatory body.
At a regional level, pooled procurement mechanisms such as the PAHO Strategic Fund provide a procurement option for Ministries of Health and Government Institutions of PAHO member countries. The PAHO Strategic Fund establishes long-term agreements with manufacturers to offer reduced prices of cardiovascular health medicines and provides technical assistance to strengthen supply management in member counties [17]. Currently, 35 countries and territories are part of the mechanism. A similar approach should be considered in other regions of the world, where variable prices and quality of antihypertensive medications still exist [16].
A number of suppliers provide BP measurement devices meeting WHO-recommended standards. Several reputable hypertension organizations have a catalog of validated BP devices that can be helpful in comparing various models for procurement [18, 19]. Consideration for sourcing should include product warranties, device connectivity, and recommended operating conditions for the given product.
Step 3G: Utilize and strengthen supply chains to distribute medicines and support monitoring of medication inventory
At a facility level, program staff should inventory the pharmacy to ensure that at least 3 months of medication stock is available to treat the number of current and anticipated new patient enrollments at the facility. The Min–Max inventory guide can be particularly useful when facilities receive stock less than once a month or irregularly (Table 3—Step 3G) [20].
Health facilities should maintain records of receipt and disbursement of all drug stocks. It is recommended that they regularly update the records and report medication status in monthly or quarterly reports to monitor stock levels. Medication records at the facility level can include a stock ledger, which should reflect both stock on hand and transaction history, and a daily consumption record to be utilized where drugs are dispensed (Table 3—Step 3G). As stock ledgers may not be updated regularly, stock verification from registers should be supplemented by the physical counting of available stock. If appropriate and feasible to implement, an electronic logistics management information system can also be helpful to monitor medication inventory. Job aids such as a “ready reckoner” can be prepared to assist facility staff in assessing stock adequacy at a health facility at any point of time (Table 3—Step 3G) [20]. When facility stock falls below a 3-month supply, there should be proactive management to request and distribute additional stock through the supply chain before drug stock decreases to a critical level. Turnaround times from request to distribution should be considered when re-ordering stock.
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