The survey covered both urban and rural areas and looked at different facets of healthcare provision including, public, private-for-profit, and private not-for-profit sectors. By convenience sampling, a minimum of 10 facilities were targeted in each country and at least three healthcare workers from each facility were interviewed.

The assessment was standardized across the participating countries through a planning workshop, which brought together collaborators from Makerere University, Harvard Centre for International health, Management Sciences for Health, and two representatives of the AIDS Control Program from each of the four countries. The workshop reviewed the data collection tools, discussed the assessment logistics and process and agreed on time lines. Data collection tools were piloted at three health facilities and two programs in Uganda and their validity and reliability ascertained. These were later excluded from the main study. Permission to carry out the survey was obtained from the national HIV/AIDS control programs of the respective countries. Appointments with heads of the facilities and respondents were made by personnel from the national AIDS control program in each country.

The heads of the National AIDS Control Programs, Ministry of Health Pharmacy Services, and HIV treatment programs were identified as key informants. Using the data collection tool information on; the general features of the country's ARV supply system [accessibility, availability, funding, monitoring and supervision], qualification and training of health care workers involved in supply management of ARVs and related commodities, and the training needs for the supply management of pharmaceuticals was sought in a face to face interview.

The heads of the facilities providing ART services in the four countries were the key informants at the program level. The survey looked at the types of HIV/AIDS services provided, the existence of guidelines for management of ARVs and related commodities, the qualification of healthcare workers managing the supply of pharmaceuticals, existence of any ongoing skills building activities, and areas covered in ongoing training programs.

Structured in-depth interviews of healthcare providers were held with physicians, pharmacists, pharmacy assistants, nurses and clinical officers. Information was sought on training background, knowledge of ARV supply management systems and the quality of the service provided.

At the end of each survey, questionnaires were checked for completeness, accuracy and consistency. At the end of each assessment, analysis of the data involved discussion with various in-country stakeholders for more in-depth interpretation of perceptions and opinion on possible interventions to address identified problems. Quantitative data were analyzed using EPI INFO Version 3.3, while qualitative data were coded and manually analyzed. No statistical comparisons were made as this was a situational analysis survey without sufficient power for such analysis.

National AIDS Control Programs were responsible for the development and implementation of HIV/AIDS treatment policies in all four countries. Public, private-not-for profit and private-for-profit institutions were involved in HIV/AIDS treatment and care in all the four countries. In the public institutions HIV/AIDS treatment was limited to district level facilities or higher at the time of the assessment.

A total of 54 facilities involved in ART services were surveyed in the four countries, comprising of 27 public, 18 private not-for-profit, 5 private-for-profit, and 4 academic institutions (Table 1). The majority of facilities were located in urban or peri-urban areas. A total of 110 health workers were interviewed, the majority of whom were pharmacists (32) followed by nurses/midwives (27), doctors (20), pharmacy technicians (20), social workers (9), clinical officer (1) other (1) (Table 2). Generally healthcare workers involved in the pharmaceutical management of ARVs included pharmacists, nurses/midwifes, pharmacy technicians, pharmacy assistants, social workers and administrative staff. In some countries not all categories of health workers were involved in the supply management of ARVs. In Uganda the supply management of HIV/AIDS pharmaceuticals is mainly by lower to mid-level health workers (Figure 1)

Guidelines for the supply management of HIV/AIDS existed in all the countries but were not always available at treatment centers. Such guidelines however varied from country to country.

Training on HIV/AIDS mainly focused on the clinical management. Very few programs included pharmaceutical supply management in their training programs. Respondents indicated that there was critical need for training on HIV/AIDS pharmaceutical supply management. Specific areas on HIV/AIDS pharmaceutical supply management where training was needed included the selection of medicines, procurement procedures, quantification of needs, distribution, inventory control/storage and rational prescribing and dispensing. Table 3 shows the areas in HIV/AIDS pharmaceutical management where skills building was required, the perceived cause of the problem and possible interventions. On the preferred modes of delivering training, on-the-job training and short workshops were the preferred by respondents.

We acknowledge with appreciation the contribution of Dr. Jenipher Orwa of Kenya Medical Research Institute, Nairobi, Kenya; Prof Amos Massele, Muhimbili College of Health Sciences, Dar es Salaam, Tanzania, and Mr Emile Bienvenu, National University of Rwanda, Butare. We also extend our thanks to the Members of International Network for Rational Use of Drugs in Kenya and Tanzania for helping in the preparation of the assessment in their respective countries. We also appreciate the support of the AIDS control programs of Uganda, Kenya, Tanzania and Rwanda for granting permission to the assessment. This article was made possible through support provided by the United States Agency for International Development, under the terms of cooperative agreement number HRN-A-00-00-00016-00. The opinions expressed herein are those of the authors and do not necessarily reflect the views of the United States Agency for International Development.