MATERNAL, NEWBORN, AND CHILD HEALTH LOGISTICS SYSTEM ASSESSMENT, ETHIOPIA MAY 2018
MATERNAL, NEWBORN, AND CHILD HEALTH LOGISTICS SYSTEM ASSESSMENT, ETHIOPIA MAY 2018
This publication was made possible by the generous support of the American people through the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) with the United States Agency for International Development (USAID) under the Cooperative Agreement Strengthening High Impact Interventions for an AIDS-free Generation, number AID-OAAA-14-00046. The information provided does not necessarily reflect the views of USAID, PEPFAR, or the U.S. Government.
AIDSFree The Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project is a five-year cooperative agreement funded by the United States Agency for International Development under Cooperative Agreement AID-OAA-A-14-00046. AIDSFree is implemented by JSI Research & Training Institute, Inc. with partners Abt Associates Inc., Elizabeth Glaser Pediatric AIDS Foundation, EnCompass LLC, IMA World Health, the International HIV/AIDS Alliance, Jhpiego Corporation, and PATH. AIDSFree supports and advances implementation of the U.S. President’s Emergency Plan for AIDS Relief by providing capacity development and technical support to USAID missions, host-country governments, and HIV implementers at the local, regional, and national level. Recommended Citation Woinshet Nigatu, Abebe Bogale, Miraf Tesfaye, Masresha Assefa, and Fantaye Teka. 2018. Maternal, Newborn, and Child Health Logistics System Assessment, Ethiopia. Arlington, VA: Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project and Pharmaceuticals Fund and Supply Agency (PFSA).
The Federal Democratic Republic of Ethiopia
JSI Research & Training Institute, Inc.
Pharmaceuticals Fund and Supply Agency
1616 Fort Myer Drive, 16th Floor
Tel: +251112751770
Arlington, VA 22209 USA
P.O. Box 21904
Phone: 703-528-7474
Addis Ababa, Ethiopia
Fax: 703-528-7480
Email:
[email protected]
Email:
[email protected]
Web: www.pfsa.gov.et
Web: aidsfree.usaid.gov
CONTENTS
Acronyms ..........................................................................................................................................................ix
Acknowledgments ..........................................................................................................................................xi
Foreword .........................................................................................................................................................xiii
Executive Summary .......................................................................................................................................xv
Background ................................................................................................................................................................. xv
Methodology............................................................................................................................................................. xvi
Findings ....................................................................................................................................................................... xvi
Recommendations.................................................................................................................................................xviii
Part 1. Introduction .........................................................................................................................................1
1.1. Background........................................................................................................................................................... 1
1.2. Country Profile..................................................................................................................................................... 2
1.3. Objectives of the MNCH Logistics System Assessment....................................................................... 3
1.4. Assessment Methodology............................................................................................................................... 3
1.5. Ethical Considerations....................................................................................................................................... 5
1.6. Limitations of the Study ................................................................................................................................... 5
Part 2. Qualitative Findings and Discussions ............................................................................................7
2.1. Organization and Staffing ............................................................................................................................... 7
2.2. Logistics Management Information System............................................................................................. 8
2.3. Quantification.....................................................................................................................................................11
2.4. Obtaining Supplies/Procurement...............................................................................................................12
2.5. Inventory Control Procedures......................................................................................................................12
2.5. Warehousing and Storage ............................................................................................................................13
2.6. Transport and Distribution............................................................................................................................14
2.7. Product Use.........................................................................................................................................................15
2.8. Finance, Donor Coordination, and Commodity Security Planning ................................................15
Part 3. Quantitative Findings and Discussions ...................................................................................... 19
3.1. Number of Facilities Assessed .....................................................................................................................19
3.2. Source of Supply and Funds for Commodities at SDPs .....................................................................19
3.3. Availability and Utilization of Stock Records..........................................................................................20
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3.4. Stock Status ........................................................................................................................................................21
References....................................................................................................................................................... 27
Appendix 1. List of Data Collectors .......................................................................................................... 29
Qualitative Discussion: Logistics System Assessment Participants ........................................................31
Appendix 2. MNCH Commodities Logistics Management Qualitative and Quantitative
Assessment ..................................................................................................................................................... 35
MNCH Commodities Availability ........................................................................................................................41
MNCH Commodities Data Quality .....................................................................................................................47
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ACRONYMS
BMGF
Bill & Melinda Gates Foundation
CHAI
Clinton Health Access Initiative
EBY
Ethiopian budget year
FMOH
Federal Ministry of Health
GHSC–PSM
Global Health Supply Chain–Pharmaceutical Supply Management
HCMIS
Health Commodity Management Information System
HC
health center
HMIS
Health Management Information System
HP
health post
IPLS
Integrated Pharmaceutical Logistics System
LIAT
Logistics Indicator Assessment Tool
LMIS
Logistics Management Information System
LSAT
Logistics System Assessment Tool
MCH LTWG
Maternal and Child Health Logistics Technical Working Group
MDG
Millennium Development Goal
MNCH
maternal, newborn, and child health
ORS
oral rehydration salts
PFSA
Pharmaceuticals Fund and Supply Agency
PLMU
Pharmaceutical Logistics Management Unit
PMED
Pharmaceutical Medical Equipment Directorate
RDF
Revolving Drug Fund
RRF
Report and Requisition Form
RHB
Regional Health Bureau
RHCS
reproductive health commodity security
RRF
Report and Requisition Form
SCMS
Supply Chain Management Systems
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SDP
service delivery point
SOP
standard operating procedure
STG
standard treatment guideline
UNFPA
United Nations Population Fund
UNICEF
United Nations Children’s Fund
USAID
United States Agency for International Development
WHO
World Health Organization
WoHO
Woreda Health Office
ZHD
Zonal Health Department
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ACKNOWLEDGMENTS
This assessment was conducted under the leadership of Ethiopia’s Pharmaceuticals Fund and Supply Agency (PFSA) with technical support from USAID’s Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project, and with the help of the Federal Ministry of Health (FMOH), Global Health Supply Chain–Pharmaceutical Supply Management (GHSC-PSM), UNICEF, and the Clinton Health Access Initiative (CHAI). PFSA would like to thank the members of the Maternal and Child Health Logistics Technical Working Group, who assisted in the study design, and all those from PFSA hubs, regional health bureaus (RHBs), Woreda Health Offices, and service delivery points who participated in the consultations and interviews. PFSA also recognizes FMOH, GHSC–PSM, UNICEF, and CHAI for their contribution during field visits and data collection. Finally, our appreciation goes to the United States Agency for International Development for its continued support and assistance.
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FOREWORD
Since its establishment in 2007, Pharmaceutical Fund and Supply Agency (PFSA), the lead organization managing the health care supply chain of the country, has been working to ensure the availability, accessibility, and affordability of essential medicines with appropriate quality, safety, and efficacy. To achieve these goals, PFSA—with support from its partners—has designed and implemented various innovative interventions to manage pharmaceuticals for different programs. The Integrated Pharmaceutical Logistics System (IPLS) is one of the major interventions designed to create a strong, unified, health care supply chain, to connect all levels of the supply chain, and to provide accurate and timely data for decision-making. A number of initiatives were devised and implemented to strengthen the supply of commodities for maternal, neonatal and child health (MNCH) including reimbursement protocol and the move to integrate the supply chain management of MNCH commodities into the IPLS. The supply of pharmaceuticals required for MNCH is supported by many stakeholders. Stakeholder contributions should, therefore, be coordinated for better outputs. The survey examines the challenges along the overall supply chain management of MNCH commodities including the management of logistics information with regard to MNCH commodities, and the status of stakeholders’ coordination and collaboration efforts. The assessment findings and recommendations provide valuable insights into the status of IPLS, including access to MNCH medicines, and the use of the LMIS formats and storage conditions. The information is expected to facilitate evidence-based planning, thus contributing to a stronger and more efficient supply chain of MNCH; increased medicine availability; and, ultimately, improved MNCH care outcomes. We strongly encourage all stakeholders involved in the health care supply chain to make the best use of this report in their planning and monitoring activities. The information will be particularly useful to government institutions and departments, MNC health development and implementing partners, training and research institutions, as well as other national and international stakeholders. PFSA acknowledges with gratitude the financial and technical support from USAID’s AIDSFree Project that made this work a reality. We also thank other partners including Clinton Health Access Initiative (CHAI), Global Health Supply Chan–Procurement and Supply Management (GHSC-PSM) project, and Results 4 Development who contributed technically to the design and implementation of this assessment. The agency also appreciates the data collectors and the informants who gave their time. Finally, we thank the dedicated personnel involved in delivering medicines to the population: staff of PFSA and partner organizations, and the dedicated pharmacy and medical staff, including the thousands of health extension workers. Dr. Loko Abraham Director General, Pharmaceuticals Fund and Supply Agency (PFSA)
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EXECUTIVE SUMMARY
Background Ethiopia has significantly reduced its maternal mortality from the 1990s estimate to an average annual reduction rate of 5 percent or more. The Ethiopian Demographic and Health Surveys of 2011 and 2016 reported maternal mortality rates of 676 and 412 per 100,000 live births, respectively. However, Ethiopia still did not meet Millennium Development Goal (MDG) 5, which relates to reducing the burden of maternal deaths. Even though Ethiopia has reduced under-five mortality by two-thirds from the 1990 figure of 204/1,000 live births to 68/1,000 live births in 2012, meeting the target for MDG 4 three years ahead of the deadline, about 190,000 children are still dying every year. The Federal Ministry of Health (FMOH) has developed a number of strategic interventions for prevention of maternal and child morbidity and mortality, all of which depend on a reliable supply of essential health commodities. However, there are significant challenges currently in the supply chain management of commodities for maternal, neonatal, and child health (MNCH), including:
Little data on stock status are readily available, particularly from service delivery points (SDPs) and from parallel distribution.
The supply chain system for MNCH commodities is inconsistent and has not been integrated into the Integrated Pharmaceutical Logistics System (IPLS).
Lack of a coordinated national supply plan for maternal and child health commodities leads to shortages and ad hoc requests to partners and stakeholders for resources.
PFSA with its partners developed and began implementing the IPLS in 2009. IPLS is intended as an integrated health commodity supply chain that includes all health program commodities. So far, commodities management of various health programs including family planning, HIV, tuberculosis, and malaria have been included, but not MNCH commodities. Strengthening the supply chain for MNCH commodities at each level of the system needs greater attention and needs to be looked at holistically. Therefore, PFSA, USAID’s Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project, the FMOH, and other supporting partners conducted a qualitative and quantitative MNCH commodities logistics system assessment. The findings of the survey are meant to raise collective awareness and sense of ownership of the system and set goals and strategies for improvement.
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Methodology The MNCH logistics assessment collected both qualitative and quantitative data using two separate tools: the Logistics System Assessment Tool (LSAT) and the Logistics Indicators Assessment Tool (LIAT), respectively. The information collected using the LSAT was analyzed to identify issues and opportunities and outline appropriate interventions. On the other hand, the data collected by LIAT was analyzed to assess the availability of commodities. Data collectors visited each of the regions in April 2017 over a two-week period to collect data. The teams visited the following sample of sites:
Central PFSA
11 PFSA branches
9 Regional and 2 City Administrative Health Bureaus
24 Woreda Health Offices (WoHOs)
100 service delivery points (SDPs) (29 hospitals and 71 health centers).
Findings Organization and Staffing: Multiple stakeholders are involved in MNCH commodity management: PFSA, the FMOH, Regional Health Bureaus (RHB) pharmacy core process owners, WoHO pharmacy/supply units, facility store managers, and partners. The assessment pointed out the availability of supply chain expertise in PFSA, availability of guidelines and standard operating procedures (SOPs) for managing and using the logistics management information system (LMIS), and the establishment of coordination mechanisms as strengths. However, most discussants agreed that supply chain expertise is limited at lower levels of the supply chain, particularly at WoHOs and facilities; key logistics task performers were overburdened; and many agencies, including PFSA, did not fill job vacancies promptly. Logistics Management Information System: Ethiopia has a well-designed LMIS used for other program commodities, including those for HIV, family planning, TB, and malaria. The Health Commodity Management Information System (HCMIS) is automated in the PFSA center and covers all 17 hubs and about 658 SDPs. Some of MNCH commodities have been included in versions of the Report and Requisition Form (RRF) and facilities request every two months with other IPLS integrated commodities. Because the MNCH commodities distribution plan is prepared using Health Management Information System (HMIS) reports and population data, facilities do not receive new stock even if they complete the RRF. In addition, there is limited visibility of commodities flowing through parallel distributions. Quantification: PFSA leads MNCH quantification, with technical support from partners. However, the linkage between forecasting and procurement/supply planning was weak. The discussions pointed out that once the quantification report is finalized, decision-making and follow-up regarding the result is feeble, sometimes resulting in parallel and uncoordinated
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supply planning and procurements either being made or not. There was no systematic follow-up of supply plans to see if they are being implemented or no periodic revisions. Procurement: PFSA is mandated to procure MNCH commodities from several funding sources—direct government funds, the United Nations’ Sustainable Development Goals pool funds, and Reproductive, Maternal, Newborn, and Child Health Trust Funds (RMNCH TFs)—but commodities. PFSA usually applies tender-based bidding for procuring products with products being purchased from the lowest bidder that satisfies bidding requirements. To ensure the quality of products, PFSA uses quality assurance mechanisms of Ethiopia’s Food, Medicine and Health Care Administration and Control Authority. The Clinton Health Access Initiative and Results for Development also use PFSA as a procurement agent for zinc and amoxicillin dispersible tablets, respectively. Inventory Control: Most MNCH commodities are distributed based on an allocation/distribution plan prepared at the FMOH using central-level HMIS data, without consumption data and stock status from the lower levels. At the SDP level, there was no defined inventory control system (minimum and maximum) for MNCH commodities since supply is often constrained as MNCH commodities are not in full supply. Warehousing and Storage: Although there are guidelines for the storage and disposal of medicines, in many cases they were said to be not available and not followed, especially at lower levels. The existing storage capacity of WoHOs and health facilities is often inadequate to handle all the required commodities, especially for cold chain items; in addition, the available space is not always well utilized or organized. Physical inventory at most sites is only done annually and the practice of first-to-expire-first-out was said to be generally followed. Expired products are a problem at all levels, although there are no organized data to quantify it. Transport and Distribution: There is no set delivery schedule for MNCH commodities. Whenever products are available, they are delivered on a bimonthly basis with IPLS integrated commodities, through an FMOH-determined allocation. External partners also provide transportation and distribution support. Product Use: Various tools such as standard treatment guidelines (STGs) exist, but their availability and use are limited. Prescribing practices and adherence to STGs often are overlooked, and compliance is not monitored. Finance, Donor Coordination, and Commodity Security Planning: Donors provided the greatest proportion of funding for MNCH commodities. While funds from the RMNCH TF and basket funds (Sustainable Development Goal-pooled fund) can be regarded as government sources, the government’s contribution from its own budget was a small portion of child health commodities over the past two years. The FMOH has established a policy to provide MNCH services and commodities free of charge at primary health care units. In 2014, FMOH designed a new “reimbursement protocol” supported with US$10 million seed funding for maternal health commodities, particularly those for delivery services at secondary- and tertiary- level hospitals. xvii
In addition, RHBs also allocate a budget seed funding once a year that can be used for MNCH items. However, there is a lack of common understanding about these policies and their implementation at different levels of the system: PFSA, RHBs, WoHOs, and SDPs, as well as among most partners, which results in limited use of these resources for MNCH commodities. FMOH and PFSA have donor coordination mechanisms related to MNCH; for example, an FMOH steering committee, a RMNCH task force, and an MNCH Logistics Technical Working Group (LTWG). These groups are fully functional and comprise government institutions, United Nations agencies, partners, and nongovernmental organizations. Logistics Tools: More than half (51%) of SDPs had bin cards; 94 percent of these maintained updated bin cards. The assessment team found SDPs did not maintain bin cards for some products that had predominantly been supplied by partners, unlike those government-supplied items. Stock Status: Stockouts of maternal health commodities range from 77 percent for misoprostol 200 mcg tabs to 9 percent for oxytocin. For child health commodities, stockout rates vary from 74 percent for chlorhexidine gel to 19 percent for zinc 20 mg dispersible tablets. The probable reason for low availability of chlorohexidine was associated with its recent introduction for newborn cord care. For maternal health commodities, one of the facilities didn’t have any of the items in stock, 6 percent had one item, 8 percent had only two items, and only 4 percent had all seven items. Child health availability was somewhat better: all sites had at least one item, 3 percent had only one, 14 percent had two items, and 3 percent had all six items. Generally, product availability was significantly higher at hospitals than health centers.
Recommendations The assessment provided valuable information that can help stakeholders better understand the MNCH logistics system and strengthen MNCH commodity availability at public-sector health facilities. The resulting recommendations focus on three major issues that can be addressed over the short and medium term where feasible intervention is possible and improvements will lead to immediate improvement and lasting impact: 1. Strengthen the linkages between forecasting, supply planning and resource mobilization. The full impact of IPLS integration can only be achieved if MNCH items (or at least priority MNCH items) are in full supply. In other words, target populations can access items sustainably and financial resources will be made available to meet program goals. The future problems in supply are more likely to relate to planning and coordination rather than availability of funding per se. PFSA leads national quantification efforts, but the full benefits of quantification will only be realized through strong linkages between forecasting and supply planning. The supply plan needs to be linked to resource mobilization through the national and partner budgetary process and budget releases for procurement.
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2. Integrate MNCH commodity management into the IPLS. IPLS has a well-developed information system with standard tools and a degree of automation, though the system needs overall strengthening; it remains by far the best option for MNCH commodity management. Integration with IPLS would mean demand-driven ordering; forms, and SOPs; leveraging existing training programs for lower-level staff on the use of those forms; and routine direct delivery to many SDPs. 3. Increase data visibility for MNCH commodities. The HCMIS is automated in the PFSA center and covers all 17 hubs and about 658 SDPs (AIDSFree 2017); remaining sites use a paper system. PFSA “supply chain dashboard,” shows stock on hand at central and hub levels and what stock has been issued to facilities. Syncing suppliers’ data, procurement data, warehouse stock on hand, and warehouse issues—to PFSA dashboards is feasible, and in the short term would allow decision-makers to better identify shortages and potential overstocks and enhance utilization of resources and supply chain performance. Utilization of stock-keeping records and improving storage conditions are important areas of interventions to increase data visibility. The assessment team believes the three issues recommended here can be championed and led by the MNCH community for quick results and real impact.
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PART 1. INTRODUCTION
1.1. Background Ethiopia has significantly reduced its maternal mortality from the 1990s estimate by an average annual rate of 5 percent or more. According to the latest United Nations’ (UN) estimate, the proportion of mothers dying per 100,000 live births has declined from 1,400 in 1990 to 420 in 2013. The Ethiopian Demographic and Health Surveys of 2011 and 2016 reported maternal mortality rates of 676 and 412 per 100,000 live births, respectively. However, Ethiopia still did not meet Millennium Development Goal (MDG) 5, reducing the burden of maternal deaths. Even though Ethiopia has reduced under-five mortality by two-thirds from the 1990 figure of 204 per 1,000 live births to 68 per 1,000 live births in 2012, meeting the target for MDG 4 three years ahead of the deadline, about 190,000 children are still dying every year. To accelerate progress and achieve post-2015 Sustainable Development Goals (SDGs), the Federal Ministry of Health (FMOH) and partners have developed a number of strategic interventions. Availability of and access to MNCH commodities is one of the key strategies for prevention of morbidity and mortality in Ethiopia. PFSA with its partners—including the USAID | DELIVER PROJECT, the United States Agency for International Development’s (USAID’s) Supply Chain Management Systems (SCMS) project, and others in the sector—developed and began implementing the Integrated Pharmaceutical Logistics System (IPLS) in 2009. With the introduction of IPLS, the Pharmaceuticals Fund and Supply Agency (PFSA) began implementing an integrated health commodity supply chain intended to include all health program commodities. During the assessment period, IPLS manages various health program commodities—family planning, HIV, tuberculosis, and malaria—but not MNCH commodities. Vaccines are managed by PFSA but distributed vertically. IPLS is now implemented in almost all of the public health facilities in the country. Routine monitoring reports show that the level of implementation of IPLS is improving over the years, as is the availability of commodities at SDPs. However, MNCH commodity availability presents current challenges as follows:
Little data on stock status are readily available, particularly from service delivery points (SDPs) and from parallel distribution.
Supply chain system for MNCH commodities is not consistent or integrated into the IPLS.
Lack of a coordinated national supply plan for maternal and child health commodities leads to shortages and ad hoc requests to partners and stakeholders for resources.
These challenges result in limited availability due to stockouts and shortages of commodities at health facilities. Availability of MNCH commodities generally is less than that for other priority program items. For example, an index of contraceptive availability at the health post level showed that in 2016 availability was 81.5 percent (i.e., four out of five priority items on average available), while for maternal health items the availability was only 46.8 percent (slightly less than half of items available), and for child health items, it was slightly better at 57.7 percent (Last 10km Project internal data). 1
Recent surveys have also identified problems with commodity availability. A 2015 United Nations Population Fund (UNFPA) study showed that only 20 percent of facilities had seven (including two essential) maternal/reproductive health medicines at the primary level, with availability increasing at the tertiary level to 86.4 percent (UNFPA 2015). Supportive supervision visits by PFSA and Clinton Health Access Initiative (CHAI) staff in 2017 found stockout rates of 18 percent for amoxicillin dispersible tablets, 27 percent for oral rehydration salts (ORS), and 9 percent for zinc dispersible tablets. Ethiopia’s national supply chain management system does not prioritize MNCH commodities, although their availability significantly reduces morbidity and mortality. To address this shortcoming and provide stakeholders with an overview of Ethiopia’s current MNCH commodities logistics system, AIDSFree Ethiopia, PFSA, and other partners conducted an assessment through the MNCH Logistics Technical Working Group (MNCHLTWG). The survey’s findings will improve stakeholders’ collective awareness and ownership of the system and inform goals and strategies for its improvement. PFSA, FMOH, and their partners strongly believe that the MNCH commodity supply chain must be strengthened at every level. Therefore, AIDSFree Ethiopia, PFSA, FMOH, and other partners through the Maternal Newborn and Child Health Logistics Technical Working Group (MNCHLTWG) conducted a qualitative and quantitative MNCH commodities logistics system assessment to provide stakeholders with a comprehensive view of all aspects of the MNCH logistics system. The survey findings would raise collective awareness and sense of ownership of the system and will set goals and strategies for improvement.
1.2. Country Profile Ethiopia’s Demographics and Socioeconomics According to the Ethiopian Central Statistics Agency, Ethiopia is the second most populous country in Africa with a total population of 90.1 million, of which more than 84 percent live in rural areas. Ethiopia’s population is young, with 45 percent under age 15 and 14.6 percent (13.2 million) under age 5. Women aged 15–49 account for 23.4 percent of the total population. The average household size is 4.8 people, the urban population having a smaller mean household size (3.6) than the rural population (5.1). World Health Organization statistics show that life expectancy at birth is 64 years on average for both sexes: 65 years for women and 62 years for men. Ethiopia covers an area of about 1.1 million square kilometers. It has great geographical diversity, with high peaks ranging from 4,550 meters above sea level to low depressions of 110 meters below sea level. The country has shown impressive economic growth over the last 10 years, although per capita income remains below the sub-Saharan average. The Poverty Head Count Index has declined from the 1996 level of 45.5 percent to 32.7 percent in 2007–08.
Ethiopia’s Health System Health care delivery in Ethiopia is a three-tier system. The primary-level health care delivery system in rural settings includes health posts accountable to health centers, which in turn are associated with 2
primary hospitals. In urban settings, the health center is the primary care entry point to the health system. Secondary-level health care includes general hospitals, and the tertiary level includes tertiary hospitals. As more than 80 percent of the Ethiopian population resides in rural areas, the Health Sector Development Plans have given significant attention to the primary health care units while also strengthening the referral system to the secondary and tertiary levels. Ensuring that every women and child can survive and thrive is a priority for Ethiopia’s health system, central to the goal of saving women’s lives and improving child health. Access to safe, high-quality, and affordable MNCH commodities is essential to achieving these national and global priorities. Many maternal, neonatal, and child deaths usually are due to preventable or treatable causes, which can be averted through skilled institutional care backed by the required health commodities and medical supplies.
1.3. Objectives of the MNCH Logistics System Assessment The general objective of the assessment was to provide stakeholders with a comprehensive view of all aspects of the MNCH logistics system and to identify MNCH commodities logistics and commodity security issues and opportunities. The assessment also looked at the MNCH commodities system management practices and the availability of selected essential medicines. The assessment was conducted under the leadership of PFSA through the MNCHLTWG, with technical and financial support from John Snow, Inc. and USAID’s Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project. The objectives of the assessment were as follows:
To identify key issues and challenges in MNCH commodities logistics and commodity security and to develop recommendations for the next steps needed for MNCH logistics system improvement. To raise collective awareness, build sense of ownership of system performance, and set goals for improvement. To assess selected MNCH commodities inventory management and logistics system management practices, such as utilization of recording and reporting formats, transport and distribution, supervision and training, and storage conditions. To assess MNCH commodities stock status information, including stock availability, and map funding sources.
1.4. Assessment Methodology The assessment collected both quantitative and qualitative data using two separate tools: the Logistics System Assessment Tool (LSAT) and the Logistics Indicators Assessment Tool (LIAT), respectively. A total of 11 teams of four to five data collectors each, were dispatched to each of the regions over a two-week period, April 3–27, 2017, to collect data. A list of data collectors can be found in Appendix I. The teams visited the following sample of sites:
Central PFSA 11 PFSA branches 9 Regional and 2 City Administrative Health Bureaus 3
24 Woreda Health Offices (WoHOs)
100 service delivery points (SDPs) (29 hospitals and 71 health centers).
Data Collection Instruments The LSAT and the LIAT were adapted and customized specifically for this assessment. The LSAT is a comprehensive, qualitative diagnostic and monitoring tool by which strengths and weaknesses of the logistics system were identified through informant interviews involving participants from all levels of the health system. The information collected using the LSAT was analyzed to identify issues and opportunities and outline appropriate interventions. The LIAT, a quantitative data collection instrument first developed by DELIVER, was used to conduct a facility-based survey to assess health commodity logistics system performance and commodity availability. For the purposes of this assessment, the LIAT was adapted specifically for Ethiopia. A copy of the LIAT used for this assessment can be found in Appendix 2.
Data Collection The assessment used the LSAT as an interview guide to collect information from key informants. Data collectors conducted interviews with key program and supply chain contacts in FMOH, UNICEF, 1 central and 11 regional PFSA warehouses, 9 Regional Health Bureaus (RHBs), 2 City Administration Health Bureaus, and 24 WoHOs. Interviews were followed by a joint stakeholder’s discussion. See Appendix 1 for a list of LSAT participants. The areas assessed included organization and staffing, LMIS, product selection, forecasting, procurement, inventory control procedures, warehousing and storage, transport and distribution, organizational support for the logistics system, product use, finance/donor coordination, and commodity security. Identification of strengths and weaknesses was done for each section, helping managers to focus on areas of concern. Quantitative data collection was done using the LIAT tool through a team of representatives from the PFSA hub, Regional Health Bureaus (RHBs), the Global Health Supply Chain Program–Procurement and Supply Management Project (GHSC–PSM), and AIDSFree. Before conducting the assessment, data collectors participated in a one-day orientation on the use of the LIAT instrument. As part of the orientation, data collection guidelines were discussed to identify the types of information to be gathered, standardize the data collection process, and promote comparability of results. At that time, input from assessment team members was integrated into the survey tool, which was then piloted in two health facilities in Addis Ababa. After the field test, slight modifications were made to the tool prior to its use in the assessment. Each team was assigned a leader responsible for overseeing the data collection process in their assigned region. The team collected the following information at each SDP: availability of essential tracer medicines at the time of the assessment and during the past six months, most common supply source for each tracer medicine, source of funds to procure tracer medicine, availability and utilization 4
of bin cards, and reporting practices. Data were entered into an Excel form by the team leader and sent to AIDSFree for compilation and summary analysis. Following data collection, the research team prepared a preliminary analysis and presented the preliminary data to PFSA and the MCHLTWG members.
1.5. Ethical Considerations Prior to data collection, PFSA branch warehouses, RHBs, WoHOs, and management of the respective facilities were informed of the assessment. During data collection, each respondent was informed about the purpose, scope, and expected outcome of the survey. A respondent who was not interested in participating in the survey had the right to refuse, and respondents could decline to answer questions or discontinue the interview at any time. All data were anonymous and no individual or facility will be identified in any reports or other publications arising from the study.
1.6. Limitations of the Study This assessment had the following limitations:
The sample size included in the survey was purposely determined and relatively small (100 facilities) compared to the total number of SDPs (3,858) in the country.
Health posts are considered dispensing units of health centers and so were not directly sampled.
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PART 2. QUALITATIVE FINDINGS AND DISCUSSIONS Qualitative findings presented are based on discussions and interviews with key informants. The recommendations presented in each subsection are based on a consensus of key informants.
2.1. Organization and Staffing Multiple stakeholders are involved in MNCH commodity management: PFSA, the FMOH Pharmaceutical Medical Equipment Directorate (PMED), the RHB pharmacy core process owners, WoHO pharmacy/supply units, facility store managers, and partners. Areas of expertise include MNCH commodities quantification and forecasting, procurement, storage and distribution, and supply chain management and decision-making. PFSA has three relevant directorates, among others, that perform key logistics tasks as follows:
The Forecasting and Capacity Building Directorate is responsible for forecasting the pharmaceutical needs of the country and providing training in supply chain management.
The Procurement Directorate leads procurement of all pharmaceutical products from local manufacturers and international suppliers.
The Stock and Distribution Directorate is responsible for storage and distribution of all pharmaceutical products.
During the study, PFSA had 17 functional branches nationwide. The discussion also pointed to the availability of supply chain expertise in PFSA, availability of guidelines and standard operating procedures (SOPs) for managing and using the LMIS, and the establishment of coordination mechanisms as strengths. However, most discussants agreed that supply chain expertise is limited at lower levels of the supply chain, particularly WoHOs and facilities; key logistics task performers are overburdened; and vacant positions are left unfilled at many levels, including at PFSA itself. In 2014, the FMOH established a Pharmaceutical Logistics Management Unit (PLMU), which was restructured in 2015 and evolved into the PMED. The Directorate is organized into three main units: the PMED, the Pharmacy Services Unit, and the Health Technology Management Unit. The PMED is responsible for bridging a perceived communication gap between FMOH programs and PFSA in forecasting for program commodities, follow-up of procurements and distribution to lower levels, improving information flow through the LMIS, and using these data for decision-making. Similarly, pharmacy units are organized at each RHB and WoHO with a mandate more or less similar to PMED, except that there is no quantification done at those levels. Donors such as UNICEF, the Bill & Melinda Gates Foundation (B MGF), and the UK Department for International Development (DFID) are involved in child health commodities; and UNFPA is involved in procurement maternal health commodities. However, there is limited coordination among key supply chain stakeholders.
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Since its start in 2007, PFSA has worked to establish an integrated health commodity supply chain that includes all health program commodities, connecting all levels with accurate and timely data for decision-making (Figure 1). PFSA, in collaboration with partners, has developed a standard training curriculum for the IPLS process. Through trainings-of-trainers of technical staff from PFSA, RHBs, and other logistics partners, more than 10,000 health professionals, from all nine regions and two city administrations, have been trained by PFSA and its partners. To reinforce the training, stakeholders, including PFSA, RHB, and other partners, make supportive supervision visits to health facilities. Job aids and essential reference materials, including SOPs and standard recording and reporting forms, have been printed and distributed to each supply chain level, including to SDPs. Donors and partners continue to support PFSA and FMOH through supportive supervision using standardized monitoring tools. On-the-job training, feedback, and orientation are provided to facilities as necessary. Routine monitoring reports show that IPLS is improving information recording and reporting, and storage and distribution systems, as well as the availability of essential commodities at SDPs for other program commodities (Shewarega et al. 2015). However, supportive supervision is mainly dependent on partners. The public sector has limited budgets to provide routine supportive supervision of lower levels. There is no clear plan and documented schedule for supportive supervision, and no logistics activities are described in the job descriptions of SDP staff managing commodities. Support given to WoHOs and SDPs is not clearly documented, and often there is no reference to previous visits. There is limited or no feedback on performance, in particular for MNCH commodities. The discussions also revealed that PFSA is not fully responsible for supply chain management of MNCH commodities. While PFSA stores and distributes medicines (apart from those that UNICEF manages directly), PFSA does not make certain key decisions on what to distribute. For example, as MNCH commodities are not integrated into the IPLS, the FMOH PMED mainly uses the Health Management Information System (HMIS) report from central level and population data to prepare a distribution plan (allocation) to lower levels. Based on the FMOH distribution plan, PFSA distributes commodities to respective hubs, and hubs in turn distribute the commodities to WoHOs. Finally, WoHOs distribute the commodities to health facilities.
Recommendations
Improve collaboration and partnership between FMOH, PFSA, RHBs, and partners.
Increase organizational and human resource capacity of the supply chain, particularly at lower levels.
Strengthen current coordination mechanisms and improve their effectiveness at all levels.
2.2. Logistics Management Information System An LMIS collects, organizes, and reports logistics data for decision-making. Ethiopia has a welldesigned LMIS used for other program commodities, including HIV, family planning, TB, and malaria. The LMIS is automated in the PFSA center and covers all 17 hubs and about 658 SDPs (AIDSFree 2017); remaining sites use a paper system. The majority of personnel responsible for managing 8
commodities in the main store (pharmacy store) are trained in LMIS and IPLS; 69 percent of health center pharmacy staff and 84 percent of hospitals staff received IPLS training in 2014 (Shewarega et al. 2015). The LMIS/IPLS forms collect essential logistics data items: stock on hand, losses and adjustments, and consumption. Facilities send bimonthly Report and Requisition Form (RRF) reports to their respective PFSA hubs if they are direct delivery sites. PFSA distributes program medicines directly to more than 1,500 sites (PFSABPR, 2017), and to the remaining sites they deliver to WoHOs and SDPs, and then collect from them. Indirect delivery sites send their RRFs to their catchment woredas. WoHOs then collect and send either non-aggregated, or in some cases aggregated, RRFs to PFSA hubs. Although there is a paper LMIS for IPLS commodities, MNCH commodities are not included,1 so there are no data on demand or stock on hand from health facilities. PFSA uses an automated transactional inventory management system, the Health Commodity Management Information System (HCMIS), in which data flow into a supply chain dashboard that provides live data on MNCH stocks at the central and hub/regional levels. Although dashboard usage is increasing, it is low overall. AIDSFree works with PFSA to track dashboard usage using Google Analytics. According to a 2017 AIDSFree quarterly report, in mid-2017 there were 158 monthly users for all PFSA locations and for FMOH. Under the IPLS, facilities report their commodity status for program commodities and reorder every two months, using the standardized RRF. This can be misleading, as the policy and process changes required to consider them as IPLS have not been made. In other words, even facilities that have completed the RRF are not resupplied based on their form. Therefore, the only advantage in having an RRF with MNCH items preprinted is that it facilitates future efforts for supply chain integration. The MNCH commodities distribution plan is prepared mainly using data from the HMIS case numbers report and population data, rather than actual demand. Finally, data are frequently not up-to-date or high-quality.
1
Some versions of the RRF do have certain MNCH items preprinted; because they are not considered IPLS items, SDPs do
not order them using the RRF, or if they do, PFSA hubs ignore the order, in which case resupply quantities are determined centrally by FMOH.
9
UNFPA
UNICEF Ethiopia
IPs 17
RHB
17
Zones
(For c. 2400 facilities)
Health Centers & Hospitals (c. 1500)
Health Centers & Hospitals (c. 2400)
Health Posts (collect)
Note: For revolving drug fund items, facilities usually collect from PFSA hubs Note: Health posts collect commodities from health center
10
Recommendations The logistics management information system (LMIS) for MNCH commodities should be managed based on IPLS. There is a well-designed logistics system (IPLS), where other program commodities, including those for HIV, family planning, TB, and malaria, are distributed directly to facilities based on their demand. PFSA also uses an automated LMIS—the HCMIS—with data flowing into commodity dashboards providing live data on MNCH stocks at the hub and regional levels. Integration would improve supply chain performance and efficiency.
Increase and improve HCMIS dashboard data utilization for decision-making.
Ensure availability and use of the revised RRF, which will include all MNCH commodities considered as part of the IPLS program.
2.3. Quantification PFSA leads MNCH quantification, with technical support from partners. However, the linkage between forecasting and procurement/supply planning was weak. Donors, partners, FMOH, and PFSA are all involved in MNCH commodities quantification. However, once the quantification report is finalized, decision-making and follow-up regarding the result is feeble, sometimes resulting in parallel and uncoordinated supply planning and inconsistently completed procurements. There was limited systematic follow-up of supply plans to see if they are being implemented and no periodic revisions. Annual quantification (forecasting and supply planning) is conducted at the central level for family planning, TB, malaria and HIV commodities using logistics and demographic data sources. In 2013, integrated community case management of commodities quantification began using morbidity data. In 2016, this forecasting process and approach was adopted for MNCH commodity quantification, and a three-year forecast, to be revised every year, was completed with technical support from JSI and other partners. The process involves all relevant donors, partners, and other stakeholders, including regional-level stakeholders, and is carried out on a schedule that coincides with the local budgeting cycle. In the forecast, programmatic plans, service expansion, quantities on order, training, and other organizational activities are considered. However, because there are limited logistics data on MNCH commodities, a single data source, morbidity data, is used to forecast MNCH commodities. The absence of a standard dispensing protocol at facilities, nonexistent LMIS, and lack of coordinated supply planning also negatively affect forecasting.
Recommendations Include financial mapping when quantifying MNCH commodities to help incorporate the budget for donors and for FMOH planning.
Ensure coordinated supply planning, including scheduling of shipments.
Clarify the roles and responsibilities of government stakeholders, PFSA, and PMED in supply planning and monitoring.
Ensure availability and use of MNCH commodities stock information for quantification.
11
2.4. Obtaining Supplies/Procurement Procurement PFSA is mandated to procure MNCH commodities from several funding sources—direct government funds, SDG-pooled funds, and RMNCH TFs—but over the past two years government has funded relatively small amounts of MNCH commodities. Child health commodities such as zinc, albendazole, gentamycin, and amoxicillin dispersible tablets are procured/funded through different organizations, including UNICEF, RMNCH TF, the Bill & Melinda Gates Foundation, and DFID. Maternal health commodities; in particular oxytocin, calcium gluconate and magnesium sulfate; are procured through UNFPA. Oral rehydration salts and chlorhexidine gel supplies are funded mainly by government sources through SDG funds and direct government funds. PFSA usually applies tender-based bidding for procuring products; that is, it accepts the lowest bidder that satisfies bidding requirements. To ensure the quality of products, PFSA uses quality assurance mechanisms of the Food, Medicine and Health Care Administration and Control Authority. There are a limited number of suppliers and few locally produced products. Of the 13 products considered in this assessment, ORS, zinc, albendazole, and chlorhexidine gel are manufactured locally. Long procurement lead times often threaten the timely availability of commodities for MNCH programs. PFSA indicated the need to plan one year ahead for international procurement to receive shipments on time. In 2016, PFSA started using HCMIS for procurement, which supports the procurement operations by providing an electronic record and facilitating electronic linkage between procurement and warehouse operations.
Recommendations
Coordinate supply planning and scheduling of shipments, including regular information sharing among donors and stakeholders.
Strengthen linkages among forecasting, supply planning, and procurement.
Procurement of MNCH commodities should be aligned with the government budget and procurement cycle.
Strengthen and ensure the use of HCMIS software for procurement of MNCH commodities.
2.5. Inventory Control Procedures The inventory control system for the IPLS is a Forced Ordering Maximum/Minimum Inventory Control System. This means that all facilities are required to report on a fixed schedule (monthly from health posts, every other month from health centers and hospitals) for all program products integrated in IPLS. Reporting and resupply are linked with bimonthly deliveries. A system is also in place for calculating resupply quantities and placing emergency orders at all levels. Although other program items are resupplied based on IPLS norms, most MNCH commodities are allocated based on an 12
allocation/distribution plan prepared at the FMOH using central-level HMIS data, without consumption data on demand or stock status from the lower levels. Certain MNCH items are also available through the Revolving Drug Fund (RDF), but clients must pay for them and facilities order them based on existing funding, going to the PFSA hub on a cash-and-carry basis. There is no defined inventory control system (minimum and maximum) for MNCH commodities since supply is often constrained as MNCH commodities are not in full supply. There is no redistribution guidance for MNCH commodities, although redistributions for facilities within a woreda may happen.
Recommendations
Use the existing IPLS system for MNCH commodities where SDPs can receive supplies according to their consumption.
Review and enforce inventory control levels and integrate them into the existing tools for inventory control.
2.5. Warehousing and Storage In interviews, respondents said that although guidelines for medical waste disposal (including sharps and biohazard materials) existed, they were unavailable in many cases, especially at lower levels. Further, where guidelines are available, facilities do not always follow them consistently. Many respondents also highlighted a lack of environmentally safe waste disposal facilities. The existing storage capacity of WoHOs and health facilities is often inadequate to handle all the required commodities; in addition, the available space is not always well utilized or organized. For example, AIDSFree supportive supervision data (April–June 2017) shows that on average 71 percent of health facilities had adequate storage conditions; however, the figure was only 59 percent for Phase III sites.2 For inventory management, the practice of first-to-expire-first-out was said to be generally followed, although not always. Physical inventory at most sites is only done annually, although PFSA says it intends to introduce continuous inventory practices in which certain items are checked more frequently. Expired products are a problem at all levels, although there are no organized data to quantify this. Assessment respondents cited the availability of cold storage assets—refrigerators, temperature monitors, fridge tags, etc., as being generally good at center and hubs. The cold chain capacity, particularly at SDPs, is inadequate; the result of shortages or lack of refrigeration is that allocations
2
IPLS implementation delineates sites as Phase I, II, or III, depending on when IPLS implementation occurred, Phase III sites
being the newest.
13
don’t take into account the cold chain capacity of the supply chain levels, including at WoHOs and SDPs. Cold chain is required for certain MNCH commodities, such as oxytocin and ergometrine.
Recommendations Improve cold chain availability and capacity at SDPs (refrigerator at facility) for MNCH commodities.
Look for other strategies or options to meet the cold chain requirement of oxytocin and ergometrine, including possible integration with vaccine supply chain management.3
Strengthen warehouse conditions at PFSA, and storage capacity at the lower levels (WoHOs and health facilities).
2.6. Transport and Distribution There is an integrated route map for distribution of program commodities, with sufficient number of functioning vehicles at PFSA hubs and a clear delivery schedule for program commodities in areas such as HIV and family planning. PFSA charges 7 percent of the total commodities cost for procurement and distribution of commodities to health facilities. As already indicated, MNCH commodities are not managed through the IPLS, so there is no routine delivery schedule for them. Distribution is done whenever products are available on an ad-hoc basis, through an FMOH-determined allocation. External partners also provide transportation and distribution support. Currently, most facilities are resupplied indirectly through WoHOs—PFSA delivers to WoHOs. However, the WoHO transport and distribution capacity is limited; most WoHOs lack the capacity to routinely or regularly deliver health supplies to facilities. In many cases, SDPs pick up, but they also lack transport. This applies to “program” items (HIV, family planning, malaria, and TB), which RDF commodities facilities collect from PFSA hubs as needed on a cash-and-carry basis. UNICEF, which procures a large amount of the child health commodities for Ethiopia, supplies some to the PFSA center but also distributes a large quantity of child health commodities through parallel and poorly defined systems (see Error! Reference source not found.). Some of the commodities go to HBs, some to implementing partners, and some directly to lower levels (zones, woredas, or, in some cases, SDPs). There is little systemic and regular visibility of parallel distribution data to FMOH and PFSA and other stakeholders, leading to potential inefficiencies.
Recommendations Integrate distribution of MNCH commodities within IPLS—this would mean regular, direct delivery to many SDPs. 3
The vaccine supply chain is managed by PFSA, with items stored mainly in cold rooms at PFSA hubs which then distribute
by refrigerated trucks to woredas, or in some cases to zones.
14
Improve distribution and transportation support to all levels.
Discontinue parallel distribution to improve system efficiency and visibility of stocks.
2.7. Product Use Universal safety precaution procedures, standard treatment guidelines (STGs), and dispensing protocols for MNCH commodities are available as written guides prepared by FMOH. Mechanisms are in place at the Ministry and its sublevels to ensure their implementation in the entire three-tier health system structure, which is connected with referrals, supportive supervision, orientation, and training on MNCH programs and services. Changes in protocols include pneumonia treatment with amoxicillin at primary health care facilities for children under five years, diarrhea treatment with oral rehydration salts and zinc, and the use of chlorhexidine gel in newborns for umbilical cord care. However, prescribing practices and adherence to STGs are often overlooked, and compliance is not monitored, commodities are distributed randomly regardless of training status, and existing guidelines are sometimes not available at health facilities. The discussions revealed that the major barriers to client access to the service are mainly stockouts, as well as slow progress on information education and communication/behavioral change communication (IEC/BCC) and training on new product introduction and regimen changes. For instance, in the treatment of diarrhea, zinc is usually overlooked, and for pneumonia, service providers continue to use cotrimoxazole or other antibiotics despite the availability of amoxicillin dispersible tablets. To improve product use, discussants recommended the following:
Recommendations
Ensure distribution, availability, and utilization of STGs at all levels.
Design and put in place a monitoring strategy for implementing STGs, include a monitoring and evaluation plan in the existing plan of action, and monitor its implementation.
Develop tools to support documentation and sharing of information on trained personnel and facilities to help programs monitor the progress in this area.
Use IEC/BCC and orientation of service providers, including supply chain personnel, on new product introduction and per regimen changes.
2.8. Finance, Donor Coordination, and Commodity Security Planning Sustainable and consistent funding for MNCH services and supplies is required as the Government of Ethiopia works to improve maternal, newborn, and child health and to increase access to MNCH services and supplies. Currently donors provide most of the MNCH commodities: UNFPA for maternal
15
health; and UNICEF, B MGF, DFID, and RMNCH TF for child health. Table 1 shows the funding landscape for child health commodities, for Ethiopian budget year (EBY) 2008 and 2009.4 The landscape shows a very high reliance on donors. Even counting funds from RMNCH TF and basket funds (SDG-pooled funds) as Government of Ethiopia expenditures, the government has funded a small portion of child health commodities over the past two years. However, this does not include funds allocated by FMOH as reimbursement for products provided free of charge. Table 1. Child Health Commodities Funding Landscape, EBYs 2008–2009, FMOH Child Health Commodities Amoxicillin DT
Lead Partner
Procurement Agency
Funding Source
Results for Development
PFSA
Bill & Melinda Gates Foundation
UNICEF
UNICEF
UNICEF
Chlorhexidine gel
UNICEF
PFSA
FMOH
Gentamycin injection 20 mg/2ml
UNICEF
UNICEF
FMOH-RMNCH TF
Oral rehydration salts
FMOH
UNICEF
FMOH-SDG PF
Zinc sulfate 20 mg
CHAI
PFSA
B MGF
UNICEF
UNICEF
DFID
UNICEF
UNICEF
UNICEF
125 mg, 250 mg
BMGF and DFID have been supporting the public sector, providing amoxicillin dispersible tablets and zinc. UNFPA has been providing lifesaving maternal health drugs such as oxytocin and magnesium sulfate through its Global Program. Through the SDG fund, UNICEF Ethiopia procured oral rehydration salts worth US$3 million in 2016, and UNICEF also donated iron–folic acid for use in antenatal care. An anonymous donor has supplied misoprostol through DKT and Ipas Ethiopia. The FMOH has established a policy to provide MNCH services and commodities for free at primary health care units. In 2014, FMOH designed a new “reimbursement protocol” supported with US$10 million seed funding for maternal health commodities, particularly those for delivery services at secondary- and tertiary-level hospitals, although at the time of writing only US$1.9 million had been disbursed to PFSA. These funds do not go directly for commodity procurement; rather, it is a reimbursement scheme for facilities providing RDF commodities free of charge to clients. In addition, RHBs allocate RDF seed funding once a year that can be used for MNCH items; there is also a drug budget line at WoHOs and SDPs for pharmaceuticals in general. These items tend to be distributed on a one-off basis.
4
Approximately mid-July to mid-July; EFY 2009 is July 2016–July 2017 in the Western calendar.
16
However, there is a lack of common understanding about these policies and their implementation at different levels of the system among PFSA, RHBs, WoHOs, and SDPs, as well as among most partners, which results in limited use of these resources for MNCH commodities. FMOH and PFSA have donor coordination mechanisms related to MNCH; for example, an FMOH steering committee; a RMNCH task force; and an MNCHLTWG. These groups are fully functional and comprise government institutions, United Nations agencies, partners, and nongovernmental organizations. Through these groups, FMOH and PFSA have received support and collaboration from their partners and stakeholders. The high-level donor coordination mechanisms (the FMOH steering committee and task force) usually overlook detailed technical issues on MNCH conditions, commodities, and logistics because of other priority issues. Finally, the RMNCH task force and MNCHLTWG do not communicate closely and did not always meet regularly. Necessary partners for commodity security, such as private sector and civil society organizations (nongovernmental organizations, community-based organizations, women’s organizations, etc.), are not being effectively mobilized to fully improve and advocate for commodity security. As stated earlier, the biggest share of the MNCH budget is donor-dependent; the Ethiopian government has only limited funds allocated, raising concerns about sustainability and providing for underserved populations.
Recommendations
Prioritize MNCH commodities in FMOH funding arrangements, including in pool funds (SDG) and budget support to RHBs and WoHOs.
Strengthen existing donor coordination mechanisms under the leadership of the Ethiopian government, with regular schedules, representatives from different relevant stakeholders, and minutes and action point tracking.
Ensure sustainable financing for MNCH commodity security.
17
18
PART 3. QUANTITATIVE FINDINGS AND DISCUSSIONS 3.1. Number of Facilities Assessed The assessment team surveyed 100 SDPs (29 hospitals and 71 health centers) which received supplies from 11 PFSA hubs. Figure 2 details the hub-based disaggregation of assessed SDPs. Figure 1. Number and Type of SDPs Visited by Hub Catchment, April 2017
3.2. Source of Supply and Funds for Commodities at SDPs As part of the assessment, respondents were asked for the main source of supply for various items, and to the best of their knowledge the funding source (Table 2). Data should be interpreted cautiously as there are multiple supply sources and supply systems and multiple funding sources; thus, respondents’ perceptions may be incorrect. Program or free items could be supplied through PFSA, by UNICEF, by other implementing partners, or by RHBs (received from UNICEF). RDF items in general will be supplied through PFSA (facilities pick up supplies). Respondents cited RHBs/WoHOs/zones, or PFSA hubs as the main supply source for MNCH commodities. As shown in Table 2, RHBs/WoHOs/zones are the main supply sources for six tracer commodities: chlorhexidine gel, gentamycin sulfate 20 mg/2ml and 80 mg/2ml, misoprostol 200 mcg tablets, amoxicillin 250 mg dispersible tablets, zinc 20 mg dispersible tablets, and ferrous sulfate + folic acid (150 mg + 0.5 mg tablets). The PFSA hub is the main supply source for ceftriaxone 1g/ml, amoxicillin 125 mg suspension, hydralazine 20 mg/ml, methyl-ergometrine maleate 0.2 mg/ml
19
injection, magnesium sulfate 50%in20ml, albendazole 400 mg tablet, oxytocin 10 IU/ml injection, and oral rehydration salts. Funding sources vary: certain items, such as amoxicillin dispersible tablets, ferrous sulfate, magnesium sulfate, misoprostol, and zinc tablets, are generally available free of charge. Others, such as oral rehydration salts and hydralazine, have a much more diverse range of funding sources. Table 2. Percentage of SDPs with Most Common Source of Supply and Funding by Medicine Type, April 2017 Source of Supply (%) Tracer List
Albendazole 400 mg tab
PFSA
RHBs/Zones/ WoHOs
Source of Funds (%)
Partners
Programs
RDFs
Both
58
40
2
58
17
25
71
26
3
15
45
40
34
64
2
100
0
0
Ceftriaxone 1 g/mL injection
78
22
0
15
42
43
Chlorhexidine gel
20
80
0
78
7
15
45
54
1
81
9
10
71
26
3
41
27
32
61
35
4
89
6
5
67
31
2
43
31
26
Misoprostol 200 mcg tablet
21
52
27
87
7
6
Oral rehydration salts
56
40
4
34
29
37
Oxytocin 10IU/ml
57
41
2
56
18
26
Zinc 20 mg dispersible tablet
38
59
3
91
4
5
Amoxicillin 125 mg suspension Amoxicillin 250 mg dispersible tablet
Ferrous sulfate + folic acid 150 mg + 0.5 mg tablet Hydralazine 20 mg/ml injection Magnesium sulfate 50%/20ml injection Methyl-ergometrin maleate 0.2 mg/ml injection
3.3. Availability and Utilization of Stock Records The assessment also recorded whether the SDP pharmacy store managers were keeping bin cards for the medicines they managed and whether those bin cards were up-to-date on the day of the visit. This was defined either by when the bin card updated with the last transaction or, if the facility was stocked out of the item, when the bin card had been updated to reflect a balance of 0. The results were: 20
More than half (51%) of SDPs had bin cards available.
Of the facilities having bin cards, on average 94 percent of items had updated bin cards.
However, there is a significant variation in availability of bin cards by tracer medicine, from as low as
16 percent for chlorhexidine gel and as high as 69 percent for ceftriaxone 1g/ml injection (Figure 3).
Bin cards are less consistently available than expected, and the wide variation in their availability is
surprising. Overall, facilities were less likely to keep bin cards for items that nongovernmental partners
had supplied and more likely to keep cards for commodities they received through governmental
mechanisms. This may be because facilities expect to be held accountable for government-supplied
commodities, but not necessarily for commodities sourced from other stakeholders.
Figure 2. Percentage of SDPs with Bin Cards Available and Updated by Tracer Medicine Type, April 2017
While the availability of bin cards was not ideal, the bin cards that were being kept were up-to-date: from 87 to 100 percent of items had up-to-date bin cards.
3.4. Stock Status The assessment team measured the stock status at each SDP they visited; this included a review of stock availability for both the current stock levels and stock levels for the six-month period prior to the assessment. However, due to the limited availability of updated bin cards, six-month availability data, including duration of stockouts is not included in this report.
21
Stock Status of Specific Tracer Medicines Figure 4 shows that the percentage of SDPs stocked out of any of the maternal and child health tracer medicines at time of visit was high. Stockouts of maternal commodities at time of visit ranged from 77 percent for misoprostol 200 mcg tablets to 9 percent for oxytocin 10IU/ml injection. For child health commodities, stockout rates vary from 74 percent for chlorhexidine gel to 19 percent for zinc 20 mg dispersible tablets. Chlorohexidine’s low availability was associated with its recent introduction for newborn cord care. Figure 3. Percentage of SDPs Stocked Out of Specific Tracer Medicines at Time of Visit, April 2017 Zinc 20mg Dispersible tab
25
Oxytocin 10units/ml
9
ORS
21
Misoprostol 200mcg tab
77
Methyl-ergometrin Maleate
68
Magnesium Sulphate 50%/20ml
31 32
Hydralazine 20mg/ml Ferrous Sulphate + Folic Acid 150mg + 0.5mg tab
47
Chlorhexidine gel
74
Ceftriaxone 1 g /mL
15
Amoxicillin 250mg Dispersible tab
25 24 21
Amoxicillin 125mg suspension Albendazole 400mg tab
0
20
22
40
60
80
100
Figure 4. Percentage of Hospitals and Health Centers Stocked Out of Specific Medicines at Time of Visit, April 2017
For all medicines, stockouts were significantly higher at health centers than at hospitals. For example, methyl-ergometrine maleate 0.2 mg/ml injection was stocked out in 54 percent of health centers mg, compared to 11 percent of hospitals. At hospitals, stockout rates varied from 0 percent for oxytocin 10IU/ml injection to 17 percent for chlorhexidine gel, while for health centers the range was 9 percent for oxytocin to 62 percent for misoprostol 200 mcg tablets. Figure 6 shows the number of items available in SDPs at day of visit disaggregated by maternal (7) and child health (6) commodities.
23
Figure 5. Percentage of SDPs with Number of Commodities Available for Maternal and Child Health Medicines on Day of Visit, April 2017
Percentage of SDPS
35%
32%
30% 22% 23%
25% 20% 14%
15% 10% 5% 0%
0
16%
12%
8%
6%
1% 0%
27% 24%
3%
3%
4%
0%
1
2
3
4
5
6
7
Number of Commodities Available Maternal
Child
For maternal health-related commodities, 6 percent had only one item, 8 percent two items, and so forth. Child health-related commodities were more available: all sites had at least one item, 3 percent had only one, 14 percent two items, and so forth. Four percent of facilities had all seven tracer maternal health commodities available, while 3 percent had all six child health items.
The Last Mile The assessment team defined health posts as dispensing units, and therefore did not directly include them in their assessment. However, in Ethiopia, a country whose largely rural, widespread population does not always have ready access to health centers or hospitals, health posts are a critical source of health commodities. While there are instances where partners may supply particular items directly to health posts, this is frequently limited and of an ad hoc nature. A reasonable assumption is that if a health center does not have an item, then the health post will also be stocked out, with the reverse not necessarily true: just because the health center has an item does not mean a health post will have it. Health posts are located often several kilometers from a health center, transport is limited, and almost always health extension workers must collect their medicines and carry them back to their health post.
Recommendations The assessment provided valuable information that can help stakeholders better understand the MNCH logistics system and strengthen MNCH commodity availability at public-sector health facilities. Many issues were identified, most of which are problems across the entire health supply chain. The recommendations presented here focus on three major issues that can be addressed over the short and medium term where significant improvement is possible and where improvements will lead to immediate and lasting impact:
24
1. Strengthen the linkages between forecasting, supply planning and resource mobilization. The full impact of IPLS integration can only be achieved if MNCH items (or at least priority MNCH items) are in full supply: in other words, target populations can access items sustainably and financial resources will be made available to meet program goals. The next concern in supply are more likely to relate to planning and coordination rather than availability of funding per se. National quantification was led by PFSA, but the full benefits of quantification will only be realized through strong linkages between forecasting and supply planning. The supply plan needs to be linked to resource mobilization through the national and partner budgetary process and budget releases for procurement. 2. Integrate MNCH commodity management into the IPLS. IPLS has a reasonably well-developed information system with standard tools and a degree of automation; though the system needs overall strengthening, it remains by far the best option for MNCH commodity management. Integration with IPLS would mean demand-driven ordering; forms and SOPs; leveraging existing training programs for lower level staff on the use of those forms; and routine direct delivery to many SDPs. 3. Increase data visibility for MNCH commodities All 17 hubs and about 658 SDPs use automated warehouse information system (AIDSFree 2017); remaining sites use a paper system. PFSA uses an automated transactional inventory management system, the HCMIS, in which data flow into a supply chain dashboard that provides live data on MNCH stocks at the central and hub/regional levels. Integrating what is being distributed by parallel mechanisms would enhance data visibility; the PFSA “supply chain dashboard” shows stock on hand at central and hub levels and what stock has been issued to facilities. Syncing suppliers’ data, including UNICEF data—procurement data, warehouse stock on hand, and warehouse issues—to PFSA dashboards is feasible, and in the short term would allow decision-makers to better identify shortages and potential overstocks and to enhance utilization of resources and supply chain performance. Even though PFSA has a web-based supply chain dashboard that provides real-time logistics data, it should be improved to increase data visibility for decisionmaking. Other important issues that must be addressed are utilization of stock-keeping records and improving storage conditions, both important areas of interventions to increase data visibility. The assessment team believes the three issues recommended above can be championed and led by the MNCHLTWG for quick results and real impact.
25
26
REFERENCES
Clinton Health Access Initiative (CHAI). 2017. “Joint Supportive Supervision Report (2nd Round SS).” CHAI: Boston, MA, USA. http://www.pfsa.gov.et/webadmin/upload/PFSA-RHBs-PFSA 2nd Round SS report final.pdf Federal Ministry of Health (FMOH). 2015. Health Sector Transformation Plan 2015/16-2019/20. Addis Ababa, Ethiopia: FMOH. Pharmaceuticals Fund and Supply Agency (PFSA). 2017. Pharmaceutical Supply Process Reengineering for Pharmaceuticals Fund and Supply Agency. Addis Ababa, Ethiopia: PFSA. Shewarega, Abiy, Paul Dowling, Welelaw Necho, Sami Tewfik, and Yared Yiegezu. 2015. Ethiopia: National Survey of the Integrated Pharmaceutical Logistics System. Arlington, VA: USAID | DELIVER PROJECT, Task Order 4, and PFSA. http://apps.who.int/medicinedocs/documents/s21807en/s21807en.pdf Strengthening High Impact Interventions for an AIDS-free Generation (AIDSFree) Project. 2017. AIDSFree Progress Report for 2017, April–June 2017. Arlington, VA: AIDSFree. United Nations Population Fund (UNFPA). 2015. National Health Facility Assessment on Reproductive Health Commodities and Services in Ethiopia 2015. UNFPA and FMOH: Addis Ababa, Ethiopia. http://ethiopia.unfpa.org/en/resources/national-health-facility-assessment-reproductive-healthcommodities-and-services-ethiopia World Health Organization (WHO). 2015. Trends in Maternal Mortality: 1990 to 2015—Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. WHO: Geneva, Switzerland. https://www.unicef.org/eapro/MMR_executive_summary_final_mid-res.pdf
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28
APPENDIX 1. LIST OF DATA COLLECTORS
No 1
2
3
4
5
6
Teams Center
Addis Ababa
Afar
Tigray
Amhara
Oromia (Team 1) Adama
Facilitators
Organization
Email
Woinshet Nigatu
AIDSFree
[email protected]
Fantaye Teka
PFSA
[email protected]
Gulilat Teshome
GHSC–PSM
[email protected]
Seid Ali
CHAI
[email protected]
Miraf Tesfaye
MOH
[email protected]
Azeb Fisseha
AIDSFree
[email protected]
Elizabeth Kassaye
GHSC–PSM/PMED
[email protected]
Tilahun Berhane
PFSA
[email protected]
Etenesh Gebreyohannes
MOH
[email protected]
Mesfin Arega
AIDSFree
[email protected]
Kedir Mohammed
AIDSFree
[email protected]
Mohammed Jude
GHSC–PSM
[email protected]
Tesfaye Molla
PFSA
n/a
RHB Representative
RHB
n/a
Habtamu Berhe
AIDSFree
[email protected]
Fantaye Teka
PFSA
[email protected]
Kahsu Aregawi
AIDSFree
[email protected]
Giday G/Michael
GHSC–PSM
[email protected]
Birhane Meressa
CHAI
[email protected]
Dawit G/Yesus
PFSA hub
[email protected]
RHB Representative
RHB
[email protected]
Woinshet Nigatu
AIDSFree
[email protected]
Miraf Tesfaye
MOH
[email protected]
Tesfaw Silesh
AIDSFree
[email protected]
Bayew Zeleke
GHSC–PSM
[email protected]
Mastewal Ezezew
PFSA
[email protected]
Fikru Bekele
USAID CO
[email protected]
Chane
RHB
[email protected]
Wondimagehu Gezahege
AIDSFree
[email protected]
Girma Habtamu
AIDSFree
[email protected]
Driba Enkossa
GHSC–PSM
[email protected]
Bezaye Kifelew
PFSA
[email protected]
29
No
Teams
8
9
10
11
Organization
Email
RHB Representative
RHB
n/a
Oromia
Readwan Mohammed
AIDSFree
[email protected]
(Team 2)
Biyensa Negera
PFSA
[email protected]
Gulilat Teshome
GHSC–PSM
[email protected]
Tadesse Dessie
AIDSFree
n/a
Tekalegn Admasu
PFSA
[email protected]
RHB Representative
RHB
n/a
Abebe Bogale
AIDSFree
[email protected]
Alula Tadesse
AIDSFree
[email protected]
Fikregiorgis Kebede
GHSC–PSM
[email protected]
Muluken Yilema
PFSA
[email protected]
RHB Representative
RHB
n/a
Welelaw Necho
AIDSFree
[email protected]
Dagne Bililign
GHSC–PSM
[email protected]
Ebrahim Abdulahmid
PFSA
[email protected]
RHB Representative
RHB
n/a
AdmasuTeshome
AIDSFree
[email protected]
Jiregna Wiratu
AIDSFree
[email protected]
Hymanot Dibaba
PFSA hub
[email protected]
RHB Representative
RHB
n/a
Admasu Teshome
AIDSFree
[email protected]
Sisay Kebu
AIDSFree
[email protected]
Tilahun Tamiru
PFSA
[email protected]
RHB Representative
RHB
n/a
Messay Tadesse
AIDSFree
[email protected]
Nejash Abdu
AIDSFree PFSA
[email protected]
Habtamu Kelemu
n/a
[email protected]
RHB Representative
RHB
n/a
Jimma
7
Facilitators
SNNP
Dire Dawa and Harari
Benshangul
Gambella
Somali
30
Qualitative Discussion: Logistics System Assessment Participants
Name
Region/Hub
Organization and Position
Muluken Moges
Addis Ababa Hub
Hub Manager
Reweda Kedir
Addis Ababa Hub
Warehouse & Distribution Officer
Solomon Getnet
Addis Ababa City HB
Pharmacy process owner
Lakew Alemayehu
Addis Ababa City HB
Logistics Officer
Tesfaye Terefe
Addis Ketema Sub City
Medical Service Process Owner
Yeshiwork
Addis Ketema Sub City
Family Health Officer
Nejib Sefa
Addis Ketema Sub City
Logistics Officer
Azeb
Addis Ketema Sub City
Family Health Officer
Tamene Chamo
Bole Sub City
Head of the Sub City Health Bureau
Senait Lulseged
Bole Sub City
Family Health Officer
Betew Admasse
Bole Sub City
Logistics Process Owner
Ato Workine Abebe
PFSA Adama Hub
Stock and Distribution Officer
Ato Ashenafi Irena
PFSA Adama Hub
HR Manager
Kebede Bejiga
Boset Woreda H.Office
MCH Coordinator
Belay Abera
Boset Woreda H. Office
Logistics Officer
Roman Demissie
Boset Woreda H. Office
WoHO Deputy Head
Ebisa Kumsa
Adea Woreda H. Office
Logistics Officer
Bizuhan Asefa
Adea Woreda H. Office
WoHO Head
Asahil Yigzawo
PFSA hub-Mekelle
Distribution Manager
Araya Teklu
PFSA hub-Mekelle
Forecasting and Capacity Building Coordinator
Alemash Micheal
Tigray RHB
Pharmacy Team Coordinator
Tsigabu Gebru
Tigray RHB
Pharmaceutical Distribution
Tazebew Alemu
Tigray RHB
Pharmaceutical Purchasing
Tirhas Asmelash
Tigray RHB
Maternal Health Expert
Yemane Hadush
Tigray RHB
Child Health Expert
Nafkot Birhanu Gemede
SNNP RHB
Medicine & Medical Equipment Supplies & Services Process Owner
Gebre Selassie Tege
Hawassa Hub
Storage and Distribution Coordinator
Muluken
Hawassa Hub
Forecasting and Capacity Building Officer
Miritus Iwaka
Aleta Wondo WoHO
Logistics Officer
Matteas Dansamo
Aleta Wondo WoHO
Logistics Coordinator
Shimeles Shigu
Aleta Wondo WoHO
MNCH Coordinator
Tesgaye Taye
Wondogenet WoHO
Logistics Officer
31
Name
Region/Hub
Organization and Position
Yifru Wakeyo
Wondogenet WoHO
Logistics Officer
Sadik Mohamed
Somali RHB
Pharmacy Services Coordinator
Tsega G/Kidan
Somali RHB
MCH Officer
Mohamed Kuma
Jigjiga PFSA
Storage and Distribution Coordinator
Samuel
Jigjiga PFSA
Forecasting and CB Officer
Mustefa Mohamed
Kebribeya WHO
Logistics Officer
Abdi Mohamed
Jigjiga City Council
MCH Officer
Addis Wondimagegn
Jigjiga City Council
Logistics Officer
Seid Mohammed
Afar RHB
Health Commodity Logistics Officer
Hawa Abdu
Afar RHB
Family Health Case Team Leader
Tatek Mulugeta
Semera PFSA
Forecasting & CB Coordinator
H/Michael G/Medihin
Semera PFSA
Human Resources Officer
Dawd Yesuf
Semera Logia WOHO
Health Promotion & Disease Prevention Logistics Officer
Abebe Deresegn
Semera Logia WoHO
Health Commodity Logistics Officer
Essie Mohammed
Semera Logia WoHO
Head WoHO
Ahmed Abubokir
Amibara WoHO
Head WoHO
Tezera Petros
Amibara WoHO
Health Commodity Logistics Officer
Awoke Mekonen
Amibara WoHO
Health Promotion & Prevention Officer
Keno Feyessa
UNICEF Ethiopia
Health Section Logistics Officer
Bizuhan Gelaw
UNICEF Ethiopia
Community-Based Health Specialist
Bizuhan Gelaw
UNICEF Ethiopia
Community-Based Health Specialist
Sergut Mulatu
UNICEF Ethiopia
Supply Specialist
Edmealem Admasu
Amhara RHB
Health Commodities Supplies Core Process Owner
Nibret Eyasu
Amhara RHB
Family Planning Officer
Simeneh Worku
Amhara RHB
Mothers and Children Case Team Leader
HaftuBerhe
Bahir-Dar
Distribution and Storage Team Leader
Tadele Awoke
Bahir-Dar
Supply Division Senior Officer and Acting Hub Manager
Yenework Alem
Mecha WoHO
Supply Officer
Andulaem Molla
Debube Achefer WoHO
Supply Officer
Tigest Tefra
Debube Achefer WoHO
Cold Chain Store Manager
Lamsgen Worket
Debube Achefer WoHO
Store Manager
Derese Abera
Oromia RHB
Pharmaceutical Logistics Management Unit Coordinator
32
Name
Region/Hub
Organization and Position
Tekalign Admasu
Jimma Hub
Forecasting and Capacity Building Officer
Nura Mohamaed
Agaro Town Health Office
Acting Logistics Officer
Wondwosen Gebremedhin
Kersa Woreda H. Office
Logistics Officer
Berhie Kalayu
Gambella RHB
Curative and Rehabilitative Process Owner
Tesfaye Zelalem
Gambella RHB
Distribution Officer
Tilahun Tamiru
Gambella PFSA
Distribution Coordinator
Nigus Abebaw
Gambella PFSA
Forecasting and Capacity Building Officer
Lua Almero
Gambella Zuria Woreda
Delegate Head
Okelo Oman
Gambella Zuria Woreda
Curative and Rehabilitative Process Owner
Habtamu Mulugeta
Gambella Woreda
Curative and Rehabilitative Process Owner
Mengistu Mengesha
PFSA Assosa
Hub Manager
Haimanot Asefa
PFSA Assosa
Forecasting and Capacity Building Coordinator
Haimanot Diba
PFSA Assosa
Distribution Coordinator
Ahmed Yesuf
Benshangul Gumuz RHB
Distribution Officer
Ahmed Sulman
Komosha Woreda
Curative and Rehabilitative Process Owner
33
34
APPENDIX 2. MNCH COMMODITIES LOGISTICS MANAGEMENT QUALITATIVE AND QUANTITATIVE ASSESSMENT Table A2.1. Facility-Level Data Collection: Logistics Indicators Assessment Tool Informed Consent Introduce all team members and ask facility representatives to introduce themselves. Good day. My name is ________________. My colleague and I are representing ______________________ (e.g., the MOH/PFSA in the country under study). We are conducting MNCH Commodities Logistics Management qualitative and quantitative assessment at selected health facilities. We will be looking at the availability of selected MNCH commodities and information how you order and receive those products. We are visiting selected health facilities throughout the country; this facility was selected to be in the assessment. The objective of the assessment is to provide stakeholders with a comprehensive view of all aspects of MNCH logistics system. The results of this national survey will provide information to make decisions and to promote improvements. The data collected during our visit will not be used to assess job performance or facility performance. We would like to ask you a few questions about the products and supplies available at this facility. In addition, we would like to actually count selected MNCH products you have in stock today and observe the general storage conditions. We will be looking at a variety of forms. These include, stock cards, ledgers, RIVs, receipt books, and forms, etc. Do you have any questions? Ask the facility-in-charge and other staff members if they have any questions before proceeding with the interview questions. May we continue?
Yes
1
No
0
STOP
Ask the in-charge person to introduce the team to the person managing commodities. Extend the invitation to the in-charge to stay with the team but explain that we are aware that he/she has other responsibilities. Offer to check back with him/her before leaving the facility. I. Information About Interview
Date:
DAY MONTH YEAR
Interviewer name(s):
35
NO.
Code Classification
II. Facility Identification
1
Name of the facility
2
Region
3
Zone
4
Woreda
5
City/town:
6
Type of facility
1=Hospital 2=Health Centre
7
Name: _____________________
Name, title and mobile phone number of person interviewed for this assessment
Title: _______________________ Mobile number: ______________
8
Number of years and months you have worked at this facility?
Years: ______ Months: ________
III. MNCH Commodities Under Assessment Oxytocin 10units/ml
Chlorhexidine
Hydralazine 20 mg/ml
Amoxicillin 250 mg tab and/or suspension
Magnesium sulfate 50%/20ml
Amoxicillin 250 mg tab
Ceftriaxone 1 g/mL
Amoxicillin 125 mg suspension
Misoprostol
ORS
Ferrous sulfate + folic acid 150 mg + 0.5 mg tab
Zinc 20 mg dispersible tab
Methyl-ergometrin maleate
Gentamycin sulfate 20 mg/ml, 40 mg/2ml
Chlorhexidine
Albendazole 400 mg tab
36
Remark
Ceftriaxone1g/ml
Misoprostol
Ferrous Sulfate+folic acid150 mg+0.5 mg
Methyl-Erogometinr maleate
Chlorhexidine
Amoxicillin 250 mg tab
Amoxicillin 125 mg suspension
ORS
Zinc 20 mg dispersible
Gentamycin Sulfate 20 mg/mlor 40 mg/ml
Albendazole 400 mg
2
3
4
5
6
7
8
9
10
11
12
13
14
15
1. Is the facility expected to manage MNCH commodities? (Yes, No) 2. What is the usual or most common source (select only one): (1=PFSA, 2=RHB, 3=ZHD, 4=WOHO, NA = for products not managed by the facility, 5=Other, specify) 3. If the direct source of supply for MNCH commodities is PFSA, how does PFSA deliver the product to the facility? 1=Direct delivery , 2=Indirect (PFSA delivers to Woreda/ zone and facility collects), 3=Other 4. How do you get the MNCH commodity—is it for free or for budget? 1=program (free), 2=RDF for budget, 3=both
37
Go To
Magnesium sulfate50%/20ml
1
Hydralazine20 mg/ml
MNCH Commodities Sources of Supply and Reporting
Oxytocin 10 units/ml
Table A2.2.MNCH Commodities Source of Supply and Reporting
Go To
Albendazole 400 mg
Gentamycin Sulfate 20 mg/mlor 40 mg/ml
Zinc 20 mg dispersible
ORS
Amoxicillin 125 mg suspension
Amoxicillin 250 mg tab
Chlorhexidine
Methyl-Erogometinr maleate
Ferrous Sulfate+folic acid150 mg+0.5 mg
Misoprostol
Ceftriaxone1g/ml
Magnesium sulfate50%/20ml
Hydralazine20 mg/ml
Oxytocin 10 units/ml
MNCH Commodities Sources of Supply and Reporting
5. Does the facility usually get the quantities of MNCH products it ordered/requested during the past six months? 1=Yes, 0=No, NA for facilities not requesting Comments: 6. If the answer to Q5 is No, why not: 1=The resupply point does not have adequate supply/the resupply point was stocked out, 2=Order amount was changed at the resupply point, 3=Not sure/Don’t know, 4=Other (specify),NA=Not applicable If no: Part III
7. Does the health facility compile and send MNCH consumption reports to higher level for resupply and/or reporting? 1=Yes, 0=No 8. If yes to Q7, sent to whom? (1=PFSA, 2=RHB, 3=ZHD, 4= WoHO, 5=Other, specify)
38
Go To
Albendazole 400 mg
Gentamycin Sulfate 20 mg/mlor 40 mg/ml
Zinc 20 mg dispersible
ORS
Amoxicillin 125 mg suspension
Amoxicillin 250 mg tab
Chlorhexidine
Methyl-Erogometinr maleate
Ferrous Sulfate+folic acid150 mg+0.5 mg
Misoprostol
Ceftriaxone1g/ml
Magnesium sulfate50%/20ml
Hydralazine20 mg/ml
Oxytocin 10 units/ml
MNCH Commodities Sources of Supply and Reporting
If no go to
9. What are the forms/format used by the facility to request and report MNCH commodities supplies/ and supplies? (1=RRF, 2=Other, specify)
Q11
10. If the answer to Q9 is RRF, Is the most recent RRF complete? 0=No, 1=Yes (Must be verified with completed report; completed report means all the columns for all products listed in the report are filled and at least one product is listed under each program — unless the facility is not managing the product.) 11. Do reports include the following essential data items? Write 1=if yes, only stock on hand; 2=if yes, only quantities used; 3=if yes, only loss adjustment; 4= if yes to 1 & 2; 5=if yes, 1&3; 6=if yes, 2&3, 7=if yes, 1, 2&3
39
12. How often are you supposed to send MNCH commodity reports to the higher level within six months? (Circle all that apply. 1=Every two months, 2=Quarterly , 3=Semiannually , 4=Not regularly, 5=Other, specify, 6=Do not know 13. How many reports have you sent to the direct supplying organization during the past six months? 1=Never, 2=One report, 3=Two reports, 4=Three reports, 5= Four reports, 6= other, 7=don’t know. 14. Do reports include the following essential data items? Write 1=yes, only stock on hand; 2=yes, only quantities used; 3=yes, only loss adjustment; 4=yes, 1&2; 5=yes,1&3; 6=yes, 2&3; 7=yes, 1, 2&3
Comments:
40
Go To
Albendazole 400 mg
Gentamycin Sulfate 20 mg/mlor 40 mg/ml
Zinc 20 mg dispersible
ORS
Amoxicillin 125 mg suspension
Amoxicillin 250 mg tab
Chlorhexidine
Methyl-Erogometinr maleate
Ferrous Sulfate+folic acid150 mg+0.5 mg
Misoprostol
Ceftriaxone1g/ml
Magnesium sulfate50%/20ml
Hydralazine20 mg/ml
Oxytocin 10 units/ml
MNCH Commodities Sources of Supply and Reporting
MNCH Commodities Availability Stock Status (Specify for a full six-month period prior to the survey and for the day of the visit.)
Column: 1. Name of all authorized products that will be counted. 2. Unit of count for the product/commodity. Note: Columns 1 and 2 will be filled out before questionnaires are printed for the survey.
3. Record whether or not the product is managed at this facility, answer Y for yes, or N for no. 4. Check if the bin card is available, answer Y for yes, or N for no. 5. Check if the bin card has been updated WITH THE LAST TRANSACTION, answer Y for yes, or N for no. Note: If the bin card was last updated with the balance of 0 and the facility has not received any of that product since the date of that entry, consider the bin card up-to-date.
6. Record the balance on the bin card. 7. Record if the facility has had any stockout of the product during the 6-month period from Meskerem 1-Yekatit 30, 2009 EC, answer Y for yes, or N for no. 8. Record how many times the product was stocked out during the 6-month period, Meskerem 1–Yekatit 30, 2009 EC, according to bin cards, if available. 9. Record the total number of days the product was stocked out during Meskerem 1–Yekatit 30, 2009 EC, only. 10. Record the quantity of product issued from the storeroom during Meskerem 1–Yekatit 30, 2009 EC, only. 11. Record the number of months the issue data represents (may be 6 months or less); record the months for which there are any data available, including 0.
41
12. Record the physical count in the storeroom. 13. Record if the facility is experiencing a stockout of the product on the day of the visit, answer Y for yes, or N for no. If products are available outside the storeroom, there is no stockout. Visually verify that usable products are in stock. 14. Record if the facility has expired products. If there are products that are near expiry (within three months), note the product and quantity in the comments section.
Note: For any product that was stocked out in the last six months (including the day of the visit), please note reasons (by product).
42
1 2 3 4
Frequency of /No. of stockouts Total number of days stocked out Total issued (most recent 6 months) Number of months of data available Physical inventory— storeroom (quantity)
6 7 8 9 10 11 12
Oxytocin 10units/ml
Hydralazine 20 mg/ml
Magnesium sulfate 50%/20ml
Ceftriaxone 1 g /mL
Misoprostol
Ferrous sulfate + folic acid 150 mg + 0.5 mg
Methylergometrinmaleate
Chlorhexidine
43
13
Availability of expired product (Y/N)
Stockout today? (Y/N)
Stockout most recent 6 months (Y/N) NA
5
Balance on bin card (quantity) NA
Bin card updated? (Y/N) NA
(Y/N)
Bin card available?
(Y/N)
Managed at this facility?
Product Units of count
Table A2.3. Store Stock Data for MNCH Commodities
(for the past 6 months and day of the visit) *for stockouts please complete Table 3
14
Amoxicillin 250 mg tab and/or suspension
Amoxicillin 250 mg tab
Amoxicillin 125 mg suspension
ORS
Zinc 20 mg dispersible tab
Gentamycin sulfate 20 mg/ml, 40 mg/2ml
Albendazole 400 mg tab
44
Availability of expired product (Y/N)
Stockout today? (Y/N)
Physical inventory— storeroom (quantity)
Number of months of data available
Total issued (most recent 6 months)
Total number of days stocked out
Frequency of /No. of stockouts
Stockout most recent 6 months (Y/N) NA
Balance on bin card (quantity) NA
Bin card updated? (Y/N) NA
(Y/N)
Bin card available?
(Y/N)
Managed at this facility?
Units of count
Product
1 2 3
Stockout most recent 6 months (Y/N)na
Frequency of /no. of stockouts
Total number of days stocked out Total issued (most recent 6 months) Number of months of data available Physical inventory— store room (quantity)
5 6 7 8 9 10 11 12
Oxytocin 10 units/ml
Hydralazine 20 mg/ml
Magnesium sulfate 50%/20ml
Ceftriaxone 1g /mL
Misoprostol
Ferrous sulfate + folic acid 150 mg + 0.5 mg
Methyl-ergometrin maleate
Chlorhexidine
Amoxicillin 250 mg tab and/or suspension
45
13
Availability of expired product (Y/N)
out today? (Y/N)
Stock
Balance on bin card (quantity) NA
4
Bin card updated? (Y/N)NA
(Y/N)
Bin card available?
(Y/N)
Managed at this facility?
Product Units of count
Table A2.4. Stock Status in Dispensary Units
14
Amoxicillin 250 mg tab
Amoxicillin 125 mg suspension
ORS
Zinc 20 mg dispersible tab
Gentamycin sulfate 20 mg/ml, 40 mg/2ml
Albendazole 400 mg tab
Comments:
46
Availability of expired product (Y/N)
out today? (Y/N)
Stock
Physical inventory— store room (quantity)
Number of months of data available
Total issued (most recent 6 months)
Total number of days stocked out
Frequency of /no. of stockouts
Stockout most recent 6 months (Y/N)na
Balance on bin card (quantity) NA
Bin card updated? (Y/N)NA
(Y/N)
Bin card available?
(Y/N)
Managed at this facility?
Units of count
Product
MNCH Commodities Data Quality Does the facility use Reporting and Requisition Form (RRF) to report and request MNCH commodities consumption and supply?
Yes =1, No = 0.
For facilities using RRF, complete the following table using the most recent LMIS report; for facilities not using RRF and find that
completing the information in Table 2 is difficult, ask the person/people you interviewed if they want to ask you any questions.
Columns: 1. Will it be pre-populated with the same products as in Table 1? 2. Whether or not the product is managed at this facility, answer Y for yes, or N if no. 3. Check if bin cards and RRF are available, answer Y for yes, or N for no. 4. Get the most recent RRF report showing the selected products, and record the stock on hand (ending balance) from the RRF report in column 3. 5. Write the quantity of usable stock on hand from the bin card from the same time (date) as the selected RRF report. 6. Note the reasons for any discrepancy, if easily determined or as reported.
47
Table A2.4. Usable Stock on Hand at Time of Most Recent LMIS Report Usable Stock on Hand (at time of most recent LMIS report) Managed at the facility Product
No = 0 Yes = 1
Are order records available (bin card and RRF)?
(If No to RRF or bin card, skip to next item—only use acceptable data sources)
Stock on hand/ending balance (according to most recent RRF report)
Stock on hand/ending balance (from bin card from same time as RRF report)
4
5
Reasons for discrepancy
No = 0 Yes = 1 1
2
3
Oxytocin 10units/ml Hydralazine 20 mg/ml Magnesium sulfate 50%/20ml Misoprostol 200 mcg tab Ceftriaxone 1 g/mL Ferrous sulfate + folic acid 150 mg + 0.5 mg tab Methyl-ergometrin maleate Amoxicillin 250 mg tab and/or suspension ORS Zinc 20 mg dispersible tab
48
6
Usable Stock on Hand (at time of most recent LMIS report) Managed at the facility Product
No = 0 Yes = 1
Are order records available (bin card and RRF)?
(If No to RRF or bin card, skip to next item—only use acceptable data sources)
Stock on hand/ending balance (according to most recent RRF report)
Stock on hand/ending balance (from bin card from same time as RRF report)
Reasons for discrepancy
No = 0 Yes = 1 Gentamycin sulphate 20 mg/ml, 40 mg/2ml Chlorohexidine gel Albendazole 400 mg tab Ask the interviewee(s) if they have any questions or would like to make any comments. Interviewee Comments: Thank the person/people who talked with you. Reiterate how they have helped the program achieve its objectives, and assure them that the results will be used to develop improvements in MNCH commodities logistics and commodity security issues and opportunities.
49
AIDSFree 1616 Fort Myer Drive, 16th Floor
Arlington, VA 22209
Phone: 703-528-7474
Fax: 703-528-7480
Email:
[email protected]
Web: aidsfree.usaid.gov
50
