Thoughts From the Last Mile

Promising Practices in Supply Chain Management

Erin

By Erin Larsen-Cooper
Program Associate

 

When VillageReach began work with the Supply and Awareness Technical Reference Team for the UN Commission on Life-Saving Commodities for Women’s and Children’s Health to document promising practices in supply chain management, I was both excited and daunted.  Excited because there is a growing recognition that strengthening supply chains is a fundamental aspect of increasing access to medicines and quality healthcare at the last mile; daunted because while there is so much work being done to improve supply chains in low and middle income countries, documentation and evidence of these interventions can be hard, if not impossible, to find.

One of the team’s first tasks was to conduct a literature review to see how many peer-reviewed articles on supply chain interventions in low and middle-income countries we could find. After a thorough search of several research databases, we came up with almost 500 articles.  Of these, only three met our criteria of using experimental or quasi-experimental methods to determine whether the interventions were successful. Even though I expected there to be limited evidence, I couldn’t help but be surprised by how limited it was. Experiments published in academic journals are not the only types of evidence, so we branched out our search to white papers, engage our professional networks, and use word of mouth to learn more about what governments, businesses and other non-governmental organizations are doing to strengthen supply chains. Many supply chain management interventions, for example, evaluate their effectiveness through key performance indicators. For instance, measuring how long it takes from the time a medication is ordered by a health center for it to be delivered, or how often hospitals are stocked out of essential medicines. The problem is, sometimes the only way to find out this information is to figure out who is working on the project and contact them personally, as many people do not have the time or resources to publish their work and results.

A year after we started, and after hours of research, interviews with experts, and conversations with those working in the field, the Promising Practices in Supply Chain Management series is complete. The team was able to identify more than 30 promising practices in public health supply chain management and find almost 50 examples of where these practices are being implemented in low and middle-income countries. This, in and of itself, is promising!

I’m excited about this work because at VillageReach we believe that more rigorous evaluation of supply chain interventions and more transparent dissemination of results is vital to increasing access to medications to those who need them the most. Creating a body of evidence on what works, advocating that evidence-based practices be implemented, and learning from each other’s progress and each other’s challenges, is the best way to make sustainable change.

Shopping Around for Vaccine Supply Chains? Try it On.

How HERMES modeling tools allow decision-makers to see the impact of vaccine supply chain system changes- before they “buy.”
wendy-300x200By Wendy Prosser
VillageReach Program Manager
USA and Mozambique

You may not think that the world of fashion relates to vaccine supply chains, but let me make the connection. When shopping for that perfect outfit, sweater or shoe- I can go to a store and try on all kinds of options—different sizes, styles, colors, and all combinations therein. And then, with a lot of help from my friends, I can pick the best option for that particular occasion.  When that purchase becomes outdated, worn out or just doesn’t fit anymore, this process can be repeated.

Along the same lines, vaccine supply chains need to be upgraded as new vaccines are introduced or new technologies become available that could bring efficiencies to distribution systems. Unfortunately, there is no supply chain store where a government can go to “try on” different systems to see if they fit properly. Trying different warehouse locations or transport loops, for example, is not as easy as trying on a dress. Yet making a change to a supply chain requires major system changes that no one would want to implement — without trying them out first.

That is why it is so exciting to see the work that the HERMES Logistics Modeling Team is doing with the Ministry of Health in Benin. Keeping with the metaphor, Benin is looking to upgrade its vaccine supply chain “wardrobe” – new vaccines are being introduced and the Ministry of Health is interested in finding efficiencies in distribution.

That is where the HERMES modeling activity has a role – as reported in the journal Vaccines. The HERMES computer modeling and simulation helped the Benin Ministry of Health evaluate different options of redesigning the vaccine supply chain. The modeling exercise looked at the current system, considered consolidating community warehouses, and examined the option of adjusting the national warehouses into a different configuration. The investigators also evaluated the effects of changing transportation routes.

This “virtual laboratory” for the vaccine supply chain identified the most cost-saving results coming from structural redesign and introducing transport loops to the vaccine supply chain. The modeling exercise estimated that the improved plan would save Benin over $500,000 in total costs over the next five years while improving vaccination rates.

As a global health advocate and program manager at VillageReach, I am most excited about the Benin experience because we can draw from it in our work with the Ministry of Health in Mozambique where leadership are using HERMES modeling to consider changes to the vaccine supply chain in order to bring efficiencies and improvements in coverage.  Together, we will be looking for the best “fit” in terms of evaluating system redesign options as new vaccines are introduced into the supply chain. The modeling exercise will consider many of the same issues as Benin: transport loops, different distributions strategies for different areas of the provinces, and inclusion of outreach activities.

Until a supply system “store” is available, a modeling exercise is the next best option. By sharing our learning in Mozambique and Benin, we help build a knowledge set that others can benefit and learn from, considering new approaches to system optimization of the vaccine supply chain. For more information on our work in Mozambique

About the Author: As Program Manager, Wendy Prosser is responsible for the design, implementation, and monitoring and evaluation of health system program for VillageReach in Mozambique. Efforts in Mozambique seek to streamline vaccine logistics with an improved logistics management information system and transport services. Wendy has over a decade of global health experience in program development and management, research and analysis, capacity building, and behavior change communications. This experience has taken her to Mozambique, Malawi, Angola, Kenya, and South Africa in various public health settings, starting with Peace Corps in Cape Verde. Wendy holds a MPA in International Development and Global Health from the University of Washington.

Vitol Foundation Report – CCPF

By Sir Brian Greenwood
Professor, Clinical Tropical Medicine
London School of Hygiene & Tropical Medicine
Advisor, Vitol Foundation

In June I was asked to  visit the Village Reach project in Malawi by one of its funders – the Vitol Fphoto 3oundation.

Dispensing is an important but neglected area and VillageReach is to be commended on recognizing the need for more investment in this area. Malawi has very few trained pharmacists or pharmacy technicians and so much dispensing at the health centre level is done by completely untrained people with a substantial risk that drugs will be wasted and that patients may be given the wrong medication. Pharmacists are trained at the School of Health Sciences in Lilongwe. Fully trained pharmacists undertake a four year course, pharmacy technicians a three course leading to a diploma. A new cadre of pharmacy assistants has been created by the Ministry of Health and VillageReach, with 150 enrolled in the first year. The ultimate goal is to place one pharmacy assistant in each health centre.

Assistants spend the first five months of their course in Lilongwe for basic training, then five months in a district hospital where they work under the supervision of more senior staff, a further five months of training in Lilongwe and then finally five months on their own in a health centre. VillageReach is supporting the training programme for pharmacy assistants with funds from Vitol\, USAID and the Barr Foundation.

I  was accompanied during my visit by Jessica Crawford, head of the Village Reach office in Malawi. . We visited Tyolo Hospital, a district hospital in the tea estates and two nearby health centres. In Tyolo four students had arrived a week previously to begin their practical training and were busy counting out tablets. They were being supervised by a lecturer from the Malawi College of Health Sciences Pharmacy Department in Lilongwe who had come to Tyolo to help the students settle in. In the two health centres we visited, individual students were in the middle of their final practical period. The assistants are responsible for both the receipt and storage of drugs and for their administration to patients. In both the hospital and the two health centres drugs were being very well stored and looked after with stock records being kept. The health centres are supplied from the district hospital and obtaining new supplies from the hospital often requires a day visit by the pharmacy assistant to obtain new supplies. ARV drugs are delivered directly and take up a large part of the storage space. All record keeping, ordering etc., is done manually using written records and it would be a big step forward if some of this could be computerised.

Jessica pointed out that there is a tendency for the assistants to spend most of their time in the store rather than doing dispensing and the two we met were encouraged to spend more time in dispensing and talking with patients about how to take their drugs. In one clinic where drugs were being dispensed by an untrained member of staff, dispensing was not being done well (drugs were being sorted by hand, packages not labelled etc, ) emphasising the need for better-trained staff in this important area.  I observed the same practices when visiting another health centre the following day with the ICEMR team.

The project is currently well supported and USAID have indicated that they may provide further funds. Jessica would like to see more support given to the teaching staff at the Malawi College of Health Sciences Pharmacy Department who are doing an excellent, but rather unrecognised job.  A risk to the project is that the staff trained under the programme, as is the case for more senior pharmacists, will be drawn off into the private sector. It will be important to follow-up the careers of students in this programme.

Overall, this is a valuable project directed at a neglected but important area and it appears from my short visit to be one which is being effectively run and a good investment for Vitol.

 Learn more about the Pharmacy Assistants Training Program

Sir Brian Greenwood
Professor, Clinical Tropical Medicine
London School of Hygiene & Tropical Medicine
Advisor, Vitol Foundation

MY JOURNEY TO THE PHARMACY ASSISTANTS TRAINING PROGRAM

 loveness By LOVENESS KASIYAMPHANJE                                                       Pharmacy Assistants Training Program- Class of 2015                             

My name is Loveness Kasiyamphanje. I am originally from Ntcheu, in the Central Region of Malawi, but I currently live in Namiyango in Blantyre District. I am pursuing a Certificate in Pharmacy Programme at Malawi College of Health Sciences (MCHS), Lilongwe Campus. The programme was created by VillageReach, the Malawi College of Health Sciences (MCHS) and their partners. The Programme is for two years and I am in the first year.

I had always desired to work in the health sector because I was sure that after training I would get a job. Secondly, the deplorable state of our health services mainly due to lack of trained human resource meant that once I get training, I will be of great help to rural communities who are the least served when it comes to health services. I was not sure about what I was getting into because the pharmacy program in Malawi is one of the least known programs, as compared to nursing and the clinical field, hence this is one of my motivating factors to take up this challenge.

While waiting to find out if I was accepted to the programme, I decided to observe some of the duties and pharmacy practices at the nearest Health Centre from my home. Although I was not trained, I could observe some of the poor services being offered at the clinic in regards to the pharmacy. The dispensers were not clearly giving instructions as to how the medicine should be taken, not mentioning the name of the drugs. I recall one time when my sister, who was asthmatic, was given aspirin which had an adverse effect on her. Some of the pharmacy personnel who were responsible for dispensing would leave patients on the queue and go to mop rooms whilst patients were waiting for them. Medicines were being dispensed without packs, with bare hands, and ailing patients were not receiving proper attention and care. For reasons like these, I was interested in the program so that I can make a difference after graduation.

I was invited for oral interviews at Lilongwe campus. It was a big challenge for me because I had never attended an oral interview in my life. This was also an opportunity for me to see the city of Lilongwe. I attended the interviews and one week later, I received a phone call from MCHS, Lilongwe Campus informing me about the good news of my admission into the programme.

When we arrived on campus, the Head of Programmes said that we would stay for ten weeks for basic orientation and half of the class would go for District practical attachments. We started learning basic courses like Anatomy and Physiology, First Aid, Microbiology, Parasitology, Chemistry, Counseling, Communication and Computer Skills. After that, we were partly introduced to programme courses like Pharmacology, Pharmaceuticals and Medicine Management. Then our group, which has 50 students, was divided into two cohorts. I was part of cohort one. Cohort two stayed at the campus while cohort one went to District Hospitals for practical attachments.

I was allocated to Mulanje District Hospital. I was under the supervision of the Pharmacy Technician. I performed a number of activities like pre packing and dispensing medicines, labeling the pill packs, issuing medicines and medical supplies, recording on the stock card any transaction carried, going to Regional Stores for emergency orders and also making sure that the pharmacy was tidy all the times. I was also compiling monthly reports and entered them in the supply chain manager computer program.

I then went to a local health centre in the same district for two weeks. I observed several problems, but the most critical problems were

1)     Dispensing personnel had not gone through an intensive training on medicines and their pharmacological properties.

2)     Poor record keeping led to the facility either having too much stock or not enough.

I managed to make changes at the Health Centre, advising them based on what I had learned at the District Hospital– to help them improve hygiene and safety standards. In addition, I informed them of the importance of keeping records properly to provide accurate consumption data, the losses and adjustments made, the stock outs experienced and the quantity to be reordered.

I was very happy to see the resolutions that I made being implemented at the facility.

This programme, therefore is very important because it will help in combating some of the problems that many health centres are experiencing in Malawi. It will help fill the gap that currently exists in terms of qualified pharmacy assistants in the health centres. With better trained pharmacy personnel, there will be proper record keeping, good dispensing skills and proper management of medicines. Patients will receive recommended combinations and full information on how to take the medication.

The need for more pharmacy assistants in Malawi cannot be over emphasized. Ward attendants, guards and drug clerks who are currently being entrusted with the responsibility of dispensing drugs leaves patients at the risk of getting adverse effects of taking medication without proper information.

Although the program is being taught by well experienced lecturers and also at an institution with a long history of producing quality products, there is still a need for more resources to support the program such as books, classroom space, full-time lecturers, and other resources.

I am looking forward to the five months health centre practical allocation. I hope I will make a much greater change than that of two weeks stay at my local health centre. I hope this programme will continue so that there are pharmacy assistants in the health centres all over the country.

Lastly, I would like to express my special thanks to the programme sponsors who make this program possible, and the Lecturers for the wonderful job that they are doing of ensuring that we get the best skills at school.

Learn more about VillageReach Pharmacy Assistants Training Program

The Illusive “Other Duties as Required”

wendy-300x200By Wendy Prosser
VillageReach Program Manager
USA and Mozambique

How many times have you seen “other duties as required” on a job description? It infers any random thing that may not fit perfectly into other well-defined responsibilities but still needs to get done, so there is a high likelihood that it may land on your desk to take care of.

In the Mozambique health system, this has become the catchall phrase for health workers. They are tasked with numerous responsibilities including the supply chain function, resulting in a crisis for human resources for health. A maternal and child health nurse, particularly in a rural area, is responsible for providing antenatal care, assisting with deliveries, vaccinating children, managing data for all health clinic activities, and completing requisitions of commodities to keep drug supplies well stocked.

Basically, a nurse in a rural area becomes a Jack of All Trades and a master of none.

Professor Saracino, the former Minister of Health in Côte d’Ivoire, summed it up well:

“When you use a nurse or a physician as a logistician, you lose the nurse or physician and you don’t get a good logistician!”

In this sense, becoming a “Master of ONE” as opposed to “NONE,” is one aspect of the Dedicated Logistics System (DLS), a different approach to supply chain management that VillageReach is developing, through the Final 20 Project supported by the Bill & Melinda Gates Foundation. The DLS has shifted supply chain management responsibilities to the hands of a few dedicated personnel. The DLS moves supply chain management functions as high up in the supply chain as is geographically feasible, consolidating tasks at the provincial level so that limited resources available can be dedicated. This frees up a health worker’s time to focus on patient care.

When I visit Mozambique and accompany a vaccine distribution, I see the benefits of this system firsthand. The dedicated logistician checks records and manages the stock while the nurse cares for the many dozens of children waiting for her. The DLS has reduced lines and waiting times, enabled the health workers to focus adequately on primary care, and dramatically improved the reliability of the supply chain, thus increasing trust in the health system.

We have documented this approach, and the role of human resource management in improving vaccine supply chains in the Reaching the Final 20 Policy Paper Series, available here.

For more information on the DLS, and VillageReach work in Mozambique

About the Author: As Program Manager, Wendy Prosser is responsible for the design, implementation, and monitoring and evaluation of health system program for VillageReach in Mozambique. Efforts in Mozambique seek to streamline vaccine logistics with an improved logistics management information system and transport services. Wendy has over a decade of global health experience in program development and management, research and analysis, capacity building, and behavior change communications. This experience has taken her to Mozambique, Malawi, Angola, Kenya, and South Africa in various public health settings, starting with Peace Corps in Cape Verde. Wendy holds a MPA in International Development and Global Health from the University of Washington.

Testing New Ways to Improve the Cold Chain

 

By Tafara Chekai, Technical Officer- VillageReach, Mozambique

As a Technical Officer with VillageReach, I am responsible for working with our partners at the provincial health department and in the health centers to support new cold chain monitoring technology.  In this role, and in my experience visiting rural health centers, I see firsthand the many challenges that exist in infrastructure, issues that greatly impact the cold chain and viability of vaccines. Energy in our communities is unreliable, so often times the refrigerators that store vaccines and other medical commodities lose power for hours or even weeks at a time.  Health workers struggle to balance the time needed to adequately treat patients with their other administrative duties, and fixing a broken refrigerator is not part of their training.   As all of these situations effect the viability of vaccines, they also affect the children who need them.  A better cold chain can save lives. That is why I am excited about the opportunity to observe a simple new technology solution that I think could have great impact in solving these challenges.

While technology has become more and more common in addressing issues of health care in low resource communities, the most effective solutions are usually the most accessible and inexpensive, and ColdTrace is an example of such a technology. ColdTrace is a low cost solution that leverages the power, coverage and availability of mobile telecommunications services in remote/hard to reach areas to improve response time to problems in the Cold Chain Storage System.  ColdTrace is a low-cost cellular phone which has a sensor added to it that can read and monitor temperature. VillageReach is working with Nexleaf to deploy and test ColdTrace devices in 90 health centers in Mozambique starting in May 2014.

How it works: 

New ColdTrace technology developed by Nexleaf provides SMS alerts with real-time information for cold-chain monitoring in Mozambique.

The phone with the built-in temperature sensor is installed in a central position of the fridge that holds the vaccines.  The phone records the temperature at pre-configured intervals. When temperatures go out of the stipulated range, i.e. 2°C – 8°C for a pre-defined period, text messages are sent from the ColdTrace device to clinic staff. If the problem is not resolved within a certain period, escalated messages are sent to the District EPI  (Extended Programme on Immunizations) Officer. If the problem is still not resolved, another escalated SMS is sent to the Provincial EPI Officer. Because this communication all happens so quickly, the time it takes to actually fix the equipment and get it back to operational is much faster than it would typically be.  The SMS sets in motion a communication that is continually managed and repeated in the daily status messages until the problem is resolved. All the data is gathered and processed by ColdTrace and is uploaded to a central server and summaries of these data are sent on a monthly basis to the Ministry of Health.

What are the benefits of ColdTrace to immunization programs?  

Through this initial deployment, we aim to show that ColdTrace:

  • Gives time back to health clinic staff enabling them to focus on their primary job of caring for patients instead of maintenance issues.
  • Decreases the time it takes to identify a problem and coordinate the resources to fix it due to an immediate and ongoing communication that initiates with ColdTrace.
  • Provides the Ministry of Health in Mozambique with critical data needed to evaluate the performance of various clinic response times, as well as different models of refrigerators, helping to improve informed decision-making.

I look forward to seeing the results of ColdTrace in Gaza Province so that VillageReach can share what we have learned about this new technology along with our partner, Nexleaf, and help bring a cost-effective, sustainable solution to more communities in need of cold chain support.

Reposted from the Bill and Melinda Gates Foundation Blog: Impatient Optimists 5.6.2014

How a Phone Call Saved a Life

A frontline perspective of the CCPF “Health Center by Phone” Program
By Novice Gauti
Hotline Supervisor
VillageReach, Malawi

When I trained as a midwife, I had no idea that I would be helping deliver babies over the phone. Technology has come a long way, especially in the district of Balaka in Malawi.

In September of this year, Mercy, a 24 year old pregnant woman from Dailesi village in Balaka, told her family that she wasn’t feeling well, and set out for Kalembo Health Center seated on the back of a bicycle driven by her neighbor. Dailesi village is 12 km away from Kalembo, the nearest health center, and is located in a hilly area far from paved roads. The only transport available is by foot, by bicycle taxi, or – in case of emergency – by ox cart or bicycle ambulance.

Dailesi village is 12 km away from the nearest health center, and is located in a hilly area far from paved roads. The only transport available is by foot, by bicycle taxi, or–in case of emergency–by ox cart or bicycle ambulance.

After an hour of traveling, Mercy started feeling intense muscle contractions signaling the birth of her baby and could no longer sit on the back of the bicycle. Mercy asked the bicycle driver to stop in a nearby village so that the women living there could help her deliver her baby.

With no other transport available, still far from the health center, and without any skilled personnel nearby to help with Mercy’s delivery, her neighbor decided to call Chipatala cha pa Foni for assistance.

Chipatala cha pa Foni (CCPF), which translates to “health center by phone,” is a toll-free hotline that women in rural Malawi can call to speak directly with a hotline worker for information on pregnancy, newborn and child health, and reproductive health issues such as family planning. A VillageReach project, CCPF provides clients with advice they can follow at home, or refers them to a health center or hospital if they’re displaying “danger signs” which require further care. Women in the community can also sign up for CCPF’s “Tips and Reminders” mobile messaging service to receive regular text or voice messages tailored to their week of pregnancy or their child’s age.

Besides information and referrals, CCPF has also linked key services to the community, as in the case of transport. After visiting the CCPF Hotline Room, the Balaka District Transport Officer was so impressed with the potential of CCPF to save lives that he offered to assist in arranging transport logistics for callers in critical condition or in need of immediate care. He gave us his telephone number and requested that we let him know of any emergency transport needs.

Less than one week later, we took him up on his offer when Mercy called the hotline.

Rose Nkupsya, a nurse and CCPF hotline worker, answered the call from Mercy. Rose understood the urgency of the situation and informed the transport officer. He immediately responded by sending the district ambulance to pick up Mercy and bring her to the nearest health facility.

Before the ambulance could reach her, Mercy delivered a baby boy. Mercy was bleeding heavily when the ambulance arrived and needed to be helped by health workers. But she was afraid of being reprimanded by them for delivering her baby outside of a facility and was concerned that the nurses would not admit her. Over the phone, Rose reassured her, and Mercy agreed to go to the health center where the nurse on duty was able to stabilize her condition and successfully stop the bleeding. Had it not been for CCPF and the transport officer, Mercy would have suffered severe bleeding and infection. Fortunately, she and her baby boy received timely and appropriate care, and both are happy and healthy today.

Chipatala cha pa Foni provides an important service to women in four districts of Malawi, but our work is far from finished. I look forward to continuing to help women have safe pregnancies and deliveries and for children to grow up happy and healthy.

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