Supply Chain Management for Community-Directed Interventions (CDIs)

1. Supply Chain Management for Community-Directed Interventions (CDIs) Module 12 Version 2

2. Learning objectives • By the end of this module, learners will be able to: • Describe the processes of procuring and storing antimalarial drugs • Explain how to estimate their community’s commodity needs* • Outline the stock recording method and reporting format* • Describe the distribution process for antimalarial medicines and other malaria commodities (e.g., insecticide-treated bed nets and long-lasting insecticidal nets [ITNs/LLINs], rapid diagnostic tests [RDTs]) • State how to monitor and report adverse drug reactions* • Discuss the role of patent medicine vendors (PMVs) in malaria commodity management *For community health workers (CHWs) as well as CDI focal persons

3. What are commodities?

4. Flow of commodities • Health commodities for CDI and integrated community case management can flow through both public and private channels • Each country is different, and in some cases: • National, subnational, and district medical/pharmacy stores order, procure, and distribute commodities/medicines • Districts or community associations can use private-sector warehouses and suppliers to buy medicines • In some countries, malaria commodities are manufactured; in other countries, these commodities are imported

5. Flow of commodities, cont. • For the Transforming Intermittent Preventive Treatment for Optimal Pregnancy project, quality-assured sulfadoxine-pyrimethamine (SP) is being imported from Guilin Pharmaceutical Company in China, which is prequalified by the World Health Organization (WHO)

6. Procurement and supply chain/cycle 1. Supply system information management 8. Clients consume stock 2. Forecasting and ordering 7. Storage, safety, and correct use 3. Procurement 6. Distribution to local level 4. Distribution to subnational/regional/district level 5. Storage and safety

7. Commodities flow from suppliers to central medical stores, then on to districts and facilities

8. Commodities reach consumers • Ultimately, commodities like artemisinin-based combination therapies (ACTs), RDTs, ITNs/LLINs, and SP need to reach the frontline clinic, and from there, the CHWs • Whatever the system, commodities must move from point of manufacture to point of use

9. The malaria drug supply chain • Community delivery of malaria medicines requires adequate supplies at all levels • Districts must monitor frontline facilities to help prevent stock-outs for facilities and the CHWs these facilities supervise • CHWs collect stocks from the nearest primary health care facility • The quality-assured SP procured by the Transforming Intermittent Preventive Treatment for Optimal Pregnancy project will be used only for community-directed intermittent preventive treatment in pregnancy (IPTp) except when there is a stock-out of routine SP supplies

10. The frontline primary health care facility provides commodity link with CHWs

11. Proper estimation of antimalarial commodities • It is important to have estimates of eligible clients/patients to determine antimalarial commodity requirements at all levels • Accurate data are required to achieve these estimates • Initial quantification of antimalarial medicines (ACTs, SP, quinine) needs to be done using population-at-risk data, by episode, based on medicine consumption • Lower-level quantification can be done through community head counts during community census

12. Malaria tasks have different schedules (forecasting) • The first task is to conduct a community census to determine number of people in need of services • An ITN/LLIN is needed as soon as a woman knows she is pregnant • IPTp occurs at least three times after quickening, at monthly intervals • Case management occurs whenever a community member has malaria (IPTp and ITNs/LLINs may lessen the need for case management) • Finally, health education is frequent

13. Identify and coordinate sources of supplies and funding

14. Sample road map country summary

15. Centralized procurement • It is recommended that drugs for home management of malaria be centrally procured • Benefits of central procurement include bulk purchasing, which can: • Reduce cost of medicines and handling charges • Ensure consistency and quality of supplies • Simplify logistics

16. Centralized procurement, cont. • These drugs should be WHO-approved (i.e., quality-assured) medicines • Ultimately these should move in a well-supervised manner from national to subnational to district to health facility and then community levels

17. Companies producing WHO-prequalified malaria medicines as of August 2010 *Only prequalified company for quality-assured SP

18. Forms track the use of antimalarial medicines • Forms are used at all levels of the health care system to track the use of antimalarial medicines • Subregions, districts, communities, and facilities use forms to track the drugs they procure and distribute • CHWs use forms to track the medicines they pick up from their supervising facility and distribute within the community

19. What is needed on forms to track antimalarial drugs? • Forms should: • Collect data on: • The consumption of different dosage packs • The manufacture and expiry (expiration) dates of medicines • Include areas to record the justification for any discrepancies in drug consumption (e.g., partial medicine usage)

20. The CDI distribution process • Commodities reach the nearest health facility • The CHW collects initial supplies and materials from the health facility • The initial stock is based on a community census that shows need • On receipt of commodities, the CHW signs an inventory register at the health facility confirming collection of supplies

21. Community preparation for distribution • The community leader and the CHWs announce to community members that commodities are available for pregnant women • The community should decide on the most acceptable processes to receive commodities, for example: • The CHW can make home visits to assess pregnant women for IPTp • People can go to the CHW’s house or the CHW can make home visits for other malaria commodities (where applicable) • Women and caregivers can seek services as needed

22. Distributing and maintaining stocks The CHW: • Visits homes of pregnant women to provide IPTp to those who are eligible (Note: All pregnant women should be referred to the health facility for antenatal care even when not eligible for IPTp) • Maintains distribution records (including blister packs of consumed SP) and summarizes these monthly • Submits summary reports to the health facility on a monthly basis • Collects supplies to replenish commodity stocks

23. Getting new stock for the community • Monthly CHW meetings at the frontline facility are a good opportunity to replenish stocks: • CHWs bring empty medicine packets to exchange for new packets • A system must also be in place for CHWs to obtain stock whenever it is needed Photo by Bright Orji, Jhpiego

24. Storing medicines in the community • During training, CDI focal persons should sensitize the CHWs to the following storage requirements: • Ideally, store SP, ACTs, and other medicines in a cool, dry, and clean place: • Keep medicines away from direct sunlight and heat • Temperature should not exceed 25°C • Medicines suspected to have come in contact with water must not be used for treatment • Damaged medicines should be returned to the health center and a new stock collected • Keep all medicines out of reach of children, at all times • Medicines should be kept separate from the other items in the house

25. CHWs need a safe place to store their stock of medicines

26. Medicines may not work as expected • These steps help ensure quality of commodities: • CHWs should report dangerous or unexpected effects of the drugs to their supervising health facility • Likewise, CHWs should take note of patients who do not get well after taking all medicine correctly: these patients should be reported and referred • The supervising facility should report to the district • This reporting is part of the pharmacovigilance system

27. Patent Medicine Vendors (PMVs) are a major source of medicines for the community • Sometimes if CHW stocks run out, community members may need medicines quickly • PMVs may be a source • We need to monitor PMVs to ensure that they provide quality medicines

28. Procurement and PMVs • PMVs: • Normally buy their stock from wholesalers • Usually do not keep records and receipts • Do know which medicines are popular • With the Affordable Medicines Facility—Malaria, PMVs: • May now be receiving specially packed Coartem from the health system • Will need to learn how to manage stocks, check expiration, and report damages

29. PMV associations can be involved in procurement and supply chain management for the private sector • Sometimes communities can restock their medicine box by buying from a reliable PMV shop

30. Summary and conclusions • CHWs: • Collect drugs from the health facility that provides services to their community • Ensure that drugs are stored appropriately • Maintain an accurate account of drug use, damages, and stock at all times • Report adverse drug reactions to the supervising health facility • Attend monthly meetings and submit monthly reports • PMV associations can also be involved in supplying approved malaria commodities

31. Thank you! Any questions or comments?