kungu_supply chain considerations

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www.micronutrient.org

Solutions for hidden hunger

Supply chain considerations

April 14, 2013

Johannesburg, South Africa

Jacqueline Kungu (PhD)


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Objectives of presentation

1. To highlight the supply chain barriers to successful IFA

supplementation

2. To present experiences from our programs about supply

chain considerations we prioritise and focus on to ensure

uninterrupted, timely, adequate and quality stocks of IFA


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Presentation outline

1. MI program theory of IFA supplementation programs

2. Supply chain barriers to IFA supplementation

3. Mitigation strategies countries

4. Key questions for discussion


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Increased birthweight

May decrease risk of

maternalmortality and obstetrical

complications

Reduction in iron deficiency anemia in women

Coverage

Do intended recipients receive the IFA?

Utilization

Do intended recipients take the IFA?

Program theory of IFA

Delivery system

Accessibility to target

group

Capacity strengthening

of health workers

Product and supply chain

Type of product

Data based forecasting

Timely ordering

Distribution system

Adequate budget

Demand

BCI to promote program

Good quality supplements

Mechanisms to improve

utilization of complete

course

monitorin

g

Eva

luation

May decrease

risk of perinatalmortality

Increasediron stores


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What are the most important barriers tosuccessful IFA supplementation

Demand side barriers are often considered main limiting

factor: Inadequate and untimely utilization of ANC

Poor adherence to supplementation due to many factors including

memory, side effects etc.

Supply side barriers may be equally or in some contexts

more important:


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Supply side barriersDo women who attend ANC

receive IFA

supplementation?

Of the 335 women who took iron

supplement during the recent pregnancy

the major reasons for non-adherence of

stopping the drug were failure to get

adequate supply for the health institutions

(61.7%), occurrence of side effects

(20%), forgetfulness (15%), and fear ofside effects (1.3%) (Ethiopia formative

assessment report, 2012)


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Supply side barriersA. Policy issues:

i. Missing or lack of clarity on preventive vs. therapeutic objectives of

program - implications for formulations

ii. Lack of clarity in essential drug list on what to procure (single

tablet, dose etc.) - and/or out of date policy that include products

not in line with current international recommendations

iii. Budget allocation/commitment to implement IFA programs


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Supply side barriersB. Procurement issues:

i. Lack of clarity on roles and responsibilities related to

procurement due to lack of coordination among departments

and international organizations etc

ii. Diversity in countries as to roles and responsibilities for

procurement

Examples of procurement models that may be in operation:MODEL 1: donations of supplements and/or multiple

organizations procuring where program is dependent on aid;


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Supply side barriersMODEL 2: National level procurement has good control that

product is procured according to specifications but would be highly

dependent on information flow for forecasting and therefore, issues

around adequate and/or excess supply may abound;

MODEL 3: in some countries national budgets are allocated to

states/districts who then they procure with likely better capacity to

forecast based on more local level need but there may be issues

with ensuring that they procure products according to national

specifications and possibly, timely availability of budget if there are

issues related to flow of funds.


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Supply side barriersC. Forecasting and information flow issues:

i. Common problem for all product based programs - even if

forecasting at a national level is relatively accurate (eg. based onpopulation size and yearly birth rate), there may be issues with

ensuring that local level needs are accurately estimated e.g. In

some Woredas supply was abundant and expiry was common while

others had stockouts (Ethiopia formative assessment report, 2012)


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Supply side barriers

D. Distribution / Supply chain issues:

i. The program should first respond to demand needs (e.g.community vs. facility based distribution) then the supply chain can

be developed and managed to meet those needs

ii. There is often a lack of clarity for some on HOW supply chain

actually works (even if in principle developed to respond to needs)

the supply chain needs to be clearly mapped and roles andresponsibilities clearly understood at all levels


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Example of push-based supply chain

(on paper)

District

Health Center, HC

Health Post, HP

Community Health Worker, CHW

District:

Budget

Procure

Store

Ship to HCHC:

Ship to HP

Inform District

HP: Ship to CHW

Inform HC

CHW:

Distribute

Inform HP


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Actual functioning in very different

District

Health Center, HC

Health Post, HP

Community Health Worker, CHW

District:

Budget

Procure

Ship to HC

HC:

Store

Inform District

HP:

NoneCHW:

Collect supp

Distribute

Inform HP


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Supply side barriersE. Supply management:

i. Training on storage and inventory control to ensure that supplies

do not expire is VERY uncommon - nutrition should learnlessons from private sector or other areas of health (vaccination

control programs)


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Mitigation strategies - Ethiopia

Ensure adequate and sustainable IFA supply at all levels of

the health care system through involving governmental and

non-governmental stakeholders.

Improve data utilization = "Information for action" . Make

use of the tracer drug report included into the HMIS on

regular bases by the woreda Health Offices ( IFA is one of

the tracer drug that the HMIS uses to capture it availability at

health facilities)


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Mitigation strategies - Ethiopia Strengthen the Community Based Health Information

Management = stock monitoring via the bin card system,

apply the standardized definition for early detection of stock

out.

Strengthen supportive supervision to improve

supply management at all levels.

Advocating for government to finance IFA supply

Improve the accessibility of routine prenatal IFA

supplementation by integrating it into outreach and home

based prenatal services.


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Alternative modes to reach pregnant womenoutside of facility-based ANC

Ethiopias Health Extension

Program, local young

women are trained to

become Health Extension

Workers (HEWs) who

provide limited services

within rural communities and

successfully encouragemodel health behaviors

including utilization of ANC

services.


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Alternative modes to reach pregnant womenoutside of facility-based ANC

Health facilities

personnelPrivate sector

Community based

personnel


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Mitigation strategies - Kenya MoH receives support from partners for the purchase of

essential drugs including IFA.

Sensitization of health workers at all levels of the new WHOIFA guidelines

On job training of health workers on qualification and

forecasting of IFA

Strengthening the coordination mechanisms of all the key

stakeholders to ensure frequent consultative meetings

intended to streamline IFA supply chain issues.


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Mitigation strategies - Nigeria Supply chain management including forecasting,

procurement and tracing of stock out of IFA done at all levels

Leveraging on existing cost recovery programs e.g. the drugrevolving funds (DRFs) being piloted, to help ensure long

term sustainable supply of IFA in the public health system in

the 4 target states.

Advocating for government ownership to ensure

sustainability


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Mitigation strategies - Senegal Generating evidence to show that IFA can be successfully

delivered by CHW


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Key issues for discussion MI formative assessments in Kenya and Ethiopia report that

women will take all the IFA supplements provided at the

health facility. To what extent does strengthening the supply

chain guarantee improved utilization of IFA?

What would be the consequence on the supply chain issues

of layering calcium supplementation onto a weak IFA

program?


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Acknowledgements

Micronutrient Initiative

Ministries of Health

CIDA

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