Malawi Logistics System and Stock Status Report 2006: Comparison of 2004 and 2006 Assessment Results

Publication date: 2006

MALAWI LOGISTICS SYSTEM ASSESSMENT AND STOCK STATUS REPORT 2006 COMPARISION OF 2004 AND 2006 ASSESSMENT RESULTS NOVEMBER 2006 This publication was produced for review by the United States Agency for International Development. It was prepared by the DELIVER project. MALAWI LOGISTICS SYSTEM ASSESSMENT AND STOCK STATUS REPORT 2006 COMPARISON OF 2004 AND 2006 ASSESSMENT RESULTS The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government. DELIVER DELIVER, a six-year worldwide technical assistance support contract, is funded by the U.S. Agency for International Development. Implemented by John Snow, Inc. (JSI), (contract no. HRN-C-00-00-00010-00) and subcontractors (Manoff Group, Program for Appropriate Technology in Health [PATH], and Crown Agents Consultancy, Inc.), DELIVER strengthens the supply chains of health and family planning programs in developing countries to ensure the availability of critical health products for customers. DELIVER also provides technical management of USAID’s central contraceptive management information system. Recommended Citation Chimnani, Jaya,Veronica Chirwa, and Erika Ronnow. 2006. Malawi Logistics System and Stock Status Report 2006: Comparison of 2004 and 2006 Assessment Results. Arlington, Va.: DELIVER, for the U.S. Agency for International Development. Abstract In March 2006, DELIVER conducted a nationally representative survey on the availability of selected health commodities at Ministry of Health (MOH) and nongovernmental organization (NGO) facilities throughout Malawi. The information provided through this survey, along with the results from any previous surveys, will allow the MOH and its partners to monitor the effectiveness and efficiency of the health commodity logistics system and to make adjustments as necessary. The Logistics Indicators Assessment Tool (LIAT), which was tailored in Malawi in 2004, was used again with minor adaptations to address current assessment needs. Comparative analysis was conducted with the results from the 2004 survey and to determine any change in the health commodity logistics system over the last two years. DELIVER John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 Email: deliver_project@jsi.com Internet: www.deliver.jsi.com CONTENTS Contents.v Acronyms.vii Acknowledgements.ix Executive Summary .xi Logistics Records. xi Reports. xii Personnel. xii Supervision . xii Storage Conditions. xii Contraceptives . xii Sexually Transmitted Infection/Opportunistic Infection Drugs.xiii Essential and Maternal and Child Health Drugs.xiii Test Kits.xiii Recommendations. xiv Background .1 Survey Purpose and Objectives.3 Survey Methodology .5 Sample Selection . 5 Indicator Choice and Instrument Development . 5 Data Collection and Analysis . 6 Findings .7 Logistics Management Practices . 7 Logistics Records (Stock cards) . 7 Reports. 9 Personnel. 9 Supervision . 10 Storage Conditions. 11 Stock Availability by Product Type. 12 Findings for Contraceptives. 14 Stockouts of Contraceptives on Day of Visit. 14 Stockouts of Contraceptives within the last six months . 15 Average Number and Duration of Stockouts of Contraceptives. 16 Months of Stock on Hand of Contraceptives. 18 Conclusions for Contraceptives . 20 Findings for STI/OI Drugs. 20 Stockouts of STI/OI Drugs on Day of Visit. 20 Malawi Logistics System Assessment and Stock Status Report - 2006 v Stockouts of STI/OI Drugs within the last six months . 22 Stockouts of Essential Drugs and Maternal and Child Health Products in the Last Average Number and Duration of Stockouts of Malaria and Child Health Average Number and Duration of Stockouts of STI/OI Drugs . 23 Months of Stock on Hand of STI/OI Drugs. 25 Conclusions for STI/OI Drugs. 26 Findings for Essential Drugs and Maternal and Child Health . 27 Stockouts of Malaria and Child health Products on Day of Visit . 27 Six Months. 28 Products . 29 Average Months of Stock on Hand for Malaria and Child Health Products 31 Conclusions for Essential Drugs and Maternal and Child Health Products. 32 Findings for Test Kits . 32 Stockouts of Test Kits on Day of Visit . 33 Stockouts of Test Kits between during the last six months . 34 Average Number and Duration of Stockouts of Test Kits . 35 Months of Stock on Hand for Test Kits . 36 Conclusions for Test Kits . 37 Recommendations .39 Appendix 1: Logistics Indicator Assessment Tool, Malawi, 2006 .43 Appendix 2: facility list- 2006 .55 Appendix 3: List of Data Collectors.59 Malawi Logistics System Assessment and Stock Status Report -2006 vi ACRONYMS ART antiretroviral therapy CDLMIS Contraceptive Distribution and Logistics Management Information System CHAM Christian Health Association of Malawi CMS Central Medical Stores DELIVER Health Logistics Strengthening Program DFID Department for International Development FEFO first-to-expire, first out FPLM Family Planning Logistics Management (project) GSI Global Information System HC health center HCT HIV counseling and testing HIV human immunodeficiency virus HLMIS Health Logistics Management Information System HMIS Health Management Information System HTSS Health and Technical Support Services LATH Liverpool Associates in Tropical Health LIAT Logistics Indicators Assessment Tool LIP Logistics Improvement Plan LMIS Logistics Management Information System MCH maternal and child health MOH Ministry of Health MSH Management Sciences for Health OI opportunistic infection ORS oral rehydration salts NGO nongovernmental organization PMTCT preventing mother-to-child transmission RHLMIS Reproductive Health Logistics Management Information System RHU Reproductive Health Unit RMS Regional Medical Stores SDPs service delivery points SIGMD integrated inventory control management system Malawi Logistics System Assessment and Stock Status Report - 2006 vii SOPs standard operating procedures SP sulfadoxine-pyrimethamine SPSS statistical analysis software SRHP Sexual and Reproductive Health Program STI sexually transmitted infection SWAp sector wide approach (basket funds) USAID U. S. Agency for International Development viii Malawi Logistics System Assessment and Stock Status Report -2006 ACKNOWLEDGMENTS This report was supported by and prepared through the Malawi Ministry of Health, Health and Technical Support Services (HTSS) Unit and was funded by the U.S. Agency for International Development. We wish to thank the district health offices that provided staff and guidance to the data collection teams. We also wish to thank all the facilities and their staff that took the time to respond to questions. Their candid and informative responses allowed the team to develop this report. We would like to thank Veronica Chirwa, John Zingeni, and James Gondwe of DELIVER/ Malawi for providing invaluable support and editing throughout the report writing process. Special appreciation goes to Godfrey Kadewele, Deputy Director (Pharmaceuticals), in the department of Health and Technical Support Services, and including the Senior Logistics Officer and Logistics Officer, Samuel Chirwa and Dorica Salamba, respectively, who provided invaluable logistics support in conducting this survey. A special thank you goes to Management Sciences for Health (MSH) for providing a training arena and data collectors for the survey. Malawi Logistics System Assessment and Stock Status Report - 2006 ix Malawi Logistics System Assessment and Stock Status Report -2006 x EXECUTIVE SUMMARY In March 2006, DELIVER conducted throughout Malawi a nationally representative survey on the availability of selected health commodities at the Ministry of Health (MOH) and nongovernmental organization (NGO) facilities. The information gathered from this survey, combined with any previous and subsequent surveys, will allow the MOH and its partners to monitor the effectiveness and efficiency of the health commodity logistics system and to make adjustments as necessary. The product categories included in the survey were— • contraceptives • STI/OI drugs • Essential and Maternal and Child Health Drugs • HIV test kits. Nine survey teams visited 70 randomly selected health facilities in 15 districts throughout the country— 62 were government (MOH) facilities and eight were NGO facilities. In addition, the country’s three Regional Medical Stores (RMS) were also included in the survey. The 70 facilities visited represent approximately 15 percent of all MOH and NGO facilities in the country that provide sexual and reproductive health services. The facilities visited for this survey were also visited in 2004; comparisons between the two studies are made throughout the report. Specific survey objectives included— • assessing inventory control procedures and logistics management practices (i.e., ordering, distribution, supervision, etc.) within the system • collecting data on stockout rates and duration, consumption/issue rates, current stock on hand, and storage conditions • providing the findings and conclusions of the survey to the MOH, USAID/Malawi, and other stakeholders. The instrument used for the survey was a version of the DELIVER Logistics Indicators Assessment Tool (LIAT), which was tailored in Malawi in 2004. The tool was used again with minor adaptations to address current assessment needs. The number and type of indicators were selected to ensure consistency with previous product availability surveys, while also providing stakeholders with up-to-date information on the current operating system. Summarized below are the findings and conclusions that resulted from this survey; see the Findings section for more detail in each logistics management practice or product category. Comparative analysis was also conducted with the results from the 2004 survey to determine any change in the health commodity logistics system during the last two years. LOGISTICS RECORDS • Overall a higher number of facilities used stock cards in 2006 than in 2004. There was a marked improvement in the RMSs updating of stock cards. In 2004, only the southern RMS consistently had updated stock cards for most of the products. Malawi Logistics System Assessment and Stock Status Report - 2006 xi • More health centers are managing HIV test kits in 2006 compared to 2004, when none of the health centers reported managing test kits. This is evidence of a successful expansion of testing services throughout the country. However, very few of the health centers keep stock cards on the kits (less than 30 percent). • A marked decrease in maintaining accurate stock card balance (both at 100 percent accuracy and within 10 percent accuracy) from 2004 to 2006 for nearly all products was noted. REPORTS • In the survey, 94 percent of the facilities reported sending the LMIS forms to the higher level within the past month. • Approximately 41 percent of the drug managers reported receiving training on how to complete the reports during a logistics workshop, as well as through on-the-job training (49 percent). The remainder of the managers reported that they taught themselves how to fill out the forms. This is a significant improvement over what was found in 2004 when 29 to 35 percent of the respondents at the health facilities reported never learning how to fill the forms. PERSONNEL Nurses are more likely to manage drugs at health centers; whereas, at the hospitals, pharmacy technicians or pharmacy assistants have the primary responsibility for managing drugs. This suggests that staff size at facilities plays a role in determining who will manage drugs. SUPERVISION • Compared to 2004, a decreased number of facilities received a supervision visit that included drug management. In 2006, 25 percent of the hospitals visited received drug management supervision within the last month compared to 41 percent in 2004. • Similarly, there was a decline in the number of drug management supervision visits at the health centers within the last month: 44 percent in 2004 compared to 38 percent in 2006. • In 2006, hospitals reported an increase in the percentage of supervision visits within the last three months: 40 percent in 2006 compared to 24 percent in 2004. STORAGE CONDITIONS • The storage conditions at the health centers showed a decline. Seven percent were found to be excellent in 2004, but in 2006 none of the health centers were categorized as maintaining excellent storage conditions. • Seventy percent of the hospitals were found to have met an acceptable percentage of the storage conditions, with five percent found to be excellent. In the health centers visited, 56 percent had acceptable storage conditions, while 44 percent were unacceptable. CONTRACEPTIVES • Because contraceptives are in full supply at the central level, no stockouts of any duration should occur. • Overall, the percentage of facilities that experienced stockouts for contraceptives during the last six months declined in 2006. Malawi Logistics System Assessment and Stock Status Report -2006 xii • Condoms are not evenly distributed in the supply chain, which resulted in some facilities receiving an overstock while others experienced a stockout of condoms. • The average months of stock on hand show overstocks of contraceptives in 2006. • In 2006, with the exception of Ovrette and condoms, the duration of the average stockout for contraceptives declined. SEXUALLY TRANSMITTED INFECTION/OPPORTUNISTIC INFECTION DRUGS • In 2006, there were significant stockouts of Nystatin and erythromycin, both at the hospital and the health center level. • With the exception of benzathine and Diflucan, all other sexually transmitted infection/opportunistic infections drugs were stocked within the required minimum and maximum level. • Stockouts occurred at a higher percentage of facilities for STI drugs than for contraceptives, although both are full supply products. ESSENTIAL AND MATERNAL AND CHILD HEALTH DRUGS • The procurement of maternal and child health (MCH) and other essential drugs differs from STI drugs and contraceptives. MCH drugs are normally non–full supply and are procured without considering consumption patterns but are procured on an ad-hoc basis, depending on the availability of funds. • A high percentage of stockouts were noted for some essential drugs on the day of the visit at both hospitals and health centers. Approximately 60 percent of the health centers and hospitals were stocked out of amoxicillin. Similarly, 60 percent and 80 percent of the health centers would not have been able to complete orders from clients for cotrimoxazole and paracetamol, respectively. • In 2006, a higher percentage of facilities experienced stockouts during the six-month review period. This suggests that either health facilities are not adequately ordering stock based on their consumption, or health facilities are not supplied with an accurate amount of stock needed to serve their clients. • Over the course of six months, all three Regional Medical Stores experienced a stockout of sulfadoxine-pyrimethamine (SP). TEST KITS • There was a decrease in the percentage of hospitals stocked out of Determine HIV test kits, but an increase at the RMS level. Determine is used as one of the first (parallel) tests; without it, testing cannot occur. Determine is the one test used for blood safety at the hospitals, many of which still rely on their own labs to test incoming blood. • In 2006 more than 20 percent of the hospitals experienced a stockout of every test kit at some time between July and December 2005. More than 80 percent of the hospitals and two of the three RMSs had stockouts of Determine HIV between July and December 2005. This finding indicates that there are still significant challenges in the logistics system for HIV test kits. • On average, the number of HIV test kit stockouts decreased between 2004 and 2006, however the duration of the stockouts increased. Malawi Logistics System Assessment and Stock Status Report - 2006 xiii RECOMMENDATIONS In the analysis of both the facility survey and the logistics system assessment completed in March 2006, a number of challenges were identified at the national level. The following recommendations are designed to address both short- and long-term needs. Some of the recommendations (e.g., storage conditions, removal of expired products) can be implemented immediately with little associated finances. • More consistent communication and coordination is needed between the MOH working groups that focus on supply chain management (e.g., Drugs and Medicines Supplies Technical Working Group and Logistics Working Group). Strengthening the coordination between various partners will ensure that all relevant stakeholders are well informed and kept abreast of key strategic decisions. • The existing procurement plan for contraceptives and essential drugs should be implemented immediately. Considering that the average procurement cycle may take eighteen months or more, and many essential drugs are currently stocked out, emergency procurement is also needed for certain essential and life saving drugs. • If feasible, an immediate replenishing exercise (top-up) needs to be implemented for all essential drugs. Although, not all essential drugs are considered full supply products, they constitute the essential health package commodity list that should be available to all Malawians. For contraceptives, which are overstocked at many facilities but understocked or stocked out at some, a redistribution of existing supplies is needed to eliminate any stockouts at health facilities. It is likely that the current rationing practices at the RMS and the facilities that do not submit timely or accurate reports, have contributed to this problem. • Create a feedback form that summarizes facility reporting rates. This quarterly form will be distributed to all District Medical Officers. • To achieve commodity security, short- and long-term procurement commitments need to be solidified. At present, both donor and MOH financial commitments are based on possibly unreliable forecasts and may prove inadequate. These commitments must ensure funding through the sector wide approach (SWAp) mechanism for the purchase of contraceptives and drugs for sexually transmitted infections, in the event of inadequate funding. • Clarify the roles and responsibilities of Central Medical Stores (CMS), MOH departments, and supporting projects (DELIVER, Management Sciences for Health, etc.) in integrated commodity management, forecasting, finance, and procurement. • Storage condition guidelines must be distributed to all levels of the system. Supervisors and facility staff should review the storage conditions during each supervisory visit. • At the Regional Medical Stores (RMS) level, there is a need for improved organization and a capital investment in proper racking and material handling equipment (forklifts). • Expired items are being kept at health facilities. CMS, in cooperation with the MOH, should disseminate and enforce guidelines for the correct disposal of expired and/or damaged drugs. These guidelines must be distributed to all health and storage facilities. • Continued supervision should emphasize the timely and accurate completion of logistics reports (LMIS 01A/B/C). Currently, if a facility fails to submit reports, they do not receive a resupply of commodities. Under-reporting is evidence of poor inventory management at the facility level and contributes to a higher rate of both stockouts and wastage. xiv Malawi Logistics System Assessment and Stock Status Report -2006 • Build logistics capacity of district pharmacy technicians who are now on the district management team. This can be done with on-the-job training for current pharmacy technicians and by continuing logistics sessions in the pharmaceutical training program. • Clarify the roles and responsibilities of the zonal supervisors to avoid an overlap of effort between supervisors at the zonal level and district management teams. • Encourage coordination between the drug managers and reproductive health coordinators at all levels to ensure that contraceptive are management correctly. For example, District Reproductive Health Coordinators could submit reports to the Reproductive Health Unit on family planning that include information on couple-years of protection achieved. This information is now readily available through Supply Chain Manager and can be produced by the Pharmacy Technician. These reports can help reproductive health coordinators determine actual consumption levels for facilities. Malawi Logistics System Assessment and Stock Status Report - 2006 xv xvi Malawi Logistics System Assessment and Stock Status Report -2006 BACKGROUND With funding provided by USAID/Malawi, the DELIVER project (follow-on to the Family Planning Logistics Management Project [FPLM]) has been providing technical and training assistance to the MOH in Malawi since the late 1980s. Until 1995, however, this was mainly limited to assisting the family planning program in forecasting its annual contraceptive needs and placing orders. Technical assistance targeted at developing and implementing a standardized logistics system in Malawi began in 1995, with the design of the Contraceptive Distribution and Logistics Management Information System (CDLMIS). The CDLMIS has been operational since the first quarter of 1997. The CDLMIS significantly improved the reliability of contraceptive supplies at health facilities; it enhanced the MOH Reproductive Health Unit’s (RHU) ability to track information about contraceptive use and distribution in the country. Based on the success of the CDLMIS, the RHU decided to integrate STI drugs procured under its Sexual and Reproductive Health Program (SRHP) into the CDLMIS. This integrated information system, the Reproductive Health Logistics Management Information System (RHLMIS), was the next phase in the development of the Malawi Health Commodities Logistics Management System (MHCLMS). The MHCLMS was intended to track all health supplies from RMSs to health facilities. In 1998, to provide a framework for the multi-donor logistics improvement activities, a national Logistics Improvement Plan (LIP) was developed by members of the MOH’s Logistics Subcommittee. The LIP described the logistics activities being conducted, identified targets for specified logistics indicators, and was intended to monitor and coordinate donor inputs into the logistics system. Ultimately, the LIP’s purpose was to strengthen the CDLMIS to the point that the system could move away from being a vertical family planning logistics system to become an integrated system. The LIP identified objectives for improving the logistics system and targets to measure the achievement of each of the goals. The objectives included ensuring continuous availability of contraceptives at health facilities and strengthening and refining the CDLMIS through improved reporting. Baseline and follow-up surveys were conducted in 1998 and 1999, respectively, to measure contraceptive availability and stock status at health facilities, and to enable future monitoring of the performance of the system. In December 2000 and 2002, and July 2004, other surveys were conducted that had the dual purpose of providing comparative data to measure progress in contraceptive availability and management and gathering new data on availability and management of STI drugs (including two HIV test kits in 2004, Determine HIV and Hemastrip). In 2002, the MOH used a process mapping methodology to conduct a work process analysis of the logistics system. This methodology focused on getting input from all levels of the organizational system to achieve exponential (as opposed to incremental) improvements. The activity identified tasks in the system that were redundant, non-value added, and not required, and made recommendations for a more streamlined and integrated supply chain. The analysis also identified potential cost and time savings expected from the future streamlined logistics system. As a result of this work process analysis, the MOH established an integrated health logistics system that ensures the availability of more than 80 essential products at the health center level. A new training program was designed based on a revised set of standard operating procedures (SOPs) that guides the improved system; it was provided to all district pharmacy technicians/assistants in September 2003. A refresher training was conducted during February and March 2005 to equip pharmacy technicians/assistants and stores personnel from the regional medical stores with the knowledge and skills Malawi Logistics System Assessment and Stock Status Report - 2006 1 on the revised set of SOP’s which includes some aspects of the computerization of some of the logistics functions at the District Level. The computerization process of the district pharmacies began in April 2004 when the Ministry, with support from JSI/DELIVER, conducted training for pharmacy personnel and other administrative staff from the eight MSH focus districts and some additional three priority districts on the use of a new version of JSI/DELIVER’s Supply Chain Manager, a software tool that provides logistics management information to distribution system managers. The computerization of the district pharmacies has since rolled out to the rest of the country since June 2005. Central Medical Stores play a pivotal role in the national drug supply chain. The major purpose of the CMS is to facilitate the purchase, storage, and distribution of medical supplies required for public purposes. CMS has three major stores, called Regional Medical Stores (RMS), located in each of the three regions of the country. Each store distributes medical supplies to district hospitals and health centers in that region. In 2001 CMS received DFID support aimed at strengthening management systems and imparting skills as prerequisites to the transformation of CMS into a trust. This support included acquisition of a computerized accounting and stock management system, called SIGMED. SIGMED is an integrated inventory control management system; this implies that cooperation among the different divisions (e.g., Accounting, Procurement, Sales) is essential. Above all, management commitment and support are essential elements for success. This system was intended to help CMS/RMS manage inventory and track supply levels throughout the system. Unfortunately, CMS has encountered some limitations, such as inherent technical issues within the application itself, and networking and communications between regional stores and headquarters. In September 2003, CMS started delivering health commodities directly to health centers in the Southern Region through RMS South. Each district pharmacist was still responsible for approving the facilities order and sending aggregated orders to RMS. Based on lessons learned from RMS South, the remaining regions adopted the system in January 2004. The three regional medical stores are delivering directly to health centers based on the orders derived by facility reports with input from district pharmacy technicians/assistants. Malawi Logistics System Assessment and Stock Status Report -2006 2 SURVEY PURPOSE AND OBJECTIVES The purpose of this survey was to provide MOH, USAID, and other stakeholders in Malawi with data on the current availability of selected products essential for primary care, family planning, maternal and child health, STI treatment, and HIV testing. This, along with previous and subsequent surveys, will allow the MOH and its partners to monitor progress over time and to adjust the logistics system as necessary. Specific survey objectives included: • assessing certain inventory control procedures and logistics management practices (i.e., ordering, distribution, supervision, etc.) within the system; • collecting data on stockout rates and duration, consumption/issue rates, current stock on hand, and storage conditions. Malawi Logistics System Assessment and Stock Status Report - 2006 3 Malawi Logistics System Assessment and Stock Status Report -2006 4 SURVEY METHODOLOGY SAMPLE SELECTION To visit the largest number of facilities in the days available, the team divided into nine teams consisting of one trained data collector and the district pharmacy technician in each of the 15 districts visited. The teams visited the following sample of sites: • three RMS • Seventy health facilities (62 MOH and 8 Christian Health Association of Malawi [CHAM]) In previous studies the sample differed in a few areas. In the 2000 study, the team visited all 27 districts. To get a larger sample of health facilities, the 2002 study sampled more facilities in each of the 12 districts. Within each of the 12 districts visited, the teams visited the health facilities visited during the 2000 study, and additional health facilities were selected at random within these districts. Based on an estimated total of 461 health facilities in the country that provide sexual and reproductive health services, the 2000 sample represented approximately 14 percent of relevant health facilities, the 2002 sample represented 12 percent, and the 2004 and 2006 sample represented 15 percent. For ease, transparency, and comparability, the facilities visited in the previous surveys were revisited, while three additional districts were added in 2004, with their sites being selected randomly. These three additional districts were selected purposefully based on their participation in the project managed by Management Sciences for Health (MSH). Same facilities were also included in the 2006 survey. In the initial sample the following selection process was used: • In 2002, the districts were divided by region, and each district was selected at random. Three districts were selected to represent the Northern Region, four for the Central Region, and five for the Southern Region. This division was felt to represent the population distribution more closely. • All of the districts and health facilities that were visited in 2002 were visited during the 2004 survey. This year the district pharmacies, which no longer handled products for other facilities, were eliminated. To keep the sample size significant, replacement health facilities were chosen randomly from the Health Management Information System (HMIS) list of existing facilities. • Each of the nine teams was assigned a list of four to six facilities to visit in each of the 15 districts. This report focuses on the MOH and CHAM facilities with a memorandum of understanding (MOU) with the MOH to provide services and commodities to the community. A list of all the facilities visited can be found in Appendix 2. A list of data collectors can be found in Appendix 3. INDICATOR CHOICE AND INSTRUMENT DEVELOPMENT The instrument used for the survey was a modified version of the DELIVER Logistics Indicators Assessment Tool (LIAT). The number and type of indicators were selected to ensure consistency with previous contraceptive availability surveys, while also providing stakeholders with up-to-date information on the current operating system. Input from survey team members was integrated into the survey tool during training and following a pilot test of the tool. The final survey instrument is included as Appendix 1. Malawi Logistics System Assessment and Stock Status Report - 2006 5 The indicators used in the first three surveys had been identified in the Ministry’s Logistics Improvement Plan (LIP). Use of consistent indicators simplified the survey training needs and allows measurement of trends through time. This was the fifth time such data have been collected for contraceptives, the third time for STI drugs and the second time for HIV test kits. This and the previous two surveys represent availability of contraceptives and STI drugs since they were integrated into the RHLMIS. There are slight differences in the data collected over the years. Comparisons with the 2004 survey are made throughout the text of the findings. Table 1: List of Indicators Indicator 1. Percentage of facilities using stock cards by product Presence of stock cards for each product in stores 2. Percentage of facilities with stock cards available and Comparison of stock card balance and physical updated by product inventory count 3. Percent of facilities with accurate stock balances on stock cards 4. Percentage of facilities with nurses or other qualifications managing drug supply (by region) 5. Percentage of facilities receiving supervision within a reasonable amount of time 6. Percentage of sites stocked out of product at time of visit 7. Percentage of sites stocked out of product in last 6 months 8. Average number of days stocked out in 6 months by product 9. Percentage of sites stocked according to plan; months of supply on hand 10. Percentage of health facilities submitting the appropriate LMIS form (LMIS-01 A, B or C) Data Source(s) Stock card and physical inventory Respondent Respondent and visitor’s book Stock card records, respondent, and physical inventory Stock card records and respondent Stock card records and respondent Average monthly consumption , physical count of product at SDP, and max-min of 1–3 months Respondent DATA COLLECTION AND ANALYSIS Before implementing the survey, data collectors participated in a three-day training in 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. Each team was assigned a leader who was responsible for overseeing the process in each district. Data sources for each indicator are identified in Table 1. During the training, sites in the Central Region were visited, after which slight modifications were made to the form. Data were collected within a week. A preliminary analysis was prepared and a report was made to MOH counterparts, USAID and other stakeholders. The data were entered into Epi Info and converted to a statistical analysis software (SPSS) for analysis. Further cleaning of the data, verification of the preliminary analysis and report writing was done in Washington in collaboration with the DELIVER/Malawi field office team. Malawi Logistics System Assessment and Stock Status Report -2006 6 FINDINGS LOGISTICS MANAGEMENT PRACTICES LOGISTICS RECORDS (STOCK CARDS) The cornerstone of inventory management lies in consistent and accurate use of stock cards. The percentage of MOH facilities that had stock cards available for each product and updated (entry within last 30 days) is illustrated in Table 2. Table 2: Percent of MOH facilities with stock cards available and updated by product (for those that manage those products) Hospitals Health Centers RMS Available Updated Available Updated Available Updated Lo-Femenal® 90 94 86 74 100 100 Ovrette 79 94 81 64 100 100 Male condom 85 94 70 91 100 67 Depo-Provera® and Petogen 90 100 88 84 100 100 Norplant 100 91 100 100 Benzathine penicillin 100 100 89 82 100 100 Doxycycline 100 100 92 94 100 100 Metronidazole 100 100 90 93 100 100 Fluconozole 73 71 N/A 100 Nystatin 85 100 70 89 100 100 Erythromycin 100 100 94 94 100 100 Metronidazole injection 100 100 100 100 Ferrous Sulphate (FeFo) 90 100 90 98 100 100 Syntometrine 79 100 66 83 100 100 SP 100 100 90 91 100 100 Cotrimoxazole 100 95 84 93 100 100 Paracetamol 100 100 90 96 100 100 ORS 90 89 64 88 100 100 Amoxicillin 95 100 84 95 100 100 Aspirin 95 100 94 98 100 100 Gloves 95 100 62 90 100 100 Determine HIV 67 100 28 80 100 100 SD Bioline 65 100 24 75 100 100 Unigold 67 100 28 80 100 100 Malawi Logistics System Assessment and Stock Status Report - 2006 7 Inventory information kept on the stock cards allows facility and district managers to make informed decisions about what and how much to order each month. Overall there was an improvement in the use of stock cards. There was a marked improvement in the RMSs updating of stock cards. In 2004 only the southern RMS consistently had updated stock cards of most of the products. More health centers are managing HIV test kits in 2006 than were in 2004; none of the health centers reported managing test kits in 2004. This is evidence of a successful expansion of testing services throughout the country. However, very few of the health centers keep stock cards on the kits (less than 30 percent). Late in 2005 the MOH specified that test kits are to be managed by the pharmacy store. In many of the facilities visited in 2006 the kits were being managed by the laboratory personnel . The accuracy of the balance on the stock cards was also observed. Table 3 shows the percent of Health facilities that had accurate balance entries and the percent of facilities that had near accurate balances (less than a 10 percent discrepancy). These percentages are based only on those facilities that had stock cards available. There has been a marked decrease in maintaining accurate stock card balance (both at 100 percent accuracy and within 10 percent accuracy) from 2004 to 2006 for nearly all products. This finding indicates that there is considerable room for improvement and additional emphasis needs to be placed on maintaining accurate up-to-date stock cards. Table 3: Percent of health facilities that had accurate or near accurate balance entries on stock cards Product Percent of facilities with accurate stock card balance where available) Percent of facilities with stock card near accurate balance (within 10 percent) 2004 2006 2004 2006 Lo-Femenal® 63 59 80 68 Ovrette 59 36 77 70 Male Condom 43 35 57 59 Depo-Provera® and Petogen 59 52 69 67 Norplant 92 43 100 60 Benzathine penicillin 54 46 80 69 Doxycycline 79 62 86 75 Metronidazole 80 54 87 63 Fluconozole 40 39 70 80 Nystatin 67 78 71 80 Erythromycin 82 83 85 84 Metronidazole Injection (not surveyed in 2004) 54 73 Ferrous Sulphate (not surveyed in 2004) 46 72 Syntrometrine (not surveyed in 2004) 56 61 Malawi Logistics System Assessment and Stock Status Report -2006 8 Sulfadoxine-pyrimethamine (SP) 73 59 79 68 Cotrimoxazole 78 74 89 79 Paracetemol 81 83 84 90 ORS 56 35 72 47 Determine HIV 78 63 89 65 SD Bioline 68 30 78 Unigold (not surveyed in 2004) 55 75 Amoxicillin (not surveyed in 2004) 82 85 Aspirin (not surveyed in 2004) 61 71 Gloves (not surveyed in 2004) 44 70 REPORTS The reported information needed for proper drug management includes the stock on hand, amount dispensed to clients, and any losses and adjustments. The LMIS forms introduced in 2003 include this information and most facilities are now using them. At the district level, pharmacists have begun using the District Monthly Order Worksheets (produced from Supply Chain Manager), which identify the amount of each drug that was ordered and approved to be delivered to each facility, and a separate form for the district hospital. Some training on the new LMIS forms (LMIS 01A, 01B and 01C) was done in 2003 when the new logistics forms were introduced and a follow-on training was conducted in 2005. However, not all health center personnel have been trained due to non availability of funds to orient them on the forms. During this survey 94 percent of the facilities reported sending the LMIS forms within the past month. Drug managers reported that they learned how to complete the reports during a logistics workshop (41 percent) as well as through on-the- job-training (49 percent). The remainder of the managers reported teaching themselves how to fill out the forms. This is an improvement to what was found in 2004 where 29 to 35 percent of the respondents at the health facilities reported never learning how to fill the forms. PERSONNEL The Ministry of Health Program of Work for the Implementation of Essential Health Package recommends the following personnel structure for the management of drugs and supplies: nurses or medical assistants at the health center level, pharmacy technicians/assistants at district level, and pharmacists at the central hospital. The MOH phased out Pharmacy Assistant training and upgraded to a diploma level to become a Pharmacy Technician. However, between December 2003 and March 2004, the MOH sent a directive that nurses should be responsible for drug management at the health centers. Nurses are more likely to manage drugs at health centers in all of the regions. Smaller staff size often makes this a necessity. At health centers, there were no pharmacy technicians or assistants managing drugs. At hospitals, the drug manager is usually a pharmacy technician or pharmacy assistant. This is consistent with the findings in 2004. None of the health centers had pharmacists managing the drugs, but there were pharmacists managing the drugs at the RMS and Hospitals. Table 4 shows a breakdown of the people currently managing the drugs at both the hospitals and health centers by regions for 2004 and 2006. Malawi Logistics System Assessment and Stock Status Report - 2006 9 Table 4: Percent of facilities in each region by type of personnel managing drugs Hospitals* (2004/2006) Northern Central Southern 2004 2006 2004 2006 2004 2006 Nurse 17 0 0 14 0 0 Clinical officer 17 14 0 0 0 0 Pharmacy technician 17 57 50 14 57 57 Pharmacy assistant 17 14 50 43 14 14 Pharmacist 33** 0 0 0 0 0 Medical assistant 17 0 0 14 29 29 Other 0 0 0 14 Health centers (2004/2006) Northern Central Southern 2004 2006 2004 2006 2004 2006 Nurse 40 29 63 44 24 41 Clinical officer 20 0 0 0 10 4 Pharmacy technician 0 0 0 0 0 4 Pharmacy assistant 0 0 0 0 0 0 Pharmacist 0 0 0 0 0 0 Medical assistant 20 71 34 50 48 48 Other 0 0 0 6 19 4 * Some hospital personnel reported multiple people managing drugs. * *Of the three hospitals visited, this 33 percent represents one pharmacist at Mzimba Hospital in the Northern Region. As illustrated in the table above, the southern region is staffing according to plan by having technicians at the district hospital level, 57 percent in 2004 and 83 percent in 2006. Similar improvements can be seen in the northern region (17/57). This is encouraging, as most vacant district posts were filled by Pharmacy Technicians. In the central region the proportions declined from 50 percent in 2004 to 14 percent in 2006. The central region also reported an increase in the “other” category for both hospitals and health centers (0/14 and 0/6 respectively). The decline of Pharmacy Technicians in place and an increase in “other”category shows that the region continues to face problems in staffing appropriate personnel to manage drugs. This is in contrast to what is seen in the southern region which recorded highest proportions in 2004 (19 percent) and reduced it to 4 percent in 2006. At the health centers drugs are consistantly being managed by nurses and medical assistants. SUPERVISION Supervision, an important element of quality assurance for the performance of any logistics system, is related to all aspects of logistics management. Supervision helps to improve individual and system performance and can alert managers to potential problems such as stockouts, poor storage conditions, and products near their expiry dates. Supervision can take several forms: the supervisor may review incoming reports, the supervisor may have face-to-face contact with those he or she supervises by bringing them to a central location, or the supervisor can visit each site. Frequency of supervision is an essential element and a useful indicator in assessing the potential quality of supervision and its effect on system performance. Supervision also presents an opportunity to reinforce Malawi Logistics System Assessment and Stock Status Report -2006 10 new systems and forms. Table 5 shows the percentage of MOH facilities that received general supervision and those that received supervision that included drug management. Compared to 2004, there has been a decrease in facilities that received a supervision visit on drug management. In 2006, 25 percent of the hospitals visited received a drug management visit within the last month compared to 41 percent in 2004. A similar trend can also be seen for health centers, where drug management supervision visits within the last month declined from 44 percent in 2004 to 38 percent in 2006. However, it is interesting to note that the hospitals in 2006 reported an increase in the percentage of supervision visits within the last three months (40 percent in 2006 compared to 24 percent in 2004). Table 5: Percentage of facilities that received general supervision and those that received supervision that included drug management in 2004 and 2006 Facilities receiving general supervision Hospitals Health Centers 2004 2006 2004 2006 Never 12 10 5 4 Within the last month 53 55 56 54 Within the last 3 months 18 10 22 18 Within the last 6 months 6 10 12 10 Over 6 months ago 12 15 5 14 Facilities receiving supervision that included drug management Never 29 5 15 20 Within the last month 41 25 44 38 Within the last 3 months 24 40 24 18 Within the last 6 months 0 10 12 12 Over 6 months ago 6 20 5 12 STORAGE CONDITIONS To provide clients with high-quality products, each facility must have safe, protected storage areas to help prevent damage and ensure efficient handling of products. In assessing storage areas, the survey examined the level of compliance with 12 guidelines for proper storage. The researchers assessed each facility’s adherence to storage conditions through direct observation and interview questions asked of facility staff. The guidelines include: 1. Products that are ready for distribution are arranged so that identification labels and expiry dates and/or manufacturing dates are visible. 2. Products are stored and organized in a manner accessible for first-to-expire, first-out (FEFO) counting and general management. 3. Cartons and products are in good condition, not crushed due to mishandling. If cartons are open, personnel check whether products are wet or cracked due to heat/radiation. 4. Facility makes it a practice to separate damaged and/or expired products from good products and remove them from inventory. 5. Products are protected from direct sunlight at all times of the day. 6. Cartons and products are protected from water and humidity. Malawi Logistics System Assessment and Stock Status Report - 2006 11 7. Storage area is visually free from harmful insects and rodents. 8. Storage area is secured with a lock and key but is accessible during normal working hours, with access limited to authorized personnel. 9. Products are stored at the appropriate temperature according to product temperature specifications. 10. Roof is maintained in good condition to avoid sunlight and water penetration at all times. 11. Storeroom is maintained in good condition (i.e., clean, all trash removed, sturdy shelves, and organized boxes). 12. The current space and organization is sufficient for existing products and reasonable expansion (i.e., receipt of expected product deliveries for the foreseeable future). 13. Fire safety equipment is available and accessible (any item identified as being used to promote fire safety should be considered). 14. Products are stored separately from insecticides and chemicals. At each facility visited, data collectors visually inspected storage areas based on the above conditions. Table 6 depicts the percentage of facilities in compliance with 0–70 percent of the conditions, 71–90 percent of the conditions, and 91–100 percent of the storage conditions. Table 6: Percentage of facility storage sites meeting acceptable percentage of storage conditions in 2004 and 2006 Hospitals Health Centers 2004 2006 2004 2006 Unacceptable (<70%) 35 25 5 44 Acceptable (between 71-90%) 47 70 24 56 Excellent (>90%) 18 5 71 0 Of the hospitals visited, 70 percent were found to have met an acceptable percentage of the storage conditions, with 5 percent found to be excellent. In 2006, percentage of hospitals with unacceptable storage conditions decreased by 10 percent. In the health centers and dispensaries visited, 56 percent had acceptable storage conditions, while 44 percent were found to be unacceptable. This represents a decline in the health center’s storage conditions where 71 percent were found to be excellent in 2004. The condition which was mostly not satisfied by health centers was lack of enough storage space, possibly due to a decline in supervision as observed above. This in turn also implied unclean environments. STOCK AVAILABILITY BY PRODUCT TYPE This section discusses findings on the most important outcome of a logistics system—stock availability. The survey collected data on both stock on hand and stockouts on the day of the visit and measured stockouts during a recent six-month period.1 While stockouts demonstrate one outcome of a poorly functioning logistics system, overstocks are another important indicator of a logistics system’s lack of effectiveness. Overstocks put the products at 1 July–Dec 2005 was selected as representing the most recently completed six months for which both records and reports should already be available at all levels as well as the duration of stockouts based on stock records. Malawi Logistics System Assessment and Stock Status Report -2006 12 greater risk of expiration or damage before they can be used; they also take up space, and other facilities may have inadequate stocks as a result. Even where stockouts are not high, facilities with too little stock at the time of the visit are either likely to stockout or will require an emergency order before they receive their next routine order. To assess a facility’s stock status, the average monthly consumption was calculated over the previous six months and adjusted for periods of stockouts. The current stock on hand was divided by average monthly consumption to determine how many months of stock were available. As noted above, this calculation could only be made for facilities maintaining adequate stock records. Therefore, figures in this report referring either to stockouts in the last six months or to months of supply are likely to underestimate improper stocking (stocking too little, too much, or none at all). The findings in this section of the report are organized by product type and include analysis of the following: • Percentage of facilities that manage the product and were experiencing a stockout on the day of the visit. • Percentage of facilities that manage the product and experienced a stockout during a six-month period before the start of the assessment. Since some facilities did not have adequate records, the stockouts that were recorded underestimate the actual frequency of stockouts. Presumably, facilities with accurate and complete records manage their stock better, so they should have fewer stockouts than facilities without records. • Average duration of stockouts. This calculation is based on stockouts observed in facilities’ records. The number and duration of some stockouts could not be derived due to poor records or staff's inability to remember. This analysis only includes facilities that had at least three months of stock keeping records; where these data are unavailable, this measurement cannot be made (i.e., “n” is lower for these indicators). Therefore, the stockouts in this section’s tables are thought to underestimate the frequency of stockouts for the products in this survey. • Mean months of stock on hand on the day of the visit by facility type. This is based only on facilities that had physical inventory and three consumption records available, thus the number of facilities included in these calculations (i.e., “n”) is lower than the number of overall facilities managing each product. The data presented in this report are the mean months of stock on hand. For most of the products, the median months of stock are lower. Where there are large months of stock on hand in the system, the mean illustrates the amount of stock that is at risk of damage and/or expiration. The minimum stock that should be held at hospitals and health centers is one month, and the maximum is three months. The minimum that should exist at the RMS is nine months, and the maximum is 15 months for contraceptives and STI drugs while for all other drugs and medical supplies the minimum at RMS is nine months and the maximum is 12 months. • All analysis by product type was done only for facilities that report managing the product. Malawi Logistics System Assessment and Stock Status Report - 2006 13 FINDINGS FOR CONTRACEPTIVES Contraceptives in the survey included Lo-Femenal, Ovrette, male condoms, Depo-Provera/ Petogen, and Norplant. STOCKOUTS OF CONTRACEPTIVES ON DAY OF VISIT From Figure1, it can be noted that of all contraceptives, Ovrette was stocked out at more than 40 percent of the hospitals in 2006 on the day of the visit unlike in 2004 when it was at 20 percent. This was due to the fact that most of the contraceptives expired in December 2005. In addition, it has been observed that there is a declining trend in the use of Ovrette as a family planning method, with more women preferring to use Depo Provera. Figure 1: Percentage of hospitals that experienced a stockout of contraceptives on the day of the visit 0 10 20 30 40 50 60 70 80 90 100 Lo- Femenal Ovrette Condom Depo- Provera Norplant Product Pe rc en t 2006 2004 The situation at the health centers as illustrated in Figure 2 was similar to the hospitals with 40 percent of the health centers visited having a stockout of Ovrette on the day of the visit. The reason for the stockout at the health centers was the same as for the hospitals. The stockouts for the other contraceptives were not due to non availability at the central level, but due to either non reporting, rationing (whereby facilities are only given one month supply which finishes before another delivery occurs), or delays in the delivery of the consignments. Norplant is not managed at the health centers. With the exception of Ovrette and Depo – Provera the situation for the other contraceptives improved in 2006 as compared to the one in 2004. Malawi Logistics System Assessment and Stock Status Report -2006 14 Figure 2: Percentage of Health Centers that experienced a stockout of contraceptives on the day of the visit 0 10 20 30 40 50 60 70 80 90 100 Lo-Femenal Ovrette Condom Depo- Provera Norplant Product Pe rc en t 2006 2004 STOCKOUTS OF CONTRACEPTIVES WITHIN THE LAST SIX MONTHS Between July and December 2005 it was noted that hospitals experienced lower levels of stockouts in 2006 as compared to 2004 with the exception of Ovrette for reasons already explained. Ten percent of the hospitals experienced a stockout of Norplant in the last six months as compared to 60 percent in 2004 which is a great improvement. Figure 3: Percentage of hospitals that experienced a stockout of contraceptives during the last six months 0 10 20 30 40 50 60 70 80 90 100 Lo-Femenal Ovrette Condom Depo-Provera Norplant Product Pe rc en t 2006 2004 Malawi Logistics System Assessment and Stock Status Report - 2006 15 The situation for health centers was similar to that of hospitals in that there were a lower number of facilities stocked out of contraceptives in 2006 than in 2004. Ten percent of the facilities were stocked out of Lo-Femenal in 2006 as compared to 20 percent in 2004. See Figure 4 below for additional details. Figure 4: Percentage of Health Centers that experienced a stockout of contraceptives during the last six months 0 5 10 15 20 25 30 35 40 Lo-Femenal Ovrette Condom Depo-Provera Products Pe rc en t 2006 2004 AVERAGE NUMBER AND DURATION OF STOCKOUTS OF CONTRACEPTIVES Figure 5 below illustrates the average number of stockouts for contraceptives between July and December 2005. When compared to 2004, with the exception of both condoms and Norplant (which experienced similar numbers of stockouts in both 2004 and 2006), there has been an increase in the average number of stockouts for Lo-Femenal and Ovrette. The exception has been Depo- Provera where the number of stockouts decreased in 2006, from 1.7 to 1.3. A higher number of stockouts for Lo-Femenal could be the result of late delivery or non-reporting by the concerned facilities. However, it is important to note that during the 2006 reporting period there was no stockout of Lo-Femenal at the central level. As for Ovrette, the reason for the increased number of stockouts in 2006 could be attributed to large amounts of stock that expired in December 2005, and Ovrette is considered a slow moving product that can be overlooked when orders are made by the health facilities. Figure 5: Average number of stockouts - Hospitals 0 0.5 1 1.5 2 2.5 3 3.5 4 Lo- Femenal Ovrette Condom Depo- Provera Norplant Product Pe rc en t 2006 2004 Malawi Logistics System Assessment and Stock Status Report -2006 16 The situation at the health centers was better compared to the hospitals. As noted below in Table 6, between July and December 2005, there had been a small decrease in average number of stockouts for all of the contraceptives, with the exception of Ovrette which experienced same number of days of stockouts in 2004 and 2006. Figure 6: Average number of stockouts – Health Centers 0 0.5 1 1.5 2 2.5 Lo-Femenal Ovrette Condom Depo-Provera Product P er ce nt 2006 2004 The duration for contraceptive stockout at hospitals ranged from less than 20 days for Lo-Femenal and Norplant to a maximum of 80 days for Ovrette. The situation for Ovrette and condoms was better in 2004 than in 2006. Condoms were not evenly distributed in the supply chain during the year with some facilities overstocked and others experiencing a stockout. However, for health centers (Figure 8), the average duration for stockouts was better in 2006 than it was in 2004 with the exception of Ovrette which had an average duration of 120 days in 2006 as compared to about 45 days in 2004. Figure 7: Average duration of stockouts - Hospitals 0 10 20 30 40 50 60 70 80 90 Lo-Femenal Ovrette Condom Depo-Provera Norplant Product N um be r o f d ay s 2006 2004 Malawi Logistics System Assessment and Stock Status Report - 2006 17 Figure 8: Average duration of stockouts – Health Centers 0 20 40 60 80 100 120 140 Lo-Femenal Ovrette Condom Depo-Provera Product Nu m be r o f d ay s 2006 2004 MONTHS OF STOCK ON HAND OF CONTRACEPTIVES Figures 9&10 show the number of months of stock on hand for contraceptives. These numbers are based on the stock available in physical inventory, divided by the average monthly issues at that facility, or in the case of the RMS, the stock available divided by the average monthly issues to all facilities in that region. Figure 9: Months of stock on hand of contraceptives - Hospitals 0 5 10 15 20 25 30 Lo-Femenal Ovrette Condom Depo- Provera Norplant Product M on th s of s to ck o n ha nd 2006 2004 Malawi Logistics System Assessment and Stock Status Report -2006 18 Figure 10: Months of stock on hand of contraceptives – Health Centers 0 5 10 15 20 25 30 35 Lo-Femenal Ovrette Condom Depo-Provera Product M on th s of S to ck o n H an d 2006 2004 In Malawi, both hospitals and health centers should maintain between one and three months of stock. Figure 9 above demonstrates that in 2006, hospitals were overstocked for all contraceptives, maintaining anywhere between 5-6 months of stock for Lo-Femenal, Ovrette and Depo-Provera. Meanwhile, both condoms and Norplant had major overstocks at sixteen and twenty-one months respectively. During data collection, it was noted that recently many districts received unsolicited shipments of condoms which has resulted in overstocks. Norplant (considered a long term method compared to other methods), is not frequently requested by clients, which can explain why there is an overstock in both 2004 and 2006. In recent years, more women seem to prefer discreet methods like Depo– Provera where they are given a shot once every three months without any obvious evidence of using contraceptives. Depo- Provera also causes some women to gain weight which is given as a reason for their preference toward injectables compared to the other methods. Additionally, Norplant record keeping is somewhat dispersed in the hospitals. Norplant is ordered and received by the Pharmacy Technician, authorized as a method by the Family Planning Coordinator and inserted into a woman by the Clinician. HMIS introduced Family Planning Registers that collect the annual number of women inserted with Norplant. In 2005 8,822 women were inserted with Norplant (35 percent were inserted in Lilongwe). Comparing the findings above with the HMIS reveals problems with collection of information on Norplant insertion. The 2006 forecasting exercise requesting a shipment of over 7,000 Norplant by June 2006 to avoid a stockout also confirms that the overstocks of Norplant could be a result of insufficient essential data. In practice, recording stock levels and reporting on condom distribution is scarce. This is confirmed from the findings above which reveal poor stock balances for condoms for both 2004 and 2006 (43/35 respectively). Additionally, since this indicator is based on the available stock divided by average months of stock, this result is anticipated for condoms because most stock keepers record receipt of condoms and seldom record what they have issued to clients. Similar to hospitals, health centers were also overstocked in 2006. Condoms and Lo-Femenal had an average of nearly twenty months of stock; meanwhile Ovrette had an average of 31 months of stock available. As mentioned earlier, this is due to the fact that there has been a declining trend in the use of Ovrette by women who are opting for Depo-Provera instead, resulting in huge overstock of both Ovrette Malawi Logistics System Assessment and Stock Status Report - 2006 19 and Lo- Femenal. The other reason for the overstock could be that facilities have been ordering the commodities without really considering their stock levels. CONCLUSIONS FOR CONTRACEPTIVES • Since contraceptives are in full supply at the central level, there should be no stockouts of any duration. Contraceptives are fully funded, and the Ministry is able to procure and distribute them to hospitals and health centers. One can conclude, therefore, that stockouts are due to a breakdown in logistics functions between the RMS and SDP levels (e.g., inappropriate ordering, not ordering on time, and/or transportation) rather than to a lack of supplies in the system. • Overall, the percentage of facilities that experienced stockouts for contraceptives during the last six months decreased in 2006. The only exception was Ovrette which is not considered a method of choice by majority of women, who instead prefer Depo-Provera. Additionally, much of the Ovrette stock expired in December 2005 which is also a contributing factor for higher a stockout rate. • Condoms are not evenly distributed in the supply chain resulting in some facilities receiving an overstock while others experiencing a stockout of condoms. This suggests that either the facilities are not ordering based on their consumption rates or the RMS is pushing condoms to the facilities in an attempt to eliminate extra inventory from their stock, resulting in an overstock at the facility level. • The average months of stock on hand show an overstock of contraceptives in 2006. This was especially evident for both condoms and Norplant at the hospital level, with an average stock on hand of sixteen and twenty-one months respectively. However, at individual facilities in the survey, there were stockouts, undersupply, and oversupply of contraceptives, even if the levels on average are overstocked. • In 2006, with the exception of Ovrette and condoms, the average stockout duration for contraceptives decreased. Ovrette on the other hand was stocked out at the health center, hospitals and the RMS level. It is also the only contraceptive stocked out at the RMS level (average of 81 days). FINDINGS FOR STI/OI DRUGS STI/OI drugs in the survey included: 2.4 mU vials of benzathine penicillin, 100 mg tablets of doxycycline, 200 mg tablets of metronidazole, 200 mg tablets of fluconazole, nystatin pessaries, and 250 mg tablets of erythromycin. STOCKOUTS OF STI/OI DRUGS ON DAY OF VISIT Since 2002, the Sexual and Reproductive Health program with support from DfID has provided for STI drugs. However, with the advent of SWAp, money through this program is now being channeled through SWAp for the procurement of these drugs. During the survey, over 50 percent of the facilities had a stockout for Erythromycin on the day of the visit with 40 percent experiencing a stockout for Nystatin pessaries. There was no stockout for Diflucan and Benzathine penicillin in 2006 as compared to close to 20 percent and 5 percent respectively in 2004. Malawi Logistics System Assessment and Stock Status Report -2006 20 Figure 11: Percentage of Hospitals that experienced a stockout of STI/OI drugs on the day of the visit 0 10 20 30 40 50 60 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Di flu ca n Ny sta tin Er yth ro my cin Product Pe rc en t 2004 2006 At the health centers, the situation for Erythromycin was worse than at the districts, with close to 80 percent experiencing a stockout of Erythromycin on the day of the visit and approximately 45 percent for Nystatin in 2006. The stockout for the two commodities was especially pronounced due to stockout at the central level. Figure 12: Percentage of Health Centers that experienced a stockout of STI/OI drugs on the day of the visit 0 10 20 30 40 50 60 70 80 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Di flu ca n Ny sta tin Er yth ro my cin Product Pe rc en t 2006 2004 Malawi Logistics System Assessment and Stock Status Report - 2006 21 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Dif luc an Ny sta tin Er yth rom yc in STOCKOUTS OF STI/OI DRUGS WITHIN THE LAST SIX MONTHS Tables 13 & 14 below provide a detailed picture of the stock outs between July and December 2005. With the exception of Doxycycline and Metronidazole, hospitals experienced higher percentage of stockouts over the last six months in 2006 when compared to 2004. Approximately 80 percent of the hospitals experienced a stockout of Nystatin pessaries in the last six months in 2006 compared to 31 percent in 2004. Similarly 68 percent of the hospitals were stocked out of Erythromycin compared to 50 percent in 2004. Similar trend can also be seen for health centers especially for Nystatin, although overall health centers seem to fare better in 2006 compared to 2004. Delays in procurement have caused major stockouts of all drugs, including STI drugs. For example, Erythromycin was stocked out at two of the three RMS’s. Another reason for the high stockouts of Erythromycin could be because it is considered a multiple usage drug. Apart from being used to treat STI’s it is also used for treating other ailments. As such, its consumption rates tend to be very high. This follows an agreement that was reached that STI drugs could also be used for treating other ailments. SRHP reported that they had enough money to provide the drugs in any quantities requested by the Ministry. Use of these drugs was increased in the treatment of HIV/AIDS opportunistic infections and treatment of STI’s in pregnant women. However, the initial forecasts for STI drugs done in the year 2002 by LATH used the information from STI registers that only record patients treated with STI and did not take into consideration the treatment of OIs or pregnant women. This has resulted in underestimation in forecasting and subsequent stockouts. Stockouts of Nystatin pessaries could have resulted due to discrepancy in using various units of count when recording Nystatin receipts and issues. Many health facilities continue to record it in units of 5 instead of 20 or 100. This inconsistent practice resulted in inaccurate forecasts for Nystatin. The last supply for Nystatin pessaries was delivered on 31st May 2005 and at the time of the survey; most facilities had run out of the commodity, including all three RMSs. There was no stockout for Diflucan or Benzathine penicillin in 2006 as compared to close to 20 percent and 5 percent respectively of the facilities in 2004. Figure 13: Percentage of Hospitals that experienced a stockout of STI/OI drugs in the last six months 0 10 20 30 40 50 60 70 80 90 Pe rc en t 2006 2004 Product Malawi Logistics System Assessment and Stock Status Report -2006 22 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Di flu ca n Ny sta tin Er yth ro my cin Figure 14: Percentage of Health Centers that experienced a stockout of STI/OI drugs in the last six months 0 10 20 30 40 50 60 70 80 90 100 Pe rc en t 2006 2004 Product AVERAGE NUMBER AND DURATION OF STOCKOUTS OF STI/OI DRUGS The highest average number of stockouts for STI drugs at hospitals occurred for Metronidazole tablets and Erythromycin in both 2004 and 2006 (Figure 15). In 2004, the average number for Erythromycin was slightly above 2 times compared to 2.5 times in 2006, and that of Metronidazole was slightly above 1.5 times in 2004 as compared to above 2.5 times in 2006. However, health centers experienced a higher average number of stockouts for Doxycycline in 2006, at 2.5 times, as compared to slightly less than 2 times in 2004. Figure 15: Average number of stockouts - Hospitals 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Di flu ca n Ny sta tin Er yth ro my cin Product N um be r o f S to ck ou ts 2006 2004 Malawi Logistics System Assessment and Stock Status Report - 2006 23 Similar to hospitals, health centers (Figure 16) also experienced higher average numbers of stockouts for both Erythromycin and Metronidazole in 2006, both at slightly above 1.5 times. However, Erythromycin, fared better in 2006 compared to 2004, at approximately 1.5 stockouts. Figure 16: Average number of stockouts – Health Centers 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Dif luc an Ny sta tin Er yth rom yc in Product N um be r o f S to ck ou ts 2006 2004 As has been established in Figure 17 & 18 below, the situation for Nystatin has significantly worsened in 2006 at both health centers and hospitals. Additionally, it was also stocked out at the central level. The average duration of stockout for Nystatin was 120 days for hospitals and 100 days for Health centers. Figure 17: Average duration of stockouts – Hospitals 0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Dif luc an Ny sta tin Er yth rom yc in Product D ur at io n of S to ck ou ts 2006 2004 Malawi Logistics System Assessment and Stock Status Report -2006 24 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Di flu ca n Ny sta tin Er yth ro my cin Figure 18: Average number of stockouts – Health Centers 0.0 20.0 40.0 60.0 80.0 100.0 120.0 140.0 D ur at io n of S to ck ou ts 2006 2004 Product MONTHS OF STOCK ON HAND OF STI/OI DRUGS Figure 19 & 20 shows the number of months of stock on hand for STI/OI drugs. These figures are based on the stock available in physical inventory, divided by the average monthly consumption at that facility, or in the case of the RMS, the stock available divided by the average monthly consumption of all facilities in that region. Figure 19: Months of stock of STI/OI drugs available - Hospitals 0.0 2.0 4.0 6.0 8.0 10.0 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Di flu ca n Ny sta tin Er yth ro my cin Product M on th s of S to ck o n H an d 2006 2004 At the hospitals, the months of stock for all the STI drugs with the exception of Benzathine Penicillin and Diflucan fell within the required one month minimum and three months maximum. Diflucan is a Pfizer supported partnership program commodity and is managed at the central level. The distribution of Diflucan is centrally controlled at the Central Medical Stores by a desk officer who monitors the use by all facilities in the country. The distribution is based on the monthly usage reported by the facilities. Registers and stock cards are used to record both service statistics and logistics information and this is confirmed in Table 2 which shows that 73 percent of facilities had stock cards, of which 71 percent of the Malawi Logistics System Assessment and Stock Status Report - 2006 25 facilities had updated stock cards. Benzathine was overstocked at both hospitals and health centers, with eight months of available stock on hand. Health centers on the other hand experienced overstock of Doxycycline and Metronidazole at six and slightly above four months respectively. However, it is important to understand that this stock on hand information is generalized for all surveyed facilities at each level, within each level, individual facilities may be overstocked, under stocked, stocked out, or adequately stocked, even if on average each level could be overstocked for a particular product. Figure 20: Months of stock of STI/OI drugs available – Health Centers 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Be nz ath ine pe n. Do xy cy cli ne Me tro nid az ole Di flu ca n Ny sta tin Er yth ro my cin Product M on th s of S to ck o n H an d 2006 2004 CONCLUSIONS FOR STI/OI DRUGS • In 2006, there were significant stockouts of Nystatin and Erythromycin, both at the hospital and the health center level. On the day of the visit, 40 percent of the hospitals and 45 percent of the health centers were stocked out of Nystatin. Similarly, over 50 percent of the hospitals and almost 80 percent of the health centers were stocked out of Erythromycin. One of the reasons for high stockout of Erythromycin is that it is considered a multiple usage drug and can be used to treat other ailments besides STI/OI. The use of Erythromycin for treatment of other illnesses was not factored into the forecast which has subsequently resulted in the high stockout rate of the drug. In the case of Nystatin, facilities have encountered problems in determining its unit of issue. Many facilities continue to record it in units of 5 instead of 100. This error in counting of inventory and record keeping could have led to underestimating the quantity of drug needed at the national level, eventually resulting in stockouts. • With the exception of Benzathine and Diflucan, all other STI/OI drugs were stocked within the required minimum and maximum level. However, as stated earlier, this information is generalized for all surveyed facilities at each level, within each level. There are individual facilities which may be overstocked, under stocked, stocked out, or adequately stocked, even if on average each level could be overstocked for a particular product. • Stockouts occurred at a higher percentage of facilities for STI drugs than for contraceptives, although both are full supply products. Malawi Logistics System Assessment and Stock Status Report -2006 26 FINDINGS FOR ESSENTIAL DRUGS AND MATERNAL AND CHILD HEALTH The malaria and child health commodities included in this survey are sulfadoxine-pyrimethamine (SP), 480 mg tablets of cotrimoxazole, 500 mg tablets of paracetamol, and ORS sachets. All of the MOH health facilities managed all of the malaria indicator drugs included in the survey. Also included were critical drugs used in maternal health like Syntometrine, Ferrous Sulphate and 5mg/mlvials of metronidazole injection. Two commonly used drugs, Amoxicillin and Aspirin were also included to check their availability. STOCKOUTS OF MALARIA AND CHILD HEALTH PRODUCTS ON DAY OF VISIT As illustrated in Figure 21, Amoxicillin was stocked out at slightly over 60 percent of the hospitals in 2006. Close to 30 percent of the hospitals also experienced stockouts on the day of the visit for paracetamol and less than 20 percent experienced stockouts for SP, Syntometrine, Aspirin and ORS. The situation for SP was slightly better in 2006 compared to 2004 although there were stockouts in the period under review at the central level. There was no stockout for gloves on the day of the visit because at the time of the visit, facilities had just been supplied with gloves after experiencing several stockouts in the previous months. The result for Metronidazole injection, a product added to the 2006 survey, indicates a stockout at slightly above 40 percent of the facilities. Figure 21: Percentage of Hospitals that experienced a stockout of essential drugs and maternal and child health products on the day of the visit 0 20 40 60 80 100 Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj.Product Pe rc en t 2006 2004 As observed in Table 22, the situation for Health Centers was similar to that of hospitals with the exception that a higher percentage of the health centers experienced stockouts for Paracetamol and Cotrimoxazole at close to 80 percent and slightly above 60 percent respectively. Malawi Logistics System Assessment and Stock Status Report - 2006 27 Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Figure 22: Percentage of Health Centers that experienced a stockout of essential drugs and maternal and child health products on the day of the visit 0 20 40 60 80 100 Pe rc en t 2006 2004 Product STOCKOUTS OF ESSENTIAL DRUGS AND MATERNAL AND CHILD HEALTH PRODUCTS IN THE LAST SIX MONTHS Figure 23 & 24 present the results on percentage of facilities that were stocked out over the last six months. Approximately 80 percent of the hospitals and health centers experienced a stockout of Amoxicillin during that time. Approximately 60 percent of the hospitals also experienced a stockout of aspirin and gloves in 2006. The situation for SP deteriorated from 2004 to 2006. In 2004, only 20 percent of the facilities experienced a stockout for SP compared to nearly 70 percent in 2006. Similar trends are also evident for health centers where 90 percent of the health centers were stocked out of SP compared to 38 percent in 2004. This increase in stockout of SP and other drugs can be attributed to the fact that all three regional medical stores (RMS) had also experienced stockouts in 2006. Figure 23: Percentage of Hospitals that experienced a stockout of essential drugs and maternal and child health products in the last six months 0 20 40 60 80 100 Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Product Pe rc en t 2006 2004 Malawi Logistics System Assessment and Stock Status Report -2006 28 Figure 24: Percentage of Health Centers that experienced a stockout of essential drugs and maternal and child health products in the last six months 0 20 40 60 80 100 Ferrous Sulphate (FeFo) Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Products N um be r o f S to ck ou ts 2006 2004 AVERAGE NUMBER AND DURATION OF STOCKOUTS OF MALARIA AND CHILD HEALTH PRODUCTS Figure 25 above illustrates the average number of stockouts for the MCH, other essential drugs and medical supplies. Over the six months under review, hospitals experienced 6.5 stockouts of gloves. This number is rather alarming considering the importance of gloves in the health care delivery system. Meanwhile, all other commodities experienced fewer numbers of stockouts in 2006, all below three. The number of stockouts for Cotrimoxazole dropped from an average of 3.5 in 2004 to 2.0 in 2006. Figure 25: Average number of stockouts - Hospitals 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 Ferrous Sulphate (FeFo) Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Product D ay s of S to ck ou t 2006 2004 The same can also be said for the health centers (Fig 26) which also experienced fewer than three stockouts for all MCH and other essential commodities. However, the average number of stockouts for SP increased from two in 2004 to three in 2006. As mentioned earlier, central level also experienced a stockout during the period under survey in 2006. The situation could have been worse had the district hospitals not provided health centers with an emergency supply of SP. Malawi Logistics System Assessment and Stock Status Report - 2006 29 Figure 26: Average number of stockouts – Health Centers 0.0 1.0 2.0 3.0 4.0 Ferrous Sulphate (F. Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Product N um be r o f S to ck ou ts 2006 2004 Average duration of stockouts for ORS at the hospitals and health centers declined in 2006, at 10 days compared to over 40 days in 2004, and above 60 days to than 20 days in 2006 respectively. The situation for Paracetamol also improved; from an average of 30 days of stockout in 2004 to 10 days in 2006. Although no comparative data is available for Amoxicillin and Syntometrine from 2004, an average stockout in 2006 lasted for over 40 days. Figure 27: Average duration of stockouts - Hospitals 0 10 20 30 40 50 60 Ferrous S ulphate (FeFo) Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Product D ur at io n of S to ck ou ts 2006 2004 The situation at the health centers was worse for Cotrimoxazole at 60 days in 2006 compared to 20 days in 2004. Health centers also experienced higher durations of stockouts in 2006 for SP lasting for approximately 40 days. In the case of Metronidazole injection, it is important to note that only one health center managed Metronidazole injection and experienced one stockout for a duration of 100 days. Malawi Logistics System Assessment and Stock Status Report -2006 30 Figure 28: Average duration of stockouts in the last six months – Health Centers 0 20 40 60 80 100 Ferrous Sulphate (FeFo) Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Product D ur at io n of S to ck ou ts 2006 2004 AVERAGE MONTHS OF STOCK ON HAND FOR MALARIA AND CHILD HEALTH PRODUCTS The months of stock for MCH and other essential commodities varied at both hospitals and health centers. Both levels are required to have a minimum of one month and a maximum of three months stock of the said commodities. ORS was overstocked at both the hospitals and the health centers at close to 10 months and 7 months respectively. While district hospitals maintained adequate stock of Syntometrine, it was heavily overstocked at the health center level- at 12 months of stock. At the time of the survey it was found that much of the Syntometrine had an expiration date of June 2006. Therefore, it is very likely that large quantities of Syntometrine will expire prior to consumption. In the case of Ferrous Sulphate, both hospitals and health centers were overstocked at 6 months. SP, cotrimoxazole, aspirin and gloves on the other hand were stocked within the set min – max levels. Figure 29: Months of stock of essential drugs and maternal & child health products - Hospitals 0 2 4 6 8 10 Ferrous Sulphate (FeFo) Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Product M on th s of S to ck o n H an d 2006 2004 Malawi Logistics System Assessment and Stock Status Report - 2006 31 Figure 30: Months of stock of essential drugs and maternal and child health products – Health Centers 0 2 4 6 8 10 12 Ferrous Sulphate (FeFo) Syntometrine SP Cotrimoxazole Paracetamol ORS Amoxicillin Aspirin Gloves Metronidazole Inj. Product M on th s of S to ck o n H an d 2006 2004 CONCLUSIONS FOR ESSENTIAL DRUGS AND MATERNAL AND CHILD HEALTH PRODUCTS • The procurement of MCH and other essential drugs differs from STI drugs and Contraceptives. While Contraceptives and STI drugs are considered full supply and financing is guaranteed by the donors, MCH drugs are normally non–full supply and are procured without considering consumption patterns. They are procured on an ad-hoc basis depending on the availability of funds. • There were stockouts on the day of the visit at hospitals and health centers. To provide comprehensive health services, facilities need adequate stock of essential and maternal and child health drugs. Analysis found that both 60 percent of the hospitals and health centers would be unable to provide Amoxicillin to their clients on the day of the visit. Similarly, 60 percent and 80 percent of the health centers would not have been able to complete orders from clients for Cotrimoxazole and Paracetamol respectively. • In 2006, higher percentage of facilities experienced stockouts during the six months under review period. This suggests that either health facilities are not adequately ordering stock based on their consumption, or health facilities are not supplied with accurate amount of stock needed to serve their clients. • Over the course of six months, all three Regional Medical Stores experienced a stockout of SP. This has resulted in major stockouts at the health facilities during that time. Furthermore, this can have a drastic impact on the health of all Malawians, especially younger children since SP is a much needed drug to combat the spread of Malaria. FINDINGS FOR TEST KITS In 2006, Determine HIV, SD Bioline, Unigold were included in the survey, with Unigold replacing Hemastrip from the 2004 survey. Approximately, 90 percent of the hospitals manage test kits compared to 35 percent of the health centers, so the analysis focused on hospitals and RMS. Although there has been an increase in the number of sites offering testing, the percentage of those sites stocked out has also Malawi Logistics System Assessment and Stock Status Report -2006 32 increased, compromising the effectiveness of the testing program. In 2004, only 71 percent of the hospitals (n=21) offered Determine HIV compared to 90 percent of the hospitals (n= 20) which now have provisions to offer on-site testing. STOCKOUTS OF TEST KITS ON DAY OF VISIT Percentage of hospitals that experienced a stockout on the day of the visit has slightly gone down in 2006, from approximately 20 percent in 2004 to 17 percent in 2006. However, approximately 19 percent of the hospitals were stocked out of SD Bioline and six percent of Unigold in 2006. Both Bioline and Unigold are considered alternative tests, therefore a stock out of Bioline at a facility that has Unigold available will not have an effect on availability of test kits so long as Unigold is available or vice-versa (provided under the assumption that the site uses both tests). Figure 31 below further illustrates this point. Approximately five percent of the facilities that manage HIV test kits were stocked out of Unigold on the day of the visit compared to 17 percent for SD Bioline. The situation at the RMS level is of particular concern since 66 percent (two of the three RMS) were stocked out of Determine HIV on the day of the visit (Figure 32). Having test kits available at the hospitals is the only way to confirm HIV status and direct clients into needed care and services, given the advent of “scaling up” for antiretroviral therapy and the need to have these tests readily available for testing clients. Figure 31: Percentage of Hospitals that experienced a stockout of test kits on the day of the visit 0 5 10 15 20 25 Determine HIV SD Bioline Unigold Product Pe rc en t 2006 2004 Figure 32: Percentage of RMS’s that experienced a stockout of test kits on the day of the visit 0 10 20 30 40 50 60 70 Determine HIV SD Bioline Unigold Product Pe rc en t 2006 2004 Malawi Logistics System Assessment and Stock Status Report - 2006 33 STOCKOUTS OF TEST KITS DURING THE LAST SIX MONTHS In 2006, there has been an increase in the average number of stockouts over the last six months. Over 80 percent of the hospitals and 66 percent (two of the three RMS) were stocked out of Determine HIV. Both SD Bioline and Unigold fared better than Determine HIV in 2006 although approximately 22 percent of the hospitals did experience a stockout in the last six months. In 2006, the stockout rate for SD Bioline significantly went down from 2004, when 100 percent of the hospitals experienced a stockout over period of six months. Additionally, there was no stockout of Unigold at the RMS level. As mentioned earlier, lack of test kits inventory at both the RMS and the hospital level has greater implications in providing testing for clients seeking services at the hospitals. Figures 33 and 34 further illustrate the results. Figure 33: Percentage of Hospitals that experienced a stockout of test kits in the last six months 0 20 40 60 80 100 Determine HIV SD Bioline Unigold Product Pe rc en t 2006 2004 Figure 34: Percentage of RMS’s that experienced a stockout of test kits in the last six months 0 10 20 30 40 50 60 70 Determine HIV SD Bioline Unigold Product Pe rc en t 2006 2004 Malawi Logistics System Assessment and Stock Status Report -2006 34 AVERAGE NUMBER AND DURATION OF STOCKOUTS OF TEST KITS Figures 35-38 illustrate the average number and duration of stockouts for test kits. In 2006 hospitals experienced an average of three stockouts for Determine HIV compared to 1.5 in 2004; however, there was improvement in the average duration of stockout in 2006 (down to 17 days compared to 38 days in 2004). In the case of SD Bioline, hospitals experienced fewer number of stockouts in 2006 (one stockout compared to 2.5 in 2004), but the average duration of stockout was much higher in 2006 compared to 2004 (100 days of stockout compared 5.2 days in 2004). The only exception is stock level of Unigold at the RMS level which did not experience any stockouts in 2006. There is no comparative data available for Unigold in 2004 as it was not included in the survey. Figure 35: Average number of stockouts - Hospitals 0 0.5 1 1.5 2 2.5 3 3.5 Determine HIV SD Bioline Unigold Product N um be r o f S to ck ou t 2006 2004 Figure 36: Percentage of RMS’s that experienced a stockout of test kits in the last six months 0 0.5 1 1.5 2 2.5 Determine HIV SD Bioline Unigold Product N um be r o f s to ck ou ts 2006 2004 Malawi Logistics System Assessment and Stock Status Report - 2006 35 Figure 37: Average duration of stockouts - Hospitals Duration of Test Kits Stockouts in the Last Six Months- Hospitals 0 20 40 60 80 100 120 Determine HIV SD Bioline Unigold Product D ur at io n of S to ck ou ts 2006 2004 Figure 38: Average duration of stockouts – RMS 0 5 10 15 20 25 30 35 40 Determine HIV SD Bioline Unigold Product D ay s of S to ck ou t 2006 2004 MONTHS OF STOCK ON HAND FOR TEST KITS Hospitals were adequately stocked between their minimum and maximum levels for Determine HIV and slightly above the maximum for Unigold (at 3.3 months). Since SD Bioline is no longer being widely used (most facilities have started using Unigold instead since both are considered alternative tests), it has most likely contributed to the major overstock of SD Bioline at time of the survey. RMS on the other hand were not adequately stocked for either Determine HIV or SD Bioline but within the required levels for Unigold. An almost complete stock out of Determine at the RMS level is rather alarming considering Determine is used as one of the first (parallel) tests and without it testing cannot occur. Decrease in the use of SD Bioline is also the probable cause for an understock at the RMS level. Malawi Logistics System Assessment and Stock Status Report -2006 36 Figure 39: Months of stock of test kits available - Hospitals 0 2 4 6 8 10 12 14 16 Determine HIV SD Bioline Unigold Product M on th s of S to ck o n H an d 2006 2004 Figure 40: Months of stock of test kits available – RMS 0 1 2 3 4 5 6 7 8 9 Determine HIV SD Bioline Unigold Product M on th s of S to ck o n H an d 2006 2004 CONCLUSIONS FOR TEST KITS • There was a decrease in the percent of hospitals found out of stock of Determine HIV test kits, but an increase at the RMS level. Determine is used as one of the first (parallel) tests and without it testing cannot occur. Determine is the one test used for blood safety at the hospitals, many of whom still rely on their own labs to test any incoming blood. • In 2006 over 20 percent of the hospitals experienced a stockout of every test kit at some point between July and December 2005. Over 80 percent of the hospitals and two of the three RMS had stockouts of Determine HIV between July and December 2005. This finding indicates that there are still significant challenges in the logistics system for HIV test kits. • On average the HIV test kits stockouts decreased between 2004 and 2006, however the duration of the stockouts increased. Malawi Logistics System Assessment and Stock Status Report - 2006 37 Malawi Logistics System Assessment and Stock Status Report -2006 38 RECOMMENDATIONS In the analysis of both the facility survey and the Logistics System Assessment completed in March 2006 there were a number of challenges identified at the national level. The following recommendations are designed to address both short and long term needs. Some of the recommendations (e.g. storage conditions, removal of expired products) can be implemented immediately with little associated finances. • There is a need for more consistent communication and coordination between the MOH working groups focusing on supply chain management (e.g. Drugs and Medicines Supplies Technical Working Group and Logistics Working Group). Strengthening the coordination between various partners will ensure that all relevant stakeholders are well informed and kept abreast of key strategic decisions. • The existing procurement plan for contraceptives and essential drugs should be implemented immediately. Considering that the average procurement cycle may take eighteen months or more, and that many essential drugs are currently stocked out, emergency procurement is also needed for certain essential and life saving drugs. • If feasible, an immediate replenishing exercise (top-up) needs to be implemented for all essential drugs. Although, not all essential drugs are considered “full supply” products, they constitute the essential health package commodity list which should be available to all Malawians. For contraceptives, which are overstocked at many facilities but understocked or stocked out at some, a redistribution of existing supplies is needed to eliminate any stockouts at health facilities. It is likely that current rationing practices at RMS and facilities not submitting timely or accurate reports have contributed to this problem. • Create a feedback form that summarizes facility reporting rates. This quarterly form will be distributed to all District Medical Officers. • Short and long-term procurement commitments need to be solidified to achieve commodity security. At present, both donor and MOH financial commitments are based on possibly unreliable forecasts and so may prove inadequate. These commitments must ensure funding for the purchase of contraceptives and STI drugs in the event of inadequate funding through the SWAp mechanism. • Clarify the roles and responsibilities of CMS, MOH departments and supporting projects (DELIVER, MSH, etc.) in integrated commodity management, forecasting finance and procurement. • Storage condition guidelines must be distributed to all levels of the system. These storage conditions should be reviewed by supervisors and facility staff during each supervisory visit. • At the RMS level there is a need for improved organization and a capital investment in proper racking and material handling equipment (forklifts). • Expired items are being kept at health facilities. CMS in cooperation with the MOH should disseminate and enforce guidelines for proper disposal of expired and/or damaged drugs. These guidelines must be distributed to all health and storage facilities. Malawi Logistics System Assessment and Stock Status Report - 2006 39 • Continued supervision should emphasize the timely and accurate completion of logistics reports (LMIS 01A/B/C). Currently if a facility fails to submit reports they do not receive a re-supply of commodities. Under- reporting is evidence of poor inventory management at the facility level and contributes to a higher rate of both stockouts and wastage. • Build logistics capacity of district pharmacy technician who are now on the district management team. This can be done with on-the-job training for current pharmacy technician and by continuing logistics sessions in the pharmaceutical training program. • Clarify the roles and responsibilities of the zonal supervisors to avoid an overlap of effort between supervisors at the zonal level and district management teams. • Encourage coordination between the drugs managers and reproductive health coordinators at all levels to ensure proper contraceptives management. For example, District Reproductive Health Coordinators could submit reports to the Reproductive Health Unit on family planning that include information on couple-years of protection achieved. This information is now readily available through Supply Chain Manager and can be produced by the Pharmacy Technician. This information can help reproductive health coordinators determine actual consumptions level for facilities. Malawi Logistics System Assessment and Stock Status Report -2006 40 REFERENCES Papworth, David, Erika Ronnow. 2004. Malawi Logistics System and Stock Status Report. Arlington, Va.: John Snow, Inc/DELIVER, for the U.S. Agency for International Development (USAID). Malawi Logistics System Assessment and Stock Status Report - 2006 41 Malawi Logistics System Assessment and Stock Status Report -2006 42 APPENDIX 1 LOGISTICS INDICATOR ASSESSMENT TOOL MALAWI, 2006 FACILITY SERVICES AND INFRASTRUCTURE FACILITY IDENTIFICATION Name of the facility______________________________ Facility location City/town: Region_______________________________________ REGION District _______________________________________ DISTRICT………………………. FACILITY Code of the facility. CODE……………………………. Facility Type: (1= District hospital; 2= Rural hospital; 3=Health centre; 4 = Dispensary; 6=RMS; 7=Other FACILITY ____________) TYPE . …………………………………. Operating Authority: 1= MOH; 2= MOH/LG; 3= CHAM; OPERATING 7= Other (Specify)________________). AUTHORITY…………………………. Facility characteristics: Tarmac to the facility? ((0=no; 1=yes)………………………. TARMAC…………………….………. Operational electricity on day of visit? (0=no; 1=yes)……. ELECTRICITY………………………. Operational water in the building on the day of visit? (0=no; 1=yes)…………………………………………………. WATER………………………………… Operational telephone or radio on day of visit? (0=no; 1=yes) EXTERNAL COMMUNICATION……. RMS/SDP? (1 = RMS; 2 = SDP)…………………….……. RMS/SDP……………………………. Malawi Logistics System Assessment and Stock Status Report - 2006 43 INFORMATION ABOUT INTERVIEW DAY/ MONTH/ YEAR Date:__________________________________________ FACILITY INFRASTRUCTURE AND PRODUCTS AVAILABLE FIRST MEET WITH THE IN-CHARGE TO INTRODUCE ALL TEAM MEMBERS AND ASK FACILITY REPRESENTATIVES TO INTRODUCE THEMSELVES. EXPLAIN THE OBJECTIVES OF THIS SURVEY: As part of their on-going monitoring and evaluation the Ministry of Health and USAID-supported programs are conducting a survey regarding the health commodity logistics system. We are looking at the availability of selected commodities and information about how you order and receive those products. We are visiting selected health facilities throughout the country and this facility was selected to be in the survey. The objectives of the survey are to collect current information on logistics system performance and stock status of key health products. The results of this national survey will provide information to make decisions and to promote improvements. The survey has been and will be conducted again in the future to measure changes in the logistics system. 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 products you have in stock today and observe the general storage conditions. Do you have any questions? FIND OUT FROM THE IN-CHARGE WHO IS THE PRINCIPLE PERSON MANAGING THE DRUGS (WHO IS FILLING THE FORMS, KEEPING STOCK CARDS AND DOING REPORTING) ASK THE IN-CHARGE THE FOLLOWING QUESTIONS NO. QUESTION CODE CLASSIFICATION GO TO 01 Can we continue? YES .1 NO .2 ÎSTOP 02 Name and title of the In- Charge interviewed for this section ______________________________ 03 Number of years and months you have worked at this facility? Years: ______ Months: __________ 04 Who is the principal person responsible for managing medical supplies at this facility? NURSE .1 CLINICAL OFFICER .2 PHARMACY TECHNICIAN .3 PHARMACY ASSISTANT .4 PHARMACIST .5 MEDICAL ASSISTANT…………….6 OTHER (SPECIFY)____________9 THANK YOU FOR YOU TIME AND INFORMATION, YOU HAVE BEEN VERY HELPFUL. OUR REMAINING QUESTIONS WILL REQUIRE LOOKING AT PRODUCTS IN THE STOREROOM AND SPEAKING WITH THE PERSON WHO OVERSEES THE STORE. WHEN IN THE STORE ROOM (IF WITH A DIFFERENT PERSON): INTRODUCE ALL TEAM MEMBERS AND ASK FACILITY REPRESENTATIVES TO INTRODUCE THEMSELVES. EXPLAIN THE OBJECTIVES OF THIS SURVEY: Malawi Logistics System Assessment and Stock Status Report -2006 44 As part of their on-going monitoring and evaluation the Ministry of Health and USAID-supported programs are conducting a survey regarding the health commodity logistics system. We are looking at the availability of selected commodities and information about how you order and receive those products. We are visiting selected health facilities throughout the country and this facility was selected to be in the survey. The objectives of the survey are to collect current information on logistics system performance and stock status of key health products. The results of this national survey will provide information to make decisions and to promote improvements. The survey has been and will be conducted again in the future to measure changes in the logistics system. 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 products you have in stock today and observe the general storage conditions. Do you have any questions? NO. QUESTION CODE CLASSIFICATION GO TO 05 Name and title and of person interviewed for this section ______________________________ 06 Number of years and months you have worked at this facility? Years: ______ Months: __________ 07 Who is the principal person responsible for managing medical supplies at this facility? NURSE .1 CLINICAL OFFICER .2 PHARMACY TECHNICIAN .3 PHARMACY ASSISTANT .4 PHARMACIST .5 MEDICAL ASSISTANT…………….6 OTHER (SPECIFY)____________ 9 FIRST, REVIEW THE FOLLOWING QUESTIONS. AFTER THE 22 QUESTIONS VISIT THE WAREHOUSE, STOREROOM OR STORAGE AREA WHERE THE HEALTH PRODUCTS LISTED ARE MANAGED. IF YOU ARE REFERED TO ANOTHER STAFF MEMBER FOR THE STOCKTAKING EXERCISE INTRODUCE THE SURVEY GOALS AND OBJECTIVES AS YOU DID IN THE INTRODUCTION. NO. QUESTIONS CODE CLASSIFICATION GO TO/ COMMENTS Do you use and fill out the following? 101 A. Stock cards YES .1 NO .0 B. Daily register YES .1 NO .0 Malawi Logistics System Assessment and Stock Status Report - 2006 45 What forms do you use for reporting logistics data (these do not include service statistics reports)? (IF NEED BE ASK TO SEE THE FORM) A. LMIS-01A YES .1 Î104 NO .0 102 B. LMIS-01B YES .1 Î104 NO .0 C. LMIS- 01C YES .1 Î104 NO .0 YES (Specify)_________________ .1 D. Other NO .0 Does this report include the following? YES .1 A. Stock on hand 103 NO………………………………….0 YES .1 B. Quantities used NO………………………………….0 YES .1 C. Losses and adjustments NO………………………………….0 Monthly . A How often are these reports (from 102) sent to Quarterly .B 104 the higher level? Semi-annually . C Annually . D Other: .W Never .1 Within the last month .2 When was the last time you sent in an CIRCLE ALL THAT APPLY 2 months ago .3 105 order/report for products at this facility? 3 months ago .4 more than 3 months ago .5 Monthly . A How often are you supposed to send these Quarterly .B reports to the higher level? 106 Semi-annually . C Annually . D CIRCLE ALL THAT APPLY Other: .W Never learned…………………………….A How did you learn to complete the During a logistics workshop .B forms/records used at this facility? 107 On the job training . C On the job (self-learning) . D CIRCLE ALL THAT APPLY Other (Specify):_________________.W None……………………………………….0 NA………………………………………….1 How many emergency orders for One .2 108 contraceptives have you placed in the last 3 Two .3 months? Three .4 More than three……………………………5 None ……………………………………….0 One .2 How many emergency orders for STI/OI drugs 109 Two .3 have you placed in the last 3 months? Three .4 More than three……………………………5 Malawi Logistics System Assessment and Stock Status Report -2006 46 110 How many emergency orders for HIV test kits have you placed in the last 3 months? None.……………………………………….0 NA………………………………………….1 One .2 Two .3 Three .4 More than three……………………………5 111 How many emergency orders for other drugs have you placed in the last 3 months? None ……………………………………….0 NA………………………………………….1 One .2 Two .3 Three .4 More than three……………………………5 112 Who determines this facility’s re-supply quantities? CIRCLE ALL THAT APPLY The facility itself .A District office .B RMS ……………………………………….C Other: .W Î114 Î114 113 How are the facility’s re-supply quantities determined? Formula (Specify) .1 Don’t know .2 Other means: .8 114 Who is responsible for transporting products to your facility? CIRCLE ALL THAT APPLY Local supplier delivers .A RMS delivers .B District delivers . C This facility collects . D Other (Specify)_______________ .W Î116 Î116 Î116 115 What kind of transportation is most often used? Facility vehicle .1 Public transportation .2 Private vehicle .3 Boat…………………………………….….4 Motorcycle .5 Bicycle .6 On foot .7 Other (Specify) _________________ …… 9 116 On average, approximately how long does it take between reporting (HC’s))/ordering (Districts) and receiving products? Less than 2 weeks.1 2 weeks to one month .2 Between 1 and 2 months .3 More than 2 months .4 117 When did you receive your most recent general supervision visit? CHECK VISITORS BOOK IF NECESSARY Never received .1 Within the last month .2 Within the last 3 months .3 Within the last 6 months .4 More than 6 months ago .5 Other (Specify) _______________.9 118 When did you receive your last supervision visit that included drug management? Never received .1 Within the last month .2 Within the last 3 months .3 Within the last 6 months .4 More than 6 months ago .5 Other (Specify) _______________ …………9 119 Is there a Health Committee at this facility? YES .1 NO .0 ÎTable 1 120 When was the last Health Committee meeting? Never.1 Within the last 3 months .2 Within the last 6 months .3 More than 6 months ago .4 Other (Specify) .8 121 Are Health Committee members routinely available to receive health commodities at this facility? YES .1 NO .0 Malawi Logistics System Assessment and Stock Status Report - 2006 47 Malawi Logistics System Assessment and Stock Status Report -2006 48 TABLE 1: STOCK STATUS (July 1– December 31, 2005 and the day of visit) 1. Name of the product 2. Unit of count for the produce 3. Whether or not the product is managed at this facility, answer Y for yes or N if no skip to the next product 4. Check if the stock card is available, answer Y for yes or N for no 5. Check if the stock card had been updated within the last 30 days, answer Y for yes or N for no. Note: If the stock card was last updated with the balance of 0 and the facility has not received any resupply consider the stock card up to date. 6. Record the balance on the stock card 7. 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 8. Record if the facility has had any stockout of the product between July and December, 2005, answer Y for yes or N for no 9. Record how many times the product stocked out between July and December, 2005 10. Record the total number of days the product was stocked out between July and December 2005 11. Record the quantity of product issued from the storeroom between July and December 2005, Note: if the answer to column 4 is No, record NA in this column 12. Record the number of months the issued data represents (may be less than 6), record the months for which there is any data recorded, including 0. Note: if column 4 is No, record NA in this column 13. Record the quantity of product in the storeroom. Estimate to ¼ of a bottle for open containers of tablets 14. Record the quantity of expired products. Count all expired products on the day of the visit. If there are products that are near expiry (within one week) please note in the comments section. P r o d u c t U n i t s o f c o u n t M a n a g e d a t t h i s f a c i l i t y ? S t o c k c a r d a v a i l a b l e ? ( Y / N ) S t o c k c a r d u p d a t e d ? ( Y / N ) B a l a n c e o n s t o c k c a r d S t o c k o u t t o d a y ( Y / N ) ? S t o c k o u t J u l y . t h r o u g h D e c e m b e r , 2 0 0 5 ( Y / N ) ( Y / N ) ? N u m b e r o f s t o c k o u t s T o t a l n u m b e r o f d a y s T o t a l i s s u e d ( J u l y . t h r o u g h D e c e m b e r , 2 0 0 5 ) # r o f m o s . o f d a t a a v a i l a b l e P h y s i c a l i n v e n t o r y – S t o r e r o o m Q u a n t i t y o f e x p i r e d p r o d u c t s 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Lo-Femenal Cycle Ovrette Cycle Male condom Piece Depo-Provera and Petrogen Vial Norplant Piece Comments: Malawi Logistics System Assessment and Stock Status Report - 2006 49 P r o d u c t U n i t s o f c o u n t M a n a g e d a t t h i s f a c i l i t y ? S t o c k c a r d a v a i l a b l e ? ( Y / N ) S t o c k c a r d u p d a t e d ? ( Y / N ) B a l a n c e o n s t o c k c a r d S t o c k o u t t o d a y ( Y / N ) ? S t o c k o u t J u l y . t h r o u g h D e c e m b e r , 2 0 0 5 ( Y / N ) ? N u m b e r o f s t o c k o u t s T o t a l n u m b e r o f d a y s T o t a l i s s u e d ( J u l y . t h r o u g h D e c e m b e r , 2 0 0 5 ) # r o f m o s . o f d a t a a v a i l a b l e P h y s i c a l i n v e n t o r y – S t o r e r o o m Q u a n t i t y o f e x p i r e d p r o d u c t s 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Benzathine penicillin 2.4 mU vial Doxycycline 100 mg Tabs Metronidazole 250 mg Tabs Fluconozole/ Diflucan 200 mg Tabs Nystatin Pessaries Erythromycin 250 mg Tabs Metronidazole injection 5mg/ml, 100ml Vial Ferrous Sulphate (FeFo) 200mg + 250 mcg Tabs Syntometrine 500mcg/ ml + 10IU/ml Ampoule Comments: Malawi Logistics System Assessment and Stock Status Report -2006 50 P r o d u c t U n i t s o f c o u n t M a n a g e d a t t h i s f a c i l i t y ? S t o c k c a r d a v a i l a b l e ? ( Y / N ) S t o c k c a r d u p d a t e d ? ( Y / N ) B a l a n c e o n s t o c k c a r d S t o c k o u t t o d a y ( Y / N ) ? S t o c k o u t J u l y . t h r o u g h D e c e m b e r , 2 0 0 5 ( Y / N ) ? N u m b e r o f s t o c k o u t s T o t a l n u m b e r o f d a y s T o t a l i s s u e d ( J u l y . t h r o u g h D e c e m b e r , 2 0 0 5 ) # r o f m o s . o f d a t a a v a i l a b l e P h y s i c a l i n v e n t o r y – S t o r e r o o m Q u a n t i t y o f e x p i r e d p r o d u c t s 1 2 3 4 5 6 7 8 9 10 11 12 13 14 SP 500 + 25mg Tabs Cotrimoxazole 480 mg Tabs Paracetamol 500 mg Tabs ORS Sachet Determine HIV Test 100/box SD Bioline Test 30/20 per box Unigold Test 20/box Amoxicillin 250mg Caps Aspirin 300mg Tabs Gloves Exam. (Medium) Boxes Gloves Exam. (Large) Boxes Comments: Malawi Logistics System Assessment and Stock Status Report - 2006 51 122 Are stock cards recorded using the smallest unit of count? YES .1 NO .0 123 Is there a record where quantity dispensed to patients is recorded for inpatients? YES .1 NO .0 124 Is there a record where quantity dispensed to patients is recorded for outpatients? YES .1 NO .0 Table 2: Storage Conditions ITEMS 1-12 SHOULD BE ASSESSED FOR ALL FACILITIES FOR PRODUCTS THAT ARE READY TO BE ISSUED OR DISTRIBUTED TO CLIENTS.PLACE A CHECK MARK IN THE APPROPRIATE COLUMN BASED ON VISUAL INSPECTION OF THE STORAGE FACILITY, NOTING ANY RELEVANT OBSERVATIONS IN THE COMMENTS COLUMN. TO QUALIFY AS “YES,” ALL PRODUCTS AND CARTONS MUST MEET THE CRITERIA FOR EACH ITEM. No Description No Yes N/A Comments 1. Products that are ready for distribution are arranged so that identification labels and expiry dates and/or manufacturing dates are visible. 2. Products are stored and organized in a manner accessible for First-Expiry / First-Out (FEFO) counting and general management. 3. Cartons and products are in good condition, not crushed due to mishandling. If cartons are open, check if products are not wet or cracked due to heat/radiation (fluorescent lights in the case of condoms) 4. The facility makes it a practice to separate damaged and/or expired products from good products and remove them from inventory. 5. Products are protected from direct sunlight at all times of the day and during all seasons. 6. Cartons and products are protected from water and humidity during all seasons. 7. Storage area is visually free from harmful insects, bats and rodents. (Check the storage area for traces of rodents, bats (droppings or insects). 8. Storage area is secured with a lock and key, but accessible during normal working hours, with access limited to authorized personnel. 9. Products are stored at the appropriate temperature during all seasons according to product temperature specifications. 10. Roof is maintained in good condition to avoid sunlight and water penetration at all times. Malawi Logistics System Assessment and Stock Status Report -2006 52 11. Storeroom is maintained in good condition (e.g. clean, all trash removed, shelves are sturdy, boxes are organized). 12. The current space and organization is sufficient for existing products and reasonable expansion (i.e., receipt of expected product deliveries for the foreseeable future). 13. Fire safety equipment is available and accessible (any item identified as being used to promote fire safety should be considered). 14. Products are stored separately from insecticides and chemicals. The additional standards below can be applied to any facility large enough to require stacking of multiple boxes. No. Description No Yes N/A COMMENTS 15. Products are stacked at least 10 cm off the floor. 16. Products are stacked at least 30 cm away from the walls and other stacks. 17. Products are stacked no more than 2.5 meters high. Additional guidelines for specific questions: Item 2: In noting proper product arrangement, the shelf life of the different products should be considered. Item 3: Cartons should be checked to determine whether they are smashed due to mishandling. The conditions of the products inside opened or damaged cartons should also be examined to see if they are wet, cracked open due to heat/radiation (e.g. because of fluorescent lights in the case of condoms) or crushed. Item 4: The discarding of damaged or expired products should be conducted according to the facility’s procedures (which may differ from one facility to another). Please specify if procedures exist and note what they are. Item 7: It is important to check the storage area for traces of rodents (droppings) or insects harmful to the products. Item 8: This refers to either a warehouse secured with a lock or to a cabinet with a key in a clinic. Item 16: Fire safety equipment does not have to meet international standards. Any item identified as being used to promote fire safety (e.g. water bucket, sand) should be considered. Empty and expired fire extinguishers do not considered as valid fire safety equipment Malawi Logistics System Assessment and Stock Status Report - 2006 53 ASK THE PERSON/PEOPLE YOU INTERVIEWED IF THEY HAVE ANY QUESTIONS FOR YOU. COMMENTS OR GENERAL OBSERVATIONS ON PRODUCTS MANAGEMENT: 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 LOGISTICS SYSTEM PERFORMANCE NOTES/COMMENTS: Malawi Logistics System Assessment and Stock Status Report - 2006 54 APPENDIX 2 FACILITY LIST- 2006 Region Region code District District code Facility name Agency Facility type Facility code Full facility code North 1 Karonga 2 Chilumba MOH Rural hospital 1 10201 North 1 Karonga 2 Karonga MOH District hospital 6 10206 North 1 Karonga 2 Mpata MOH HC 9 10209 North 1 Karonga 2 Nyungwe MOH HC 11 10211 North 1 Karonga 2 Sangilo CHAM HC 12 10212 North 1 Nkahata Bay 3 Chintheche MOH Rural hospital 5 10305 North 1 Nkahata Bay 3 Kachere MOH HC 8 10308 North 1 Nkahata Bay 3 Kande MOH HC 9 10309 North 1 Nkahata Bay 3 Nkhata Bay MOH District hospital 15 10315 North 1 Mzimba 5 Ekwendeni CHAM Rural Hospital 4 10504 North 1 Mzimba 5 Mzimba hospital MOH District hospital 32 10532 North 1 Mzimba 5 Euthini MOH Rural hospital 9 10509 North 1 Mzimba 5 Jenda MOH HC 11 10511 Central 2 Ntchisi 12 Chinguluwe MOH CH 1 21201 Central 2 Ntchisi 12 Malomo MOH HC 6 21206 Central 2 Ntchisi 12 Mkhuzi MOH HC 7 21207 Central 2 Salima 14 Chinguluwe MOH HC 1 21401 Central 2 Salima 14 Chipoka MOH HC 2 21402 Central 2 Salima 14 Lifuwu MOH HC 7 21407 Malawi Logistics System Assessment and Stock Status Report - 2006 55 Region Region code District District code Facility name Agency Facility type Facility code Full facility code Central 2 Salima 14 Makiyoni MOH HC 9 21409 Central 2 Salima 14 Dedza East (previously Mtakataka) MOH HC 12 21411 Central 2 Lilongwe 15 Malingunde CHAM HC 22 21522 Central 2 Lilongwe 15 Ming'ongo MOH HC 29 21529 Central 2 Lilongwe 15 Mitundu MOH Rural hospital 30 21530 Central 2 Lilongwe 15 Nkhoma CHAM Hospital 38 21538 Central 2 Mchinji 16 Kaigwazanga MOH HC 4 21604 Central 2 Mchinji 16 Kochilira MOH Rural hospital 7 21607 Central 2 Mchinji 16 Mchinji MOH District hospital 9 21609 Central 2 Mchinji 16 Mikundi MOH HC 10 21610 Central 2 Mchinji 16 Mkanda MOH HC 11 21611 Central 2 Mchinji 16 Tembwe MOH Dispensary 13 21613 Central 2 Ntcheu 18 Bilira MOH HC 1 21801 Central 2 Ntcheu 18 Dzunje MOH Dispensary 7 21807 Central 2 Ntcheu 18 Nsiyaludzu MOH HC 26 21826 Central 2 Ntcheu 18 Ntcheu MOH District hospital 27 21827 Central 2 Ntcheu 18 Mlangeni MOH HC 20 21820 Central 3 Ntcheu 25 Mtonda health CHAM Rural hospital 23 32323 South 3 Mangochi 18 Katuli MOH HC 7 22507 South 3 Mangochi 25 Nagalamu-replacement MOH HC 25 32525 South 3 Mangochi 25 Lungwena MOH HC 12 32512 South 3 Mangochi 25 Mangochi hospital MOH District hospital 17 32517 South 3 Mangochi 25 Monkey Bay MOH HC 20 32520 South 3 Mangochi 25 Namwera MOH HC 23 32523 South 3 Zomba 27 Chancol University 32799 South 3 Zomba 27 Pirimiti CHAM HC 18 32718 South 3 Zomba 27 Chamba MOH Dispensary 2 32702 South 3 Zomba 27 Makwapala MOH HC 11 32711 South 3 Zomba 27 Thondwe MOH Dispensary 21 32721 South 3 Blantyre 29 Makata MOH Dispensary 12 32912 South 3 Blantyre 29 Chikowa MOH HC 3 32903 South 3 Blantyre 29 Chileka MOH/LG HC 4 32904 South 3 Blantyre 29 Mdeka MOH HC 13 32913 Malawi Logistics System Assessment and Stock Status Report -2006 56 Region Region code District District code Facility name Agency Facility type Facility code Full facility code South 3 Blantyre 29 Ndirande MOH Urban HC 18 32918 South 3 Blantyre 29 Soche clinic SDA CHAM 20 32920 South 3 Mwanza 30 Mwanza MOH District hospital 8 33008 South 3 Mwanza 30 Neno MOH HC 10 33010 South 3 Mwanza 30 Tulonkhondo MOH HC 13 33013 South 3 Mulanje 32 Mulanje MOH District hospital 11 33211 South 3 Mulanje 32 Mulanje Mission CHAM Hospital 12 33212 South 3 Mulanje 32 Namphungo MOH/LG HC 16 33216 South 3 Mulanje 32 Mbiza MOH/LG HC 0 33207 South 3 Nsanje 34 Masenjere MOH HC 5 33405 South 3 Nsanje 34 Ndamera MOH HC 8 33408 South 3 Nsanje 34 Nsanje MOH District hospital 9 33409 South 3 Nsanje 34 Nyamithuthu-not visited, still active MOH HC 10 33410 South 3 Nsanje 34 Sorgin MOH HC 12 33412 South 3 Nsanje 34 Tengani MOH HC 13 33413 South 3 Balaka 36 Balaka MOH District hospital 1 33601 South 3 Balaka 36 Phimbi MOH HC 7 33607 South 3 Balaka 36 Ulongwe CHAM HC 8 33608 South 3 Balaka 36 Kalembo MOH Dispensary 3 33603 North 1 RMS 19999 Central 2 RMS 29999 South 3 RMS 39999 Malawi Logistics System Assessment and Stock Status Report - 2006 57 Malawi Logistics System Assessment and Stock Status Report -2006 58 APPENDIX 3 LIST OF DATA COLLECTORS Region District Team leader N or th Karonga Veronica Chirwa, JSI Nkhata Bay Ntchisi John Zingeni, JSI/George Mangani, MOH Salima C en tra l Mzimba E. Mwenelupembe, MOH RMS (N) Mchinji Erika Ronnow, JSI Lilongwe RMS (C ) Ntcheu Cynthia Kamtengeni, MSH/Jaya Chimnani, JSI So ut h Balaka Nsanje Sam Chirwa, MOH RMS (S) Mangochi Texas Zamasiya, MSH Blantyre Dorica Salamba, MOH Mwanza Mulanje James Gondwe, JSI Zomba Malawi Logistics System Assessment and Stock Status Report - 2006 59 Malawi Logistics System Assessment and Stock Status Report -2006 60 For more information, please visit www.deliver.jsi.com. DELIVER John Snow, Inc. 1616 North Ft. Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 www.deliver.jsi.com << /ASCII85EncodePages false /AllowTransparency false /AutoPositionEPSFiles true /AutoRotatePages /All /Binding /Left /CalGrayProfile (Dot Gain 20%) /CalRGBProfile (sRGB IEC61966-2.1) /CalCMYKProfile (U.S. Web Coated \050SWOP\051 v2) /sRGBProfile (sRGB IEC61966-2.1) /CannotEmbedFontPolicy /Warning /CompatibilityLevel 1.4 /CompressObjects /Tags /CompressPages true /ConvertImagesToIndexed true /PassThroughJPEGImages true /CreateJDFFile false /CreateJobTicket false /DefaultRenderingIntent /Default /DetectBlends true /DetectCurves 0.0000 /ColorConversionStrategy /LeaveColorUnchanged /DoThumbnails false /EmbedAllFonts true /EmbedOpenType false /ParseICCProfilesInComments true /EmbedJobOptions true /DSCReportingLevel 0 /EmitDSCWarnings false /EndPage -1 /ImageMemory 1048576 /LockDistillerParams false /MaxSubsetPct 100 /Optimize true /OPM 1 /ParseDSCComments true /ParseDSCCommentsForDocInfo true /PreserveCopyPage true /PreserveDICMYKValues true /PreserveEPSInfo true /PreserveFlatness true /PreserveHalftoneInfo false /PreserveOPIComments false /PreserveOverprintSettings true /StartPage 1 /SubsetFonts true /TransferFunctionInfo /Apply /UCRandBGInfo /Preserve /UsePrologue false /ColorSettingsFile () /AlwaysEmbed [ true ] /NeverEmbed [ true ] /AntiAliasColorImages false /CropColorImages true /ColorImageMinResolution 300 /ColorImageMinResolutionPolicy /OK /DownsampleColorImages true /ColorImageDownsampleType /Bicubic /ColorImageResolution 300 /ColorImageDepth -1 /ColorImageMinDownsampleDepth 1 /ColorImageDownsampleThreshold 1.50000 /EncodeColorImages true /ColorImageFilter /DCTEncode /AutoFilterColorImages true /ColorImageAutoFilterStrategy /JPEG /ColorACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /ColorImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000ColorACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000ColorImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasGrayImages false /CropGrayImages true /GrayImageMinResolution 300 /GrayImageMinResolutionPolicy /OK /DownsampleGrayImages true /GrayImageDownsampleType /Bicubic /GrayImageResolution 300 /GrayImageDepth -1 /GrayImageMinDownsampleDepth 2 /GrayImageDownsampleThreshold 1.50000 /EncodeGrayImages true /GrayImageFilter /DCTEncode /AutoFilterGrayImages true /GrayImageAutoFilterStrategy /JPEG /GrayACSImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /GrayImageDict << /QFactor 0.15 /HSamples [1 1 1 1] /VSamples [1 1 1 1] >> /JPEG2000GrayACSImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /JPEG2000GrayImageDict << /TileWidth 256 /TileHeight 256 /Quality 30 >> /AntiAliasMonoImages false /CropMonoImages true /MonoImageMinResolution 1200 /MonoImageMinResolutionPolicy /OK /DownsampleMonoImages true /MonoImageDownsampleType /Bicubic /MonoImageResolution 1200 /MonoImageDepth -1 /MonoImageDownsampleThreshold 1.50000 /EncodeMonoImages true /MonoImageFilter /CCITTFaxEncode /MonoImageDict << /K -1 >> /AllowPSXObjects false /CheckCompliance [ /None ] /PDFX1aCheck false /PDFX3Check false /PDFXCompliantPDFOnly false /PDFXNoTrimBoxError true /PDFXTrimBoxToMediaBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXSetBleedBoxToMediaBox true /PDFXBleedBoxToTrimBoxOffset [ 0.00000 0.00000 0.00000 0.00000 ] /PDFXOutputIntentProfile () /PDFXOutputConditionIdentifier () /PDFXOutputCondition () /PDFXRegistryName () /PDFXTrapped /False /Description << /CHS <FEFF4f7f75288fd94e9b8bbe5b9a521b5efa7684002000500044004600206587686353ef901a8fc7684c976262535370673a548c002000700072006f006f00660065007200208fdb884c9ad88d2891cf62535370300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c676562535f00521b5efa768400200050004400460020658768633002> /CHT <FEFF4f7f752890194e9b8a2d7f6e5efa7acb7684002000410064006f006200650020005000440046002065874ef653ef5728684c9762537088686a5f548c002000700072006f006f00660065007200204e0a73725f979ad854c18cea7684521753706548679c300260a853ef4ee54f7f75280020004100630072006f0062006100740020548c002000410064006f00620065002000520065006100640065007200200035002e003000204ee553ca66f49ad87248672c4f86958b555f5df25efa7acb76840020005000440046002065874ef63002> /DAN <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> /DEU <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> /ESP <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> /FRA <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> /ITA <FEFF005500740069006c0069007a007a006100720065002000710075006500730074006500200069006d0070006f007300740061007a0069006f006e00690020007000650072002000630072006500610072006500200064006f00630075006d0065006e00740069002000410064006f006200650020005000440046002000700065007200200075006e00610020007300740061006d007000610020006400690020007100750061006c0069007400e00020007300750020007300740061006d00700061006e0074006900200065002000700072006f006f0066006500720020006400650073006b0074006f0070002e0020004900200064006f00630075006d0065006e007400690020005000440046002000630072006500610074006900200070006f00730073006f006e006f0020006500730073006500720065002000610070006500720074006900200063006f006e0020004100630072006f00620061007400200065002000410064006f00620065002000520065006100640065007200200035002e003000200065002000760065007200730069006f006e006900200073007500630063006500730073006900760065002e> /JPN <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> /KOR <FEFFc7740020c124c815c7440020c0acc6a9d558c5ec0020b370c2a4d06cd0d10020d504b9b0d1300020bc0f0020ad50c815ae30c5d0c11c0020ace0d488c9c8b85c0020c778c1c4d560002000410064006f0062006500200050004400460020bb38c11cb97c0020c791c131d569b2c8b2e4002e0020c774b807ac8c0020c791c131b41c00200050004400460020bb38c11cb2940020004100630072006f0062006100740020bc0f002000410064006f00620065002000520065006100640065007200200035002e00300020c774c0c1c5d0c11c0020c5f40020c2180020c788c2b5b2c8b2e4002e> /NLD (Gebruik deze instellingen om Adobe PDF-documenten te maken voor kwaliteitsafdrukken op desktopprinters en proofers. De gemaakte PDF-documenten kunnen worden geopend met Acrobat en Adobe Reader 5.0 en hoger.) /NOR <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> /PTB <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> /SUO <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> /SVE <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> /ENU (Use these settings to create Adobe PDF documents for quality printing on desktop printers and proofers. Created PDF documents can be opened with Acrobat and Adobe Reader 5.0 and later.) >> /Namespace [ (Adobe) (Common) (1.0) ] /OtherNamespaces [ << /AsReaderSpreads false /CropImagesToFrames true /ErrorControl /WarnAndContinue /FlattenerIgnoreSpreadOverrides false /IncludeGuidesGrids false /IncludeNonPrinting false /IncludeSlug false /Namespace [ (Adobe) (InDesign) (4.0) ] /OmitPlacedBitmaps false /OmitPlacedEPS false /OmitPlacedPDF false /SimulateOverprint /Legacy >> << /AddBleedMarks false /AddColorBars false /AddCropMarks false /AddPageInfo false /AddRegMarks false /ConvertColors /NoConversion /DestinationProfileName () /DestinationProfileSelector /NA /Downsample16BitImages true /FlattenerPreset << /PresetSelector /MediumResolution >> /FormElements false /GenerateStructure true /IncludeBookmarks false /IncludeHyperlinks false /IncludeInteractive false /IncludeLayers false /IncludeProfiles true /MultimediaHandling /UseObjectSettings /Namespace [ (Adobe) (CreativeSuite) (2.0) ] /PDFXOutputIntentProfileSelector /NA /PreserveEditing true /UntaggedCMYKHandling /LeaveUntagged /UntaggedRGBHandling /LeaveUntagged /UseDocumentBleed false >> ] >> setdistillerparams << /HWResolution [2400 2400] /PageSize [612.000 792.000] >> setpagedevice

View the publication