Mexico: Contraceptive Logistics System (DGSR): Review of Accomplishments and Lessons Learned

Publication date: 2001

Mexico Contraceptive Logistics System (DGSR): Review of Accomplishments and Lessons Learned Nora Quesada Sandhya Rao Steve Kinzett FPLM Mexico: Contraceptive Logistics System (DGSR) Review of Accomplishments and Lessons Learned Nora Quesada Sandhya Rao Steve Kinzett FPLM FPLM The Family Planning Logistics Management (FPLM) project is funded by the Office of Population of the Bureau of Global Programs of the U.S. Agency for International Development (USAID). The agency’s Contraceptives and Logistics Management Division provides a centralized system for contraceptive procurement, maintains a database on commodity assistance, and supports a program for contraceptive logistics management. Implemented by John Snow, Inc. (JSI) (contract no. CCP-C-00-95-00028-00), and subcontractors (The Futures Group International and the Program for Appropriate Technology in Health [PATH]), the FPLM project works to ensure the continuous supply of high-quality health and family planning products in developing countries. FPLM also provides technical management and analysis of two USAID databases, the contraceptive procurement and shipping database (NEWVERN), and the Population, Health, and Nutrition Projects Database (PPD). This document does not necessarily represent the views or opinions of USAID. It may be reproduced if credit is given to FPLM/JSI. Recommended Citation Quesada, Nora, Sandhya Rao, and Steve Kinzett. 2001. Mexico: Contraceptive Logistics System (DGSR): Review of Accomplishments and Lessons Learned. Arlington, Va.: Family Planning Logistics Management/John Snow, Inc., for the U.S. Agency for International Development (USAID). Abstract Documents a study of the logistics system of Mexico’s General Directorate for Reproductive Health and the results of FPLM’s technical assistance. FPLM Family Planning Logistics Management John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 E-mail: fplm_project@jsi.com Internet: www.fplm.jsi.com Contents Acronyms .v Preface. vii Executive Summary .ix 1. Objectives.1 2. Technical Assistance Strategy.3 3. Study Methods .5 4. Findings and Recommendations .7 Training.7 Supervision.7 Logistics Management Information System .8 Contraceptive Forecasting.8 Procurement .9 Stock Levels and Distribution.9 Storage .12 5. General Findings .15 Policy .15 Sustainability.15 Decentralization and Maximum-Minimum Levels .15 Budget .16 Training.17 6. Lessons Learned.19 Sustainability Following Withdrawal of Donations.19 Political Support and Budget .19 Training, Supervision, and Monitoring .19 7. Future Challenges.21 Appendix A Persons Contacted .23 Appendix B Blank Questionnaires .25 Appendix C Qualitative Responses for the Four Questionnaires .51 iii Mexico: Contraceptive Logistics System (DGSR) Tables 1. Training Activities, 1993–1995.4 2. DGSR Personnel Interviewed and Trained between 1993 and 1995 .7 3. Facilities Out of Stock by Method.9 4. Maximum and Minimum Stock Levels (in months) at Various Levels (average for all contraceptives).11 Figures 1. Mexico States Visited during Assessment.5 2. Stock Levels: Condoms.10 3. Stock Levels: Pills .10 4. Stock Levels: Bimonthly Injectables.10 5. Stock Levels: Monthly Injectables .10 6. Stock Levels: IUDs.11 7. Warehouse Conditions .13 iv Acronyms CF contraceptive forecasting DMC district medical coordinator DGSR General Directorate for Reproductive Health (Dirección General de Salud Reproductiva) DWM district warehouse manager FEFO first-to-expire, first-out FEMAP Mexican Federation of Private Health and Community Development Associations (Federacíon Mexicana de Asociaciones Privadas de Salud y Desarrollo Communitario, A.C.) FP family planning FPP Family Planning Program FPLM Family Planning Logistics Management project IMSS Mexican Social Insurance Institute (Instituto Mexicano del Seguro Social) IUD intrauterine device JSI John Snow, Inc. LMIS logistics management information system max-min maximum-minimum MEXFAM Mexican Foundation for Family Planning (Fundación Mexicana para la Planeación Familiar, A.C.) OU operations unit RH reproductive health SISPA health information system for the uninsured population (Sistema de Información en Salud para Población Abierta) SPM state program manager SPSS Statistical Package for the Social Sciences SSA Secretariat of Health (Secretaría de Salud) UNFPA United Nations Population Fund USAID U.S. Agency for International Development v Mexico: Contraceptive Logistics System (DGSR) vi Preface The Family Planning Logistics Management (FPLM) project, managed by John Snow, Inc., and funded by the U.S. Agency for International Development (USAID), provided technical assistance to two private sector nongovernmental organizations and two government agencies in Mexico. FPLM began its assistance to the private sector in 1992 and ended in 1999. In the case of the public sector (DGSR and IMSS), the assistance began in 1990 and ended in 1995. However, assistance for IMSS was reinitiated in 1996 and ended in 1999. Recently, the FPLM project conducted assessments of these four organizations to document the impact of the technical assistance provided and to distill “lessons learned” from the processes and strategies. This report focuses on the General Directorate for Family Planning of the Mexican government’s Secretariat of Health—the current General Directorate for Reproductive Health. It details the strategies and processes used and assesses these efforts. To carry out this study, visits were made to the states of Guanajuato, Jalisco, México, Michoacán, Nayarit, Nuevo León, Tabasco, and Veracruz. A total of 15 districts (including district warehouses) and 30 operations units were visited. In-depth interviews were carried out with key personnel at various levels to determine the conditions of the logistics systems and document lessons learned. The study took place nearly four years after technical assistance ended, providing an interesting picture of how the program progressed over time. This report is one component of a three-part comprehensive overview of the FPLM’s activities in Mexico. The remaining two documents focus on the other three organizations that received technical assistance from FPLM: the Mexican Social Insurance Institute (IMSS) and the two nongovernmental organizations, Mexican Federation of Private Health and Community Development Associations (FEMAP) and Mexican Foundation for Family Planning (MEXFAM). It is hoped that each of these reports will allow the organizations under study to understand better the strengths and weaknesses of their logistics systems and develop appropriate activities to improve them in the future. The authors wish to acknowledge the many people at various levels of the government organizations contacted during this process and interviewed as part of the assessment for sharing their perceptions and comments. In particular, we would like to thank Gregorio Pérez Palacios, National Director, DGSR; Yolanda Varela, Management System Director, DGSR; and Oscar Trocino, Head of Logistics, DGSR, who were the key informants for this study. In addition, we appreciate the cooperation of the staff at the USAID Mission in Mexico, especially Marie McCleod and Lisa Luchsinger of CLM/USAID/ Washington, who gave generously of their time and expertise. We also wish to acknowledge the staff of FPLM/Washington, particularly Timothy Williams and Lisa Mueller, who contributed to and edited the final report for publication. vii Mexico: Contraceptive Logistics System (DGSR) viii Executive Summary The Family Planning Logistics Management (FPLM) project, funded by the U.S. Agency for International Development (USAID) and implemented by John Snow, Inc. (JSI), works to ensure the continuous supply of high-quality health and family planning products in developing countries. Between 1993 and 1995, FPLM provided technical assistance in logistics to the General Directorate for Family Planning of the Mexican Government’s Secretariat of Health—now called the General Directorate of Reproductive Health (DGSR). As part of this support, the project provided training in contraceptive logistics information system for 16 states, which represented 70 to 80 percent of all contraceptives consumed in Mexico. This assistance supported the Mexican Government’s Secretariat of Health in light of USAID/Mexico decreasing its donations of contraceptives to Mexico, beginning in 1990. In January 1999, FPLM examined the status of the contraceptive logistics systems at the four organizations that had received technical assistance in logistics in Mexico. The DGSR was one of these four organizations; the others were IMSS, MEXFAM, and FEMAP. This paper is concerned with the DGSR only. It includes a description of the study methodology, main findings, and development of several lessons learned derived from the study. A number of recommendations were made as a result of field data collection and interviews with key stakeholders in the system, including— • Develop training strategies for new employees and refresher training for current staff in contraceptive logistics. • Establish standard monitoring and supervisory practices. • Use appropriate record systems for inventory control. • Ensure provision of up-to-date logistics data to enable decision making. • Build political support for the provision and purchase of the contraceptives required. • Address the problems of inventory control and the procedures for establishing new maximum and minimum stock levels given changing circumstances of supply. • Improve storage conditions. In addition to the above recommendations, a number of lessons learned were derived from the study: • Withdrawal of donations poses tremendous challenges to organizations or programs that have received them for many years, and sufficient time should be allowed for the process to succeed without devastating shocks. • Donor coordination during phaseout of support is essential. • A specific budget should be allocated to purchase contraceptives to ensure sufficient funds to that end. This often requires political support, which may take time and be difficult to obtain, especially when resources are scarce. Once support is gained, it must be respected and used well. • Training programs should recognize not only existing needs when training begins, but new developments that may require a shift in emphasis or a whole new approach as well. ix Mexico: Contraceptive Logistics System (DGSR) • Training alone is not sufficient to ensure that knowledge and skills gained are put to use. It is necessary to have a supervision, follow-up, and monitoring plan to ensure that training becomes institutionalized. The main challenges facing the DGSR are to— • Develop a strategy to ensure political support at the federal and state levels to ensure that funding is allocated for timely procurement of contraceptives, and that it is enough to cover procurement needs and continued training and monitoring activities. • Design and implement a permanent monitoring, follow-up, and supervision program—with manuals, reference guides, etc.—to update and standardize the logistics system. • Update logistics training guides with methodologies that allow personnel to modify the system as it changes—i.e., to adjust maximum-minimum inventory levels, contraceptive forecasting, and budget requirements. x 1. Objectives The Family Planning Logistics Management (FPLM) project, a five-year project (1995–2000), was funded by the U.S. Agency for International Development (USAID) and was implemented by John Snow, Inc. (JSI). FPLM worked to ensure the continuous supply of high-quality health and family planning products in developing countries. In Mexico, FPLM worked with several different organizations, including the General Directorate for Reproductive Health (DGSR) from 1993 through 1995. The DGSR, part of the Secretariat of Health (SSA) in Mexico, provides all reproductive health (RH) services to the general population. In March 1999, USAID terminated all financial support and technical assistance in population and reproductive health to Mexico. Just before this phaseout, and almost four years after USAID stopped donating contraceptives and technical assistance in logistics to the public sector in Mexico, FPLM completed a case study assessment. The purpose of the assessment was to document the general operation of the DGSR logistics system in the face of this reduced donor support. The objectives of the study were to— • Determine the degree to which the training implemented by the DGSR was institutionalized. • Document lessons learned from the training and technical assistance provided by FPLM to DGSR. • Identify future challenges for which the SSA will need support and technical assistance. The study objectives, based on FPLM’s work with the DGSR, also factored in termination of donations by USAID and the changes in the SSA, which were a result of the decentralization of functions and budgets to the states. It is hoped that, as a result of the study, donors and other stakeholders will understand the effects of such factors on the sustainability of logistics systems, and the DGSR will be better able to plan for the future. 1 Mexico: Contraceptive Logistics System (DGSR) 2 2. Technical Assistance Strategy The SSA began receiving donations of contraceptives from USAID in 1974 when Mexico began its Family Planning Program (FPP). Donations remained consistent until they began decreasing in 1992. Donations met 75 percent of contraceptive needs in 1992, 50 percent in 1993, and 25 percent in 1994. By 1995, the SSA was entirely responsible for procuring contraceptives for the FPP. The SSA Family Planning Program is currently managed by the DGSR. In 1993, while contraceptives were being phased out, the SSA began receiving technical assistance from FPLM, which was financed by USAID/Mexico. The first component of the assistance was an assessment of the contraceptives logistics system. The assessment highlighted a few problems: • Lack of theoretical and practical knowledge regarding management of the contraceptive logistics system at all levels, which resulted in activities being carried out without proper planning. • Lack of qualified personnel at the national, state, and district levels to conduct training and monitor the logistics system. • Lack of coordination between the officials in charge of the FPP and warehouse managers at all levels, which created problems for contraceptive distribution and supply management. • Lack of technical documentation about contraceptive logistics and SSA standards. To resolve these problems, the DGSR conducted logistics training from 1993 to 1995, with technical support from FPLM and financing from USAID. The purpose of this training was to reinforce staff knowledge of programming, procurement, distribution, storage, and contraceptive supply management at the various administrative and operational levels, in preparation for purchasing contraceptives and managing personnel and resources. The general objective was to improve the contraceptive logistics system at the Family Planning Program’s national, state, district, and operations levels. Table 1 shows the training activities that were conducted. Training at the central and national levels was carried out first in 1993, followed by training at the state and district levels during 1993–1995. The training of medical coordinators and warehouse managers at the district level included participants from 16 states. These states consumed 70–80 percent of all contraceptives provided by the SSA in 1992. They included Guanajuato, Guerrero, Hidalgo, Jalisco, Estado de México, Michoacán, Nayarit, Nuevo León, Oaxaca, Puebla, Sonora, Tabasco, Veracruz, Mexico D.F., Tamaulipas, and Zacatecas. A training folder containing training guides for conducting logistics workshops at other levels was distributed to each state that received training. At the end of the project, in June 1995, the training activities were evaluated. The DGSR used these evaluation results to prepare a training plan for 12 additional states using combined federal and state funds. This made it possible to train people in 28 of Mexico’s 32 states and their districts. 3 Mexico: Contraceptive Logistics System (DGSR) Table 1. Training Activities, 1993–1995 Dates Level Personnel Content Number May 1993 Central Technical personnel/supervisors July 1993 Central Technical personnel/supervisors September 1993 National National health system organizations receiving funds from DGSR August 1993– State Officials in charge at the state level, FPP April 1994 department heads, warehouse managers September 1993– District Medical coordinators, warehouse February 1995 managers Logistics management Adult learning techniques Logistics management Logistics management Logistics management 17 17* 17 97 432 Total 563* * The personnel trained in “Adult learning techniques” were the same people trained in the May 1993 logistics management workshop. 4 Figure 1. Mexico States Visited during Assessment 3. Study Methods From February 21 to March 13, 1999, DGSR staff and technical consultants from FPLM made visits to eight states (Guanajuato, Jalisco, México, Michoacán, Nayarit, Nuevo León, Tabasco, and Veracruz), 15 districts (including district warehouses), and 30 operations units. Using a convenience sample that factored in geographic accessibility, cost, and the three-week timeframe available for the study, eight states were selected from the 16 states whose personnel were trained between 1993 and 1995 (see figure 1). FPLM developed four separate questionnaires to use in interviewing the eight state program managers (SPMs), 15 district warehouse managers (DWMs), 15 district medical coordinators (DMCs), and 30 contraceptive managers at the operations unit level. In addition, the assessment team counted contraceptives in stock, reviewed records of contraceptive flows, and verified storage conditions during visits to the district warehouses and operations units. Two three-person teams were formed to carry out the study, consisting of one JSI/FPLM or USAID consultant and two staff members of the DGSR. The teams spent one or two days in each state. Within each state, activities were conducted first at the state level, followed by visits to the districts (and district warehouses), and concluding with the operations units. The first person interviewed in each state was the official in charge of the state’s FPP. That person, together with other state personnel, then joined the interviewers at the selected health districts to interview DMCs and DWMs. From there, the teams traveled to medical units, with the DMC, and often a Zone Supervisor, to interview logistics personnel who were responsible for local management of the contraceptives logistics system. The team usually visited two districts per state, two operations units per district, and a variety of health centers in urban areas and in scattered and concentrated population areas in rural settings. Whenever possible, the team met again with state authorities after the visits to inform them of the preliminary results of the visit. Once the questionnaires and observations were completed in all states and at all levels, the FPLM information system and evaluation teams developed a program to enter the quantitative data into the Statistical Package for the Social Sciences (SPSS) software to calculate frequencies and analyze results. The answers to qualitative questions were assessed and ranked by key issues. The head of logistics at the DGSR met with the FPLM and USAID team to discuss the main findings of the study and their implications for future planning. The main findings and conclusions from the study follow. 5 Mexico: Contraceptive Logistics System (DGSR) 6 4. Findings and Recommendations Training One of the essential elements for proper operation of a logistics system is to have trained personnel who understand the system and know how to use it, pursuant to policy guidelines. Personnel rotation is common at the SSA, and this presents continuity and consistency problems in logistics work. Data collected during field visits showed that 55 percent of the personnel interviewed (21 of 38 interviewees) had received training between 1993 and 1995 (see table 2). Table 2. DGSR Personnel Interviewed and Trained between 1993 and 1995 Personnel Personnel interviewed No. trained Percentage (%) trained State program managers 8 4 50 District medical coordinators 15 11 73 District warehouse managers 15 6 40 Total 38 21 55 More than half the personnel interviewed were trained between 1993 and 1995 and were still in their jobs at the time of the study four years later. Although this is a positive sign, it still demonstrates the high rate of turnover within the institution, and shows that even though personnel have been trained, they are not applying their knowledge well. Recommendation: Implement a system that will ensure that newly hired personnel receive logistics training and current personnel continually attend refresher courses to update skills. In addition, manuals, quick reference guides, and logistics system documentation are badly needed to ameliorate the effects of personnel rotation on regular logistics system functions. This type of training could also be included in a pre-service education program, such as in nursing schools and university curricula. Supervision Supervision, follow-up, and monitoring of logistics activities are essential to ensure that activities are carried out in accordance with system objectives, and that the system functions efficiently and effectively. Eighty-eight percent of the SPMs and 93 percent of the DMCs interviewed said they performed monitoring visits, and all of them said the visits included logistics elements. Ninety percent of operations units said they had received a monitoring visit in the last six months, and 77 percent indicated they had received advice or recommendations on logistics matters, but not necessarily as a result of these visits. The two major logistics elements included in monitoring districts and operations units are warehouse conditions and contraceptive expiration dates. In addition, record keeping is monitored at the operations unit level. However, the survey found that the months of stock on hand and inventory levels at the various levels were not standardized, and warehouse managers often reported inadequate warehouse conditions. This finding questions the effectiveness and usefulness of the supervision. 7 Mexico: Contraceptive Logistics System (DGSR) Recommendation: Provide standard monitoring procedures manuals to supervisors to assess whether recommendations are followed and to chart the progress made in complying with suggestions made during previous supervisory visits. Logistics Management Information System For a logistics management information system (LMIS) to be effective, there must be appropriate procedures records for collecting essential logistics information to ensure a sufficient number of contraceptives and to track inventory levels at all times. Therefore, it is important to determine whether a program has all the necessary records to keep track of contraceptive flows. Of the district warehouses visited, 67 percent used a Kardex (stock control card), 20 percent used inventory control cards, and 20 percent used other tools. Therefore, 87 percent of the warehouses used appropriate records to keep track of contraceptive flows. Recommendation: Make an effort to encourage wider use of appropriate records systems, ensure that information is used in decision making, and ensure that records are kept at all system levels. The information can be used to place orders based on maximum-minimum (max-min) inventory levels, transfer excess inventory to other facilities, and monitor expiration dates. Contraceptive Forecasting Even though this topic was not included in the actual questionnaires, central-level personnel were interviewed on what methodology they use for CF. According to the personnel interviewed, the method used by the DGSR to calculate the annual need for contraceptives was— 1. Contraceptive consumption was estimated based on the number of new users, continuing users, and visits. To determine consumption, a fixed number of contraceptives dispensed by method was considered, taking into account the kind of user (i.e., new, continuing). For example, new users receive one cycle of pills, continuing users receive three cycles. 2. To forecast the need for the following year, the above figure was compared with the linear trend over the last five years (calculated in the same manner as above). Other methods used included— 1. Contrasting inventories by taking the inventory at the beginning of the year, adding supplies received throughout the year, and subtracting what is left at the end of the year. This figure was then checked against the linear trend. 2. Calculating the use of contraceptives on the basis of the logistics information obtained from the health information system for the uninsured population (SISPA). This source of data was the least likely to be used in contraceptive forecasting, however. At other times, such as in the forecasting done by DGSR in September 1998, the estimate was based on population data to ensure that all service users were included. Therefore, logistics data on use were not the main factor in making projections. Recommendation: Consumption data are not the principal base used to estimate needs. Register logistics data in the system regularly to apply the data to contraceptive forecasting and decision making, in general. 8 Findings and Recommendations Procurement In accordance with a presidential decree, contraceptives are provided free of charge to clients in Mexico. This means that there is no potential for income production to offset operating costs and help bear the expense of future purchases. At the time of the study, contraceptives were purchased with Mexican government funds assigned to the SSA annually and delivered in monthly budgetary allocations, beginning in April of each year. These allocations, however, were insufficient to cover all contraceptive needs. At the time of the study, the budget for contraceptives was insufficient to meet the demand in DGSR programs. Because of this, a rationing system sometimes was used instead of max-min inventory control levels established when full supply from donors was available. This rationing resulted from the max-min levels being too high for the amount of stock purchased now that the DGSR was buying its own supplies (this is explained more fully below). Significant changes resulted, such as distributing contraceptives by assigned amounts instead of in response to orders. It also affected the LMIS and the way contraceptives were requested. In addition, there seemed to be a preference for procuring monthly injectables over bimonthly injectables, even though this decision was not cost-effective. This might have been because there were far fewer side effects reported with the one-month injectable (Cyclofem) than with the bimonthly injectable. Managers and policymakers must be made aware of the importance of the family planning program and the need to allocate sufficient funds for contraceptives separate from those assigned to essential drugs. Recommendation: Build political support for procurement at various levels to have a separate budget for contraceptives and to be able to purchase the quantities of contraceptives needed. Stock Levels and Distribution Keeping adequate inventory levels and preventing stockouts and/or overstock is another indication of the effectiveness of the logistics system, and shows that the skills, techniques, and methodologies acquired during training are being put to good use. Thirty-eight percent of the states and 67 percent of the districts reported a total stockout for at least one contraceptive method in the previous year, and 87 percent of district warehouses and 33 percent of operations units reported having been understocked in the last six months. Table 3 shows the situation at the operations units (OUs) and district warehouses visited. Table 3. Facilities Out of Stock by Method Method Operations units N=29* Warehouses N=15 IUD Oral contraceptives Monthly injectables Bimonthly injectables Condoms 5 (17.2%) 3 (10.3%) 9 (31.0%) 17 (58.6%) 6 (20.6%) 1 (6.6%) 1 (6.6%) 8 (53.3%) 7 (46.6%) 3 (20.0%) *Data not available for one operations unit. Stockouts occurred primarily in the contraceptive methods bought with DGSR funds (both kinds of injectables and, to a lesser extent, condoms); this may have been because of insufficient funds. For oral 9 Mexico: Contraceptive Logistics System (DGSR) contraceptives and intrauterine devices (IUDs), the lack of funding was not a problem because there was still stock from a donation received from the United Nations Population Fund (UNFPA) in 1995. That donation covered needs for both methods for almost three and one-half years. The number donated was higher than expected and led to the DGSR’s decision to use this remaining stock before making a new budget request. This donation had other important effects on the DGSR program, discussed later. With regard to IUDs and pills, the inventory levels found in 29 operations units show that some units were overstocked and others were out of stock. The method most frequently overstocked was the pill; injectables were most likely to be out of stock or understocked. Fewer than half of the operations units were within max-min levels for any method (see figures 2–6). Five of the 15 district warehouses visited had an overstock of both monthly and bimonthly injectables, although even more were out of stock in those methods. As in the case of the operations units, fewer than half the warehouses were within the max-min levels for any method (see figures 2–6). Figure 2. Figure 3. Stock Levels: Condoms Stock Levels: Pills 21 17 38 24 20 33 33 14 0 10 20 30 40 50 60 Out of stock Under- stocked Stocked correctly Over­ stocked pe rc en t o f f ac ili tie s Operations Units District Warehouses 10 7 38 45 7 33 27 33 0 10 20 30 40 50 60 Out of stock Under- stocked Stocked correctly Over­ stocked pe rc en t o f f ac ili tie s Operations Units District Warehouses Figure 4. Figure 5. Stock Levels: Bimonthly Injectables Stock Levels: Monthly Injectables 59 3 21 17 47 7 13 33 0 10 20 30 40 50 60 Out of stock Under- stocked Stocked correctly Over­ stocked pe rc en t o f f ac ili tie s Operations Units District Warehouses 31 17 41 14 53 33 14 0 0 10 20 30 40 50 60 Out of stock Under- stocked Stocked correctly Over­ stocked pe rc en t o f f ac ili tie s Operations Units District Warehouses 10 Findings and Recommendations Figure 6. Stock Levels: IUDs 17 21 31 31 7 47 26 20 0 10 20 30 40 50 60 Out of stock Under- stocked Stocked correctly Over­ stocked pe rc en t o f f ac ili tie s Operations Units District Warehouses Recommendation: Investigate and address why the warehouse was overstocked and the operations unit was understocked in the districts. A comparison was made between contraceptive stock levels, in general, and those of district warehouses, and it was found that the warehouses that were out of stock were not necessarily the ones for which the DWM had not received training. The findings show that district warehouses can be out of stock regardless of whether personnel have been trained. There is insufficient coordination and/or transfer of contraceptives among the various supply levels to achieve good distribution throughout the system. Max-min inventory levels should be adjusted to reflect current conditions, and these levels should be taken into account when allocating supplies. These levels were based on past conditions, when contraceptives were donated and logistics were centrally managed. Table 4 shows that the system maintained max-min inventory levels that did not reflect conditions at the time. Now that contraceptive procurement has been delegated to local agencies, it takes considerably less time to restock; thus, max-min levels should have been reduced accordingly. However, the distribution system continued to apply the same max-min levels as when contraceptives were shipped from abroad. Table 4. Maximum and Minimum Stock Levels (in months) at Various Levels (average for all contraceptives) Designated Actual Actual Designated Actual Actual working minimum average working maximum average minimum level minimum maximum level maximum level range level level range level Operations units 2 1–2 1.3 3 2–4 2.7 Districts 3 2–3 2.3 6 3–5 4.8 States 6 2–6 3.75 12 4–12 7.5 As shown in table 4, the system did not comply with the designated max-min inventory levels, and such levels did not take into account current conditions. 11 Mexico: Contraceptive Logistics System (DGSR) Recommendation: Adjust the designated max-min levels in view of the time it takes to restock and the budget available now that restocking is done at the local level. This should be done as soon as possible to reflect actual procurement and supply conditions. Supply distribution is one of the essential activities of a logistics system because it means shipping the contraceptives to the places where users need them. To ensure that the amounts ordered and/or shipped are appropriate, it is important to establish max-min inventory levels and calculate the amounts to be shipped/ordered based on those levels. This should help avoid problems, such as expired contraceptives, excess or insufficient inventory, and stockouts. Seventy-five percent of the SPMs and 71 percent of DMCs said they used max-min inventory levels; only 27 percent of DWMs reported doing so. Only 38 percent of SPMs and 47 percent of DMCs calculated the amounts to be shipped to the lower levels following established parameters (maximum amount less inventory levels). DWMs do not have a say in the amounts shipped, so they were not required to establish max-min inventory levels or to monitor inventories on the basis of those levels. Also, it seems that max-min levels were not always observed because some contraceptives were overstocked while others were out of stock, even at sites that calculated max-min levels. This could result in expired contraceptives or an undersupply of needed methods. Recommendation: Train newly hired staff in the use of max-min levels for supply distribution decisions, and training techniques. Their implementation must respond to the current needs of the program and the level where they will be applied. Based on the information collected, it seems that the principle of max-min inventory levels was not necessarily applied in practice at the DGSR sites. The facilities that should have applied it—warehouses and operations units—determined their max-min levels inconsistently, and, as a result, many carried excess or insufficient inventories of particular contraceptives. Part of the problem was that the max-min used by the DGSR did not reflect conditions at the time. Recommendation: DGSR must adjust max-min levels to actual needs and review the methodology and content of training programs to provide managers with procedures that can be realistically implemented and adapted to program changes. Storage One way of guaranteeing that enough contraceptives will be available is to have storage practices and conditions that ensure adequate inventory and preserve product quality. The role of warehouses, and the management and activities that take place at that level, are essential for the efficient operation of the logistics system. Eighty-seven percent of the warehouses visited indicated they had conducted a physical inventory in the previous three months, and 62 percent of them had recorded the results. Most warehouses, therefore, comply with the requirement to take inventories. Only 60 percent of the district warehouses visited reported using the first-to-expire, first-out (FEFO) distribution system; however, only one warehouse reported having contraceptives expire during the previous six months. No operations units had expiries during that period. The warehouses visited were complying with some storage criteria and not with others, so it is difficult to generalize when describing their conditions. Overall, however, storage conditions were good, which is reflected in the summary of conditions in figure 7. However, to reduce the possibility of product losses and preserve product quality, there was room for improvement in almost all cases. 12 Findings and Recommendations Recommendation: Improve storage conditions by— • making sure that expiration dates are visible to comply better with FEFO • reorganizing warehouses to make better use of the space available • eliminating dampness • spraying for insects and rodents. Figure 7. Warehouse Conditions 8 12 14 14 14 13 1 9 8 12 11 12 15 9 9 Appropriate size Clean Secure Protection from sun Protection from fluorescent light Well ventilated Thermometer used Protection from humidity Protection from insects/rodents Protection from damaging substances Shelves Pallets used Original boxes Expiration dates visible FEFO Note: Fifteen warehouses were surveyed—bars represent number of warehouses meeting each of the storage conditions. 13 Mexico: Contraceptive Logistics System (DGSR) 14 5. General Findings Policy Real change requires support from those in charge of decision making and program priorities. The Family Planning Program (FPP) is of the utmost importance to the states and their leaders. However, FFP faces other, more pressing challenges that pose a threat to the health and lives of the population covered by such services. As a result, questions of life and death always take precedence and are considered to be more important. They are given priority over family planning issues. Yet, it is necessary to show family planning’s positive impact on the health, well-being, and social and economic development of Mexico and its people. Otherwise, other health programs may suffer from the detrimental effects of the absence of an effective family planning program. To achieve this—apart from having an effective and efficient logistics system—it is necessary to engage in advocacy. The states, which make budgetary decisions and prioritize problems and needs, and the central government need to approve a separate budget to purchase contraceptives, and funds should be assigned to finance supervision, training, and monitoring activities for the logistics system. This can be achieved only if all involved consider family planning a priority. To this end, it is necessary to document and evaluate the impact of family planning services on economic, social, and health indicators. Information must be collected, analyzed, and expressed in the same language as that used by decision makers. It is also important to show the political windfall that can be derived from family planning services. The increased well-being of the population may reflect positively on the political leaders in power at the time. Sustainability The DGSR has worked hard to deal with the challenge of purchasing its own contraceptives, preserving operation of the logistics system, and ensuring ongoing availability of contraceptives at all levels. This has been no easy task. It requires sufficient funds to update training as systems change; regular implementation of standard monitoring procedures; supply that responds to local needs (actual demand for contraceptives and max-min levels); and a budget large enough to cover the demand for contraceptives. Although the logistics system was working adequately at the time of the study, its quality and effectiveness were not the same as when there was external support (in terms of contraceptives and technical assistance). As such, unless certain improvements are made, there is a risk that the system will no longer be able to provide an adequate, sufficient, and timely supply of contraceptives. Decentralization and Maximum-Minimum Levels Administrative officials at both the SPM and DMC levels were aware of, and knew how to calculate, max-min inventory levels. However, this knowledge was not often used in practice to make stocking and distribution decisions, and when it was applied, it was done inconsistently. For example, fewer than half of the operations units and warehouses visited kept stocks within the targeted max-min levels. 15 Mexico: Contraceptive Logistics System (DGSR) Further, the target levels themselves were probably unrealistic at the time of the study, due to evolving conditions at the DGSR. Operations have become increasingly decentralized in recent years, and procurement is now done mainly at the local level. This has changed the procurement system completely. The regions now purchase locally produced contraceptives directly from vendors (sometimes in consolidated amounts), and the vendors deliver the products directly to the sites where they are needed, in the amounts and at the times required by the states. The time required for restocking, therefore, is substantially less than it was in the early 1990s when contraceptives were donated and procurement was centralized. Also, the fact that the budget for these purchases now comes from federal and state governments provides an incentive to keep inventories low to avoid overspending. As a result, smaller inventories can be carried at most sites and warehouses. Theory and practice behind the max-min approach need to be adjusted, in light of these new conditions, for the approach to remain a meaningful tool for distribution decisions. The impact of decentralization on the DGSR went beyond the effects on max-min calculations. In general, priorities shifted from concerns, such as adequate storage space, to issues like accurate and efficient forecasting. Because many of the effects of decentralization were unforeseen, the DGSR was not fully prepared for the new conditions when they emerged. The original JSI/FPLM training was tailored to existing realities and was finished before many of the new trends became apparent. To prepare the DGSR adequately for these new conditions, it would have been beneficial to carry out additional training and technical assistance two to three years after the decentralization process began. Budget In 1991, following the USAID/Mexico decision to phase out its donations of contraceptives to Mexico, the DGSR began seeking funds from the federal government to purchase contraceptives. The DGSR was successful in getting the Mexican Ministry of Finance to approve a budget item for procurement of drugs and medical treatment—both of which include contraceptives. However, no amounts were allocated specifically for contraceptive purchases within that budget. The DGSR did not have experience purchasing contraceptives and could not anticipate their actual cost. In fact, the budget was not adequate to purchase even essential drugs. Thus, purchase of sufficient amounts of contraceptives was not possible. Another event that weakened the DGSR’s ability to develop an adequate budget for contraceptives was a significant and unexpected donation of oral contraceptives and IUDs from the UNFPA to the DGSR in 1995. This donation represented approximately three and one-half years’ worth of pills and almost three years of copper IUDs, based on average monthly use of those methods in 1994 among the population served by the DGSR. At first glance, this donation appeared to be highly welcome in the face of the imminent cutoff of donated contraceptives from USAID. It allowed the DGSR to continue offering those two methods without running out of stock at the national level. Unfortunately, however, the donation occurred just after the DGSR had struggled—and succeeded—in obtaining funding for contraceptives through the Ministry of Finance budget, meaning that the allocated budget would not be needed for pills and IUDs for the next few years. The DGSR chose not to request local purchase of either of those methods, which set a precedent of not using the established budget that had been so difficult to obtain. A fight was waged to get the budget approved, but then most of it was not used for contraceptives. The family planning program did try to get the states to submit budgets for future contraceptive needs, but some states viewed this as “crying wolf,” believing instead that the donations would continue indefinitely. Thus, not enough provisions were made to justify a sufficient budget for future purchases of contraceptives once the donations dried up. All of this was exacerbated by the massive devaluation in 16 General Findings 1995, which reduced the 1995 budget, in dollar terms, by 50 percent of its value. At the time of this study, the 1995 budget still had not been modified to adjust for this devaluation. Also, the UNFPA donation could have been put to better use if the DGSR had anticipated the donation and the amount in question (it was almost double the amount the UNFPA originally offered). That is, the donation could have been considered a budget “in kind,” and the original budget renegotiated with the federal government. The already assigned budget could have been used to purchase additional contraceptives, such as injectables and condoms. This also would have sent the federal government the message that it would receive a request to adjust the original budget after the UNFPA donation dried up, and estimates could have been made for such a budget based on actual state needs. The precedent of not using the established budget for contraceptives probably led to the idea that contraceptives did not require a specific budgetary allocation because there had not been significant purchases of contraceptives to compare to purchases of other medicines and medical treatment. The lack of political support that resulted, in turn, led to insufficient budget allocations at the state level. A final unfortunate outcome related to the UNFPA donation was that the use of oral contraceptives turned out to be less than expected. Expiration dates observed during this study revealed, ironically, that many pill cycles would expire in 1999 before they could be used. This entire saga is instructive; it shows that donations occasionally can cause problems that may outweigh their benefits, and all potential consequences should be studied and planned for. Training The DGSR has a central team of instructors with excellent skills and knowledge, and the training they have conducted has been very effective. However, the techniques and methodologies taught were conceived under the old system of donations and centralized roles. Also, at the time of the training, it did not include personnel in other key areas of the logistics system—such as procurement and statistics personnel. Including them would have ensured continuity in the processes and involved all areas that affect the logistics system in one way or another. The current situation at the DGSR requires techniques and methodologies that enable the trainees to deal with decentralization of functions and procurement. In addition, technical adjustments must be made to the logistics system (max-min inventory levels and information systems) to ensure uninterrupted logistics operations and to preserve the effectiveness and efficiency of the system. 17 Mexico: Contraceptive Logistics System (DGSR) 18 6. Lessons Learned Sustainability Following Withdrawal of Donations Lesson Learned: Organizations and programs that have received donations for many years face tremendous challenges when the donations are withdrawn. Sufficient time should be allowed for the process to succeed without causing devastating shocks. USAID/Mexico phased out contraceptive donations over four years, and key personnel were trained in various aspects of logistics management to ensure continued operation of the system. However, unforeseen developments, such as decentralization and devaluation, presented new challenges, and there was no plan to prepare the DGSR to adapt. In the end, two to three years of additional training after decentralization began would have been beneficial. Donors should be flexible about such external occurrences that may be more the rule than the exception, and they should plan for additional technical assistance if this is justified and beyond the control of the recipient organization. Lesson Learned: Donor coordination is essential during phaseout of support. In the case of the DGSR, there should have been greater donor coordination, especially regarding the unexpected donation of pills and IUDs from UNFPA. That donation caused unexpected long-term problems that almost outweighed the obvious short-term benefits. The potential consequences of such donations should be studied and planned for by all major donors. Political Support and Budget Lesson Learned: To have sufficient funds, it is necessary to allocate a specific budget to purchase contraceptives. This often requires political support, which may take time and be hard to obtain, especially in the face of scarce resources. Once support is gained, it must be respected and used well. The case of the DGSR shows what can happen if budget requests are not done proficiently when the support exists. When money was not requested for pills and IUDs during the period of the UNFPA donation, the federal government’s budgetary expectations changed, and the support that was so hard to win quickly dissipated. A separate and sufficient budget for contraceptives for DGSR programs was still lacking at the time of this study. Training, Supervision, and Monitoring Lesson Learned: Training programs should recognize not only existing needs at the time training begins, but new developments that may require a shift in emphasis or a whole new approach as well. The training program for DGSR, for example, was designed based on the situation that existed in 1993 but without strategies that would allow the system to adapt to changes and become institutionalized. Flexibility is required by donors, training organizations, and training recipients to quickly perceive these new developments and make needed adjustments. Lesson Learned: Training is not sufficient by itself to ensure that knowledge and skills gained are put to use. Supervision, follow-up, and a monitoring plan are necessary to ensure that the system becomes institutionalized. 19 Mexico: Contraceptive Logistics System (DGSR) 20 7. Future Challenges The main challenges for the DGSR are to— • Develop a strategy to ensure political support at the federal and state levels so funding is allocated for a timely procurement of contraceptives, and there is enough funding to cover procurement needs and continued training and monitoring activities. • Improve the precision of contraceptive forecasting with sufficient budgetary funds. • Design and implement a permanent monitoring, follow-up, and supervision program—with manuals, reference guides, etc.—to update and standardize the logistics system. • Update logistics training guides with methodologies that allow personnel to modify the system as it changes—i.e., to adjust max-min inventory levels, contraceptive forecasting, and budget requirements. If these challenges are addressed in a timely manner, the DGSR should be able to develop a sustainable logistics system that meets the needs of stakeholders at all levels and results in an appropriate supply of a range of methods available to family planning users of the DGSR program. 21 Mexico: Contraceptive Logistics System (DGSR) 22 Appendix A Persons Contacted USAID/Mexico Marie McLeod, Programming Official DGSR, Central Level Gregorio Pérez Palacios, National Director Yolanda Varela, Management System Director Oscar Trocino, Head of Logistics DGSR, State Level and Below Name Job Title State Jurisdiction SDP Dr Maria Rodriguez State Medical Coordinator Nuevo León Dr Dolores Zepeda State Medical Coordinator Jalisco Dr Juana Martinos State Medical Coordinator Tabasco Martha Gonzalez State Medical Coordinator Veracruz Dr Jose Arteago State Medical Coordinator Nayarit Guillermo Aguilar State Medical Coordinator Guanajuato Rosa Ponce State Medical Coordinator Michoacan Dr Angel Sanagua State Medical Coordinator Mexico City Maria Jasso Jurisdiction Medical Coordinator Nuevo León Cadarezta Dr Jesus Silva Jurisdiction Medical Coordinator Nuevo León Monterrey Jesus Flores Jurisdiction Medical Coordinator Jalisco Libertad Tous Dr Sergio Velasquez Jurisdiction Medical Coordinator Jalisco La Barca Rosa Morena Jurisdiction Medical Coordinator Tabasco Nacajuca Dr Maria Lutrillo Jurisdiction Medical Coordinator Veracruz Veracruz Merceded Herrero Jurisdiction Medical Coordinator Veracruz Jalapa Dr Jose Ponce Jurisdiction Medical Coordinator Nayarit Tepic Enrique Perez Jurisdiction Medical Coordinator Guanajuato Irapuato Martha Linan Jurisdiction Medical Coordinator Guanajuato Leon Manuel Camarillo Jurisdiction Medical Coordinator Michoacán Zamobo Rosa Ortiz Jurisdiction Medical Coordinator Michoacán Morelia Dr Martin Martinez Jurisdiction Medical Coordinator Mexico City Toluca Angela Urbina Jurisdiction Medical Coordinator Mexico City Xonacatlan Guillerno Rodriguez Warehouse/Storekeeper Tabasco Centro Arturo Casarin Warehouse/Storekeeper Veracruz Veracruz Jose Carmena Warehouse/Storekeeper Veracruz Jalapa Luis Mendosa Warehouse/Storekeeper Nayarit Tepic Irma Acosta Warehouse/Storekeeper Guanajuato Irapuato Martin Juarez Warehouse/Storekeeper Guanajuato Leon 23 Mexico: Contraceptive Logistics System (DGSR) Name Job Title State Jurisdiction SDP Griselda Villaneva Warehouse/Storekeeper Michoacán Zamobo Miguel Alverez Warehouse/Storekeeper Michoacán Morelia Leticia Salgado Warehouse/Storekeeper Mexico City Toluca Julio Cisneros Warehouse/Storekeeper Mexico City Xonacatlan Dr Tamez Responsible de la unidad Nuevo León Cadarezta Higueras Dr Gonzalez Responsible de la unidad Nuevo León Cadarezta Dr Canavati Responsible de la unidad Nuevo León Cadarezta Mavin Dr Castoveda Medico Aplicatno Nuevo León Monterrey Nus Morelos Maria Hernandez Eucargado di farmacie Nuevo León Monterray Granja Sanitaira Eva Sermeno Aux de Enfermeria Jalisco Libertad Tous La Laja Dr Irene Pozos Medico Aplicatno Jalisco Libertad Tous Yugoslavia Dr Thelma Silva Medico Pasante Jalisco La Barca San Joses de las Moras Dr Fermin Estrada Director de la Unidad Jalisco La Barca Jamay Dr Robles Medico en servicio Social Tabasco Nacajuca Tucta Luis Camberos Medico Pasante Tabasco Nacajuca Masatiupa Rosa Diaz Aux de Enfermeria Tabasco Centro Miguel Hidalgo Dr Luis Jorge Coordinador Medico Tabasco Centro Maximiliano Doesntes Dr Rosa Lagunas Medico General Veracruz Veracruz Boca del Rio Dr Pas Director Medica Veracruz Veracruz Jamapa Dr Imelda Bueno Director Medica Veracruz Jalapa Jose Moroboto Dr Casilda Fuentes Resp. de consulta general y PF Veracruz Jalapa Giaston Melu Dr Bertina Maverrete Medico Pasante en Servicco Social Nayarit Tepic Bella Upsta Dr Alma Rodriguez Medico de Consulta Externa Nayarit Tepic Juan Escutia Mirta Loas Enfermen General Guanajuato Irapuato Colonia Juarez Fernando Bolanos Medico General Guanajuato Irapuato Colon Dr Carmen Renteria Responsible de la unidad Guanajuato Leon Peritas Sandra Tapia Medico General Guanajuato Leon Las Troses David Alonso Responsible de la unidad Michoacán Zamobo Ixtlon Juana Torres Gil Enfermera General Michoacán Zamobo Ario de Rayon Jalme Rodriguez Responsible de la unidad Michoacán Morelia Tarimbaro Laura Justiniani Enfermera General Michoacán Morelia Morelia Luis Hernandez Medico General Mexico City Toluca Nueva Oxtotituan Norma Olmedo Medico de UAPS Mexico City Toluca Metepec Sergio Coris Medico de Consulta Externa Mexico City Xonacatlan San Mateo Atenco 24 Appendix B Blank Questionnaires 25 Mexico: Contraceptive Logistics System (DGSR) 26 EVALUACION DE LOS RESULTADOS Y DEL IMPACTO DE LA CAPACITACION EN LOGISTICA CUESTIONARIO PARA RESPONSABLES DE ALMACEN Estado: ___________________________________________________ Jurisdicción: ____________________________________________ Nombre Nombre del entrevistado: ______________________________________________ Cargo: ______________________________________________________ (1) Jefe de Recursos Materiales (2) Responsable del Almacén (3) Responsable del control de material anticonceptivo (4) Otro __________________________________________ (especifique) Antiguedad en el puesto ______________________ Fecha: Día |__|__| Mes |__|__| Año |__|__| 27 Mexico: Contraceptive Logistics System (DGSR) 1. Asistió a alguno de los cursos de logística de anticonceptivos organizados por la Dirección General de Salud Reproductiva (DGSR) durante 1993 o 1994? (1) Sí (2) No 2. Qué documentos utiliza para controlar el movimiento de material anticonceptivo en el almacén? (Entrevistador: Señale todas las respuestas que mencione el entrevistado (1) Tarjeta de Control de Existencias (2) Kardex (3) Cuaderno (4) Inventario físico de material (5) Marbete (6) Otro __________________________________________________ (especifique) 3. Quién determina la cantidad de material anticonceptivo que se distribuye de este almacén? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) (1) El Responsable Estatal del programa (2) El Responsable del almacén (3) El Coordinador Médico Jurisdiccional (4) Otro __________________________________________________ (especifique) 4. Regularmente cada cuándo se distribuye material anticonceptivo a las unidades? (1) Cada mes (2) Cada dos meses (3) Cada tres meses (4) Cada seis meses (5) Es variable (6) Otro __________________________________________________ |__| (especifique) 5. Regularmente cada cuándo recibe material anticonceptivo en su almacén? (1) Cada mes (2) Cada dos meses (3) Cada tres meses (4) Cada seis meses (5) Es variable (6) Otro __________________________________________________ |__| (especifique) 28 Appendix B 6. Ha realizado algún inventario físico de material anticonceptivo en los últimos tres meses? (1) Sí (2) No 7. Actualiza el kardex o la tarjeta de control de existencias con los datos obtenidos a través del inventario físico? (1) Sí (2) No (Entrevistador: Si la respuesta es afirmativa, solicite que le muestren el kardex o la tarjeta de control de existencias para verificar que se encuentre registrado el dato obtenido a través del conteo físico; en caso contrario, señale la respuesta NO en esta pregunta) 8. Cuál es el principal criterio que utiliza para seleccionar el material anticonceptivo a distribuir? (1) De acuerdo con el número de lote (2) El primero que entra al almacén es el primero que se distribuye (3) El primero que caduca es el primero que se distribuye (4) Otro __________________________________________________ |__| (especifique) 9. Se han establecido niveles mínimos y máximos de existencias de material anticonceptivo en el almacén? (1) Sí (2) No Pase a la pregunta 11 10. Cuáles son los niveles de existencias establecidos en meses? 10.1 Nivel mínimo |__________| 10.2 Nivel máximo |__________| 11. Ha caducado algún material anticonceptivo en este almacén en los últimos seis meses? (1) Sí (2) No Pase a la pregunta 13 12. Qué cantidad de material caducó en este almacén? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) 12.1 Dispositivos intrauterinos |__________| 12.2 Hormonales orales ______________________ |__________| 12.3 Hormonales inyectables de aplicación bimensual |__________| 12.4 Hormonales inyectables de aplicación mensual) |__________| 12.5 Preservativos |__________| 29 ___________________________________________________________________ ___________________________________________________________________ Mexico: Contraceptive Logistics System (DGSR) 13. Ha habido desabasto de material anticonceptivo en este almacén durante los últimos seis meses? (1) Sí (2) No Pase a la pregunta 16 (3) No sabe Pase a la pregunta 16 14. Qué tipo de material anticonceptivo es el que hizo falta en este almacén? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) (1) Dispositivos intrauterinos (2) Hormonales orales (3) Hormonales inyectables de aplicación bimensual (4) Hormonales inyectables de aplicación mensual (5) Preservativos 15. Cuál fue la razón por la que hizo falta dicho material en el almacén? (1) Porque no había material en el almacén que les surte (2) Porque no se solicitó a tiempo (3) Porque se tuvo más demanda de material que la esperada (4) Otra __________________________________________________ (especifique) 16. Desea realizar algún comentario adicional con respecto al manejo y/o condiciones de almacenamiento? 30 Appendix B (Entrevistador: Anote las existencias de anticonceptivos según registros en la columna correspondiente, en seguida haga un conteo físico del material existente en el almacén y anótelo también. Posteriormente transcriba los consumos mensuales promedio de material que le señaló el responsable del programa en ese nivel y calcule los meses de existencias disponibles de material, utilizando los datos obtenidos a través del conteo físico. Por último, indique si existen problemas de desabasto o sobreabasto de material en la columna correspondiente. Método Anticonceptivo Existencias de material en almacén Consumo Mensual Promedio Meses de Existencia Disponibles Situación de abastecimiento* Registros Conteo Físico Dispositivos intrauterinos Hormonales orales Hormonales inyectables mensual Hormonales inyectables bimestral Preservativos * En esta columna se debe indicar alguna de las siguientes claves, de acuerdo con el número de meses de existencias disponibles calculadas D Desabasto Total S Sobreabasto M Existencias por debajo del nivel mínimo OK Dentro de los límites deseables 31 Mexico: Contraceptive Logistics System (DGSR) (Entrevistador: Marque con una (x) la columna correspondiente a las condiciones de almacenamiento que observe) Condiciones del almacén SI NO Tamaño adecuado Limpio Seguro Anticonceptivos protegidos de la luz directa del sol Anticonceptivos protegidos de iluminación con luz fluorescente Ventilación Termómetro Libre de humedad Libre de insectos y roedores Anticonceptivos separados de otros productos dañinos Estantes, anaqueles o tarimas Cajas apiladas apropiadamente Anticonceptivos en las cajas originales Fechas de caducidad visibles Primero en caducar, primero en salir  Muchas gracias ! 32 EVALUACION DE LOS RESULTADOS Y DEL IMPACTO DE LA CAPACITACION EN LOGISTICA FEBRERO-MARZO 1999 CUESTIONARIO PARA COORDINADORES MEDICOS JURISDICCIONALES Estado: _____________________________________________________ Jurisdicción Sanitaria: ____________________________________ Fecha de aplicación: Día |__|__| Mes |__|__| Año |__|__| Nombre del entrevistado: _____________________________________________ Antigüedad en el puesto: _________________________________________________ 33 ______________________ ___________________ Mexico: Contraceptive Logistics System (DGSR) 1. ¿Asistió a algún curso de logística de anticonceptivos organizado por la Dirección General de Salud Reproductiva (DGSR) durante 1993 o 1994? ( ) Sí ( ) No 2. ¿Sabe usted cuál es el consumo mensual promedio de material anticonceptivo en su jurisdicción sanitaria? ( ) Sí Pase a la pregunta 3 ( ) No Porque?__________________________________________ Pase a la pregunta 4 3. ¿Cuál es el consumo mensual promedio de material anticonceptivo según tipo de método en toda la jurisdicción? ( ) Dispositivos intrauterinos ________________________ ( ) Hormonales orales ________________________ ( ) Hormon. inyectable mensual ________________________ ( ) Hormon. inyectable bimensual ________________________ ( ) Preservativos ________________________ Periodo utilizado en el análisis de consumos: _______________ 4. ¿Cuál es el consumo mensual promedio de material anticonceptivo según tipo de método en las unidades que se van a visitar: TIPO DE MATERIAL U N I D A D E S ( ) Dispositivos intrauterinos ______________________ ___________________ ( ) Hormonales orales ______________________ ___________________ ( ) Hormon. inyectable mensual ______________________ ___________________ ( ) Hormon. inyectable bimensual ______________________ ___________________ ( ) Preservativos ______________________ ___________________ 5. ¿Se han establecido niveles mínimos y máximos de existencias de material anticonceptivo en los diferentes niveles administrativos del programa (jurisdiccional y aplicativo)? ( ) Sí ( ) No Pase a la pregunta 7 34 Appendix B 6. Indique los niveles de existencias mínimos y máximos que se han establecido en la jurisdicción Nivel Administrativo Nivel mínimo (en meses) Nivel máximo (en meses) Jurisdiccional Módulos Unidades aplicativas (Entrevistador: Una vez llenado el cuadro pase a la pregunta 8) 7. ¿Cuál es la principal razón por la que no se han establecido niveles mínimos y máximos de existencias en la jurisdicción sanitaria? ( ) Porque se desconoce el procedimiento ( ) Por falta de información ( ) Por falta de coordinación con el almacén ( ) Por falta de tiempo ( ) Otra ____________________________________________ (especifique) 8. ¿Qué tipo de problemas ha tenido en el último ano con respecto al abastecimiento de material anticonceptivo de parte del nivel estatal? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) ( ) Ninguno Pase a la pregunta 10 ( ) Desabasto de algunos métodos ( ) Sobreabasto de algunos métodos ( ) Otro tipo de problema ____________________________________________ (especifique) 9. Señale en qué tipo de anticonceptivos se tuvieron problemas de desabasto o sobreabasto en los últimos seis meses Método Anticonceptivo Sobreabasto Desabasto Total Existencias por debajo del nivel mínimo Dispositivos intrauterinos Hormonales orales Hormonales inyectables mensual Hormonales inyectables bimestral Preservativo 35 _______________________________________________ _______________________________________________ _______________________________________________ Mexico: Contraceptive Logistics System (DGSR) 10. ¿Quién determina las cantidades a distribuir de material anticonceptivo a las unidades médicas? ( ) El Coordinador Médico Jurisdiccional ( ) El responsable del almacén ( ) El Responsable Estatal del Programa ( ) El Responsable de la unidad ( ) Otro __________________________________________________ (especifique) 11. ¿Qué metodologia se utiliza para determinar las cantidades a distribuir a las unidades medicas? (1) Cantidad maxima menos existencias (2) Consumos reportados en el SISPA (3) Consumo mensual promedio (4) Solicitud de la unidad (5) Logros de usuarios (6) Otro __________________________________________________ (especifique) 12. ¿Se ha realizado un inventario físico de material anticonceptivo en los últimos tres meses? ( ) Sí ( ) No 13. ¿Ha recibido alguna visita de supervisión del nivel estatal durante los últimos 12 meses? (1) Sí (2) No Pase a la pregunta 15 14. ¿Recibió alguna recomendación durante las visitas de supervisión que tuvo para mejorar el sistema logístico? (1) Sí Cuáles? (2) No 15. ¿Realiza visitas de supervisión a las unidades médicas? ( ) Sí ( ) No Por que?______________________________________________ Pase a la pregunta 17 36 _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ ______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Appendix B 16. ¿En sus visitas de supervisión a unidades médicas se incluyen aspectos en materia de logística de anticonceptivos? (1) Sí Cuáles? (2) No Por qué? 17. ¿Qué tipo de problemas se han tenido en la jurisdicción en materia de logística de anticonceptivos durante el último ano? 18. Desea realizar algún comentario adicional con respecto al sistema logístico? ¡ Muchas gracias ! 37 Mexico: Contraceptive Logistics System (DGSR) 38 EVALUACION DE LOS RESULTADOS Y DEL IMPACTO DE LA CAPACITACION EN LOGISTICA FEBRERO-MARZO 1999 CUESTIONARIO PARA RESPONSABLES DEL PROGRAMA A NIVEL ESTATAL Estado: _________________________________________________________ Fecha de aplicación: Día |__|__| Mes |__|__| Año |__|__| Nombre del entrevistado: _________________________________________________ Cargo: __________________________________________________________ 1. Jefe del Departamento de Salud Reproductiva 2. Responsable Estatal del Programa 3. Otro _______________________________________________ (especifique) Antiguedad en el puesto: _____________________ 39 Mexico: Contraceptive Logistics System (DGSR) 1. Asistió a alguno de los cursos regionales de logística de anticonceptivos organizados por la Dirección General de Salud Reproductiva (DGSR) durante 1993 o 1994? ( ) Sí ( ) No 2. Se realizó algún curso de logística de anticonceptivos dirigido a personal del nivel jurisdiccional en los últimos tres años organizado por la DGSR? ( ) Sí ( ) No ( ) No sabe 3. ¿Participó usted en algún curso de logística de anticonceptivos dirigido a personal jurisdiccional? ( ) Sí ( ) No 4. ¿Se han establecido niveles de existencias mínimos y máximos en el estado? ( ) Sí, ¿Cuáles? Nivel Administrativo Nivel mínimo (en meses) Nivel máximo (en meses) Estatal Jurisdiccional Unidades Aplicativas ( ) No, ¿porqué? ( ) Porque se desconoce el procedimiento ( ) Por falta de información ( ) Por falta de coordinación con el área de recursos materiales ( ) Por falta de tiempo ( ) Otra __________________________________________________ (especifique) 40 ______________________________________________________ ______________________________________________________ Appendix B 5. Han tenido problemas en el último año con respecto al abastecimiento de material anticonceptivo? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) ( ) No ( ) Si (indicar tipo) ( ) Desabasto de algunos métodos ( ) Sobreabasto de algunos métodos ( ) Otro tipo de problema ______________________________________ (especifique) ( ) Ninguno 6. ¿Quién determina la cantidad de material anticonceptivo a distribuir a las jurisdicciones sanitarias? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) ( ) El responsable del programa ( ) El responsable del almacén ( ) El Coordinador Médico Jurisdiccional ( ) Otro ____________________________________________________ (especifique) 7. ¿Qué metodología se utiliza para determinar las cantidades a distribuir? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) ( ) Cantidad maxíma, menos existencia. ( ) Consumos reportados en el SISPA. ( ) Consumo Mensual Promedio por jurisdicción sanitaria. ( ) Solicitud de la jurisdicción sanitaria. ( ) Logro de usuarios. ( ) Otros ________________________________________________ (especifique) 8. ¿Realiza visitas de supervisión a las jurisdicciones sanitarias? ( ) Sí ¿Con qué frecuencia? ___________________________________ ( ) No ¿Por qué? (Entrevistador:Si la respuesta es negativa pase a la pregunta 10) 41 _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Mexico: Contraceptive Logistics System (DGSR) 9. En sus visitas de supervisión a las jurisdicciones sanitarias se incluyen aspectos en materia de logística de anticonceptivos? ( ) Sí ¿Cuál? ( ) No ¿Por qué? 10. ¿Que apoyos conoce que haya otorgado la Agencia Internacional para el Desarollo o John Snow, Inc.? 11. En su opinion, cual de los apoyos que Ud. conoce realmente ha mejorado el sistema logístico en su entidad y cuales continuan validas y utiles? 12. ¿Cómo ha sido la experiencia del estado en cuanto a la compra de insumos anticonceptivos? 42 _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ _______________________________________________________________ Appendix B 13. En su opinión, ¿este mecanismo de compras consolidadas favorece al estado? Por qué ? 14. En su opinion, ¿considera que el sistema logístico ha sufrido modificaciones, una vez que finalizó el apoyo de USAID? Sí___, No____. ¿En cuáles aspectos? (adquisición, almacenamiento, etc.) 15. En su opinión, ¿qué necesitaría su institución en el futuro para asegurar un sistema logístico adecuado de anticonceptivos, con respecto a adquisición, proveedores, presupuesto, sistema de información, almacenamiento, distribución, y disponibilidad suficiente de insumos? 16. ¿Desea realizar algun comentario adicional con respecto al sistema logistico? Muchas Gracias!! 43 Mexico: Contraceptive Logistics System (DGSR) 44 EVALUACION DE LOS RESULTADOS Y DEL IMPACTO DE LA CAPACITACION EN LOGISTICA FEBRERO-MARZO 1999 CUESTIONARIO PARA UNIDADES APLICATIVAS Estado: __________________________________________________________ Jurisdicción: ______________________________________________ Nombre de la unidad _________________________________________________ Tipo de Unidad ______________________________________________________ 1. Centro de salud urbano 2. Centro de salud rural concentrado 3. Centro de salud rural disperso Nombre del entrevistado: _________________________________________________ Cargo: ________________________________________________________________ Fecha de aplicación: Día |__|__| Mes |__|__| Año |__|__| 45 Mexico: Contraceptive Logistics System (DGSR) 1. Qué tipo de material anticonceptivo se utiliza en esta unidad? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) (1) Dispositivos intrauterinos (2) Hormonales orales (3) Hormonales inyectables de aplicación bimensual (4) Hormonales inyectables de aplicación mensual (5) Preservativos (6) Otro _________________________________________________ (especifique) 2. Regularmente cada cuándo se le surte material anticonceptivo a esta unidad? (1) Es variable (2) Cada semana (3) Cada mes (4) Cada dos meses (5) Cada tres meses (6) Otro __________________________________________________ (especifique) 3. Quién determina la cantidad de material anticonceptivo que se le debe surtir a la unidad? (1) El responsable de la unidad (2) El médico aplicativo (3) El responsable de la farmacia (4) El Coordinador Médico Jurisdiccional (5) Otro __________________________________________________ (especifique) 4. Cómo se determina la cantidad de material anticonceptivo que se le debe surtir a esta unidad? (1) No sabe (2) Es una cantidad fija cada vez que se surte (3) De acuerdo con los consumos y las existencias (4) Depende del logro de usuarios obtenido en el último mes o periodo (5) Otro __________________________________________________ (especifique) 5. Se ha quedado sin algún método anticonceptivo en los últimos seis meses? (Entrevistador: Revisar registros de los últimos seis meses) (1) Sí (2) No (3) No sabe 46 Appendix B 6. Qué tipo de material anticonceptivo es el que hizo falta en la unidad? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) (1) Dispositivos intrauterinos (2) Hormonales orales (3) Hormonales inyectables de aplicación bimensual (4) Hormonales inyectables de aplicación mensual (5) Preservativos 7. Cuál fue la razón por la que hizo falta dicho material en la unidad? (1) Porque no había material en el almacén de la jurisdicción (2) Porque no se solicitó a tiempo (3) Porque se tuvo más demanda de material que la esperada (4) Otra __________________________________________________ (especifique) 8. Ha caducado algún material anticonceptivo en la unidad en los últimos seis meses? (1) Sí (2) No Pase a la pregunta 10 9. Qué tipo de material caducó en la unidad? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) (1) Dispositivo intrauterino (2) Hormonales orales (3) Hormonales inyectables de aplicación bimensual (4) Hormonales inyectables de aplicación mensual (5) Preservativos 10. Ha recibido alguna visita de supervisión de la jurisdiccion en los últimos seis meses? (1) Sí (2) No 11. Ha recibido alguna capacitación, asesoría o recomendación para mejorar el control de material anticonceptivo en la unidad? (1) Sí (2) No Pase a la pregunta 13 47 _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _____________________________________________________________________________________ _________________________________________________________________ Mexico: Contraceptive Logistics System (DGSR) 12. Qué tipo de asesoría o recomendación recibió para mejorar el control del material anticonceptivo en la unidad? (Entrevistador: Señale todas las respuestas que mencione el entrevistado) (1) Como calcular el consumo de material en la unidad (2) Como calcular la cantidad a solicitar de material (3) Como almacenar el material (4) Como mejorar el registro de la información (5) Otra __________________________________________________ (especifique) 13. Ha tenido algún problema relacionado con el material anticonceptivo en la unidad? (1) Sí (2) No Pase a la pregunta 15 Qué tipo de problema (s) ha tenido? 14. Desea hacer algún comentario adicional con respecto al abasto de material anticonceptivo?  Muchas gracias ! 48 Appendix B Entrevistador: Haga un conteo físico del material existente en la farmacia, los consultorios y el almacen (si hay) de la unidad y anote las existencias de anticonceptivos en la columna correspondiente. Posteriormente transcriba los consumos mensuales promedio de material que le señaló el CMJ y calcule los meses de existencias disponibles. Por último, indique si existen problemas de desabasto o sobreabasto de material en la columna correspondiente. Método Anticonceptivo Existencias de material en la unidad Consumo Mensual Promedio Meses de Existencia Disponibles Situación de abastecimiento* Dispositivos intrauterinos Hormonales orales Hormonales inyectables mensual Hormonales inyectables bimestral Preservativos * En esta columna se debe indicar alguna de las siguientes claves, de acuerdo con el número de meses de existencias disponibles calculadas D Desabasto Total S Sobreabasto M Existencias por debajo del nivel mínimo OK Dentro de los límites deseables 49 Mexico: Contraceptive Logistics System (DGSR) 50 Appendix C Qualitative Responses for the Four Questionnaires DGSR 1 Respuestas Cualitativas, Responsables de Almacen ¿Desea realizar algún comentario adicional con respecto al manejo y/o condiciones de almacenamiento? (Q16) [101] Que quiere mas capacitación [101] A veces, el lapso de reabastacimiento es largo [101] Les faltan que me traigan los vales [103] Problema de espacio para almacenar material [105] Mejorar el abasto de material ya que este es muy limitado y a destiempo [106] Lo dejaría como esta, no cambiaría nada [107] Que se de cumplimiento a la dotación continua y oportuna de los metodos [107] No cuenta con vehiculo de transporte de materiales a los unidades [109] Implementar los niveles mínimos y máximos [110] Daría dotaciones para 2 o 3 meses a las unidades, porque el almacen esta saturado de algunos métodos (tienen mucho y distribuyen muy poco.) [111] Le gustaría saber en que se basa la CMJ para determinar las cantidades a distribuir a las unidades medicas [113] Se dote a la jurisdiccion de una computadora para poder llevar un mejor control de cada uno de los insumos DGSR 2 Respuestas Cualitativas, Coordinadores Medicos Jurisdiccionales Q14 ¿Recibió a1guna recomendación durante las visitas de supervisión que tuvo para mejorar el sistema logístico? Si, ¿Cuales? [201] reforzar el reporte de anticonceptivos almacenamiento [210] almacenamiento [201] fechas de caducación [209] sistema PEPE [202] niveles máximos y mínimos [207] perdidas de métodos [207] distribución de progestina al hospital regional [209] verificar cantidades (inventario físicos) [210] redistribución de material sobre abastecido [214] calculo del consumo promedio mensual 51 Mexico: Contraceptive Logistics System (DGSR) Q15 ¿En sus visitas de supervisión a unidades médicas se incluyen aspectos en materia logística de anticonceptivos? Si, ¿Cuales? [201] existencias suficientes [201] almacenamiento [201] registro de consumo [201] Levar los formatos bien [203] abasto a usuarías de acuerdo a la norma de entrega [203] revisión del llenado de la hoja de movimiento mensual de material [203] manejo de la tarjeta P.F.S. [203] inventario físico [205] corroboran la información reportada (SISPA) [206] checan número de usuarías Q17 ¿Qué tipo de problemas se han tenido en la jurisdicción en materia de logística de anticonceptivos durante el último año? No, ¿Por qué? [201] ninguno [203] problema de desabasto [209] surtimiento parcial del inyectable mensual [207] el sistema de información no coincide entre el SISPA y los formatos de inconsistencias en la información [208] las unidades no reportan sus existencias por lo que vamos a encontrar sobre abastos pero no desabastos no hay [210] el cambio de presentación de los métodos, trae consigo descontrol de las usuarias. [213] las cantidades recibidas del nivel estatal no son suficientes en algunos métodos [213] subregistro del consumo de métodos [215] faltan de seguimiento al sistema PEPE por el nivel estatal Q18 Desea realizar algún comentario adicional con respecto al sistema logístico? [201] ampliamos en cuanto a los métodos, más variedad, inyectables [201] siempre mantengamos la cantidad necesaria [201] tenemos suministros suficientes [202] volver a dar un curso si hay algo más nuevo [202] sería mejor si los médicos se abalizan a llenar los formatos [203] contar con el presupuesto adecuado para la adquisición de los insumos [204] no hemos tenido alguna problemática, tenemos buena supervisión, coordinación [205] el nivel estatal debería de surtir el doble los últimos 3 meses del año, ya que el 1er trimestre de cada año siempre hay desabastos [208] se mejore la distribución periódica de todos los métodos anticonceptivos por parte del nivel estatal [206] establecer niveles max-min en las unidades [207] la rotación de personal responsable de los insumos, descontrola las actividades y hay necesidad de reforzar la capacitación en logística de métodos anticonceptivos [209] establecer mi lapso de reabasticimiento [210] cambiar el almacén con un espacio físico adecuado 52 Appendix C DGSR 3 ¿En sus visitas de supervisión a las jurisdicciones sanitarias, se incluyen aspectos en materia de logística de anticonceptivos? Sí, cuál ? : (Q9) [301] Existencias [301] Consumos [304] Reportes del SISPA [301] Situación de abasto/desabasto [301] Max-min [301] Consumo Promedio Mensual [301] Sistema de información [302] Condiciones de almacenamiento [302] Tarjetas Kardex [303] Visita al almacen juris. para conocer como surte a las UMs [305] Sistemas de control ¿Que apoyos conoce que haya otorgado la Agencia Internacional para el Desarrollo o John Snow, Inc.? (Q10) [301] Capacitación de logística [301] Donaciones de anticonceptivos [301] Carteles de almacenamiento ¿En su opinion, cual de los apoyos que Ud. conoce realmente ha mejorado el sistema logístico en su entidad y cuales continuan validas y utiles? (Q11) [301] La capacitación nos ha dado la pauta sistematizar los insumos [301] Tratamos ahora practicar al nivel mas operativo [302] La capacitación ha servido para que cada nivel (estatal, jurisd., y 70% del nivel aplicativo) sepa manejar el sistema logístico [302] Ahora el CMJ sabe estimar sus requerimientos y compararlo con lo que estima el nivel estatal [303] En los almacenes y unidades saben que cantidad se van a utilizar y para que tiempo [304] La capacitación es muy favorable para el desarrollo del programa pero los continuos cambios del personal han dado al traste [307] La capacitación ha sido de utilidad a que anteriormente la logística se llevaba a cabo de manera empirica [308] Crear una metodología para dar a conocer el sistema logistico que en conjunta con contraloria interna y auditores se lleva un mejor control 53 Mexico: Contraceptive Logistics System (DGSR) ¿Como ha sido la experiencia del estado en cuanto a la compra de insumos anticonceptivos? (Q12) [302] Han tenido problemas. No se compró lo requerido iny.mens. y preserv. [303] Al nivel estatal no asignaron presupuesto suficiente para cubrir las necesidades de met. [304] Se lleva un control muy estricto del material [305] Ha sido adecuada, se han cubierto las necesidades en un 90% en dos metodos: preservativos y inyectable mensual. No se ha comprado el iny. bimensual. Las DIUs y orales se ha tenido sobreabasto [306] Muy buena [307] El año pasado se tuvieron problemas porque no se entro a la compra consolidada y tuvieron que hacer compras de emergencia para no quedar en desabasto [307] Este año se entró a la compra consolidada [308] Vino a mejorar todo, el edo se compromete a adquirir casi el 100% de los insumos En su opinion, ¿este mecanismo de compras consolidadas favorece al estado? ¿Por qué? (Q13) [301] Si, ya existe un calendario de entrega de metodos (feb, jun, oct) que abarata el precio de los consumos por la cantidad [301] Garantizamos insumos al estado [302] No aplica – el estado compra directamente [303] Algunos de los precios de compra consolidada sale mas caro que la compra directa del estado [304] No, porque se encarecio mas el material anticonceptivo y es muy tardada la entrega [305] Si, da una mayor seguridad en la compra. Favorece los costos y el proveedor adecuado. [306] Si, porque se realiza una metodologia que favorece y garantiza la compra para cubrir necesidades al 100 % [307] Si, los costos son menores solo que existe atrazo en la entrega [308] Si, garantiza el abasto suficiente de metodos anticonceptivos En su opinion, ¿considera que el sistema logístico ha sufrido modificaciones, una vez que finalizó el apoyo de USAID? (Q14) [301] Nos han dado una metodología; aprendió la lección porque asimilaron muy bien. AID nos dio las herramientas [301] Esta implementado (institucionalizado). Pienso que eso fue la importante [304] El quitarnos la dotacion del material vino a afectar la distribucion. Ahora hay un control mucho mas estricto. Nos hace falta mas apoyo de met. Anticonceptivo [307] El hecho de hacer las compras nos han llevado a tener que tomar mas en serio el sistema logistico [308] Consideran que se continua aplicando la misma metodologia 54 Appendix C En su opinion, ¿qué necesitaría su institución en el futuro para asegurar un sistema logístico adecuado de anticonceptivos, con respecto a adquisición, proveedores, presupuesto, sistema de información, almacenamiento, distribución, y disponibilidad suficiente de insumos? (Q15) [301] Continuar recapacitando a médicos y nuevos responsables del almacen. Crear un modelo de capacitación para el nivel operativo- porque faltaría darles la importancia de información del logístico y las ventajas que fortalecen. [301] Que contaran en las unidades con un sistema computerizado. [301] Un sistema de evaluación que permitiría evaluar el sistema logístico [302] Dar capacitación continua [302] Que se realice la compra a tiempo por parte del area responsible [302] Que en las visitas de supervisión, se revisen las existencias, condiciones de almacenamiento, etc. [303] Que se respete lo que uno esta presupuestando [303] Tener capacitación continua al personal de nuevo ingreso [304] La dotacion del material por la falta de vehiculos suficientes acarrea retrazos en las entregas [305] Seguimiento periodico de estas acciones para ver que se este dando cumplimiento a la normalidad [306] Se tiene contemplado seguir integrados a la compra consolidada de metodos anticonceptivos [307] Un area física mas adecuada para el almacenamiento del material [308] Continuar reforzando la capacitacion principalmente al personal de nuevo ingreso y el edo periodicamente cambia del personal [308] Dar capacitacion formal [308] La distribucion a las jurisdicciones de dificulta por la falta de vehiculos suficientes ¿Desea realizar algun comentario adicional con respecto al sistema logístico? (Si estuviera en sus manos, que haría para mejorar el sistema logístico? (Q16) [302] Que el area de adquisiciones realice las compras a tiempo [302] Realizar visitas de supervisión para revisar la existencia de material [303] Asegurar el abasto suficiente, hay que realizar o aumentar la supervision y capacitacion para evitar desabastos [304] El sist. Log. se esta aplicando a todos los insumos del estado y no solo a PF por lo que se considera necesario una nueva capacitacion ya que hoy mucha rotacion del personal [305] Que el personal sea idoneo para que realice esta actividad y que no este cambiando [305] Que se capacite en forma periodica [306] Capacitar al personal de nuevo ingreso que desafortunadamente es muy frecuente [306] Dar permanencia en su puesto y funciones al personal [307] Agilizar las acciones administrativas con otras areas [307] Manejaría un colchon de seguridad para preveer desabastos [308] Continuar reforzando el sistema logistico ya que este ayuda al administrador es el correcto manejo del material no solo metodos anticonceptivos, sino para el resto de los insumos [308] Capacitacion 55 Mexico: Contraceptive Logistics System (DGSR) DGSR 4 Quien determina la cantidad de material anticonceptivo que se le debe surtir a la unidad? Det1 [408] Enfermera (Q3) [413] Supervisor Zonal Jurisdiccional [419] Area de Epidemiologia [422] Supervisor del Sector I [430] Coordinador Municipal Como se determina la cantidad de material anticonceptivo que se le debe surtir a esta unidad? Det2 [403] De acuerdo a consumos (Q4) Cual fue la razon por la que hizo falta dicho material en la unidad? SO9 [414] Porque no mandan a la jurisdiccion (Q7) [429] Lo ignora Que tipo de asesoria o recomendacion recibio para mejorar el control del material anticonceptivo en la unidad? (5) Otra : t5 [401] Fechas de caducidad (Q12) [402] Normas de prescripciones, indicaciones, contraindicaciones [403] Vida util de anticonceptivos [405] PEPE [405] Calcular existencias [406] Condiciones de almacenamiento [406] Muestrarios [407] Cantidad de otorgar a usuarias [414] Recomendaciones dirigidas al encargado de la farmacia Que tipo de problema(s) ha tenido (relacionado con el material anticonceptivo en la unidad)? p1 (Q14) [411] Les cambiaron el inyectable mensual (cyclofem) por el inyectable bimensual (noretistirona) [413] Se cambio el resguardo de la farmacia a la oficina y bajo llave [416] Falta un espacio fisica para su adecuado almacenamiento [419] Desabasto de inyectable mensual [423] No hay jeringas para las inyectables [424] Las usuarias estan inconformes cuando hay desabasto [425] Desabasto de preservativos [429] Las marcas varian mucho y esto descontrola a las usuarias 56 Appendix C Desea hacer algun comentario adicional con respecto al abasto de material anticonceptivo? {Si estuviera en sus manos hacer un cambio para el mejoramiento del sistema logistico, que haria Ud. ?) (Q15) [402] Siempre estamos abastecidos [402] Tenemos buena coordinacion [403] Nos dan un buen margen de cantidad [404] Proveer una dotacion mayor para fines de ano, ya que la unidad no trabaja la segunda quincena de diciembre [409] Recien nos han dado mas anticonceptivos que en el ultimo ano [415] Solicitar un espacio fisico mas grande para almacenamiento [417] Que se de varios tipos de anticonceptivos y tratar de evitar cambios de marca [421] Que haya dotacion suficiente para darle doble dotacion a las usuarias que vivan lejos y no puedan acudir mensualmente [422] Mantener comunicacion y coordinacion para que no falte material anticonceptivo [423] Capacitar y sensibilizar al personal medico para promover el uso de los metodos anticonceptivos entre las usuarias [423] Se ampliara la infraestructura de la unidad ya que no hay privacia para las usuarias de DIU [423] Dotar de mayor material de promocion [424] Solucionar el abastacimiento oportuno [426] Uniformar las indicaciones para el manejo de los sistemas de informacion (Tarjeta PF-5) [427] Que nos surtan de acuerdo a nuestras necidades [428] Que el personal responsable del modulo de PF se al que directamente le surtan los met. anticonceptivos sin intermedianos de la enfermeria [429] Fortaleceria el control logistico de los metodos anticonceptivos [429] Seria mas estricto con los niveles minimos y maximos [429] Daria continuidad al tipo de metodo por usuaria [430] Promover mas la PF y los met. Anticonceptivos ya que este C.S. es un lugar de transiciones 57 Mexico: Contraceptive Logistics System (DGSR) 58 S Training Supervision Logistics Management Information System Contraceptive Forecasting Procurement Stock Levels and Distribution Storage Policy Sustainability Decentralization and Maximum-Minimum Levels Budget Training Sustainability Following Withdrawal of Donations Political Support and Budget Training, Supervision, and Monitoring FEBRERO-MARZO 1999

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