Uganda's NAKASONGOLA District: Contracetive Logistics System Assessment and Action Plan - Covering the Last Mile to Ensure Availability

Publication date: 2008

UGANDA’S NAKASONGOLA DISTRICT: CONTRACEPTIVE LOGISTICS SYSTEM ASSESSMENT AND ACTION PLAN COVERING THE LAST MILE TO ENSURE CONTRACEPTIVE AVAILABILITY NOVEMBER 2008 This publication was produced for review by the U.S. Agency for International Development. It was prepared by the USAID | DELIVER PROJECT, Task Order 1. UGANDA’S NAKASONGOLA DISTRICT: CONTRACEPTIVE LOGISTICS SYTEM ASSESSMENT AND ACTION PLAN COVERING THE LAST MILE TO ENSURE CONTRACEPTIVE AVAILABILITY The authors' views expressed in this publication do not necessarily reflect the views of the U.S. Agency for International Development or the United States Government. USAID | DELIVER PROJECT, Task Order 1 The USAID | DELIVER PROJECT, Task Order 1, is funded by the U.S. Agency for International Development under contract no. GPO-I-01-06-00007-00, beginning September 29, 2006. Task Order 1 is implemented by John Snow, Inc., in collaboration with PATH, Crown Agents Consultancy, Inc., Abt Associates, Fuel Logistics Group (Pty) Ltd., UPS Supply Chain Solutions, The Manoff Group, and 3i Infotech. The project improves essential health commodity supply chains by strengthening logistics management information systems, streamlining distribution systems, identifying financial resources for procurement and supply chain operation, and enhancing forecasting and procurement planning. The project also encourages policymakers and donors to support logistics as a critical factor in the overall success of their health care mandates. Recommended Citation USAID | DELIVER PROJECT, Task Order 1. 2008. Uganda’’s Nakasongola District: Contraceptive Logistics System Assessment and Action Plan: Covering the Last Mile to Ensure Contraceptive Availability. Kampala, Uganda: USAID | DELIVER PROJECT, Task Order 1. Abstract In September and October 2008, the Ministry of Health (MOH), with technical assistance from the USAID | DELIVER PROJECT, Task Order 1, conducted an assessment of the performance of the logistics management and supply chain systems for selected family planning commodities and developed an action plan aimed at assisting Nakasongola district in covering the last mile and ensuring availability of contraceptives. The survey’’s overall objective was to assess how the logistics systems managed selected family planning commodities at public health institutions. This report presents the findings of the assessment as well as the short and long-term action plan to improve the contraceptive logistics systems and cover the last mile to ensure product availability in Nakasongola district. Cover photo: District officials and health centre in-charges together with USAID | DELIVER project staff during a Logistics System Assessment Tool session that took place at the Metropole Hotel in Kampala in 2008. The photo was taken by Dr. Kenneth Ofosu-Barko. USAID | DELIVER PROJECT John Snow, Inc. Plot 2 C, Nakasero Hill Road Nakasero Kampala, Uganda Phone: (256) 414-253-246 Fax: (256) 414-253-245 E-mail: askdeliver@jsi.com Internet: deliver.jsi.com CONTENTS Acronyms. v Acknowledgements . vii Executive Summary . ix Background.1 Nakasongola District Profile.1 Structure of the Health System .1 Objectives .2 Methodology . 3 Logistics System Evaluation . 3 Contraceptive Logistics System Assessment . 5 I. Organization and Staffing.5 II. Logistics Management Information System.6 III. Obtaining Supply and Procurement.7 V. Inventory Control Procedures.8 V. Warehousing and Storage .9 VI. Transportation and Distribution .10 VII. Organizational Support for Logistics .10 VIII. Product Use .11 IX. Finance and Donor Coordination.12 X. Contraceptive Logistics System Assessment Conclusion .13 Appendices Figures Tables Action Plan .15 Appendix A: List of People Interviewed.19 Appendix B: Site Visit Locations .21 Appendix C: List of Participants to the LSAT and Action Plan Development Workshop .23 Figure 1. Logistics Cycle. 5 Table 1: Nakasongola District Score Summary by LSAT Component . ix Table 2. Health Sector Performance for Individual Sub Counties FY 2007/08. 1 Table 3: Logistics Systems Assessment Action Plan for Contraceptives for Nakasongola District – October 2008.15 iii Table 4: List of People Interviewed.19 Table 5: Site Visit Locations .21 Table 6: List of Participants to the LSAT and Action Plan Development Workshop.23 iv ACRONYMS CAO Chief Administrative Officer CRWs Community Reproductive Workers DADI District Assistant Drug Inspector DCCA District Cold Chain Assistant DFID Department for International Development (UK) DHE District Health Educator DHI District Health Inspector DHO District Health Officer DHT District Health Team FEFO First Expiry First Out FP Family Planning FY Financial Year HC Health Centre HF Health Facility HMIS Health Management Information System HSD Health Sub-District IEC Information, Education, and Communication IUD Intrauterine Device JMS Joint Medical Stores LMIS Logistics Management Information System LSAT Logistics Systems Assessment Tool MAX Maximum MIN Minimum MOH Ministry of Health NDA National Drug Authority NGO Non-Governmental Organization NMS National Medical Stores OPD Out Patient Department PHC Primary Health Care v RH Reproductive Health SDP Service Delivery Point USAID U.S. Agency for International Development vi ACKNOWLEDGEMENTS We would like to extend our appreciation for the support of the following persons: Dr. Gerald Sekito, the District Health Officer Nakasongola; Mr. Moses Zziwa, the DHE; Dr. Godfrey Kasibante, in charge Nakasongola HSD; Paul Mutumba, in charge Nakitoma HC III; Ayo Josephine, District Stores Assistant; Mulinde Harriet and Namirembe Miriam of Mayirikiti HC II; Epuat Israel and Lusibe Janet of Nakasongola Military Hospital; and Sekago James and Acipa Dorcas of Nakasongola HC IV. Last, but not least, thank you to all the management and health personnel within district, sub- district, and health units who contributed to the field visits for taking time to answer our questions and helping us understand your work. Special thanks to the USAID | DELIVER PROJECT Finance and Administrative team for all the financial and logistical support extended to us during this exercise. vii viii EXECUTIVE SUMMARY BACKGROUND The Logistics System Assessment Tool (LSAT) is a data-gathering tool developed by DELIVER and used to assess the health commodity logistics system and provide contextual information about the environment within which the system operates. The LSAT is a comprehensive, qualitative, diagnostic, and monitoring tool from which strengths and weaknesses of the logistics system are identified in a group discussion format, involving participants from all levels of the health system. The information collected using the LSAT is analyzed to identify issues and opportunities and, from those, to outline appropriate work plan activities and/or targeted interventions. METHODOLOGY The LSAT was implemented in Nakasongola district and involved visits to five health facilities. Study sites included the District medical stores, the Health Centre IV, Health Centre III, and Health Centre II targeting both public and non-governmental organization (NGO) facilities. During these visits, the health facility in-charge and/or contraceptives focal person were interviewed and the LSAT tool was completed. This process included use of a formal letter and discussion with the District Health Officer (DHO) on the purpose of this assessment. The sites to be visited were selected to cover one facility at each level of the Ministry of Health’’s structure, including the District’’s medical stores. RESULTS Following completion of the visits to study sites, responses to the interviews were scored and tallied according to LSAT instructions. Table 1 summarizes the scoring for each LSAT component category, and the following sections describe in detail what factors lead to each score. Table 1: Nakasongola District Score Summary by LSAT Component LSAT components Scoring (%) Organization and staffing 5.4% Logistics management information system 45% Obtaining supply and Procurment 27% Inventory control procedures 29% Warehousing and storage 23% Transportation and distribution 0% Organizational support for logistics 56% Product use 54% Finance and donor coordination 7% ix ORGANIZATION AND STAFFING: The district health department is comprised of the DHO working with the district health team (DHT) to oversee health sector activities in the district. This team undertakes all management responsibilities to ensure smooth implementation of health service in the district. Since there is no designated logistics unit in the district, logistics functions are included in overall management of health service implementation. Some health facilities have established records officers who are in charge of data and records management. Although the local government staffing and organization structure does not include a logistics unit, in practice, logistics activities are incorporated within various sections under the health department and handled by the responsible staff at all levels. The challenge, however, is the small number of staff, heavy workload, and inadequate skills and capacity of health workers in proper logistics management, especially at lower levels. LOGISTICS MANAGEMENT INFORMATION SYSTEM: Logistics management information system (LMIS) data is collected at the health facility level but not systematically reported to upper levels for use in decision-making. The system provides for ordering and bi-monthly reporting to the Health Sub-District (HSD) and the District. The District aggregates all of its facilities’’ orders and sends this information to the National Medical Stores (NMS) and the Joint Medical Stores (JMS). Health facilities currently take too long to place orders, so the HSD and District compensate by estimating the facilities’’ need and making one consolidated order for all facilities within the District. LMIS forms used at the facility level include requisition and issue vouchers, stock cards, client registers, and health management information system (HMIS) forms 018 and 105 for ordering and reporting to district level. A significant challenge for the system has been a lack of standard and adequate LMIS tools at all levels. OBTAINING SUPPLY AND PROCUREMENT: Contraceptive orders are based on estimated needs, which are consolidated by the HSD in-charge in consultation with the Stores Assistant. Ordering is tagged to credit line orders through the national pull system from NMS. Order fulfillment is dependant upon the available credit line funds and stocks balances. There are also delays in processing orders at NMS. INVENTORY CONTROL PROCEDURES: Contraceptive inventories are managed using a pull system at all levels. Although all levels successfully apply the first expiry first out (FEFO) inventory management policy for contraceptive commodities, health facilities are often re-supplied with products that have a short shelf life. This issue of short remaining shelf life is the primary cause of expired commodities in health facilities. Inventory control procedures are not followed systematically, which is due to limited LMIS tools at all levels and lack of guidelines and knowledge among health workers in determining max-min stock levels. x WAREHOUSING AND STORAGE: The size of the district store is adequate, with shelves and pallets fixed on one side of the store. It is not in good order, however, as expired products, obsolete non-medical supplies and equipment, including hazardous materials, are stored together with other items. Support is urgently needed for de-junking and re-organizing the store, including fitting more shelves and pallets in the available storage space. Health facilities have adequate storage space but lack secure and accessible storage areas, such as locking cupboards, at these levels. There is a general lack of fire extinguishing equipment at all levels, as well as a lack of written and posted guidelines regarding proper disposal and destruction of damaged and expired products. TRANSPORTATION AND DISTRIBUTION: Health facilities are responsible for collecting supplies from the district stores and health workers typically use public transportation to carry these items from the district back to their facilities. Transportation resources are generally limited at all levels, resulting in delays in delivery of health facilities’’ monthly reports. ORGANIZATIONAL SUPPORT FOR LOGISTICS: The DHT is responsible for supervision activities using a variety of tools, including supervision checklists, manuals, and job aids. No external assistance is provided to the district for managing contraceptive logistics or for supervision activities. The district has made efforts, however, to strengthen community mobilization and commodity distribution to reach as many clients as possible through establishment of a network of Community Reproductive Workers (CRWs), with support from Save the Children. PRODUCT USE: Short-term contraceptive methods are available for use at all levels in the district. Long-term method availability depends largely on availability of trained and skilled health workers at the facility to manage such methods. FINANCE AND DONOR COORDINATION: Contraceptive commodities are donated and therefore offered to the public free of charge at all levels. The coordination and financing for family planning commodities is done at the national level for procurement, shipment, and storage of commodities. There are inadequate financial resources at the district level to manage logistics activities in the district. CONCLUSION: Further improvements to the logistics system are needed at all levels in order to cover the last mile and improve product availability at Service Delivery Points. xi xii BACKGROUND NAKASONGOLA DISTRICT PROFILE Nakasongola district is located in central Uganda, bordering the districts of Masindi to the West and Northwest, Luweero and Nakaseke to the South, Kayunga to the East, Amolatar to the Northeast, and Apac to the North. It is located on latitudes 055N 1 40’’N and Longitudes 31 55E and 3250E. It covers an area of 3424 km2 representing about 1.42% of the country’’s total surface area. Within this area, an estimated 321.6 km2 is occupied by swamps (wetlands) and Lake Kyoga. The temperature range is between 25oC –– 35oC maximum and 18oC–– 25oC minimum. The district population (2008) is estimated at 142,800 people, extrapolated from the 2002 population and housing census at a growth rate of 1.8% per year. Gender distribution reflects an estimated 71,700 males and 71,100 females within the population. The district is made up of one HSD with nine sub-counties, namely Kakooge, Kalongo, Kalungi, Lwampanga, Lwabiyata, Nabiswera, Nakitoma, Nakasongola Town, and Wabinyonyi The primary economic activity in the district is farming, with over 80.1% of the economically active population engaged in agricultural production. Fishing and livestock (cattle-rearing) are the other principal economic activities. The district literacy rate is 59.1%. STRUCTURE OF THE HEALTH SYSTEM The district health services are headed by the District Health Officer (DHO) and supported by the District Health Team (DHT), which is made of the technical staff such as the District Health Educator (DHE), the District Assistant Drug Inspector (DADI), the DHV, the District Cold Chain Assistant (DCCA), the HSD manager, and representatives from hospitals and Health Center (HC) IV. The DHT is responsible for overseeing and ensuring logistics functions, including procurement and distribution, for family planning commodities and other supplies. The district has 30 functional health units, including three for NGOs and 27 for Governments. Table 2. Health Sector Performance for Individual Sub Counties FY 2007/08 Sub county OPD attendances Deliveries in Health unit DPT3 coverage (%) Latrine coverage (%) Contraceptive prevalence Kakooge 20648 260 49 78 213 Kalongo 16740 235 112 75 255 Kalungi 14,457 138 81 73 463 Lwampanga 28,855 246 81 63 596 Lwabiyata 17,512 297 124 59 243 Nabiswera 17,103 68 58 66 325 Nakitoma 14,250 120 77 73 249 Nakasongola Town Council 24,386 663 142 86 250 1 Sub county OPD attendances Deliveries in Health unit DPT3 coverage (%) Latrine coverage (%) Contraceptive prevalence Wabinyonyi 13,825 123 25 73 586 District 74% 71.4% OBJECTIVES The specific objectives of applying the LSAT tool in Nakasongola district are: x To assess the performance of the logistics management and supply chain systems for selected family planning commodities in the district. x To develop an action plan for the district to ensure availability of contraceptives to the last mile. 2 METHODOLOGY The Logistics System Assessment Tool (LSAT), developed by DELIVER, was used for this assessment. The LSAT is a qualitative and diagnostic questionnaire which evaluates the processes involved in logistics activities and some outputs/outcomes of program interventions. The questionnaire is given to health workers at all levels of the logistics system through a combination of central workshops and visits to select health facilities. This assessment provided the district with information on the characteristics and the performance (strengths and weaknesses) of the system and its ability to contribute to the availability of family planning commodities and information in the district. The results of this assessment will provide information for planning and USAID | DELIVER PROJECT support and interventions to the district. A survey was conducted in Nakasongola district where five health facilities were visited. The study sites included the district medical stores, HC IV, HCIII, and HCII, targeting both public and NGO facilities. Interviewees for the LSAT included the health facility in charges and/or the contraceptives focal persons. The process involved providing a formal letter to the DHO introducing the survey team and the general purpose of the assessment. The teams also held formal discussions with members of the DHT and provided the detail of the study. Together with the district team, the sites to be visited were selected in order to cover one facility at each level of the Ministry of Health’’s established structure, including the district medical stores. While at each health facility, the team filled the questionnaire and conducted physical inventory of all contraceptives in the facility. LOGISTICS SYSTEM EVALUATION FIELD VISIT The two member team visited the district and conducted interviews over two days, September 22- 23, 2008. In the morning of the first day, the team met with the DHO and briefed him on the purpose of the assessment and requested for one officer to accompany the team for the field survey. With the district officer, the team spent the two days in the field, visiting health facilities (HC II, III and IV). At each facility visited, interviews with health workers were conducted using the LSAT. Completed questionnaires were reviewed by the team members to clarify any data inconsistencies and ensure collection of complete and accurate data. The team left on the third day and started preparing the analysis and the district report in preparation for the planned workshop the following week after the field visits. The three-day LSAT and action plan development workshop was held and attended by the USAID | DELIVER PROJECT team and participants from the six districts which were visited. It was the occasion to give the field visits findings, to identify strengths and weaknesses with the group, and to conclude with recommendations. 3 The final output of the workshop was for the teams to determine an action plan based on recommendations and results from the field visits and workshop discussions. LSAT AND ACTION PLAN DEVELOPMENT WORKSHOP An action plan for Nakasangola was drafted by the district team with the support and the facilitation of USAID | DELIVER PROJECT staff. Following the field visit group discussion and finalization of the district summary reports by the survey team, a three-day workshop was organized in the week following field visits. Attendees included officers representing all six districts that had been assessed. These district-level participants included the DHO or a representative, the district contraceptives focal person, district stores officer and health facility in-charges from three of the facilities visited during the survey. The objective of the workshop was to review strengths, weaknesses, and recommendations identified through the assessment and to draft an action plan for each individual district to help guide future assistance from the USAID | DELIVER PROJECT to the contraceptive program. Groups went through all nine sections of the LSAT to determine the activities, interventions, and actions to be taken as well as identifying the responsible parties, expected outcomes, performance indicators and time frames. By the end of the three-day workshop, each of the six districts had a fully-developed action plan with activities for immediate and medium-term implementation, clear indictors, time line, responsible parties, and the expected outcomes. 4 CONTRACEPTIVE LOGISTICS SYSTEM ASSESSMENT The Logistics System Assessment Tool (LSAT) allows for a comprehensive system-level assessment of the performance of a logistics system for any health program managing any health commodity. The tool follows the logistics cycle (see figure 1) and includes questions on all components of the cycle. It can be used with the Logistics Indicators Assessment Tool (LIAT)* to provide an overall assessment of a program’’s ability to ensure the continuous availability of health commodities at service delivery points (SDPs). Figure 1. Logistics Cycle Policy Serving Customers Forecasting & Procurement Product Selection Supervision Evaluation Qu ali ty Mo nit ori ng Quality Monitoring Quality Monitoring Qu alit y Mo nit ori ng LMIS Pipeline Monitoring Organization & Staffing Budgeting Inventory Management • Storage • Distribution Adaptability I. ORGANIZATION AND STAFFING The local Government staffing and organization structure does not provide for the logistics unit, however the logistics activities are incorporated within the various sections under the health department and are handled by the responsible staff at all levels. At the district level, the health department is made up the DHO working with the DHT (the technical team) to oversee health sector activities in the district. This team is responsible for managing all health services in the district to ensure that they are implemented smoothly. Since there is no designated logistics unit at the district, the team is also responsible for all of the logistics function within the district. This situation propagates to the lower health facilities in the system, where the facility in charges and staff are responsible for all activities including the logistics functions at that level. 5 The challenge to this structure is the small number of staff at the district, their heavy workload, and inadequate skills and capacity of health workers in proper logistics management, especially at lower levels. Finally, while dedicated logisticians are lacking in the district, there are specific individuals in some health facilities who take lead responsibility for maintaining records and for overall data management. The specific strengths and weaknesses of the district’’s organization and staffing are summarized below, along with specific recommendations to strengthen this area: STRENGTHS WEAKNESSES x The district has a team of officers who manage the various components of logistics activities x Some facilities have specific individuals responsible for maintaining records x Lack of regular coordination meetings x No specific budget allocated for logistics activities x Lack of relevant guidelines for key organizational and staffing activities x The Local Government Staffing structure does not provide for a full-fledged logistics unit within the health department RECOMMENDATIONS x Provide guidelines for management of organizational and staffing activities x The district should organize for periodic coordination meetings, ideally on a bi-monthly basis II. LOGISTICS MANAGEMENT INFORMATION SYSTEM The current logistics management information system (LMIS) used in the district consists of a series of established reporting practices between health facilities and the district, and then between the district and the NMS/JMS. Each health unit is supposed to send a report or order bi-monthly to the HSD, which is then responsible for aggregating all the reports and sending the information to the District. The District then aggregates all the facility orders to NMS /JMS. To support these functions, the system uses a set of basic LMIS forms at all levels, including requisition and issue vouchers, stock cards, and client registers. Furthermore, at the HSD, the health management information system (HMIS) form 018 is used to order for products from NMS and JMS. The problem is that there is a lengthy ordering delay on the part of health facilities and essential logistics data collected at the health facility level is not systematically reported to the upper level and is of questionable quality. This situation forces the HSD and District to estimate consumption and consolidate orders for all the facilities in the district based on these approximations. 6 Additionally, health workers at all levels do not adequately understand how to determine max-min stock quantities, which has further contributed to creating imbalances in stock status at various levels. In short, estimates of consumption at the health facility level are used to consolidate orders based on a questionable max-min policy. Finally, the assessment found an overall lack of proper and adequate LMIS tools at all levels, leading health facilities to improvise and use other means to capture LMIS data. The specific strengths and weaknesses of the district’’s LMIS are summarized below, along with specific recommendations to strengthen this area: STRENGTHS WEAKNESSES x A logistics system is in place x Health workers are knowledgeable about the use of the LMIS tools x No system for sustaining adequate supply and availability of logistic tools at all levels within the district x Due to high attrition rate, some health workers are not properly trained to use the LMIS tools x Lack of a specific budget for submission of the reports from one level to the other x Predominate use of a manual LMIS to process, order, and analyze data at all levels x Overwhelming workload at SDP’’s has lead to incomplete and inaccurate logistics data RECOMMENDATIONS x Re-orient health workers on the use of LMIS forms x Automate the LMIS at least to the district level x Provide a separate budget line for printing and distributing LMIS tools, and for report submission III. OBTAINING SUPPLY AND PROCUREMENT At the district level, ordering for contraceptives is based on estimated needs consolidated by the HSD in charge in consultation with the stores Assistant. Orders are tagged to credit line orders through the national pull system from NMS, and NMS’’s ability to process orders is dependant upon its available credit line funds and stock balances. At the lower-level health facilities, ordering is done using the requisition and issue vouchers, which are completed by the health unit in charges. Quantities are reviewed and issued by the stores assistant depending on the available stocks and where stocks are inadequate, rationing is practiced. 7 The specific strengths and weaknesses of the district’’s ordering and procurement operations are summarized below, along with specific recommendations to strengthen this area: STRENGTHS WEAKNESSES x National system for obtaining supplies is in place x Quick responsiveness to emergency orders by NMS x Obtaining supplies with a short shelf life especially for donated commodities x Delays in processing of routine orders by NMS x Irregular update on credit limit funds balance at all levels RECOMMENDATIONS x Need for regular updates on credit limit balances at all levels x Supply of products with at least two year shelf life IV. INVENTORY CONTROL PROCEDURES Because of limited transport resources, untrained health workers, and unavailability of adequate LMIS tools at all levels, inventory control procedures are not followed systematically. For instance, many facilities do not have adequate stationary and therefore prepare only one copy of the requisition and issue voucher which is sent to the district, leaving no copy at the health facility. This makes it difficult to keep track of the quantities ordered over a period of time. Related to difficulties in reporting, the contraceptive inventory control system is, in theory, a pull system at all levels, but a number of different factors result in its sub-optimal performance. First, the lower health facility level has an established order interval of two months. This policy is not usually followed, however, because of the delays by the NMS in delivering the supplies to the district stores. The lower health facilities can therefore only submit their orders when they have been advised of the availability of the supplies at the district stores, which may or may not align with the established order interval. Furthermore, health workers at all levels do not know how to determine max-min stock levels, creating imbalances in stock levels as some facilities are over-stocked while others are under-stocked. With regards to inventory management, the first expired first out (FEFO) system is well-applied for contraceptive commodities at all levels; however, the health facilities are often re-supplied with products that have a short shelf life or are near expiration. This situation results in most of the product expirations that are observed in health facilities. Finally, in spite of the problems encountered in the inventory control procedures, stockouts of contraceptive commodities at health facilities is not a major problem. This is due to re-distribution of supplies between the facilities. The specific strengths and weaknesses of the district’’s inventory control procedures are summarized below, along with specific recommendations to strengthen this area: 8 STRENGTHS WEAKNESSES x Re-distribution of supplies within health facilities x FEFO inventory management practice is followed at all levels. x The pull system enables health facilities to order for what they require. x Push of some supplies such as condoms leads to over stocking, expiries and pressure on storage space. x Expired supplies not physically removed from inventory at district stores x Lack of guidelines on max-min stocks at all levels RECOMMENDATIONS x Provide support supervision to improve on inventory management at all levels. x Develop and distribute guidelines on max-min stock for all health facilities. x Expired supplies should be physically separated from inventory at district stores x The pull system should be applied at all levels V. WAREHOUSING AND STORAGE The storage space available at the district store is adequate, with shelves and pallets fixed on one side of the store. The district store accommodates all health-related products and items, including essential drugs, IEC material, STI drugs, contraceptives, and equipment. Where the district store is lacking, however, is in its capacity to adequately handle expired products, obsolete non-medical supplies and equipment, including hazardous materials which are stored in the same areas as other items. This situation has made it impossible to conduct a physical inventory without having to take all the items outside. The district store will therefore need support for de- junking and re-organizing by fitting shelves and pallets in the available storage space. Health facilities, meanwhile, seem to have adequate storage space but lack secure and accessible storage facilities, such as cupboards. STRENGTHS WEAKNESSES x Adequate storage space at the district store x Lack of store organization with pallets, and the health facilities shelves and racks at district stores and lower level units x Lack of fire fighting equipment x Inadequate cleanliness and manpower at the district stores x Lack of written guidelines and procedures on good storage practices x Lack of guidelines for destruction of damaged and expired products at all levels 9 RECOMMENDATIONS x Provision of cupboards at lower level units for storage of commodities x Provisions of shelves, pallets and fire fighting equipments at the district stores x Plan and budget for immediate disposal of expired and damaged products at the district stores x Provide guidelines for proper storage of commodities and disposal of expired commodities x Provide a sustainable budget to support proper management and organization of district stores VI. TRANSPORTATION AND DISTRIBUTION The health facilities are responsible for collecting and transporting supplies from the district stores to the facilities and health workers commonly rely on public transportation to accomplish this task. In general, transport resources are limited at all levels and are especially stretched to the limit at the lower facility levels. The district health department has only one operational vehicle to cover all health activities in the district, while the remaining vehicles are grounded. The specific strengths and weaknesses of the district’’s transportation and distribution operations are summarized below, along with specific recommendations to strengthen this area: STRENGTHS WEAKNESSES x Committed staff that collect supplies using x Lack of resources to transport the supplies to public transport the lower level units x Lack of resources to repair and maintain the vehicles RECOMMENDATIONS x Support district with a vehicle and maintenance budget for effective distribution of supplies. x Develop an optimized distribution plan and seek resources for its implementation. VII. ORGANIZATIONAL SUPPORT FOR LOGISTICS The DHT is responsible for supervision activities within the district, and they make use of various tools to carry out these responsibilities, including field supervision checklists, manuals, and job aids. Communications between the district, HSD, and lower levels is good and functions mainly through mobile telephones. This method of communication can be difficult at the lower levels, however, 10 where network connectivity is not consistently reliable, not to mention the fact that health workers must use their own funds to buy air time and make calls. No external assistance is provided to the district for contraceptives management and supervision activities, but an effort was made by the district to strengthen community mobilization and reach many clients through establishment of the Community Reproductive Workers (CRWs), supported by Save the Children. Staff lack capacity in adequately using and maintaining the LMIS and managing information within the overall HMIS. With the introduction of new forms for ordering and or reporting, it is necessary to provide all levels with appropriate procedures, guidelines, manuals, training, and supervision. The specific strengths and weaknesses of the district’’s organizational support for logistics are summarized below, along with specific recommendations to strengthen this area: STRENGTHS WEAKNESSES x Some written procedures and guidelines that help staff carry out logistics responsibilities x Availability of supervision structure within the district x Irregular supervision activities due to insufficient funds, means of transport, and materials. x Inadequate utilization of available reference materials, manuals, and job aids. x High attrition rate for trained staff RECOMMENDATIONS x Provide continuous on-the-job training for health workers at all levels x Provide resources for regular supervision activities VIII. PRODUCT USE Short-term methods are available for use at all levels in the district, whereas access to long-term methods depends on the availability of trained and skilled health workers to manage and administer such methods. The DHT provides health facilities with a number of tools to ensure the implementation of standard treatment guidelines and universal safety precautions, including written national standard guidelines, safety boxes, and injection safety posters. The district reports that these tools are consciously used by health facility personnel. 11 STRENGTHS WEAKNESSES x Availability of short-term methods for use at all levels of the district x Clinical guidelines are distributed to all the service delivery points x Mechanisms and resources are in place to ensure the implementation of standard treatment guidelines and universal safety precautions. x Lack of written procedures for monitoring and supervision of prescribing practices x Religious barriers limit client access to contraceptives x Inadequate skill by health workers in provision of some contraceptive methods x Inadequate promotional activities for increased use of contraceptives within communities. RECOMMENDATIONS x Train health workers in administration of all methods x Provide written procedures for monitoring and supervising prescribing practices x Develop strategies for promotional activities to encourage use of contraceptives IX. FINANCE AND DONOR COORDINATION All contraceptive commodities are donated and therefore family planning services are offered freely at all levels. The coordination and financing for family planning commodities is done at national level, and is in place for procurement, shipment and storage of commodities at national stores (NMS). Little or no financing and coordination is done at district, HSD, and health facility level. STRENGTHS WEAKNESSES x Finance and donor coordination x Inadequate financial resources to support activities are handled at the national logistics activities within the district level, allowing districts to focus their efforts on delivery of services and commodities. RECOMMENDATIONS x Advocate to the national level the need for increased budget to support logistics activities within the district 12 X. CONTRACEPTIVE LOGISTICS SYSTEM ASSESSMENT CONCLUSION The Nakasangola District has demonstrated several strengths with regards to its management of the logistics system for contraceptive commodities. Most notably, there is a management team, made up of the DHO and DHT, that is committed to ensuring efficient delivery of commodities to health facilities and continued improvements to the overall logistics system. Secondly, the district has numerous tools available to guide health workers in essential logistics operations, including stock management, ordering, and proper storage of commodities. Finally, the flexibility of the system in managing lateral transfers of commodities between health facilities has helped to ensure that stockouts are minimized. With these strengths in mind, it is necessary to also highlight the most serious challenges to improving the logistics system in Nakasangola District. The attrition of health workers in the facilities is relatively high, meaning that the DHO and DHT must develop systematic methods of keeping personnel properly trained on numerous topics, including correct use of LMIS forms, the importance of timeliness in reporting and ordering cycles, calculation of max-min inventory policies, proper storage conditions, proper disposal of expired commodities, adherence to established standard treatment guidelines, and administration of both short-term and long-term contraceptive methods. The first step in addressing the challenges of building health worker capacity is to ensure that the District has all the tools it will need to accomplish the task, including printed guidelines and forms for all facilities, and established policies to address the various logistics system challenges listed in previous sections. Secondly, the DHO and DHT should work to coordinate a comprehensive system of supervision, on-the-job training, communication, and occasional workshops to make optimal use of the tools developed to manage the logistics system in the District. To complement the activities addressing overall coordination and capacity building among health facilities, the District should work to de-junk the district store of expired, damaged, and non- essential commodities. Furthermore, efforts should be made adhere to the standard max-min inventory management policy, as well as to the established order interval. When combined with the capacity building activities described above, these actions should allow the District to optimize its ability to order, store, and distribute contraceptive commodities. Finally, a significant challenge throughout the entire logistics system is where to find available budget to accomplish many of the tasks, especially those related to transportation, training for personnel, development and distribution of guidelines and other essential forms, and communication. Since financing for programs is made at the National level, the District is encouraged to use data available on health worker turnover and the costs associated with different system operations to advocate for increased budget allocation. 13 14 ACTION PLAN Table 3: Logistics Systems Assessment Action Plan for Contraceptives for Nakasongola District – October 2008 Logistics components Objectives Activities Indicators Objectively verifiable Timeline Responsible Assumptions/remarks Organizational Context and Staffing: Set up a logistics management team with clearly defined roles and responsibilities. Minutes December 2008 HSD – In charge Team to be comprised of DHO, HSD In- charge, stores assistant, DADI and one representative from lower level health unit. The team should be able to coordinate contraceptives logistics activities in the district. Conduct regular review meetings Minutes December 2008 HSD – In charge The first meeting to be held in December 2008 with bi-monthly review meetings. LMIS: Orientation of health workers on LMIS tools. Number of people oriented / trained January 2009 HSD – In charge The health workers have some skills but need to be re- oriented especially in the use of LMIS tools. Updating stock management records at the district stores Updated records January 2009 District stores Assistant Conduct Physical inventory with help of two support staff. Monthly update of stock records Need some technical support from USAID|DELIVER during the initial stage of the exercise. Print and distribute the necessary LMIS tools to all health units. All appropriate LMIS forms available at respective user levels By January 2009 USAID|DELIVER Project. Not all health units have full range of LMIS tools 15 Logistics Activities Indicators Timeline Responsible Assumptions/remarks components Objectively Objectives verifiable Obtaining Supply Advocate for timely Availability of January 2009 USAID | DELIVER Monthly and Procurement: provision of credit line credit line PROJECT These balances will then be balances from central balances at the communicated from the district to lower level to districts districts level health units by the logistic team. Inventory Control Procedures: Train health workers on proper inventory control procedures such as max-min order levels, re-order quantities and lead times Number of health workers trained April 2009 HSD – In charge The health worker lack skills in use of proper inventory management practices. The Logistics management team will be responsible for this activity. Warehousing and Storage: Print and distribute guidelines for proper storage of commodities and Guidelines in all health facilities April 2008 USAID | DELIVER PROJECT and DRH focal person The guidelines will be utilized at all levels proper disposal of damaged and expired supplies to health facilities Make a plan and All expired January 2009 DADI / Stores Expect to obtain support from all the budget for immediate products Assistant key player (DADI, NDA, Luwero withdraw of expired withdrawn from Industries, USAID | DELIVER PROJECT) and damaged products all facilities from the health destroyed. facilities and de-junk the district stores Procure and distribute cupboards for storage of drugs and supplies and counting trays to aid in dispensing at lower level health units. Number of cupboards procured and distributed March 2009 USAID | DELIVER PROJECT USAID | DELIVER PROJECT will provide funding in time. Once the store equipment is in place the stores will be better managed. 16 Logistics Activities Indicators Timeline Responsible Assumptions/remarks components Objectively Objectives verifiable Procurement of shelves, pallets and fire fighting equipments for the district stores Shelves, pallets and fire fighting equipment installed in the district store. Transportation and Distribution: Develop and implement a distribution plan and share with all stake Plan developed and in place February 2009 Stores Assistant The facility in-charges will observe and follow the schedule. holders. Organizational Conducting support Visits conducted January 2009 HSD – In charge Supervision to be conducted on a Support for supervision visits to quarterly basis. Logistics System: health facilities, Community Reproductive Health Workers (CRWs) in the entire district. Product Use: Increase public awareness about family planning services at health facilities through use of film shows, radio talk shows and rallies . -Number of film / talk shows conducted. -Increased demand for contraceptives March 2009 DHE District can mobilize for a public address systems USAID | DELIVER PROJECT will provide operational funds. Orientation of health Number of health February 2009 DHE The health workers have some skills but workers on use of all workers oriented need to be re-oriented especially in the contraceptive / trained in use of use of long term and permanent methods. contraceptives. methods of family planning. Financing and Donor Coordination / RHCS Planning: Develop a comprehensive budget for management of Logistics activities in the district Budget developed November 2008 HSD – In charge USAID | DELIVER PROJECT will fully provide the necessary funds for all these activities 17 18 APPENDIX A: LIST OF PEOPLE INTERVIEWED Table 4: List of People Interviewed N Name Qualification/Title Facility/Institution Contacts 1 Paul Mutumba Senior Nursing Officer (SNO) Nakitoma HCIII 0751-866657 2 Ayo Josephine Stores Assistant Nakasongola HSD Stores 0774198986 3 Mulinde Harriet Nursing Assistant Mayirikiti HC II –– NGO (C.O.U) 075-4106880 4 Epuat Israel Public Health Assistant Nakasongola Military Hospital O782 251094 5 Lusibe Janet Enrolled Midwifery Nakasongola Military Hospital 0772 875928 6 Sekago James Medical Theatre Assistant / Acting Stores Assistant Nakasongola HC IV 0772 332691 7 Acipa Dorcas Registered Midwifery Nakasongola HC IV 0773 119363 8 Dr. Gerald Sekito DHO Nakasongola District Health Office 0752 464674 9 Dr. Godfrey Kasibante HSD –– In Charge Nakasongola HC IV 0772 428134 10 Mr. Moses Zziwa District Health Inspector (DHI) Nakasongola District Health Office 19 20 APPENDIX B: SITE VISIT LOCATIONS Table 5: Site Visit Locations Facilities Visited 1. Nakitoma HCIII 2. Nakasongola HSD Stores 3. Nakasongola Military Hospital 4. Nakasongola HC IV 5. Mayirikiti HC II –– NGO (C.O.U) . 21 22 APPENDIX C: LIST OF PARTICIPANTS TO THE LSAT AND ACTION PLAN DEVELOPMENT WORKSHOP Table 6: List of Participants to the LSAT and Action Plan Development Workshop N Name Qualification/Title Facility/Institution Contacts 1 Paul Mutumba Senior Nursing Officer (SNO) Nakitoma HCIII 0751866657 2 Ayo Josephine Stores Assistant Nakasongola HSD Stores 0774198986 3 Namirembe Miriam Nursing Assistant Mayirikiti HC II –– NGO (C.O.U) 0754106880 4 Dr. Godfrey Kasibante HSD –– In Charge Nakasongola HC IV 0772428134 5 Kajura Justine Nakityo District Health Educator DHO office 23 24 For more information, please visit deliver.jsi.com. USAID | DELIVER PROJECT John Snow, Inc. Plot 2 C, Nakasero Hill Road Nakasero Kampala, Uganda Phone: (256) 414-253-246 Fax: (256) 414-253-245 Email: askdeliver@jsi.com Internet: deliver.jsi.com

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