IH722Spring 2015

Katie BroeckerBethany Bryant

Jennifer JohnsonLiz Nerad

Zambia ARV Supply Chain

Table of Contents

Country

Context…………………………………………………………………………

…………………….3

ARV Pipeline Overview…………………………….

……………………………………………………….4

LMIS………………………………………………………………………………

..……………………………….5

Inventory Control System…………………………….

……………………………………….………...6

Quantification…………………………………………………………………

……………………………….7

Human

Resources………………………………………………………………………

…………………….8

Challenges……………………………………………………………………

………………………………….9

Potential

Solutions…………………………………………………………….

…………….………. 10,11

Lessons

Learned…………………………………………………………………………

………………….12

In December 2013, it was estimated that only 80% of patients living with HIV were currently on antiretroviral treatment (ARV). Although access to ARV is high and increasing among adults, coverage among children remains worryingly low, with only 1 in 3 children in need of treatment receiving it in 2011. According to a recent study conducted by BUSPH Professor David Hamer, antiretroviral treatment for HIV+ patients was available at 11% of health posts, 61% of health centers, and all hospitals. Pediatric care for HIV+ children was available at 32%of health posts, 69% of health centers, and 77% of hospitals. Zambia continues to scale-up the ARV program each year, with the goal of achieving near universal access. To meet commodity demand, the supply chain will play an important role in delivering ARVs to all ARV sites.

Zambia is a large, landlocked and sparsely populated sub-Saharan nation with 13 million inhabitants. Over two-thirds of the population live in rural areas and below the poverty line. Most communities in rural areas have limited access to health care. In contrast, nearly all urban households are located within 5km of a health facility. The first case of HIV was reported in Zambia in 1984. Zambia now has an HIV epidemic spreading through the population. There are approximately 1.1 million people in Zambia living with HIV (14-15% of the total population).

The USAID Deliver Project with JSI was implemented in Zambia beginning September 2006 to improve essential health commodity supply chains. Zambia established national ARV guidelines in 2004. However, in 2007 approximately half of the 140 facilities distributing ARVs were stocked out. By January 2009 with the DELIVER Project’s assistance, Zambia achieved 100% reporting rate at 172 ARV distribution sites. This was achieved through linking the monthly reporting to the resupply of ARVs— “No report, No product”. With this new policy in place, the ARV stock out rate had decreased from 50% to 5% at 172 facilities.

Country Context: HIV and ARV in Zambia

3

Medical Stores Limited (MSL)

MOH Logistics Management Unit

(LMU)

Clients

District Community Medical Office

(DCMO)

Health CentersNGO Health

Facilities

Provincial Health

Office

District Hospital Level

1,2,3

Overview of ARV Pipeline in Zambia

Within Zambia’s ARV supply system, there are approximately 40 types of ARVs (including Nucleoside Reverse Transcriptase Inhibitors, Non-Nucleoside Transcriptase Inhibitors, Protease Inhibitors in Triple fixed dose, single dose and pediatric solutions; very few 3rd line ARVs available). ARV procurement for the public health system is limited to those listed on the Essential Medicines List.  Each level of the supply chain is a PULL system. The review period at each level is 1 month.  ARVs are provided for free at public facilities.  • Tier 1 consists of the MSL central

warehouse and the LMU• Tier 2 consists of the DCMO and district

level 1 hospital• Tier 3 consists of service delivery points

including level 2, 3 hospitals, health centers and NGO health facilities

Zambia is currently rolling out a new design, which includes regional hubs and cross-docking at DCMO. This will be explained further on slides 10-11. 

4

Product Flow

Information Flow

Supply Chain Information Flow (LMIS)

Medical Stores Limited (MSL)

MOH Logistics Management Unit

(LMU)

Clients

District Community Medical Office

(DCMO)

Health CentersNGO Health

Facilities

Provincial Health

Office

District Hospital Level

1,2,3

  Forms Form Movements

SCCStock Control

Card∙ Stays in facility

DARDaily Activity

Reports∙ Stays in facility

FRFeedback Reports

∙ Sent to lower levels (DCMO, Hospitals, Health Centers)

∙ Sent to Provincial Medical Office (PMO)

R&RRequest and Requisition

Report

∙ Sent to higher levels from lower level facilities

CR&R

Computerized Copy of

Request and Requisition

Report

∙ Sent to lower levels where it is then signed and returned to higher level

∙ Copy of signed C-R&R is kept at the receiving facility

RFRPReports for Returning Products

∙ Sent to higher levels from lower level facilities

SVSupply

Voucher

∙Signed and returned upon receipt of product

**IF product is held at DCMO, take SV with you to get your product

MDN,

PH81-N

MSL Dispatch Note, MOH

Issue Voucher

∙Sent with products to the DCMO and Hospitals.

∙Signed and copy is sent back to MSL

∙Copy of signed MSL is filed at Hospitals/DCMO

RFRP

R&RDAR SCC

CR&RRFRPMDN

CR&R

MDN R&R SCC

DAR SCC R&R

CR&RPH81-N

FR

CR&RMDN

FRFR

CR&R

RFRP

R&RFR

R&RRFRPSV

R&RRFRP

5

Stays on siteDelivers DownDelivers Up

Inventory Control System The ARV supply chain operates as a PULL system at each level. The review period is 1 month. If stock levels ever fall below 2 weeks (0.5 months) of stock before the end of the month, an emergency order should be placed.

Tier 1

SDP

Tier 2

At the end of the month, health centers should: Report stock on hand, consumption, and losses and adjustments. As this is a forced ordering system, facilities should order enough stock to bring stock level up to the maximum (3 months) and submit the order to the District by the 5th day of the following month. The minimum stock level is 2 months, the EOP is 0.5 months. Hospitals submit their order to the MSL LMU by the dates published in the MSL Delivery Schedule.

At the end of the month, districts submit the orders for their Health Centers to the MSL-LMU by the dates published in the MSL Delivery Schedule. The district reviews and approves the health center orders. The DCMO operates as a cross docking station and only stores stock for health centers without the space or capacity.

Information about the max/min/EOP ordering protocol at the MSL level is unavailable at this time. MSL procures and supplies 40 different types of ARVs including:

● Nucleoside reverse transcriptase inhibitors (NRTI)

● Non-nucleoside Transcriptase inhibitors (NNTIs)● Protease Inhibitors

Medical Stores Limited (MSL)

MOH Logistics Management Unit

(LMU)

Clients

District Community Medical Office

(DCMO)

Health CentersNGO Health

Facilities

Provincial Health

Office

District Hospital Level

1,2,33 months MAX2 months MIN0.5 months EOP

Cross-docki

ng Statio

n

6

Information Flow

If the morbidity data does not make sense when compared with the consumption data, members of the quantification meeting will deliberate until they can agree on a final forecast reconciliation and adjust to consumption trends or following projected morbidity trends

Quantification

Ministry of Health HQ

Clinton Health Access Initiative

Church Health Association of

Zambia

University Teaching Hospital

LSK DHO ARV

Kalulushi General HospitalMCDMCH

National AIDS & Tuberculousis

Council Arthur District

HospitalMinistry of Health

PMUMedical Stores

LimitedMaina Soko Hospital

USAID Deliver ZambARV

Center for Infectious Disease Research in

ZambiaLusaka PHO

Muchinga Public Health Office

CSOMOH G Fund PR

Process for Quantification

There is one annual quantification planning meeting followed by 1-2 review meetings during the year.The date of the annual meeting varies. For example: This year it was in September, with a review meeting in March. At the review meetings the quantification team looks at how closely the assumptions they made are reflecting reality. Historically, quantification was updated every quarter, but the system has since matured to the point that there are not many changes in the data throughout the year.

Stakeholders Involved in

Process

Pre-quantification: Meeting consists of a small group of technical experts from MSL, MOH, and MCDMCH who review the data and agree on questions & process for the main quantification meeting. This structure allows MSL, MOH, and MCDMCH to increase their sense of ownership as they lead the main quantification meeting.

Quantification: Meeting includes representatives from multiple NGOs, donors and government entities involved in the ARV program review the data trends developed in the pre-quantification meeting, agree on the assumptions for building the next quantification and present any preliminary results

Presentation: Final results with expected forecast, proposed procurement plans and funding gaps is presented. Donors make commitments to the procurement of the commodities in an agreed upon time frame. MOH and MCDMCH agree on how to address any funding gaps that may result.

Morbidity-based forecast using current ARV patient numbers and the expected increase in ARV patient number, combined withARV trends from partners

Once a morbidity forecast is complete, the morbidity forecast is compared with consumption data

Data Used for Quantification

Quantification Timeframe

7

Level Personnel Roles and Responsibilities

MSL

Pharmacists and Laboratory Specialist

• Review and approves R&R for ARV forms submitted by districts and hospitals• Communicate with procurement units and donor partners for procurement of

ARV drugs

Data Entry Clerk• Enter report and order information from R&R forms received from Districts and

Hospitals into Supply Chain Manager Software

Central Warehouse

Warehouse Manager, Logistics

Directors & other technical staff

• Supervise management of ARV drugs into MSL central store• Receive ARV drugs and issue ARV drugs to hospitals and districts• Adhere to quality standards for storing ARV drugs• Coordinate distribution of ARV drugs according to MSL Schedule and ensure

secure delivery• Ensure Stock control software are updated every time ARV drugs are issued or

received

Provincial Medical Office

Principal Pharmacist

• Receive quarterly feedback reports from MSL LMU on provincial ARV logistics performance

• Conduct supervision visits to the DCMOs and Level 2 and 3 Hospitals in the province

Health Center and District 1

District Pharmacist

• Receives pre-packaged ARV orders for each HC providing ARV in their district• Review ARV Drug feedback reports received from MSL LMU and take

appropriate actions• Make quarterly supervision visits to Health Centers

Hospitals: District Level

Hospital Pharmacists

• Fill in ARV DAR every time ARV Drugs dispensed• Maintain SCC for all ARV Drugs held in storage• Complete physical count of Hospital ARV stock monthly and enter on SCC and in

R&R Form• Authorize R&R for ARVs and send to MSL/LMU when sending MSL essential drug

orders• Conduct visual inspection of products received

Health Centers

ARV Focal Person

• Fill in ARV DAR every time ARV Drugs dispensed• Maintain SCC for all ARV drugs held in storage• Complete physical count every month and enter in SCC and in the R&R

for ARV Drugs• Send unusable ARV Drugs to District after filling out the Report for

Returning Products• Conduct visual inspection of products received• If storing drugs at District: when notified of receipt of order at District,

go to District and conduct receiving procedures; bring Supply Voucher and pick up weekly order

Human Resources in the Supply Chain

8

Bottlenecks occurring at the DCMOs are a major challenge for ZambiaA few challenges faced by Zambia’s supply

chain have been the uncertain availability of commodities, commodity expiries, and wastage of funds and stock. These shortcomings have especially impacted the facility level as they often faced stock out, while commodities are available at the district and central levels. A significant cause of these inefficiencies has been the bottlenecking of commodities at DCMOs. Relying on the centralized commodity distribution from the DCMOs lead to suboptimal distribution to health care facilities (HC) because of:

• inadequate last mile logistics by the DCMOs;

• lack of vehicles able to navigate difficult terrain, lack of adequate amounts of fuel, and no available truck drivers were in the region;

• lack of personnel dedicated to distribution, which forced pharmacists to coordinate distribution in addition to their official duties;

• lack of a set distribution schedule, which meant commodities were only distributed when a proper vehicle, sufficient fuel and a driver were simultaneously available.

The DCMOs were responsible for providing commodities to 2,000 pharmacies and health facilities throughout Zambia. These challenges were urgently addressed as they resulted in direct violation of the Six Rights of Supply Chain Management.

Difficult Last-Mile Logistics

Bottlenecks Occur at DCMOs

HCDCMO

MSL

Hospitals

Source: ColaLife. Supply Chain Pilot Results

Hospitals get direct delivery from MSL

Orders get backed up at the DCMO: lack of trucks and staff

9

Model A: Storage of drugs at district level. Establishes a commodity planner (CP) whose responsibilities include coordinating orders from health facilities and stock management at the district level.  Health facilities place orders to CP.  The CP places orders to the MSL.  CP receives stock from MSL and manages district store room.  They also process, pick and pack the stock for each facility.  Monthly, the health facilities receive facility packages from CP.

Model B: Eliminates intermediate storage of drugs at district level. These district stores function as a cross-docking facility.  MSL sends shipments pre-packed for individual health facilities.  One advantage of this model is the potential to reduce pilferage and leakages because it enables better shipment tracking.  Health facilities place orders directly to MSL. MSL compiles one customized pack for each health facility delivering packages to districts.  CP receives facility packages from MSL. Health facilities with limited storage space receive shipment twice monthly; health facilities with adequate storage space receive packages from CP monthly.

Days of reported stock outs for the 3 pilot districts.

Model A Model B

A pilot study was performed in 2011 focusing on improving logistics capacity at the district level and reducing the number of stockholding points in order to improve customer service and reduce stock-outs.

Potential Solutions to Bottlenecks

10

Preliminary Results: Regional hubs reduce bottlenecks and improve delivery

As a result of the pilot study, there was a significant increase in product availability and decrease in stock out rates under both models. Model B performed significantly better than Model A and comparison districts. There was a significant decrease in the stock out rates in Model B districts (from 1-33% vs baseline of 40-72% stock out) compared to comparison districts (72%). In Model B, clinics were stocked out an average of 5 days compared to 18 days in Model A and 29 days in comparison districts. Reporting rates from district health offices to MSL significantly increased to nearly 100% in Model B districts.

A hub is a stock cross-docking warehouse or transit point which keeps already pre-packed drugs for a short duration for onward distribution to the DCMOs and facilities, removing one level from the supply chain. The cross-docking hub takes on the role previously played by the DCMO in performing last mile distribution. The hub does not hold buffer stock nor does it have the mandate to re-pack commodities.

Zambia is currently implementing Model B districts nationally. The implementation of the MSL regional hubs decentralizes the distribution system. These hubs reduce the impact of district level bottlenecks and provide more vehicles to deliver supplies to SDPs, allowing for “last mile” distribution. This new regional hub system allows each health center order to be centrally processed at MSL and transported to the regional hubs in bulk. The deliveries are received at the hubs and sent on monthly delivery routes utilizing smaller MSL vehicles. This results in a more efficient transportation and distribution network and the cross-docking hub serve as a regional MSL presence in the community. Currently 3 regional hubs of the proposed 7 are open and functioning.

Regional Cross-Docking Hubs

Model B Reduces Stock-out Rates

MSL

HC

Regional

Cross-Docking Hub

Pre-packing occurs here

Hospitals

Model AModel B

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DCMO

Lessons Learned

Without information, the supply chain system does not function. Information flow is the key to meeting the Six Rights of supply chain management and the ultimate goal of reducing adverse health effects and improving public health.

Ensuring that supplies efficiently reach the last-mile can be affected by many factors including: lack of transportation, lack of human resources, difficult terrain. Supplies may also not reach the last mile due to mis-calculations in forecasting and budgeting that lead to stock-outs. Without many options, those at the end of the supply chain are most vulnerable to these inefficiencies and inadequacies.

Challenges upstream in the supply chain can have serious consequences downstream, where patients may require medicines and supplies the most.

Making a change at one point of the supply chain has ripple effects to other parts. When making changes, the effects should be anticipated at other points to ensure that the system will still run properly.

There is a domino effect when making changes in the supply chain, because everything is connected.

A robust LMIS system (preferably electronic) is essential to running a supply chain effectively.

It takes time to change a system because there are many stakeholders and factors at play. It’s often necessary to make small incremental changes so that the effects can be properly observed and subsequent modifications can be made.

Change is a slow and difficult process.

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References

World Bank. World Bank Policy Note: Enhancing Public Supply Chain Management In Zambia [Internet]. Available from: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2012/08/16/000333037_20120816012127/Rendered/PDF/718560WP0P12520ain0Innovation0final.pdfMinistry of Health. The Health Logistics Press. Zambia Ministry of Health [Internet]. 2013 Oct;(17). Available from: http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/ZM_NewsOct2013.pdfMinistry of Health. The Health Logistics Press. Zambia Ministry of Health [Internet]. 2013 Jun;(16). Available from: http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/ZM_NewsJune2013.pdfAliza Marcus. The Challenge of Ensuring Adequate Stocks of Essential Drugs in Rural Health Clinics [Internet]. World Bank, Human Development Network; 2010. Available from: http://siteresources.worldbank.org/EXTHDOFFICE/Resources/5485726-1288802844934/Zambia-Evid-to-Pol.pdfColaLife. Supply Chain Pilot Results | Zambia | May 2010 [Internet]. 2010 May [cited 2015 Feb 23]. Available from: http://www.slideshare.net/ColaLife/supply-chain-pilot-results-zambia-may-2010Livingstone. MSL Regional Cross-docking Strategy-  A Case of Choma Hub [Internet]. 2013 Dec. Available from: http://www-wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2012/08/16/000333037_20120816012127/Rendered/PDF/718560WP0P12520ain0Innovation0final.pdfUSAID. Logistics Brief: Improving Access to Malaria Medicines in Zambia [Internet]. USAID; 2011. Available from: http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/ZM_ImprAccMalaMed.pdfDerrick Nyimbili. Lessons Learned: Designing and Implementing the Hybrid Essential Medicines System Strategy to Improve Product Accessibility in Zambia [Internet]. USAID; 2014. Available from: http://web.ics.purdue.edu/~aiyer/7ghscs_submission_27.pdfMSL. Briefing paper on the external verification and evaluation of the Medical Stores Limited (MSL) Choma Regional Cross-Docking Hub Performance. MSL; 2015.

DELIVER, JSI, USAID. Standard Operating Procedures Manual for the Management of the National ARV Logistics System. Republic of Zambia Ministry of Health; 2013.

References

Ministry of Health, Zambia National Formulary Committee. 2008. Standard Treatment Guidelines, Essential Medicines List, Essential Laboratory Supplies for Zambia. 2nd ed Lusaka, Zambia: Zambia Ministry of health. http://apps.who.int/medicinedocs/documents/s19280en/s19280en.pdf

Nicodemus W. Interviewed by: Nerad L. 22 Jan 2015.

Yadav, Prashant. 2007. Appendix E: Analysis of the public private, and mission sector supply chains for essential drugs in Zambia. A study conducted for DFID Health Resource Center under the Aegis of the META Project.

Zambia National Formulary Committee (2011) 2011-2013 Zambia National Formulary http://www.moh.gov.zm/docs/znf.pdf

CDC. (2015). Increasing Patient Access to Antiretrovirals Recommended Actions for a More Efficient Global Supply Chain. CDC. Retrieved 5 March 2015, from http://www.cgdev.org/doc/HIVAIDSMonitor/ARV_Background-FINAL1.pdf

Murray, L., Semrau, K., McCurley, E., Thea, D., Scott, N., & Mwiya, M. et al. (2009). Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: a qualitative study. AIDS Care, 21(1), 78-86. doi:10.1080/09540120802032643

UNAIDS,. (2014). UNAIDS. ZAMBIA COUNTRY REPORT. Retrieved 5 March 2015, from http://www.unaids.org/sites/default/files/country/documents/ZMB_narrative_report_2014.pdf

UNICEF. (2015). UNICEF Zambia - Resources - HIV and AIDS. Unicef.org. Retrieved 5 March 2015, from http://www.unicef.org/zambia/5109_8459.html

USAID,. (2015). USAID. USAID | DELIVER PROJECT Helps Zambia Reduce ARV Stockouts, Create Model Logistics System. Retrieved 5 March 2015, from http://pdf.usaid.gov/pdf_docs/PNADR855.pdf

WHO. (2015). Zambia. World Health Organization. Retrieved 5 March 2015, from http://www.who.int/hiv/HIVCP_ZMB.pdf

Hamer, David. 2015. Health Facility and Health Worker Baseline Assessment for Reproductive, Maternal, Neonatal, Child Health and Nutrition Services Final Report. Government of the Republic of Zambia, Ministry of Community Development/Mother and Child Health.