CDI Module 14: Supply Chain Management for CDI

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The Johns Hopkins UniversityA Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services

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Module 14 Objectives

By the end of this module, learners will: Describe the process of anti-malarial drug procurement and

storage Explain how to estimate their community’s commodity

needs Outline the stock recording method and reporting format Describe the distribution process for anti-malarial medicines

and other malaria commodities (long-lasting insecticide-treated nets [LLINs], rapid diagnostic tests [RDTs])

State how to monitor and report adverse drug reactions (ADRs)

Discuss the role of patent medicine vendors (PMVs) in malaria commodity management

What Are Commodities?

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Procurement and Supply Chain/Cycle

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Clients consume

stock

Supply system information

managementForecasting and ordering

Procurement

Distribution to first level

Storage, safety and correct use

Distribution to next level

Storage and safety

Commodities Flow from Suppliers to Central Medical Stores, Then on to LGAs and Facilities

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Flow of Commodities

Health commodities for community-directed intervention (CDI) and integrated community case management (iCCM) can flow through both public and private channels

Each country is different, and in some cases: National, regional and district medical/pharmacy stores

order, procure and distribute commodities/medicines Districts or community associations can use private

sector warehouses and suppliers to buy medicines In some countries, malaria commodities are

manufactured; in other countries, these commodities are imported

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Commodities Reach Consumers

Ultimately, commodities like artemisinin-based combination therapies (ACTs), RDTs, LLINs and sulfadoxine-pyrimethamine (SP) need to reach the frontline clinic, and from there, the community-directed distributors (CDDs)

Whatever the system, commodities must move from point of manufacture to point of use

(Present a chart that shows movement of malaria and other iCCM commodities in your country so that it finally reaches CDDs/villages)

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Proper Estimation of Anti-Malarial Commodities

It is important to have estimates of eligible clients/patients to determine anti-malarial commodity requirements at all levels

Accurate data are required to achieve these estimates Initial quantification of anti-malarial medicines (ACTs, SP,

quinine) needs to be done using population-at-risk data, by episode, based on medicine consumption

Lower level quantification can be done through community “head counts” during community census

Malaria Tasks Have Different Schedules (Forecasting)

The first task is to conduct a community census to determine numbers of people in need of services

An insecticide-treated net (ITN) is needed as soon as a woman knows she is pregnant

Intermittent preventive treatment in pregnancy (IPTp) occurs at least twice after quickening, at monthly intervals

Case management occurs whenever a community member has malaria IPTp and ITNs may prevent most of the need for case

management

Finally, health education is frequent

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Identify and Coordinate Sources of Supplies and Funding

LLINS ACTs SP

Global Fund

World Bank

USAID

UNICEF

Ministry

10Present details from your own country

Sample Roadmap Country Summary

Need to 2010 Funded and expected to be

distributed before end 2010

Gap

LLINs 63 million LLINs 49 million 14 million

ACTs 129 million doses

94 million 35 million

IRS 2.8 million households

800,000 2 million

RDTs 59 million tests 34 million 25 million

IPTp 18 million doses

18.3 million 0

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Procurement and Supply

It is recommended that drugs for home management of malaria (HMM) be centrally procured

Benefits of central procurement include bulk purchasing, which can: Reduce cost of medicines and handling charges Ensure consistency and quality of supplies Simplify logistics

These drugs should be World Health Organization (WHO)-approved medicines

Ultimately these should move in a well supervised manner from national to sub-national to district to health facility and then community

Companies Producing WHO Prequalified Malaria Medicines as of August 2010

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Amodiaquine + Artesunate Ipca Laboratories Limited Dadra and Nagar Haveli (U.T.),

India Guilin Pharmaceutical Co. Ltd Guilin, Guangxi, China Cipla Ltd Patalganga, India; Goa, India Sanofi-Aventis Group MAPHAR Laboratories,

Casablanca, MoroccoArtemether + Lumefantrine Novartis Pharma Beijing, China; Suffern, USA Ajanta Pharma Ltd Paithan, Aurangabad,

Maharashtra, India Ipca Laboratories Ltd Dadra and Nagar Haveli (U.T.),

India Cipla Ltd Patalganga, India; Himachal

Pradesh, India

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The Frontline Primary Health Care (PHC) Facility Provides Commodity Link with CDDs

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The Malaria Drug Supply Chain

Community delivery of malaria medicines requires adequate supplies at all levels

Districts must monitor frontline facilities to help prevent stock-outs for facilities and the CDDs these facilities supervise

CDDs collect stocks from the nearest PHC facility

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Forms Track the Use ofAnti-Malarial Medicines

Forms are used at all levels of the health care system to track the use of anti-malarial medicines

States/municipalities use forms to track the drugs they procure and distribute

Facilities also use forms to track the drugs they procure and distribute

CDDs use forms to track the medicines they pick up from their supervising facility and distribute within the community

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Why Use Anti-MalarialDrug-Tracking Forms?

These forms collect data on: The consumption of different dosage packs The manufacture and expiry (expiration) dates of

medicines

These forms also include areas to record the justification for any discrepancies in drug consumption (e.g., partial medicine usage)

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The Distribution Process for CDI

Commodities reach the nearest health facility The community representative or CDD collects

initial supplies and materials from the health facility The initial stock is based on a village census that

shows need On receipt of stocks, the CDD or community

representative signs an inventory register at the health facility confirming collection of supplies

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CDDs Need a Safe Placeto Store Their Own Medicines

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Maintaining Stocks and Distribution

The community is informed that commodities are available from the CDD

Women and caregivers seek these services, when needed

The CDD maintains distribution records and summarizes these on a regular basis

The community or the CDD submits summary reports to the health facility on a regular basis

Then they collect replenishment supplies

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Community Preparation

The community and the CDD announce to community members that commodities are available

The community decides on a distribution system for commodities For ivermectin, people could go house-to-house or

distribute the drug from a central location For malaria commodities, people could go to the

CDD’s house, or the CDD could make home visits The community should decide on the most acceptable

processes

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Storage

During training, CDI focal persons should sensitize the CDDs to the following storage requirements: Keep medicines away from direct sunlight and

heat Ideally store SP, and ACTs in a cool, dry place—

temperature should not exceed 25°C Keep all medicines out of reach of children, at all

times

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Keeping Medicines in the Community

Keep community case management (CCM) kits in dry, clean places in the house

Medicines should be kept separate from the other items in the house

Medicines suspected to have come in contact with water must not be used for treatment

Damaged medicines should be returned to the health center and a new stock collected

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Medicines May Not Work as Expected

CDDs should report dangerous or unexpected effects of the drugs to their supervising health facility

The supervising facility should report to the district This reporting is part of the pharmaco-vigilance

system Likewise, CDDs should take note of patients who do

not get well after taking ALL medicine correctly These patients should be reported and referred

These steps help ensure quality of commodities

Getting New Stock for the Community

A system of stock collection is needed

Monthly CDD meetings at the frontline facility is one way to accomplish this: CDDs bring empty

medicine packets to exchange for new packets

A system must be in place to obtain stock whenever it is needed

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PMVs Are a Major Source of Medicines for the Community

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Sometimes if CDD stocks run out, community members may need medicines quickly

PMVs may be a source

We need to monitor PMVs to ensure that they provide quality medicines

Procurement and PMVs

PMVs: Normally buy their stock from wholesalers Usually do not keep records and receipts Do know which medicines are popular

With the Affordable Medicines Facility for Malaria (AMFm), PMVs: May now be receiving specially packed Coartem

from the health system Will need to learn how to manage stocks, check

expiration and report damages

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PMV Associations Can Be Involved in Procurement and Supply Chain Management (PSM) for the Private Sector

Sometimes communities can re-stock their medicine box by buying from a reliable PMV shop

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Summary and Conclusions

CDDs: Collect drugs from the health facility that provides

services to their community Ensure that drugs are stored appropriately Maintain an accurate account of drug use, damages and

stock at all times Report ADRs to the supervising health facility Attend monthly meetings and submit monthly reports

PMV associations can also be involved in the supply of approved malaria commodities