District-Level Assessment of Pharmaceutical Management of Life...

District-Level Assessment of Pharmaceutical Management of Life-

Saving RMNCH Commodities: Lakshmipur, Bangladesh

January 2016

District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh

Sheena Patel Sheikh Asiruddin Javedur Rahman Azim Uddin Anwar Hossain January 2016

District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:

Lakshmipur, Bangladesh.

ii

This report is made possible by the generous support of the American people through the US

Agency for International Development (USAID), under the terms of cooperative agreement

number AID-OAA-A-11-00021. The contents are the responsibility of Management Sciences for

Health and do not necessarily reflect the views of USAID or the United States Government.

About SIAPS

The goal of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program is

to ensure the availability of quality pharmaceutical products and effective pharmaceutical services to

achieve desired health outcomes. Toward this end, the SIAPS result areas include improving

governance, building capacity for pharmaceutical management and services, addressing information

needed for decision-making in the pharmaceutical sector, strengthening financing strategies and

mechanisms to improve access to medicines, and increasing quality pharmaceutical services. About MaMoni HSS

MaMoni Health Systems Strengthening (HSS) project is an Associate Award under the Maternal and

Child Health Integrated Program (MCHIP), with the goal of improving utilization of integrated

maternal, newborn, child health, family planning and nutrition (MNCH/FP/N) services in Bangladesh.

MaMoni HSS focuses on strengthening the systems and standards for services, which will lead to

declines in maternal, newborn and child mortality at scale. MaMoni HSS’s inputs are aligned to

improve the performance and capacity of district level health systems, which in turn ensures that

interventions result in increased access to and utilization of services by the most vulnerable.

Recommended Citation

This report may be reproduced if credit is given to SIAPS and MCHIP. Please use the following

citation. Patel S, Asiruddin S, Rahman,J, Uddin A, Hossain A. 2015. District-Level Assessment

of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh.

Submitted to the US Agency for International Development by the Systems for Improved Access

to Pharmaceuticals and Services (SIAPS) Program and Maternal and Child Health Integrated

Program (MCHIP). Arlington, VA: Management Sciences for Health.

Key Words

pharmaceutical management, reproductive health, maternal health, newborn health, child health,

Bangladesh

Systems for Improved Access to Pharmaceuticals and Services

Center for Pharmaceutical Management

Management Sciences for Health

4301 North Fairfax Drive, Suite 400

Arlington, VA 22203 USA

Telephone: 703.524.6575

Fax: 703.524.7898

E-mail: [email protected]

Website: www.siapsprogram.org

iii

CONTENTS

Acronyms ....................................................................................................................................... iv

Acknowledgments........................................................................................................................... v

Executive Summary ....................................................................................................................... vi

Introduction ..................................................................................................................................... 1

Background ..................................................................................................................................... 2 RMNCH in Bangladesh .............................................................................................................. 2 Health System Structure for RMNCH Services.......................................................................... 3

Supply Chain Management ......................................................................................................... 4

Methodology ................................................................................................................................... 6

Purpose and Objectives ............................................................................................................... 6 Tracer Medicines ........................................................................................................................ 6 Site Selection .............................................................................................................................. 7 Data Collection Methods ............................................................................................................ 7

Data Collection and Analysis...................................................................................................... 8 Limitations of the Assessment .................................................................................................... 8

Results ............................................................................................................................................. 9 Pharmaceutical Management Practices in DGFP ....................................................................... 9 Pharmaceutical Management Practices in DGHS..................................................................... 13

Availability of RMNCH Commodities ..................................................................................... 19

Discussion ..................................................................................................................................... 27

Recommendations ......................................................................................................................... 29

Annex A. Availability of MNCH Commodities in the Last Six Months...................................... 32

References ..................................................................................................................................... 34

iv

ACRONYMS

BEmOC Basic emergency obstetric care

CC community clinic

CMSD Central Medical Stores Depot

CSO Civil Surgeon’s Office

DDS drug and dietary supplement kits

DGFP Directorate General of Family Planning

DGHS Directorate General of Health Services

DRS District Reserve Store

DT dispersible tablet

EDCL Essential Drugs Company Limited

FP family planning

FWV family welfare volunteer

FWA female welfare assistant

HA health assistant

HPNSDP Health, Population, and Nutrition Sector Development Program (Bangladesh)

LD line director

LMIS logistics management information system

MCH Maternal and child health

MCHIP Maternal and Child Health Integrated Program

MCWC Mother and Child Welfare Center

MDG Millennium Development Goal

MMR maternal mortality rate

MNCH Maternal, newborn, and child health

MOHFW Ministry of Health and Family Welfare

PE/E preeclampsia and eclampsia

POM Procurement Operations Manual (SIAPS and MOHFW)

PPA Public Procurement Act of 2006

PPH postpartum hemorrhage

PPM Procurement Procedures Manual (DGFP)

PPR Public Procurement Rules of 2008

RMNCH reproductive, maternal, newborn, and child health

SBA skilled birth attendants

SIAPS Systems for Improved Access to Pharmaceuticals and Services [Program]

SOP standard operating procedure

UFPS Upazila Family Planning Store

UHC upazila health complex

UNCoLSC United Nations Commission on Life-Saving Commodities

USAID US Agency for International Development

v

ACKNOWLEDGMENTS

We would like to thank the Director Management Information System (MIS) and Additional

Director General, DGHS, the Civil Surgeon and Upazila Health Managers of Lakshmipur district

under the Directorate General of Health Services and the Deputy Director and Upazila Family

Planning Officers under the Directorate General of Family Planning of Lakshmipur district for

their support for assessment. We would also like to thank the staff of MaMoni HSS Dhaka and

Lakshmipur including its implementing partner, Dustho Sahthya Kend (DSK), for their efforts

and dedication in supervision and data collection.

We also express our sincere appreciation to the storekeepers and health managers of the district

stores, upazila health and family planning stores, union sub-centers, family welfare centers, and

community clinics who took time to answer the survey questions.

vi

EXECUTIVE SUMMARY

Bangladesh has made great strides in improving the lives of women and children. From 2000 to

2010, maternal mortality rates (MMR) in Bangladesh decreased from 400 to 194 deaths per

100,000 live births.i,ii

This decrease is associated mostly with the drop in fertility and the

increased use of health facilities for both deliveries and for cases of maternal complications.iii

Infant and child mortality rates have also declined. From 2007 to 2014, the infant mortality rate

reduced from 52 to 38 deaths per 1,000 live births and the child mortality rate dropped from 65

to 46 deaths per 1,000 live births.iv

Nevertheless, there are significant disparities in maternal,

newborn and child health status between divisions within the country, and access to maternal and

child health services remains low.v Furthermore, availability of essential medicines is also a

concern in Bangladesh.vi

The USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS)

Program has been working to increase access to reproductive, maternal, newborn, and child

health (RMNCH) medicines and supplies in Bangladesh. In 2014, SIAPS conducted an

assessment of local procurement practices for three maternal health medicines in three districts.

The assessment found that availability was suboptimal in all three districts visited—Dhaka,

Khulna, and Sylhet.vii

However, the scope of this assessment did not go beyond the district level

and left many questions related to pharmaceutical management, such as quantification practices

and processes for logistics management information systems, unanswered.

Save the Children’s MaMoni Health Systems Strengthening (HSS) project works at national,

district, and sub-district levels. To better understand the pharmaceutical management practices at

the upazila, union, and community levels, SIAPS and MaMoni HSS project, conducted a district-

level assessment in Lakshmipur district focused on forecasting mechanisms, supply and

distribution practices and procedures, and recording and reporting practices and information

flows related RMNCH commodities.

This assessment focused on describing pharmaceutical management practices for essential

reproductive health and RMNCH medicines and supplies at all levels of the public health system

in Lakshmipur district to guide interventions to improve availability and use of these

commodities.

Specifically, the assessment sought to (1) describe the pharmaceutical management practices and

procedures at the district level and below, (2) analyze the availability of key medicines and

supplies for RMNCH at all levels within the district, and (3) identify possible interventions to

improve the pharmaceutical management and thereby improve availability of essential RMNCH

medicines and supplies in the district. Through consultations with Directorate General for Health

Services (DGHS) and Directorate General for Family Planning (DGFP) officials, a tracer list of

medicines was developed for the assessment. The tracer list consists of five maternal health

medicines, six newborn health medicines and supplies, four child health medicines, and six

family planning commodities.



vii

Overall, the assessment found:

Limited availability of RMNCH commodities, particularly maternal and child health

medicines

Lack of local level guidelines for key pharmaceutical management functions, namely

procurement, forecasting, inventory management and distribution.

Lack of guidelines detailing which medicines should be available at each level of

facility, or by type of provider

No standardized inventory management tools in DGHS

No standardized logistics management information system (LMIS) in DGHS

This year will mark the end of the Millennium Development Goals, and while Bangladesh is on

track for meeting the goals for reducing maternal and child mortality, there is still a long way to

go to achieve the targets set by the new, more ambitious Sustainable Development Goals. To

meet the goals by 2030, there needs to be increased focus on ensuring the availability of

RMNCH commodities at the district and sub-district levels through systems strengthening

approaches. Based on the challenges found in this assessment, the following recommendations

should increase access to life-saving RMNCH commodities:

Finalize and disseminate the maternal and newborn health standard operating procedures

at all levels of the system.

Improve the capacity of staff members at the local level to manage pharmaceutical

management processes including procurement, supply, and distribution; and logistics

management.

Strengthen pharmaceutical information systems to provide the data needed for robust

forecasting and supply planning.

Advocate for inclusion of amoxicillin dispersible tablets (DTs) and oral rehydration

solution (ORS) in DGFP and DGHS procurement plans.

Provide facilities with the infrastructure necessary to maintain cold chain storage

conditions for oxytocin.

Ensure that magnesium sulfate is available wherever women give birth.



viii

1

INTRODUCTION

Bangladesh has made considerable progress in reducing maternal and child mortality and is one

of the few Countdown countries that were on track to meet both the Millennium Development

Goals (MDG) 4 and 5. To maintain this progress and work towards even further reductions in

mortality, it is essential that women and their children have access to a range of safe and high-

quality contraceptives and essential maternal, newborn, and child health commodities at service

delivery points. The US Agency for International Development (USAID)/Bangladesh has been

providing support to ensure the availability of contraceptives and other reproductive health

commodities in Bangladesh for over 20 years. This support has included assistance to the public

sector to improve systems for supply chain management of family planning commodities.

The USAID-funded Systems for Improved Access to Pharmaceutical and Services (SIAPS)

Program has also been working to address supply chain management issues related to

Reproductive, Maternal, Neonatal, and Child Health (RMNCH) commodities. In 2014, SIAPS

conducted an assessment on local procurement practices for three maternal health medicines in

three districts. The assessment found that availability was suboptimal in all three districts

visited—Dhaka, Khulna, and Sylhet. However,availability or lack of availability was not related

to whether the medicines were supplied from the central level or procured but more so to the

procurement practices at the local level and coordination with the central level.viii

Major findings

of the assessment related to access to maternal health medicines include the following—

Lack of coordination and information sharing between the central and subnational level

No district-level guidance for quantification or local procurement of medicines

Insufficient training of the procurement committee members about quantification or

procurement

No standard evidence-based method for forecasting maternal health medicines at the

district level

The sub-national procurement assessment was conducted at only the Civil Surgeon’s Office

(CSO)/District Reserve Store (DRS) and Mother and Child Welfare Centers (MCWC) at the

district level; the assessment did not cover pharmaceutical management practices at the sub-

district. Additionally, information on this at the lower levels of the system is scarce. In regards to

logistics management information systems (LMIS) which tracks family planning commodities,

DGFP has an upazila inventory management system and a warehouse inventory management

system. However, DGHS has no LMIS for tracking RMNCH drugs. While DGHS has a

digitalized health information system (DHIS-2) to track coverage of health services, the system

currently does not have information on logistics. To better understand the pharmaceutical

management practices at the upazila, union, and community levels, SIAPS and Save the

Children’s MaMoni HSS project, conducted a district-level assessment in Lakshmipur district

focusing more on forecasting mechanisms, supply and distribution practices and procedures, and

LMIS or available information related to RMNCH commodities.

2

BACKGROUND

RMNCH in Bangladesh

Bangladesh has made great strides in improving the lives of women and children. From 2000 to

2010, the maternal mortality ratio (MMR) in Bangladesh decreased from 400 to 194 deaths per

100,000 live births.ix,x

That decrease is associated mostly with the drop in fertility and the

increased use of facilities for both deliveries (from 9% in 2001 to 23% in 2010) and for cases of

maternal complications (from 16% in 2001 to 29% in 2010).xi

From 2001 to 2014, the total

fertility rate decreased by 23%, from 3.0 to 2.3 births per woman and the percentage of married

women with an unmet need for family planning decreased from 17% to 12%.xii

Infant and child

mortality rates have also declined. From 2007 to 2014, the infant mortality rate reduced from 52

to 38 deaths per 1,000 live births and the child mortality rate dropped from 65 to 46 deaths per

1,000 live births. Both are on track for meeting the Millennium Development Goal (MDG)-4 of

reducing the under-five mortality rate by two-thirds.xiii

Nevertheless, there are significant disparities in maternal, newborn, and child health status

between divisions within the country. For example, the 2010 Bangladesh Maternal Mortality

Survey found that, although MMR in Khulna division is 74 (per 100,000 live births), MMR in

divisions such as Dhaka and Chittagong are 196 and 186, respectively; Sylhet division has the

highest MMR at 425 per 100,000 live births.xiv

Similarly, according to the 2011 Bangladesh

Demographic Health Survey, infant mortality rates range from 35 deaths per 1,000 live births in

Chittagong to 59 deaths per 1,000 live births in Sylhet and child mortality rates range from 54

deaths per 1,000 live births in Dhaka to 71 deaths per 1,000 live births in Sylhet division.xv

MMR still must drop by 25% to meet 2015 targets for MDG-5.

Access to maternal and child health services remain low.xvi

Neonatal mortality declined at a

much slower rate than both infant and child mortality. Only 26% of pregnant women receive the

recommended four antenatal visits and only 32% of births are attended by a skilled birth

attendant.xvii

Additionally, while pneumonia is one of the leading causes of child deaths, only

35% of children under five with symptoms of pneumonia were taken to an appropriate health

provider.xviii

Availability of essential MNCH medicines is also a concern in Bangladesh. For example, the two

leading causes of maternal deaths—postpartum hemorrhage (PPH) and preeclampsia and

eclampsia (PE/E)—account for 31% and 20% of maternal deaths, respectively.xix

According to

international guidelines, essential medicines to prevent and treat PPH and PE/E include oxytocin,

misoprostol, and magnesium sulfate. However, ensuring availability of those essential maternal

health medicines remains a challenge, especially at the district level. A study conducted in 2009

found that only 55% of district hospitals and 38% of upazila health complexes (UHCs) reported

having oxytocin in stock on the day of the visit.xx

Availability of magnesium sulfate was also

limited: only 42% of district hospitals and 23% of UHCs reported having the injection in the

facility.xxi

Background

3

Health System Structure for RMNCH Services The delivery of maternal health services at the district level through the Ministry of Health and

Family Welfare (MOHFW) in Bangladesh is divided primarily between two parallel agencies:

the DGHS and DGFP. The organization and delivery of health services within DGHS and DGFP

differ at each level of the health system. After the central level, the next levels of care are the

district level, upazila, union, and community level. Bangladesh’s Health, Population, and

Nutrition Sector Development Program (HPNSDP) for 2011–2016 is the government’s national

strategy for increasing access to quality health care and the overarching national strategy

dictating which services and, thereby, medicines should be available at each level of the health

system for both DGHS and DGFP.xxii

Family planning services are provided only through the DGFP; however, both directorates are

mandated to provide primary MNCH services at all levels of the health system and basic

emergency obstetric care (BEmOC), which includes management and treatment of PPH and

PE/E, at the district, upazila, and union levels.1,2

Primary maternal, newborn, and child services

include antenatal care (ANC), maternal nutrition counseling, postnatal care (PNC), management

of birth asphyxia, newborn umbilical cord care, integrated management of childhood illnesses

(IMCI), and routine immunizations. Comprehensive emergency obstetric care (CEmOC) is

provided at health centers at the central and district level only.

At the community level, health workers in both DGFP and DGHS have been trained as skilled

birth attendants and conduct home visits, perform deliveries, and provide newborn care, such as

newborn resuscitation. Within DGFP, female welfare assistants (FWA) provide basic family

planning (FP) counseling services and some are trained to conduct home deliveries (referred to

as FWA–skilled birth attendants [SBA]). Similarly, in DGHS, female health assistants (HA)

work at the community level and those trained as SBAs are referred to as HA-SBA. Table 1

provides a snapshot into where and what levels RMNCH services should be provided within the

structures of both DGHS and DGFP.

1 While facilities may be mandated for providing BEmOC and CEmOC, roll out of these services at different levels

of the health system and among districts may vary. For example, while HPNSDP indicated that prevention and

treatment of PE/E should be provided at MCWCs, currently, this is still being piloted in one district and is not rolled

out nationally. 2 The HPNSDP, 2011-2016, indicates that management and treatment of PE/E should be provided at MCWCs

however discussions with DGFP indicated that currently, this is not the case as MCWCs do not have the capacity to

provide MgSO4 due to lack of trained physicians. Currently, MCWCs refer PE/E cases to the district hospitals.



4

Table 1. Delivery of RMNCH Services within DGHS and DGFP, Based on HPNSDP, 2011–2016

Health system

DGHS DGFP

Facility RMNCH Services Facility RMNCH Services

Central level Teaching hospitals

CEmOC, management/ treatment of PPH and PE/E, primary maternal health services

Mohammadpur Fertility Services and Training Centre, Dhaka; Maternal and Child Health Training Institute

CEmOC, management/ treatment of PPH, FP, and other RH services

District level District hospitals

CEmOC, management/ treatment of PPH and PE/E, MNCH services

Mother and child welfare center (MCWC)

CEmOC, management/ treatment of PPH, Primary MNCH services, FP, and other RH services

Upazila level UHC BEmOC, management/ treatment of PPH and PE/E, primary MNCH health services

Upazila health complex, family planning (UHC-FP)

FP services, Primary MNCH services

Union Union sub- center (USC)

BEmOC, management/primary MNCH services

Upgraded Union Health and Family Welfare Center

a

BEmOC, management and treatment of PPH, Primary MNCH services, FP services

xxiii

Union Health and Family Welfare Center

BEmOC, primary MNCH services, FP services

Community Community Clinic

Primary MNCH services and nutrition

FWA-SBA

FP counseling and conduct home deliveries, prevention of PPH, basic newborn care

3

Female Health Assistants

Conduct home deliveries, basic newborn care

a. There are 3,924 FWC’s in Bangladesh. Among them, 1,414 are upgraded FWCs. The MOH plans to upgrade 800 more by 2016 within DGHS. Ungraded FWC’s are expected to have two extra rooms and are meant to provide 24/7 BEmOC and delivery services. A medical officer-family planning (MO-FP) is also expected to be there.

Supply Chain Management Supply chain management of medicines and supplies also differs between DGHS and DGFP,

particularly in the supply and distribution of commodities. Figure 1 illustrates the differences in

the supply chain structure and flow of RMNCH commodities within DGHS and DGFP.

Within DGHS, the Central Medical Store Depot (CMSD) is responsible for the procurement,

supply, and distribution of health commodities. Health commodities are supplied to the District

Reserve Store (DRS) for distribution to the District Hospitals, UHCs, and Union Sub-Centers

(USCs). Additionally, at the district level, the CSO not only manages the DRS but also has the

authority to locally procure medicines to avert stock-outs. At the community level, community

3 A special Government Order (GO) no. MCH/AMSTL-64/2011/944 issued on 4 Nov 2013 by the MCH unit of

DGFP indicated that trained FWAs will give two tablets of Misoprostol to mothers after 32 weeks of pregnancy who

will deliver at home to prevent PPH.

Background

5

clinic kits (CC kits) are procured at the central level from the Essential Drugs Company Limited

(EDCL), which distribute directly to the UHCs that in turn send on to the Community Clinics.

In DGFP, however, commodities are procured by the Line Director for Logistics and Supply and

distributed to the regional warehouses which are responsible for distribution to the Upazila

Family Planning Store (UFPS). The UFPS then supplies the Mother and Child Welfare Centers

(MCWC) and FWCs. Additionally, MCWC is also responsible for locally procuring medicines

that are not procured at the central level, such as oxytocin. At the community level, FWAs and

SBAs receive their medicines and supplies from the UFPS.

Figure 1. Supply chain structure and flow of RMNCH commodities within DGHS and DGFP

6

METHODOLOGY

Purpose and Objectives The purpose of this assessment is to describe pharmaceutical management practices for essential

RMNCH medicines and supplies at all levels of the public health system in Lakshmipur district

to inform the development of interventions to improve availability and use of these commodities.

Specifically, the assessment sought to:

• Describe the pharmaceutical management practices and procedures at the district level

and below

• Analyze the availability of essential medicines and supplies for RMNCH at all levels

within the district

• Identify possible interventions to improve the pharmaceutical management and thereby

improve availability of key RMNCH medicines and supplies in the district.

Tracer Medicines

Through consultations with DGHS and DGFP officials, a tracer list of medicines was developed for

the assessment. The tracer list consists of five maternal health medicines, six newborn health

medicines and supplies, four child health medicines, and six family planning commodities (table 2).

Table 2. Tracer RMNCH Medicines List

Tracer Medicine

Maternal Health Injectable oxytocin, 5 IU

Tablet, misoprostol, 200 mcg

Injectable, magnesium sulfate, 4 g in 100 ml

Iron folate, 60 mg + 0.4 mg

Calcium, 500 mg or 600 mg; 300 mg

Newborn Health Injectable, gentamicin, 80 mg

Oral amoxicillin, suspension (125 mg/5 ml) 100 ml

Dexamethasone, 5 mg

Bulb sucker

Ambu bag

Mask, infant

Child Health ORS

Zinc sulfate

Amoxicillin DT, 250 mg

Vitamin A

Methodology

7

Tracer Medicine

FP Condoms

Pills

Depo-Provera

IUDs

Implants (Jadelle)

Implants (Implanon)

Site Selection

Lakshmipur district in the Chittagong division was selected for the assessment because of the

field presence and work of the MaMoni HSS project. All five upazilas under the district were

also selected and both DGHS and DGFP sites from the district, upazila, union, and community

levels were randomly selected from the Lakshimpur District Health Care Service Facility List

which was provided by MaMoni HSS. Both health care facilities and medicine stores were

selected. Table 3 indicates the DGHS and DGFP sites that were selected from each level of the

health system.

Table 3. Number of DGHS and DGFP Sites/Respondents Selected at District and Sub-District Levels

DGHS DGFP

Facility/Personnel Number Facility/Personnel Number

Regional N/A Regional Warehouse 1

District CSO/DRS 1 MCWC 1

District hospital 1 District Family Planning Office 1

Upazila UHC 4 Upazila Health Complex, Family Planning (UHC-FP) or Upazila Family Planning Store (UFPS)

4

Union USC/ Sub-Assistant Community Medical Officer (SACMO)

4 Family Welfare Center/Family Welfare Volunteer (FWC-FWV)

20

FWC/SACMO 16

Community Community Clinic/Community Health Care Provider (CC-CHCP)

20 FWA 20

SBA 6 SBA/FWA 14

Data Collection Methods Both qualitative and quantitative data collection methods were used to assess pharmaceutical

management practices. Specifically, quantitative data collection tools were developed and

customized for each type of facility that was selected. The assessment tools collected data on

product management, local procurement practices, distribution and supply of medicines,



8

inventory management, and LMIS as well as collected data on the availability of RMNCH

commodities.

Also, in-depth interviews were conducted with selected facility managers at each level using an

interview guide. The interviews were designed to complement the assessment tool and provide

detailed qualitative data; they were heavily focused on pharmaceutical information flows.

Data Collection and Analysis

The study team consisted of SIAPS and MaMoni HSS staff, including district level

implementing partner Dustho Sahthya Kendro. The data was collected by10 data collectors

provided by the implementing partner and 2 supervisors provided by the MaMoni HSS field

office in Lakshmipur.

The data collectors and supervisors were given a three-day training which included an

orientation in pharmaceutical management, training on the data collection tools, and practice

sessions in a neighboring district using the tools. Following the practice session, the data

collectors and supervisors provided feedback on the tools and discussed issues that they

encountered. The tools were slightly modified based on the feedback given by the data collectors

and supervisors.

The quantitative data collection for the assessment was conducted during August 24–31, 2014,

and SIAPS staff conducted in-depth interviews with facility managers from November 16–20,

2014.

Limitations of the Assessment A general limitation of the assessment was reporter and interviewer bias, as the respondents were

DGFP and DGHS officials who are responsible for logistics management and the survey was

conducted in MaMoni HSS project areas by MaMoni HSS staff. However, to minimize

interviewer bias, the interviewers were not allowed to collect data in their own working area and

were assigned to other upazilas.

Weak record keeping and management information systems also limited the quality of data, level

of details, and verification of data. Also, on the day of data collection, some data were not

readily available and due to time constraints and availability of key personnel and efforts were

made to follow-up with the respondents.

9

RESULTS

This section is organized first by pharmaceutical management practices in facilities in each

directorate followed by the availability of RMNCH commodities in the district, across all

facilities. The pharmaceutical management practices for each directorate are presented beginning

with sources of medicines, local procurement practices including forecasting, supply and

distribution, LMIS, and inventory management and storage.

The availability data is organized slightly different. It is presented first based on commodity

type—family planning, maternal health, newborn health, and child health—and organized by

directorate.

Pharmaceutical Management Practices in DGFP Sources of Medicines

Among the DGFP sites, only the MCWC conducts local procurement. At the time of the

assessment, the only medicine that could be and was locally procured by the MCWC was

oxytocin. Of the total amount of oxytocin received, 33% was from local procurement and 68%

was from donations from United Nations Population Fund. Besides iron folate and oral

amoxicillin, no other maternal or newborn health medicines were received from the UFPS and

no child health medicines were requested, received, or locally procured by the MCWC. Finally,

all family planning commodities were received from the UFPS.

Local Procurement Practices

The MCWC has an operating procurement committee specifically responsible for managing the

local procurement process. The respondent at the MCWC indicated that they have received

training on local procurement and the procurement committee is responsible for drug selection,

quantification/ forecasting of needs, determining procurement quantity, preparing tender

documents, supplier selection (evaluating bids and final selection), and approval of specifications

(product description, packaging and labeling, and quality assurance standards).

While there are no district level operational guidelines on local procurement, the respondent

indicated that the procurement committee refers to the 2006 Public Procurement Rules (PPR)

and the 2008 Public Procurement Act (PPA) for guidance on conducting local procurement of

medicines (table 4).



10

Table 4. Local Procurement Practices at Lakshmipur Mother and Child Welfare Center

Mother and Child Welfare Center (MCWC, DGFP)

District-level guidelines/standard operating procedures (SOPs) for local procurement of medicines available

No

Refer to 2006 PPR and the 2008 PPA for guidance on local procurement of medicines

Yes

Functioning procurement committee exists

Procurement committee is responsible for all aspects of local procurement according to Good Procurement Practices from MDS-3

a

At least one procurement committee member has received training of procurement of medicines

Evidence-based forecasting of medicines No

a. Drug selection, quantification/ forecasting of needs, determining procurement quantity, preparing tender documents, supplier selection (evaluating bids and final selection), and approval of specifications (product description, packaging and labeling and quality assurance standards)

xxiv

Forecasting Medicine Needs

The Lakshmipur assessment sought to understand what, if any, forecasting methods are used at

the lower levels of the health system. The assessment found that little or no forecasting of

medicine needs is done at the district and sub-district levels and none is done at the DGFP sites.

This is due mostly to the fact that commodities are pushed from the central level to the facilities.

Additionally, because the LMIS within DGFP is established at all levels of the system, facilities

managers fill out the LMIS reports instead of forecasting medicine needs. The LMIS reports

inform the central level of the quantities of medicines that should be sent to the facilities.

Supply and Distribution

DGFP has a well-structured four-tier management system which starts at the central warehouse

and ends at the service delivery point (SDP). The central warehouse is responsible for supplying

commodities to the regional warehouse and they in turn are responsible for supplying the UFPS.

The UFPS then supply the SDP level. This process is well documented in the DGFP Supply

Manual,xxv

which also includes guidelines for all aspects of logistics planning including duties

and responsibilities of staff, storage, commodity supply, record keeping (i.e., maximum-

minimum stock levels, push and pull method, determining supply quantity), record keeping and

report preparation, management of unusable commodities, monitoring and supervision, and

electronic LMIS.

The UFPS supplies medicines to the MCWC and FWCs. Supply and distribution plans are

developed using the upazila inventory management system and guidelines are provided in the

DGFP Supply Manual. Data on consumption and stock on hand are put into the upazila inventory

system and a minimum-maximum stock level policy is used to determine quantities of medicines

and supplies to be sent to facilities. Commodities and supplies are received by the regional

warehouse and distributed to the service delivery points every month. None of the respondents

indicated any challenges related to the distribution of commodities.

Results

11

Logistics Management Information System

DGFP has a well-established LMIS implemented at all levels of the health system.xxvi

The LMIS

in DGFP is a combination of manual and electronic reporting and is implemented at all levels of

the system. Manual reporting is done at the union and community levels while electronic

reporting is done until the upazila level. Figure 2 illustrates the reporting structure and flow of

logistics information in DGFP taken from the DGFP Supply Manual.

The assessment specifically sought to identify any challenges or feedback on the system. Despite

commodities not being 100% available at all DGFP sites, none of the respondents at DGFP sites

indicated having challenges or issues related to LMIS.

Figure 2. DGFP logistics management information flow chart (taken from DGFP Supply Manual)xxvii



12

Inventory Management and Storage

The assessment examined inventory management and storage conditions at the upazila stores and

service delivery points. The inventory management system of DGFP is being implemented

according to the DGFP Supply Manual. For example, the MCWC did not indicate having

guidelines and only one FWC-FWA and two FWC-SACMOS indicated having guidelines for

inventory management.

Among the sites, the regional warehouse, DFPO, and MCWC indicated having trained staff

responsible for inventory management; however, only one UHC-FP, 10% of FWC-FWAs (n =

20) and 25% of FWC-SACMOs (n =16) indicated having trained staff in inventory management.

While the majority of the sites visited at the district, upazila, and union levels know when they

will be receiving new stock, at the community level only 50% of FWAs and none of the FWA-

SBAs are aware of when they will receive new stock. Almost all sites indicated visually

inspecting products upon arrival.

Direct observation of storage conditions at the storage facilities and service delivery points found

that neither the regional warehouse nor the DFPO had storage layout plans. In fact, only the

UHC-FP sites had storage layout plans with allocated space in the storeroom. In regards to good

storage conditions, it was observed that while the DFPO follows most of the good storage

practices, the regional warehouse only followed some. For example, while products were stored

in secure locations and protected from sun, water and moisture; products were not arranged so

that the labels and expiration dates are visible or according to first expiry, first out procedures.

Among the service delivery points, the majority of the UHC-FPs, FWC-FWAs and FWC-

SACMOs maintained good storage conditions. Challenges were found mostly at the community

level. Only 30% of FWAs and 14% of FWA-SBAs were storing products protected from the sun.

In regards to cold chain storage for oxytocin, neither the MCWC nor UHC-FP sites were storing

the medicine in cold chain because they do not have operational refrigerators. Table 5 indicates

the percent of service delivery points that were maintaining good storage conditions.

Table 5. Inventory Management and Storage Practices at DGFP Service Delivery Points

Good Storage Conditions MCWC UHC-FP FWC-FWA FWC-SACMO FWA FWA-SBA

N 2 4 20 16 20 14

Secure storage location 1; 50% 3; 75% 8; 40% 9; 56% 5; 25% 1; 7%

Ceiling/exhaust fan present 1; 50% 3; 75% 5; 25% 4; 25% NAa

NA

Products arranged so that the identification labels and expiration or manufacture dates are visible

0; 0% 2; 50% 20; 100% 13; 81% NA NA

First expiry, first out procedures observed

1; 50% 4; 100% 18; 90% 14; 88% NA NA

Boxes in good condition 1; 50% 4; 100% 20; 100% 13; 81% 18; 90% 4; 29%

Products protected from water and moisture

1; 50% 4; 100% 20; 100% 13; 81% 13; 65% 3; 21%

Products protected from sun 1; 50% 2; 50% 12; 60% 5; 31% 6; 30% 2; 14%

a. NA is not applicable

Results

13

Pharmaceutical Management Practices in DGHS

Sources of Medicines

Among the tracer RMNCH medicines, only oxytocin is being locally procured by the CSO while

all other medicines and supplies are procured by CMSD and supplied by either CMSD or EDCL.

Table 5 shows the breakdown of the sources of MNCH medicines at the CSO/DRS.

For maternal health commodities, local procurement accounts for 68% of the total amounts of

oxytocin supplied to the CSO/DRS during the last fiscal year (June 2014–July 2015) with CMSD

supplying the rest. The rest of the medicines, although procured by CMSD on behalf of the CSO,

are supplied by EDCL and go directly to the CSO/DRS. In Lakshmipur, newborn resuscitation

supplies are procured by nongovernmental organizations, such as Save the Children, as part of

the Helping Babies Breathe project. Therefore, they are not expected to be ordered or supplied

by the CSO/DRS.

While vitamin A is supplied through Expanded Program on Immunization, the CSO/DRS did not

request or receive any other child health commodities. Upon follow-up with CMSD, it was found

that amoxicillin DTs were not purchased by the government this year because the price was too

high because of the limited number of local manufacturers. UNICEF purchased the medicine but

none was distributed to Lakshmipur district. Currently, the country is in the process of phasing

out amoxicillin 250 mg capsules and introducing amoxicillin DTs; however, the implementation

is at various stages throughout the country. ORS and zinc sulfate were not requested or supplied

to the CSO/DRS.

Table 6. Medicines Supplied by the Central Level versus Acquired through Local Procurement by the CSO/DRS

Central Level Local Procurement, % CMSD, % EDCL, %

Maternal Health Calcium 5 95 0

Iron folate 100 0 0

Oxytocin 32 0 68

Newborn Health Gentamicin 0 100 0

Oral amoxicillin 0 100 0

Dexamethasone 0 100 0

Child Health *No child health commodities were requested by or supplied to (via central level or local procurement) to the CSO/DRS.

Local Procurement Practices

Within DGHS, only the CSO is responsible for locally procuring medicines. Similar to the

finding at DGFP’s MCWC, the CSO indicated that while they refer to the 2006 PPR and the



14

2008 PPA for guidance on conducting local procurement of medicines, district level guidelines

do not exist for local procurement procedures. As such, the CSO indicated having operating

procurement committees responsible for managing the local procurement process ranging from

drug selection and quantification/forecasting of needs to supplier selection and approval of

specifications. The CSO, however, indicated that he has not been trained in local procurement

practices and has learned this on the job. Table 7 summarizes the findings from Lakshmipur

related to local procurement for DGFP.

Table 7. Local Procurement Practices at Lakshmipur Civil Surgeon’s Office

Civil Surgeon’s Office (CSO, DGHS)

District-level guidelines/SOPs for local procurement of medicines available

No

Refer to 2006 PPR and the 2008 PPA for guidance on local procurement of medicines

Yes

Functioning procurement committee exists Yes

Procurement committee is responsible for all aspects of local procurement according to Good Procurement Practices from MDS-3

a

Yes

At least one procurement committee member has received training of procurement of medicines

No

Evidence-based forecasting of medicines No

a. Drug selection, quantification/ forecasting of needs, determining procurement quantity, preparing tender documents, supplier selection (evaluating bids and final selection), and approval of specifications (product description, packaging and labeling and quality assurance standards)

xxviii

Forecasting Medicine Needs

Within DGHS, the CSO collects medicine demands/ requisitions from the health facilities it

supplies—UHCs, USCs, and District Hospital (DH). These demands are consolidated and

adjusted for stock on hand and sent as a requisition to CMSD. The DH medicine requests are

based on the previous distribution and requests from hospital wards. The DH storekeeper also

indicated that while stock on hand is not considered when making medicine requests,

buffer/safety stock is maintained. When there is a stock-out, the storekeeper requests that the

DRS supply the medicine. Demand requests from the UHC and USC is based on the average

consumption from the previous quarter; the UHC further adjusts this by 10%. The store keeper at

one UHC indicated that there is provision to adjust for stock-outs. There is no forecasting done at

the community clinics as they only receive two community clinic kits per quarter via a push

system.

Supply and Distribution

Supply and distribution of medicines at the district level is done by the DRS and UHC-HS for the

DGHS sites. The DRS supplies medicines to the UHC, USC, and DH, and the UHC supplies

community clinic kits to the CC-CHCPs. Procurement is done by CMSD on behalf of the CSO;

however, local procurement is also done by the CSO. CMSD supplies the CSO and District Reserve

Results

15

Store (DRS) which then supplies the health facilities such as the district hospital, UHC, and USC.

Flow of CC kits is different; procurement is done directly by the Director of the CC Program and

EDCL distributes the kits to the UHC which then supplies them quarterly to the clinics.

The assessment found that no distribution plans are developed; medicines are supplied quarterly

and when needed. There are no SOPs or guidelines for distribution nor are their guidelines or

provisions in place to redistribute between facilities or place emergency orders to avoid stock-outs.

Logistics Management Information System

While there is currently no LMIS in place within DGHS, medicine information flows were

identified that specifically relate to requisitions and orders. Figure 3 illustrates both the current

medicine flow and information flows at all levels of the system. Quarterly medicine requisitions

are submitted to the CSO by the district hospital, UHCs, and USCs. The medicine requisitions

are aggregated by the Civil Surgeon and submitted to CMSD. Additionally, “demand forms” are

completed and submitted to the UHC on a quarterly basis by the community clinics to receive the

CC kits (figure 3).

Figure 3. Current DGHS medicines and information flow4,5

4 In general, UHCs supply USCs with health commodities however, in Lakshmipur, due to the lack of space in the

store at the UHC, commodities are supplied to the USC directly by the DRS. To keep with the general practice and

procedures, USCs still send a copy of requisitions and receipt vouchers to the UHC.



16

Ordering Medicines

Community Clinics are the only facilities that receive CC kits directly from the UHCs. The

“demand forms” further serve as receipts, indicating how many kits were received. While there is

no written policy outlining how many kits each community clinic should receive, Community

Clinic project staff reported that, in practice, the clinics usually receive two kits per quarter. The

medicine requisitions are completed quarterly by the USCs, UHCs, and district hospitals and are

submitted to the CSO.

The assessment found that not only are there no guidelines on how to determine medicine

requisitions but also there is no standardization in the forms as they are handwritten. All sites

indicated that they used the average monthly consumption of the previous quarter or last three

months and stock on hand to determine requisitions. None of the respondents indicated receiving

any formal training; however, some noted that the CSO showed them how to fill out the form.

All the USCs had the same medicine requisition forms except for one USC that added an

additional column for last quarter’s average consumption. Emergency orders are also submitted

to the DRS using the same form but indicating “emergency” on the form. At the district hospital,

the wards submit handwritten medicine request or demand forms to the pharmacy whenever they

need medicine.

At the CSO/DRS level, the medicine requisitions are consolidated taking into consideration the

budgets allocated to the facilities and sent to CMSD annually. The same form is used to also

submit annual orders to local suppliers (through local procurement) and quarterly orders to

EDCL.

Receiving Medicines

At the community level, the CHCP goes directly to the UHC to pick up the kits. The demand

form mentioned above is also used as the receipt for the kits. Unfortunately, the CHCP visited

indicated that she does not know how to fill out this form and was never trained to do so. Once

the kits are received and opened, the medicines are managed through the stock registers. The

CHCP suggested that it would be better to itemize the medicines to see which ones are needed

more because some medicines are used more than others.

At all other sites, the medicine requisition form is further used are a receipt/issues voucher for

when medicines are received as well. The supply column on the form is completed and signed by

the CSO. Copies are maintained at the CSO and the recipient facility. In Lakshmipur, the

medicines are supposed to flow to the USCs via the UHC; however, because of the lack of

storage space and transportation at the UHCs, the DRS directly supplies the USC. Therefore,

copies of the form are maintained by the CSO, USC, and the UHC.

While no LMIS reports are completed, one USC indicated that they fill out a monthly form for

services statistics and send to the Upazila Health and Family Planning Officer (UH&FPO) who

manages the UHC. The storekeeper at the district hospital indicated preparing and sending

medicine stock reports related to disaster preparedness and management to the MIS Unit of

5 Note that the district hospital and UHC departments also send weekly requisitions to the respective facility store.

Results

17

DGHS and commodity specific monthly reports for the rabies vaccine to the Institute of

Epidemiology, Disease Control, and Research. Additionally, the district hospital wards use the

same form to request medicines and as receipts; a copy is maintained in the wards.

When medicines are received by the DRS, three receipts are made based on the supplier (local

supplier, CMSD, or EDCL) and the issue voucher is signed by both the DRS storekeeper and the

supplier.

Stock Management

All sites indicated having stock registers to manage medicines stock, however, only the CC

visited indicated having standard guidelines on stock management and guidelines on how to fill

out the stock registers and one UHC indicated having inventory management guidelines from the

Director of Primary Health Care who oversees UHC, USC, and CC activities. While the USCs

do not have guidelines for stock management, the respondents did indicate receiving an

orientation in stock management.

At the CCs, two registers are maintained for stock management; one is for the total number of

community clinic kits received and the other is to manage the individual medicines in the kits.

CHCPs also manage a services register which is used to consolidate medicine stock information

into the medicines stock register. The CSO/DRS indicated managing a total of seven stock

registers based on the type of commodity or medicine (e.g., tab, cap, syrup).

Bin cards were only found to be maintained at UHCs, district hospital, and at the DRS. At the

UHC, the bin cards and issue vouchers for medicines issued to UHC wards are handwritten and

at the district hospital and CSO/DRS they are made on the computer and printed.

Finally, none of the respondents indicated having guidelines on how to manage expired or

damaged products or having any standard reports or forms for unusable products. The UHCs did

indicate, however, that if they receive such products, an official letter is sent to the CSO.

Although a circular for condemnation of medical and surgical requisites (includes medicines)

and linen items was sent to all facilities in February 2010, none of the respondents were aware of

the circular. Interestingly, around the time of data collection, the Procurement and Logistics

Management Cell (PLMC) had also requested all UHCs to send a report on expired products;

however, there was no standard format for this report and it is unknown if this will be a regular

report that is to be submitted to the PLMC. None of the sites indicated reporting on adverse drug

reactions.

Supplying Medicines

Within the DGHS structure, only the DRS and UHC are responsible for supplying medicines to

other health facilities, and the UHCs and the district hospital supply medicines internally to the

different wards in their respective facility. The UHC only supplies community clinic kits to the

CHCP; only an issue voucher or “demand form” is used to document how many kits have been

supplied and these are handwritten. Similarly, handwritten issue vouchers are also used by both

the UHCs and district hospital when supplying medicines to the facility wards.



18

The DRS indicated using the requisition forms as issue vouchers when supplying medicines with

the addition of filling out the “quantity supplied” column for each facility. A copy of this is kept

with the DRS, the UHC (for supplying to USCs), and the recipient facility. These forms are not

standardized and handwritten; no other forms or reports are filled out when supplying medicines.

All respondents indicated that having standardized forms, registers, and reports would be very

helpful as they will not have to write up the forms every time they are needed. Additionally,

having refresher trainings in inventory management and distribution and standard guidelines was

also suggested by most of the respondents.

Storage Conditions

Unlike DGFP, DGHS does not have standardized guidelines and SOPs for inventory

management and handling of products. While the DRS, two UHCs, and two CCs indicated

having designated and trained staff specifically for inventory management, the majority of the

sites did not.

The district hospital and the majority of the service delivery points indicated that they are usually

aware when they will be receiving new stock, but the DRS said that they generally do not know

when they will be receiving stock. Most sites are also not visually inspecting stock upon arrival

such as the DRS, 75% of the UHCs, and 50% of USCs.

The majority of DGHS sites are maintaining proper storage conditions. It was observed that the

DRS, district hospital, and most of the UHCs and USCs are maintaining most of the

recommended good storage conditions. At the community level, however, recommended storage

conditions are not being maintained. For example, only 55% of CCs were storing the products in

a secure location and one HA-SBA had products protected from water and. Only one UHC is

maintaining cold chain storage of oxytocin; the DRS, district hospitals, and all other sites do not

have an operational refrigerators.

Table 8 summarizes the percent of DGHS sites maintaining recommended storage conditions.

Table 8. Inventory Management and Storage Practices at DGHS Storage Facilities and Service Delivery Points

Good Storage Conditions DRS DH UHC-HS USC-SACMO

CC HA-SBA

n 1 1 4 4 20 6

(Y/N) a (Number and percentage)

Secure storage location Y N 3; 75% 2; 50% 11; 55% 1; 17%

Ceiling/ exhaust fan present Y Y 4; 100% 2; 50% NA NA

Products arranged so that the identification labels and expiration or manufacture dates are visible

Y Y 4; 100% 4; 100% 0; 0% NA

First expiry, first out procedures observed Y Y 4; 100% 4; 100% 0; 0% NA

Results

19

Good Storage Conditions DRS DH UHC-HS USC-SACMO

CC HA-SBA

Boxes in good condition Y Y 3; 75% 3; 75% 16; 80% 1; 17%

Products protected from water and moisture Y N 3; 75% 3; 75% 18; 90% 1; 17%

Products protected from sun Y Y 3; 75% 1; 25% 8; 40% 0; 0%

a. Y = yes, N = no.

Availability of RMNCH Commodities RMNCH commodities availability was assessed in two ways: (1) comparing which commodities

are actually managed at health facilities to what is theoretically supposed to be managed (i.e.,

according to national guidelines and strategies), and (2) assessing availability on the day of the

visit and within the last six months of the assessment among sites that were managing RMNCH

commodities.

Theoretical management of RMNCH commodities was determined by reviewing the 2011–2016

HPNSDP, the Maternal and Newborn Health draft strategy, and through discussions with various

officials from MOHFW, DGHS, and DGFP. A major challenge is that there is no consolidated

document or standard treatment guideline that clearly indicates where RMNCH commodities

should be available at each level of the health system and who should be managing these

commodities.

Family Planning

Family planning commodities should only be available at DGFP sites. A commodity was

considered to be managed by the site if the site had a stock register or bin card available for that

commodity. The assessment found that family planning commodities are mostly managed and

available at both the storage sites and service delivery points that are supposed to be managing

them.

The regional warehouse and UHC-FP are responsible for managing all six of the tracer family

planning commodities because they are the upper level supply source to their corresponding

service delivery points. Table 9 indicates at which service delivery points the six tracer family

planning commodities should be available (theoretical) and where they were actually being

managed (actual).

None of the FWC-SACMO indicated managing any of the family planning commodities because

there are designated FWVs’ posted in the FWC who are supposed to distribute all the

contraceptives to the clients. But, if there is no FWV posted at the FWC, the SACMO can play

the role of the FWV to distribute pills and condoms only. While the majority of the facilities at

each level indicated managing family planning commodities, only 5 of the 14 SBA-FWAs were

managing stock of condoms and pills. Five SBA-FWAs were also managing Depo-Provera.

Implants were found to be managed according to what is expected; the majority of the UHC-FP

stores had both types of implants (75%, 3/4). Only one FWC-FWV indicated managing both

types of implants which should only be managed by trained physicians.



20

Table 9. DGFP Service Delivery Points Managing Family Planning Commodities that are Supposed to be Managing It (%)

Tracer Medicine MCWC (n = 1)

UHC-FP (n = 4)

FWC-FWV (n = 20)

FWC-SACMO (n = 16)

FWA (n = 20)

SBA-FWAb

(n = 14)

Condoms

Theoretical Ya Y Y N

a Y Y

Actual Y Y 95% (19/20) N Y 36% (5/14)

Pills

Theoretical Y Y Y N Y Y

Actual Y Y 90% (18/20) N Y 36% (5/14)

Depo-Proverab

Theoretical Y Y Y N Y N*

Actual Y Y Y N Y 36% (5/14)

IUDs

Theoretical Y Y Y N N N

Actual Y Y 90% (18/20) N N N

Implants (Jadelle)

Theoretical Y Y N N N N

Actual Y 75% (3/4) 5% (1/20) N N N

Implants (Implanon)


Actual Y 75% (3/4) 5% (1/20) N N N

a Y = yes, N = no. b -SBA-FWAs should only be managing Depo-Provera if they have been specially trained.

Almost 100% of family planning commodities were found to be available at all sites that are

supposed to be managing the commodity. IUDs were found to be 100% available both on the day

of the visit and throughout the past six months at all sites that were managing it. Implants, both

Jadelle and Implanon, were also 100% available on the day of the visit at the regional warehouse,

MCWC, and FWC-FWVs; however, the RW did experience a stock out of Jadelle implants for a

total of 30 days within the last 6 months. Additionally, two of the three UHC-FPs managing

implants had both types available on the day of the visit. Surprisingly, one FWC-FWV (n = 20)

indicated managing both Jadelle and Implanon implants; these were available both on the day of

the visit and throughout the past six months.

Maternal Health

DGFP

Among the maternal health medicines, magnesium sulfate, iron folate, and calcium should be

managed and available at and above the union level (MCWC, UHC-FP, and FWCs). Oxytocin

should only be managed at the MCWCs at the district level, and misoprostol should only be

managed at the UHC-FP and community level by FWAs and SBA-FWAs.

However, while the assessment found that oxytocin was being managed at the MCWC, a small

number of FWC-FWVs (3/20) were also handling the medicine. Availability and management,

Results

21

particularly of iron folate and calcium, were low. Most of the sites that are supposed to be

handling these medicines were in fact not managing them or were found to be managing other

formulations of the product. The Deputy Director of FP in Lakshmipur indicated that calcium is

not supplied by the central level nor is it included in the Bangladesh drug and dietary supplement

(DDS) kits. This would explain the limited availability across DGFP sites. Additionally, because

calcium is not considered a “life-saving” medicine, it is not locally procured by the MCWC.

Overall, the majority of the sites managing maternal health medicines had the medicine available

on the day of the visit. Table 10 indicates the management and availability of maternal health

medicines on the day of the visit at DGFP service delivery points. Also, the majority of the sites

handling maternal health medicines did not experience stock-outs within the last six months of

the assessment. For example, all 3 FWC-FWVs managing oxytocin did not experience stock-outs

and all 18 FWC-FWVs that indicated managing misoprostol had it available throughout the last

six months (annex A1).

Table 10. Management and Availability on the Day of the Visit of Maternal Health Medicines at DGFP Sites

Tracer Medicine MCWC (n =1 )

UHC (n = 4)

FWC-FWV (n = 20)

FWC-SACMO (n = 16)

FWA (n = 20)

SBA-FWA (n = 14)

Oxytocin

Theoretical Y N Y N N N

Actual Y N 15% (3/20) N N N

Availability Y N Y N N N

Misoprostol

Theoretical N Y N N Y Y

Actual N 75% (3/4)

90% (18/20) N 90% (18/20) 57% (8/14)

Availability N 67% (2/3)

89% (16/18) N 94% (17/18) Y

Magnesium sulfate

In Lakshmipur, magnesium sulfate has not been rolled out for the prevention of PE/E as it is still being piloted. However, according to the HPNSDP, once it is rolled out, it should be managed and available at the MCWC, UHC-FP, and FWCs.

Iron folateb

Theoretical Y Y Y Y N N

Actual N Y N* 19% (3/16)* N N

Availability Y Y N* 67% (2/3) N N

Calcium*

Theoretical Y Y Y Y N N

Actual N 25% (1/4)

N N N N

Availability N N N N N N a Y = yes, N = no. b. For iron folate, other formulations were indicated to be managed such as 200 mg + 0.2 mg. At the FWC-FWV and FWC-SACMO, 95% and 75% of the sites indicated managing other formulations; of these, 89% and 83% had it available on the day of the visit, respectively.



22

DGHS Within DGHS, oxytocin and magnesium sulfate should only be managed and available at the

district and upazila levels with iron folate and calcium being available at all levels except by

SBAs. Misoprostol is not currently being rolled out in DGHS and therefore should not be

available at any DGHS sites.

While maternal health medicines were mostly found to be managed at the sites that were

expected to manage them, one SBA-HA indicated managing oxytocin, one USC indicated

managing magnesium sulfate, and only 50% of the UHCs indicated managing oxytocin and

magnesium sulfate—two life-saving medicines for PPH and PE/E. Similar to some DGFP sites,

various formulations of iron folate and calcium were also found to be managed at all levels.

For sites managing maternal health medicines, medicines available on the day of the visit ranged

from 50% to 100% (table 11). Among the maternal health medicines being managed at DGHS

sites, magnesium sulfate was least available at sites throughout the past six months. For example,

the CSO/DRS, DHs, and the one USC-SACMO that indicated managing the medicines

experienced periods of stock-out ranging from 15 to 30 days in the past six months (annex A2).

Table 11. Management and Availability of Maternal Health Medicines on the Day of the Visit to DGHS Service Delivery Points

Tracer Medicine DH (n = 1)

UHC-HS (n = 4)

USC-SACMO (n = 4)

CC-CHCP (n = 20)

SBA-HA (n = 6)

Oxytocin

Theoretical Y Y N N N

Actual Y 50% (2/4) N N 17% (1/6)

Availability Y Y N N Y

Misoprostol

Theoretical N N N N N

Actual N N N N N

Availability N N N N N

Magnesium sulfate


Actual Y 50% (2/4) 25% (1/4) N N

Availability Y Y Y N N

Iron folate

Theoretical Y Y Y Y N

Actual Y 50% (2/4)* 50% (2/4) 30% (6/20) N

Availability Y Y 50% (1/2) 83% (5/6) N

Calcium


Actual Y 75% (3/4)* 25%, (1/4) N* N

Availability N* Y Y N* N a Y = yes, N = no. *Other formulations of iron folate and calcium were found to be managed at these sites.

Results

23

Newborn Health

DGFP

All tracer newborn health commodities are supposed to be managed at MCWC and UHC-FP

sites, and only the newborn resuscitation equipment should be managed by trained SBA-FWAs

at the community level. At the FWCs, the SACMO should be managing only oral amoxicillin

since DDS kits do not contain gentamicin or dexamethasone, and the FWV manages the

newborn resuscitation equipment. The assessment found that no newborn health medicines and

supplies were being managed at the MCWC or UHC-FPs.

For oral amoxicillin, it was found that 65% of the FWC-FWVs and 81% of the FWC-SACMOs

indicated managing oral amoxicillin with 30% and 6% indicating managing other formulations

of the medicine. Among these sites, oral amoxicillin was found to be mostly available with 83%

to 100% of the sites having the medicine available on the day of the visit. No other DGFP sites

were found to be managing oral amoxicillin. Only one SBA-FWA visited was managing

newborn resuscitation equipment at the community level (table 12).

Table 12. Management of Newborn Health Medicines at DGFP Service Delivery Points

Tracer Medicine MCWC (n = 1)

UHC-FP/UFPS (n = 4)

FWC-FWV (n = 20)

FWC-SACMO (n = 16)

FWA (n = 20)

SBA-FWA

(n = 14)

Gentamicin

Theoretical Ya Y N N N N

Actual Na N N N N

Oral amoxicillin

Theoretical Y Y N Y N N

Actual N N 65% (n = 13)

b

81% (n = 13)

b

N

Dexamethasone


Actual N N N N N

Bulb sucker

Theoretical Y Y Y N N Y

Actual N N N N N 7% (n = 1)

Bag


Actual N N N N N N

Mask, infant


Actual N N N N N 7% (n = 1)

a. Y = yes, N = no. b. 30% and 6% of the FWC FWVs and SACMOs, respectively, also managed other formulations of oral amoxicillin.



24

DGHS

All newborn health commodities, except dexamethasone, should be available at and above the

upazila level. Gentamicin should be available until the union level and oral amoxicillin available

until the community level at the community clinics. SBA-HAs should not be managing any of

the tracer newborn health medicines.

The CSO/DRS is expected to manage all of the newborn health commodities; however, the

assessment found that the Lakshmipur CSO/DRS was managing only oral amoxicillin which was

available on the day of the visit.

Newborn health commodities were often found to be managed at sites that are not authorized

to manage these medicines, especially among the UHCs and USCs. The district hospital had all

the newborn health commodities available on the day of the visit, but they were not managing

the newborn resuscitation equipment. Among the UHCs, 50% indicated managing gentamicin

and oral amoxicillin, but only one UHC indicated managing newborn resuscitation supplies.

Among the UHCs that indicated managing the newborn health medicines, only 25% to 50% of

them had gentamicin and oral amoxicillin available on the day of the visit. One UHC did not

have gentamicin and oral amoxicillin on the visit day as they were experiencing a stock-out; at

the time of the assessment, the sites indicated having a stock-out of gentamicin and oral

amoxicillin for 27 and 4 days respectively. Also, 40% (n = 6) of the 15 CC-CHCPs that are

managing oral amoxicillin experienced stock-outs of the medicine within the past 6 months for

an average of 9 days total. One UHC also indicated managing dexamethasone, which should be

managed only at district hospitals.

Finally, while SBA-HAs are not supposed to be managing any newborn health medicines, one

SBA-HA indicated managing gentamicin, oral amoxicillin, and dexamethasone; and two

indicated managing newborn resuscitation equipment (table 13).

Table 13. Management and Availability on the Day of the Visit of Newborn Health Medicines at DGHS Service Delivery Points

Tracer Medicine

DH (n = 1)

UHC-HS (n = 4)

USC-SACMO (n = 4)

CC-CHCP (n = 20)

SBA-HA (n = 6)

Gentamicin

Theoretical Y Y Y N N

Actual Y 50% (2/4) 25% (1/4) N 17% (1/6)

Availability Y 50% (1/2) Y N Y

Oral amoxicillin


Actual Y 50% (2/4) 50% (2/4) 75% (15/20) 17% (1/6)

Availability Y 50% (1/2) 50% (1/2) 75% (13/15) Y

Dexamethasone

Theoretical Y N N N N

Actual Y 25% (1/4) N N 17% (1/6)

Availability Y Y N N Y

Results

25

Tracer Medicine

DH (n = 1)

UHC-HS (n = 4)

USC-SACMO (n = 4)

CC-CHCP (n = 20)

SBA-HA (n = 6)

Newborn resuscitation


Actual N 25% (1/4) N N 33% (2/6)

Availability N N N N Y a. Y = yes, N = no.

Child Health

DGFP

Among the child health tracer medicines, ORS, zinc sulfate and amoxicillin DT are supposed to

be managed at the district, upazila, and union levels by all DGFP sites. At the community level,

only ORS is supposed to be managed by the FWAs and SBA-FWAs.

The assessment found that none of the child health tracer medicines are being managed in any of

the DGFP sites. However, the MCWC, 45% of the FWC-FWVs, and 69% of the FWC-SACMOs

indicated managing other formulations of amoxicillin used for child health.. Among these sites,

amoxicillin was available at 73% to 100% of the sites on the day of the visit. Additionally, only

three FWC-SACMOs indicated having a stock-out in the past six months for an average of seven

days.

DGHS

DGHS sites are responsible for ensuring the availability of all of the child health medicines at the

district, upazila, and union levels (DH, UHC, and USC sites). At the community clinics and

among SBAs, only ORS is expected to be managed. As such, the CSO/DRS are also expected to

manage all of the child health commodities. The assessment found that while most of the child

health commodities are being managed at the district level, the CSO/DRS and DH were not

managing amoxicillin DTs or any other formulations of amoxicillin used for child health.

Additionally, very few of the DGHS sites were found to be managing zinc sulfate and

amoxicillin DTs. For example, while all UHCs were managing ORS, only half of the sites visited

were managing amoxicillin DT and one site was managing vitamin A.

Table 14 shows the child health medicines that are being managed and were available on the day

of the visit at DGHS service delivery points. Among those service delivery points, over 88% of

them had the medicine available on the day of the visit. However, both ORS and zinc sulfate

were not available on the day of the visit at the CSO/DRS as they had experienced a stock-out

that day. While 100% of the UHCs and USCs visited had each of the child health medicines

available on the day of the visit, one UHC experienced a stock-out of zinc sulfate for a total of 30

days within the last 6 months and one USC indicated having a stock out of amoxicillin DTs for 7

days within the last 6 months. Among the community clinics, 81% and 79% of sites that were

managing ORS and zinc sulfate, respectively, experienced stock-outs in the last 6 months for 6

days for each medicine.



26

Table 14. Management and Availability on the Day of the Visit of Child Health Medicines at DGHS Service Delivery Points

Tracer Medicine DH

(n = 1) UHC-HS (n = 4)

USC-SACMO (n = 4)

CC-CHCP (n = 20)

SBA-HA (n = 6)

ORS

Theoretical Ya Y Y Y Y

Actual Y Y 50% (2/4) 80% (16/20) N

Availability Y Y Y 94% (15/16)

Zinc Sulfate


Actual Na 25% (1/4) 25% (1/4) 70% (14/20) N

Availability N Y Y 93% (13/14)

Amoxicillin DTb


Actual N 50% (2/4) 25% (1/4) 10% (2/10) N

Availability N Y Y Y

Vitamin A

Theoretical Y Y

Actual N 25% (1/4) N 80% (16/20) 17% (1/6)

Availability N Y 88% (14/16) Y

a. Y = yes, N = no. b. Oral amoxicillin capsules 250 mg have been procured in the past for the CC kits and other facilities so the country is still in the process of phasing out the 250 capsules before providing DTs.

27

DISCUSSION

Ensuring continuous availability of RMNCH commodities requires a supply chain that is

responsive to the health needs of the population. To achieve this, efficient procurement, and

supply and distribution systems with strong LIMS to inform decisions that affect the availability

of medicines at service delivery points are required. In Bangladesh, district level facilities also

conduct local procurement of medicines to ensure continuous availability. In 2014, SIAPS

conducted an assessment on local procurement practices for three maternal health medicines in

three districts. Major findings of the assessment that affect access to maternal health medicines

included—

Lack of coordinating and sharing information between the central and subnational level

No standard evidence-based method for forecasting maternal health medicines at the

district level

No district-level guidance for quantification or local procurement of medicines

Insufficient training of the procurement committee members about quantification or

procurement

Procurement of medicines begins with evidence-based forecasting of medicine needs at each

level of the system. This informs the central level and health facility managers as to how much

medicine to procure and distribute to SDPs by providing data on consumption and availability of

essential medicines. Building the capacity of health facility managers to accurately forecast

medicine needs and requests and procure the needed quantities entails access to guidance

documents and procedures, and training customized for the local level. And, to ensure that this

information is conveyed, coordinated, and considered when making decisions at the central level,

a LMIS must be in place. DGFP has a well-functioning, institutionalized electronic LMIS system

for family planning commodities and is currently in the process of including some newborn and

maternal health commodities. However, DGHS has no such system to track the consumption and

availability of essential MNCH commodities.

The purpose of this assessment was to describe pharmaceutical management practices for

essential RMNCH medicines and supplies at all levels of the public health system in Lakshmipur

district to aid with developing interventions to improve availability and use of these

commodities. While touching upon local procurement practices, such as forecasting medicine

needs, this assessment went a step further and assessed the supply and distribution systems at the

lower levels, information flows related to pharmaceuticals, particularly at DGHS sites, and

availability of essential RMNCH commodities at the district and sub-district levels.

As noted in the subnational procurement assessment, health facilities are either not using any

evidence-based method for forecasting medicine needs or are not forecasting needs at all. At

DGFP sites, the reason for not forecasting medicine needs is due to the push system. DGHS sites

forecast medicine needs; however, the forecast is based on the previous quarter’s consumption



28

and sometimes adjusted by 10% when facilities submit quarterly requisitions to the CSO. Also,

no local level guidelines exist for both forecasting and local procurement of medicines. While

both DGFP and DGHS sites indicated referring to the 2006 PPR and 2008 PPA, there is no

standardized method used.

Medicines need to be distributed on time and efficiently to ensure continuous availability of

RMNCH medicines at service delivery points. SIAPS has been supporting DGFP in both

streamlining procurement processes at the central level and strengthening inventory management

practices and distribution systems with regional warehouses through the Warehouse Inventory

Management System. None of the DGFP sites indicated any issues in the supply and distribution

of RMNCH commodities and follow SOPs such as developing distribution plans that are

generated through warehouse inventory system. On the other hand, neither the CSO/DRS nor the

UHCs responsible for distributing RMNCH supplies to lower system levels within DGHS have

SOPs related to distribution or generate distribution plans. Some even indicated that medicines

are supplied to health facilities when needed. Developing SOPs and distribution plans for

distributing medicines could reduce delays in supplying facilities, preventing stock-outs of

medicines.

To inform decision making at the central and facility level, particularly for forecasting medicine

and distributing medicines to service delivery points, an LMIS that collects availability data is

needed. While the DGFP has a well-functioning electronic LMIS that provides data on

availability of family planning commodities, it does not include essential medicines for maternal,

newborn, and child health that DGFP health facilities are managing. DGHS, however, has no

such logistics management system and information related to pharmaceuticals is scattered,

unorganized and not standardized across DGHS sites. While medicine requisitions are submitted,

there are no standardized forms, operating procedures, or guidelines on how medicine requests

are calculated. In combination with poor forecasting methods, this can lead to stock-outs of

essential MNCH commodities as decisions made at the facility and central level would not take

into account realities at the local level.

There is no standard treatment guideline or RMNCH strategy that dictates where services and

medicines should be available at which levels of the system and who should manage them. This

leads to confusion as to where RMNCH medicines should be available and at which service

delivery points within DGFP and DGHS. Except for family planning commodities, the

assessment found that many SDPs were managing medicines that they are not supposed to be

managing or vice versa, affecting the availability of life-saving MNCH commodities. Moreover,

among the sites that were managing MNCH medicines, medicines were not always available.

29

RECOMMENDATIONS

This year will mark the end of the MDGs and while Bangladesh is on track for meeting these

goals for reducing maternal and child mortality, there is still a long way to go to achieve the

targets set by the new, more ambitious Sustainable Development Goals. By 2030, countries must

reduce neonatal mortality to at least 12 per 1,000 live births, child mortality to 25 per 1,000 live

births, and maternal mortality to less than 70 per 100,000 live births. Given the geographic

disparities within the country to access to life-saving RMNCH services, there needs to be

increased focus on ensuring the availability of RMNCH commodities at the district and sub-

district levels through systems strengthening approaches.

Therefore, the following actions are recommended.

Finalize and Disseminate Maternal and Newborn Health Standard Operating Procedures at all System Levels

Currently, the MNH standard operating procedures are in the final stages of approval. This

guideline not only includes the treatment guidelines for MNH but also clearly indicates which

medicines need to be managed at the different health system levels and facilities. While this is a

major step to ensure the right medicines are available when and where they are supposed to be, it

is only for maternal and newborn health. There needs to be one consolidated document that also

includes reproductive and child health commodities. This must be endorsed by all relevant

stakeholders including MOHFW, DGHS, and DGFP, and disseminated and rolled out nationally

at all levels to facility managers and health service providers.

Improve the Capacity of Staff Local Level Members to Manage Pharmaceutical Management Processes

The DGFP has a well-established supply manual that describes guidelines for all aspects of

logistics planning. However, at the service delivery points, use of the guidelines was limited,

particularly for forecasting and inventory management. The MCWC indicated not having the

guidelines and only one FWC-FWA and two FWC-SACMOS indicated having guidelines for

inventory management. Additionally, local procurement guidelines are not included in the DGFP

Supply Manual. Including district level guidelines or a checklist for best practices for local

procurement can enhance the capacity of staff responsible for conducting local procurement.

DGHS does not have institutionalized SOPs, guidelines, standardized forms, or inventory

management tools needed for managing storage, inventory, supply and delivery, and logistics

reporting as well local procurement. District level guidelines that are practical and easy to use are

essential to improving procurement practices. This was also a finding from the 2014 sub-national

procurement assessment. Since then, SIAPS has developed inventory management tools such as

bin cards, stock ledgers, issue vouchers, indenting and issue vouchers, and logistics reporting

forms, and is in the process of getting them endorsed by the MOHFW. Once endorsed, they will



30

be printed and disseminated to the health facilities and DGHS logistics personnel will be trained

throughout the country. Trainings, along with supportive supervision, will help improve

knowledge and skills to ensure best practices in logistics management.

For local procurement practices, while facility managers indicated referring to PPR 2008 and

PPA 2006 for guidance, it was found that many sites visited were not adhering to good

procurement practices. Based on the recommendations from the sub-national procurement

assessment, SIAPS is developing both local procurement guidelines and a curriculum for

managing local procurement processes that includes quantification. Trainings on these guidelines

will be piloted in 10 districts and then rolled out nationally.

Strengthen Pharmaceutical Information Systems to Provide Data needed for Robust Forecasting and Supply Planning

For DGFP, a well-established LMIS is in place that collects data on consumption and availability

of family planning commodities from all levels across the systems. This data has been

successfully used for forecasting and supply planning at the national level for family planning

commodities. There is a need to include essential maternal health and child health commodities

that are also managed at DGFP health facilities, such as oxytocin, misoprostol, amoxicillin DT,

and ORS. Information on the use and availability of these medicines needs to be captured and

visible at the national level to enhance decision making that can affect their availability.

Within DGHS, there is no LMIS system to collect logistics data to track the availability of

medicines at health facilities and stores. With SIAPS support, a technical working group for

setting up an LMIS in DGHS was formed and a module using the DHIS-2 platform was

developed to collect data on the availability of MNCH commodities at all systems’ levels. The

LMIS is currently being piloted on Gazipur and will be rolled out to 10 districts. This can serve

as a model that can be rolled out nationally by the MOHFW and DGHS.

Advocate for Inclusion of Amoxicillin DTs and ORS in DGFP and DGHS Procurement Plans

The findings from the assessment revealed that amoxicillin DT is not purchased under DGHS or

DGFP, and ORS was not available in DGFP facilities. The MOHFW needs to take an active lead

in ensuring that amoxicillin DT is included in the procurement plans of both DGFP and DGHS.

Also, if the DGFP continues the use of DDS kits, inclusion of amoxicillin DT and ORS in kits

could be considered as well as inclusion in DGHS CC kits. The MOH would need to be involved

in the revision process.

Recommendations

31

Provide Facilities with the Infrastructure Necessary to Maintain Cold Chain Storage Conditions for Oxytocin. Storage conditions continue to be a concern in Bangladesh as most of the facilities that manage

the medicine do not have operational refrigerators or other means to maintain the recommended

storage temperature. It is essential that health facilities have the proper infrastructure in place to

maintain cold chain storage to ensure the quality of the medicine.

Ensure that Magnesium Sulfate is Rolled Out Wherever Women Give Birth.

The standard management protocols on services at district and upazila levels have recommended

the use of magnesium sulfate. This has already been rolled out at district and upazila level

facilities of DGHS. There is a need for clarity at the UHCs, on the management and use of

magnesium sulfate as half of the facilities were not managing the medicine. DGFP district level

facilities also need to roll out the use of magnesium sulfate at MCWCs, while union level FWCs

can be an option for providing the loading dose and facilitate referral.

32

ANNEX A. AVAILABILITY OF MNCH COMMODITIES IN THE LAST SIX MONTHS

Table A1. Availability of Maternal Health Medicines among DGFP Service Delivery Points

MCWC (N = 1)

UHC-FP (N = 4)

FWC-FWV (N = 20)

FWC-SACMO (N = 16)

FWA (N = 20)

SBA-FWA (N = 14)

Oxytocin (# sites that had no recorded stock outs)

Indicated not managing the medicine


100%; 3/3 Indicated not managing the medicine



Average # days out of stock

NAa

NA NA NA NA NA

Misoprostol (# sites that had no recorded stock outs)


67%; 2/3 100%;18/18 Indicated not managing the medicine

94%; 17/18 88%; 7/8

Average # days out of stock

NA 2; N = 1 NA NA 25; N = 1 25; N = 1

Iron folate (60 mg + 0.4 mg) (# sites that had no recorded stock outs)





Average # days out of stock (n)

NA NA NA 16; N = 1 NA NA

Iron folate (other) (# sites that had no recorded stock outs)

0%; 0/1 100%; 1/1 89%;17/19 75%; 9/12 Indicated not managing the medicine


Average # days out of stock (n)

23; N = 1 NA 11; N = 2 6; N = 3 NA NA

a. NA is not applicable if the facility reported not managing the medicine or if the facility reported no stock outs of the medicine during the time of the visit.

Table A2. Availability of Maternal Health Medicines among DGHS Service Delivery Points

CSO/DRS N

= 1 DH

N = 1 UHC-HS

USC-SACMO CC-CHCP SBA-HA

Oxytocin (# sites that had no recorded stock outs)

100% 100% 100%; N = 2



100%; N = 1

Average # days stock out

NA NA NA NA NA NA

Magnesium sulfate (# sites that had no recorded stock outs)

0% 0% 50%; N = 2

0%, N = 1 Indicated not managing the medicine


Annex A

33

CSO/DRS N

= 1 DH

N = 1 UHC-HS

USC-SACMO CC-CHCP SBA-HA

average # days stock out

25 24 30 15 NA NA

Iron folate (60mg + 0.4mg) (# sites that had no recorded stock outs)


100% 100%; N = 2

50%; N = 2 67%; N= 6 Indicated not managing the medicine


NA NA NA 4 5 NA

Iron folate (other) (# sites that had no recorded stock outs)

0% Indicated not managing the medicine

100%; N = 2

100%; n = 1 60%; N = 10 Indicated not managing the medicine


12 NA NA NA 4 NA

Calcium (500 mg) (# sites that had no recorded stock outs)

0% Indicated not managing the medicine

67%; N = 3

100%; N = 1 Indicated not managing the medicine


Average # days stock out

25 NA 30 NA NA NA

Calcium (300 mg, 600 mg) (# sites that had no recorded stock outs)

100% 100% 100%; N = 2

0%; N = 1 53%; N = 15 Indicated not managing the medicine

average # days stock out (n)

NA NA NA 30 8 NA

a. NA is not applicable if the facility reported not managing the medicine or if the facility reported no stock outs of the medicine during the time of the visit.

34

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