Supply chain considerations

April 14, 2013 Johannesburg, South Africa Jacqueline Kungu (PhD)

www.micronutrient.org Solutions for hidden hunger

Objectives of presentation
1. To highlight the supply chain barriers to successful IFA supplementation 2. To present experiences from our programs about supply chain considerations we prioritise and focus on to ensure uninterrupted, timely, adequate and quality stocks of IFA

www.micronutrient.org Solutions for hidden hunger

Presentation outline
1. MI program theory of IFA supplementation programs
2. Supply chain barriers to IFA supplementation 3. Mitigation strategies countries 4. Key questions for discussion
www.micronutrient.org Solutions for hidden hunger

Program theory of IFA

May decrease risk of maternal mortality and obstetrical complications Increased iron stores Increased birth weight May decrease risk of perinatal mortality

Reduction in iron deficiency anemia in women

Coverage
Do intended recipients receive the IFA?

Utilization

monitoring

Delivery system
Accessibility to target group Capacity strengthening of health workers

Product and supply chain

Type of product Data based forecasting Timely ordering Distribution system Adequate budget

Demand
BCI to promote program Good quality supplements Mechanisms to improve utilization of complete course

Evaluation

Do intended recipients take the IFA?

What are the most important barriers to successful IFA supplementation

Demand side barriers are often considered main limiting factor:
Inadequate and untimely utilization of ANC Poor adherence to supplementation due to many factors including memory, side effects etc.

Supply side barriers may be equally or in some contexts more important:

www.micronutrient.org Solutions for hidden hunger

Supply side barriers

Do women who attend ANC receive IFA supplementation?
Of the 335 women who took iron supplement during the recent pregnancy the major reasons for non-adherence of stopping the drug were failure to get adequate supply for the health institutions (61.7%), occurrence of side effects (20%), forgetfulness (15%), and fear of side effects (1.3%) (Ethiopia formative assessment report, 2012)

www.micronutrient.org Solutions for hidden hunger

Supply side barriers

A. Policy issues: i. Missing or lack of clarity on preventive vs. therapeutic objectives of program - implications for formulations Lack of clarity in essential drug list on what to procure (single tablet, dose etc.) - and/or out of date policy that include products not in line with current international recommendations

ii.

iii. Budget allocation/commitment to implement IFA programs

www.micronutrient.org Solutions for hidden hunger

Supply side barriers

B. Procurement issues: i. Lack of clarity on roles and responsibilities related to procurement due to lack of coordination among departments and international organizations etc Diversity in countries as to roles and responsibilities for procurement Examples of procurement models that may be in operation: MODEL 1: donations of supplements and/or multiple organizations procuring where program is dependent on aid;
www.micronutrient.org Solutions for hidden hunger

ii.

Supply side barriers

MODEL 2: National level procurement has good control that product is procured according to specifications but would be highly dependent on information flow for forecasting and therefore, issues around adequate and/or excess supply may abound; MODEL 3: in some countries national budgets are allocated to states/districts who then they procure with likely better capacity to forecast based on more local level need but there may be issues with ensuring that they procure products according to national specifications and possibly, timely availability of budget if there are issues related to flow of funds.
www.micronutrient.org Solutions for hidden hunger

Supply side barriers

C. Forecasting and information flow issues: i. Common problem for all product based programs - even if forecasting at a national level is relatively accurate (eg. based on population size and yearly birth rate), there may be issues with ensuring that local level needs are accurately estimated e.g. In some Woredas supply was abundant and expiry was common while others had stockouts (Ethiopia formative assessment report, 2012)

www.micronutrient.org Solutions for hidden hunger

Supply side barriers

D. Distribution / Supply chain issues: i. The program should first respond to demand needs (e.g. community vs. facility based distribution) then the supply chain can be developed and managed to meet those needs There is often a lack of clarity for some on HOW supply chain actually works (even if in principle developed to respond to needs) the supply chain needs to be clearly mapped and roles and responsibilities clearly understood at all levels
www.micronutrient.org Solutions for hidden hunger

ii.

www.micronutrient.org

Example of push-based supply chain (on paper) District:

District Health Center, HC

Health Post, HP

Community Health Worker, CHW

Budget Procure Store Ship to HC HC: Ship to HP Inform District HP: Ship to CHW Inform HC CHW: Distribute 12 Inform HP

www.micronutrient.org

Actual functioning in very different

District Health Center, HC District: Budget Procure Ship to HC HC: Store Inform District HP: None CHW: Collect supp Distribute Inform HP 13

Health Post, HP

Community Health Worker, CHW

Supply side barriers

E. i. Supply management: Training on storage and inventory control to ensure that supplies do not expire is VERY uncommon - nutrition should learn lessons from private sector or other areas of health (vaccination control programs)

www.micronutrient.org Solutions for hidden hunger

Mitigation strategies - Ethiopia

Ensure adequate and sustainable IFA supply at all levels of the health care system through involving governmental and non-governmental stakeholders. Improve data utilization = "Information for action" . Make use of the tracer drug report included into the HMIS on regular bases by the woreda Health Offices ( IFA is one of the tracer drug that the HMIS uses to capture it availability at health facilities)

www.micronutrient.org Solutions for hidden hunger

Mitigation strategies - Ethiopia

Strengthen the Community Based Health Information Management = stock monitoring via the bin card system, apply the standardized definition for early detection of stock out.

Strengthen supportive supervision to improve supply management at all levels.

Advocating for government to finance IFA supply Improve the accessibility of routine prenatal IFA supplementation by integrating it into outreach and home based prenatal services. www.micronutrient.org
Solutions for hidden hunger

Alternative modes to reach pregnant women outside of facility-based ANC

Ethiopias Health Extension Program, local young women are trained to become Health Extension Workers (HEWs) who provide limited services within rural communities and successfully encourage model health behaviors including utilization of ANC services.
www.micronutrient.org Solutions for hidden hunger

Alternative modes to reach pregnant women outside of facility-based ANC

Health facilities personnel Private sector

Community based personnel

www.micronutrient.org Solutions for hidden hunger

Mitigation strategies - Kenya

MoH receives support from partners for the purchase of essential drugs including IFA. Sensitization of health workers at all levels of the new WHO IFA guidelines On job training of health workers on qualification and forecasting of IFA

Strengthening the coordination mechanisms of all the key stakeholders to ensure frequent consultative meetings intended to streamline IFA supply chain issues.
www.micronutrient.org Solutions for hidden hunger

Mitigation strategies - Nigeria

Supply chain management including forecasting, procurement and tracing of stock out of IFA done at all levels Leveraging on existing cost recovery programs e.g. the drug revolving funds (DRFs) being piloted, to help ensure long term sustainable supply of IFA in the public health system in the 4 target states. Advocating for government ownership to ensure sustainability

www.micronutrient.org Solutions for hidden hunger

Mitigation strategies - Senegal

Generating evidence to show that IFA can be successfully delivered by CHW

www.micronutrient.org Solutions for hidden hunger

Key issues for discussion

MI formative assessments in Kenya and Ethiopia report that women will take all the IFA supplements provided at the health facility. To what extent does strengthening the supply chain guarantee improved utilization of IFA?

What would be the consequence on the supply chain issues of layering calcium supplementation onto a weak IFA program?

www.micronutrient.org Solutions for hidden hunger

Acknowledgements
Micronutrient Initiative
Ministries of Health CIDA

www.micronutrient.org Solutions for hidden hunger