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Latest Learning and Resources for iCCM_Briggs
 

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  • Components for supply chain <br />
  • Children and caregivers have a preference for liquids, but syrups and suspensions are bulky to transport, store, and manage. <br /> Ideally, countries should: <br /> Select products in pediatric dosages and formulations, e.g., dispersible tablets to facilitate administration <br /> Select individual courses of treatment (blister packs) or individually packed rapid diagnostic tests (RDTs) to facilitate manipulation by CHWs <br /> Ensure selected formulation is on the National Essential Medicines List and in standard treatment guidelines <br />
  • The process of quantification consists of 2 phases: <br /> 1. Estimating needs or forecasting the needs of the CHWs <br /> 2. ensuring there is adequate inventory at all levels of the system so products will reach the CHWs (or supply planning) <br /> Historical data are ideal for forecasting needs (such as consumption or case data) but if CCM is new, there is no such data. Demographic data, e.g., number of episodes/child/year for each condition can be used, for the initial quantification based on solid assumptions. But these assumptions will need to be adjusted as the CCM program is implemented and real data can be used. <br /> In the planning, it is key to be realistic about scale-up rates and patterns of use of service. It is easy to get carried away at the beginning of a program and hope for high utilization rates. This is unlikely from the very beginning, as it depends on demand generation in the community as well as the confidence people gain to use the CHWs. Additionally, scale-up can take longer than expected, e.g., delays in training, etc. <br /> If you assume services at scale and high levels of utilization, this would be an overestimate and result in overstocking. This surplus then creates a risk for misuse of products, e.g., for adults or other conditions, diversion of products, and expiry and wastage. <br /> A clear plan for CCM implementation is crucial for the forecasting phase; if there is no plan, it is very hard to forecast. What area/population should be considered for how long, etc., are questions that are essential for the forecasting phase. <br /> Quantifying CHW needs as part of the national quantification will increase the chances that there are enough medicines in the supply chain for the community level. It is important to remember that if the same products are used at the community level as well as at other levels in the system, the CHW is the last point of distribution and may not receive enough if products are not in full supply throughout the system. <br />
  • The output of a quantification exercise should be a supply plan that indicates when products are required in-country to meet the forecast need. <br /> The supply plan takes into account: <br /> Timing and availability of funding from all sources <br /> Stock on hand (SOH) of products currently in the system and any orders already placed in the pipeline, or on the way <br /> Estimated supplier lead-time for each product <br /> The key thing to remember is that the supply plan should guide procurement, not the forecast. <br /> The output is a monitoring tool that allows you to estimate future stock levels based on current SOH, your forecast consumption, and planned receipt of future shipments – and then determine when shipments need to arrive to help coordinate procurement. <br /> When you can start procurement, it is important to connect the product selection with the procurement and ensure the technical specifications are respected for the very 1st procurement. Obvious, you may say! But a number of countries have run into this problem! For example, many years ago in Senegal, when CCM was just starting on a pilot basis, the Senegal CCM managers defined pneumonia treatment to be 120 mg co-trimoxazole, but the first supplies to arrive were co-trimoxazole 480 mg tablets; all the training materials were for 120 mg and so the careless procurement of 480 mg caused confusion, which should be avoided whenever possible. <br /> Quarterly reviews should be carried out regularly through the year of the consumption against the forecasted needs, and the supply plan should be adjusted accordingly. This is especially important in new programs where assumptions were used in the initial forecasting; these assumptions need to be adjusted with experience of implementation to avoid stock imbalances, over stocking, or stock outs. <br /> Communication and coordination are key for procurement because: <br /> Demand is complex and changing rapidly in new programs <br /> There are many partners, some conducting direct procurement and distribution. Coordination is needed to fill gaps and plan effectively. Sharing information is key. <br /> Medicines used at the community level are also used at other levels, and so there is a need to coordinate procurement plans. <br /> It is important to advocate for sufficient funding for these products throughout the health system as well as at the community level or differentiate these products from what is in use at other levels, as in Rwanda for example. <br />
  • Design a resupply system that is appropriate for the CHW context <br />
  • Storage is particularly challenging for CHWs, as they often work from their homes and in remote places. Health products must always be protected from water, sunlight, heat, humidity, rodents, and insects and kept out of the reach of children. <br />
  • Limit data collected from the community level to include only essential data, e.g., SOH and consumption, so as to not overburden the CHWs with reporting. <br />

Latest Learning and Resources for iCCM_Briggs Latest Learning and Resources for iCCM_Briggs Presentation Transcript

  • How to Assure Availability of Medicines and Supplies in CCM: Supply Chain Management Considerations Preconference Session CORE Group Global Health Practitioner Conference May 5, 2014 by the Supply Chain Management Sub-Group of the CCM Taskforce
  • Overview 1. Importance of supply chain management (SCM) for community case management (CCM) 2. Challenges for CCM 3. Coordination and planning for supply 4. Product flow: • Resupply mechanism • Storage conditions • Inventory management 5. Data flow - supply chain reporting 6. Effective people 7. Summary
  • Why Worry About Supply Chain? Stock outs at the community level can pose a major bottleneck to integrated CCM (iCCM) program goals •Public health supply chains in resource-limited settings are often characterized by frequent and persistent stock outs of essential medicines. •Without reliable availability of iCCM medicines and related products, iCCM programs cannot be effective. Consistent availability of high quality iCCM products to community health workers (CHWs) is key to CHW motivation, public demand for, and trust in CHW services.
  • Challenges of Getting Products to the Community • Rural areas, difficult geography • Limited or challenging transportation networks • Often relying on volunteer CHWs who work out of their homes or villages and have no dedicated physical space • At the end of the supply chain Photo: Millenium Promise Good planning of SCM is essential to overcome these challenges.
  • Planning: Product Selection UN Commission on Life-Saving Commodities for Women and Children Recommended products: Amoxicillin – 250 mg dispersible tablets in blister packaging of 10 Oral rehydration salts (ORS) – low- osmolarity sachets (0.2, 0.5, 1.0 L sachets) Zinc – 10 mg or 20 mg dispersible tablets in blister packaging of 10 Children and caregivers prefer liquids. However, syrups and suspensions are bulky to transport, store, and manage. Countries should: •Select products as pediatric dispersible tablets to facilitate administration •Select individual courses of treatment •Ensure selected formulation is on the National Essential Medicines List
  • Plan for Supply Chain in CCM • Establish a plan for the pilot or introductory phase and scale- up so that medicines and supplies can be estimated and procured (procurement can take up to a year; need to coordinate donations and partners) • Define resupply mechanism and design tools and materials for resupply ahead of training CHWs • Ensure that the supplies are ready to give an initial stock to the CHWs as they complete their training and that they are trained in the resupply mechanism
  • Quantification • Forecasting: ideally, historical data (such as consumption or case data) is used to predict future need, but if CCM is new, there is no such data • Demographic and morbidity data, e.g., the number of episodes/child/year for each condition, can be used Quantification involves: 1.Forecasting future consumption at the CHW level (estimating needs) 2.Ensuring that there is adequate inventory at all levels of the system so products will reach the CHWs (supply planning)
  • Supply Planning and Coordination The supply plan is a monitoring tool that facilitates coordination of procurements and should be reviewed quarterly. The supply plan should guide procurement, not the forecast. The output of a quantification exercise should be a supply plan that indicates when products are required in-country to meet the forecast need. The supply plan takes into account: 1.Timing and availability of funding 2.Stock on hand (SOH) of products currently in the system and any orders already placed 3.Estimated supplier lead-time for each product
  • Product Flow: Resupply Mechanism • Clearly define the resupply point; choose the nearest health facility if possible • Harmonize resupply with existing monthly meetings or reporting to minimize unnecessary travel • Consider transportation & terrain– bicycles, public transport, by foot • Consider number of CHWs per resupply point and feasibility • Consider distribution of medicines by supervisors if supervision is regular to all CHWs
  • Storage Storage conditions should ensure the physical integrity, quality, and safety of products and their packaging. • CHWs should be provided with practical storage solutions, such as lockable, dry, dark containers. • e.g., wooden boxes heat up less than metal ones • Health products must always be protected from rodents and insects and kept out of the reach of children. • Products should be arranged to facilitate counting and general management . • Expiry dates should be monitored; if this is too difficult for CHWs, this can be part of supervision.
  • Inventory Management Simple systems are needed to help CHWs manage their stock and record and report consumption without the need for complicated calculations or to shift responsibility for calculations to higher levels. • Inventory control systems guide facility staff and CHWs in when to order and how much to order to ensure a continuous supply and to minimize or prevent stock outs and overstocking. • Resupply quantities should be based on consumption and how much the CHW needs to last them until their next order.
  • Typical data collected through LMIS: (1) Stock on hand (2) Consumption (or issues) data (3) Losses and adjustments (4) Days stocked out Consumption and stock data need to be available and usable for supply chain decision making and problem solving. Data Flow: Supply Chain Reporting A Logistics Management Information System (LMIS) is needed to collect important data to inform routine resupply, respond to emergency situations (e.g., stock outs), monitor performance, and forecast quantities.
  • Effective People Training Supervision Meetings • CHWs need to be trained in resupply and reporting as well as storage of products • One-off training is not enough • Use job aids to show procedures • When defining mechanism, consider numbers of CHWs per supervisor • Use checklists • Do not forget SCM • Train supervisors to supervise • Regular meetings need to be structured and effective • Observe case management • Team needs to have goals and track progress • Teams work together to solve SC problems • Recognition of performing CHWs • Teamwork and problem solving used to improve the supply chain. • CHWs and district staff motivated to do the job
  • Summary of Key Points • Coordination and planning for SCM in CCM – Product selection – Quantification – Planning for procurement • Product and data flow – Resupply mechanism and tools – Reporting system – Data analyzed and used • Effective people: a skilled and motivated workforce to achieve supply chain goals – Train CHWs – Equip supervisors to supervise – Motivate CHWs and supervisors to perform their SCM tasks – Track progress and aim for continuous improvement