Final components of the Zambia ARV Supply Chain for BUSPH course IH722

1. IH722
Spring 2015
Katie Broecker
Bethany Bryant
Jennifer Johnson
Liz Nerad
Zambia ARV Supply Chain

2. Table of Contents
Country Context……………………………………………………………………………………………….3
ARV Pipeline Overview…………………………….……………………………………………………….4
LMIS………………………………………………………………………………..……………………………….5
Inventory Control System…………………………….……………………………………….………...6
Quantification………………………………………………………………………………………………….7
Human Resources…………………………………………………………………………………………….8
Challenges……………………………………………………………………………………………………….9
Potential Solutions…………………………………………………………….…………….………. 10,11
Lessons Learned…………………………………………………………………………………………….12

3. In December 2013, it was estimated that only 80% of
patients living with HIV were currently on antiretroviral
treatment (ARV). Although access to ARV is high and
increasing among adults, coverage among children remains
worryingly low, with only 1 in 3 children in need of treatment
receiving it in 2011. According to a recent study conducted
by BUSPH Professor David Hamer, antiretroviral treatment
for HIV+ patients was available at 11% of health posts, 61% of
health centers, and all hospitals. Pediatric care for HIV+
children was available at 32%of health posts, 69% of health
centers, and 77% of hospitals. Zambia continues to scale-up
the ARV program each year, with the goal of achieving near
universal access. To meet commodity demand, the supply
chain will play an important role in delivering ARVs to all ARV
sites.
Zambia is a large, landlocked and sparsely populated sub-Saharan
nation with 13 million inhabitants. Over two-thirds of the population
live in rural areas and below the poverty line. Most communities in
rural areas have limited access to health care. In contrast, nearly all
urban households are located within 5km of a health facility. The first
case of HIV was reported in Zambia in 1984. Zambia now has an HIV
epidemic spreading through the population. There are approximately
1.1 million people in Zambia living with HIV (14-15% of the total
population).
The USAID Deliver Project with JSI was implemented
in Zambia beginning September 2006 to improve
essential health commodity supply chains. Zambia
established national ARV guidelines in 2004.
However, in 2007 approximately half of the 140
facilities distributing ARVs were stocked out. By
January 2009 with the DELIVER Project’s assistance,
Zambia achieved 100% reporting rate at 172 ARV
distribution sites. This was achieved through linking
the monthly reporting to the resupply of ARVs— “No
report, No product”. With this new policy in place,
the ARV stock out rate had decreased from 50% to
5% at 172 facilities.
Country Context: HIV and ARV in Zambia
3

4. Medical Stores Limited (MSL)
MOH Logistics
Management Unit (LMU)
Clients
District Community
Medical Office (DCMO)
Health Centers
NGO Health
Facilities
Provincial
Health
Office
District Hospital
Level 1,2,3
Overview of ARV Pipeline in Zambia
Within Zambia’s ARV supply system, there are
approximately 40 types of ARVs (including Nucleoside
Reverse Transcriptase Inhibitors, Non-Nucleoside
Transcriptase Inhibitors, Protease Inhibitors in Triple
fixed dose, single dose and pediatric solutions; very
few 3rd line ARVs available). ARV procurement for the
public health system is limited to those listed on the
Essential Medicines List.
Each level of the supply chain is a PULL system. The
review period at each level is 1 month. ARVs are
provided for free at public facilities.
• Tier 1 consists of the MSL central warehouse and
the LMU
• Tier 2 consists of the DCMO and district level 1
hospital
• Tier 3 consists of service delivery points including
level 2, 3 hospitals, health centers and NGO
health facilities
Zambia is currently rolling out a new design, which
includes regional hubs and cross-docking at DCMO.
This will be explained further on slides 10-11.
4
Product Flow
Information Flow

5. Supply Chain Information Flow (LMIS)
Medical Stores Limited (MSL)
MOH Logistics
Management Unit (LMU)
Clients
District Community
Medical Office (DCMO)
Health Centers
NGO Health
Facilities
Provincial
Health
Office
District Hospital
Level 1,2,3
Forms Form Movements
SCC
Stock Control
Card
∙ Stays in facility
DAR
Daily Activity
Reports
∙ Stays in facility
FR
Feedback
Reports
∙ Sent to lower levels (DCMO, Hospitals,
Health Centers)
∙ Sent to Provincial Medical Office (PMO)
R&R
Request and
Requisition
Report
∙ Sent to higher levels from lower level
facilities
CR&R
Computerized
Copy of Request
and Requisition
Report
∙ Sent to lower levels where it is then
signed and returned to higher level
∙ Copy of signed C-R&R is kept at the
receiving facility
RFRP
Reports for
Returning
Products
∙ Sent to higher levels from lower level
facilities
SV Supply Voucher
∙ Signed and returned upon receipt of
product
**IF product is held at DCMO, take SV
with you to get your product
MDN,
PH81-N
MSL Dispatch
Note, MOH Issue
Voucher
∙ Sent with products to the DCMO and
Hospitals.
∙ Signed and copy is sent back to MSL
∙ Copy of signed MSL is filed at
Hospitals/DCMO
RFRP
R&R
DAR SCC
CR&R
RFRP
MDN
CR&R
MDN R&R SCC
DAR SCC R&R
CR&R
PH81-N
FR
CR&R
MDN
FR
FR
CR&R
RFRP
R&R
FR
R&R
RFRP
SV
R&R
RFRP
5
Stays on site
Delivers Down
Delivers Up

6. Inventory Control System
The ARV supply chain operates as a PULL system at each level. The review
period is 1 month. If stock levels ever fall below 2 weeks (0.5 months) of stock
before the end of the month, an emergency order should be placed.
Tier 1
SDP
Tier 2
At the end of the month, health centers should: Report stock on
hand, consumption, and losses and adjustments. As this is a forced
ordering system, facilities should order enough stock to bring stock
level up to the maximum (3 months) and submit the order to the
District by the 5th day of the following month. The minimum stock
level is 2 months, the EOP is 0.5 months. Hospitals submit their order
to the MSL LMU by the dates published in the MSL Delivery
Schedule.
At the end of the month, districts submit the orders for their Health
Centers to the MSL-LMU by the dates published in the MSL Delivery
Schedule. The district reviews and approves the health center
orders. The DCMO operates as a cross docking station and only
stores stock for health centers without the space or capacity.
Information about the max/min/EOP ordering protocol at the MSL
level is unavailable at this time. MSL procures and supplies 40
different types of ARVs including:
● Nucleoside reverse transcriptase inhibitors (NRTI)
● Non-nucleoside Transcriptase inhibitors (NNTIs)
● Protease Inhibitors
Medical Stores Limited (MSL)
MOH Logistics
Management Unit (LMU)
Clients
District Community
Medical Office (DCMO)
Health Centers
NGO Health
Facilities
Provincial
Health
Office
District Hospital
Level 1,2,3
3 months MAX
2 months MIN
0.5 months EOP
Cross-
docking
Station
6
Information Flow

7. If the morbidity data does not make sense
when compared with the consumption
data, members of the quantification meeting
will deliberate until they can agree on a final
forecast reconciliation and adjust to
consumption trends or following projected
morbidity trends
Quantification
Ministry of Health HQ
Clinton Health Access
Initiative
Church Health Association
of Zambia
University Teaching
Hospital
LSK DHO ARV
Kalulushi General Hospital
MCDMCH
National AIDS &
Tuberculousis Council
Arthur District Hospital
Ministry of Health PMU
Medical Stores Limited
Maina Soko Hospital
USAID Deliver
ZambARV
Center for Infectious
Disease Research in
Zambia
Lusaka PHO
Muchinga Public Health
Office
CSO
MOH G Fund PR
Process for Quantification
There is one annual quantification planning meeting followed by 1-2 review meetings during the year.
The date of the annual meeting varies. For example: This year it was in September, with a review meeting
in March. At the review meetings the quantification team looks at how closely the assumptions they made
are reflecting reality. Historically, quantification was updated every quarter, but the system has since
matured to the point that there are not many changes in the data throughout the year.
Stakeholders
Involved in
Process
Pre-quantification: Meeting consists of a small group of technical experts from MSL, MOH, and MCDMCH
who review the data and agree on questions & process for the main quantification meeting. This structure
allows MSL, MOH, and MCDMCH to increase their sense of ownership as they lead the main quantification
meeting.
Quantification: Meeting includes representatives from multiple NGOs, donors and government entities
involved in the ARV program review the data trends developed in the pre-quantification meeting, agree on
the assumptions for building the next quantification and present any preliminary results
Presentation: Final results with expected forecast, proposed procurement plans and funding gaps is
presented. Donors make commitments to the procurement of the commodities in an agreed upon time
frame. MOH and MCDMCH agree on how to address any funding gaps that may result.
Morbidity-based forecast
using current ARV patient
numbers and the expected
increase in ARV patient
number, combined with
ARV trends from partners
Once a morbidity
forecast is complete,
the morbidity forecast is
compared with
consumption data
Data Used for Quantification
Quantification Timeframe
7

8. Level Personnel Roles and Responsibilities
MSL
Pharmacists and
Laboratory Specialist
• Review and approves R&R for ARV forms submitted by districts and hospitals
• Communicate with procurement units and donor partners for procurement of ARV drugs
Data Entry Clerk
• Enter report and order information from R&R forms received from Districts and Hospitals into Supply
Chain Manager Software
Central
Warehouse
Warehouse Manager,
Logistics Directors &
other technical staff
• Supervise management of ARV drugs into MSL central store
• Receive ARV drugs and issue ARV drugs to hospitals and districts
• Adhere to quality standards for storing ARV drugs
• Coordinate distribution of ARV drugs according to MSL Schedule and ensure secure delivery
• Ensure Stock control software are updated every time ARV drugs are issued or received
Provincial
Medical Office
Principal Pharmacist
• Receive quarterly feedback reports from MSL LMU on provincial ARV logistics performance
• Conduct supervision visits to the DCMOs and Level 2 and 3 Hospitals in the province
Health Center
and District 1
District Pharmacist
• Receives pre-packaged ARV orders for each HC providing ARV in their district
• Review ARV Drug feedback reports received from MSL LMU and take appropriate actions
• Make quarterly supervision visits to Health Centers
Hospitals:
District Level
Hospital Pharmacists
• Fill in ARV DAR every time ARV Drugs dispensed
• Maintain SCC for all ARV Drugs held in storage
• Complete physical count of Hospital ARV stock monthly and enter on SCC and in R&R Form
• Authorize R&R for ARVs and send to MSL/LMU when sending MSL essential drug orders
• Conduct visual inspection of products received
Health Centers ARV Focal Person
• Fill in ARV DAR every time ARV Drugs dispensed
• Maintain SCC for all ARV drugs held in storage
• Complete physical count every month and enter in SCC and in the R&R for ARV Drugs
• Send unusable ARV Drugs to District after filling out the Report for Returning Products
• Conduct visual inspection of products received
• If storing drugs at District: when notified of receipt of order at District, go to District and conduct
receiving procedures; bring Supply Voucher and pick up weekly order
Human Resources in the Supply Chain
8

9. Bottlenecks occurring at the DCMOs are a major challenge for Zambia
A few challenges faced by Zambia’s supply chain have
been the uncertain availability of commodities,
commodity expiries, and wastage of funds and stock.
These shortcomings have especially impacted the
facility level as they often faced stock out, while
commodities are available at the district and central
levels. A significant cause of these inefficiencies has
been the bottlenecking of commodities at DCMOs.
Relying on the centralized commodity distribution
from the DCMOs lead to suboptimal distribution to
health care facilities (HC) because of:
• inadequate last mile logistics by the DCMOs;
• lack of vehicles able to navigate difficult terrain, lack of
adequate amounts of fuel, and no available truck drivers
were in the region;
• lack of personnel dedicated to distribution, which forced
pharmacists to coordinate distribution in addition to their
official duties;
• lack of a set distribution schedule, which meant
commodities were only distributed when a proper vehicle,
sufficient fuel and a driver were simultaneously available.
The DCMOs were responsible for providing
commodities to 2,000 pharmacies and health facilities
throughout Zambia. These challenges were urgently
addressed as they resulted in direct violation of the Six
Rights of Supply Chain Management.
Difficult Last-Mile Logistics
Bottlenecks Occur at DCMOs
HCDCMO
MSL
Hospitals
Source: ColaLife. Supply Chain Pilot Results
Hospitals get direct delivery from MSL
Orders get backed up at the DCMO: lack of trucks and staff
9

10. Model A: Storage of drugs at district level. Establishes a
commodity planner (CP) whose responsibilities include
coordinating orders from health facilities and stock
management at the district level. Health facilities place
orders to CP. The CP places orders to the MSL. CP
receives stock from MSL and manages district store
room. They also process, pick and pack the stock for
each facility. Monthly, the health facilities receive
facility packages from CP.
Model B: Eliminates intermediate storage of drugs at
district level. These district stores function as a cross-
docking facility. MSL sends shipments pre-packed for
individual health facilities. One advantage of this
model is the potential to reduce pilferage and leakages
because it enables better shipment tracking. Health
facilities place orders directly to MSL. MSL compiles
one customized pack for each health facility delivering
packages to districts. CP receives facility packages
from MSL. Health facilities with limited storage space
receive shipment twice monthly; health facilities with
adequate storage space receive packages from CP
monthly.
Days of reported stock outs for the 3 pilot districts.
Model A Model B
A pilot study was performed in 2011 focusing on improving logistics capacity at the district level and reducing
the number of stockholding points in order to improve customer service and reduce stock-outs.
Potential Solutions to Bottlenecks
10

11. Preliminary Results: Regional hubs reduce bottlenecks and improve delivery
As a result of the pilot study, there was a significant increase in
product availability and decrease in stock out rates under both
models. Model B performed significantly better than Model A and
comparison districts. There was a significant decrease in the stock
out rates in Model B districts (from 1-33% vs baseline of 40-72%
stock out) compared to comparison districts (72%). In Model B,
clinics were stocked out an average of 5 days compared to 18 days
in Model A and 29 days in comparison districts. Reporting rates
from district health offices to MSL significantly increased to nearly
100% in Model B districts.
A hub is a stock cross-docking warehouse or transit point which
keeps already pre-packed drugs for a short duration for onward
distribution to the DCMOs and facilities, removing one level from
the supply chain. The cross-docking hub takes on the role
previously played by the DCMO in performing last mile distribution.
The hub does not hold buffer stock nor does it have the mandate
to re-pack commodities.
Zambia is currently implementing Model B districts nationally. The
implementation of the MSL regional hubs decentralizes the
distribution system. These hubs reduce the impact of district level
bottlenecks and provide more vehicles to deliver supplies to SDPs,
allowing for “last mile” distribution. This new regional hub system
allows each health center order to be centrally processed at MSL
and transported to the regional hubs in bulk. The deliveries are
received at the hubs and sent on monthly delivery routes utilizing
smaller MSL vehicles. This results in a more efficient transportation
and distribution network and the cross-docking hub serve as a
regional MSL presence in the community. Currently 3 regional hubs
of the proposed 7 are open and functioning.
Regional Cross-Docking Hubs
Model B Reduces Stock-out Rates
MSL
HCRegional
Cross-
Docking
Hub
Pre-packing
occurs here Hospitals
Model A
Model B
11
DCMO

12. Lessons Learned
Without information, the supply chain system does not function. Information flow is the key to meeting the Six
Rights of supply chain management and the ultimate goal of reducing adverse health effects and improving public
health.
Ensuring that supplies efficiently reach the last-mile can be affected by many factors including: lack of
transportation, lack of human resources, difficult terrain. Supplies may also not reach the last mile due to mis-
calculations in forecasting and budgeting that lead to stock-outs. Without many options, those at the end of the
supply chain are most vulnerable to these inefficiencies and inadequacies.
Challenges upstream in the supply chain can have serious consequences downstream,
where patients may require medicines and supplies the most.
Making a change at one point of the supply chain has ripple effects to other parts. When making changes, the effects
should be anticipated at other points to ensure that the system will still run properly.
There is a domino effect when making changes in the supply chain, because everything is
connected.
A robust LMIS system (preferably electronic) is essential to running a supply chain
effectively.
It takes time to change a system because there are many stakeholders and factors at play. It’s often necessary to
make small incremental changes so that the effects can be properly observed and subsequent modifications can be
made.
Change is a slow and difficult process.
12

13. References
World Bank. World Bank Policy Note: Enhancing Public Supply Chain Management In Zambia [Internet]. Available from: http://www-
wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2012/08/16/000333037_20120816012127/Rendered/PDF/718560WP0P12
520ain0Innovation0final.pdf
Ministry of Health. The Health Logistics Press. Zambia Ministry of Health [Internet]. 2013 Oct;(17). Available from:
http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/ZM_NewsOct2013.pdf
Ministry of Health. The Health Logistics Press. Zambia Ministry of Health [Internet]. 2013 Jun;(16). Available from:
http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/ZM_NewsJune2013.pdf
Aliza Marcus. The Challenge of Ensuring Adequate Stocks of Essential Drugs in Rural Health Clinics [Internet]. World Bank, Human Development
Network; 2010. Available from: http://siteresources.worldbank.org/EXTHDOFFICE/Resources/5485726-1288802844934/Zambia-Evid-to-
Pol.pdf
ColaLife. Supply Chain Pilot Results | Zambia | May 2010 [Internet]. 2010 May [cited 2015 Feb 23]. Available from:
http://www.slideshare.net/ColaLife/supply-chain-pilot-results-zambia-may-2010
Livingstone. MSL Regional Cross-docking Strategy- A Case of Choma Hub [Internet]. 2013 Dec. Available from: http://www-
wds.worldbank.org/external/default/WDSContentServer/WDSP/IB/2012/08/16/000333037_20120816012127/Rendered/PDF/718560WP0P12
520ain0Innovation0final.pdf
USAID. Logistics Brief: Improving Access to Malaria Medicines in Zambia [Internet]. USAID; 2011. Available from:
http://deliver.jsi.com/dlvr_content/resources/allpubs/logisticsbriefs/ZM_ImprAccMalaMed.pdf
Derrick Nyimbili. Lessons Learned: Designing and Implementing the Hybrid Essential Medicines System Strategy to Improve Product
Accessibility in Zambia [Internet]. USAID; 2014. Available from: http://web.ics.purdue.edu/~aiyer/7ghscs_submission_27.pdf
MSL. Briefing paper on the external verification and evaluation of the Medical Stores Limited (MSL) Choma Regional Cross-Docking Hub
Performance. MSL; 2015.
DELIVER, JSI, USAID. Standard Operating Procedures Manual for the Management of the National ARV Logistics System. Republic of Zambia
Ministry of Health; 2013.

14. References
Ministry of Health, Zambia National Formulary Committee. 2008. Standard Treatment Guidelines, Essential Medicines List, Essential
Laboratory Supplies for Zambia. 2nd ed Lusaka, Zambia: Zambia Ministry of health.
http://apps.who.int/medicinedocs/documents/s19280en/s19280en.pdf
Nicodemus W. Interviewed by: Nerad L. 22 Jan 2015.
Yadav, Prashant. 2007. Appendix E: Analysis of the public private, and mission sector supply chains for essential drugs in Zambia. A study
conducted for DFID Health Resource Center under the Aegis of the META Project.
Zambia National Formulary Committee (2011) 2011-2013 Zambia National Formulary http://www.moh.gov.zm/docs/znf.pdf
CDC. (2015). Increasing Patient Access to Antiretrovirals Recommended Actions for a More Efficient Global Supply Chain. CDC. Retrieved 5
March 2015, from http://www.cgdev.org/doc/HIVAIDSMonitor/ARV_Background-FINAL1.pdf
Murray, L., Semrau, K., McCurley, E., Thea, D., Scott, N., & Mwiya, M. et al. (2009). Barriers to acceptance and adherence of antiretroviral
therapy in urban Zambian women: a qualitative study. AIDS Care, 21(1), 78-86. doi:10.1080/09540120802032643
UNAIDS,. (2014). UNAIDS. ZAMBIA COUNTRY REPORT. Retrieved 5 March 2015, from
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UNICEF. (2015). UNICEF Zambia - Resources - HIV and AIDS. Unicef.org. Retrieved 5 March 2015, from
http://www.unicef.org/zambia/5109_8459.html
USAID,. (2015). USAID. USAID | DELIVER PROJECT Helps Zambia Reduce ARV Stockouts, Create Model Logistics System.
Retrieved 5 March 2015, from http://pdf.usaid.gov/pdf_docs/PNADR855.pdf
WHO. (2015). Zambia. World Health Organization. Retrieved 5 March 2015, from http://www.who.int/hiv/HIVCP_ZMB.pdf
Hamer, David. 2015. Health Facility and Health Worker Baseline Assessment for Reproductive, Maternal, Neonatal, Child Health and
Nutrition Services Final Report. Government of the Republic of Zambia, Ministry of Community Development/Mother and Child Health.