An assessment conducted in collaboration with the Ministry of Health in Malawi in 2010 by the Supply Chains for Community Case Management project (SC4CCM), managed by JSI with funding from the Bill & Melinda Gates Foundation, showed only 27% of CHWs on the day of the survey had the medicines needed to treat all three targeted childhood illnesses that they were trained to treat – diarrhea, malaria and pneumonia. At the same time, central and district level managers had little access to community logistics data as only 43% of community health workers (CHWs) reported this data to their resupply health center, and little to none of that data reached district or national levels. With 94% of CHWs owning simple mobile phones, the project chose to design and implement an mHealth solution that was simple, affordable, interoperable and could be sustained by the country. Eighteen months after implementation a mixed-methods evaluation of the intervention was conducted. The evaluation found cStock: 1) improved visibility into stock data (reporting rates now above 80%); 2) was now a primary means for CHWs to order medicines (93% use cStock instead of other forms); 3) saved significant time in CHWs’ submitting reports (99% of CHWs); and 4) yielded data that was used by district coordinators for planning and coordinating. cStock has now been scaled up to 15 of the 30 districts in Malawi and has proven to be an affordable and effective way to improve data visibility: an important step in paving the way for supply chain integration. As one CHW said about cStock “the report goes the fastest and gets me the supplies I need in time”. Presented by Megan Noel at the 62nd Annual American Society of Tropical Medicine and Hygiene Meeting, Washington DC, Nov 2013.

1. cStock:
A simple, affordable
mHealth solution for
improving visibility of
community health
logistics data
Megan Noel
Monitoring & Evaluation Advisor

2. SC4CCM is a learning project that seeks to identify proven, simple,
affordable solutions that address unique supply chain challenges faced
by CHWs. The project seeks to foster a sustainable approach to scale up
and to ensure that MOH can own and adapt successful models to
strengthen community supply chain practice. This will be achieved
through facilitating the establishment of coordination mechanisms to
guide stakeholders as they embark on institution building.

3. Part of Solution:
Country Context
• Heath Surveillance Assistants (CHWs) introduced in 1970s for health promotion
and sanitation activities
• CHWs are paid cadre of MOH
• CCM was initiated in Malawi in 2008, CHWs in hard to reach areas provide CCM
• There are currently over 3000 village clinics
• CHWs can manage up to 19 products for CCM, FP and HIV Testing
Malawi Overview
SMS-based system to
manage reporting and
resupply process: cStock
Baseline Findings - 2010
• Only 27% of CHWs had all CCM products*
needed in stock DOV
• 43% of CHWs reported they submit a report
containing logistics data to HCs
• Only 13% of HCs reported CHW data
separately from their own data to districts
• 94% of HSAs surveyed had a mobile phone,
85% had network coverage at least
sometimes
*cotrimoxazole, LA1x6 and/or LA2x6, ORS

4. Product Flow
Data Flow
District, Zonal
and Central staff
access HSA
logistics data via
dashboard
Health Center
supplies the HSA
based on SMS
message
HSA sends SMS
with SOH each
month
The database calculates - MOS
and resupply quantities,
reporting rates, number and
duration of stock outs, displays
on dashboard
cStock: Data and Product Flow

5. In addition to cStock, SC4CCM introduced District Product Availability
Teams (DPATs) that use the increased data visibility to improve
performance
Performance Plan
• Supply chain performance
indicators and targets
• cStock data and resupply
worksheets used to track
performance
• Formal recognition system
to drive SC performance
• Management diaries used
to track issues and actions
taken
DPAT/HPAT Meetings
• Quarterly District Meetings
with District staff and CHW
supervisors
• Monthly HC Meetings with
HC and CHWs
• Topics discussed include
‐ Performance plans &
recognition
‐ Reporting timeliness
and completeness
‐ Stock management ,
expiries & overstocks,
and product availability
cStock Data
Enhanced Management (EM)
• DPATs have proven
to be an important
complement to
cStock.
• DPATs continuously
“demand”
updated data that
cStock “supplies,”
thereby reinforcing
the importance of
the data and
motivating CHWs
to continue
reporting.
District Product Availability Teams

6. 2013
Midline
Results

7. Malawi Midline Sample (Baseline)
EPT EM NI
TotalMachinga, Nkhatabay,
Mulanje
Nkhotakota, Nsanje,
Kasungu
Zomba, Ntchisi, Salima,
Mzimba North
District 3 (3) 3 (3) 4 (4) 10 (10)
HC 25 (26) 23 (25) 28 (26) 76 (77)
HSAs 78 (85) 81 (80) 90 (85) 249 (249)
Focus Group Discussion (FGD) Sampling
Two FGDs of 6-10 people per intervention district,
from 3-4 HCs outside the LIAT sample: 1) HSAs (2
male/female per HC);
2) HC staff handling CCM products (HSA
Supervisors, Drug Store In-Charge, HC In-Charge)

8. 99% of HSAs and HC
staff have mobile phones
81% HSA and 78% HC staff
have network coverage at work
all the time, (100% at least
sometimes)
80% HSAs have access to a
phone charger all the time and
10% at least sometimes
Few HSAs (24%) reported challenges
• 7% didn’t always have access to
phone charger
• 6% reported network not always
available
• 3% cited error messages
• 1% mentioned not being able to send
messages with Airtel because of no
credit.
FGDs: we walk long distances to
charge our phones. (Nkhotakota)
cStock: Environmental Viability;
User-friendliness & Acceptance

9. cStock: Efficiency
Paper
20 minutes or
less
More than 20
minutes
cStock
FGDs: “…. as for cStock , the
report goes the fastest and gets
me the supplies I need in time,
whilst the paper form can take 3
days, cStock does not.” (HSAs,
Kasungu)
“It is within 5min we are done
with the report.” ( HSAs, KK)
cStock has saved HSAs
time in preparing
orders/requests compared
to paper forms, in
submitting requests, and
in collecting products
99% respondents found cStock saved
them time in collecting products
FGDs: “the travel time has been reduced
because we are only forced to travel when
our products are ready” (HSAs,
Nkhotakota)
Time taken to prepare report
Time taken to prepare and submit
cStock report

10. cStock: Role in Resupply
0
10
20
30
40
50
60
70
80
90
100
EM EPT NI
cStock
LMIS-01G
Form 1A
Request form / Other
cStock has become
primary tool for
requesting
resupply from HC
− Request includes
reporting partial
logistics data (SOH,
receipts)
− Less consistency in
comparison districts
in forms used to
request products
cStock has not replaced paper logistics reporting
form, 100% of HSAs submit Form 1A, which
contains logistics data
Tools Used by HSAs to
Request Health Products
91% Drug Store in Charges use cStock
to determine how much to resupply
HSAs

11. cStock: Communications Flow
Reported frequency districts access
dashboard (n=6)
EM EPT
Once/mo - 2
1-2 x /week 2 1
3-5 x/ week 1 -
District IMCI Coordinators
in EM received training in
the dashboard, and as a
result appear to use cStock
for coordination and
planning
Benefits of cStock dashboard
• Provides data for
coordination***
• Provides data for planning**
• Cheaper, fastest way of
delivering information*
Majority of districts (5) report
that cStock website takes 1
minute or less to load
All (6) respond not being
discouraged from using cStock
because of page loading time

12. Reporting Rates
EM
EPT
Since October 2012 reporting rates have
consistently been above 80% for all
districts (vs. 43% at baseline).
Challenges with data transmission do not
seem to be affecting reporting rates.

13. On average HC’s in EM group took
7.6 days to respond after a request
and the EPT group took 13.5 days.
Lead Time
0
5
10
15
20
25
30
35
Aug-11
Sep-11
Oct-11
Nov-11
Dec-11
Jan-12
Feb-12
Mar-12
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Days
Order-Order Ready
EM O-R
EPT O-R
HCs in EPT districts in
recent months have taken
up to 30 days to respond
Greatest contributor to long
lead time in EPT is “order to
order ready” period (this is
how long HC takes to check
stock, pack and send order
ready message so that HSA
can come collect)

14. % HSAs with 3 Key Drugs in
Stock on DOVMidline
Machinga
Salima
Nkhatabay
Kasungu
Mulanje
Zomba
Nsanje Ntchisi Mzimba N
Nkhotakota Product availability
increased overall in ALL
districts
HSAs in districts using
cStock and DPATs had 14%
fewer stock outs or low
stocks than other districts
on day of visit
cotrimoxazole, LA 1x6, LA 2x6, ORS
Baseline
Machinga
Salima
Nkhatabay
Kasungu
Mulanje
Zomba
Nsanje
Ntchisi
Mzimba N
N.B. No HSAs in Nkhotakota managed health products at baseline

15. Conclusions
• cStock has improved community logistics data visibility,
saved time, and is well understood and liked by users
• DPATs work hand in hand with cStock to improve SC
practices & processes, by facilitating teamwork, better
performance monitoring, problem solving, action planning,
and decision making
• Enhanced Management helped to contribute to a
significant increase in CCM product availability between BL
and ML in Malawi
cStock has proven to be an affordable and
effective way to improve data visibility: an important step in paving the
way for supply chain integration.

16. Thank You!
Sc4ccm.jsi.com