Emerging Lessons

SC4CCM is continuously learning about how to improve the supply chain at the “last mile” or community level. Here are some themes that have emerged so far. Click on a step on the supply chain to see the lesson.

Include CCM requirements as a specific focus during national quantification exercises and update regularly. Few programs in sub-Saharan Africa have sufficient funding to purchase all their essential medicine requirements for the public sector. Ensuring that CCM requirements are specifically forecasted for as part of the overall essential medicine quantification will increase the likelihood of having sufficient CCM products available at the community level or generate data that can be used for advocacy to increase funding or procurement levels. Furthermore, quantification is not a one-time event, but should be conducted annually with at least six monthly or quarterly updates to be sure the supply chain can respond to changes in demand.

Advocate for dedicated funding for CCM products and visibility into procurement and national stock levels of the same essential medicines. The lack of dedicated funding for CCM products creates challenges with supply planning. This can be further hampered by limited or no visibility into procurement and consumption of essential meds by other programs that buy and use the same CCM products. The lack of visibility limits a program’s ability to quantify the gap in funding for CCM products; so even if a gap exists, knowing the extent of the gap and advocating to fill it is virtually impossible.

Procuring pediatric and supply chain friendly products for CCM can move countries closer towards optimal product choices, thereby enhancing quality of care for children and ease of management for CHWs supply chain performance. The childhood survival community is committed towards rapidly scaling up and increasing access to antibiotics to treat pneumonia as a key strategy for reducing high infant and child mortality rates. While there is still a lack of commitment to a specific antibiotic, and many countries still use cotrimoxazole, WHO defines the optimal product as dispersible amoxicillin in 250mg tablets in blister packaging. Regardless of the antibiotic of choice, countries can move forward along the pathway towards an optimal product by selecting dispersible, blister-packed, pediatric-dose products for treating pneumonia in children under five. Products with these characteristics can move more efficiently through the supply chain, maintain their efficacy during storage at the community level, are easier for caregivers to transport and store at home, are easier to administer to sick children (compared to syrups or split adult tablets), and, most importantly, ensure more precise dosing, thus enhancing quality of care and efficacy of treatment. Read More

Planning for scale-up, institutionalization and sustainability of successful supply chain practices at the community level can start early, but ultimately takes strong supply chain leadership, capacity, resources and the vision for an integrated supply chain for the public system. When designing solutions for the community level of the supply chain, implementers should consider factors affecting  scalability and sustainability, such as available funding, organizational and individual  capacity and skills, among other factors  before starting. As implementation progresses, however, comprehensive planning for scaling up and institutionalization of a new or innovative practice can prevent stops and starts due to unanticipated bottlenecks, and can ensure early changes in strategy to accommodate changing environments. Planning for scale-up and institutionalization is more effective when strong program leaders and committed partners are involved and shape the direction. From a SC perspective, having a clear vision of the characteristics associated with an integrated supply chain will enable priorities to be clearly defined. Learn more about how to assess readiness for scale-up and institutionalization using The Pathway to Supply Chain Sustainability.

Develop supply chain champions at district or intermediate levels as well as centrally. District and health center staff are on the frontline of supporting, training, mentoring and supervising CHWs. Discovering and building supply chain champions at these levels is important for reinforcing key SC practices and priorities and ultimately improving product availability at the community level. Ensuring the presence of corresponding advocates for community level supply chain at the central level will help prioritize resources needed for CCM supply chains while providing support for districts to push for improvements in supply chain operations and performance.

Product Availability at the resupply point is necessary but not always sufficient for product availability at community levels: Having CCM products available at the resupply point is not a guarantee that they will be available at the community level, although of course if there are no products at the resupply point, they are unlikely to flow down to the community level.  In Malawi the resupply point for the community level, the health center, has recently started receiving primary health care kits. In some cases, because the products in the kit are sold and the funds go into a revolving drug fund to purchase more products, when there are products available at the health center they don’t necessarily flow to the community level.   In Ethiopia, there is a similar challenge, where products are designated to be sold at the health center but are provided free at health posts. Thus, community level CCM products currently are distributed via kits, but given the vast distances and terrain challenges in Ethiopia and the fact that the integrated pharmaceutical logistics system (which will deliver directly to health centers) is still at a nascent stage and woredas don’t have sufficient transport to deliver to health posts, the community level often experience significant delays in receiving products.  In Rwanda, they have solved the free vs paid for dichotomy using uniquely packaged products for the community level. However, an ongoing challenge is ensuring that health center pharmacists synchronize collection of community level products with those designated for the health center.

Focusing on appropriate and adequate storage conditions is important for ensuring product quality. While none of the three baseline surveys demonstrated that storage conditions had an impact on product availability, they did identify that storage plays an important role in preserving (or not) product quality down to the community level. In Rwanda, as part of a focus on storage during quality improvement team activities, cell coordinators invested in padlocks to better secure products in their drug boxes. The Ministry of Health is also investing in waterproof bags that can be used by CHWs to protect products when transporting them from resupply points to their villages.

Supply chain knowledge and skills for HC staff and CHWs and visibility into community logistics data are needed for effective decision-making at all levels. In Malawi, cStock provides data for health center staff to respond more rapidly and accurately to resupply HSAs while reducing the reporting burden on HSAs themselves and districts have been trained in how to use performance management reports to make better decisions.  In Rwanda, the resupply procedures standardize the mechanism for CHWs to receive orders and include a “magic calculator” to help cell coordinators determine resupply quantities based on actual consumption without requiring any calculations. In Ethiopia, essential SC skills for HEWs have been distilled down to five, one-hour lessons that can be taught at lower levels of the system.

Transport is an important and ongoing challenge for CHWs who are expected to travel to collect products themselves, often on foot. In Malawi, the Ministry of Health and partners provide bicycles for each HAS that can be used to transport products. To prolong the life of bicycles, SC4CCM has trained HSAs in preventive and corrective bicycle maintenance and provided them with illustrated job aids as reminders of how frequently each task must be conducted. There is little available funding for significant repairs, so some HSAs still walk to collect products. In Rwanda, as part of both the QC and IcSCI interventions, cell coordinators receive a small allowance as a contribution towards transport costs, both for conducting supervision of the 8-10 CHWs in their cell as well as for travelling to the monthly meeting and collecting products. In Ethiopia, distances and the terrain remain a challenge and HEWs are expected to collect resupply quantities for upto 50 products on a monthly basis from health centers or woredas. Download bicycle maintenance materials from Malawi.

Explore opportunities to increase CHW motivation to perform supply chain tasks specifically. CHWs, and health workers generally, mainly sign up or volunteer in their positions to be able to save lives and work with people. Rarely do CHWs understand in advance that there are key supply chain tasks that come with the role and motivation to perform these often mundane tasks can be low. In Malawi, participation in cStock has increased HSA’s motivation levels since it makes them feel less isolated and they receive more immediate feedback in the form of a text message from the system. Group messaging has increased motivation for SC tasks as well, when HSAs are congratulated for achieving a certain level of reporting rate or avoiding stockouts. In Rwanda, contributing a token amount towards transport and communication costs increases the likelihood that reporting and product collection will be undertaken regularly, particularly since CHWs are volunteers and often have to pay for these costs themselves.

CHWs need usable, quality medicines available at all times to appropriately treat common childhood illnesses. In all three countries at baseline, product availability was found to be weak, with more than half of CHWs stocked out of at least one tracer product on the day of the assessment. No CHWs managed all five products of interest, namely cotrimox or amox for pneumonia, ORS and zinc for diarrhea, ACTs for malaria and RUTF for malnutrition. Over 60% of CHWs who managed antibiotics, ORS, zinc and RUTF had those products in stock in all three countries, but most CHWs reported stockouts of at least one product on the day of the assessment. Without all products in stock all the time, CHWs may not be able to treat all sick children under five that seek care.

Deliberately design community supply chains with CHW needs in mind. Often the community level of the supply chain may have default processes, procedures and tools that are an extension of higher levels of the system, which is often why they may fall short in providing a continuous supply of products. The community level of the supply chain needs its own deliberate system design that has processes and tools which are simple to use and follow, and reflect the reality of CHWs location and mobility patterns.  Information and product flow procedures need to be synchronized with the higher levels that resupply CHWs and the design needs to ensure that prioritizing customer service is the main factor driving decisions.

Create a community supply chain that is agile and adaptable to the unique and changing environment. Implementing procedures and processes is often hampered by realities on the ground where different CHWs may experience different challenges in completing their supply chain tasks. Teaching CHWS and their resupply staff to use data to monitor their system and find local solutions creates a more robust and adaptable supply chain. Simplified quality improvement methodologies can be successfully used with CHWs.

Investing in helping CHWs and their supervisors learn how to identify and behave as a team, and providing them with basic problem solving tools and approaches can empower them to take on more responsibility for implementing solutions that are appropriate for their unique problem or situation.