Making products available among community health workers: Evidence for improving community health supply chains from Ethiopia, Malawi, and Rwanda

Abstract

BackgroundA UNICEF review of the challenges to scaling up integrated community case management (iCCM) found that drug shortages were a common bottleneck. In many settings, little thought has gone into the design of supply chains to the community level and limited evidence exists for how to address these unique challenges. SC4CCM’s purpose was to conduct intervention research to identify proven, simple, affordable solutions that address the unique supply chain challenges faced by CHWs and to demonstrate that supply chain constraints at the community level can be overcome.MethodsSC4CCM selected three countries to implement supply chain innovations and developed a theory of change (TOC) framework for the learning phase, which identified the main drivers of product availability and was used for baseline assessments, design, implementation and evaluation of interventions in Ethiopia, Malawi, and Rwanda. Interventions were developed in each country and tested over 12–24 months. Mixed–method follow up assessments were conducted in each country in 2012–2013. The Supply Chain for Community Case Management (SC4CCM) Project then simplified the TOC into a Community Health Supply Chain (CHSC) framework to enable cross country analysisResultsThe findings from interventions in the three countries suggest that the greatest supply chain benefits are realized when all three CHSC framework elements (data flow, product flow, and effective people) are in place and working together. The synergistic effect of these three elements on supply chain performance was most effectively demonstrated by results from the Enhanced Management and Quality Collaborative interventions in Malawi and Rwanda, respectively, which were characterized by lower mean stockout rates and higher in stock rates on day of visit, when compared to other interventions.ConclusionsMany conditions are necessary to ensure continuous product availability at the community level, however a supply chain works best when three key elements (product flow, data flow, and effective people) are deliberately included as an integral part of the system design. Although these elements may be designed differently in different settings, streamlining and synchronizing them while ensuring inclusion of all components for each element improves supply chain performance and promotes product availability at the community level.

Operational challenges to continuous LLIN distribution: a qualitative rapid assessment in four countries

“…While there was an improvement in accountability of supplies in some commodity chains, the system did not fix the concerns of poor data and monitoring all together [22]. Both Rwanda and Malawi have recently been involved in a project to strengthen community health supply chains, focusing on antibiotics, ACT, ARTs, and ORS [23]. These evaluations both identified the need for products to be ordered based on facility need, through clear procedures [23].…”

“…Both Rwanda and Malawi have recently been involved in a project to strengthen community health supply chains, focusing on antibiotics, ACT, ARTs, and ORS [23]. These evaluations both identified the need for products to be ordered based on facility need, through clear procedures [23]. They also noted the need for strong data management and use to ensure accurate information is available to inform management decisions [23].…”

“…These evaluations both identified the need for products to be ordered based on facility need, through clear procedures [23]. They also noted the need for strong data management and use to ensure accurate information is available to inform management decisions [23]. …”

“…In one study in Ghana, the transportation aspect of the supply chain, specifically, was seen as a contributor to stock-outs and supply shortages, which was not identified as a specific barrier in the four countries included in this study [16]. Beyond LLIN distribution, supply chain management has been a major focus of health systems research, for essential medicines, health commodities and vaccinations [23, 31–35]. …”

The way forward for integrated community case management programmes: A summary of lessons learned to date and future priorities

“…For example, engaging “champions” of iCCM (at policy and technical levels) has been difficult in many countries in sub–Saharan Africa [12]. Similarly, the collection and use of routine data for programming as well as collection of financing data on iCCM programmes [5,7,8], ensuring continuous medicine and supplies [6,13], and retention and motivation of trained and remunerated community–based health workers have been challenging [10,11,14]. …”