Quality improvement practices to institutionalize supply chain best practices for iCCM: Evidence from Rwanda and Malawi

Abstract

BackgroundSupply chain bottlenecks that prevent community health workers (CHWs) from accessing essential medicines significantly increase under-5 child mortality, particularly in poor and rural areas.ObjectiveUsing implementation research, interventions aimed at improving supply chain practices and access to medicines were tested in Malawi and Rwanda. These interventions included simple demand-based resupply procedures, using mobile technology and traditional methods for communication, and multilevel, performance-driven quality improvement (QI) teams.MethodsMixed-method evaluations were conducted at baseline (2010), midline (2013), and endline (2014). Baseline assessments identified common bottlenecks and established performance levels. Midline assessments identified which intervention package had the greatest impact. Endline surveys measured the progress of scale-up and institutionalization of each innovation.ResultsIn both Rwanda and Malawi CHWs, health center staff, and district managers all cited many benefits of the establishment of resupply procedures and QI teams: such as providing structure and processes, a means to analyze and discuss problems and enhance collaboration between staff.ConclusionsImplementing simple, streamlined, demand-based resupply procedures formed the basis for informed and regular resupply, and increased the visibility of appropriate and timely community logistics data. QI teams played a critical role in reinforcing resupply procedures and routinely unlocking the bottlenecks that prevent the continuous flow of critical health products. While simple, streamlined, demand-based resupply procedures provide the basis for regular, functional, and efficient resupply of CHWs, the procedures alone are not sufficient to create consistent change in product availability. Supporting these procedures with multilevel QI teams reinforces the correct and consistent use of resupply procedures.

The procurement and supply chain strengthening project: Improving public health supply chains for better access to HIV medicines, Uganda 2011-2016

“…Furthermore the use of WhatsApp® and mobile technology greatly improved our outcomes by improving the timeliness of order delivery. Another study has had similar findings using short message service [16].…”

“…Our end goal is to sustain high performance (quality service provision) with supervision visits slowly removed due to cost. It will be important to assess sustainability given that a similar study found that sites revert back to baseline performance once interventions are discontinued [16].…”

Institutionalization of integrated community case management into national health systems in low- and middle-income countries: a scoping review of the literature

“…The MoH of Rwanda together with its implementing partners developed tools for improved forecasting of community level demand of medical supplies to strengthen the PSM systems. The tools consisted of improved versions of paper-based resupply calculators and improved communication approaches designed by quality improvement teams [24,36]. In Malawi, similar efforts led to countrywide adoption of cStock, a simple mHealth reporting and resupply system that led to improvements in communication between the Health Surveillance Assistants (HSAs) and their resupply points.…”

“…In Malawi, similar efforts led to countrywide adoption of cStock, a simple mHealth reporting and resupply system that led to improvements in communication between the Health Surveillance Assistants (HSAs) and their resupply points. The application is reported to improve visualization of iCCM drug stocks at the district and central levels of the MoH through alert systems which enable supply chain managers to respond on a timely basis [36]. The Mozambique MoH together with its implementing partners are scaling up a digital community health system, called upSCALE, that enables supervisors to monitor medicine stokes by providing real-time data visualization [37].…”

“…However, other add-on components such as screening for acute malnutrition, referral of newborns and maternal follow-ups varied between countries, reflecting the national community health policies of the specific countries. The literature showed that in most countries there were frequent stock-outs of iCCM essential medicines and commodities affecting service delivery [36]. There was also evidence that referral linkages to health facilities existed in theory but in practice, several iCCM programs fell short in adherence to referral advice [39].…”