Supply Chain Management for Community-Directed Interventions (CDIs) Module 12 Version 2

Learning objectives By the end of this module, learners will be able to: Describe the processes of procuring and storing antimalarial drugs Explain how to estimate their community’s commodity needs* Outline the stock recording method and reporting format* Describe the distribution process for antimalarial medicines and other malaria commodities (e.g., insecticide-treated bed nets and long-lasting insecticidal nets [ITNs/LLINs], rapid diagnostic tests [RDTs]) State how to monitor and report adverse drug reactions* Discuss the role of patent medicine vendors (PMVs) in malaria commodity management *For community health workers (CHWs) as well as CDI focal persons

What are commodities?

Flow of commodities Health commodities for CDI and integrated community case management can flow through both public and private channels Each country is different, and in some cases: National, subnational, and district medical/pharmacy stores order, procure, and distribute commodities/medicines Districts or community associations can use private-sector warehouses and suppliers to buy medicines In some countries, malaria commodities are manufactured; in other countries, these commodities are imported

Flow of commodities, cont. For the Transforming Intermittent Preventive Treatment for Optimal Pregnancy project, quality-assured sulfadoxine- pyrimethamine (SP) is being imported from Guilin Pharmaceutical Company in China, which is prequalified by the World Health Organization (WHO)

Procurement and supply chain/cycle 8. Clients consume stock 1. Supply system information management 2. Forecasting and ordering 3. Procurement 4. Distribution to subnational/ regional/district level 7. Storage, safety, and correct use 6. Distribution to local level 5. Storage and safety

Commodities flow from suppliers to central medical stores, then on to districts and facilities

Commodities reach consumers Ultimately, commodities like artemisinin-based combination therapies (ACTs), RDTs, ITNs/LLINs, and SP need to reach the frontline clinic, and from there, the CHWs Whatever the system, commodities must move from point of manufacture to point of use Facilitator: Present a chart that shows movement of malaria and other commodities for integrated community case management in your country so that they finally reach CHWs/villages.

The malaria drug supply chain Community delivery of malaria medicines requires adequate supplies at all levels Districts must monitor frontline facilities to help prevent stock-outs for facilities and the CHWs these facilities supervise CHWs collect stocks from the nearest primary health care facility The quality-assured SP procured by the Transforming Intermittent Preventive Treatment for Optimal Pregnancy project will be used only for community-directed intermittent preventive treatment in pregnancy (IPTp) except when there is a stock-out of routine SP supplies

The frontline primary health care facility provides commodity link with CHWs

Proper estimation of antimalarial commodities It is important to have estimates of eligible clients/patients to determine antimalarial commodity requirements at all levels Accurate data are required to achieve these estimates Initial quantification of antimalarial medicines (ACTs, SP, quinine) needs to be done using population-at-risk data, by episode, based on medicine consumption Lower-level quantification can be done through community head counts during community census

Malaria tasks have different schedules (forecasting) The first task is to conduct a community census to determine number of people in need of services An ITN/LLIN is needed as soon as a woman knows she is pregnant IPTp occurs at least three times after quickening, at monthly intervals Case management occurs whenever a community member has malaria (IPTp and ITNs/LLINs may lessen the need for case management) Finally, health education is frequent

Identify and coordinate sources of supplies and funding ITNs/LLINS ACTs SP Global Fund to Fight AIDS, Tuberculosis and Malaria World Bank United States Agency for International Development UNICEF Ministry of health Local nongovernmental organizations Others Facilitator: Present details from your own country

Sample road map country summary Commodity/intervention Need through end 2010 Funded and expected to be distributed before end 2010 Gap ITNs/LLINs 63 million 49 million 14 million ACT doses 129 million 94 million 35 million Indoor residual spraying for household 2.8 million 800,000 2 million RDTs 59 million 34 million 25 million IPTp doses 18 million 18.3 million 300,000 Facilitator: You may use the sample data (shown in the slide) as an example, but if you can, use similar data from your country. ITNs/LLINs example: 100% coverage for population of 126 million = 63 million nets needed before end of 2010 Already covered (distributed in 2008—so nets will last beyond 2010) = 30 million Funded and expected to be distributed before end 2010 = 19 million Gap = 14 million (note if gap = 0, then 2010 targets are achieved) ACTs example: Number of expected fever cases (129 million) = needed doses per year Need for January–December 2010 = 129 million ACT doses Already funded = 94 million doses Gap = 35 million ACT doses Summarize resources available in your country to support the identified needs. Are there any financial or commodity gaps?

Centralized procurement It is recommended that drugs for home management of malaria be centrally procured Benefits of central procurement include bulk purchasing, which can: Reduce cost of medicines and handling charges Ensure consistency and quality of supplies Simplify logistics

Centralized procurement, cont. These drugs should be WHO-approved (i.e., quality- assured) medicines Ultimately these should move in a well-supervised manner from national to subnational to district to health facility and then community levels

Companies producing WHO-prequalified malaria medicines as of August 2010 Manufacturer Location Artesunate + Amodiaquine Cipla Ltd. Patalganga, India; Goa, India Guilin Pharmaceutical Co. Ltd. Guilin, Guangxi, China Ipca Laboratories Limited (Ltd.) Dadra and Nagar Haveli Union Territory, India Sanofi-Aventis Group, Maphar Laboratories Casablanca, Morocco Artemether + Lumefantrine Ajanta Pharma Ltd. Paithan, Aurangabad, Maharashtra, India Patalganga, India; Himachal Pradesh, India Ipca Laboratories Ltd. Novartis Pharma Beijing, China; Suffern, USA SP Guilin Pharmaceutical Co. Ltd.* Facilitator: Please use updated information if available. *Only prequalified company for quality-assured SP

Forms track the use of antimalarial medicines Forms are used at all levels of the health care system to track the use of antimalarial medicines Subregions, districts, communities, and facilities use forms to track the drugs they procure and distribute CHWs use forms to track the medicines they pick up from their supervising facility and distribute within the community

What is needed on forms to track antimalarial drugs? Forms should: Collect data on: The consumption of different dosage packs The manufacture and expiry (expiration) dates of medicines Include areas to record the justification for any discrepancies in drug consumption (e.g., partial medicine usage)

The CDI distribution process Commodities reach the nearest health facility The CHW collects initial supplies and materials from the health facility The initial stock is based on a community census that shows need On receipt of commodities, the CHW signs an inventory register at the health facility confirming collection of supplies

Community preparation for distribution The community leader and the CHWs announce to community members that commodities are available for pregnant women The community should decide on the most acceptable processes to receive commodities, for example: The CHW can make home visits to assess pregnant women for IPTp People can go to the CHW’s house or the CHW can make home visits for other malaria commodities (where applicable) Women and caregivers can seek services as needed

Distributing and maintaining stocks The CHW: Visits homes of pregnant women to provide IPTp to those who are eligible (Note: All pregnant women should be referred to the health facility for antenatal care even when not eligible for IPTp) Maintains distribution records (including blister packs of consumed SP) and summarizes these monthly Submits summary reports to the health facility on a monthly basis Collects supplies to replenish commodity stocks

Getting new stock for the community Monthly CHW meetings at the frontline facility are a good opportunity to replenish stocks: CHWs bring empty medicine packets to exchange for new packets A system must also be in place for CHWs to obtain stock whenever it is needed Photo by Bright Orji, Jhpiego

Storing medicines in the community During training, CDI focal persons should sensitize the CHWs to the following storage requirements: Ideally, store SP, ACTs, and other medicines in a cool, dry, and clean place: Keep medicines away from direct sunlight and heat Temperature should not exceed 25°C Medicines suspected to have come in contact with water must not be used for treatment Damaged medicines should be returned to the health center and a new stock collected Keep all medicines out of reach of children, at all times Medicines should be kept separate from the other items in the house

CHWs need a safe place to store their stock of medicines

Medicines may not work as expected These steps help ensure quality of commodities: CHWs should report dangerous or unexpected effects of the drugs to their supervising health facility Likewise, CHWs should take note of patients who do not get well after taking all medicine correctly: these patients should be reported and referred The supervising facility should report to the district This reporting is part of the pharmacovigilance system

Patent Medicine Vendors (PMVs) are a major source of medicines for the community Sometimes if CHW stocks run out, community members may need medicines quickly PMVs may be a source We need to monitor PMVs to ensure that they provide quality medicines

Procurement and PMVs PMVs: Normally buy their stock from wholesalers Usually do not keep records and receipts Do know which medicines are popular With the Affordable Medicines Facility—Malaria, PMVs: May now be receiving specially packed Coartem from the health system Will need to learn how to manage stocks, check expiration, and report damages

PMV associations can be involved in procurement and supply chain management for the private sector Sometimes communities can restock their medicine box by buying from a reliable PMV shop

Summary and conclusions CHWs: Collect drugs from the health facility that provides services to their community Ensure that drugs are stored appropriately Maintain an accurate account of drug use, damages, and stock at all times Report adverse drug reactions to the supervising health facility Attend monthly meetings and submit monthly reports PMV associations can also be involved in supplying approved malaria commodities

Thank you! Any questions or comments?