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

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

3. What are commodities?

4. 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

5. 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)

6. 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

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

8. 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.

9. 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

10. The frontline primary health care facility provides commodity link with CHWs

11. 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

12. 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

13. 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

14. 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?

15. 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

16. 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

17. 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

18. 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

19. 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)

20. 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

21. 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

22. 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

23. 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

24. 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

25. CHWs need a safe place to store their stock of medicines

26. 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

27. 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

28. 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

29. 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

30. 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

31. Thank you!
Any questions or comments?