Improving Supply Chain Management for Malaria: Lessons from Angola
In Angola, the National Malaria Control Program (NMCP)’s 2013 annual report suggests that malaria alone represents 35 percent of all curative treatment demands, 20 percent of hospital admissions, 40 percent of perinatal deaths, and 25 percent of maternal deaths. Universal and continuous availability of recommended artemisinin-based combination therapy (ACT) and rapid diagnosis tests (RDTs) are a critical prerequisite for the effective management of clinical malaria. However, across Africa stock-outs of ACTs are frequently reported, resulting in compromised access to effective treatment, suboptimal case management practices, and increased childhood mortality. One of the causes of stock-outs is weak supply chain management. Conversely, there is also wastage due to excessive stock. Monitoring stock levels is paramount to ensure a continuous availability of health commodities and or reducing any wastage due to overstocking.
The US Agency for International Development (USAID)-funded Systems for Improving Access to Pharmaceuticals and Services (SIAPS) Program, implemented by Management Sciences for Health (MSH), has collaborated with the Angolan National Malaria Control Program, Central Procurement Agency for Medicines and Medical Supplies (CECOMA), and provincial malaria control program teams to improve the availability of ACTs, RDTs, and Sulphadoxine-pyrimethamine (SP) for better malaria case management.
This collaboration included a number of important interventions: supporting the receipt and distribution of USAID-funded commodities from the national to the provincial level, and developing and implementing training and supportive supervision tools and approaches to build the capacity of medical warehouse and health facility staff to better manage medicines and health commodities. SIAPS also worked with their government partners to embed strategic monitoring tools, including End Use Verification (EUV) and Procurement Plan and Monitoring Report for antimalarial products (PPMRm) to inform decisions related to the procurement and supply chain management of medicines and health commodities.
In coordination with NMCP and CECOMA, data on availability of antimalarial products at the provincial level are collected on a monthly basis, entered into the database, and analyzed to inform decisions such as the preparation of distribution plans for all 18 provinces and stock replenishment if the need arises.
To date, a database of stock levels has been created that captures monthly stock data from all 18 provinces and CECOMA since September 2012. Data collection includes stock levels at the beginning of the month, all the stock received during the month and its origin, quantities distributed during the month, and the stock at hand at the end of the month. Regular emails and phone calls are used to contact all 18 provincial warehouse managers and malaria supervisors. To validate these actively collected data, verification is done with the ones that are regularly reported by the provinces to NMCP through a normal paper-based reporting system and punctual field visits are organized for data quality assessments and improvements.
Once data are captured, an analysis is done to detect issues in the stock levels such as:
- Provinces that are keeping high-level stocks for a certain period of time
- Provinces that are reporting an increasing demand in antimalarial products
- Products that are being distributed at a very high rate
- Provinces that are reporting stock-outs of antimalarial products
- Provinces that have received replenishment from CECOMA
- Available stocks at CECOMA level
As a result of this regular monitoring, NMCP has been able to coordinate stock exchanges between provinces where there was a significant reduction in movement of stocks to provinces that were in need. At least two provinces (Huambo and Cunene) have been requested to send some of their stock to other provinces in need (Namibe, Bié, Luanda, Uige, and Kwanza Norte), and the distribution plans were revised to take into consideration the current progress in malaria case reductions in some provinces. Results of this routine monitoring showed that RDTs and the presentation of Artemether Lumefantrine (AL) 6x3 experience the most stock-outs at the provincial level. On average, at least three provinces out of 18 have had stock-outs of one of the two products for a period of 25 months, with a maximum of 10 provinces stocking out RDTs at least once in November 2013 and six provinces stocking out AL 6x3 in May 2014.
Despite these achievements some challenges remain, such as the current passive “push” supply chain, whereby quantities are pre-determined by NMCP independent of the actual needs of the provinces. Other challenges are low reporting rates on consumption and the overall insufficiencies of stocks of some products at the national level due to gaps in timely procurement. Subsequently, some provinces have reported recurrent stock-outs, especially the provinces with poor and low rates of reporting. The biggest challenges remain inaccuracy and delays in logistics reporting from the health facility to the national level and low use of pharmaceutical management tools, such as stock cards, to maintain records of stock movements.
SIAPS will continue to support NMCP and CECOMA to improve the Logistics Management Information System. This will result in minimizing inventory costs, a better and timely response to fluctuations in supply and demand, and a more efficient distribution system.