A New Medicine Monitoring System Helps Prevent Antimalarial Stock-Outs in the Americas Region
USAID's regional program, the Amazon Malaria Initiative (AMI), was established to address malaria control in countries that form the Amazon Basin. Initial members included Bolivia, Brazil, Colombia, Ecuador, Guyana, Peru, and Suriname. AMI and its partner organizations helped the countries introduce artemisinin-based combination therapies around 2006 to treat Plasmodium falciparum malaria, which causes the most severe malaria cases. Plasmodium vivax, the most common species of malaria in AMI countries, is still treated with traditional antimalarials, such as chloroquine.
While introducing the new treatment, the partners documented the countries' supply issues, such as over- and understocked antimalarials. Both types of malaria cases have declined in the region—from almost 1.2 million in 2000 to 560,000 cases in 2008, and that decrease has influenced antimalarial stock situations. Fewer cases made providers lose interest in supplying small quantities of medications, which contributed to understocking. In contrast, orders based on historically higher numbers of cases left countries with too much stock. In addition, countries with poorly functioning management information systems placed medication orders after buffer stocks had already been used, which caused stock-outs. Countries with too much stock risk losing valuable medicines to expiration, while stock-outs mean that sick patients do not receive needed treatment.
AMI countries reviewed stock levels in 2009 and discovered stock shortages in some countries and overstocks in others. To confront this problem, Management Sciences for Health's Strengthening Pharmaceutical Systems Program proposed a regional monitoring system for antimalarial stock with the following characteristics:
- One indicator based on information already available, to be used to compile a quarterly report.
- Two data collection points for the indicator—the central medical store and the regional store. In most countries, a stock-out in a peripheral facility can be corrected in 24 hours, but a stock-out in the central warehouse (usually due to deficient procurement practices) takes 6-12 months to correct, depending on the procurement cycle.
- Information immediately used at the data collection point to correct identified antimalarial supply problems.
Intervention and Results
The indicator used was called months of available medication according to distribution (MAMAD). It requires two pieces of data for each medication that should be routinely available at central and regional warehouses:
- stock level on the last day of the quarter and
- average monthly distribution during the previous 12 months.
The stock level is divided by the average distribution, which equals MAMAD.
Since June 2010, when regional data was first collected, there have been seven data collection periods and regional reports. Stock problems identified in the national and regional reports in July 2010 triggered an immediate redistribution of medicines. For example, one effort involved three countries: Colombia and Bolivia combined to donate 700,000 units of chloroquine 150mg to Peru.
In another example, the Pan American Health Organization's Strategic Fund used the reports to coordinate an AMI-funded donation of medicines for severe malaria and special cases. As of December 2011, AMI had donated 50,000 units of medication to member countries at an estimated value of 14,000 US dollars (USD).
Countries have consistently been using the indicator results as a solicitation-donation mechanism. By the end of 2011, 1.5 million units of medication valued at about USD 54,000 had been transferred among countries. Much more critical than just the worth of these medicines, these exchanges have solved overstock problems in some countries and stock-outs in others.
A multicountry information system on antimalarial stock helps assure uninterrupted treatment availability in regions that have declining malaria incidence. The sustainability of such a monitoring system depends on the use of a simple indicator with two data collection points in the supply chain. Data collection is not time consuming and provides information for immediate decision making and redistribution of medications within the region.