Improving Supply Chain Management for a Strengthened Health System in Benin

NOVEMBER 2017This document was prepared by the USAID/Benin Advancing Newborn, Child and Reproductive Health (ANCRE) program. The ANCRE program is funded by the United States Agency for International Development (USAID)/Benin under Agreement Number AID-680-A-14-00001. The program is implemented by University Research Co., LLC (URC), and sub-recipients Dimagi, Inc. and the Results for Development Institute (R4D).

Background

Benin is one of many African countries struggling to develop adequate healthcare for its population, particularly in regard to local treatment and

access to drugs. The USAID/Advancing Newborn, Child and Reproductive Health Program (ANCRE) program is working with Benin’s Ministry of Health (MOH) to alleviate supply chain management challenges, specifically those that affect the availability of necessary commodities for quality health service delivery of its package of high-impact interventions (PHII). These challenges include: (i) the lack of consumption data to ensure adequate quantification; (ii) poor logistics data quality and analysis; (iii) lack of national standards and procedures for health product management; and (iv) failure to comply with good inventory management practices. The data used to assess and determine demand is based on distribution not consumption, which results in stock-outs and/or recurrent storing and perishing of commodities and supplies.

According to a situational analysis of 232 public health facilities conducted in January 2015, 65% of the facilities experienced stock-outs the previous quarter for at least one commodity necessary to support the delivery of Benin’s PHII. Fifty-six percent (56%) had contraceptive1 stock-outs during the same period. The analysis further revealed that in 2014 no health facility had submitted PHII logistics reports.2 In 2015, supervision of public

health providers on commodity management showed that only 11% of the reports (84 out of 753 reports) were submitted that year.3

USAID/ANCRE’s Strategic ApproachThe USAID/ANCRE approach aims to strengthen the capacity of health providers and health zone management teams to be self-sustaining in PHII logistics management. To build a sustainable supply chain system, the program focuses its efforts on streamlining facility-level supply chain systems and improving healthcare worker skills in quantification, ordering and commodity management through targeted and integrated coaching, regular formative supervision and logistics management trainings.

Key Activities and InterventionsStandardizing logistics data collection tools: At the beginning of the program, there were multiple parallel supply chain systems set up by implementing partners for their specific needs, creating challenges for a sustainable logistics systems. In 2016, USAID/ANCRE worked in partnership with the national committee for health commodities, including MOH’s National Directorate for Pharmacy and Drugs (DPMED), other MOH directorates, and key stakeholders to develop a standardized tool to collect logistics data: the A7 register. This register

Advancing Newborn, Child and Reproductive Health Program (ANCRE)

compiles health facility level data on stock, ordering, expiration dates, stock outs, inventory, and average monthly consumption for more than 50 PHII products, including contraceptives, antibiotics, and antiretroviral drugs. Endorsed by the MOH, the A7 register integrates information needs from different implementing partners. It allows the MOH to efficiently quantify PHII tracer4 commodities based on consumption data, thus optimizing commodity supplies at the health facility level. USAID/ANCRE supported the training of health zone (HZ) commodity warehouse managers and facility-level health workers on how to correctly complete the A7 register. Registers have been distributed to all 10 project HZs: 10 to zonal commodity warehouses and 256 to health facilities.

Improving data availability through an automated logistics management systems: At the onset of USAID/ANCRE, most commodity reports were prepared by implementing partners and used through their individual database. Through a participative process at the national level, the program supported harmonization of the national logistics management systems, including the A7 register, for tracking supplies and logistics data

A provider at CS AYELAWADJE, Cotonou 2&3 health zone, checking commodities she just received

(stock and consumption status) from health facilities to HZs. ANCRE worked with the Directorate of Planning and Policy (DPP) to integrate the A7 register information into the national health information and management system (SNIGS). This integration allows for logistic data entry into the DHIS2, which USAID/ANCRE has actively supported. To date 1,942 of 2,136 logistic reports (91%) have been entered into the DHIS2 from the 10 target HZs.

Developing SOPs for supply management: USAID/ANCRE collaborated with DPMED, other MOH officials, USAID-funded Systems for Improved Access to Pharmaceutical Services (SIAPS), Expertise France, and other key partners to develop standard operating procedures (SOPs) for commodity and supply management at all levels. These procedures are designed to harmonize the systems for requisition, authorization, and use of supplies at the facility level. The SOPs include the use of A7 registers, which will further improve accountability for PHII supplies. In addition, a pocket guide for community health workers (CHWs) was developed. Upon MOH approval, the SOPs will be disseminated to all health providers and the pocket guides will go to all CHWs.

Training decentralized teams in logistics management: USAID/ANCRE trained teams who are involved in supply management at the Health Department Directorate (HDD) level to monitor the logistics of PHII supplies. These teams in turn trained HZ commodity warehouse managers and health providers from 256 public health facilities and 61 private health facilities in logistics management. Since the trainings, USAID/ANCRE, HDD staff, and the Directorate for Maternal and Child Health (DSME) staff have been providing on-site coaching to these facilities. Coaching sessions allow for analysis of indicators for decision-making, which has led to improvement in product availability.

Using a mobile health (m-health) service platform to improve community-level supply management: USAID/ANCRE introduced the use of CommCare, a mobile health service platform, to CHWs in two program-supported HZs. CommCare is used by 235 CHWs to manage community PHII commodities, such as Paracetamol®, Amoxicillin®, and Oral Rehydration Serum. Twenty-nine health facility managers also use CommCare to supervise and provide tailored support to CHWs. The project is currently working with the MOH to

PHII commodity and supply quantifications for health facilities are also more accurate.

Additionally, joint follow-up visits (MOH, SIAPS, and USAID/ANCRE) have led to improvements in both the availability of PHII products (particularly through better storage) and the reporting of logistics data, resulting in better data accuracy.

Retrospective data entry of 2016 health facility logistics reports into the DHIS2 began in the first quarter of 2017. Figure 2 shows the situation as of March 31, 2017.

Joint visit of MOH, SIAPS, and USAID/ANCRE at CoZO HZ commodity warehouse

establish interoperability links with DHIS2 for real-time transmission of logistics data from the community level.

Key Achievements

Improved logistics data completenessAs shown in Figure 1, data completeness improved from 0% in 2014 to 73% in 2016 (2,255 reports out of 3,093). Because of this, the availability of logistics data at the HZ level has improved over time, positively influencing evidence-based decision-making. With this,

Figure 1. Data completeness trends for monthly reports of PHII supplies, transmitted by health facilities, in USAID/ANCRE’s 10 target HZs

80%

70%

60%

50%

40%

30%

20%

10%

0%FY2014 FY2015 FY2016

0% 11%

73%

Figure 2. Proportion of 2016 health facility logistics reports entered in the DHIS2 by HZ as of March 31, 2017

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%AS

100%

COT 2&3

100%

COZO

100%

DCO

100%

KGS

100%

SABA

100%

Bassila

100%

AZT

84%

CBGH

60%

TCH

58%

Average

91%

Improved stock managementAs a result of USAID/ANCRE’s support to the HZs, the proportion of health facilities without stock-outs of PHII tracer commodities increased from 52% in the first quarter of 2016 to 74% in the first quarter of 2017 (see Figure 3).

Trained personnel. The project trained and set up a pool of HDD trainers who are responsible for training public and private health providers and commodity warehouse managers on managing and monitoring PHII supplies. These trainers have trained all the 10 HZ commodity warehouse managers and 317 health providers in facilities supported by USAID/ANCRE.

Lessons Learnedu Complete and reliable data ensures that managers

make appropriate supply chain decisions. USAID/ANCRE’s experience has shown that consistent coaching of HZ commodity warehouse managers and service providers is critical to improving the completeness and reliability of logistics data at the HZ level. MOH ownership of this process for continued coaching and support to HZs across the country will ensure that logistic data is complete and usable for making critical supply decisions.

Advancing Newborn, Child and Reproductive Health Program (ANCRE)Lot No. 131, Patte d’Oie, Rue 12151, Maison No. 117, Cotonou, Benin u +229 21 30 67 60 u www.projetancre.org

u The A7 register provides HZs with a tool to track and manage PHII commodities and share the information with decision makers. To date, this tool is being used only in USAID/ANCRE’s 10 target HZs. An assessment of the A7 register’s use and effectiveness in the ANCRE-supported HZs will be conducted with support from USAID/ANCRE during fiscal year 2018. If found to be a valuable tool, USAID/ANCRE will work with MOH’s DPMED to institutionalize the tool. Institutionalization of the tool will ensure its use in all 34 HZs of the country.

u The availability of quality data remains a challenge, even though there has been some identifiable progress. Quality control of data and real-time data entry of logistics reports into DHIS2 are crucial to the use of consumption data in quantifying PHII supply needs in Benin. It is recommended that the MOH provide continuous support to HZ management teams, that will outlive USAID/ANCRE, in order to improve supportive supervision of health providers as well as the use of logistics data from DHIS2 for decision-making.

Figure 3. Proportion of health facilities with stock-out of MNCH/RH tracer commodities, first quarter 2016- first quarter 2017 in USAID/ANCRE’s 10 targeted HZs

50%

40%

30%

20%

10%

0%Q2 Q3 Q4 Q1

2017Q1

2016Q2

48% 46% 35%32% 30%

26%

1 Contraceptives are part of PHII tracer commodities

2 ANCRE. Situational analysis of health workers’ performance. 2016

3 ANCRE. Health zone profiles. 2016

4 PHII tracer commodities cover Maternal, Neonatal, and Child Health/ Reproductive Health (MNCH/RH).