Situational Analysis of Options for Delivery Systems of...

This publication was prepared by staff of the Health Policy Project.

Situational Analysis of

Options for Delivery Systems

of Insecticide-Treated

Mosquito Nets Through

Antenatal Care Clinics

Deliverable 5: Final report

Libby Levison

Wayne Stinson

Peter Cross

IDEAS: Innovative Development Expertise & Advisory

Services, Inc

April 10, 2015

Suggested citation: Health Policy Project. 2015. Situational Analysis of Options for Delivery Systems of

Insecticide-Treated Mosquito Nets Through Antenatal Care Clinics. Washington, DC: Futures Group, Health

Policy Project.

The Health Policy Project is a five-year cooperative agreement funded by the U.S. Agency for International

Development under Agreement No. AID-OAA-A-10-00067, beginning September 30, 2010. It is implemented

by Futures Group, in collaboration with Plan International USA, Avenir Health (formerly Futures Institute),

Partners in Population and Development, Africa Regional Office (PPD ARO), Population Reference Bureau

(PRB), RTI International, and the White Ribbon Alliance for Safe Motherhood (WRA).

Situational Analysis of Options for

Delivery Systems of Insecticide-

Treated Mosquito Nets Through

Antenatal Care Clinics

Deliverable 5: Final Report

This publication was prepared by staff of the Health Policy Project.

The information provided in this document is not official U.S. Government information and does not

necessarily represent the views or positions of the U.S. Agency for International Development.

iii

CONTENTS Abbreviations ........................................................................................................................... v 1. Introduction .......................................................................................................................... 1

1.1 Organization of Final Report .............................................................................................................. 1 2. Activities ............................................................................................................................... 1 3. Delivery System Selection Process ..................................................................................... 2

3.1 Four Delivery System Options ............................................................................................................ 2 3.2 Two Delivery System Options ............................................................................................................ 3

4. Selected Delivery System.................................................................................................... 4 5. Calculations of Required Volumes of ITNS In Target Health Zones .................................. 6 6. Discussion Points .................................................................................................................. 8

6.1 First Storage Location: Sub-national Level ........................................................................................ 8 6.2 Transport to Sub-national Level.......................................................................................................... 8 6.3 Bale Size ............................................................................................................................................. 8 6.4 Transport to Facilities ......................................................................................................................... 8 6.5 Storage at Facilities ............................................................................................................................. 9 6.6 Documentation: Report & Requisition ................................................................................................ 9 6.7 Checks and Balances on ITN Quantities ............................................................................................. 9 6.8 Information Systems and Access to Information .............................................................................. 10 6.9 Commodity Security ......................................................................................................................... 10 6.10 Buffer Stocks................................................................................................................................... 11 6.11 Supportive Supervision ................................................................................................................... 11

7. Conclusion ......................................................................................................................... 12 8. Acknowledgements .......................................................................................................... 13 9. References ......................................................................................................................... 14 Annex 1: Scope of Work: Deliverables ................................................................................. 15

A1.1 Revised Scope of Work: Deliverables (March 16, 2015) .............................................................. 15 A1.2 Original Deliverables (January 23, 2015) ...................................................................................... 17

Annex 2: Deliverable 3: Summary of Lessons Learned From Field Visits ........................... 18 Facility/Office Visits ...................................................................................................................... Annex 3: ITN delivery system options: PPTs .......................................................................... 55

A3.1: First Working PowerPoint on Delivery System Options .............................................................. 56 A3.2: Deliverable 4: Second PowerPoint Describing Two Delivery System Options ........................... 72 A3.3: PowerPoint Presented at NATNETS Steering Committee Meeting ............................................. 87

Annex 4: Deliverable 2: Summary of PMI ITN Delivery Systems in Other Countries .......... 90 Annex 5: Variation in First ANC Attendance ........................................................................ 98 Annex 6: Preliminary Cost Parameters Analysis for ITN Delivery System ........................... 99

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v

ABBREVIATIONS

ANC Antenatal Clinic

CDC Centers for Disease Control (US)

CHW Community health worker

DHMT District Health Management Team

DMO District Medical Office/Officer

DPS Directorate of Preventative Services

EGPAF Elizabeth Glaser Pediatric AIDS Foundation

eLMIS Electronic Logistics Management Information System

FBO Faith-based organizations

HMIS Health management information system

IDEAS Innovative Development Expertise & Advisory Services, Inc.

ILS Integrated Logistics System

IP Implementing partner

ITN Insecticide Treated Net

JSI John Snow, Inc.

LLIN Long Lasting Insecticidal Net

LMU Logistics Management Unit

MEDA Mennonite Economic Development Associates

MESI Monitoring and Evaluation Strengthening Initiative

MoHSW Ministry of Health and Social Work

MSD Medical Stores Department

MSH Management Sciences for Health

NATNETS National Insecticide Treated Nets Programme

NGO Non-governmental organization

NMCP National Malaria Control Program

PMI President’s Malaria Initiative

PMO/RALG Prime Minister’s Office, Regional Administration and Local Government

PS Permanent Secretary

PSI Population Services International

PSS Pharmacy Services Section

R&R Report and Requisition form

RCHU Reproductive and Child Health Unit

RHMT Regional Health Management Team

RMO Regional Medical Office/Officer

RTI Research Triangle Institute

SOP Standard operating procedures

SOW Scope of work

TNVS Tanzania National Voucher Scheme

USAID United States Agency for International Development

WHO World Health Organization

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1. INTRODUCTION

The USAID- and PEPFAR-funded Health Policy Project (HPP) contracted Innovative Development

Expertise & Advisory Services, Inc. (IDEAS) to conduct a situational analysis for potential delivery

systems of Insecticide-Treated Mosquito Nets (ITN) through public sector Antenatal Care Clinics (ANCs)

in Tanzania. In addition, IDEAS was tasked with facilitating the stakeholder review process to identify a

preferred ITN delivery system.

This document is the final report and includes a description of the work accomplished and the delivery

system approach stakeholders identified.

This report and the system designs presented are understood to be merely an outline of how the supply

chain will operate. Numerous details must still be defined and could result in changes to the ITN delivery

system designs presented in this report.

1.1 Organization of Final Report

The report first describes the activities undertaken under IDEAS’ contract in Section 2. In Section 3, the

support to the President’s Malaria Initiative (PMI) and the NATNETS Steering Committee to select a

delivery system is discussed. The selected system is then described in detail in Section 4. Section 5

provides a forecast of the number of ITNs required for the target health zones and section 6 includes a

discussion of various factors that impact the ITN supply chain. Section 7 is the conclusion, with

acknowledgements found in Section 8. Annex 1 contains the Scope of Work. Annex 2 presents lessons

learned during field visits in Tanzania. Annex 3 contains the PowerPoint presentations on ITN delivery

system options. Annex 4 holds a summary of PMI ITN Delivery Systems in other Countries. Annex 5

discusses quarterly variation in first ANC usage and Annex 6 presents a preliminary identification of cost

parameters impacting the ITN supply chain.

2. ACTIVITIES

Situational Analysis

The HPP team conducted a desk review into the Tanzanian context on malaria and demographics and ITN

distribution programs in Tanzania and other African countries before conducting site visits to RMOs,

DMOs, and health facilities to better understand on-the-ground constraints as part of the situational

analysis (see Annex 4). The team also met with stakeholders in-country, including: USAID/PMI, NMCP,

relevant divisions within the MoHSW, and several NGOs. A summary of the insights gained from these

activities is found in Annex A2. These analyses helped the team develop four system options for ITN

delivery systems that were presented for USAID/PMI’s consideration.

Data Analysis and Reporting

The HPP team worked closely with USAID/PMI to refine the options for ITN delivery systems. PMI

chose two of the four proposed ITN delivery systems for further development. The team estimated ITN

need in the two target regions (Section 5) and prepared a summary of PMI-supported ITN delivery

systems through ANCs in other African countries.

Stakeholder Discussions and Report Development

The HPP team facilitated discussions on the ITN delivery systems at the NATNETS Steering Committee

which chose the final delivery system. Finally, the team worked with PMI to produce this report, which

compiles the collected data and analyses and documents the selection process.

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3. DELIVERY SYSTEM SELECTION PROCESS The HPP team worked closely with PMI to identify and refine possible ITN delivery system options.

3.1 Four Delivery System Options

The PowerPoint describing these options is provided in Annex A3.1.

Using background research on the Tanzanian health system and malaria burden, insights gained

from meetings and field visits in Tanzania, and desk reviews of PMI-supported ITN delivery

systems in other African countries, the team identified four possible supply chain options for

ITN delivery system through ANCs:

1. An all-public delivery system, with ITNs going to Medical Stores Department (MSD) and MSD

delivering to facilities;

2. An all-private delivery system, with ITNs going to sub-national private warehouse and private

sector distribution to facilities;

3. A public-private partnership system, with ITNs going to sub-national private warehouses and the

private sector delivering to the District Medical Office; with either the District Health

Management Team (DHMT) or the private sector responsible for distribution from the DMO to

the health facilities;

4. A ‘mixed’ delivery system, in which:

a. For one health zone or group of regions, ITNs would be delivered to MSD and MSD would

deliver them to the health facilities and

b. For the remaining target area, ITNs would be delivered to a sub-national private warehouse;

the private sector would deliver them to the District Medical Office; and either the DHMT or

the private sector would distributes the ITNs from the District Medical Office/Officer (DMO)

to the health facilities.

HPP also identified six cross-cutting issues:

1. Given what was observed on the ground in Mtwara and Mwanza, the delivery system will need to

adapt to the local context, as differences were observed between hospitals and dispensaries,

between public and Faith-based Organizations (FBO) facilities, and between Mtwara and

Mwanza demographics.

2. Any delivery system should reinforce and support existing systems; i.e., use existing resupply

procedures.

3. Given the required ITN quantities and volumes, a single item supply chain is therefore

appropriate, and given the practice of shipping ITNs in containers, it is possible to have all ITNs

sent directly to the sub-national level, thereby avoiding handling and storage at the central level.

4. Any delivery system needs to provide delivery of ITNs directly to the facility level and avoid

storage at DMOs.

5. The delivery system should include procedures to ensure accountability for and tracking of

deliveries.

6. Order and re-supply decisions should be data driven, with different data used to crosscheck

quantities discrepancies, including over supply and signs of loss.

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Finally, HPP proposed a matrix for grouping and comparing costs between proposed systems. Costs were

divided into five supply chain functions: Quantification & orders, Storage, Distribution, Management and

Information flow/Communication at each of four levels of the supply chain: National, Sub-national,

District and Facility.

3.2 Two Delivery System Options

The PowerPoint describing these options is provided in Annex A3.2.

Following internal meetings with USAID, PMI chose two delivery system options and

determined the following changes to the scenarios:

Remove system 1, the all-public delivery system, due to lack of storage and distribution

capacity.

Remove system 3, the public-private partnership system, as the option did not include

MSD.

Modify system 4, which had ITNs moving through the DMO; ITNs need to move directly

from sub-national storage to health facilities, both public and FBO.

Add an arrow to delivery system option 2 and option 4 indicating that the IP Logistics

will provide program management oversight including of sub-national storage and

distribution.

The HPP team continued to work with PMI to revise the two remaining delivery system options.

Ultimately, these became:

1. System 1, an all-private delivery system, with ITNs going to sub-national private warehouses and

with private sector distribution to health facilities;

2. System 2, a mixed delivery system, in which:

a. For one health zone or group of regions, ITNs are delivered to MSD, which then stores and

delivers them to health facilities

b. For the remaining target areas, ITNs are delivered to sub-national private warehouses and

private sector transporters deliver the ITNs directly to the health facilities.

The six cross-cutting issues remained the same.

The team further developed the work on cost parameters. For each of the five functional areas

(quantification, storage, distribution, management, and information), the team identified where costs

would be incurred and determined the likely funding source. Analysis suggests that program supply chain

costs and likely funding sources will be the same for both system options at the central, district, and

facility level. The differences in cost parameters between the two proposed delivery systems occur at the

sub-national level and reflect MSD’s participation in the program.

After PMI’s approval of the two system options, HPP developed a narrative to accompany the

presentation.

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4. SELECTED DELIVERY SYSTEM

The NATNETS Steering Committee selected System 2, the mixed delivery system option that will use a

public sector delivery system for selected regions and a private sector delivery system for the remaining

target regions. This can be considered to be two separate systems running simultaneously.

The above diagram is understood to be just an outline of how the supply chain would operate. Numerous

details remain to be defined and are beyond the scope of this situational analysis.

The Implementing Partner Logistics (IP Logistics) is the group expected to support implementation and

provide oversight of the ITN 2 ANC program.

The Implementing Partner Procurement (IP Procurement) will procure ITNs, following the order

specifications received from USAID/PMI and will arrange direct delivery to the sub-national level using a

private transport company (red arrows). Because this is a single, bulky item, ITNs will be transported in

containers. With two target health zones and good road infrastructure to all health zones, split deliveries

direct to the target health zones and/or regions, avoiding storage and handling in the Dar region, is

feasible and a pragmatic, cost-effective option (red arrows to MSD and red boxes).

At the sub-national level, ITNs will be stored either at MSD (green box) or at private storage facilities

(red boxes) to be determined in each target health zone or region. It is possible that in some areas the IP

Procurement may be directed to deliver directly to the regional level. The yellow border on the boxes

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indicates that PMI (via the future IP Logistics) will contribute to the costs of storage, including, possibly,

at MSD. The IP Logistics may provide oversight of the sub-national level (purple arrow).

ITNs will be distributed by MSD (green arrows) or by private sector companies (red arrows) from private

sector storage, again with financial support from the PMI program. All deliveries will go from sub-

national storage as direct deliveries to the health facilities (blue box). Two points should be highlighted:

first, there could be multiple private sector storage locations in a health zone or region, and multiple

private sector distributors; however the intention is that there is only one storage location between

procurement and the health facility. Second, rather than complicating the slide with many boxes, a single

blue box represents all target health facilities. Both public and FBO health facilities will likely be

included in the ITN 2 ANC program.

Information flow will work in the following way: Each health facility will fill out an ITN Report and

Requisition (“R&R”)1 and send it to their DMO (blue arrow). Health facilities will continue to report

health statistics (ANC attendance and other services) to their DMO (orange arrow). At the DMO the

“R&R” will be entered into the electronic Logistics Management Information System (eLMIS). The

“R&R” information is then available to the storage facility for order preparation and to the IP Logistics

for oversight purposes. The health statistics are entered into HMIS (orange arrows) by the DMO and are

available to the RMO and NMCP in the MoHSW.

NMCP shares the health statistics (first ANC attendance) with the IP Logistics. Sub-national storage

locations keep the IP Logistics updated about their ITN stock on hand (blue arrow out of MSD). MSD

currently has access to R&Rs in the eLMIS. The IP Logistics uses first ANC attendance data and

population data in conjunction with the “R&R” data (remaining stock balance of ITNs) to monitor each

health facility’s requisition (purple arrow). The data is also used by NMCP and the IP Logistics to plan

the program going forward (bi-directional black arrow).

Finally, the IP Logistics, in consultation with NMCP, uses first ANC attendance, ITN consumption data

and current ITN stock on hand data to estimate future ITN need; the estimate is sent to USAID/PMI for

processing. When approved, the IP Procurement (black dashed arrow) begins their procurement process.

It is worth repeating that this is only a very broad outline of how the ITN 2 ANC delivery system will

work. Numerous details remain to be defined (for example, in the future, NMCP might need and have

access to the eLMIS; at the time of this study they did not). Routine processes remain to be developed and

will require flexibility to adjust to emerging situations; e.g. changes in population or the subdivision of

one region into two.

1 The NATNETS Steering Committee requested that "R&R” be put in quotes. The current R&R does not list ITNs; it is expected that the ordering system will use the current R&R or a similar mechanism.

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5. CALCULATIONS OF REQUIRED VOLUMES OF ITNS IN TARGET

HEALTH ZONES

The volume of commodities that move through a supply chain have a direct impact on how the supply

chain will function. There must be a balance between available storage capacity at each level of the

system, the capacity of the vehicles doing the deliveries and the frequency of deliveries. If the volume

exceeds available storage capacity, then more deliveries are required; if the vehicles are too small to carry

a complete order for a facility, then either a second delivery is needed or the transporter might need to

rent a larger vehicle.

Under the Tanzanian National Voucher System (TNVS), ITNs were not part of the MoHSW’s health

commodity supply chain. PMI requested a rough calculation of the number of ITNs to be delivered

quarterly to the zonal and regional levels. The following calculation is an estimate of ITN need based on

reported first ANC attendance for 2014. See Section 6.7 for a discussion on cross checking the calculation

using population and consumption data.

For each of the target health zones, the number of first ANC visits in 20142 was totaled and divided by 12

to get the average monthly attendance in 2014. Next, assuming no change in population or increase in

usage of ANC services, the quantity required for a 3-month, 6-month and 12-month period was calculated

by multiplying the monthly average by three, six and 12.3 The number of ITNs, the number of 40-net

bales of ITNs, and the number of 40-foot containers (based on an assumption of 22,000 ITNs per 40-foot

container) were calculated.4

In the new calculations:

Blue numbers are numbers of 40-net bales of ITNs

Purple numbers are numbers of 40-foot containers.

Figure 1: Southern Zone, required ITNs

In the Southern Zone, there was an average of 10,863 first ANC visits a month during 2014. Figure 1

gives the breakdown by region.

2 NMCP provided data on 1st ANC attendance in the Southern and Lake health zones, broken down by region and district, for

2014.

3 These estimates are preliminary and are based on 2014 data. These calculations should be redone for program implementation.

4 Various stakeholders interviewed in Dar es Salaam reported that they estimate 22,000 – 25,000 ITNs per 40-foot container in

their calculations.

Avg/Q Avg/m # ITN 40' containers # ITN 40' containers # ITN 40' containers

Region Annual 40-net bales 40-net bales 40-net bales

Lindi 31,914 7,979 2,660 7,979 0.36 15,957 0.73 31,914 1.45

Mtwara 41,514 10,379 3,460 10,379 0.47 20,757 0.94 41,514 1.89

Ruvuma 56,923 14,231 4,744 14,231 0.65 28,462 1.29 56,923 2.59

1.48 2.96 5.93

Year total 130,351 32,588 10,863 32,588 815 65,176 1,629 130351 3,259

ITNs 6m ITNs 12m

Total 1st ANC visits

ITNs 3m

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The Southern Zone would need two containers (1.48) or 815 40-net bales for a 3-month period, three

containers (2.96) or 1,629 40-net bales for a 6-month period and six containers (5.93) or 3,259 40-net

bales for a 12-month period.

Figure 2: Lake Zone, Required ITNs

In the Lake Zone, there was an average of 49,085 first ANC visits a month reported during 2014. Figure 2

gives the breakdown by region.

The Lake Zone would need 7 containers (6.69) or 3,681 40-net bales for a 3-month period, 14 containers

(13.39) or 7,363 40-net bales for a 6-month period and 27 containers (26.77) or 14,725 40-net bales for a

12-month period.

The difference in number of ITNs required illustrates that the delivery system will need to be tailored to

each sub-national target area. In the Southern Zone the quantities are small enough that in all likelihood

they should be delivered to, and stored at, the zonal level, since none of the regions require a full

container per quarter. In the Lake Zone there might be an option of delivering and storing ITNs at the

regional level, since these initial calculations indicate that each region appears to require a container per

quarter. Alternatively some ITNs could be delivered to and stored at the zonal level and some at regional

level.

Limitations

The data provided includes all first ANC visits in Tanzania, for public, FBO and private

health facilities. It was not possible during the course of the situational analysis to

disaggregate the private sector data from the other health facilities.

The scope of this situational analysis did not include planning for buffer stocks at

different levels of the distribution system (sub-national, health facilities). Thus there are

no buffer stocks included in the 3-month, 6-month and 12-month totals. The location and

size of buffer stocks will be a program design decision.

Both the Southern and Lake health zones show significant variation in first ANC

attendance from Q1 to Q4. Calculations are provided in Annex 5.

Both health zones illustrate variations in attendance between reporting periods; a supply

system which determines stock re-supply quantities based on previous consumption could

see stock shortages – specifically if they use Q4 data to calculate Q1 need.

Avg/m # ITN 40' containers # ITN 40' containers # ITN 40' containers

Region Annual 40-net bales 40-net bales 40-net bales

Geita 105,947 8,829 26,487 1.20 52,974 2.41 105,947 4.82

Kagera 90,973 7,581 22,743 1.03 45,487 2.07 90,973 4.14

Mara 87,791 7,316 21,948 1.00 43,896 2.00 87,791 3.99

Mwanza 130,600 10,883 32,650 1.48 65,300 2.97 130,600 5.94

Shinyanga 85,558 7,130 21,390 0.97 42,779 1.94 85,558 3.89

Simiyu 88,148 7,346 22,037 1.00 44,074 2.00 88,148 4.01

6.69 13.39 26.77

Year total 589,017 49,085 147,254 3,681 294,509 7,363 589,017 14,725

ITNs 3m ITNs 6m ITNs 12 m


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6. DISCUSSION POINTS

This section describes several supply chain design variables that informed the ITN delivery system

options. The discussions held with USAID/PMI and other partners during the course of the situational

analysis are summarized and issues that will impact the ITN delivery system going forward are presented.

6.1 First Storage Location: Sub-national Level

ITNs are bulky items that are needed in large quantity and fill several 40-foot containers. As the previous

section showed, the Southern health zone will need six 40-foot containers in a year, and the Lake zone

will require approximately 27 40-foot containers (based on the assumption of 22,000 ITNs per container

and the preliminary estimates based on 2014 first ANC visits). Many ITN continuous distribution

programs, including other PMI programs in Africa, choose not to store ITNs at the central level but ship

them directly to the sub-national level. There is good road infrastructure between Dar and the health

zones and regional capitals, the volumes of ITNs needed total multiple containers, and there will be a

reduction in workload that will result with having a single storage location between the port and the

health facility. After discussions with PMI it was decided to not store ITNs centrally but to have the first

ITN storage location at the sub-national level.

ITN storage specifications will need to be included in contracts with private sector storage providers.

6.2 Transport to Sub-national Level

Discussions with PMI indicated that the IP Procurement will handle the ITN procurement, international

shipping (if necessary) and domestic transport to the first storage location. Based on the delivery system

selected and the discussion in 6.1, the IP Procurement would arrange delivery to the sub-national level.

6.3 Bale Size

ITNs are packed in bales at the factory. Keeping ITNs in bales until they are delivered to the health

facility has several advantages: reduced handling fees (no repacking required), uniform bale sizes makes

packing of vehicles easier, reduced loss, easier stock management (inventory at the sub-national level can

be in bales rather than individual nets). However if the bale is too large it can be difficult to move (ITN

bales are heavy and little warehouse equipment is available below the sub-national level); larger bales

might also constitute more than a 3-month supply of ITNs for smaller facilities. If the bale is too small

(e.g., a 10-net bale) then larger facilities will need numerous bales.

Tanzania has used 40-net bales in the past. This size can be moved by hand. A detailed analysis of ITN

need at a sample of health facilities of different sizes could not be done in this situational analysis, but

should be done as part of program planning. Another option would be to order the majority of the ITNs in

40-net bales and the remaining ITNs in a smaller bale size for those health facilities with low first ANC

attendance. However two bale sizes will complicate stock management at the sub-national level so the

benefits and risks should be evaluated.

6.4 Transport to Facilities

ITNs will move from sub-national storage to facilities in bales. For those regions using MSD storage and

transport, interviews with MSD Mtwara and MSD Mwanza indicate that the volume of ITNs will likely

require a separate delivery from the quarterly deliveries currently made by MSD to each health facility.

For those regions using private sector storage and transporters, the delivery frequency will be specified in

the contract.

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The contract(s) with the private sector will need to specify the requirements for ITN good distribution

practices. Specifications should include establishment of a delivery schedule, including the times at which

deliveries can arrive at health facilities; appropriate temperature range during transport; and the

commodities that should not be shipped with ITNs (to mitigate any risk of; e.g., decreasing their efficacy).

6.5 Storage at Facilities

The majority of interviewed facilities suggested that ITNs for daily use be stored in the ANC clinic with

bales stored in the facility’s medical storeroom. Visits to the ANC clinics and storerooms of these 11

facilities indicated available space.

ITNs have not been stored in public sector health facilities in the past few years. The issue of stock

management of ITNs was discussed at the NATNETS Steering Committee meeting and it was agreed that

management of ITNs would follow existing standard operating procedures (SOPs) for stock management

that are currently followed in health facilities.

Facilities offered different suggestions on when the ITNs should be given to the client. The majority felt

that the nurse doing the counseling should ‘dispense’ the ITN, including explaining why the ITN is

important. However in some health facilities the client changed rooms repeatedly and the staff felt that the

ITN should be handed out later in the visit so that the client did not have to carry the ITN through the

facility.

6.6 Documentation: Report & Requisition

Health facilities use the R&R to report on their stock status each quarter. The R&R form is a standard

stock management tool with columns for: beginning balance, stocks received, losses & adjustments,

ending balance, consumption, maximum stock level and the quantity to order. The R&R moves from

health centers and dispensaries to the DMO, where the data in entered into the eLMIS. Hospitals enter

their data directly into the eLMIS.

ITNs are not currently listed in the R&R. Different stakeholders expressed different views on the amount

of time required to change the MoHSW R&R. One stakeholder felt this could be done quickly, while

another reported that a previous change had required 18 months. Printing and distributing new R&Rs can

take additional time. All stakeholders agreed, however, that there are blank lines on an R&R where the

facility can request additional items (ITNs) – but the user has no reminder to order that commodity.

Exactly how ITNs stock levels are reported and resupply requested will be an implementation detail of the

program. However the information sent should be consistent with the information collected for other

commodities on the R&R.

Stakeholders felt that this is only an issue at the health facility level. Adding items to the eLMIS was

reported to be much easier and could happen quickly.

6.7 Checks and Balances on ITN Quantities

Calculations of required quantities of ITNs will be more accurate if multiple sources of data are used.

Using different methods to estimate need will also highlight unexpected variations.

There are three types of data that can be used to calculate ITN need:

Service data, i.e., number of reported first ANC attendances in the previous year

or quarter

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Population data, specifically expected pregnancies in a region

Past consumption data.

Section 5 presented the calculations of needed ITNs based on 2014 first ANC attendance data. First ANC

attendance figures should be less than or close to the expected number of pregnancies in a year.

Tanzania’s Demographic Health Survey 2010 gives the pregnancy incidence rate per region; the Tanzania

2012 census gives the population. The expected number of pregnancies (population * pregnancy

incidence) will give an upper bound on the number of ITNs needed in a district or region. If the service

data significantly exceeds the pregnancy incidence it merits investigating whether data is reported

correctly or if there was an error in calculation. A more accurate upper bound can be achieved by

adjusting for ANC uptake (the DHS reports that 95% of women attend an ANC at least once during their

pregnancy.)

Once the program has been running for a year, it will also be possible to use past ITN consumption data

as a check on requisition quantities. The consumption patterns for the same quarter in the previous year

will provide a lower bound on the number or ITN required in a region. This can be adjusted for with

changes in population size and planned program growth.

These calculations depend on high levels of reporting of accurate, up-to-date data. Recently several

regions and districts have been sub-divided into two, resulting in a significant decrease in population and

service statistics data for the old region or district. The ITN 2 ANC program will need to take such

changes into consideration going forward.

Data triangulation will be important to ensure availability of ITNs in health facilities.

6.8 Information Systems and Access to Information

All supply chains depend on timely and accurate information. The flow of commodity and health statistics

from each facility to the national level was described in Section 4. Facilities complete an R&R quarterly,

and then meet with the DMO to review the R&R. The DMO and facility finalize the quantity of each

commodity that is being requisitioned and the data is entered in the eLMIS. What facilities do not know is

how much of their requisition can be filled by the sub-national storage facility and when the order will be

delivered.

Tanzania is working to expand the reach of the eLMIS. Stakeholders reported that by 2016 it is hoped that

facilities will be able to access eLMIS data directly.

In the meantime, the ITN 2 ANC program might benefit from a mechanism that allowed health facilities

to alert the Regional Health Management Team (RHMT) and DHMT of potential problems with stock

availability, e.g., stock outs, delayed deliveries, damage to existing stocks or a significant increase in

patient uptake. Under the TVNS system, facilities used SMS for Life to report stock levels of malaria

commodities monthly. This program does not seem to be currently running. A similar mechanism to

allow facilities to communicate issues with the ITN delivery system could strengthen the program.

6.9 Commodity Security

Commodity security has been discussed in sections 6.3, 6.4 and 6.5. ITNs will need to be tracked

following MoHSW stock management SOPs, including filling out stock cards, correct use of way bills

and shipping documents, etc.

11

It is expected that all contracts with storage and transport suppliers will include explicit requirements for

reporting any losses within a fixed amount of time. Penalties for failing to meet contractual obligations

should also be defined in the contract, as well as incentives for consistent excellent performance.

Commodity security within the health facility is the responsibility of the facility. However as discussed in

6.5, it is likely that ITNs will be stored in two locations at the facility: in the medical storeroom and a

small quantity for daily use in the ANC. It is expected that systems consistent with MoHSW existing

stock security SOPs will be established to track and move ITNs within each facility.

6.10 Buffer Stocks

The ITN 2 ANC program will need to establish ITN buffer stocks so that additional ITNs are available at

various levels should health facilities experience shortages.

6.11 Supportive Supervision

Field observations suggest that current supportive supervision quality is likely to be inadequate in some

locations. The ITN 2 ANC program will depend on implementation of new procedures and

documentation by health facility staff. Adequate implementation of the new procedures and

documentation will depend on both training and quality supportive supervision provided by the

responsible staff on the Regional and District Health Management Teams (RHMT and DHMT). The ITN

2 ANC program may have to provide, at a minimum, start-up support to some RHMTs and/or DHMTs to

ensure the adequate performance of the new functions.

12

7. CONCLUSION

The situational analysis began with discussions with USAID/PMI staff and staff of USAID grantees and

contractors, incorporated field visit observations, and included insights gained from a document review of

similar ITN programs in other African countries. Four system options for the delivery of ITNs to

antenatal clinics in Tanzania were identified. USAID/PMI staff evaluated these options, requested

clarifications and adjustments, and finally identified two delivery system designs to be presented to, and

discussed with, the NATNETS Steering Committee. The Steering Committee selected the “mixed”

delivery system option, which includes both private and public sector storage and distribution of ITNs to

public and faith-based health facilities.

The selected delivery system anticipates that the ITNs for the program will be delivered in containers

directly to the sub-national level (either health zones or regions), where the ITNs will be stored and from

where they will be delivered directly to health facilities. Depending on future decisions, MSD and the

private sector partners will be assigned specific health zones and regions, in which each will provide

storage and last-mile delivery of ITNs to health facilities. The quantities to be delivered to the health

facilities will follow current ordering mechanisms: requests from ANCs will be reviewed, approved and

entered into the eLMIS by members of the District Health Management Teams, then forwarded to the

warehouse for order preparation and delivery.

The mixed system will permit the ITN 2 ANC program to take advantage of the strengths of the public

and private sectors and to compare their performance and costs. The mixed delivery system also provides

flexibility, permitting the program to increase or decrease the role of either sector based on their

performance and cost. The advantages afforded by the mixed option should more than offset the

additional cost of managing and monitoring the performance and costs of two distinct sub-options.

The selected delivery system has only been described in general terms. Implementation will involve the

development of more descriptive and operational detail, the triangulation of data from multiple sources

and the flexibility to respond to the different characteristics of the target health zones. The mixed delivery

system option has the potential to provide the required service at a cost controlled by a competitive

market.

The situational analysis for the future ITN 2 ANC program received exceptional support and

collaboration from all stakeholders, officials and staff of the Government of Tanzania, Ministry of Health

and Social Welfare, USAID/PMI staff and staff of its grantees and contractors, and members of

Tanzania’s private sector. Such collaboration bodes well for the future ITN 2 ANC program.

13

8. ACKNOWLEDGEMENTS

This situational analysis would have not have been possible without the support of numerous parties. PMI

and the CDC offices in Tanzania, in particular Naomi Kaspar and Chonge Kitojo, helped schedule and

direct us to all appointments in Dar es Salaam. Dr George Greer, Dr Lynn Paxton, and Ana Bopelo-

Memba at PMI and CDC, and USAID Supply Chain Advisor Kelly Hamblin and Supply Chain Specialist

Lulu Msangi made themselves available for numerous meetings and discussions. The staff of NMCP

helped select field visits locations, provided data on the ANC/malaria program, and accompanied us to

the field: thanks to Dr Renata Mandike, Dr Karen Kramer, Wilhelmina Rimisho and Ally Mwanza.

Futures’ DC office helped to get invitation letters for Tanzanian visas, and Futures’ Tanzania office

helped book internal flights and accommodation in Mtwara and Mwanza.

In Mtwara, the field visit was possible thanks to the support of the Mtwara EGPAF office, which

provided a vehicle and driver, and whose clinical officer Dr Peter Nagunwa spent three days in the field

with us. RMO Mtwara allowed Albertina Mlowola (RCH coordinator) and Mary Mkama (Regional

malaria focal person) to work with us for three days and Mtwara Municipal Council let Mahmoud Kaisi

reprogram his work to spend a morning with us in the field.

The Mwanza field visit was facilitated by the Mwanza Regional Medical Office (especially the Regional

Nursing Officer, Agnes Hassan) and by staff of the URC-MSH Tibu-Homa project: Naiman Msangi and

Michael Bajile. Thanks to the leadership of these two organizations for availing valuable staff time, as

well as to the numerous local health personnel and private sector representatives for contributing

information for this assessment.

Thanks also to the staff of Jhpiego, RTI, PSI, JSI/Deliver, MEDA, the Tanzania Red Cross Society, DfID,

MoHSW/NMCP, MoHSW/RCHU, MoHSW/MESI, MoHSW/DPS, MoHSW/PSS/LMU and Achiles for

making time to meet with us. Last but not least, we thank all of the health staff at health facilities in the

Dar, Coastal, Mtwara and Mwanza regions who agreed to meet with us and answer our questions.

14

9. REFERENCES

See also references listed in Annex 4, Summary of PMI net delivery programs in other African countries.

Amenyah, Johnnie, Barry Chovitz, Erin Hasselberg, Ali Karim, Daniel Mmari, Ssanyu Nyinondi, and

Timothy Rosche. 2005. Tanzania: Integrated Logistics System Pilot-Test Evaluation: Using the Logistics

Indicator Assessment Tool. Arlington, Va.: DELIVER, for the U.S. Agency for International

Development.

Koenker, Hannah, Joshua Yukich, Alex Mkindi, Renata Mandike, Nick Brown, Albert Kilian, Christian

Lengele. Analysing and recommending options for maintaining universal coverage with long-lasting

insecticidal nets: the case of Tanzania in 2011. Malaria Journal2013,12:150. Available online at:

http://www.malariajournal.com/content/12/1/150.

McCord, Joseph, Marie Tien, and David Sarley. 2013. Guide to Public Health Supply Chain Costing: A

Basic Methodology. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 4.

Mikkelsen-Lopez, Inez, Winna Shango, Jim Barrington, Rene Ziegler, Tom Smith, Don deSavigny. The

challenge to avoid anti-malarial medicine stock-outs in an era of funding partners: the case of Tanzania.

Malaria Journal2014,13:181. Available online at: http://www.malariajournal.com/content/13/1/181

Musau, Stephen, Grace Chee, Rebecca Patsika, Emmanuel Malangalila, Dereck Chitama, Eric Van Praag

and Greta Schettler. July 2011. Tanzania Health System Assessment 2010. Bethesda, MD: Health

Systems 20/20 project, Abt Associates Inc.

National Bureau of Statistics (NBS) [Tanzania] and ICF Macro. 2011. Tanzania Demographic and Health

Survey 2010. Dar es Salaam, Tanzania: NBS and ICF Macro.

President’s Malaria Initiative, Tanzania Malaria Operational Plan FY 2014

President’s Malaria Initiative, Tanzania Malaria Operational Plan FY 2015

Printz, Naomi, Johnnie Amenyah, Brian Serumaga, and Dirk Van Wyk. 2013. Tanzania: Strategic Review

of the National Supply Chain for Health Commodities.

Tien, Marie, Elaine Baruwa, and Darwin Young. 2013. Supply Chain Costing Tool User’s Manual.

Arlington, Va.: USAID | DELIVER PROJECT, Task Order 4.

UNICEF Supply Division. Long Lasting Insecticidal Nets Supply Update. Denmark. Available online at:

http://www.unicef.org/supply/files/LLIN_Revised_Update_May_2014.pdf. May 2014.

USAID. USAID/Tanzania National Voucher Scheme Evaluation. Public-Private Partnership to Distribute

Insecticide-Treated Bednets to Pregnant Women and Infants. Report No. 11-01-496, available online at

http://resources.ghtechproject.net. September 2011.

15

ANNEX 1: SCOPE OF WORK: DELIVERABLES

The original SOW was signed on January 23, 2015. During the first field visit, USAID/PMI requested

modifications to some of the deliverables in the IDEAS contract. The final Scope of work and

Deliverables is provided in Annex A1.1 (extracted from the revised SOW issued by the Health Policy

Project on March 16, 2015). The original list of deliverables is presented in Annex A1.2 (approved

January 23, 2015).

A1.1 Revised Scope of Work: Deliverables (March 16, 2015)

Attachment 1: Scope of Work

Background

Futures Group develops and delivers innovative, locally relevant, evidence-based solutions to improve the

health and well-being of people around the world. Since 1971, we have assisted governmental and non-

governmental agencies, foundations, and the private sector by designing, implementing and evaluating

programs in HIV/AIDS, sexual and reproductive health, population and family planning, maternal and

child health, infectious diseases, and gender. Futures Group has deep expertise in policy and advocacy,

research and strategic information, health markets and private sector engagement, modeling and economic

analysis, patient monitoring and management/HMIS, strategic consulting, and program management.

In Tanzania, Futures Group is working with USAID through the global five year cooperative agreement,

the Health Policy Project (HPP), and the President’s Malaria Initiative (PMI) to improve ITN distribution

to pregnant women. This is a key component of Tanzania’s 2014-2020 National Malaria Strategic Plan,

which aims to reduce the average country malaria prevalence from 10% in 2012 to less than 1% in 2020.

The current strategy uses insecticide treated nets, LLINs in particular, as the principal vector control

measure in most of the country. High LLIN coverage, achieved as a result of national mass campaigns

from 2009 to 2011, has been a major factor responsible for a dramatic increase in the number of

households owning and using LLINs and a corresponding decrease in malaria prevalence from 18.1% in

2008 to 10% in 2012. The Tanzania National Voucher Scheme (TNVS), a public-private partnership, is

part of the national strategy to ensure high LLIN ownership over time via continuous distribution

channels. Since 2004, the scheme provided 13 million LLINs via subsidized LLIN vouchers given to

pregnant women receiving ANC at health facilities and to caretakers of infants receiving the measles

vaccine. However, the program faces significant supply and demand side constraints, as well as uptake

issues in rural areas. Faced with these challenges, the Government of Tanzania and donors are now

considering developing a new LLIN distribution system.

In response to these issues, and to sustain LLIN coverage, PMI requested HPP to conduct a situational

analysis that will present factors that must be considered in designing a LLIN distribution through public

sector ANC clinics.

Scope of Work

The contractor will conduct an analysis of the logistic needs, resources available and resource gaps at

critical levels (with a particular focus on the district and health facility levels), and projected costs of a

new system designed to deliver LLINs to pregnant women through public sector ANC clinics. The new

delivery system will meet following parameters:

LLINs for ANC clinics will be procured and delivered to central level storage using USAID’s

central procurement mechanism. This mechanism is responsible for procuring and importing all

PMI commodities;

16

Delivery of LLINs from central level to district level will be the responsibility of a new PMI

implementing partner;

Storage of LLINs at district-level will be the responsibility of the district political and medical

authorities, with financial and technical support from PMI; and

Delivery of LLINs from the district level to facility level will be a joint responsibility of the

district political and medical authorities and a new PMI implementing partner.

Research questions

This situational analysis will inform the development of a new PMI/USAID procurement and all results

collected as part of this activity will be shared with the Government of Tanzania through the NMCP. The

recommended delivery mechanisms should be robust across various volumes of LLINs delivery to ANC.

Specifically, the following research questions will be answered:

1. What are the cost and practical considerations of two distinct delivery mechanisms for LLINs

from central level to district level? The response could consider potential private sector

engagement in one of the mechanisms.

2. What is the most cost-efficient and feasible option for storage of LLINs at district level?

3. The response will consider general capacity for storage/stock management of LLINs, security,

controls to prevent leakage, and monitoring mechanisms.

4. What are the cost and practical considerations of two distinct delivery mechanisms for LLINs

from district to health facility level? The response can consider push and pull mechanisms.

Methodology

The study will draw on ANC delivery systems in other PMI countries for comparisons and consult the

USAID|DELIVER project in Tanzania as well as globally, which procures LLINs for PMI and handles

the delivery to subnational levels in some cases, as an additional resource. Technical experts will engage

in one fact finding mission at the national and district levels in Tanzania to inform key elements of the

approach, which include:

Identifying opportunities in the public and private sector for storage and delivery of LLINs from

central level to districts

Determination of the general capacity for storage and stock management of LLINs at district and

health facility levels

Description of the current district level health system functioning in relations to commodity

distribution to facilities and the capacity gaps

Description of capacity to ensure the security of LLINs at various levels

Identification of controls that are needed to prevent leakage at various levels of the supply chain

Description of record keeping approaches that will ensure accurate tracking of LLINs to the

end user

Description of the information flow needed for the supply chain, i.e. to ensure timely delivery of

LLINs to district level and from district level to health facility level and prevention of stock outs

Description of a minimum of two scenarios for delivery of LLINs from district level to health

facility level

Description of PMI net delivery programs in other countries.

17

The subawardee will be expected to hold in-country talks with USAID/PMI, the NatNets

Steering Committee and additional stakeholders on system design issues and considerations prior to the

development of the final report.

Expected Deliverables:

No. Description

1 5-10 page narrative on key system design issues

2 2 page summary of PMI net delivery programs in other countries

3 Summary of lessons-learned from field visits in Tanzania

4 PowerPoint presentation describing the report and including system design options and

methodology

5 10-15 page report outlining the system design options, including distribution and cost parameters

and remaining system design questions

A1.2 Original Deliverables (January 23, 2015)

The original table of Expected Deliverables appears below.

Expected Deliverables:

No. Description

1 Draft Excel-based costing tool to assess the cost feasibility of different modes of delivering

LLINs through ANC, considering volume and decisions at every tier of the supply chain

2 Final Excel-based costing tool

3 10-15 page report outlining the situation and factors needed to develop a LLIN distribution

system. The report will include cost elements and distribution scenarios.

4 PowerPoint presentation describing the report and including LLIN net distribution from

districts to health facility scenarios for consideration (also include methodology)

18

ANNEX 2: DELIVERABLE 3: SUMMARY OF LESSONS LEARNED

FROM FIELD VISITS

Situational Analysis of Options for Delivery Systems of Insecticide-

Treated Mosquito Nets through Antenatal Care Clinics

Deliverable 3: Summary of lessons-learned from field visits in

Tanzania

Libby Levison

Wayne Stinson

Peter Cross

IDEAS: Innovative Development Expertise & Advisory Services, Inc.

April 8, 2015

Acronyms



DHMT District Health Management Team

DMO District Medical Office/Officer


HMIS Health management information system




JSI John Snow, Inc.


MESI Monitoring and Evaluation Strengthening Initiative

19







R&R Report and Requisition (form)

RHMT Regional Health Management Team

RMO Regional Medical Office/Officer

RCH Reproductive and Child Health

RHU Reproductive Health Unit


SP Sulfadoxine/pyrimethamine (Fansidar)

TNVS Tanzania National Voucher Scheme


20

Table of Contents

Summary of Lessons Learned

Annex 1: Trip 1 Report, February 2-13, 2015

Attachment 1: Respondents

Attachment 2: Detailed program

Attachment 3: Data collection tools

Annex 2: Trip 2 Report, March 9-13, 2015


Attachment 2: Detailed program

21

Summary of Lessons Learned

Introduction

Drs. Levison and Stinson spent 10 days in Tanzania in February, and Levison returned for 5 additional

days in March. The consultants met with numerous

stakeholders of both the proposed program and other ITN

distribution programs (mass-campaign, school net, previous

ANC ITN program), in both Dar es Salaam and in two health

zones: Mwanza and Mtwara. The consultants also met with

several private transporters and Duka la Dawas. During the

first trip the consultants spent 4 of the 10 days in the field.

This document is a compilation of insights gathered during

meetings and site visits. Trip reports for Trips 1 and 2 are

submitted as Annexes 1 and 2. Each of these annexes includes

a program of activities and a list of people met.

Methodology

At RMOs, DMOs, and health facilities, data was collected thru

informal interviews with staff following a memory aide data

collection form (Annex 1: Attachment 3). At MSD, consultants had prepared a set of questions to ask

MSD about their requisition processing and packing and the direct delivery system. Meetings with NGOs

and partners in Dar were conducted as informal interviews.

On 6 February, the IDEAS consultants visited a regional medical office (RMO), accompanied by a

representative of the National Malaria Control Program (NMCP). They also visited a district medical

office (DMO), a rural health center and a peri-urban dispensary, all located relatively close to Dar es

Salaam. From 9 to 11 February the consultants separately visited two Tanzanian health zones: the

Southern Zone and the Lake Zone. The text box indicates the type and number of facilities visited

including those close to Dar es Salaam. The following sections will follow the major functions of the

ITN supply chain5 and cross-cutting issues.

Limitations

The consultants visited each of the two health zones that will be included in the first phase of the project.

The districts and health facilities visited were selected by NMCP/NetCell after discussion with the

consultants. The districts and health facilities visited were not selected randomly. In one region the

RMO preferred to have the consultant visit facilities in his region and changed the visit list, possibly

influenced by an understandable preference to direct the consultants to better performing facilities.

Quantification

Population estimates are available and should be used more frequently as a check on reported service

data. One regional office provided a DHIS2 report for 2014, showing 362 1st ANC visits for the regional

total, while regional staff reported that the actual number had been approximately 29,000. In other

instances reported 1st ANC visits appear to be greater than the number of anticipated pregnancies. The

MOHSW’s Monitoring and Evaluation Strengthening Initiative (MESI) unit indicates that it has an 86%

5 Management Sciences for Health. 2012. MDS-3: Managing Access to Medicines and Health Technologies. Arlington, VA:

Management Sciences for Health.

FACILITY/OFFICE

VISITS

Regions 4

Districts 7

RMOs 3

DHOs 5

MSD (zonal stores) 2

Hospitals 3

Health Centers 4

Dispensaries 4

Duka la Dawas 2

Private transporters 5

22

HMIS reporting rate, but respondents indicated that reports may not complete and that there are data

quality issues.

In the urbanized Mwanza Region, private-for-profit facilities represent 15.6% of all facilities. Their

proportion of 1st ANC visits was not available, but is probably relevant for quantification, if nets are not

to be provided to women receiving 1st ANC services at private facilities.

Procurement

Procurement of ITNs and transport to the first in-country warehouse was not included in the scope of

work of the situational analysis. As noted below, however, the consultants observed adequate storage

possibilities at the zonal and/or regional level, such that ITNs could be delivered directly to the sub-

national level (zones or regions).

Storage

In both zones, however, Medical Stores Department (MSD) lacked sufficient storage capacity, and in one

zone MSD had no place to park a container, let alone several. In one case MSD suggested containers

might be parked at the Government Procurement Service Agency. An informant in the Pharmacy

Services Section (PSS) of the MoHSW expressed serious concerns about MSD zonal stores’ capacity to

store and transport the ITNs.

Private transporters, on the other hand, indicated that they had storage capacity or could easily hire it. In

at least one region, they confirmed flexible storage space, if necessary through rental of space in private

houses.

The team meet with several NGOs in Dar, which are implementing malaria control programs. One NGO

told the team that temporary local storage for spraying supplies could be found in agricultural warehouses

(cooperatives). These warehouses are used seasonally, however, and would probably not be available

year-round, as required for continuous distribution of ITNs.

MSD implemented a system of Direct Delivery in 2013, delivering all public health commodities, but not

including ITNs, directly to hospitals, health centers and dispensaries. The consultants observed that the

health facilities that they visited have adequate storage capacity, while the district medical offices which

they visited do not. (Note that storage requirements depend on the frequency of routine deliveries as well

as the volume of services.) The DMOs also lacked a storekeeper or staff with storekeeper skills.

Transport (Supply and Resupply)

The Mwanza zonal offices of the Medical Stores Department expressed interest in delivering ITNs for the

ANC program but noted they would need to be paid for this service. MSD has its own trucks in both

zones, but MSD Mtwara reported that their trucks are often fully booked. MSD, however, is legally

authorized to contract with pre-qualified private distributors, when necessary. Delivery to health facilities

is on a fixed quarterly schedule. In at least one zone,

MSD charges TSh 36,000 ($20) for packing each order and TSh 130,000 ($74)/for delivery to each

facility in the zone, regardless of distance. Informants indicated that emergency deliveries are only rarely

made to health centers and dispensaries, while hospitals, which often have their own vehicle, are able to

directly pick up emergency supplies at MSD warehouses. MSD/Dar shared the current charging

mechanism for vertical programs which is currently based on the value of the order. MSD is developing a

proposal to convert the charging mechanism to be volume-based.

23

Staff in two District Health Offices indicated that the DMO has a monthly visit schedule to health

facilities to distribute vaccines and to conduct supervision, and thought ITNs could be added. Many

health facility respondents felt that private sector transporters would be more reliable than MSD, both in

terms of flexibility of scheduling and with regard to ensuring that the requested quantities are delivered.

Private transporters are common at both the regional and district levels. The consultants visited five

transport companies. All indicated that they have, or could hire the required transport capacity.

One shopkeeper at a private retail pharmacy, a Duka la Dawa, reported that she places an order every 2 to

3 months with a distributor in Dar es Salaam. She calls in the order, pays with mPesa (a mobile banking

system), and the order is delivered in 2 days.

Management

The consultants were told that MSD’s order-to-receipt cycle is lengthy. Health facilities prepare a stock

report and requisition (R&R) form, which is reviewed and entered in the electronic logistics information

system at the DMO. Health facilities report receiving partially filled orders after significant delays; e.g.

facilities in Mwanza rarely had SP during 2014. Stock outs at facilities were attributed to inadequate

order fill-rates by MSD.

Information

The consultants checked several health facility stock cards, some were accurate, but in one instance it

appeared that there was a substantial difference between stock-in-hand and that indicated by the stock

card.

The quarterly Report & Requisition form (R&R) is the mechanism for moving stock availability and need

data from health facilities to the DMO and on to MSD. DMOs review the R&R with facility staff and

enter the R&R data into the Integrated Logistics System, a computerized system that includes 150 items

(HIV/ARV, Lab and TB items are not included in ILS). MSD uses the R&R to prepare each facility’s

order. Rollout of the electronic logistics management information system (eLMIS) began in mid-2014.

The eLMIS includes all the items in the R&R, plus the HIV/ARVs, Lab and TB items.

ILS Gateway is a text-based system which is implemented at the facility level. Each month facilities

report on stock levels of 20 tracer products via text message. Again, ITNs are not currently included. ILS

Gateway provides a monthly snapshot of stock availability of the tracer products across the country.

Under the previous Tanzania National Voucher System (TNVS), malaria product stock levels were

reported monthly using SMS-for-Life; one informant reported that the response rate for SMS-for-Life was

lower than for ILS Gateway.

ITNs are not currently included in the R&R, ILS, eLMIS and ILS Gateway systems, as they have not

previously moved through the public sector.

Security

MSD has some control systems for their drivers and vehicles. At least one source, however, felt that a

large fraction of MSD purchases were “lost” before reaching the intended public sector or FBO patient.

Public sector health facilities have standard operating procedures for receiving orders, managing stock

cards and issuing items.

24

Behavior Change Communication and Training

While the need for BCC addressed to expectant mothers to encourage consistent use of ITNs is well-

understood, Dar informants also stressed the need for substantial efforts to explain the new ANC

distribution system to clinic staff and supervisors and to train them in their new responsibilities. They

suggested that BCC should target multiple audiences: pregnant women, ANC staff and MoH staff

(especially the District and Regional malaria focal persons).

Supportive Supervision

Field observations suggest that current supportive supervision quality is likely to be inadequate in some

locations. The ITN 2 ANC program will depend on implementation of new procedures and

documentation by health facility staff. Adequate implementation of the new procedures and

documentation will depend on both training and quality supportive supervision provided by the

responsible staff on the Regional and District Health Management Teams (RHMT and DHMT). The ITN

2 ANC program may have to provide, at a minimum, start-up support to some RHMTs and/or DHMTs to

ensure the adequate performance of the new functions.

Planning for ITN distribution

The Tanzania Red Cross Society (TRCS) has participated in both school-net and mass catch-up

campaigns. They described how they prepare for each distribution: a significant amount of time is spent

on mapping the storage and transport options in each target district. TRCS uses their volunteer network

across the country for this mapping activity: identifying secure locations for (short-term) storage of ITNs

and reporting on road conditions and transport agents. The TRCS stressed the importance of

understanding the local context of each distribution point and establishing a logistics system that could

adjust to local conditions and requirements.

25



Annex 1: Trip 1 Report, Tanzania February 2-13, 2015

Libby Levison

Wayne Stinson

Peter Cross


April 8, 2015

26

Acronyms

AIDS Acquired Immunodeficiency Syndrome


CDC Centers for Disease Control

CoP Chief of Party

DC District of Columbia

DfID Department for International Development

DMO District Medical Office

EGPAF Elizabeth Glazier Pediatric AIDS Foundation

HC Health Center

HIV Human Immunodeficiency Virus

HMIS Health and Management Information System



JSI John Snow, Inc.

M&E Monitoring & Evaluation

MCH Maternal and Child Health

MCSP Maternal and Child Survival Program

MDG Millennium Development Goals






PMORALG Prime Minister’s Office, Regional Administration and Local Government


RA Regional Advisor

27

RCH Reproductive and Child Health

RCHS Reproductive and Child Health Services (MoHSW)

RFP Request for Proposals

RH Reproductive Health

RMO Regional Medical Office

RN Registered Nurse


SoW Scope of Work

TA Technical Advisor

UK United Kingdom

US United States


28

As part of the work under the Futures Group under Contract 17495.001.IDEAS.03, Situational Analysis

of the Delivery of Insecticide-Treated Mosquito Nets through Antenatal Care Clinics in Public Health

Facilities in Tanzania, the IDEAS team – Dr. Libby Levison and Dr. Wayne Stinson – traveled to

Tanzania to conduct a situational analysis.

Summary of work accomplished:

Week 1:

The focus of the first week was to collect information in Dar es Salaam, to understand the requirements

for the proposed program and to begin to explore the various options for delivering ITNs through ANCs.

Meetings were held with: USAID/PMI, CDC, USAID/Supply chain, Jhpiego, PSI International, RTI, The

Tanzania Red Cross Society, UK Department for International Development, JSI/Deliver, and MEDA. In

the Tanzania Ministry of Health and Social Welfare (MoHSW), meetings were held with: the National

Malaria Control Program, the Department of Reproductive and Child Health, the Department of

Preventive Services, the Prime Minister’s Office, Regional Administration and Local Government and the

Monitoring and Evaluation Strengthening Initiative/HMIS division. In the private sector, we met with

Achelis Trading company, a logistics service provider.

Friday the team traveled to the field in the environs of Dar to practice data collection and to test the data

collection tools. This involved visiting the Kinondoni District health office, Kimara Dispensary, the

Pwani Regional Medical Office and the Mlandazi Health Center.

The weekend was spent revising data collection tools, conducting additional background research and

preparing for the following week.

Week 2:

In week two Dr. Levison traveled to the southern health zone (Mtwara region) and Dr. Stinson traveled to

the lakes zone (Mwanza region) to conduct data collection. Meetings were held with Medical Stores

Department in both zones, with Regional Medical Teams, District Health Teams, private sector transport

agents and health facilities between Monday and Wednesday. A complete list of people met is found in

Annex A.

Both team members returned to Dar by Thursday and spent the day preparing materials for a PMI

debriefing on Friday. A few meetings were held on Friday afternoon (with Achilles and the M&E

department of the MoHSW).

Results:

The trip was highly productive. Not only was IDEAS able to collect information on how the previous

ITN distribution system (the Tanzanian Voucher Program) ran, but also to understand several of the

constraints and considerations that will impact the new program. IDEAS received significant support

from PMI, who scheduled our meetings, and from Futures, who helped us with internal travel.

One significant issue was discovered early on, and discussed with Arin Dutta while he was in Dar: the

RFP and resulting SOW specified that IDEAS would construct an Excel-based supply chain costing tool.

Discussion with USAID/PMI and key stakeholders in country, however, revealed that several important

decisions regarding the ITN distribution system design have yet to be finalized. Without these, the supply

chain is notwell enough delineated to be costed.

29

Instead, USAID/PMI has requested that IDEAS provide guidance on what system design parameters will

impact the cost and feasibility, security and robustness of the supply chain to distribute ITNs through

ANCs across Tanzania. These parameters could also be used by USAID/PMI and partner(s) in the

development of the delivery system for ITNs through ANCs.

After discussion between Arin Dutta and PMI, Arin informed IDEAS that he understood the need to

revise the Scope of Work and that the priority was to deliver the product that PMI currently needs. To

this end, IDEAS has submitted a revised scope of work and deliverables, consistent with the PMI’s

identified needs to Futures for its consideration.

Next Steps

IDEAS continues to analyze the data collected on how medical supply chains operate in Tanzania and to

identify the costing parameters at each level of the supply chain for different system design options.

IDEAS is also writing a lessons learned brief and is preparing a discussion on key system design issues.

The foregoing will be presented and discussed at a meeting of the NatNets Steering Committee with

IDEAS, when Dr. Levison returns to Dar during the week of March 9.

Annexes:


Attachment 2: Detailed Program

Attachment 3: Data Collection ToolsAttachment 1: Respondents

Date Informant Position. Organisation

National Level

2/2/15 Dr George Greer RA PMI, USAID

2/2/15 Dr Lynn Paxton Case Mgmt & Surveillance, CDC

2/2/15 Ms Naomi Kaspar

2/2/15 Raz Stevenson Quality and Service Delivery, USAID

2/2/15 Kelly Hamblin Sr Supply Chain Advisor, USAID

2/2/15 Lulu Msangi Khery Supply Chain Specialist, USAID

2/2/15 Janean Davis HIV/AIDS team lead, USAID

2/2/15 Ana Bodipo-Memba Community-based Service Team Lead, USAID

Formatted: Heading 2

30


2/2/15 Harriet Hamis Program Officer Integration, Jhpiego

2/2/15 Rose Mnzava Mid-wife advisor, Jhpiego

2/2/15 Dunstan Bishanga Chief of Party MCSP, Jhpiego

2/2/15 Rita Willilo Sr TA, RTI

2/2/15 Dr Stephen Magesa Dir. Vector Control Operations, RTI

2/2/15 Mubita Lifwatila Director, Finance and Administration, RTI

2/2/15 Jeremiah Ngondi Sr Epidemiologist, RTI

2/2/15 Shabbir Lalji Sr M&E Specialist, RTI

2/2/15 Arin Dutta Futures DC

2/3/15 Dr Neema Rusibamayila Director, Dept of Preventive Services, MoHSW

2/3/15 Romanus Mtung’e Dep Country Director, PSI

2/3/15 Issack Kitururu Head, MCH, PSI

2/3/15 Robinson Katule Sales & Distribution, PSI

2/4/15 Dr Renata Mandike Manager, National Malaria Control Program

2/4/15 Karen Kramer Team Leader, NetCell, NMCP

2/4/15 Wilhelmina Rimisho Regional and District Coord, NetCell, NMCP

2/4/15 Faith Patrick Methodist Economic Development Authority

2/4/15 Dr Georgina Msemo Reproductive and Child Health Services, MoHSW

2/4/15 Dr Heavington Mshiu Prog Officer, Safe Motherhood, RCHS, MoHSW

2/4/15 Liz Tayler MDG Team Leader, DFID Tanzania

2/4/15 Essau Amenye Deputy Chief of Party, Futures

2/4/15 Flora Daniel Program Assistant, Futures

2/5/15 Ally Mnzava NatNets

31


2/5/15 Deo Kimera Country Director, JSI/Deliver

2/5/15 Marasi Mwencha Strategic and Technical Support, JSI/Deliver

2/5/15 Ms Ssanyu Nyinondi Procurement and global collaboration, JSI/Deliver

2/5/15 Dr Deo Mtasiwa Deputy Permanent Secretary, Prime Minister’s Office, Regional Administration and Local Government

2/5/15 Mrs Bertha Mlay Director of Health Services, Tanzania Red Cross Society

2/5/15 Jane Lweikiza Program Manager Malaria, Tanzania Red Cross Society

2/13/15 Chonge Kitojo USAID

2/13/15 Dino Stengel Managing Director, Achiles

2/13/15 Adarsha Krishnan Sales Manager, Achiles

2/13/15 Claud Kumalija Dep M&E Strengthening Initiative, MoHSW

2/13/15 Enock Mhehe M&E, MoHSW

32

Zonal field work

Date Informant Position, Organisation

Kinondoni District

2/6/15 Dr Hemedi District Malaria focal person, transport coordinator

2/6/15 Dr Sirilla Mwanisi

2/6/15 Edith Mboga District RCH coordinator

2/6/15 Sophia ? District Pharmacist

Kimara Dispensary

2/6/15 Dr Julia Kibereti Clinical officer, Asst in charge

2/6/15 Sister Husna Saidi Nurse in charge of facility

2/6/15 Marcelina Saura Supplies officer

Pwani Region

2/6/15 Grace Chuwa Regional RCH Focal person

2/6/15 Abus Hincha Regional Immunization Focal person

2/6/15 Mhando Muia Regional Malaria Focal person

2/6/15 Rashid Elober HMIS

Mlandazi Health Center

2/6/15 Goudencia Ndegea Hospital Secretary, Mlandazi

2/6/15 Mary Kohema RN, District RH Coordinator, Mlandazi

2/6/15 Dr Andronicus Aloyce Medical Officer in charge

Southern health zone

Mtwara region

2/9/15 Dr Peter Nagunwa Program Officer, EGPAF, Mtwara

33

2/9/15 Mary Mkama Regional Malaria focal person, Mtwara

2/9/15 Albertina Mlowola Regional RCH advisor, Mtwara

2/9/15 Dr Joseph Mwiru Acting Regional Medical Officer, Mtwara

2/9/15 Mrs Hawa Chikuyu Hospital Supplies Officer, Ligula Regional Hospital

2/9/15 Ms Emiliana Rosh Asst Hospital Supplies Officer, Ligula Regional Hospital

2/9/15 Herman Mng’ong’o Zonal Manager, MSD Mtwara

2/10/15 Dr Shaib Maarifa Regional Medical Officer, Mtwara

2/10/15 Alfred Luanda Regional Administrative Secretary, Mtwara

Mtwara Municipal District

2/9/15 Dr Mahala Njile District Medical Officer

2/9/15 Mahmoud Kaisi District Malaria Focal person

2/9/15 Dr Tito Shengena Mtwara Clinical Officers’ Training School

2/10/15 Lillian Mlaponi RN, Responsible Storeroom, Mikindani HC

2/10/15 George Kaluma Clinical Officer in charge, Rwelu Dispensary

2/10/15 Rehema Ngoyama ANC, Rwelu Dispensary

2/10/15 Fatuma Mwamba RCH, Kitere Health Center

2/10/15 Asteria Mlelwa Clinical officer, Kitere Health Center

Date Informant Position, Organization

Masasi District

2/11/15 Matron Christina Ngaambeki Matron, Nursing, St Benedicts/ Ndanda Regional Referral Hospital

2/11/15 Amanda Kapwapwa RCH in charge, St Benedicts

2/11/15 Cecil Mwanache Procurement officer, responsible Stores

34

2/11/15 Raheem Ngaweje District Health Secretary, Masasi District Council

2/11/15 Saigilu Loishiye Pharmacy Technician, action medeor, Masasi

Lake health zone

Mwanza Region

2/9/15 Naiman Msangi Logistics Advisor, Tibu Homa

2/9/15 Victor Masbayi COP, Tibu Homa

2/9/15 Agnes Hassan Regional Nursing Officer

2/9/15 Esperance Mukasi Regional RCH Assistant

2/9/15 Esther Mariki Regional Health Secretary

2/9/15 Egidus Rwezaura MSD Senior Sales Officer

2/9/15 Chahe Omari Representative, Musa Transporter

2/9/15 Emmanuel Peter Lusata Representative Vinoj Bei Distributors

2/9/15 Dr. Seif Hamidi Honorable Minister of Health

2/9/15 Elizabeth Shukalage Registrar Pharmacy Council

2/9/15 Dr. Irundue Chief Pharmacist

Misungwi District

2/10/15 Ngole Mabeyo District Nursing Officer

2/10/15 Dismas Simon Dotto malaria/IMCI focal person

2/10/15 Laurent Mtimvike Health Secretary

2/10/15 Mary Joseph Magengeni District Medical Officer

2/10/15 Celestine Ernest In-charge, Msasi Health Center

2/10/15 Ponga Masaga Bulihe Distributor, Misungwi

2/10/15 Deus John Massele Transporter, Misungwi

2/10/15 Kaniaga Mlingwa In-charge, Idetemia Dispensary

35

Sengerema District

2/11/15 Michael Bajile Pharmacist Tibu Homa

2/11/15 Mary Mgoa RCH Focal person

2/11/15 Sister Dr. Marie Voeten Director, Designated District Hospital

2/11/15 Joyce Peter Record Keeper, Mark Investment Company

2/11/15 Zeihuron Ramadhli In-charge Nyanizeze Dispensary

2/11/15 Valentina John RCH, Nyanizeze Dispensary

36


Week 1: Dar es Salaam

Date Activity Time Place

Day 1

Monday

2 February 2015

Introductory meeting USAID

George Greer, Lynn Paxton, Ana Bodipo-Memba, Levison, Stinson

8:00-9:00 USAID office

Continuation Meeting USAID, planning

Greer, Paxton, Raz Stevenson, Levison, Stinson


Tanzanian Health Supply Chain

Kelly Hamblin, Lulu Msangi Khery, Levison, Stinson

10:00-11:30

USAID office

Lunch

Greer, Levison, Stinson

12:00-13:00

USAID office

Meeting Jhpiego

Harriet Hamis, Rose Mnzava, Dunstan Bishanga, Levison, Stinson

14:00 – 15:00

Jhpiego office

Meeting RTI

Dr Stephen Magesa, Mubita Lifwatila, Jeremiah Ngondi, Shabbir Lalji, Rita Willilo,Levison, Stinson

15:30-16:30

RTI office

Meeting: Futures

Dr. Arin Dutta, Levison

18:00-19:00

Hotel

Day 2

Tuesday

3 February

Meeting Dept of Preventive Services

Dr. Neema Rusibamayila, Greer, Levison, Stinson

9:00-10:30 Ministry of Health

Meeting PSI

Romanus Mtunge, Issack Kitururu, Robinson Katule, Levison, Stinson

11:30-12:30

PSI office

Planning meeting

Levison, Stinson

14:00-17:00

hotel

Identification of ITN supply chain cost categories

Levison

18:00-22:00

Hotel

37

Week 1: Dar es Salaam, cont.


Day 3

Wednesday

4 February

Briefing USAID on supply chain cost categories


8:15-8:45 Hotel

Meeting with National Malaria Control Program

Dr Renata Mandike, Karen Kramer, Wilhelmina Rimisho, Paxton, Levison, Stinson

9:00-10:30 CDC office

Meeting Methodist Economic Development Authority

Faith Patrick,Levison, Stinson

11:00-12:00

CDC office

Meeting: Department of Reproductive and Child Health Services

Dr Georgina Msemo, Dr Heavington Mshiu, Greer

Levison, Stinson

13:00-14:00

MoHSW

Meeting DfID

Liz Tayler, Levison, Stinson

15:00-16:00

Oyster Bay Plaza

Courtesy call, Futures

Essau Amenye, Flora Daniel, Levison, Stinson

16:30 Futures office

Day 4

Thursday

5 February

Meeting: JSI Deliver

Deo Kimera, Marasi Mwencha, Ssanyu Nyinondi, Levison, Stinson

8-9:30 JSI office

Planning meeting, PMI


11:00-11:30

Transit

Meeting , Prime Minister’s Office, Regional Administration and Local Government

Dr. Deo Mtasiwa, Greer, Levison, Stinson

11:30 – 12:30

PMORALG office

Lunch meeting

Greer, Kramer, Levison, Stinson

13:00-14:00

NMCP cafeteria

Meeting: Tanzania Red Cross Society

Bertha Mlay Jane Lweikiza Levison, Stinson

15:00-16:30

Tanzania Red Cross Society office

Create data collection tools

Levison, Stinson

20:00-22:00

Hotel

Day 5

Friday

6 February

Field visit, Dar and Pwani Regions

Ally Mnzava, Levison, Stinson

8:00-17:00 Kinondoni DHO, Kimara Dispensary, Pwani RMO,

Mlandazi Health Center

Day 6

Saturday

7 February

Revise data collection tools, background research, review first week, field work planning

Levison, Stinson

10:00-17:00

Hotel

38

Week 2: Field trip Mtwara Region


Day 8

Monday

9 February

Travel to Mtwara

Greer, Levison

4:30- 9:00

Meeting Mtwara Regional Medical Office management team

Mary Mkama, Albertina Mlowola, Joseph Mwiru, Peter Nagunwa, Greer, Levison,

9:30-10:30 RMO Mtwara

Visit Ligula Regional Referral Hospital Store room

Hawa Chikuyu, Emiliana Rosh, Nagunwa, Mkama, Mlowola, Greer, Levison

10:30-11:00

Ligula Referral Hospital

Meeting Medical Stores Department Mtwara

Herman Mng’ong’o, Nagunwa, Greer, Levison

11:30-13:00

MSD Mtwara

Meeting Mtwara District Health Office

Dr Mahala Njile, Mahmoud Kaisi, Nagunwa, Mkama, Mlowola, Greer, Levison

13:30-14:30

Mtwara DHO

Visit DHO Store room

Kaisi, Nagunwa, Mkama, Mlowola, Greer, Levison

14:30-15:00

Mtwara DHO

Lunch, review & planning meeting

Nagunwa, Mkama, Mlowola, Greer, Levison

15:00-16:00

Visit Mtwara Clinical Officers Training school

Dr Tito Shengena, Nagunwa, Greer, Levison

16:30-17:00

Clinical Officers Training school

39

Week 2: Field trip Mtwara Region, cont.


Day 9

Tuesday

10 February

Meeting Regional Medical Officer Dr Shaiib Maarika, Nagunwa, Mkama, Mlowola, Greer, Levison

8:00-9:00 Mtwara RMO

Meeting Regional Administrative Secretary, Mtwara

Alfred Luanda, Nagunwa, Mkama, Mlowola, Greer, Levison

9:00-10:00 Mtwara Regional and Local Govt

Visit Mitingani Health center

Lillian Mlaponi, Kaisi, Nagunwa, Mkama, Mlowola, Greer, Levison

10:30-11:30

Mitingani Health center

Visit Rwelu Dispensary Dr George Kaluma, Rehema Ngoyama, Kaisi, Nagunwa, Mkama, Mlowola, Greer, Levison

12:00-13:00

Rwelu Dispensary

Transit to Kitere Nagunwa, Mkama, Mlowola, Greer, Levison

14:00-15:00

Visit Kitere Health Center

Asteria Mlelwa, Fatuma Mwamba, Nagunwa, Mkama, Mlowola, Greer, Levison

15:00-16:00

Kitere Health Center

Visit Duka la Dawa

Beatrice ??, Nagunwa, Mkama, Mlowola, Greer, Levison

16:00-16:15

Kitere

Return to Mtwara


16:15-17:30

Day 10

Wednesday

11 February

Transit to Masasi


7:30-10:00

Visit St Benedicts Regional Referal Hospital

Christina Ngaambeki, Amanda Kapwapwa, Cecil Mwanache, Nagunwa, Mkama, Mlowola, Greer, Levison

10:00-11:30

Ndanda

Meeting Masasi District Council Health Office

Raheem Ngaweje, Nagunwa, Mkama, Mlowola, Greer, Levison

12:00-13:00

Masasi District Council Health Office

Visit Action Medeor Ltd

Saigilu Loishiye, Nagunwa, Mkama, Mlowola, Greer, Levison

13:15-13:45

Action medeor, Masasi

Visit Duka La Dawa

Nagunwa, Greer, Levison

14:00 Masasi town

Return to Mtwara


15:00-17:00

40

Week 2: Field trip Mwanza Region


Day 8

Monday

9 February

Travel to Mwanza

Stinson

4:30- 8:00

Meeting Mtwara Regional Medical Office management team

Neiman Masangi, Agnes Hassan, Mukasi, Stinson

9:30 -10:30 RMO Mtwara

Meeting MSD Zonal Office

Masangi, Hassan, Rwezaura, Stinson

10:30 – 11:30

MSD

Meeting Distributor

Msangi, Stinson

11:45-12:30

Shop

Meeting Transporter

Msangi, Stinson

12:30-13:30

Transporter

Lunch 14:00-15:30

Restaurant

Introductions

Dr. Seif Hamidi, Dr. Elizabeth Shukalage, Dr. Irundue, Msangi, Hassan, Stinson

15:30-15:45

Restaurant

Day 9

Tuesday

10 February

Travel to Misungwi

Mary Joseph Magengeni, Msangi, Hassan, Stinson

8:00-8:30

Meeting District medical office

Magengeni, Msangi, Hassan, Stinson

8:30-9:15 Misungwi District Medical Office

Site visit: Msasi

Msangi, Hassan, Magengeni, Stinson

10:00 – 10:45

Msasi Health center

Meeting Distributor: Magengeni, Msangi, Hassan, Stinson

11:15-12:15

Misungwi town

Site visit Idetemia Dispensary

Magengeni, Msangi, Hassan, Stinson

12:45-13:45

Idetemia Dispensary

Lunch 14:00-15:30

41

Week 2: Field trip Mwanza Region, cont.


Day 10

Wednesday

11 February

Transit to Sengerema 7:30

Ferry crossing 8:15 – 9:30

Courtesy call: Sengerema District Medical Office

Michael Bajile, Hassan, Stinson

9:30 – 10:00

Sengerema District Medical Office

Site visit: Designated District Hospital

Sister Dr. Naria Voeten, Bajile, Hassan, Stinson

10:30 – 12:00

Sengerema District Hospital

Meeting: Distributor and transporter

Bajile, Hassan, Stinson

12:15 – 13:15

Sengerema town

Site visit: Nyamizeze Dispensary

Hassan, Bajile, Stinson

14:00-14:30

Sengerema

Travel to Dar

Stinson

21:30 Mwanza

42

Week 2: Dar es Salaam


Day 11

Thursday

12 February

Travel to Dar

Greer, Levison

6:00-10:00

Evaluation team debrief, review of field work; preparation USAID debriefing

Levison, Stinson

10:00-20:00

Hotel

Stinson departure to US

Stinson

20:00

Finalization USAID debrief

Levison

20:00-23:00

Hotel

Day 12

Friday

13 February

Meeting USAID

Greer, Bodipo-Memba, Kaspar, Chonge Kitojo, Levison


Meeting Achiles

Dino Stengel, Adarsha Krishnan, Levison

12:00-13:00

Achiles office

Meeting M&E/HMIS at MoHSW

Claud Kumalija, Enock Mhehe, Levison

14:00-15:00

MoHSW

Levison departure to US

Levison

20:00

43

Attachment 3: Data collection tools

RMO

44

Date: Interviewer

District Interviewee

Facility Contact info

Demographic data

# districts population

# births No. ANC1 visits

Facility data Private

# hospitals

# health centers

# dispensaries

Systems

Describe the infrastructure (roads, phone network) in your region; challenges

Describe the medical supply system and this facility's role. Schedule? Challenges?

Who manages the medical stock? # staff?

Describe the stock reporting system

How is data used?

Does this facility have vehicles that can transport ITNs? Number? Schedule?

Describe health statistics reporting and this facility's role. Schedule? Challenges?

Describe supervision system and this facility's role. Schedule? Challenges?

Logistics options

What other storage options exist?

What other transport options exist?

Discussion

What should a new program look like?

Other: security?

Visit:

Storage areas (store room, warehouse)

Public FBO

45

DMO

Date: Interviewer



Demographic data

population No. ANC1 visits

# births


# hospitals

# health centers

# dispensaries

Systems

Describe the infrastructure (roads, phone network) in your district challenges

Describe the medical supply system and this facility's role. Schedule? Challenges?

Does this facility have storerooms that can hold ITNs? Capacity? Avg use?



How is data used?



Describe supervision system and this facility's role. Schedule? Challenges?

Do you have a buffer stock? # months?

Logistics options



Discussion


Other: security?

Visit:

Storage areas (store room, warehouse)

Public FBO

46

Zonal MSD

Date: Interviewer



Infrastructure data

# regions serve # districts serve

# Facilities

deliver to Private

# hospitals

# health centers

# dispensaries

Systems

Describe the infrastructure (roads, phone network) in your Zone; challenges

Describe your warehouse capacity, average use



Describe the supply system (receiving orders, processing, delivery)

Does this facility have vehicles that can transport ITNs? Number? How add to chedule?

What is the total length of routes to all facilities served?

Is there a schedule for deliveries? Describe the schedule.

How many emergency orders are delivered?

Is there a buffer stock?

Logistics options

Describe other storage options in zone

Describe other transport options in zone

Discussion


Other: security?

Visit:

Storage areas (warehouse)

Public FBO

47

Health facility

Date: Interviewer



Demographic data

# districts population

# births No. ANC1 visits


# hospitals

# health centers

# dispensaries

Systems

Describe the infrastructure (roads, phone network) in your region; challenges



How is data used?



Describe supervision system. Schedule? Challenges?

Logistics options



Discussion


Other: security?

Visit:

Storage areas (store room, dispensary, ANC dispensing)

ANC, see patient flow

Public FBO

48



Annex 2: Trip 2 report, Tanzania March 9-13, 2015

Libby Levison

Wayne Stinson

Peter Cross


April 8, 2015

Acronyms

AIDS Acquired Immunodeficiency Syndrome



eLMIS Electronic Logistics Management Information System





MCH Maternal and Child Health





PS Permanent Secretary


49


RCHU Reproductive and Child Health Unit

TB Tuberculosis

TRCS Tanzania Red Cross Society


WHO World Health Organization

50

As part of the work under the Futures Group under Contract 17495.001.IDEAS.03, Situational Analysis

of the Delivery of Insecticide-Treated Mosquito Nets through Antenatal Care Clinics in Public Health

Facilities in Tanzania, one member of the IDEAS team –Libby Levison – returned to Tanzania to

continue work with USAID/PMI on the situational analysis from March 9 to 13, 2015.

Summary of work accomplished

The focus of the work was to collect feedback from USAID/PMI on the documents produced to date, to

facilitate a discussion of delivery options for ITNs to ANC clinics at the NatNets (National Insecticide

Treated Nets) steering committee quarterly meeting, and to conduct any remaining interviews required.

Meetings were held with: USAID/PMI, USAID/Supply Chain, Medical Stores Department in Dar (the

Procurement and Finance divisions) and the Logistics Management Unit of the Pharmacy Services

Section of the MoHSW. The meeting with USAID/Supply Chain was to explore the functionality and

status of the electronic tools being used to monitor supply chain performance: the Integrated Logistics

System (ILS), the ILS Gateway and the electronic Logistics Management Information System (eLMIS)6.

IDEAS’ central task for the week was to present and facilitate a discussion on the two remaining possible

system designs, identified by USAID/PMI, for delivering ITNs through ANCs at both public and faith-

based facilities. The presentation was made on Wednesday at the quarterly NatNets Steering Committee

meeting. Members in attendance included the Deputy Permanent Secretary Prime Minister’s Office,

Regional Administration and Local Government; National Malaria Control Program (NMCP; WHO;

Swiss Agency for Development and Cooperation; Population Services International (PSI); the Tanzania

Red Cross Society, USAID/PMI and CDC.

Results

The central accomplishment of the trip was that the NatNets Steering Committee selected the system

design to be used to deliver ITNs through ANCs: a mixed system was selected, in which some regions

will use MSD to store and distribute ITNs, while other regions will use private sector storage and

distribution partners.

The meetings with MSD (IDEAS met both the Director of Procurement, formerly the Director of

Logistics, and the Director of Finance) gave insight into how MSD operates as an autonomous entity

supporting health delivery in Tanzania and with respect to their capacity to store and distribute bulky

ITNs.

At the debrief with USAID on Thursday PMI outlined what they require in the final report.

Next Steps

IDEAS will produce the final report on the situational analysis, delivery systems presented, the decisions

made by USAID/PMI and the MoHSW/NMCP and document all work accomplished.

The report will be submitted to USAID/PMI and Futures for comments; IDEAS will submit a revised and

finalized report 5 business days after receiving feedback.

Attachments:


6 A summary of the electronic systems is available in Deliverable F3, Summary of Insights

51


52



Dar es Salaam

3/9/15 Dr George Greer Resident Advisor PMI, USAID

3/9/15 Dr Lynn Paxton Resident Advisor, Case Mgmt & Surveillance, CDC

3/9/15 Ana Bodipo-Memba Community-based Service Team Lead, USAID/PMI

3/9/15 Ms Naomi Kaspar Communication Lead & PMI Program Support, USAID/PMI

3/10/15 Kelly Hamblin Senior Supply Chain Advisor, USAID

3/10/15 Lulu Msangi Khery Supply Chain Specialist, USAID

3/11/15 Dr Deo Mtasiwa Deputy Permanent Secretary, Prime Minister’s Office, Regional Administration and Local Government

3/11/15 Dr Renata Mandike Manager, National Malaria Control Program

3/11/15 Karen Kramer Team Leader, NetCell, NMCP

3/11/15 Dr Elizeus Kahigwa Health Advisor, Swiss Agency for Development and Cooperation

3/11/15 Mrs Bertha Mlay Director of Health Services, Tanzania Red Cross Society

3/11/15 Dr Ritha Njau WHO, AIDS/TB & Malaria officer

3/11/15 Romanus Mtung’e Dep Country Director, PSI

3/11/15 Issack Kitururu Program manager MCH, PSI

3/11/15 Ally Mnzava NatNets, NMCP

3/11/15 Charles Mwalimu NMCP

3/11/15 Yusuf Mwita NMCP

3/12/15 Heri S. Mchunga Director of Procurement, Medical Stores Department

3/13/15 Joseph F. Tesha Director of Finance and Planning, Medical

53


Stores Department

3/13/15 Adam Omary Upstream Logistics Coordinator, Logistics Management Unit, MoHSW

54



Day 1

Monday

9 March 2015

In-briefing USAID

George Greer, Lynn Paxton, Ana Bodipo-Memba, Naomi Kaspar, Levison


Meeting

Greer, Levison

10:00-11:00

USAID office

Report writing

Levison

12:00-7:00 Hotel

Day 2

Tuesday

10 March

Tanzanian Health Supply Chain

Kelly Hamblin, Lulu Msangi Khery, Levison

11:00-12:00

USAID

Meeting USAID

Greer, Levison

12:30-1:30 USAID

Preparation NatNets meeting

Levison

14:00-17:00

hotel

Day 3

Wednesday

11 March

NatNets Steering Committee meeting

Greer, Paxton, Bodipo-Memba, Kaspar, Romanus Mtunge, Issack Kitururu Levison

9:30-15:00 NMCP

Report writing

Levison

15:00-18:00

Hotel

Day 4

Thursday

12 March

Meeting: MSD

Heri Mchunga, Greer, Levison

9-10:30 MSD warehouse

Debrief, PMI

Greer, Paxton, Hamblin, Msangi, Levison

11:00-12:00

USAID

Report writing

Levison

13:00-18:00

Hotel

Day 5

Friday

13 March

Meeting: MSD Finance

Joseph Tesha, Levison

10:00-11:15

MSD office

Meeting: Logistics Management Unit

Adam Omary, Levison

12:00-

13:15

NMCP office

Report writing

Levison

12:00-17:00

Hotel

55

ANNEX 3: ITN DELIVERY SYSTEM OPTIONS: PPTS

Annex A3.1 is the PowerPoint provided to PMI for meetings held in late February and early March.

Annex A3.2 is revised version of this PowerPoint, also submitted as Deliverable 4. Annex A2.3 is the

PowerPoint used at the NATNETS Steering Committee meeting on March 11, 2015.

56

A3.1: First Working PowerPoint on Delivery System Options

Slide 1

Situational Analysis of the

Delivery of Insecticide-Treated

Mosquito Nets through Antenatal

Care Clinics

Libby Levison

Wayne Stinson

Peter Cross

The original version of this PowerPoint was used in the debriefing with USAID/PMI on 2/13/15 after

which minor (typing) corrections were made (reflected here) for 2/18/15.

Subsequently PMI selected two delivery system options to explore farther; these are reflected in

Deliverable F4.

Some minor changes to the diagrams were requested by the NatNets Steering committee on 3/11/15; these

are not reflected here.

57

Slide 2

Levison, Stinson & Cross, IDEAS

Work to date

• Literature review

• Dar:

– Meetings: USAID/PMI, CDC, NMCP/NatNets, TRCS,

PSI, RTI, Jhpiego, MoHSW/DPS, RCHU,

PMO/RALG, DfID, JSI, MEDA

– Field visits:

• Kinondoni DMO, Kimara Dispensary

• Pwani/Coastal RMO, Mlandizi HC

• Mwanza: RMO, Sengerema, Misungwi

• Mtwara: RMO, Mtwara Municipal District, Masasi

The voucher program provided vouchers for LLINs in FBO ANCs as well – need to evaluate the

necessity to include FBO ANCs in this program

In addition, the IDEAS team visited two Duka la Dawas (medicine sellers) and 5 transporters

58

Slide 3


System 1, public

Public distribution

Private distribution

Stock info

Health stats

Order request

MOHSW/

NMCP

Implementing Partner,

Logistics

DMORMO

Zonal

MSD

Health

Facility

Implementing

Partner

Procurement

R&ReLMIS

Mention: 16 Transporters prequalified by MSD

Partner colors:

Blue: Min of Health

Yellow: non-govt entity, will require USAID financial contribution for program

Green: MSD

Red: private sector interest

MSD: since there is only one commodity, can send containers directly to MSD in the Health Zone; no

need to storage at central level

59

Slide 4


Pros: Supports existing TZ system

One ‘touch’ between port & HF

Cons: MSD won’t add tasks without funding

Inflexibility of quarterly deliveries?

Volume could overwhelm MSD

System 1, public

MOHSW/

NMCP


Logistics

DMORMO

Zonal

MSD

Health

Facility

Implementing

Partner

Procurement

R&ReLMIS

60

Slide 5


System 2, private

MOHSW/

NMCP

DMORMO

Health

Facility

R&ReLMIS

Zone 1Impl.

Partner

Procurement


Logistics

Region 2

Public distribution


Stock info

Health stats

Order request

Zone1/Region 2: Implies storage not at central level; procurement partner to ship directly to sub-national

level. Depending on volumes and availability, it might be possible to split one Health Zone’s shipments

and ship to and store at the Regional level .

Partner colors:

Blue: Min of Health

Yellow/yellow border: non-govt entity, will require USAID financial contribution

for program

Red: private sector

61

Slide 6


System 2, private

Pros: Transport agents: flexible, on-

demand systems

Build on other private distribution systems

Clarity on logistics service costs

Cons: Dependent on donor funding

Need to clarify reporting to MoH

MOHSW/

NMCP

DMORMO

Health

Facility

R&ReLMIS

Zone 1Impl.

Partner

Procurement


Logistics

Region 2

Regional transport agents in Mwanza reported they can subcontract to district transporters (not pictured

here)

Make reporting to IP Logistics part of the contract

Other Pros: The Private sector is more responsive to bonuses for high-accuracy, on-time performance.

Multiple partner options in the Private sector: if one partner does not perform, select another

Q: Should distributors report to IP Log % delivered?

62

Slide 7


System 3, PPP

MOHSW/

NMCP

RMO

Health

Facility

R&ReLMIS

Impl.

Partner

Procurement


Logistics

Region 2

Zone 1

Last-mile

delivery:

choose public

or outsource

DMO

Public distribution


Stock info

Health stats

Order request

System 3: Public private partnership. Private sector storage at Zone or Region, but distribute to Public

sector DMO who will do last mile delivery.

Between DMO and HF have option to use DMO or outsource delivery (ie public or private)

63

Slide 8


Cons: Districts need new systems & funds

HFs unlikely to collect ITNs

Multiple public-private hand-offs

System 3, PPP

Pros: Reinforces role of District in

distribution

Uses gvmt/community resources

to bridge last-mile

MOHSW/

NMCP

RMO

Health

Facility

R&ReLMIS

Impl.

Partner

Procurement


Logistics

Region 2

Zone 1

Last-mile

delivery:

choose public

or outsource

DMO

Between DMO and HF: have option to use DMO or outsource delivery

Districts have limited distribution experience and limited budgets for fuel costs

Health facilities have limited funds and access to transport, will be very hard for them to collect ITNs

at DHO

64

Slide 9


System 4, mixed

MOHSW/

NMCP

RMO

Health

Facility

R&ReLMIS

Impl.

Partner

Procurement


Logistics

Region 2

MSD Z1

Zone 2

Last-mile

delivery:

choose public

or outsource

DMO

Public distribution


Stock info

Health stats

Order request

A mixed system: in one Zone use MSD delivering to the HF (ie, last mile); and in another region or

zone use the private sector or a private/public collaboration

No yellow border on MSD as existing programs are working to strengthen MSD capacity

65

Slide 10


System 4, mixed

Cons: More complicated

Dependent on donor funding

Pros: Collect comparison data on

systems and costs in public and

private sectors

MOHSW/

NMCP

RHO

Health

Facility

R&ReLMIS

Impl.

Partner

Procurement


Logistics

Region 2

MSD Z1

Zone 2

Last-mile

delivery:

choose public

or outsource

DHO

A mixed system: in one Zone/region use MSD delivering to the HF (ie, last mile); and in remaining

Zone/regions use the private sector or a private/public collaboration

No yellow border on MSD as existing programs are working to strengthen MSD capacity

66

Slide 11


Cross-cutting issues

• Designing the system: – One size will not fit all; must define for local context

• Reinforce sustainable systems: – Support government efforts to contract out

– MSD ordering and reporting forms, MSD prequalified distributors

– Avoid weak existing systems

• How and where to store nets: – Supplier to deliver nets to sub-national level (zone or

region) - no central storage

– Possible at many levels; more flexible in private sector

Local context: possible different designs in each health zone: Mtwara population: 1.4m; Mwanza

population: 2.72m. Need forecast volumes at Zone, Region, District

Govt outsourcing: MSD has just prequalified 16 transport companies to help with delivery

MSD: a number of projects and donors have, and are now, supporting MSD; change is very slow to

happen.

No central storage: No gain in this project to store at central. Initial shipment to go directly to subnational

destination

67

Slide 12


Cross-cutting issues

• Last-mile distribution: – USG, local government support last-mile distribution

– Districts: limited experience distributing commodities

– Communities lack capacity/funds to collect nets

• Security and accountability: – Manage ITNs tightly; loss may deter future donors

– Require signatures for receipt at every level

– Compare service and consumption data monthly

• Availability of service statistics– Needed at all operation levels

– Robustness, synchronization, used in decision making

– Triangulation

Security:

Signatures from women: community involvement? Give LLIN out in ANC clinic – the

nurse knows the woman qualifies

Service stats:

Observed variable quality data in field

68

Slide 13


Identifying costs

Quantification/

Order

Information

flow

Management

Distribution

Storage

Health facilityDistrictSub-nationalNational

For each system, need to identify what costs in five categories: Quantification/Orders, Storage,

Distribution, Management and Information flow at each level of the system.

Some costs will not be applicable to a level.

Sub-national: Zonal or regional

69

Slide 14


Insights

• Include both public & FBO health facilities

• MSD fixed delivery schedule + limited capacity =>

inflexible system

– HFs collect emergency orders at MSD

• Flexibility of private sector (storage and transport)

• Have ANC nurse ‘dispense’ ITNs to women

• Distribution unit 40-net bale, no ‘packing’

• Storage: limited at DMOs but adequate at peri-

urban & rural HFs

Probably distribution unit: 40-net bale: Goal is to avoid splitting bales before they reach the health

facility. Numbers and quantities probably need to be calculated and reviewed.

If health facilities place an emergency order, they often collect the order when they are in town. Larger

facilities with vehicles and funds for fuel have the ability to collect than do smaller HFs.

70

Slide 15


Next steps

PMI

1. Provide IDEAS 1st ANC attendance data

2. Identify set of possible system designs

3. Clarify stakeholder role in ITN 2 ANC project

IDEAS:

• Report: narrative to accompany PowerPoint

• Provide lessons-learned report from field visits

• Calculate volume of nets /region & /zone based on 1st

ANC attendance data (#1)

• Provide outline of costing parameters (#2, #3)

Numbers in parentheses indicate requirements/preconditions

IDEAS has access to and will use population data from the DHS 2010

71

Slide 16


Next steps, trip 2

PMI

4. Advise IDEAS on ITN 2 ANC partnership structure, assumptions, division of responsibility

5. Review system design narrative

IDEAS:

• Draft report on system design options(#4)– Parameters that define program

– Required information, M&E mechanisms

– Identify cost parameters for each partner

• Revise report (#5)

Parameters that define program: cost, feasibility, M&E, security, info, mgmt, etc

72

A3.2: Deliverable 4: Second PowerPoint Describing Two Delivery

System Options

Slide 1




Care Clinics

Libby Levison

Wayne Stinson

Peter Cross

A first version of this PowerPoint was used in a debriefing with USAID/PMI on 2/13/15.

NB: Some minor changes to the diagrams were requested by the NatNets Steering committee on 3/11/15;

these are not reflected here.

73

Slide 2


Work to Date

• Literature review

• Dar:

– Meetings: USAID/PMI, CDC, NMCP/NatNets, TRCS,

PSI, RTI, Jhpiego, MoHSW/DPS, RCHU,

PMO/RALG, DfID, JSI, MEDA

– Field visits:

• Kinondoni DMO, Kimara Dispensary

• Pwani/Coastal RMO, Mlandizi HC

• Mwanza: RMO, Sengerema, Misungwi

• Mtwara: RMO, Mtwara Municipal District, Masasi

The voucher program provided vouchers for LLINs in FBO ANCs as well – need to evaluate the

necessity to include FBO ANCs in this program

In addition, the IDEAS team visited two Duka la Dawas (medicine sellers)

74

Slide 3


System 1, Private

Public distribution


Stock info

Health stats

Order request

Program management

MOHSW/

NMCP

DMORMO

Health

Facilities

“R&R”eLMIS

Zone 1Impl.

Partner,

Procurement


Logistics

Zone 2

Zone1/Zone 2: Implies storage not at central level; procurement partner to ship directly to subnational

level. Depending on volumes, it might be possible to split one Health Zone’s shipments and ship to and

store at the Regional level.

R&R : Report and Requisition: MoHSW reporting and ordering form

Partner colors:

Blue: Min of Health


for program

Red: private sector

75

Slide 4

System 1, Private

Pros: Transport agents: flexible, on-

demand systems

Build on other private distribution systems

Clarity on logistic service costs

Cons: Dependent on donor funding

Need to clarify reporting to MoH

MOHSW/

NMCP

DMORMO

Health

Facilities

“R&R”eLMIS

Zone 1Impl.

Partner,

Procurement


Logistics

Zone 2

Regional transport agents in Mwanza reported they can subcontract to district transporters (not pictured

here)

Make storage/delivery reporting to IP Logistics part of contract

Other Pros: The Private sector is more responsive to bonuses for high-accuracy, on-time performance.

Multiple partner options in the Private sector: if one partner does not perform, select another

Q: Should distributors report to IP Log % delivered?

76

Slide 5


System 2, Mixed

Public distribution


Stock info

Health stats

Order request

Program management

MOHSW/

NMCP

RMO

Health

Facilities

eLMIS

Impl.

Partner,

Procurement


Logistics

MSD Z1

Zone 1

DMO“R&R”

Zone 2

A mixed system: in one Zone use MSD delivering to the HF (ie, last mile) in one or more regions; and in

another region or zone use the private sector

77

Slide 6

System 2, Mixed

Cons: More complicated

MSD delivery calendar fixed; responsive enough?

Dependent on donor funding

Pros: Collect comparison data on

systems and costs in public and

private sectors

MOHSW/

NMCP

RMO

Health

Facilities

eLMIS

Impl.

Partner,

Procurement


Logistics

MSD Z1

Zone 1

DMO“R&R”

Zone 2

A mixed system: in one Zone use MSD delivering to the HF (ie, last mile); and in another zone use the

private sector collaboration (could be different storage/distrib companies in different regions)

78

Slide 7


Cross-cutting Issues

• System design: – One size will not fit all; must define for local context

• Reinforce sustainable systems: – Support government efforts to contract out

– MSD ordering and reporting forms; prequalified transporters

– Avoid weak existing systems

• How and where to store nets: – Supplier to deliver nets to sub-national level (zone or

region) - no central storage

– Possible at many levels; more flexible in private sector

Local context: possible different designs in each health zone/region: Mtwara population: 1.4m; Mwanza

population: 2.72m. Need forecast volumes at Zone, Region, District.

Govt outsourcing: MSD has just prequalified 16 transport companies to help with delivery

MSD: a number of projects and donors have, and are now, supporting MSD; change is very slow

to happen.

No central storage: Single item shipment, in containers, so there is no need to store centrally. Initial

shipment could go directly to subnational destination

79

Slide 8


Cross-cutting Issues

• Last-mile distribution: – USG, local government support last-mile distribution

– Districts: limited experience distributing commodities

– Communities lack capacity/funds to collect nets

• Security and accountability: – Manage ITNs tightly; loss may deter future donors

– Require signatures for receipt at every level

– Compare service and consumption data for each order

• Availability of service statistics– Needed at all operation levels

– Robustness, synchronization, used in decision making

– Triangulation

Security:

Signatures from women: community involvement? Give LLIN out in ANC clinic – the

nurse knows the woman qualifies

Service stats:

Observed variable data quality in field

80

Slide 9


Data-driven systems

• Census data: – Upper bound on ITN need at region and district levels

– Basis for annual quantification

• 1st ANC attendance:– Basis for quarterly orders (minus available ITNs in HF)

– Have historical data for program start-up

• Triangulate data for monitoring– ITN consumption to 1st ANC attendance

– 1st ANC attendance to census data

Service stats:

Observed variable data quality in field. M&E Division report an 86% reporting rate

81

Slide 10


Identifying costs & funding sources

�

Management, Supervision &

Oversight

Storage

Distribution, Transport

Information Systems

Orders & QuantifIcation

Supply Chain Functions

Health System LevelsCentral

Sub-

nationalDistrict

Health

Facility

For each system, need to identify what costs in five categories: Storage, Distribution, Management and

Information flow at each level of the system.



82

Slide 11

Funding sources by function & level

MOHSW MSD PMI No TSh

Color key to Funding sources

1 P

riv

ate


Sub-

nationalDistrict

Health

Facility�


Supply Chain Functions 2 Selected Options

1 P

riv

ate

2 M

ixe

d

1 P

riv

ate

2 M

ixe

d

2 M

ixe

d

1 P

riv

ate

2 M

ixe

d


Information Systems


Oversight

Storage

This is work in progress.

For each system, need to identify what costs in five categories: Quantification, Storage, Distribution,

Management and Information flow at each level of the system.


Orders and Quantification: Includes Report & Requisition preparation, review, and approval.

Storage: Cost to store ITNs at this level. NB: in some zones MSD may have to contract additional storage

space (Option 2). In Option 1 is the cost to rent the Storage needed. Storage is not anticipated at the

national and district levels in current designs

Distribution and Transport: Is the cost to move ITNs from manufacture direct to sub-national level, and

from sub-national level direct to health facilities.

Management, Supervision and Oversight: Includes problem identification, solutions developed, decisions

taken and implementation

Information Systems: Includes data collection, reporting, entry in electronic systems, analysis and quality

control. Also includes costs for an SMS-for-Life like system allowing facilities to contact higher level to

alert them to stock level concerns


83

Slide 12


Funding sources, sub-national level

�


Oversight

Storage


Information Systems



1 P

rivate

2 M

ixed

Health System Levels Sub-

national

In each column heading: eg Central, “1”, “2” refer to system design.

Blue: MoH

Green: MSD

Yellow: USAID/PMI support

Grey: Not implicated

84

Slide 13


Insights

• Include both public & FBO health facilities

• MSD fixed delivery schedule + limited capacity =>

inflexible system

– HFs collect emergency orders at MSD

• Flexibility of private sector (storage and transport)

• Have ANC nurse ‘dispense’ ITNs to women

• Distribution unit 40-net bale, no ‘packing’

• Storage: limited at DMOs but adequate at peri-

urban & rural HFs

Probably distribution unit: 40-net bale: Goal is to avoid splitting bales before they reach the health

facility. Numbers and quantities probably need to be calculated and reviewed.

IF health facilities place an emergency order, they often collect the order when they are in town. Larger

facilities with vehicles and funds for fuel have the ability to collect than do smaller HFs.

85

Slide 14


Next steps

PMI

1. Provide IDEAS 1st ANC attendance data

2. Identify set of possible system designs

3. Clarify stakeholder roles in ITN 2 ANC project

IDEAS:

• Report: narrative to accompany PowerPoint

• Provide lessons-learned report from field visits

• Calculate volume of nets /region & /zone based on 1st

ANC attendance data (#1)

• Provide outline of costing parameters (#2, #3)

Numbers in parentheses refer to the numbered items in the PMI list above

IDEAS has access to and will use population data from the DHS 2010

86

Slide 15


Next steps, trip 2

PMI

4. Advise IDEAS on ITN 2 ANC partnership structure, assumptions, division of responsibility

5. Review system design narrative

IDEAS:

• Draft report on system design options (#4)– Parameters that define program

– Required information

• Revise report (#5)

Parameters that define program: cost, feasibility, M&E, security, info, mgmt, etc

87

A3.3: PowerPoint Presented at NATNETS Steering Committee Meeting

Slide 1




Care Clinics

Libby Levison

Wayne Stinson

Peter Cross

IDEAS

March 11, 2015

88

Slide 2


System 1, private

Public distribution


Stock info

Health stats

Order request

Program management

MOHSW/

NMCP

DMORMO

Health

Facilities

“R&R”eLMIS

Zone 1Impl.

Partner,

Procurement


Logistics

Zone 2

Zone1/Zone 2: Implies storage not at central level; procurement partner to ship directly to subnational

level. Depending on volumes, it might be possible to split one Health Zone’s shipments and ship to and

store at the Regional level.

R&R : Report and Requisition: MoHSW reporting and ordering form

Partner colors:

Blue: Min of Health


for program

Red: private sector

89

Slide 3


System 2, mixed

Public distribution


Stock info

Health stats

Order request

Program management

MOHSW/

NMCP

RMO

Health

Facilities

eLMIS

Impl.

Partner,

Procurement


Logistics

MSD Z1

Zone 1

DMO

“R&R”

Zone 2

A mixed system: in one Zone use MSD delivering to the HF (ie, last mile); and in another region or

zone use the private sector

90

ANNEX 4: DELIVERABLE 2: SUMMARY OF PMI ITN

DELIVERY SYSTEMS IN OTHER COUNTRIES

Situational Analysis of Options for Delivery Systems of

Insecticide-Treated Mosquito Nets through Antenatal Care

Clinics

Deliverable 2: Summary of PMI net delivery programs in other

countries

Libby Levison

Wayne Stinson

Peter Cross

IDEAS: Innovative Development Expertise and Advisory Services, Inc.

April 7, 2015

Acronyms


CHW Community health worker

EPI Expanded Program on Immunization



JSI John Snow, Inc.

LLIN Long Lasting Insecticidal Net

NGO Non-governmental organization



91



92

1. LLIN Distribution through Public Health Facilities in PMI Africa

Countries

National malaria control programs universally prioritize pregnant women because of their

heightened vulnerability to malaria, but some PMI/Africa countries have lacked the

organizational and human resources to develop and implement full continuous distribution

strategies. According to 2015 Malaria Operational Plans, the following countries have ANC

distribution programs: Ghana, Kenya, Malawi, Mali, Mozambique, Nigeria (variable by state),

Rwanda (first pregnancy only), Senegal, Uganda, Zambia, and Zimbabwe. (Tanzania had a

program until recently, but is not currently distributing nets to pregnant women.)

Based on field experience, the Vector Control Working Group (Continuous LLIN Distribution

Work Stream) of Roll Back Malaria has developed a Country-to-Country Guide for Implementers

of LLIN Keep-up.7 (Continuous distribution efforts through public health service delivery points

commonly serve infants as well as pregnant women, generally through well-child/EPI programs;

In most cases, these parallel programs share logistics, storage, record-keeping and management

systems.)

For this overview, we looked particularly at the work of Roll Back Malaria as well as individual

case studies by the Networks project, focused on Ghana, Kenya, Malawi, Mali, Rwanda and

Senegal. Limited information is also available for Mozambique. As amplified in the matrices

below, analysis focused particularly on:

Overall structure

Storage and transport

Quantification and buffer stocks,

Record keeping and validation, and

Security measures and fraud prevention

2. Overall structure

Direct vs. indirect distribution

Distribution may occur at the health facility itself during service delivery (direct), or it may occur

separately through voucher or coupon redemption at a separate location (indirect). Tanzania was

an exception in distributing indirectly in its now terminated Tanzania National Voucher Scheme.

Using coupons, Ghana also implemented indirect distribution in the Eastern Region between

2012 and 2014. Other programs studied distributed nets directly at the point of ANC/EPI service.

Integration with national storage and supply systems

Virtually every program has worked closely with national systems, but only a few have integrated

completely. Integration has been particularly tight at the policy level and in terms of technical

guidelines and information systems, but much less so for procurement, storage and distribution.

LLINs take enormous storage space and are difficult to transport; requirements are very different

than for routine pharmaceutical products, and planners in most countries have judged that central

7 “Country-to-Country Guide for Implementers of LLIN Keep-up: A Guide for Continuous Delivery of

LLINs via ANC, EPI and Other Routine Health Services,” Roll Back Malaria December 2011.

93

medical stores and similar parastatal organizations have lacked the physical capacity, human

resources and systems to adequately manage LLIN storage and distribution. In addition, public

and parastatal organizations are generally thought to lack the rapid response capacity considered

essential for LLIN distribution. As shown in Table 1, only Rwanda, an exceptional country in

many respects, has a fully integrated system.

NGOs and the private commercial sector

Many programs rely on NGOs for storage and distribution: PSI in Kenya, Malawi, and Mali; the

Malaria Consortium in Uganda. Transportation from national to regional stores (Kenya, Malawi,

Ghana, Mozambique, Senegal) and to facilities (most countries) is often contracted to NGOs,

which may in some cases sub-contract to private transporters. (PSI relies on its own fleet in

Malawi.) Use of public systems does occur in some countries; notably Rwanda, Ghana and

Senegal.

Table 1: Program Integration

Mode of

delivery

Integration:

storage/delivery

Role of

NGOs

Role of

private

sector

Ghana Indirect Central Medical

Stores

Kenya Direct Separate from

routine supplies

PSI/Kenya Commercial

firms for

distribution

Malawi Direct Separate from

routine supplies

PSI/Malawi

Mali

Direct Separate from

routine supplies

(but integrated

from district

below)

PSI/Mali

Mozambique Direct “temporary

semi-parallel

supply chain”

Rwanda Direct Totally

integrated

JSI distributed

PMI nets

Senegal Direct Project and

government

collaboration

Project

transported

nets

94

3. Storage and transport

First offloading point

All of the countries in this review have offloaded internationally procured supplies at the national

level, but several (including Rwanda and Ghana) have moved quickly from that level to regions

because of limited central storage capacity. (As a partial exception, Uganda dispatched part of the

supply for a universal coverage campaign directly to districts.) Kenya, Malawi and Mali have

used NGO (PSI) warehouses, but others (most notably Rwanda) have used government or

parastatal warehouses.

Intermediate storage and distribution

Rwanda (again an exception) moves nets directly from national storage to facilities. As detailed

below, other countries move ITNs to regional warehouses or (in one case) to districts.

Some programs issue tenders for transport support, although this may be more appropriate for

campaign-style rather than continuous distribution. PSI in Malawi operates its own small fleet of

transport vehicles, appropriate for monthly deliveries to relatively small facilities. Physical

security during transit is an explicit concern in Rwanda, Mali and Malawi, but is undoubtedly an

issue elsewhere as well. In Malawi, nets move in sealed trucks. Rwanda requires police escorts

for all vehicles, but the agent for PMI-managed transport is currently looking for cheaper

arrangements. (Uganda used national defense forces for a recent universal coverage campaign.)

Table 2: Storage and distribution

First

offloading

point

Intermediate

storage

Distribution

to delivery

point

Local

storage

constraints

Security

Ghana Central

Medical

Stores, but

space

constraints

Medical Stores

Dept.

delivered to

regional stores

Kenya Central PSI 3 regional PSI

warehouses

Private

truckers hired

by PSI

crowded but

adequate for

4 month

supply

Malawi Central PSI 3 regional PSI

warehouses

3 trucks, 6

dedicated

Land Cruisers

Adequate

for one

month

Trucks have

tracking

monitors;

complete

monthly

reconciliation

Mali Central PSI Delivery to

districts

Districts

deliver to

Reportedly

tight, with

concerns

Concerns

about facility

95

facilities about

security

security

Mozambique Central Regional

Rwanda Central, but

space

constraints

None National

program or

JSI

Police escort

Senegal Central Regional Districts

responsible

for

distribution

4. Quantification and buffer stocks

Estimation of need

At national level, every program appears to base procurement quantities on population, generally

calculating that 4.0 (Kenya) to 5.0 (Malawi) or 5.2% (Angola) of the population becomes

pregnant each year. New programs and those with unreliable ANC attendance data use population

estimates at sub-national levels as well; as programs mature, however, many gain confidence in

ANC data and begin to use it for local quantification. On a routine basis, Rwanda determines all

needs centrally while Kenya relies on a combination of central- and facility-generated

quantification.

Frequency and amounts

Malawi attempts monthly distribution, and Kenya quarterly. Mali has had quarterly distribution

but is attempting to move to a four or five month schedule. Rwanda distributes twice yearly. Only

a few reports indicate how much is distributed with each delivery, except that Malawi determines

a storage “ceiling” for each facility and refills to that level during each monthly delivery.

(Malawian managers decided to distribute 10-net bales rather than the more common 40-net bales

to increase precision and facilitate, inventory control, and replenishment.)

Reordering and buffers

While national quantification of local needs has “pushed” initial supplies to lower levels, most

programs use a mix of “push” and “pull” quantification for periodic restocking and for emergency

needs. Those using “pull” methods have generally attempted to validate existing distribution data,

but at least one program says it may “correct” local orders because of distrust in ANC reporting.

Buffer stocks for one (Ghana) to three months (Kenya) are stored at regional levels, while

individual facilities appear to retain one month buffer stocks in most cases.

Table 3: Quantification, Delivery frequency and buffer stocks

Use of

census data

Use of

ANC data

Frequency

of delivery

Amounts

delivered

Reordering Buffers

96

Ghana Pull system 1 month

Kenya National

quantification

based on

census (4%

pregnant)

Local

numbers

based on

ANC

Quarterly Sufficient

to bring

stock to 4

months’

supply

Facilities

reorder

from PSI

10%

central;

2-3

months

at region

Malawi Population-

based (5%

pregnant)

Monthly Up to pre-

determined

maximum

PSI tops up

monthly

Mali

Population-

based (5%

pregnant)

Not

considered

reliable

Quarterly

but moving

to 5 months

“Pull”

system but

national

level may

“correct”

Rwanda Based on

CHW

population

counts

Every 6

months

Mostly

push

system but

facility can

order if

stocks low

Senegal National

quantification

based on

census

Based on

utilization

5. Record-keeping and validation

Every program appears to maintain ANC registers and individual user-retained patient cards, both

of which record nets received. Kenya, Malawi and Rwanda also maintain separate LLIN

registries to record dates, names and sometimes village of residence. (These LLIN registries

generally list all nets, regardless of the sponsoring source or program, and are intended to account

for all nets distributed.)

Programs using combined push-pull mechanisms for quantification and ordering (see above)

generally require validation of ANC attendance and LLIN distribution prior to resupply.

Aggregated monthly reports usually combine service and distribution data, facilitating direct

managerial review of distribution, but data in Mali are considered too unreliable for that purpose.

6. Security measures and fraud prevention

The physical security of nets is an issue for transport and storage. Rwanda’s is the only program

known to require police escort during transit, although Uganda also had security service escort for

some phases of the recent universal coverage campaign.

97

But fraud may also occur through distribution to unauthorized persons or improper recording.

Programs which record net distribution through ANC registers only may be open to fraud because

registry checkmarks can easily be added later for women who did not actually receive a net.

Separate LLIN registries may provide more information, including name and residence; but

informants in several programs have indicated that they are less useful for monitoring ANC

attendance.

Available documentation provides very little information on country practices for both “Record-

keeping and validation” and “Security measures and fraud prevention”, therefore a summary table

is not possible for these system components.

7. References

From Networks (USAID project through Johns Hopkins University Center for Communication

Programs):

Continuous Distribution Lessons in Brief: Country case studies on continuous distribution: all

available at https://www.k4health.org/toolkits/continuous-distribution-malaria/case-studies

Kenya: Making It Work – The Big Picture

Kenya: Making It Work – Integrated supply and Supervision:

Malawi: Accountable Partnership – Singing from the Same Song Sheet and

Knowing the Score

Malawi: Logistics, logistics, logistics

The Tanzania National Voucher Scheme – Keeping Up With Keep Up

Tanzania: Making vouchers fast and flexible – the eVoucher in Tanzania

Senegal’s Push and Pull Combination Strategy:

Ghana: Ghana’s Mixed Model Scores Coverage Points

Country to Country Guide for Implementers of LLIN Keep-Up: A Guide for Continuous Delivery

of LLINs via ANC, EPI and Other Routine Health Services: accessed on 20 March 2015 at

http://www.rbm.who.int/partnership/wg/wg_itn/docs/ws3/4-LLIN_Keep_Up_Guide.pdf.

LLIN Continuous Distribution through antenatal care and immunization services (The following

were provided by PMI/Tanzania in draft and have not been published.)

Kenya Rapid Assessment

Mali Rapid Assessment

Malawi Rapid Assessment

Rwanda Rapid Assessment

President’s Malaria Initiative, Malaria Operational Plan FY 2015 (Angola, Benin, Democratic

Republic of the Congo, Ethiopia, Ghana, Guinea, Kenya, Liberia, Madagascar, Malawi, Mali,

Mozambique, Nigeria, Rwanda, Senegal, Tanzania, Uganda, Zambia, Zimbabwe)

98

ANNEX 5: VARIATION IN FIRST ANC ATTENDANCE

The estimate of required quantities of ITNs by health zone and region presented in Section 5 also

revealed variations in first ANC attendance between reporting periods.

For example, in Lindi there were 8,884 first ANC visits in Q1, compared to 6,853 in Q4 (Figure

3). Across the Southern health zone, usage falls from 34,596 in Q1 to 30,057 in Q4 (Figure 3).

Across the Lake health zone, usage falls from 150,996 first ANC visits in Q1 to 143,427 visits in

Q4 (Figure 4).

Figure 3: Variation in attendance by quarter

Figure 4: Variation in attendance by quarter

Both zones illustrate these variations across reporting periods; a supply system which determines

stock re-supply quantities based on previous consumption could see stock shortages – specifically

if they use Q4 data to calculate Q1 need.

Region Q1 Q2 Q3 Q4 Annual

Lindi 8,884 8,316 7,861 6,853 31,914

Mtwara 11,636 10,670 9,979 9,229 41,514

Ruvuma 14,076 14,591 14,281 13,975 56,923

Q Totals 34,596 33,577 32,121 30,057 130,351


Region Q1 Q2 Q3 Q4 Annual

Geita 27,052 25,565 26,328 27,002 105,947

Kagera 24,466 22,812 22,114 21,581 90,973

Mara 23,339 22,775 21,343 20,334 87,791

Mwanza 31,376 33,796 34,269 31,159 130,600

Shinyanga 21,642 20,922 21,618 21,376 85,558

Simiyu 23,121 22,036 21,016 21,975 88,148

Totals 150,996 147,906 146,688 143,427 589,017


99

ANNEX 6: PRELIMINARY COST PARAMETERS ANALYSIS

FOR ITN DELIVERY SYSTEM

IDEAS was originally asked to create a supply chain costing tool for the ITN delivery system.

Given the timing of the consultancy, and that numerous program implementation details remain

to be defined, creating such a tool was determined to be premature. Furthermore, given that some

of the storage and transport of ITNs will be competitively procured from the private sector, a

detailed costing tool might not be useful for program management. It is likely that the ITN 2

ANC program will use fixed-price contracts, which will spell out exactly what services are

included, performance requirements, metrics for monitoring performance and a reward and

penalty system, etc.; in this case the ITN 2 ANC program will not need to have a line by line cost

break down of supply chain activities.

Instead of a supply chain costing tool, PMI asked for an overview of cost categories related to

supply chain activities and to identify, for each level of the ITN supply chain, which partner

would contribute the support. Support consists of financial resources as well as in-kind

contributions, including human resources (e.g., 10 minutes of a staff member’s time per week)

and logistical resources (e.g., a half cubic meter of storage space for storing ITNs in a health

facility). A preliminary judgment was made as to whether the partner might be able to provide the

resource with its own funds or whether the funds might come from PMI.

The analysis of cost parameters of the delivery system was done in the following manner. Costs

were divided into five supply chain functions: Quantification & orders, Storage, Distribution,

Management and Information Flow/Communication at each of four levels of the supply chain:

National level, Sub-national level, District and Facility, and for both of the delivery mechanisms

in the mixed system, as shown in Figure 5 below.

Figure 5: ITN supply chain costs by function and health system level

For each supply chain function, two or three major budget lines were identified (e.g., costs for

renting a warehouse and human resource costs), resulting in 12 budget lines. Finally, each of the

96 cells (12 budget lines * 4 levels of health system * two delivery systems) were analyzed and

via

MS

D

via

MS

D

via

priva

te

via

MS

D

via

priva

te


Oversight

Storage




Information Systems

via

priva

te

via

MS

D


Sub-

nationalDistrict

Health

Facility

via

priva

te

100

the ‘payer’ and source of ‘funds’ identified. This analysis is shown in Figure 6 below. The key

below the table gives the color correspondence.

This analysis of cost parameters is a preliminary work; as the ITN 2 ANC program is further

designed and as agreements are reached with program partners, this analysis will likely change.

For each budget line, at each level, there can be multiple partners contributing to the activity. For

example, for Quantification and Ordering at the Health Facility level, the HR will be provided by

health facility staff from both the public and FBO sectors, and DHMT staff will support the

quarterly requisition. For the same activity at the sub-national level the HR is provided by

MoHSW and MSD, with likely financial support from PMI.

Quantification and Ordering means slightly different things at the central and subnational levels

compared to the district and health facility levels. At the district and health facility levels, this is

the quarterly requisition, and there is need for training staff on how to order ITNs, staff time to do

the orders, supportive supervision from the DHMT and RHMT, perhaps meetings

(miscellaneous) to introduce the new procedures, etc. At the central level, it is likely that multiple

players will need to meet periodically to quantify future ITN need: MSD and the IP Logistics will

know about available ITN stock throughout the country, NMCP will have attendance data, and

PMI and the IP Logistics will know program expansion plans. (The ordering and procurement

will be done by the IP Procurement after approval by PMI.)

The Storage and Distribution activities are relatively straight forward. The ITN delivery system

selected by the NATNETS Steering Committee will store ITNs at the sub-national and facility

level. There should be no storage or distribution costs incurred at the Central and District levels.

In Figure 6 cells shaded gray indicate that no cost is incurred for that function at that level of the

health system; all cells for the storage and distribution functions at the central and district level

are gray. Nor are there Transport costs incurred at the health facility level (facilities do not

transport ITNs).

The Management/Oversight activity is intended to be performed by the ITN 2 ANC program

partners. For the Operating Costs budget line, the IP Logistics is shown as the payer at all levels

of the health system, with PMI as the source of funds. For the Program Management budget line

there are multiple contributors: staff time for activities like reporting will be important for the

program.

The Information function has three line items. First, the Information system costs line covers the

eLMIS operation from the Central to District level. The HR costs line covers the time required to

enter the ITN order into the eLMIS, for the warehouse to update the ITN order with the quantity

allocated and the quantity left in their stocks. The Communication costs line represents a direct

mechanism so that all participants in the ITN 2 ANC program can communicate up the supply

chain if they are having an issue with availability of ITNs. This might be a text messaging system

similar to the old SMS for Life; but it will be a separate mechanism that PMI or another partner

will need to fund to ensure adequate information to make the ITN 2 ANC program successful.

This identification of partners’ roles and contributions to the ITN 2 ANC program will change as

the program is further defined and partner roles are better understood. But what can already be

seen when looking at Figure 6 is a good distribution of color: the MoHSW (blue) is involved at

all levels of the selected delivery system; MSD (green) is involved at the central and sub-national

levels, and the FBOs (purple) is contributing at the health facility level; other contributions might

be identified in the future. The chart is not a single color. The selected mixed delivery system

shows broad partner participation.

101

Knowing what each partner is contributing to each cost category is helpful in designing the

supply system and defining contract deliverables. The same metric can be used to monitor the

program, expected program costs and partner performance.

102

Figure 6: Draft cost parameters of ITN 2 ANC program

.

Category Description

Payer Source Payer Source Payer Source Payer Source Payer Source Payer Source Payer Source Payer Source

Quantification & Ordering

MOHSW/

NMCP MOHSW

MOHSW/

NMCP MOHSW MoHSW MOHSW MoHSW MOHSW RHMT MOHSW RHMT MOHSW DHMT MOHSW DHMT MOHSW

IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI

MOHSW/

NMCP MOHSW

MOHSW/

NMCP MOHSW MoHSW MOHSW MoHSW MOHSW

RHMT/

DHMT MOHSW

RHMT/

DHMT MOHSW DHMT/ HF MOHSW DHMT/HF MOHSW

MSD PMI MSD PMI FBO HF FBO FBO HF FBO

Misc IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI

Storage

MSD MSD HF MOHSW HF MOHSW

IP Log PMI IP Log PMI FBO HF FBO FBO HF FBO

MSD MSD HF MOHSW HF MOHSW

IP Log PMI IP Log PMI FBO HF FBO FBO HF FBO

Transport & distribution

MSD MSD

IP Log PMI IP Log PMI

HR: transport MSD PMI

Management/Oversight

Operating costs IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI

MOHSW/

NMCP MOHSW

MOHSW/

NMCP MOHSW MoHSW MOHSW MoHSW MOHSW DHMT MOHSW DHMT MOHSW HF MOHSW HF MOHSW

MSD MSD MSD MSD FBO HF FBO FBO HF FBO


Information

MOHSW/

NMCP MOHSW

MOHSW/

NMCP MOHSW MoHSW MOHSW MoHSW MOHSW DHMT MOHSW DHMT MOHSW

MSD MSD


Communication costs IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI

MoHSW MoHSW MSD MSD DHMT MOHSW CHMT MOHSW

IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI IP Log PMI

Program support and

supervision

Transport services

Program mgmt

HR costs

Info system costs

Storage services

HR: stock mgmt

HR

Central Level

via private sector via MSD

Sub-national Level District Level Health Facility Level

via private sector via private sector via MSDvia MSDBudget items

via MSD via private sector

MOHSW MSD PMI FBO HF No TSh

Key to Funding sources

For more information, contact:

Health Policy Project

Futures Group

1331 Pennsylvania Ave NW, Suite 600

Washington, DC 20004

Tel: (202) 775-9680

Fax: (202) 775-9694

Email: [email protected]

www.healthpolicyproject.com

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