Mr. Farhad Ali

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Exploring supply chain management issues in childhood diarrhea prevention and treatment– research findings in Stop Diarrhea Initiative of Save the Children in four States in India :

Exploring supply chain management issues in childhood diarrhea prevention and treatment– research findings in Stop Diarrhea Initiative of Save the Children in four States in India Farhad Ali, Arindam Ghatak, Abhik Dutta, Prasann Thatte Save the Children , India


Introduction Childhood diarrhea is a leading cause of under-five morbidity and mortality in India and globally. WHO and Unicef have suggested 7 point plan for comprehensive diarrhea control. The success of this plan depends on availability of range of supplies . Save the Children India conducted a study in Uttar Pradesh, Uttarakhand, Delhi and West Bengal under ‘Stop Diarrhea Initiative’ that reveals that only 48.6% of under-5 children received ORS, 9.4% received zinc and cumulative coverage of measles and vitamin A was 69.3 % and 45.3% respectively . In this study we wanted to understand the bottlenecks in the supply chain of ORS, zinc and vaccines.


Objectives Assess the procurement and supply of ORS, Zinc, vitamin ‘A’ and vaccine (measles) from state/ district levels to the health facilities and community level health workers in public system, and to RMPs and other private practitioners in the private sector; Identify the key bottlenecks and reasons thereof in the supply chain management of ORS and zinc from procurement to distribution through to health facilities and community health workers, to beneficiaries; Identify the gaps in knowledge, skills and practices of staff responsible (ex. pharmacists, medical officer in-charge, private practitioner/s) for and involved in monitoring ORS and Zinc; and Present the findings for each state/district and make recommendations for strengthening supply chain management of ORS, Zinc and vaccines for each state.




Respondents Level Respondents State Level Store Manager, Chief Pharmacist Regional Level Store Manager, Chief Pharmacist District Level CMHO , DIO, Pharmacist Block Level BMO , MOIC , Superintendent CHC, Pharmacists (PHC, CHC ) Village Level ANM, ASHA, Anganawadi Worker

Coverage Area Under the Study:

Coverage Area Under the Study


Structured Questionnaire Details of logistics and arrangements for receipt of supplies – List the items received per month over the last two years period; Distribution pattern – list the items and quantity issued per month over the last two years; Type and quality of equipment being used for storage, distribution and transportation; Check List for In-depth Interviews Availability of Human Resources for Store Management Infrastructure Facilities, Demand, Indenting, Supply, Stock management, and Transportation Research Tools

Limitations of the study :

Limitations of the study Refusal of officials to share information with the study team due to fear of some action against them . Non-availability of previous year’s documents and records at some CHCs and most of the sub centers . In such cases the investigators depended on the information collected from the respective staff and officials.

Key findings :

Key findings


District CMSD operational in makeshift building not having adequate storage space and infrastructure to keep medicines and supplies as per required standards Store at Amariya block requires repair and maintenance . Store furniture in poor condition and needs to be repaired and / or replaced. Overall the physical infrastructure requires repair and maintenance In Tulsipur block, the reported infrastructural problem was of seepage especially in rainy season which requires urgent repair Overall Poorly maintained storage space in Sub-centres in both the districts In Pilibhit district, at few places ANMs mentioned about the frequent theft in Sub-centre because of which stock and records are not kept there. CMSD Infrastructure – Key Issues


Inadequate space for vaccine storage Non-operational cold chain equipment Lack of proper temperature monitoring of Deep Freezers Overall physical infrastructure requires repair and maintenance Non-operational cold chain equipment and stabilizers Lack of proper temperature monitoring of Deep Freezers due to shortage of functional thermometers Seepage in walls during the rainy season Cold Chain Infrastructure – Key Issues


Human Resource Reported shortage of support staff like loaders, sweepers, office attendants and guards At district and block level, the posts of vaccine handler were handled by Health Supervisors and LHVs. Training status No formal induction and / or on-job training to district and block level staff on the logistic and stock management Lack of budget for training sessions Human Resource and Training – Key Issues


Demand Assessment Demand estimation - by state level Child Health unit established under NHM This is done scientifically based on the 0-5 year population of children District wise demand estimation is done and conveyed to DPMs for allocation of adequate budget in their respective district PIPs. ORS is also procured from state health fund given to CMOs of each district This procurement is only for hospitals for which the demand is calculated by chief pharmacist and SMO store based on patient load, previous year’s consumption and 10% increment in that Demand estimation of Measles vaccine is done by State Immunization Officer based on the population of 0-1 year children Estimation is done district wise and conveyed to respective DIOs who then distribute that among blocks. Vaccines are distributed by state government to all the districts.


ANM is responsible for indenting at the Sub-centre level. Pharmacist at the CHC / PHC prepares the indent , Medical Superintendent / MOIC approves and submits that to district level. At district stores, Chief pharmacist prepares the indent, SMO stores verifies it and CDMO signs it. Chief pharmacist then directs the computer operator to generate the indent on Drug Procurement & Inventory Control System (DPICS), a web based application developed by NIC, UP State Unit. Separate indents for each item are created on this which gets automatically delivered to the drug manufacturer / supplier. Indenting Officers CDMO : District MO IC : PHC ANM: Sub Centre Frequency Block - monthly indents or whenever required basis to the district CMSD. SC level – ANM collects medicines monthly or as and when required from the Block level. For measles vaccine indenting is done usually on monthly basis. However for special programs like Mission Indradhanush and Biannual rounds, indenting is done before the start of program. Indenting


Blocks sends indents on a monthly or whenever required basis. Block pharmacists send handwritten indents to district pharmacist ANMs do not submit any formal indent to pharmacist at block level. It is done orally. Indenting – Key Issues


Procurement of medicines in Uttar Pradesh happens at district level State officials of CMSD - Finalize suppliers for each medicine and fix the RC. Product wise name of the suppliers and unit rate of each medicine is uploaded in the Drug Procurement & Inventory Control System (DPICS) system. The procurement at the district level against the annual budget - Chief pharmacist prepares the list, SMO store verifies & approves it and puts it to District Purchase Committee. Committee decides the drug list for purchase Approved list is then sent to SMO store and district CMSD for procurement of drugs Chief Pharmacist raises the indent on DPICS , separate indent is raised for each drug Separate record for drugs purchased under NHM fund and state budget For measles vaccine, there is no budget allocated. State takes whole supply from the centre. For this, indent is submitted to a Vaccine Depot of Government of India as per the requirement and availability of vaccines. Procurement


Supply chain


Supply chain – Key Issues Supply to the CHCs/PHCs by district stores is always based on the availability of stock rather than the demand


Chief Pharmacist / Pharmacist at state, district, block level and ANM at SC level responsible for stock keeping of ORS, Zinc and Vitamin A solution Immunization officer responsible for the stock keeping of vaccines Separate record of all the supplies of ORS, Zinc and Vitamin A solution maintained which includes batch number and their expiry date Bin cards are not used for stock management in Pilibhit and Balrampur districts. In general the stock keeping for measles compared to ORS, Zinc and Vitamin A solution at all levels was found good Key issues Not adequate orientation towards First-in-first-out (FIFO) method of stock keeping FIFO method could not be applied effectively due to lack of space and time crunch Stock Management


Bottlenecks in supply chain Procurement Bottlenecks Policy of having one vendor for each product Distribution Bottlenecks Improper indenting Transportation issues Distribution decision


Gaps in knowledge, skills and practices of staff Administrative posts Confusion about the budgetary allocation Timely arranging adequate quantities of ORS and zinc and ensuring its distribution to ANMs and ASHAs before the start of IDCF Establishing effective coordination with ICDS department Chief pharmacist/pharmacist Basic concepts of supply chain management and its impact on drugs Knowledge about Supply Chain SOPs developed by the state Prioritizing the indent list based on the consumption trends and seasonal variations Demand calculation based on consumption Anticipating seasonal variation in demand of ORS and Zinc Gaps in knowledge and skill to use standard indent formats Knowledge about inventory control systems like FIFO and how to implement it effectively in the store


Gaps in knowledge, skills and practices of staff Medical Officer-in-charge Skills to provide guidance to pharmacist for effective management of drugs in the store Indentify training requirements of pharmacists and make appropriate arrangements for their capacity building Practice of not encouraging other medical officers to prescribe zinc with ORS to children with diarrhea Practice of not repeatedly orienting ANMs on the use of zinc and ORS Frontline workers of Health and ICDS Practice of not prescribing ORS and zinc to children with diarrhea Lack of knowledge in ASHAs and AWWs about the use of zinc and vitamin A solution Skills to maintain proper and accurate records of supplies Private Practitioner Practice of prescribing antibiotics, anti-diarrheal and ORS to children with diarrhea missing out zinc tablets Lack of knowledge in Registered Medical Practitioners (RMPs) about the use of zinc and vitamin A Skills of Registered Medical Practitioners (RMPs) to convince mothers about the proper use of ORS and zinc for children with diarrhea


Gaps in knowledge, skills and practices of staff Existing gaps Legend: Knowledge, skills and practices related to Supply Chain Management Knowledge, skills and practices related to Job Districts Blocks Demand Forecasting Indenting Scheduling Transportation Logistics Inventory Management Store Keeping and stock management Quality assurance Documentation and record keeping State policies, formats, SOPs Roles and Responsibilities Balrampur Tulsipur Pilibhit Amariya


Conclusion The study concludes that poor drug storage infrastructure, improper cold chain maintenance, improper demand estimation, inadequate procurement of Zinc, inadequate drug storage at facility level, transportation issues and poor distribution decisions are key bottlenecks in the logistic and supply chain management. State and district level committees should be formed to develop short and medium term goals for allocating more funds, improving infrastructure and processes and reviewing procurement policies including capacity building of staff on procurement and supply chain management.

Acknowledgement :

Acknowledgement Financial support from RB and technical support for save the children UK is duly acknowledged.

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