1. CDI Module 14: Supply Chain Management for CDI
©Jhpiego Corporation
The Johns Hopkins University
A Training Program on Community- Directed Intervention (CDI) to Improve Access to Essential Health Services

2. Module 14 Objectives By the end of this module, learners will:
Describe the process of anti-malarial drug procurement and storage
Explain how to estimate their community’s commodity needs
Outline the stock recording method and reporting format
Describe the distribution process for anti-malarial medicines and other malaria commodities (long-lasting insecticide-treated nets [LLINs], rapid diagnostic tests [RDTs])
State how to monitor and report adverse drug reactions (ADRs)
Discuss the role of patent medicine vendors (PMVs) in malaria commodity management

3. What Are Commodities?

4. Procurement and Supply Chain/Cycle
Supply system information management
Clients consume stock
Forecasting and ordering
Storage, safety and correct use
Procurement
Supply system information management
Forecasting and ordering
Procurement
Distribution to first level
Storage and safety
Distribution to next level
Storage, safety and correct use
Clients consume stock
Distribution to next level
Distribution to first level
Storage and safety

5. Commodities Flow from Suppliers to Central Medical Stores, Then on to LGAs and Facilities
In the slide title above, LGA = local government area.

6. Flow of Commodities
Health commodities for community-directed intervention (CDI) and integrated community case management (iCCM) can flow through both public and private channels
Each country is different, and in some cases:
National, regional and district medical/pharmacy stores order, procure and distribute commodities/medicines
Districts or community associations can use private sector warehouses and suppliers to buy medicines
In some countries, malaria commodities are manufactured; in other countries, these commodities are imported

7. Commodities Reach Consumers
Ultimately, commodities like artemisinin-based combination therapies (ACTs), RDTs, LLINs and sulfadoxine-pyrimethamine (SP) need to reach the frontline clinic, and from there, the community-directed distributors (CDDs)
Whatever the system, commodities must move from point of manufacture to point of use
(Present a chart that shows movement of malaria and other iCCM commodities in your country so that it finally reaches CDDs/villages)

8. Proper Estimation of Anti-Malarial Commodities
It is important to have estimates of eligible clients/patients to determine anti-malarial commodity requirements at all levels
Accurate data are required to achieve these estimates
Initial quantification of anti-malarial medicines (ACTs, SP, quinine) needs to be done using population-at-risk data, by episode, based on medicine consumption
Lower level quantification can be done through community “head counts” during community census

9. Malaria Tasks Have Different Schedules (Forecasting)
The first task is to conduct a community census to determine numbers of people in need of services
An insecticide-treated net (ITN) is needed as soon as a woman knows she is pregnant
Intermittent preventive treatment in pregnancy (IPTp) occurs at least twice after quickening, at monthly intervals
Case management occurs whenever a community member has malaria
IPTp and ITNs may prevent most of the need for case management
Finally, health education is frequent

10. Identify and Coordinate Sources of Supplies and Funding
LLINS
ACTs SP
Global Fund
World Bank
USAID
UNICEF
Ministry
Present details from your own country

11. Sample Roadmap Country Summary
Need to 2010
Funded and expected to be distributed before end 2010
Gap
LLINs
63 million LLINs
49 million
14 million
ACTs
129 million doses
94 million
35 million
IRS
2.8 million households
800,000
2 million
RDTs
59 million tests
34 million
25 million
IPTp
18 million doses
18.3 million
In the chart above:
IRS = indoor residual spraying
Facilitator Note: You may use the sample data (shown above) as an example, but you may also want to add similar data from the country where the module is being presented.
Example:
LLINs (100% coverage)—population of 2 million = 1 million nets needed before end of 2010
Already covered (distributed in 2008—so nets will last beyond 2010) = 500,000
Funded and expected to be distributed before end 2010 = 200,000
Gap = 300,000 (note if gap = 0, then 2010 targets are achieved)
ACTs example:
Number of expected fever cases = need per year (160,000 cases expected per year)
Need from January–December 2010 = 160,000 ACTs
Already funded = 100,000 ACTS
Gap = 60,000 ACTs
Summarize resources available in your country to support the identified needs.
Is there any financial gap?

12. Procurement and Supply
It is recommended that drugs for home management of malaria (HMM) be centrally procured
Benefits of central procurement include bulk purchasing, which can:
Reduce cost of medicines and handling charges
Ensure consistency and quality of supplies
Simplify logistics
These drugs should be World Health Organization (WHO)-approved medicines
Ultimately these should move in a well supervised manner from national to sub-national to district to health facility and then community

13. Companies Producing WHO Prequalified Malaria Medicines as of August 2010
Amodiaquine + Artesunate
Ipca Laboratories Limited
Dadra and Nagar Haveli (U.T.), India
Guilin Pharmaceutical Co. Ltd
Guilin, Guangxi, China
Cipla Ltd
Patalganga, India; Goa, India
Sanofi-Aventis Group
MAPHAR Laboratories, Casablanca, Morocco
Artemether + Lumefantrine
Novartis Pharma
Beijing, China; Suffern, USA
Ajanta Pharma Ltd
Paithan, Aurangabad, Maharashtra, India
Ipca Laboratories Ltd
Patalganga, India; Himachal Pradesh, India
In the chart above, U.T. = Union Territory

14. The Frontline Primary Health Care (PHC) Facility Provides Commodity Link with CDDs

15. The Malaria Drug Supply Chain
Community delivery of malaria medicines requires adequate supplies at all levels
Districts must monitor frontline facilities to help prevent stock-outs for facilities and the CDDs these facilities supervise
CDDs collect stocks from the nearest PHC facility

16. Forms Track the Use of Anti-Malarial Medicines
Forms are used at all levels of the health care system to track the use of anti-malarial medicines
States/municipalities use forms to track the drugs they procure and distribute
Facilities also use forms to track the drugs they procure and distribute
CDDs use forms to track the medicines they pick up from their supervising facility and distribute within the community

17. Why Use Anti-Malarial Drug-Tracking Forms?
These forms collect data on:
The consumption of different dosage packs
The manufacture and expiry (expiration) dates of medicines
These forms also include areas to record the justification for any discrepancies in drug consumption (e.g., partial medicine usage)

18. The Distribution Process for CDI
Commodities reach the nearest health facility
The community representative or CDD collects initial supplies and materials from the health facility
The initial stock is based on a village census that shows need
On receipt of stocks, the CDD or community representative signs an inventory register at the health facility confirming collection of supplies

19. CDDs Need a Safe Place to Store Their Own Medicines

20. Maintaining Stocks and Distribution
The community is informed that commodities are available from the CDD
Women and caregivers seek these services, when needed
The CDD maintains distribution records and summarizes these on a regular basis
The community or the CDD submits summary reports to the health facility on a regular basis
Then they collect replenishment supplies

21. Community Preparation
The community and the CDD announce to community members that commodities are available
The community decides on a distribution system for commodities
For ivermectin, people could go house-to-house or distribute the drug from a central location
For malaria commodities, people could go to the CDD’s house, or the CDD could make home visits
The community should decide on the most acceptable processes

22. Storage
During training, CDI focal persons should sensitize the CDDs to the following storage requirements:
Keep medicines away from direct sunlight and heat
Ideally store SP, and ACTs in a cool, dry place—temperature should not exceed 25°C
Keep all medicines out of reach of children, at all times

23. Keeping Medicines in the Community
Keep community case management (CCM) kits in dry, clean places in the house
Medicines should be kept separate from the other items in the house
Medicines suspected to have come in contact with water must not be used for treatment
Damaged medicines should be returned to the health center and a new stock collected

24. Medicines May Not Work as Expected
CDDs should report dangerous or unexpected effects of the drugs to their supervising health facility
The supervising facility should report to the district
This reporting is part of the pharmaco-vigilance system
Likewise, CDDs should take note of patients who do not get well after taking ALL medicine correctly
These patients should be reported and referred
These steps help ensure quality of commodities

25. Getting New Stock for the Community
A system of stock collection is needed
Monthly CDD meetings at the frontline facility is one way to accomplish this:
CDDs bring empty medicine packets to exchange for new packets
A system must be in place to obtain stock whenever it is needed

26. PMVs Are a Major Source of Medicines for the Community
Sometimes if CDD stocks run out, community members may need medicines quickly
PMVs may be a source
We need to monitor PMVs to ensure that they provide quality medicines

27. Procurement and PMVs PMVs: Normally buy their stock from wholesalers
Usually do not keep records and receipts
Do know which medicines are popular
With the Affordable Medicines Facility for Malaria (AMFm), PMVs:
May now be receiving specially packed Coartem from the health system
Will need to learn how to manage stocks, check expiration and report damages

28. PMV Associations Can Be Involved in Procurement and Supply Chain Management (PSM) for the Private Sector
Sometimes communities can re-stock their medicine box by buying from a reliable PMV shop

29. Summary and Conclusions
CDDs:
Collect drugs from the health facility that provides services to their community
Ensure that drugs are stored appropriately
Maintain an accurate account of drug use, damages and stock at all times
Report ADRs to the supervising health facility
Attend monthly meetings and submit monthly reports
PMV associations can also be involved in the supply of approved malaria commodities