District-Level Assessment of Pharmaceutical Management of Life- Saving RMNCH Commodities: Lakshmipur, Bangladesh

Transcription

1 District-Level Assessment of Pharmaceutical Management of Life- Saving RMNCH Commodities: Lakshmipur, Bangladesh January 2016

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3 District-Level Assessment of Pharmaceutical Management of Life- Saving RMNCH Commodities: Lakshmipur, Bangladesh Sheena Patel Sheikh Asiruddin Javedur Rahman Azim Uddin Anwar Hossain January 2016

4 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. This report is made possible by the generous support of the American people through the US Agency for International Development (USAID), under the terms of cooperative agreement number AID-OAA-A The contents are the responsibility of Management Sciences for Health and do not necessarily reflect the views of USAID or the United States Government. About SIAPS The goal of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program is to ensure the availability of quality pharmaceutical products and effective pharmaceutical services to achieve desired health outcomes. Toward this end, the SIAPS result areas include improving governance, building capacity for pharmaceutical management and services, addressing information needed for decision-making in the pharmaceutical sector, strengthening financing strategies and mechanisms to improve access to medicines, and increasing quality pharmaceutical services. About MaMoni HSS MaMoni Health Systems Strengthening (HSS) project is an Associate Award under the Maternal and Child Health Integrated Program (MCHIP), with the goal of improving utilization of integrated maternal, newborn, child health, family planning and nutrition (MNCH/FP/N) services in Bangladesh. MaMoni HSS focuses on strengthening the systems and standards for services, which will lead to declines in maternal, newborn and child mortality at scale. MaMoni HSS s inputs are aligned to improve the performance and capacity of district level health systems, which in turn ensures that interventions result in increased access to and utilization of services by the most vulnerable. Recommended Citation This report may be reproduced if credit is given to SIAPS and MCHIP. Please use the following citation. Patel S, Asiruddin S, Rahman,J, Uddin A, Hossain A District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. Submitted to the US Agency for International Development by the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program and Maternal and Child Health Integrated Program (MCHIP). Arlington, VA: Management Sciences for Health. Key Words pharmaceutical management, reproductive health, maternal health, newborn health, child health, Bangladesh Systems for Improved Access to Pharmaceuticals and Services Center for Pharmaceutical Management Management Sciences for Health 4301 North Fairfax Drive, Suite 400 Arlington, VA USA Telephone: Fax: siaps@msh.org Website: ii

5 CONTENTS Acronyms... iv Acknowledgments... v Executive Summary... vi Introduction... 1 Background... 2 RMNCH in Bangladesh... 2 Health System Structure for RMNCH Services... 3 Supply Chain Management... 4 Methodology... 6 Purpose and Objectives... 6 Tracer Medicines... 6 Site Selection... 7 Data Collection Methods... 7 Data Collection and Analysis... 8 Limitations of the Assessment... 8 Results... 9 Pharmaceutical Management Practices in DGFP... 9 Pharmaceutical Management Practices in DGHS Availability of RMNCH Commodities Discussion Recommendations Annex A. Availability of MNCH Commodities in the Last Six Months References iii

6 ACRONYMS BEmOC Basic emergency obstetric care CC community clinic CMSD Central Medical Stores Depot CSO Civil Surgeon s Office DDS drug and dietary supplement kits DGFP Directorate General of Family Planning DGHS Directorate General of Health Services DRS District Reserve Store DT dispersible tablet EDCL Essential Drugs Company Limited FP family planning FWV family welfare volunteer FWA female welfare assistant HA health assistant HPNSDP Health, Population, and Nutrition Sector Development Program (Bangladesh) LD line director LMIS logistics management information system MCH Maternal and child health MCHIP Maternal and Child Health Integrated Program MCWC Mother and Child Welfare Center MDG Millennium Development Goal MMR maternal mortality rate MNCH Maternal, newborn, and child health MOHFW Ministry of Health and Family Welfare PE/E preeclampsia and eclampsia POM Procurement Operations Manual (SIAPS and MOHFW) PPA Public Procurement Act of 2006 PPH postpartum hemorrhage PPM Procurement Procedures Manual (DGFP) PPR Public Procurement Rules of 2008 RMNCH reproductive, maternal, newborn, and child health SBA skilled birth attendants SIAPS Systems for Improved Access to Pharmaceuticals and Services [Program] SOP standard operating procedure UFPS Upazila Family Planning Store UHC upazila health complex UNCoLSC United Nations Commission on Life-Saving Commodities USAID US Agency for International Development iv

7 ACKNOWLEDGMENTS We would like to thank the Director Management Information System (MIS) and Additional Director General, DGHS, the Civil Surgeon and Upazila Health Managers of Lakshmipur district under the Directorate General of Health Services and the Deputy Director and Upazila Family Planning Officers under the Directorate General of Family Planning of Lakshmipur district for their support for assessment. We would also like to thank the staff of MaMoni HSS Dhaka and Lakshmipur including its implementing partner, Dustho Sahthya Kend (DSK), for their efforts and dedication in supervision and data collection. We also express our sincere appreciation to the storekeepers and health managers of the district stores, upazila health and family planning stores, union sub-centers, family welfare centers, and community clinics who took time to answer the survey questions. v

8 EXECUTIVE SUMMARY Bangladesh has made great strides in improving the lives of women and children. From 2000 to 2010, maternal mortality rates (MMR) in Bangladesh decreased from 400 to 194 deaths per 100,000 live births. i,ii This decrease is associated mostly with the drop in fertility and the increased use of health facilities for both deliveries and for cases of maternal complications. iii Infant and child mortality rates have also declined. From 2007 to 2014, the infant mortality rate reduced from 52 to 38 deaths per 1,000 live births and the child mortality rate dropped from 65 to 46 deaths per 1,000 live births. iv Nevertheless, there are significant disparities in maternal, newborn and child health status between divisions within the country, and access to maternal and child health services remains low. v Furthermore, availability of essential medicines is also a concern in Bangladesh. vi The USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program has been working to increase access to reproductive, maternal, newborn, and child health (RMNCH) medicines and supplies in Bangladesh. In 2014, SIAPS conducted an assessment of local procurement practices for three maternal health medicines in three districts. The assessment found that availability was suboptimal in all three districts visited Dhaka, Khulna, and Sylhet. vii However, the scope of this assessment did not go beyond the district level and left many questions related to pharmaceutical management, such as quantification practices and processes for logistics management information systems, unanswered. Save the Children s MaMoni Health Systems Strengthening (HSS) project works at national, district, and sub-district levels. To better understand the pharmaceutical management practices at the upazila, union, and community levels, SIAPS and MaMoni HSS project, conducted a districtlevel assessment in Lakshmipur district focused on forecasting mechanisms, supply and distribution practices and procedures, and recording and reporting practices and information flows related RMNCH commodities. This assessment focused on describing pharmaceutical management practices for essential reproductive health and RMNCH medicines and supplies at all levels of the public health system in Lakshmipur district to guide interventions to improve availability and use of these commodities. Specifically, the assessment sought to (1) describe the pharmaceutical management practices and procedures at the district level and below, (2) analyze the availability of key medicines and supplies for RMNCH at all levels within the district, and (3) identify possible interventions to improve the pharmaceutical management and thereby improve availability of essential RMNCH medicines and supplies in the district. Through consultations with Directorate General for Health Services (DGHS) and Directorate General for Family Planning (DGFP) officials, a tracer list of medicines was developed for the assessment. The tracer list consists of five maternal health medicines, six newborn health medicines and supplies, four child health medicines, and six family planning commodities. vi

9 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. Overall, the assessment found: Limited availability of RMNCH commodities, particularly maternal and child health medicines Lack of local level guidelines for key pharmaceutical management functions, namely procurement, forecasting, inventory management and distribution. Lack of guidelines detailing which medicines should be available at each level of facility, or by type of provider No standardized inventory management tools in DGHS No standardized logistics management information system (LMIS) in DGHS This year will mark the end of the Millennium Development Goals, and while Bangladesh is on track for meeting the goals for reducing maternal and child mortality, there is still a long way to go to achieve the targets set by the new, more ambitious Sustainable Development Goals. To meet the goals by 2030, there needs to be increased focus on ensuring the availability of RMNCH commodities at the district and sub-district levels through systems strengthening approaches. Based on the challenges found in this assessment, the following recommendations should increase access to life-saving RMNCH commodities: Finalize and disseminate the maternal and newborn health standard operating procedures at all levels of the system. Improve the capacity of staff members at the local level to manage pharmaceutical management processes including procurement, supply, and distribution; and logistics management. Strengthen pharmaceutical information systems to provide the data needed for robust forecasting and supply planning. Advocate for inclusion of amoxicillin dispersible tablets (DTs) and oral rehydration solution (ORS) in DGFP and DGHS procurement plans. Provide facilities with the infrastructure necessary to maintain cold chain storage conditions for oxytocin. Ensure that magnesium sulfate is available wherever women give birth. vii

10 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. viii

11 INTRODUCTION Bangladesh has made considerable progress in reducing maternal and child mortality and is one of the few Countdown countries that were on track to meet both the Millennium Development Goals (MDG) 4 and 5. To maintain this progress and work towards even further reductions in mortality, it is essential that women and their children have access to a range of safe and highquality contraceptives and essential maternal, newborn, and child health commodities at service delivery points. The US Agency for International Development (USAID)/Bangladesh has been providing support to ensure the availability of contraceptives and other reproductive health commodities in Bangladesh for over 20 years. This support has included assistance to the public sector to improve systems for supply chain management of family planning commodities. The USAID-funded Systems for Improved Access to Pharmaceutical and Services (SIAPS) Program has also been working to address supply chain management issues related to Reproductive, Maternal, Neonatal, and Child Health (RMNCH) commodities. In 2014, SIAPS conducted an assessment on local procurement practices for three maternal health medicines in three districts. The assessment found that availability was suboptimal in all three districts visited Dhaka, Khulna, and Sylhet. However,availability or lack of availability was not related to whether the medicines were supplied from the central level or procured but more so to the procurement practices at the local level and coordination with the central level. viii Major findings of the assessment related to access to maternal health medicines include the following Lack of coordination and information sharing between the central and subnational level No district-level guidance for quantification or local procurement of medicines Insufficient training of the procurement committee members about quantification or procurement No standard evidence-based method for forecasting maternal health medicines at the district level The sub-national procurement assessment was conducted at only the Civil Surgeon s Office (CSO)/District Reserve Store (DRS) and Mother and Child Welfare Centers (MCWC) at the district level; the assessment did not cover pharmaceutical management practices at the subdistrict. Additionally, information on this at the lower levels of the system is scarce. In regards to logistics management information systems (LMIS) which tracks family planning commodities, DGFP has an upazila inventory management system and a warehouse inventory management system. However, DGHS has no LMIS for tracking RMNCH drugs. While DGHS has a digitalized health information system (DHIS-2) to track coverage of health services, the system currently does not have information on logistics. To better understand the pharmaceutical management practices at the upazila, union, and community levels, SIAPS and Save the Children s MaMoni HSS project, conducted a district-level assessment in Lakshmipur district focusing more on forecasting mechanisms, supply and distribution practices and procedures, and LMIS or available information related to RMNCH commodities. 1

12 BACKGROUND RMNCH in Bangladesh Bangladesh has made great strides in improving the lives of women and children. From 2000 to 2010, the maternal mortality ratio (MMR) in Bangladesh decreased from 400 to 194 deaths per 100,000 live births. ix,x That decrease is associated mostly with the drop in fertility and the increased use of facilities for both deliveries (from 9% in 2001 to 23% in 2010) and for cases of maternal complications (from 16% in 2001 to 29% in 2010). xi From 2001 to 2014, the total fertility rate decreased by 23%, from 3.0 to 2.3 births per woman and the percentage of married women with an unmet need for family planning decreased from 17% to 12%. xii Infant and child mortality rates have also declined. From 2007 to 2014, the infant mortality rate reduced from 52 to 38 deaths per 1,000 live births and the child mortality rate dropped from 65 to 46 deaths per 1,000 live births. Both are on track for meeting the Millennium Development Goal (MDG)-4 of reducing the under-five mortality rate by two-thirds. xiii Nevertheless, there are significant disparities in maternal, newborn, and child health status between divisions within the country. For example, the 2010 Bangladesh Maternal Mortality Survey found that, although MMR in Khulna division is 74 (per 100,000 live births), MMR in divisions such as Dhaka and Chittagong are 196 and 186, respectively; Sylhet division has the highest MMR at 425 per 100,000 live births. xiv Similarly, according to the 2011 Bangladesh Demographic Health Survey, infant mortality rates range from 35 deaths per 1,000 live births in Chittagong to 59 deaths per 1,000 live births in Sylhet and child mortality rates range from 54 deaths per 1,000 live births in Dhaka to 71 deaths per 1,000 live births in Sylhet division. xv MMR still must drop by 25% to meet 2015 targets for MDG-5. Access to maternal and child health services remain low. xvi Neonatal mortality declined at a much slower rate than both infant and child mortality. Only 26% of pregnant women receive the recommended four antenatal visits and only 32% of births are attended by a skilled birth attendant. xvii Additionally, while pneumonia is one of the leading causes of child deaths, only 35% of children under five with symptoms of pneumonia were taken to an appropriate health provider. xviii Availability of essential MNCH medicines is also a concern in Bangladesh. For example, the two leading causes of maternal deaths postpartum hemorrhage (PPH) and preeclampsia and eclampsia (PE/E) account for 31% and 20% of maternal deaths, respectively. xix According to international guidelines, essential medicines to prevent and treat PPH and PE/E include oxytocin, misoprostol, and magnesium sulfate. However, ensuring availability of those essential maternal health medicines remains a challenge, especially at the district level. A study conducted in 2009 found that only 55% of district hospitals and 38% of upazila health complexes (UHCs) reported having oxytocin in stock on the day of the visit. xx Availability of magnesium sulfate was also limited: only 42% of district hospitals and 23% of UHCs reported having the injection in the facility. xxi 2

13 Background Health System Structure for RMNCH Services The delivery of maternal health services at the district level through the Ministry of Health and Family Welfare (MOHFW) in Bangladesh is divided primarily between two parallel agencies: the DGHS and DGFP. The organization and delivery of health services within DGHS and DGFP differ at each level of the health system. After the central level, the next levels of care are the district level, upazila, union, and community level. Bangladesh s Health, Population, and Nutrition Sector Development Program (HPNSDP) for is the government s national strategy for increasing access to quality health care and the overarching national strategy dictating which services and, thereby, medicines should be available at each level of the health system for both DGHS and DGFP. xxii Family planning services are provided only through the DGFP; however, both directorates are mandated to provide primary MNCH services at all levels of the health system and basic emergency obstetric care (BEmOC), which includes management and treatment of PPH and PE/E, at the district, upazila, and union levels. 1,2 Primary maternal, newborn, and child services include antenatal care (ANC), maternal nutrition counseling, postnatal care (PNC), management of birth asphyxia, newborn umbilical cord care, integrated management of childhood illnesses (IMCI), and routine immunizations. Comprehensive emergency obstetric care (CEmOC) is provided at health centers at the central and district level only. At the community level, health workers in both DGFP and DGHS have been trained as skilled birth attendants and conduct home visits, perform deliveries, and provide newborn care, such as newborn resuscitation. Within DGFP, female welfare assistants (FWA) provide basic family planning (FP) counseling services and some are trained to conduct home deliveries (referred to as FWA skilled birth attendants [SBA]). Similarly, in DGHS, female health assistants (HA) work at the community level and those trained as SBAs are referred to as HA-SBA. Table 1 provides a snapshot into where and what levels RMNCH services should be provided within the structures of both DGHS and DGFP. 1 While facilities may be mandated for providing BEmOC and CEmOC, roll out of these services at different levels of the health system and among districts may vary. For example, while HPNSDP indicated that prevention and treatment of PE/E should be provided at MCWCs, currently, this is still being piloted in one district and is not rolled out nationally. 2 The HPNSDP, , indicates that management and treatment of PE/E should be provided at MCWCs however discussions with DGFP indicated that currently, this is not the case as MCWCs do not have the capacity to provide MgSO4 due to lack of trained physicians. Currently, MCWCs refer PE/E cases to the district hospitals. 3

14 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. Table 1. Delivery of RMNCH Services within DGHS and DGFP, Based on HPNSDP, Health system Central level Teaching hospitals District level DGHS DGFP Facility RMNCH Services Facility RMNCH Services District hospitals Upazila level UHC Union Community Union subcenter (USC) Community Clinic Female Health Assistants CEmOC, management/ treatment of PPH and PE/E, primary maternal health services CEmOC, management/ treatment of PPH and PE/E, MNCH services BEmOC, management/ treatment of PPH and PE/E, primary MNCH health services BEmOC, management/primary MNCH services Primary MNCH services and nutrition Conduct home deliveries, basic newborn care Mohammadpur Fertility Services and Training Centre, Dhaka; Maternal and Child Health Training Institute Mother and child welfare center (MCWC) Upazila health complex, family planning (UHC- FP) Upgraded Union Health and Family Welfare Center a Union Health and Family Welfare Center FWA-SBA CEmOC, management/ treatment of PPH, FP, and other RH services CEmOC, management/ treatment of PPH, Primary MNCH services, FP, and other RH services FP services, Primary MNCH services BEmOC, management and treatment of PPH, Primary MNCH services, FP services xxiii BEmOC, primary MNCH services, FP services FP counseling and conduct home deliveries, prevention of PPH, basic newborn care 3 a. There are 3,924 FWC s in Bangladesh. Among them, 1,414 are upgraded FWCs. The MOH plans to upgrade 800 more by 2016 within DGHS. Ungraded FWC s are expected to have two extra rooms and are meant to provide 24/7 BEmOC and delivery services. A medical officer-family planning (MO-FP) is also expected to be there. Supply Chain Management Supply chain management of medicines and supplies also differs between DGHS and DGFP, particularly in the supply and distribution of commodities. Figure 1 illustrates the differences in the supply chain structure and flow of RMNCH commodities within DGHS and DGFP. Within DGHS, the Central Medical Store Depot (CMSD) is responsible for the procurement, supply, and distribution of health commodities. Health commodities are supplied to the District Reserve Store (DRS) for distribution to the District Hospitals, UHCs, and Union Sub-Centers (USCs). Additionally, at the district level, the CSO not only manages the DRS but also has the authority to locally procure medicines to avert stock-outs. At the community level, community 3 A special Government Order (GO) no. MCH/AMSTL-64/2011/944 issued on 4 Nov 2013 by the MCH unit of DGFP indicated that trained FWAs will give two tablets of Misoprostol to mothers after 32 weeks of pregnancy who will deliver at home to prevent PPH. 4

15 Background clinic kits (CC kits) are procured at the central level from the Essential Drugs Company Limited (EDCL), which distribute directly to the UHCs that in turn send on to the Community Clinics. In DGFP, however, commodities are procured by the Line Director for Logistics and Supply and distributed to the regional warehouses which are responsible for distribution to the Upazila Family Planning Store (UFPS). The UFPS then supplies the Mother and Child Welfare Centers (MCWC) and FWCs. Additionally, MCWC is also responsible for locally procuring medicines that are not procured at the central level, such as oxytocin. At the community level, FWAs and SBAs receive their medicines and supplies from the UFPS. Figure 1. Supply chain structure and flow of RMNCH commodities within DGHS and DGFP 5

16 METHODOLOGY Purpose and Objectives The purpose of this assessment is to describe pharmaceutical management practices for essential RMNCH medicines and supplies at all levels of the public health system in Lakshmipur district to inform the development of interventions to improve availability and use of these commodities. Specifically, the assessment sought to: Describe the pharmaceutical management practices and procedures at the district level and below Analyze the availability of essential medicines and supplies for RMNCH at all levels within the district Identify possible interventions to improve the pharmaceutical management and thereby improve availability of key RMNCH medicines and supplies in the district. Tracer Medicines Through consultations with DGHS and DGFP officials, a tracer list of medicines was developed for the assessment. The tracer list consists of five maternal health medicines, six newborn health medicines and supplies, four child health medicines, and six family planning commodities (table 2). Table 2. Tracer RMNCH Medicines List Maternal Health Newborn Health Child Health Tracer Medicine Injectable oxytocin, 5 IU Tablet, misoprostol, 200 mcg Injectable, magnesium sulfate, 4 g in 100 ml Iron folate, 60 mg mg Calcium, 500 mg or 600 mg; 300 mg Injectable, gentamicin, 80 mg Oral amoxicillin, suspension (125 mg/5 ml) 100 ml Dexamethasone, 5 mg Bulb sucker Ambu bag Mask, infant ORS Zinc sulfate Amoxicillin DT, 250 mg Vitamin A 6

17 Methodology FP Tracer Medicine Condoms Pills Depo-Provera IUDs Implants (Jadelle) Implants (Implanon) Site Selection Lakshmipur district in the Chittagong division was selected for the assessment because of the field presence and work of the MaMoni HSS project. All five upazilas under the district were also selected and both DGHS and DGFP sites from the district, upazila, union, and community levels were randomly selected from the Lakshimpur District Health Care Service Facility List which was provided by MaMoni HSS. Both health care facilities and medicine stores were selected. Table 3 indicates the DGHS and DGFP sites that were selected from each level of the health system. Table 3. Number of DGHS and DGFP Sites/Respondents Selected at District and Sub- District Levels DGHS DGFP Facility/Personnel Number Facility/Personnel Number Regional N/A Regional Warehouse 1 District CSO/DRS 1 MCWC 1 District hospital 1 District Family Planning Office 1 Upazila UHC 4 Upazila Health Complex, Family Planning (UHC-FP) or Upazila Family Planning Store (UFPS) Union Community USC/ Sub-Assistant Community Medical Officer (SACMO) Community Clinic/Community Health Care Provider (CC-CHCP) 4 Family Welfare Center/Family Welfare Volunteer (FWC-FWV) 4 20 FWC/SACMO FWA 20 SBA 6 SBA/FWA 14 Data Collection Methods Both qualitative and quantitative data collection methods were used to assess pharmaceutical management practices. Specifically, quantitative data collection tools were developed and customized for each type of facility that was selected. The assessment tools collected data on product management, local procurement practices, distribution and supply of medicines, 7

18 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. inventory management, and LMIS as well as collected data on the availability of RMNCH commodities. Also, in-depth interviews were conducted with selected facility managers at each level using an interview guide. The interviews were designed to complement the assessment tool and provide detailed qualitative data; they were heavily focused on pharmaceutical information flows. Data Collection and Analysis The study team consisted of SIAPS and MaMoni HSS staff, including district level implementing partner Dustho Sahthya Kendro. The data was collected by10 data collectors provided by the implementing partner and 2 supervisors provided by the MaMoni HSS field office in Lakshmipur. The data collectors and supervisors were given a three-day training which included an orientation in pharmaceutical management, training on the data collection tools, and practice sessions in a neighboring district using the tools. Following the practice session, the data collectors and supervisors provided feedback on the tools and discussed issues that they encountered. The tools were slightly modified based on the feedback given by the data collectors and supervisors. The quantitative data collection for the assessment was conducted during August 24 31, 2014, and SIAPS staff conducted in-depth interviews with facility managers from November 16 20, Limitations of the Assessment A general limitation of the assessment was reporter and interviewer bias, as the respondents were DGFP and DGHS officials who are responsible for logistics management and the survey was conducted in MaMoni HSS project areas by MaMoni HSS staff. However, to minimize interviewer bias, the interviewers were not allowed to collect data in their own working area and were assigned to other upazilas. Weak record keeping and management information systems also limited the quality of data, level of details, and verification of data. Also, on the day of data collection, some data were not readily available and due to time constraints and availability of key personnel and efforts were made to follow-up with the respondents. 8

19 RESULTS This section is organized first by pharmaceutical management practices in facilities in each directorate followed by the availability of RMNCH commodities in the district, across all facilities. The pharmaceutical management practices for each directorate are presented beginning with sources of medicines, local procurement practices including forecasting, supply and distribution, LMIS, and inventory management and storage. The availability data is organized slightly different. It is presented first based on commodity type family planning, maternal health, newborn health, and child health and organized by directorate. Pharmaceutical Management Practices in DGFP Sources of Medicines Among the DGFP sites, only the MCWC conducts local procurement. At the time of the assessment, the only medicine that could be and was locally procured by the MCWC was oxytocin. Of the total amount of oxytocin received, 33% was from local procurement and 68% was from donations from United Nations Population Fund. Besides iron folate and oral amoxicillin, no other maternal or newborn health medicines were received from the UFPS and no child health medicines were requested, received, or locally procured by the MCWC. Finally, all family planning commodities were received from the UFPS. Local Procurement Practices The MCWC has an operating procurement committee specifically responsible for managing the local procurement process. The respondent at the MCWC indicated that they have received training on local procurement and the procurement committee is responsible for drug selection, quantification/ forecasting of needs, determining procurement quantity, preparing tender documents, supplier selection (evaluating bids and final selection), and approval of specifications (product description, packaging and labeling, and quality assurance standards). While there are no district level operational guidelines on local procurement, the respondent indicated that the procurement committee refers to the 2006 Public Procurement Rules (PPR) and the 2008 Public Procurement Act (PPA) for guidance on conducting local procurement of medicines (table 4). 9

20 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. Table 4. Local Procurement Practices at Lakshmipur Mother and Child Welfare Center District-level guidelines/standard operating procedures (SOPs) for local procurement of medicines available Refer to 2006 PPR and the 2008 PPA for guidance on local procurement of medicines Functioning procurement committee exists Procurement committee is responsible for all aspects of local procurement according to Good Procurement Practices from MDS-3 a At least one procurement committee member has received training of procurement of medicines Evidence-based forecasting of medicines Mother and Child Welfare Center (MCWC, DGFP) a. Drug selection, quantification/ forecasting of needs, determining procurement quantity, preparing tender documents, supplier selection (evaluating bids and final selection), and approval of specifications (product description, packaging and labeling and quality assurance standards) xxiv No Yes No Forecasting Medicine Needs The Lakshmipur assessment sought to understand what, if any, forecasting methods are used at the lower levels of the health system. The assessment found that little or no forecasting of medicine needs is done at the district and sub-district levels and none is done at the DGFP sites. This is due mostly to the fact that commodities are pushed from the central level to the facilities. Additionally, because the LMIS within DGFP is established at all levels of the system, facilities managers fill out the LMIS reports instead of forecasting medicine needs. The LMIS reports inform the central level of the quantities of medicines that should be sent to the facilities. Supply and Distribution DGFP has a well-structured four-tier management system which starts at the central warehouse and ends at the service delivery point (SDP). The central warehouse is responsible for supplying commodities to the regional warehouse and they in turn are responsible for supplying the UFPS. The UFPS then supply the SDP level. This process is well documented in the DGFP Supply Manual, xxv which also includes guidelines for all aspects of logistics planning including duties and responsibilities of staff, storage, commodity supply, record keeping (i.e., maximumminimum stock levels, push and pull method, determining supply quantity), record keeping and report preparation, management of unusable commodities, monitoring and supervision, and electronic LMIS. The UFPS supplies medicines to the MCWC and FWCs. Supply and distribution plans are developed using the upazila inventory management system and guidelines are provided in the DGFP Supply Manual. Data on consumption and stock on hand are put into the upazila inventory system and a minimum-maximum stock level policy is used to determine quantities of medicines and supplies to be sent to facilities. Commodities and supplies are received by the regional warehouse and distributed to the service delivery points every month. None of the respondents indicated any challenges related to the distribution of commodities. 10

21 Results Logistics Management Information System DGFP has a well-established LMIS implemented at all levels of the health system. xxvi The LMIS in DGFP is a combination of manual and electronic reporting and is implemented at all levels of the system. Manual reporting is done at the union and community levels while electronic reporting is done until the upazila level. Figure 2 illustrates the reporting structure and flow of logistics information in DGFP taken from the DGFP Supply Manual. The assessment specifically sought to identify any challenges or feedback on the system. Despite commodities not being 100% available at all DGFP sites, none of the respondents at DGFP sites indicated having challenges or issues related to LMIS. Figure 2. DGFP logistics management information flow chart (taken from DGFP Supply Manual) xxvii 11

22 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. Inventory Management and Storage The assessment examined inventory management and storage conditions at the upazila stores and service delivery points. The inventory management system of DGFP is being implemented according to the DGFP Supply Manual. For example, the MCWC did not indicate having guidelines and only one FWC-FWA and two FWC-SACMOS indicated having guidelines for inventory management. Among the sites, the regional warehouse, DFPO, and MCWC indicated having trained staff responsible for inventory management; however, only one UHC-FP, 10% of FWC-FWAs (n = 20) and 25% of FWC-SACMOs (n =16) indicated having trained staff in inventory management. While the majority of the sites visited at the district, upazila, and union levels know when they will be receiving new stock, at the community level only 50% of FWAs and none of the FWA- SBAs are aware of when they will receive new stock. Almost all sites indicated visually inspecting products upon arrival. Direct observation of storage conditions at the storage facilities and service delivery points found that neither the regional warehouse nor the DFPO had storage layout plans. In fact, only the UHC-FP sites had storage layout plans with allocated space in the storeroom. In regards to good storage conditions, it was observed that while the DFPO follows most of the good storage practices, the regional warehouse only followed some. For example, while products were stored in secure locations and protected from sun, water and moisture; products were not arranged so that the labels and expiration dates are visible or according to first expiry, first out procedures. Among the service delivery points, the majority of the UHC-FPs, FWC-FWAs and FWC- SACMOs maintained good storage conditions. Challenges were found mostly at the community level. Only 30% of FWAs and 14% of FWA-SBAs were storing products protected from the sun. In regards to cold chain storage for oxytocin, neither the MCWC nor UHC-FP sites were storing the medicine in cold chain because they do not have operational refrigerators. Table 5 indicates the percent of service delivery points that were maintaining good storage conditions. Table 5. Inventory Management and Storage Practices at DGFP Service Delivery Points Good Storage Conditions MCWC UHC-FP FWC-FWA FWC-SACMO FWA FWA-SBA N Secure storage location 1; 50% 3; 75% 8; 40% 9; 56% 5; 25% 1; 7% Ceiling/exhaust fan present 1; 50% 3; 75% 5; 25% 4; 25% NA a NA Products arranged so that the identification labels and expiration or manufacture dates are visible First expiry, first out procedures observed 0; 0% 2; 50% 20; 100% 13; 81% NA NA 1; 50% 4; 100% 18; 90% 14; 88% NA NA Boxes in good condition 1; 50% 4; 100% 20; 100% 13; 81% 18; 90% 4; 29% Products protected from water and moisture 1; 50% 4; 100% 20; 100% 13; 81% 13; 65% 3; 21% Products protected from sun 1; 50% 2; 50% 12; 60% 5; 31% 6; 30% 2; 14% a. NA is not applicable 12

23 Results Pharmaceutical Management Practices in DGHS Sources of Medicines Among the tracer RMNCH medicines, only oxytocin is being locally procured by the CSO while all other medicines and supplies are procured by CMSD and supplied by either CMSD or EDCL. Table 5 shows the breakdown of the sources of MNCH medicines at the CSO/DRS. For maternal health commodities, local procurement accounts for 68% of the total amounts of oxytocin supplied to the CSO/DRS during the last fiscal year (June 2014 July 2015) with CMSD supplying the rest. The rest of the medicines, although procured by CMSD on behalf of the CSO, are supplied by EDCL and go directly to the CSO/DRS. In Lakshmipur, newborn resuscitation supplies are procured by nongovernmental organizations, such as Save the Children, as part of the Helping Babies Breathe project. Therefore, they are not expected to be ordered or supplied by the CSO/DRS. While vitamin A is supplied through Expanded Program on Immunization, the CSO/DRS did not request or receive any other child health commodities. Upon follow-up with CMSD, it was found that amoxicillin DTs were not purchased by the government this year because the price was too high because of the limited number of local manufacturers. UNICEF purchased the medicine but none was distributed to Lakshmipur district. Currently, the country is in the process of phasing out amoxicillin 250 mg capsules and introducing amoxicillin DTs; however, the implementation is at various stages throughout the country. ORS and zinc sulfate were not requested or supplied to the CSO/DRS. Table 6. Medicines Supplied by the Central Level versus Acquired through Local Procurement by the CSO/DRS Central Level CMSD, % EDCL, % Local Procurement, % Maternal Health Calcium Iron folate Oxytocin Newborn Health Gentamicin Child Health Oral amoxicillin Dexamethasone *No child health commodities were requested by or supplied to (via central level or local procurement) to the CSO/DRS. Local Procurement Practices Within DGHS, only the CSO is responsible for locally procuring medicines. Similar to the finding at DGFP s MCWC, the CSO indicated that while they refer to the 2006 PPR and the 13

24 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh PPA for guidance on conducting local procurement of medicines, district level guidelines do not exist for local procurement procedures. As such, the CSO indicated having operating procurement committees responsible for managing the local procurement process ranging from drug selection and quantification/forecasting of needs to supplier selection and approval of specifications. The CSO, however, indicated that he has not been trained in local procurement practices and has learned this on the job. Table 7 summarizes the findings from Lakshmipur related to local procurement for DGFP. Table 7. Local Procurement Practices at Lakshmipur Civil Surgeon s Office District-level guidelines/sops for local procurement of medicines available Refer to 2006 PPR and the 2008 PPA for guidance on local procurement of medicines Functioning procurement committee exists Procurement committee is responsible for all aspects of local procurement according to Good Procurement Practices from MDS-3 a At least one procurement committee member has received training of procurement of medicines Evidence-based forecasting of medicines Civil Surgeon s Office (CSO, DGHS) a. Drug selection, quantification/ forecasting of needs, determining procurement quantity, preparing tender documents, supplier selection (evaluating bids and final selection), and approval of specifications (product description, packaging and labeling and quality assurance standards) xxviii No Yes Yes Yes No No Forecasting Medicine Needs Within DGHS, the CSO collects medicine demands/ requisitions from the health facilities it supplies UHCs, USCs, and District Hospital (DH). These demands are consolidated and adjusted for stock on hand and sent as a requisition to CMSD. The DH medicine requests are based on the previous distribution and requests from hospital wards. The DH storekeeper also indicated that while stock on hand is not considered when making medicine requests, buffer/safety stock is maintained. When there is a stock-out, the storekeeper requests that the DRS supply the medicine. Demand requests from the UHC and USC is based on the average consumption from the previous quarter; the UHC further adjusts this by 10%. The store keeper at one UHC indicated that there is provision to adjust for stock-outs. There is no forecasting done at the community clinics as they only receive two community clinic kits per quarter via a push system. Supply and Distribution Supply and distribution of medicines at the district level is done by the DRS and UHC-HS for the DGHS sites. The DRS supplies medicines to the UHC, USC, and DH, and the UHC supplies community clinic kits to the CC-CHCPs. Procurement is done by CMSD on behalf of the CSO; however, local procurement is also done by the CSO. CMSD supplies the CSO and District Reserve 14

25 Results Store (DRS) which then supplies the health facilities such as the district hospital, UHC, and USC. Flow of CC kits is different; procurement is done directly by the Director of the CC Program and EDCL distributes the kits to the UHC which then supplies them quarterly to the clinics. The assessment found that no distribution plans are developed; medicines are supplied quarterly and when needed. There are no SOPs or guidelines for distribution nor are their guidelines or provisions in place to redistribute between facilities or place emergency orders to avoid stock-outs. Logistics Management Information System While there is currently no LMIS in place within DGHS, medicine information flows were identified that specifically relate to requisitions and orders. Figure 3 illustrates both the current medicine flow and information flows at all levels of the system. Quarterly medicine requisitions are submitted to the CSO by the district hospital, UHCs, and USCs. The medicine requisitions are aggregated by the Civil Surgeon and submitted to CMSD. Additionally, demand forms are completed and submitted to the UHC on a quarterly basis by the community clinics to receive the CC kits (figure 3). Figure 3. Current DGHS medicines and information flow 4,5 4 In general, UHCs supply USCs with health commodities however, in Lakshmipur, due to the lack of space in the store at the UHC, commodities are supplied to the USC directly by the DRS. To keep with the general practice and procedures, USCs still send a copy of requisitions and receipt vouchers to the UHC. 15

26 District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities: Lakshmipur, Bangladesh. Ordering Medicines Community Clinics are the only facilities that receive CC kits directly from the UHCs. The demand forms further serve as receipts, indicating how many kits were received. While there is no written policy outlining how many kits each community clinic should receive, Community Clinic project staff reported that, in practice, the clinics usually receive two kits per quarter. The medicine requisitions are completed quarterly by the USCs, UHCs, and district hospitals and are submitted to the CSO. The assessment found that not only are there no guidelines on how to determine medicine requisitions but also there is no standardization in the forms as they are handwritten. All sites indicated that they used the average monthly consumption of the previous quarter or last three months and stock on hand to determine requisitions. None of the respondents indicated receiving any formal training; however, some noted that the CSO showed them how to fill out the form. All the USCs had the same medicine requisition forms except for one USC that added an additional column for last quarter s average consumption. Emergency orders are also submitted to the DRS using the same form but indicating emergency on the form. At the district hospital, the wards submit handwritten medicine request or demand forms to the pharmacy whenever they need medicine. At the CSO/DRS level, the medicine requisitions are consolidated taking into consideration the budgets allocated to the facilities and sent to CMSD annually. The same form is used to also submit annual orders to local suppliers (through local procurement) and quarterly orders to EDCL. Receiving Medicines At the community level, the CHCP goes directly to the UHC to pick up the kits. The demand form mentioned above is also used as the receipt for the kits. Unfortunately, the CHCP visited indicated that she does not know how to fill out this form and was never trained to do so. Once the kits are received and opened, the medicines are managed through the stock registers. The CHCP suggested that it would be better to itemize the medicines to see which ones are needed more because some medicines are used more than others. At all other sites, the medicine requisition form is further used are a receipt/issues voucher for when medicines are received as well. The supply column on the form is completed and signed by the CSO. Copies are maintained at the CSO and the recipient facility. In Lakshmipur, the medicines are supposed to flow to the USCs via the UHC; however, because of the lack of storage space and transportation at the UHCs, the DRS directly supplies the USC. Therefore, copies of the form are maintained by the CSO, USC, and the UHC. While no LMIS reports are completed, one USC indicated that they fill out a monthly form for services statistics and send to the Upazila Health and Family Planning Officer (UH&FPO) who manages the UHC. The storekeeper at the district hospital indicated preparing and sending medicine stock reports related to disaster preparedness and management to the MIS Unit of 5 Note that the district hospital and UHC departments also send weekly requisitions to the respective facility store. 16

27 Results DGHS and commodity specific monthly reports for the rabies vaccine to the Institute of Epidemiology, Disease Control, and Research. Additionally, the district hospital wards use the same form to request medicines and as receipts; a copy is maintained in the wards. When medicines are received by the DRS, three receipts are made based on the supplier (local supplier, CMSD, or EDCL) and the issue voucher is signed by both the DRS storekeeper and the supplier. Stock Management All sites indicated having stock registers to manage medicines stock, however, only the CC visited indicated having standard guidelines on stock management and guidelines on how to fill out the stock registers and one UHC indicated having inventory management guidelines from the Director of Primary Health Care who oversees UHC, USC, and CC activities. While the USCs do not have guidelines for stock management, the respondents did indicate receiving an orientation in stock management. At the CCs, two registers are maintained for stock management; one is for the total number of community clinic kits received and the other is to manage the individual medicines in the kits. CHCPs also manage a services register which is used to consolidate medicine stock information into the medicines stock register. The CSO/DRS indicated managing a total of seven stock registers based on the type of commodity or medicine (e.g., tab, cap, syrup). Bin cards were only found to be maintained at UHCs, district hospital, and at the DRS. At the UHC, the bin cards and issue vouchers for medicines issued to UHC wards are handwritten and at the district hospital and CSO/DRS they are made on the computer and printed. Finally, none of the respondents indicated having guidelines on how to manage expired or damaged products or having any standard reports or forms for unusable products. The UHCs did indicate, however, that if they receive such products, an official letter is sent to the CSO. Although a circular for condemnation of medical and surgical requisites (includes medicines) and linen items was sent to all facilities in February 2010, none of the respondents were aware of the circular. Interestingly, around the time of data collection, the Procurement and Logistics Management Cell (PLMC) had also requested all UHCs to send a report on expired products; however, there was no standard format for this report and it is unknown if this will be a regular report that is to be submitted to the PLMC. None of the sites indicated reporting on adverse drug reactions. Supplying Medicines Within the DGHS structure, only the DRS and UHC are responsible for supplying medicines to other health facilities, and the UHCs and the district hospital supply medicines internally to the different wards in their respective facility. The UHC only supplies community clinic kits to the CHCP; only an issue voucher or demand form is used to document how many kits have been supplied and these are handwritten. Similarly, handwritten issue vouchers are also used by both the UHCs and district hospital when supplying medicines to the facility wards. 17