Post on 21-Mar-2020
District-Level Assessment of Pharmaceutical Management of Life-
Saving RMNCH Commodities: Lakshmipur, Bangladesh
January 2016
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
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
ii
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-11-00021. 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. 2015. 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 22203 USA
Telephone: 703.524.6575
Fax: 703.524.7898
E-mail: siaps@msh.org
Website: www.siapsprogram.org
iii
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..................................................................... 13
Availability of RMNCH Commodities ..................................................................................... 19
Discussion ..................................................................................................................................... 27
Recommendations ......................................................................................................................... 29
Annex A. Availability of MNCH Commodities in the Last Six Months...................................... 32
References ..................................................................................................................................... 34
iv
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
v
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.
vi
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 district-
level 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.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
vii
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.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
viii
1
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 high-
quality 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 sub-
district. 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.
2
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
Background
3
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 2011–2016 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, 2011-2016, 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.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
4
Table 1. Delivery of RMNCH Services within DGHS and DGFP, Based on HPNSDP, 2011–2016
Health system
DGHS DGFP
Facility RMNCH Services Facility RMNCH Services
Central level Teaching hospitals
CEmOC, management/ treatment of PPH and PE/E, primary maternal health services
Mohammadpur Fertility Services and Training Centre, Dhaka; Maternal and Child Health Training Institute
CEmOC, management/ treatment of PPH, FP, and other RH services
District level District hospitals
CEmOC, management/ treatment of PPH and PE/E, MNCH services
Mother and child welfare center (MCWC)
CEmOC, management/ treatment of PPH, Primary MNCH services, FP, and other RH services
Upazila level UHC BEmOC, management/ treatment of PPH and PE/E, primary MNCH health services
Upazila health complex, family planning (UHC-FP)
FP services, Primary MNCH services
Union Union sub- center (USC)
BEmOC, management/primary MNCH services
Upgraded Union Health and Family Welfare Center
a
BEmOC, management and treatment of PPH, Primary MNCH services, FP services
xxiii
Union Health and Family Welfare Center
BEmOC, primary MNCH services, FP services
Community Community Clinic
Primary MNCH services and nutrition
FWA-SBA
FP counseling and conduct home deliveries, prevention of PPH, basic newborn care
3
Female Health Assistants
Conduct home deliveries, basic newborn care
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.
Background
5
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
6
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
Tracer Medicine
Maternal Health Injectable oxytocin, 5 IU
Tablet, misoprostol, 200 mcg
Injectable, magnesium sulfate, 4 g in 100 ml
Iron folate, 60 mg + 0.4 mg
Calcium, 500 mg or 600 mg; 300 mg
Newborn Health Injectable, gentamicin, 80 mg
Oral amoxicillin, suspension (125 mg/5 ml) 100 ml
Dexamethasone, 5 mg
Bulb sucker
Ambu bag
Mask, infant
Child Health ORS
Zinc sulfate
Amoxicillin DT, 250 mg
Vitamin A
Methodology
7
Tracer Medicine
FP 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)
4
Union USC/ Sub-Assistant Community Medical Officer (SACMO)
4 Family Welfare Center/Family Welfare Volunteer (FWC-FWV)
20
FWC/SACMO 16
Community Community Clinic/Community Health Care Provider (CC-CHCP)
20 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,
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
8
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,
2014.
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.
9
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).
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
10
Table 4. Local Procurement Practices at Lakshmipur Mother and Child Welfare Center
Mother and Child Welfare Center (MCWC, DGFP)
District-level guidelines/standard operating procedures (SOPs) for local procurement of medicines available
No
Refer to 2006 PPR and the 2008 PPA for guidance on local procurement of medicines
Yes
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 No
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
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., maximum-
minimum 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.
Results
11
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
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
12
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 2 4 20 16 20 14
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% NAa
NA
Products arranged so that the identification labels and expiration or manufacture dates are visible
0; 0% 2; 50% 20; 100% 13; 81% NA NA
First expiry, first out procedures observed
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
Results
13
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 Local Procurement, % CMSD, % EDCL, %
Maternal Health Calcium 5 95 0
Iron folate 100 0 0
Oxytocin 32 0 68
Newborn Health Gentamicin 0 100 0
Oral amoxicillin 0 100 0
Dexamethasone 0 100 0
Child Health *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
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
14
2008 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
Civil Surgeon’s Office (CSO, DGHS)
District-level guidelines/SOPs for local procurement of medicines available
No
Refer to 2006 PPR and the 2008 PPA for guidance on local procurement of medicines
Yes
Functioning procurement committee exists Yes
Procurement committee is responsible for all aspects of local procurement according to Good Procurement Practices from MDS-3
a
Yes
At least one procurement committee member has received training of procurement of medicines
No
Evidence-based forecasting of medicines No
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
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
Results
15
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 flow4,5
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.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
16
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.
Results
17
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.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
18
The DRS indicated using the requisition forms as issue vouchers when supplying medicines with
the addition of filling out the “quantity supplied” column for each facility. A copy of this is kept
with the DRS, the UHC (for supplying to USCs), and the recipient facility. These forms are not
standardized and handwritten; no other forms or reports are filled out when supplying medicines.
All respondents indicated that having standardized forms, registers, and reports would be very
helpful as they will not have to write up the forms every time they are needed. Additionally,
having refresher trainings in inventory management and distribution and standard guidelines was
also suggested by most of the respondents.
Storage Conditions
Unlike DGFP, DGHS does not have standardized guidelines and SOPs for inventory
management and handling of products. While the DRS, two UHCs, and two CCs indicated
having designated and trained staff specifically for inventory management, the majority of the
sites did not.
The district hospital and the majority of the service delivery points indicated that they are usually
aware when they will be receiving new stock, but the DRS said that they generally do not know
when they will be receiving stock. Most sites are also not visually inspecting stock upon arrival
such as the DRS, 75% of the UHCs, and 50% of USCs.
The majority of DGHS sites are maintaining proper storage conditions. It was observed that the
DRS, district hospital, and most of the UHCs and USCs are maintaining most of the
recommended good storage conditions. At the community level, however, recommended storage
conditions are not being maintained. For example, only 55% of CCs were storing the products in
a secure location and one HA-SBA had products protected from water and. Only one UHC is
maintaining cold chain storage of oxytocin; the DRS, district hospitals, and all other sites do not
have an operational refrigerators.
Table 8 summarizes the percent of DGHS sites maintaining recommended storage conditions.
Table 8. Inventory Management and Storage Practices at DGHS Storage Facilities and Service Delivery Points
Good Storage Conditions DRS DH UHC-HS USC-SACMO
CC HA-SBA
n 1 1 4 4 20 6
(Y/N) a (Number and percentage)
Secure storage location Y N 3; 75% 2; 50% 11; 55% 1; 17%
Ceiling/ exhaust fan present Y Y 4; 100% 2; 50% NA NA
Products arranged so that the identification labels and expiration or manufacture dates are visible
Y Y 4; 100% 4; 100% 0; 0% NA
First expiry, first out procedures observed Y Y 4; 100% 4; 100% 0; 0% NA
Results
19
Good Storage Conditions DRS DH UHC-HS USC-SACMO
CC HA-SBA
Boxes in good condition Y Y 3; 75% 3; 75% 16; 80% 1; 17%
Products protected from water and moisture Y N 3; 75% 3; 75% 18; 90% 1; 17%
Products protected from sun Y Y 3; 75% 1; 25% 8; 40% 0; 0%
a. Y = yes, N = no.
Availability of RMNCH Commodities RMNCH commodities availability was assessed in two ways: (1) comparing which commodities
are actually managed at health facilities to what is theoretically supposed to be managed (i.e.,
according to national guidelines and strategies), and (2) assessing availability on the day of the
visit and within the last six months of the assessment among sites that were managing RMNCH
commodities.
Theoretical management of RMNCH commodities was determined by reviewing the 2011–2016
HPNSDP, the Maternal and Newborn Health draft strategy, and through discussions with various
officials from MOHFW, DGHS, and DGFP. A major challenge is that there is no consolidated
document or standard treatment guideline that clearly indicates where RMNCH commodities
should be available at each level of the health system and who should be managing these
commodities.
Family Planning
Family planning commodities should only be available at DGFP sites. A commodity was
considered to be managed by the site if the site had a stock register or bin card available for that
commodity. The assessment found that family planning commodities are mostly managed and
available at both the storage sites and service delivery points that are supposed to be managing
them.
The regional warehouse and UHC-FP are responsible for managing all six of the tracer family
planning commodities because they are the upper level supply source to their corresponding
service delivery points. Table 9 indicates at which service delivery points the six tracer family
planning commodities should be available (theoretical) and where they were actually being
managed (actual).
None of the FWC-SACMO indicated managing any of the family planning commodities because
there are designated FWVs’ posted in the FWC who are supposed to distribute all the
contraceptives to the clients. But, if there is no FWV posted at the FWC, the SACMO can play
the role of the FWV to distribute pills and condoms only. While the majority of the facilities at
each level indicated managing family planning commodities, only 5 of the 14 SBA-FWAs were
managing stock of condoms and pills. Five SBA-FWAs were also managing Depo-Provera.
Implants were found to be managed according to what is expected; the majority of the UHC-FP
stores had both types of implants (75%, 3/4). Only one FWC-FWV indicated managing both
types of implants which should only be managed by trained physicians.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
20
Table 9. DGFP Service Delivery Points Managing Family Planning Commodities that are Supposed to be Managing It (%)
Tracer Medicine MCWC (n = 1)
UHC-FP (n = 4)
FWC-FWV (n = 20)
FWC-SACMO (n = 16)
FWA (n = 20)
SBA-FWAb
(n = 14)
Condoms
Theoretical Ya Y Y N
a Y Y
Actual Y Y 95% (19/20) N Y 36% (5/14)
Pills
Theoretical Y Y Y N Y Y
Actual Y Y 90% (18/20) N Y 36% (5/14)
Depo-Proverab
Theoretical Y Y Y N Y N*
Actual Y Y Y N Y 36% (5/14)
IUDs
Theoretical Y Y Y N N N
Actual Y Y 90% (18/20) N N N
Implants (Jadelle)
Theoretical Y Y N N N N
Actual Y 75% (3/4) 5% (1/20) N N N
Implants (Implanon)
Theoretical Y Y N N N N
Actual Y 75% (3/4) 5% (1/20) N N N
a Y = yes, N = no. b -SBA-FWAs should only be managing Depo-Provera if they have been specially trained.
Almost 100% of family planning commodities were found to be available at all sites that are
supposed to be managing the commodity. IUDs were found to be 100% available both on the day
of the visit and throughout the past six months at all sites that were managing it. Implants, both
Jadelle and Implanon, were also 100% available on the day of the visit at the regional warehouse,
MCWC, and FWC-FWVs; however, the RW did experience a stock out of Jadelle implants for a
total of 30 days within the last 6 months. Additionally, two of the three UHC-FPs managing
implants had both types available on the day of the visit. Surprisingly, one FWC-FWV (n = 20)
indicated managing both Jadelle and Implanon implants; these were available both on the day of
the visit and throughout the past six months.
Maternal Health
DGFP
Among the maternal health medicines, magnesium sulfate, iron folate, and calcium should be
managed and available at and above the union level (MCWC, UHC-FP, and FWCs). Oxytocin
should only be managed at the MCWCs at the district level, and misoprostol should only be
managed at the UHC-FP and community level by FWAs and SBA-FWAs.
However, while the assessment found that oxytocin was being managed at the MCWC, a small
number of FWC-FWVs (3/20) were also handling the medicine. Availability and management,
Results
21
particularly of iron folate and calcium, were low. Most of the sites that are supposed to be
handling these medicines were in fact not managing them or were found to be managing other
formulations of the product. The Deputy Director of FP in Lakshmipur indicated that calcium is
not supplied by the central level nor is it included in the Bangladesh drug and dietary supplement
(DDS) kits. This would explain the limited availability across DGFP sites. Additionally, because
calcium is not considered a “life-saving” medicine, it is not locally procured by the MCWC.
Overall, the majority of the sites managing maternal health medicines had the medicine available
on the day of the visit. Table 10 indicates the management and availability of maternal health
medicines on the day of the visit at DGFP service delivery points. Also, the majority of the sites
handling maternal health medicines did not experience stock-outs within the last six months of
the assessment. For example, all 3 FWC-FWVs managing oxytocin did not experience stock-outs
and all 18 FWC-FWVs that indicated managing misoprostol had it available throughout the last
six months (annex A1).
Table 10. Management and Availability on the Day of the Visit of Maternal Health Medicines at DGFP Sites
Tracer Medicine MCWC (n =1 )
UHC (n = 4)
FWC-FWV (n = 20)
FWC-SACMO (n = 16)
FWA (n = 20)
SBA-FWA (n = 14)
Oxytocin
Theoretical Y N Y N N N
Actual Y N 15% (3/20) N N N
Availability Y N Y N N N
Misoprostol
Theoretical N Y N N Y Y
Actual N 75% (3/4)
90% (18/20) N 90% (18/20) 57% (8/14)
Availability N 67% (2/3)
89% (16/18) N 94% (17/18) Y
Magnesium sulfate
In Lakshmipur, magnesium sulfate has not been rolled out for the prevention of PE/E as it is still being piloted. However, according to the HPNSDP, once it is rolled out, it should be managed and available at the MCWC, UHC-FP, and FWCs.
Iron folateb
Theoretical Y Y Y Y N N
Actual N Y N* 19% (3/16)* N N
Availability Y Y N* 67% (2/3) N N
Calcium*
Theoretical Y Y Y Y N N
Actual N 25% (1/4)
N N N N
Availability N N N N N N a Y = yes, N = no. b. For iron folate, other formulations were indicated to be managed such as 200 mg + 0.2 mg. At the FWC-FWV and FWC-SACMO, 95% and 75% of the sites indicated managing other formulations; of these, 89% and 83% had it available on the day of the visit, respectively.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
22
DGHS Within DGHS, oxytocin and magnesium sulfate should only be managed and available at the
district and upazila levels with iron folate and calcium being available at all levels except by
SBAs. Misoprostol is not currently being rolled out in DGHS and therefore should not be
available at any DGHS sites.
While maternal health medicines were mostly found to be managed at the sites that were
expected to manage them, one SBA-HA indicated managing oxytocin, one USC indicated
managing magnesium sulfate, and only 50% of the UHCs indicated managing oxytocin and
magnesium sulfate—two life-saving medicines for PPH and PE/E. Similar to some DGFP sites,
various formulations of iron folate and calcium were also found to be managed at all levels.
For sites managing maternal health medicines, medicines available on the day of the visit ranged
from 50% to 100% (table 11). Among the maternal health medicines being managed at DGHS
sites, magnesium sulfate was least available at sites throughout the past six months. For example,
the CSO/DRS, DHs, and the one USC-SACMO that indicated managing the medicines
experienced periods of stock-out ranging from 15 to 30 days in the past six months (annex A2).
Table 11. Management and Availability of Maternal Health Medicines on the Day of the Visit to DGHS Service Delivery Points
Tracer Medicine DH (n = 1)
UHC-HS (n = 4)
USC-SACMO (n = 4)
CC-CHCP (n = 20)
SBA-HA (n = 6)
Oxytocin
Theoretical Y Y N N N
Actual Y 50% (2/4) N N 17% (1/6)
Availability Y Y N N Y
Misoprostol
Theoretical N N N N N
Actual N N N N N
Availability N N N N N
Magnesium sulfate
Theoretical Y Y N N N
Actual Y 50% (2/4) 25% (1/4) N N
Availability Y Y Y N N
Iron folate
Theoretical Y Y Y Y N
Actual Y 50% (2/4)* 50% (2/4) 30% (6/20) N
Availability Y Y 50% (1/2) 83% (5/6) N
Calcium
Theoretical Y Y Y Y N
Actual Y 75% (3/4)* 25%, (1/4) N* N
Availability N* Y Y N* N a Y = yes, N = no. *Other formulations of iron folate and calcium were found to be managed at these sites.
Results
23
Newborn Health
DGFP
All tracer newborn health commodities are supposed to be managed at MCWC and UHC-FP
sites, and only the newborn resuscitation equipment should be managed by trained SBA-FWAs
at the community level. At the FWCs, the SACMO should be managing only oral amoxicillin
since DDS kits do not contain gentamicin or dexamethasone, and the FWV manages the
newborn resuscitation equipment. The assessment found that no newborn health medicines and
supplies were being managed at the MCWC or UHC-FPs.
For oral amoxicillin, it was found that 65% of the FWC-FWVs and 81% of the FWC-SACMOs
indicated managing oral amoxicillin with 30% and 6% indicating managing other formulations
of the medicine. Among these sites, oral amoxicillin was found to be mostly available with 83%
to 100% of the sites having the medicine available on the day of the visit. No other DGFP sites
were found to be managing oral amoxicillin. Only one SBA-FWA visited was managing
newborn resuscitation equipment at the community level (table 12).
Table 12. Management of Newborn Health Medicines at DGFP Service Delivery Points
Tracer Medicine MCWC (n = 1)
UHC-FP/UFPS (n = 4)
FWC-FWV (n = 20)
FWC-SACMO (n = 16)
FWA (n = 20)
SBA-FWA
(n = 14)
Gentamicin
Theoretical Ya Y N N N N
Actual Na N N N N
Oral amoxicillin
Theoretical Y Y N Y N N
Actual N N 65% (n = 13)
b
81% (n = 13)
b
N
Dexamethasone
Theoretical Y Y N N N N
Actual N N N N N
Bulb sucker
Theoretical Y Y Y N N Y
Actual N N N N N 7% (n = 1)
Bag
Theoretical Y Y Y N N Y
Actual N N N N N N
Mask, infant
Theoretical Y Y Y N N Y
Actual N N N N N 7% (n = 1)
a. Y = yes, N = no. b. 30% and 6% of the FWC FWVs and SACMOs, respectively, also managed other formulations of oral amoxicillin.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
24
DGHS
All newborn health commodities, except dexamethasone, should be available at and above the
upazila level. Gentamicin should be available until the union level and oral amoxicillin available
until the community level at the community clinics. SBA-HAs should not be managing any of
the tracer newborn health medicines.
The CSO/DRS is expected to manage all of the newborn health commodities; however, the
assessment found that the Lakshmipur CSO/DRS was managing only oral amoxicillin which was
available on the day of the visit.
Newborn health commodities were often found to be managed at sites that are not authorized
to manage these medicines, especially among the UHCs and USCs. The district hospital had all
the newborn health commodities available on the day of the visit, but they were not managing
the newborn resuscitation equipment. Among the UHCs, 50% indicated managing gentamicin
and oral amoxicillin, but only one UHC indicated managing newborn resuscitation supplies.
Among the UHCs that indicated managing the newborn health medicines, only 25% to 50% of
them had gentamicin and oral amoxicillin available on the day of the visit. One UHC did not
have gentamicin and oral amoxicillin on the visit day as they were experiencing a stock-out; at
the time of the assessment, the sites indicated having a stock-out of gentamicin and oral
amoxicillin for 27 and 4 days respectively. Also, 40% (n = 6) of the 15 CC-CHCPs that are
managing oral amoxicillin experienced stock-outs of the medicine within the past 6 months for
an average of 9 days total. One UHC also indicated managing dexamethasone, which should be
managed only at district hospitals.
Finally, while SBA-HAs are not supposed to be managing any newborn health medicines, one
SBA-HA indicated managing gentamicin, oral amoxicillin, and dexamethasone; and two
indicated managing newborn resuscitation equipment (table 13).
Table 13. Management and Availability on the Day of the Visit of Newborn Health Medicines at DGHS Service Delivery Points
Tracer Medicine
DH (n = 1)
UHC-HS (n = 4)
USC-SACMO (n = 4)
CC-CHCP (n = 20)
SBA-HA (n = 6)
Gentamicin
Theoretical Y Y Y N N
Actual Y 50% (2/4) 25% (1/4) N 17% (1/6)
Availability Y 50% (1/2) Y N Y
Oral amoxicillin
Theoretical Y Y Y Y N
Actual Y 50% (2/4) 50% (2/4) 75% (15/20) 17% (1/6)
Availability Y 50% (1/2) 50% (1/2) 75% (13/15) Y
Dexamethasone
Theoretical Y N N N N
Actual Y 25% (1/4) N N 17% (1/6)
Availability Y Y N N Y
Results
25
Tracer Medicine
DH (n = 1)
UHC-HS (n = 4)
USC-SACMO (n = 4)
CC-CHCP (n = 20)
SBA-HA (n = 6)
Newborn resuscitation
Theoretical Y Y N N N
Actual N 25% (1/4) N N 33% (2/6)
Availability N N N N Y a. Y = yes, N = no.
Child Health
DGFP
Among the child health tracer medicines, ORS, zinc sulfate and amoxicillin DT are supposed to
be managed at the district, upazila, and union levels by all DGFP sites. At the community level,
only ORS is supposed to be managed by the FWAs and SBA-FWAs.
The assessment found that none of the child health tracer medicines are being managed in any of
the DGFP sites. However, the MCWC, 45% of the FWC-FWVs, and 69% of the FWC-SACMOs
indicated managing other formulations of amoxicillin used for child health.. Among these sites,
amoxicillin was available at 73% to 100% of the sites on the day of the visit. Additionally, only
three FWC-SACMOs indicated having a stock-out in the past six months for an average of seven
days.
DGHS
DGHS sites are responsible for ensuring the availability of all of the child health medicines at the
district, upazila, and union levels (DH, UHC, and USC sites). At the community clinics and
among SBAs, only ORS is expected to be managed. As such, the CSO/DRS are also expected to
manage all of the child health commodities. The assessment found that while most of the child
health commodities are being managed at the district level, the CSO/DRS and DH were not
managing amoxicillin DTs or any other formulations of amoxicillin used for child health.
Additionally, very few of the DGHS sites were found to be managing zinc sulfate and
amoxicillin DTs. For example, while all UHCs were managing ORS, only half of the sites visited
were managing amoxicillin DT and one site was managing vitamin A.
Table 14 shows the child health medicines that are being managed and were available on the day
of the visit at DGHS service delivery points. Among those service delivery points, over 88% of
them had the medicine available on the day of the visit. However, both ORS and zinc sulfate
were not available on the day of the visit at the CSO/DRS as they had experienced a stock-out
that day. While 100% of the UHCs and USCs visited had each of the child health medicines
available on the day of the visit, one UHC experienced a stock-out of zinc sulfate for a total of 30
days within the last 6 months and one USC indicated having a stock out of amoxicillin DTs for 7
days within the last 6 months. Among the community clinics, 81% and 79% of sites that were
managing ORS and zinc sulfate, respectively, experienced stock-outs in the last 6 months for 6
days for each medicine.
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
26
Table 14. Management and Availability on the Day of the Visit of Child Health Medicines at DGHS Service Delivery Points
Tracer Medicine DH
(n = 1) UHC-HS (n = 4)
USC-SACMO (n = 4)
CC-CHCP (n = 20)
SBA-HA (n = 6)
ORS
Theoretical Ya Y Y Y Y
Actual Y Y 50% (2/4) 80% (16/20) N
Availability Y Y Y 94% (15/16)
Zinc Sulfate
Theoretical Y Y Y N N
Actual Na 25% (1/4) 25% (1/4) 70% (14/20) N
Availability N Y Y 93% (13/14)
Amoxicillin DTb
Theoretical Y Y Y N N
Actual N 50% (2/4) 25% (1/4) 10% (2/10) N
Availability N Y Y Y
Vitamin A
Theoretical Y Y
Actual N 25% (1/4) N 80% (16/20) 17% (1/6)
Availability N Y 88% (14/16) Y
a. Y = yes, N = no. b. Oral amoxicillin capsules 250 mg have been procured in the past for the CC kits and other facilities so the country is still in the process of phasing out the 250 capsules before providing DTs.
27
DISCUSSION
Ensuring continuous availability of RMNCH commodities requires a supply chain that is
responsive to the health needs of the population. To achieve this, efficient procurement, and
supply and distribution systems with strong LIMS to inform decisions that affect the availability
of medicines at service delivery points are required. In Bangladesh, district level facilities also
conduct local procurement of medicines to ensure continuous availability. In 2014, SIAPS
conducted an assessment on local procurement practices for three maternal health medicines in
three districts. Major findings of the assessment that affect access to maternal health medicines
included—
Lack of coordinating and sharing information between the central and subnational level
No standard evidence-based method for forecasting maternal health medicines at the
district level
No district-level guidance for quantification or local procurement of medicines
Insufficient training of the procurement committee members about quantification or
procurement
Procurement of medicines begins with evidence-based forecasting of medicine needs at each
level of the system. This informs the central level and health facility managers as to how much
medicine to procure and distribute to SDPs by providing data on consumption and availability of
essential medicines. Building the capacity of health facility managers to accurately forecast
medicine needs and requests and procure the needed quantities entails access to guidance
documents and procedures, and training customized for the local level. And, to ensure that this
information is conveyed, coordinated, and considered when making decisions at the central level,
a LMIS must be in place. DGFP has a well-functioning, institutionalized electronic LMIS system
for family planning commodities and is currently in the process of including some newborn and
maternal health commodities. However, DGHS has no such system to track the consumption and
availability of essential MNCH commodities.
The purpose of this assessment was to describe pharmaceutical management practices for
essential RMNCH medicines and supplies at all levels of the public health system in Lakshmipur
district to aid with developing interventions to improve availability and use of these
commodities. While touching upon local procurement practices, such as forecasting medicine
needs, this assessment went a step further and assessed the supply and distribution systems at the
lower levels, information flows related to pharmaceuticals, particularly at DGHS sites, and
availability of essential RMNCH commodities at the district and sub-district levels.
As noted in the subnational procurement assessment, health facilities are either not using any
evidence-based method for forecasting medicine needs or are not forecasting needs at all. At
DGFP sites, the reason for not forecasting medicine needs is due to the push system. DGHS sites
forecast medicine needs; however, the forecast is based on the previous quarter’s consumption
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
28
and sometimes adjusted by 10% when facilities submit quarterly requisitions to the CSO. Also,
no local level guidelines exist for both forecasting and local procurement of medicines. While
both DGFP and DGHS sites indicated referring to the 2006 PPR and 2008 PPA, there is no
standardized method used.
Medicines need to be distributed on time and efficiently to ensure continuous availability of
RMNCH medicines at service delivery points. SIAPS has been supporting DGFP in both
streamlining procurement processes at the central level and strengthening inventory management
practices and distribution systems with regional warehouses through the Warehouse Inventory
Management System. None of the DGFP sites indicated any issues in the supply and distribution
of RMNCH commodities and follow SOPs such as developing distribution plans that are
generated through warehouse inventory system. On the other hand, neither the CSO/DRS nor the
UHCs responsible for distributing RMNCH supplies to lower system levels within DGHS have
SOPs related to distribution or generate distribution plans. Some even indicated that medicines
are supplied to health facilities when needed. Developing SOPs and distribution plans for
distributing medicines could reduce delays in supplying facilities, preventing stock-outs of
medicines.
To inform decision making at the central and facility level, particularly for forecasting medicine
and distributing medicines to service delivery points, an LMIS that collects availability data is
needed. While the DGFP has a well-functioning electronic LMIS that provides data on
availability of family planning commodities, it does not include essential medicines for maternal,
newborn, and child health that DGFP health facilities are managing. DGHS, however, has no
such logistics management system and information related to pharmaceuticals is scattered,
unorganized and not standardized across DGHS sites. While medicine requisitions are submitted,
there are no standardized forms, operating procedures, or guidelines on how medicine requests
are calculated. In combination with poor forecasting methods, this can lead to stock-outs of
essential MNCH commodities as decisions made at the facility and central level would not take
into account realities at the local level.
There is no standard treatment guideline or RMNCH strategy that dictates where services and
medicines should be available at which levels of the system and who should manage them. This
leads to confusion as to where RMNCH medicines should be available and at which service
delivery points within DGFP and DGHS. Except for family planning commodities, the
assessment found that many SDPs were managing medicines that they are not supposed to be
managing or vice versa, affecting the availability of life-saving MNCH commodities. Moreover,
among the sites that were managing MNCH medicines, medicines were not always available.
29
RECOMMENDATIONS
This year will mark the end of the MDGs and while Bangladesh is on track for meeting these
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. By 2030, countries must
reduce neonatal mortality to at least 12 per 1,000 live births, child mortality to 25 per 1,000 live
births, and maternal mortality to less than 70 per 100,000 live births. Given the geographic
disparities within the country to access to life-saving RMNCH services, there needs to be
increased focus on ensuring the availability of RMNCH commodities at the district and sub-
district levels through systems strengthening approaches.
Therefore, the following actions are recommended.
Finalize and Disseminate Maternal and Newborn Health Standard Operating Procedures at all System Levels
Currently, the MNH standard operating procedures are in the final stages of approval. This
guideline not only includes the treatment guidelines for MNH but also clearly indicates which
medicines need to be managed at the different health system levels and facilities. While this is a
major step to ensure the right medicines are available when and where they are supposed to be, it
is only for maternal and newborn health. There needs to be one consolidated document that also
includes reproductive and child health commodities. This must be endorsed by all relevant
stakeholders including MOHFW, DGHS, and DGFP, and disseminated and rolled out nationally
at all levels to facility managers and health service providers.
Improve the Capacity of Staff Local Level Members to Manage Pharmaceutical Management Processes
The DGFP has a well-established supply manual that describes guidelines for all aspects of
logistics planning. However, at the service delivery points, use of the guidelines was limited,
particularly for forecasting and inventory management. The MCWC indicated not having the
guidelines and only one FWC-FWA and two FWC-SACMOS indicated having guidelines for
inventory management. Additionally, local procurement guidelines are not included in the DGFP
Supply Manual. Including district level guidelines or a checklist for best practices for local
procurement can enhance the capacity of staff responsible for conducting local procurement.
DGHS does not have institutionalized SOPs, guidelines, standardized forms, or inventory
management tools needed for managing storage, inventory, supply and delivery, and logistics
reporting as well local procurement. District level guidelines that are practical and easy to use are
essential to improving procurement practices. This was also a finding from the 2014 sub-national
procurement assessment. Since then, SIAPS has developed inventory management tools such as
bin cards, stock ledgers, issue vouchers, indenting and issue vouchers, and logistics reporting
forms, and is in the process of getting them endorsed by the MOHFW. Once endorsed, they will
District-Level Assessment of Pharmaceutical Management of Life-Saving RMNCH Commodities:
Lakshmipur, Bangladesh.
30
be printed and disseminated to the health facilities and DGHS logistics personnel will be trained
throughout the country. Trainings, along with supportive supervision, will help improve
knowledge and skills to ensure best practices in logistics management.
For local procurement practices, while facility managers indicated referring to PPR 2008 and
PPA 2006 for guidance, it was found that many sites visited were not adhering to good
procurement practices. Based on the recommendations from the sub-national procurement
assessment, SIAPS is developing both local procurement guidelines and a curriculum for
managing local procurement processes that includes quantification. Trainings on these guidelines
will be piloted in 10 districts and then rolled out nationally.
Strengthen Pharmaceutical Information Systems to Provide Data needed for Robust Forecasting and Supply Planning
For DGFP, a well-established LMIS is in place that collects data on consumption and availability
of family planning commodities from all levels across the systems. This data has been
successfully used for forecasting and supply planning at the national level for family planning
commodities. There is a need to include essential maternal health and child health commodities
that are also managed at DGFP health facilities, such as oxytocin, misoprostol, amoxicillin DT,
and ORS. Information on the use and availability of these medicines needs to be captured and
visible at the national level to enhance decision making that can affect their availability.
Within DGHS, there is no LMIS system to collect logistics data to track the availability of
medicines at health facilities and stores. With SIAPS support, a technical working group for
setting up an LMIS in DGHS was formed and a module using the DHIS-2 platform was
developed to collect data on the availability of MNCH commodities at all systems’ levels. The
LMIS is currently being piloted on Gazipur and will be rolled out to 10 districts. This can serve
as a model that can be rolled out nationally by the MOHFW and DGHS.
Advocate for Inclusion of Amoxicillin DTs and ORS in DGFP and DGHS Procurement Plans
The findings from the assessment revealed that amoxicillin DT is not purchased under DGHS or
DGFP, and ORS was not available in DGFP facilities. The MOHFW needs to take an active lead
in ensuring that amoxicillin DT is included in the procurement plans of both DGFP and DGHS.
Also, if the DGFP continues the use of DDS kits, inclusion of amoxicillin DT and ORS in kits
could be considered as well as inclusion in DGHS CC kits. The MOH would need to be involved
in the revision process.
Recommendations
31
Provide Facilities with the Infrastructure Necessary to Maintain Cold Chain Storage Conditions for Oxytocin. Storage conditions continue to be a concern in Bangladesh as most of the facilities that manage
the medicine do not have operational refrigerators or other means to maintain the recommended
storage temperature. It is essential that health facilities have the proper infrastructure in place to
maintain cold chain storage to ensure the quality of the medicine.
Ensure that Magnesium Sulfate is Rolled Out Wherever Women Give Birth.
The standard management protocols on services at district and upazila levels have recommended
the use of magnesium sulfate. This has already been rolled out at district and upazila level
facilities of DGHS. There is a need for clarity at the UHCs, on the management and use of
magnesium sulfate as half of the facilities were not managing the medicine. DGFP district level
facilities also need to roll out the use of magnesium sulfate at MCWCs, while union level FWCs
can be an option for providing the loading dose and facilitate referral.
32
ANNEX A. AVAILABILITY OF MNCH COMMODITIES IN THE LAST SIX MONTHS
Table A1. Availability of Maternal Health Medicines among DGFP Service Delivery Points
MCWC (N = 1)
UHC-FP (N = 4)
FWC-FWV (N = 20)
FWC-SACMO (N = 16)
FWA (N = 20)
SBA-FWA (N = 14)
Oxytocin (# sites that had no recorded stock outs)
Indicated not managing the medicine
Indicated not managing the medicine
100%; 3/3 Indicated not managing the medicine
Indicated not managing the medicine
Indicated not managing the medicine
Average # days out of stock
NAa
NA NA NA NA NA
Misoprostol (# sites that had no recorded stock outs)
Indicated not managing the medicine
67%; 2/3 100%;18/18 Indicated not managing the medicine
94%; 17/18 88%; 7/8
Average # days out of stock
NA 2; N = 1 NA NA 25; N = 1 25; N = 1
Iron folate (60 mg + 0.4 mg) (# sites that had no recorded stock outs)
Indicated not managing the medicine
100%; 3/3 Indicated not managing the medicine
67%; 2/3 Indicated not managing the medicine
Indicated not managing the medicine
Average # days out of stock (n)
NA NA NA 16; N = 1 NA NA
Iron folate (other) (# sites that had no recorded stock outs)
0%; 0/1 100%; 1/1 89%;17/19 75%; 9/12 Indicated not managing the medicine
Indicated not managing the medicine
Average # days out of stock (n)
23; N = 1 NA 11; N = 2 6; N = 3 NA NA
a. NA is not applicable if the facility reported not managing the medicine or if the facility reported no stock outs of the medicine during the time of the visit.
Table A2. Availability of Maternal Health Medicines among DGHS Service Delivery Points
CSO/DRS N
= 1 DH
N = 1 UHC-HS
USC-SACMO CC-CHCP SBA-HA
Oxytocin (# sites that had no recorded stock outs)
100% 100% 100%; N = 2
Indicated not managing the medicine
Indicated not managing the medicine
100%; N = 1
Average # days stock out
NA NA NA NA NA NA
Magnesium sulfate (# sites that had no recorded stock outs)
0% 0% 50%; N = 2
0%, N = 1 Indicated not managing the medicine
Indicated not managing the medicine
Annex A
33
CSO/DRS N
= 1 DH
N = 1 UHC-HS
USC-SACMO CC-CHCP SBA-HA
average # days stock out
25 24 30 15 NA NA
Iron folate (60mg + 0.4mg) (# sites that had no recorded stock outs)
Indicated not managing the medicine
100% 100%; N = 2
50%; N = 2 67%; N= 6 Indicated not managing the medicine
average # days stock out
NA NA NA 4 5 NA
Iron folate (other) (# sites that had no recorded stock outs)
0% Indicated not managing the medicine
100%; N = 2
100%; n = 1 60%; N = 10 Indicated not managing the medicine
average # days stock out
12 NA NA NA 4 NA
Calcium (500 mg) (# sites that had no recorded stock outs)
0% Indicated not managing the medicine
67%; N = 3
100%; N = 1 Indicated not managing the medicine
Indicated not managing the medicine
Average # days stock out
25 NA 30 NA NA NA
Calcium (300 mg, 600 mg) (# sites that had no recorded stock outs)
100% 100% 100%; N = 2
0%; N = 1 53%; N = 15 Indicated not managing the medicine
average # days stock out (n)
NA NA NA 30 8 NA
a. NA is not applicable if the facility reported not managing the medicine or if the facility reported no stock outs of the medicine during the time of the visit.
34
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