Logistics and Supplies
Supplies are still the major limiting factor in delivering the integrated package. From Demographic and Health Surveys, coverage of IFA supplementation, IPTp, and deworming are unacceptably low in most countries. Supply chains have improved for some commodities, particularly long-lasting insecticide-treated bednets and ARVs. But for most anemia control commodities, coverage remains low. Lessons can be learned, however, from logistics supply strengthening programs. Click here and here for presentations on improving supplies.
- A first step to improving supplies and logistics is to accurately estimate the commodities for the integrated package. Forecasting is often based on use rather than need. That is, supplies are ordered based on the number of women coming in for antenatal care rather than the estimated number of pregnant women in the catchment area. Where use of ANC is high, forecasting by use works but where it is not high, forecasting underestimates the need. In addition, supplies may be determined by Central Supplies (usually the main stroage site for drugs and IFA in most countries), based on no estimates of pregnant women, and “pushed out” to health centers rather than health centers doing the forecasting themselves and “pulling” supplies from Central Health Supplies. However, if ANC use is limited, supplies need to be available in the community (delivered by community workers or drug sellers) in order to ensure they are used. A simple method for calculating IFA supplements for routine use in a catchment area where ANC use is low or late:
Total population x fertility rate (or 4% of the total population if the fertility rate is not known) x 180 IFA tablets (required amount for supplementation) = Total number of tablets
In Thailand, each fiscal year, the central division of the Ministry of Public Health (MOPH) sets funds aside to purchase IFA tablets (Winichagoon, 2002) but the IFA is estimated at the provincial level not the national level. The estimates are based on the number of pregnant women in the provinces or attending ANC which works well because ANC use is high. Estimates need to include additional commodities—sulphadoxine-pyrimethamine (SP) for treatment of malaria and severe anemia. Knowledge about the prevalence of anemia and malaria will be needed to estimate the additional SP and IFA needed for treatment. These estimates should be done yearly. Data on prevalence of anemia can come from Demographic Health Surveys, other survey estimates, or from the WHO database on anemia.
- Bottlenecks for logistics and supply systems for anemia control commodities must be identified and cleared. It is probably most effective to do this in coordination with efforts to improve the logistics situation for all drugs. In India, the IFA supply system was decentralized to the state and district levels and a special unit to monitor supplies was created (Galloway, 2003).
- Providing a buffer stock or other back-up sources for anemia control commodities is good ensure to prevent lengthy stock-outs. To ensure a continuity of supplies, an additional buffer stock of 20% of the estimated need should be provided. In Thailand, multiple mechanisms exist to ensure no gaps in supplies occur. Health clinics maintain funds to use when stocks run low which they can use to purchase IFA at emergency depot centers without central level approvals.
- Provide anemia control commodities through community-based and private/retail outlets. Distribution of long-lasting, insecticide-treated bed nets (LLINs) already exists. These nets may not get to pregnant women and children without intervention by the public health sector. Vouchers can be provided to women at ANC to purchase LLINs which works to attract women to ANC and provide a partial or complete subsidy directly to women to obtain their own LLIN. Small shops also can be used to sell IFA which may be convenient for women for resupply. Shop owners should be given messages about taking IFA (why, when, how often, how to manage side effects). In Indonesia, the Ministries of Health and Industry teamed up to create packaging for private sector sales of IFA. The packaging was similar to the IFA sachets obtained through the public health sector so women could easily identify the right product.