BackgroundA UNICEF review of the challenges to scaling up integrated community case management (iCCM) found that drug shortages were a common bottleneck. In many settings, little thought has gone into the design of supply chains to the community level and limited evidence exists for how to address these unique challenges. SC4CCM’s purpose was to conduct intervention research to identify proven, simple, affordable solutions that address the unique supply chain challenges faced by CHWs and to demonstrate that supply chain constraints at the community level can be overcome.MethodsSC4CCM selected three countries to implement supply chain innovations and developed a theory of change (TOC) framework for the learning phase, which identified the main drivers of product availability and was used for baseline assessments, design, implementation and evaluation of interventions in Ethiopia, Malawi, and Rwanda. Interventions were developed in each country and tested over 12–24 months. Mixed–method follow up assessments were conducted in each country in 2012–2013. The Supply Chain for Community Case Management (SC4CCM) Project then simplified the TOC into a Community Health Supply Chain (CHSC) framework to enable cross country analysisResultsThe findings from interventions in the three countries suggest that the greatest supply chain benefits are realized when all three CHSC framework elements (data flow, product flow, and effective people) are in place and working together. The synergistic effect of these three elements on supply chain performance was most effectively demonstrated by results from the Enhanced Management and Quality Collaborative interventions in Malawi and Rwanda, respectively, which were characterized by lower mean stockout rates and higher in stock rates on day of visit, when compared to other interventions.ConclusionsMany conditions are necessary to ensure continuous product availability at the community level, however a supply chain works best when three key elements (product flow, data flow, and effective people) are deliberately included as an integral part of the system design. Although these elements may be designed differently in different settings, streamlining and synchronizing them while ensuring inclusion of all components for each element improves supply chain performance and promotes product availability at the community level.

The widespread use of multidose vaccine containers in low and middle income countries' immunization programs is assumed to have multiple benefits and efficiencies for health systems, yet the broader impacts on immunization coverage, costs, and safety are not well understood. To document what is known on this topic, how it has been studied, and confirm the gaps in evidence that allow us to assess the complex system interactions, the authors undertook a review of published literature that explored the relationship between doses per container and immunization systems. The relationships examined in this study are organized within a systems framework consisting of operational costs, timely coverage, safety, product costs/wastage, and policy/correct use, with the idea that a change in dose per container affects all of them, and the optimal solution will depend on what is prioritized and used to measure performance. Studies on this topic are limited and largely rely on modeling to assess the relationship between doses per container and other aspects of immunization systems. Very few studies attempt to look at how a change in doses per container affects vaccination coverage rates and other systems components simultaneously. This article summarizes the published knowledge on this topic to date and suggests areas of current and future research to ultimately improve decision making around vaccine doses per container and increase understanding of how this decision relates to other program goals.

BackgroundSupply chain bottlenecks that prevent community health workers (CHWs) from accessing essential medicines significantly increase under-5 child mortality, particularly in poor and rural areas.ObjectiveUsing implementation research, interventions aimed at improving supply chain practices and access to medicines were tested in Malawi and Rwanda. These interventions included simple demand-based resupply procedures, using mobile technology and traditional methods for communication, and multilevel, performance-driven quality improvement (QI) teams.MethodsMixed-method evaluations were conducted at baseline (2010), midline (2013), and endline (2014). Baseline assessments identified common bottlenecks and established performance levels. Midline assessments identified which intervention package had the greatest impact. Endline surveys measured the progress of scale-up and institutionalization of each innovation.ResultsIn both Rwanda and Malawi CHWs, health center staff, and district managers all cited many benefits of the establishment of resupply procedures and QI teams: such as providing structure and processes, a means to analyze and discuss problems and enhance collaboration between staff.ConclusionsImplementing simple, streamlined, demand-based resupply procedures formed the basis for informed and regular resupply, and increased the visibility of appropriate and timely community logistics data. QI teams played a critical role in reinforcing resupply procedures and routinely unlocking the bottlenecks that prevent the continuous flow of critical health products. While simple, streamlined, demand-based resupply procedures provide the basis for regular, functional, and efficient resupply of CHWs, the procedures alone are not sufficient to create consistent change in product availability. Supporting these procedures with multilevel QI teams reinforces the correct and consistent use of resupply procedures.

Recent rapid increases in implant procurement have not resulted in system overstocks to date. We found no standard factor for relating inventory quantities to consumption rates. Rather, that relationship requires specific understanding of the country supply chain, inventory control parameters, and current and future demand.

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