Category Archives: Procurement Supply Management

Setting the Stage to Introduce a Groundbreaking Community Approach to Prevent Malaria in Pregnancy in Sub-Saharan Africa

Maya Tholandi, Lolade Oseni, Anne McKenna, Herbert Onuoha, Solofo Razakamiadana, Elsa Nhantumbo, Alain Mikato, Elaine Roman of Jhpiego and the Johns Hopkins Bloomberg School of Public Health shared important Baseline Readiness Assessment Findings from Democratic Republic of the Congo, Mozambique, Madagascar, and Nigeria from the UNITAID-supported TIPTOP on Intermittent Preventive Treatment of malaria in pregnancy at the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene as seen below.

Intermittent preventive treatment of malaria in pregnancy (IPTp) is unacceptably low in most of sub-Saharan Africa. A Jhpiego-led consortium is implementing the Transforming Intermittent Preventive Treatment for Optimal Pregnancy (TIPTOP) project, which supports community distribution of quality-assured sulfadoxine-pyrimethamine (SP).

TIPTOP aims to increase IPTp3 coverage from 19% to 50% of eligible pregnant women in project areas in Democratic Republic of the Congo (DRC), Madagascar, Mozambique, and Nigeria. The project, operating from 2017 to 2022, provides quality-assured SP, promotes community awareness, and supports supervision and coordination efforts between health facilities and community health workers (CHWs).

In 2017, a baseline assessment examined facility readiness for malaria in pregnancy management, antenatal care (ANC) provider knowledge, CHW characteristics and health facility linkages, and health management information system (HMIS) quality. TIPTOP assessed 140 facilities and interviewed 175 ANC providers and 67 CHW supervisors.

At project startup, the teams examined SP stock, ANC providers and CHW availability. SP Stock assessment showed a disparate stock maintenance processes and stock-out next steps indicate lack of a coherent and consistent approach to stock monitoring. In half of all cases, caregivers offer a prescription when stock is not available in the facility, with smaller numbers requesting.

Among ANC providers, 80% on average correctly reported that at least three doses of IPTp are recommended. On average, 64% correctly responded that SP should be initiated in the second trimester. Out of the 170 providers interviewed across countries, only five knew all the key signs of suspected malaria.

A low numbers of CHWs in some districts may limit their reach and capacity. Inadequate CHW education and ANC familiarity may diminish training effectiveness. In particular, low numbers of female CHWs may decrease community acceptance and pregnant women’s acceptability of receiving IPTp from CHWs.

Data Quality and Availability from the routine services would affect monitoring of interventions. Over-reporting of ANC contacts and IPTp service provision is a data quality challenge. The HMISs in Nigeria and Mozambique record IPTp3 provision, but only at the local level. Supervising facilities do not always review data before HMIS entry for accuracy.

Concerning Monitoring and Evaluation System Components, Mozambique’s HMIS is the strongest of the four countries in terms of linking to the national system, current tools and reporting forms available in the facilities, and providers reporting an understanding of indicators and data reporting processes. Nigerian facilities had limited knowledge of indicators and their definitions, despite this information being available in Federal Ministry of Health-provided registers. Madagascar struggled with indicator definitions and data management processes. DRC faced the most challenges: Tools and reporting forms were not available in health facilities, and there were limited monitoring and evaluation structures and processes.

In Conclusion, Results from the baseline assessment are Informing efforts to improve data quality and CHW facility data flow in TIPTOP implementation areas. There is need to strengthen ANC provider knowledge through TIPTOP-supported trainings. One also needs to address CHW variation by country and support health facilities to monitor their SP stock. These findings are being shared with ministries of health and key stakeholders to inform malaria implementation and data quality efforts.

One SMS Saves Lives in Madagascar

Haja Andriamiharisoa, Eliane Razafimandimby, Jean Pierre Rakotovao, Jean Eugene Injerona, Zo Harifetra, Lalanirina H. Ravony, Rado Randriamboavonjy, Jocelyn Razafindrakoto, and Laurent Kapesa have been working with the USAID Maternal and Child Survival Program. At the 2018 Annual Meeting of the American Society of Tropical Medicine and Hygiene they presented their experiences on “Improving Procurement and Redeployment of Malaria Commodities Using SMS and Web Mapping at a District Level in Madagascar,” and are also sharing via this posting.

Malaria is a public health problem in Madagascar. In 2016, the frequency of diseases at health center level, places malaria at the 4th cause of hospital morbidity and mortality. Out of about 30 thirty diseases, malaria accounts for 5.6% of all cases.

Health facilities often experience commodity stock-outs of products used for malaria prevention and case management. The existing logistics reporting system does not allow for macro or micro views of the monthly stock situation at the health facility level, which inhibits rapid decision-making.

On January 2018, implementation of a fast data collection system and easy-to-use data visualization began. The tool was based on the use of SMS and web mapping to map the level of monthly keys stock of commodities. The data are sent by providers at facility level via structured SMS and are published by a web server by a web mapping process. Note that sending a monthly SMS costs 9 US cents per facility. Providers at 773 health facilities in 16 regions of Madagascar sent monthly SMS (each message cost $0.09) with ART, ACT, and ITN stock levels.

  • Sample message: “Please send the quantity in stock at the end of month in: ART, ACT, ITN.”
  • Structure like: “palu csbcode year month ART ACT ITN. Thank you.”
  • Sample of answer received: “palu 520241031 D A 200 25 0”

Thus was created an easy-to-use tool from data received. It was free to use, and no password was needed. The SMS is simple and short (of 40 forty characters, composed of:

  • “palu” diminutive of malaria so that the system is ready for data collection from other cases
  • the health facility code : 520241031
  • year : here D : as project has implemented sms data collecting system since 2015 = A
  • month : here A that means January
  • stock of Injectable Artesunate (ART) : 200
  • stock of tablet for Artemisininbased combination therapy (ACT) : 25
  • stock of Insecticide Treated Nets (ITN) : 0

Providers send SMS after completing the Monthly Activity Report. (CSB = Centre de Santé de Base, or basic health center). The received data are then displayed as web mapping on a Google map background, embedded on a web page. From this screen shot, The page displays a map of stock outs for the selected month, and monthly charts of the stock status of the three commodities. Accessing this website, is open, without restriction.

From the end of January to the end of June 2018, a hundred health facilities sent SMS each month. The data we received shows that on average:

  • 75% Average stock-out of ITN
  • 53% Average stock-out of ART
  • 9% Average stock-out of ACT

The attached three-map picture provides a broad view from three screenshots of the system, showing the evolution of stock-outs at a facility level

  • Each point represents health facilities:
  • When the dot is green, this means that the 03 commodities are available in stock
  • When in brown, at least one of the 03 elements is unavailable
  • At first sight, there are more stockouts than stock availability and a tendency of the reduction of green points over the months
  • Appropriate decision-making would change the points of the map of the following months to green

After this broad view of the country’s overall situation and given the large number of facilities with out of stock, an emergency supply for all districts was done for some medicine since February 2018. Based on maps and stats, we could improve our interventions at a CSB level through rapid and adequate decision-making as in the supply of ITN and ART.

In conclusion, the use of SMS data collection to map stock-outs online can quickly improve input supply through simple spatial analysis. Sending SMSs to alert district-level officials about overstock in facilities at the same district level can solve many stock-out issues. All districts were restocked using this SMS and Web mapping system, but routing to the CSBs remains a challenge. Punctual stock-out reporting could significantly reduce the morbidity and mortality caused by malaria.

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A- 14-00028. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government.

Progress on Malaria in Pregnancy in 12 PMI Focus Countries

The challenges of implementing programs to control malaria in pregnancy based on experiences with US President’s Malaria Initiative Countries was presented at the Malaria World Congress in Melbourne this week. The team included Katherine Wolf, MCSP/Jhpiego, Marianne Henry, PMI/USAID, Lia Florey, PMI/USAID, Gabrielle Conecker, MCSP/Jhpiego, Betsy Hendrickson, MCSP/Jhpiego, Katherine Lilly, MCSP/Jhpiego, Nicholas
Furtado, GFATM, Maria Petro, GFATM, Susan Youll, PMI/USAID, and Julie Gutman, PMI/CDC, and their findings are shared below.

What is the danger of malaria in pregnancy (MiP)? Each year MIP is responsible for 20% of stillbirths in Sub-Saharan Africa, 100,000 Newborn deaths globally, 11% of newborn deaths in Africa and 10,000 maternal deaths globally. Four interventions are aimed at MIP, Intermittent Preventive Treatment in Pregnancy (IPTp), consistent use of insecticide treated nets, effective diagnosis and treatment and low-dose folic acid during antenatal care. IPTp with sulfadoxine-pyrimethamine reduces low birth weight by 29%, severe maternal anemia by 38% and neonatal mortality by 31%. What can be done?

  • Scale-up and full coverage of the WHO lifesaving interventions
  • Promote early and regular ANC
  • Preserve SP efficacy by avoiding its use for treating clinical cases of malaria
  • Reserve SP stocks for IPTp at ANC clinics

Methodology for MiP country review: Initial survey took place in 23 PMI countries. PMI resident advisors were surveyed, Qualitative and quantitative responses were collected and Input from NMCP/partners was obtained. Country selection resulted in 12 that were Tiptop-implementing countries, represented Geographic diversity, had varied IPTp coverage, and made clear progress or best practices to share.

Desk review including HMIS and house hold survey data, current studies and recent assessments, Selected interviews with PMI resident advisors, Jhpiego field staff and current/former NMCP staff. Analysis was a Review and clarification of qualitative and qualitative data.

The 12 countries included Angola, Benin, Burkina Faso, DRC, Ghana, Kenya, Liberia, Madagascar, Malawi, Nigeria, Senegal, and Zimbabwe (see map). The figure shows that none of these attained 80% of 2 doses of IPTp. The current recommendations are for monthly dosages from the 13th week of pregnancy. Often less that half of those receiving IPTp2 also got IPTp3.

Several health systems findings helped explain the IPT results. For Policy & Implementation, Countries reporting strong, coordinated leadership delivered
high IPTp coverage. With Community Engagement, countries reported a diversity of approaches to community health promotion and service delivery.

Concerning Service Delivery, Many countries struggle to implement MiP policies consistently and with quality in the private sector. Commodities were a challenge. Some countries continue to struggle with SP stockouts at facility level, whether ongoing or episodic. Monitoring and Evaluation processes need to catch up. Countries’ routine information systems are transitioning from tracking IPTp2 to IPTp3.
The team offered several Recommendations.

  1. Strengthen consistency of IPTp policies across malaria and reproductive health programs
  2. Scale up of evidence-based country appropriate
    community engagement strategies
  3. Alleviation of supply chain bottlenecks at peripheral level
  4. Inclusion and harmonization of key MIP indicators in routine information systems

For more information please visit www.mcsprogram.org, facebook.com/MCSPglobal and twitter.com/MCSPglobal

This presentation was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative AgreementAID-OAA-A-14-00028. The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States Government.

Many Neglected Tropical Diseases: What About Eliminating Them?

Testing to see if transmission of lymphatic filariasis has stopped in Burkina Faso

Two things we need to note about the list of 20 diseases that the World Health Organization and partners classify as Neglected Tropical Diseases (NTDs). First, diseases like Rabies, Snakebite/envenoming, and Leprosy, while certainly more common in the tropics now, have in the past been global in distribution. Secondly some of the diseases have not been neglected. Onchocerciasis or river blindness has been the focus of a global partnership since 1975, and transmission in the America’s and much of the Sahel in Africa has been halted. Elimination of Dracunculiasis or Guinea Worm has also been the subject of many World Health Assembly Resolutions, and concerted effort has brought the number of cases down from 3.5 million in 1986 to 30 in 2017.  What is more to the point about these diseases is that they affect neglected people, the poor and vulnerable in remote rural areas or urban slums.

Still when we can compare NTD control programs with the rise of major disease control efforts like the Global Fund to fight AIDS, Tuberculosis and Malaria, the President’s Emergency Program For AIDS Relief, the President’s Malaria Initiative, World Bank Malaria Booster Program, Global A Vaccine Initiative among others, we can see that the global community has been able to focus major financial resources on a few diseases.  Now with the Sustainable Development Goals, that focus expanded from infectious to Non-Communicable Diseases.  It is natural therefore to fear that tropical health problems that are responsible for major loss of life and economic capacity will not be adequately addressed.

A system of rewards helped identify the last cases in many guinea worm endemic countries

Based on the World Health Organization’s 2020 Roadmap on NTDs, the London Declaration on NTDs recognized a “tremendous opportunity to control or eliminate at least 10 of these devastating diseases by the end of the decade” (i.e. by 2020). These include eradication of Guinea worm disease, and elimination by 2020 of lymphatic filariasis (LF), leprosy, sleeping sickness {human African trypanosomiasis) and blinding trachoma. In addition drug access programmes should help control by 2020 schistosomiasis, soil-transmitted helminthes (STH), Chagas disease, visceral leishmaniasis and river blindness (onchocerciasis).

Five of the diseases are notable in that they can either be controlled or eliminated through Mass Drug Administration (MDA) using Preventive Chemo-Therapy (PCT). This effort is aided by drug donation programs at the global level and community based MDA at the local level. Ten companies were signatories to the London Declaration and contributed to drug donation programs to achieve MDA. According to WHO,

Preventive chemotherapy is aimed at optimizing the largescale use of safe, single-dose medicines and offers the best means of reducing the extensive morbidity associated with four helminthiases (lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiases) (6). Additionally, the large-scale administration of azithromycin – a key component of the SAFE strategy for trachoma (that is, lid surgery (S), antibiotics to treat the community pool of infection (A), facial cleanliness (C) and environmental improvement (E)) – is amenable to close coordination and, in future, possibly co-administration with interventions targeted at helminthiases.

Community health workers are the cornerstone of many NTD elimination programs

Targets for the 5 PCT diseases vary. The aim is to eliminate LF and Trachoma by 2020. Although the efforts against onchocerciasis have been running the longest, the refocus from control to elimination meant increasing the geographical scope of intervention, and now elimination may not be feasible until 2025.  With a focus mainly on the school aged and based populations, programs against schistosomiasis and STH talk of control, not elimination, although some endemic countries hope that elimination may be possible if the focus of these programs expands. So far, Togo is the only Sub-Saharan African country to have eliminated LF, and Ghana to have eliminated Trachoma.

Partnerships, funding and drug donations need to be strengthened if more countries are to join the ranks of Togo and Nepal.

Ministry of Health’s Effort in Developing and Implementing a Quality Assurance Plan for Global Fund-Supported Antimalarial Drugs: A Case Study of Nepal in the Context of Malaria Elimination

Prakash Raj Pant and Bhim Acharya of the USAID Supported Maternal and Child Survival Program/Jhpiego (MCSP)and the Epidemiology and Disease Division, Ministry of Health, Nepal presented their case study of developing a quality assurance approach for the Global Fund supported provision of antimalarial drugs at the 7th Multilateral Initiative for Malaria Conference in Dakar. Below are their experiences.

Nepal is in the malaria elimination phase, with a target of 2026 through the Global Fund (GF) malaria grant in process for 2018–2021. The Maternal and Child Survival Program (MCSP) also supported GF HIV/AIDS, TB, and malaria grant implementation.

Quality assured antimalarials are a prerequisite for malaria elimination. This is Mandated by GF quality control policies on pharmaceuticals National Malaria Strategic Plan 2016 states: “quality assured antimalarials should be available at all points of service delivery”. Nepal National Drug Regulation Agency (NDRA) does not have a written quality assurance (QA) policy for GF pharmaceuticals

Developing and Implementing a Successful QAP requires the following Key considerations:

  • Effective coordination of National Malaria Control Program (NMCP) and stakeholders with NDRA
  • Approval of QAP by ministry of health (MOH) and GF
  • Presence of laboratories in the region that are prequalified by the World Health Organization or certified by ISO 17025
  • Advocacy among high-level MOH officials
  • Intersectoral collaboration among implementing partners
  • NDRA’s active role in scheduling inspections
  • Building the capacity of government entities by bilateral agencies (e.g., WHO, United States Agency for International Development) in the initial phase of QAP implementation
  • Budgeting for QA activities in grant funds

Next Steps in QAP Implementation start with identifying GF-approved laboratories in region for quality control testing of existing grant-funded products. Then partners must strengthen national medicine testing capacities, and seek accreditation of government laboratories by international bodies in 2–3 years. It is important to Mainstream grant-funded QA activities into the NDRA

Challenges in Resource-constrained countries like Nepal include weak pharmaceutical QA testing capacity of domestic laboratories with no accreditation from international bodies. There is inadequate attention of decision-makers in implementing QA policies.

Take-Home Messages from the experience in Nepal include the fact that QA of pharmaceuticals is a mandatory but often neglected area in many GF grant recipient countries. There is need to integrate QA measures into country’s mainstream drug regulation. Coordination with in-country stakeholders is critical.

This poster was made possible by the generous support of the American people through the United States Agency for International Development (USAID), under the terms of the Cooperative Agreement AID-OAA-A-14-00028. The contents are the responsibility of the Maternal and Child Survival Program and do not necessarily reflect the views of PMI, USAID, or the United States Government.

Experiences in Vaccine Procurement for Middle Income Countries: the Swaziland Experience

Njabuliso Lukhele of the Ministry of Health Swaziland shared Swaziland’s experiences in Vaccine Procurement at the recent Regional Immunization Technical Advisory Group (RITAG) Meeting, Johannesburg, South Africa, 05-08 December 2017. A summary of his presentation appears below.

As a Lower Middle Income Country (MIC), Swaziland is not and has never been eligible to receive financial support for its immunization programs through the GAVI Alliance. Therefore, 83% of the health care budget is financed through domestic sources, and only 17% comes from from WHO and UNICEF.

Swaziland has a comprehensive Multi-Year plan (cMYP) that drives investment in immunization covering the period 2017–2021. The Government of Swaziland has been fully funding 100% of vaccine costs and average 96% of routine immunization costs over the last years. The Government of Swaziland procures vaccines and distribute to all service providers (government, regional referral and mission hospitals, public as well as private sector clinics and health facilities).

The vaccine Procurement Process begins as Requisitions are sent by Expanded Program of Immunizations (EPI) unit to the procurement unit through the chief pharmacist through documented minutes. This Minute is approved by the Financial Controller (FC) acknowledging availability of funds to furnish the procurement of the vaccines. Then a Tender document is drafted by both the EPI and procurement unit. Advertisement of tender document then takes place. Tender runs for 30 days as per procurement policy. Procurement of vaccines is done through open tender.

The 5 top vaccines (PCV, IPV, OPV, Rota, Penta) in Swaziland represented 98% of the total costs in 2015-16. While this is a major internal financial obligation, Vaccine procurement for the relatively small population of Swaziland represents approximately 0.2 percent of the overall African market by volume and about 0.4 percent by value. This puts smaller countries at a disadvantage in terms of getting good pricing and negotiating with suppliers.

Swaziland was one of the first countries for the Middle Income Country (MIC) strategy mission The MIC strategy mission recommended the need on generating efficiencies in the management of the programme, in particular in the area of procurement, with a need to explore pooled procurement as well as other options with the aim of maximizing savings on the high costs of vaccines. Government desires to achieve economic efficiency in procurement and consideration of pool procurement mechanism.

The current supplier charged 81,256,196.50 Swaziland Lilangeni (SZL) or roughly $5.8 million for the total package of vaccines needed in 2016. If UNICEF were to provide the same package it would cost SZL 62,215,336.34. or $4.5 million. While commercial suppliers can be paid on delivery, UNICEF requires approval from Ministry of Finance for the advance payment with the need to make sure the funds are sufficient for full payment.

This comparative information had valuable advocacy effect. Earlier this year (2017) a MOU signed between MOH and UNICEF. A commitment letter was sent to UNICEF supply division. Now Swaziland has a more reliable supplier and a more affordable cost, enhancing the Ministry’s capacity to save lives of its citizens. Swaziland can also serve as an example for the many other MICs and countries who are ‘graduating’ from GAVI support.

Ghana – spotlight on malaria indicators

The Demographic and Health Surveys has released a brief on key indicators from the Ghana Malaria Indicator Survey of 2016. While much of the malaria community is discussing the elimination framework and processes, the reality is that many high burden countries are still trying to scale up basic interventions to achieve universal coverage.

The overall prevalence across the country in children aged 6-59 months at the time of the survey was 27% using Rapid Diagnostic test and 20% using microscopy.  Among children reporting fever in the previous two weeks care/advice was sought for only 72%. Although only only 30% received some sort of blood based diagnostic test, 61% of the febrile children were given the antimalarial artemisinin-based combination therapy drugs.

Children are still being treated without the benefit of parasitological testing, a key procedure highlighted in WHO case management guidelines. Presumptive treatment for malaria without testing means that a child could inappropriately receive antimalarial drugs and die of another underlying febrile illness. Appropriate testing and adherence to test results is one of the main areas of focus of Ghana’s grants from the US President’s Malaria Initiative. Improved testing is also an important element in Ghana’s current Global Fund support. Clearly more value for money is needed from these inputs.

Preventive measures as documented in the MIS fare somewhat better., but at present only 73% of households own an insecticide treated bednet. When considering the recommended 1 net for every 2 household members, the indicator drops to 50%. Concerning the typical ‘vulnerable’ populations, we see that only 52% of children below the age of 5 years slept under an ITN the night before the survey; only 50% of pregnant women did likewise.

Malaria prevention in pregnancy results reflect the fact that Ghana has promoted at least three IPTp doses for around ten years. Most pregnant women (78% ) had received the previously recommended minimum of two doses, and now 60% have received at least three doses.

One of the important issues stressed in WHO’s new malaria elimination framework is stratifying the country by prevalence to the lowest level possible in order to plan appropriate interventions. Fortunately the Ghana 217 MIS key indicator brief does stratify prevalence and intervention coverage by region.  Prevalence through RDT testing ranges from nearly 5% in the urbanized greater Accra area to 44% in the Central Region. Interestingly ITN use is nearly 20% higher in Central than greater Accra.

Hopefully future planning in Ghana will build on this stratification. Better mobilization of donor, national and private sector resources will address likely issues of stock-outs and increase the likelihood of universal coverage of basic interventions that is needed to move the country along the road to malaria elimination.

Malaria Funding Allocations by the Global Fund and the Need to Mitigate Risk

The Global Fund Observer (aidspan) has provided information on the 2017-19 allocations by the Global Fund to Fight AIDS, TB and Malaria. Here we take a closer look at the malaria component.

Overall malaria grants account for $US 3.3b or 32% of total funding for the period. This includes 71 countries as follows:

  • 41 countries in WHO’s Africa Region
  • 6 in the Eastern Mediterranean Region
  • 7 in the Americas
  • 10 in Southeast Asia
  • 7 in the Western Pacific
malaria-fund-allocation-2017-19

2017-2019 GFATM Allocation

The Global Fund Observer also noted that the GFATM board is very much aware of risks to these grants. An example comes from the management pharmaceuticals. Risks can be found along the whole supply chain process. The GFATM found that, “artemisinin-based combination therapies (ACTs) are more commonly targeted for theft or illegal diversion than are antiretrovirals (ARVs) or medicines for opportunistic infections (OIs).”

In fact the GFATM has identified 40 high or very high risk countries, most of which overlap with the list receiving current grant allocations. Therefore while we praise the provision of needed malaria funds for the upcoming three years, we also call on the Global Fund managers, country coordinating mechanisms, grant recipients and watchdogs in civil society and the media to ensure these grants continue to save lives from malaria.

Improving IPTp uptake and mitigating Stock-outs in Bungoma County, Kenya

A poster entitled “Improving Pregnancy Outcomes: Alleviating Stock-Outs of Sulfadoxine-Pyrimethamine in Bungoma, Kenya” was presented by Augustine Ngindu, Gathari Ndirangu, Waqo Ejersa, David Omoit, and Mildred Mudany from Jhpiego’s Kenya Team at the 65th annual meeting of the American Society of Tropical Medicine and Hygiene in Atlanta. The abstract follows …

policyWHO recommends intermittent preventive treatment of malaria in pregnancy using sulfadoxine pyrimethamine (IPTp-SP) to be provided at antenatal care (ANC) clinic. The Malaria Policy in Kenya requires that All pregnant women in malaria-endemic areas receive free intermittent preventive treatment of malaria in pregnancy using sulfadoxine-pyrimethamine (IPTp-SP), have access to free malaria diagnosis and treatment when presenting with fever, and have access to long-lasting insecticidal nets.

Kenya’s Strategic Direction between 2014–2018 was revised to reflect the following:

  • All pregnant women in the 14 malaria-endemic counties shall receive at least three doses of IPTp-SP
  • Annual quantification of SP based on consumption to ensure adequate supplies
  • Training, retraining and supervision of health care workers
  • Dissemination of appropriate IPTp messages and materials

coverageMinistry of Health (MOH) used to procure SP until 2013 when health services were devolved to counties and procurement of became the responsibility of county governments. This presented a major challenge as counties had not factored SP in their budgets. Consequently, counties experienced SP stock-outs from October 2014. In Bungoma County the number of pregnant women receiving IPTp dropped by 51% from 7,845 in October 2014 to 3,865 in February 2015.

To alleviate the situation (MOH) at national level requested counties to procure SP. Advocacy efforts with Bungoma County by the Maternal and Child Survival Program focused on prioritization of SP procurement at least once every quarter. As a result of this intervention, Bungoma County procured SP from February to July 2015.

core-indicatorsThe county advised health facilities to procure additional SP doses if the supplied stocks ran out. The procurement led to a 117% increase in the number of pregnant women receiving IPTp; from 3,865 in February to 8,404 in July 2015.

The fiscal year ended in June 2015 and no funds were available to procure additional SP until October 2015. This contributed to a 33% decrease in the number of pregnant women receiving IPTp from 8,404 in July to 5,672 in October 2015. As a response to support counties, MOH at national level procured 2.24 million SP doses in November/December for 14 MIP-focus counties which were received at health facilities in February 2016.

In conclusion, Bungoma County applied feasible mitigation measures including county level procurement of SP, supplemented by additional procurement at health facility and national levels. This is a practice which is replicable in other counties to ensure continued availability of SP to protect pregnant women from effects of malaria in pregnancy.

Kenya: Tackling stock-outs of medicines for intermittent preventive treatment of malaria in pregnancy

Augustine Ngindu of Jhpiego/MCSP Kenya shared with the Jhpiego Malaria Team at their pre-ASTMH 2016 Annual Meeting retreat the experience in Kenya of drug stock-outs and efforts to combat this.

dscn0339Kenya has experienced periods of Sulfadoxine-Pyrimethamine (SP) stock-outs thus threatening the coverage of intermittent preventive treatment to prevent malaria in pregnant women (IPTp). The situation has stabilized from March 2016 through efforts by Jhpiego and the USAID Maternal and Child Survival Program (MCSP) in collaboration with Kenyan health authorities and partners at national, county and facility levels.

Jhpiego’s key interventions focused at several levels. At the national level technical assistance was provided to relevant Ministry of Health (MOH) departments (e.g. malaria, reproductive health and community strategy). In particular the situation on the ground has been used for advocacy with decision makers and managers on prioritizing procurement of SP.

At the County level Jhpiego is building capacity of counties in provision of MIP services by developing clinical mentors. Again advocacy was carried out on prioritizing inclusion of budget itesp-stock-out-affects-iptp-coveragem for SP.

At the health facility level Jhpiego is strengthening the capacity of health facilities to provide MIP services. These activities include training of health care workers and monitoring their performance in terms of maintaining, ordering and redistribution of SP stocks. In addition Jhpiego worked with the MOH to establish malaria in pregnancy (MIP) service standards to enhance the provision of quality services in 336 facilities providing ANC services.

Then at the community level Jhpiego and partners promote MIP service utilization at community level by sensitizing pregnant women to start IPTp early in second trimester. Community health volunteers sensitize pregnant women to start IPTp early in second trimester. Hopefully increased demand will also pressure program managers to supply regular SP stocks.

Concerning the service standards, baseline data collected after immediately training found that 50% of facilities were maintaining SP stocks. A second assessment done during supportive supervision 3 months after training found 86% of facilities now met the standard. As a result of county level advocacy, redistribution of SP was done from over-stocked to under-stocked health facilities.

In conclusion, advocacy is a powerful tool in getting things done as evidenced by responses of County Directors of Health, national government and health development partners on prioritizing procurement of SP. This led to availability of adequate SP stocks to last the country up to 2019.