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ANGOLA NATIONAL SUPPLY CHAIN ASSESSMENT RESULTS MARCH 2017 16 March 2017 DISCLAIMER The authors’ views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or of the United States government.
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM PROCUREMENT AND SUPPLY MANAGEMENT
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Acknowledgements Thank you to the Angolan Ministry of Health (MOH) for their support and partnership in the implementation of the supply chain assessment. Particular thanks to Dr. Domingos Filipe, Pedro Quiancueno, and Fernando Miguel for participating in key informant discussions and interviews in the field with our team. Also, a special thanks to Dra. Katiza Mangueira (DNME), Dra. Júlia Simão (CECOMA), Dr. Miguel de Oliveira Santos (DNSP), Dra. Henda Vasconcelos (DSR), Dra. Rosa Bessa (Gabinete Provincial de Saúde de Luanda), Dr. Rafael Dimbu (NMCP), Dra. Lúcia Furtado (INLS) for help facilitating letters of introduction of our work and project to Provincial staff to ensure a successful assessment implementation.
About GHSC-PSM The purpose of the USAID Global Health Supply Chain – Procurement and Supply Management Project (GHSC-PSM) is to ensure uninterrupted supplies of health commodities in support of U.S. government-funded public health initiatives around the world. The project provides direct procurement and supply chain management support to the President’s Emergency Plan for AIDS Relief (PEPFAR), the President’s Malaria Initiative (PMI), and USAID’s family planning and reproductive health program. To support U.S. government-funded global health activities, GHSC-PSM manages a wide array of health commodity procurement services and provides related systems-strengthening technical assistance encompassing all elements of a comprehensive supply chain.
At the country level, GHSC-PSM supports country strategies and priorities that fall under the following three project objectives:
• Global commodity procurement and logistics• Systems strengthening technical assistance• Global collaboration to improve long-term availability of health commodities
This publication was produced for review by the United States Agency for International Development. It was prepared by Chemonics International Inc. under USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) Contract No. AID-OAA-I-15-00004; Task Order 01 Contract No. AID-OAA-TO-15-00007; Task Order 02 Contract No. AID-OAA-TO-15-00009; and Task Order 03 Contract No. AID-OAA-TO-15-00010.
Recommended citation: USAID Global Health Supply Chain Program-Procurement and Supply Management Single Award IDIQ. 2016. GHSC-PSM Angola National Supply Chain Assessment Results. Washington, D.C.: Chemonics International Inc.
Chemonics Contact: Anthony Savelli Procurement and Supply Management Project Director
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CONTENTS
CONTENTS .......................................................................................................................... 3
LIST OF FIGURES .................................................................................................................. 4
ACRONYMS .......................................................................................................................... 5
EXECUTIVE SUMMARY ......................................................................................................... 6
1. BACKGROUND ...................................................................................................................................6
2. METHODOLOGY.......................................................................................................................................6
3. RESULTS .....................................................................................................................................................6
4. RECOMMENDATIONS ..............................................................................................................................8
I. BACKGROUND .......................................................................................................... 10
1. ABOUT ANGOLA & THE HEALTH SYSTEM ......................................................................................... 10
2. HEALTH SUPPLY CHAIN IN ANGOLA ................................................................................................... 10
3. PURPOSE OF THE NSCA ........................................................................................................................ 16
II. METHODOLOGY ........................................................................................................ 17
1. NSCA TOOLKIT ..................................................................................................................................... 17
2. SCOPE OF THE ASSESSMENT ................................................................................................................. 18
3. DATA COLLECTION .............................................................................................................................. 19
4. CMM TOOL ............................................................................................................................................ 19
5. KPI TOOL ................................................................................................................................................ 21
6. CHALLENGES & LESSONS LEARNED..................................................................................................... 22
III. DATA ANALYSIS & RESULTS ..................................................................................... 22
1. PRODUCT SELECTION .......................................................................................................................... 22
6. FORECASTING & SUPPLY PLANNING .................................................................................................. 23
7. PROCUREMENT ...................................................................................................................................... 26
5. WAREHOUSE & INVENTORY MANAGEMENT ..................................................................................... 27
6. TRANSPORTATION ............................................................................................................................... 34
5. OVERALL ASSESSMENT RECOMMENDATIONS ................................................................ 35
REFERENCES ...................................................................................................................... 38
APPENDIX I: KPI FORMULAS ............................................................................................ 38
APPENDIX II: MALARIA SPECIFIC RESULTS FROM ADDITIONAL QUESTIONS .................. 39
APPENDIX III: HIV/AIDS PROGRAM SPECIFIC RESULTS FROM ADDITIONAL QUESTIONS........................................................................................................................................... 42
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LIST OF FIGURES
Figure #
Figure Name Page Number
1 Angola Supply Chain Assessment Results 7 2 Capability & Performance Comparison 8 3 Organogram of CECOMA 11 4 Distribution of Medicines in the Angola Supply chain1 12 5 Reproductive Health Supply Chain Map 12 6 HIV/AIDS Supply Chain Map 13 7 Malaria Supply Chain Map 13 8 LMIS Manual Reporting System in Angola 15-169 Tracer Commodities 18 10 Functional Area Implementation by Level 20 11 Maturity Level Descriptions 21 12 Functional Area Implementation by Level 21 13 KPI List & Data Sources 21-2214 Product Selection Capability by Enabler 23 15 Forecasting & Supply Planning Capability by Enabler 24 16 Central Level Forecast Accuracy [Forecasted Amount vs.
Consumption from Jan-Aug 2016] 25-26
17 Procurement Maturity Capability by Enabler 27 18 Warehousing & Inventory Management Capability by Enabler 28 19 Stock Accuracy of Tracer Commodities 29-3020 Number of Facilities Stocked Out by Tracer Commodity in
the last 6 Months 30
21 Total & Average Number of Days Facilities Stocked Out by Tracer Commodity
31
22 CECOMA Stock According to Plan by Tracer Commodity Jan-Aug 2016
32
23 Transportation Capability by Enabler 33 24 Capability and Performance Comparison 35
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ACRONYMS
CECOMA Central Procurement and Supply of Medicines of Angola
CENSO National Census
CPLP Community of Portuguese-speaking Countries
DNME National Directorate for Essential Medicines
FO field office
FY fiscal year
GHSC-PSM Global Health Supply Chain-Procurement and Supply Management Project
GPS Provincial Health Cabinet
HIV/AIDS human immunodeficiency virus/acquired immune deficiency syndrome
HR Human Resources
INLS National Institute for the Fight Against AIDS
IT information technology
KPI Key Performance Indicator
LLIN long lasting insecticidal net
LMIS logistics management information system
MOF Ministry of Finance
MOH Ministry of Health
NEMLIST National Essential Medicines List
NEPAD Partnership for Africa's Development
NGO Non-Governmental Organization
PALOP African Countries with Portuguese as the Official Language
PEPFAR President’s Emergency Plan for AIDS Relief
PMI President’s Malaria Initiative
UNICEF United Nations International Children’s Emergency Fund
UNFPA United Nations Population Fund
USAID U.S. Agency for International Development
WHO World Health Organization
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EXECUTIVE SUMMARY
1. BACKGROUND
The Angolan health supply chain system is defined and has infrastructure to support the acquisition, distribution and use of health products. There is also government support through agencies as well as companies that make health products available and accessible.
The national supply chain system in Angola includes facilities owned by Nova Angomedica company where the Central Procurement and Supply of Medicines of Angola (CECOMA) is located. CECOMA is in the process of being registered as a unit budgeted to the Ministry of Finance and 4 warehousesare being constructed: a central warehouse in Luanda and three (3) regional warehouses in Benguela, Malanje and Huíla. CECOMA has assumed responsibility for the storage and distribution of pharmaceutical products throughout the country.
Despite the existence of defined administrative structures and guiding documents to support the supply chain management system, Angola's supply chain has notable challenges. Many of these challenges are consequences of the last three decades of civil war that ended in 2002 including, a lack of human resources, a lack of defined negotiation processes (for example, purchasing structures), inadequate quantification mechanisms, a weak Logistics Management Information System (LMIS), and inadequate storage and distribution infrastructure.
2. METHODOLOGY
GHSC-PSM used the National Supply Chain Assessment (NSCA) tool 4 drawing on primary and secondary data collection to implement the Capability Maturity Model (CMM), Key Performance Indicator (KPI), and Supply Chain process mapping modules using direct observation and interviews of key stakeholders. The NSCA methodology has been implemented in more than a dozen countries.
CECOMA, DNME and PMI coordinated the selection of provinces to be included in NSCA. The NSCA implementation was carried out from November 2016 to March 2017 including data analysis at 4 levels: Central, Provincial, Municipal and Health facilities. Given the 18 provinces of the country, the 7 provinces with highest malaria incidence were selected. In total, 100 health facilities were randomly selected out of 2,356 from the 7 provinces. The number of health institutions that were visited in each province depended on the number of municipalities that each province has. For this sample size given the total number of facilities in the country, we have a confidence interval of 84% with a margin of error at 13%.
3. RESULTS
Results show average capability scores with the strongest functional area being Procurement and the weakest functional area being Warehousing & Inventory Management. There is a very high stock out rate of tracer commodities at 58.3% and this may be attributed to the fact that there is a very low KPI score for Stocked According to Plan at 13.3%. When facilities are not
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receiving stock according to their needs, stock out rates will remain high. This is tempered by very high and very low performance depending on the functional area.
Stock Accuracy is nearly perfect when it comes to stock cards accurately reflecting the number of physical stock on hand in the country; therefore, training of local staff on stock card management would not impact current stockout rates.
The Forecast Accuracy KPI is extremely inaccurate. The forecast overestimated the requirements and procurement does not follow the forecasted actuals. When procurement does not follow the forecast, this indicator will always show a negative result. As imperative as it is to have thorough quantification and forecasting in-country, it is also extremely important that the procurement activities match these forecasts so a true measuring against the forecast can be conducted based on real consumption data. This is one major reason Angola has suffered from stock-outs for almost all the tracer commodities in this study.
Figure 1: Angola Supply Chain Assessment Results
National Supply Chain Overall Results Functional Area CMM Score KPI Score Product Selection 55% National Essential Medicines List Adherence 60.1% Forecasting & Supply Planning 48% Forecast Accuracy -827%Procurement 62%
Warehousing & Inventory Management 36%
Expiry (Qty) 0% Stock Out Rate 58.3% Stocked to Plan 13.3% Stock Accuracy 96.7%
Transportation 41%
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Figure 2: Capability and Performance Comparison
4. RECOMMENDATIONS
Overall, Forecasting & Supply Planning and Warehousing & Inventory Management have the greatest room for improvements and focused efforts. The MoH together with partners should consider focusing on the following recommendations to mitigate performance decline.
Recommendations to address current capability and performance issues in the near term include:
Short-Term 1. Needs-based quantification using models that account for not only consumption but
morbidity, stock levels, number of cases (actual needs) and endemicity/seasonality ofdisease that will be addressed and re-visited on a quarterly basis throughout the year.
2. Specific central level Standard Operating Procedures (SOPs) to be finalized forCECOMA
Medium-Long Term 1. Efforts to increase procurement autonomy, forecasting accuracy, transportation
independence and security, and overall stock management and active distribution.2. Robust training plans are needed across all levels of the supply chain to include the
practical application and dissemination of National SOPs for supply chain management.
Warehousing & Inventory Management
TransportationProcurement
Product Selection
Forecasting & Supply Planning
-900.00%
-700.00%
-500.00%
-300.00%
-100.00%
100.00%
300.00%
500.00%
700.00%
900.00%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Perf
orm
ance
Capability
Supply Chain Capability & Performance
Note: No KPIs were able to be collected for Transportation & Procurement Functional Areas
Capability Maturity Model
Nat
iona
l Sup
ply
Cha
in K
PIs
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These SOPs currently sit with the Minister for approval. Once approved, the training curriculum can be based on these and coupled with practical on-the-job mentoring on stock management and reporting.
3. Improved reporting and communication practices to clarify and streamline the numberof focal points involved in the reporting hierarchy while tackling the issue of a constantlack of cell phone minutes for staff to make phone calls. Improvements made to thecurrent manual, paper-based system will serve a future national roll-out of an LMIS.
4. An overall need for greater supervision and oversight across all levels of the supplychain seems to indicate that it would be worthwhile to update and specify positiondescriptions for personnel in supervisory roles within MoH to ensure that activesupervision is part of their job description and they are compensated fairly for thatwork.
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I. BACKGROUND
1. ABOUT ANGOLA & THE HEALTH SYSTEM
Angola is located in the western region of southern Africa, occupying an area of about 1.246 million km2, making it the sixth largest country in Africa. The length of its coastline is over 1,600 km, bordering the Atlantic Ocean. Angola has 18 provinces, which are divided into 163 municipalities. The municipalities are, in turn, divided into a total of 618 communes. According to the general CENSO of May 2014, the resident population of Angola is 25,789,024. Nearly two-thirds (63%) of inhabitants live in the urban area and 37% live in the rural area. Angola has an economy based largely on oil, which accounts for about 95% of exports, 70% of government revenues and 46% of GDP.
In addition to the oil sector, which continues to be the main contributor to GDP, the mining sector (excluding oil) accounts for 2.5% of GDP, mostly dominated by diamond production, in which Angola is the sixth largest supplier in the world. Agriculture, construction and manufacturing are slowly increasing in importance along with the services sector.
Angola operates on the basis of a structure organized in Central-level Regulatory and Executive Units (National Directorates and Departments), of support and advice to the Minister (Offices) and of an advisory nature (Consultative Councils and Commissions). At the intermediate or peripheral level, MoH is represented by the Provincial and Municipal Directorates. The Directorates are responsible for studying, planning and coordinating activities related to health at the provincial level. The political, economic and administrative duties of the provincial directorates is the responsibility of the provincial governments.
2. HEALTH SUPPLY CHAIN IN ANGOLA
Angola operates a centralized health supply chain through the Central Depository (CECOMA), the public institute in charge of procuring, storing, and distributing medical and non-medical resources in coordination with the National Directorate of Medicines and Equipment and The Office of Studies, Planning and Statistics. CECOMA was created under Presidential Decree No. 34/11 of 14 February, 2011. The distribution made by CECOMA passes directly to the Provincial Deposits that in turn supply the hospitals, centers and health posts of the respective provinces. The MoH oversees 2,356 public health facilities in 18 provinces, including national hospitals, provinces, municipalities, facilities and posts.
The Government of Angola continues to be the largest funder of healthcare. Law 21-B / 92 establishes the participation of third parties in the financing of healthcare as well as the citizens’ participation in health costs. The main partners of development assistance (bilateral and multilateral) in the health sector are: Sweden, the Netherlands, Spain, Portugal, the United Kingdom, the United States (USAID, CDC), Japan, CIDA, IOM, UNICEF, UNFPA, World Bank, GFATM, ADB, European Commission and WHO. It should also be noted that some NGOs, civil associations, companies (national and international) are actively contributing to the sector. Some of these include private sector oil companies and Rotary International. Regional and sub-regional organizations such as Partnership for Africa's Development (NEPAD), the African Union (AU),
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the community of Portuguese-speaking countries (CPLP), and the Portuguese-speaking African countries (PALOP) have also provided support to the health sector in Angola.
Serving as the main entity in the health supply chain in Angola, CECOMA, is led by a General Manager appointed by the Minister of Health. CECOMA has two (2) main services: Executive Services (Service of Planning and Statistics, Technical Service and Quality Management And Service of Equipment and Maintenance) and Group support services (Director Support Service, HR Management Service and Information Technician and Administration Service and general services). See the Organization Chart below for more detail on CECOMA’s organization (Figure 3):
Figure 3: Organogram of CECOMA6
SEVIÇO DE PLANIFICACÃO E
ESTATISTICA
SERVIÇO TECNICO E GESTÃO DE QUALIDADE
SERVIÇO EQUIPAMENTO E MANUNTENÇÃO
SERVIÇO DE APOIO AO DIRECTOR
SERVIÇO DE GESTÃO DE RH E TEC. DE INFORMACÃO
SERVIÇO DE ADMINISTRAÇÃO E SERVIÇOS GERAIS
SECÇAO DO PROGRAMAS
SECÇAO DE INSPECÇÃO SECÇAO DO EQUIPAMENTO
SECÇAO DE SECRETARIA GERAL SECÇAO DE GESTÃO DE RRHH
SEÇAO DO PATRIMONIO-TRANSPORTE
SECÇAO DE ESTATISCA SECÇAO DO CONTROL QUALIDADE
SECÇAO DE MANUNTENÇÃO
SECÇAO DE SECRETARIA SECÇAO DE FORMAÇÃO E INVESTIGACION CIENTIFICA
SECÇÃO DE CONTABILIDAD E FINANÇAS
SECÇAO DE PLANIFICACION
SECÇAO DE SERVIÇIOS GERAIS
CONSELHO DIRECTIVO
SERVIÇOS EXCUTIVOS SERVIÇOS DE APOIO AGRUPADOS
DEPOSITOS REGIONAISCOORDINADORA IRACELMA BRAVO DA COSTA
SECÇÃO DE ESTOQUE E DISTRIBUCÃO DOS PRODUCTOS
SECÇÃO ADMINISTRATIVA
DIRECTOR GERAL
CONSELHO FISCAL DIRECTOR GERAL ADJUNTO
CONSELHO TÉCNICO
CONSULTIVO
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For detail on the flow of medicines in the Angolan health supply chain, see Figure 4 below:
Figure 4: Distribution of Medicines in the Angola Supply chain1
The following are supply chain maps by program area that were created to show additional details on how the supply chain differs across program areas. Note that AP= Provincial Store; AM=Municipal Store; US= Health Facility; HN=National Hospital.There are parallel supply chains currently running for HIV/AIDS and Malaria programs.
Figure5: Reproductive Health Supply Chain Map
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Figure 6: HIV/AIDS Supply Chain Map
Figure 7: Malaria Supply Chain Map
As part of this assessment, GHSC-PSM analyzed the reporting channels and process flow by which information travels across the supply chain and impacts the availability of medicines across all levels of the supply chain. The below diagram (Figure 8) shows the Logistics Management Information System (LMIS) specific to Angola.
At the time that a request is made to solicit medicines from the health facilities based on a three-month forecast for facilities and a six-month forecast for warehouses, the document is sent from the facility (US) to the municipal warehouse (DM), compiled at the municipal warehouse to send to the provincial warehouse (DP), then compiled at the provincial warehouse to be send to the Central Store (CECOMA), the National Health Programs, and GEPE.
Once goods are distributed, the delivery note is signed at all levels of the supply chain and returned to the next highest level in the chain as in the above scenario. An occurrence report is only sent in the instance that medicines should be returned because of overstock.
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Once goods are being managed at the warehouse, the stock card tool is used to register receipt and dispatch on goods keeping the inventory balance and noting where the goods are sent. These are even used at the facility level to note where within a hospital or facility the medicines are sent i.e. testing site, treatment and care, pharmacy, etc.
The physical inventory reports are carried out monthly within the facilities and warehouses and sent by electronic submission from CECOMA to partners, GEPE, DPs, National Hospitals (NH) and Provincial Health Directorate; from DPs electronically to partners, CECOMA, HPs, RMs, HNs and hand delivered to DMs; and from DMs hand delivered to partners and USs.
The physical inventory reports differ from the monthly and quarterly reports in that they contain information regarding the consumption of the drugs and not the physical balance in stock in addition to case/register data. They are sent in person by the USs to the RMs who compile the database and hand deliver to the Provincial Directorate which in turn, submit electronically to the National Health Programs. The HNs normally submit electronically directly to the DPS or the National Health Programs.
Both the quarterly, monthly and inventory balance reports are used for quantification and planning at the national level. These technical working groups rely on this information together with health program norms and census data to complete forecasting and supply planning activities. The outcome from these meetings is sent to the purchasing agent who handles the acquisition process whether it be CECOMA, GEPE or partners.
The goods are then distributed from CECOMA to DPs and HNs and from there, to DM and HPs, and from there to the USs and health posts.
At any point throughout the LMIS lifecycle, we note that if there is a breakdown in information flows and communication all parts of the chain are affected as all stages are interdependent upon one another.
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Figure 8: LMIS Manual Reporting System in Angola
Anexo Legenda Explicativa/Annex Explanatory Legend
Simbolo/Symbol Nom Portugues English Name
CECOMA Central de Aprovisionamentos de medicamentos e meios médicos
Center for the Provision of Medicines and Medical Facilities
DM Depósito Municipal Municipal Warehouse DP Depósito Provincial Provincial Warehouse
GEPE Gabinete de Estudos, Planeamento e Estatístico
Office of Studies, Planning and Statistics
US Unidades Sanitárias Health Units HN Hospital nacional National Hospital
PNME Programa Nacional dos Medicamentos Essenciais
National Program for Essential Medicines
Ad.Mun Administração Municipal Municipal Administration HPeM Hospital Provincial e Municipal Provincial and Municipal Hospital
RM Repartição Municipal Municipal Headquarters DPS Direcção Provincial da Saúde Provincial Health Directorate
Programa de Saude Programa de Saude National Health Programs
Parceiros parceiros Partners
Grupos Tecnicos Grupos Tecnicos de Quantificação Tecnical Quantification Working Groups
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Programa Nacional de luta conta Malária National Malaria Control Program
Programa Nacional de luta conta HIV National Fight against AIDS Program
Programa Nacional de saude reprodutiva National Reprodutive Health Program
Regulamento Regulamento Regulation Censo Censo Demografico Demographic Census
Consumos e Casos Consumos e Casos Consumption and cases Aquisição Aquisição Aquisition
Distribuição Distribuição Distibution Requisição e Solicitação Requisição e Solicitação Request and Solicitation
Guia de Remessa Guia de Remessa Shipping Guide
Relatório de Consumo Relatório de Consumo Consumer Report
Ficha de Estoque Ficha de Estoque Stock Record Sheet Inventário Inventário Inventory
Relatórios Mensais e Trimestrais
Relatórios Mensais e Trimestrais Monthly and Quarterly Reports
Quantificação e Planificação
Quantificação e Planificação Quantification and Planning
Entrega de veículos Vehicle Delivery
Entrega de e-mail Email Delivery
3. PURPOSE OF THE NSCA
Today, Angola still struggles with the stock out of essential medicines and public health commodities in part due to poor performance of the national supply chain system and the Logistics Management Information System (LMIS) currently in place. CECOMA was created to be able to separate the logistics function of support (procurement and supply chain) from the regulatory function for medicines managed by the Directorate of National Essential Medicines (DNME) as well as improve the efficiency of the distribution of public health products to health facilities throughout Angola. For this reason, under the coordination of CECOMA and GHSC-PSM, the purpose of the National Assessment Supply Chain was to identify as strengths of the supply chain
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as well as opportunities to improve bottlenecks within the system providing a baseline to track annual progress in the coming years of the work to be undertaken together.
Building on the evidence-based results, MoH and partners will create work plan activities to strengthen health systems. MoH can then use the data to make more evidence-based decisions with the identification of key priorities and procurement in the context of strengthening the health system. Working in close collaboration with the MOH, donors like USAID, PMI, PEPFAR and The Global Fund can use recommendations from the NSCA to set benchmarks for re-integrating in the national supply chain health commodities that are currently distributed through parallel systems.
II. METHODOLOGY1. NSCA TOOLKIT
This assessment utilized relevant elements of USAID’s National Supply Chain Assessment tool4. The NSCA is a comprehensive toolkit for assessing the capability and performance of supply functions to inform process improvement, training and capacity building needed, as well as data quality and reporting gaps. The toolkit consists of three main components:
1. The Capability Maturity Model (CMM) – a diagnostic tool that qualitatively assessescapability across functional areas and cross-cutting enablers.
2. Key Performance Indicator (KPI) Assessment – measures supply chain performance andeach functional level of the supply chain.
3. Supply Chain process mapping – documents the flow of commodities and informationthroughout the supply chain.
The NSCA’s modular nature allows users to tailor the tool to meet their specific needs. The assessment implementers used the NSCA’s functional modules to conduct a targeted assessment focusing on specific sites, levels, and functional areas within the supply chain that apply to the Angolan context specifically. Outputs of the supply chain assessment conducted in Angola include supply chain distribution maps for selected tracer commodities, KPIs for an approximate measure of performance, and CMM data collection throughout the country for statistical significance.
Specific methods included: • Document review of prior assessments conducted• Historical reporting data review of key informant interviews (key stakeholders include
Global Fund, CECOMA, relevant MOH Departments, NMCP, INLS, members of thesupply chain coordinating committee, Provincial and Municipal Warehouses, etc.)
• Direct observation of warehouse management, actual stock levels and storage, and dataquality at all levels of the supply chain
• Data aggregation and analysis using survey metrics and KPI scaling• Preliminary Root Cause Analysis (RCA) and evaluation of external influences on supply
chain gaps (e.g. commercial and economic environment, climate impacts, political context,etc.)
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2. SCOPE OF THE ASSESSMENT
CECOMA, DNME and PMI coordinated the selection of provinces to be included in NSCA. The NSCA implementation was carried out at 4 levels: Central, Provincial, Municipal and Health facilities. Given the 18 provinces of the country, 7 provinces were selected. In total, 100 health facilities were randomly selected from the 7 provinces. The number of health institutions that were visited in each province depended on the number of municipalities that each province has. For this sample size given the total number of facilities in the country, we have a confidence interval of 84% with a margin of error at 13%. 23 tracer commodities were selected by USAID for monitoring and data collection of this NSCA. Figure 8 below shows the list of tracer commodities for which KPIs were calculated.
Figure 9: Tracer Commodities
Tracer Commodities Product Name Product Category
1 Quinine comprimidos Malaria 2 Artesunate injectável Malaria 3 Artesunate-Amodiauiine comprimidos Malaria 4 Artemether injectável Malaria 5 SulpfadoxinePyrimethamine comprimidos Malaria 6 ArteLumef B6 comprimidos Malaria 7 ArteLumef B12 comprimidos Malaria 8 ArteLumef B18 comprimidos Malaria 9 ArteLumef B24 comprimidos Malaria 10 LLINs Malaria 11 Malaria RDT Malaria 12 Depo-Provera Reproductive Health 13 Implants (Jadelle) Reproductive Health 14 IUD Reproductive Health 15 Microgynon Reproductive Health 16 TDF+3TC/FTC+EFV (Preferred 1st line for
Adults) HIV/AIDS 17 ABC+3TC+EFV (Preferred 1st line for
children) HIV/AIDS
18 Determine RDT HIV/AIDS 19 Unigold RDT HIV/AIDS 20 Condoms (male) HIV/AIDS 21 Lamivudine (3TC) + Zidovudine (AZT) +
Nevirapine (NVP) 150/300/200mg, comp HIV/AIDS
22 Lamivodine (3TC) + Stavudine (30mg/D4T) + Nevirapine (NVP), 30/6/50mg, comp
HIV/AIDS
23 Tenofovir (TDF)+ Lamivudine (3TC)+ Efavirenz (EFV) 300/300/600mg, comp
HIV/AIDS
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3. DATA COLLECTION
Primary data collection included direct observation and key informant interviews conducted while visiting the facilities in seven provinces.
The teams were trained before departure to conduct: • Interviews with managers of health institutions, mainly managers of pharmaceutical
management and warehouse/inventory management. During the interviews, storageconditions, space and other relevant aspects of the supply chain were observed.
• Data collection/register review for Key Performance Indicator (KPI) data through amanual questionnaire, stock listings, and other paper-based sources of information atthe facilities. The different sources of information are detailed on page 17 (See Figure12).
Data collection teams were comprised of three technicians. There were four teams in total visiting seven provinces, distributed as follows:
• Lunda Norte and Benguela: 2 GHSC-PSM technicians and 1 HQ-based CountryAssociate
• Zaire and Cunene: 1 GHSC-PSM Data Analyst and 2 short-term consultants• Bié and Kwanza Norte: 1 PSM technique and 2 national MoH supervisors• Luanda: Country Director, 1 GPS-Luanda MoH representative, and 1 short-term
consultant
The data collection occurred between December 13, 2016 and January 29, 2017.
Additionally, secondary data was collected through a Desk Review/Literature Analysis of the following documents:
• UNOPS CECOMA assessment entitled, “UNICEF Angola support to the Ministry ofHealth Central Unit for Procurement and Provision of Medicines and Medical Supplies(CECOMA): Procurement Efficiency/General heath Supply Chain Status”
• Presentations from the October 13, 2016 Procurement and Supply ManagementWorkshop on CECOMA in Luanda
• USAID Angola Country Development Cooperation Strategy 2014-2017• Analysis of the Angolan Public Health Supply Chain System: SIAPS Report• Draft National Supply Chain Strategy (2016)• Presentations from the Supply Chain stakeholders’ workshop held October 13th, 2016• SIAPS End-of-Project Transition Planning presentation• Angola’s Health Systems Strengthening Concept Note to the Global Fund• Technical Documentation for CHANNEL and OpenLMIS software (for comparison)• End-Use Verification Reports from 2016• Joint Strategy for Supply Chain Integration in Malawi• National supply chain strategy, MoH• SIAPS CECOMA SOPs
4. CMM TOOL
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The Capability Maturity Model (CMM) is a diagnostic tool that assesses supply chain capability, from the central level down to service delivery points, across functional areas and cross-cutting organizational “enablers,” such as human resources, processes, and infrastructure. 4 The tool includes a set of questionnaires that assess key supply chain capabilities from levels 1 through 5. These capability levels were designed to fit the context of a public health supply chain in a developing country and based on private sector best practices. Key informant interviews are used to implement the CMM, conducted at each site visit from the central level to service delivery points. 4
In addition to measuring supply chain functional areas, the CMM measures cross-cutting enablers (see Figure 9). These enablers support and facilitate activities within the supply chain that ultimately determine the capability, performance, and sustainability of supply chain functions.
Figure 10: Functional Area Implementation by Level4
An overall maturity scale guides the definitions within the CMM tool, broadly defining each capability level (1-5). For each specific capability there are defined components at each level of the capability maturity scale that represent these broadly defined levels. For example, minimal capability (1) for the warehouse process of checking is that “orders are not checked to ensure correct items are picked” and best practice capability (5) is “dispatch weighs product to validate weight of carton is in range of items confirmed as picked.” 4
Figure 11: Maturity Level Descriptions4
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In Angola, the CMM tool was implemented at the central, provincial, municipal and health facilities levels and interviews were conducted for each of the functional areas (Figure 11).
Figure 12: Functional Area Implementation by Level Functional Area Level
Product Selection Central Forecasting & Supply Planning Central
Procurement Central Warehousing & Inventory Management Central, Provincial, Municipal, Facility
Transportation Central, Provincial, Municipal, Facility
5. KPI TOOL
At each site visit, the data collection teams also collected data for several KPIs (shown in Figure 12 below). The data sources were reviewed, data extracted and entered into an excel score sheet. KPIs were then calculated using formulas shown in Annex 1 created specifically for each indicator in Excel.
Figure 13: KPI List & Data Sources # KPI Data Source Timeframe
1.1
Stock out Rates by Tracer
All levels: Stock registers, Primary data collection and direct observation
July-Dec 2016
1.2 Stocked According to Plan Central: CECOMA Jan-Aug 2016 2.2 Percentage of products procured
listed on the National Essential Medicines List
Central: CECOMA 2016
3.1 Forecast Accuracy
CECOMA Consumos Totais with Annual Plan
Jan-Aug 2016
5.1 Percent of Total Tracer Commodity Stock that Expired during a reporting period
Interviews and direct observation for all sites visited
July-Dec 2016
22
5.2 Stock Accuracy
All visited facilities; interviews w/direct observation
July-Dec 2016
8.1
Staff Turnover Rate
All health facilities visited [Central, Provincial depots not included]
2016
6. CHALLENGES & LESSONS LEARNED
• Data collection at some facilities was complicated by the absence of hospital managersand/or pharmacists who were not available to provide access to archives or answerclarifying questions regarding available records.
• Order fill rate was not tracked and calculated in this study because facilities do not placeorders. There is not a pull system in place, but rather a push system whereby shipmentsare sent based on national quantification and budget availability therefore, that KPI wasnot a part of this NSCA.
• % of International Reference Price Paid and % of Procurement Placed as Tenders werealso not KPIs that we were able to include in this NSCA but would like to look at afuture study or analysis in greater detail regarding procurement processes andmedicines pricing at the national level.
III. DATA ANALYSIS & RESULTSAnalysis was completed in Microsoft Excel. For the purpose of presentation of results, all CMM scores were converted to a 0-100% scale rather than 1-5 scale.
1=20% 2=40% 3=60% 4=80% 5=100%
1. PRODUCT SELECTION
Capability Percentage: 55%
Angola currently has a National Essential Medicines List (Nemlist) and there is an oversight body who ensures that imported medicines fall under that list ranking that capability at 70%. There is a need for processes and tools to be put in place to facilitate the addition of new manufacturers being registered in country and a decision-making committee to meet on a regular basis to update the National List, monitor quality control, and approve new vendors.
Figure 14: Product Selection Capability by Enabler
23
KPI Percentage of products procured listed on the National Essential Medicines List is 60.1%.This indicator only accounts for the central store. Most hospitals supplement their stock by doing some of their own procurement and those individual procurements are not counted here.
Recommendations
1. Review and update the Nemlist on a regular basis.2. Try to focus more procurement to those on the list so that the Nemlist stays relevant.
DNME should have regular coordination meetings with the procurement team atCECOMA.
3. An act should be written with SOPs put into place for the governing committee as tohow often they meet, how they operate, establishing ethical principles and policies forhow manufacturers and medicines are selected.
4. Institute a process and department for quality assurance testing.5. Create and communicate a clear process for the registration of new product vendors in
country who meet quality assurance requirements and whose products are on theNemlist.
6. FORECASTING & SUPPLY PLANNING
70%
40%
0%10%20%30%40%50%60%70%80%90%
100%
Oversight Process & Tools
Product Selection Capability by Enabler
24
Capability Percentage: 48%
Figure 15: Forecasting & Supply Planning Capability by Enabler
Currently, there are forecasting and quantification working groups in place at the National Directorate of Public Health (DNSP). There are enough human resources to accomplish better forecasting and there are systems in place for reporting logistics information; however, the process and tools as well as the regularity of the supervision and oversight can be improved. Forecasting is done at the National level but not at other levels of the system. These forecasts use the consumption data that was actually received by the National Programs from the Provinces during a given reporting period. The National programs then send the information to CECOMA based on the consumption data and number of cases that they have available. Standard formulas and algorithms are not used in practice.
Also, the forecast accuracy numbers can be explained by the fact that CECOMA does not have the financial autonomy to procure based on their forecasts conducted. Therefore, the number of goods they receive reflect the number of goods dispatched, or consumed. Another factor can be that each health facility interviewed in the NSCA does not demonstrate a consistent understanding of which reports must be submitted, to whom, and at what time; therefore, the actual aggregate consumption data is not reflective of the actual needs. Monthly reports are sent to the Provincial and National levels but not with enough consistency to trust the data is valid.
There are multiple drafts of SOPs that partners have worked on together with CECOMA, but final, approved, technical SOPs to inform forecasting methodology have not been included in the National strategy and approved by MOH at all necessary levels.
Regular monthly quantification meeting from the National Programs can also help inform CECOMA of better actual numbers rather than receiving one annual forecast so that changes can be made in an iterative way. Regular validation of quarterly quantification can help to inform better forecasting practices.
50%42%
60% 60%
0%10%20%30%40%50%60%70%80%90%
100%
Oversight Process & Tools Human Resources ManagementInformation System
Forecasting & Supply Planning Capability by Enabler
25
Even if the forecasting is accurate and the procurement follows that plan, the delayed procedures associated with approvals required for any logistics distribution plan for anti-malarials, ARVs, and family planning medicines can contribute to low numbers of dispatched goods from the National Stock. Also, even when National distribution plans are approved and goods dispatched to the Provinces, the Provincial distribution plans are often drafted based on morbidity data alone without regard to actual needs-based data incorporating higher-risk areas and case counts.
Also, given that there is not one central procurement mechanism, the lack of coordination between partners and programs that procure outside of CECOMA presents further challenges to stocking according to forecast.
As presented in the Forecast Accuracy KPI table below, for those tracer commodities which are carried and stored at CECOMA, the amount consumed or actually dispatched from CECOMA is significantly less than the amount forecasted in the annual plan in all cases.
Figure 16: Central Level Forecast Accuracy [Forecasted Amount vs. Consumption from Jan-Aug 2016]
Tracer Commodity Forecast Accuracy Quinine comprimidos -2309%Artesunate injectável N/A (consumption 0) Artesunate-Amodiauiine comprimidos N/A (consumption 0) Artemether injectável -1949%SulpfadoxinePyrimethamine comprimidos -1378%ArteLumef B6 comprimidos -1302%ArteLumef B12 comprimidos -839%ArteLumef B18 comprimidos -2267%ArteLumef B24 comprimidos -553%LLINs -1190187%Malaria TDR N/A Depo-Provera -51%Implants (Jadelle) -61194%IUD -641%Microgynon -2685%TDF+3TC/FTC+EFV (Preferred 1st line for Adults) N/A ABC+3TC+EFV (Preferred 1st line for children) N/A Determine RDT N/A Unigold RDT N/A Condoms (male) -737%Lamivudine (3TC) + Zidovudine (AZT) + Nevirapine (NVP) 150/300/200mg, comp N/A Lamivodine (3TC) + Stavudine (30mg/D4T) + Nevirapine (NVP), 30/6/50mg, comp N/A
26
Tenofovir (TDF)+ Lamivudine (3TC)+ Efavirenz (EFV) 300/300/600mg, comp N/A Average Forecast Accuracy -97,216%
Recommendations
1. Needs based forecasting using population based and needs based algorithms should beused regularly together with the consumption data.
2. Hold regular quantification meetings throughout the year to reassess the needs in thecountry and request that the data regarding consumption per Health Unit on a regularbasis to the right levels of the supply chain;
3. Create a committee for inter-program logistics’ coordination for all health programs;4. Advocacy for financial autonomy of CECOMA to MoH and MoF;5. Together with DNME, demand/ensure that the monthly reports of consumption per
municipality as well as the provincial stocks are sent/shared on time;6. Greater supervision of health facilities and municipalities to ensure that the reports are
correctly filled in and that the managing tools are appropriately used;7. Identification of key focal points to validate the reports and ensure deadlines are met;
this person can also work on necessary follow-up;8. Together with the health programs through the focal points, define the reports and the
due dates for sending such reports to the municipal and provincial levels.
7. PROCUREMENT
27
Capability Percentage: 62%
CECOMA is lacking the financial and administrative autonomy to be able to close out bid processes to place orders and fulfill procurement. There is a small team of three in the procurement department but they are currently only tracking the arrivals of orders placed and approved by the Ministry of Finance.
Figure 17: Procurement Maturity Capability by Enabler
Recommendations
1. Name one focal point who will serve as the overseeing body with decision-makingpower to move procurements forward and serve as the intermediary with one focalpoint from MoF to understand financial status of orders;
2. Defining a streamlined process for the steps to achieve all necessary approvals in theapproval process, CECOMA will be better able to facilitate procurement at their levelwith a bit more autonomy.
3. When an LMIS is selected to install at CECOMA, it should have the modular capacity totake on the bidding and procurement process so that ROs can be tracked against POsand actual arrivals. This will enable the oversight bodies from within the Ministry tobetter track the procurement cycle as well as the supply chain per consignment.
4. A follow-on study should be done to analyze the number of procurements that areplaced as tenders as well as to conduct a cost-benefit analysis for goods procured inAngola from certain vendors as compared to the international pricing indices.
5. WAREHOUSE & INVENTORY MANAGEMENT
51%
71%80%
60%
0%10%20%30%40%50%60%70%80%90%
100%
Oversight Process & Tools Human Resources ManagementInformation System
Procurement Maturity Capability by Enabler
28
Capability Percentage: 36%
Figure 18: Warehousing & Inventory Management Capability by Enabler
Issues
Inventory
Warehousing and inventory management has the most potential for improvement in Angola at all levels of the supply chain. There is a lack of supervision at the facility level which trickles up through the municipal and provincial levels. Also, oftentimes, due to a lack of adequate supply chain personnel, human resources who are responsible for managing inventory are often cross-trained personnel like nurses or administrative staff who do not receive adequate training in warehouse and inventory management and therefore, are unable to report on-time with good data accuracy. Stock cards are used differently across facilities whereby some facilities write the inventory quantity by doses whereas others write the inventory quantity by number of blisters and still others write the inventory quantity by number of boxes so cleaning and aggregating data on a national scale is not accurate at this point.
There is still a need for standardized tools to be used within health facilities. Many facilities are using notebooks and backs of medicines boxes to try to track inventory because they do not receive copies of the proper Ministry tools they should be using.
In some cases, there are three places within one facility where drugs are stocked and managed and this presents management challenge in terms of how, when and where to define the consumption data.
Security
35% 36% 31% 36% 37%
0%10%20%30%40%50%60%70%80%90%
100%
Oversight Process & Tools HumanResources
ManagementInformation
System
Infrastructure
Warehousing & Inventory Management Capability by Enabler
29
The issue of security in health facilities and warehouses continues to be worrisome due to a lackof control of existing contracts between security companies and health entities by MINSA's regulatory bodies specifically for medicines’ commodity security. Also worthy of note is a lack of adequate security mechanisms in place such as camaras, alarms, staff on guard during after hours and weekends in most health facilities and medicines’ warehouses.
CECOMA as the central medicine warehouse has benefited a few years ago from a permanent national police station to identify visitors, monitor commodity reception and dispatch, and also to watch over the supposed diversions or thefts of medicines. It should be noted that since the camaras currently installed are not sufficient for full coverage of the drug storage area, CECOMA is lacking proper security footage in some key areas of relevance within the warehouse.
Also, this central store does not have sufficient lighting inside to accommodate a basic secure parameter. Apart from that there are many unprotected accesses (windows, glass and doors) allowing for potential infiltration of unwanted visitors.
Others
Also, distribution plans are not consistent nor based on need; therefore, staff cannot always guarantee that they have infrastructure sufficient to store goods that are received. There are consistent stock-outs of medicines across all programs including essential medicines.
It is difficult to track inventory that does not make it from CECOMA to the provincial warehouses and from those warehouses to municipal depots and from municipal depots to the health facilities. Drugs enter the private sector markets but there is not a good tracking mechanisms in place to understand at which point in the supply chain this is occurring. There are also limited security measures and SOPs in place to monitor the movement of persons entering and exiting the warehouse.
Other issues include a lack of conducive working environments for technical staff working at warehouses like no A/C, no lighting, no gas/diesel available in the province, lack of motivation from staff working at warehouses due to constant stock outs and a lack of funding to repair air conditioners or transport goods, lack of trust that good reporting practices will result in goods received, and a consistent struggle to find adequate transportation of the drugs from the provincial to municipal levels.
Communication of works at the depots to health facility staff regarding incoming goods and goods availability is hindered by a lack of available funds for telephone credits to purchase talking minutes. There is a constant shortage and that dependency causes poor communication.
Specific challenges with Coartem and ARV tracer commodities include the ability to track multiple combinations. Even well-trained staff, struggle to maintain good record-keeping when drugs are split for different dosing and combinations are issued at differing ratios.
The percent of total stock that expired within a given reporting period appears to be a perfectly scored KPI of 0%; however, this is primarily because there are too few drugs available and more stock outs than excess medicines that need to be managed.
30
The accuracy of stock cards compared with physical quantity is one of the stronger KPIs for Angola scoring nearly 100% across all tracer commodities.
Stock Accuracy Figure 19: Stock Accuracy of Tracer Commodities
Tracer Commodity Stock Accuracy Quinine comprimidos 100% Artesunate injectável 80% Artesunate-Amodiauiine comprimidos 92.6% Artemether injectável 99% SulpfadoxinePyrimethamine comprimidos 134.5% ArteLumef B6 comprimidos 99.5% ArteLumef B12 comprimidos 97.1% ArteLumef B18 comprimidos 97.1% ArteLumef B24 comprimidos 83.1% LLINs 100% Malaria TDR 96.1% Depo-Provera 100% Implants (Jadelle) 100% IUD 100% Microgynon 90.6% TDF+3TC/FTC+EFV (Preferred 1st line for Adults) 100% ABC+3TC+EFV (Preferred 1st line for children) 100% Determine RDT 122.7% Unigold RDT 96.1% Condoms (male) 85.7% Lamivudine (3TC) + Zidovudine (AZT) + Nevirapine (NVP) 150/300/200mg, comp 101.5% Lamivodine (3TC) + Stavudine (30mg/D4T) + Nevirapine (NVP), 30/6/50mg, comp 50% Tenofovir (TDF)+ Lamivudine (3TC)+ Efavirenz (EFV) 300/300/600mg, comp 97.7%
Stock Out Rates
Figure 20: Number of Facilities Stocked Out by Tracer Commodity in the last 6 Months
31
Figure 21: Total & Average Number of Days Facilities Stocked Out by Tracer Commodity
Tracer Commodity %
Facility Stock
out
Total # of Days Tracer stocked out in last 6.5 months
Average # of Days Facility
stocked out in the last 6.5
months Quinine comprimidos 60.7% 4385 129.0 Artesunate injectável 74.3% 3649 140.3 Artesunate-Amodiauiine comprimidos 59.6% 4537 133.4 Artemether injectável 58.7% 4493 121.4 SulpfadoxinePyrimethamine comprimidos 52.5% 4340 135.6 ArteLumef B6 comprimidos 61.5% 5554 115.7 ArteLumef B12 comprimidos 60.0% 5178 107.9 ArteLumef B18 comprimidos 61.3% 5806 118.5 ArteLumef B24 comprimidos 53.1% 5012 116.6 LLINs 65.5% 2850 150.0 Malaria TDR 59.0% 5192 112.9
56
35
5763 61
78 80 80 81
29
78
19
32 3141
32 33
55 53 5651
26
383426
34 3732
48 48 4943
19
46
14 17 1723
18 18 22 24 22 22 18 22
0102030405060708090
# of Facilities Stocked Out by Tracer Commodity in the last 6 Months
Total # facilities w/ tracer commodity # facilities stockout
32
Depo-Provera 73.7% 2550 182.1 Implants (Jadelle) 53.1% 2524 148.5 IUD 54.8% 2679 157.6 Microgynon 56.1% 3099 134.7 TDF+3TC/FTC+EFV (Preferred 1st line for Adults) 56.3% 2430 135.0 ABC+3TC+EFV (Preferred 1st line for children) 54.5% 2635 146.4 Determine RDT 40.0% 2750 125.0 Unigold RDT 45.3% 3148 131.2 Condoms (male) 39.3% 2983 135.6 Lamivudine (3TC) + Zidovudine (AZT) + Nevirapine (NVP) 150/300/200mg, comp 43.1% 2957 134.4
Lamivodine (3TC) + Stavudine (30mg/D4T) + Nevirapine (NVP), 30/6/50mg, comp 69.2% 2790 155.0
Tenofovir (TDF)+ Lamivudine (3TC)+ Efavirenz (EFV) 300/300/600mg, comp 57.9% 2981 135.5
Stocked According to Plan Figure 22: CECOMA Stock According to Plan by Tracer Commodity Jan-Aug 2016
Tracer Commodity Stocked According to Plan Y/N
# of Months of Stock on
Hand Quinine comprimidos N 0 Artesunate injectável N 0 Artesunate-Amodiauiine comprimidos N 0 Artemether injectável N 0 SulpfadoxinePyrimethamine comprimidos N 0 ArteLumef B6 comprimidos N 0 ArteLumef B12 comprimidos N 0 ArteLumef B18 comprimidos N 0 ArteLumef B24 comprimidos N 0 LLINs N 0 Malaria TDR N/A N/A Depo-Provera Y 1
33
Implants (Jadelle) N 0 IUD N 0 Microgynon N 0 TDF+3TC/FTC+EFV (Preferred 1st line for Adults) N/A N/A ABC+3TC+EFV (Preferred 1st line for children) N/A N/A Determine RDT N/A N/A Unigold RDT N/A N/A Condoms (male) Y 1 Lamivudine (3TC) + Zidovudine (AZT) + Nevirapine (NVP) 150/300/200mg, comp N/A N/A Lamivodine (3TC) + Stavudine (30mg/D4T) + Nevirapine (NVP), 30/6/50mg, comp N/A N/A Tenofovir (TDF)+ Lamivudine (3TC)+ Efavirenz (EFV) 300/300/600mg, comp N/A N/A
Recommendations 1. Staff at the health facilities need to have more supervisory visits to ensure inventory is
properly managed, stock cards and monthly consumption reports are filled out withproper data integrity.
2. On-the-job training and capacity building regarding how to manage inventory as well asoverall warehouse management.
3. Regularized and consistent distribution plans based on actual need to ensure stockavailability at all levels of the supply chain to permit planning for receipt of goods forbetter warehouse space management.
4. Making the infrastructure in place more conducive to work staff including improvedlighting and air condition with guaranteed availability of electricity
5. Consider instating dedicated phone lines at zero cost to Ministry workers to be inconstant touch regarding stock and logistics issues.
6. Installing LMIS software system for greater transparency in the supply chain and real-time status updates on stocks making reporting and data aggregation easier.
7. A supervisory body should review reporting at the Municipal, Provincial and Nationallevels of the supply chain to take corrective and supportive actions to improve thesupply chain at the moment the issues are reported rather than waiting for actions totrickle down from the National level only.
8. Advocacy with INLS so that the ARV treatment regimens permitted are simplified.9. Sensitize and motivate the staff to the importance of timely monthly reporting and stock
management, as these will be crucial for the decision-making processes.10. Implement incentive programs for warehouse and supply chain staff including
recognition awards to the best staff (i.e. merit certificate, one extra day off, bonus, etc.)11. Ensure uninterrupted supply of medicines to prevent stock outs at such high levels
shown in Figures 19 & 20 by including buffer and safety stocks in the quantificationnumbers.
34
6. TRANSPORTATION
Capability Percentage: 41%
Figure 23: Transportation Capability by Enabler
Issues
Overall, there is a lack of infrastructure to ensure timely deliveries of medicines. CECOMA has major difficulty in securing adequate funding to cover annual distribution and lacks their own fleet to ensure timely deliveries. The provincial level normally uses a project/program vehicle to distribute medicines if they are able, but most often, they call the Provincial hospitals and Municipal directors to inform them of medicine availability so that they can arrange for transport to come and pick up the medicine. Most hospitals then send an ambulance to the Provincial depots to pick up medicines. At the municipal level there are rarely drivers dedicated to active distribution. If there is a municipal vehicle available, it is usually multi-purposed to distribute medicine but is no solely dedicated.
Missing processes, tools and an LMIS to help coordinate active distribution plans and timely deliveries presents additional challenges. Even with the procurement of additional and solely dedicated vehicles, there would be a lack of personnel to drive the trucks and supervisory oversight would also be needed.
Transportation is, overall, a huge challenge facing the Angolan Health Supply Chain.
Recommendations 1. Advocacy for purchase of vehicles that allow for adequate transport of products at the
National and Provincial levels;2. Advocacy to discourage hospitals from misusing ambulances to search for medicines
coupled with active push modeled distribution plans
50%40%
55%
37%45%
0%10%20%30%40%50%60%70%80%90%
100%
Oversight Process & Tools HumanResources
ManagementInformation
System
Infrastructure
Transportation Capability by Enabler
35
3. Create distribution plan based on the most dire needs taking access and routingoptimization into consideration so that resources are effectively utilized to ensuregeographic coverage
5. OVERALL ASSESSMENTRECOMMENDATIONSFigure 24: Capability and Performance Comparison
36
Overall, Forecasting & Supply Planning and Warehousing & Inventory Management have the greatest room for improvements and focused efforts. The MoH together with partners should consider focusing on the following recommendations to mitigate performance decline.
Recommendations to address current capability and performance issues in the near term include:
Short-Term 1. Needs-based quantification using models that account for not only consumption but
morbidity, stock levels, number of cases (actual needs) and endemicity/seasonality ofdisease that will be addressed and re-visited on a quarterly basis throughout the year.
2. Specific central level Standard Operating Procedures (SOPs) to be finalized forCECOMA
Medium-Long Term 1. Efforts to increase procurement autonomy, forecasting accuracy, transportation
independence and security, and overall stock management and active distribution.2. Robust training plans are needed across all levels of the supply chain to include the
practical application and dissemination of National SOPs for supply chain management.These SOPs currently sit with the Minister for approval. Once approved, the trainingcurriculum can be based on these and coupled with practical on-the-job mentoring onstock management and reporting.
3. Improved reporting and communication practices to clarify and streamline the numberof focal points involved in the reporting hierarchy while tackling the issue of a constant
Warehousing & Inventory Management
TransportationProcurement
Product Selection
Forecasting & Supply Planning
-900.00%
-700.00%
-500.00%
-300.00%
-100.00%
100.00%
300.00%
500.00%
700.00%
900.00%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Perf
orm
ance
Capability
Supply Chain Capability & Performance
Note: No KPIs were able to be collected for Transportation & Procurement Functional Areas
Capability Maturity Model
Nat
iona
l Sup
ply
Cha
in K
PIs
37
lack of cell phone minutes for staff to make phone calls. Improvements made to the current manual, paper-based system will serve a future national roll-out of an LMIS.
4. An overall need for greater supervision and oversight across all levels of the supplychain seems to indicate that it would be worthwhile to update and specify positiondescriptions for personnel in supervisory roles within MoH to ensure that activesupervision is part of their job description and they are compensated fairly for thatwork.
38
REFERENCES 1. Ministry of Health (MoH). 2016. Angola National Supply Chain Strategy Plan. Luanda,
Angola2. CECOMA and MSH/SIAPS Project. March 2016. Manual de qualidade. Luanda, Angola3. CECOMA and MSH/SIAPS Project. 2014. CECOMA SOPs. Luanda, Angola4. Kathleen Bartram, Elizabeth Kelly, and Melissa Levenger. 2015. National Supply Chain
Assessment User’s Guide. Arlington, Va. Supply Chain Management System.5. UNOPS CECOMA Assessment6. Análise do Sistema da Cadeia de Abastecimento da CECOMA, Janeiro 2014
APPENDIX I: KPI FORMULAS
# Indicator Formula Result Level of Implementa
tion
1.1 Stock out rates by tracer
(𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑡𝑡𝑁𝑁𝑡𝑡𝑡𝑡𝑁𝑁𝑁𝑁 𝑡𝑡𝑐𝑐𝑐𝑐 𝑠𝑠𝑡𝑡𝑐𝑐𝑡𝑡𝑠𝑠 𝑐𝑐𝑁𝑁𝑠𝑠𝑁𝑁𝑁𝑁𝑜𝑜𝑡𝑡𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜𝑠𝑠 𝑁𝑁𝑒𝑒𝑒𝑒𝑁𝑁𝑁𝑁𝑜𝑜𝑁𝑁𝑜𝑜𝑡𝑡𝑜𝑜𝑜𝑜𝑒𝑒 𝑡𝑡 𝑠𝑠𝑡𝑡𝑐𝑐𝑡𝑡𝑠𝑠𝑐𝑐𝑠𝑠𝑡𝑡 𝑑𝑑𝑠𝑠𝑁𝑁𝑜𝑜𝑜𝑜𝑒𝑒 𝑡𝑡ℎ𝑁𝑁 𝑁𝑁𝑁𝑁𝑒𝑒𝑐𝑐𝑁𝑁𝑡𝑡𝑜𝑜𝑜𝑜𝑒𝑒 𝑒𝑒𝑁𝑁𝑁𝑁𝑜𝑜𝑐𝑐𝑑𝑑𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑜𝑜𝑠𝑠𝑐𝑐𝑁𝑁𝑁𝑁𝑁𝑁 𝑐𝑐𝑜𝑜 𝑡𝑡𝑁𝑁𝑡𝑡𝑡𝑡𝑁𝑁𝑁𝑁 𝑡𝑡𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑑𝑑𝑜𝑜𝑡𝑡𝑐𝑐 𝑠𝑠𝑡𝑡𝑐𝑐𝑡𝑡𝑠𝑠 𝑐𝑐𝑁𝑁𝑠𝑠𝑁𝑁𝑁𝑁𝑜𝑜𝑡𝑡𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜𝑠𝑠
Central: 7*100/12=
58.3% All
1.2 Stocked according to plan
(𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 𝑡𝑡𝑁𝑁𝑡𝑡𝑡𝑡𝑁𝑁𝑁𝑁 𝑡𝑡𝑐𝑐𝑐𝑐 𝑐𝑐𝑁𝑁𝑠𝑠𝑁𝑁𝑁𝑁𝑜𝑜𝑡𝑡𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜𝑠𝑠 𝑤𝑤𝑜𝑜𝑡𝑡ℎ 𝑐𝑐𝑐𝑐𝑜𝑜𝑡𝑡ℎ𝑠𝑠 𝑐𝑐𝑜𝑜 𝑠𝑠𝑡𝑡𝑐𝑐𝑡𝑡𝑠𝑠 𝑁𝑁𝑡𝑡𝑤𝑤 𝑁𝑁𝑠𝑠𝑡𝑡𝑡𝑡𝑁𝑁𝑇𝑇𝑜𝑜𝑠𝑠ℎ𝑁𝑁𝑑𝑑 𝑐𝑐𝑜𝑜𝑜𝑜 𝑡𝑡𝑜𝑜𝑑𝑑 𝑐𝑐𝑡𝑡𝑒𝑒 𝑠𝑠𝑡𝑡𝑐𝑐𝑡𝑡𝑠𝑠 𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑜𝑜𝑠𝑠𝑐𝑐𝑁𝑁𝑁𝑁𝑁𝑁 𝑐𝑐𝑜𝑜 𝑡𝑡𝑁𝑁𝑡𝑡𝑡𝑡𝑁𝑁𝑁𝑁 𝑡𝑡𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑐𝑑𝑑𝑜𝑜𝑡𝑡𝑐𝑐 𝑐𝑐𝑁𝑁𝑠𝑠𝑁𝑁𝑁𝑁𝑜𝑜𝑡𝑡𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜𝑠𝑠
2*100/15= 13.3% Central
2.2
Percentage of products procured
listed on the National Essential Medicines
List (𝑁𝑁𝑠𝑠𝑐𝑐𝑁𝑁𝑁𝑁𝑁𝑁 𝑐𝑐𝑜𝑜 𝑒𝑒𝑁𝑁𝑐𝑐𝑑𝑑𝑠𝑠𝑡𝑡𝑡𝑡𝑠𝑠 𝑒𝑒𝑁𝑁𝑐𝑐𝑡𝑡𝑠𝑠𝑁𝑁𝑁𝑁𝑑𝑑 𝑐𝑐𝑜𝑜 𝑡𝑡ℎ𝑁𝑁 𝑁𝑁𝑁𝑁𝑁𝑁𝑁𝑁 )𝑒𝑒 100
𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑜𝑜𝑠𝑠𝑐𝑐𝑁𝑁𝑁𝑁𝑁𝑁 𝑐𝑐𝑜𝑜 𝑒𝑒𝑁𝑁𝑐𝑐𝑑𝑑𝑠𝑠𝑡𝑡𝑡𝑡 𝑒𝑒𝑁𝑁𝑐𝑐𝑡𝑡𝑠𝑠𝑁𝑁𝑁𝑁𝑑𝑑
110*100/183= 60.1% Central
3.1 Forecast accuracy (1− (𝑜𝑜𝑐𝑐𝑁𝑁𝑁𝑁𝑡𝑡𝑡𝑡𝑠𝑠𝑡𝑡𝑁𝑁𝑑𝑑 𝑡𝑡𝑐𝑐𝑜𝑜𝑠𝑠𝑠𝑠𝑐𝑐𝑒𝑒𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜 − 𝑡𝑡𝑡𝑡𝑡𝑡𝑠𝑠𝑡𝑡𝑇𝑇 𝑡𝑡𝑐𝑐𝑜𝑜𝑠𝑠𝑠𝑠𝑐𝑐𝑒𝑒𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜))𝑒𝑒 100
𝐴𝐴𝑡𝑡𝑡𝑡𝑠𝑠𝑡𝑡𝑇𝑇 𝑡𝑡𝑐𝑐𝑜𝑜𝑠𝑠𝑠𝑠𝑐𝑐𝑒𝑒𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜
(1-644785165) x100/77841927 = -827%
Central
5.1 (𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑞𝑞𝑠𝑠𝑡𝑡𝑜𝑜𝑜𝑜𝑡𝑡𝑜𝑜𝑡𝑡𝑐𝑐 𝑐𝑐𝑜𝑜 𝑒𝑒𝑁𝑁𝑐𝑐𝑑𝑑𝑠𝑠𝑡𝑡𝑡𝑡 𝑠𝑠𝑜𝑜𝑠𝑠𝑠𝑠𝑡𝑡𝑁𝑁𝑇𝑇𝑁𝑁 𝑑𝑑𝑠𝑠𝑁𝑁 𝑡𝑡𝑐𝑐 𝑁𝑁𝑒𝑒𝑒𝑒𝑜𝑜𝑁𝑁𝑐𝑐) 𝑒𝑒 100
𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑞𝑞𝑠𝑠𝑡𝑡𝑜𝑜𝑜𝑜𝑡𝑡𝑜𝑜𝑡𝑡𝑐𝑐 𝑐𝑐𝑜𝑜 𝑒𝑒𝑁𝑁𝑐𝑐𝑑𝑑𝑠𝑠𝑡𝑡𝑡𝑡 𝑡𝑡𝑜𝑜𝑡𝑡𝑜𝑜𝑇𝑇𝑡𝑡𝑁𝑁𝑇𝑇𝑁𝑁 𝑑𝑑𝑠𝑠𝑁𝑁𝑜𝑜𝑜𝑜𝑒𝑒 𝑡𝑡ℎ𝑁𝑁 𝑁𝑁𝑁𝑁𝑒𝑒𝑐𝑐𝑁𝑁𝑡𝑡𝑜𝑜𝑜𝑜𝑒𝑒 𝑒𝑒𝑁𝑁𝑁𝑁𝑜𝑜𝑐𝑐𝑑𝑑 0% All
39
APPENDIX II: MALARIA SPECIFIC RESULTS FROM ADDITIONAL QUESTIONS
1. How ACTs and RDTs are received
40% of ACTs and RDTs are received by normal delivery “classical pathway”, 17.5% in kits and 5% through both methods. However 37.5% responded to the questionnaire that they are received through “other” methods.
Percent of total stock that expired during a
reporting period
5.2 Stock accuracy (𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑞𝑞𝑠𝑠𝑡𝑡𝑜𝑜𝑡𝑡𝑜𝑜𝑡𝑡𝑐𝑐 𝑐𝑐𝑜𝑜 𝑒𝑒𝑁𝑁𝑐𝑐𝑑𝑑𝑠𝑠𝑡𝑡𝑡𝑡 𝑐𝑐𝑜𝑜 𝑠𝑠𝑡𝑡𝑐𝑐𝑡𝑡𝑠𝑠 𝑡𝑡𝑡𝑡𝑁𝑁𝑑𝑑 𝑐𝑐𝑁𝑁 𝑜𝑜𝑜𝑜𝑜𝑜𝑁𝑁𝑜𝑜𝑡𝑡𝑐𝑐𝑁𝑁𝑐𝑐 𝑐𝑐𝑡𝑡𝑜𝑜𝑡𝑡𝑒𝑒𝑁𝑁𝑐𝑐𝑁𝑁𝑜𝑜𝑡𝑡 𝑠𝑠𝑐𝑐𝑜𝑜𝑡𝑡𝑤𝑤𝑡𝑡𝑁𝑁𝑁𝑁) 𝑒𝑒 100
𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑞𝑞𝑠𝑠𝑡𝑡𝑜𝑜𝑡𝑡𝑜𝑜𝑡𝑡𝑐𝑐 𝑐𝑐𝑜𝑜 𝑡𝑡ℎ𝑁𝑁 𝑠𝑠𝑡𝑡𝑐𝑐𝑁𝑁 𝑒𝑒𝑁𝑁𝑐𝑐𝑑𝑑𝑠𝑠𝑡𝑡𝑡𝑡 𝑜𝑜𝑁𝑁𝑐𝑐𝑐𝑐 𝑒𝑒ℎ𝑐𝑐𝑠𝑠𝑜𝑜𝑡𝑡𝑡𝑡𝑇𝑇 𝑜𝑜𝑜𝑜𝑜𝑜𝑁𝑁𝑜𝑜𝑡𝑡𝑐𝑐𝑁𝑁𝑐𝑐 𝑡𝑡𝑐𝑐𝑜𝑜𝑑𝑑𝑠𝑠𝑡𝑡𝑡𝑡𝑁𝑁𝑑𝑑 𝑑𝑑𝑠𝑠𝑁𝑁𝑜𝑜𝑜𝑜𝑒𝑒 𝑡𝑡 𝑠𝑠𝑜𝑜𝑡𝑡𝑁𝑁 𝑜𝑜𝑜𝑜𝑠𝑠𝑜𝑜Mean= 96.7% All
8.1 Staff turnover rate (𝑁𝑁𝑠𝑠𝑐𝑐𝑁𝑁𝑁𝑁𝑁𝑁 𝑐𝑐𝑜𝑜 𝑠𝑠𝑡𝑡𝑡𝑡𝑜𝑜𝑜𝑜 𝑤𝑤ℎ𝑐𝑐 𝑜𝑜𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑡𝑁𝑁𝑑𝑑 𝑡𝑡ℎ𝑁𝑁𝑜𝑜𝑁𝑁 𝑒𝑒𝑐𝑐𝑠𝑠𝑜𝑜𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜 𝑑𝑑𝑠𝑠𝑁𝑁𝑜𝑜𝑜𝑜𝑒𝑒 𝑡𝑡ℎ𝑁𝑁 𝑁𝑁𝑁𝑁𝑒𝑒𝑐𝑐𝑁𝑁𝑡𝑡𝑜𝑜𝑜𝑜𝑒𝑒 𝑒𝑒𝑁𝑁𝑁𝑁𝑜𝑜𝑐𝑐𝑑𝑑) 𝑒𝑒 100 𝑇𝑇𝑐𝑐𝑡𝑡𝑡𝑡𝑇𝑇 𝑜𝑜𝑠𝑠𝑐𝑐𝑁𝑁𝑁𝑁𝑁𝑁 𝑐𝑐𝑜𝑜 𝑠𝑠𝑡𝑡𝑡𝑡𝑜𝑜𝑜𝑜 𝑁𝑁𝑐𝑐𝑒𝑒𝑇𝑇𝑐𝑐𝑐𝑐𝑁𝑁𝑑𝑑 𝑁𝑁𝑐𝑐 𝑡𝑡ℎ𝑁𝑁 𝑐𝑐𝑁𝑁𝑒𝑒𝑡𝑡𝑜𝑜𝑜𝑜𝑜𝑜𝑡𝑡𝑡𝑡𝑜𝑜𝑐𝑐𝑜𝑜 𝑜𝑜𝑜𝑜 𝑡𝑡ℎ𝑁𝑁 𝑠𝑠𝑡𝑡𝑐𝑐𝑁𝑁 𝑁𝑁𝑁𝑁𝑒𝑒𝑐𝑐𝑁𝑁𝑡𝑡𝑜𝑜𝑜𝑜𝑒𝑒 𝑒𝑒𝑁𝑁𝑁𝑁𝑜𝑜𝑐𝑐𝑑𝑑
15*100/300= 5% All
17.5%
40.0%
5.0%
37.5%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
In kits Classical pathway Both in kits andclassical pathway
Other
40
2. Whether ACTs and RDTs are receivedtogether with the Essential MedicinesProgram (EMP)
The majority of the ACTs and RDTs are not received with EMP medicines and only 33.3% are always received with the EMP.
3. Knowledge concerning the expiry date of kits
The staff showed a lack of knowledge and understanding the concept of expiry dates within kits, which hinders their capacity at the facility level to manage the stock of kits efficiently.
Recommendations: • Systematize the methods of distribution of ACTs
and RDTs, considering the possibility of sendingunkitted distribution;
• If this is not possible, the National MalariaControl Program could train staff on how tomanage different expiry dates within one kit.
4. The frequency with which packs areopened and rearranged when the ACTcombination pack is not available:
ACT packs are opened and rearranged often due to the limited availability of the specific treatment packs at the facilities.
33.3%
2.1%
52.1%
12.5%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Always receivedwith the EMP
Often receivedwith the EMP
Rarely receivedwith EMP
Other
27.5%
19.6%19.6%
33.3%
Kit expiry date
Expiry date of thefirst item expiring
Do not know
Other
31.51%
12.33%
26.03%17.81%
12.33%
0.00%10.00%20.00%30.00%40.00%50.00%60.00%70.00%80.00%90.00%
100.00%
≥ once a week
≥ once a month
Not everymonth
Never Other
41
5. Registering drug substitution when packsare open or rearranged
More than 40% of the facilities will register the package that should have been given instead of the actual combination of pills given rendering stock management data unreliable.
Recommendations: • All stock outs of specific pre-set ACT
packages should be informed to the nextlevel of the supply chain immediately to avoid opening and substituting packages as thiswill result in waste and also create confusion for stock registration and dosing;
• In case of a stock out of specific pre-set packages, the substituting of drug regimens shouldbe registered appropriately;
6. Reporting consumptionConsumption is primarily reported (60% for ACTs and 58.2% for RDTs) through the monthlyreports. The majority of the reports are sent on a monthly basis (81.3% for ACTs and 95.9% forRDTs).
PROVINCIAL
1. How consumption data for ACTs isaggregated
43.5%
40.6%
15.9%Registered thetreatment given
Registered thetreatment that shouldahve been given
Other
16.7%
33.3%
16.7%
16.7%
16.7%Aggregate all data in asingle report
Aggregate data from eachlevel
Send each report as theyarrive
Not receive monthly report
Other
42
2. How consumption data for RDTs isaggregated
Issues • There is currently no consistency in the methodology of compiling consumption data in
the provinces.
Recommendation • Harmonize/standardize the methodology of compiling consumption data in the provinces
to inform better stock and supply chain management at decision making levels.
APPENDIX III: HIV/AIDS PROGRAM SPECIFIC RESULTS FROM ADDITIONAL QUESTIONS ARVs
1. Reception of ARVs in facility
a. Source of ARVs in facility
Over 40% of the ARV drugs health facilities received were directly from the Provincial level, followed by the District level (13.2%) and Hospital (1.5%). Over 44% of the ARV stock came from other sources than the aforementioned.
1.5% 13.2%
41.2%
44.1%
Hospital
District
Provincial
Outro
42.9%
28.6%
14.3%
14.3%Aggregate all data in asingle report
Aggregate data from eachlevel
Send each report as theyarrive
Not receive monthlyreport
Other
43
b. How the ARVs arrive to facility
Almost two thirds of the facilities reported that they must send transport to search for the medicines from the depots, whereas the remaining minority receive deliveries of ARVs directly to their facilities.
c. Frequency ARVs are received
Just over one fourth of the ARVS are received on a monthly basis, whereas almost one third are received as needed. Over 40% of the facilities reported other (less consistent) frequencies.
Issues:
• There is currently a lack of consistency regarding the source, methods for reportingconsumption, and frequency by which the ARVs are sent and received by the facilities incountry;
• There is a very high rate of facilities that have to collect ARVs which puts pressure onscarce human and financial resources at the facility levels;
• Almost one third of the facilities receives ARVs on a “as needed” basis whereby 41%receive them more sparingly than “as needed” which will hinder facilities’ ability to treatpatients with HIV/AIDS appropriately.
Recommendations:
• Harmonize the sources, methods and frequency that ARVs are dispatched to the facilitylevel to ensure a predictable, sustainable and sufficient supply of ARVs;
2. Assessing ARVs needs at facilities
66.1%
33.9%Facilitycollects
Deliveredto facility
25.7%
32.9%
41.4% Monthly
As needed
Other
44
a. Determining ARV quantity needed
Over 35% of facilities interviewed used a fixed requisition routinely, whereas over 16% used the official ministry form (Monthly map of ARVSs information - MMIA) and in 8.1% of the cases, the supervising unit determined the quantity needed basing on the consumption at the facility level. More than 40% of the facilities reported other mechanisms to determine the quantity of ARVs needed.
b. Formula used to determine ARV needs
Over one third of the facilities used the formula “2 X consumption - stock on hand”, whereas just over 3% used “ 3 X consumption – stock on hand.” Over 60% of the facilities used other formulas to determine the needs.
Issues: • There is a high discrepancy in the forms used to
determine the quantity of ARVS needed and reporting stock outs, which hinders thecapacity of INLS to assess whether the ARVs are being distributed according to plan aswell as to compile all the reports and evaluate the overall distribution and managementof ARVs;
• Lack of consistency in the formulas used to calculate needs and request ARVs;
Recommendations: • INLS does not typically issue ARVs to facilities who only report stock outs and do not
send monthly consumption reports or do not use the pre-approved Ministry forms soMoH and partners should ensure that facility personnel receive proper training regardingthe importance of standard reports with proper quality.
• Standardize and train on proper needs-based forecasting calculations used to requestARVs so that ARVS are distributed according to facility needs.
3. Reporting ARV consumption data
a. Forms to report ARV use
35.5%
16.1%
8.1%
40.3%
Fixedrequisition
Using officialMinistry form
Determined bysurpervisingunit
Other
35.0%
3.3%
61.7%
Consumption x 2 – stock on hand
Consumption x 3 – stock on hand
Other
45
A wide range of forms are used to report consumption showing different information and causing incorrect analysis. This hinders the capacity of INLS to have coherent reports of ARV consumption as well as to forecast based on actual needs.
b. Forms received by Province
This graph demonstrates different forms and reports received by the provincial level.
c. Training received on Forms
More than 28% of the staff did not receive training on how to complete required forms and almost one fourth were trained by other staff from within the same facility. Only 12.7% were trained by PEPFAR in provincial trainings. Lack of adequate training might explain the misuse of different forms and confusion around what exactly is needed to fulfill reporting requirements.
Recommendations: • Standardization of the forms to report
consumption;• INLS to train of staff to complete the standardized forms (training of trainers if applicable)
and conduct supervisory visits to ensure that the correct forms are being used in thecorrect way;
Rapid Diagnostic Tests (RDTs)
13.3%
40.0%13.3%
33.3%
Monthly map of ARVsinformation (MMIA)
Generic ARVs registry
Other
Does not receivereports
20.9%9.0%
22.4%10.4%
37.3%
0.0%20.0%40.0%60.0%80.0%
100.0%
28.6%
23.8%6.3%
12.7%
28.6%
No training
Trained by health stafffrom this/other facility
Trained in specificcourse (May-August2016)Trained by PEPFAR -provinvial trainings
Other
46
3. Methods of HIV RDT delivery
The majority of the HIV RDTs arrive from other methods of transportation besides the classical pathway and/or together with ARVs.
4. Means of transportation that HIV RDTsare delivered (Health Facility responses)
Over one third of the HIV RDTs are delivered by Government vehicles, 13.9% are received from the level above, whereas, over 50% are received by other means of transportation.
5. Means of transportation that HIV RDTsare delivered (Provincial level responses)
Over 20% more of goods received at the Provincial level are delivered using government vehicles while only 42% note that they have to use other means to receive deliveries.
31.0%
8.5%
5.6%
54.9%
Classical pathway routinetransport
Together with ARVs
Classical pathway routinetransport or Togetherwith ARVsOther
34.7%
0.0%
13.9%
51.4%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Transported bygovernment
vehicle
CHAI/”Coca Cola” system
Received fromthe level above
Other
52.6%
0.0%5.3%
42.1%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Transported bygovernment
vehicle
CHAI/”Coca Cola” system
Received fromthe level above
Other
47
6. Frequency by which monthly consumption of HIVRDTs reports are submitted
7. To whom the reports are submitted
Issue • No consistency in the methods and means of transportation for HIV RDTs, as well as, the
frequency and to whom the reports of consumption are submitted
Recommendation • Harmonize/standardize the methods and means of transportation between level of the
supply chain in Angola, as well as, clarify the reporting mechanisms and frequency.
PROVINCIAL LEVEL
8. How requests for RDTs are receivedfrom facilities
85.45%
5.45%
1.82%
7.27%
Monthly
Quarterly
Not sent
Other
60.0%
20.0% 20.0%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
The orders are sentfrom the level below
Only receive monthlyreport of HIV RDT
consumption
Other
54.4%
10.3%20.6%
14.7%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
District Hospital Provincial Other
48
9. How RDT consumption data isaggregated
10. How HIV RDTs are delivered to thehealth facilities
Issue • No consistency in the methodology of
receiving and/or compiling the data regarding consumption in the provinces.
Recommendation • Harmonize/standardize methodology of receiving and/or compiling the data regarding
consumption in the provinces coupled with designing regular, active distribution plans.
66.7%
0.0%
33.3%
0.0%0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Aggregate alldata in a single
report
Aggregate datafrom each level
Send each reportas they arrive
Not receivemonthly report
0.0% 0.0%
75.0%
25.0%
0.0%10.0%20.0%30.0%40.0%50.0%60.0%70.0%80.0%90.0%
100.0%
Together withEssentialMedicine
Programme kits
ClassicalPathway
HIV RDTs senttogether with
other products
HIV RDTs sentseparate fromother products
