Title THE MAGNITUDE AND TREND OF ARTIMETHER–LUMEFANTRINE (LA) STOCK-OUTS AT PUBLIC HEALTH CENTRES...

SP031310 FINAL REPORT_26 JUNE 2013

Title

THE MAGNITUDE AND TREND OF ARTIMETHER–LUMEFANTRINE (LA)

STOCK-OUTS AT PUBLIC HEALTH CENTRES IN BLANTYRE

Investigators

Thuboy Blessings R (B.Pharm (Hons) IV), Tailos Vongaishe M (B.Pharm (Hons) IV)

Supervisors

Mr. R Mwale (Senior Lecturer, Department of Pharmacy, College of Medicine)

Mr. W Chalira (General Manager, Malawi Pharmacies Limited; Part-time Lecturer,

Department of Pharmacy, College of Medicine)

Institution under whose umbrella the research project will be conducted

The College of Medicine - University of Malawi


Abstract

This is a descriptive survey where out-of stock situations were recorded retrospectively and

the number of public health centres in Blantyre that experienced LA stock-outs as well as the

trend of the stock-outs between November 2011 and April 2013 were assessed. The pharmacy

manager’s ability to estimate drug requirements and procure drugs as well as the pharmacy

store manager’s use of the drug stock management support tool of record keeping were also

assessed. In addition to that contributing management factors to LA stock-outs were

identified.

Data recording forms were used to record LA stock-out situations and their durations. The

pharmacy manager’s ability to estimate drug requirements and procure drugs as well as the

pharmacy store manager’s use of the drug stock management support tool of record keeping

were recorded on structured questionnaires. The data was then analysed using Microsoft

Office excel 2013 and Epi Info version 3.5.

The number of health centres that experienced stock-outs was observed to be high within the

period February to May while the numbers were low during the months of September,

October and November. The highest number of health centres to experience stock-outs was

15 (65.2%) for LA 6 tablet pack, 16 (69.6%) for LA 12 tablet pack, 18 (78.3%) for LA 18

tablet pack and 20 (87%) for LA 24 tablet pack; all in March 2013 (plus February 2013 for

LA 12 tablet pack). 13 health centres (56.5%) experienced a stock-out in all the LA packs

within the same month, March 2013. None of the months within the 18 month period under

study had a zero stock-out in any of the LA packs.

While 8 (47.1%) of the pharmacy managers demonstrated to lack knowledge to estimate drug

requirements and procure drugs only 1 (5.9%) of the managers was not conversant with

management support tool of record keeping. Only 3% of the stock-out situations could be

attributed to inability to use management skills and support tools.

We continue to experience large number of stock-outs in the months of February to May

despite existence of evidence that this is the period with highest malaria incidence in Malawi

since 2006 (18), with all the worst cases reported in March 2013. Within the 18 month period

under study at least one health centre experienced a stock-out in at least one of the LA packs

every month. Most of the participants (pharmacy managers) had problems with estimation of

drug requirements and procurement, and although they had good record keeping practices

some accidental losses were recorded.

The weak association between ability to use management skills and stock-outs suggests that

there are other factors that contribute to the stock-outs. Participants reported that inadequate

LA quantities delivered by the supplier in relation to demand, frequent stock-outs at the

district health office drug store and delayed transportation were some of the contributing

factors to the stock-outs.


Table of Contents

Title ................................................................................................................................................................ 1

Investigators .................................................................................................................................................. 1

Supervisors .................................................................................................................................................... 1

Institution under whose umbrella the research project will be conducted .............................................. 1

Abstract ......................................................................................................................................................... 2

List of Tables ................................................................................................................................................. 4

List of Figures ................................................................................................................................................ 4

List of Appendices ......................................................................................................................................... 4

List of Abbreviations and Acronyms ........................................................................................................... 4

Introduction ................................................................................................................................................... 5

Literature Review ......................................................................................................................................... 6

Rationale ........................................................................................................................................................ 7

Broad Objective ............................................................................................................................................ 7

Specific Objectives ........................................................................................................................................ 7

Methods and Materials ................................................................................................................................. 8

Type of research study ........................................................................................................................ 8

Study place .......................................................................................................................................... 8

Study population ................................................................................................................................. 8

Inclusion criteria ................................................................................................................................. 8

Exclusion criteria ................................................................................................................................ 8

Selection criteria ................................................................................................................................. 8

Study period ........................................................................................................................................ 8

Sample size ......................................................................................................................................... 8

Data Collection ................................................................................................................................... 8

Data Management and Analysis ......................................................................................................... 9

Results ............................................................................................................................................................ 9

Conclusion ...................................................................................................................................................14

Recommendations .......................................................................................................................................14

Acknowledgements .....................................................................................................................................15

Appendices ...................................................................................................................................................15

Appendix 1: Data recording form .................................................................................................... 15

Appendix 2: Questionnaire for health centre management .............................................................. 16

Appendix 3: Graph showing incidence of Malaria in Malawi (reproduced from the Ministry of

Health Health Management Information System Bulletin Draft July 2005 to June 2006 (18) ......... 18

References ....................................................................................................................................................18


List of Tables

Table 1: Range of stock-outs duration of LA 6 Tab by month




Table 5: Measure of the pharmacy stores manager’s ability to measure drug requirements and

procure drugs

Table 6: Measure of the manager’s use of drug management tools

List of Figures

Figure 1: Magnitude and trend of LA stock-outs

Figure 2: LA 6 Tab average stock-out duration by month




List of Appendices

Appendix 1: Data recording form

Appendix 2: Questionnaire for health centre management

Appendix 3: Graph showing incidence of Malaria in Malawi (reproduced from the Ministry

of Health, Health Management Information System Bulletin Draft July 2005 to

June 2006

List of Abbreviations and Acronyms

ACT : Artemisinin based Combination Therapy

CMS : Central Medical Stores

HSA : Health Surveillance assistant

IPTp : Intermittent Preventive Treatment in Pregnancy

IRS : Indoor Residual Spraying

ITN : Insecticide Treated Nets

LA : Artimether-Lumefantrine

PMI : United States Presidential Malaria Initiative

SP : Sulfadoxine-Pyrimethamine

Tab : Tablet


UNICEF: United Nations Children’s Fund

USAID: United States Aid for International Development

Introduction

Malaria is one of the leading causes of morbidity and mortality in Malawi with an estimate of

98% of the cases due to the Plasmodium Falciparum and the remaining 2% caused by

Plasmodium Ovale (1). For example, according to the ministry of health malaria still

accounts for 34% of all outpatient visits i. e six million suspected cases treated every year. It

is also noted that malaria remains the leading cause of hospitalizations among under five

children accounting for 40% of hospital admissions in this age group (1).

Many interventions have been rolled out to control malaria namely; use of Insecticide-treated

nets (ITNs), Indoor residual spraying (IRS), intermittent preventive treatment in pregnancy

(IPTp) and Case management. Case management involves the use of antimalarial

chemotherapy such as Artimether - Lumefantrine (LA) as a first-line therapy for

uncomplicated malaria (2).

In Malawi the current malaria treatment guideline that recommends the use of Artimether -

Lumefantrine (20mg/120mg) as first-line treatment for uncomplicated malaria was officially

launched in December 2007 after 14 years (1993 - 2007) of Sulfadoxine – Pyrimethamine

(SP) use whose efficiency had been compromised by parasite resistance (3) (4). The

Artemisinin based Combination Therapy (ACT) is dispensed for free for all ages in the public

sector.

Financing for the purchase and distribution of LA is done by United States Aid for

International Development (USAID) (under the Presidential Malaria Initiative (PMI)

program), the Malawi government, Global fund and also the World health organization

(through the United Nations Children’s Fund - UNICEF) in order of decreasing level of

contribution (2).

LA comes in packs of 24, 18, 12 and six tablets designed for specific age groups administered

in three days with an initial two dose spacing of 8 hours followed by 12 hour spaces between

doses. A stock-out in any of these packs hinders a particular age group from getting the

treatment. Stock-outs of the large packs can easily be improvised by the smaller packs for

example an adult may be given 4 six-tablet packs in cases where the health centre has run out

of the 24-tablet packs. However such a practice makes treatment costly as the cost of four six

tablet packs is by far higher than the cost of one 24 tablet pack (>150%) (5). Likewise, the

vice versa is not practical as issues of quality maintenance and contamination come in. For

instance, to give six tablets to a child would involve breaking the 24 tablet pack to count out

the tablets. In the absence of LA stock alternative anti-malarial prescribing is employed e. g

Quinine and sulfadoxine-pyrimethamine (SP) whose effectiveness is not guaranteed due to

parasite resistance (4).

In Malawian public health centres management of drug stocks including LA rests in the hands

of Health Surveillance Assistants (HSA) who have undergone drug management trainings and

continue going through seminars that equip them with the necessary basic skills in drug stock


management. Blantyre, Malawi’s commercial city, has no district hospital and hence the

majority of its residents depend on the health centres for medical attention from where a

referral to the tertiary Queen Elizabeth hospital is made. Being the first port of call for the

city’s residents, LA availability at all times cannot and should not be undermined. It is also

the wish of the government donor partners that LA is available at all times such that for

example children less than five years old take an antimalarial drug within 24 hours of the

commencement of fever (6).

Stock-outs of essential drugs is common news in the country and they have been reported on

various scales in different public domains like the media with worst cases occurring in the

early months of 2013 where stocks went below 5% at the Malawi Central Medical Stores (7).

LA is an essential medicine and the causes of stock-outs vary, but often reflect the weak drug

management systems of a country. Poorly resourced supply chains, bad stock management

practices, and inadequate lead-time planning can threaten the regular availability of drugs in

the public health system. In addition, unpredictable funding flows in many countries,

combined with inadequate distribution from central warehouses to peripheral points of care,

undermine the ability to ensure that essential drugs are always available at the last mile (8).

Malawi’s pharmaceutical management system has been plagued with problems. Stock outs of

antimalarials and other essential drugs occur regularly due to issues related to financing,

quantification, ordering, tendering, receipt, storage, and distribution (9).

Literature Review

Stock-outs of any drug in government health facilities results in health hazards and the

relapse of illnesses due to non-adherence to treatment regime and exposure to fake, expired,

and adulterated drugs as people turn to alternative health care in prayer houses, herbal homes,

patent medicine vendors, and traditional birth attendants (10). Frequent stock-outs of drugs

do not only deny patients of access to the drugs but also reflect a failure of the health system

to live up to its obligation consequently wearing out the trust people had in the health system

that indisputably diminishes health seeking behavior (11). In many African countries the

information about the existence of essential drugs stock-outs is everywhere but limited

accurate information exists on the magnitude and trend of the problem. It is worth noting that

publicizing ACT stock-outs is a crucial element to raise awareness of this problem and

initiate interventions aimed at elimination of ACT stock-outs at the point of care (12).

Despite pooled efforts by governments and the donor community essential drugs stock-outs

still haunt and threaten access to the first-line treatments in sub-Saharan African countries for

example those under the United States Presidential Malaria Initiative (PMI). In 2007 a cross

sectional retrospective study on the deficiency of drugs for life threatening diseases found out

that anti-malarial drugs were out of stock for periods ranging from 42 to 138 days in the

targeted 37 Lilongwe district health centres, Malawi, within a space of one year (13). In

addition to that, another research on the magnitude and trend of Artimether-Lumefantrine

stock-outs in 170 public health facilities in Kenya revealed that 11.6% of the facilities had no

any LA at the point of a random visit in 2012 (14).


LA stock-outs in health centres have also been marked as one of the major problems

impeding progress in the control of Malaria by the Christian Reformed World Relief

Committee in their October 29, 2010 annual report on Building Community Capacity to

Control Malaria in Central Malawi (3). In this paper we intend to report the magnitude and

trend of LA stock-outs in Blantyre district public health centres as well as the quality of drug

management skills of the drug store managers.

Rationale

Prompt treatment of uncomplicated malaria with effective anti-malarials is a cornerstone of

malaria control efforts, providing individual benefits by curing infection and preventing

progression to severe disease or death and community-level benefits by reducing the

infectious reservoir and thus averting the emergence and spread of drug resistance (15). As a

result there is need for determined efforts to ensure that all health facilities have the first line

therapy in stock throughout the year if at all timely treatment is to be realised. Lack of

sufficient information on the current situation of the magnitude and trend of Artimether –

Lumefantrine stock-outs in the Malawian health facilities make it impossible for

implementation of such activities.

Currently there is no record of what percentage of the health centres experience LA stock-

outs and which period of the year are the health centres mostly hit by the stock-outs. In this

study we have conducted a survey in the health centres in Blantyre in order to determine the

magnitude and the trend of LA stock-outs. Results of this research may help policy makers

empower the human resource with information through Continued Professional Development

in drug management as well as revise the quantities supplied to the health centres during the

period drug stock-outs are more likely. Information on the pharmaceutical sector is vital for

the optimal management of any essential drugs program (16).

Broad Objective

To assess the number of public health centres in Blantyre that experienced LA stock-outs

between November 2011 to April 2013 and the contributing management factors.

Specific Objectives

1. Determine the number of health centres with total LA stock-outs or at least one type

of LA pack stock-outs within the past 18 months.

2. Determine the trend (pattern) of LA stock-outs within the period November 2011 to

April 2013.

3. Assess the pharmacy managers’ ability to estimate drug requirements and procure

drugs.

4. Assess the pharmacy managers’ use of the drug stock management support tools (17).

5. Measure the association between LA stock-outs and poor/lack of use of various drug

management skills and tools.


Methods and Materials

Type of research study

The nature of our study design was a retrospective quantitative survey.

Study place

The study took place in Blantyre District.

Study population

Our study population was the public health centres in Blantyre District.

Inclusion criteria

The centre had to be a government/ public health centre and located within Blantyre

District.

Exclusion criteria

Any centre outside Blantyre or not public/ government based was excluded.

Selection criteria

We included every public health centre that is within Blantyre District.

Study period

The data was collected from the 6th

of May to 15th

of May 2013. Data entry and analysis

took place from the 16th

of May to the 24th

of May.

Sample size

There are 24 public health centres in Blantyre. Therefore since our study is a survey and

the population is manageable all health centres were included, so the sample size was 24.

Data Collection

To determine the number of health centres that experienced any type of stock-out and the

months that they experienced the stock-outs, we used the stock records of the clinics after

seeking consent from the management. We recorded the findings on our own data recording

forms (see appendix 1).

The drug management cycle consists of four important aspects namely: selection,

procurement, storage and distribution; and lastly use (17). In the public sector in Malawi the

selection is done at central level and the pharmacy managers in the health centres are mainly

responsible for the other parts of the cycle. In our study the main focus is to assess the

procurement skills and the use of important management tools. In public health centres

procurement consists of ordering drugs from the district health office or supplier (mostly a

donor). Drugs ordered from the district health office are those that are not on the donor’s list

and those that are on the donor’s list but have run out of stock before the next scheduled day

of delivery. To order drugs from the district health office exact quantities are requested but

ordering for drugs from the donors is done through writing reports on the amount of drugs

used monthly: based on the report the supplier will quantify the amount of drugs the health

centre should receive and sends them directly to the health centre. Direct delivery to health

centres contributes to an apparently smooth procurement process. Hence it is important for

the manager to know how to estimate drug requirements for their centre and also to know


how to use drug management tools. Therefore; to find out about the manager’s ability to

estimate drug requirements and procure drugs as well as level of use of management tools we

used a structured non-disguised questionnaire (see appendix 2) i. e the purpose of the study

was not hidden from the participants.

Data Management and Analysis

Data was entered into Microsoft Office Excel 2013. Using Microsoft Office Excel 2013

we presented magnitude of stock-outs in a line graph with the trend being indicated by shape

of the line. Questionnaires were used to assess the pharmacy manager’s ability to estimate

drug requirements and procure drugs, also to assess the pharmacy store manager’s use of the

drug stock management support tools. For each section a pass was given only to those who

scored either a 3 or 4 out of the 4 questions asked, where a pass represented by a one

indicated that one is able to calculate drug requirements and procure drugs correctly or use

management tools depending on the section. Procurement skills and use of management tools

results were entered into Microsoft Office Excel 2013. Analysis to find the percentage of drug

store managers who were able/unable to procure drugs correctly and use management support

tools especially stock record keeping correctly was done using EPI INFO version 3.5 and

represented in frequency tables. After collection and grouping of the data we measured the

association between stock-outs (binary-yes/no) and the correct use of management skills and

support tools (binary-able/unable) using the Phi (correlation) coefficient.

Results

We set out to collect data from 24 health centres but due to transport constraints we only

managed to visit 23 health centres and of those 23, six of the managers were not present

during our visit, therefore only 17 questionnaires were filled.

0

10

20

30

40

50

60

70

80

90

100

N O V 1 1

D E C 1 1

J A N 1 2

F E B 1 2

M A R 1 2

A P R 1 2

M A Y 1 2

J U N 1 2

J U L 1 2

A U G 1 2

S E P 1 2

O C T 1 2

N O V 1 2

D E C 1 2

J A N 1 3

F E B 1 3

M A R 1 3

A P R 1 3 P

ERC

ENTA

GE

OF

HEA

LTH

CEN

TRES

WIT

H S

TOC

KO

UT

MONTH-YEAR

F I G U R E 1 : M A G N I T U D E A N D T R EN D O F L A S T O C K - O U T S

6 Tab 12 Tab 18 Tab 24 Tab All within 1 month



Month NOV 11

DEC 11

JAN 12

FEB 12

MAR 12

APR 12

MAY 12

JUN 12

JUL 12

AUG 12

SEP 12

OCT 12

NOV 12

DEC 12

JAN 13

FEB 13

MAR 13

APR 13

Range (days)

17-19 1-9 6-31 2-19 1-27 2-30 1-20 2-30 9-27 1-16

10-13 1-10 1-17 1-5 3-7 1-28 3-21 1-26


Month NOV 11

DEC 11

JAN 12

FEB 12

MAR 12

APR 12

MAY 12

JUN 12

JUL 12

AUG 12

SEP 12

OCT 12

NOV 12

DEC 12

JAN 13

FEB 13

MAR 13

APR 13

Range (days)

3-18 2-9

1-31 2-20 1-29 3-30 2-27 2-20 3-28 3-28

12-27 2-11 1-7 9-16 1-9 3-24 1-31 1-28

18

4

16.2

8.8

14.5 15.4

8

12.2

15.8

8.8

11

5.5

8.3

2.8 4.7

7.4

12 13.2

NOV11

DEC11

JAN12

FEB12

MAR12

APR12

MAY12

JUN12

JUL 12 AUG12

SEP12

OCT12

NOV12

DEC12

JAN13

FEB13

MAR13

APR13

Du

rati

on

of

sto

ck-o

ut

(day

s)

Month-Year


11.3

5

13.8

10.6 12.3 11.9

14.7

9.2 11.3 12.5

19.5

6.5 3

12.3

5

13.4

17.9

11.1

NOV11

DEC11

JAN12

FEB12

MAR12

APR12

MAY12

JUN12

JUL12

AUG12

SEP12

OCT12

NOV12

DEC12

JAN13

FEB13

MAR13

APR13D

ura

tio

n o

f st

ock

-ou

t (d

ays)

Month-Year




Month

NOV 11

DEC 11

JAN 12

FEB 12

MAR 12

APR 12

MAY 12

JUN 12

JUL 12

AUG 12

SEP 12

OCT 12

NOV 12

DEC 12

JAN 13

FEB 13

MAR 13

APR 13

Range (days) 7-30 1-31 1-31 2-20 2-29 3-30 2-30 5-30 1-29 6-30 2-30 1-20 1-13 2-16 1-10 5-24 3-31 4-26


Month

NOV 11

DEC 11

JAN 12

FEB 12

MAR 12

APR 12

MAY 12

JUN 12

JUL 12

AUG 12

SEP 12

OCT 12

NOV 12

DEC 12

JAN 13

FEB 13

MAR 13

APR 13

Range (days) 1-21 1-15

2-31 1-19

1-29 1-30 4-26

1-25

2-26 7-25

8-27

3-20 1-23 1-19 1-31 1-28 1-31 1-26

15.5

12.2

16.3

8.6

16.8

20.6

13.9 15 15

17.1 15

12.9

8.4 10.3

3.8

12.9

17.7 16

NOV11

DEC11

JAN12

FEB12

MAR12

APR12

MAY12

JUN12

JUL 12 AUG12

SEP12

OCT12

NOV12

DEC12

JAN13

FEB13

MAR13

APR13

Du

rati

on

of

sto

ck-o

ut

(day

s)

Month-Year


11.1

8

17.1

7.9

14 14 14.1

10.4

13.9

19.3

16.2

10.5

6.9 8.2

9.7

13.7

17.8

13.1

NOV11

DEC11

JAN12

FEB12

MAR12

APR12

MAY12

JUN12

JUL 12 AUG12

SEP12

OCT12

NOV12

DEC12

JAN13

FEB13

MAR13

APR13

Du

rati

on

of

sto

ck-o

ut

(day

s)

Month-Year



Table 5: Section A was used to measure the pharmacy stores manager’s ability to

measure drug requirements and procure drugs. (0 represents inability)

Table 6: Section B was used to measure the manager’s use of drug management tools (0

indicates inability)

Using Epi-Info we found r2, the correlation coefficient between the number of stock-outs and

the ability to use management skills and support tools, to be 0.03.

Discussion

The trend of stock-outs

General overview of the trend of the stock-outs shows that the number of health centres that

experienced stock-outs is high within the period February to May while the numbers

plummet during the months of September, October and November (figure 1). This

observation corresponds with the annual pattern of malaria incidence in Malawi as reported

by the Health Management Information Bulletin annual report for July 2005 to June 2006

(see Appendix 3) (18). This clearly demonstrates that during periods of high malaria

incidence there is also an increased number of health centres that experience LA stock-outs.

The Magnitude of stock-outs

The highest reported number of health centres that experienced LA 6 tablets stock-outs is 15

(65.2%) which was in March 2013 with the lowest being 2 (8.7%) in the months of

November 2011 and October 2012 (figure 1). The duration of the stock-outs for March 2013


averaged 12 days and ranged from 3 to 21 days. During the 18 months the monthly average

duration of stock-outs ranges from 2.8 to 18 days (figure 2).

16 health centres (69.6%) experienced LA 12 tablets stock-outs in February 2013 and March

2013 respectively while the lowest number of health centres that experienced LA 12 tablets

stock-outs is 2 (8.7%) in September and October 2012 (figure 1). The duration of the stock-

outs for February and March 2013 averaged 13.4 (range 3-24 days) and 17.9 days (range 1-31

days) respectively (figure 3, table 2). During the 18 months the monthly average duration of

stock-outs ranges from 3 to 19.5 days (figure 3).

18 health centres (78.3%) had LA 18 tablets stock-out in March 2013 and the lowest number

of health centres to experience LA 18 tablets stock-outs is 6 (26.1%) which was noted in

September 2012, December 2012 and January 2013 (figure 1). In March 2013 the duration of

LA 18 tablets stock-outs averaged 17.7 days (range 3-31 days) and the monthly average

durations ranges from 3.8 days to 20.6 days for the 18 months period (figure 4, table 3).

The highest reported number of health centres that experienced LA 24 tablets stock-outs is 20

(87%) which was in March 2013 with the lowest being 4 (17.4%) in the month of December

2011 (figure 1). The duration of the stock-outs for March 2013 averaged 17.5 days and

ranged from 1 to 31 days (table 4). During the 18 months the monthly average duration of

stock-outs ranges from 6.9 to 19.3 days (figure 5).

In March 2013 13 health centres (56.5%) experienced a stock-out in all the LA packs within

the same month while in October 2012 no health centre (0%) experienced a stock-out in all

the LA packs within the same month (figure 1). Overall, 18 health centres had a stock-out

within the same month at some point within the 18 months.

Pharmacy managers’ ability to estimate drug requirements and procure drugs

Out of the 17 pharmacy store managers interviewed 8 demonstrated to be unable to estimate

drug requirements and procure drugs. This represents 47.1% at 95% confidence level. This

means that 47.1% of the participants passed less than 3 out of the 4 questions.

4 (23.5%) of the participants did not know how to calculate drug requirements

(quantification) and 8(47.1%) of the participants did not know how to calculate reorder

levels. 7 (41.2%) of the participants reported to have rarely applied the principle of lead time

when ordering drugs and 11(64.7%) do not compensate for discrepancies (inadequate

quantity supplied as well as broken or missing tablets and packs) when ordering drugs.

Pharmacy managers’ use of the drug stock management support tools

Out of the 17 pharmacy store managers interviewed 1 demonstrated to be unable to use the

drug stock management support tool of record keeping. This represents 5.9% at 95%

confidence interval. This means that 5.9% of the participants passed less than 3 out of the 4

questions.

While all the participants (100% at 95% confidence interval) have stock card daily use

records in their pharmacies 2 (11.8%) of the participants do not enter data as frequently as

they should i. e after every transaction in the drug store. All the participants keep documents


from past transactions but 17.6% of the participants accidentally lose some of the documents

kept within less than three years.

Association between management skills and stock-outs

R which is the measure of association or relationship between poor management skills and

stock-outs is 0.17. This shows that there is an association between the two but it is quiet weak

(because R is not close to one). The correlation coefficient (R2) is 0.03; meaning that only 3%

of the stock-outs can be attributed to poor or lack of management skills.

Conclusion

March 2013 is the month that experienced the most stock-outs in all categories and we

continue to experience large number of stock-outs in the months of February to May despite

existence of evidence that this is the period with highest malaria incidence in Malawi since

2006 (18). None of the months within the 18 month period under study had a zero stock-out

in any of the LA packs. Close to half of the participants (pharmacy managers) had problems

with estimation of drug requirements and procurement mainly in the areas of use of lead time,

calculating reorder levels and compensation of discrepancies. Most of the participants have

good record keeping practices although accidental losses may occur once in a while.

Our research findings show that there is weak association between ability to use management

skills and support tools and stock-outs. This suggests that there are other factors that

contribute to the stock-outs. Although our focus was mainly on management factors,

participants reported that inadequate LA quantities delivered by the supplier in relation to

demand, frequent stock-outs at the district health office drug store and delayed transportation

were some of the contributing factors to the stock-outs.

Recommendations

Since the trend shows an increase in stock-outs with increasing incidence of malaria we

recommend forecasting methods be revised with emphasis on use of current data on the

pattern of malaria incidence in Malawi. We also recommend that the size of the catchment

areas of some of the health centres should be revised due to the magnitude and frequency of

some of the stock-outs.

Considering that most health centres reported transport delays as one of the causes of the

stock-outs we suggest that measures should be taken to ensure timely delivery of drugs

ordered from the district health office drug store. Since the DHO orders drugs from the

central medical stores and then distribute them to health centres, this could be a reasonable

bottleneck in the supply chain. Hence we suggest direct delivery of drugs from the central

medical stores to the health centres.

With regard to ability of the pharmacy managers to use management skills we recommend

further training in basic requirements estimation and procurement skills i. e quantification,

use of lead time, calculation of reorder levels and compensation for discrepancies.

We also recommend improvement of document storage through the use of storage cabinets.


Lastly we recommend that further studies should be done to closely look into other possible

factors leading to stock-outs e. g financing programs, transport delays and outdated

information on size of the catchment area.

Acknowledgements

We would like to extend our gratitude to the following for their contribution to our study; our

supervisors Mr R Mwale and Mr W Chalira, The Blantyre District Health Office for the

authorization of the research and assistance, Health Centre managers, Mr Kumitawa

(Statistician) and the undergraduate research coordinator – Sarah White.

Appendices

Appendix 1: Data recording form

Code Number of Health Centre ………………………… Date: …………………………

Where LA drugs were available throughout the month tick

Where LA drugs were out of stock on any day of the month cross out (duration in brackets)

LA Pack

Month

6 tablet pack 12 tablet pack 18 tablet pack 24 tablet pack

Sep-11

Oct-11

Nov-11

Dec-11

Jan-12

Feb-12

Mar-12

Apr-12

May-12


Jun-12

Jul-12

Aug-12

Sep-12

Oct-12

Nov-12

Dec-12

Jan-13

Feb-13

Investigators

Vongaishe Tailosi ………………………………………………….

Thuboy Blessings R ………………………………………………….

Appendix 2: Questionnaire for health centre management

Code Number of Health Centre ………………………… Date: …………………………

Section A:

This section is addressing the ability of the pharmacy store manager to estimate drug

requirements and procure drugs.

How do you calculate drug requirements?

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

How do you estimate reorder levels?

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Do you use lead time when ordering new stocks?

Always Sometimes Never


Comments

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

………………………………………………………………………………………….

How often do you compensate for discrepancies in drugs supplied from the

central medical stores?


Comments

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Section B:

This section is addressing the quality of the pharmacy store manager’s use of drug

management tools.

1. Do you have stock cards daily use records in the pharmacy store?

Yes No

Comments

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

2. How often do you use of stock cards daily use records?


Comments

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

3. Do you keep documents from the past transactions?

Yes No


Comments

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

4. If yes, please specify for how long you keep documents from the past

transactions.

…………………………………………………………………………………………

…………………………………………………

Comments

…………………………………………………………………………………………

…………………………………………………………………………………………

…………………………………………………………………………………………

Investigators

Tailos Vongaishe M ………………………………….

Thuboy Blessings R …………………………………..

Appendix 3: Graph showing incidence of Malaria in Malawi (reproduced from the Ministry

of Health Health Management Information System Bulletin Draft July 2005 to June 2006 (18)

References

1. USAID-Malawi. Malawi Malaria Operational Plan. FY 2013. PRESIDENT’S MALARIA

Figure 25: Malaria cases by month, Malawi Jul 2005 - Jun 2006

0

50,000

100,000

150,000

200,000

250,000

300,000

Jul-05 Aug-05 Sep-05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 Apr-06 May-06 Jun-06

Malaria under 5 years - new Malaria 5 years and older - new


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Health Management Unit; July 2005 - June 2006.

Title THE MAGNITUDE AND TREND OF ARTIMETHER–LUMEFANTRINE (LA) STOCK-OUTS AT PUBLIC HEALTH CENTRES...

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