Realities From the Field

Supply Chain – Strengthening the Foundation of

Botswana’s Healthcare System Link by Link

Peace Corps Volunteer Panel DiscussionJune 16, 2015

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Agenda• Introduction of Panelists• Country Context• Supply Chain Successes• Supply Chain Challenges• PCV Interventions• The Way Forward

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PCV Panelist

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• Name: Marcy Frank• Site: Thamaga• Placement: Thamaga Clinic

Thamaga Facts• Population: 19,547• Thamaga was named

after the color of a horse

THAMAGA

PCV Panelist• Name: Camille “CJ” Jones• Site: Mochudi• Placement: Kgatleng DHMT

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Mochudi Facts• Population: 44,815• Mochudi was created

by a South African tribe escaping Boer oppression

MOCHUDI

PCV Panelist• Name: Tiphaine Monroe• Site: Gobojango• Placement: Gobojango Clinic

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Gobojango Facts• Population: 1,631• A young

entrepreneur just started the village’s first egg-selling business

GOBOJANGO

PCV Panelist• Name: Anna Payton• Site: Tsabong• Placement: Kgalagadi South

DHMT

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Tsabong Facts• Population: 8,939• Tsabong has a camel

park; one of the camels in this park was a gift from Qaddafi

TSABONG

PCV Panelist• Name: Marshall Washick• Site: Shoshong• Placement: Shoshong Clinic

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Shoshong Facts• Population: 7,490• Shoshong had an

estimated population of 30,000 people in 1866, which was about the same as the Cape Town population at that time

SHOSHONG

Country Context

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In the past 10 years, the USG has assisted the GOB in making incredible strides to strengthen its supply chain.

Nevertheless, recent challenges stemming from the MOH’s contract with Botswana Couriers have threatened the progress that Botswana has made.

Additionally, the USG has decided to only continue funding supply chain activities through TA for the time

being.

It is expected that Botswana’s supply chain will continue to worsen before the situation improves.

PCV & Supply Chain Survey

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Clinic & Health Team

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Local Gov-

ernment Capacity Building

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Life Skills6

NGO Capacity Building2

Assignment Areas of the “Botswana PCVs and Supply Chain” Survey Participants As the effects of the

supply chain are far-reaching, many PCVs in different assignment areas often work to support the supply chain in various ways at their sites.

Approximately 30 PCVs are currently working in this capacity – 28 of which responded to a survey about their observations of Botswana’s supply chain and how they support the supply chain at their sites. Their responses informed this presentation.

SUPPLY CHAIN SUCCESSES

Successes in Botswana’s supply

chain as observed by Peace Corps Volunteers

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Supply Chain Successes

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Yes No Skipped0

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4

6

8

10

12

1413

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3

Number of PCVs who have observed positive aspects of Botswana's supply chain at their sites (e.g., people get their drugs on time, a health facility staff member is trained on reporting, condom availability, limited number of expired

drugs, etc.)

Supply Chain Successes

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• High levels of condom supply and distribution

• Creative and discreet condom distribution techniques

• People are able to acquire ARVs most of the time

• Many pharmacists are trained in supply chain

PCV Observation“When there was a Condom Focal Person at the DHMT in 2012-2013, we distributed 1.7 million condoms as a district.”

PCV Observation“Access to ARVs is prioritized by healthcare providers. Pharmacists and technicians genuinely care about dispensing drugs to HIV+ patients and monitoring the supply of ARVs.”

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SUPPLY CHAIN CHALLENGES

Challenges to Botswana’s supply

chain as observed by Peace Corps Volunteers

Supply Chain Challenges

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Yes No Skipped0

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10

15

20

25

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Number of PCVs who have observed supply chain issues at their sites (e.g., drug and testing kit stockouts, transport

issues, expired drugs, etc.)

Supply Chain Challenges• Appropriate staffing to

demand is needed• Many clinic staff are not

trained in supply chain• Lack of ownership of supply

chain management responsibilities

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PCV Observation“Most of what I've observed was challenges with staff. Testing counselors would not show up to work or not be available to test people during office hours. Doctors sometimes also don’t show up.”

PCV Observation“Nurses and staff usually don't have channels to voice their complaints or issues. Many times it is their superiors who are not doing their jobs with the supply chain, so they have no one to speak to and often don't want to speak out, so no lasting changes are made.”

Supply Chain Challenges• Facilities often make up

inventory numbers or fail to report

• Lack of empowerment among health facility staff

• Unclear reporting expectations

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PCV Observation“A lot of facilities make up their inventory numbers or refuse to report at all, rather than reporting accurately because they feel that the MOH and ‘higher ups’ are always handing down new reporting methods and conflicting expectations.”

Supply Chain Challenges• Shortages of drugs

and commodities at CMS

• Shortages of drugs and HIV testing kits at the clinic level

• Expired drugs and commodities

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PCV Observation“We are constantly stocked out of things like basic antibiotics. Over the holidays, we were stocked out of ARVs for a few weeks. For several weeks we were out of blood pressure medicines as well, and we have had to admit several patients because of high blood pressure this month – likely as a result. I would estimate from my recent physical count that we are stocked out of about 20 different drugs. The drugs are generally not expired, but medical supplies that are not used as frequently often are (the oldest was from 2010).”

Supply Chain Challenges

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PCV Observation“Often there are no condoms, HIV tests, or basic medication to be provided to the clinics. The vehicles break down and can't transport medications/supplies.”

• Confusion as to where expired drugs are taken to be destroyed

• Delay in or absence of transportation for drugs and commodities

• Poor storage conditions for drugs

PCV Observation“I've noticed that testing kits that need to be kept refrigerated or at a certain temperature are left just on shelves. I am uncertain as to whether tests are done to ensure the viability of the batches of testing kits.”

PCV INTERVENTION

SInterventions implemented by PCVs to

address these challenges

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PCV Interventions

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• Create condom distribution targets for clinics to monitor supplies

• Teach IT skills to staff• Encourage paper

recording and reporting at facilities in addition to reporting electronically

PCV Observation“I have worked with the DHMT to create targets for condom distribution to individual facilities so that supply can be more easily monitored.”

PCV Observation“I’ve begun encouraging paper reporting so that all health facilities, even those without electricity or computers, can monitor supplies and properly report.”

PCV Interventions

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• Work with the DMSAC to resolve transportation issues

• Network with stakeholders to find alternative distribution routes

• Work with the DAC office to use its supply of condoms to supplement the DHMT’s limited supply

PCV Observation“I’ve offered to deliver condoms to outlying farms on my bicycle. It may not be a sustainable intervention, but it can assist in getting condoms to rural areas while the transport situation is being sorted.”

PCV Interventions

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• Mobilize staff to count inventory and check for expiries

• Train clinic staff on stock card issues and storage guidelines

• Implement additional methods for stock card tracking

• Create and modify recording tools to be more user-friendly for clinic staff

• Facilitate on-the-job trainings and refresher courses on taking stock each month

PCV Observation“I work to ensure that we have a day at the end of each month in order to do a physical count and make sure drugs and commodities aren't expired.”

PCV Interventions – Supply Chain Training

• Supply Chain Management Systems (SCMS) trainings– Training of Trainers

November 2014• 3 PCVs• 2 Counterparts

– Logistics Management Training February 2015• 19 PCVs• 2 Peace Corps Staff

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PCV Observation“I recently gave a short overview of the Supply Chain Management workshop I attended to the nurses at my clinic. I also implemented more methods for drug stock tracking - monitoring how many drugs are dispensed each month, how many are received, and what the current stock is. I stress the importance of this, especially in regard to ARVs.”

PCV Interventions – SCMS Committee

• SCMS Committee– The first committee of its

kind in Peace Corps worldwide

– Partner with MOH and health facilities to strengthen Botswana’s supply chain

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PCV Observation“Through my work with Peace Corps and supply chain management, I’m developing an intervention for correct stock card usage and easy-to-read storage guidelines. Next week I’m going to the DHMT to address more large scale problems there.”

The Way Forward

How PMT Can Support This Issue

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Suggestions for PMT

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• Support condom distribution

• Address the inconsistent and incorrect use of reporting tools

• Promote transport alternatives

• Strengthen and clarify communication channels between MOH, CMS, DHMTs, warehouses, and health facilities

• Support MOH’s maintenance of the Standard Operating Procedures for Logistics Management of Health Commodities and Related Supplies

• Address reporting of drug availability

You, the members of PMT, have the ability to set the agenda and influence outcomes. We suggest your

engagement to address the following:

Health Systems Strengthening

Suggestions for PMT

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Human Resource Issues• Train clinic-level staff on

supply chain, the importance of reporting, how to report, etc.

• Support the appointment of a supply chain focal person at health facilities

• Place a trained third-year PCV in the Logistics Management Unit

Infrastructure Issues• Bring attention to

infrastructure needs, such as the necessity of proper storage for drugs and testing kits

PCV Observation“Not everybody has been trained, yet the MOH seems to expect all clinics and health posts to be on the same page. Really unrealistic expectations, especially in light of storage challenges and lack of real support from those above.”

Questions for the Panelists

Ask a Peace Corps Volunteer

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Realities From the Field

RE A LEBOGA!

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