Summary

The activities proposed within this area are aimed at overall capacity-building and support for the Central

Medical Stores (CMS) system to better procure, supply, and manage the distribution of HIV/AIDS-related

commodities such as HIV test kits, drugs for Opportunistic Infections (OI's) and ultimately antiretrovirals

(ARV's) to points of service. The DELIVER Project will second Regional Logistics Officers (RLO) to provide

support to the District and Service Delivery Points (SDP) levels; and support targeted minor improvements

to commodity facilities when needed. In addition to the activities focused on CMS, the project also

proposes to develop a supply chain logistics Pre-Service Training Curriculum with local partners, including a

component for handling of HIV/AIDS-related commodities.

Background

The role of CMS is the procurement, storage, and distribution of public medical supplies. Under the health

Sector Wide Approach (SWAp), the Ministry of Health and its collaborating partners recognize the need for

efficient reforms of the drug and supply system to improve access to drugs and are committed to, among

other things, improving stock management controls and strengthening accountability mechanisms at CMS

and RMS. The USG through the DELIVER Project has been supporting supply chain system strengthening

since 2000 with special focus on the lower levels of the distribution system using reproductive health

funding. This is a wrap-around project that combines EP funding with PMI and reproductive health

resources to build an integrated supply chain management system within the MoH.

Under the DELIVER Project, USG funds were used to computerize processing of MoH logistics data from

400+ service delivery points at 26 district-level facilities using Supply Chain Manager, which was in turn

used to order electronically contraceptives, sexually transmitted infection (STI) products, EHP drugs, and

other products from the RMS's. Use of the computerized system resulted in improved availability of

contraceptives and information for decision making for other essential drugs at the SDPs. In the first year of

the DELIVER Project, the USG funds had been used to assist the MOH including CMS to use effectively

the available information to guide their forecasting and quantification exercise for selected drugs and

medical supplies.

With FY 2008 EP funding, the DELIVER Project will provide assistance at the national and regional levels to

strengthen the capacity of CMS to manage and distribute HIV related commodities like HIV Test kits, OI's

and eventually the system will have the capacity to support management of ARV's which until now are

managed through a parallel system. The activities will also contribute to ensuring continuous, uninterrupted

and adequate supply of approved quality and affordable HIV/AIDS commodities.

Activity 1: Secondment of three Regional Logistics Officers

The first activity under this is to support the logistics function at Malawi's three Regional Medical Stores by

seconding a Regional Logistics Officer (RLO) to each office. The Regional Logistics Officer will be

responsible for maintaining a sound, efficient, and effective drug storage (warehousing) and distribution

system for all commodities, including HIV/AIDS-related commodities, handled by the RMS. In addition,

he/she will provide direct support to districts and health centers through constant supervisory visits and on-

the-job training to ensure that drugs are requisitioned, stored and issued/dispensed properly. The RLO will

prepare and submit regular (monthly and quarterly) progress reports to the Pharmacist In-Charge for

onward submission/transmission to the Director.

These positions are a continuation of positions created in 2007, and will eventually be funded from within

CMS.

Activity 2: Curriculum development

The second activity will be to develop a Pre-Service Curriculum for Pharmacy Technicians, Nurses, and

other Service Delivery Point (SDP) workers. The curriculum will focus on integrating a logistics module/unit

into the training programs for each group, focused on Standard Operating Procedures for HIV/AIDS-related

and other health commodities. This curriculum follows the National Training Strategy developed by the

project in 2007, and will be developed in partnership with the appropriate units at the Ministry of the Health,

the national universities, pre-service trainers, and non-university training programs.

Key components of the proposed curriculum will include:

• Introduction to basic principles of supply chain logistics for health commodities

• Overview of Malawi's supply chain for HIV/AIDS-related and other health commodities

• In-depth, position-specific training on forms for ordering, reporting, and record-keeping

• Storage requirements for ARVs, test kits, and other commodities

• Training on Supply Chain Manager and other LMIS software as needed for district-level pre-service

personnel and pharmacists

• Testing and evaluation criteria for the module/unit

Activity 3: Storage improvements

The third activity in the area is general storage improvements for facilities at the RMS, District, and SDP

levels with specific focus on the improvements required for improved management of ARVs, HIV/AIDS Test

Kits, and Laboratory supplies. As part of the supervisory visits, Regional Logistics Officers (activity 1 in this

area), will also be asked to regularly report any areas in need of minor improvements. In addition, facilities

at any level reporting the need for minor improvements will be eligible for improvements on a case by case

basis, as requested by CMS. This could include, for example, shelving units or added security for high-

demand commodities.

Summary

Critical to any functional national laboratory system is a well-designed and managed supply chain system.

Malawi has encountered many challenges with the national laboratory system mostly resulting from a very

inefficient forecasting, procurement, and distribution system managed by the Central Medical Stores (CMS).

This program proposes a baseline assessment to discern the supply chain's present capacity to handle

laboratory supplies, as well as to identify any gaps in the system. Once the assessment has been

conducted, the information will be used to advocate for a comprehensive strategic plan and policy for

laboratory supplies, including a standardization exercise for laboratories that will provide the basis for a

laboratory logistics system redesign and an implementation strategy. In order to better facilitate all of these

activities, the project would also hire a dedicated focal person.

Background

While improved laboratory services was included as a vital element of Malawi's Essential Health Package

(EHP) in 2002, laboratory infrastructure development has lagged behind other components as national

implementation plans have moved forward. The DELIVER project's technical assistance (TA) has been

requested by the Ministry of Health (MoH) through the Health and Technical Support Services department

to implement more effectively this element of the EHP. Strengthening of laboratory supply chain

management also will support care and treatment programs, improving the laboratory infrastructure upon

which care and treatment depend. Once implemented, it is expected that these activities will help improve

laboratory services and thereby contribute to the success of the EHP.

Activity 1: Lab Focal Person

The DELIVER project will recruit and place a locally-based Laboratory Focal Person (LFP) to provide in-

country support and activity monitoring. The LFP will serve as the main point of contact with the MoH and

CMS for laboratory-related issues. The LFP will directly monitor each of the activities outlined herein. If

necessary, the LFP will receive training in logistics and supply chain management to increase his/her

efficacy. The project will discuss the possibility of transitioning the LFP into a government position within

the MoH when proposing the position. In addition to the LFP, the Country Director and Resident Logistics

Advisor will also play a large part in conducting these activities.

Activity 2: Base Line Assessment

The DELIVER project will conduct a baseline assessment of the current supply chain capacity for laboratory

supplies management, using a laboratory assessment tool, ATLAS, in order to identify needs and gaps in

the system. As the current laboratory system has not yet undergone a full assessment, this activity will

provide essential information regarding context and system structure as well as informing all of the

additional activities planned for FY 2009. The system-wide assessment will include counterparts from the

MoH and CMS. To be initiated in early FY 2009, this activity will draw upon TA from both the local office

(Lilongwe) and headquarters (Washington DC) of the DELIVER project.

Activity 3: Lab Supply Chain Management

The DELIVER project will facilitate the development of a strategic plan and policy on laboratory supply chain

management issues. This will be through advocacy meetings and strategic planning sessions with key

stakeholders, including the MoH, CMS, Regional Medical Stores, District Laboratory Technicians, and

potential counterparts from the private sector. To ensure long-term commitment to policy implementation,

the formation of a laboratory logistics working group will be strongly recommended. As part of this activity,

drawing on members of the logistics working group, a standardization exercise will be conducted to provide

the foundation for future quantification and system design work.

Activity 4: National Forecasting

The DELIVER project will work with the MoH on a national forecasting exercise to estimate laboratory

commodity requirements and identify any funding gaps for the current and next fiscal year. This activity will

include TA from the local office (Lilongwe) and headquarters (Washington, DC) of the DELIVER project.

Representatives from the MoH, CMS, and other potential members of the laboratory working group will

participate in the exercise and assist in drafting a plan to help address any funding gaps.

Activity 5: Lab Supply Logistics System

The DELIVER project will design a national logistics system for laboratory supplies, in collaboration with

Regional Medical Stores, CMS, and the MoH. In addition to filling the gaps identified by the baseline

assessment (Activity 2), the new design will include special requirements for monitoring and handling of

those supplies that cannot be distributed with other essential commodities. Also, the system will incorporate

key indicators identified as part of the initial assessment for monitoring purposes.

Activity 6: Standard Operating Procedures (SOPs)

The DELIVER project will develop Standard Operating Procedures and a preliminary training curriculum for

system users in the handling and ordering of laboratory supplies. In conjunction with the curriculum, a

training roll-out plan targeting all District Laboratory Technicians, will be developed. A preliminary training

of trainers will be rolled out to at least one group of potential local trainers, identified from among local

laboratory technicians, the CMS, and Regional Medical Stores staff. A Performance Improvement

Specialist from the Washington, DC office will join local staff to help develop and give the training of

trainers. This activity will begin in FY 2009 with definite implications for continuation into FY 2010.

Summary

As part of the Deliver project's ongoing system strengthening work in Malawi, the project proposes to

develop the infrastructure and personnel capacity required to facilitate more timely data collection remotely.

In addition, the project will also address the need for updates to the District-level Supply Chain Manager to

meet the requirements of the HIV/AIDS system design from the previous year as well as the laboratory

system design proposed for 2008-2009.

Background

Despite computerizing (automating) management of information at district level country wide, through the

first Deliver Project using Supply Chain Manager software, the central level (Central Medical Stores (CMS)

and its Regional Medical Stores (RMS)) have maintained a manual information system where electronically

processed data at the lower level is handled manually at RMS and CMS level. It is against this background

that the following activities are being proposed to improve on availability of strategic information at the

central level to be used in decision making. The need to develop the MIS system at the Central and

Regional medical stores level stems from the fact that until recently CMS/RMS were not responsible for

managing the distribution of PMTCT supplies including test kits and other OI drugs. It is hoped that the

success resulting from these activities will facilitate integration of ARV's into the supply chain system, which

until now continues to be parallel.

As a result of the activities proposed under Strategic Information, with FY 2008 USG support, all 26 Health

Districts will have functioning internet connections in order to facilitate more timely data reporting and

transmission to the central level. In addition, Supply Chain Manager software will be modified to improve its

features on reporting and monitoring for HIV test kits, OI's and eventually, ARV's as well.

Activity 1: Logistics Management Information System

The first activity will be development of standardized recording, reporting and transaction forms that will be

used to collect information for program and planning purposes. The existing forms will be modified or

changed to take into consideration the introduction of HIV/AIDS related commodities like HIV test kits, OI's

and other related commodities into the Logistics Management Information System for both the service

delivery level and that of the regional and central medical stores. This will also necessitate modifications to

the existing supply chain manager software at the district level, to accommodate the new developments.

Activity 2: Supply Chain Manager Software

The second activity will be modifying the existing Supply Chain Manager Software (currently in place at all

District-Level facilities) to fully integrate all HIV/AIDS related drugs and medical supplies into the system, as

well as to develop any specific reporting requirements needed to help monitor and improve the system.

Though ARV's are currently managed in a parallel structure, they will be included in the reporting and

recording forms to make available consumption and other related information useful for decision making at

the central level.

Activity 3: Strategic Information

The third activity under Strategic Information will be to facilitate the districts ability to send data to the central

level remotely. Many of the 26 Health Districts in Malawi have no system put in place to enable information

transfer using the Internet, greatly increasing the amount of time it takes to send reporting and ordering

information to the Central Medical Stores and Regional Medical Stores. This activity will provide to districts

and if need be to central hospitals as well, phone lines and hand sets in the pharmacy to facilitate dial up

connections. However, since files to be sent through the email system will be bigger, software like WinZip

11.0 will be used to split files of bigger size into smaller sized files that can be sent over a dialup internet

connection with less difficulty. The activity will take advantage of the recently introduced MTL dialup system

which is freely available with no Internet Service provider fees attached.

Activity 4: Pharmacy Technicians

The fourth activity will be to train the pharmacy technicians and other cadres responsible for the

management of information at various levels in the supply chain to be able to use the internet in sending the

information to the central level.