Iramba health supply chain goes from failing to model system in Tanzania

Facilities are mentored and encouraged to conduct ongoing, in-house capacity building to ensure sustainability of effective reporting.
In 2009, key staff at Tanzania’s Ministry of Health and Social Welfare (MOHSW) and Medical Stores Department (MSD) declared the council health management team (CHMT) of the Iramba district to be one of the poorest performing teams in the country in the stock management of medicines and supplies. Shortages of supplies occurred in one part of the district and overstocks and expiries in another. Reporting of consumption to MSD was well below expectations. The politicians in Iramba echoed the cries of villagers who constantly complained about the unavailability of medicines, which in turn contributed to poor health services.

“First, we needed to identify the magnitude of the problem,” said Dr. Dorothy Kijugu, then district medical officer (DMO) for Iramba district, who has led the improvement of health service provision through better commodity management. Together with the CHMT, she conducted a baseline assessment, noting the situation in each facility.

"On July 13, 2010,” she said, “we visited one center, believed to be the best performing facility. The floors were sparkling clean, but we found expired medicines in the fridge.” The CHMT also noted a gap in skills on management of infection control. Moving to other facilities, they encountered similar challenges, finding no trace of patient or medicine records at one location. These results could have discouraged the team but at least three facilities of the 49 in the district were performing well—if these three could succeed, they reasoned, there must be a way for all to do so.

This new process produced instant results: reporting rates rose from an average of 2 percent to 100 percent.
A root cause analysis showed that the system was plagued with poor reporting caused, in part, by a lack of funds. For example,health facility representatives were forced to use personal monies to send reports to the district. Therefore, facilities did not send reports and, when they did, the reports were often based on incoherent data. Even available funds accessed through patients presenting membership with the National Health Insurance Fund (NHIF) were not properly collected.

As a first step toward improvement, the DMO allocated funds to facilitate reporting in the first quarter. The CHMT members were also required to countercheck the figures reported before accepting the report. Poor quality reports were penalized, requiring the responsible official to use his or her own funds to report. This new process held more staff members accountable and produced instant results:

• reporting rates rose from an average of 2 percent to 100
• all 49 facilities reported
• report quality improved.

In subsequent months, facilities were educated on fund management, proper documentation of dispensed medicines and, as with reporting, were required to track the funds generated from the services provided. In one quarter, one health center’s monthly collections increased from 80,000 TZS (U.S.$50) to 500,000 TZS (U.S.$300). Increased funding and improved reporting meant more funds were available to facilitate reporting and procure additional medicines not stocked at the Medical Stores Department (MSD).

Prior to the interventions, the CHMT played a passive role in medicines management, providing limited supportive supervision to the facilities. When it was conducted, supportive supervision focused only on commodities in the reproductive program and on HIV and AIDS commodities. CHMT members are now required to conduct more holistic supportive supervision visits.

District staff attribute their success to both a growing spirit of teamwork and to a new culture of ownership that holds all management team members accountable for their roles, especially in regard to report quality assurance. “Managers cannot perform alone, they need a strong team to support them,” commented Dr. Kijugu. The careful delegation of activities and roles has also been critical.

The USAID | DELIVER PROJECT, implemented in Tanzania by John Snow, Inc., designed the original integrated logistics system (ILS) for health commodities in Tanzania and continues to work with the MOHSW to improve and strengthen the ILS through monitoring, supervision, and assessments. Through funding from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), the Supply Chain Management System SCMS has developed facility staff skills in appropriate commodity management and the use of logistics tools.

Having learned to sustain its supply chain improvements, Iramba has been named a center of excellence for health commodity management by the project and SCMS. District representatives will continue to share their wealth of experiences with supply chain managers and staff in other regions throughout the country.