Democratize stock allocation for scarce pharmaceutical products

Frontline workers are overburdened with planning, stock requests and mitigating the impact of stock-outs and stock expiring on the shelves. While minimizing their level of effort, our solution democratizes allocation at the point-of-care through an integrated, reliable, and replicable model.

Cobus Rossouw, Vitalliance Chairperson

Stock-outs of essential medicines are very common. For instance, in the South African public healthcare system, the 2017 Stock Outs National Survey show that a third of facilities experienced a current or recent stock-out with 25% of stock-outs lasting more than a month. This issue is not unique to South Africa and is found across the whole of Africa.

This situation leads to a range of issues: stress for staff who feel powerless to help patients; patients not receiving treatment; staff resorting to sharing stock between clinics rendering stock visibility initiatives less accurate; clinical staff dedicating more time to stock management instead of attending to patients; poor access to healthcare is also widely acknowledged to push people into poverty.

Equitable distribution of stock becomes especially important where you have priority patient populations to treat with limited supply as can be seen with the COVID pandemic. The supply of medicines is not always symmetrical to demand resulting in a situation where there is not enough stock available in the right place at the right time resulting in the inability to treat a patient or having too much stock and risking to eventually have to dispose of stock.  

Ultimately our solution serves patients, making new treatments available as quickly as possible.  Directly this will help healthcare providers, avoiding stress of not being able to serve patients and waste of expired stock or the cost of repositioning.

Our target audience would be all points in the supply chain where a decision needs to be made regarding the distribution of stock. This could be at a national level for distribution to regional levels or it could be a regional level for distribution to points of care. Ideally it would be both. This applies to the private as well as public sector. The countries currently supported by the systems we seek to engage with include Angola, Benin, Côte d’Ivoire, Eswatini, Ghana, Guinea, Nigeria, Malawi, Mozambique, Rwanda, Tanzania, South Africa and Zambia.

We would seek to support thousands of locations in these countries to efficiently distribute millions of items of stock, particularly in periods of short supply. As part of the research phase of the engagement we will engage with the targeted countries and solutions to better understand their needs and constraints. During the testing phase (on OpenLMIS) we will consult with countries to test the relevance of the results. 

The public good of the solution would include the dissemination of knowledge through a research paper, documentation of the solution and the implementation of the methodology in service provisioned by an open source eLMIS solution (OpenLMIS) for the benefit of both current and future users. 

Equitable access – or transparent decision making is necessary to develop public trust in the system and drive participation of funders. This solution will provide humanitarian organisations also with a mechanism to know and plan how interventions related to access to medicines will be delivered and therefore improve impact of initiatives for the wider public.

The wider essential medicines delivery ecosystem in countries where this will be implemented will benefit from the creation of a technical function that ensures that large, disparate datasets can be interpreted and used for decision making on the distribution function. This will be available as open access systems and therefore is a public good.

OpenLMIS is the leading supply chain management platform on the market with a growing userbase. The system facilitates hundreds of thousands of stock and requisition-related transactions, with new countries added each year.

Open LMIS is a Certified System and was named a “Qualified LMIS Software Solution” in 2019 by Gavi and the Global Fund, i.e.  recommended for country use based on prioritized software standards. OpenLMIS is an approved Global Good for investments through Digital Square.

Proven outcomes achieve after the implementation of OpenLMIS for patients and front-line workers:

• Reduced stock-out rates:  Mozambique public health stockout rates dropped from 19% to 5%; Zambia’s noted significant decreases in both stockout incidence (Reduced from 32% to 23%) and stockout duration (24% to 15%).
• Save healthcare worker’s time: time to report supply chain data reduced from several hours to less than one minute.
• Promote alignment: 100% of deployments in partnership with national health ministries – aligning closely with national priorities and connecting adjacent systems.
• Improve data visibility enables demand-driven access to information.

The system leads to benefits for government and decision makers involved in the medicines supply chain:

• Promote alignment: 100% of deployments in partnership with national health ministries – aligning closely with national priorities and connecting adjacent systems.
• Improve data visibility enables demand-driven access to information.

Year 1: Development of the concept demonstrator: The first 6 months to year will focus on research for the methodology and publishing the research paper. After this a concept demonstrator will be developed to test the method through a use case. During the initial stage of the project the data quality and completeness of datasets will be evaluated for selection of the pilot implementation. 

Year 2: Piloting and evaluation of the solution: Over the course of the next year, we would apply the methodology in a pilot country and evaluate the outcomes achieved.

Year 3: Integration on LMIS countries: The stage will focus on OpenLMIS and its client base. This has the potential to impact millions of lives in multiple countries.

Should it be appropriate, and funding allows, we could start with the development of the methodology before the final paper is published to allow the gathering of statistics on the improvement of performance.  

Ultimately, we want to monitor the supply chain’s ability to provide appropriate care to patients. This is measured in availability of stock at the point of care.

The evaluation must quantify the effectiveness and performance of the system as well as the outcomes that have been achieved for patients and the Public Health System. It is important to develop a solid baseline in countries where this will be deployed.  

Process evaluation will focus on tracking progress of implementation through Log data analysis which is a rich quantitative data source for developing user insights to refine the solution over time. This can consider usage patterns (intervals of usage, deviation from intended use) through frequency, location, time, sequence and retention of users of the system (drop-out points, technology uptake and retention curve, phases of adoption).

Outcomes can be tracked through:

• Level and trends in stock-outs (broken down: type of stock; high to lowest, geographical locations).
• Level and trends in reasons for stock-outs and stock lost.
• Costs and savings to supply chain system through this solution.
• Estimate of patient health outcomes achieved as a result of the solution (DALYs).
• Estimate of patient economic outcomes achieved.
• Reduced waste and improved supplier management.

The current key challenge is policy. By executing and publishing the research we hope to frame more clearly the approach/methodology for policymakers. We fully expect there to be barriers in difference markets (cultures) and in the technical execution, but we feel comfortable we can overcome them. 

Large initiatives have been launched in terms of OpenLMIS for instance where whole countries utilise the technology. Implementation of these systems tend to be costly – also where implementation of visibility has been patchy and where different systems have been implemented – creating issues for interoperability, data security, cross border data sharing challenges.

Technical challenges include reliability, developing appropriate capacity in the system to utilise the technology and eventually and scaling the solution. Cost is also a challenge currently as it takes an inordinate amount of effort to collect even the most rudimentary of data at the clinic level.

Policy and institutional (“soft”) challenges include Interoperability; Security; Privacy; Data localisation; Access to data / Open data; Legacy regulatory models; IPR; Data sovereignty issues.

Implementation challenges can be overcome as we will tap into the collective skill and knowledge of Imperial Logistics (JSE Listed), Stellenbosch University and OpenLMIS partners to address these challenges.

Vitalliance 

Imperial Logistics

Department of Industrial Engineering, University of Stellenbosch

Department of Logistics management, University of Stellenbosch

In order to make this engagement successful we would need by-in from a few ministries as well as the trusted implementation partners. It would be our hope that beyond the financial support, the Trinity Challenge members would assist in:
• Encourage the participation and input from ministries/departments of health of target countries.
• Co-ordinate the engagement with the trusted implementation partners. 
• Provide for peer review of model.

Trusted partners involved in the country implementations including but not limited to:

• VillageReach
• USAID GHSC-PSM
• John Snow Inc.
• Guidehouse
• PATH

Critical to this would be the respective ministries/departments of health in the target countries.

We would be open to working with CHAI (Clinton Health Access Initiative) as a Trinity Challenge Member organization. CHAI has some background experience with digital supply changes and even with deploying OpenLMIS to solve health system challenges.