Welcome to our course on Understanding and Strengthening Health Systems for Global Health. During the course we will provide you with an overview of the main elements or building blocks of a health system based on the World Health Organization’s guidance. You will have the opportunity to explore four main areas of health systems in global health with particular reference to low and middle income countries. The first area focuses on understanding health service organizations, the challenges. Our second module looks at WHO’s six major building blocks or health systems components with particular reference to primary health care and the need for community participation in planning, delivery and assessment of these systems components. in our third module we examine the specific systems component of human resource development and capacity building. The fourth area consists of health policy making and advocacy with stakeholders. This course is geared toward learners who are already involved in managing health and development programs on the ground in low and middle income countries or who are preparing for such a management role. The main lectures will span a four-week period with approximately 2-4 hours of viewing learning materials per week. We have one peer graded essay wherein you will use skills in ‘organizational’ diagnosis to better understand a challenge in an organization where you are or have worked. There are also quizzes. We hope you will engage with your fellow learners in discussion forums to learn from each other.
Procurement and Flow of Commodities to the Community
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From the course by Johns Hopkins University
Understanding and Strengthening Health Systems
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From the lesson
Health Systems: Basic Functions and Building Blocks
The World Health Organization has described six major components or building blocks of a health system. In this module we will examine those components and delve more deeply into the aspects of financing, commodities and service delivery, especially through Primary health Care. We examine a ‘missing’ component, community systems.
Meet the Instructors
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
So now we're going to look at the procurement and
flow of commodities to the community.
As mentioned, what we're dealing with in community health worker programs is
usually an extension or part of the public health service.
Before, when we talked about the medicine sellers,
we were talking about the commercial private sector.
But now we're talking more about the public sector.
And in most countries, of course,
there's a central medical store where supplies come in.
Whether they're supplies that are purchased by the ministry of health,
whether they're supplies that are donated by NGOs or other agencies.
And then from that central medical store, they need to be shipped out to states and
regions, further out to districts, and from districts to the health facilities.
And ideally, it's at the health facility level where the communities
collect their supplies that their community health volunteers will use.
So this is a bit of a long process, but it's important to plan this.
We've had situations at the frontline health facility level where they say,
we have a challenge of having enough drugs to even
treat the patients that come in let alone giving more drugs to the community.
This gets back to the need of proper forecasting of the total needs.
The health center may only be treating half or
less of the people who have problems.
The rest are out there in the community finding alternative ways of
handling their health problems.
So if community health workers are involved,
the staff at the health center need to incorporate the potential
breach that they can have into their forecasting and ordering for new drugs.
Countries have different systems.
You can have a system where a health center puts together its request and
it's packaged for that health center and sent out from the central,
or regional, or state stores.
Sometimes you have a situation where the districts do their own procurement and
they put tenders out and get suppliers to provide them the medicines.
And then from there, they distribute it to the health centers.
You have various things like push and pull systems that people talk about.
Where as standard supplies are pushed out, the same number,
whatever, to every health center.
Versus the pull system, where proper forecasting is used so
that health centers estimate what they really need and request that.
All of these ultimately raise the question of, do we get enough
medicines at the facility level so that after the health
staff at that frontline health facility have trained community volunteers,
they can also guarantee that they have enough stock in their storeroom to
give out to the communities for frontline community case managers?
So what we've often seen though is that the health commodities for
community interventions can flow through both the public and the private channels.
We've had situations where community and
health volunteers do not have enough medicines.
And so they may band together and purchase from a large medicine shop to supply
themselves until government gets back on its feet in terms of the supply chain.
Regardless, each country is different, so we have to figure out whether there
is a national supply system or there is a local
system where districts put in tenders and procure from the private sector.
Or sometimes there's a mix.
We find that in some districts they may procure some things from the state or
regional medical stores.
But when they're out,
they may then put out a tender to get other things from the private sector.
This takes careful planning, careful observation,
careful support of districts to ensure that they get the supplies they need.
Not just for the health facilities based on the clientele that come there,
but also the health facilities with the additional estimations needed for
the village health workers that have been trained.
Another issue that comes up that may affect the supply
is that in some countries commodities are manufactured locally.
There's a strong pharmaceutical industry in the country.
And in other countries, the supplies are imported.
When they're imported, of course, that opens up an extra hurdle for
getting things in in a timely manner.
There may be disagreements between the ministry of health and
the customs about what duties should be paid or not.
And sometimes medicines can sit in a warehouse at the airport or
the port for a long time.
So this is a challenge that needs to be worked out.
The people in the village may not know why
the village health workers' drug box is empty.
Again, if this kind of program is being set up, the people involved need to look
at the whole flow of commodities to ensure that the community does get its supply.
Ultimately, these supplies will reach the village health worker.
They should have a nice box that can be locked where they keep things in order.
Regardless of whether these are the oral rehydration solution packets, or
the malaria drugs, or often approved antibiotics that they can give.
Whatever system of whatever commodities are used, we must
ensure that they move somehow from the point of manufacture to the point of use.
Again, the community members are responsible also.
It's not just the job of the community health worker, but
the community members themselves must be vigilant and supportive to ensure that
the community health worker has the supplies he or she needs.
That they're kept in a safe way, and that the community health worker submits
their regular, often monthly, summaries so that they can get new supplies.
In a number of projects we've worked on,
the community health worker saves the empty packet of the medicine.
Whether it's a packet of malaria drugs for children, whether it's a packet or
intermittent preventive treatment for a pregnant woman, whatever it is,
and brings them back to the health center to exchange for new packets.
This is a good way of keeping records and
verifying that the summary that the village health worker submits,
the records match the actual medicines that were used.
Again, the proper estimation is our biggest challenge to prevent stock-out
of our essential medicines.
Records, even at the village level, they may have to be simple, they may be tally
sheets, because some of the village health workers don't have much formal education,
but there needs to be a way of determining how many medicines were used.
And in some medicines, like the malaria medicine,
there are four different packets for different age groups.
Often starting under 2 years, under 5 or
6 years, up through maybe 12 years, and then beyond as adult.
So we need not just to say how many people were treated but
which size packets and age groups were treated.
So without this information,
it's difficult to make estimates of how many new products you need.
The initial quantification is probably the more challenging.
Once you start using medicines, once you start treating people in the community,
you have records to go by.
But what about the initial quantification?
And this is why With the community-directed intervention approach,
one of the first steps is the community developing its census and
actually converting that into a register.
So on the register, each family has a page.
So when you look at that, you can estimate,
what are the number of pregnant women in the community at any given time?
What are the number of children below school age at any given time?
So you can use those population estimates to help you make
your first initial orders.
So these are important skills that the community health worker and
the community members need to learn, and back to the basic issue of supervision.
The frontline clinic staff not only trains
community volunteers in proper management of these common illnesses, but
also trains them in terms of the management of the medicines,
how to keep them safely, how to forecast the needs.
A key thing that must be done to set up any kind of community health
worker program is mapping, knowing where the villages are.
And we found in most clinics in Nigeria, the nurse in charge has hand drawn
a map that shows the different [LAUGH] villages that come to her clinic.
And therefore, she knows how to reach out to those villages
to discuss with the leaders about getting involved in a community
distribution of essential commodities program.
Then clearly, they may also benefit from some census data,
that may or may not be completely accurate, but oftentimes, for
these catchment areas for the villages, there can be supplementary census data.
But the key thing is to know, what are the villages,
where are they located, that actually come to that clinic.
That way it'll help the nurse not only reach out to get trainees and
supervise them, but also give her a good idea of the potential size of
her catchment area and how many of each type of drug should be ordered.
Again, we recognize that the clinic may not be treating
most of the people who are in need.
But by reaching out to the village, getting these village registers going,
the nurse can learn more about procurement requirements for the whole catchment area,
not just for whoever walks into the clinic.
So again, the simple steps for
this forecasting, start with having a community census.
So, you know the number of people who need services, but you know them by age group,
you know whether they are pregnant or not, so this can help with the different
kinds of medicines to estimate the maximum need might be.
It's important for forecasting the need for insecticide treated bednets.
What we know is that the goal for
any kind of campaign is one net for every two people.
But where are those two people?
The village register, organized by the villagers and their community health
worker will let us know because they have a page in their register for each family.
We also need to provide bednets for every pregnant woman.
Even beyond the normal campaign distribution of one net per two people,
we should ensure that a pregnant woman gets a new net as soon as possible,
because this is a good way of protecting her.
We know that if we're doing this intermittent preventive treatment of
malaria and pregnancy, we know that it would start at 13 weeks.
If the woman gets a monthly dose of this, a full treatment dose on a monthly basis,
so she comes in the very early part of the second trimester,
she may be able to get three, four, even five, sometimes, doses.
So, knowing the number of pregnant women will help forecast the need for this,
the IPT, if the health system has set it up on a community basis.
And again we need to alternately, as time goes on, recognize the case management
from malaria is based on the estimated number of people who get malaria.
We know that small children may get malaria three or
four times a year, older children and adults may only get it once a year.
One thing in terms of forecasting the malaria tests,
the diagnostic test, is that we go beyond the number of cases.
Because we want to test every suspected malaria case which means, at minimum,
every case of fever.
So we need to estimate how many people have complained of fever
in our summary reports and our statistics.
So we would probably, depending on the season and
the level of endemicity in community, we could order double or more
the number of diagnostic kits compared to the number of actual malaria treatments.
So these are some of the skills that need to be taught
to the village health workers but also of course to the frontline health facilities.
So that they can do their own estimations, and
they can train the village health workers to order the right amounts of medicine.
The process of distributing for the community, and again,
I'm using the example of our community directed intervention,
is that the commodities for the villages in the Catchman area that the nurses map,
should be available in a safe place.
Properly organized shelves and everything at the nearest health facility.
The staff at the health facility would have reached out,
gotten the community involved.
The community would have selected the volunteers.
The staff would have trained them and
the staff is going to be supervising them on a technical basis.
One thing that we found is very helpful is a monthly meeting.
Yes, we want the nurse to go out to every village, as often as possible, but
that may not solve all the supervision problems.
So if the village health volunteers, the community distributors,
whatever, come to the health facility once a month, not only can they receive
refresher training, supervision, discussion of problems,
problem solving, but they can get new stocks of their basic medicines.
Like I said, we've encouraged many communities that
the volunteer bring in the used packets of these medicines to present.
So you bring your monthly summary sheet to the monthly meeting,
you bring the empty packets to the meeting.
And so in addition to any refresher course,
any supervision in problem solving, if you also use that meeting
to get stocks from the health facility where they're kept.
And so this seems to have been a very valuable opportunity for
a number of program support activities, these monthly meetings.
Storage in the community, we stress this but we can't stress it enough.
We want to make sure that each community health worker
does have a safe place to lock up their medicines.
We want to make sure that they keep it in a place in their home
that the temperature is not extreme.
That children or goats or other animals cannot get to these medicines.
That they will not get wet, that they're not exposed to sunlight or heat.
So these are some of the things that should go into the training
of the community health worker.
As we said before, the staff at the facility need to be trained on proper
storage and management of their supplies, and
they need to pass this training on to the village health worker.
So it's not just enough to train them on the management of the disease.
They must know how to manage their medical supplies.
Including of course the forecasting element that we've talked about.
When the stocks actually come in.
This was the case for ivermectin, for example.
It was an annual distribution.
And when the community had collected the drug, and it was with the community health
worker, they would announce to the community the drug was available.
The same can happen for
other supplies, in terms of letting the community know that bed nets have arrived.
Encouraging the community to come and
get malaria treatment because the stocks are available.
So this is the type of communication that must go on in the community.
So the community feels an ownership of these supplies, uses them appropriately.
And then the community health worker is in a position to keep the records,
submit them on a monthly basis, and collect the supplies for replenishment.
As we've said, it's important for the community health worker to keep
the community informed about the availability of commodities.
Again, figuring out the distribution system for the ivermectin,
as we said before, the community has decided someone to do house to house,
someone to have a central location.
Some do a combination.
They do a central location and
they do follow-up house to house people who were not there.
The commodities for malaria,
you could certainly go house to house to distribute nets.
But oftentimes, it's probably more appropriate for
people to come to the house of the community health worker when the child or
any other family member needs malaria treatment.
Often, home visits are important because then you discover their challenges.
So the community needs to work out how they want to access and
what is the most acceptable way for doing that.
We can't overstress the partnership that should
develop between the health center and the communities
when we're doing community case management, community prevention programs.
The same people who train the community health workers then become supervisors.
Ideally, they should visit the village.
Work together with the village health worker.
In the picture here, one of the supervisors is showing the village health
worker about checking for anemia in a child.
And then the village health worker will practice that.
Just as a refresher, the supervisor can check what medicines are in the drug kit,
how it's being kept.
The village health workers can share their concerns with the supervisor.
The supervisor meet with village leaders to see if there are any concerns.
We've had situations, for example, where the village leaders will complain,
the person to we selected is not very bright.
He doesn't seem to manage the things correctly.
And then when the supervisor say, okay, you selected him.
Why did you select him?
We felt sorry for him because he had gone off to the city to find work and
he couldn't.
And he came back home and just started farming.
But he's been very good at anything, and so we thought we would help him.
And then the supervisor asks,
well, how is that helping you [LAUGH] if he doesn't do the job well?
And then they realize they probably need to select someone else.
Another aspect of supervision is when the supervisor arrived in one village and
they said, our neighboring villages, they're getting these medicines but
our village health workers always complain that the medicines are out of stock and
we don't understand.
So the supervisor monitored what was happening and found out that those village
health workers were taking the medicines and selling them in the market.
So once the villagers learned about this, they fined the two
community health workers a goat to be eaten by the community.
And then they quote, unquote fired them and select a new.
So the importance of visits to supervise and
find out what's happening to the medicines,
what's the community attitudes are, what support is being given is very important.
And as we said, when we come together for our monthly meetings,
this is a good time not only for supervision by the health worker but
also peer supervision and peer problem solving.
Where the village health workers, together, can discuss what their needs and
problems are.
So in summary,
we found that communities are very capable of managing essential medicine supplies.
The big question of sustainability exists.
Because even if they're willing, even if they're able to treat and
manage these conditions, it's imperative for the health system to
guarantee that supplies of essential medicines reach the community.
Again, all the way from the manufacturer down to the community level,
looking at all the different places where there could be a challenge.
Figuring out all the different solutions to transportation.
Making sure there's proper forecasting to begin with, so you don't run out of drugs.
So these are some of the issues that the health system as a whole needs to address
in order to support the community in its efforts to provide accessible healthcare.
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