In 2010 when the Supply Chains for Community Case Management (SC4CCM) project conducted a baseline assessment of the community health supply chain in Malawi, we noticed two notable findings: very low product availability rates but high mobile phone ownership among community health workers – called Health Surveillance Assistants (HSAs). Like many countries at the time, Malawi was embarking on the ambitious task of tackling Millennium Development Goal 4 of reducing childhood mortality, but to do so, they needed HSAs trained to treat sick children in their villages, where there is the greatest potential to save lives, and a supply chain that could consistently deliver low-cost medicines to the community level. We worked jointly with the Ministry of Health and stakeholders to develop and implement a “game-changing” innovation that would lead to significant rather than incremental changes in product availability. From the data and our experience, we knew that poor logistics data visibility and weak coordination between HSAs, HFs and districts, were challenges plaguing the system. In identifying solutions, we looked for simple and affordable innovations so that uptake by HSAs could be fast and easy, scale-up was feasible, and the MOH could sustain the system and its costs after our project ended.
The innovation was cStock, a SMS-based and web-accessible logistics management information system that helps HSAs and HFs with reporting and resupply of up to 19 health products managed at the community level. cStock has streamlined the reporting and resupply process, reduced time for preparing and sending reports, reduced the travel burden and wait times of HSAs when collecting products, improved HF responsiveness to HSA orders, and most importantly, enhanced communication, coordination and collaboration between HSAs, HFs and districts. cStock is complemented by a supporting team approach called DPATs (district product availability teams) which brings staff from these different levels together around a common goal of reducing stockouts. Teams focus on maintaining or improving key supply chain performance indicators—including reporting rates and lead times—and problem solve around supply related issues. All data used for performance monitoring is derived from the same two data messages HSAs send in once a month – stock on hand and quantity received – and cStock also uses that data to send SMS alerts to districts when HFs are not able to fulfill orders or HSAs are out of stock. This means districts have timely information about a problem, and the team approach encourages them to respond quickly so HSAs can continue saving lives.
Fast forward to the present: the Ministry of Health in Malawi and its key partners have much to be proud of. cStock and DPATs have been scaled up to all 29 districts, with teams in the last district trained in October. Many partners have supported the Ministry of Health and SC4CCM in this effort by funding training and running costs of cStock and DPATs so that this important approach will continue after SC4CCM ends this year. Scale up and ongoing support has come from: WHO, SSDI (through USAID), Save the Children, and from a UN Innovation Working Group (IWG) Catalytic mHealth Grant and a RMNCH Grant.
cStock has significantly changed visibility of logistics data, with reporting rates consistently above 80%, even as the system was scaled up, and timely and complete reporting rates above 70% as well. District and central level managers can access HSA data on the web at any time and review these and other key supply chain indicators for districts or the country. Lead times – a measure of how responsive HFs are to HSA orders – are on average 5 days or less, which in my experience is very laudable and hard for even higher levels in the system to achieve consistently. And cStock and DPATs have had an effect in improving product availability by reducing stockout rates and thereby increasing the reliability of supply. Unfortunately, recent data from the endline evaluation shows that when stockouts do occur they last a long time, suggesting that HFs and possibly even districts are not able to resolve them. One reason may be that Malawi has undergone several years of economic hardship and scarce funding for essential medicines has become even scarcer, with the lowest levels of the supply chain most vulnerable to shortages. To me, though, this underlines even more that cStock has and can continue to help manage supplies effectively, since key system indicators have improved despite chronic essential medicine shortages.
We still have a lot of work to do before we can confidently claim that children under five can count on receiving treatment whenever they need it in their villages. But we have come a long way thanks to the leadership of our colleagues in Malawi who caught the vision for a different kind of solution, one that hadn’t been tried before, and who most of all were committed to achieving MDG 4. And a big cheer for cStock, which has transformed people’s expectations about the feasibility of having timely, accurate data at the tips of your fingers for making decisions in the public sector.