Bangladesh: Contraceptive Logistics System, Review of Accomplishments and Lessons Learned
Publication date: 2000
Bangladesh Contraceptive Logistics System Review of Accomplishments and Lessons Learned Steve Kinzett Jim Bates FPLM Bangladesh: Contraceptive Logistics System Review of Accomplishments and Lessons Learned Steve Kinzett James Bates FPLM FPLM The Family Planning Logistics Management (FPLM) project is funded by the Office of Population of the Bureau for Global Programs, Field Support and Research of the U.S. Agency for International Development (USAID). The agency’s Contraceptives and Logistics Management Division provides a centralized system for contraceptive procurement, maintains a database on commodity assistance, and supports a program for contraceptive logistics management. Implemented by John Snow, Inc. (JSI) (contract no. CCP-C-00-95-00028-00), and subcontractors (The Futures Group International and the Program for Appropriate Technology in Health [PATH]), the FPLM project works to ensure the continuous supply of high-quality health and family planning products in developing countries. FPLM also provides technical management and analysis of two USAID databases, the contraceptive procurement and shipping database (NEWVERN); and the Population, Health, and Nutrition Projects Database (PPD). This document does not necessarily represent the views or opinions of USAID. It may be reproduced if credit is given to FPLM/JSI. Recommended Citation Kinzett, Steve, and James Bates. 2000. Bangladesh: Contraceptive Logistics System, Review and Lessons Learned. Arlington, Va: Family Planning Logistics Management (FPLM)/John Snow, Inc., for the U.S. Agency for International Development (USAID). Abstract This report documents the status of technical assistance provided by the USAID-funded Family Planning Logistics Management project to the Bangladesh Family Planning Program in developing a countrywide contraceptive logistics system. A study conducted in November 1999 to evaluate the impact of technical assistance on logistics management and contraceptive security is detailed. The report concludes with findings from the study, lessons learned, and recommendations to continue improvements in the system. FPLM Family Planning Logistics Management John Snow, Inc. 1616 North Fort Myer Drive, 11th Floor Arlington, VA 22209 USA Phone: 703-528-7474 Fax: 703-528-7480 E-mail: email@example.com Internet: www.fplm.jsi.com Contents Acronyms .v Preface. vii Executive Summary .ix 1. Study Protocol.1 Study Objectives .1 Study Methods .1 2. The Technical Assistance Strategy .3 HSR and Contraceptive Logistics .3 Logistics Stakeholders .4 3. Study Results.7 Regional and District Levels.7 Thana Level.7 SDP Level .8 4. General Findings .11 Success Factors .12 Barriers to Institutionalization.12 Resistance to Major Changes That Favor Efficiency.13 Internal Politics .13 5. Lessons Learned.15 6. Recommendations .17 Appendix A. Survey Instruments.19 Appendix B. Key Informants.39 Appendix C. Evaluation Team Schedule.43 Appendix D. Translation of Government Memo Concerning Integration.47 Appendix E. Stakeholder Activities .53 Appendix F. Field Visit Data .59 Appendix G. Future Directions for FPLM Technical Assistance.63 Tables 1. Number and Type of Study Sites, November 1999.2 2. Stock Levels of Pills at Thana Stores, by Percentage, Bangladesh, 1993, 1994, 1996, and 1999 .11 iii Bangladesh: Review and Lessons Learned iv Acronyms ADB Asian Development Bank ATFPO assistant thana family planning officer AVSC Association for Voluntary and Safe Contraception BRAC Bangladesh Rural Advancement Committee CA cooperating agency CDS Centre for Development Services CIDA Canadian International Development Agency CPR contraceptive prevalence rate CPT contraceptive procurement table CWH central warehouse DDS district drug supply DFID Department for International Development (United Kingdom) DFP Directorate of Family Planning DG/FP Director General/Family Planning DHS Directorate of Health Services ESP essential services package FEFO first-to-expire, first-out FP family planning FPAB Family Planning Association of Bangladesh FPI family planning inspector FPLM Family Planning Logistics Management FPLM/B Family Planning Logistics Management/Bangladesh FPLM/W Family Planning Logistics Management/Washington FWA family welfare assistant FWC Family Welfare Centre FWV family welfare visitor GOB Government of Bangladesh HPSP Health and Population Sector Program HSR health sector reform IEC information, education, and communication IUD intrauterine device JSI John Snow, Incorporated KFW Kreditanstalt für Wiederaufbau (Germany) LMIS logistics management information system LMT logistics management training LSO logistics support officer LSU Logistics and Supply Unit MAX-MIN maximum and minimum supply levels MCH maternal and child health MCWC Maternal and Child Welfare Centre MIS management information system MOH&FW Ministry of Health and Family Welfare MOS months of stock MSH Management Sciences for Health MSR medical supplies requisites NGO nongovernmental organization NIPHP National Integrated Population and Health Program v Bangladesh: Review and Lessons Learned NIPORT National Institute of Population Research and Training OJT on-the-job training ORS oral rehydration solution PATH Program for Appropriate Technology in Health PIACT Program for the Introduction and Adaptation of Contraceptive Technology PPC Project Planning Centre RSDP Rural Service Delivery Project RWH regional warehouse SDP service delivery point SMC Social Marketing Company S/L stock level S/O stockout TA technical assistance TASC Technical Assistance and Support Contract TFPO thana family planning officer TS thana store UFHP Urban Family Health Partnership UK United Kingdom UMIS United Management Information System UNFPA United Nations Population Fund UNICEF United Nations Children’s Fund USAID U. S. Agency for International Development WB World Bank vi Preface With the recent advent of health sector reform in Bangladesh, the Ministry of Health and Family Welfare has started developing plans for integrating the various vertical programs under its aegis, including family planning. This paper contains a status report on the USAID-funded Family Planning Logistics Manage ment project’s technical assistance to the Bangladesh Family Planning Program in developing a countrywide contraceptive logistics system. The Family Planning Logistics Management project undertook this study in November 1999 to evaluate the impact of health sector reform actions on logistics management and contraceptive security. The study findings could help the Government of Bangladesh plan strategically for the next five years, 1999–2004, to ensure that gains made in the smooth delivery of family planning programs in all sectors continue even as health sector reform takes hold. The study could also help stakeholders maximize these gains by further institutionalizing and localizing the logistics functions. Evaluating the contraceptive logistics system in Bangladesh involved the collection of qualitative data through key informant interviews and a review of documents relating to the contraceptive logistics system. Discussed in this report are the study protocol, the setting in which the logistics management information system has been developed, and the results of the study. Also discussed are the lessons learned from the Bangladesh experience that may be generalized to other countries and the recommen dations of the study team for future logistics management efforts in Bangladesh. The authors would like to acknowledge the knowledge, guidance, and assistance of Mr. Nurul Hussain, Chief of Party, FPLM/Bangladesh during this assessment and the efficient support and administrative facilitation of Mrs. Fowzia Virji who organized the program for field trips and key informant interviews so diligently. We extend our gratitude to Mr. Md. Anwar Hossein and Mr. Nazmul Huda Khan, logistics advisors at FPLM/Bangladesh for their guidance during the assessment and intimate knowledge of the system, which was invaluable. We appreciate the cooperation of the staff at the USAID Mission in Dhaka, particularly Mr. Matthew Friedman and Mr. Md. Nasiruzzaman who gave generously of their time and expertise, and guided some of the findings of this report. We are grateful for the cooperation, percep tions, and comments of the government and nongovernmental staff of all organizations contacted during this process, and to all the people of Bangladesh who were interviewed as part of the assessment. We also acknowledge the staff at FPLM/Washington, particularly Lisa Mueller, who contributed to and edited the final report for publication as well as other senior staff who reviewed the report for technical content. Finally, we would like to thank the drivers, administrative, and ancillary staff of FPLM/Bangladesh who were helpful in every way in facilitating the smooth running of this assessment, despite numerous hartals that occurred. vii Bangladesh: Review and Lessons Learned viii Executive Summary The Family Planning Logistics Management project is a five-year project (1995–2000) funded by the United States Agency for International Development. Implemented by John Snow, Inc., the Family Planning Logistics Management project works to ensure the continuous supply of high quality health and family planning products in developing countries. The FPLM project has been providing technical assistance to Government of Bangladesh since 1985. The study described in this report, which took place in November 1999, had three objectives: • Assess the current logistics system in Bangladesh. • Identify lessons learned. • Recommend the direction of further FPLM technical assistance. The evaluation team found that the stores and warehouses visited during the study at the regional and district levels generally used good warehousing practices. All facilities were well maintained, sufficiently large, and well functioning. Low levels of stockouts for condoms, intrauterine devices, and Shukhi (the brand of oral contraceptive) were found. However, in all facilities visited, Depo-Provera® and Shukhi were below acceptable stock levels. Three types of thana stores were assessed: family planning stores built by USAID, stores attached to the thana-level store, and stores in administrative buildings. All the stores at the thana level were well main tained, sufficiently large, and functioning well. The USAID-built stores were generally the cleanest and the best organized. In the last five years, the thana family planning officer, the assistant thana family planning officer, and the thana storekeeper received training in logistics and storekeeping. Staff at the thana level, as well as those at the regional level, were universally happy with the training they received, and reported that it was both useful and interesting. They also reported that where supervisory visits were made, the visits had been useful. Several years ago, constraints on the system would have included poor storage facilities, ineffective stock control procedures, lack of training in basic logistics skills, lack of a functional LMIS, and stock expiring in storage. Such situations have largely been overcome. However, there are still significant barriers to the institutionalization of the logistics management information system in Bangladesh, including absence of a procurement agent, institutionalization of some functions but not others, and systems management problems. Through key informant interviews, field data, and the review of reports and documents, the evaluation team was able to identify lessons that can be useful to both the Government of Bangladesh, as health sector reform gains momentum, and other countries in similar situations. For example— • Government commitment is important to the success of a contraceptive logistics system. • Good forecasting of contraceptive needs must be matched with appropriate, coordinated procurement practices. ix Bangladesh: Review and Lessons Learned • Active government support of nongovernmental organizations that donate or fund contraceptive supplies or provide logistics support can greatly extend the reach of a family planning program. • Extensive training at all levels makes a system agile. The following recommendations represent a way to capitalize on the excellent logistics situation in Bangladesh: • Thana storekeepers should visit the service delivery points periodically—perhaps visiting two to three sites per month—to offer advice on how the service delivery points can better organize their small contraceptive stock. • The Directorate of Family Planning should change the max-min levels for Depo-Provera® back to two and three months, the same as for other contraceptives. • The Directorate of Family Planning should review security at all levels, making special arrangements to have bars installed on the windows of the thana stores or guards stationed at the stores on nights and weekends. The final few recommendations are dependent on the continuance of the FPLM project in Bangladesh. The first two continue activities currently performed by FPLM/Bangladesh. • FPLM should ensure the reliable forecasting, procurement, distribution, storage, and transportation of contraceptives for both government and nongovernmental organization facilities. • FPLM should explore viable opportunities to improve the efficiency of the current contraceptive logistics system. • FPLM should support the Government of Bangladesh in its effort to develop an integrated logistics system for all health and family planning commodities. x 1. Study Protocol The Family Planning Logistics Management (FPLM) project is a five-year project (1995–2000) funded by the United States Agency for International Development (USAID). Implemented by John Snow, Inc. (JSI), the FPLM project works to ensure the continuous supply of high quality health and family planning products in developing countries. FPLM has been providing technical assistance to the Government of Bangladesh since 1986. In the first phase, FPLM I (1986–1990), the intent was to help the country im prove family planning logistics management and contraceptive availability under the vertical program set up in the Ministry of Health and Family Welfare (MOH&FW), Directorate of Family Planning (DFP). Under FPLM II (1990–1995), technical assistance was continued, this time with an emphasis on institutionalizing the logistics management functions and looking at the ways in which the private sector could contribute to systems operation. The emphasis in FPLM III (1995–2000) is on improving the quality rather than the quantity of logistics functions and to continue improving the efficiency of the system. Study Objectives The FPLM evaluation had three separate but linked objectives. • Conduct a brief assessment of the current logistics system in Bangladesh. Through field trips and analysis of data routinely collected by the Bangladesh logistics management information system (LMIS), obtain an overview of the present state of the family planning logistics system. • Conduct a lessons-learned evaluation. Through key informant interviews and review of reports and documents, establish the main lessons learned during the past five to ten years, with an emphasis on the current project, FPLM III. • Determine the direction of further FPLM technical assistance. Through key informant interviews and analysis of the present plans for health sector reform (HSR) and other related developments in Bangladesh, describe factors affecting FPLM assistance in the future and provide recommendations. Study Methods Before leaving for Bangladesh from the United States, the evaluation team drafted three instruments for collecting data and conducting interviews. • A semi-structured questionnaire for use when interviewing staff at the regional-, district-, and thana-level stores. • A semi-structured questionnaire for use with staff at service delivery points (SDP) in both government and nongovernmental organizations (NGO). • A guide for conducting interviews with key informants. Many of the questions were quantitative in nature, thus requiring definite answers. Others were quali tative, so the answers would be subjective. The two questionnaires and the interview guide appear in appendix A. 1 Bangladesh: Review and Lessons Learned When a series of strikes (hartals) disrupted the original schedule after the team’s arrival, the study team shortened and rearranged the schedule. Interviews with key informants (see appendix B) had to be squeezed into a tighter timeframe, shortened, and rearranged to compensate for the missed days. The final schedule for field data collection and key informant interviews appears in appendix C. There was no opportunity to pilot test the questionnaires. Two teams of two people each, one FPLM/Washington (FPLM/W) and one FPLM/Bangladesh (FPLM/B) representative, assessed system performance using the following quantitative indicators: • Stocked according to plan • Stockout rate • Wastage rate • Percentage of staff trained in logistics • Percentage of good warehouse practices present (out of a checklist of 20 items). Following the field work, two evaluators from FPLM/W and one from FPLM/B conducted a systematic round of key informant interviews with representatives from the MOH&FW, donors, NGOs, and FPLM/B staff. They recorded the resulting qualitative information on the interview forms for analysis and interpretation. The study sites selected—Bogra region in the northwest and Chittagong region in the southeast—are in two of Bangladesh’s six regions. The sample size was small because of the restricted time available for the study. Accessibility was a key determinant of which districts and SDPs to visit. Even though the sites were not statistically representative of Bangladesh’s family planning system, the coverage was quite diverse, comprising the warehouse at the central level, 2 of the 4 regional warehouses, 3 of the 26 district reserve stores, 7 of the 467 thanas, and 7 SDPs (see table 1). Table 1. Number and Type of Study Sites, November 1999 Sites Visited Level Central Regional Warehouses District Reserve Stores Thana Stores Service Delivery Points Total Central 1 1 Chittagong Region Bogra Region 1 1 1 2 3 4 5 2 10 9 Total 1 2 3 7 7 20 2 2. The Technical Assistance Strategy Prior to 1985, USAID had been donating substantial numbers of contraceptives to the country’s family planning effort (FPLM NEWVERN Records 2000). In 1985, at the government’s request, the agency assigned a direct-hire advisor to work with the MOH&FW. This appointment marked the start of USAID support of the country’s LMIS. Two important activities then took place. One was setting up the LMIS for family planning in the Central Warehouse (CWH). The second was setting up a comprehensive training program for logistics manage ment with the collaboration of the National Institute of Population Research and Training (NIPORT). At this time, USAID was the major contraceptive donor in the country. FPLM was asked to set up an office in Bangladesh in 1988. The initial staff consisted of two expatriate advisors and four local technical staff. The organization grew to a staff of 22 (seven in LMIS and 15 in training, plus three expatriate advisors) in 1991. Subsequently, staff were reduced to 10 technical experts and the Chief of Party in 1996 and 1997, including four regional logistics support officers (LSO) who worked through one central warehouse and three regional warehouses together with their counterparts. FPLM has divided its activities into five technical areas (forecasting, procurement, storage, distribution, and transport). Preparation for institutionalization covered each area so that FPLM staff, particularly the expatriate staff, could be reduced over the years. Indeed, capacity building has been a priority of the FPLM project. In preparation for institutionalization, for example, the LSOs and their counterparts go out together from the regional warehouses to trouble shoot and monitor activities in the field. Since 1996, FPLM has also been conducting an internship program that brings government employees to work with FPLM for six months at a time. This on-the-job training (OJT) has gradually increased the capacity of the government’s logistics unit. HSR and Contraceptive Logistics For several years health sector reform has been gathering pace in Bangladesh. In 1997, the MOH&FW started to break away from its predominantly vertical health programs, announcing its intention to integrate government health activities in 1998. At the time of our study (and after a two-year delay), the Government of Bangladesh had just laid out a structure for integrating health and family planning activities at the thana and SDP levels (see appendix D). The new structure was to fall in line with the World Bank’s sector-wide Health and Population Sector Program (HPSP). Under HPSP, the World Bank persuaded many donors in Bangladesh, as in other countries, to put some or their entire donor funds into a common basket for health and education programs. Another result of HPSP was the termination of World Bank credits for contraceptive procurement by the United Nations Population Fund (UNFPA) for the government. The World Bank is insisting that procurement of any commodities, goods, or services be performed through international competitive bidding. Thus, Bangladesh’s MOH&FW is now obligated to hire its own procurement agent to use credits to purchase pills and Depo-Provera®. 3 Bangladesh: Review and Lessons Learned Logistics Stakeholders The major stakeholders in the Bangladesh contraceptive logistics system include the government; NGOs (including cooperating agencies [CAs]); donors; and the World Bank. Appendix E distills the major stakeholder activities that are expected to continue for the next two or three years. The Government Bangladesh’s MOH&FW has two separate directorates, the Directorate of Family Planning (DFP) and the Directorate of Health Services (DHS). DFP has a number of departments with varying responsibilities for managing and distributing contraceptive supplies. The most important are the Logistics and Supply Unit (LSU) and the CWH, which oversee the supply of contraceptives, family planning related consumables, and equipment; their distribution; and the implementation of the FPLM contraceptive logistics manage ment information system. DFP also plays a central coordinating role in forecasting annual contraceptive commodity needs. There are equivalent departments within the DHS for essential drugs, equipment, and other health consumables. The contraceptive LMIS operates at five levels: central, regional, district, thana, and SDP. At present, contraceptives continue to move through this system, independent of other supplies, to the service delivery points. Even at the thana level there is still a separate thana family planning officer (TFPO) whose only responsibility is for family planning and associated logistics—although this may change shortly given the process of integration taking place. Nongovernmental Organizations NGOs are plentiful in Bangladesh and contribute greatly to the nation’s overall family planning effort. Some NGOs not only provide contraceptives and technical assistance to government family planning programs, but also support LMIS activities and deliver maternal and child health (MCH) and family planning services. Some local NGOs also provide technical assistance to the DFP. All NGOs have to be registered with the government and approved to conduct activities. A number of international NGOs (and CA) operate under the USAID-funded National Integrated Population and Health Program (NIPHP). FPLM works directly with a number of NGOs as well as those under NIPHP in ensuring that contraceptives are available to them through the government thana-level stores.1 FPLM has also instituted a monthly LMIS report for the NGOs. At present, there is pressure from the government to integrate these reports into the overall LMIS reporting schedule for contraceptives handled by the DFP. The Centre for Development Services (CDS) is a local NGO that has just completed a subcontract with FPLM to train 300 thana-level storekeepers and 55 district-level storekeepers in logistics management. The Social Marketing Company (SMC), a private company that socially markets condoms and pills, has recently started offering Depo-Provera® through trained doctors in the private sector. More than 300 sales people promote its products, which are funded by USAID. FPLM requests port clearance from the Director General/Family Planning (DG/FP) for SMC shipments to avoid the import tax. FPLM has also trained SMC staff to prepare annual contraceptive procurement tables (CPT) and monthly pipeline reports, a task they now handle themselves. 1 NIPHP partners are Association for Voluntary Surgical Contraception (AVSC), Pathfinder/Rural Service Delivery Project (RSDP), JSI/Urban Family Health Partnership (UFHP), JSI/FPLM Project, and BASICS. Other major NGOs are the Bangladesh Rural Advancement Committee (BRAC), Family Planning Association of Bangladesh (FPAB), and Marie Stopes Clinics, who receive most of their contraceptive and other supplies from the government system at the thana level. 4 The Technical Assistance Strategy Donors Among the donors involved in procuring contraceptives or supporting the logistics management activities of the country are the following: • USAID, working through the NIPHP partners, provides major support to NGOs, and some support to the GOB through FPLM, for health, population, and nutrition activities. These activities include the donation of oral contraceptives and condoms to the SMC. • UNFPA provides substantial support for reproductive health programs; information, education, and communication (IEC); and advocacy for family planning through ongoing five-year plans devel oped together with the Government of Bangladesh. At the time of the study, UNFPA also supplied some contraceptives to Bangladesh and was serving as a procurement agent for other donors, such as the Canadian International Development Agency (CIDA) and the Department for International Development (DFID), who also donate supplies. Supportive of the FPLM logistics management effort, UNFPA has conducted two studies of contraceptive requirements and logistics management needs in Bangladesh. In 1994, UNFPA and FPLM jointly organized a forecasting workshop where the next five-year forecasts were developed. • The Kreditanstalt für Wiederaufbau (KfW), the German Government Aid Bank, provides money for contraceptive procurement on the part of the Bangladesh government and, until recently, used UNFPA as its procurement agent. With the delay over appointment of a government procurement agent, KfW is procuring pills for the government on its own. • CIDA has been providing assistance with contraceptive procurement for the Bangladesh govern ment for more than 20 years. CIDA uses UNFPA as a procurement agent but holds some money back for emergency supplies. CIDA has also been supportive of family planning logistics management for the past three years. • DFID, of the British government, has been providing increasing support since 1990. In particular, they supplied the social marketing program with some pills in 1998 and 1999. • United Nations Children’s Fund (UNICEF) acts as a procurement agent for the district drug supply kits, and works mostly in MCH. They also play a large role in supporting the existing vertical health programs that are to be integrated under HPSP. There are many other donors in the health sector in Bangladesh, but the donors mentioned above have the most to do with contraceptive and ancillary supplies in the country. The World Bank As part of the overall loan agreement, World Bank credits were to be used to procure contraceptives, as well as fund a variety of other activities in Bangladesh, including building and other capital projects and the purchase of drug supplies. World Bank regulations for the procurement of any commodity or service must be performed according to open international tendering and bidding standards. In Bangladesh there have been some problems with following these complex procedures, not least the question over an appro priate procurement agent. Both the World Bank and the GOB underestimated the lead time for the quan tities of commodities required which may have resulted in shortages of some commodities. 5 Bangladesh: Review and Lessons Learned 6 3. Study Results The results presented here derive mainly from the field visits. Field visit data is presented in appendix F. Regional and District Levels The stores and warehouses visited by the evaluation team at the regional and district levels had a median score of 18 out of 20 (90%) for good warehousing practices. All facilities were well maintained, suffici ently large, and well functioning. Stockouts of condoms, intrauterine devices (IUD), and Shukhi were found. Depo-Provera® and Shukhi were below acceptable levels in all facilities, an average of 1.0 and 0.2 months, respectively. At the district store in Chittagong, Shukhi had been stocked out for 67 days over the last six months (37% of the time). Shukhi is rationed from the regions to their districts (and then to the thanas), resulting in an under- stock of pills all the way down the system. For example, one regional store in Chittagong could provide only one-third of the Shukhi required by one of its districts; Comilla District was completely stocked out of pills. The situation for Depo-Provera was not as acute; stock levels for IUDs and condoms were satisfactory. The number of expired and damaged products (i.e., the wastage rate) was low, but much of this stock (TCu-380A, Noristerat, and Multi-load IUDs) was very old and no longer used. A few condoms were damaged, but the numbers were very small compared to the total issued, giving a wastage rate of less than 1 percent. In the last five years, all staff at the regional and district levels has received between 5 and 30 days of training in logistics and storekeeping; many received one or more refresher courses in the last two years. Staff were universally happy with the training, reporting that it was both useful and interesting. There were no suggestions for improvement or change. Nearly all the staff interviewed felt that the LMIS was working well, with no problems other than the current short supply of Depo-Provera and Shukhi. They report that supervisory visits, where conducted, have been useful. A major problem emerging at all levels of the system is theft, especially of Depo-Provera. As a result, the DFP decided to reduce the max-min levels for Depo-Provera from one and three months to 0.8 and 2 months respectively. All padlocks at regional and district storage facilities have been sealed with signed paper, wax, and string that must be broken to get into the store. Transport from both the regional and district levels to distribute supplies to the thana level is adequate. Routing plans are efficient, and the majority of vehicles are operational. Computerization of the system had gone smoothly. Training is high quality, producing managers able to assess stock status, needs, and receipts easily. Thana Level Three types of thana stores were assessed: family planning only stores that had been built by USAID, stores attached to the thana-level store, and stores in administrative buildings. 7 Bangladesh: Review and Lessons Learned All the stores at the thana level were well maintained, sufficiently large, and functioning well. The USAID-built stores were generally the cleanest and the best organized. A median score of 18 out of 20 (90%) for good warehousing practices was recorded (see appendix F). Thanas continue to supply the SDPs in full. Even so, some SDPs were stocked out of pills because of the systemic shortage. Median stock levels for IUDs and condoms at the sites visited in both regions were satisfactory at 2.9 and 3.0 months of supply, respectively, and stockouts of Depo-Provera and Shukhi were usually only a few days short of replenishment. In the Coxs Bazaar district in the Chittagong region, however, where Depo-Provera had been stocked out 60 days out of the last six months (33% of the time), both Depo-Provera and Shukhi were at 0.8 and 1.5 months of stock at the time of the visit, respectively. However, given the revised max-min level for Depo-Provera, these stockouts may be considered satisfactory. The number of expired and damaged products (only a few condoms) is very low, resulting in a wastage rate of less than 1 percent. In the last five years, the TFPO, the assistant thana family planning officer (ATFPO), and the thana storekeeper had received three to five days training in logistics and storekeeping. Many had attended one or more refresher courses in the last two years. Staff were universally happy with the training they received, reporting that it was both useful and interesting. There were no suggestions for improvement or change. They also reported that where supervisory visits were made, the visits had been useful. Two of the thana stores had been subject to theft of contraceptives; as a result, Depo-Provera is now stored in a more secure place. Theft is particularly bad at the thana stores where there are no night guards, despite the use of heavy bars, doors, and padlocks to secure the store. Two thana respondents reported that supplying all SDPs with contraceptives on the day SDP represen tatives came in for their monthly meeting was proving to be too heavy a workload. SDP Level SDPs pick up monthly supplies from their thanas using public transport (usually a pedal rickshaw) for a round trip that can take up to one day. All submit a monthly consumption report that the thanas can use to determine the amounts required to meet SDP needs. The max-min levels for SDPs are two months and three months for all products except Depo-Provera, which has a max-min of one to two months. At least one-half of the SDPs complained about this recently lowered level because it resulted in very low stock levels whenever demand went up. At nearly all SDPs, new and continuing users of the pill can receive a three-month supply of Shukhi, but providers often dispense only one cycle even to continuing users. At the NGO facilities, however, some of the clients can afford to buy only one or two cycles at a time. Some government facilities were dispen sing between 24 and 36 condoms at a time, depending on the provider’s instructions. The NGO clinic was selling as many condoms as the client wanted. SDP stock registers were recording quantities of contraceptives received and issued, the balance, and, where appropriate, adjustments. At most sites, staff updated the registers periodically. A physical inven tory was usually taken each month and recorded on a separate monthly report rather than on the stock register. At two sites, the physical inventory count did not match the records but, in both cases, the stock was available in larger quantities than recorded. 8 Study Results Stockouts of Depo-Provera in the Chittagong SDPs and of Shukhi in the Bogra SDPs were reported, although the stockouts lasted only a few days. Storage ranged from a locked cabinet to a cardboard box under a bed. Even with the fairly low levels of stock, the storage was not good in most cases (appendix F). The staffing situation was usually satisfactory, with the number of family welfare visitors (FWV) determined by the size of the SDP. Other staff included several outreach workers, sometimes a medical officer or a pharmacist, and various ancillary staff. Most SDP staff were satisfied with the present system and could not suggest any changes, other than the need for a little more training in the logistics field. 9 Bangladesh: Review and Lessons Learned 10 4. General Findings Despite the small sample size, the survey data suggest a well-performing logistics system that undoubt edly has contributed to the rising contraceptive prevalence in Bangladesh. In addition, over the last few years the DFP has increasingly taken on the roles that FPLM/B has traditionally undertaken, paving the way for increased institutionalization. The evaluation team found that institutionalization of training at NIPORT was not successful; conse quently, FPLM had to contract this job out to other NGOs. On the other hand, institutionalization of the LMIS has been very successful, with the government running the LMIS itself since 1998. In terms of indicators of FPLM work in Bangladesh, some impressive statistics can be quoted. As table 2 shows, stockout rates were consistently low during the 1990s, and efforts to maintain satisfactory stocks with lower inventories have been moderately successful. Table 2. Stock Levels of Pills at Thana Stores, by Percentage, Bangladesh, 1993, 1994, 1996, and 1999 1993 1994 1996 1999 Months of Stock (n=46) (n=76) (n=49) (n=100) Stockout 0.0 1.3 0.0 0.0 0–1 (potential S/O) 13.0 5.3 12.2 12.0 1–2 (understock) 17.4 18.4 30.6 25.0 2–4 (satisfactory) 37.0 64.5 44.9 45.0 4+ (overstock) 32.6 10.5 12.2 18.0 Source: Adapted from table 3.2, 1999 Stock Level Survey, Program for the Introduction and Adaptation of Contraceptive Technology/Bangladesh. Perhaps more impressive is the increase in the number of SDPs reporting dispensed to user data to the thana level. In 1993, the reporting rate for SDPs was only 25 percent. By 1999, it stood at 98 percent, with more than 85 percent reporting in a timely fashion. The contraceptive prevalence rate (CPR) increased from about 42 percent to 52 percent during this time. Although the relationship cannot be directly attributed to low stockout rates, the rise in CPR is almost unprecedented in a developing country. The evaluation team also found some important LMIS functions are operating at exceptionally high levels of effectiveness. For example— • The reports provide good data for forecasting. • The pipeline is monitored continually. • Stockout levels have been minimal until very recently. • Storage conditions in thana stores are generally good. • First-to-expire, first-out (FEFO) warehouse management is observed. • Pipeline wastage at all levels is virtually zero. 11 Bangladesh: Review and Lessons Learned Success Factors There are two explanations for this generally positive situation. The starting point is the country’s long- term commitment, maintained by successive governments, to creating and expanding an effective family planning program. This stance has been accompanied by a concomitant long-term commitment from MOH&FW to support the program with an effective logistics system. Another factor was USAID’s decision to provide long-term support by supplying contraceptives, first through direct donations and then to support other donors. The construction of storage facilities and provision of technical assistance has also helped the government achieve its ambitious goals for the LMIS. Yet another factor is the broad range of design and implementation activities conducted by FPLM in close collaboration with MOH&FW counterparts. The activities have included— • A “push” distribution system with appropriate max-min levels suitable to MOH&FW’s organization structure. • An LMIS that provides regular and reliable information on the balance of contraceptives in the system, issues, and dispensed to user data. • Routine pipeline monitoring. • Routine forecasting and procurement based on good data provided by the thanas through the LMIS. • Good response to requests for contraceptive supplies by the USAID contraceptive procurement system. • Countrywide training programs for MOH&FW staff. • Internships for staff from MOH&FW and other local organizations. • Advanced offshore training for selected staff. • A satisfactory degree of supervision by MOH&FW staff. Participation by FPLM staff in such routine activities as data processing, forecasting, procurement order quantification, supervision, and troubleshooting has also contributed to the LMIS success. The same holds true in great part for contraceptive availability. With UNFPA unable to act as a procure ment agent for the extra contraceptives needed and with the process of appointing a procurement agent by the GOB taking much longer than anyone anticipated, national stocks of pills and Depo-Provera have been falling dangerously low since March 1999. To ameliorate the situation, logistics staff at the central, regional, and district levels were going beyond normal practice, pushing available contraceptive supplies down to the thanas for redistribution to SDPs. Ironically, the current procurement problems may have produced the best definition of a well-functioning storage and distribution system: namely, that a line staff routinely makes management decisions in favor of assuring product availability at SDPs. Barriers to Institutionalization It is interesting to consider the nature of the current barriers discussed briefly below. Several years ago, constraints on the system would have included poor storage facilities, ineffective stock control proce dures, lack of training in basic logistics skills, lack of a functional LMIS, and stock expiring in storage. Such situations have largely been overcome. Indeed, if LMIS success were to be defined merely as an 12 General Findings effective, self-sufficient system implemented by MOH&FW, with extensive support from a USAID- funded technical assistance team, the issue of barriers would not be a concern today. However, the ultimate goal of the FPLM project—institutionalization of the LMIS—faces some significant constraints. Institutionalization of Certain Functions But Not Others Storage, inventory management, and transport to the thana level are effectively managed by MOH&FW staff. However, FPLM continues to provide support and has tried to localize such specialized functions as forecasting and data processing. For data processing, FPLM has equipped and trained a data processing unit and continues to pay for some staff. (The systems analyst post will become a government-funded position by July 2000, and it is hoped that FPLM payment of salaries in the short term will not develop into a long-term arrangement). For forecasting, FPLM has engaged local experts to play central roles in this work. Systems Management Problems There is anecdotal evidence that some MOH&FW decision makers have yet to take full personal respon sibility for system management, with all its ups and downs. For example, on occasion, FPLM’s field- based logistics support officers have to report problems to district or regional decision makers so that the problems can be fixed. However, senior MOH&FW staff have asked FPLM to report these problems (such as danger of stockouts) orally and not in writing. Resistance to Major Changes That Favor Efficiency Since 1997, with FPLM support, U.S. logistics experts from the private sector have made substantial assessments of the distribution systems for health and family planning commodities and the LMIS in Bangladesh. Among their recommendations are setting up a single, modern central distribution center for health and family planning commodities, achieving economies of scale through use of commercial transport, and reducing the number of tiers in the distribution system. However, the MOH&FW has been unreceptive to the proposed changes mainly for political, social, and cultural reasons. Apparently, the views of parties with vested interests in the existing arrangements play an important role in effecting change. Internal Politics The major constraints to contraceptive logistics involve issues over which donors have little control. Decisions to reject or delay recommendations for major restructuring take place in political arenas where donors have limited access and scant influence. FPLM can help manage the contraceptive procurement crises and other problems arising from Health and Population Sector Program (HPSP), but cannot solve them. This also explains the reluctance of MOH&FW staff to take personal responsibility for certain problems. 13 Bangladesh: Review and Lessons Learned 14 5. Lessons Learned Through key informant interviews, field data, and the review of reports and documents, the evaluation team identified seven lessons that can be useful to both the Government of Bangladesh and other countries in similar situations, as HSR gains momentum. 1. Government commitment is important to the success of a contraceptive logistics system. The long-term commitment to family planning and contraceptive logistics by successive governments, MOH&FW, and donors is one fundamental reason for the good logistics situation in Bangladesh. 2. Good forecasting of contraceptive needs must be matched with appropriate, coordinated procurement practices. Forecasting has been crucial to the well-being of the Bangladesh family planning program, and continual donor coordination is required if procurement schedules are to be followed under HSR. Technical assistance can help achieve coordination, but the impetus must come from MOH&FW. 3. Good outcomes for all logistics operations, including forecasting and procurement coordination, depend on a well-functioning LMIS. The solid LMIS now in place in Bangladesh has thus far prevented severe shortages and stockouts of contraceptives, ensuring contraceptive availability at the SDPs. In turn, the LMIS will help increase contraceptive prevalence if trends continue. 4. Experiences with HSR in other countries can be a basis for conducting good situation analyses and planning to preserve contraceptive security. As HSR gains momentum in Bangladesh with the implementation of the HPSP, it is important to note the risks that HSR poses for the contraceptive LMIS. In Mali, where integration plans ignored the implications of HSR, the contraceptive LMIS ceased to exist. In Zambia, where the reform plans also failed to consider contraceptive logistics, the LMIS below the central level in Zambia was seriously disrupted. Such negative consequences are not inevitable. Good situation analyses and planning can spare Bangladesh from taking steps backward. 5. Active government support of NGOs that donate or fund contraceptive supplies or provide logistics support can greatly extend the reach of a family planning program. Bangladesh’s MOH&FW seems to have made it a principle to service NGOs through the government’s contraceptive logistics system, and NGO staff routinely express appreciation for this support. This situation stands in contrast to many countries where Ministries of Health regard NGOs as intruders. 6. Some elements of logistics system development are easier to institutionalize than others. Although nothing about designing and maintaining a good logistics system is easy, the task of changing attitudes and gaining political support for changes in the system should not be under estimated. The Bangladesh experience suggests that systems design and training activities, which can enable line staff to develop a system to functional effectiveness with some external support, are relatively much easier to accomplish. 7. Extensive training at all levels makes a system agile. As a result of training, personnel at the thanas and SDPs in Bangladesh are able to make appropriate logistics management decisions that result in SDPs having adequate stock despite shortages caused by procurement delays. 15 Review and Lessons Learned: Bangladesh 16 6. Recommendations The following recommendations represent a way to capitalize on the excellent logistics situation in Bangladesh by strengthening the current LMIS and establishing an information system in line with HSR objectives that works equally well for contraceptives and essential drugs. The first several recommendations are practical in nature and relatively easy to implement in the short term. 1. SDP Commodity Storage: Although storage facilities at the thana level and above were generally good, the way in which commodities were stored at the SDP level was quite variable. Recommendation: Thana storekeepers should visit the SDPs periodically—perhaps going out to two to three SDPs per month—to offer advice on how the SDPs can better organize their small contraceptive stock. Potential clients who see that the commodities look well kept will have more confidence in the products. SDP staff would also find it relatively easy to perform inventories each month, recording the results on the stock register so they can tighten the system. 2. Stockouts of Depo-Provera® and Shukhi: Understocks of Depo-Provera and Shukhi at the SDP level are systemic problems caused not only by the understock of Shukhi in the whole system, but also by the decision to reduce the max-min levels for Depo-Provera. Recommendation: The DFP should return the max-min levels for Depo-Provera to two and three months, the same as for other contraceptives. Procurement orders of Depo-Provera and Shukhi need to be expedited to replenish stock levels. 3. Theft Prevention: In light of reports of frequent thefts—especially Depo-Provera—extra security measures need to be taken to protect contraceptive supplies. Recommendation: DFP should review security at all levels, making special arrangements to have bars installed on the windows of the thana stores or guards stationed at the stores on nights and weekends. 4. Thana Staff Workload: Some thanas already resupply NGOs and SDPs on separate days. However, even with this structure in place, the thanas supplying large numbers of SDPs often cannot cope with resupplying all SDPs in one day. Recommendation: DFP should consider having thanas, especially those supplying a large number of SDPs, service SDPs on two or three separate days. This change would mean the TFPO would have to hold more than one meeting a month, but thana staff would benefit from dealing with fewer people at a time. The following points are long-term recommendations largely dependent on the continuance of the FPLM project’s work in Bangladesh. The first two continue activities currently performed by FPLM/B. 5. Recommendation: Ensure the reliable forecasting, procurement, distribution, storage, and transportation of contraceptives for both government and NGO facilities. 6. Recommendation: Explore viable opportunities to improve the efficiency of the MOH&FW contraceptive logistics system. 17 Review and Lessons Learned: Bangladesh 7. Potential Integration of Systems: A decision to begin integration at the thana level makes sense. Although such integration may not be easy to accomplish, it could produce useful results more quickly at this level than at higher levels. However, such an activity for FPLM/B represents a departure from its usual activities. If integration is to be as successful as the technical assistance provided for family planning commodities, selecting appropriate technical assistance and personnel will require great care. Recommendation: FPLM should support the MOH&FW in its effort to develop an integrated logistics system for all health and family planning commodities by (1) obtaining agreement from all stake holders on the roles of participants, (2) conducting a situation analysis, (3) designing a new LMIS system, (4) training personnel in its use, and (5) expanding logistics to the dispensing level. Where appropriate, FPLM should use logistics-related materials developed by other partners (NGOs and CAs) and also help develop good connections between these partners and the MOH&FW. See appendix G for a complete description of the intended future directions for the FPLM project in Bangladesh. 18 Appendix A. Survey Instruments 19 Review and Lessons Learned: Bangladesh A-1: SDP Quantitative Instrument BANGLADESH ASSESSMENT OF THE MINISTRY OF HEALTH CONTRACEPTIVE LOGSITICS SYSTEM SERVICE DELIVERY POINT LEVEL Code Date of the Interview Interviewer Service Delivery Point Region/District/Thana Name of the establishment Name of the person(s) interviewed Job Title(s) Length of time in the current position 20 Distribution Appendix A (continued) Code 1. From where do you receive your contraceptive supplies? � Regional Warehouse ………………………1 � District Stores………………….……………2 � Thana Stores……….……………………….3 � Other (specify)……………………………….4 2. How often do you receive your contraceptive supplies from the level up? � Weekly ……………1 � Monthly……………2 � Quarterly………….3 � Other ………………4 3. How long does it take you to pick your contraceptives from the Thana store? � Less than a day……….1 � One day…………………2 � Two days ……………….3 � Three days or more……4 � Other ……………………5 4. We understand that for family planning you prepare reports What types of reports do you prepare and who do you give these reports or send it to? (List all reports) Report Sent to Prepared by Frequency 5. What are the minimum and maximum levels that you have established for your system Min_________________ Max_________________ Other system: 6. How much of the FP product do you give to each client? � Pills New users ……… Continuing Users ………. � Condoms New users ………… Continuing Users ………. � Other…………………………………………………… 21 Review and Lessons Learned: Bangladesh Code 7. (Look at the stock register to review this information) What information is recorded on the stock register? ( )Quantities received ( )Quantities issued ( )Balance of stock available ( )Expiration date ( )Adjustments 8. With what frequency do you register the movement of contraceptives on the stock register at this facility? By transaction ……….1 Daily ……………………2 Weekly …………………3 Other ……………………4 9. With what frequency do you carry out physical inventories for the contraceptive products weekly ……………1 monthly……………2 quarterly………….3 other………………4 10. Verify that the physical inventory levels are recorded on the stock register Yes (in all cases)………….1 No (in some cases)……….2 No (in no cases)……………3 Note to interviewers : With the stock registers, family planning acceptor registers and other reports still out complete the grids for amount dispensed, stockouts, and expired stock. Complete as much as possible from the records BEFORE moving to the store to count the stock 22 Appendix A (continued) 11. Complete the survey of expired and or damaged during: Use the last six months (May 1 to October 31, 1999) Brand of Contraceptives reason for loss Total loss in system (in 6 months) Total issued (in 6 months) Pipeline wastage rate Reason for losses #damaged #expired #lost Condoms no-logo Norplant Depo-Provera® IUDs CuT 200B Sukhi Other …………. Other …………. 12. Complete the Stock out survey of contraceptives (May 1 to October 31): Brand of Contraceptives Stock out Duration of stock out in weeks Source of stockout information Informant Information Start Date End Date Records Reason Condoms no-logo Norplant Depo-Provera® IUDs CuT 200B Sukhi Other …………. Other …………. 13. Enter Stock level data from records and then conduct a physical inventory (total consumption for last six months to be taken from records (May 1 to October 31, 1999). Brand of Contraceptives Total consumption in the last 6 months Expiry Date Records Physical Count Condoms no-logo Norplant Depo-Provera® IUDs CuT 200B Sukhi Other …………. Other …………. 23 Review and Lessons Learned: Bangladesh Storage 14. Describe the current storage area where the contraceptives are stored? (does it have stacking racks?, shelving, picking space, what is the condition of the store?) 15. Are there any expired products in storage? (where are they stored compared to the non-expired products?) 16. Complete the checklist below to determine the quality of storage. Place a checkmark in the appropriate column according to visual inspection of the storage facility. No Description Yes No 1 Storeroom is regularly cleaned and maintained in good condition. 2 The storeroom is regularly disinfected and sprayed to kill insects. 3 Contraceptives are stacked at least 10 cm (4 inches) off the floor. 4 Cartons arranged so identification labels, expiry dates, and manufacturing dates are visible. 5 Cartons of different lot numbers are not open at the same time (FEFO). 6 Contraceptives are stored separately away from insecticides/chemicals/other materials. Total Number of Check marks . 24 Personnel and Training Appendix A (continued) 17. How many people work in this FP clinic? What are they job titles? Are they full-time? Name of the Persons Job Title % of time spent working in service delivery of FP 18. Have any of the staff received any formal training in warehousing or logistics management? Staff Name Type of training Duration of the training Training content Month/Year 19. If you have received training what parts were most useful – what parts were not very useful ? 20. Have you received any supervisory visits from the level above in the past six months for family planning? ( ) Yes ( ) No 21. Have you received any training, assessment, or recommendation on improving the management of contraceptive products in the unit? If yes, what type of support? 22. Do any parts of the logistics process cause any problems for you ? (explain) 23. What parts of the system work best ? 24. If you could make any changes in the way the system works, what would you change? 25 Review and Lessons Learned: Bangladesh Transportation 25. What method of transport is used to collect the contraceptives ? 26. Are the contraceptive supplies picked up with other supplies? If so, which other supplies? 27. Are targets set for FP achievement? If so what are they? THANK YOU FOR YOUR ASSISTANCE IN COMPLETING THIS QUESTIONNAIRE 26 Appendix A (continued) A-2: Regional/District/Thana Stores Quantitative Instrument BANGLADESH SYSTEM ASSESSMENT Regional/District/Thana Stores Data Region: . Name of the Site: . Location (district/thana/town): . Name of the respondent(s): . (And job titles if available) . . . Date: . ID Number: . Any other general information …………………………………………………. 27 Review and Lessons Learned: Bangladesh A. Checklist to verify Storage/Warehouse conditions Place a checkmark in the appropriate column according to visual inspection of the storage facility. No Description Yes No 1 Storeroom is regularly cleaned and maintained in good condition. 2 The roof is maintained in good condition to avoid water penetration. 3 The storeroom is dry and does not suffer from damp conditions. 4 The storeroom is well lit. 5 The storeroom is well ventilated. 6 The storeroom is regularly disinfected and sprayed to kill insects. 7 Products are stored out of direct sunlight. 8 Condoms/Pills are stored away from electric motors and fluorescent lights. 9 Contraceptives are stacked at least 10 cm (4 inches) off the floor. 10 Contraceptives are stacked at least 30 cm (1 foot) away from the walls and other stacks. 11 Stacks are no more than 2.5 meters (8 feet) high. 12 Products are separated by lots and are stored in a manner accessible for First-Expiry / First-Out (FEFO), counting and general management. 13 Cartons are arranged so that identification labels, expiry dates, and manufacturing dates are visible. 14 Cartons of different lot numbers are not open at the same time. 15 Fire safety equipment is available and accessible. 16 Storage is accessible at any time within normal work hours. 17 Damaged and/or expired contraceptives are separated from good products. 18 Damaged/expired products are destroyed according to established procedures. 19 Contraceptives are stored separately away from insecticides and chemicals. 20 Contraceptives are stored away from office supplies and other materials. Total Number of Check marks . Dimensions of Store :- length …………. Width ………… Height ………… (storage height – not building height) 28 Appendix A (continued) B. Stockouts Circle the number of the brands of contraceptives available or authorized for use in this facility. You may add other brands as necessary. 1. Depo-Provera 2. Noristerat 3. Sukhi 4. Maya 5. Duofem 6. IUD (Cu-T 200B) 7. Condoms No-logo 8. Raja 9. Panther Gold 10.Other (1) _________ (specify) 11. Other (2) _________(specify) 12. Other (3) _______(specify) Was there a stockout of any of the circled (authorized) contraceptives during the last six months? Yes No If yes, complete the table below. Enter the date (or estimated date) of the stockout (column 2), and the date of the end of the stockout (column 3). Calculate or estimate the duration of the stockout in weeks and enter it into column 4. Check column 5 if the date of the stockout has been taken from the stock cards or other logistics information or check column 6 if the date of the stockout has been estimated Brand of the contraceptives Stockout start date Stockout end date Duration of stockout (in weeks) Source of stockout information Stock cards or other records Informants knowledge Depo-Provera Noristerat IUD (CuT 200b) Sukhi (pill) Maya (SM Pill) Duofem Condom No-logo Raja condom Panther Gold Norplant Other 1 . Other 2 . Other 3 . Frequency of stockouts can only be used for methods authorized at this facility. 29 Review and Lessons Learned: Bangladesh C. Stock levels For this storage give the Max/Min levels in months: Max. Min. For each authorized brand of contraceptive (see previous page) calculate the total consumption for the last six months (May 1 to October 31) and enter it in column 2. Divide column 2 by 6 to obtain the average monthly consumption and enter the result in column 3. When making a physical inventory, please assess the quantity of the available and usable stock and enter it in column 4. Calculate the months of stock on hand by dividing column 4 by column 3 and enter the result in column 5. Indicate if the storage is above the maximum (+), below the minimum (-), or at normal levels (=) and enter the result in column 5. Brand of the contraceptives Total consumption in the last 6 months Average Monthly Consumption Available stock on hand Months of Stock Stock status (-, + =) Depo-Provera Noristerat IUD (CuT 200b) Sukhi (pill) Maya (SM Pill) Duofem Condom No-logo Raja condom Panther Gold Norplant Other 1 . Other 2 . Other 3 . Other 4 . Stocked according to plan levels can only be calculated for methods authorized at this facility. 30 Appendix A (continued) D. Expired and/or damaged contraceptives Are there contraceptives which have expired or have been damaged (or otherwise rejected) during the last six months? If yes make a list of the circumstances in the table below. Brand of contraceptive number expired number damaged number lost Total wasted total good contraceptives issued in last 6 months Pipeline wastage rate (divide total wasted by total issued Brief reason for expiry/ damage Approx i-mate dates 31 Review and Lessons Learned: Bangladesh E. Logistics and/or Warehouse Training Has anyone at this facility ever received training in logistics and/or warehousing/storekeeping? If yes please give a list of the persons trained and the date of the training. Staff Name Type of training Duration of the training Training content Month/Year E2. If you have received training what parts were most useful – what parts were not very useful ? E3. Have you received any supervisory visits from the level above in the past six months? ( ) Yes ( ) No E4. Have you received any training, assessment, or recommendation on improving the management of contraceptive products in the unit? If yes, what type of support? E5. Have any of the staff in the level below you received training for logistics ? If yes what effect has the training produced ? E6. Do any parts of the logistics process cause any problems for you ? (explain) E7. What parts of the system work best ? 32 Appendix A (continued) E8. If you could make any changes in the way the system works, what would you change? F. Transport Available for delivery or obtaining supplies Make Type Year Who owns the vehicle Is it operational 33 Review and Lessons Learned: Bangladesh A-3: Qualitative Guide for Key Informant Interviews GUIDELINE FOR QUALITATIVE “LESSONS LEARNED” SECTION FOR BANGLADESH 1-17 NOVEMBER, 1999 GUIDE FOR THE INTERVIEW OF MANAGERS, DECISION-MAKERS, AND RESPONSIBLE STAFF FOR FAMILY PLANNING PROGRAMS FROM THE MINISTRY OF HEALTH AND FAMILY WELFARE AT CENTRAL LEVEL; NIPHP PARTNERS; DONORS (INCLUDING USAID BANGLADESH); AND FPLM STAFF. Date: Site: Name of Interviewed Position/Title of Manager Name of Institution Type of Institution INTRODUCTION Introduce yourself and FPLM, and express our appreciation to his/her willingness for interviewing with us. Explain that we plan to use the information for documenting lessons learned from the efforts made in contraceptive logistics in Bangladesh. Please be candid in your responses to our questions. We will hold your feedback in strict confidence and any written report would not attribute quotations and comments to the individuals interviewed. WARM UP • How does your position relate to family planning and contraceptive supply? How long have you been in this position? How often does your program deal with contraceptive supply information? • Do you ever communicate with MOHFW or their staff? If so, how often? For what reasons? How do you communicate? To whom you address this communication? • Do you ever communicate with NGOs or SMC or their staff? If so, how often? For what reasons? How do you communicate? To whom you address this communication? • Do you ever communicate with FPLM or their staff? If so, how often? For what reasons? How do you communicate? To whom you address this communication? 34 Appendix A (continued) • Have you, or your staff, attended any training on contraceptive logistics? (Continue regardless of whether the interviewed has or has not been trained for family planning logistics, just record this.) When did you and your staff receive the training? Who sponsored the training? What were the salient ideas presented? MAIN QUESTIONS I. Current roles and responsibilities of the stakeholders in Bangladesh: • What, from your perspective, are the relative roles of MOHFW, the NGOs and SMC in the overall family planning effort of the country? • What are the influences of the donors in this respect - particularly in the light of Health Sector Reform now being implemented in the country? • What commitments of resources for logistics have been given in the past (concerning your own organization) and what commitment is there for the future ? • What relationship/contact have you had with FPLM in the past five years and what can you see changing for the future ? II. Respondent's attitudes on the logistics system in Bangladesh: 1. Resources: • Is there a person assigned to conduct logistics and supply activities? If so, how many? At what level? Are there enough resources to continue conducting these activities? • What is the level of support by the donors in contraceptive logistics in approximate terms? 2. Contraceptive supply: • What problems with contraceptive supply have there been in the last three years ? What trends in contraceptive use have you seen and have these trends affected supply? • How has the supply of contraceptives been at the service delivery points of MOHFW during the past three years? In your opinion, what have been the factors for this level of supply? Do your service providers know who the donor of each type of contraceptives is? 35 Review and Lessons Learned: Bangladesh 3. Management of stores: • Have you ever visited the MOHFW central store for contraceptives? Have you visited any stores at the regional/district/thana level? If so, how do you feel these are run? What could be improved in the stores? What is very appropriate in these stores? Do you believe the store’s records are accurate? • Have you ever visited any of the equivalent health supply stores? In the light of HSR what should be the solution to the storage of MOHFW commodities? 4. Training components • What is the outcome of the logistics training activities carried out by FPLM? Have they been useful to people who have attended them? Have the people who have been trained applied any new skill or knowledge when back in their posts? Have the contents been relevant to their work? 5. Use of information for decision making • Do you believe that data generated from the logistics information system provide the necessary information to make decisions for your FP program? (yes or no, and continue). Why? What type of logistics information does it provide? Who is responsible for processing and analyzing the information? • Does the information come in a timely manner to you? Is it of use to you? What do you do with the information your receive? • Who is responsible for forecasting contraceptive yearly needs of the program? What information do you use for making these estimations? III. Lessons Learned • What have been the major barriers to successful logistics in the country? How could these barriers or constraints be overcome? • What really worked? and why did it work? • From your experience what mechanisms should be put in place to improve the logistics system in order to ensure that customers (clients) obtain the contraceptive supplies they require? • What messages can we give to other countries from the Bangladesh experience? 36 Appendix A (continued) IV. Strengths and weaknesses: • What role does MOHFW/NGOs/SMC play in national family planning and reproductive health strategies? What has been the strength of the logistics model? • What have been key elements for ensuring the availability of contraceptive supply? • What are some of the weaknesses? Have there been appropriate supply levels at all levels? Only at some levels? Which ones? • What difficulties the current model has faced? What strategies have been used to overcome these difficulties? V. Future Strategies • What impact do you think, the impending integration of the health and family planning directorates in the MOHFW may have on the contraceptive logistics system? And, on the availability of contraceptives? • What impact do you think integration of health commodities with the contraceptive logistics system may have in contraceptive availability? • What role do you see for FPLM, bearing in mind the proposed integration? VI. Wrap up • What lessons have been learned from the current model? • Are there any points that you would like to discuss that we have not covered in relation to contraceptive distribution? 37 Review and Lessons Learned: Bangladesh 38 Appendix B. Key Informants 39 Review and Lessons Learned: Bangladesh GOB/MOH&FW Dhiraj Kumar Nath, Director General, DFP Prof. Nurul Anwar, Director General, DHS Md. Habibur Rahman, Director, Logistics and Supply, DFP SK Ghosh, Assistant Chief, MOH&FW Tofayel Ahmed, Director Kabirrudin Ahmad, Director, Additional Central Warehouse Ziauddin Khan, PPC Kabir Uddin, Additional Director, CWH USAID/Bangladesh Matthew Friedman, TASC Advisor Md. Nasiruzzaman, Project Management Specialist, Population and Health Team FPLM/Bangladesh Md. Nurul Hossain, Chief of Party R. Halder, Senior Administrative and Finance Officer James H. Gain, Office Support Officer Md. Anwar Hossain, Logistics Advisor Nazmul Huda Khan, Logistics Advisor Sayeedur Rahman, Logistics Specialist Amatur Razzaque, MIS Advisor Shaheed Hossain, Logistics Advisor Fowzia P. Virji, Personnel Officer UNFPA Janet Jackson, Deputy UNFPA Representative S.P.Tarafder, Procurement Officer Canadian International Development Agency (CIDA) Dr. A.N. Zafar Ullah, Senior Programme Monitor Department For International Development (DFID), UK Dr. Frank Atherton, Senior Advisor (Health and Population) UNICEF Farhana Huq, Senior Child Health Advisor Wanda A. Krekel, Chief Supply and Procurement Section 40 Appendix B (continued) Other NGOs Peter Connell, Chief of Party, Urban Family Health Partnership (JSI) Waliiur Rahman, Director, Social Marketing Company Dr. Abu Jamil Faisel, Country Representative, AVSC International Peter Thompson, Health and Life Sciences Partnership, based in PPC (DFID-supported position) E.G.P. Haran, Senior Child Health Advisor, Immunization & Other Child Health Project, PATH Syed Izaz Rasul, Technical Officer, Immunization & Other Child Health Project, MSH Dr. M. Allauddin, Country Representative, Pathfinder International, Rural Services Delivery Partnership Jamil Akhter, Technical Officer, Logistics Management, Pathfinder International, Rural Services Delivery Partnership Centre for Development Services (CDS) Omar Faraque Chawdry, Executive Director Md. Endad, Director Jalaluddin Ahmed, Logistics Training Coordinator Omar Khaiyam, Logistics Trainer Abdul Awal, Logistics Trainer Rafique Uddin Ahmed, Director 41 Review and Lessons Learned: Bangladesh 42 Appendix C. Evaluation Team Schedule 43 Review and Lessons Learned: Bangladesh 10/26/99 Tentative Schedule for Steve Kinzett and Jim Bates November 1 -21, 1999 Date Time Program Monday Nov. 1, 99 8:45 - 10 a.m. 10 - 11 a.m. 11am-1pm Afternoon Briefing on LL Evaluation by Steve Kinzett and Jim Bates Meeting with USAID Field visit questionnaire review at FPLM/B Departure for field visit [flights for Rajshahi & Chittagong leave at 3 p.m.& 3:35 p.m.respectively] Jim Bates arrives on 29 October Steve Kinzett arrives on 31 October Tue-Thurs Nov. 2 – 4 Field Visit Each team will also include a logistics advisor from FPLM/B Team A Will proceed to visit: - RWH Chittagong - Anwara [non-constructed] and Mirsarai [constructed] thana stores - NGO [UFHP] Mamata Clinic in Chittagong City - DRS Comilla - MCWC Comilla - FWC under Comilla HQ Thana Team B Will proceed to visit: - RWH Bogra - DRS Rajshahi - Nawabgonj [non-constructed] and Tanore [constructed] thana stores - Rajshahi MCWC - NGO [RSDP] Clinic in Paba thana - FWC near Natore Fri - Sat. Nov. 5 – 6 Return to Dhaka from Field Visit Week-End 44 Appendix C (continued) Date Time Program Sun – Tue. Nov. 7 – 9 Key Interviews at Dhaka with: - Director General, FP - Director [L&S], DFP - Director [Services], DFP - Addl. Director, CWH - Program Manager, UMIS - Managing Director, SMC - Donor Representatives [CIDA, WB, UNFPA, UNICEF] Wed- Thurs. Nov.10 – 11 Additional field trip to Barisal and Sylhet [Details to be worked out] Shyam arrives on 10 November Shyam and Nurul to attend NIPHP mtg Fri - Sat. Nov. 12 – 13 Return to Dhaka from Field Visit Week-End Tony arrives on 13 November Sun – Mon Nov. 14 – 15 Report Writing/preparation of draft for discussion/review in Comilla session Obtain feedback from Rich via email on key recommendations and strategic plans Nurul to review proposed MIS work with Tony and Shyam Monday Nov. 15 3:00 p.m. Leave for BARD Comilla Tue – Wed. Nov. 16 – 17 Strategic Planning Meeting at BARD Wed. Nov. 17 Late afternoon Return to Dhaka Final draft of year-wise workplan review with USAID in Comilla 45 Review and Lessons Learned: Bangladesh Date Time Program Thursday Nov. 18 Morning Evening - Finalization of Report on Strategic Planning Meeting - Prepare templates for presentation to DFP Presentation on the key features of Strategic Planning Meeting to DG, FP and his Colleagues Completion of year-wise workplan Final review with FPLM/B staff Fri - Sat. Nov. 19 – 20 Jim's departure on Nov. 19 Week End Sunday Nov. 21 Morning till lunch time Afternoon 2 short seminars on Forecasting & Evaluation by Steve Kinzett Free (This may be moved up to earlier date after discussing with Steve) (Shyam to review the workplan with Nurul and FPLM team) Monday Nov. 22 Steve Kinzett's departure Shyam and Tony also leave on Monday 46 Appendix D. Translation of Government Memo Concerning Integration 47 Review and Lessons Learned: Bangladesh 48 Appendix D (continued) 49 Review and Lessons Learned: Bangladesh 50 Appendix D (continued) 51 Review and Lessons Learned: Bangladesh 52 Appendix E. Stakeholder Activities 53 Review and Lessons Learned: Bangladesh A summary of the main logistics activities conducted by FPLM and other donor organizations in Bangladesh appears in table E-1, where they are subdivided by function: forecasting, procurement, storage and supply, inventory control, LMIS, logistics management training, supervision and monitoring, and localization and institutionalization. More detailed descriptions of FPLM activities in Bangladesh appear in a series of reports available from the FPLM office in Dhaka. Table E-1: Logistics Activities by FPLM and Other Donor Organizations, Bangladesh, November 1999 Government FPLM and NGOs Donors Forecasting: Government conducts systematic long-term forecasting once in 5-yr with the technical assistance of FPLM and donors. Forecasting Forum does mid-term review and adjusts, if required. Short-term forecasting is done every month through the Monthly Pipeline Report published by DFP. Both long- and short-term forecasting is consumption based. Convene the forecasting forum held by DFP and to review half-yearly the procurement situation. Commitment of the donors for commodity assistance WB, USAID, KfW, UNFPA, CIDA, DFID, UNICEF Procurement: All family planning commodities are procured centrally, either from offshore or from the local suppliers. Procurement by donors is delivered to CWH for distribution and is performed under the agreed forecasts (see above) FPLM assists DFP in preparing shipping schedule and tracking shipments of procurements. WB: Depo-Provera , IUDs, Norplant , DDS kits USAID: formerly pills, IUDs, condoms KfW: pills UNFPA: Procurement agent for others, pills CIDA: pills DFID: condoms UNICEF: DDS kits (procurement agent) 54 Appendix E (continued) Government FPLM and NGOs Donors Storage and Supply: Family planning has a 5-tier storage and supply system. Central (CWH)-1 Regional (RWH)-3 District (DRS)-18 Thana (TS)-467 Field (SDPs)-thousands All the procured commodities are received at the CWH and are supplied monthly to the RWHs (DRSs and TSs). RWHs supply to the DRSs (and TSs) DRSs supply to the thana stores. Thana stores supply monthly to the SDPs FPLM used to help with transportation to lower levels when the CWH and RWH (Chittagong) were at full capacity FPLM operationalized the 200 thana stores constructed with USAID funding FPLM provided TA for private transport: private carrier covers 20% of Bangladesh. Aim to cover the whole country – funds available in HPSP. FPLM will fund a national physical inventory (covering every facility) through an NGO. USAID built 200 thana stores World Bank built RWH Chittagong ADB built DRSs Inventory Control: In the family planning program, broadly there are 3 types of commodities, i.e. contraceptives, medical and surgical requisites (MSRs–e.g.: gloves, gauze, anesthesia, iron tablets etc) and medical equipment in kits (e.g., kidney dishes, beds). There is a max-min months of stock level (MOS) for each level of the system. Level Max MOS Min MOS CWH 3 2 RWH 3 2 DRS 3 2 TS 4 2 SDP 3 2 Total: 16 10 In the normal situation, efforts are made to keep the levels within the max-min MOS. FPLM tracks max-min levels at each level using the LMIS report as the primary instrument. FPLM assists the DFP to adjust levels depending on reports. LSOs based at regional level also assist their counterparts in ensuring the max- min MOS to the level below. PIACT/B carries out stock level survey on average every two years (last one in 1999): stockouts at thana level for condoms and pills was 0% injectables 2% and IUDs 3%. (This was 0% for all last year but because of HPSP procurement problems this has risen) USAID (UNFPA around 8 years ago had a monitoring team but this no longer exists) 55 Review and Lessons Learned: Bangladesh Government FPLM and NGOs Donors LMIS: Reporting is monthly in the family planning program and its starts from the bottom and ends at the top. • FWAs submit to FPI (FWAs’ supervisor) • FPI consolidate and submits to TS • Clinics submit to TS • TS consolidates FPIs’ and Clinics’ reports and submit to source & LMIS • DRS/RWH/CWH prepares & submit to source and LMIS • LMIS compiles & publishes and distribute within the month. DRS/RWH/CWH uses LMIS report to: a. Determine issue quantity b. For selecting monitoring sites, etc. LMIS located in the DHS regularly publishes the logistics report based on F7 and F7b reports submitted by warehouse/DRS and thana stores respectively. The logistics unit of DFP publishes the monthly pipeline report with minimal FPLM assistance. LMIS being developed for NGOs by FPLM. USAID Logistics Management Training: GOB provides training facilities (e.g.: NIPORT). GOB ensures participation/attendance of the participants (attendance 98% at last course) FPLM has been continuously providing support for the knowledge and skill development of the FP logistics personnel. FPLM has planned to provide LMT to the store-in-charge and thana managers of NIPHP NGOs. FPLM contracts out (to CDS one of the 5 NGOs developed for providing LMT) to train 300 thana storekeepers and 98 newly appointed TFPOs and 55 warehouse/district storekeepers. USAID 56 Appendix E (continued) Government FPLM and NGOs Donors Supervision & Monitoring: A monitoring checklist has been developed, approved by DFP and used during field monitoring . Government central and district level officials do their own supervision visits FPLM field staff (LSOs), based at the regional level, either jointly with counterparts or alone regularly monitors the logistics supply situations. LSOs provide structured OJT using the checklists and job-aids, if knowledge and skills gaps are identified. LSOs submit their monthly report to FPLM, Dhaka. They suggest central level interventions if they cannot resolve locally. FPLM prepares a monthly highlights based on the LSOs reports and the field trip reports of Headquarters Staff and suggest the DFP for taking remedial actions. Both DFP and FPLM review the monthly LMIS report and identify the problematic sites where immediate interventions are needed. DFP & FPLM either jointly visit those sites (3-4 in a month) or separately visit those sites and share experiences. USAID Localization & Institutionalization: GOB has supported the plan of localization and institutionalization of the activities listed in column two: FPLM ultimate goal is to develop the knowledge skills of: a. FPLM local staff and gradually hand over the responsibilities of the expatriate advisors to local Bangladeshi staff. b. Develop the knowledge and skills of government and NGO counterparts and gradually transfer the ongoing activities to them. FPLM has 100% achieved its first goal. The project started in 1988 with 3 expatriate advisors. The advisors gradually developed the local staff and hand over their responsibilities to them. The phase out expatriate advisors was completed 3 years ago FPLM has been trying hard to achieve its second goal but so far only limited success has been achieved. • LMIS has been completely handed over to DFP • LMT has been given to local NGOs Forecasting has been institutionalized within DFP. USAID GOB 57 Review and Lessons Learned: Bangladesh 58 Appendix F. Field Visit Data 59 Review and Lessons Learned: Bangladesh Table F-1 Regional Stores Stockout/Expiry/Stock Levels/and Transport Data, Bangladesh, November 1999 ID Number 10 11 20 21 22 Median values Region Chittagong Bogra Chittagong Bogra Bogra All Regions District Comilla Rangpur Rajshahi Type Regional Warehouse Regional Warehouse District Reserve Store District Reserve Store District Reserve Store Storage (max 20) 15 19 18 18 20 18 Size (sq ft) 13,373 9,000 12,000 2,600 2,600 9,000 S/O 1 name IUD Depo- IUD Shukhi Condom Provera S/O 1 days 10 4 16 12 10 10 S/O 2 name Shukhi Shukhi Shukhi Shukhi Condom S/O 2 days 1 1 7 7 36 7 S/O 3 name IUD Shukhi Condom S/O 3 days 1 60 12 12 Stock Level 6.3 0.3 1.0 0.8 1.3 1.0 Depo-Provera Stock Level 2.8 1.7 1.6 2.2 2.4 2.2 IUD(TCu-200B) Stock Level Pill 0.2 0.2 0.0 0.4 0.4 0.2 (Shukhi) Stock Level 34.8 5.2 2.5 1.5 1.3 2.5 Condom (no-logo) Exp1 name Condom Condom Exp1 number 29,299 24,272 26,785.5 Exp1 wastage rate 0.0065 0.01 0.0 Exp2 name IUD Exp2 number 124 124.0 Exp2 wastage rate 0.03 0.0 Transport 5 ton 2 1 0 0 0 0.0 Transport 3 ton 1 0 0 0 0 0.0 Transport 1.5 ton 0 1 1 1 1 1.0 Transport Pickup 1 1 2 1 1 1.0 Not running 1 0 1 0 0 0.0 Note: S/O: stock out S/L: stock level Exp: expiry 60 Appendix F (continued) Table F-2. Thana Stores Stockout/Expiry/Stock Levels, Bangladesh, November 1999 ID Number 30 31 32 33 34 36 Median value Region Chittagong Chittagong Chittagong Bogra Bogra Bogra Thana Sitakunda Coxs Bazaar Comilla Nawabgouy Giobindaganj Adamdighi Type Thana Family Plan Store Thana Family Plan Store Thana Family Plan Store Thana Family Plan Store Thana Family Plan Store Thana Family Plan Store Storage (out of 20) 19 18 16 18 19 18 18 Size (square feet) 3,000 3,000 2,600 2,600 2,600 S/O 1 name Depo- Provera Depo- Provera Depo- Provera Depo- Provera S/O 1 duration days 13 5 10 7 S/O 2 name Depo- Provera Depo- Provera Shukhi Depo- Provera S/O 2 duration days 22 7 24 17 S/O 3 name Depo- Provera S/O 3 duration days 25 S/L Depo- Provera 1.0 0.8 1.1 1.0 2.7 1.6 1.1 S/L IUD (TCu-200B) 3.7 1.4 3.7 1.7 2.8 2.9 2.9 S/L Pill (Shukhi) 0.2 1.5 1.2 0.5 0.5 0.2 0.5 S/L Condom (no-logo) 2.3 2.9 3.0 3.0 5.6 2.8 3.0 Exp 1 name Condom Exp 1 number 6,164 6,164 Exp 1 wastage rate 0.09 0.1 SO rate Depo- Provera 0.0 33.3 6.7 0.0 5.6 13.3 6.1 Note: S/O: stock out S/L: stock level Exp: expiry 61 Review and Lessons Learned: Bangladesh Table F-3 Months of Stock by Level and Method, Bangladesh, November 1999 Region/District Thana SDP (FWVs) min 2 2 2 max 3 4 3 Depo-Provera 1.0 1.1 0.9 IUD (TCu-200B) 2.2 2.9 3.8 Pill (Shukhi) 0.2 0.5 2.1 Condom (no-logo) 2.5 3.0 4.0 62 Appendix G. Future Directions for FPLM Technical Assistance 63 Review and Lessons Learned: Bangladesh USAID and FPLM staff met at Comilla on November 16 and 17 for the purposes of reviewing the “lessons learned” suggested by this study and considering the best directions for the future. There already exists an approved “FPLM/Bangladesh Work Plan: October 1999–September 2000” that lists in great detail the activities proposed to be carried out during this period. While generally reaffirming the content of this document, USAID participants requested that it be supplemented by a “template” that groups all activities under three objectives. A draft has been produced and it may be summarized as follows: A. Ensure the reliable forecasting, procurement, distribution, storage and transportation of contraceptives for both GOB and NGO facilities: � Maintain the practice of sound logistics principles for FP/MCH commodities; � Ensure forecasting and procurement of FP/MCH commodities among all relevant stakeholders in an effort to maintain reliable procurement schedules; � Assist in the management and coordination of the DFP procurement cell as it relates to FP/MCH commodities; and � Expand training of GOB and NGO logistics staff using private organizations in an effort to improve the overall logistics program. B. Explore viable opportunities to improve the efficiency of the MOH&FW FP/MCH logistics system: � Refine and improve the national distribution system for GOB and NGO FP/MCH commodities; � Refine and maintain the logistics system to supply Essential Service Package (ESP) commodities for NGOs; � Explore options for expanding national storage facilities for FP/MCH; � Explore the feasibility of changing the existing distribution to improve efficiency; and � Expand the use of private carriers for transport of FP/MCH commodities to improve efficiency and effectiveness of distribution of commodities. C. Support the MOH&FW in its effort to develop an integrated logistics system for health and family planning commodities: � Contribute towards establishment of a new integrated logistics system; � Train thana staff in integrated logistics management; and � Set up a functional LMIS for ESP products. 64 Appendix G (continued) It is noted that the first two objectives, important though they are, represent “business as usual” for the FPLM/Bangladesh team. The objectives are familiar and the staff is well prepared to carry out all required activities. The third objective, however, breaks new ground. It is anticipated that as this work goes forward, greater than average support from FPLM/Washington staff will be required. Because the plan to assist with integration is an important new departure, it will be useful to give some details of current thinking, as they emerged from the Comilla workshop. “Integration,” is an overarching theme of the HPSP and refers to a range of specific operations. Two of the most prominent are the Essential Services Package and integration of the logistics services of the Health and Family Planning wings of MOH&FW. So much complexity and confusion goes along with the integration of logistics services, that many reasonable people sincerely doubt that it will take place in the near future. Recently, however, there has been a potential breakthrough, with the issue in August 1999 of a “Government Order for Unified Activities at thana Level and below.” A translated version of this document appears in appendix D. Also, in September, the Director General for Health requested that FPLM assist with developing an LMIS for health commodities and training staff in its use. Although these developments do not guarantee anything, they are at least promising of a near future opportunity to assist with integration. A decision to begin the integration process at the thana level is logical; it may be difficult, but it could produce useful results sooner than would be the case for starting at higher levels. FPLM is currently carrying out a multi-country study on the implications of health sector reform for contraceptive logistics. Results so far have provided some useful insights of what works well and what types of mistakes have been made in other countries. For example, vulnerability of the LMIS was mentioned above. FPLM has also carried out in Bangladesh two preparatory studies concerning logistics integration. They are “An Overview of Health Logistics System,” prepared in October 1997, and “Selected Issues in Drug Management,” prepared in August 1998. Review of the Government Order cited above reveals that it is a reasonable statement of goals to be achieved. It does not present, however, a system design for how integrated logistics would work at the thana level and below. It is extremely important to note that the contraceptive and drug logistics systems work very differently. With contraceptives, procurement takes place at the top of the system, products are in full supply, stock levels are regulated through a max-min system and stockouts are a rarity. With drugs, about 70 percent of procurement takes place at the district level, many products are never in full supply, rationing, rather than max-min, is the primary inventory control mechanism, and stockouts are common. The preceding summary may be overly simplified, but it does demonstrate one important point. That is, staff working in the contraceptive and drug logistics systems work not only in different systems, but also in systems with very different operating principles. Given this, bringing all concerned parties together into one reasonably productive system will pose some formidable challenges. FPLM believes the first step should include a qualitative analysis in a sample of districts and thanas to gather the clearest possible understanding of facilitating and constraining factors for integration. An important part of this would be an understanding of what system participants think about integration and the best ways to go forward. Without this, and it should be done as soon as possible, there is real danger that important system design decisions will be made in Dhaka without a clear understanding of the realities at the thana level. 65 Review and Lessons Learned: Bangladesh Therefore, concerning work plan objective C, Support the MOH&FW in its effort to develop an integrated logistics system for health and family planning commodities, FPLM recommends that the following activities be carried out as soon as possible: • Obtain agreement from all stakeholders on the roles of participating partners, including FPLM. • Conduct a situation analysis of facilitating and constraining factors. Consider concluding this exercise with a presentation workshop with staff from all levels participating. • Design a new system, based on MOH&FW directives and input from staff at all levels. • Train staff to operate the new system. • Expand the definition of “logistics” to include good dispensing practices and waste disposal. • Where appropriate, make use of logistics-related materials developed by NIPHP partners: � Dispensing materials � Vaccine-logistics related materials � ESP related materials � Waste disposal materials • Build in good connections between thana level stores and registered NGOs for non- contraceptive products, for example, vaccines, vitamin A and ORS (the same level of MOH&FW/NGO cooperation does not exist for these products as for contraceptives). Concurrently with this, and as a beneficiary of the situation analysis, work would go forward for the LMIS for health drugs and medical supply requisites (MSR). This represents a way forward which capitalizes on the excellent work already completed under family planning in order to establish similar information systems and commodity management for health drugs and MSRs in line with the HSR process, at the same time maintaining contraceptive security. 66 References NEWVERN Information System. 2000. Arlington, Va.: John Snow, Inc./Family Planning Logistics Management (FPLM). Choudhury, Abu Yusuf, Iqbal Ahammed, Neelofar Raza Chowdhury, and Billal Hossain. 1999. 1999 Stock Level Survey. Dhaka, Bangladesh: Program for the Introduction and Adaptation of Contraceptive Technology (PIACT). 67 Contents Acronyms Preface Executive Summary Study Protocol Study Objectives Study Methods The Technical Assistance Strategy HSR and Contraceptive Logistics Logistics Stakeholders The Government Nongovernmental Organizations Donors The World Bank Study Results Regional and District Levels Thana Level SDP Level General Findings Success Factors Barriers to Institutionalization Institutionalization of Certain Functions But Not Others Systems Management Problems Resistance to Major Changes That Favor Efficiency Internal Politics Lessons Learned Recommendations Appendix A. Survey Instruments Appendix B. Key Informants Appendix C. Evaluation Team Schedule Appendix D. Translation of Government Memo Concerning Integration Appendix E. Stakeholder Activities Appendix F. Field Visit Data Appendix G. Future Directions for FPLM Technical Assistance
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