EXECUTIVE SUMMARY
More than three quarters (88 percent) of total number of health facilities visited were staffed by employees who received training in Logistics management from the Ministry of Health.
The resulting impact of the nationwide training in logistics management for health centres and the subsequent distribution of logistics job tool wall charts have made 77 percent of the storekeepers fully knowledgeable about the First Expiry First Out (FEFO) storage principle; however, less than half of the storekeepers religiously practice FEFO on a day-to-day basis.
68 percent of the storekeepers interviewed knew how to calculate the average monthly consumption (AMC) and 61 percent of them are calculating AMC before they order their stock replenishment.
64 percent of the storekeepers knew the correct formulae to order stock replenishment, but only half of them actually ordered their stock correctly.
All the facilities visited offered family planning services and 80 percent (45 out of 56) claimed that community based distribution activities were complimenting their services.
The majority of health facilities visited had appropriate private counselling rooms together with adequate displays of birth spacing related IEC materials.
With the exception of IUD CT 380A, stock-outs of contraceptives are reasonably low at the 56 surveyed facilities. Only nine percent of the surveyed facilities are stocked-out of one or more of the contraceptives they should have [i.e. Condom, DMPA (150mg/ml), Progesterone (.075mg) OC, Progestrone (.15mg)+Oestradiol (.03mg) OC]. 54 percent of the facilities surveyed were found to have satisfactory stocks of contraceptives.
Finally, the method mix for contraceptive used in the public sector birth spacing program is 53 percent DMPA, thirty seven percent oral contraceptives (1 percent POP, 36 percent COC), 6 percent IUD, and 4 percent condom.
INtroduction
This report presents the findings of an assessment of the stock level of the full range of contraceptives in 56 health centres, and the performance of storekeepers in these facilities.
This report will make recommendations to the Ministry of Health (MoH) regarding:
· Developing future strategic plan on training programs in logistics management.
· Developing an action plan to ensure contraceptive stock security for long and short term.
Methodology
Two teams from NCHP, EDB and RACHA visited a total of 56 Health Centre Storekeepers and one Referral Hospital Storekeeper in 26 ODs in nine provinces, to ensure a varied sample of health centres nation-wide. (It was decided not to include RACHA-supported ODs due to the fact that they are receiving ongoing logistics technical assistance from RACHA, and are therefore not representative of drugstores in Cambodia).
Fifty-six health facilities were chosen for investigation using a computerised random site selection process. Appointments were made with each facility, however in some cases, due to flooding, difficult access and/or absence of the Storekeeper, some selected sites had to be replaced with others for more convenient access. (See Appendix 1 for a list of the 56 health facilities).
At each of the above sites, a team of monitors conducted informal interviews with Storekeepers using a structured questionnaire (see Appendix 2). Interviews lasted approximately 30 minutes, and consisted of questions about the stock level of contraceptives. The following additional instruments were then also used for the assessment of stock level:
· Observation of stock status, including conducting a physical count of the stock of all contraceptives held at the facility
· Record sheets
· Birth spacing consultation registers
· Other relevant documents containing records of the facility's contraceptive consumption.
The full range of contraceptives, distributed through the public sector, was selected for the purpose of this investigation activity.
FINDINGS & ANALYSIS
1. CONTRACEPTIVE STOCK STATUS
CONTRACEPTIVES STOCK STATUS OF 56 HEALTH FACILITIES
Note: All annual calculations are based on the following definitions for stock levels (month of stock or MoS is being used to categorize stock level. The MoS is calculated using the following formula : Stock on hand divided by 3 months average consumption). Most surveyed facilities are supplied every month and the maximum stock set by the Ministry of Health is two months worth of stock. Satisfactory = Maximum MoS (set by the Ministry of health) to volume of stock required to last until next delivery (i.e. re-supply period multiplied by 0.5)
Ø Stock-out = Nil Stock
Ø Potential Stock-out = Stock level ranging from nil stock to less than or equal to re-supply period multiplied by 0.5.
Ø Over Stocked = Stock on hand higher than Maximum MoS
1.1. Mycrogynon (Progesterone + Oestradiol Oral Contraceptive (0.03 mg + 0.15 mg)
This oral contraceptive, also commonly known as COC, is widely used in the public sector as well as in the private sector. High overstocks were found in Koh Kong, Kratie and Svayrieng provinces, whereas some facilities in Kandal and Modulkiri had stock-outs. The average monthly consumption (AMC) of this contraceptive fluctuates from 5 to 641 cycles.
1.2 Ovrette (Progesterone Oral Contraceptive (0.075 mg)
More than half of the sites surveyed (29/56) do not carry stock of this contraceptive within their store. High volumes of overstocks of this commodity were found in 24 facilities. The highest stock holding found was 190 cycles and the lowest was 1 cycle, and the AMC ranges from 1 to 9 cycles.
1.3 Condoms
There are seven different brands of condoms in circulation within the public sector, they are manufactured in Thailand, Indonesia, Malaysia and India. 87% of the facilities visited (49/56) stocked condoms. Overstocked situations were found in Svayrieng, Mondulkiri and in some facilities in Banteay Meanchey and Battambang. The AMC of this commodity ranges from 5 to 1000 pieces.
1.4 DMPA
There are three different types of DMPA currently in circulation. Depoprovera 2ml, Petogen 150mg and Petogen 3ml. Only three sites out of 56 were found to be stocked-out whereas more than half of them were satisfactorily stocked ( 31/56). The AMC of this commodity ranges from two vials to 121 vials. The highest rates of consumption were in Kandal, Banteay Meanchey and Svayrieng provinces whereas lowest consumption was in Koh Kong, Kratie and Kompong Chhnang provinces.
1.5 IUDs
IUDs currently supplied through the Public Sector are manufactured in Germany, Thailand, India and Canada. Only four health facilities visited had IUDs in stock and yet only seven sites had consumption history (i.e. stocked IUDs in the past). The AMC of this commodity ranges from one to eight kits. Due to its very low consumption rate, stock status analysis for this particular commodity cannot be classed as being a realistic national consumption pattern.
1.6 Examination stocked-out frequency
# of Health facilities stocked-out / Sample Size[1]Never stocked-out in last 6 months / 1 stocked-out episode
in last
6 months / 2 stocked-out episodes in last
6 months / 3 stocked-out episodes in the
last 6 months / 4 stocked-out episodes
in the last
6 months
COC / 43 / 9 / 2 / 2 / 0 / 56
POP / 31 / 1 / 0 / 0 / 1 / 32
DMPA / 49 / 4 / 0 / 3 / 0 / 56
Condom / 41 / 10 / 2 / 1 / 0 / 54
IUD / 7 / 0 / 0 / 0 / 0 / 7
The above table suggested that episodes of stocked-out were very low for the full range of contraceptives currently distributed through the public sector.
1.7. Analysis of usable versus unusable contraceptive stock.
The majority of contraceptive pills and injectable stock held at service delivery points is usable.
Only for IUDs and condoms however was a significant amount of unusable stock found. 17% of condom stocks were unusable and 62% of IUD stocks were also unusable.
Usable versus UnusableUsable stock / Unusable stock
Shelf life< 3 months / Shelf life>= 3 months
COC / 5 % / 95 % / 0 %
POP / 1 % / 97 % / 2 %
DMPA / 0 % / 99 % / 1 %
Condoms / 0 % / 83 % / 17 %
IUDs / 0 % / 38 % / 62 %
1.8 Contraceptive Method Mix
There appeared to have a slight change in method mix over the past few years. In 1998, only 17 percent of users chose COCs as a contraceptive method and 71 percent received DMPA. Three years later, however, many avenues have been used to reach the unmet birth spacing needs of the community through village feedback committees, as well as outreach activities. This has contributed to the percentage of pill users more than doubling over this period. The percentage of family planning clients now using DMPA has fallen by 18 percent.
Contraceptive Method mix comparison 1998 versus 2001
Calculation of contraceptive Method Mix Percentages:
For each type of contraceptive, the average monthly amounts dispensed were calculated for all surveyed facilities. These monthly figures were then multiplied by twelve to obtain the average yearly amounts dispensed. Couple Year Protection (CYP) factors were then divided into these yearly amounts to determine the number of couple years of protection for each contraceptive. The CYP of each contraceptive was then converted to a percentage of the total CYPs. The CYP conversion factors used in this analysis were: Condom =150, DMPA(150mg/ml)= 4, IUD CT 380 A = .28, Progesterone Oral Pill (0.075 mg)= 15 and Progesterone + Ostradiol Pill (0.03mg+0.15mg)= 15.
1.9 Change of Consumption pattern
Further evidence of active efforts to reach the community can be shown by the sharp increase in consumption of COCs and condoms when consumption patterns are compared between 1998 and 2001.
Consumption of COCs has dramatically increased by 164 percent, consumption of condoms were also up by 71 percent. According to MoH guidelines, only outreach activities conducted by health centre staff are authorised to provide DMPA, whereas other channels of community-based birth spacing services (using feedback committees or volunteers) mobilise birth spacing clients to use condoms and pills.
Contraceptive Average monthly Consumption comparison from 1998 to 2001Contraceptive type / 1998
AMC / 1999
AMC / % change
1998 vs. 1999 / 2001
AMC / % change
1998 vs. 2001
DMPA / 37 / 49 / + 32 % / 38 / + 3 %
POP / 5 / 5 / No change / 2 / - 40 %
COC / 37 / 60 / + 62 % / 98 / + 164%
Condoms / 64 / 78 / + 22 % / 110 / + 71 %
Of the 45 health facilities providing community-based birth spacing services, in 13 sites (or 29%) only health centre staff are exclusively involved in providing this service. The table below also shows that other providers such as RHAC, Feedback Committees, Women’s Affairs volunteers and other NGOs most of the time teamed up with health centre staff to conduct this activity.
Providers of Community Based ServicesHealth Centre staff / RHAC / Feedback committee / Women’s Affairs Volunteers / Other NGOs / %
of health facilities
ü / 29%
ü / ü / ü / 2%
ü / ü / ü / ü / 9%
ü / ü / ü / 2%
ü / ü / 13%
ü / ü / ü / 2%
ü / ü / ü / ü / 2%
ü / ü / ü / 9%
ü / ü / 9%
ü / ü / 18 %
ü / ü / ü / 2 %
ü / 3 %
Sample size: 45 sites.
1.10. Logistics Management Knowledge versus Practice.
The teams interviewed staff responsible for the logistics management of drug storerooms to check whether they had received any kind of logistics management training. They systematically validated whether those storekeepers could apply the knowledge gained through the training to complete their day-to-day tasks correctly. The following were found:
· 77 percent (43 storekeepers out of 56) knew what First Expiry First Out (FEFO) principle meant and yet only 46 percent (26 storekeepers out of 56) applied this principle to manage their stock.
· 68 percent of the storekeepers interviewed could define AMC correctly, but only 61 percent of them were actually using this principle to manage the inventory.
The concept of Months of Stock (MoS), mainly used to assess stock status at a given time, was somehow not so well grasped by storekeepers. Only 27 percent of storekeepers interviewed knew how to define and use this concept correctly.
The teams also checked whether storekeepers knew and used the correct formulae to request their stock. 64 percent of the interviewees (36 out of 56) knew how to define it correctly and 50 percent of the interviewed audience correctly used the formulae to order their stock replenishment.
It is interesting to observe that 30 percent of the interviewees became storekeepers (either through staff turnover or new health centre opening) after the nation-wide training in logistics management conducted by RACHA and the EDB in the last quarter of 1999. This percentage is very close to the percentage of interviewees who could neither define AMC, and hence order their stock replenishment accurately, nor apply these two concepts to do their work correctly.
Questions / % of storekeepersStorekeepers holding post from 1996 to date / 70%
Storekeepers holding post from 2000 to date / 30%
Know how to define FEFO / 77 %
Apply FEFO correctly / 46 %
Know how to define AMC / 68 %
Apply AMC correctly / 61 %
Know how to define MoS / 27 %
Apply MoS correctly / 27 %
Know how to define formulae / 64 %
Apply correct formulae / 50 %
2. BIRTH SPACING SERVICE DELIVERY
2.1 Location and set-up
All the sites visited offered birth spacing services and the majority of them (82% of the sites) are appropriately located in populated areas. The joint efforts of the Ministry of Health and collaborating stakeholders to promote reproductive health were also very evident at service delivery points. 95 percent of the facilities visited had appropriate consultation areas and 96 percent of them displayed relevant IEC materials within the consulting areas.
Observation topics / % of health facilitiesAvailability of birth spacing services / 100%
Located in populated catchment area / 82 %
Located on main road/track road / 95 %
Existence of complimentary CBD/CBS / 80 %
Evidence of consulting timetable / 34 %
Existence of appropriate consulting room. / 95 %
Existence of demonstration kits & IEC / 96 %
Existence of fees scale on display / 59 %
2.2. Fees