Strengthening community health supply chain performance through an integrated approach: Using mHealth technology and multilevel teams in Malawi

Abstract

Background: In 2010, 7.6 million children under five died globally - largely due to preventable diseases. Majority of these deaths occurred in sub-Saharan Africa. As a strategy to reduce child mortality, the Government of Malawi, in 2008, initiated integrated community case management allowing health surveillance assistants (HSAs) to treat sick children in communities. Malawi however, faces health infrastructure challenges, including weak supply chain systems leading to low product availability. A baseline assessment conducted in 2010 identified data visibility, transport and motivation of HSAs as challenges to continuous product availability. The project designed a mHealth tool as part of two interventions to address these challenges.

Methods: A mobile health (mHealth) technology - cStock, for reporting on community stock data - was designed and implemented as an integral component of Enhanced Management (EM) and Efficient Product Transport (EPT) interventions. We developed a feasibility and acceptability framework to evaluate the effectiveness and predict the likelihood of scalability and ownership of the interventions. Mixed methods were used to conduct baseline and follow up assessments in May 2010 and February 2013, respectively. Routine monitoring data on community stock level reports, from cStock, were used to analyze supply chain performance over 18-month period in the intervention groups.

Results: Mean stock reporting rate by HSAs was 94% in EM group (n = 393) and 79% in EPT group (n = 253); mean reporting completeness was 85% and 65%, respectively. Lead time for HSA drug resupply over the 18-month period was, on average, 12.8 days in EM and 26.4 days in EPT, and mean stock out rate for 6 tracer products was significantly lower in EM compared to EPT group.

Conclusions: Results demonstrate that cStock was feasible and acceptable to test users in Malawi, and that based on comparison with the EPT group, the team component of the EM group was an essential pairing with cStock to achieve the best possible supply chain performance and supply reliability. Establishing multi-level teams serves to connect HSAs with decision makers at higher levels of the health system, align objectives, clarify roles and promote trust and collaboration, thereby promoting country ownership and scalability of a cStock-like system.

Figure 1

Components of the two intervention groups (EM – Enhanced Management and EPT – Efficient Product Transport). DPAT – district product availability teams.

Figure 2

Feasibility, acceptability and effectiveness framework.

Figure 3

Mean reporting rates to cStock by HSAs, on all commodities in EM (Enhanced Management, n = 393) and EPT (Efficient Product Transport, n = 253) districts, January 2012 – June 2013.

Figure 4

Mean reporting completeness by HSAs (health surveillance assistants), on all commodities, in EM (Enhanced Management, n = 393) and EPT (Efficient Product Transport, n = 253) districts, January 2012 – June 2013. Asterisk – findings from a two sample t–test with equal variances suggest that the differences in means between the EM and EPT districts are statistically significant (P < 0.001).

Figure 5

Lead time for HSA (health surveillance assistant) drug resupply calculated by cStock, in number of days, in EM (Enhanced Management, n = 393) and EPT (Efficient Product Transport, n = 253) districts, January 2012 – June 2013. Asterisk – findings from a two sample t–test with equal variances suggest that the differences in means between the EM and EPT districts are statistically significant (P < 0.001).

Figure 6

Mean percentage stockout rate over 18 months, by product, for EM (Enhanced Management) vs EPT (Efficient Product Transport) districts, (January 2012 – June 2013). Asterisk – P < 0.001.