Assessment of Micronutrient Supplement Supply and Demand Systems

Abstract

• Name: Assessment of Micronutrient Supplement Supply and Demand Systems

• Purpose: To enable public health managers understand how the supply and demand systems for micronutrient supplements operate, and identify and address supply and demand constraints and problems affecting program effectiveness.
• Design: Cross-sectional throughout the health system with verification of record keeping and inventories.
• Sample Size: N/A
• Where Used: India, Sri Lanka, Honduras, and Bolivia

To survey tool

Basic Information

Name: Assessment of Micronutrient Supplement Supply and Demand System

Origin: Developed and tested in India by OMNI and the Nutrition Foundation of India.

Source: OMNI/NFI

Basic Description: The two sets of instruments were designed to be used for systematic identification of supply and demand constraints and problems.

Country Applications: Used in India and Sri Lanka. A modified version of the first section (supply) was used in Honduras and Bolivia, where demand issues were covered as part of formative research on Information, Education and Communications (IEC).

Languages: English. Local language in Sri Lanka, Spanish (supply section only). The instruments and manuals used in India and Sri Lanka are available in English. Modified versions specifically focused on the supplement supply system that were used in Honduras and Bolivia are available in Spanish.

Technical Scope: Assessment of the national and local supply and demand systems for micronutrient supplements.

Purpose: To enable public health managers understand how the supply and demand systems for micronutrient supplements operate, and identify and address supply and demand constraints and problems affecting program effectiveness.

Type of Methods: Quantitative and qualitative information is gathered throughout the entire health system from central to district, sub-district and local levels. Document review, interviews with key personnel, direct observation and verification of records and inventories at storehouses, exit interviews with mothers and health care personnel are employed.

Design: Cross-sectional throughout the health system with verification of record keeping and inventories.

Frequency of Administration: At program inception and periodically as needs arise. Some of the tools may be used periodically for monitoring purposes after corrective actions are taken.

Key Users of Information

Primary Users: Health sector program planners, managers and evaluators, particularly those responsible for supplementation program planning and implementation.

Secondary Users: Some of the tools, in particular those addressing supplement demand issues, may also be used by NGOs involved in supplements distribution.

Objectives and Scope of Tool

Objective: Gather key information for identification of problems related to supplement supply and demand systems affecting program performance and effectiveness.

Scope: The tools collect and analyze information for an action-oriented situation analysis on supply and demand systems for micronutrient supplements, anti-helminths and anti-malarials.

Key Monitoring Needs and Evaluation Questions Tool Seeks to Address

The following questions are to be answered:

On the supply system:

• Current process for estimating supplement needs at different levels, and for procurement and distribution of supplements and related pharmaceutical products from the central to all other levels of the health system.
• Existing practices for storage, quantification of stocks, supply and re-supply of supplements at the central, district and sub-district levels.
• Operation of the supplement distribution system in the past six months at the central, district, and sub-district levels.
• Use of micronutrient supplements at the different health facilities.

On the demand system:

• Current situation of pregnant women's demand for supplements and related products, and factors influencing it.
• Current situation of preschool children's demand for supplements and related products, and factors influencing it.
• Type of supplements and related products available in health service pharmacies, in what amounts, and how are they prescribed.
• Health care providers' knowledge and practice on micronutrient supplements and related products.

Key Indicators

Stores management:

• % of micronutrient related products for which there is a written stock and recording method.
• % of listed micronutrient related products in stock.
• % of accurate stock records.
• Number (%) of service facilities achieving minimum storage (15 from 20 items) below standards.
• % of facilities achieving an annual stock take for micronutrient related supplements
• % product where expired stock is mixed with usable stock.

Quantification and re-supply decisions:

• % of micronutrient related product's re-supply decisions made quantitatively at district level.
• % of micronutrient related re-supply decisions made by appropriately trained staff at district level.
• Average frequency of ordering micronutrient related products by category.
• % of standard systems for reordering micronutrient related products.
• Average % time stock out for each micronutrient related product.
• Average number of stock outs for all micronutrient related products.

Distribution:

• Frequency of delivery/collection by product category in the last six months.
• Average number of transportation methods for micronutrient related product.
• % of micronutrient related products distributed to non-governmental health care providers.

Rational use:

• % of health facilities in district with a functional Hospital or Health Center Drug and Therapeutics Committee (i.e. meets every two months).
• Availability of an official government publication in health facility (e.g. standard treatment guidelines, essential drugs and supplies list, treatment and prevention protocols) providing essential public health supplies information to prescribers, revised and published within the last five years.

Demand by pregnant women:

• % women who reported having received any iron/folate supplements in their last pregnancy and distribution of sources of supply.
• Mean number of iron/folate tablets received during last pregnancy.
• % of women reporting side effects from using iron/folate supplements in last pregnancy.
• % of women reporting suspending use of iron/folate tablets because of side effects.

• % of women reporting having received anti-helminths in their last pregnancy and distribution of sources of supply.
• % of women having received an anti-malarial treatment.

Demand by preschool children:

• % of preschool children having received iron/folate supplements in the last six months and distribution of sources of supply.
• % of preschool children reporting side effects from using iron/folate supplements.
• % of preschool children having received vitamin A supplement in the last six months, and distribution of source of supply.

Health care providers' knowledge and practice:

• % of health care providers with adequate knowledge of the importance, clinical signs, risk factors, causes and implications of vitamin A deficiency, and of actions to control it.
• % of health care providers with adequate knowledge of the importance, clinical signs, risk factors, causes and implications of iron deficiency anemia, and of actions to control it.
• % of health care providers with adequate knowledge of the importance, clinical signs, risk factors, causes and implications of iodine deficiency disorders, and of actions to control it.
• % of health care providers with adequate knowledge of the use and protocols for vitamin A, iron/folate and iodine supplementation.
• % of health care providers with adequate knowledge of the use and protocols for anti-helminths and anti-malarials.

Research Design

The tools are used for collecting cross-sectional information throughout all levels of the health system. Data at the central level are obtained through interviews with key personnel responsible for supplementation policies, technical guidelines, planning, procurement and distribution to health districts, as well as through review of pertinent documentation and observation of central storage facilities, existing stocks of supplements, and entry and distribution records, with verification of inventories.

Similar information is collected from a sample of health districts, sub-districts and local facilities (number of units covered contingent upon country size and complexity of the health system), through interviews with managers, technical personnel and health care providers, as well as observation visits and review of supplement stocks, entry and distribution records, and verification of inventories in storage facilities and local health service units. Information on supplement demand is gathered mostly through exit and household interviews with health service clients (mothers) and pharmacy staff.

Implementation

Implementation usually requires specially trained groups of interviewers, a team leader in charge of interviews and documentation review at all levels. Implementation time depends on country size, complexity of the health system, sample size, and number of staff involved in the assessment. Usually the supplement supply system is an integral component of the overall pharmaceutical supply system, although eventually some supplements, often those donated, are managed by especial units, e.g. the Maternal and Child Health Unit. Therefore, problems identified in the supplements supply system are often generic to the general pharmaceutical supply system rather than specifically related to micronutrients.

Common problems affecting a system's efficiency and generating lost opportunities for supplementation include: poor overall planning; unplanned supplement procurement and logistical problems related to timely distribution of supplies from central to health district levels and, more often, from district or sub-district levels to health facilities; as well as untrained personnel in charge of managing supplies; absence of technical guidelines in health units; and poor staff motivation and lack of commitment to keep records and make the best use of supplements.

Analysis

Despite the relatively large amount of quantitative and qualitative information to be collected, data analysis using EPI-INFO is straight forward and does not involve a great deal of staff time. Most indicators (percent rates) are easily estimated although, in some cases, reliability of the information collected through interviews may be questionable and verification is not always possible. Whether a specific assessment of the supplement demand system is best carried out as part of formative research for IEC, rather than concurrently with an assessment of the supply system, is still an unresolved issue. A supplement demand system would be better understood when qualitative information is collected that may help interpreting the quantitative data resulting from formal interviews; likewise, appropriate research approach and methods for exploring demand issues may be somewhat different from those required for assessing the supply system. On the other hand, IEC formative research is often complex, costly and time consuming, and may require especial expertise, which would make it less timely for early planning of supplementation programs. At any rate, IEC formative research is envisaged to include more in depth information on demand issues than general supply/demand assessments.

Reporting

The assessment report highlights major findings, identifies main problems and, frequently, proposes options and makes recommendations to solve them. In many cases, potential solutions to supply problems pertain to the entire pharmaceutical supply system rather than just to micronutrient supplements. Likewise, some of the demand problems may be more properly address through IEC strategies.

Dissemination of Results

The results of comprehensive assessments of the micronutrient supplement supply and demand systems are of potential interest and should be disseminated to policy and program decision makers at high levels of the health system, as well as to program implementers at district, sub-district and local levels. They will be ultimately responsible for planning and implementation of corrective measures. The results may also be shared with health authorities responsible for management of the general pharmaceutical system, particularly when the supplements supply system is not independent but an integral part of the overall pharmaceutical supply system.

Manuals and Guidelines

Manuals on the use of the instruments, data analysis and interpretation are not available. Current documentation is restricted to specific guidelines on how to fill the questionnaires and suggestions as to how to present the results. Manuals for assessment of general pharmaceutical systems may be available from other sources (e.g. health management, administration and/or health financing projects).

References

Nutrition Foundation of India. Comprehensive Situational Analysis Study on Demand and Supply of Micronutrient Supplements (Iron & Vitamin A), Anti-helminthes and Anti-malarials, and their Consumption Patterns in Bhopal Division of Madhya Pradesh, 1 997-98. Nutrition Foundation of India, C-13, Qutub Institutional Area, New Delhi - 110016, 1998.

Godoy, R. Analisis de la Situacion Global del Suministro de Hierro y Vitamina A en el Sistema de Salud de Honduras, 1994-1997. Secretaria de Salud Pdblica de Honduras, Programa para el Desarrollo de la Infancia y la Mujer (PRODIM). Tegucigalpa, Honduras, 1998.

Other

There are prototype instruments available for a situation analysis of overall pharmaceutical supply systems, some of which were consulted before these instruments were developed and tested in India.