Working With Community-Based Health Committees to reduce stock outs of SRH supplies in a crisis-affected setting

Location:

Introduction:

North Kivu province in eastern DRCDemocratic Republic of the Congo is a land of great natural beauty and resources. It is also home to a decades-long conflict that has brutalized the population, disrupted social networks, and ravaged the public healthcare system. CARE’s Supporting Access to Family Planning and Post-Abortion Care (SAFPAC) Initiative has been working in eastern DRCDemocratic Republic of the Congo since July 2011 to reduce unintended pregnancies and deaths from unsafe abortion in crisis-affected settings. The SAFPAC Supporting Access to Family Planning and Post-Abortion Care Initiative supports government health systems at primary and referral levels to provide a wide range of contraceptive services, including long-acting reversible contraception, to people affected by conflict and/or displacement. This initiative has the following components:

1. Clinical skills training, assessment, and coaching;
2. Supportive supervision;
3. Supply chain support;
4. Quality improvement; and
5. Community mobilization.

Project Description:

In the absence of a functioning public-sector supply chain for SRHSexual and reproductive health supplies in our operational areas, CARE supplied all the contraceptives, medicines, and supplies required to provide quality family planning and post-abortion care services. CARE procured SRHSexual and reproductive health supplies from ASRAMES (the Regional Association for the Supply of Essential Medicines) and international vendors and gave them to district health authorities for distribution to health facilities on a quarterly basis (“push” system). The initiative tracked stock outs of 8 tracer products (oral contraceptive pills, injectables, implants, intrauterine devices, manual vacuum aspiration kits, pain medicine, high-level disinfectant, and gloves) through routine monthly reports submitted by the health center.

In the first phase, the initiative experienced recurring stock outs of implants, pain medicine, and high-level disinfectant. To some extent, this was due to factors beyond CARE’s control such as a global shortage of implants and insecurity impeding resupply. It was also because health facilities did not restrict the use of pain medicine and high-level disinfectant purchased by CARE to family planning and post-abortion care services. Since CARE was the only supplier of these essential inputs to health facilities, CARE did not discourage this practice. However, CARE needed to find a way to strengthen forecasting and inventory management practices to prevent future stock outs.

To begin, CARE trained stock keepers, pharmacists, providers, and community representatives on stock inventory management practices and tools for heath commodities in accordance with national guidelines. The community representatives were members of Health Area Development Committees known as CODESAHealth Area Development Committees. The CODESAHealth Area Development Committees is a community-based structure that represents all the villages/streets in the area served by a health center. It plays a vital role in holding health centers accountable to the communities they serve by reporting to them how health centers use their resources. CODESAHealth Area Development Committees members meet with the health center team once a month to analyze the results achieved, identify strengths and weaknesses to plan corrective actions. Initially, the initiative did not engage with CODESAHealth Area Development Committeess, but CARE realized this was a missed opportunity for improving the management of SRHSexual and reproductive health supplies since one of CODESAHealth Area Development Committeess’ roles is to oversee the health center resources and, as the primary consumers of health services, they have a vested interest in good stewardship of health supplies.

In addition to training CODESAHealth Area Development Committees members on stock inventory management, CARE invited them to participate in monthly supportive supervision visits to health centers during which they conducted physical inventories to compare stock holdings to stock inventory records and to make sure that products in short supply got re-ordered right away. CARE also invited them to help receive deliveries from the district health pharmacy to verify the contents and documentation.

CARE helped to motivate CODESAHealth Area Development Committeess to take on these additional tasks by seeking their inputs during monthly supportive supervision visits to health facilities that CARE conducted jointly with district health officials and recognizing their efforts during quarterly project review meetings with all stakeholders. In addition, CODESAHealth Area Development Committeess got a percentage of the money that CARE paid to health centers that performed well on specified criteria, such as stock outs.

Results:

By involving CODESAHealth Area Development Committeess in routine stock inventory management, CARE reduced the number of stock outs in the health centers CARE supports to nearly zero, even during periods when insecurity prevented access to certain health centers. In the process, CARE succeeded in building mutual confidence between CODESAHealth Area Development Committeess and health staff in the health districts where CARE works, which, in turn, improved overall quality and uptake of SRHSexual and reproductive health services.

There have been some challenges along the way. In the beginning, health staff did not trust or have confidence in the CODESAHealth Area Development Committees because they perceived it as a policing body that lacked health credentials. CARE addressed this by collaborating with the Ministry of Health to define the roles and  responsibilities of CODESAHealth Area Development Committeess and health staff in the management of health supplies and equipment. Subsequently, CARE oriented CODESAHealth Area Development Committeess and health staff on their roles and responsibilities during the stock inventory management training and supported them to make quarterly stock management plans and review progress during quarterly stakeholder meetings.

Lessons Learned:

Community participation in the management and control of SRHSexual and reproductive health supplies at the health-facility level is an effective mechanism for ensuring accountability of public health services, including commodities to users. In addition to improving the availability of essential SRHSexual and reproductive health supplies, it is an effective way to build mutual trust between communities and government health authorities, and is a particularly useful tool for helping crisis-affected societies to lay the foundation for peace and a better future.