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Table of Contents
ORIGINAL ARTICLE
Year : 2020  |  Volume : 6  |  Issue : 2  |  Page : 114-119

A discrepancy in logistics and supply chain management: Findings from national iron plus initiative process documentation in Odisha


1 Executive Director, All India Institute of Medical Sciences, Bibinagar, Telangana, India
2 Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India
3 Department of Community Medicine, JIPMER (Karaikal), Puducherry, India
4 Department of Community Medicine, VCSG Government Medical Sciences and Research Institute, Srinagar, Uttarakhand, India
5 All India Institute of Medical Sciences, Raebareli, Uttar Pradesh, India

Date of Submission02-May-2020
Date of Decision13-May-2020
Date of Acceptance10-Oct-2020
Date of Web Publication24-Dec-2020

Correspondence Address:
Dr. Swayam Pragyan Parida
Department of CM and FM, All India Institute of Medical Sciences, Bhubaneswar, Odisha
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCFM.IJCFM_42_20

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  Abstract 

Introduction: Anemia is highly prevalent in India affecting all age groups. In 2016, process documentation program was done in Odisha by Department of Health and family Welfare, Government of Odisha with the aid of UNICEF and All India Institute of Medical Sciences, Bhubaneswar to assess National Iron Plus Initiative program. The objectives were to assess facilitating factors and hindrances in implementation of program. In the present study, hurdles in logistics and supply chain management are discussed.
Material and Methods: A mixed-methods study was done among four districts (3 poor performing and one good performing) based on Iron folic acid tablets consumption. Two blocks from Keonjhar and Jagatsinghpur and one block from Bhadrak and Kalahandi were selected. In depth interviews and Focus group discussion were done among 170 respondents (officials and beneficiaries). By probability proportion to size, 50 sub-centres were chosen and front line workers interviewed. Data was collected by survey team and analysis was done using Nvivo qualitative research software program for qualitative surveys and Microsoft Excel for quantitative surveys.
Results: It was seen that there were discrepancies in the method (bypassing officials), frequency of indenting (quarterly, bi-annual and annual), supply chain, stock out management (informal methods) and flow of supply (prolonged quarantine period). It was also seen that only 41% of sub-centres had IFA tablets at the time of survey.
Conclusion: Logistics and supply chain management play a crucial role in the success of any program. Timely and orderly management, centralised method and formal approach need to be incorporated.

Keywords: Anemia, logistics, National Iron Plus Initiative, Odisha, stock management, supply chain


How to cite this article:
Bhatia V, Parida SP, Mahajan PB, Palepu S, Paul S. A discrepancy in logistics and supply chain management: Findings from national iron plus initiative process documentation in Odisha. Indian J Community Fam Med 2020;6:114-9

How to cite this URL:
Bhatia V, Parida SP, Mahajan PB, Palepu S, Paul S. A discrepancy in logistics and supply chain management: Findings from national iron plus initiative process documentation in Odisha. Indian J Community Fam Med [serial online] 2020 [cited 2021 Apr 18];6:114-9. Available from: https://www.ijcfm.org/text.asp?2020/6/2/114/304794


  Introduction Top


Anemia, a condition defined by the decrease in the number or the oxygen carrying capacity of red blood cells,[1] is an issue of concern since ages. Although, India is growing economically and politically, the burden of anemia still persists with negligible decline over the decades. Improved living conditions, financial stability, sanitation and hygiene, and educational status of people have ceased to show any influence on this major nutritional deficiency. National Family Health Survey-4 reveals that the prevalence of anemia is high ranging from 53% in women of 15–49 years of age to 58.5% in children of 6–59 months of age.[2] Anemia has profound ill effects on health varying from shortness of breath, fatigue, headache to irregular heartbeat, and arrhythmia. Furthermore, anemia accounts for decreased school performance and productivity. Hence, this preventable cause of nutritional deficiency needs to be addressed. National iron plus initiative (NIPI) is one such program designed to combat anemia through the life cycle approach. Supplementing iron and folic acid (IFA) and Albendazole to 6 months to 19 years of age, women in reproductive age group, and pregnant and lactating females, this program strives to overcome anemia.[3]

NIPI was launched in 2013.[3] In the year 2016, with 3 years into the launch of the program, a process documentation program to investigate the progress and assess the hurdles in the ground level implementation was planned. Odisha was chosen to assess the process documentation as the prevalence of any anemia and severe anemia is very high in the state. Hence, Department of Health and Family Welfare, Government of Odisha in collaboration with UNICEF and All India Institute of Medical Sciences (AIIMS), Bhubaneswar, planned to review the process documentation in March–May 2016. The objectives of the process documentation were to evaluate the key state and district experiences in implementing NIPI, success factors and challenges in provision of IFA to children, adolescents, pregnant and lactating women, explore the programmatic lapses and suggest future recommendations.

For successful implementation of any supplementation program, special emphasis should be placed upon monthly monitoring of stocks at each level of distribution, scheduling of orders to ensure regular supply, and quality control measures by periodic sample checking.[4] In Odisha, OSMCL was established in 2013 for ensuring procurement and supply of high quality drugs in the state. All the information related to indent, purchase order, quality control and supply chain is entered online in “e-Aushadhi” system of OSMCL. Distribution of drugs is ensured down till block level with the help of several vehicles. However, the monitoring and tracking of supply and utilization of drugs at grass-root level remains a big constraint.[5]

In this present article, we intend to discuss the procurement and supply chain management issues incurred during the process documentation of NIPI.


  Material and Methods Top


A mixed methods approach was adopted for conducting process documentation in NIPI.

Selection of study site

Among 30 districts of Odisha,[6] four districts were planned to be a part of the study based on the IFA consumption by mothers and children as assessed by Annual Health Survey 2012–2013.[7] One poorest performing district from each revenue division (three districts: Bhadrak, Keonjhar, and Kalahandi) was selected, and the overall best-performing district (Jagatsinghpur) was selected as the fourth to assess the differences among poor and best performing districts. From the districts selected, one good and one bad performing block were selected from Keonjhar and Jagatsinghpur. However, as much data variability did not occur among the blocks of the district, only one block each was selected in Bhadrak and Kalahandi.

Surveys

Both qualitative surveys to assess the perceptions of the respondents (n = 170) toward NIPI program and quantitative surveys to compute the outputs and outcomes were undertaken. As a part of qualitative survey, in depth interviews (IDD) were purposively conducted among state (n = 12) and district level officials (n = 27) from the departments of Health, Education, and Integrated Child Development Services (ICDSs). District officials were chosen evenly across the four districts, and block and sector officials (n = 32), field workers (n = 49), and beneficiaries (n = 34) were chosen evenly across the six blocks. Both IDD and focus group discussions (FGDs) were conducted among respondents at block, sector/cluster, and field level. Among beneficiaries, only FGDs were conducted as a part of process documentation. For quantitative survey, facility-based survey was done to understand the supply chain management. From four districts, 8 community health centers and 24 primary health centers were included. Based on probability proportion to size sampling method, 50 sub-centres, 99 schools, 90 Anganwadi centers, and 48 village health and nutrition day (VHND) sites were further selected. From these centers, 245 anganwadi workers (AWWs), 235 Accredited Social Health Activists (ASHA), and 39 auxiliary nurse wid-wives (ANM) were interviewed.

Questionnaire development

Facility survey questionnaires were designed according to the platform (health centres, schools, and VHND) of IFA interventions and survey team administered the same.

Data collection

Data collection for qualitative surveys was done by a survey team who were trained in a 6 day phase wise training method. Following training, the survey team conducted IDDs either in offices or in private places, depending on the availability of the official. FGDs were conducted in the group of 12–15 years. A review meeting was held every day to discuss the obstacles faced and reforms needed for further data collection. Supervisory visits were done by the investigators intermittently to monitor the survey team and ensure the smooth conduct of the process documentation. All the qualitative interviews and FGDs were tape recorded and labelled with time, date, and place.

Data analysis

The transcripts were later entered into Nvivo qualitative research software program. Analysis was done under 15 different arenas which included logistics procurement and supply chain.

Ethical clearance

Ethical clearance was obtained from ethical committee of AIIMS, Bhubaneswar. Written informed consent was obtained from the participants, and their identity was kept confidential.


  Results Top


Evaluation of indenting mechanisms and supply chain management were among the other subsets of the process documentation of NIPI. The existing mechanisms in the field and differences in regard to the routine indenting mechanisms were evaluated by IDDs of various health officials and stake holders. The indent orders are made by Health and Family Welfare department based on the number of students enrolled in the school at the beginning of an academic year and bi-annual household survey by AWWs.

Qualitative surveys

Assessment of drug requirements

Various stakeholders including ANMs were interviewed as they are the first contact of health care for the population. Regarding IFA requirement of pregnant women, they had two schools of thoughts. One group assumed that most of the pregnant women are anemic and needed 2 doses of IFA per day. Another group assumed that 80% of women are anaemic and need 2 doses of IFA per day and 20% need one IFA tablet. When Medical Officer Incharges (MO I/Cs) were interviewed, it was revealed that a surplus of 10% stock is ordered.

These different school of thoughts lead to over/under estimation of stock requirement.

Method of drug indenting

Flow of indenting was consistent in all the four districts [Figure 1]. The indent request from MO I/C and BPM, with the help of Block Pharmacist is sent to Chief District Medical Officer (CDMO) through District Pharmacist. The CDMO is then entrusted with the responsibility of sending the indent to State Drug Management Unit/OSMCL.
Figure 1: Flow of indenting of IFA and albendazole at various health sectors. (a) Health officials indenting. *Requirements (iron and folic acid and Albendazole) of pregnant women and children from 6 to 59 months are assessed. (b) Integrated Child Development Service indenting. *Requirements of iron and folic acid tablets and Albendazole for out of school adolescent girls and children of 6 months to 5 years are assessed. (c) Education officials indenting. *Requirements of iron and folic acid tablets (pink and blue) for in school children of 5–10 years of age (standard 1–5) and adolescent girls and boys is done

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It was seen that the indent requirement for the health department bypassed Lady Health Visitor and MOIC received directly from health workers. In one district, the indent was once sent directly to sector supervisors from ANMs without consulting MOIC. Another major discrepancy was seen in Bhadrak district wherein indent was being prepared by ICDS workers and officials rather than health workers. For the ICDS, the Child Development Program Officer (CDPO) prepared the indent for MOIC rather than District Social Welfare Officer. For the Education department, the BEO compiled the report for BPM rather than for District Education Officer (DEO) as per the guidelines.

Frequency of indenting

Most of the officials reported annual indenting. Few exceptions were noted as some officials reported bi-annual indenting, one CDPO and ANM reported quarterly indenting and one group of ANMs reported stock based indenting (indent whenever there is stock out).

Receipt of drug supply

OSMCL officials reported that supply is received in 2–3 instalments of 30%, 30%, and 40%. According to them, the receipt of supply depends on the requirement and storage space at warehouse. At the level of district, field and block, officials mentioned that supply is bi-annual. The receipt of supply stock at the field level however varied with one CRCC notifying as yearly and the other as quarterly. Two ANMs reported as receiving the stock in every quarter.

Another issue of concern is the poor storage conditions for drugs at warehouses of OSMCL (lack of ventilation and sufficient space).

Flow of supply

The flow of supply was consistent among the four districts.

As per Health officials, for pregnant women, supply was sent from CDMO/District Pharmacist to CHC Pharmacist/MOIC/BPM and then to ANM. Similar mechanism is maintained for children 6 months to 5 years. ANM later distributes the stock to ASHA (for children <3 years) and AWW (for children 3–5 years). ICDS officials revealed that from CHC, the supplies are sent to CDPO, then to ICDS supervisors and AWW and ASHA. Education department officials revealed that the supply from CHC is sent to BEO and then to CRCC and headmasters of schools.

However, in three districts, the District Pharmacist transported to CHC/Block and in one district the Block Pharmacist collected it from District Pharmacist. The District Pharmacist supplied directly to schools in one district. Irregularities were seen in distribution from CRCC to head masters. Various officials said that the supply takes 2–4 months to reach from district to block after clearance of quarantine (for every new batch of IFA), and it usually takes 10 days for the supply to be delivered from block to CDPO/CRCC/Sub-centre.

Stock–out of drugs

Most of the interviewees revealed that there were no experiences of major stock out. Most of them perceived that the supply was good, and this is a positive sign.

However, few experiences of stocks outs did occur at some places. Stock out of IFA for out of school adolescent girls occurred in two districts (4–5 months in one block and 10 months in another block) as told by ICDS supervisors and officials. Drugs were not available even at the time of interview. Lack of IFA (blue tablets) supply was observed for a year after the implementation of NIPI in one cluster of a district as told by CRCC. Shortage of supply was also seen in schools of one block as said by a DEO and an ANM at the time of interview. Lack of supply was seen in one PHC as explained by MOI/C and Pharmacist. They perceived that the PHC was not a priority destination for implementation of NIPI programme, and hence, there was no supply. ASHA, ANMs, and AWWs reported stock out for 2–4 months. Even in early 2016, stock outs occurred in three districts. Women in one of these districts also mentioned that there was no IFA supply for their young children.

An episode of stock out of Albendazole occurred in two districts as told by a BEO. Another episode occurred wherein Albendazole ran out of supply amidst distribution as told by Block Pharmacist and CRCC.

Management of stock-outs

In times of crisis, supply sent to the peripheries is less than the demand placed. A Block Pharmacist told that “Requirement could be more but as per the availability of the drug, they send accordingly.” When interviewed, an AWW also expressed the same. Another mechanism is to procure from areas where buffer stock is kept as said by a Block Pharmacist and PHC Pharmacist. A CRCC expressed that “If no one is able to give, we bring it from PHC”. Another mechanism which is most commonly practiced and expressed through interviews was informal i.e., local sharing of stock followed by AWWs and ASHA in accordance to ICDS supervisors. Another mechanism which involves technical inputs is cross district sharing requiring access to online drug portal (e-Aushadi) of OSMCL. A pharmacist in one district had shared the experience of sharing stocks across another district using this interface. Also, lack of adherence to drug formulations during stock out phases was observed.

Expiry of received supply

From the officials interviewed, there were hardly any reports of receipt of expired stock. If occurred, they are aware that the stock expired should be returned. However, fear of expiry of IFA tablets was expressed countless times by teachers, head masters, CRCC and frontline workers.

Distribution of drugs

As told by a block Pharmacist, supply of IFA and Albendazole was received prior to the assessment made by survey report. Hence, difficulty occurred in distribution of supplies. One CRCC mentioned that it can take 1 month to distribute stock within a cluster due to transportation issues. Education department officials said that difficulties occurred in delivery of supply to schools as the CRCC is often not available to receive the supply from Block Pharmacist. In one instance, the time taken for quarantine clearance of supply was as long as 4 months. Many pharmacists expressed dissatisfaction over prolonged time taken for clearance.

Receipt of drugs by beneficiaries

When beneficiaries were interviewed, it was seen that a group of adolescent girls received IFA only once, and in another district, the college girls received IFA from AWC rather than from the college.

Quantitative surveys

From the quantitative surveys, it was seen that 41% of subcenters had a stock of IFA syrup, 63% had IFA tablets, and none had iron injections at the time of survey. Regarding PHCs, none had the stock of IFA syrup, only 8% had IFA for therapeutic purposes, and only 5% had iron injections. Only 25% of CHCs had stock of IFA syrup, and only 75% had stock of IFA tablets. The low stock of IFA syrup in CHCs is consistent with reports of qualitative surveys as the supply is transported down to ANMs. When enquired, only a small proportion of frontline workers thought that stocks were adequate. It was seen that 15% of ASHAs in Kalahandi and 49% in Keonjhar perceived that stocks for children under 3 years were adequate. Varied responses were received from AWWs regarding adequacy of supply. For children of 3–5 years, 4% AWWs in Kalahandi, and 45% in Bhadrak perceived the stock to be adequate. For adolescent out of school girls, 13% of AWWs in Kalahandi and 64% in Jagatsinghpur perceived the stock to be adequate. For junior college girls, 4% of AWWs in Kalahandi and 36% in Jagatsinghpur perceived the stock to be adequate.


  Discussion Top


From the process documentation, it is evident that a well-networked supply chain management operates for NIPI implementation. Howsoever, it was enumerated from qualitative surveys that two instances of stock outs did occur. The reasons varied as inadequate procurement by state and inadequate indenting below district level. Stock outs affect the implementation of program. A qualitative study in Pondicherry reported that regular supply of IFA was one of the facilitators for successful iron supplementation.[8] A captivating mechanism was seen in the field as front line workers act as agents of support and share stocks locally to avoid stock outs. Bossert et al. reported that “inventory management” function better when centralized rather than decentralized.[9] Hence, this mechanism of informal stock sharing can be harnessed and introduced into the routine implementation of programme. All the front-line workers and pharmacists can be educated about the use of electronic supply chain software and overcome crisis in critical phases of stock outs. Another area of concern was the limited storage space for IFA and Albendazole supply. In a process documentation done in Bihar, similar constraints of limited supply and unhygienic storage area leading to stock damage were reported.[10] Regarding indent placement, it was seen that discrepancies occurred in the flow of indenting at various levels. Uniform methods should be encouraged across the districts to avoid under or over placement of indent. Another major area of concern was the transportation of supply to schools from CRCC. The issues of accessibility should be assessed further and alternate delivery mechanisms in hard to reach areas should be formulated. Majority of the pharmacists expressed discontentment over the prolonged time for quarantine clearance of every new batch. Strict regulations should be in place to avoid delays and ensure timely dispatch of the supply.

With the launch of Intensified NIPI (I-NIPI) under Anaemia Mukt Bharat, concerted efforts are made to effectively decrease the prevalence of anemia.[11] From the findings of this study, various loopholes observed in the administrative and management aspect of program implementation can be taken care of in effective implementation of I-NIPI. Periodic surveys involving both qualitative and quantitative aspects are needed to monitor functioning of the I-NIPI program and address the drawbacks without delay.


  Conclusion Top


Logistics and supply chain management plays a pivotal role in the success of any program. Timely and orderly management of logistics and stock, being the core elements of program implementation should be focused upon. From the present mixed methods analysis of NIPI process, documentation few shortcomings are observed. Few recommendations are suggested henceforth in parallel with the study findings. Mechanisms (electronic preferably) should be in place to check the possible stock outs in any region at a given point of time. Real-time monitoring of logistics and stock and thereby tracking of supply chain below sub-district level should be developed and monitoring to be done accordingly. Management of stock outs should be more formalised enabling hassle free transfer in case of need. Furthermore, expansion and improvement of storage space for stock are required at all levels of distribution. Training and periodic meetings to ensure appropriate supply and distribution of IFA, manage online transfer of stocks, and efficient procurement should be reinforced. The impact of anemia on overall health and economy of nation should be emphasized through these trainings. This will enable them to take ownership and thereby optimally engaged to combat anemia. With the suggested recommendations and inputs from process documentation of NIPI, the drawbacks in program implementation can be addressed and the vision of “Anemia Mukht Bharat” can be made possible.

Acknowledgments

The authors would like to acknowledge Ms. Kathleen Kurz for her significant contribution in the qualitative methods of this study.

Financial support and sponsorship

United Nation International Children's Emergency Fund (UNICEF).

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
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2.
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Guidelines for Control of Iron Deficiency Anaemia. Available from: http://www.pbnrhm.org/docs/iron_plus_guidelines.pdf. [Last accessed on 2020 Mar 07].  Back to cited text no. 3
    
4.
Iron Deficiency Anaemia Assessment, Prevention, and Control a Guide for Programme Managers. WHO/NHD/01.3, Geneva: World Health Organization; 2001. Available from: http://www.who.int/nutrition/publications/en/ida_assessment_prevention_control.pdf. [Last accessed on 2020 Mar 07].  Back to cited text no. 4
    
5.
Odisha State Medical Transport Corporation Ltd.,a Government of Odisha Undertaking. Available from: http://osmcl.nic.in/?q=about-the-directorate. [Last accessed on 2020 Mar 07].  Back to cited text no. 5
    
6.
Government of Odisha-Official Portal. Available from: http://odisha.gov.in/content/dist. [Last accessed on 2020 Mar 07].  Back to cited text no. 6
    
7.
Annual Health Survey 2012-13 Fact Sheet, Odisha. Available from: http://www.censusindia.gov.in/vital_statistics/AHSBulletins/AHS_Factsheets_2012-13/FACTSHEET-Odisha.pdf. [Last accessed on 2020 Mar 10].  Back to cited text no. 7
    
8.
Dhikale PT, Suguna E, Thamizharasi A, Dongre AR. Evaluation of Weekly Iron and Folic Acid Supplementation program for adolescents in rural Pondicherry, India. Int J Med Sci Public Health 2015;4:1360-5.  Back to cited text no. 8
    
9.
Bossert TJ, Bowser DM, Amenyah JK. Is decentralization good for logistics systems? Evidence on essential medicine logistics in Ghana and Guatemala. Health Policy Plan 2007;22:73-82.  Back to cited text no. 9
    
10.
Wendt AS, Stephenson R, Young MF, Verma P, Srikantiah S, Webb-Girard A, et al. Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: A mixed-methods study. BMC Health Serv Res 2018;18:281.  Back to cited text no. 10
    
11.
Anaemia Mukt Bharat. Available from: https://anemiamuktbharat.info/wp-content/uploads/2019/09/Anemia-Mukt-Bharat-Brochure_English.pdf. [Last accessed on 2020 Mar 07].  Back to cited text no. 11
    


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