There is a Liberian adage that says, “Water can’t pass by a hole.” Unfortunately, in providing Community health workers (CHWs) the essential medicines and health commodities they need to do their jobs, we still encounter many systemic “holes”. The “water” can’t pass by, and the communities at the end of the supply chain often go without.
I remember talking to Liberia’s Chief Pharmacist and Manager for Supply Chain, John Tutu Harris, about strengthening the supply chain for CHWs. He said, “I don’t know where the decision to give CHWs 20% of the health facility’s commodities came from. There is no policy document to support it. How can a facility that receives grossly inadequate supplies of medicines give 20% of that to the 10 CHWs attached to the facility?”
Community health workers require these essential supplies to provide preventive and curative primary health care services within their communities. However, the current 20% commodities concept used to resupply them has never been a reliable way to increase CHWs’ access to commodities. Here, we encounter a hole.
Health facility staff in Liberia have always prioritized the facility’s needs, reserving the limited commodities supplied from the central level. This has made it challenging for CHWs (also known as Community Health Assistants (CHAs) in Liberia) to receive the right quantity of medicines and supplies they need. Stockouts have been consistently reported at all levels of the supply chain. The quarterly medicine and supply distributions have often been delayed, and the four annual distribution cycles have yet to be achieved on target. For the most part, the quantities supplied are adequate to serve the facility’s needs. However, the community is at the very end of the pipeline leaving them at the mercy of the facilities to be supplied.
Developing and adapting a system that packages CHW commodities in a sealed container known as a CHW medical kit to cross the potential “holes” of the upper levels of the health supply chain has drawn a lot of interest and shown great potential for addressing CHW commodities needs at the community level.
The Supply Chain for Community Health Workers Project: A Human-Centered Approach
The Ministry of Health, VillageReach and other partners launched the Supply Chain for Community Health Workers (SC4CHW) Pilot Project on November 2, 2021, in Kakata, Margibi County, to increase access and improve the delivery of commodities to the community level. Under this project, VillageReach introduced a kitting system to deliver commodities for CHAS in Bomi and Margibi Counties. This system is a novel approach that is meant to ensures each CHW receives the right quantity and type of commodities to serve their communities. Supplying the actual CHWs’ commodities needs using consumption data was a key consideration in designing the appropriate system for them.
Since this is a novel approach for routine supply chains, we used a human centered design approach to develop the kitting system for the CHWs in the two counties to ensure it was feasible, viable and accepted by the users The consensus on the design was to make sure the kit contents and labels are individualized for all CHWs and that packaging should be done at the Central Medical Stores (CMS).
CHA Commodities Kitting: Streamlining the Process!
When the CHA kitting materials arrived in Liberia on August 22, 2022, we coordinated with the CMS management to assign space for the kit packaging materials and all the key national programs to process the requisitions needed to inform the CMS how much of each commodity to allocate to each health facility. The National Community Health Program Pharmacist and Supply Chain Management Unit then used the facility commodity allocations and the past consumption data to determine the apportionments for each individual CHA. The maiden set of kits were prepared and delivered to Bomi and Margibi Counties in November 2022. How did we ensure we closed the systemic holes to get the products to the CHAs?
- Adherence to Standard Operating Procedures: The adoption of nationally approved supply chain SOPs – for getting approvals to generate the commodity allocations, followed by picking, packing and dispatch processes – helped to streamline the process, ensuring supply chain staff saw this as part of their routine jobs. Adopting existing SOPs instead of introducing new ones, to minimize staff burdens, was a key lesson learnt during the design workshop.
- Continuous stakeholder consultations and communication: Despite the actual picking and packing process commencing over six months after the design workshop, continued communication and visualization of the process with all stakeholders helped to ensure all understood their roles and responsibilities in getting the kits into the hands of each individual CHA. The kits were secured with special tape to avoid tampering as they moved through the supply chain. At each stage in the supply chain, key stakeholders verified whether the kits were intact and they contained the right labels before they could be passed down to the next tier. The County Health Team through the County Pharmacist and the Community Health Services Supervisors ensured that distribution schedules were developed and adhered to, reducing the lead time for kit delivery to all CHAs from approximately one month to five days.
CHA Kits: Measuring the Impact
Receiving their medicines and supplies in a kit is exciting for CHWs. More importantly, having their own ID number and name printed on the kit was a monumental experience for CHWs. In a field visit, CHWs shared that they felt gratified and honored by the fact that their ID number and name were printed on the kit containing their medicines. They said this showed that central-level managers valued their work and knew their identity.
After the first kit distribution, a commodities verification and capacity assessment exercise was conducted in Bomi and Margibi Counties in the first half of 2023. The results from those exercises showed a remarkable improvement in CHA commodities availability as compared to non-kitting counties. Bomi and Margibi Counties no longer needed to rely on 20% of their health facility commodities. The kitting system also improved commodities security and accountability in the pipeline. Through this process everyone at each level knows how much medicines and supplies were allocated to the CHA, eliminating the black hole that exists with lack of visibility for what goes into the last mile. By enhancing security, the CHAs’ commodities remained sealed up until they received them – they would easily notice any tampering with the kit when the seal was broken.
CHWs are motivated by having adequate medicines and supplies to treat their community’s sick members. “Community people respect and listen to us when we have commodities to do our work,” said James Duowe, a CHA from Beajah community in Bomi County. Similar positive feedback was expressed by other CHWs, as well as both the Directors of the Community Health Services Division and the Supply Chain Management Unit; they are both committed to advocating for CHA commodities procurement. CHA Commodities Kitting has gained a lot of interest across the community health supply chain landscape, and expectations are high for the pilot project’s final evaluation report.
The CHA kit is a success story in supply chain management. It has transformed the way CHWs receive commodities, and it has significantly impacted their ability to provide care to their communities. The CHA kit is a living example of how a simple change can make a big difference, by patching up “the holes” in the system, so that water can continue to pass and communities will never have to go without.