E-DRUG: Logisitcs systems in the less developed world
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[Here is a long important message - an interesting angle to the problem. It does not address the problem of the organisation of the CMS itself (under the MoH) as a root cause, but recommends an inspectorate (how to make that non-corrupt?). Nor does it address the issue of appropriate quantification (ideally based on records of rational use) for procurement for maintenance of reliable supplies. Comments are encouraged. Moderator]
Boniface Fundafunda has raised the comment that the pharmacist is part of a
healthcare team. In many cases the pharmacist is launched into the supply
chain with minimal training in medical logistics and is then castigated when
the system works less than perfectly. This is in no way a snipe at the
competence of pharmacists but a suggestion as to how pharmaceutical service
delivery could be enhanced. As a team consisting of a Pharmacist and a
Medical logistician who have extensive experience in the Central and
Southern African environment we would like to submit our comments on the
need for a functional audit organisation outside of the health profession
but linked to pharmaceutical delivery.
"The establishment of sustainable medicines distribution systems in emerging
nations is a problem that has faced numerous governments and even more donor
funding entities.
Billions of Dollars, Pounds, Euros and other currencies have been poured
into the seemingly bottomless abyss. Regardless of the form of donation, be
it cash or kind, there is still a shortfall between the need and the deed.
The health systems in Africa in particular are littered with a history of
well-meaning consultancies and projects to upgrade warehouses, distribution
processes, stock accounting systems, and personnel skills.
Counteracting both donor efforts and the dedicated efforts of honest
hardworking local health professionals are the legions of less dedicated
people who are:
* Susceptible to bribery, corruption, intimidation,
* Involved in the drugs 'mafia',
* Disinclined to follow policy,
* Lazy,
* Have little incentive to perform a days work for a days pay,
* Susceptible to subtle or less subtle political pressure,
* Promoted beyond their capabilities as a result of nepotism or
political favouritism,
Exacerbating the already fragile local environments are donor organisations
scrambling for favour and publicity. Amongst the plethora of consultants
there are so called logisticians having:
* an academic perspective of the problem,
* a perception fixed into a grass roots paper based process that they
may or may not try to computerise, or
* a first world computerised/mechanised perspective of the problem.
One has to investigate the attitudes and capabilities of the health
personnel involved in drugs (medicines) distribution/storage. There are
dedicated health professionals genuinely trying to improve the lot of their
fellow man, but there are others to whom it is merely a job. The inherent
nature of health workers is to provide a service and let others worry about
the resources required. This plays into the hands of the less dedicated who
tend to exploit the situation to divert medical stores for their own gain.
The comment has oft been heard that "I am not a policeman" or "It is not my
job to investigate the discrepancy". It is true that the nature of a
caregiver is not normally accompanied by an aggressive or militaristic
attitude. In many countries the health care personnel are also not always
the best paid civil servants.
How then to combat:
* Bribery, corruption,
* Intimidation,
* A lack of attention to policy and processes to inhibit shrinkage,
* Laziness and lack of incentive to perform a days work for a days pay,
* Sheer weariness with an inability to fight existing defects in the system,
* The pressure of political pressure,
* The attraction of appointments based on of nepotism or political favouritism instead of ability and dedication.
At this stage one has to ask how theft and misappropriation of medical
stores can thrive in environments where medical treatment is either free or
supplied at minimal cost. One of the reasons could be that the more state
stock is diverted, the slower and more erratic the free treatment is. This
in turn feeds the need for a grey market supply chain.
The current focus is not wrong when it comes to:
* Training,
* Writing procedure manuals,
* Arranging quality contracts at favourable prices,
* Providing warehouses and other infrastructure to store and
distribute medical stores.
but,
There is however a total lack of attention to the cement that will hold the
whole process together.
Presupposing the existence of valid and complete policies and regulations,
there is a need for a body or organisation that is independent of the
operational process and has no ability to gain from its subversion, which
can monitor adherence to processes and measure output against expectations.
What would be the requirements for this body? The first would be to drop
all previous connotations with historic internal or external audit
processes. Many of these were flawed and staffed by cronies of the very
people that they were supposed to monitor. Similarly "monitoring and
evaluation" teams have the same inherent flaws. Ideally this
'inspectorate' would be manned by a rotating cadre of personnel to prevent
the building of illicit relationships. Countries that have community
service for professionals leaving university could well use young
accountants to perform these "functional process audits".
Suggested guidelines for formation and staffing this inspectorate could
include:
* Reporting to a department external to the health department, (Ministry of Finance maybe)
* Intensive functional audit training before deployment,
* Links or facilitated access to police anti corruption or criminal investigation services,
* No family links to the personnel in health units being monitored,
* Financial incentives based on identified shrinkage reduction,
* Absolutely no way to influence the outcome of medical tenders/contracts.
* Geographic rotation of postings on an annual basis
* Regular polygraph testing
* Background checking
The type of activities to be performed by the inspectorate would include but
not be limited to:
* Verifying adherence to policies and regulations.
* Tracing samples of transactions of incoming and outgoing stock with analysis of whether there are complete paper trails.
* Verifying receipt of all stock at institutions that has been dispatched from depots.
* Verifying stock-take transactions and compliance with stock audit processes.
* Investigating losses of stock in transit.
* Investigating unresolved stock-take discrepancies, be they surpluses or deficiencies.
* Investigate negligence as well as premeditated deviation from policy.
* Analyse stockholding levels to determine if excess stockholdings exist.
* Investigate dead stock.
* Analyse problems in warehouses - poor security, poor stock management, power supply interruptions, running fridges off UPS etc
Investigations should not only identify deviant activity but should also
identify perpetrators, apportion blame, and recommend corrective action.
In order to understand the reasoning used, the following needs to be
explained. Computer stock accounting systems must be defined in one of the
two following categories.
a. Post posting
This is a recording system whereby the transaction, be it an issue or
receipt is recorded on the system, regardless of the running balance on the
ledger (bin card). This system allows the running balance to run into a
negative balance and depends entirely on the actual shelf quantity. This
system is favoured by organisations that prefer a less disciplined approach
for reasons of ineptitude or dishonesty.
b. Pre posting
This is a stock management accounting system whereby the ledger balance
predominates. Issue vouchers are based on the requisition quantity and the
quantity recorded on the ledger. Shrinkage from the shelf causes an
inability to fulfil the issue voucher and requires immediate investigation.
This system tends to be the better for combating illicit and negligent
processes
As a progression from the pre-posting system one needs to progress to an
integrated system whereby the issuing of stock from one entity creates an
electronic expectation of a receipt at the receiving entity.
The more integrated the system, the more difficult it is to hide shrinkage.
There will be tremendous efforts on the part of criminal and lazy parties to
discredit and or sabotage the system.
In the absence of integrated systems there is a strong administrative need
to implement "proof of delivery" documentation. Proof of delivery either by
integrated systems or administrative documentation is only as effective as
the persons executing the tasks.
Always remember that one cannot computerise chaos. People have too high
expectations, as computers are seen as the answer to all problems.