Katelyn Payne, SIAPS Project Associate; Gashaw Shiferaw, SIAPS Senior Technical Advisor; Phetsile Dlamini, SIAPS Senior Technical Advisor; Kidwell Matshotyana, SIAPS Country Project Director; and Wonder Goredema, SIAPS Senior Technical Advisor
The double burden of HIV/AIDS and TB has exacerbated already high poverty rates in Swaziland, with 63% of the county’s 1.25 million residents falling below national poverty lines. In response to the devastating impact the HIV/AIDS and TB epidemics have taken on its population, Swaziland is expanding free HIV and TB diagnosis, treatment and care at public and private health care facilities. According to the World Health Organization (WHO), the prevalence of HIV among adults aged 15 to 49 in Swaziland was 27.4% in 2013, and the incidence of TB rose to 1,382 cases per 100,000 people in the same year. Employing good warehousing practices at the central level is the first step toward ensuring that life-saving ART and TB medicines are readily available and accessible to patients at health care facilities throughout Swaziland.
Assessing CMS’s past performance in storing and distributing pharmaceuticals
A good warehouse management and inventory control system is required for effective and efficient procurement, storage and distribution of priority pharmaceuticals. By ensuring product availability and minimizing product expiry, a strong warehouse management and inventory control system can prevent wasted spending on pharmaceuticals, amplifying critical efforts to end preventable maternal and child deaths. In Swaziland, the Central Medical Store (CMS) of the Ministry of Health (MOH) is responsible for the warehousing and distribution of all pharmaceuticals to their final destination. Pharmaceuticals purchased by the MOH are stored at two central warehouses, the main warehouse and the ART warehouse, before they are distributed to health facilities. Guaranteeing the effective procurement, storage and distribution of pharmaceuticals at CMS has become critically important due to the countrywide scale-up of HIV and TB services, increase in the quantity and variety of essential health products, and focus on improved management of patients with non-communicable diseases.
Various human resource (HR) constraints have limited CMS’s capacity to optimally execute its responsibilities. An overwhelming percentage of CMS personnel do not have formal training in warehouse operations and, as a result, have had to develop their skills on-the-job. Adding to HR challenges, CMS is also undergoing infrastructure improvements to ensure that all products are stored correctly and securely. Implementing optimized warehousing and distribution procedures that are in line with internationally recommended best practices is a key objective for CMS as the organization strives to provide better service to health facilities. Overall, challenges at CMS have contributed to erratic product availability, resulting in an urgent need to strengthen the warehouse management team’s capacity to design key performance indicators (KPIs), standards, and benchmarks to measure staff and warehouse performance.
In collaboration with the MOH, the USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program is supporting CMS in the design and implementation of appropriate interventions to strengthen pharmaceutical supply management, including quantification, procurement, inventory management, and HR capacity building, to help the country reach objectives outlined by the Swaziland Pharmaceutical Strategic Plan (2012-2016). In partnership with Imperial Health Sciences (IHS), SIAPS conducted a rapid assessment of the MOH’s existing warehousing system and HR capabilities in November 2014. Surveys, informational interviews, and facility observational visits highlighted the need for a staff development program, updates to CMS’s standard operating procedures (SOPs), and the creation of a performance monitoring system. The rapid assessment informed the development of a customized training program and related materials specific to the country’s situation and CMS’s identified gaps.
Empowering warehouse managers on the job
In December 2014, 16 members of CMS’s operations and management team—including storekeepers, senior pharmacists, and pharmacy technicians—participated in a two-week capacity development and performance improvement training for warehousing and distribution. Instead of sending CMS staff to professional development courses internationally, the training was hosted locally in Swaziland near the CMS warehouses. As a result, more CMS personnel could attend the training, resulting in a greater return on investment.
The training program was a locally led intervention, launched to address CMS warehousing challenges and provided adaptive solutions to strengthen warehouse operations capacity. The training developed participants’ planning, organizational, and time management skills through practical examples and group work. The training also incorporated hands-on, real-world skills-building sessions at the CMS warehouse, allowing participants to demonstrate how they internalized the warehousing management techniques taught in the first week of the training. At the training, MOH Director of Health Services Dr. Vusi Magagula urged participants to apply the skills they learned to improve CMS’s performance.
Using a participatory approach to engage participants, 23 KPIs for CMS were developed as part of the organization’s performance monitoring initiative, encouraging managers to quantitatively track progress towards fulfilling CMS’s mission of ensuring that there are no commodity stock-outs at healthcare facilities. Together, participants reviewed the baseline data for each KPI and enhanced their skills in situational analysis, problem solving, and the use of decision-making tools and techniques. Instruction was given on how to track and measure warehouse performance using the selected process-related and outcome-related KPIs. CMS staff is now equipped to measure indicators, such as the percentage of orders from healthcare facilities that are processed within 30 days, to clearly identify performance progress or gaps.
“We were able to come up with our KPIs together as a team,” Mavis Magongo, a strategic information analyst at CMS, said. “We have even agreed on how we will measure them, monitor them, and evaluate ourselves.”
Armed with a clear vision after designing KPIs, CMS worked with SIAPS to create a targeted Performance Improvement Plan. The key objectives of the plan are to improve customer service, operations management, HR, performance management, and safety and security. Within the plan, CMS also recognizes the need to purchase equipment and tools to help the day-to-day operations at the warehouses run smoothly.
Monitoring progress towards CMS’s key goals
Empowered by the skills and competencies they learned, participants embraced the hands-on, on-site capacity-building and performance improvement training as a useful, cost-effective and sustainable initial step of a continuous quality improvement process at CMS. Using the Performance Improvement Plan and 23 KPIs that were developed at the training, CMS can track its progress towards improving the critical service it provides to healthcare facilities nationwide. Managers can identify warehouse system gaps and associated contributing factors and respond by implementing mitigation plans within Swaziland’s supply chain.
“I now have the capacity to improve the internal processes of the procurement unit in order to better serve CMS,” said Kenneth Dlamini, a senior procurement officer at CMS. “This will allow CMS to improve on its warehousing performance, enabling them to better serve the healthcare facilities and, ultimately, the patients.”
SIAPS will provide ongoing support to CMS as the organization works diligently to monitor and evaluate its progress towards the KPIs. CMS’s progress towards the KPIs will be reviewed bi-annually, and results will be shared with stakeholders to hold CMS accountable to its future goals. The Performance Improvement Plan and new KPIs will help propel CMS to greater heights in service provision.