Improving health service delivery is an ever-present objective in the communities in Kenya and Tanzania. One crucial component is refining supply chain management practices for essential medicines and supplies. For the last five years, inSupply Health has been working to enhance the effectiveness, sustainability, and resilience of public health supply chains in East Africa. The company has introduced innovative intervention strategies at service delivery points (dispensaries, health centers, hospitals, etc.) and administrative (national/county/regional/sub-county/district/council) levels. Since the challenges and opportunities at both levels differ, the interventions strategically address these subtleties and provide solutions covering the entire supply chain. This involves an innovative approach that uses human-centered design to create contextualized solutions by integrating the voices and inputs of users and stakeholders in the design process.
Two Countries. One Impact
inSupply Health operates under the principle that innovation must be grounded in a deep understanding of the individual or community that the design is targeting. This calls for the Information Mobilized for Performance Analysis and Continuous Transformation Teams (IMPACTT) approach, which weaves in change management and leadership to connect people and processes with data and technology to improve the performance of the supply chain. The IMPACTT approach is co-designed with sub-national leaders and managers who build on existing structures to set key supply chain targets and corresponding indicators. During this design and throughout the implementation phase, the stakeholders plan for the sustainability of the approach. The teams are trained to develop, interpret, and set targets using these key supply chain indicators. The approach uses an action-oriented dashboard to follow a structured, problem-solving process to facilitate data use for operational and strategic decisions. During the training, the teams self-assess themselves to identify competencies and gaps around competencies that have been identified as critical for the effectiveness of the approach. The IMPACTT Approach fosters team and individual growth through the learning packages. These are modularized self-paced online courses developed for the teams to acquire key competencies and bridge the gaps identified through the role profile assessment. The approach enables the teams to work together to identify practical solutions to address their identified challenges and establish and implement systems for recognizing and rewarding improved performance. This incentivizes the teams to work towards meeting their set targets and sustaining good performance. In addition, cross-learning forums provide a platform for peer-to-peer learning, which is helpful for complex challenges or rapidly scaling up best practices.
The IMPACTT Approach cultivates a data use culture for sub-national managers to continuously review their data to prioritize and address specific supply chain problems. Examples include enhancing data availability and quality by addressing the root causes of low reporting or poor data quality. Ultimately, the objective is to ensure an uninterrupted flow of commodities by strengthening processes and practices to build more responsive and resilient supply chains. The design of the IMPACTT approach acknowledges the realities of high turnover, overstretched health workers, and the need for diverse skills and spheres of influence required to solve some of these problems. The approach embeds a shared vision, targets, and aligned commitment within and across teams to enhance supply chain outcomes. It trains stakeholders to create their vision of the supply chain and continuously monitor performance to track their targets towards their goals. It revolves around a continuous improvement cycle of Plan-Do-Study-Act. The IMPACTT design package was also created as a virtual module to facilitate institutionalization and sustainability while addressing the high turnover challenge. New team members take this self-directed module alongside the other learning packages during onboarding.
In introducing the IMPACTT approach within health systems in Kenya and Tanzania, inSupply Health recognized the significant differences in administrative structures, levels, and logistics management information systems (LMIS) in both countries. Kenya’s health system is devolved across 47 counties, while Tanzania has a centralized approach to health system implementation. Kenya lacks an end-to-end eLMIS for all essential medicines; instead, it captures logistics data for priority programs and products through the Kenya Health Information System (KHIS), while Tanzania’s electronic LMIS captures logistics data on all the essential medicines in the country.
inSupply Health combined the Data Use Kenya project and a partnership with the Ministry of Health (MOH) at the county and sub-county levels in Nairobi, Nyeri, Mombasa, and Transnzoia to co-design the IMPACTT implementation approach with the county leadership, sub-county Health Management Teams (HMTs), service delivery teams, and key partners. Team leadership was diverse and customized to each setting. Some teams were led by the sub-county pharmacists, and others were led by the nursing officer, medical officer, or health records officer.
In Tanzania, discussions on the design of the IMPACTT approach were led by the MOH and the President’s Office of Regional Administration and Local Government (PORALG) in collaboration with inSupply Health and other implementing partners. The design builds on the country’s supply chain system’s administrative levels: national, regional, council, and facility. inSupply Health incorporated adaptive learning into its implementation approach to enable iterative and evolving rollout models before settling on the final and effective strategy. For example, at the council level, the team lead was changed from the district pharmacist to the District Medical Officer to improve accountability for implementing activities listed in action plans.
Promoting a Data Use Culture
The IMPACTT approach successfully laid the groundwork for promoting a data-use culture in supply chain management in Kenya and Tanzania, an essential component of enhancing the efficiency and effectiveness of healthcare services in both countries.
In Kenya, while counties have mature supply chain management practices, data is still recorded and reported manually, with data aggregated into a monthly report at facilities and submitted to the sub-county level for entry into KHIS. This manual process can lead to inaccurate reporting and loss of these reports before entry into KHIS, all of which, coupled with insufficient copies of the reporting tools, might result in non-submission of reports. Institutionalizing a data use practice starts with teams examining the visibility and availability of their data and addressing root causes before progressing to other key performance indicators (KPIs), including those that look at data quality, inventory management, and product availability.
The IMPACTT Approach provides a mechanism that facilitates and aims to institutionalize data use practices within key health programs, such as the National Vaccines Immunization Program (NVIP) and the Division of Health Products and Technology (DHPT). At the request of the DHPT, inSupply Health expanded the decision support dashboard, namely the Indicator Tracking Tool (ITT), to capture and track key supply chain indicators for important tracer essential medicines across all 47 counties in the country. The ITT automatically extracts data from the KHIS and analyzes and visualizes logistics and service delivery data reported by counties in a way that can be easily interpreted and used for actions and decisions. The initial version of the ITT was developed for family planning and vaccine program commodities, but user demand has seen it expand over time. The ITT had previously undergone another expansion to include nutrition and malaria program commodities before the expansion to include the tracer essential medicines.
In Tanzania, even with the versatile eLMIS, which contained a lot of data, the supply chain managers did not examine data routinely. They would only look at it when issues needed to be resolved, such as a disruption in routine service delivery related to stockouts. No processes existed for supply chain managers to use data systematically, nor was it a designated responsibility of these managers to review data and performance routinely.
The IMPACTT approach transformed the practice so that teams routinely examine the data, conduct root cause analyses and develop solutions and actions to improve performance, such as product redistribution, order adjustments to orders, etc. In both countries, some teams use the continuous process approach to running meetings for issues outside the supply chain domain. For example, in the Sikonge district in Tanzania, the IMPACTT approach is used to solve challenges related to finance, health insurance, and blood banks.
The Ministries of Health in Kenya and Tanzania play a fundamental role in ensuring that supply chain management systems are streamlined and efficient. Their roles involve policymaking and addressing logistical issues in the distribution of medical commodities.
Challenges and Triumphs
The IMPACTT approach has been a game-changer in addressing several aspects of supply chain management. Family planning is a critical component of maternal and child health and is widely recognized in Kenya and Tanzania as a vital driver of the development agenda. However, family planning programs continue to experience stockouts, reducing women’s options around method choice. Immunization programs are another critical area where effective commodity management makes a significant difference. Vaccines, often sensitive to temperature variations, require meticulous handling and distribution.
Kenya
In Kenya, inSupply Health conducted an assessment to establish the effect of the IMPACTT approach on supply chain performance. This involved evaluating the family planning performance of ten counties implementing the approach during the same period when the Data Use Kenya project was implemented (2019 – 2021). Their performance was then compared with that of ten similar counties that were not implementing the approach. Both sets of counties were matched by factoring in demographic data such as population, women of reproductive age, socio-economic livelihood, geographical (neighboring counties, whether urban or rural), religion, and cultural dynamics. There was a more rapid increase in performance and overall higher reporting rates in the counties that adopted the IMPACTT approach. On average, the counties had higher reporting rates over the three years (as high as 92 percent) than the comparison counties (as high as 88 percent). In addition, ITT counties saw greater improvements in reporting rates between 2019 and 2021 (11 percent) compared to the comparison counties (eight percent). Similar trends are observed for on-time reporting rates where IMPACTT approach counties (87 percent) have a three percent higher reporting rate than comparison counties (84 percent) in 2019 and increased reporting rates by ten percent compared to nine percent, as reflected in the graph below. Although percentage increases are not vast, it is notable that these upward trends were seen during the COVID lockdowns and immediately afterwards, when many other health metrics were on downward trajectories.
The quality of reporting also improved for the counties using the IMPACTT approach. The percentage of facilities with an Absolute Percentage Difference (APD) of less than ten increased by more than 15 percent across the family planning commodities, while the comparison counties saw changes from negative five to seven percent. The APD reflects the difference between the beginning and ending balances across reports, and it is expected that there should be no variance or discrepancy. The negative change for the comparison counties reflects a decline, suggesting they had more facilities with more data discrepancies. Although inadequate stock levels can be affected by factors outside of the control of the health facility of the sub-county and county HMTs, the improved inventory management practices by the IMPACTT approach counties is reflected in their better performance as these counties had a higher percentage of facilities that were adequately stocked than the comparison counties over the years. These counties consistently performed better by having additional facilities adequately stocked with family planning commodities than the comparison counties.
The leadership from the respective counties developed sustainability plans that spelled out their specific commitments to sustaining and institutionalizing the approach. For example, action points were considered in Mombasa, Nairobi, Nyeri, and Trans-Nzoia counties, covering people management, coordination activities, resource allocation, and leadership. Trans-Nzoia County partnered with another USAID-funded project to integrate the approach. Nairobi County integrated supply chain recognition as part of its overall quality improvement approach and intends to use capacity building to address the supply chain gaps at the facility level. Health workers at the facility level will also receive orientation on the ITT, providing facilities with visibility of their performance for the key supply chain indicators and supporting performance reviews even as the plans to cascade the IMPACTT approach to the health facility level continue through the support of inSupply Health.
Tanzania
The Tanzania National IMPACTT Team has developed the Standard Operating Procedure Manual to standardize IMPACTT processes, structure, roles and responsibilities. This SOP has guided the teams and stakeholders on how they should be constructed, the composition of members and leadership, roles and responsibilities of members and standardize some processes such as training methodologies, performance indicators to adopted, data analysis, problem solving, how to conduct effective meetings at all levels and reporting for regional and district-level IMPACTT Teams. This standardization has simplified the performance monitoring by the national level and the reporting processes from the subnational level, as reports are submitted quarterly. By receiving these reports, the supply chain performance identifies gaps and corrective action can be promptly taken and additional processes, such as meetings can be monitored at the national level, while the status of implementing action items can be monitored at the subnational level. The national IMPACTT Team also routinely analyzes data and identifies regions with inadequate performance, then plans for supportive supervision visits to help the team address the skills gap in data analysis. This kind of monitoring from the national level sends a message to IMPACTT Teams at the subnational level that their performances are being observed, which automatically pushes them to implement the approach and share the expected outputs, such as reports, meeting notes, and actions requiring higher-level attention.
During implementtion of the Data Use Project in Tanzania (2019 – 2021) inSupply health supported 3 councils from different regions where a significant improvement of performance for some indicators was observed. A good example is the Sikonge district council that managed to improve the availability of essential health products after a series of interventions made to overcome supply challenges. Such challenges that pulled down the performance included inadequate funding from the Governmentto procure essential commodities, low enrollement and collections from insurance schemes; NHIF and i-CHF, burden from the large number of excempeted patients and data quality issues of the reported logistics data and filling the patient insurance forms. The Sikonge IMPACTT managed to resolve these challenges and immediately an observed upward trend on commodity availability was consistently observed from 57% in September 2020 to 89% in November 2021 for essential commodities.
The Influence of IMPACT Approach in Financial Resource Mobilization to Improve Availability of Essential Health Commodities in Sikonge DC
The Future Beckons
Although staff turnover has created some limitations, the IMPACTT approach has successfully fostered country ownership of the supply chain management system for essential medicines in both countries. In Kenya, the dashboards created are embedded within the health information system and in Tanzania, the government has adopted the approach to improve supply chain performance and commodity availability across all levels from national, district, and facility level.
The IMPACTT approach also highlights the indispensable role of collaboration and evidence-based approaches in designing targeted interventions. By fostering a culture where data is systematically collected, analyzed, and utilized, supply chain managers and operators in Kenya and Tanzania can prevent stockouts and reduce wastage. This data-driven approach leads to better inventory control and an overall improvement in patient care. The journey continues, with each stakeholder playing their part in the collective mission to ensure that every individual, regardless of their location, has access to the essential health services they need and deserve.
