Problem Description & Addressing the Challenges with the S+ Solution
A focus on Stock Management
September 2023
Based on a lives-saved modelling tool, developed by the Johns Hopkins Bloomberg School of Public Health it has been estimated that nearly 1 million lives could be saved in LMICs with a 10% reduction in stockouts of non-vaccine medicines during the coming five years 2023 to 2027. 1,2
Billions of dollars are spent by governments, international organizations and donors to provide access to medicines and quality care. Availability of Essential Medicine and Health Supplies (EMHS) are essential for universal access to appropriate care . Lack of access to EMHS can result in increased avoidable morbidity and mortality, economic losses and poverty . One-third of the world’s population lack access to quality essential medicines and diagnostics .
StockoutsofessentialmedicinesinLMICs
The prevalence of stock-outs of EMHS in LMICs is high. A recent review including 28 studies, 62,372 community healthworkersand2,383healthcentresinLMICs,showed that29%ofthecommunityhealthworkersand9%ofthe health centres experienced stock-outs of essential medicinesduringtheentirereviewperiod(2006-2021) A recent study from Uganda showed that 80% of commodities are stocked out by the time they are eventuallyre-stocked
Stockandinventorymanagementchallengesin ruralfacilities
Ahealthfacility’sabilitytorespondtopatients’needs is linked to the facility’s capacity to place EMHS ordersandadequatelymanagetheirmedicines.Most last-milehealthfacilitiesusepaper-basedsystemsto manage their inventory . This system is manual and time-consuming, so the information is often not accurate or up to date The paper-based system is also not efficient for aggregating and transmitting stock-level information to upstream facilities This can delay the process and make it difficult to make real-timeorderingdecisions
Astrategytomitigatemedicine stockoutsistomovefrompaperbasedtoelectronicinformation sharingsystems.
Digitalized last-mile supply chain management systems can improve the supply and distribution of health commodities by automating the different steps, thus reducing stockouts and supply chain inefficiencies . For example, a positive association was found between electronic stock managementbyhealthfacilitiesandthe accuracyoftheirstockrecords .APATH and Digital Square analysis identified a 5–14%pointreductioninstockoutswith digitalized last-mile supply chain managementinLMICs .
Poortechnologyinfrastructureanddata visibility
ICT has become vital in health care management and digital technologies have the potential to play a significant role in improving health . However, critical challengesfortheimplementationofsuchtechnologiesin rural facilities include financial and operational sustainability, digital literacy, infrastructure, and connectivity .ThelevelofInternetuseinLMICs(22%) remains far below that of high-income countries, which are close to universal usage (91%), and the share of InternetusersinLMICsistwiceashighinurbanareasas inruralareas .
Community healthcare workers in rural and remote communities are often unable to reliably use digital solutions in their daily workflows. Expensive hardware, weak connectivity, and power outages are common. Failed digital systems in supply chain management lead to a lack of data collection and visibility, commodity shortages, wasted investment on non-functional systems and most importantly compromised health outcomes
Anappropriatetechnologyforhealth careworkersinremotesettings shouldbe:
Patient-centric features suitable for thelevelofdigitalliteracyofusers.
Able to function anywhere regardless of local availability of internet or electricity.
Ensure 100% uptime even in areas withoutreliableinfrastructure.
Securely provide data visibility on all health information and commodities inandbetweenhealthfacilities.
Scalabile and adaptable to accommodate existing systems and futurehealthcareneeds
Aim for minimal maintenance and lifecycle costs, both financial and environmental
The Signalytic solution combines renewable solar power, reliable signal connectivity, durable hardware, and custom off-grid blockchain-like distribution ledger technology (DLT) to connect remote health facilities and health providers to a common decentralized network, even in facilities with no electricity or no/poor mobile network coverage.
Effectsofdisruptedhealthsupplychainson healthoutcomes
Due to drug shortages, patients face issues such as suboptimal treatment, delayed care, increased hospitalization,adverseevents,treatmentfailure,relapseof illness, or even death . For example, stock-outs of contraceptives can lead to unwanted pregnancies, psychologicaldistress,unsafeabortions,andincreasedcosts for the family In the case of antiretroviral (ARV) drugs, weaknesses or disruptions in ARV supply chains are often underestimatedcontributorstothedevelopmentofhuman immunodeficiencyvirus(HIV)drugresistance(HIVDR)
Substandardandfalsifiedmedicines
Stockouts, stock shortages and poor supply chain management can lead to the use of alternative vendors of medicines including unregulated drug suppliers, which increases the risk of receiving and using counterfeit and substandard medicines . Poor-quality medicines cause more than one million deaths per year , reduce the effectiveness of authentic medical treatment, waste national resources, and contribute to antimicrobial resistance .
THE
The Signalytic blockchain-like ecosystem allows the identification and recording of supplies and medicines at every point in its journey from the warehouse to the health facility, preventing substandard or falsifiedmedicinestoenter Redundant datastorage andaccesscontrolacross facilities combined with cryptographic methodsprovidedbytheDigitalLedger Technology blockgraph network prevent bad actors to decrypt, view, and modify records. Corrupted, or lost data in one facility can be automatically recovered and restored from the private network of other facilities.
SIGNALYTIC APPROACH TO SOLVE THE CHAIN OF PROBLEMS
Availability of EMHS is essential for appropriate care
Stock-outs of EMHS result in compromised health outcomes
facilities face challenges by using paper-based stock management
S+ combines appropriate technologies to manage supply chain digitally
References
1.Transform Health. Closing the digital divide: more and better funding for the digital transformation of health. A conceptual framework to guide investments and action towards health for all in the digital age. October 2022. Available at: https://transformhealthcoalition.org/investing-in-digital-healthnew-report-key-recommendations-by-transform-health/
2.Fritz, Herrick and Gilbert, “Estimation of Health Impact from Digitalising Last-mile Logistics Management Information Systems (LMIS) in Ethiopia, Tanzania, and Mozambique: A Lives Saved Tool (LiST) model analysis”.
3.UN General Assembly. Sustainable Development Goals. SDGs Transform Our World, United Nations General Assembly. 2030; 2015.
4.WHO. Towards Access 2030: WHO Essential Medicines and Health Products Strategic Framework 2016–2030. Geneva: Switzerland, World Health Organization; 2017.
5.WHO. Ten years in public health, 2007–2017: report by Dr Margaret Chan, Director-General, World Health Organization, World Health Organization; 2017.
6.WHO. Access to medicines: making market forces serve the poor. Geneva: Switzerland, World Health Organization; 2017.
7.Lugada, E., Komakech, H., Ochola, I. et al. Health supply chain system in Uganda: current issues, structure, performance, and implications for systems strengthening. J of Pharm Policy and Pract 15, 14 (2022).
8.Leung NHZ, Chen A, Yadav P, Gallien J (2016) The Impact of Inventory Management on Stock-Outs of Essential Drugs in Sub-Saharan Africa: Secondary Analysis of a Field Experiment in Zambia. PLoS One 11(5).
9.Bjørn-Ingar Bergum, Petter Nielsen and Johan Ivar Sæbø, “Patchworks of Logistics Management Information Systems: Challenges or Solutions for Developing Countries?” IFIP Advances in Information and Communication Technology, 504. Springer, Cham. (2017): 47–58. https://doi.org/10.1007/978-3319-59111-7_5.
10.Bowser DM, Chang AY, Bossert TJ, Mabirizi D (2014) Facility-Level Practices and Behaviors that Affect the Performance of the Supply Chain of Antiretroviral Medicines (Arlington, USA).
11.World Health Organization. (2021). Global strategy on digital health 2020-2025. Available at: https://apps.who.int/iris/handle/10665/344249
12.Noreña I, Shah N, Ndenkeh J Jr, Hernandez C, Sitoe N, Sillah A, Shin A, Han WW, Devaera Y, Mosoba M, Moonga G, Hendl T, Wernick A, Kiberu VM, Menke M, Guggenbuehl Noller JM, Pritsch M. Proceedings from the CIHLMU Symposium 2020 on "eHealth: Trends and innovations". BMC Proc. 2020 Dec 7;14(Suppl 18):17.
13.Investing in Digital Healthcare: The UNCDF Way. Available at: https://www.uncdf.org/article/7942/investing-in-digitalizing-healthcare-the-uncdf-way
14.Sub-Saharan Africa-the new breeding ground for global digital health. Lancet Digit Health. 2020 Apr;2(4):e160-e162.
15.Global Connectivity report 2022, ITU. Available at: https://www.itu.int/hub/publication/d-ind-global-01-2022/
16.Mclaughlin, M., Kotis, D., Thomson, K., Harrison, M., Fennessy, G., Postelnick, M., et al. (2013). Effects on Patient Care Caused by Drug Shortages: a Survey. Jmcp 19, 783–788.
17.Rider, A. E., Templet, D. J., Daley, M. J., Shuman, C., and Smith, L. V. (2013). Clinical Dilemmas and a Review of Strategies to Manage Drug Shortages. J. Pharm. Pract. 26, 183–191.
18.Souliotis, K., Papageorgiou, M., Politi, A., Ioakeimidis, D., and Sidiropoulos, P. (2014). Barriers to Accessing Biologic Treatment for Rheumatoid Arthritis in Greece: the Unseen Impact of the Fiscal Crisis-The Health Outcomes Patient Environment (HOPE) Study. Rheumatol. Int. 34, 25–33.
19.Blaine, K. P., Press, C., Lau, K., Sliwa, J., Rao, V. K., and Hill, C. (2016). Comparative Effectiveness of Epsilon-Aminocaproic Acid and Tranexamic Acid on Postoperative Bleeding Following Cardiac Surgery during a National Medication Shortage. J. Clin. Anesth. 35, 516–523.
20.Yang, C., Wu, L., Cai, W., Zhu, W., Shen, Q., Li, Z., et al. (2016). Current Situation, Determinants, and Solutions to Drug Shortages in Shaanxi Province, China: a Qualitative Study. PloS one 11, e0165183.
21.Alruthia, Y. S., Alkofide, H., Alajmi, R. h., Balkhi, B., Alghamdi, A., Alnasser, A., et al. (2017). Drug Shortages in Large Hospitals in Riyadh: a Cross-Sectional Study. Ann. Saudi Med. 37, 375–385.
22.Darroch JE, Sedgh G, Ball H (2011) Contraceptive Technologies : Responding to Women’s Needs (Guttmacher Institute, New York, USA).
23.World Health Organization. HIV Drug Resistance Surveillance Guidance: 2015 update. Geneva, Switzerland: World Health Organization; 2015. Available at : http://www.who.int/hiv/pub/drugresistance/hiv-drug-resistance-2015- update/en/.
24.Asio J, Watera C, Namuwenge N, Kirungi W, Musinguzi J, Mugagga K, Busobozi R, Tusiime BJ, Lutalo T, Mbidde EK, Kaleebu P; Uganda HIV Drug Resistance Technical Working Group. Population-based monitoring of HIV drug resistance early warning indicators in Uganda: A nationally representative survey following revised WHO recommendations. PLoS One. 2020 Apr 14;15(4):e0230451.
25.Fokam J, Elat JB, Billong SC, Kembou E, Nkwescheu AS, Obam NM, Essiane A, Torimiro JN, Ekanmian GK, Ndjolo A, Shiro KS, Bissek AC. Monitoring HIV Drug Resistance Early Warning Indicators in Cameroon: A Study Following the Revised World Health Organization Recommendations. PLoS One. 2015 Jun 17;10(6):e0129210. doi: 10.1371/journal.pone.0129210. PMID: 26083364; PMCID: PMC4471113.
26.Fokam J, Nangmo A, Wandum C, Takou D, Santoro MM, Nlend AN, Ateba FN, Ndombo PK, Kamgaing N, Kamta C, Essiane A, Lambo V, Fokunang C, Mbanya D, Colizzi V, Perno CF, Ndjolo A. Programme quality indicators of HIV drug resistance among adolescents in urban versus rural settings of the centre region of Cameroon. AIDS Res Ther. 2020 May 12;17(1):14. doi: 10.1186/s12981-020-00270-7. PMID: 32398107; PMCID: PMC7216382.
27.Minior T, Douglas M, Edgil D, Srivastava M, Crowley J, Firth J, Lapidos-Salaiz I, Williams J, Lee L. The Critical Role of Supply Chains in Preventing Human Immunodeficiency Virus Drug Resistance in Low- and Middle-Income Settings. J Infect Dis. 2017 Dec 1;216(suppl_9):S812-S815.
28.Parienti JJ, Das-Douglas M, Massari V et al.. Not all missed doses are the same: sustained NNRTI treatment interruptions predict HIV rebound at low-tomoderate adherence levels. PLoS One 2008; 3:e2783.
29.Olaniran, A., Briggs, J., Pradhan, A. et al. Stock-outs of essential medicines among community health workers (CHWs) in low- and middle-income countries (LMICs): a systematic literature review of the extent, reasons, and consequences. Hum Resour Health 20, 58 (2022).
30.Southwick, N. Counterfeit drugs kill 1 mn people annually: Interpol. InSight Crime. October 24, 2013. Available at: https://www.insightcrime.org/news/brief/counterfeit-drugs-kill-1- million-annually-interpol/.
31.Andersson DI, Hughes D. Microbiological effects of sublethal levels of antibiotics. Nat Rev Microbiol. 2014;12(7):465-478. doi:10.1038/ nrmicro3270.
