The government of Angola is working with NGOs to initiate a series of aggressive HIV prevention activities and information campaigns. Twenty-five years of civil war, however, have robbed the country of its ability to procure enough contraceptives for these programmes, and even to guarantee a regular supply of essential medicines to meet other basic health needs of the Angolan population. A similar story emerges in the Democratic Republic of the Congo. Condoms are rarely available, particularly in the east, where population movements, military presence and the use of rape as a weapon of war contribute to the increased transmission of HIV. An OCHA assessment of health facilities in Kinshasa found stock-outs of many basic medicines, especially those needed for safe motherhood programmes. And although family planning supplies can be found in many pharmacies, they are too expensive for most women.
Health programmes are rendered ineffective when the products they require are not available to users. This is where logistics systems become critical - making sure that the right amount of the right product arrives at the right place, at the right time, in the right condition and at the right cost. Logistics planning is often overlooked in the struggle to create, support and fund reproductive health (RH) programmes for the world's 37 million refugees and IDPs. Women without access to RH care face the increased risk of birth complications, unintended or mis-timed pregnancies, unsafe abortions, infectious disease and death.
It is time to dispel the myth that logistics systems are too complicated or merely a secondary part of programme planning. True, operating a RH logistics system for refugee and internally displaced populations can be particularly challenging. But any provider capable of running a RH programme in these settings can design and implement a simple logistics management system to help decide what to stock, how much to stock and when to reorder supplies. As shown in the following diagram, logistics management is not a one-time event but is instead a routine, cyclical process.
At the outset, the main objective of implementing a logistics system for a RH programme for refugees and displaced persons is to move needed supplies to users without gross waste. This only requires understanding a few concepts, implementing a simple set of steps, and gathering and using information. As refugee populations grow and stabilise, logistics systems can become more robust, allowing providers to expand the range of products and improve the routine efficiency of programmes.
Ideally, the cycle begins with use of the products by clients. This way, information about actual consumption can be employed as the basis for deciding what products to procure and in what quantities to procure them. In new refugee or IDP settings, such data may be difficult or impossible to obtain. Without the experience of having provided RH commodities to a population, it is virtually impossible to know what methods and what brands are preferred (both are critical elements to ensuring effective and continued use of contraceptives). In the meantime, though, forecasting and procurement of supplies can be carried out on the basis of best guesses. Good estimations can be formulated using survey data from the affected population during more stable times, or perhaps extrapolated from conducting a small sample.
One of the most important concepts for a programme manager to factor into initial planning is lead time - the number of weeks or months that elapse between the time an order is placed and the time products are received and made available in health facilities. It is critical to have an idea of donors' lead times both in emergency response and routine order fulfillment, to avoid long gaps when essential supplies are out of stock. Although donors can often meet emergency needs quickly, their systems are best set up to conduct routine procurement and make standard shipping arrangements. So the sooner a refugee or IDP setting can shift to routine ordering, the better.
Storing and transporting products are usually thought of as the classic logistics functions. In the case of refugee RH programmes, these distribution functions involve hardly any complicated choices. After all, service delivery points are few in number, product quantities are generally not overwhelming, and special storage facilities are probably not available. However, this means that the programme manager must tailor the contraceptive supply chain to local conditions. To the extent possible, RH products - including oral contraceptives, condoms and injectables - should be stored securely to prevent misuse or pilferage. They should also be kept in a clean, dry area at a temperature of between 15 and 30 degrees Celsius. Clearly, these conditions cannot always be met but an effort to do so can prevent a significant amount of product damage and deterioration.
Logistics management decisions become easier and more reliable when programmes begin to function on a more regular basis. Using actual usage data from target populations is the best way to accurately estimate future needs. Thus, the primary logistics responsibility of a RH programme manager is to routinely collect information on a simple set of three essential data items:
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stock on hand (how much of each product is in the system already)
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stock on order (how much has already been ordered and what the lead time for delivery is)
- average monthly consumption (how much of each product is used)
Knowledge of these three elements helps guarantee that the quantity of products ordered from a donor is not only sufficient to meet user demand but is also not so great that unnecessary wastage occurs when commodities expire on the shelves before they can be used.
Implementing logistics systems is of paramount importance for health programmes that address the needs of stable and transitional populations alike. Until the relief community truly embraces the importance and feasibility of RH logistics, all interventions are doomed to only partial success, if not outright failure.
Paul Crystal is Communications Officer, JSI Logistics Services. Email: paul_crystal@jsi.com.
Lisa Ehrlich is a JSI Reproductive Health for Refugees Project Intern. Email: lisa_ehrlich@jsi.com.
An in-depth description of designing a contraceptive logistics management system for refugee settings, the Contraceptive Logistics Guidelines for Refugee Settings, is available without charge at http://deliver.jsi.com/2002/Pubs/Pubs_Guidelines/index.cfm