3.1 Suboptimal warehousing, inventory management and transport

This module was prepared by Tamara Hafner. May 2018

2

Technical Efficiency Guide Pharmaceutical Products

About the Health Finance and Governance Project The Health Finance and Governance (HFG) Project works to address some of the greatest challenges facing health systems today. Drawing on the latest research, the project implements strategies to help countries increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions. The project also assists countries in developing robust governance systems to ensure that financial investments for health achieve their intended results. With activities in more than 40 countries, HFG collaborates with health stakeholders to protect families from catastrophic health care costs, expand access to priority services – such as maternal and child health care – and ensure equitable population coverage through:

► Improving financing by mobilizing domestic resources, reducing financial barriers, expanding

health insurance, and implementing provider payment systems;

► Enhancing governance for better health system management and greater accountability and

transparency;

► Improving management and operations systems to advance the delivery and effectiveness of

health care, for example, through mobile money and public financial management; and

► Advancing techniques to measure progress in health systems performance, especially around

universal health coverage.

The HFG project (2012-2018) is funded by the U.S. Agency for International Development (USAID) and is led by Abt Associates in collaboration with Avenir Health, Broad Branch Associates, Development Alternatives Inc., the Johns Hopkins Bloomberg School of Public Health, Results for Development Institute, RTI International, and Training Resources Group, Inc. The project is funded under USAID cooperative agreement AID-OAA-A-12-00080. To learn more, visit www.hfgproject.org

About the Technical Efficiency Guide Health system stakeholders in low- and middle-income countries are exploring ways to achieve more with available resources, and realize savings that can be used to fill the gap in resources needed to expand effective health coverage to all. Where other guides and tools focus on improving allocative efficiency (“doing the right things”), this guide focuses on technical efficiency (“doing things right”). It is intended to help diagnose and address technical inefficiencies across health systems.

3

Technical Efficiency Guide Pharmaceutical Products

3.1.1 Poor warehousing and inventory management

What’s the inefficiency? In some lower- and middle-income countries (LMICs), warehousing of pharmaceutical products is outsourced to a third party. Typically, however, government-owned central and regional medical stores manage the warehousing, which contributes significantly to the costs of public health systems (Yadav et al. 2011). Medical stores also often perform inventory management – the process of ordering, receiving, storing and issuing stocks – but inadequately, making it a critical bottleneck in supply chains in LMICs (Govindaraj and Herbst 2010).

Why does this happen? Inadequate physical infrastructure and maintenance undermine warehousing systems. A lack of storage installations may lead to improper storage practices. For example, staff may store boxes on the floor, resulting in moisture damage. Similarly, staff may pile boxes very high, exceeding the weight limit of existing pallets or shelves, causing damage to products stored on lower levels; also, manually retrieving the boxes from high piles may damage the products, and injure staff. In hot, humid climates, a lack of air conditioning and fans can mean that products are stored at temperatures that are higher than what is recommended, which can cause products to degrade (Daniel 2014, White et al. 2014). Some products, such as vaccines, need to be stored at precisely controlled temperatures to maintain quality and efficacy. Even when adequate cold chain storage exists, unreliable electricity or the lack of back-up generators can lead to cold chain failure and product degradation. Poor cleaning can lead to pest problems and an accumulation of flammable cartons and boxes, which is a fire hazard. Faulty electrical wiring in poorly maintained buildings can also create fire hazards, and poorly maintained plumbing can increase the risk of water damage. Buildings may be old, with structural damage and inadequate security. Without routine inspections and maintenance, signs of pests, physical damage, fire hazard, and theft can go undetected, leading to catastrophic failures and unnecessary, high expenditures to remedy these issues and the resulting product loss (MSH 2012). Insufficient human resources and a lack of well-defined standard operating procedures (SOPs) can cripple inventory management. Medical supplies need to be stored so that they are easily accessible and protected from damage. This requires that staff have clearly defined roles, adequate training, and the incentives to comply with SOPs for stock storage and handling. Poor warehouse organization, which is often associated with a lack of physical infrastructure, makes inventory management difficult, and products can become inaccessible or untraceable. In some countries, staff numbers are inadequate to run an efficient warehouse operation at the central level and existing staff lack training in inventory management. They are therefore unable to use the available inventory management tools appropriately and thus they are unable to make evidence-based decisions and to adequately monitor stock status and expiration dates. These shortcomings increase the risk of stock-outs, overstock, and expiry. In some cases, SOPs are poorly defined, making it difficult for staff to comply with best practices. For example, two approaches for minimizing product expiry are first expiry/first out (FEFO) and first-in/first-out (FIFO) (MSH 2012). With FEFO, products with the earliest expiry date are the first products issued, regardless of the order in which they are received. With FIFO, the first products received are the first products issued. If staff lack the training or fail to follow SOPs, then it is unlikely that product expiry will be minimized, especially for products with low turnover or short shelf-life (MSH 2012). Access to reliable information on inventory is a critical constraint for inventory control and management in LMICs. Logistics management information systems or inventory management systems,

4

Technical Efficiency Guide Pharmaceutical Products

which provide information on inventory, tend to be inadequate and fragmented in LMICs (Bergum et al. 2017, Theiss-Nyland et al. 2016). Some countries use paper-based systems, which can be time-consuming and prone to error. Electronic systems tend to be more reliable and time efficient and less vulnerable to error, but, as with paper-based systems, require consistent use and compliance with reporting requirements. Additionally, staff may lack the adequate training to use the electronic systems, which contributes to inaccuracies and lack of use (Chuchu et al. 2015, Privett and Gonsalvez 2014). The absence of, or poor compliance with, SOPs for storage and record keeping can exacerbate data quality problems in both paper-based and electronic systems. These problems make it difficult to know stock status at the different levels of the public health system, which in turn makes it difficult to determine appropriate inventory levels at the central level and to ensure uninterrupted supply throughout the health system. Poor warehousing and inventory management are often linked to insufficient financing and human resources, or other inefficiencies higher up in the supply chain. Rigid financing rules may prevent medical stores from allocating their revenue to adequately fund operational needs (see Inefficiency 4.1.1 for more on insufficient autonomy in decision-making about spending resources). If medicine selection and quantification are not adequately guided by the essential medicines list and standard treatment guidelines, this can lead to the procurement of unnecessary quantities. If forecasts and supply planning do not account for available storage space, then there may be insufficient storage space for the procured stock. Similarly, uncoordinated, parallel procurement systems can lead to the procurement of unnecessary quantities (Nakyanzi et al. 2010, Daniel and Taban 2016). Procurements from partner disease programs may also be stored at central medical stores and a lack of coordination can lead to storage space shortages. These programs may require different inventory managements systems, which can overwhelm warehouse staff, especially when human resources are limited. Surplus medicines may also result from donations that do not align with the country’s needs or comply with its standard treatment guidelines (Kamba et al. 2017). These overstocked inventories can strain warehouse storage capacity, increase holding costs and increase the risk of product expiry.

What makes it technically inefficient? Poor warehouse infrastructure and maintenance lead to product loss from physical damage, contamination, degradation, or expiry and create opportunities for theft or diversion of stock, all of which contribute to stock-outs. The inefficient and suboptimal use of storage space can cause physical damage to both products and staff, or make it difficult to locate products and fill orders efficiently and on time. Poor warehouse organization makes it hard to monitor stock levels, which can lead to overstock, expiry, and stock-outs. Temperature-sensitive products may degrade because of failure to maintain the cold chain. Pest problems can lead to product contamination. If the buildings are not properly managed or lack adequate security, then there is opportunity for theft. Product losses are wasted resources. Poor warehouse infrastructure and maintenance undermine inventory management, and suboptimal inventory management exacerbates the effects of poor warehouse infrastructure and maintenance. Warehouse managers and staff cannot fulfill their inventory management responsibilities effectively without timely and accurate information: if they do not know what stock they have, they won’t know what is due to expire, be understocked or out of stock, or may have been pilfered. There will be little evidence for proper inventory control, the process of determining appropriate stock levels at the lowest possible costs, therefore leading to overstock or stock-outs and their associated costs. As important, it will be difficult to effectively monitor warehousing/inventory management performance. Warehouse personnel will not be able to locate stock easily and fill orders efficiently. Problems in inventory

5

Technical Efficiency Guide Pharmaceutical Products

management can also lead to a lack of or inaccuracies in consumption and logistics data, which can result in unreliable quantifications and wasted financial resources (see Inefficiency 3.2.1 for more on poor quantification). Suboptimal inventory management results in persistent problems with overstock, expiry, and stock-outs. Overstocked medical supplies, especially those with low turnover or short shelf-life, are vulnerable to expiry. Stock-outs disrupt the availability of medicines at service delivery points, interrupt treatment regimens, reduce population coverage, and increase health system costs. They increase the frequency of emergency orders, which are more costly than planned orders. They can also contribute to the emergence and spread of antimicrobial resistance, the treatment for which adds to overall health systems costs. Persistent stock-outs can diminish the public’s trust in the public health care system. Patients may instead seek medicines in the private sector, which tends to have higher prices, meaning higher out-of-pocket costs. Expired products are a major source of product waste in public health systems (Kamba et al. 2017, Privett and Gonsalvez 2014). They may result in stock-outs and the associated costs. Further, the disposal of expired medicines has both financial and environmental costs (Kamba et al. 2017). Improper disposal of expired medicines can contribute to environmental pollution and the emergence of drug-resistant microbes – which require a funded response by the public health system. Equally important, delays with or improper disposal of expired medicines, particularly where warehouses are not secure or adequately managed, can create opportunities for stock diversion and resale of expired, and therefore substandard, products (Kamba et al. 2017). The resale of substandard medicines can negatively affect health outcomes, which may in turn increase the costs for the public health systems.

What questions can help us diagnose the inefficiency? Poor warehousing management and infrastructure

How are operational costs financed?

Is the central medical store (warehousing system) autonomous? o How is it organizationally related to the Ministry of Health (MOH)?

Are there systems for monitoring and evaluating warehousing costs and performance o If so, are these systems effective? o If not, which elements are missing?

What is the storage capacity of central medical stores (warehousing system)?

Are storage conditions adequate or acceptable? o Is storage space too small, adequate, or excessive? o Are effective pest control procedures in place? o What is the physical condition of the facility?

What is the condition of the floors? The roof? Is there any firefighting equipment? If so, is the fire equipment functional? What is the condition of the windows? Is there water supply? Is there adequate drainage?

o What is the condition of advanced systems? Is there functional mechanical handling equipment? Is there electricity supply? If so, is the electricity supply reliable?

6

Technical Efficiency Guide Pharmaceutical Products

If electricity supply is unreliable, is there a functional generator? Are there telephones?

o What storage systems are used? Is there shelving? Are there floor pallets? Is there pallet racking? Are these systems adequate?

How frequently is there a mechanical breakdown of vital temperature control equipment such as cold rooms or air conditioners?

Are warehouse guidelines or standards in place that define the security measures? o Are there physical security systems in the buildings?

Are these systems adequate?

Describe staff levels at the warehouse. o Are these levels adequate?

Poor inventory management

Do SOPs for inventory management exist? o If so, are they readily available? o Is warehouse staff aware of these procedures? o Do the SOPs adequately describe current procedures and responsibilities? o What steps are taken to ensure compliance with these procedures? o If procedures do not exist, will they be developed in the future?

What inventory management system is in place? o Is it adequate?

How accurate are inventory records? o Do they supply information needed for quantification, procurement, and distribution

decisions?

What information is used for inventory control? o Are maximum and minimum stock levels defined?

How are stock levels determined? Are stock levels adhered to?

How do managers and operations personnel determine which products should be held in stock and which (if any) should be ordered only as needed?

How are pharmaceutical products zoned in the warehouse?

Are vaccines stored and monitored in accordance with the recommendations of the World Health Organization (WHO) Expanded Programme on Immunization?

Are products issued using the first expiry/first out or first-in/first-out principle?

What was the average stock-out rate over the last year? o What was the average stock-out duration over the last year?

How many expired medicines are in stock? o What is their value? o How are expired products handled?

7

Technical Efficiency Guide Pharmaceutical Products

Whom should we interview? This list of potential interview respondents is given as an example. Their titles and positions may change depending on context and are not always representative of their level of knowledge in a particular domain. Thus, the list should be adapted and can change over the course of the interviews. Stakeholders from:

► MOH’s pharmaceutical services department/division at both the national and subnational levels ► Selection expert/coordinating committee or its equivalent ► Quantification coordinating committee or its equivalent ► Procurement board/agency/committee (may be in the Ministry of Finance (MOF) or there may

separate entities for each disease program) ► Central medical stores ► Partner disease programs ► Transport fleet (if separate from central medical stores)

What indicators can help diagnose the inefficiency?

Indicator Calculation/precise definition*

What it is supposed to measure (i.e. “benefit”)

Potential sources of data

Source of indicator

1. Stock-out rates at central and/or regional medical stores

Number of products for which there was a stock-out/divided by total number of products, multiplied by 100 Calculate for a defined time period, typically one year

Product unavailability and quality of inventory management

LMIS reports/stock records Site visits (physical inventory)

Aronovich et al. 2010

2. Product losses due to expired products, damage, and theft per value received, at central and/or regional medical stores (percentage and number)

Quantity of expired, damaged, and stolen products, divided by quantity of total inventory (including expired, damaged, and stolen products), multiplied by 100 Calculate for a defined time period

Wastage and the ability of personnel to properly manage and handle inventory during storage and transport

LMIS reports Facility survey

Aronovich et al. 2010, JSI 2017

3. Average response cost

Total costs of fulfilling orders, divided by total number of orders

Cost-efficiency of order processing procedures (part of inventory management)

LMIS reports Inventory records Human resource records Yearly accounting sheets

Aronovich et al. 2010

8

Technical Efficiency Guide Pharmaceutical Products

4. Inventory holding costs

Sum of all capital and non-capital costs for a defined period, usually annual

Annual costs of carrying inventory at a specific facility

LMIS reports Inventory records Yearly accounting sheets

Aronovich et al. 2010, JSI 2017

5. Inventory accuracy rate

Number of items where stock record count equals physical stock count, divided by number of items counter, multiplied by 100

Whether recorded stock balances match actual inventory on hand – the quality of inventory management for specified facilities

Facility survey Inventory records LMIS records Site visits/physical counts

Aronovich et al. 2010, JSI 2017

*Definitions have been taken directly or adapted from the listed sources, which provide indicator reference sheet information.

What are some examples of the inefficiency? ► Insufficient human resources, poor inventory management, and transport bottlenecks disrupt

family planning services (Daff et al. 2014). In Senegal, persistent contraceptive stock-outs disrupted family planning services, denying women access to their preferred contraceptive method. Injectable contraceptives and implants had, on average, annual stock-out rates of 43 percent and 83 percent respectively. At least 60 percent of the stock-out at service delivery points occurred despite stock availability at the national level. The distribution system included an excessive number of steps, making it complex and inefficient. Transportation was a critical bottleneck as facilities were responsible for picking up supplies from warehouses at their own expense and staff had to disrupt service delivery to do so. There was no dedicated supply chain personnel at the lower levels. Midwives managed inventory at service delivery points but lacked training on inventory management. Further, they lacked time because of their service delivery duties. This led to poor stock records and a lack of timely and accurate data, which limited the government’s ability to monitor and manage its family planning program.

► The unregulated donation of medicines in response to the Ebola epidemic in Sierra Leone led to the accumulation of expired medicines (SIAPS 2017). Storage spaces were cluttered with expired medicines and created a shortage of storage at all levels of the health system. This made inventory management difficult. At service delivery points, the cluttered storage decreased dispensing efficiency and increased the risk that providers might mistakenly dispense the wrong or expired products. Expired products at the central level were sent to a private for-profit company, which burned them in the open with no regard for public or environmental safety.

9

Technical Efficiency Guide Pharmaceutical Products

3.1.2 Suboptimal transport systems

What’s the inefficiency? Many LMIC governments struggle to establish and maintain well-functioning transport systems, which are typically managed by central medical stores. Transport systems are a significant cost contributor to public health systems (Yadav et al. 2011). They are chronically underfunded, and are often considered the weakest link in the distribution system – one that limits the availability of medicines at service delivery points (MSH 2012).

Why does this happen? Poor transport planning and vehicle maintenance, along with noncompliance with vehicle use policies, often lead to a shortage in well-functioning vehicles for the distribution of medicines (Yadav et al. 2011). Poor road infrastructure can damage vehicles and/or disrupt deliveries (Vledder et al. 2015), which underscores the need for adequate vehicle maintenance and planning to select appropriate routes and delivery schedules. Improper packaging and inadequate equipment to protect products from the weather can also lead to product damage or loss. If products are not adequately secured before, during, and after transit, this can create opportunities for theft. Poor transport systems are often a consequence of insufficient financing. There is little political motivation to prioritize resources for funding operating costs such as vehicle maintenance (Yadav 2015).

What makes it technically inefficient? Poor transport management result in unnecessarily high transportation costs, delivery delays and product loss, thereby increasing the risk of stock-outs and costs to the public health system. The inadequate maintenance of vehicles, for example, can increase vehicle repair and replacement costs, or lead to a shortage of vehicles at different levels of the system to ensure delivery of orders. Similarly, the inappropriate selection of route or vehicle for route and the inefficient use of vehicle capacity can increase fuel and per diem costs (MSH 2012). Insufficient transport can disrupt medicines distribution and contribute to product damage or loss, and stock-outs at service delivery points. With respect to the products, inadequate packaging and poor transport conditions can lead to product breakage or other damage. Products, especially temperature-sensitive ones, may degrade from exposure to inclement weather or hot temperatures during transit. The distribution and use of contaminated, degraded or expired – therefore substandard – products can negatively affect patient safety and health outcomes, a response to which raises additional health system costs.

What questions can help us diagnose the inefficiency? How is transport financed?

Are there systems for monitoring and evaluating transport costs and performance? o If so, are these systems effective? o If not, which elements are missing?

Are vehicles available to distribute orders from the warehouse(s)? o What is the frequency of vehicle breakdowns?

What types of vehicles are used? (List all types used and the source, model, quantity, age, mileage, condition, and location of each).

How are transport routes determined? o Do they make effective use of vehicles? (e.g. are SUVs available for rough terrain,

refrigerated vans/trucks reserved for products requiring cold chain)?

10

Technical Efficiency Guide Pharmaceutical Products

What percentage of vehicles is in working condition?

Is there a policy to control and monitor vehicle use? o If so, is it effective? o If not, will this policy or guideline be developed in the future?

What measures are taken to ensure security and quality of products during transport?

Whom should I interview? This list of potential interview respondents is given as an example. Their titles and positions may change depending on context and are not always representative of their level of knowledge in a particular domain. Thus, the list should be adapted and can change over the course of the interviews. Stakeholders from:

► MOH’s pharmaceutical services department/division at both the national and subnational levels ► Selection expert/coordinating committee or its equivalent ► Quantification coordinating committee or its equivalent ► Procurement board/agency/committee (may be in the MOF or there may separate entities for

each disease program) ► Central medical stores ► Partner disease programs ► Transport fleet (if separate from central medical stores

What indicators can help diagnose the inefficiency?

Indicator Calculation/precise definition*

What it is supposed to measure (i.e. “benefit”)

Potential sources of data

Source of indicator

1 Average transportation cost per km/volume/weight

Sum of all transportation costs divided by total number of km driven or m3/kg of product shipped

Average transport cost

Receipts, financial statements, fuel logs, maintenance logs, and freight bills during a specified time period Vehicle logs of km traveled Requisition and issue vouchers Airway bills/shipping invoices

Aronovich et al. 2010, JSI 2017

2 Vehicle use availability

Total number of days in a defined period, minus total number of days a vehicle was unavailable in that period because it was out of service,

The amount of time a vehicle was unavailable for use during a defined period because it was out of service. An indication of condition of vehicle

Vehicle logs Maintenance records

Aronovich et al. 2010, JSI 2017

11

Technical Efficiency Guide Pharmaceutical Products

divided by total number of days in the defined period, multiplied by 100

fleet and how well vehicles are being maintained and used.

*Definitions have been taken directly or adapted from the listed sources, which provide indicator reference sheet information.

What are some examples of the inefficiency? ► Insufficient human resources, poor inventory management, and transport bottlenecks disrupt family

planning services (Daff et al. 2014). In Senegal, persistent contraceptive stock-outs disrupted family planning services, denying women access to their preferred contraceptive method. Injectable contraceptives and implants had, on average, annual stock-out rates of 43 percent and 83 percent respectively. At least 60 percent of the stock-out at service delivery points occurred despite stock availability at the national level. The distribution system included an excessive number of steps, making it complex and inefficient. Transportation was a critical bottleneck as facilities were responsible for picking up supplies from warehouses at their own expense and staff had to disrupt service delivery to do so. There was no dedicated supply chain personnel at the lower levels. Midwives managed inventory at service delivery points but lacked training on inventory management. Further, they lacked time because of their service delivery duties. This led to poor stock records and a lack of timely and accurate data, which limited the government’s ability to monitor and manage its family planning program.

Materials for Team Leading Next Steps While beyond the scope of the Technical Efficiency Guide process, the sections below share some ideas that may be a useful starting point for the team responsible for leading next steps, if inefficiencies covered in this module are prioritized. If the country/region needs more detailed information, these leaders can consider using some of the tools and resources listed. If they want to brainstorm areas for potential efficiency gain, they can browse the table with high-level ideas to consider.

Additional tools and resources ► These indicators are for assessing supply chain performance (Aronovich et al. 2010):

Measuring Supply Chain Performance: Guide to Key Performance Indicators for Public Health Managers

► This is a course on managing sustainable, cost-effective transport systems (Cuninghame et al. 2010): Transport Management: A Self-Learning Guide for Local Transport Managers of Public Health Services

► This handbook introduces the key principles and concepts of supply chain management for health commodities (JSI 2017): The Supply Chain Manager’s Handbook, A Practical Guide to the Management of Health Commodities

► This is the leading reference on managing essential medicines and provides indepth detail on warehouse, inventory and transport management (MSH 2012): MDS-3: Managing Access to Medicines and Health Technologies

12

Technical Efficiency Guide Pharmaceutical Products

► This brief provides an overview of practices and interventions for addressing common challenges faced in warehousing and inventory management (SIAPS 2014a): Promising Practices: Warehousing and Inventory Management

► This brief provides an overview of practices and interventions for addressing key bottlenecks in distribution (SIAPS 2014c): Promising Practices: Distribution

► These are guidelines for addressing the challenges of operating a warehouse (USAID|DELIVER 2014): Guidelines for Warehousing Health Commodities

Potential areas for efficiency gain

Cause of inefficiency Potential interventions Resources

Poor warehousing and inventory management

Stock leakage and security issues, including traceability throughout the supply chain

► Improve inventory management practices and security

► Consider barcoding or other identification to track products

JSI 2017, MSH 2012 SIAPS 2014a SIAPS 2014a

Inadequate storage space and conditions

► Determine space requirements ► De-junk warehouse and optimize storage

space utilization ► Introduce infrastructure improvement ► Outsource warehousing

JSI 2017 JSI 2017 SIAPS 2014a JSI 2017, SIAPS 2014a

Poor adherence to inventory management best practices (e.g. FEFO, physical inventory)

► Develop SOPs and ensure compliance ► Adopt FEFO principle to minimize expiries ► Adopt appropriate inventory management

system and train staff

MSH 2012, SIAPS 2014a MSH 2012 JSI 2017, MSH 2012

Lack of capacity of staff managing inventory

► Train staff ► Clarify or define roles and responsibilities ► Performance management and supportive

supervision

SIAPS 2014b JSI 2017 JSI 2017

Central medical stores lacks autonomy

► Consider changes in administrative structure (e.g. semiautonomy) or possible flexibilities in making financial decisions.

SIAPS 2014a

Disposal policies absent or not followed

► Develop SOPs and ensure compliance MSH 2012

Suboptimal transport systems

13

Technical Efficiency Guide Pharmaceutical Products

Limited funds to support transport costs

► Assess resupply system ► Reduce tiers in the distribution system ► Define needs and engage in dialogue with

relevant agencies regarding revenue sources ► Outsource transport/distribution

SIAPS 2014c SIAPS 2014c SIAPS 2014c

Inconsistent availability, reliability, and quality of vehicles

► Develop and implement a formal transport management system

► Outsource transport/distribution

JSI 2017, MSH 2012 SIAPS 2014c

Poor transport planning

► Develop and implement a formal transport management system

► Reduce tiers in the distribution system ► Outsource transport/distribution

JSI 2017, MSH 2012 SIAPS 2014c SIAPS 2014c

14

Technical Efficiency Guide Pharmaceutical Products

References

► Aronovich, Dana, Marie Tien, Ethan Collins, Adriano Sommerlatte, and Linda Allain. 2010. “Measuring Supply Chain Performance Guide to Key Performance Indicators for Public Health Managers.” Arlington, VA. http://deliver.jsi.com/dlvr_content/resources/allpubs/policypapers/AddrProcBottl.pdf.

► Bergum, Bjørn-Ingar, Petter Nielsen, and Johan Ivar Sæbø. 2017. Patchworks of Logistics Management Information Systems: Challenges or Solutions for Developing Countries? IFIP Advances in Information and Communication Technology. Vol. 504. https://doi.org/10.1007/978-3-319-59111-7_5.

► Chuchu, Sarah Akoth, Maureen Adoyo, and Ben Onyango Osuga. 2015. “Information Management for Essential Medicines Supplies in Public Primary Care Facilities in Nairobi County, Kenya.” African Journal of Pharmacy and Pharmacology 9 (19): 532–39.

► Cuninghame, Christopher, Gary Forster, and Chris Saunders. 2010. "Transport Management: A Self-Learning Guide for Local Transport Managers of Public Health Services. Arlington, VA: USAID | DELIVER Project, Task Order 1.

► Daff, B. M., C. Seck, H. Belkhayat, and P. Sutton. 2014. “Informed Push Distribution of Contraceptives in Senegal Reduces Stockouts and Improves Quality of Family Planning Services.” Global Health: Science and Practice 2 (2): 245–52. https://doi.org/10.9745/GHSP-D-13-00171.

► Daniel, Gabriel. 2014. Warehouse Improvement for CENAME Cameroon. Arlington VA: Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, Management Sciences for Health. http://apps.who.int/medicinedocs/documents/s21680en/s21680en.pdf.

► Daniel, Neni, and Pasquale Taban. 2016. Improving Storage Conditions through de-Junking at County Health Department Medical Stores in South Sudan. Arlington, VA: Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, Management Sciences for Health. http://siapsprogram.org/publication/improving-storage-conditions-in-south-sudan/.

► Govindaraj, Ramesh, and Christopher H Herbst. 2010. Applying Market Mechanisms to Central Medical Stores Experiences from Burkina Faso, Cameroon, and Senegal. Quality. http://siteresources.worldbank.org/HEALTHNUTRITIONANDPOPULATION/Resources/281627-1095698140167/ApplyingMarketMechanisms.pdf.

► John Snow Inc (JSI). 2017. The Supply Chain Manager’s Handbook, A Practical Guide to the Management of Health Commodities. Arlington, Va.: JSI. http://supplychainhandbook.jsi.com.

► Kamba, Pakoyo Fadhiru, Munanura Edson Ireeta, Sulah Balikuna, and Bruhan Kaggwa. 2017. “Threats Posed by Stockpiles of Expired Pharmaceuticals in Low- and Middle-Income Countries: A Ugandan Perspective.” Bulletin of the World Health Organization 95 (8): 594–98. https://doi.org/10.2471/BLT.16.186650.

► Management Sciences for Health (MSH). 2012. MDS-3: Managing Access to Medicines and Health Technologies. Arlington, VA: MSH. https://www.msh.org/sites/msh.org/files/mds3-jan2014.pdf.

► Nakyanzi, Josephine Katabaazi, Freddy Eric Kitutu, Hussein Oria, and Pakoyo Fadhiru Kamba. 2010. “Expiry of Medicines in Supply Outlets in Uganda.” Bulletin of the World Health Organization 88 (2): 154–58. https://doi.org/10.2471/BLT.08.057471.

► Privett, Natalie, and David Gonsalvez. 2014. “The Top Ten Global Health Supply Chain Issues: Perspectives from the Field.” Operations Research for Health Care 3 (4): 226–30. https://doi.org/10.1016/j.orhc.2014.09.002.Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program. 2014a. Promising Practices: Warehousing and Inventory Management. Arlington, VA: SIAPS, Management Sciences for Health.

15

Technical Efficiency Guide Pharmaceutical Products

http://siapsprogram.org/wp-content/uploads/2014/07/3_Warehousing-final.pdf ► ———. 2014b. Promising Practices: Human Resources. Arlington, VA: SIAPS, Management

Sciences for Health. http://siapsprogram.org/wp-content/uploads/2014/07/7_Human-Resources-final.pdf

► ———. 2014c. Promising Practices: Distribution. Arlington, VA: SIAPS, Management Sciences for Health. http://siapsprogram.org/wp-content/uploads/2014/07/4_Distribution-final.pdf

► ———. 2017. Sierra Leone Project Update. A Preliminary Response to Controlled Disposal of Expired Products. Arlington, VA: SIAPS, Management Sciences for Health.

► Theiss-Nyland, Katherine, Waqo Ejersa, Corine Karema, Diakalia Koné, Hannah Koenker, Yves Cyaka, Matthew Lynch, Jayne Webster, and Jo Lines. 2016. “Operational Challenges to Continuous LLIN Distribution: A Qualitative Rapid Assessment in Four Countries.” Malaria Journal 15 (1). BioMed Central: 1–11. https://doi.org/10.1186/s12936-016-1184-y.

► USAID | DELIVER PROJECT,Task Order 4. 2014. Guidelines for Warehousing Health Commodities. Arlington, Va.: USAID | DELIVER PROJECT, Task Order 4.

► Vledder, Monique, Jed Friedman, Thomas Brown, and Jed Friedman. 2015. “Optimal Supply Chain Structure for Distributing Essential Drugs in Low Income Countries : Results from a Randomized Experiment,” no. No. 1269.

► White, Jonathan, Wonder Goredema, Patrick Gaparayi, Abre van Buuren, and John Horrocks. 2014. Technical Assistance to Strengthen the Angola Central Medical Warehouse System. Arlington, VA: Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program, Management Sciences for Health. http://siapsprogram.org/publication/altview/technical-assistance-to-strengthen-the-angola-central-medical-warehouse-system/english/.

► Yadav, Prashant. 2015. “Health Product Supply Chains in Developing Countries: Diagnosis of the Root Causes of Underperformance and an Agenda for Reform.” Health Systems & Reform 1 (2): 142–54. https://doi.org/10.4161/23288604.2014.968005.

► Yadav, Prashant, Helen Lega Tata, and Magali Bababley. 2011. “Storage and Supply Chain Management.” In The World Medicines Situation, 22. Geneva: World Health Organization. http://apps.who.int/medicinedocs/en/d/Js20037en/.