Assessment of Inventory Management Practice and Associated Challenges of Maternal, Newborn, and Child Health Life-Saving Drugs in Public Hospitals of Southwest Ethiopia: A Mixed-Method Approach

Introduction

Sustainable Development Goal 3.2 aims to end preventable child mortality, reduce neonatal mortality to less than 12 per 1000 live births, and reduce under-child mortality to less than 25 children per 1000 live births per country by 2030.¹ On the other hand, neonatal and under five mortality remains slower in developing countries, which suffers from 80% of women’s deaths and 44% of all childhood deaths every single day from preventable causes.² Indeed, most sub-Saharan African countries had a low implementation of maternal, newborn, and child health programs due to operational and management inefficiency, poor quality of health services, inequities in the distribution of the health workforce, and low capacity of planning, budgeting, and controlling programs.³ Accordingly, the main Global Strategy for Women’s and Children’s Health should be improving financing, policy, and service delivery for the most vulnerable women and children.⁴ Suitably, in 2012, the United Nations Commission on the life-saving commodity for every woman and child movement started⁵ and endorsed an initial list of 13 unnoticed life-saving drugs that, if more commonly accessed and properly used, could save the lives of more than 6 million women and children.⁶ Yet, there are persistent disparities in the availability and accessibility of life-saving drugs due to the costly and complex nature of pharmaceutical supply chain management.⁷ A fragile drug supply management system and inappropriate ways of managing inventories results in wastage, over- or under-stocking, loss, increased out-of-pocket expenditure, and a decline in the quality of MNCH services.⁸ Studies conducted in Zambia and Nigeria identified a limited storage capacity, lack of reliable data, lack of adequate human resources, and poor performance of health care workers.⁹ Likewise, in Kenya, inappropriate use, wastage, and MNCH drugs were reported out of stock following inadequate procurement and inventory management practices and poor data quality of logistic records and reports.¹⁰ Studies showed that maintaining the optimal stock level and avoiding wastages are major challenges of pharmaceutical inventory management, and successful interventions are required to ensure usable stocks and reduce preventable wastages of life-saving drugs.^7,11,12 Correspondingly, in Ethiopia, the data quality of logistic records and reports was low and resulted from drug stock-out and wastage.¹¹ Furthermore, assessing the existing inventory management practice is required¹³ to intervene and achieve health sector targets.¹⁴ Thus, this study aimed to assess the inventory management practice and associated challenges of Life-Saving MNCH drugs in selected public hospitals of Jimma zone and Jimma city.

Methods

Study Area

The study was conducted in Jimma city and Jimma Zone public hospitals. Jimma city is surrounded by Jimma Zone, and it is one of 17 Zones in the Oromia region located in southwest Ethiopia, 365 km away from the capital city Addis Ababa. A total of 770 health facilities are found in the Zone and the City. Out of them, 7 public hospitals were found in both Jimma Zone and City serving a total population of 2,486,155 (Source: human resource and program offices of Jimma zone and city).

Study Design and Period

A hospital-based mixed-method cross-sectional study was conducted from October 1 to 30, 2020. The qualitative concurrent explanatory approach was used for the triangulation to advance the results of the quantitative research with qualitative findings.¹⁵

Study Units and Participants

The study parts were all public hospitals in Jimma City and the Jimma zone including bin card records, reporting and resupply forms (RRFs), internal facility reporting and resupply forms (IFRRs), and selected MNCH life-saving drugs. As well, pharmacy heads, store managers, and dispensary unit coordinators participated in the study.

Eligibility Criteria

All public hospitals functioned at least for a year before data collection and respondents involved in inventory management of MNCH drugs for six years and above were included. On the other hand, private and army hospitals in both Jimma zone and Jimma City were excluded from the study because program drugs were resupplied differently. One hospital (Shene Gibe general hospital) used as a coronavirus-19 service center at the time of data collection was excluded. Respondents unwilling to participate and absent during the data collection period were excluded from the study.

Sample Size and Sampling Process

Out of the total seven public hospitals found in both Jimma city and zone, six hospitals were eligible for this study. Thus, six hospitals were included in the actual study excluding the one (Shene Gibe general hospital) used for the coronavirus-19 service center. Based on the United Nations endorsement of 2016, all of the 13 MNCH life-saving drugs¹⁶ were considered. The sample size of logistics records and reports was determined by the Ethiopian Integrated Pharmaceutical Logistics System, which states that hospitals and health centers should submit RRF reports every two months to their corresponding suppliers.¹⁷ Furthermore, the Logistics Indicators Assessment Tool (LIAT) revealed that a quantitative logistics health facilities assessment is recommended to review RRF reports for a minimum of six months¹⁸ which is about three reports (1 RRF bimonthly is equivalent to three RRF reports within six months) from each hospital. To increase the generalizability of the study, the 6-monthly reports (generated per year) were included in the study. Thus, 36 RRF reports (6 RRF reports from each facility and a total of 6 hospitals ie 6 × 6=36) and 78 bin cards (13 drugs per hospital ie 13 × 6= 78) were reviewed.

Data Collection Procedures

The data were collected by three data collectors, who had received two hours of training about study objectives and questionnaire administration, using semi-structured questionnaires and checklists adapted from LIAT and inventory management assessment tools.^18,19 The data were gathered through in-depth interviews, observation, a physical count of drugs, and a review of selected logistics management information system (LMIS) tools (one-year RRFs, bin card records, and IFRRs).

The Qualitative Study

Regarding the qualitative data, twelve in-depth interviews were conducted with the key informants. Thus, six store managers and six pharmacy heads based on their position for information to identify challenges related to inventory management of MNCH life-saving drugs. Interviews were interactive and conducted by one of the researchers with a witness among the data collectors, using a semi-structured interview guide (Supplementary File-1) adapted from the logistics system assessment tool,²⁰ a tool designed to guide a qualitative logistics system assessment, and each key informant interview lasted between 25 and 30 minutes. The collected data were analysed manually using a thematic approach after authors closely examined and familiarized themselves with responses by taking notes, then coded using an Excel sheet. Finally, results were reported using texts.

Data Quality Assurance

A pilot study was conducted in a hospital excluded from the actual study to check the content and consistency of the data collection tools. Two hours of training were given for data collectors regarding the data collection tools and processes. The data collection was closely supervised throughout the data collection process by one of the researchers for data consistency and completeness.

Data Processing and Analysis

After checking for completeness and consistency of information, the computable data were entered into Epi-data software version 3.1. Then, the output was exported to a statistical package for Social Science (SPSS) version 24 for analysis. Statistical values were determined significant at p < 0.05. Finally, results were presented using texts, tables, and graphs. The following standard indicators were used to measure quantifiable variables but it is difficult to measure the overall inventory management practice using a single indicator.²¹

Operational Definitions

Stock Wastage: unusable item over the total items value during the review period and the acceptable standard was <2%.²²

Data quality of RRF reports: It is the measurement of data accuracy, completeness, timeliness, and facility reporting rate.²³

Completeness of reports: a report is considered complete if all the columns for each product listed in the report are filled unless the facility does not manage the product.²³

Timelines of reports: as per the standard operating procedure of the integrated pharmaceutical logistics system of Ethiopia;¹⁷

1. Hospitals and health centers should submit their RRF report to the Ethiopian pharmaceutical agency or zone health department until the 10th day of the next month.
2. Health centers that send their RRF report via the district health office should submit their RRF to the district health office until the 5th day of the next month of the reporting period.

Bin card updated: if the bin card was last updated with a balance of zero and the facility has not received any of those products within the previous 30 days.²³

Data accuracy: Data is accurate when there is no discrepancy between stock balances on the bin card record (manual, electronic) compared with the physical count and the balance on the bin card to the balance on the RRF report; inventory accuracy was good if (≥80%).²²

Near accurate report: The report is considered to be near accurate if a ±10% discrepancy between the balance on the bin card to the physical count and the RRF report is considered near accurate.²³

Acceptable storage conditions: Health facility storage condition is said to be acceptable if that facility has fulfilled at least 80% of the criteria for acceptable storage conditions.²²

Results

Availability and Utilization of LMIS Tools

The availability and utilization of LMIS tools such as bin card records, RRF, and IFRR reports were available and used by all study facilities.

Bin Card Updating Practice

Out of the total bin cards, 65 (83.33%) of them were updated. It was determined that bin card updating practice had statistically significant association with the increasing the level of education, X² (1, N = 13) = 79.02, p = 0.048, years of experience, X² (1, N = 13) = 193.60, p = 0.004 and receiving LMIS training, X² (1, N = 13) = 54.1, p = 0.025. Furthermore, the range of bin card updating practices varied among lifesaving MNCH drugs (Table 1).

Table 1 Bin Card Updating Practice in Hospitals of Jimma City and Jimma Zone, 2020

Data Accuracy of Bin Cards

The average bin card accuracy was 59 (90.77%) ranging from 75% for Chlorhexidine gel and Gentamicin injection to 100% for Magnesium sulfate 50%/20 mL, Misoprostol 200 mcg tablet, and Amoxicillin 250mg dispersible tablet (Table 2).

Table 2 Data Accuracy of Bin Cards in Hospitals of Jimma City and Jimma Zone, 2020

Data Accuracy of RRF Reports

The average data accuracy of RRF reports was 396 (84.61%) and ranging from 36 (100%) to 24 (66.66%) (Table 3). The annual average data accuracy of RRF reports was 84.61% with a reporting rate of 34 (94.44%). Most of the RRF reports were completed 35 (97.22%) and timely reported 24 (66.67%). The chi-square test was computed and found that the accuracy of RRF reports was significantly associated with the increasing level of education, X² (16, N = 13) = 297.7, p = 0.019. Yet, there was no statistically significant association between the accuracy of RRF reports and years of experience, X² (8, N = 13) = 134.4, p = 0.097, and LMIS training, X² (5, N = 13) = 54.1, p = 0.368.

Table 3 Data Accuracy of RRF Reports in Hospitals of Jimma City and Jimma Zone, 2020

Availability of MNCH Drugs

The availability of lifesaving MNCH drugs was 59 (75.64%). Oxytocin 10 units/mL and Ampicillin or benzylpenicillin injection were mostly found in the normal stock level. Calcium gluconate 4 (66.66%) and oral rehydration solutions 5(83.33%) were the most overstocked products (Table 4).

Table 4 Stock Status During the Hospital Visit of Jimma City and Jimma Zone, 2020

Stock-Out of MNCH Drugs

About half of the drugs had 22 stock-outs in a year with a stock-out rate and mean stock-out duration of 83.3% and 1.69 months, respectively. Misoprostol 200 mcg and Chlorhexidine gel were the most stocked-out items (Table 5).

Table 5 Number of drug stock out within the past six months in Hospitals of Jimma City and Jimma Zone, 2020

Emergency Ordering

This study revealed that all hospitals placed at least one emergency order a year. The majority, 4 (66.67%) of the hospitals placed one or two emergency orders and the other 2 hospitals placed 2 and more emergency orders per year. Two-thirds of the hospitals waited for one to two months to receive their orders, and the fastest orders were filled between two to four weeks.

Wastage of MNCH Drugs

About half of the lifesaving MNCH drugs were wasted due to expiration, damage or failure to practice the first expired first out (FEFO) stock rotation principle. The wastage rate was determined by using unusable stock divided by the sum of the usable and unusable stock value obtained from model 19 (receiving voucher). The total value of usable stocks was 14,534 Ethiopian Birr (ETB), while unusable stock (expired or damaged) accounted for 2183 ETB per year (Figure 1) with a wastage rate of 13.1%.

Figure 1 Percentage of wasted drugs in hospitals of Jimma city and Jimma zone, 2020.

Reasons for Product Wastage

This study identified three major reasons for the wastage of lifesaving MNCH drugs such as product expiration, receiving near the expired product, and failure to practice FEFO (Figure 2) stock rotation, which varies among the type of drugs.

Figure 2 Reasons of drugs wastage in hospitals of Jimma city and Jimma zone, 2020.

Storage Conditions

Five (83.33%) out of the six hospitals fulfilled the criteria of acceptable storage condition (at least 80% of 13 criteria) with an average fulfilled criteria of 65 (83.33%). Out of the 13 criteria for acceptable storage conditions, products stacked at least 30 cm away from the walls were the least fulfilled criteria (Table 6).

Table 6 Storage Practices of Selected Drugs in Hospitals of Jimma City and Zone, 2020

Qualitative Findings

Twelve in-depth interviews were conducted with store managers and pharmacy heads based on their position for information to identify challenges related to storage management and inventory control with immediate possible solutions.

Storage Management-Related Challenges

The results from the in-depth interview identified inadequate human resources following high staff turnover and a lack of financial incentives. Almost all hospitals experienced deprived staff commitment in updating bin card records, lack of supportive supervision, and inadequate storage space. A pharmacy head in one of the study hospitals replied that;

We are required to submit RRF reports every two months, but suppliers do not fulfill orders according to our requirements, especially in terms of item quantities. This has an undesirable effect that we have identified as misappropriation of information.

Human Resource-Related Challenges

Assessment of the current study identified the lack of close monitoring and frequent staff turnover. Furthermore, lack of supportive supervision, weak management cooperation, and lack of incentives are identified across all hospitals. One of the key informants reacted as follows;

Our staff has to endure heavy workload and sometimes one member is required to work as store manager and dispenser in pharmaceutical service units. In addition, dispensing units send their request to the store as an urgent order outside the predetermined schedule. So, we don’t have time to save and compile reports.

Capacity Building-Related Challenges

The present study found that on-job training, supportive supervision, and experience sharing with good-performing institutions were unsuccessfully implemented. Even though the hospitals tried to create decent working conditions using a kaizen approach, minimum efforts were made by higher health facilities and hospital administrations. Thus, disengagement of staff, manipulating reports, and lack of commitment were common among hospitals. One of the pharmacy heads replied to the situation as follows;

We do not have enough qualified personnel to compute e-registration tools in a complete and timely manner. As we believe that training can fill these skills gaps, some training has been provided in limited numbers and most of them have been misused by the management as a tool of income.

Discussions

Appropriate inventory management practices are critical to avoiding stock-out and ensuring the data quality of logistics records and reports.²⁴ Bin card updating practice is one of the key measures to convey reliable and consistent logistic information. The present study showed that the overall bin card updating practice was 65(83.33%), which is significantly associated with the increasing the level of education, X2 (1, N=13) = 79.02, p=0.048, years of experience, X2 (1, N=13) = 193.60, p=0.004 and LMIS training, X2 (1, N=13) = 54.1, p=0.025. Proper implementation of LMIS is 3.3 times more likely to be efficient than in the case where there are no proper LMIS services.²⁵ To this point, the current figure, 83.3% is higher than the previous similar practice (33.5%) but below the national normal (100%).²² The larger the current figure might be because of the expansion of electronic health commodity management information systems as indicated by the qualitative finding. Regarding the data quality of RRF reports, an average of 396 (84.61%) reports were filled correctly with a reporting rate of 34(94.44%). This is nearly similar to the accuracy of RRF reports reported in Cameroon 75% and Burundi 90%.²⁶ As well, our finding found that most RRF reports were complete 35 (97.22%) and timely reported 24 (66.67%), which implies that some RRF reports were submitted late and remain incomplete. Our study showed more promising results than a similar study in that 69 (59.48%) reports were accurate with a reporting rate of 116 (84.06%) in which 47 (40.52%) reports were reported on time and 73 (62.93%) were complete reports.²⁷ The difference might be due to the difference in sample size that the previous study included more health facilities including health centers so that more low-performing health facilities could be involved. On the other hand, the difference could be related to the counter agreement with the qualitative finding that some hospitals manipulated their reports. As well, our study showed that the average bin card accuracy was 59 (90.77%), ranging from 75% to 100%, therefore, there is some inconsistent data among the physical stock and stock balance in the bin card record that could lead to under or over-reporting. Still, the current figure is higher than the previous study that 374 (52.45%) bin cards were accurate²⁷ that the difference might be to the difference in sample size and settings while both studies encounter similar challenges and another finding indicated that there was poor to no visibility of stock position for most dispensed products.²⁸ No doubt increasing access and use of essential drugs ensures women and children are protected from preventable causes of death and disease. Our finding indicated that the average availability of MNCH drugs was 59(75.64%), which is fairly high but below the normal (100%), with a mean stock-out duration of 1.69 months in which at least one stock-out per month for one or more of closely half of life-saving MNCH drugs mainly due to inadequate supply. This finding shows that mothers, neonates, and children lost or endangered their life following the stock-out of some lifesaving drugs given that all hospitals placed at least one emergency order within a year. With its gaps, this study indicated a stock-out 59(75.64%) which is higher than the previous studies, 14 (61.30%),²⁷ 54.3%,²⁹ and 74.3%³⁰ with a mean stock-out duration of 70.71²⁷ and 26²⁹ days. The new kaizen approach and enactment of Dagu 2.0 were the possible means for the availability of MNCH drugs over the previous studies. Developing countries not only have limited resources but are also mismanaged. Deprived inventory management in public hospitals results in wastage of financial resources.³¹ In this study, the overall wastage rate was 13.1% which is more than twice the national normal,²² and higher than a similar previous study where wastage due to expiration was 8.04%.³² The difference from the standard may be attributed to poor adherence to the Federal Hospitals Pharmacy directive³³ and lower commitment of the store managers. Furthermore, medicines stored in acceptable conditions enable the maintenance of the quality of medicines and reduce the wastage of scarce resources. In our study, 5(83.33%) hospitals fulfilled the criteria of acceptable storage conditions, which is optimal but below the national maximum of²² and closely similar to the result of the previous survey, in which 80% of hospitals met the acceptable storage conditions. It is higher than a finding in Lesotho (57.43%)³⁴ but lower than a finding from the west of the Wollega zone that 4(100%)³² hospitals met storage criteria. The study is not without limitation, and it was limited to public hospitals. Therefore, to get to the overall conclusion, higher-level and lower level (medical centers and clinics) public health facilities shall be the subject of future studies. This study is suggested to be helpful for healthcare facility leaders, non-governmental organizations, and product service managers to make informed decisions so that they could take policy measures.

Conclusion

In conclusion, both bin card accuracy and the data quality of report and resupply forms were lower than the maximum target value (100%) and need significant improvement. The availability of life-saving MNCH drugs was low. Almost all hospitals placed an emergency order and encountered at least one stock-out per year. The wastage rate was twice more than the national normal and failed to first-expiry-first-out stock rotation, whereas most of the hospitals met acceptable storage conditions. Findings from the in-depth interview identified scanty storage management practice, inadequate human resources, and unreliable capacity building. Effective storage management, retaining sufficient human resources, and increasing the capacity of hospital staff could boost efforts of inventory management practice. Further study is recommended to identify factors associated with poor inventory management practices.