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Objectives:• Understand the scope of the Medical Supply Chain• Understand the specific supply chain characteristics and features that are required for medical aid

programmes• Understand what medical items are used in medical aid programmes

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Recognized standards – WHO essential drugs list and/or approved essential drugs list of the country concerned.

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Medical logistics is the logistics of pharmaceuticals, medical and surgical supplies, medical devices and equipment, and other products needed to support doctors, nurses, and other health and dental care providersBecause it’s final customers are responsible for the lives and health of their patients, medical logistics is unique in that it seeks to optimize effectiveness rather than efficiency.

An ordinary way to distinguish among effectiveness, efficacy, and efficiency:Efficiency: Doing the "right" thingsEffectiveness: Getting things done

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Typical NetworkMore complex than normal supply chains, more storage locations and movementsOther characteristics of medical supply chains

• Items ordered, stored and moved (diverse sourcing, procurement, storage, transportation)• Legal requirements (narcotic and psychotropic drugs, hazardous goods, individual country regulations for

import/export)• Quality Assurance (protection of beneficiaries/drug administration, substandard and counterfeit drugs)• Demand Requirements (service levels, demand distortion, demand surges)• Medical knowledge required (different levels or knowledge, varies along the chain)• Responsibilities for managing the chain

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Product characteristics that have supply chain implications• Weight, Volume and Physical State: (weight varies significantly - e.g.: cotton wool to x-ray machines,

requiring different transport and storage. Weight does not always equate volume (light/bulky-dressings v heavy/small-liquids) Not always evident in item description

• Dangerous/Hazardous: Gases, flammable liquids, oxidizing substances, toxic and infectious, corrosive – impact on transport and storage

• Sterility: (need protection throughout supply chain, packaging cannot be damaged)• Value: (not only monetary value, might be low value but of value to people – susceptible to theft. Some

items have high value (e.g.: ARV’s)• Sensitivity (temperature, humidity, light can deteriorate items)• Shelf life (deterioration over time, reducing efficacy or becoming toxic)• Susceptibility to damage (sensitivity to damage if not purchased, packaged, transported and stored

adequately)• Regulated (by individual countries or internationally regulated.)• Complement or Dependent (Multiple items relying on other items for use (e.g.: vaccine: vaccine, diluent,

syringe, needle, refrigerator, vaccine carrier, sharps disposal)• Packaging requirements (country regulations (as listed above), organizational requirements, (e.g.:

packaging of small kits within larger kits)• Sources of supply (consideration for quality, safety and efficacy – from manufacturer throughout the

supply chain)• Ordered/Supplied in Kits (standardized kits to accommodate variety of possible medical emergency

interventions + variance in medical programme requirements. Can be pre-packed and stockpiled into kits (midwife kit, emergency health kit) and modules (medical equipment module – part of an emergency health kit) Limitations: wastage – not all parts of the kit used, different expiry dates)

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Explain where kits fit in the early phase of an emergency.Explain what a kit isExplain where and how to use kitsDiscuss the inter-agency kitList of main medical kitsProcurement Red Cross catalogueInter-Agency Health Kit websiteDifferent types of kits(2 Click) Kits v individual items

• Kits in initial phase of emergency• Establish supply chain (medical standards lists for individual items)• Stock monitoring (historical stock out / consumption / estimated consumption)• Establish order / replenishment cycle to phase out kits into individual items

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Types of kits on the Red Cross procurement catalogue website – Focus on main kits for medical Kits. This is similar to the layout of the website. Outline the main kits (first Aid, Cholera, Immunizations, Reproductive and the Inter-agency kit) Interagency Kit will be the main focus in the following 2 slides.Explain how in some kit types there are multiple kits or modules (e.g.: Cholera kit has 8 modules per kit (water testing, disinfection, drugs, logistics material etc.) and can be ordered separately as requiredKits are often for a pre-determined patient load (e.g.: Immunization Kits is for 10,000 immunizations for 5 teams)Problems with kits – If one part of the kit is missing/expired the kit cannot be used – compare this to non-kit i.e.: food, one bag of rice missing does not produce a problem to the remaining items

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Inter-Agency Kit:Designed to meet the initial primary healthcare needs of a displaced population in areas where there is no access to medical facilities:

• isolated areas• where medical facilities have been disrupted in the aftermath of a natural or manmade disaster• or by an ongoing emergency.

The IEHK provides medical supplies to care for a population of 10,000 for a period of 3 months.To improve access to care, and permit response to various situations, the kit is divided into

• 10 Basic Units intended for primary health care workers and one Supplementary Unit for medical doctors.

The Basic Units contains• essential medicines and medical devices

The Supplementary Unit contains• essential medicines (orals, injectables and external applications), infusions, medical devices, and

basic medical equipment, including 1 autoclave (20 or 24 liters)• Does not contain any of the medicines or medical devices already provided in the Basic Units.

Does not include equipment for resuscitation or major surgeries.Is not designed for immunization or nutritional programmes, for reproductive health services, or for the treatment of HIV/AIDS, tuberculosis or leprosyIncludes only limited treatment for chronic diseases

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The Medical Kit contains generic treatment for 10,000 people for 3 monthsTotal Weight/Vol.: 1 MT – 4.75 CBM

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2 x ClickBasic Health Unit:

• 9900kg / 89m³• This emergency unit has a principal capacity of up to 30'000 population served• Using a modular approach adjusting to the actual needs.• There is a secondary capacity of 20 overnight beds.• The unit is self-contained for one month.

Rapid Deployment Emergency Hospital• 9900kg / 89m³• Rapid Deployment Emergency Hospitals provide safe medical and surgical interventions• Offers limited medical/surgical care including OPD for up 50 to 100 patients for maximum 10 days.

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Same principles apply, except the difference are:Fake/counterfeitRequirements for procuring medical items: There are 11 requirements, this covers 6 key steps:

• Need, Specify, Source, Method, Enquiry, Evaluation, Order, Progress, Delivery, Payment, ReviewMaintaining Supply Chain FlowActivities and actions that can cause performance problems:

• Medical programme planning• Understanding programme needs and items required• Providing information to programme• Transport and storage

The conditions that are needed to maintain supply chain flow:• Understand characteristics of medical items• Clear responsibilities• Procedures established, maintained, understood and followed• Communication and information sharing• Good working relationships

Medical personnel in charge of ordering

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• Logistics personnel to provide accurate figures on stock levels;• Logistics triggers minimum level ordering;• Logistics to ensure regular ordering, avoid emergency orders;• Logistics to ensure correct labeling and terminology requested

Logistics personnel in charge of Procurement• Project , Capital , international• Most drugs are ordered through big pharma’s for the quality control;• Donations of drugs are not advised;• Order tracking and tracing

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Outline the main problems associated with medical supply donationsThe outline below the guidelines for drug donations

• Based on the needs detected and accordingly with morbidity• Clinical use approved by the recipient country• Present on national or WHO essential drugs list• Correspond to quality standards of both donors and recipients• No “second hand” drugs or medical free samples• At least one year before expiration (unless campaign or epidemic)• Presentation, strength and formulation of donated drugs must be similar to those used in the recipient

country

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Cold countries – vaccines glass shatters and freezes the products• Area for immediate distribution/ pharmacy;• Area for non-priority distribution;• Storing area (bulk supplies);• Space/volume (1m2 storage = 3m2 floor space);• Security (doors, locks, windows, ceilings);• Separate areas for dispensing and warehousing;• Proper ventilation;• Insulation;• Concrete construction with concrete floors;• Cold countries – cold chain needs to be maintained just the same;• Shelves (Metal, no wood);• Receiving area/distribution area;• Stock control (stock cards & other paperwork);

Note: Red Areas corresponds to pharmacy, black areas to bulk items

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Describe the various types of equipment:Vaccine carriers:

• Similar to cold boxes, vaccine carriers are insulated containers that when lined with ice packs can be used for short periods/temporary storage. They do not stay cold as long as a cold box, the maximum cold life is approximately 48 hours. They are usually used during vaccination campaigns

Temperature control equipment (monitor cards)• Every temperature controlled storage area (cold room, refrigerator, and freezer) should be fitted with a

continuous temperature monitoring device. For vaccines this ideally should include an automatic alarm that provides an alert whenever the temperature of the vaccine is outside the limits required. Where automatic alarms are not used then regular monitoring and recording of temperatures needs to be carried out.

• Temperatures can fluctuate which means that even though the temperature of an item may be within the limit when it is recorded, the temperature may have fluctuated outside the limit between recordings. It is particularly important to monitor the temperature that vaccines are exposed to.

Refrigerators & Freezers:• Refrigerators and freezers can be used for storing up to approximately 1000 liters. As a guide the largest

ice lined vaccine refrigerators currently available store approximately 170 liters and the largest vaccine freezers store approximately 270 liters.

• Refrigerators can be powered by electricity, gas, kerosene or solar energy. Electric refrigerators are usually the most cost effective and easiest to maintain, but they obviously need a reliable electricity supply.

Cold box:• A cold box is an insulated container that can be lined with ice-packs and will keep items cold for short

periods of storage. They can also be used to store items when a refrigerator is out of order or is being defrosted, cleaned or maintained. Different models will have a cold life of two to seven days, depending upon the outside temperature

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Definitions:WIF – Walk in FreezerWIC – Walk in CoolerDF – Deep FreezerILR – Ice lined Refrigerator

Facilitator to describe the various types of equipment and carrying options used throughout the supply chain when transporting various temperature-controlled items.

Slide 25: Transportation of Medical Items

The role of transport in Medical Supply Chains• Role of transport is no different in medical supply chains compared to other supply chains but,• The nature of medical programmes and characteristics of items place specific requirements on how

movements are carried outAs a result, transportation needs to be carried out in a way to prevent

• Deterioration of the quality of the items• Infiltration of counterfeit and substandard items into the supply chain• Minimize the risk of theft

It involves• Understanding programme objectives• Importance of different items• Speed at which items need to be moved through the supply chain• Understanding item characteristics to aid loading, transportation and unloading correctly to avoid damage,

loss and possible injuryNotes - Movements

• This transportation can include movements both international and national and can involve movements from:

• Suppliers/donors within the origin country, through border crossings, through ports/airports to ports and airports in a destination country

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• Across international borders from origin to the final destination country.• Ports/airports to warehouses and stores.• One warehouse to another.• Warehouses to stores in hospitals, dispensaries and pharmacy in health centers.• Dispensing from storage facilities to health professionals and patients.

Requirements for transporting and handling Medical Items:• Ideally dedicated transport for movements of medical supplies and not used for other items (especially

food and fuel)• Cleanliness of vehicles and equipment is also important• Integrity and quality of the items are not compromised (breakdown of transport must not impact cold

chain)• International and national regulations need to be considered

The main specific requirements when transporting medical items:• Mode suitability (sea, road, air depends on sensitivity of items, dangerous goods, large/bulky, high value,

speed, frequency of transport between locations, security conditions)• Security (current and anticipated)• Safety (dangerous goods)• Temperature sensitivity and cold chain (insulated containers that will last the duration of the

transportation – cold boxes and vaccine carriers, refrigerated containers or insulated and refrigerated vehicles, monitoring equipment: VVM, CC cards, Freeze indicators, Temperature data loggers, thermometers)

Documentation(As well as the usual transportation documentation e.g.: Packing List, BoL/AWB, Invoice, there are specific documents that may be required to move medical items:

• Certificate of Analysis• Certificate of Origin• Certificate of Pharmaceutical Product (added this)• Narcotics notices (added this)• Release Certificate• Dangerous Goods Declaration• Import/export Licenses• Import and export requirements

Handling• (size, shape, weight, value of items, degree of fragility, danger and flammable nature of the items, speed

at which items may deteriorate during transportation – e.g.: cold chain), equipment required (pallets, tail lifts, conveyors, cranes)

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Importance of disposal – Controlled by MoH and approved by MoHTwo types of disposal – (medical waste) and witnessed and approved disposal (expired drugs etc.) rules and regulations based on MoH requirements(Images: Encapsulation)The Importance and Role of Disposal

• Prevent health risks associated with exposure to the waste and potential contamination.• Prevent harm to people through the exposure to, reuse or resale of expired, damaged or recalled items

and the exposure to hazardous waste.• To protect public health and the environment.

Types of medical waste• (by-products & unwanted)• Categorized by (general & hazardous)

Reason to dispose• (Expired, damaged, overstock, rejected etc.)• Aim to avoid wastage

The Disposal Process• Decision to dispose / Approval to dispose / Planning disposal / The people, procedures and equipment

needed / Sorting the waste / Security of waste / Recording of wasteCriteria for selecting disposal methods:

• Type of waste needing treatment and disposal.• Quantity of waste needing treatment and disposal• Treatment options and technologies available• Possible risks to health and environment• Disposal facilities available• Quality of disposal facilities• Expertise available• National legislation and regulations affecting waste disposal• Organization rules and procedures• Acceptability to the local population• Cultural aspects• Investment and operating costs of disposal facilities

Disposal MethodsMost common treatment methods:

• Encapsulation• Inertization

The following are appropriate disposal methods:• Incineration• Landfill• Return to donor/supplier/manufacturer

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• Sewer

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In order to meet the demand we need to supply. Ultimately we should trace this back to the source of the raw materials used to make the goods, (e.g. pharmaceutical goods, where we need to be able to trace individual production batches back to its source, in case there is the need to recall specific items).The nature of drug products (value, controlled substances, implications of poor quality, etc.) means that it is important that they can be traced through the entire supply chain. This means that the records, documentation and communication on movements and storage of drugs need to be kept accurate and up to date. If a drug manufacturer finds that there is a quality problem with a specific drug that was manufactured on a specific day in a specific location, then they must be able to locate all of the affected drugs and destroy them. To be able to trace where drugs are shipped to after production, manufacturers must strictly control the production process. This is done using batch numbers, so if necessary a manufacturer can issue a product recall for a particular batch of drugs. They can then trace where all items under that batch number were sent. This is a very important aspect of traceability.

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There are several reasons for holding inventory:• To decouple supply from demand• In anticipation of an increase in demand• To protect against any uncertainty in supply and demand• To maintain permanent stock of drugs and essential products of quality• To reduce costs• To save time and optimize work of staff• To facilitate management verification and continuous evaluation of consumable products

Inventory in Medical Supply ChainsStock levels

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• (depend on procurement and replenishment policies, actions of people managing procurement and inventory at the warehouse or stores, level of donations, changes in medical programmes, supplier deliver reliability)

• This can lead to overstocking (long storage times leads to deterioration, exceed expiration date, result in need for disposal, added costs for disposal, can increase holding costs).

• Understocking (stock ruptures can result in less appropriate substances used, , disruption in treatment regime which can lead to prolonged suffering, deterioration in health status or death).

Stock control• FEFO (First Expired, First Out – for medical items that have an expiration date)• FIFO (First In, First Out – for medical items that do not have an expiration date)

Stock count• Stock count is used to identify overstocking and understocking, incorrect storage practices, discrepancies

between physical and records, near expiry, prevent theft, for inventory control and calculating replenishment orders.

Stock records• To track and trace items in/out, batch tracing, donor reports, inventory control, reconcile stock balances

with physical spot checks, tracking shortages and anticipated excess, stock rotation

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ORDERING QUANTITY = Safety + Average Order Cycle Consumption x Lead TimeLEAD TIME: time from order (from the pharmacy) to delivery (to the pharmacy)SAFETY STOCK: Stock that should be always present to avoid rupture. In general it is equalling the consumption for the reordering time. Take the example above: Lead Time 2 weeks, consumption 20 per week, meaning the Safety Stock will be: 2 weeks Stock+ 40 unitsReview Period = Ordering Cycle: depend of programs/organisations but in general it is 3 months.MINIMUM STOCK = Safety + Average Monthly Consumption x (Review period+ Lead time)

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Exercise: Reordering/Review Period

Handouts to be given to participants: 2.2a Medical Logistics Exercise – Order Quantity - HandoutIf lack of time, ask each group to do only one item

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Handouts to be given to participants

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See excel sheet for more details: 3.2.2b & 3.2.2c Medlog Exercise – Order Quantity

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