Reaching the last mile in the fight against malaria in Niger

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New Insights Approaches: Article 3
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Related Supply Chain Topics
Related Global Health Areas
Date
December 7, 2022
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In this new series from GHSC-PSM, we are sharing recent insights and lessons learned from across our country programs. The third article introduces the call center solution that GHSC-PSM and partners are implementing in Niger to improve the visibility of stocks of malaria products and facilitate supply chain management. With three teleoperators collecting monthly data on the available stock at 417 facilities in the regions of Dosso and Tahoua, the response rate has reached 99 percent, while stockout rates of six categories of commodities have dropped from 20.5 to 6.6 percent on average. Thanks to the call center, GHSC-PSM is helping the government of Niger obtain the visibility it lacked in its regional supply chain. 

In Niger, malaria is the second leading cause of death. Access to diagnosis and treatment is crucial for rapid case management, particularly in hard-to-reach areas. However, the country’s limited health and transportation infrastructure pose enormous barriers to the timely distribution of malaria products. 

In addition, the lack of accurate visibility on stock levels and consumption at service delivery points (SDPs) constitutes a significant challenge for the Nigerian government to manage the health supply chain adequately. Stockouts frequently occur in many facilities, mainly due to the limited implementation of the logistics management information system (LMIS), and little training in data collection, reporting, and analysis. 

The USAID Global Health Supply Chain-Procurement and Supply Management (GHSC-PSM) project, with funding from the U.S. President’s Malaria Initiative (PMI), supports the government of Niger to assist in the regions of Dosso and Tahoua to help fight malaria and save lives. In these two regions, GHSC-PSM is piloting a new distribution model that eliminates the bottleneck of commodity distribution at the district level. As such, monthly delivery of malaria commodities occurs directly from the regional warehouses to the SDPs (this is referred to as the last-mile distribution model). In 2021, GHSC-PSM began the pilot and now conducts reliable monthly distribution of malaria pharmaceuticals, rapid diagnostic tests, and bed nets to the last mile, rigorously accounting for all quantities of commodities distributed using warehouse management software, online forms, and GPS trackers. As part of PMI’s 2021-2026 global strategy to “reach the unreached,” reducing malaria commodity stockout at SDPs is a key objective to achieve.

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Niger Call Center Diagram
Niger Call Center Diagram
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A call center solution to provide monthly inventory visibilty at health facilities
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Until 2020, the only logistical data available to the National Malaria Control Program was the national paper-based reporting system, which reports stock-on-hand and consumption data from SDPs to the district and regional levels before being available at the national level. But  paper-based reporting was characterized by incomplete data reported and insufficient reporting rates and a lack of quality control systems, which prevented a regular flow of data for timely decision-making. 

The paper-based logistics management information system needed to allow for receiving complete stock data quickly enough to plan monthly distribution cycles.  GHSC-PSM identified the call center as a solution with the capacity to quickly and regularly collect stock data from all health centers to calculate their monthly consumption in order to inform the quantities to be delivered each month. (Simultaneously, GHSC-PSM is providing support to strengthen the current paper-based LMIS and the upcoming electronic LMIS, as the call center aims to complement not replace a functioning LMIS.) The call center is being used to inform the last-mile distribution model.

GHSC-PSM previously implemented the call center model in South Sudan to increase stock data visibility and availability for malaria, family planning and reproductive health commodities. Haiti, Mali, and Burkina Faso are also successfully using call centers.

In March 2020, GHSC-PSM started piloting the call center to collect stock data from 417 sites in Dosso and Tahoua and, in January 2021, the last mile distribution pilot began in both regions. During the first 15 days of each month, three GHSC-PSM teleoperators collect data on the stock available at each target health facility, with facility staff providing data from its up-to-date stock card. The project verifies data quality over the phone and by collecting sample stock cards for comparison both electronically and when making site visits.  Call center operators have access to the Integrated Call Center tool that provides a list of all SDPs for which monthly inventory is required. When placing a call, the operators select the desired SDP and the call is routed through a gateway equipped with multiple SIM cards allowing the three operators to place simultaneous calls. The call center is also an auditable system since all calls are recorded. The Integrated Call Center tool has online inventory forms that the teleoperators fill out directly during their calls. The call center data allows for the calculation of the average monthly consumption for each product to estimate the quantities needed by each health facility. The call center is thus an available and accessible data source that can be used to triangulate with other data sources (such as patient records data or surveillance data on epidemic response) while waiting for the full operationalization of an electronic LMIS that will be interoperable with other data management systems.

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A solution with already visible impacts
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Although it was a low-tech solution, receiving regular calls to communicate inventory data over the phone was new to the stock keepers. The operators have a set script to guide the conversation and go over all commodities one after the other. 

Initially, in 2020, in part because it was a new concept for health facility staff, the call center experienced low response rates. However, the call center also has the advantage of using a technology that everyone already uses. The same process is repeated on each call. Over time it becomes predictable, and the duration of the call gets shorter, thus reducing the burden of the recipient. Hiring a third call center operator, resolving telecommunication network issues with local providers, and adding a toll-free hotline for contacting the call center consistently increased response rates. Over time, GHSC-PSM’s teleoperators (who have not changed since they were hired) have developed strong working relationships and a mutual respect with the people they call.

"Because resupply schedules and processes are on a tight schedule, GHSC-PSM must collect data from all 417 health facilities between the 1st and the 15th of each month. A key challenge is holidays (especially a religious holiday) that fall within the data collection period. “In July 2022 we had the Tabaski, which is a very important holiday. It requires a lot of advance planning, and we set up appointments to maximize the chance of getting the data we needed. Despite the challenges we were able to achieve a close to 97% response rate,” said Frederick Persoons, GHSC-PSM’s country director for Niger.

When the call center became fully effective in January 2021, with reporting rates beginning to exceed 80 percent, the stockout rates observed were alarming; sometimes over 40 percent for some products. By June 2021, more than 95 percent of the 417 health facilities reported their stock levels almost every month, a percentage that remains as high to date. The call center has contributed to increase the quality of reported data by following up with questions in case of incoherent data. From October 2021, data from the call center allows for adjustment of quantities to be delivered based on average consumption rate to better respond to needs and prevent stockouts. Call center staff also follow up to assess the impact of these adjustments. After this change, the stockout rates dropped even more, from 20.5 to 6.6 percent on average.

 

For all four commodities, the average monthly stockout rates for October-December 2021 were lower than the same period in 2020.

For all four commodities, the average monthly stockout rates for October-December 2021 were lower than the same period in 2020. 
 

During the pilot, the main impacts of the call center system have been:

  • Reduction of the stockout rate and the number of stockout days in both regions
  • Availability of reliable consumption data at the last-mile
  • Better tracking of commodity expiration dates at health facilities
  • Keeping stock cards up-to-date (inventory is only recorded if stock cards are up-to-date; otherwise calls are postponed)
  • Visibility of data flows at all levels: central, regional, and last mile

Data from the call center not only help to optimize the quantities to distribute to each facility and reduce stockouts but also contribute to improving communication with health centers at the last mile. GHSC-PSM will share improved analyses based on the data collected to better inform decision-making at the national, regional, and district levels. The data to be shared includes analyses specific to each level of decision-making–including monthly stock levels, stockout rates by commodity and district, quantities distributed to each health center, and average monthly consumption calculated based on all the inventory and distribution data generated by the project. 


For others considering implementing a similar solution, the Niger country team offered this advice: “Start small but communicate on the scalability of the system”.

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The GHSC-PSM call center model can be applied in other settings
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The call center design is technologically simple and financially cost-effective. A call center can be a good way to quickly and efficiently collect logistics data and test a country's readiness to use that data. The Voice Over Internet Protocol (VoIP) system can be easily used to monitor more commodities across additional SDPs. By adding more operators, the call center can be applied across more health areas and regions, and include other health products. The low maintenance requirements and low cost per call make the call center a sustainable solution for tracking key commodity inventories and easily connecting with health centers. 

As GHSC-PSM enters its consolidation phase in Niger, the project is working to not only build buy-in and confidence in the call center data, but to get the government of Niger to recognize the tool's potential to build communication, exchange and trust with hundreds of health workers. Perhaps the most important aspect of call centers is not so much the technology and the approach to collecting logistical data, but the fact that it is also an excellent communication tool. Even when inventory data is available through a fully functional eLMIS, the call center can still be an effective tool for connecting with hundreds of healthcare providers.  A call center will not replace a LMIS or eLMIS but can be a valuable tool to complement the national system. With this human connection, the call center could support remote supervision and coaching efforts to improve the quality of the logistic data.