Accelerating Multi-Month Dispensing for ART in LMICs: Supply Chain Insights
Is there sufficient stock to
implement multi-month
dispensing (MMD)? Using
supply chain constraint
analyses to accelerate MMD
for ART during COVID-19 in
LMICs
presented at the 2020 Health and Humanitarian Logistics
Conference
Photo: GHSC-PSM
The Essential Question
Given
a)
the forecasted consumption
b)
stock on hand, and
c)
incoming shipments
What's the stock impact of providing or
expanding MMD3 or MMD6 to patients (in
an immediate or phased manner)?
2
Applying the Multi-Month Simulation (MuMS)
tool to a real country
3
•
If this is what the
current months of stock
looks like, what are the
consequences of moving
all 1
st
line ARV patients
to MMD 6 immediately
(scenario A)?
•
What happens if we
phase in MMD6
(scenario B)?
What does the Multi-Month Simulation
(MuMS) tool tell us?
•
Scenario A shows an
immediate drop
below the minimum
number of months
from Jul-Nov 2020
•
Scenario B also
shows a drop below
min, but it is less
significant
•
Decision-makers
should consider if
the dip below
minimum is too high
a risk of stockouts at
some locations, but
no national stockout
will occur
4
What else can MuMS tell us?
5
Scenario B: TLD90
Scenario C:
Scenario C: TLD90
And we model incoming shipments as only
75% of the quantities ordered for TLD90:
If keep Scenario B as a phased transition:
Why is MuMS limited to changes in
consumption and changes in shipments?
6
Consider the complexity of the environment in which these changes are being
implemented. For the sample country here’s where things stood at the end of testing
the tool:
What does MuMS need as inputs?
1.
PipeLine Database
2.
Start Month
3.
Patient # by Regimen
(drug, bottle size, MMD)
4.
Select options for
scenarios
Immediate:
All patients start in month 1
Phased:
Patients transition over 3-6 months
What does MuMS produce as outputs?
Patient splits
across MMD
Overall
Stock Status
for first Line
ARVs
Stock Status
graphs
for each
commodity
Stock Status table
for each commodity,
highlighting stock
issues & stockouts
User Feedback
“MuMS will help guide discussions around
stock requirements for multi-month ART
dispensing scale up. It will make it quite
easy for the logistics teams to quickly review
projected consumption and supply plans to
accommodate various levels of multi-month
scripting while ensuring optimal stock levels
moving forward.”
—a GHSC-PSM MuMS
field tester
9
Might we need MuMS in the future?
MuMS was created to help during
COVID, but can be used to transition
between any two products and
changes to multi-month packs:
•
How many of Product A will be in the
market when Product B is introduced?
How long will current stock last?
•
How many bottles of Product A are still
in warehouses/in production? How
many months of future demand will
that supply?
•
When will Product B need to arrive
to replace Product A, without
affecting the Product A demand?
Consider use of MuMS for
optimization of pediatric formulations.
10
Conclusions
MuMS helps programs determine if the
supply of commodities will be a constraint in
the implementation of MMD. The Excel-
based tool requires stock on hand,
consumption, and planned shipment data
from the Pipeline software and models
changes in consumption, shipment timing,
and shipment quantity, to determine the
consequences of implementing MMD.
11
Barry Chovitz
Technical Director, Leadership &
Governance, Health Systems Strengthening
Team
bchovitz@ghsc-psm.org
13
14
15
16
17
Photo: Lan Andrian
Photo: GHSC-PSM
Greetings HHL Colleagues,
My name is Barry Chovitz and I’m the Technical Director, Governance & Leadership from the Health Systems Strengthening Team of the Global Health Supply Chain—Procurement and Supply Management project at Chemonics and funded through the US Agency for International Development.
I am presenting the work of our Forecasting and Supply Planning team in developing a tool to determine, as the title of this presentation indicates, if there is sufficient stock to implement multi-month dispensing using supply chain constraint analyses to accelerate multi-month dispensing (sometimes also referred to as multi-month scripting) for ARV during COVID-19 for lower and middle-income countries.
In light of the COVID 19 pandemic or perhaps even despite COVID, GHSC-PSM understood that many countries were looking to accelerate and/or further scale multi-month dispensing (MMD) of ARV treatment, particularly through the use of the triple, fixed-dose combination of tenofovir, lamivudine, and dolutegravir (TLD), which is packaged in bottles of 30, 90, or 180 tablets and is taken once daily, meaning a 1, 3, or 6-month supply. The aim was to give patients a sufficient supply during a single visit to minimize visits by otherwise healthy clients to facilities that were attending to potentially contagious patients.
This content discusses the utilization of supply chain constraint analyses to expedite Multi-Month Dispensing (MMD) for ART during COVID-19 in Low- and Middle-Income Countries (LMICs). It explores the stock impact and consequences of implementing MMD3 or MMD6, scenarios of moving patients to MMD6 immediately or phased, and the insights provided by the Multi-Month Simulation (MuMS) tool. Decision-makers are advised to evaluate risks of stockouts and consider phased transitions. The limitations of MuMS in managing consumption and shipment changes in a complex implementation environment are also highlighted.
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Presentation Transcript
USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM Procurement and Supply Management Is there sufficient stock to implement multi-month dispensing (MMD)? Using supply chain constraint analyses to accelerate MMD for ART during COVID-19 in LMICs Photo: GHSC-PSM presented at the 2020 Health and Humanitarian Logistics Conference
The Essential Question Given a) b) c) What's the stock impact of providing or expanding MMD3 or MMD6 to patients (in an immediate or phased manner)? the forecasted consumption stock on hand, and incoming shipments USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 2
Applying the Multi-Month Simulation (MuMS) tool to a real country If this is what the current months of stock looks like, what are the consequences of moving all 1st line ARV patients to MMD 6 immediately (scenario A)? What happens if we phase in MMD6 (scenario B)? USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 3
What does the Multi-Month Simulation (MuMS) tool tell us? Scenario A shows an immediate drop below the minimum number of months from Jul-Nov 2020 Scenario B also shows a drop below min, but it is less significant Decision-makers should consider if the dip below minimum is too high a risk of stockouts at some locations, but no national stockout will occur USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 4
What else can MuMS tell us? And we model incoming shipments as only 75% of the quantities ordered for TLD90: If keep Scenario B as a phased transition: Scenario C: Scenario B: TLD90 Scenario C: TLD90 USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 5
Why is MuMS limited to changes in consumption and changes in shipments? Consider the complexity of the environment in which these changes are being implemented. For the sample country here s where things stood at the end of testing the tool: MMD3: Implementation complete MMD6: Implementation in Progress 5% on monthly = mostly new patients 20+% on MMD6 Implementation Guidelines developed Supply - MOH procures (PEPFAR-supplied booster) Implementation Guidelines developed Implementing with both TLD30 and TLD90 Big increase in patient issues ~June 2020, due to increased community distribution of medicines to avoid clinic visits Challenges Risk: Supply Availability Government stock slow, tender only for TLD30 (Supplier agreed to supply a portion as 90, but need more). TLD90 stock issues (Apr-Jun 2020) Risk: Exchange rate fluctuations impact budget Information Systems & Data User and system challenges hindering accurate MMD6 reporting. The clinical management information system, may be under-reporting USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 6
What does MuMS need as inputs? 1. PipeLine Database 2. Start Month 3. Patient # by Regimen (drug, bottle size, MMD) 4. Select options for scenarios Immediate: All patients start in month 1 Phased: Patients transition over 3-6 months USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
What does MuMS produce as outputs? Patient splits across MMD Overall Stock Status for first Line ARVs Stock Status graphs for each commodity Stock Status table for each commodity, highlighting stock issues & stockouts USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
User Feedback MuMS will help guide discussions around stock requirements for multi-month ART dispensing scale up. It will make it quite easy for the logistics teams to quickly review projected consumption and supply plans to accommodate various levels of multi-month scripting while ensuring optimal stock levels moving forward. a GHSC-PSM MuMS field tester USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 9
Might we need MuMS in the future? MuMS was created to help during COVID, but can be used to transition between any two products and changes to multi-month packs: How many of Product A will be in the market when Product B is introduced? How long will current stock last? How many bottles of Product A are still in warehouses/in production? How many months of future demand will that supply? When will Product B need to arrive to replace Product A, without affecting the Product A demand? Consider use of MuMS for optimization of pediatric formulations. USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 10
Conclusions MuMS helps programs determine if the supply of commodities will be a constraint in the implementation of MMD. The Excel- based tool requires stock on hand, consumption, and planned shipment data from the Pipeline software and models changes in consumption, shipment timing, and shipment quantity, to determine the consequences of implementing MMD. USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management 11
Barry Chovitz Technical Director, Leadership & Governance, Health Systems Strengthening Team bchovitz@ghsc-psm.org The USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project is funded under USAID Contract No. AID-OAA-I-15-0004. GHSC-PSM connects technical solutions and proven commercial processes to promote efficient and cost-effective health supply chains worldwide. Our goal is to ensure uninterrupted supplies of health commodities to save lives and create a healthier future for all. The project purchases and delivers health commodities, offers comprehensive technical assistance to strengthen national supply chain systems, and provides global supply chain leadership. For more information, visit ghsupplychain.org. The views expressed in this presentation do not necessarily reflect the views of USAID or the U.S. government. USAID GLOBAL HEALTH SUPPLY CHAIN PROGRAM-Procurement and Supply Management
