The Central Medical Store – Central de Medicamentos e Artigos Médicos (CMAM), which is at national directorate level (World Bank-IDA, 2014), manages Mozambique’s public health supply chain. Its mandate is to manage the procurement, importation, central-level warehousing and distribution to provinces for medicines and commodities used by the public health system. The CMAM, the MISAU and their partners are guided by the Supply Chain Logistic Plan of Action 2012 (MISAU, 2012) and the new Pharmaceutical Logistics Strategic Plan 2013 (MISAU, 2013). Both of these plans have performance indicator framework and monitoring plans.
The strategic and action plans aim to address several key issues:
• Improved quality and timeliness of information flow between districts, provinces, and CMAM and better use of this information for planning and procurement purposes
• Better planning for distribution from provincial warehouses to the districts
• Stronger supervision and internal audit of province/district stores by CMAM The CMAM receives assistance from multiple donors and implementing partners. Most recently, this has included technical assistance and commodities from the U.S. government (USG); operational funding and commodities from the World Bank; and commodities from GFATM related to each of the GFATM programmes. The USG alone invests, on average, US$10 million – $15 million annually on technical assistance to CMAM through such projects as the Supply Chain Management System (SCMS), the USAID - DELIVER PROJECT, and Fortalecimento dos Sistemas de Saúde e Acção Social (FORSSAS). Rapid diagnostic tests, ACTs and SP fall under the remit of CMAM. However, long lasting insecticidal nets (LLINs) are supplied through a temporary semi-parallel system that operates to directly deliver nets from port of entry to provisional and then district levels in target provinces.
Long lasting insecticidal nets are also distributed in coordination with the Expanded Programme on Immunization to Ante-Natal Clinics (ANCs) for their routine distribution. Quantification for RDTs and ACTs is done using demographics and Logistics.
Management Information System (LMIS), i.e. consumption and distribution data. Distribution of ACTs, RDTs and SP is carried out through two systems. A “push” system delivers pre-packaged kits, per 1,000 consultations for US and 250 consultations for APEs, from CMAM to the provincial level on a quarterly basis. From there, kits are delivered to districts and to health centres once a month by the provincial and district health authorities, respectively.
The APEs receive kits that include RDTs, ACTs and artesunate suppositories that they collect either at district level or from health facilities depending on their catchment area. Malaria kits to US are delivered alongside essential medicine kits and only contain RDTs and ACTs.
The second system is the “pull” / via classica mechanism that allows health facilities to request extra quantities of RDTs and drugs based on consumption rates, including antimalarials. Requests from US are made to the district warehouse. Should the district warehouse not have enough stock, they then request stocks from the provincial warehouse. The district warehouse is then responsible for delivering requested stock to the US. This mechanism is reported to be functioning well for malaria, with facilities requesting antimalarials when out of stock, though there can sometimes be a delay in distribution to facility level due to logistical challenges. It is currently estimated that of the total number of ACTs consumed, two-thirds are from the kits and one-third is by requisition through the classica system.
There is currently no mechanism for redistribution of anti-malarials at district level. Currently, there is limited, even no data, on stock availability on a routine basis for Mozambique. Studies examining stock availability of essential medicines, including antimalarials and RDTs, have found that in one region (Sofala) between 4% and 18% of malaria consultations did not have an RDT or ACT available (Wagennaar, 2014).
Hasselback et al (2014), examining stock availability of RDTs in the Cabo Delgado region, found that average monthly proportions of 59%, 17% and 17% of health centres reported a stock-out on stock cards, laboratory and pharmacy forms, respectively. Estimates of lost RDT consumption percentages were significantly high; ranging from 0% to 149%; with a weighted average of 78%. Each 10-unit increase in monthly-observed consumption was associated with a nine-unit increase in lost consumption percentage, indicating that higher rates of stock-outs occurred at higher levels of observed consumption. While there is limited routine data stock-outs or otherwise, there has been significant investment to improve the availability of data on stocks.
At the central level, a warehouse management system, known as MACS3, has been established and is being used by CMAM to provide tools to better control and manage stock and data. A monitoring and evaluation (M&E) framework have been developed and a dedicated M&E unit created within CMAM to routinely track performance (Spisak and Morgan, 2014).
The plan, as of 2015, is to continue the roll-out of the SIMAM system to all districts with USG and GFATM support (PMI, 2015; World Bank, 2014). In addition to support from PMI through the JSI | Deliver programme, CMAM distribution also received some support from CHAI, which is piloting the introduction of outsourced distribution with tablets for data collection.
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