A Jug of Milk

Picture the contents of your refrigerator.  If you’re one of those young people whose refrigerator contains only an empty bottle of ketchup and a few beers, I want you to picture your mother’s refrigerator instead, resplendently filled to the brim with food.  If your mother’s refrigerator doesn’t fit this description, I’m sorry, I guess I just won out in the Awesome Mom category.  Now, inside that full fridge, I want you to find a commonly-used item, the milk. My Awesome Mom’s refrigerator has regular and soy milk, but for the purposes of this exercise, I’ll just picture the jug of regular milk.  Now, as you’re picturing that jug of milk, answer this question – do you need to buy more?

You probably instantly thought of several other questions that need answering in order for you to decide if you need more milk.  How full is the current jug?  How many people are drinking it and how often do they drink it?  I don’t particularly like milk, so a half-full jug would last me a week at least.  With my boyfriend around, it wouldn’t last until dinner.  Is there perhaps a second jug hiding at the back of the shelf?  How long will it take you to get more milk?  Is it something you can get at the corner store next door, or does it require strategic planning in advance? 

When you manage the milk in the fridge so that you always have the right amount, you’re doing supply chain management.  In fact, you do a simplified version of supply chain management any time you analyze items in your house and decide whether or not you need to purchase more.  My fellowship with the Clinton Health Access Initiative here in Rwanda focuses on improving the supply chain for pharmaceuticals within one of Rwanda’s thirty districts - Burera.  Why only in one district?  Our partners in the Pharmacy Task Force at the Ministry of Health hope that I might find some useful methods for improvement that might be ‘scaled-up’ in other districts in the future.

Stock on the shelves at CAMERWA

Historically, development organizations like SCMS (the Supply Chain Management System) have taken a top-down approach to improving pharmaceutical supply chains.  In Rwanda, they’ve done a fantastic job of improving the inventory and functionality of CAMERWA, the central medical store.  In our milk supply chain metaphor, this is akin to the manager ensuring that she orders milk, that it arrives well before its expiration date, and is available on the shelves to customers.  However, as a consumer, you know this is not the complete picture of how you manage your milk supply chain.  Imagine that you buy a gallon of milk once a week, regardless of how much is consumed.  What’s wrong with this approach?  Perhaps you run out of milk halfway through the week, and should actually be buying milk twice a week or two jugs at a time.  Maybe a jug a week is way too much, and pretty soon you’ve got nothing but half-drunk cartons of milk taking up all the space in your refrigerator. 

As you can see, the consumption component of supply chain management is a vital one.  In cash-strapped facilities like rural health centers, it is crucially important that monthly orders for drugs accurately reflect client (patient) consumption.  At the facility level, if you over-order on a drug that’s costly and not used frequently, you’re going to have a lot of expensive waste sitting on your stock shelves.  From a government perspective, getting drug ordering right is highly important. 

Pharmaceuticals make up the largest share of the Ministry of Health’s budget in Rwanda.   Let’s say that when a health facility does their monthly ordering, they over-order by $30 worth of drugs.  This doesn’t seem like a big deal until the $30 problem is magnified by more than 400 health facilities, leaving the government with over $150,000 in wasted cash per year that could have been saved if the system were tightened up.  Even if drugs are donated for free to a country, like antiretrovirals to treat HIV and AIDS, the donor organization is still expecting their valuable gift to be managed effectively.  After all, even if the government doesn't pay for them, someone does.  With the Global Fund reporting that they’re experiencing a shortfall in funding for AIDS drugs, you can bet they’re going to expect an even greater level of oversight when it comes to their list of expenditures, and drug expenses are near the top, if not first, on that list.

That’s a big picture view of the situation, but the point I want to drive home is that after governments take the crucial step of making drugs available, it becomes incredibly important to ensure that ordering is appropriate based on patient consumption.  Don’t buy two milks if you really only need one, but make sure you always have what you need.  This is the essence of my work in Burera District – getting down to the nitty gritty of things and working to improve ordering from the lowest level – the health facilities.  If I’m successful (and that’s a big ‘if’), I’ll be able to give the Ministry of Health some ideas about how to improve the drugs supply chain system from the bottom up so that it can meet the top-down organizations in the middle.

In closing, I’d like to leave you with a picture I took last week on a data-collection visit.  It’s a consumption register from the distribution pharmacy of a health center and represents one day’s worth of drug distribution to patients.  The entire pharmacy system in Rwanda relies on registers like this one for a crucial component of the supply chain – consumption – how fast the milk is being drunk. 

Note: This post can also be found on the Global Health Corps blog, where my fellow GHC crew are writing about their own experiences, debating development, and generally saying interesting things.