1

REPUBLIC OF RWANDA

MINISTRY OF HEALTH

Health Supply Chain Management

Training Module for Hospitals and
Health Centers

March 2021

3
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!"#$%"#&'
! ! Foreword
!"#$%"#&'
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Strong public health supply chains require trained and skilled staff who are both familiar with
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empowered
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to participate in decision and policy-making processes related to health supplies and supply
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chains. A0&4!
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product stock outs and expiries. This is compounded by a lack of recognition among many
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health institutions of the vital role supply chain personnel play in the performance of health
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systems.
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In all public institutions, current supply chain workers are recruited based on being a pharmacist
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or nurse.
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their&%#!
career, to fulfill
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0&4!chain
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those that do
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job descriptions at the central level (procurement, quantification, warehousing, distribution,
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etc.).
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Lack
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the competency models for
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knowledge,
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even absent), sometimes subjective
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employee
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human resource
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Training of some store managers, pharmacists, and lab technologists are carried out with the
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support
1)((%$#! of MOH
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%#./$! stakeholders, and
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a designated training %6!of(.0$80-,1#1:!
pharmacists.
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Development partners also support the pre- and in-service training
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91(1)0&2" 1%" %/0" (1%#'(1-=" 5#2%&#.%=" 1(5" /01-%/" 71.#-#%3" -0@0-;" E'80@0&=" %/0&0" 1&0" ('"
the national, district, and health facility level. However, health supply chain cadres at lower
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levels do not have any standardized materials or training manual for in service training. This
+/?/+1!4%!&%#!.0?/!0&2!1#0&40$4,C/4!80#/$,0+1!%$!#$0,&,&'!80&)0+!6%$!,&!1/$?,-/!#$0,&,&':!>.,1!
.'9*&'9#20"%/0"4+1-#%3"'7"%&1#(#()"*&'@#505"%'"2+**-3"./1#("2%177"1%"5#2%&#.%"1(5".0(%&1-"
compromises the quality and capacity of skills provided to facility staff.
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The Ministry of Health is pleased to introduce the first training manual intended to be used by
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supply chain cadres for in-service training at service delivery points, for self- learning, and on
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job training during supervision. This manual will serve as a standard tool that can be used not
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only to build capacity but as a source for identifying supply chain management best practices
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at service delivery
,+#-5" .1*1.#%3" ,+%"points in Rwanda.
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0#!1/$?,-/!4/+,?/$2!(%,&#1!,&!N70&40:!
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would like to urge all stakeholders from government institutions to use this manual for the
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purpose intended for. I also appreciate the pharmaceutical sector development partners for their
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continued support to Rwanda’s health development.
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*1&%(0&2"7'&"%/0#&".'(%#(+05"2+**'&%"%'"N81(51O2"/01-%/"50@0-'*90(%;"

!"
!" Dr. NGAMIJE M. Daniel
"
"#$!%&'()*+!($!",-./0!!
" Minister of Health
(.-.12/#!34!5/,026!
!"#$%&'()*+$(#$!,-./0$"
!!! (.-.12/"$34$5/,026$
!
Acronyms
!

!"
!"3
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AMC Average Monthly Consumption

BUFMAR Bureau des Formations Médicales Agréées du Rwanda

CHW Community Health Worker

DH District Hospital

DP RMS Ltd District Branches

EML essential medicines list

EOP emergency order point

FEFO first to expire first out

FIFO first in first out

MOS months of stock

RMS Ltd Rwanda Medical Supply Ltd

NMP National Medicine Policy

SOH stock on hand

SOP standard operating procedure

STG standard treatment guidelines

WHO World Health Organization

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Background

In 2006, WHO identified health workforce performance as one of the six building blocks essential to
strengthening health systems. An essential component of a robust health system is an effective supply
chain which provides health workers and clients vital public health commodities. An effective supply
chain, in turn, involves engaging the right people in the right quantities with the right skills in the
right place at the right time to implement the procedures that direct supply chain operations and
ensure the supply of health commodities.

Strong public health supply chains require trained, skilled staff who are both familiar with the
standard operating procedures required for each logistics function and are also empowered to
participate in the decision and policy-making processes related to health supplies and supply chains.
A lack of trained staff with the right skills is a frequent cause of supply chain system breakdown and
poor performance, ill- functioning product management, and, ultimately, product stock outs. This is
compounded by a lack of recognition among many health institutions of the vital role supply chain
personnel play in the performance of health systems.

In all public institutions, current supply chain workers are recruited based on being a pharmacist or
nurse. Many nurses and pharmacists are asked, at some points in their career, to fulfill supply chain
tasks. Job descriptions for supply chain cadres are not widely available, and those that do exist are
not standardized, although the Ministry of Health (MOH) has selected supply chain job descriptions
at the central level (procurement, quantification, warehousing, distribution, etc.).

Competency models for supply chain roles do not exist now. This results in: 1) inability to base
workforce planning, performance management, training, career path, and job descriptions on supply
chain knowledge, skills, and ability standards; and 2) ad hoc (or even absent), sometimes subjective
employee development and, consequently, an inability to strategically allocate appropriate human
resource funds to those areas and skills most essential to supply chain human resources.

Training of some store managers, pharmacists, and lab technologists are carried out with the support
of MOH and other stakeholders, and there is a designated training of pharmacists. Development
partners also support the pre- and in-service training of supply chain managers at the national, district,
and health facility level. However, health supply chain cadres at lower levels do not have any
standardized materials or training manual for in service training. This compromises the quality and
capacity of skills provided to facility staff.

This manual is intended for use by new supply chain cadres and by current staff for in-service training
at service delivery points for self-learning and on job training during supervision, respectively. This
manual also aims to improve Rwanda’s health commodity supply chains by strengthening human
resource capacity to manage supply chain management activities at lower levels. The manual will
serve as a standard tool that can be used not only to build capacity but as a source for identifying
supply chain management best practices at service delivery points in Rwanda.

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TABLE OF CONTENTS

UNIT 1: INTRODUCTION TO LOGISTICS ................................................................................................... 1

MANAGEMENT SYSTEM................................................................................................................................. 1
1.1. Logistics concept and terms ................................................................................................................... 2
1.1.1. Logistics .............................................................................................................................................. 2
1.1.2. Supply chain........................................................................................................................................ 2
1.1.3. Supply chain management .................................................................................................................. 2
1.1.4. Health supply chain management ....................................................................................................... 2
1.2. Logistics cycle ........................................................................................................................................ 2
1.3. Components of a Logistics cycle ............................................................................................................ 2
1.3.1. Product Selection ................................................................................................................................ 3
1.3.2. Quantification ..................................................................................................................................... 3
1.3.3. Procurement ........................................................................................................................................ 3
1.3.4. Inventory Management ....................................................................................................................... 3
1.3.5. Storage and distribution ...................................................................................................................... 3
1.3.6. Serving customers ............................................................................................................................... 3
1.3.7. Logistics management information system (LMIS) ........................................................................... 3
1.3.8. Other activities at the heart of the logistics cycle ............................................................................... 3
1.3.9. Policy and Legislation......................................................................................................................... 3
1.3.10. Adaptability ....................................................................................................................................... 4
1.3.11. Quality monitoring ............................................................................................................................ 4
1.4. Rwanda health supply chain system ....................................................................................................... 5
1.5. Flow of health supply chain information and health commodities in Rwanda ...................................... 5
FLOW OF INFORMATION AND COMMODITIES IN RWANDA SUPPLY CHAIN SYSTEM ..................... 6
UNIT 2: PRODUCT SELECTION ..................................................................................................................... 7
2.1. Product selection .................................................................................................................................... 8
2.11. National medicine policy................................................................................................................... 8
2.12. Standard treatment guidelines ........................................................................................................... 8
2.13. Essential medicines list ..................................................................................................................... 8
2.14. The process of product selection ....................................................................................................... 9
2.15. Selection criteria ................................................................................................................................ 9
2.16. The purpose of product selection ...................................................................................................... 9
2.17. Health facilities’ roles and responsibilities in product selection ..................................................... 10
UNIT 3: QUANTIFICATION ........................................................................................................................... 11
3.1. Quantification ....................................................................................................................................... 12
3.1.1. Terms used in quantification .............................................................................................................. 12
3.2. Key steps and processes in quantification ............................................................................................ 14
3.2.1. Preparation process ............................................................................................................................ 14
3.2.2. Forecasting process............................................................................................................................ 15
3.2.3. Supply planning process .................................................................................................................... 16
3.3. Quantification methods ......................................................................................................................... 16
3.3.1. Consumption method ......................................................................................................................... 16
3.3.2. Morbidity method .............................................................................................................................. 17
3.4. Reviewing quantification for ordering .................................................................................................. 18
3.5. The purpose of quantification ............................................................................................................... 19

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UNIT 4: PROCUREMENT ............................................................................................................................... 20

4.1. Procurement .......................................................................................................................................... 21
4.2. Fundamental principles in public procurement .................................................................................... 21
4.2.1. Transparency................................................................................................................................... 21
4.2.2. Competition .................................................................................................................................... 21
4.2.3. Economy ......................................................................................................................................... 21
4.2.4. Efficiency ........................................................................................................................................ 21
4.2.5. Fairness ........................................................................................................................................... 21
4.2.6. Accountability................................................................................................................................. 21
4.3. Methods used for public procurement .................................................................................................. 22
4.3.1. The purpose of procurement in the health supply chain ................................................................. 22
4.3.2. Procurement procedures ................................................................................................................. 23
4.4. Key stakeholders in the procurement process ....................................................................................... 23
UNIT 5: INVENTORY MANAGEMENT ....................................................................................................... 24
5.1. Inventory management ......................................................................................................................... 25
5.1.1. Inventory management: .................................................................................................................. 25
Inventory Management Cycle ....................................................................................................................... 25
5.1.2. Importance of inventory management ............................................................................................ 26
5.2. Receiving products ............................................................................................................................... 26
5.2.1. Receiving products ......................................................................................................................... 26
5.2.2. Importance of receiving products ................................................................................................... 26
5.2.3. Procedures for receiving health products ....................................................................................... 27
5.2.4. Common product quality problems and mitigating actions ............................................................ 29
5.3. Storage .................................................................................................................................................. 30
5.3.1. Storage ............................................................................................................................................ 30
5.3.2. The importance of good storage ...................................................................................................... 31
5.3.3. Key storage activities ...................................................................................................................... 31
5.3.4. Storage procedures.......................................................................................................................... 31
5.3.5. Storage best practices ...................................................................................................................... 31
5.3.6. Cold chain storage instructions ....................................................................................................... 33
Arrangement of cold chain commodities in the refrigerator ......................................................................... 34
5.3.7. Storing vaccines and using the fridge correctly .............................................................................. 35
5.3.8. Use of cold box and a vaccine carrier ............................................................................................. 36
5.3.9. Temperature monitors ..................................................................................................................... 36
5.3.10. Stock rotation ................................................................................................................................ 37
5.3.11. Summary of good storage practices .............................................................................................. 37
5.4. Inventory controls ................................................................................................................................. 38
5.4.1. Assessing stock status ..................................................................................................................... 38
5.4.2. How to assess stock status .............................................................................................................. 38
Stock on hand (SOH) ................................................................................................................................. 38
5.4.3. Physical count ................................................................................................................................. 39
5.4.4. Management of donations............................................................................................................... 40
5.4.5. Disposal of medicines and medical sundries .................................................................................. 41
5.5. Distribution ........................................................................................................................................... 41
5.5.1. The country distribution system: .................................................................................................... 41
5.5.2. The importance of distribution ....................................................................................................... 41
5.5.3. National distribution ....................................................................................................................... 42
UNIT 6: RATIONAL USE OF MEDICINES .................................................................................................. 43

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6.1. Rational use of medicines..................................................................................................................... 44

6.2. The importance of rational use of medicines ....................................................................................... 44
6.3. Example of irrational use of medicines................................................................................................. 44
6.4. Factors underlying irrational use of medicines ..................................................................................... 45
6.4.1. Patients............................................................................................................................................. 45
6.4.2. Prescribers (health care workers, nurses, and doctors) .................................................................... 45
6.4.3. Dispenser ......................................................................................................................................... 45
6.4.4. Supply Chain ................................................................................................................................... 45
6.5. The adverse impact of irrational medicines uses................................................................................... 45
6.6. How do we address the problem of irrational use of medicines? .......................................................... 46
6.7. Who is responsible for curbing irrational use of medicines in health facilities? ................................. 50
6.8. Key interventions to promote rational use of medicines ....................................................................... 50
UNIT 7: LOGISTICS MANAGEMENT.......................................................................................................... 51
INFORMATION SYSTEM ............................................................................................................................... 51
7.1. Logistics management information system........................................................................................... 52
7.2. The importance of a logistics management information system ........................................................... 52
7.3. The six "rights" for logistics data ......................................................................................................... 52
7.4. Essential data for decision making ........................................................................................................ 53
7.5. Three types of records .......................................................................................................................... 53
7.5.1. Stock keeping records ..................................................................................................................... 53
7.5.2. Transaction records ......................................................................................................................... 53
7.5.3. Consumption records ...................................................................................................................... 53
7.6. Electronic logistics management information system (eLMIS) ............................................................ 55
7.6.1. Composition of an eLMIS .............................................................................................................. 55
7.6.2. Importance of recording and reporting through an eLMIS ............................................................ 55
UNIT 8: MONITORING & EVALUATION ................................................................................................... 58
AND SUPERVISION ......................................................................................................................................... 58
8.1. Monitoring: ........................................................................................................................................... 59
8.2. Evaluation:............................................................................................................................................ 59
8.3. Supervision: .......................................................................................................................................... 59
8.4. The purpose of monitoring and evaluation (M&E) .............................................................................. 59
8.5. The purpose of supervision .................................................................................................................. 60
8.6. Conducting monitoring and evaluation (M&E) and supervision ......................................................... 60
8.6.1. Monitoring can be conducted using various methods. ................................................................... 60
8.6.2. Evaluation can be conducted through five phases .......................................................................... 60
8.7. Characteristics of indicators used in supervision ................................................................................. 61
8.8. Conducting supervision ........................................................................................................................ 61
8.9. The tools used for supervision of the health supply chain ................................................................... 63
8.10. Expectation from supervisee .............................................................................................................. 63
8.11. Using M&E and supervision findings in problem solving ................................................................. 63
8.11.1. Problem identification ................................................................................................................... 63
8.11.2. Strategic problem-solving approach ............................................................................................. 64
UNIT 9: COMMUNICATION, LEADERSHIP .............................................................................................. 66
AND MANAGEMENT ...................................................................................................................................... 66
9.1. Communication .................................................................................................................................... 67
9.1.1. Importance of communication ........................................................................................................ 67

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9.1.2. Communication methods ................................................................................................................ 67

9.1.3. Feedback ......................................................................................................................................... 67
9.2. Leadership ............................................................................................................................................ 69
9.2.1. Things to be considered in leadership ............................................................................................ 69
9.2.2. Similarities between managers and leaders .................................................................................... 69
9.3. Leadership and change management .................................................................................................... 70
PARTICIPANTS LIST ............................................................................................................................................ 74
REFERENCE DOCUMENTS ................................................................................................................................... 75

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Unit 1: Introduction to Logistics

Management System

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Objectives:

By the end of this module, participants will be able to:

• Define the concept logistics and terms
• Describe the logistics cycle and components
• Describe Rwanda’s health supply chain system

1.1. Logistics concept and terms

1.1.1. Logistics
Logistics refer to what happens within an organization while purchasing and materials from
suppliers to distributors to end-users.

1.1.2. Supply chain

A supply chain refers to products, services, finances, and information flowing from a supplying
organization to end users. It can also be defined as a system of organizations, people, activities,
information, and resources involved in moving a product or service from supplier to end-users.

1.1.3. Supply chain management

Supply chain management is the process of managing and coordinating activities, flows of
goods, services, information, and funds from the source to end-users?

1.1.4. Health supply chain management

Health supply chain management is the management of health products and information flow
in a supply chain system at a value-for-money cost to provide adequate, appropriate supplies
to patients.

1.2. Logistics cycle

A logistic cycle shows how the different components of health supply chain systems are
interdependent.

1.3. Components of a Logistics cycle

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1.3.1. Product Selection

Product selection is the first activity in the logistics cycle. In Rwanda, the national formulary
and therapeutics committee manages product selection. Product selection in Rwanda is done
based on the essential medicines list (EML) and standard treatment guidelines that are normally
used to serve patients.

1.3.2. Quantification
Quantification is the process of estimating quantities and costs of health products required for
a specific health program and determining when they should be delivered to ensure an
uninterrupted supply.

1.3.3. Procurement
Procurement is a critical function within the supply chain. Its effective management is essential
to ensure the availability of health products at the right time and place.

1.3.4. Inventory Management

After products have been procured and received, they must be stored until needed. The
inventory manager is responsible for overseeing product storage in service delivery points
before and after distribution.

1.3.5. Storage and distribution

Proper storage and distribution are needed to ensure maintenance of product quality, and storage
capacity must be enough for all the products in the system.

1.3.6. Serving customers

The logistics system is designed to optimize customer service. Each person who works in
logistics must remember that he or she selects, procures, stores, or distributes products to meet
customer needs. The logistics system ensures excellent customer service by fulfilling the “six
rights” of a logistic system: the right goods, in the right quantities, in the right condition, to the
right place, at the right time and at the right cost.

1.3.7. Logistics management information system (LMIS)

A logistics management information system (LMIS) is a system of records and reports whether
paper-based or electronic, used to aggregate, analyze, validate, and display data from all levels
of the logistics system. These data can be used to make logistics decisions and manage the
supply chain.
The LMIS is the motor that drives the logistics cycle. Without information, the logistics system
would not be able to run smoothly.
Managers gather and analyze information about each activity in the system to coordinate future
actions. Logistic information is also known as a heart or an engine of a logistics system.

1.3.8. Other activities at the heart of the logistics cycle

Other activities that help to drive or support the logistics cycle include organization and staffing,
budget, supervision, and monitoring and evaluation.

1.3.9. Policy and Legislation

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These are government regulations and procedures which affect all elements of a logistics
system. Therefore, healthcare workers need to stay up to date on current policies and follow
them.

1.3.10. Adaptability
The adaptability of the logistics system is the ability to obtain resources needed to address
increase in demand.

1.3.11. Quality monitoring

It is important to understand the role of quality monitoring in ensuring an efficient
and effective logistics system. Quality monitoring refers not only to the quality of the product
but also to the quality of service.
Quality monitoring appears between each activity of the logistics cycle, from selection to use.
This is done to ensure that end users get their value for money by receiving the right products.

1. Quality monitoring appears four times in the logistics cycle:

Between product selection and quantification and procurement. Quality monitoring plays an
important role in quantifying and procuring the right products. Products that are quantified
should be on the national EML, be approved and registered for use in the country, and be
included in appropriate standard treatment guidelines (STGs). Also, service providers must be
trained to correctly use the products before they are procured and distributed to facilities.
2. Between quantification and procurement and inventory management. Procurement
decisions should be based on the supply plan that is developed during quantification. To ensure
product quality, procurement documents must include detailed product and packaging
specifications, and the expectations for quality at the time of receipt. After procurement,
program managers must check the quality of health commodities before they enter the
distribution system. Products that are procured should be quickly cleared through customs or
other inspections before being distributed to facilities.
3. Between inventory management and serving customers. When products are received,
stored, and distributed (and when customers receive them), it is important to monitor their
quality. Furthermore, the quality of the storage conditions and transportation mechanisms
should be monitored. The inventory control system must be designed so that, if followed,
customers will receive the products they need at the time they need them.
4. Between serving customers and product selection. Even after customers receive the
products, the program must continue to monitor their quality. Programs must determine if
customers are satisfied with both the quality of the products and with the service they received.
Health workers must adhere to standard treatment guidelines when serving clients. Quality
monitoring of both the product and the service is critical to the success of efforts to promote the
appropriate use of products. Customers should correctly use the products they receive and be
satisfied with them and with the service they received. The results of monitoring customer
satisfaction can be used to inform decision makers about changes in product selection and use
for the next procurement cycle. Serving customers is at the top of the logistics cycle, and that
means getting the right goods to those customers. The importance of effective logistics system

Effective supply chain management not only helps to ensure commodity security but also
determines the success or failure of any public health program. A well-functioning supply

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chain benefits public health programs in many ways such as increasing program impact,
enhancing the quality of care and improving cost effectiveness and efficiency of the health care
system. Below are the key points to keep in mind as to why health logistics system is important:

• Medicines save lives and improve health. Medicines represent a cost- effective way to
prevent and treat many diseases.

• Medicines promote trust and participation in health services. Medicines are an

essential component of the services that health workers provide to patients, and their
continuous availability affects demand for these services.

• Medicines are costly. Medicines can represent a big percentage of household health
expenditures. Their management should ensure that they do not get lost or damaged along
the supply chain.

• Medicines are different from other consumer products. Medicines are mostly prescribed
and dispensed; patients do not choose them. This requires ethics and standards for
prescribers.

1.4. Rwanda health supply chain system

Medical products and technologies in Rwanda flow through the supply chain as follows:
The MOH coordinates the supply of medical products and technologies through the Rwanda
Medical Supply Ltd (RMS Ltd)/Bureau des Formations Médicales Agréées du Rwanda
(BUFMAR) and private pharmaceutical wholesalers which procure and distribute them to
RMS Ltd branches and referral hospitals. At RMS Ltd branches, medical products and
technologies are stored and distributed to health facilities (district hospitals, health centres and
health posts). Health Centres distribute medical products and technologies to community
health workers. All health facilities and community health workers serve the end users/clients.

1.5. Flow of health supply chain information and health commodities in Rwanda

The health supply chain information flows in two directions. Community health workers report
to health centers, and health centers and district hospitals report to RMS Ltd Branches. After
aggregation of information, all RMS Ltd Branches report to the national level. Each level of
receiving information should provide feedback.

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FLOW OF INFORMATION AND COMMODITIES IN RWANDA SUPPLY CHAIN SYSTEM

RMS Ltd
Branches

HEALTH DISTRICT
POSTS

Flow of Information
Flow of Commodities

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Unit 2: Product Selection

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Objectives
By the end of this module, participants will be able to:
• Describe product selection and the use of NMP, STG and EML
• Explain how the product selection is done
• Explain the purpose of product selection
• Explain the responsibilities of health facilities in product selection

2.1. Product selection

Product selection is directly linked to serving customers by defining products that are to be
procured and used in the health facilities. Product selection aims to limit the variety of products
made available at public sector facilities for the health supply chain to be easily manageable.
MOH usually selects products based on national medicine policy, standard treatment
guidelines, and essential medicines lists.

2.11. National medicine policy

All countries have a national medicine policy (NMP) which outlines country goals when
considering medicines to procure. This policy also explains individual roles and
responsibilities with respect to supply and using medicines in the country.

The aims of the national medicines policy are:

• To make and maintain the laws (legislation) and rules (regulations) to ensure
availability and accessibility of adequate essential medical products and
technologies.
• To select essential medicines to be used in the country
• To provide guidance for medical product and technologies supplies financing.
• To ensure the medical products and technologies supply system works well.

2.12. Standard treatment guidelines

A standard treatment guideline document aims to guide decisions and criteria regarding
diagnosis, management, and treatment in specific areas of health care. Standard treatment
guidelines show the best way to treat a disease in the country. A committee of health
professionals (physicians, nurses, and pharmacists) with the best understanding of what
happens in your country is responsible for developing these guidelines. After being approved
by MOH, standard treatment guidelines are often printed as small booklets and disseminated
to all health care providers.

2.13. Essential medicines list

The EML is a set of medicines that satisfy the priority health care needs of the population; they
should, therefore, be available always in adequate amounts and inappropriate dosage forms, at
a price the community can afford.

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An EML helps not only to ensure procurement of the medicines that are both efficacious and
cost-effective but also helps to determine which category of health facility levels are
appropriate for these medicines.
The advantages of a limited EML are that it:
• Contributes to the improvement of medical supplies and technologies, with easier
procurement, storage, and distribution due to a limited number of products.
• Allows for rational prescribing: more experience with fewer medicines
• Ensures lower prices and more competition
• Improves medicines availability and treatment adherence

2.14. The process of product selection

The following should be considered to ensure the safety, efficiency, and cost effectiveness of
medicines:
• Use International Non-Proprietary Names during the selection process
• Select medicines according to needs, i.e., majority of the population and prevalent disease
patterns
• Give preference for single pharmacologically active ingredients affordability

2.15. Selection criteria

Recommended treatments and drugs selected depend on many factors, such as the pattern of
prevalent diseases, treatment facilities, the training and experience of available personnel,
financial resources, and genetic, demographic, and environmental factors.

The following criteria are used by the WHO Expert Committee on the Use of Essential Drugs:
• Only drugs with sound and adequate evidence of efficacy and safety in a variety of
settings should be selected.
• Relative cost-effectiveness is a major consideration in the choice of drugs. In
comparing drugs, the total cost of the treatment; not only the unit cost of the drug
must be considered and be compared with its efficacy.
• In some cases, drug selection may also be influenced by the availability of local facilities
for manufacture.
• Each drug selected must be available in a form in which adequate quality, including
bioavailability, can be ensured. Its stability under the expected conditions of storage and
use must be determined.
• Most essential drugs should be formulated as single compounds. Fixed-ratio combination
products are acceptable only when the dosage of each ingredient meets the requirements
of a defined population group, and when the combination has a proven advantage over
single compounds administered separately, in terms of therapeutic effect, safety, or patient
adherence to treatment.

2.16. The purpose of product selection

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• Enables the development and implementation of a coordinated logistics system.

• Facilitates access to more affordable commodity price.
• Identifies the products that should be quantified. The fewer products to quantify from the
easier and more relevant the procurement process becomes.
2.17. Health facilities’ roles and responsibilities in product selection
Health facility staff have limited responsibility for selection because this process is carried out
at a national level. However, as a member of the Drug Therapeutic Committee in their
respective health facilities, health professionals can contribute to the revision of the EML as
described in the terms of reference. Health facility staff are responsible for ensuring that:

• The formulary list derives from the EML

• The medicines are prescribed as per the STGs and are featured in the EML
• The ordering/procurement of medicines are based on the EML

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Unit 3: Quantification

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Objectives:

By the end of this module, participants will be able to:

• Define quantification and related terms
• Describe the purpose of quantification
• Describe key steps, processes, and methods used in quantification
• Apply quantification methods

3.1. Quantification

Quantification is the process of estimating the quantities and costs of the products required for
a specific health program and determining when the products should be delivered to ensure an
uninterrupted supply. Quantification is conducted annually before the beginning of a fiscal
year and reviewed after six months. Implementation monitoring is conducted on quarterly
basis.

3.1.1. Terms used in quantification

• Supplies, commodities, goods, products, and stock: These are all the items that flow
through the supply system.
• Users, clients, patients and customers: People who receive supplies to use.
• Pipeline: The entire chain of storage facilities and transport links through which supplies move
from the manufacturer to the consumer, including port facilities, central warehouse, regional
warehouses, district warehouses, all clinics, hospitals, and transport vehicles. In a supply
setting, the supply system is often called a pipeline.
• Push System: A system in which staff at the next higher level decide how much stock to send to
the next lower level. The decision is made at a higher level and is based on data in reports from
the lower level. For example, a clinic may send a monthly report to the provincial hospital on
how many supplies it has given to clients and how much stock it has on hand, and the provincial
office uses that information to determine what to send to that clinic.
• Pull System: A system where the staff at the lower level decide how much stock they
want to order. Ideally, this will be based on their usage rates and remaining stock on hand.
Some systems are mixed: pull part way down the supply chain and then switch to push.
• Lead-Time: Time between when new stock is ordered and when it is received and
available for use. This is the time needed to send an order or a report from a lower level, get
the shipment filled, and have the goods delivered, unloaded, and ready to give to patients. Note
that this is the full process, which is always longer than just the time it takes for an order or
report to get to the next higher level. In island countries, the lead time may be up to several
weeks.
• Ordering period: How often an order is placed in a system. The order interval is different
for various clinics, districts, and regions and usually depends on transport. It would usually be
from one to two months.

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• Dispensing Data: The quantities of supplies that are given to clients.

This information only comes from the clinic level because this is where patients are seen. Good
dispensing data is better than issues data for determining how much stock is needed because
they tell what was given. Dispensing data may not always be available.
• Issues Data: The quantity of supplies shipped from one level of a system to another, such
as from region to district to clinic. While ideally, everything that is shipped eventually will be
dispensed to clients, it is difficult to know; it could just be piling up unused, or it could be that
what was issued (shipped) is not nearly enough to serve clients. Issues data can be used to
predict use in case dispensing data are not available. For the most reliable findings, it is best to
get issues data from the lowest possible level of the pipeline.
• Stock on hand: The quantities of usable stock available at the facility. This is determined
by doing a stock take or inventory. (Unusable items are not considered part of the stock on
hand.)
• Losses and adjustments: Losses are the quantity of stock removed from the pipeline for
any reason other than consumption by clients (such as expiration, theft, damage, and so on).
Adjustments are made on an item’s stock card when quantities are issued to or received from
other facilities.
Adjustments may be used to explain administrative changes — for example, when you count
stock and find a different amount from the quantity listed on the stock card. For this reason,
adjustments may involve either an increase or decrease in the stock value on the stock card.
• Adjusted monthly consumption: The monthly quantity expected to be dispensed or sold
to consumers obtained from the stock cards and patient registers or tick sheets. Also defined
as the quantity of a commodity that was consumed during the months that were adjusted to
cater for unusual situations such as stockout.

Consumption data are adjusted when data are incomplete because of any missing stock deliveries,
or incomplete reporting or stockouts. When data are incomplete, the following techniques must be used:
1. Use the dispensed-to-user data from previous reports
2. Adjust incomplete data to estimate complete reporting
3. Adjust data for stockouts
4. For dispensed data, substitute issues data from the lowest possible level
• Average monthly consumption: The number of units that a facility is likely to use in a
month. Use rates can be variable by month. The average is the quantity that is usually used
during a month.
• Stock on order: Stock ordered but not yet received.
• Security stock: A buffer, cushion, or reserve stock kept on hand to protect against
stockouts caused by delayed deliveries or markedly increased demand.
• Ordering/review period: At the health facility and RMS Ltd branches level, the ordering
period is one month.

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3.2. Key steps and processes in quantification

1. Preparation: This involves assembling a quantification team, describing the program

performance as well as strategic plans, defining the purpose and scope of the quantification
exercise, and collecting required data.
2. Forecasting: This involves organizing, analyzing, and adjusting data to obtain consensus
on the forecasting assumptions while calculating consumption for each product, as well as
comparing and reconciling results of different forecasts.
3. Supply planning: This involves organizing data for analysis, building supply planning
assumptions, estimating total commodity requirements, developing a supply plan, and
comparing costs to available funding.

3.2.1. Preparation process

During preparation for the quantification exercise, team members begin to collect program
background information and data from as many sources as possible. The four types of data
needed are demographic, morbidity, services and consumption.
• Demographic data are data on population characteristics, growth, and trends. They are not
usually recommended for forecasting health commodity needs for procurement purposes
unless they are combined with other sources of data. However, when forecasting, usually find
reliable demographic data in the demographic and health surveys, or national census data to
have more accurate forecasts.
• Morbidity data are data on estimated incidence or prevalence rates of specific disease or
health conditions occurring within a defined population group. The data can be extrapolated to
define the total estimated need and then refined to determine specific targets, or percentage of
total need, to be reached. Because forecasts using morbidity data tend to overestimate
commodity needs, they should be compared to forecasts that use consumption and service data.
Morbidity data are not used to forecast for preventive services such as family planning.
• Services data include a number of services provided and number of service visits at which
products are dispensed, tests conducted, episodes of a disease or health condition treated, or number of
patients have been on continuous treatment during the last 12-month period (when data are available
or can be estimated).

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• Consumption data are data on the actual quantities of health commodities.

Consumption data include actual dispensed-to-user data (numbers of commodities that were
given to clients). Issue data on the number of commodities transferred from one level of the
supply chain to another can also be used as a proxy for consumption data.

Four steps of preparation

Step 1: Assemble a quantification team
Most quantification teams have 6-15 members. Team members should include program
managers, a procurement specialist, an M&E officer or other information specialists, warehouse
managers, service providers, donor agencies, implementing partners and technical experts in
quantification.
Step 2: Describe the program performance, policies, and strategic plans
Step 3: Define the purpose and scope of the quantification exercise, e.g. timing and products
Step 4: Collect required data (for forecasting and supply planning)
3.2.2. Forecasting process
Forecasting, the second step in the quantification process, uses the data collected during the
preparation step to estimate the quantity of each product that will be dispensed or used during
each year of the quantification.

Four steps of the forecasting process:

Step 1: Organize, analyze, and adjust data

After collecting the available data, you need to assess its quality before estimating the data to
be reported. This means one should adjust for incomplete or unreliable consumption and
service data. If the program experienced a stockout, adjust the reported consumption data to
account for that. Some types of data require conversions.

Step 2: Build and obtain consensus on the forecasting assumptions

In many cases, data are incomplete, outdated, unreliable, or unavailable. Therefore, to develop
the forecast, it will be necessary to make some assumptions about program performances,
targets, and future demand.
Step 3: Calculate the forecasted consumption for each product
Regardless of the data the quantification team uses for the exercise, the team must document
the sources of the historical data, actual data collected, data quality issues, and any data
adjustments. For each product, estimate the future consumption, the future type and a number
of services that will be provided, or the average absolute number of increase or decrease from
one reporting period to the next.
Step 4: Compare and reconcile results of different forecasts
If the availability and quality of data permits, the quantification team can use different types
of data to conduct multiple forecasts. The forecasting steps must be repeated for each of these
data types. Use at least two types of data and prepare separate forecasts, if possible. Compare
the final forecast consumption quantities from each forecast and consider the implications of
the different forecast for the program, including service capacity, storage, and distribution
capacity, funding availability, and other issues that could affect demand, supply, and use of
commodities.

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3.2.3. Supply planning process

To be successful, public health programs must always have enough medicines and supplies to
meet the needs of their clients. At the same time, programs must avoid surpluses that waste
products and money. Supply planning is used to estimate the total commodity.
requirements and costs for the program within a specific period. To calculate this estimate,
start with the forecasted consumption for each product. Consider the stock on hand, any
quantities of the product already on order but not yet received, and the established maximum
and minimum stock level. Be sure to include procurement and supplier lead times and provide
a buffer stock for unexpected delays. The pipeline, a desktop software tool, has helped program
managers in many countries to plan optimal procurement and delivery schedules for health
commodities, and it monitors their orders throughout the supply chain.

Supply Planning Process Steps

Step 1: Organize and analyze data

Data for the supply planning step are different from the data for the forecasting step.
However, it is important to collect data types at the same time.

Step 2: Build supply planning assumption

As with the forecasting step, make assumptions in the supply planning step to account for
missing, or low-quality data. However, the data user will then need to build consensus around
the assumptions. Remember, it is important to document clearly and specifically the sources of
information and the key informant inputs on the assumptions.

Step 3: Estimate total commodity requirements and costs

To estimate the total commodity requirements, you must determine the quantity of each the
product needed to meet the forecasted consumption and ensure the in- country supply pipeline
has adequate stock levels to maintain a continuous supply to service delivery points.

Step 4: Develop the supply plan

Developing a supply plan, including the shipment quantities and delivery schedules, will ensure
a continuous supply of products to the country. Developing the supply plan helps program
managers to enter and track forecasting consumption data, identify funders and funding
commitments for each product, identify suppliers for each product, coordinate timing of funding
commitments and procurements, and schedule shipments according to procurement lead times.

3.3. Quantification methods

There are two common methods of quantification:

3.3.1. Consumption method

Consumption method: past consumption records of individual medicines are used to project
future needs. It is essential to adjust for stockouts, projected changes in utilization (program
scale up), and losses (pilferage, wastage, damage). In other words, the consumption method
estimates the quantity of products expected to be consumed.

This is the most precise method of quantification, provided consumption data are complete,
accurate, and properly adjusted.

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The data required to use the consumption method are limited to the consumption reports. The
data can be obtained from the basic forms of the national logistics management information
system (a daily consumption register filled out in health facilities).

A monthly report and requisition form on consumption extracted from eLMIS

It is recommended to use as many months of data as possible (12 months is recommended) to estimate
the average needs, identify trends, mitigate the impact of seasonality and outliers, and analyze factors
that could affect change in consumption.

Limitations of the consumption method

• The consumption data must be reliable, extracted from a system with
uninterrupted supplies and a full supply pipeline;
• The consumption data might not reflect rational use of the products (i.e., use
according to the STGs);
• It cannot be used for a program that is new or scaling up, where consumption is
unpredictable

In the absence of quality consumption data from health facilities and community health workers, the
morbidity-based quantification method can be used.

3.3.2. Morbidity method

Morbidity method : estimates the need for specific medicines based on the expected number
of attendances, the incidence of common diseases, and standard treatment (as per national
STGs) for the diseases and then translates these into the number of products expected to be
consumed. This method is based on morbidity statistics, prevalence and incidence rates,
demographic data and STGs.

Incidence is a measure of disease that allows us to determine a person's probability of being

diagnosed with a disease during a given period. Therefore, the incidence is the number of
newly diagnosed cases of a disease. An incidence rate is the number of new cases of disease
divided by the number of persons at risk for the disease. If, over the course of one year, 5 women
are diagnosed with breast cancer, out of a total female study population of 200 who did not have breast
cancer at the beginning of the study period, then we would say the incidence of breast cancer in this
population was 0.025 (or 2,500 per 100,000 women).

Limitations of this method

• Compared to the other methods, the morbidity method is the most complex and time-
consuming
• Morbidity data may not be easily available for the disease condition
• This method requires strict adherence to the STGs, but standard treatments may not be
used by prescribers in that area

Most often, complete data are not available for quantification. The most critical point in
making assumptions is to document clearly and specifically which assumptions were made and
on what basis. If there are few or no data, the forecast will rely heavily on assumptions.

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Two kinds of assumptions need to be made during the forecasting step:

• Assumptions on adjustments made to historical program data, when data are missing,
unreliable, outdated, or incomplete.
• Assumptions on future program performance, based on factors influencing demand for
services and commodities.

How to calculate the quantity to be ordered:

The quantity to be ordered is obtained using the following formula, based on consumption:

Quantity to be ordered = AMCj X (LT+OP) +SS-(SOH+SO)

AMCj: Adjusted average monthly consumption

LT: Lead time
OP: Ordering period
SS: Security stock
SOH: Stock on hand
SO: Stock on order

If the result is >0, then the calculated amount must be procured for the program to satisfy
estimated demand and still maintain the desired stock at the end of the period.

If the result is <0, there is a possible oversupply situation; in such cases, no procurement is
needed for the period.

Formula based on morbidity:

QE=DXDDXTD
QE= Quantity to order by condition episode
D= Quantity per dose
DD= Daily dose
TD= Treatment duration

In the context of medicines ordering at health facilities: Adjusted consumption is the monthly
consumption adjusted considering the number of days of stockout and the morbidity
information.

In summary, the quantification process uses the information on patients and medicines from
the facility level linked with the national program and plan to determine which quantities of
which products should arrive in the health facility.

3.4. Reviewing quantification for ordering

Quantification does not end after determining the final quantities and costs. It is an ongoing
process of monitoring, reviewing, and updating the forecasting data and assumptions, and
recalculating the total commodity requirements and costs as needed. For the quantification
exercise to be useful and more effective, the forecasting assumptions and supply plan should
be reviewed at least every six months.
Ongoing monitoring and updating of the quantification are critical to keep health care workers
informed on the availability of health commodities and to make timely decisions.

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Reviewing and updating the quantification includes the following activities.

• Reviewing and updating the forecasting data and assumptions
• Calculating or recalculating the forecasted consumption
• Updating the stock on hand for each product
• Assessing national stock status for each product
Reviewing and updating shipment delivery schedules to ensure a continuous supply and
maintain desired stock levels.

3.5. The purpose of quantification

Quantification is done to ensure:

Optimal accuracy in forecasting, supply planning, procurement planning and budgeting
• Mobilization and allocation of funding for commodity procurement
• Coordination of multiple sources of funding for procurement
• Identification of areas for advocacy such as strengthening data collection, reporting
system and inventory management procedures.

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Unit 4: Procurement

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Objectives:
By the end of this module, participants will be able to:
• Define procurement
• Describe the purpose of procurement
• Describe procurement principles and methods based on laws and regulations
• Identify procurement stakeholders

4.1. Procurement

Procurement is the procedure through which h an entity acquires good or services from outside
in return for a price. (Ref: Law governing public procurement No 62/2018 of 25/08/2018.)
Good public-sector procurements rely on documentation and transparency throughout the
process to ensure that no party can claim that one group was unfairly favored over another.

The procurement of the right medicines is one of the largest expenditures in the national health
budget, after personnel costs. Good procurement practices must be followed to ensure the
procurement of high-quality medicines and supplies at the lowest possible price.

4.2. Fundamental principles in public procurement

4.2.1. Transparency
Transparency means applying procedures in a manner which is open, clear, easily accessible,
and predictable. Bidders should see the procurement as being transparent.

4.2.2. Competition
Competition means providing the bidders with equal opportunity and treatment in bidding for
procurement contracts. Competition should be seen to be open and fair.

4.2.3. Economy
Procurement should prioritize the best value for money, with value comprising both price and
quality. The lowest initial price may not equate to t h e lowest cost over the operating life of
the item procured. The ultimate purpose of sound procurement is to obtain maximum value for
money.

4.2.4. Efficiency
Efficiency means being simple, timely, practical, and adhering to the budget of the procuring
entity to achieve positive results without any unnecessary delays in the program
implementation. Efficiency implies being practical in terms of compatibility with the
administrative resources and professional capabilities of the procuring entity and its
procurement personnel.

4.2.5. Fairness
Fairness is about being impartial, consistent, and reliable. Potential bidders should have a level
playing field which directly expands their options and opportunities, thereby encouraging them
to compete.
4.2.6. Accountability

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Accountability is about bestowing a sense of responsibility by enforcing established rules and

procedures. Good procurement holds its practitioners responsible for enforcing and obeying
the rules. It makes them subject to challenge and to sanction, if appropriate, for neglecting or
bending those rules.

4.3. Methods used for public procurement

Method Advantage Disadvantage

Open • Competition (tender • Long time in assessment due to many bids

is open to all) • High workload
• Low prices • Long lead times
• Transparency • Need for assessment is high
• New suppliers,
experience, and
technologies

Restricted • Known suppliers (in • Less price competition

terms of • No chance to get new suppliers
performance) • Less transparency
• Prices are usually • Long time in establishment (prior
favorable prequalification of suppliers)
• Need for assessment is high

Request for • Known suppliers • Less transparency

quotations • Reduce prices • Need for assessment is high
• Short lead times
• Prices can be
favorable

Direct purchase • Very short lead time • High prices

(Single source • Low workload • No competition
tender) • Need for assessment is high

Note: Following good procurement principles and standard procedures ensure that medicines
and health products are acquired at the lowest possible cost, in the right quantities, of the
desired quality, in the right place and at the right time.
4.3.1. The purpose of procurement in the health supply chain
Procurement is an important part of the logistics activities that ensure correct products
availability meet the six rights of a logistic cycle and ensure that national procurement
regulations and procedures are properly implemented. Procurement is a complex activity that
requires adequate regulations, policies, coordination, experienced and skilled personnel, and
funding. Therefore, any procurement process needs to follow good procurement principles
(transparency, competition, economy, efficiency, fairness, and accountability) and should:
• Allow some flexibility to adapt to change in consumption patterns, treatment

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protocols, or regulations.
• Be aligned with good procurement practices which promote transparency and
accountability by ensuring the consistent use of documented procedures, segregation of
duty (the person requesting and the person buying cannot be the same individual),
transparent criteria for the selection of suppliers, and regular reporting to the
donors/government based on a plan and key performance indicators.
• Ensure that the products meet national quality requirements and are featured on the
essential medicines list and national formulary list.
• Ensure that medicines to be procured are identified using their international
nonproprietary name.
• Acquire the largest possible quantities to achieve economies of scale.
• Be based on competitive procurement methods except for the procurement of small
emergency orders.
• Ensure that suppliers are pre-qualified and monitor selected suppliers based on product
quality, service reliability, delivery time, and financial viability.

4.3.2. Procurement procedures

The Rwanda Medical Supply Ltd (RMS Ltd) and Bureau des Formations Médicales Agréées
du Rwanda (BUFMAR) are the two central medical stores importing medicines and
consumables for the public sector.

RMS Ltd Branches, referral hospitals, national blood transfusion centers, and national
reference laboratories procure medicines and medical supplies from central medical stores
(RMS Ltd and BUFMAR) and private wholesale pharmacies (once medicines and medical
supplies are not available at central medical stores).
Provincial hospitals, district hospitals, and health centers procure medicines and medical
supplies from RMS Ltd Branches.

4.4. Key stakeholders in the procurement process

• Rwanda Medical Supply Ltd (RMS Ltd)

• BUFMAR
• RMS Ltd Branches
• Referral, provincial, and district hospitals
• Teaching hospitals
• Health centers
• Rwanda Public Procurement Authority (RPPA)
• Ministry of Health
• Ministry of Finance
• Donors
• Private sector
• Other health-related nongovernment organization

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Unit 5: Inventory Management

(Receiving, storage and distribution)

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Objectives:

By the end of this module, participants will be able to:

• Define inventory management and its importance
• Define the receiving process of health products and its importance
• Demonstrate the process of receiving health products
• Define good storage practice and its importance
• Describe key storage activities and procedures Describe cold chain storage instructions
• Discuss inventory management controls/terms
• Eexplain the management of donations and disposal of medical products Define
distribution and its importance
• Discuss good distribution practices
• Explain the national distribution system

5.1. Inventory management

5.1.1. Inventory management:

Inventory management comprises the activities related to ordering, receiving, storing,

distributing and issuing, and re-ordering commodity stock. All these activities are tracked and
documented; thus, good record-keeping is critical.

Inventory Management Cycle

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5.1.2. Importance of inventory management

Inventory management is important for the following reasons:
• To ensure availability in most drug supply systems
• To maintain patient and health facility personnel confidence in the health care system
• To reduce the costs of health commodities: Buying large volumes at once allows
access to bulk discounts from suppliers and reduces transport and customs clearance
costs.
• To avoid the costs of stockout: If emergency orders are needed to prevent or manage
a stockout, the unit cost will likely be much higher than for a regular order.
• To avoid the costs of excess stock and product loss
• To minimize procurement costs: Procurement costs increase when products are ordered
frequently.
• To minimize transport costs: Good inventory management will enable less frequent
deliveries of health commodities, allowing more efficient use of transportation.
• To cope with variability in demand: Changes in demand for specific health commodities
are often unpredictable, and adequate stock management allows the system to mitigate
the effect of variability in demand.
• To monitor the quality of medicines through visual inspection

5.2. Receiving products

5.2.1. Receiving products

Receiving products is one of the steps of the supply chain cycle where purchased or/and
donated products are distributed within a health institution and all stock is processed for storage
in accordance with requirements.

5.2.2. Importance of receiving products

• Guarantee the quality of products

• Ensure the availability of the right quantity
• Avoid financial losses caused by products ordered but not received, damaged, and/or
expired

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5.2.3. Procedures for receiving health products

• Receiving and checking your order
• Receive the products.
• Check the quantity of received products. Check for pilferage or damage of products.
• Check the supplies received against the items on the purchase order and delivery notes.
• Check the quality of received products.
• Sign documents related to product delivery (e.g. Delivery notes).
• Fill in management tools (e.g. stock cards, eLMIS).
• File signed delivery notes, invoices, and purchase order.
• Contact RMS Ltd district branch if any problem is identified.
• Ensure the storage area is enough, clean, and in good condition.

If you have any problems with your order, then contact your pharmacy issuing store.
Always tell them if:
• Any stock is missing from your order.
• Any stock is broken or damaged.
• You are unsure of anything.

Receive the products

A staff member should receive all orders at the time of delivery. A reception committee
receives and checks products and makes reception reports that serve as a reference for
administration purposes (feedback to suppliers, payment if applicable). In case any products
are refused, the reception committee fills out and signs the commodity return form with
approval by the head of the health facility, and products are returned to the supplier (see
commodity return form in appendix).
Detailed steps for receiving commodities are described below.
• Check the quantity of received products
• Check for pilfered or damaged products
a. Check all the boxes ordered.
b. Check if any of the boxes have been opened, are wet, or are damaged.
c. If any order is not complete or stock is damaged, contact the RMS Ltd branches.
• Check the products received against the items on the purchase order and
delivery notes
a. The RMS Ltd Branch includes delivery notes and invoices with the details of
products supplied.
b. Remove the products from the box and group all items that are the same
together.
c. Read the delivery notes and check off each item.
d. Check received products against ordered ones on the purchase order.
e. Make sure that the quantity received have a good shelf life.

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• Check the quality of received products

To check for signs of damage or deterioration:
a. Check refrigerated items.
Refrigerated items should be stored first. If refrigerated items are not packed
in cold packs, do NOT accept them. If refrigerated items are not cold, contact
RMS Ltd branches.
b. Check the color of the products.
If products are discolored, they have deteriorated; do NOT accept them.
c. Check for broken containers. Check for leaks.
Carefully remove broken containers. If there is a leak, remove any products
damaged from the leak.

d. Check for unsealed or unlabeled items.

If items are unsealed, someone may have tampered with them. Also, it is
dangerous to use unlabeled items. Do NOT accept them.

e. check for the unusual odor of products.

If products have unusual odors, they may have deteriorated. Do NOT accept
them.

f. Check injectable liquids.

Shake the vial and then hold it to the light. Clear liquids should have no particles
that reflect light. If a vial has small particles, the medicine has deteriorated. Do
NOT accept the vial.

• Sign documents related to product delivery (e.g. delivery notes).

After checking the products, all parties should sign delivery notes. However, if the
products are not checked for any reason, the documents should be indicated as
“unchecked.”

• Fill in management tools (e.g. stock cards, eLMIS)

After checking and signing documents, an authorized person should fill in management
tools according to standard operating procedures (SOPs).

• File signed delivery notes, invoices and purchase orders

Authorized persons should file the related documents appropriately. A copy of
delivery notes will be filed in the main store while original invoices, delivery notes, and
purchase orders will be sent to financial departments.

• Ensure the storage area is sufficient, clean and in good condition

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5.2.4. Common product quality problems and mitigating actions

WHAT TO LOOK FOR WHAT TO DO ABOUT IT?

Damage to packaging (tears, perforations, Remove any damaged products and put them in
water or oil stains, or other damage) and the quarantine space, and/or destroy them
products (such as broken or crumbled pills or according to established procedures.
tablets or torn packets of condoms or IUDs). Distribute the remaining products as normal.
Unlike cartons that are torn or dirty because of
handling, cartons with holes or frayed edges
may have pests.

Check boxes for signs of termite damage and

rats, which are attracted to pills. Inspect inner
boxes and products for mechanical damage.
Cartons unlabeled with the date of Ensure that lot number, manufacturer’s name
manufacture or expiration on outer and inner and product storage requirements are recorded
packaging on bin cards and storage labels. If expiration
dates are not visible, open outer
carton and check dates on inner boxes. If
expiration dates are not visible on inner
boxes, check individual units. Use a large
marker to write the expiration date on
unmarked boxes and cartons.
Information on cartons or boxes is illegible Check inner boxes or products and write on
outside of box; distribute normally. If
information is illegible due to exposure to
water or chemicals, thoroughly inspect
product f o r damage. If you are unsure
whether damage has occurred, quarantine
supplies for testing or destruction.
Dirty, torn, or otherwise damaged boxes Check the product visually for mechanical
damage. Remove any damaged products and
destroy according to established procedures.
Distribute the rest as normal.
Missing products or empty boxes This may indicate pilferage, removal by the
upper level or removed by a donor for
testing. Notify upper level about missing
Contents not identified on multiple unit Open the box and check contents. If contents
cartons all have t h e same product and the same
expiration date (and lot number, if possible),
write information on t h e outer box. If
contents
are mixed, separate and repackage according to
product type, brand, expiration date, and lot
number. Visually check for damage. Remove
any damaged products and destroy

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5.3. Storage

5.3.1. Storage
Storage is keeping health products in a safe, secure, accessible location while awaiting to be
used.

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5.3.2. The importance of good storage

Good storage conditions ensure that the quality of the products is maintained.

5.3.3. Key storage activities

The key storage activities in the supply chain are medicines receiving, visual inspection, put
away (putting supplies in their respective storage areas), picking, and packing. For health
facilities, the first three are the most common storage activities whereas the last would only
apply to the upper levels (RMS Ltd Branches and central warehouse). At the health facility
level, the main storage activity is serving the internal requisition.

Products receiving and a visual inspection: This activity occurs during the offloading of vehicles
and includes the visual inspection of delivered packages to ensure that products were not
damaged during transport or storage at RMS Ltd Branches.
The verification process includes checking.

• Whether the following are correct:

• Number of containers delivered
• Number of packages in each container
• Quantity in each package
• Medicine (do not confuse generic name and brand name)
• Dosage form (tablet, liquid, other)
• Strength

5.3.4. Storage procedures

Irrespective of the location system, medicines must be stored within each zone in a way that
would make them easily accessible to personnel while protecting their integrity. They can
either be put on shelves (for small volume and weight), pallets, block-stacked pallets, and pallet
racks.

The storage room has designated areas for receiving, usable stock, and quarantine space. The
quarantine space can be divided for unusable products to be disposed of, and for products
awaiting a quality control check.

5.3.5. Storage best practices

1. Choose a secured room or cupboard to be the store.
Keeping products in a store makes it easy to always know what is available. It is also an easy
way to keep products safe. The store should be large enough to fit all the products.

2. Keep the store locked always when it is not in use

The store should be a secured room or locked cupboard.
To secure the store, keep it locked and give keys only to
persons who are responsible for the supplies in the store.
Keep an extra set of keys in a safe place. Secure all
openings with grills or bars to prevent theft.

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3. Keep the store in good condition.

High temperatures, light, or humidity may damage products. Heat affects liquids, ointments,
and suppositories. Some medicines, such as injectables and eye or ear drops, spoil quickly
when exposed to light. Tablets and capsules can easily absorb water from the air, making them
sticky and damaged.

The following actions are needed to keep the products in good condition:
1. Inspect the physical structure of the store regularly
Repair any damage to the roof, walls, door, windows, and floor.
2. Control the temperature in the store
Check that there is a ceiling in the store. Allow warm air to escape.
Open the door and windows while someone is in the store. Install air vents/conditioners.
Record temperature twice a day.
3. Control the light in the store
Block any direct light that enters the store through windows. Either paint the windows white
or hang curtains.
4. Control humidity (moisture) and prevent water damage
Check that there is good drainage. There should be drainage channels around your store. The roof
should have gutters. Secure drainage areas. Allow air to move freely. Secure air vents and windows.
Repair leaks as soon as they occur to reduce moisture and water damage. Containers of tablets and
capsules may be packed with a sachet of desiccant (nonedible drying crystals). The desiccant keeps the
inside of the container dry. Do NOT open the sachet.
• Keep the sachet in the container.
• Keep the container closed except when dispensing medicines.
• Keep all cartons on pallets.
• Keep the store free of insects and pests.
Some common pests are rats, roaches, ants and wasps.
• Clean spills which may attract pests and remove broken
• Containers immediately.
• Use screens to keep out insects.
5. Keep your store clean and organized
In a clean and organized store, it is easy to find products. The supplies are likely to be in good
condition and ready to be used.

To organize the store:

a. Clean the store and keep it tidy
Dust contaminates products and makes labels difficult to read. Spills and breakages collect
dirt. Mop the floor, dust the shelves, and wipe down the walls regularly. Do not sweep the floor
in the storeroom.
b. Store products on shelves.
Using shelves is an easy way to organize products. Place the boxes or boards on pallets.
Do NOT put boxes or boards directly on the floor, which might be wet. Moisture can rot the
cardboard or wood.

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Products arrangement in the store

How to store health commodities on shelves

• Arrange products on shelves off the floor in groups according to your
order form (e.g. externals, internals, and injectables).
• Store tablets, capsules, and other dry medicines (such as ORS packets)
in airtight containers on the upper shelves.
• Store liquids, ointments, and injectables on the middle shelves.
• Store supplies, such as surgical items, condoms, and labels, on the
bottom shelves and away from electric motors.

Products can be arranged in one of three ways:

1. Alphabetical order by generic name
Often seen in both large and small facilities.
2. Therapeutic or pharmacologic category
Most useful in small storerooms or dispensaries where the health care worker
knows what the medicines are used for (e.g. antibiotics, pain, non- communicable and
communicable diseases).
3. Dosage form
Medicines come in different forms, such as tablets, syrups, injectables, and external use
such as ointments and cream. In this system, medicines are categorized according to their
dosage.

5.3.6. Cold chain storage instructions

Cold chain is the supply system used to keep vaccines and other medical supplies at full
strength by keeping them at +2oC to +8oC. This temperature needs to be maintained from the
manufacturer until the moment the vaccine is used. The cold chain manager is responsible for
all cold chain equipment repairs on refrigerators, vaccine carriers, and cold boxes. This person
is the main contact for questions about the cold chain."

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Arrangement of cold chain commodities in the refrigerator

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5.3.7. Storing vaccines and using the fridge correctly

• Check the fridge temperature DAILY and record it on the FRIDGE TEMPERATURE
CHART.

• The layout in the picture above is the best way to organize your fridge.

• NEVER let Hepatitis B, DPT or TT vaccines FREEZE or come in direct contact with
ICE.

• Keep vaccines in separate containers in the main compartment of the fridge. Stack the
vaccines carefully so that air can move between the boxes.

• Keep the diluent (to reconstitute measles and BCG) in the MAIN compartment with the
vaccine.

• Freeze ice packs in the FREEZER only two at a time so that you don't exceed the cooling
power of the fridge.

• Only open the door when you need to get refrigerated medicines and vaccines out (opening
the door lets the HOT air in).

• NEVER keep food in the fridge. Food makes the temperature of the fridge uneven, which
can damage vaccines.

• NEVER keep EXPIRED vaccines or PARTLY USED BCG and measles vaccines.
Dispose of properly.

• All vials of opened BCG and measles vaccines MUST be discarded at the end of the day
or six hours after diluent has been added, even if they are kept at a sustained temperature
of +2oC to +8oC.

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5.3.8. Use of cold box and a vaccine carrier

Vaccine carriers and cold boxes have thick walls and lids. They are insulated.
This means that they are made of a special material which does not allow heat to pass through it.
An insulated container cannot keep vaccines or ice packs cold, but only a refrigerator can make
them cold.

Cold Boxes
Cold boxes usually have a cold life of two to seven days.
Cold boxes are used to transport vaccines from the Expanded Vaccination
Program store all the way to the health facility, and from the facility to the
immunization sites.

Vaccine Carriers
Vaccine carriers are smaller than cold boxes. They can keep vaccines cold for only
48-72 hours (1-3 days), and only if used carefully.
Vaccine carriers are used to:
• Take vaccines to outreach sites and for temporary storage during
health center immunization sessions.
• Transport vaccine easily by motorbike or walking.
• Temporarily store vaccines to be used during immunization sessions.
• Store vaccines for a short time while defrosting the fridge, or when the fridge breaks
down.
Note: When an order is placed, the RMS Ltd Branch must inform health facilities when it will
be delivered. Vaccines should not be kept in cold boxes for a long time and should be placed in
a fridge upon receipt.

5.3.9. Temperature monitors

Temperature monitors are used to showing when a fridge, icebox, or vaccine carrier has
reached a temperature too warm or too cold for safe storage of vaccines.

The main way to monitor the fridge temperature is to use a fridge thermometer and temperature
record chart. The fridge thermometer is designed to read temperatures above and below zero.
The temperature is recorded by looking where the silver or red line has risen to.

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Some fridges have a digital thermometer which displays the temperature in numbers.
The fridge temperature should be checked twice daily to make sure it is correct. These
temperatures should be recorded on a Fridge Temperature Record Chart. This chart acts as a
record of the fridge temperature and can be used to tell if there are problems with the fridge.
A sample chart appears at the back of this manual.

The facility should keep a record of its completed monthly temperature record chart to show
supervisors that the fridge has been working properly over many months. If the temperature
deviates from the normal range, this should be reported to the upper level and appropriate
measures should be immediately taken.

5.3.10. Stock rotation

FEFO (First to Expire = First Out!)

FEFO means that the medicines with the earliest expiry date are distributed first, regardless of
the order in which they are received.

When the order is unpacked, the stock with a long shelf life should be placed in the back and
stock with the earliest expiry date should be moved to the front. This is called “stock rotation.”
FIFO (First In = First Out!)

FIFO means that you use the medicines that have been in your facility the longest first.

If your medicines have the same expiry date or you have medical sundries with no expiry date,
then you should use the item that has been in your facility the longest first.

5.3.11. Summary of good storage practices

• Clean and disinfect storeroom regularly
• Store supplies in a dry, well lit, well ventilated storeroom out of direct sunlight.
• Secure storeroom from water penetration.
• Ensure that fire safety equipment is available and accessible, and personnel are trained to
use it.
• Store condoms and other latex products away from electric motors and fluorescent lights.
• Maintain cold storage, including a cold chain, for commodities that require it.
• Keep narcotics and other controlled substances in a locked place.
• Store flammable products separately from other products. Take appropriate safety precautions
• Stack cartons at least 10 cm (4 in) off the floor, 30 cm (1 ft) away from the walls and other
stacks, and not more than 2.5 m (8 ft) high.
• Store medical supplies away from insecticides, chemicals, old files, office supplies, and
other materials.
• Arrange cartons so that arrows point up. Ensure that identification labels, expiry dates, and
manufacturing dates are clearly visible.
• Store supplies in a manner accessible for FEFO, counting, and general management.
• Separate and routinely dispose of damaged or expired products.

Note: Narcotics and psychotropic medicines and other controlled medicines must be stored in a double-
locked cupboard as required by law No03/2012 of 15/02/2012 governing narcotic drugs, psychotropic
substances, and precursors in Rwanda.

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5.4. Inventory controls

5.4.1. Assessing stock status

Assessing stock status is a management function primarily to guide decisions related to resupply.
Stock status assessments should be conducted regularly at least monthly to avoid stockouts. Stock
status should also always be assessed during quantification exercise.
The importance of assessing stock status
Being able to work out how long the stock will last will tell if supplies are running too low or if
the stock might expire before use. It helps also to know the stock value in terms of money or
whether the facility is overstocked.

5.4.2. How to assess stock status

Stock on hand (SOH)
SOH is the quantity of usable stock at the facility. (Items that are unusable are not considered as
part of the stock on hand.) SOH is obtained from store cards or from eLMIS after running a
physical count.
Average monthly consumption (AMC)
AMC is the amount of stock used on average in one month. The quantity of medicines used over
time must be known to calculate this. AMC can be calculated by using your stock card or
eLMIS.
The best way to calculate your AMC is to use information on stock given to the patients
(consumption data). To calculate the AMC, first calculate a simple average by finding the sum
of a set of monthly consumption, and then divide by the number of months used. This
information can be found from:

• The daily consumption registers

• eLMIS
• ticksheets patient registers
• stock cards
Because AMC can change over time, it is important to derive an average from the last three to
six months, and AMC should be checked about every six months for changes.

Max (maximum stock level)

Max is short for maximum stock level in a Max/Min inventory control system. It represents the
highest acceptable stock level. Any order placed should not exceed the maximum level, which
is either two or three times the AMC (the former for the health facility level, and latter for the
RMS Ltd branches level).

Min (minimum stock level)

Min is short for minimum stock level. If the ordering system is working well, stock should be
no lower than the min level when the next order arrives. The store manager is responsible for
ensuring that stock never goes below the minimum.

At the RMS Ltd branches level, the minimum is defined as: AMC x 2 = Min. At the health
facility level, the minimum is defined as: AMC X 1=Min

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Months of stock (MOS)

This is the length of time in months that the stock will last. This can be calculated when the
AMC and SOH are known. MOS is calculated by dividing SOH by AMC.
Emergency order point (EOP)
The EOP is the level at which stock is at high risk of stocking out, necessitating immediate
placement of an emergency order. Efforts must be made beyond regular ordering processes to
get the products to avoid a stockout. The EOP is calculated as: EOP=0.25 X Mi

5.4.3. Physical count

Physical count is when you physically count all the stock that you have. A team which has
been appointed by the authority of the entity should do this. It is mandatory to conduct a
physical count at the end of the month.

Before doing a physical inventory, always check that all the stock is in its correct place and
that it is not expired or damaged.

Only count FULL units of stock. An opened bottle is considered damaged and should not be
counted. This is often referred to as a broken pack and should be marked with a cross on the
pack/bottle/lid and put in the quarantine zone. The quarantine zone must be marked.

A physical count can take a couple of hours in a primary health care facility. As it requires
focus and concentration, ideally it should be conducted when the health facility is closed.
When conducting a physical count, all movements and transactions within the stock area
should be limited to minimize the possibility of discrepancies.
After conducting a physical count, print out a report disclosing some of the following
information: item description, park size, lot number, quantity, expiry date, and the value (see
annex).

Instruction on conducting a physical inventory

Check that the stock is in the correct place.

Clean the shelves to remove dust and insects.
Check for expired/damaged stock.
If the stock is expired/damaged, remove it from the shelf, write it out on the stock
card, and put it in the quarantine zone. (Do not forget to note this on your inventory
reporting form too)
Any expired/damaged stock and open containers should NOT be counted.
Carefully count the number of full current units you have.
Write this number on the stock card and on your inventory reporting form. (Watch
carefully that you count using the SAME units that you use on the stock card, e.g.
tablets or bottles of 1000
 40

The report should be signed by the team which participated in the inventory and approved by
the head of a health facility. Follow the order of the items on the inventory reporting form
when doing the physical count. This will help ensure nothing is missed during the count.

Any stock with less than three months until expiry should be noted and reported to the RMS
Ltd branches, which can determine whether the stock can be used somewhere else, so it is
not wasted.

5.4.4. Management of donations

Often visitors from other countries may have medicines with them that they want to donate
to you. These visitors include travelers, foreign workers, church groups, or visiting medical
teams. Donations can be useful, but they can also be dangerous or even illegal, and sometimes
can cost you money and waste your time.

Tips on how to dispose of health commodities:

• Separate each unusable (expired and damaged) medicine from the stock in
use immediately after its identification and quarantine it prior to disposal.
Mark the quarantine zone, by sorting of unusable medicines should be done
carefully with respect to SOPs in place.
• Make a list of all medicines to be disposed of. The list must include the
following information: the name, strength, form, batch number, expiry date,
the monetary value of each item on the list, and the quantity for each
medicine. The list must be approved by a competent authority at the health
facility level.
• For district hospitals, the board of directors will approve the list; for health
centers, the list will be approved by COSA (comité) de santé) (reference: law
no 50/2008 of 9/9/200 8 determining the procedure for disposal of state
private assets).
• The disposal process is conducted using the nearest appropriate incinerators.
Provide report to competent entities and include the date of activity, disposed
volume (kg), and monetary cost.

For ALL donations, use the following guidelines:

• People must have permission from Rwanda FDA and the Ministry of Health
BEFORE they donate any health commodities. (Check before accepting)
• ALL donations should be on the Essential Medicines List.
• They should be from a reliable source. (If not sure then do not accept.)
• All medicines should be labeled in English/French with the medicine name,
strength, form, batch and expiry, storage conditions and manufacturers name
clearly printed.
• All donations should not be expired. (No out of date stock)

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Note: The donation to any health facility must be integrated into the existing supply chain.
Therefore, count used donations as consumed stock to keep accurate records.

5.4.5. Disposal of medicines and medical sundries

Expired and unwanted medicines need to be disposed of properly. Disposing of medicines
helps ensure the safety of the local people and the environment. Keep expired and unwanted
medicines separate from normal medicine and equipment supplies.

Dispose of them properly according to the standard operating procedures.

5.5. Distribution

5.5.1. The country distribution system:

is a system where products flow from central medical stores to districts and, ultimately, to
health facilities and communities. The distribution plays an essential role in the medicines
logistics system and consists of moving products down the pipeline from the national central
warehouse until they are dispensed to the patients.

5.5.2. The importance of distribution

Medicine distribution is a key element of the medicine management cycle, and its primary
objective is to ensure the smooth delivery of medicines and medical supplies to the final user,
the patient, through different internal services. The process of ensuring optimal operation of
distribution in the supply chain is also known as optimization.

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Good distribution practices of health commodities ensure that:

• There is a constant and uninterrupted commodity supply
• Commodities stay in good condition until they are used
• Losses due to spoilage and expiry are minimized
• Theft and fraud are prevented
• Adequate stock is maintained
• Storage locations that allow for on-time delivery are used
• The collection of accurate information for forecasting is enabled (World Bank, 2004)

A distribution system needs to be able to move medicines from a central warehouse to lower
levels of the supply chain. The following considerations should be kept in mind when setting
up a distribution system:
• Define appropriate roles in the distribution system
• Design an efficient network of storage facilities with the fewest number of levels appropriate
to the country’s geography
• Select an appropriate strategy for delivery
• Keep reliable records of medicine stocks and consumption
• Allocate supplies based on actual workload and treatment needs
• Maintain accountability procedures and secure storage at each level of the system
• Construct or renovate facilities to be appropriate for storing medicines
• Manage storage facilities to maintain pharmaceutical quality and efficiently serve health
units
• Make reliable transport arrangements
• Reinforce reporting and supervision arrangements

5.5.3. National distribution

Country distribution starts when the goods arrive in the country and are released from customs
(port clearing) for delivery to the central warehouse. In Rwanda, products flow through a
supply system that consists of a central medical store that carries out procurement, storage and
delivery, RMS Ltd branches, and service delivery points (SDPs) including primary, secondary,
and tertiary facilities. A cadre of community health workers completes the system. The national
distribution system to supply pharmaceuticals across the country is mostly active. The central
warehouse delivers medicines to RMS Ltd branches, which in return supply health facilities.

At the district level, health facilities place orders at the RMS Ltd branches based on their need,
and the district distributes ordered products. Medicine orders are placed through the eLMIS.
At the health facility level, products move from the main pharmacy store to different service
providers (outpatient department, family planning, community health workers, and health
posts) based on normal requisitions.

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Unit 6: Rational Use of Medicines

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Objectives:
By the end of this module, participants will be able to:

• Define the rational use of medicines and its importance

• Discuss examples of irrational use of medicines and underlying factors
• Explain the adverse impact of irrational medicine use
• Identify effective strategies to promote rational use of medicines

6.1. Rational use of medicines

The rational use of medicines requires that patients receive the medicines appropriate to their
clinical needs, in doses that meet their own individual requirements, for an adequate period,
and at the lowest cost to them and their community (World Health Organization).

6.2. The importance of rational use of medicines

Inappropriate use of pharmaceuticals is a significant health and economic problem, and it can
undo the benefits of the entire pharmaceutical management cycle.

6.3. Example of irrational use of medicines

1. Prescriber-related problems

2. Wrong diagnoses

3. Under prescription (incomplete dosage, short treatment period, etc.)

4. Over prescription (unnecessary medicines, high dosage, long treatment period, etc.)

5. Unjustified prescription (expensive medicines, generic, etc.)

6. Polypharmacy

7. Wrong prescription (unclear prescription)

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6.4. Factors underlying irrational use of medicines

- May have misleading beliefs

6.4.1. Patients - May not be able to communicate problems to health care workers
- May not be able to get to where the medicines are
- May not be able to understand the instructions they are given
- May not able to afford medicines as prescribed
- May have family and community constraints

6.4.2. Prescribers - May be overworked

(health care workers, - May be put under pressure from patients to supply
nurses, and doctors) medicines when they are not needed
- May not be up to date with the current treatment guidelines
- May not understand what the medicine
does/misunderstanding about drug efficacy
- May be pressured to promote drugs by
pharmaceutical representatives

6.4.3. Dispenser - May be overworked

- May not be up to date with the current treatment guidelines
- May not understand what the medicine does
6.4.4. Supply Chain - Required medicines may not be available
- Weak supply chain (stockouts, expiries)
- Noncompliance on law and regulations

Inappropriate use of pharmaceuticals is a significant health and economic problem, and it can
undo the benefits of the entire pharmaceutical management cycle.

Dispensers at health facilities should be pharmacists and pharmacy technicians.

6.5. The adverse impact of irrational medicines uses.

Irrational use of medicines can have significant adverse effects on health care costs and the
quality of treatment. It can lead to:

• Increased morbidity and mortality

• Increased cost of medicines and medical supplies
• Increased risk of adverse drug reactions
• Increased risk of antimicrobial resistance
• Patients’ reliance on unnecessary medication (like injections)
• Potential stockout as needs quantification using a morbidity method assumes that the
prescriber complies with STGs

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6.6. How do we address the problem of irrational use of medicines?

The picture above shows how medicines come to be used. We call this the “medicines use cycle.”
• Diagnosis: The health care worker decides what is wrong with the patient.
• Prescribing: The health care worker decides what medicine the patient needs. (Sometimes
patients will not need medicine for their illness.)
• Dispensing: The medicine is given to the patient to take home.
• Adherence: The patient takes the medicine according to the instructions.
Problems can occur at each of these stages. These problems often result in medicines NOT being used
correctly, which can harm the patient.

To effectively address the issue of irrational use of medicines, one needs to understand its
various underlying causes related to the patient and/or the prescriber.

Patient-related: Problems can stem from patients’ drug misinformation, misleading beliefs, inability
to communicate problems, and inability to obtain medicine due to access and/or affordability
challenges. When medicine is dispensed to a patient, it is important that the patient receives: The
correct medicine, the correct dose and the correct information (which may involve counselling) on
how to use the medicine.

Collecting, counting and packaging the medicine.

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To prepare medicines and supplies

1. Go into the store. Work out what you will need and place the bulk containers on a tray.
Take them to the dispensing area.
Estimate the number of units of each item that will be needed for the day or the clinic session.
Use bulk bottles that you have already opened first. If you need to open a new bottle, write
this on the stock card.
Once items are issued to a dispensing area, do NOT reissue them to the store. Keep them in
the dispensing area. Secure the items between clinic sessions.

Do NOT dispense to patients directly from the store!

2. Keep supplies in the dispensing area organized.

Organize medical supplies in the dispensing area until you are ready to dispense to your
patients.

3. Check that the prescription is appropriate for the patient.

Review the prescription. Find its generic name. If you cannot read it or have any questions,
ask the person who wrote the prescription to explain it to you.
Check that the prescription is appropriate for the age, weight, and sex of the patient. Also
check that the medicine prescribed is appropriate in form, strength, and dosage.
If more than one item has been prescribed, do NOT combine them. Review and prepare one
prescription at a time.

4. Collect a container of the item and check its expiry date.

Some medicines look the same and may easily be confused. Read the generic name on the
label of the container. Check that you collected the correct medicine and that you have the
correct form, strength and unit size. Use a plastic medicine envelope to package the item for
the patient.

5. Label the package clearly with the patient's name, date, name of the item, quantity dispensed,
and written instructions for the patient.
Use pictures or numbers to record the dose. Include written instructions also. Ensure that the
label is written clearly.

6. Open the container. Check the quality of its contents. Count the quantity needed in a clean,
safe manner.

6.a. Solid forms

Once the container is opened, if medicines have an odd smell, they may have gone bad. If
tablets or capsules are cracked, broken, powdery or sticky, they are damaged.

If capsules are swollen, softened or stuck together, they are damaged.

Do NOT give patients poor quality medicines. Dispose of those medicines properly.

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Count tablets or capsules using a counting tray with a clean tongue depressor. Do NOT use
your hands; doing so can contaminate both the medicine and your hands. If you do not have
a tray, you can make one from a sheet of paper or you can use a clean surface covered with
paper.

6.b. Liquid forms

Check if the liquid is well mixed.
Check if the kit is complete (when the product normally goes with its diluent, sometimes the
latter is missing).
Check to be sure there is no change of color.
Check if the product is correctly and completely labelled. Check to be sure the container is
not leaking.

7. Put the medicine into the package for the patient to take home.
Put any extra tablets or capsules back into the appropriate container immediately.
If more than one medicine has been prescribed, close one container before you open another
container. Prepare all the prescribed items before you give them to the patient.

8. Handing out the medicine to the patient

The dispenser should carefully and clearly explain to the patient how to take the medicine or
how to use the device (e.g., condom). If the patient has more than one prescription, explain one
item at a time. This is very important. Medicines and devices are effective only if used correctly.
The dispenser should check that the patient understands how to take the medicine. The patient
should be able to repeat to the dispenser how they will take the medicine. (Ask for feedback
from the patient.)

If a product is given to the carer and not to the patient) the same process should be used to
ensure the carer fully understands how the patient is to take/use what has been dispensed.

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8.a. Tell the patient the name of the medicine, its form (tablet, syrup, etc.), what it is for, and
the dosage.
The dosage includes:

1. When to take the medicine (for example, in the morning)

2. How much of the medicine to take (for example, how many tablets)?
3. How to take the medicine (for example with food)
4. For how long to take the medicine (for example, two days)

8.b. Show the patient or carer how to prepare the dose. Let the patient/carer practice.
If a dose is less than a whole tablet, show the patient how to divide the tablet. If it should be
mixed with food, show how to crush the tablet and mix it with food. If you are dispensing
syrup, show how to measure the correct amount. Use the cap of the syrup bottle or show the
patient common spoons to use.

Ask the patient to practice measuring the dose. Use the medicine that you have already
packaged for the patient to take home.

When you are dispensing oral suspension (powder to be diluted), show the patient/carer how
to dilute.

When you are confident that the patient understands how to prepare the dose, ask the patient
to take the first dose. Watch the patient carefully and give feedback, as necessary.

8.c. Tell the patient how long to take the medicine.

Some medicines are taken only when needed, but many medicines must be taken until the
course is finished. If it is important for the full course to be taken, make sure you tell the
patient. Emphasize that even if they feel better before finishing the entire dose, they must take
all the medicine, so they will stay well. This is especially true for antibiotics or anti- malarial
because bacteria or parasites may still be present even after symptoms disappear.

8.d. Ask the patient/carer to tell you how they will take the medicine.
Each time you dispense a medicine, check the patient's understanding. If a patient answers
correctly, compliment them! If not, explain the dosage to them again.
Explain until they can answer you correctly.

If you are giving the patient more than one prescription, dispense one item at a time. Dispense
the next item only after you are sure the patient knows how to take the first medicine.
Explain to the patient/carer that they should come back immediately for further medical
consultation in case of serious side effects of the treatment.

Medicines taken incorrectly may be toxic or may not work. Always check the patient's
understanding.

9. Tell the patient to keep all medicines and medical supplies in a safe place at home and out of
the reach of children.
The medicine should be stored in a cool, dark, dry place that is out of reach of children and
safe from pests. For products requiring refrigeration, explain to the patient/carer how to keep
them.

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Medicines taken incorrectly may be toxic or may not work.

Always check that the patient understands to take their medicines.

6.7. Who is responsible for curbing irrational use of medicines in health facilities?

As explained above, rational use is the responsibility of the health system, prescribers,
dispensers, and patients themselves. However, it can be possible only in a conducive
environment rooted in sound regulations and supportive health financing mechanisms, such
as the Drug Therapeutics Committee.

6.8. Key interventions to promote rational use of medicines

• Establish a national body to coordinate policies on medicine use

• Use standard treatment guidelines
• Develop and use EML
• Establishment of Drug and Therapeutic Committees in health facilities
• Conduct problem-based pharmacotherapy training
• Continue offering in-service medical education as a licensure requirement Provide
supervision, auditing, and feedback
• Provide public education about medicines
• Avoid perverse financial incentives when determining if/what medicines to use
• Use appropriate and enforced regulation
• Ensure enough government expenditure for the availability of medicines and staff.
• When medicines are NOT used correctly….
• Patients may get sicker or even die.
• More medicines are used that do not need to be, and this costs more money.
• There is an increased risk of patients getting side effects from medicines.
• Patients rely on unnecessary medicines.
• Always follow the standard treatment guidelines when prescribing medicine for patients.
Using medicines correctly saves money and saves lives.

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Unit 7: Logistics Management

Information System

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Objectives:
By the end of this module participants will be able to:
• Define logistics management information system (LMIS)
• Explain the importance of LMIS for decision making
• Explain the six “rights” for logistics data
• Explain the importance of LMIS vs. eLMIS

7.1. Logistics management information system

A logistics management information system (LMIS) is the system of records and reports to
collect, organize, and present logistics data gathered across all levels of the system. An LMIS
enables people involved in medicines management to collect the data needed to make informed
decisions that will ultimately improve medicines availability to patients.

7.2. The importance of a logistics management information system

Information is the engine that drives the entire logistics cycle. We collect information to make
decisions; the better information we have, the better decisions we can make.

The LMIS can be used to make decisions in a variety of areas, including

• Quantification
• Procurement
• Calculating maximum stock level and reporting
• Inventory management and control at the health facility level
• Monitoring program performance
• National pipeline monitoring
• Redistribution of health commodities when necessary
• Capturing information on where consumption is highest or lowest, which helps
determine whether more resources are required.
An effective LMIS for medicines will thus contribute to preventing stockouts and stock
imbalances of medicines at health facilities. However, it heavily relies on good record- keeping
practices of the staff responsible for medicines management at health facilities.

7.3. The six "rights" for logistics data

The logistics six right which also apply to data, are the six key elements needed for an effective
LMIS. MOH and programs need:
1 the right data (also called the essential data items)
2 at the right time (in time to act)
3 at the right place (the place where the decisions are made), and
4 in the right quantity (having all essential data from all facilities)
The data must be of
5 the right quality (we must believe that the data are complete and accurate) and
6 at the right cost (we should not spend more to collect information than we spend on supplies).

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7.4. Essential data for decision making

To make supply decisions, three pieces of information are needed:

• stock on hand: Quantities of usable stock available at any level or at all levels of the
system at a point in time.
• rate of use (consumption): The average quantity of commodities dispensed to users in
a given time.
• losses and adjustments: Losses are the quantity of health commodities removed from
the distribution system for any reason other than consumption by clients (e.g., losses,
expiry, and damage). Adjustments may include receipt or issue of supplies to/from one
facility to another at the same level (e.g., a transfer) or a correction for an error in
counting. Losses/adjustments may, therefore, be a negative or positive number.
• These are the three MINIMAL and ESSENTIAL data required to manage a logistics
system.
• They must be recorded as well as reported through the LMIS.

7.5. Three types of records

In the supply pipeline, only three activities can happen: supplies are stored, moved (in transit),
or consumed (used). Because we want to be able to monitor supplies always in the pipeline,
we need three types of records to track the supplies.

7.5.1. Stock keeping records

These keep information about products in storage (stock on hand, receipts, issues, losses, and
adjustments). This information is recorded on the stock cards (see SOP Annex 10).

7.5.2. Transaction records

These keep information about products being moved (requesting, receiving, and reporting
form as well as delivery notes) (see SOP annex 12).

7.5.3. Consumption records

These keep information about products being used (consumption data - this can be found, for
example, in the Daily Consumption Register, which records the medicines dispensed to
patients or end user at a facility).

Note: Apart from these record tools, an electronic logistic management information system
(eLMIS) also can be used for recording, moving, and reporting data

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STOCK CARD No.

REPUBLIC WANDA
Maximum

Emergency Order
MINISTRY OF HEALTH
P.O. BOX 84, KIGALI

Product
Province: (Name, Dosage,
District: Unit of
Facility Name: Storage

Received
of
Issued
Balance Carried Forward

Monthly January February March April May June July August September October November December
Consumption/
Distribution -- -- -- --

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7.6. Electronic logistics management information system (eLMIS)

The Ministry of Health has strengthened national supply chain management planning by
implementing an electronic logistics management information system (eLMIS) to improve
supply chain processes and best standard practices, and to ensure availability of accurate
logistic data in a timely manner for informed decision making.

7.6.1. Composition of an eLMIS

An eLMIS has various components, with its users' roles and responsibilities assigned
depending on health care levels. These components are order management, inventory
management, transportation, warehouse management, price configuration, and replenishment
planning.

7.6.2. Importance of recording and reporting through an eLMIS

Rwanda is benefiting from the use of an eLMIS to collect and use more complete and accurate
data which allows for a timely decision-making process.

The advantages of using an electronic version over a paper-based system include reducing
stockouts, managing waste and losses, and operating an effective and efficient supply chain.
In addition, preparing a summary and feedback report is easier and less time consuming when
the LMIS is automated. An eLMIS application can automatically populate report elements,
especially if the system is also used for routine inventory control, and for opening balance,
receipts, consumption, losses, or adjustments that are recorded with every transaction.

With the click of a button, the eLMIS can generate a summary report and a requisition order
with suggested replenishment quantities. The eLMIS can also streamline and customize a
feedback report by generating and transmitting notifications, reminders, and alerts.
A notification might be a short message to a manager to log in, review, and approve a
requisition, or to a health care worker that a consignment is ready for pick up or delivery.
A reminder can help personnel to attend to routine activities, such as conducting physical
inventory at the end of the month and submitting their requisition orders.

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An alert flags a problem, such as a product that has limited shelf life remaining, or an
impending stockout.

An eLMIS can also enable routine reporting to other stakeholders, programs, and divisions
within the Ministry of Health and development partners.
Likewise, an eLMIS enables an analysis of supply chain performance by displaying dashboards
that are specific to each user and role within the system. At higher levels, these dashboards can
help supply chain managers see the big picture based on key performance indicators, and to
drill down into specific indicators.

Finally, an eLMIS can be integrated into the broader supply chain and health information
systems to enable deeper analysis, better workflows, and greater visibility across health
domains. An eLMIS can be linked with electronic medical records and other health systems.

An LMIS is at the heart of key decisions making in the supply chain. It is therefore important
that:
• Health center (HC) and hospital health supply chain staff review their data before
entering it in the eLMIS.
• Both HC and hospital health supply chain staff enter data into the eLMIS on a regular
basis.

See next illustration depicting how an eLMIS operates

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ELECTRONIC LOGISTICS MANAGEMENT INFORMATION SYSTEM CHART

Order state in The order shipment must be

Awaiting after the confirmation Date
Approval State After pick up action
The carrier must be
order moved in transit state
RwandaMOHPrivateFleet

Confirm Shipment goes in Execute pick Shipment moves to Shipment moves to

shipment pick Ready state Up Action "Intransit" state Delivered state

Order state in
open state
Generate Pick list Create invoice Order is Closed

Warehouse Manager Vendor CRS

Vendor Accepts Order

Order
state in se Order received/
New Execution Appear in received
(Receipt)

order closes

6
Buyer creates and confirms an Order Warehouse Man

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Unit 8: Monitoring & Evaluation

and Supervision

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Objectives:
By the end of this module participants will be able to:
• Describe the purpose of M&E and supervision
• Describe the process of M&E and supervision and related tools
• Describe how to solve problems systematically throughout M&E and supervision
findings.

8.1. Monitoring:

is the systematic collection and analysis of information as project progress. It is a planned,

systematic process of observation that closely follows a course of activities and compares what
is happening with what is expected to happen.

8.2. Evaluation:

is the comparison of actual project impacts against the agreed strategic plans. It looks at what
you set out to do, what you have accomplished, and how you accomplished it. The process
assesses an achievement against present criteria. The process of evaluation follows distinct
methodologies (process, outcome, performance, etc.).

8.3. Supervision:

is a way of supporting often isolated primary health care workers and ensuring the quality of
the health services they provide, for example by introducing interventions to improve
performance. However, supervisory visits require time and transport and can be relatively
costly. Supervision plays a critical role in effecting change both at the facility and within the
health care system.

8.4. The purpose of monitoring and evaluation (M&E)

M&E shows whether a service/program is accomplishing its goals. It identifies program

weaknesses and strengths, areas of the program that need revision, and areas of the program
that meet or exceed expectations.

Monitoring helps identify shortcomings and provides guidance for modifying original plans
during implementation. It also provides elements of analysis as to why progress fell short of
expectations.

Evaluation attempts to measure the service’s relevance, efficiency, and effectiveness. It

measures whether and to what extent the program’s inputs and services are improving the
quality of people’s lives. It aims to determine the extent to which service needs and results
have been or are being achieved and analyses the reasons for any discrepancy.

The process of monitoring and evaluation allows you to

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• Review progress
• Identify problems in planning and/or implementation
• Adjust improve the project or organizational efficiency, effectiveness, and impact
• Keep the work on track and let management know when things are going wrong.
If done properly, it is an invaluable tool for good management, and it provides a useful base for
evaluation.
• Determine whether the resources available are sufficient and are being well used, whether the
capacity you have is sufficient and appropriate, and whether you are doing what you planned
to do.

In the context the medicines supply chain, logistics monitoring is essential to inform
managers on how logistics operations are impacting service delivery — for example, if they
are providing enough, not enough or too many medicines, or whether the management of the
supply chain effectively contributes to the achievement of health care system goals.

Data collected through continuous monitoring and measurement can be used to improve
logistics systems to be more cost effective, have a greater impact on service quality and
utilization, and to adequately support all other activities aiming to achieve program goals.

8.5. The purpose of supervision

Regular supportive supervision by knowledgeable staff is key to ensuring that data used to
assess whether the right medicines are available in the right quantities and at the right places
are reliable and accurate.

Supervision allows the RMS Ltd district branches and central level to check that:
• Patients get the health commodities needed when they need them;
• Planned logistics activities are carried out according to schedule;
• Records are correctly maintained, and reports submitted in a timely manner for re-
supply and decision making;
• Qualified health professionals are in place and performing supply chain activities;
• Pharmaceuticals management activities are performed according to the norms and
guidelines.

8.6. Conducting monitoring and evaluation (M&E) and supervision

8.6.1. Monitoring can be conducted using various methods.

•Supervision, which consists of overseeing and providing direction, guidance, and
instruction
• Routine reporting of data, using a management information system
• Sentinel sites for more detailed reporting and monitoring of developing situations, most
passive surveillance systems receive data from as many health workers or health facilities
as possible. This is called a sentinel system.
• Special studies to gather additional information or to resolve problems
in the health facility, supply chain managers can receive internal or external audits.
The inspection may also apply in case of suspected malpractice or fraud.
8.6.2. Evaluation can be conducted through five phases

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• Planning the evaluation

• Selecting appropriate evaluation methods
• Collecting and analyzing information
• Reporting findings
• Implementing evaluation recommendations

M&E is part of “Quality Assurance,” as it contributes to the continuous improvement of

quality. Because information is so important in the medicines supply system, it is necessary to
monitor that all required information is available on a regular basis.

Regular monitoring of your medicines supply system is

needed to make sure it works well!

8.7. Characteristics of indicators used in supervision

Logistics performance can be tracked in a variety of ways; regardless of the method used, it is
important to focus on indicators that have the following characteristics: Example of an
indicator in quantification is “the existence of forecasting tool or method”. This indicator
should be:
• Measurable (quantitative): rates, proportions, percentage, common denominator (e.g.,
population), or “yes/no” response
• Motivates “correct” behavior
• Defined mutually by the parties concerned (including health facilities staff)
• Multi-dimensional: balance among quality, utilization, and performance
• Benefits of the measure outweigh the costs of collection and analysis
• Indicators must be characterized by the following traits:
• Clear: easily understandable by everybody
• Useful: represent all the important dimensions of performance
• Reliable: can be collected consistently by different data collectors
• Valid: measure what we mean to measure

8.8. Conducting supervision

Over the past several years, the MOH adopted the integrated supervision system of health
activities across the health system. The integrated supervision tools are used at various levels
the community health system, and each tool applies to a specific activity area. The central level
supervises the RMS Lt d district branches, and the RM S Lt d district branches supervise
hospitals, health centers, and health posts. Health care providers at health centers supervise
community health workers (CHWs) at the community level. At each level, supportive
supervision is needed to build capacity to provide good quality services.

The supervisory activities comprise assessing the comprehensiveness of the implementation,

identifying challenges, and proposing solutions without delaying the implementation process.

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The supervisory teams comprise representatives or those in charge of the CHW activities at
the health system levels (district hospitals, RMS Ltd branches, health centers), including the
directorate of maternal and child health, MOH planning and budgeting, HMIS, the MOH health
financing unit, and chief accountants in the MOH.

All Supervision will include different tasks at different system levels:

District hospital (DH) and RMS Ltd District Branches

• The RMS Ltd District Branches and DH pharmacists ensure the supportive supervision
of staff in charge of stock management at HC level.
• The person in charge of CHW activities at the district hospital ensures the availability
of commodities at the community level, supervises and verifies the accuracy of data
reporting, and checks any misreporting issues that might arise.
• It is at t h e district level that each health center/cooperative report is entered
• into the database.
• Conduct field visits to assess how effectively and efficiently maternal and child health
interventions are being implemented toward achieving the set performance goals.
• DH staff in charge of vaccination ensure that orders are prepared and issued on time to
the HCs

The nutrition officer ensures the availability of nutrition support products and their distribution
to HCs and collect related reports.

In addition to the supervisory visits conducted in the context of the PBF, the RMS Ltd
district branches supervise activities related to medicines management (including inventory
management and reporting using eLMIS) in health facilities.

Health center

• Oversees and participates in the training of CHWs in the health center catchment area.
• The store manager oversees ordering, storage, and distribution
• Supervises health posts

During supervision, the data quality is assessed using a three-step process:

• Records and forms check: Which LMIS records and forms are being used?
• Records and forms review: Are the records and forms properly maintained and
kept up to date?
• Cross check for data consistency within facilities: Are the records within
this facility consistent with one another? That is, do shipping/receiving records
match stock cards? Do stock records match a physical inventory taken at the
time of the assessment?
This involves checking data consistency:
• between inventory record and physical inventory (balance on hand)
• between inventory record and daily activity register (quantity dispensed to consumers)
• between daily activity register and stock report (quantity dispensed to consumers)
• between inventory record and delivery notes and invoice (quantity received)

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• between quantity ordered and quantity received

8.9. The tools used for supervision of the health supply chain

Currently, the following tools exist for supervising and evaluating the supply chain:
• Integrated supervision checklist, which includes some indicators relevant to
inventory management and medical products and technologies storage conditions
• DHMT Supervision Checklist
• Quality Management Improvement Approach (QMIA) checklist

The areas covered during supervision

• Storage practices
• Inventory management (using a selected number of tracer and measuring stock
occurrences)
• Availability of supplies
• Human resources
• Infrastructure and information, communication, and technology equipment
• eLMIS utilization
• Dispensing practices

8.10. Expectation from supervisee

All parties know health supply chain areas which monitoring teams review. Staff are therefore
expected to include the review of these areas through a routine evaluation to improve
performance with respect to such areas, i.e. storage, inventory management, reporting, and
dispensing.

8.11. Using M&E and supervision findings in problem solving

8.11.1. Problem identification

Based on findings from either supervision or M&E activities, three types of problems should
be identified:
• Physical problems
These are problems with “things,” such as a leaking roof, no lock on the door, etc. Report
physical problems to the Ministry of Health to have them fixed. You may need to follow up a
few times before the problem is addressed.
• System problems
These are problems with procedures or systems. For example: the stock take is not completed
regularly, or the fridge temperature is not checked daily. For system problems, check that the
staff are trained to do what is required and are followed up at the next visit to ensure
improvements are being made.
• People problems
These are problems due to the attitude or behavior of people, such as staff not coming to work
or not fully executing their job responsibilities. These can be difficult to fix and need the
cooperation of a senior supervisor. The senior supervisor’s findings can be reported to the
competent authorities for redress.

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8.11.2. Strategic problem-solving approach

This systematic approach can be followed when addressing any of the problems described
above.

• Identify the problem : What do we want to change?

A problem can be defined in one of three ways: 1) anything that is a deviation from the standard;
2) the gap between the actual condition and the desired condition; and 3) unfilled customer need.
Current State: Desired State:

• Analyze the problem : What is preventing us from reaching the “desired state”?
This is also a good time to study and analyze the different inputs and outputs of the process
so that you can effectively y prioritize your efforts.
Causes: Effects:

• Clear, concise problem statement (identify sub-problems where applicable) — This will
help you identify the actual factors that caused the issue in the first place. Often, there are
multiple root causes to analyze. Make sure you are considering all potential root causes
and addressing them properly.
• Control : Are we the right people to t ac kl e this problem? Who are other stakeholders?
• Importance and difficulty : How much does it matter whether this problem is solved?
Is it possible? Do we have the will?
• Time and resources :How long will it take to resolve this problem? Do we have what
it will take to do this job?
• Return on Investment : What is the payoff? Does it justify the investment of
resources?
• Force-field Analysis : What could help or hinder our efforts?
• Brainstorm Solutions : How can we make the change? How can problems caused be
eliminated? How can barriers be minimized? What positive forces can be maximized?
• Select and plan the solution :What is the best way to do it? Criteria for evaluating
solutions
• Resources (budget, people, materials, etc., available to the group)
• Time (length of time it takes to solve the problem)
• Acceptability (stakeholders and organization will accept solution and changes involved)
• Return on investment (expected pay-off from solution)
• Control (implementation is within control of group)

Appropriateness (solution solves the problem)

Solution(s) Chosen: As the root cause is already identified, that information can be used
to develop the countermeasures/solutions needed to address the root causes. The working
team should develop as many countermeasures needed to directly address all root causes.

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Ø Action Plan - Who, what, where, when, and how to evaluate? The action plan will
specify who to involve, enroll, and get input from. Once countermeasures /solutions
are developed and narrowed down, they must be seen through in a timely manner.

In the end, success and achievements encountered along the problem-solving path will help to
set the new processes as the new standard within the organization, and these will be shared
throughout the organization. The M&E process is also a good time to reflect on what has
been learned and address any possible unresolved issues or troubles that may have come up.
In fact, ignoring unresolved issues will only lead to more problems down the road.

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Unit 9: Communication, Leadership

and Management

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Objectives
By the end of this part of the training, participants will be able to:
• Define communication and related terms
• Explain the importance of communication
• Describe different communication methods available for use
• Explain feedback and its importance in communication
• Describe things that affect good communication
• Define leadership and management
• Explain the similarities and differences between leadership and management
• Describe relationship management between leaders/managers and patients
• Explain the process of change management

9.1. Communication

Communication is the way people share their ideas, information, opinions, and feelings.
Communication is a two-way activity between two or more people. There are many ways we
can communicate in our work activities.

9.1.1. Importance of communication

Communication is important in sharing ideas, information, opinions, and feelings, organizing
health commodity supplies activities, and making sure that orders are sent and received
properly. This involves asking questions when you are not sure and always checking if
something that you are expecting to happen does not.

All health care workers need to communicate well to ensure that the health
commodity supply chain works.

9.1.2. Communication methods

Communication can be:
• Face-to-face with verbal and non-verbal messages, e.g. to a patient at the
dispensary window, to health workers on the wards and fellow staff.
• Verbal only (non-face to face), e.g. over the telephone or on the radio.
• Written, e.g. letters, memos, faxes, and e-mails
Good communication requires skills in listening watching others and understanding the
messages of others.

9.1.3. Feedback
Sending the message and receiving feedback
For communication to work well, it must be a two-way process. Good communication means
that the receiver must get the same message intended by the sender and is able to respond
appropriately.
Feedback
Feedback is getting information from the person receiving the message to find out whether
the message was understood. When feedback is received, the person sending that feedback

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becomes the sender of a message. For example, a patient may say "I'm afraid to take my
medicine!" as you are handing him or her the prescription. Instead of telling patients, "take all
of these" reassure them by saying,” these tablets are to treat the infection. Even if the signs and
symptoms disappear, it is important to complete the course, so that the infection will not come
back."

The importance of feedback

Feedback helps the communicator to see if enough information has been given, and it allows
the communicator to give clarity where there is ambiguity. Feedback ensures that the receiver
listened to the message carefully.

Things that affect communication

People
We each have thoughts and things that happened in our lives that make us different from others.
The more shared experiences you have with others, the easier it is to communicate with them.
Not everyone sees or hears things in the same way. While communicating, think about the needs
and experience of the receiver.
Needs
We all have the same basic human needs of survival, making friends, and feeling good about
ourselves, and we like to be part of making things. Individual needs are different from one
person to the other and from one ‘situation to the next. This affects communication because one
may understand or misunderstand a message depending on his/her needs at the time. For
example, if a person is feeling pain then he/she may not feel like spending time with people.
Background
The way we are brought up, our culture, and what village we come from affects our needs,
values, and expectations.
Education
How much and what type of education we have affects the way we think and understand life.
For example, peoples understanding of their body and health’ – where people have not had the
education to understand how their body works and how medicines work then they will need
more support and explanation to ensure they follow instructions and understand why.
Language
The way we speak and the words we understand, and use affect our communication. If English
is not the first language, then it is harder to understand it.
Interests
Whether we like reading books, listening to music, playing outdoor activities, sports, or staying
at home affects how we think about things.
Occupation
Our jobs lead us to have different ideas and outlooks.
Personality
Whether we are energetic, quiet, mix well with people, shy, secure, or scared, these all affect
the way we communicate.

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Race
Our nationality or the village we come from affects the way we see and respond to the world
Age
People of different ages have different interests, thoughts, and needs. You would probably speak
to an old person in a different way than you would to a person of your own age. Therefore, be
aware that these things can affect the way we communicate with other people. It will help you
to communicate better with them.
Attitude
Our attitude to those we communicate with will affect our communication with them. It is very
important to respect the person you are communicating with.
Body language
What you say with your body can say more than your words. The impressions you send is very
important.
Appearance
Appearance leads others to form "first impressions" about us. Their first thoughts
about our appearance can influence what they think about us as a person or a health care worker.

Channel of communication and feedback for health facilities

Information and feedback flow from the central level to service delivery points. Therefore,
it is important that supply chain cadres respect the channel put in place to communicate better.
Refer to the diagram on the flow of health commodities and information covered in the first
module.

9.2. Leadership

Good leadership is exhibited when health facilities can provide services to the community in an
appropriate, efficient, equitable, and sustainable manner. This can only be achieved if the key
resources for service provision, including human resources, finances, hardware and process
aspects of care delivery are brought together at the point of service delivery and are carefully
synchronized.

9.2.1. Things to be considered in leadership

Effective assessment and planning, managing of the entire care process, human resources,
interacting with the community, and managing information are critical for any leadership style.

9.2.2. Similarities between managers and leaders

Management and leadership are important for the delivery of good health services. Although the
two may sound similar, it is vital that good managers strive to be good leaders, and good leaders
must strive to have management skills to be more effective.

Good leaders/managers who have a vision of what they need to achieve must communicate this
to others and devise strategies for realizing the vision. They motivate people and can negotiate
for resources and other support to achieve their goals.
Good leaders/managers ensure that resources are well organized and applied to produce the best
results. In a resource-constrained and difficult environment, a leader/manager must also use his/her
leadership skills to be able to achieve good results.

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How should health supply chain leaders/managers manage their relations with their team
and supervisors?
In most health systems, health facilities are linked to the
national health system through the district and therefore are
accountable to district teams.
All operational health system activities are
implemented via the district, including health
commodities procurement, human resources,
infrastructure and technical support.
Local facility leaders or managers must
have clear lines of communication
and ensure optimal off-site support
and supervision so that they can
report to districts accurately.

How should health supply chain leaders/managers manage their relations with patients and
achieve patient satisfaction?
Health facilities exist for the sole purpose of providing health services to patients in
communities. Therefore, good leaders/managers need to ensure that client satisfaction is of
utmost importance and that all staff are trained to understand patients’ rights.

9.3. Leadership and change management

We live in a world where change in inevitable. Therefore, any leaders should be prepared to
manage change well. There are many theories about how to "do" change. Many originate with
leadership and change management guru, John Kotter. A professor at Harvard Business School
and world-renowned change expert, Kotter introduced his eight-step change process in his
1995 book, "Leading Change."

Kotter s 8 Step Change Model

Identify the true leaders in your organization, as well as your key stakeholders.

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Step 1: Create a Sense of Urgency

For change to happen, it helps if the whole organization really wants it. Develop a sense of
urgency around the need for change. This may help you spark the initial motivation to get
things moving.

What you can do:

• Identify potential threats and develop scenarios showing what could happen in the future.
• Examine opportunities that should be, or could be, exploited.
• Start honest discussions and give dynamic and convincing reasons to get people thinking.
• Request support from external stakeholders to strengthen your argument.

Step 2: Form a Powerful Coalition

Convince people that change is necessary. This often takes strong leadership and visible
support from key people within your organization. Managing change isn't enough; lead it.
What you can do:
• Ask for an emotional commitment from these key people.
• Work on team building within your change coalition.
• Check your team for weak areas and ensure that you have a good mix of people from
different departments and different levels within your organization.

Step 3: Create a Vision for Change

A clear vision can help everyone understand why you are asking them to do something. When
people see for themselves what you are trying to achieve, then the directives they are given
tend to make more sense.

What you can do:

• Determine the values that are central to the change.
• Develop a short summary (one or two sentences) that captures what you see.
• Create a strategy to execute that vision.
• Ensure that your change coalition can describe the vision in five minutes or less.
• Practice your "vision speech" often.

Step 4: Communicate the Vision

What you do with your vision after you create it will determine your success. Your message
will probably have strong competition from other day-to-day communications within the
company, so you need to communicate it frequently and powerfully, and embed it within
everything that you do. Don't just call special meetings to communicate your vision. Instead,
talk about it every chance you get. Use the vision daily to make decisions and solve problems.
When you keep it fresh on everyone's minds, they will remember it and respond to it. It's also
important to "walk the talk." What you do is far more important - and believable
than what you say. Demonstrate the kind of behavior that you want from others

What you can do:

• Talk often about your change vision.
• Address peoples' concerns and anxieties, openly and honestly.
• Apply your vision to all aspects of operations from training to performance reviews.
• Tie everything back to the vision.
• Lead by example

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Step 5: Remove Obstacles

If you follow these steps and reach this point in the change process, you have been talking
about your vision and building buy-in from all levels of the organization. Hopefully, your staff
wants to get busy and achieve the benefits that you have been promoting. But is anyone
resisting the change? And are there processes or structures that are getting in its way? Put in
place the structure for change, and continually check for barriers to it. Removing obstacles can
empower the people you need to execute your vision, and it can help the change move forward

What you can do:

• Identify, or hire, change leaders whose main roles are to deliver the change.
• Look at your organizational structure, job descriptions, and performance and reward
systems.
• Recognize and reward people for making change happen.
• Identify people who are resisting the change and help them see what is needed.
• Act to quickly remove barriers.

Step 6: Create Short-Term Wins

Nothing motivates more than success. Give your organization a taste of victory early in the
change process. Within a short time, frame (this could be a month or a year, depending on the
type of change), you'll want to have some "quick wins" that your staff can see. Without this,
critics and negative thinkers might hurt your progress. Create short-term targets, not just one
long-term goal. You want each smaller target to be achievable, with little room for failure.
Your change team may have to work very hard to come up with these targets, but each "win"
that you produce can further motivate the entire staff.

What to do:
• Look for projects that you can implement without help from any strong critics.
• Do not choose early targets that are expensive.
• Thoroughly analyze the potential pros and cons of your targets.
• Reward the people who help you meet the targets.

Step 7: Build on the Change

Kotter argues that many change projects fail because victory is declared too early. Real change
runs deep. Quick wins are only the beginning of what needs to be done to achieve long-term
change. Launching one new product using a new system is great. But if you can launch 10
products, that means the new system is working. To reach that tenth success, you need to keep
looking for improvements. Each success provides an opportunity to build on what went right
and identify what you can improve.

What you can do:

• After every win, analyze what went right and what needs improving.
• Set goals to continue building on the momentum you have achieved.
• Keep ideas fresh by bringing in new change agents and leaders for your change coalition.

Step 8: Anchor the Changes in Organizational Culture

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Finally, to make any change stick, it should become part of the core of your organization. Your
organizational culture often determines what gets done, so the values behind your vision must
show in day-to-day work. Make continuous efforts to ensure that the change is seen in every
aspect of your organization. This will help give that change a solid place in your organization's
culture. It is also important that your organization's leaders continue to support the change.
This includes existing staff and new leaders who are brought in. If you lose the support of these
people, you might end up back where you started.

What you can do:

Talk about progress every chance you get.
• Include the change ideals and values when hiring and training new staff.
• Publicly recognize key members of your original change coalition.

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Participants List

Names Institution Position

Clement Rurangwa Bugesera DP Pharmacy Director

Ephrem Mfizi Nyamagabe DP Pharmacy Director
Eugene Shumbusho Rutsiro DP Pharmacy Director

Evariste Ndaribumbye Kayonza DP

Pharmacy Director
Fiacre Rutaganda Ngoma DP Pharmacy Director
Francois Mbonyinshuti Kirehe DP Pharmacy Director
Gasabo DP
Gaspard Harerimana Pharmacy Director
Gatsibo DP
Joseph Desire Nyirimanzi Pharmacy Director

Kamonyi DP
Thelesphore Habimana Pharmacy Director

Theogene Hakuzimana Gakenke DP Pharmacy Director

Evariste Byomuhangi Ministry of Health Pharmacist in charge of Management
Information System
Theobald Habiyaremye Ministry of Health CPDS technical coordination officer

Olivier Ngenzi Wane Ministry of Health Senior MCCH logistic Officer

Biziyaremye Floribert RBC/TB TB drug management senior officer

Ndekezi Ignace RBC/RMS LTD Procurement Specialist

Stella Matutina Tuyisenge WHO NPO/WHO Specialist

Patrick Nganji Pharmacy Council Pharmacy Council Executive
Secretary
Felix Hitayezu GHSC-PSM Senior Health System Strengthening
Anitha Batamuliza Kalema GHSC-PSM Workforce Development Advisor

Vincent Sabagirirwa GHSC-PSM eLMIS Techinical Lead

Nathalie Ngabo GHSC-PSM Malaria Logistics Advisor

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Reference documents

Rwanda MOH 2014. Pharmacy Policy.

Rwanda MOH 2014. Rwanda drugs management SOPs at health facilities.

Rwanda MOH 2012. Logistics Management Office (LMO) provisional terms of reference.
Rwanda MOH 2010. The Coordinated Procurement and Distribution System, governance document.

UNFPA’s supply chain for reproductive health commodities

http://www.unfpa.org/public/home/procurement/supplychain

USAID DELIVER project. The guidelines for proper storage of health commodities
http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/GuidStorEsse_Pock.pdf.

USAID 2013. Rwanda: Harmonized LMIS System Design Review and SOP/Curriculum Development -
Technical Report
http://deliver.jsi.com/dlvr_content/resources/allpubs/countryreports/RW_HarmLMIS.pdf

USAID DELIVER project. The Logistics Handbook: A Practical Guide for the Supply Chain
Management of Health Commodities;
http://www.jsi.com/JSIInternet/Inc/Common/_download_pub.cfm?id=10340&lid=3

Initiating In-Country Pre-Service Training in Supply Chain Management for Health Commodities:
Process Guide and Sample Curriculum Outline
http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/InitiatInCount PreServeTrain.pdf

WHO. The role of education in rational medicine use

http://apps.who.int/medicinedocs/documents/s16792e/s16792e.pdf

Vaccine stock management - Guidelines on stock records for immunization programme

and vaccines store managers
http://whqlibdoc.who.int/hq/2006/WHO_IVB_06.12_eng.pdf

WHO 2004. Management of Drugs at Health Centre Level

http://apps.who.int/medicinedocs/pdf/s7919e/s7919e.pdf

Assessment of Medicine Quality Assurance in Rwanda: Overview of Findings and Recommendations

for Consideration http://apps.who.int/medicinedocs/documents/s18411en/s18411en.pdf

WHO Operational principles for good pharmaceutical procurement www.who.int/3by5/en/who-edm-

par-99-5.pdf

WHO good distribution practices for pharmaceutical products

http://www.who.int/medicines/areas/quality_safety/quality_assurance/GoodDistributionPracti
cesTRS957Annex5.pdf

WHO Guide to good storage practices for pharmaceuticals

http://apps.who.int/prequal/info_general/documents/TRS908/WHO_TRS_908 Annex9.pdf.

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