Poor supply chain management and stock-outs of point-of-care diagnostic tests in Upper East Region’s primary healthcare clinics, Ghana

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Study Justification:
– The study aimed to evaluate the supply chain management of point-of-care (POC) diagnostic tests in primary healthcare clinics in the Upper East Region of Ghana.
– The study aimed to determine the reasons/causes of POC test deficiencies in rural Ghana’s primary healthcare clinics.
– The study aimed to identify barriers and challenges in inventory management and human resource capacity for POC testing in resource-limited settings.
Study Highlights:
– The study found that there is poor supply chain management of POC diagnostic tests in the primary healthcare clinics of the Upper East Region.
– The study identified inventory management as the area with the lowest compliance, while distribution guidelines had the highest compliance.
– The study revealed complete stock-outs of blood glucose tests in seven districts, haemoglobin and hepatitis B virus tests in three districts, and urine protein tests in two districts.
– The study identified significant predictors of complete test stock-outs, including stock-outs at the Regional Medical and District Health Directorates stores, high clinic attendance, lack of documentation of expiry dates, poor documentation of inventory levels, poor monitoring of monthly consumption, and failure to document unexplained losses of POC tests.
Recommendations for Lay Reader and Policy Maker:
– Improve inventory management practices in primary healthcare clinics to ensure the availability of POC diagnostic tests.
– Strengthen the supply chain management system for POC tests, including distribution guidelines and monitoring of monthly consumption levels.
– Enhance human resource capacity for POC testing in resource-limited settings to ensure accessibility and sustainability of POC diagnostic services.
– Implement measures to prevent stock-outs of POC tests, such as improving documentation of expiry dates, addressing unexplained losses, and ensuring adequate stock levels at the Regional Medical and District Health Directorates stores.
– Address high clinic attendance by considering strategies to manage patient flow and ensure timely availability of POC tests.
Key Role Players:
– Primary healthcare clinic managers/supervisors
– Regional Medical and District Health Directorates
– Ministry of Health
– Supply chain management experts
– Healthcare providers
– Community health workers
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers on inventory management and supply chain management of POC tests
– Development and implementation of monitoring systems for monthly consumption levels and stock levels of POC tests
– Procurement and distribution of POC diagnostic tests
– Development and implementation of strategies to manage high clinic attendance and ensure timely availability of POC tests
– Monitoring and evaluation of the supply chain management system for POC tests

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study conducted a review of accessible point-of-care (POC) diagnostic tests in 100 primary healthcare clinics in the Upper East Region of Ghana. They used a monitoring audit tool to assess compliance with supply chain management guidelines. The results showed an overall composite compliant score of 81% for supply chain management, with the highest compliance in distribution guidelines (93.8%) and the lowest in inventory management (53.5%). The study also identified complete stock-outs of certain POC tests in several districts. The findings suggest that poor supply chain management is a significant barrier to accessibility and sustainability of POC diagnostic services in resource-limited settings. The study was approved by relevant ethics committees and followed a prior study on the accessibility of POC diagnostic services in the same region. To improve the evidence, the abstract could provide more specific details on the methodology, such as the sample size and characteristics of the clinics. Additionally, it would be helpful to include the statistical significance of the logistic regression analysis and any limitations of the study.

Introduction Several supply chain components are important to sustain point-of-care (POC) testing services in rural settings. To evaluate the availability of POC diagnostic tests in rural Ghana’s primary healthcare (PHC) clinics, we conducted an audit of the supply chain management for POC diagnostic services in rural Upper East Region’s (UER) PHC clinics, Ghana to determine the reasons/causes of POC tests deficiencies. Material and methods We conducted a review of accessible POC diagnostics in 100 PHC clinics in UER, Ghana from February to March 2018. We used a monitoring audit tool adopted from the World Health Organization and Management Science for Health guidelines for supply chain management of diagnostics for compliance. We determined a clinic’s compliance with the stipulated guidelines, and a composite compliant score was defined as a percentage rating of 90 to 100%. We used univariate logistic regression analysis in Stata 14 to determine the level of association between supply chain management and the audit variables. Results Overall, the composite compliant score of supply chain management for existing POC tests was at 81% (95%CI: 79%–82%). The mean compliance with distribution guidelines was at 93.8% (95%CI: 91.9%–95.6%) the highest score, whilst inventory management scored the lowest, at 53.5% (95%CI: 49.5%–57.5%) compliance. Of the 13 districts in the region, the results showed complete stock-out of blood glucose test in all selected PHC clinics in seven (53.8%) districts, haemoglobin and hepatitis B virus test in three (23.1%), and urine protein test in two (15.4%) districts. Based on our univariate logistics regression models, stock-out of tests at the Regional Medical and District Health Directorates stores in the region, high clinic attendance, lack of documentation of expiry date/expired tests, poor documentation of inventory level, poor monitoring of monthly consumption level, and failure to document unexplained losses of the various POC tests were significant predictors of complete test stock-out in most of the clinics in the Upper East Region. Discussion There is poor supply chain management of POC diagnostic tests in UER’s PHC clinics. Improvement in inventory management and human resource capacity for POC testing is critical to ensure accessibility and sustainability of POC diagnostic services in resource-limited settings PHC clinics.

This study was approved by the Navrongo Health Research Centre Institutional Review Board/Ghana Health Service (approval number: NHRCIRB291) and the University of KwaZulu-Natal Biomedical Research Ethics Committee (approval number: BE565/17). Permission was obtained from the Upper East Regional Health Directorate prior to the conduct of this study. All study participants also signed an informed consent prior to participating in the study. This is a cross-sectional study, which involved an audit of the role of supply chain management of POC diagnostic test accessibility in rural PHC clinics in the UER of Ghana. This current study is a follow-up on a prior study involving 100 rural PHC clinics from all 13 districts aimed at assessing the accessibility of POC diagnostic services for maternal health in rural PHC clinics in the UER [13]. The findings of the previous study demonstrated low availability of POC test (less than 5 tests for most of the clinics. Supply chain management was found to be a major barrier hence; informing our decision to conduct this follow-up study to audit the supply chain management for POC diagnostic tests to determine the reasons for POC tests deficiencies. This study was conducted in the UER of Ghana. The region was chosen because it is the least (21%) urbanized in Ghana with a maternal mortality ratio of 108/100000 live births [20]. It is located in the north-eastern corner of Ghana, bordered by Burkina Faso to the north, Togo and the Upper West Region to the east and west respectively, and the Northern Region to the south. The region had 1188800 people in 2016 and is considered largely (79%) rural and scattered in dispersed settlements [20]. The main source of income for the majority of the population is farming. The region is divided into 13 administrative districts (Fig 1) and all were used in this study. This was a follow-up study to a prior study aimed at assessing the accessibility of POC diagnostic services for maternal healthcare in rural health facilities in the UER, Ghana [13]. The previous study used a multistage sampling strategy comprising stratified sampling, probability proportionate to size and simple random sampling to select 100 rural PHC clinics with representation from all the thirteen districts in the UER. All 100 PHC clinics were surveyed in this current study. This study was conducted from February to April 2018, using an audit tool adopted from Management Science for Health (MSH) laboratory diagnostic supply chain management [17] and WHO guidelines for selection of POC tests for rural PHC clinics [18]. The audit tool (S1 Table) was pre-tested in ten non-participating rural PHC clinics in the UER and adjusted to suit the local context based on feedback from respondents. The audit tool consisted of a set of questions, each aimed to assess the selection, inventory management, distribution, and human resource capacity for POC testing in the selected PHC clinics. In order to ensure the accuracy of the audit, the PHC clinics managers/supervisors were informed about the purpose of the audit and the procedures that would be followed. Data on the selection of POC diagnostics was obtained based on the WHO quality-ASSURED criteria for POC diagnostic selection for rural PHC clinics [18]. Data on the distribution of POC diagnostics, POC diagnostics storage and inventory management, and human resource capacity for POC testing were obtained using the audit tool in order to investigate the supply chain management of POC diagnostic tests of the selected rural PHC clinics. We also obtained data on stock levels of eight (8) POC tests: HIV, malaria, syphilis, haemoglobin, urine protein/albumin, urine pregnancy, blood glucose, and hepatitis B, in order to investigate deficiency and determine its relationship with the supply chain management. These tests were the top eight POC tests in the majority of the PHC clinics. These POC tests are also included in the first WHO essential list of diagnostics for resource-limited settings [1]. Finally, we took data on the average clinic attendance per month to facilitate the determination of the relationship between clinic attendance and POC test stock-out. The primary outcome of this study included supply chain management and stock levels of POC tests in all selected PHC clinics in the UER of Ghana. For supply chain management, one point (100%) was allotted to each question if all the requirements for the question were fulfilled for each of the components. A sum of the scores for each component was obtained to provide the overall percentage score. A score of 90 to 100% was considered “compliant” supply chain management, indicating strong, reliable, and satisfactory compliance with the stipulated guidelines. A rating of less than 90% was considered “non-compliant” supply chain management, indicating unsatisfactory compliance of the clinic to the stipulated MSH and the WHO guidelines. POC test stock-out was measured as either “Yes” or “No” of HIV test, malaria test, syphilis test, haemoglobin test, urine protein/albumin test, urine pregnancy test, blood glucose test, and hepatitis B test. That is, Yes = availability of test, and No = complete stock-out of test. Clinic attendance was measured as: 0–100 patients/clients per month = low attendance and > 100/month = high attendance. Data were analysed using Stata version 14. Frequencies, means, standard deviation as well as 95% confidence intervals (CI) were calculated for all eight POC tests audited. We used Univariate logistic regression to associate the independent (reasons for test stock-outs) variables with the dependent variable (POC tests for HIV, malaria, syphilis, haemoglobin, urine protein/albumin, urine pregnancy, blood glucose, and hepatitis B test) and p<0.05 was reported. Data from this study are the property of the University of KwaZulu-Natal and can be made publicly available. All interested researchers/readers/persons who meet the criteria for access to confidential data can access the dataset via Dr Tivani Mashamba-Thompson, the project supervisor and the Academic Leader (Research) for the School of Nursing and Public Health via this email address: az.ca.nzku@nospmohT-abmahsaM. Data access may also be requested from the University of KwaZulu-Natal Biomedical Research Ethics Committee (BREC) from the following contacts: The Chairperson BIOMEDICAL RESEARCH ETHICS ADMINISTRATION Research Office, Westville Campus, Govan Mbeki Building University of KwaZulu-Natal P/Bag {"type":"entrez-nucleotide","attrs":{"text":"X54001","term_id":"2135","term_text":"X54001"}}X54001, Durban, 4000 KwaZulu-Natal, South Africa Tel.: +27 31 260 4769 Fax: +27 31 260 4609 Email: az.ca.nzku@CERB.

Based on the information provided, here are some potential innovations that could improve access to maternal health in the context of poor supply chain management and stock-outs of point-of-care diagnostic tests in primary healthcare clinics in Ghana:

1. Implement a robust inventory management system: Develop and implement a digital inventory management system that tracks the availability and expiration dates of point-of-care diagnostic tests in real-time. This system can help clinics monitor stock levels, anticipate shortages, and ensure timely replenishment.

2. Strengthen supply chain coordination: Establish a centralized supply chain coordination mechanism that involves collaboration between the Regional Medical and District Health Directorates, clinics, and suppliers. This coordination can help streamline the procurement, distribution, and monitoring of point-of-care diagnostic tests, reducing stock-outs and improving accessibility.

3. Enhance training and capacity-building: Provide comprehensive training and capacity-building programs for healthcare workers involved in supply chain management. This can include training on inventory management, data recording and reporting, and quality assurance practices. By improving the skills and knowledge of healthcare workers, the efficiency and effectiveness of the supply chain can be enhanced.

4. Implement demand forecasting: Develop a system for forecasting the demand for point-of-care diagnostic tests based on clinic attendance and historical data. This can help clinics anticipate the quantity of tests needed and ensure an adequate supply is available, reducing the risk of stock-outs.

5. Improve data management and documentation: Implement a standardized system for documenting and tracking the usage, expiration, and loss of point-of-care diagnostic tests. Accurate and up-to-date data can help identify trends, identify areas for improvement, and ensure accountability in the supply chain.

6. Strengthen monitoring and evaluation: Establish a regular monitoring and evaluation system to assess the performance of the supply chain management for point-of-care diagnostic tests. This can include routine audits, data analysis, and feedback mechanisms to identify gaps and implement corrective actions.

7. Explore alternative diagnostic technologies: Investigate the feasibility of using alternative diagnostic technologies, such as rapid diagnostic tests or mobile health applications, that are more resilient to supply chain challenges. These technologies may offer more accessible and cost-effective solutions for maternal health diagnostics in resource-limited settings.

It is important to note that the implementation of these innovations should be context-specific and tailored to the specific challenges and needs of the primary healthcare clinics in the Upper East Region of Ghana.
AI Innovations Description
The recommendation to improve access to maternal health in the Upper East Region of Ghana is to address the poor supply chain management and stock-outs of point-of-care diagnostic tests in primary healthcare clinics. This can be achieved through the following steps:

1. Strengthen inventory management: Implement robust systems for tracking and managing inventory levels of point-of-care diagnostic tests. This includes regular monitoring of stock levels, timely reordering, and proper documentation of expiry dates to prevent wastage.

2. Improve distribution guidelines: Ensure that there is an efficient and reliable distribution system in place to deliver diagnostic tests to primary healthcare clinics in a timely manner. This may involve establishing partnerships with reliable suppliers and optimizing transportation logistics.

3. Enhance monitoring and supervision: Provide training and support to healthcare workers in primary healthcare clinics to improve their capacity in managing and monitoring the supply chain for diagnostic tests. Regular supervision and feedback can help identify and address any gaps or challenges.

4. Increase human resource capacity: Allocate sufficient human resources to manage the supply chain for diagnostic tests. This may involve hiring additional staff or providing training to existing staff to ensure they have the necessary skills and knowledge.

5. Implement data management systems: Establish a centralized data management system to track and analyze data on diagnostic test availability, stock levels, and usage. This can help identify trends, predict demand, and inform decision-making.

By implementing these recommendations, the supply chain management for point-of-care diagnostic tests can be improved, leading to better availability and accessibility of maternal health services in the Upper East Region of Ghana.
AI Innovations Methodology
Based on the provided information, the study focuses on the poor supply chain management and stock-outs of point-of-care diagnostic tests in primary healthcare clinics in the Upper East Region of Ghana. The goal is to improve access to maternal health services in these clinics.

To simulate the impact of recommendations on improving access to maternal health, the following methodology can be used:

1. Identify potential recommendations: Based on the findings of the study, potential recommendations can be identified to address the supply chain management and stock-out issues. These recommendations may include improving inventory management, enhancing human resource capacity, implementing better monitoring systems, ensuring documentation of expiry dates, and addressing unexplained losses of diagnostic tests.

2. Develop a simulation model: A simulation model can be developed to assess the impact of the identified recommendations on improving access to maternal health. The model should consider factors such as clinic attendance, stock levels of diagnostic tests, and compliance with supply chain management guidelines.

3. Define input parameters: The simulation model should define input parameters such as clinic attendance rates, stock levels of diagnostic tests, and compliance scores for supply chain management. These parameters can be based on the data collected during the study.

4. Run simulations: The simulation model can be run multiple times with different scenarios to simulate the impact of the recommendations. For example, the model can simulate the effect of improving inventory management on reducing stock-outs of diagnostic tests and increasing their availability in the clinics.

5. Analyze results: The results of the simulations can be analyzed to determine the impact of the recommendations on improving access to maternal health. This analysis can include metrics such as the reduction in stock-outs, increase in availability of diagnostic tests, and improvement in compliance with supply chain management guidelines.

6. Validate the model: The simulation model should be validated by comparing the simulated results with real-world data. This validation process ensures the accuracy and reliability of the model in predicting the impact of the recommendations.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of implementing specific recommendations to improve access to maternal health services. This information can guide decision-making and resource allocation to address the supply chain challenges and ultimately enhance maternal healthcare in the Upper East Region of Ghana.

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