Applying Lessons Learned from the Birmingham Free Clinic Dispensary to Inform Pharmaceutical Supply Chain Management in Low-Resource Settings

Ensuring an uninterrupted supply of drugs is a critical part of providing healthcare in a low-resource setting. Therapeutics is an essential component of every health system and largely relies on accurate and timely management of the drug supply chain. Stock outs are frequently encountered in these settings and can result in detrimental effects on patient care, not only poor outcomes but also drug-resistance in the cases of chronic diseases like HIV and TB. The drug supply chain includes procurement, shipping, storage and dispensing medication to patients. Accurate information on current stock counts and projections of future medication requirements is necessary to minimize stock outs and expired stock, keeping critical drugs on the shelves and preventing low-usage medications from expiring. A common approach to tracking the shipment and use of drug supplies in developing countries is to calculate the amount of drugs that enter and leave the warehouse each month. In addition, the daily or weekly consumption of medications needs to be tracked in the pharmacies to project upcoming demand on the warehouse. While this approach may be effective in certain environments, it often fails to gather accurate data regarding daily consumption at the health facility level, which may lead to inadequate drug supplies and stock outs. Capturing consumption data at the health facility would significantly contribute to an uninterrupted medication supply chain in low-resource settings. The doctoral work described here builds on my master's research developing a prototype system for Prescription Management and General Inventory Control (RxMAGIC) at the Birmingham Free Clinic (BFC) in Pittsburgh, PA, USA, a free, walk-in clinic that services medically vulnerable populations through the use of volunteer providers and an on-site medication dispensary. Volunteer pharmacists at the BFC recognized challenges in certain areas of their workflow surrounding the medication management processes, which can primarily be attributed to their use of a paper-based inventory management and dispensing system. To inform the design of a problem-driven solution, we used a mixed-methods approach to identify and quantify process inefficiencies in the dispensary. Contextual inquiry was used to document workflow and produce themes describing workflow challenges. A time-motion study was completed to quantitatively assess how much time pharmacists spend on tasks. These studies uncovered inefficiencies that may benefit from the introduction of a management information system, including: handwritten medication labeling, insufficient process notification, redundant documentation, and a lack of inventory control. We developed RxMAGIC to mitigate workflow challenges by streamlining the dispensing process and improving medication management and inventory control. The Center for Health Informatics for the Underserved has a longstanding relationship with the Ministry of Health (MoH) in Malawi, Africa. This 15-year collaboration has resulted in the development and deployment of health information technology interventions in more than 60 Malawian hospitals. The Malawi Health Sector Strategic Plan describes the drug supply chain as a challenging area for the MoH. This doctoral research focuses on designing, developing and evaluating a supply chain management system that links to service delivery in health facilities, utilizing electronic dispensing to quantify consumption. Lean management principles have been adopted for use in the healthcare domain and are grounded in the concept of continuous improvement, an approach that systematically seeks to achieve incremental changes in processes to improve efficiency and quality while reducing costs. We plan to use value stream mapping, a lean-management method for analyzing the current state and designing a future state for the series of events that take a product or service from its beginning through to the customer, to design and develop a simple and sustainable electronic pharmacy supply chain management system to track drug acquisition, storage, distribution, and utilization. Value stream mapping will facilitate the identification of waste in the therapeutics value chain, allowing us to redesign the workflow, eliminate waste, and standardize the process before developing and implementing a technological intervention. Although RxMAGIC was developed in the context of the BFC dispensary, we believe the medication management challenges, while at different magnitudes, are similar in a low-income country to those in a low-resource setting in the United States. We plan to generalize aspects and principles of RxMAGIC to manage drug supply chain in Malawi. We hypothesize that pharmacy informatics interventions designed to alleviate these challenges can be successful both domestically and internationally.