Managing the essential medicines stock at rural healthcare systems in India.

PURPOSE: The purpose of this paper is to eliminate the medicine stock-out problem by building an optimum medicine stock in rural healthcare centers in India. DESIGN/METHODOLOGY/APPROACH: Data associated with inflow and outflow of a specific medicine (folic acid tablets) arer collected from all consecutive supply chain stages during the survey. While conducting the survey, it is found that several medicines are out of stock owing to uncertain lead time and demand. Integrating with quantity discount and min-max ( s, S) inventory policy, two models are developed using system dynamics: one is Model 1 with constant lead time and uncertain demand, and the other is Model 2 with both uncertain lead time and demand. FINDINGS: Both models are simulated for a period of one year on Stella 9.1 platform. The results are compared with actual data, and the comparison shows significant improvement of the medicine stock at all downstream stages, while maintaining a certain safety stock. Further, Model 2 suggests a larger stock than Model 1 at each point of time. PRACTICAL IMPLICATIONS: Despite numerous issues, the stocks of medicine in rural healthcare systems can be improved as suggested by the models. The models depict the behavior of inventory stock at each stage of the supply chain and act as a function of time that could be used in the form of a prediction tool for the policymakers. ORIGINALITY/VALUE: This paper is one of the first papers that had developed the model of the medicine supply chain in rural parts of a developing country. It provides a generic framework for the stock assessment and improvement throughout the supply chain.

Effect of high dose folic acid supplementation in pregnancy on pre-eclampsia (FACT): double blind, phase III, randomised controlled, international, multicentre trial.

OBJECTIVE: To determine the efficacy of high dose folic acid supplementation for prevention of pre-eclampsia in women with at least one risk factor: pre-existing hypertension, prepregnancy diabetes (type 1 or 2), twin pregnancy, pre-eclampsia in a previous pregnancy, or body mass index ≥35. DESIGN: Randomised, phase III, double blinded international, multicentre clinical trial. SETTING: 70 obstetrical centres in five countries (Argentina, Australia, Canada, Jamaica, and UK). PARTICIPANTS: 2464 pregnant women with at least one high risk factor for pre-eclampsia were randomised between 2011 and 2015 (1144 to the folic acid group and 1157 to the placebo group); 2301 were included in the intention to treat analyses. INTERVENTION: Eligible women were randomised to receive either daily high dose folic acid (four 1.0 mg oral tablets) or placebo from eight weeks of gestation to the end of week 16 of gestation until delivery. Clinicians, participants, adjudicators, and study staff were masked to study treatment allocation. MAIN OUTCOME MEASURE: The primary outcome was pre-eclampsia, defined as hypertension presenting after 20 weeks' gestation with major proteinuria or HELLP syndrome (haemolysis, elevated liver enzymes, low platelets). RESULTS: Pre-eclampsia occurred in 169/1144 (14.8%) women in the folic acid group and 156/1157 (13.5%) in the placebo group (relative risk 1.10, 95% confidence interval 0.90 to 1.34; P=0.37). There was no evidence of differences between the groups for any other adverse maternal or neonatal outcomes. CONCLUSION: Supplementation with 4.0 mg/day folic acid beyond the first trimester does not prevent pre-eclampsia in women at high risk for this condition. TRIAL REGISTRATION: Current Controlled Trials ISRCTN23781770 and ClinicalTrials.gov NCT01355159.

Identifying bottlenecks in the iron and folic acid supply chain in Bihar, India: a mixed-methods study.

BACKGROUND: Maternal anaemia prevalence in Bihar, India remains high despite government mandated iron supplementation targeting pregnant women. Inadequate supply has been identified as a potential barrier to iron and folic acid (IFA) receipt. Our study objective was to examine the government health system's IFA supply and distribution system and identify bottlenecks contributing to insufficient IFA supply. METHODS: Primary data collection was conducted in November 2011 and July 2012 across 8 districts in Bihar, India. A cross-sectional, observational, mixed methods approach was utilized. Auxiliary Nurse Midwives were surveyed on current IFA supply and practices. In-depth interviews (n = 59) were conducted with health workers at state, district, block, health sub-centre, and village levels. RESULTS: Overall, 44% of Auxiliary Nurse Midwives were out of IFA stock. Stock levels and supply chain practices varied greatly across districts. Qualitative data revealed specific bottlenecks impacting IFA forecasting, procurement, storage, disposal, lack of personnel, and few training opportunities for key players in the supply chain. CONCLUSIONS: Inadequate IFA supply is a major constraint to the IFA supplementation program, the extent of which varies widely across districts. Improvements at all levels of infrastructure, practices, and effective monitoring will be critical to strengthen the IFA supply chain in Bihar.

Lessons learned from implementation of a demonstration program to reduce the burden of anemia and hookworm in women in Yen Bai Province, Viet Nam.

BACKGROUND: Iron deficiency, anemia and hookworm disease are important public health problems for women of reproductive age living in developing countries and affect the health of newborns and infants. Iron supplementation and deworming treatment are effective in addressing these problems in both pregnant and non-pregnant women. Daily iron supplementation and deworming after the first trimester is recommended for pregnant women although these programs usually do not operate efficiently or effectively. Weekly iron-folic acid supplementation and regular deworming for non-pregnant women may be a viable approach for improving iron status and preventing anemia during the reproductive years. Addressing these diseases at a population level before women become pregnant could significantly improve women's health before and during pregnancy, as well as their infants' growth and development. METHODS AND RESULTS: This paper describes the major processes undertaken in a demonstration intervention of preventive weekly iron-folic acid supplementation with regular deworming for all 52,000 women aged 15-45 years in two districts of Yen Bai province, in northern Viet Nam. The intervention strategy included extensive consultation with community leaders and village, commune, district and provincial health staff, and training for village health workers. Distribution of the drugs was integrated with the existing health service infrastructure and the village health workers were the direct point of contact with women. Iron-folic acid tablets and deworming treatment were provided free of charge from May 2006. An independent Vietnamese NGO was commissioned to evaluate compliance and identify potential problems. The program resulted in effective distribution of iron-folic acid tablets and deworming treatment to all villages in the target districts, with full or partial compliance of 85%. CONCLUSION: Training for health staff, the strong commitment of all partners and the use of appropriate educational materials led to broad support for weekly iron-folic acid supplementation and high participation in the regular deworming days. In March 2008 the program was expanded to all districts in the province, a target population of approximately 250,000 WRA, and management was handed over to provincial authorities.

Providing iron/folic acid tablets free of charge improves compliance in pregnant women in Senegal.

Iron (Fe) deficiency and anemia during pregnancy remain highly prevalent in Senegal because of low compliance with Fe supplementation. Improving women's access to supplements may increase compliance. Six prenatal centers in Dakar were randomly assigned to either a control group in which women received routine prenatal visits, including prescriptions to purchase iron/folic acid tablets (IFA) according to the guidelines of the current Senegalese supplementation program (n=112), or to an intervention group in which women received free IFA (n=109) in addition to routine prenatal care. Compliance was assessed 20 weeks after enrollment by pill count and interviews. Hemoglobin, erythrocyte protoporphyrin and serum ferritin were measured at baseline and follow-up. Compliance was 48% and 86% in the control and intervention groups, respectively (P<0.001). After adjustment for confounding, prevalence of anemia was 62% in the control group versus 31% in the intervention group (P<0.001); prevalence of Fe deficiency was 49% and 21% in the control and intervention groups, respectively (P<0.001). Improving access to IFA for pregnant women visiting health centers could dramatically increase their compliance, improve Fe status and decrease the incidence of anemia.

Why do adult women in Vietnam take iron tablets?

BACKGROUND: Conducting iron supplementation programs has been a major strategy to reduce iron deficiency anemia in pregnancy. However, only a few countries have reported improvements in the anemia rate at a national level. The strategies used for control of nutrition problems need regular review to maintain and improve their effectiveness. The objective of this study was to analyze the factors in compliance with taking iron tablets, where daily doses of iron (60 mg) and folic acid (400 microg) were distributed in rural Vietnamese communes. METHODS: A cross sectional survey was conducted in Nghe An province, Vietnam in January, 2003. The study population was adult women aged less than 35 years who delivered babies between August 1st 2001 and December 1st 2002 (n = 205), of which 159 took part in the study. Data for the study were collected from a series of workshops with community leaders, focus group discussions with community members and a questionnaire survey. RESULTS: Improvements in the rate of anemia was not given a high priority as one of the commune's needs, but the participants still made efforts to continue taking iron tablets. Two major factors motivated the participants to continue taking iron tablets; their experience of fewer spells of dizziness (50%), and their concern for the health of their newborn baby (54%). When examining the reasons for taking iron tablets for at least 5-9 months, the most important factor was identified as 'a frequent supply of iron tablets' (OR = 11.93, 95% CI: 4.33-32.85). CONCLUSION: The study found that multiple poor environmental risk factors discouraged women from taking iron tablets continuously. The availability (frequent supply) of iron tablets was the most effective way to help adult women to continue taking iron tablets.