MINISTRY OF HEALTH LIP-H PROGRAM

Strategic problem solving to decrease stock out days of nutrition medical commodities: The case of
felegehiwot comprensive specialized hospital, Bahirdar, Ethiopia

By:-

1. TAZEBEW ALEMU

2. HIWOT TILAHUN

JULY 1, 2022
BAHIR-DAR, ETHIOPIA

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Contents
ABSTRACT...................................................................................................................................................iii
ACKNOWLEDGEMENTS........................................................................................................................iv
CHAPTER ONE: BACKGROUND............................................................................................................1
1.1. INTRODUCTION............................................................................................................................1
1.2. STATEMENT OF THE PROBLEM..................................................................................................21
1.3. SIGNIFICANCE OF THE PROJECT.................................................................................................21
CHAPTER TWO: OBJECTIVES.............................................................................................................22
CHAPTER THREE: ROOT CAUSE ANALYSIS....................................................................................22
CHAPTER FOUR: LITRATURE REVIEW.............................................................................................24
CHAPTER FIVE: METHODS AND MATERIALS.................................................................................26
5.1. STUDY AREA AND PERIOD..............................................................................................................26
5.2. STUDY DESIGN................................................................................................................................26
5.3. POPULATION...................................................................................................................................26
5.4. SAMPLE SIZE AND SAMPLING TECHNIQUE/SAMPLING PROCEDURE..............................................26
5.5. DATA COLLECTION PROCEDURES (INSTRUMENT, PERSONEL AND TECHNIQUE)............................27
5.6. STUDY VARIABLES...........................................................................................................................27
5.7. OPERATIONAL DEFINITION.............................................................................................................27
5.8. DATA ANALYSIS PROCEDURE..........................................................................................................28
5.9. ETHICAL CONSIDERATION...............................................................................................................28
5.10. DISSEMINATION PLAN..................................................................................................................28
CHAPTER SIX: ALTERNATIVE INTERVENTION.............................................................................................29
6.1. Choosing the best alternative solution.......................................................................................29
6.2. Adapt and customized HIV/RTK RRF system is the best alternative solution...........................30
CHAPTER SEVEN: PROJECT IMPLEMENTATION............................................................................30
CHAPTER EIGHT: RESULTS (PRE-POST INTERVENTION EVALAUTION)...................................31
8.1. PRE-INTERVENTION RESULT...........................................................................................................31
8.2. POST-INTERVENTION RESULT.........................................................................................................31
CHAPTER TEN: CONCLUSION AND RECOMMENDATION...........................................................................34
CHAPTER ELEVEN: COST OF THE PROJECT.................................................................................................34
REFERENCES..............................................................................................................................................35

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APPENDICES/ANNEXES..............................................................................................................................35

List of tables and figures

Table 1 Root cause verification................................................................................................................23

Table 2 Interventions Comparison matrix................................................................................................29
Table 3 Stock out duration status at Felegehiwot and Adisalem hospital before implementation of the
capstone project:-.....................................................................................................................................31
Table 4 Project implementation plan.......................................................................................................36

Figure 1 Fish bone Diagram......................................................................................................................22

ABSTRACT

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BACKGROUND: Stock out and Shortage of nutritional medical commodities at health facilities
of developing countries is the main factor for poor quality of health services for under five
children and lactating mothers. Despite Ethiopia aimed to achieve MD4 goal (reducing child
mortality) and had good progress, there is high mortality of children that caused by shortage and
stock out of essential medicines including nutritional medical commodities. As a country, there is
integrated logistics management system aimed to strengthen supply chain management system of
the country that ensures consistent availability of essential medicines at health facilities.
However, Nutritional medical commodities such as Plumpy nut, F-100 and F-75 are not
integrated to the national system which results high stock out of these medicines are the
consistence challenge at health facilities that results children mortality as reported by eye
witness. Thus, there should be regional effective and efficient management system of nutritional
medical commodities until these products integrated to the national system
PROJECT OBJECTIVE: The main objective of this capstone project to decrease average stock out
days of nutritional medical supplies by 25 % at Felegehiwot Comprhensive specialized hospital
and Adisalem primary hospital of Amhara region, at the end of October 2022
METHODOLOGY: Strategic problem solving technique and procedures were employed. All
relevant stakeholders at regional health bureau, zonal health departments and hospitals were
engaged and designed a tool called “Logistic and morbidity data reconciled Monthly Report
and Requisition Form - For Nutritional Medical products” adapted and customized from
HIV/RTK RRF system. Baseline and magnitude of the problem data were collected using standard
checklist. This system is implemented and monitored prospectively at Felegehiwot comprehensive
specialized hospital and Adisalem primary hospital. Data analysis was done using Microsoft Excel 2010.
RESULTS: The average stock out days of nutritional medical products decreased from 0.65 to
0.54(by 20%) and from 0.8 to 0.67(by 17%) at Felegehiwot comprehensive specialized hospital
and Adisalem primary hospital respectively.
CONCLUSION:- Logistic and morbidity data reconciled Monthly Report and Requisition Form -
For Nutritional Medical products has been significantly minimize stock out days of nutritional
products. So that it should be scaled up to other public health facilities of Amhara region
Key words: Stock out day, nutritional medical products

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ACKNOWLEDGEMENTS

First, we would like to thank God and his mother, St. merry without whom anything is possible.

We would like to thank beloved sister and our Leadership incubation program for health 4 th
cohort coordinator Mrs. Nurhan Tofik for her unreserved advice and strong support throughout
the session. Her effort and commitment to change us was unforgettable and possible to say she
by herself was our lesson for many things.

We also very grateful to our coach Dr. Rute Nigatu, FMOH Minster secriaterait office head,
Sualiha.Abdulkader, from IPHCE and our shadowing program lead, Dr. Firew Tegegn, Presidant
of Bahirdar university for their unreserved support to coach and sharing their leadership skill by
practice

At last but not the least, our appreciation goes to our Trainers who taught us the session and participants
as trainee who shares their experiences throughout our stay and our bureau, Amhara regional health
bureau who facilitate and understand to take the program.

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CHAPTER ONE: BACKGROUND

1.1. INTRODUCTION
Amhara regional state is the second most populous region in the country. 79.9% of the
population derives its livelihood from agriculture and related activities. Administrative Division
is 21 Zones, 238 Woreda, 98 public hospitals, and more than 917 health center (1)
Stock out and Shortage of essential medicines including nutritional medical commodities at
health facilities of developing countries is the main factor for poor quality of health services(2).
Stock out and shortage of nutritional commodities in Ethiopia is one of the main reason
identified that results high mortality of children (3)However, it is the aim of every country to
achieve MDG4 (reducing child mortality)(4) . In order to achieve this goal, there should be
adequate supply of essential nutritional medical supplies which are needed for efficient and
effective service delivery at health service delivery point(5). Thus, there should be Effective and
efficient nutritional commodities supply chain system to decrease child mortality ((6)(7)).

Amhara regional health bureau in collaboration with UNICEF-Ethiopia has made great effort to
provide quality health services for malnutrition children’s by ensuring consistent availability of
nutrition medical commodities(8). However, stock out of essential nutritional commodities is a
consistent challenge that is reported by health facilities at Bahirdar city particularly at
Felegehiwot comprehensive specialized hospital ((5), (8)).

Strengthening nutritional commodities supply chain management at health facilities is essential

to ensure consistent availability of nutritional commodities that are important to provide quality
health services. In addition, Consistent availability and ensuring its rational use is very crucial to
provide quality health care to fewer than five years children. However, it is also reported that
irrational nutritional medical supplies a bottle neck that exacerbated stock out of commodities
(8).

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Felegehiwot comprehensive specialized
hospital is one of the three hospitals in Felegehiwot Comprehensive Specialized
Bahir-dar town of which higher number of hospital and Adisalem primary hospital
malnutrition cases get treatment. Despite report malnutrition cases to Regional health
higher number of malnutrition cases at bureau monthly to nutrition case team.
felegehiwot, hospital stock out of essential Nutrition case team aggregate and provide
nutritional medical commodities is the request of nutritional medical products from
consistent challenge to provide quality UNICEF-Ethiopia quarterly.
health care to malnutrition children. Thus,
strengthening supply chain management at UNICEF Ethiopia allocates nutrition
hospital and ensuring its rational use commodities to respective zonal health
mandatory to ensure its consistent departments including Bahiradar ZHD to
availability (6) serve health facilities found in the city. Thus,
Felegehiwot Comprehensive specialized
A. The existing nutritional hospital and Adisalem primary hospital
commodities supply chain system receive its product from Bahiradr ZHD by
at Felegehiwot and Adisalem
requesting with official letter. Mostly zonal
hospital
health department allocate nutrition
commodities without considering
consumption and morbidity data that results
frequent stock outs of essential nutritional
commodities that negatively affects quality
of health care of children

Thus, implementing systems that

strengthening supply chain of nutritional
medical supplies and its rational use is
should be secured at all level of the system

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1.2. STATEMENT OF THE PROBLEM

High Stock out days of nutritional medical products at Felegehiwot comprehensive specialized hospital
and Adisalem primary hospital

1.3. SIGNIFICANCE OF THE PROJECT

It is known that strengthening nutritional commodities supply chain management system at

health facilities is essential to ensure consistent availability of nutritional commodities that are
important to provide quality health services. However, there is no system on Plumpynut, F-100
and F-75 management that resulted frequent stock out, wastage and irrational use at different
health facilities of the region. To alleviate this problem, Strategic problem solving technique was
employed to design system that will strengthen supply chain management of the nutritional
medical products that have a significant contribution to minimize the average stock out days at
public hospital of felegehiwot and Adisalem hospital

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 CHAPTER TWO: OBJECTIVES

To decrease average stock out days of nutritional medical products by 25 % (from average 0.65
stock out days to 0.45 stock out days and from average 0.8 stock out days to 0.6 stock out days
at Felegehiwot and Adisalem primary hospital respectively) at the end of October 2022

CHAPTER THREE: ROOT CAUSE ANALYSIS

Root cause analysis is done by fish bone diagram method by engaging important stakeholders that
potentially involved on the area of nutrition medical commodities supply chain management. Pharmacy
professionals at PMED, Nutrition case team, Bahirdar Town ZHD, and Adisalem primary hospital are
participated to identify possible root cause of the problem. The main root causes are thermalized in 4
categories as shown below by fish bone diagram

Figure 1 Fish bone Diagram

People

Environment Lack of trained personnel

-Lack of suppliers Poor management ownership

Lack of storage space Poor adherence to STG

Theft for market

High
Stock
Policy Equipment

Lack of Logistic management system - Wastage

reconciled with morbidity data - Lack of
transportation
Lack of rules and regulation
- Lack of Technology to
manage the products

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List of root causes identified by stakeholders are verified by using standard check list and
observation to identify the real root cause. The detail result of verification shown below in the
table
Table 1 Root cause verification
.N Root Cause Method Accept/Reject
1 Lack of trained personnel questionnaire Reject
2 Lack of adherence to STG questionnaire Accept
3 Lack of management ownership questionnaire Reject

4 Lack of logistic management system reconciled questionnaire Accept

with morbidity data
5 Lack of technology for managing medical supplies observation Reject
6 Lack of vehicle for transportation questionnaire Reject

7 Lack of storage space observation Reject

8 Lack of suppliers questionnaire Reject

Root cause verification showed that Lack of adherence STG and Lack of logistic management
system reconciled with morbidity data were the main root cause for high stock out days of
nutritional products at hospitals. Despite the two root causes are identified, the stakeholders
agreed that Lack of logistic management system reconciled with morbidity data is the major
root cause for high stock out as compared with Lack of adherence to STG.

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CHAPTER FOUR: LITRATURE REVIEW

1. Study conducted at university of Gondar comprehensive specialized hospital showed

that the effective logistic management practice resulted high availability essential
medicine that improves quality health service(9).
2. Study conducted at Adama town showed that poor inventory management practices
influences availability of essential medicines at health facilities. The average stocked
out days of tracer medicines at six health centers of Adama Town was 73.9 days(10).
3. Ministry of health of Ethiopia developed standardized inventory management tools
expected to be utilized by public health facilities throughout the country whether
operated manually or use Logistic management information system however some of
nutritional products are not included to system (6)(11).
4. As per the WHO recommendation, availability of EMs should be 100%, but it is
estimated that about one-third of the world population does not have access to
medicines, particularly in Africa and Asia (12)(13)
5. The study conducted in shegaw mota hospital and mota health center showed that the
average stock-out duration of essential medicines in the last six months period was 38.8
days (ranges from 10 days to 157 days) in the hospital and 11.2 days in the health
center(14).
6. The provision of quality health services can be adversely affected by a stock-out of
even a small number of essential medicines. Health service readiness is impacted by
stock-outs, since clinics without consistent and adequate availability of essential
medicines cannot provide quality care(15,16).
7. It is essential to understand the degree, reasons for, and implication of stock-outs of
essential medicines at different healthcare levels in order to optimize quality of care.
Approximately one-third of the world’s population lacks regular access to full and
effective treatment with the necessary medicine (16).
8. Severe acute malnutrition is critical health problem in under-five aged children in all
over world. Globally, an estimated 20 million children are suffering from Severe Acute
Malnutrition (SAM)(17).

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 9. The World health organization standards for the treatment of malnutrition in children
specify the use of two formulas during initial treatment F-75 and F-100 and ready to
use therapeutic food (Plumpy nut).(17)
10. Malnutrition in children under-five years is an important public health issue that
contributes greatly to morbidity among children globally and there is insufficient
progress to achieve the Sustainable Development Goals(18).
11. A study in Uganda pointed out that several factors influenced the availability of EMs.
Out of this drug requisitions based on neither morbidity nor consumption methods of
quantification(19).

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CHAPTER FIVE: METHODS AND MATERIALS

5.1. STUDY AREA AND PERIOD

This capstone project has been implemented at public hospital of Felegehiwot comprehensive
specialized hospital and Adisalem Primary hospital found at Bahirdar town starting from
Nehasie20/2015 E.C. Bahirdar is the capital city of Amhara national regional state of Ethiopia,
564 km away from Addis Ababa, the capital city of Ethiopia. In the town there are 3 public
hospitals and 10 public health centers.

5.2. STUDY DESIGN

Institution based strategic problem solving technique and procedures were employed. Relevant
stakeholders at regional health bureau, zonal health departments and hospitals were engaged and
identified the root cause of high stock out days of nutritional medical products. The best
intervention identified out of alternatives called “Logistic and morbidity data reconciled
Monthly Report and Requisition Form - For Nutritional Medical products” designed and
implemented at the two hospitals and has been followed the progress.

5.3. POPULATION

The study population of this project was public hospitals with high stock out days of nutritional
medical products at Bahirdar town which are Felegehiwot Comprehensive specialize hospital
and Adisalem primary hospital.
Nutritional medical products which are not integrated to national logistic management
information system are incorporated to this project. These are Plumpy nut, F-100 and F-75 which
are critical to severely malnutritioned under five children.

5.4. SAMPLE SIZE AND SAMPLING TECHNIQUE/SAMPLING PROCEDURE

The two public hospitals with high stock out days of nutritional medical products were purposely
selected. All nutritional medical products which are not managed by the national logistic
management information system are included in this study.

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5.5. DATA COLLECTION PROCEDURES (INSTRUMENT, PERSONEL AND
TECHNIQUE)
A structured questionnaire adapted from Logistics Indicator Assessment Tool (LIAT ) and
designed standard check list from the health sector transformational plan of Ethiopia were used
to collect data to assess the magnitude of high stock out days at Felegehiwot specialized hospital
and Adisalem primary hospital before the project implementation and After the implementation
to assess the progress.

In addition, as intervention of the problem a standard tool called “Logistic and morbidity data
reconciled Monthly Report and Requisition Form - For Nutritional Medical products”
designed and implemented at the two public hospital Logistic and morbidity data reconciled
Monthly Report and Requisition Form - For Nutritional Medical products” adapted and
customized from the national HIV/RTK RRF system of Ethiopia . This system is implemented
and monitored prospectively at Felegehiwot comprehensive specialized hospital and Adisalem
primary hospital
The Data was collected by two project owner professionals working at Amhara regional health
bureau. Data quality was assured by pretesting at Han health center to ensure data quality of
actual project baseline and post intervention.

5.6. STUDY VARIABLES

Stock out duration is the dependent variable and Implementing Logistic and morbidity data
reconciled Monthly Report and Requisition Form - For Nutritional Medical products is
independent variable of the project

5.7. OPERATIONAL DEFINITION

Nutritional commodities: _Refers Plumpy nut, F-100 and F-75 commodities

Stock out days: The number of days at which nutritional commodities stocked out during the
reporting period
Average stock out days:- Refers to the average of total number of stock out days of all
nutritional commodities during the reporting period per total number of days of all nutritional
commodities’ during the reporting period

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5.8. DATA ANALYSIS PROCEDURE.

The collected quantitative data analysis was done using Microsoft Excel 2010. The descriptive
data of stock out duration of the nutritional medical products summarized as average. The
implementation of the system monitored with established monitoring indicators throughout the
project implementation.

5.9. ETHICAL CONSIDERATION

Ethical clearance” Support letter” was obtained from regional health bureau management. The
two hospital respective staffs were informed by formal letter.

5.10. DISSEMINATION PLAN

The outcome of this project was it has high impact to minimize high stock out days at piloted
project areas. So that it is planned to implement at all health facilities managing Plumpy nut, F-
100 and F-75

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 CHAPTER SIX: ALTERNATIVE INTERVENTION

Stakeholders are engaged to identify the possible intervention that minimizes stock out day’s
nutritional medical supplies at health facilities. Stakeholders identified the possible alternative
interventions mentioned below:-
1. Provide training on the overall nutritional medical supplies supply chain management and
its rational use for stakeholders found in hospital
2. Design and implement Logistic management information system (Adapt and customized
HIV/RTK RRF system)
3. Implement monitoring and Evaluation system
4. Review performance monthly

6.1. Choosing the best alternative solution

A comparative analysis of side-by-side comparison of the strategic alternatives using evaluative

criteria to select the best option. Evaluation criteria are selected by relevant stakeholders
including the hospital staff that is agreed up on it. The criteria’s are: - The impact of the
intervention to minimize stock out, with minimum cost to implement, it’s feasibility to
implement with in specified period of time were the evaluation criteria’s used
Table 2 Interventions Comparison matrix
s.no Interventions Evaluation criteria
Impact Cost Feasibility Time Total
1 Provide training on nutrition medical supplies management 3 2 3 5 13
2 Adapt and customized HIV/RTK RRF system 5 4 5 4 18
3 Implement monitoring and Evaluation system 4 3 3 4 14
4 Review performance monthly 4 1 2 3 10

Each option in the above table is ranked on a score 1 to 5 to the most positive rating IMPACT
and FEASIBILIY and score 5 to 1 score negative rating to TIME and COST (if it needs high cost
and long period of time rate starting from 1 up to 5 for those low cost and short period)

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6.2. Adapt and customized HIV/RTK RRF system is the best alternative solution

After long discussion with stakeholders Adapt and customized HIV/RTK RRF system chosen as
best solution on its high impact to minimize stock out, it is feasible to implement and agree that
minimum cost incurred and possible to implement and see the result with in short period of time

CHAPTER SEVEN: PROJECT IMPLEMENTATION

The new identified intervention “Logistic and morbidity data reconciled Monthly Report and
Requisition Form - For Nutritional Medical products” tool were verified and evaluated by
the implementer’s and by other related higher experts and professionals at zonal health
departments and hospitals. After taking the comments on the tool, organized orientation
was given to all stakeholders at different level of the health care system of the region and
staffs who actually implement the system at Felegehiwot and Adisalem hospital.
After taking other comments and suggestions from orientation, Regional health bureau deputy
head ordered legally with available communication plat forms to implement the new system to
prevent the current challenges of stock out and shortage of nutritional medical products .Actual
implementation started at 20/12/2014 E.C in the region particularly at Felegehiwot
comprehensive specialized hospital and Adisalem primary hospital.

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CHAPTER EIGHT: RESULTS (PRE-POST INTERVENTION EVALAUTION)

8.1. PRE-INTERVENTION RESULT

Strategically the best intervention to minimize high stock out days of nutritional medical
products implemented to be a best solution. Before this Capstone project implementation, the
total number of stock out days of plumpy nut, F-100 and F-75 in the last three month period
(Ginbot 1-Hamle 30/2014E.C) was calculated that ranges from 35 days (F-75) to 90 days (F-100)
at Felegehiwot hospital and that ranges from 63 days (F-75&F-100) to 81 days (Plumpy nut) at

Adisalem primary hospital. On average stock out days at Felegehiwot hospital was 0.65 days

(more than 15 hours per day stock out) and 0.8 days (more than 19 hours per day stock out)

Table 3 Stock out duration status at Felegehiwot and Adisalem hospital before
implementation of the capstone project:-

Stock out days of nutritional medical supplies from (Ginbot 1-

Hamle 30/2014E.C), 3 month

Nutritional #Stock out days in the last 3 month period

unit
commodities
Advisable Primary
s.n Felegehiwot Comprehensive hospital
o specialized hospital
Plumpy nut of 150
1 sachet ctn 50 81
2 F-100 of 24 tin ctn 90 63
3 F-75 of 24 tin ctn 35 63
Total number of stock out days of all
nutritional commodities 175 207

Total number of days 270 270

Average stock out days 0.65 0.8

8.2. POST-INTERVENTION RESULT

As project intervention, the new system implemented starting from Nehasie 30/2014 E.C aimed
to ensure consistence availability of essential nutritional medical supplies by ensuring rational

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utilization at health facilities. As we discussed earlier, responsible stakeholders were trained on
the overall project objective of the capstone project and expected outcome from the project. After
implementation the project coordinators has been following the progress using the established
indicators that leads the needed outcome essential to ensure quality health service to under five
children malnutritioned by securing the needed therapeutic supplies at the needed period of time

The stock out duration was evaluated after 37 days of implementation which is displayed below
in the table.

The average stock out days of nutritional medical products is 0.54 (Near to13 hour’s stock out
per day) and 0.67(16 hours stock out per day).

As compared to the baseline assessment, the average stock out days of nutritional products
decreased from 0.65 to 0.54 at Felegehiwot Comprehensive specialized hospital and the average
stock out days decreased from 0.8 to 0.67 at Adisalem primary hospital.

Stock out days of nutritional medical supplies from (Nehase

30/2014-Tikimt7/2015E.C),

Nutritional #Stock out days in the last 37 days

unit
commodities
Adisablem Primary
s.n Felegehiwot Comprehensive hospital
o specialized hospital
Plumpy nut of 150
1 sachet ctn 30 30
2 F-100 of 24 tin ctn 15 20
3 F-75 of 24 tin ctn 15 24
Total number of stock out days of all
nutritional commodities 60 74

Total number of days 111 111

Average stock out days 0.54 0.67

CHAPTER NINE: DISCUSSION

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Severe acute malnutrition is critical health problem in under-five aged children in all over world.
Globally, an estimated 20 million children are suffering from Severe Acute Malnutrition (SAM)
(16). As per the WHO recommendation, availability of EMs should be 100%, but it is estimated
that about one-third of the world population does not have access to medicines, particularly in
Africa and Asia (11, 12). Lack of nutritional medical products is the major reasons for higher
under five children mortality and mortality at health facilities of Amhara region (7). To ensure
the consistence availability of essential medicines government of Ethiopia implemented
integrated logistics management system however some programs particularly nutritional medical
products such as Plumpy nut, F-100 and F-75(6).

Considering the existing situation of the nutritional medical products supply chain management,
strategic problem solving techniques followed and identified the best solution to provide a
solution. The project owner implemented the capstone project at Felegehiwot comprehensive
specialized hospital and Adisalem primary hospital. At the project evaluated the overall stock out
days of the nutritional products are minimized within 37 days of implementation at both
hospitals. It is because of the implementation of the new system strengthens supply chain system
of these products. The result of this capstone project similar to the study conducted in shegaw
mota hospital and mota health center showed that the average stock-out duration of essential
medicines was small due to strong logistic management practice at health center and hospital
(13). It is also similar to the study conducted at Adama showed that poor inventory management
practices influences availability of essential medicines at health facilities (9).

Study conducted at university of Gondar comprehensive specialized hospital showed that the
effective logistic management practice resulted high availability essential medicine that improves
quality health service(8). Ministry of health of Ethiopia developed standardized inventory
management tools expected to be utilized by public health facilities throughout the country
whether operated manually or use Logistic management information system however some of
nutritional products are not included to system (7, 10). That is why this capstone project titled
with “Logistic and morbidity data reconciled Monthly Report and Requisition Form - For
Nutritional Medical products” designed and implemented to manage nutritional medical
products such as Plumpy nut, F-75 and F-100 at Amhara region particularly at Felegehiwot and

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Adisalem which showed the progress of minimizing stock out duration of these products at 37
days evaluation. In 37 days of implementation, the average stock out days of nutritional products
decreased from 0.65 to 0.54 (by 20%) at Felegehiwot Comprehensive specialized hospital and
the average stock out days decreased from 0.8 to 0.67 (by 17%) at Adisalem primary hospital.
This indicates availability of these products will be improved if managed with system because it
ensures its rational availability and prevents abuse due to the accountability with available data
produced by this system.

CHAPTER TEN: CONCLUSION AND RECOMMENDATION

Based on the result of this capstone project, the average stock out days of nutritional medical
products significantly minimized with in short period of project implementation. Due to this
consistence availability of essential nutritional medical products will improve the quality health
care for fewer than five years children that need nutritional therapy. Thus, Responsible health
care leaders from regional health bureau to health facility management and other stakeholders
should work in harmony to scale up the new system to other health facilities to ensure
uninterrupted supply nutritional medical products.

CHAPTER ELEVEN: COST OF THE PROJECT

This project cost more than 335, 000 Ethiopia birr for capacity building and evaluation of the
capstone project funded from Amhara public health institute in collaboration with regional health
bureau

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REFERENCES
1. Amhara National regional government Plan commission 2015 E C Population estimation
Bahir Dar 2022. Amhara National regional government.
2. Dr. T.Belachew DHN. Assessment of OTP for SAM in three regions of Ethiopia. 2007.
3. Unicef. A Supply Chain Analysis of Ready-to-use Therapeutic Foods for the Horn of
Africa. Report. 2009;(May):1–136.
4. Manso JF, Annan J, Anane SS.
5. USAID Deliver. The Logistics Handbook: A Practical Guide for the Supply Chain
Management of Health Commodities. USAID | Deliv Proj Task Order 1 [Internet].
2011;174. Available from:
http://deliver.jsi.com/dlvr_content/resources/allpubs/guidelines/LogiHand.pdf
6. PFSA/Ethiopia. Standard Operating Procedures ( Sop ) Manual for the Integrated
Pharmaceuticals Logistics System. Ipls [Internet]. 2014;1–92. Available from:
https://www.academia.edu/41440688/Standard_Operating_Procedures_SOP_Manual_for_
the_Integrated_Pharmaceuticals_Logistics_System_in_Health_Facilities_of_Ethiopia_Sec
ond_Edition
7. PFSAEthiopia Standard Operating Procedures Sop Manual for the Integrated
Pharmaceuticals Logistics System.
8. Amhara regional health bureau Review conference on nutritional medical supplies
security from Miazia 29 Ginbot 2 2014 E C Enjibara town.
9. Woldeyohanins AE, Meseret B, Teka M, Teshome T. Assessment of the availability of
essential medicines and inventory control practice at university of Gondar comprehensive
specialized hospital , Amhara regional state of Ethiopia : institutional based cross-
sectional study design. 2020;6(9):349–52.
10. Kefale AT. Availability of essential medicines and pharmaceutical inventory management
practice at health centers of Adama town ,. 2019;0:1–7.
11. FMOH EPSA Standard Operating Procedures SOP Manual For The Integrated
Pharmaceuticals Logistics System in Health Facilities of Ethiopia2013.
12. World Health organization WHO policy perspectives on medicines equitable access to
essential medicines a framework for collective action Geneva 2004.
13. Rustamadji, Omar CMZBC. The effect of strategic management and organizational
commitment on employees’ work achievement. Manag Sci Lett. 2019;9(3):399–412.
14. Centre MH, Bahiru B, Id T, Tafere C, Id AY, Mebratu E. Availability and stock-out
duration of essential medicines in Shegaw Motta general hospital. 2022;1–10. Available
from: http://dx.doi.org/10.1371/journal.pone.0274776
15. Wagenaar BH Gimbel S Hoek R Pfeiffer J Michel C Manuel JL et al Stock outs of

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 essential health products in Mozambique longitudinal analyses from 2011 to 2013.
16. Leisinger KM Garabedian LF Wagner AK Improving access to medicines in low and
middle income countries.
17. Wagh VD, Deore BR. Ready to Use Therapeutic Food ( RUTF ): An Overview.
2015;2(1):1–15.
18. UNICEF WHO World Bank Group Levels and Trends in Child Malnutrition 2019
UNICEF WHOWorld Bank Group 2020.
19. A study in Uganda pointed out that several factors influenced the availability of EMs Out
of this drug requisitions based on neither morbidity nor consumption methods of
quantification.

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APPENDICES/ANNEXES
Table 4 Project implementation plan

Responsible

September

November
No Activities

October
August
People

July
1 Develop SPS project Hiwot & Tazie
2 Consultant meeting Hiwot & Tazie
3 Adapt HIV/RTK RRF system to Hiwot & Tazie
nutritional medical commodities
4 Provide orientation for hospital Hiwot & Tazie
U5 clinic, pharmacy
professional’s and ART clinic
5 Implement new nutritional Hiwot & Tazie
medical supplies in the RRF
system
6 Monitor the implementation Hiwot & Tazie
status
7 Evaluate the progress of Hiwot & Tazie
implementation

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Annex 1

Baseline Assessment check list on nutrition medical supplies management at Adisalem Hospital
and Felegehiwot comprehensive specialized hospital

Part 1:- Stock Status of nutritional medical supplies

s.no Item Unit Is available Was stock Total number of Remark
Description today? out in the stock out days in
last 3 month the last 3 month
period ?( from
Ginbot 1 to
hamilie30)
1 Plumpy nut 92 150 1. Yes 1. Yes
gm sacket 2. No 2. No
2 F-75 24 tin 1. Yes 1. Yes
2. No 2. No
3 F-100 24 tin 1. Yes 1. Yes
2. No 2. No
Average % availability at time of
visit
Average stock out days

Part 2: Basic Logistic management information system status

s.no Questions Answer Remark

1 Is up to date Bin card available for 1. Yes See bincard of Plumpy nut,
nutritional medical supplies? 2. No F-100 and F-75. Say yes if
the 3 bincards are up to date
2 Is the hospital uses IFRR to nutritional 1. Yes Say yes, if Plumpy nut, F-
medical supplies regularly 2. No 100 and F-75 are included?
3 Is the hospital uses RRF report 1. Yes
reconciled with malnutrition cases to 2. No
request from ZHD?

If yes , how many RRF reports in the

last 3 recent period?

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 Part 3: Questionnaire:-

The objective of this Questionnaire is to verify the root causes identified by the
stakeholder’s on nutrition medical supplies management

I. Back ground information

1.1 Health Facility Information

Name of Health Facility Health Facility Level

Facility Telephone

Region Zone Woreda Nutrition medical

supplies supplier
Amhara Bahirdar Town Bahirdar Town
ZHD
1.2 Supervisors Name
Name Telephone Signature E-mail Address

Tazebew Alemu

Hiwot Tilahun
1.3 Names Key Staffs Contacted
Position Name Telephone E-mail

II. BASELINE ASSESSEMENT To verify the main root causes identified by stakeholders

IPLS or nutrition commodities management Training Remark

No pharmacy professionals working at Store Answer:-__ Ask Pharmacy
and supply chain management unit head or delegate
No pharmacy professionals working at Store Answer:-__
and supply chain management unit
% trained personnel those responsible to
request nutritional commodities

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 A.Prescribers Adherences to STG Remark
Does prescribers prescribe nutrition medical 1. Yes Ask prescribers at under 5
supplies only to Under 5 malnutrition cases 2. No children &
Verify by using 10
Does prescribers prescribe nutrition medical 1. Yes prescriptions and reconcile
supplies for adult malnutrition cases 2. No with patient card. Yes, if all
are adhere to STG
Does prescribers prescribe nutrition medical 1. Yes
supplies HIV patient malnutrition cases 2. No
Adherence %

Management ownership Remark

Does the hospital allocate budget to strengthen 1. Yes Ask the hospital pharmacy
nutrition commodities management 2. No unit head and verify with
evidence
Does the hospital management/pharmacy unit 1. Yes Ask the hospital pharmacy
review nutrition commodities management 2. No unit head and verify with
information system evidence
Management ownership

Logistic management information system reconciled with morbidity

Remark
Does the hospital regularly request the needed 1.Yes See recent 3
nutritional medical supplies? 2. no regular periods
Does the hospital use standard RRF system to 1. Yes If yes, See recent
request of nutritional medical supplies to be 2. no 2 consecutive RRF
summited to ZHD? reports summited
to ZHD
Does the hospital received nutritional 1. yes
commodities 80% or above the requested 2. no
Quantity
Does the hospital have consumption quantity 1. yes
and malnutrition case number reconciliation 2. no
trend to minimize stock out?
Number of malnutrition cases in the last six Answer:______ See DHIS2 report
month period
Quantity of See model 19 or
1. Plumpy nut of 150 sacket received? 1.ZHD___2.Other__3.To bincard
2. F-100 of 24 tin received? tal__
3. F-75 of 24 tin received? 1.ZHD___2.Other__3.To
tal__
1.ZHD___2.Other__3.To

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 tal__

Does the ZHD uses requested quantity of 1. Yes Ask zone logistic
nutritional medical supplies information to 2. No head
decide for allocation
If the above Question is no, What method used Answer_____________ Ask zone logistic
by ZHD to allocate nutrition medical supplies head
to health facilities
Does the hospital uses malnutrition case data to 1. Yes Ask zone logistic
allocate nutritional products 2. No head

General Comment:- Give a chance to recommend or raise issues on the current management of
nutritional medical supplies system
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_________________________________________

Transportation, Using Technology , storage space, supplier

Does the hospital challenged by lack of vehicle 1. Yes observation
to receive supplies from ZHD? 2. No
Does the hospital use Dagu system to manage 1. Yes observation
nutritional medical supplies? 2. No
Does the hospital medical store adequate to 1. Yes Observation
store nutritional medical supplies 2. No
Does the hospital/Zone have alternative 1. Yes Should be
supplier to nutritional medical supplies 2. No asked at
ZHD

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The new system implemented at Felegehiwot and Adisalem hospital
Monthly Report and Requisition Form - For Nutritional Medical products
Health Facility: Region: Zone: Woreda:
Supplying Zone Health Maximum Stock Level = 2 Months of Stock
Reporting Period: From: Emergency Order Point = 0.25 Months of Stock
Report Part Requisition Part Reconcilation part
Ending Balance
Quantity Standard Quantity needed
Days Maximum Factor for
Beginning Quantity Loss/ Calculated neeeded Quantity for treatement of
Out of Stock treatement Difference
Ser. Balance Received Adjustment Dispensing unit Store Consumption to reach Ordered the cases per Trigger
Product Description Unit of Issue Stock Quantity (Should be
No. Max specified) standard

H=
A B C D E F= A+B+C - D- E G (60xF)/(30- I= H-E-D J K L=K* SAM cases M=F-L
G)

Nutrition commodities
1 Therapeutic spread sacket, 92gm 150 sacket 0 0 0 0 0 1 0 0 #DIV/0!
2 F-75 Therapeutic Milk 400gm Each 0 0 0 0 3.5 0 0 #DIV/0!
3 F-100 Therapeutic Milk 400gm Each 0 0 0 0 3 0 0 #DIV/0!
Remarks and explanation of losses/adjustements

Number of SAM cases

Products with shelf life < 6 months (S/No, Quantity and Expiry date):
Completed by : Signature: Date:
Verified by : Signature: Date:
Approved by : Signature: Date:

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