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THE IMPACT OF REVERSE LOGISTICS IN PUBLIC HOSPITALS; A CASE OF KAMUZU CENTRAL HOSPITAL AND NTCHISI DISTRICT HOSPITAL
DORICA C. SALAMBA CHIRWA
Submitted in partial fulfillment of the requirements for the degree of MSc Supply Chain Management
University of Bolton , Off Campus
The University of Bolton
23 April, 2015
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Abstract
The Malawi Ministry of Health and its partners ensure that quality health care services
are being offered in public hospitals, including the availability and accessibility of quality
medicines that are in good condition, and that the hospitals are adequately stocked of
pharmaceuticals for treating common illnesses. In spite of the efforts that the Ministry of
Health has put in place to ensure efficiency in supply chain, and availability of medicines
at all times, significant quantities of medicines and other medical supplies have been
expiring in facility medicines store and warehouses, leading to a stock out of that
product, on the other hand, overstocks of medicines have been experienced as they
could not be consumed at certain particular time causing a challenge in supply chain as
it is costly because most medicines end up expiring.
The study concludes that policy on waste management and reverse logistics has
significant financial and operational advantages to the Malawi health pharmaceutical
supply chain and in public hospitals. This is very important as it will reduce expiry of
medicines in hospitals while overstocks shall be reallocated or redistributed within the
system.
In this regard, the paper recommends immediate formulation of policy on reverse
logistics procedures and waste management that would guide health workers to
properly manage medicines in public hospitals. In addition, Ministry of health should
build capacity in health workers that manage medicines so that they follow proper
procedures of reverse logistics in case of stock imbalances and be able to make
informed decisions.
The push system of distribution should be based on the actual needs of hospitals so as
to minimize expiry of medicines in hospitals.
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Table of ContentsAbstract............................................................................................................................. i
Acronyms......................................................................................................................... v
Dedication.......................................................................................................................vii
Acknowledgement..........................................................................................................viii
1.1 Introduction.........................................................................................................1
1.2 Problem Statement.............................................................................................3
1.3 Justification of Study...........................................................................................6
1.4 Aim of the Study..................................................................................................6
1.4.1 Specific Objectives.......................................................................................6
1.4.2 Research Questions.....................................................................................6
1.5 Format of the Study............................................................................................7
1.5.1 Chapter One.................................................................................................7
1.5.2 Chapter Two.................................................................................................7
1.5.3 Chapter Three..............................................................................................7
1.5.4 Chapter Four................................................................................................7
1.5.5 Chapter Five.................................................................................................7
1.6 Chapter Summary...............................................................................................8
CHAPTER 2: LITERATURE REVIEW..............................................................................9
2.1 Introduction.......................................................................................................10
2.2 Policy governing reverse Logistics in Malawi’s Health Commodities Supply Chain System.............................................................................................................10
2.2.1 Definitions of Reverse Logistics.....................................................................11
2.2.2 Information Sharing and collaboration...........................................................14
2.2.3 Reverse Logistic in other Hospitals...............................................................14
2.3 Malawi Supply Chain System............................................................................17
2.4 Why Consider Reverse Logistics?....................................................................21
2.5 Why Are Products Returned.............................................................................22
2.6 Management of Expired/Returned or Recalled Products..................................23
2.7 Waste Management Practices..........................................................................25
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2.8 Why Reverse Logistics Strategies....................................................................26
2.9 Improving Process of Returns/Recalls..............................................................27
2.9.1 Local Screening.............................................................................................27
2.9.2 Collection.......................................................................................................27
2.9.3 Sorting...........................................................................................................28
2.9.4 Disposition.....................................................................................................28
2.10 Waste Management Policy...............................................................................28
2.11 Chapter Summary.............................................................................................32
CHAPTER 3: RESEARCH METHODOLOGY................................................................33
3.1 Introduction.......................................................................................................34
3.2 Research Philosophy........................................................................................34
3.2.1 Research Approach.......................................................................................34
3.2.2 Research Strategy.........................................................................................35
3.3 Sample size......................................................................................................35
3.4 Data Technique and Collection.........................................................................37
3.4.1 Document review...........................................................................................37
3.4.2 Expert Interview Guide..................................................................................37
3.5 Time Horizons...................................................................................................37
3.6 Data Analysis....................................................................................................37
3.7 Data Validity and Reliability...............................................................................38
3.8 Ethical Consideration........................................................................................38
3.9 Interpretation of Data........................................................................................38
3.10 Chapter Summary.............................................................................................39
CHAPTER 4: SURVEY FINDINGS AND DISCUSSION................................................40
4.1 Introduction.......................................................................................................41
4.2 Findings from primary Data...............................................................................41
4.2.1 Reverse Logistics..........................................................................................41
4.2.2 Management of Overstocks at Hospital level.................................................42
4.2.3 Reasons for Overstocks in Hospital Pharmacy..............................................42
4.2.4 Management of Expiries at Hospital level......................................................44
4.2.5 Challenges with Reverse Logistics................................................................47
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4.2.6 Expert interview Guide...................................................................................49
4.2.6.1 Policy on Reverse Logistics........................................................................49
4.2.6.2 Role of Partners and Stakeholders.............................................................50
4.3 Findings from secondary Date..........................................................................51
4.3.1 Assessment of stock imbalances in fifty facilities...........................................51
4.3.2 Facilities experiencing stock imbalances per month in 2014.........................52
4.3.3 Stock imbalance by Product..........................................................................53
4.3.4 Chapter Summary..........................................................................................55
CHAPTER 5: CONCLUSION AND RECOMMENDATIONS..........................................56
5.1 Introduction.......................................................................................................57
5.2 Conclusion........................................................................................................57
5.3 Recommendations............................................................................................57
Bibliography...................................................................................................................68
APPENDICES................................................................................................................59
Appendix 1: Checklist for primary data Collection.......................................................60
Appendix 2: Approval Letters to undertake the study.................................................64
a) Request letter to the Ministry of Health to collect data in health facilities for academic use..............................................................................................................
64
b) Letter from Ministry of Health to Health Facilities collect data in health facilities for academic use.....................................................................................................65
Appendix 3: List of Facilities where secondary was collected.....................................66
List of Tables Table 1.1: Overstocked Medicines and Medical Supplies in CHAM facilities...................4
List of Figures Figure 2. 1: Cost of expiration in Mwanza, Chikhwawa and Thyolo among 30 commodities...................................................................................................................20Figure 2.2: Conceptual Framework................................................................................31Figure 4.1: Reasons for overstocks................................................................................42Figure 4.2: Management of Expiries..............................................................................46
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Figure 4.3: Challenges with Reverse Logistics..............................................................47Figure 4.4: Comparative analysis of stock imbalance 2013/2014..................................51Figure 4.5: Facilities experiencing stock imbalances per month in 2014.......................52Figure 4.6: Comparative analysis of Facilities that experienced stock imbalance by product-2013/2014 amongst essential medicines, according to therapeutic use of medicines.......................................................................................................................53Figure 4.7: Comparative analysis of Facilities that experienced stock imbalance by product-2013/2014 amongst Anti-malarials....................................................................54
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Acronyms
3TC Lamivudine
ABC abacavir
AIDS Acquired Immunodeficiency Syndrome
ART Anti-retroviral Therapy
ARVs Anti-Retroviral
CHAI Clinton Health Access Initiative
CHAM Christian Health Association of Malawi
CHBC Community Home-Based Care
CMST Central Medical Stores Trust
DANCED Danish Co-operation for Environment and Development
DANIDA Danish International Development Agency
DBSA Development Bank of Southern Africa
DFID Department for International Development
FEFO first to expire first out
FICA Flanders International Cooperation Agency
GAVI Global Alliance for Vaccines International
GF Global Fund
GTZ Deutsche Gesselschaft Fur Technische Zusammearbeit Gmbh
H/C Health Centre
HIV Human Immunodeficiency Virus
HTC HIV Testing and Counseling
HTSS Health Technical Support Services
KfW Kreditanstalt für Wiederaufbau (Reconstruction Credit Institute)
MoH Ministry of Health
MRI Manchester Royal Infirmary hospital
MSH Management Sciences for Health
NGO Non-governmental Organization
O&M A Malawian Supply Chain consulting Firm
ODPP Office of the Director of Public Procurement
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PHC Primary Health Care
PMPB Pharmacy Medicines and Poisons Board
PMTCT Prevention of Mother-to-Child Transmission of HIV
QECH Queen Elizabeth Central Hospital
RHZ rifampicin+ isoniazid+ pyrazinamide
RL Reverse Logistics
SOP Standard Operating Procedures
SSDI Support to Service Delivery Integration
TV Television
UNFPA United Nations Population Fund
UNICEF United Nations Children’s Fund
USAID United States Agency for International Development
USAID | DELIVER PROJECT: A USAID funded supply chain project
WHO World Health Organization
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DedicationThis research paper is dedicated to my late dad, Lester Salamba who always encouraged me to work hard at school. May his soul Rest in Peace.
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Acknowledgement
I would like to thank my supervisors Mr Peter Mwanza and Dr Farr, for the guidance and
untiring support at the time of putting together this dissertation. Their knowledge in
research approach and speed in providing feedback on work submitted for review was
outstanding and invaluable in the success of this work.
I am grateful to my Husband, Sam, for his moral support during my module studies and
at the time of assembling this dissertation. I thank God for him into my life.
To my dear mother, Grace Imelda Salamba and my lovely sister Dora Salamba
Makwinja for the encouragement and untiring support during my entire study period. My
entire family and friends, receive my gratitude for your support.
Lastly, but not least am grateful to Dr Frank Chimbwandira and Logistics team at the
department of HIV and AIDS, who understood that l needed some days off from work in
order to meet my academic requirements
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1.1 IntroductionThe Malawi Ministry of Health’s (MoH’s) public sector healthcare system provides
health care services in three levels namely primary healthcare (in Health centers
(H/C) and community clinics) and mostly located in rural areas; the secondary
healthcare (district hospitals) which currently are twenty-eight in number; and lastly
the tertiary level, with four Central Hospitals and one Mental Hospital. The Ministry
and its partners ensure that these hospitals are adequately stocked of
pharmaceuticals for treating common illnesses. The Central Medical Stores Trust
(CMST) is the major supplier of essential medicines to all the public hospitals,while
The Global Fund (GF) provides support in acquisition of HIV related commodities
and anti-malarial medicines; USAID and UNFPA/DFID support with family planning
commodities; GAVI, FICA, KfW and the government of Malawi have ensured
vaccines are always available in-country; whereas DFID, Norway and KfW pooled
together financial resources to procure essential medicines when the country had
serious stock outs, just to mention a few with DFID singularly following up with a
further eighteen months medicines project.
In recent years, the Malawi health supply chain system has seen mushrooming of
donor-driven parallel distribution systems and mostly using either monthly or
quarterly “push” replenishment systems. As for CMST commodities, hospitals “pull”
monthly to top-up to three months of stock from its three regional warehouses
strategically allocated according to political regions demarcating the country:
Northern, Southern and Central. Each regional warehouse supplies medicines to
health facilities in the corresponding political regional border.
A “Pull system” is where the decision on quantities to resupply facilities is arrived at
by the person placing the order. In this system, the service delivery points order
commodities as may be needed mostly based on what the hospital is able to
consume at a particular period of time. “Logistics Handbook (2011). While “Push
system” is where the decision on quantities to resupply facilities is determined by
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the person who fulfills the order. The Central level decides what commodities to
push down and when to move or redistribute. This is the system that is being
implemented by parallel supply chain to ensure availability of medicines in
hospitals, clinics all the times.
Note should be taken that use of “Product” and “Commodity” have been
interchangeable in the dissertation as both mean the same thing: Medicine or
Medical Supply.
In spite of the efforts that the Ministry of Health has put in place to ensure
efficiency in supply chain, and availability of medicines at all times, significant
quantities of medicines and other medical supplies have been expiring in facility
medicines store and warehouses, damaged due to non-compliance to proper
storage management of medicines leading to a stock out of that product, on the
other hand, overstocks of medicines have been experienced as they could not be
consumed at certain particular time causing a challenge in supply chain as it is
costly because most medicines end up expiring.
With the foregoing, it is therefore valuable to consider the proper ways of managing
the stock imbalances in the public hospitals with focus on overstocks and expired
medicines.
With this in mind, Reverse Logistics becomes key to the health supply chain
system to help manage unused medicines due to either expiration or damages or
oversupply to improve efficiency in supply chain. Up to now, the Ministry has not
considered documenting procedures for ‘proper reverse logistics. However, the
department of HIV, under Ministry of Health is implementing a system called
‘relocation of ARVs’ within or in a neighboring district. This is where a facility that is
stocked out of ARVs would actually report to district hospital for resupply while
waiting for the next round of distribution or if facility has excess or expired stock
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would report to central level that would eventually facilitate redistribution or
recollection for proper disposal, ART/PMTCT Guidelines (2014).
Reverse Logistics considers issues of management of expired and overstocks.
According to Rogers et al, (2010) reverse logistics includes processes of planning,
implementing, and controlling the efficient, cost effective flow of raw materials, in-
process inventory, finished goods and related information from the point of
consumption to the point of origin for the purpose of recapturing value or proper
disposal.
If Reverse Logistics system is implemented in hospitals, it would ensure that
proper procedures are in place to manage the overstocks through redistribution to
recapture value, and to manage expiries or obsolete stocks by properly disposing
them to prevent endangering the environment.
The study therefore focused on how public hospitals manage overstocks and
expired/obsolete medicines, and made some recommendations to incorporate
issues of reverse logistics in pharmaceutical supply chain.
1.2 Problem StatementThe Ministry of Health policy on drug management accords only registered
pharmacy personnel to manage medicines and medical supplies in all public
hospitals. This cadre undergoes a though pre-service course on management of
medicines including dispensing. Currently, the pharmacy cadre in Malawi is
responsible for not only managing medicines and medical supplies but also
analyzing and using logistics datafor decision-making. However with shortage of
human resource to manage medicines, Medical Assistants, Nurses and Health
Surveillance Assistance are also responsible for management of medicines and
medical supplies in almost all the health facilities in the country.
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The health system also provides that the district teams conduct supportive
supervision in lower level health facilities regularly so that decisions on stock
imbalances are handled properly within that level of care. However, reports from
the districts show that this is not done due to resource constraints, and most health
personnel at facility level do not have capacity to determine overstocks besides
failure to decide on what to do with them. Worse still, expired medicines are hardly
removed from shelves.
The mushrooming of parallel systems in the country coupled with poor coordination
and the use of “push distribution system” by most of the parallel supply chains, has
seen huge volumes of short shelf-life commodities being distributed to public health
facilities resulting into expiry of most of these commodities. Some of the parallel
systems have distributed slow-moving commodities, resulting into expiry. In
addition, some facilities have received commodities they do not want but may be of
importance in other facilities also resulting into expiration.
O&M with support from UNICEF conducted an assessment in sixty-three Christian
Health Association of Malawi (CHAM) health facilities in December 2013 who
noted that on average forty-four of the sixty-three health facilities were overstocked
with 10 health commodities assessed, representing seventy per cent. Latest expiry
date for these commodities was May 2014 and therefore it means a good
proportion of these commodities expired before all were consumed.
Table 1.1: Overstocked Medicines and Medical Supplies in CHAM facilities
Commodity #of Facilities(out of 63) Percentage
Cotrimoxazole tablets 47 75%Doxycycline tablets 51 81%Erythromycin tablets 43 68%Promethazine tablets 48 76%Ferrous Sulphate 42 67%
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Commodity #of Facilities(out of 63) Percentage
Hydrochlorothiazide tablets 41 65%Metronidazole tablets 33 52%Albendazole tablets 52 83%50% Dextrose 46 73%BBE paint 39 62%AVERAGE 44.2 70%
Source: O & M, January 2014
While in Table 1.1 above, Doxycycline, Erythromycin, Cotrimoxazole and
Metronidazole were among the overstocked commodities in CHAM facilities, a
similar assessment in September 2013 noted that government hospitals were in
need of the same medicines and medical supplies. This means an opportunity was
missed to have re-distributed the overstocked commodities in CHAM before
expiring. In Thyolo district, almost all the health facilities were lacking
Hydrochlorothiazide tablets when other districts and CHAM facilities were
overstocked.
The September 2014 HTSS monitoring report indicated that fifty-six percent of
commodities in six hundred and thirty-two (632) health facilities were overstocked.
This proportion undoubtedly includes “slow-moving” commodities and short shelf-
life commodities that are at risk of expiring even before use.
All this is experienced in an economy where the government budget alone cannot
afford to cover all the required quantities of medicines to treat basic health
conditions.
The foregoing triggers the need to study how the expired, damaged and overstocks
are managed at public hospital level and suggest strategies of designing proper
reverse logistics system in the health supply chain system that would direct proper
procedures of managing expiries and overstocks.
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1.3 Justification of StudyThe current health supply chain system does not pay much attention to reverse
logistics and there are hazy regulations for management of expired, damaged
medicines as well as disposal procedures, but none for management of stock
imbalances (SOPs 2014). The only clause of regulation related to reverse logistics,
outlines disposal of goods, old vehiclesand supplies ODPP policy 2012.
This has forced hospitals to makeshift procedures for disposal of medicines
because there is no standard way of doing it. It is against this background that the
researcher found it vital to conduct this study as it would endeavorto influence
introduction of a proper reverse logistics into the Malawi health supply chain.
1.4 Aim of the StudyThe overall aim of the study was to assess the impact of reverse logistics in Malawi
public hospitals.
1.4.1 Specific Objectives1. To evaluate procedures of reverse logistics in public hospitals
2. To assess challenges associated with reverse logistics in public hospitals
3. To recommend strategies for the reverse logistics system in Malawi Health
Supply chain system
1.4.2 Research Questions1. How is reverse logistics done in public hospitals?
2. What are the challenges of reverse logistics in public hospitals?
3. What strategies should be developed for the implementation of reverse logistics
in Malawi Health Supply Chain system?
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1.5 Format of the Study
1.5.1 Chapter One
The study has five chapters with chapter one introducing the study and the
background to the statement of the problem. It goes further to provide the aim and
objectives of the study and research questions. Lastly the chapter also provides
the justification of conducting the study and the chapter summary as well as study
format.
1.5.2 Chapter TwoChapter two analyses the literature related to the study, the aim and objectives that has been sourced from supply chain experts who have written something on reverse logistics, books, journals and newspapers. Finally, the literature review chapter summary
1.5.3 Chapter ThreeChapter three outlines the approach the study applied. It describes the research
design, methodology for sampling, data collection techniques and tools that were
used to collect data. Finally how the validity and reliability of the data was
ascertained and limitations of the study.
1.5.4 Chapter FourChapter four discusses the research findings mostly through graphs and pie charts that will assist in demonstrating trends in responses from different respondents. The findings also provide answers to the research questions
1.5.5 Chapter FiveChapter five provides the researcher’s conclusions and recommendations, based on the research findings. These demonstrates the findings from literature review and the responses from the supply chain experts of the public hospitals where the study took place.
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1.6 Chapter SummaryIn this chapter, the researcher set out the framework for an investigation into the
impact of reverse logistics in public hospitals, set out the goal, objectives and
research questions. It further made statement on the justification of the study and
finally the chapter presented the format of the study.
In the next chapter, the researcher tried to understand what other studies have
done in relation to reverse logistics in public hospitals, and analyzed the literature
related to the study topic.
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CHAPTER 2: LITERATURE REVIEW
19
2.1 Introduction
Chapter 2 reviewsany relevant literature on supply chain and reverse logistics in
public hospitals and other sectors. It is very imperative to have a literature reviewas
it provides a basisin clarity on the research objectives and questions of the study.
Review materials havederived from academic textbooks, contributions in journals
and newspapers by commentators and experts in supply chain; research papers
on stock imbalances, reports and literature by supply chain experts, international
and local organisations. This literature review is grounded on the theories and
principles of reverse logistics (RL), and focusing mainly on the policy framework on
reverse logistics, definition of the reverse logistics, the pivotal role of information in
implementation of reverse logistics, experience of reverse logistics in other
hospitals, overview of the Malawi health commodities supply chain with focus on
management of supply chain imbalances, and evidence of need for a proper
reverse logistics. The chapter will then proceed as follows:
Policy governing reverse Logistics in Malawi’s Health Commodities Supply
Chain System
The meaning of reverse logistics in a perspective of a hospital setting
Information sharing and collaboration
Learning from other hospitals on reverse logistics
Overview of the Malawi health commodities supply chain with focus on
management of stock imbalances
Significance of a proper reverse logistics system in Malawi setting;
Borrowing a leaf from waste management practices
2.2 Policy governing reverse Logistics in Malawi’s Health Commodities Supply Chain System
Supply chain ensures that there is seamless flow of procedures and processes for
medicines availability, that includes efficiency in product selection based on the
standard treatment guidelines that Malawi adopts, quantification of medicines
20
based on the number of patients seen over a particular period or previous
consumption trends, efficiency in procurement of the recommended medicines or
treatment in the right quantities and proper storage and distribution of medicines in
hospitals for use by patients or clients upon certification by the quality assurance
unit of the Pharmacy Medicines and Poisons Board (PMPB). These procedures
and processes endeavor to avert overstocks, damages, expiries and/or poor
quality of medicines. Therefore, before an attempt to procure or resupply, products
need to be redistributed between facilities from overstocked to
under-stocked/stocked out facilities in order to maximize the readily available
resources within the system.
While there are some hazy instructions to manage expiration and overstocks,
Standard Operating Procedures(2014), it is crucialto put in place regulations to
manage these supply chain vices considering the inverse impact they have to the
pharmaceutical supply chain. If unchecked, these can become hazardous to the
community and environment and if expired and unwanted medicines are
improperly disposed through illegal vending or contamination of drinking water or
sharp containers, might cause harm to the community.
2.2.1 Definitions of Reverse Logistics
Reverse logistics is a fairly new concept in logistics, and even in Malawi public
health facilities where the study is focusing on, and it has been defined in several
ways, however all the definitions address similar issues. Some of these include:
The council of logistics management (1992) published reverse logistics definition
as “.the term often used to refer to the role of logistics in recycling, waste disposal,
and management of hazardous materials; a broader perspective includes all
relating to logistics activities carried out in source reduction, recycling, substitution,
reuse of materials and disposal.”
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While Pohlen et al (1992) defined reverse logistics as “movement of goods from
consumer towards a producer in a channel of distribution.”
Kopicky et al (1993) defined reverse logistics “as a broad term that refers to the
logistics management and disposing of hazardous or non-hazardous waste from
packaging and products that includes reverse distribution which causes goods and
information to flow in the opposite direction of normal logistics activities.”
Rogers et al (1999) defined reverse logistics, by stressing and describing the goal
and processes involved as“the process of planning, implementing, and controlling
the efficient, cost effective flow of raw materials, in-process inventory, finished
goods and related information from the point of consumption to the point of origin
for the purpose of recapturing value or proper disposal.”
Precisely, reverse logistics is the process of moving products from the final
destination back to the source. In case of hospitals, it means taking expired,
damaged and excess medicines back to the warehouse for proper storage,
redistribution and disposal. It is imperative that management of expired
pharmaceuticals be closely monitored to ensure they are handled properly after
leaving their control and ensure secure chain of custody (Kabir, M. 2013).
Based on the above definitions, two things are worth considering: reverse logistics
helps in (1) re-capturing or adding value and (2) proper disposal. In a hospital
setting, value recapturing is not mostly possible with expired or damaged
medicines. Value in proper disposal of unwanted products is more qualitative that
quantitative. It contributes positively to the quality of care as patients or clients are
dispensed with only quality products. In addition, it preserves the face of the health
facility and eventually increases the number of patients seeking services at the
facility, leading to reduction of avoidable deaths. Moving excess medicines from
22
low-volume to high-volume facilities, however, may add value to the system as this
would avert the concerned medicines from expiring on shelf.
An example of a company in Malawi practicing reverse logistics is Southern
Bottlers Limited, a company that produces water and soft drinks for retail and also
owning Coca-Cola franchise. The company usually recollects all the usable plastic
bottles and reuses them for repacking. Plastics industry also recollects all plastics
from a plastic bagto a container and recycles them for reuse. This is a good
example of reverse logistics that can be adapted in the health sector and precisely
at hospital level. Some plastic bottles that had some medicines could be battered
back to the manufacturers in exchange for medicines of similar value. This would
reduce the cost on the part of the manufacturer and the client. As for excess
products, re-distribution can be done in order to add value by extending the
products to health facilities with the capacity to consume before they expire.
Disposal of medicines vary from one type to the other. Improper disposal may
therefore have inverse effects to the community. Depending on the nature of the
health product to be disposed of, an appropriate disposal method should be
chosen to present from further damage.
Pharmaceutical supply chains are characterized by high level of expiries, wastage
and spillover, issues of returns and recalls of drugs; therefore in order to solve
these challenges, a proper system has to be put in place to deal with such
challenges. Expiry of medicines is a common challenge in most countries as
reported in the study conducted in Uganda, whereby volumes of medicines expired
at the National medical Stores, in district and hospital stores. Similar problem was
reported in Botswana, India and United Republic of Tanzania. Nakyanzi, J., K., et
al (2008).
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2.2.2 Information Sharing and collaboration
Malawi’s supply chain system has significant quantities of slow-moving
commodities. These see their way into the system through various channels which
include uncoordinated distributions by some donors and political leaders;
procurement of specific medicines for specific patients which when not all is
consumed cannot be administeredto another patient. In some instances, CMST
has supplied products with short shelf-life. In such circumstances, improving
efficiency is a must to avoid wastage. Hence, introducinga sound reverse logistics
system in hospitals is one of the ways to achieve this.Information sharing in this
regard is a crucial tool to achieve eminence. Lack of quality date and the sharing
thereof is an undoubted contributor towards stock imbalances including medicines
expiration in hospitals. The culture of data analysis to provide direction in
managing the stock imbalances is therefore an asset to promote in the health
system to help maximize utilization of the country’s scarce resources by
immediately reacting to stock imbalances. This would trigger reverse logistics to
save most products from expiration.
A report on the study conducted by Olorunnwo et al (2014), on the importance of
information sharing and collaboration, emphasizes the ability of various players to
collaborate and share information in reverse logistics as it is in forward supply
chain. That is what makes forward supply chain successful because of visibility,
transparency, collaboration and trust of various entities in the chain. This is also
true for the reverse chain, especially since RL process is also heavily demand
driven that is, the downstream customers make the final decision in orders and
returns.
2.2.3 Reverse Logistic in other Hospitals
Manchester Royal Infirmary (MRI) hospital pharmacy in the United Kingdom that
practices reverse logistics had to examine the returned stock from twenty-eight
hospital units and to assess how effectively and efficiently stock was being
24
returned from the hospital wards, clinics and other departments, and lastly to
assess how much of the stock being returned could be re-used in order to reduce
hospital drug budget.
The overall conclusion proved that there are significant financial and operational
advantages to the National Health Services (NHS) and other organizations, in
developing effective revere logistics processes, Richie, L., et al (2000). Specifically
the research confirmed existence of procedures to facilitate returns and recycle.
However some concerns were raised with regards the effectiveness of the
procedures, and some of them being: No one person or group appeared to have
ownership of the process; there were no standardized assessment criteria for
classifying the re-usability of returned items; there was no mechanism or policy for
reviewing the returns process as a whole; and there was no recognition of the need
to improve the efficiency of the Pharmacy's distribution process in order to reduce
overstocking and thus reduce the level of returns.
Another assessment by Sasa, S., et al (2012) was conducted in four hospitals in
Ghana that were randomly selected, assessing the pharmaceutical waste
management in order to monitor how safe and secure the environment is owing to
the potential risk it poses to human being. The outcome of the assessment was
that, all the hospitals visited did not have any separate collection and disposal
programmer for pharmaceutical waste.
Another assessment by Sasa, S., et al (2012) was also carried out among the
general public in Ghana involving the questioning of randomly selected participants
in order to investigate the household disposal of unused and expired
pharmaceuticals. The results from the survey showed that more than half of the
respondents confirmed having unused, left-over or expired medicines at home and
out of that, over sevent-five percent confirmed that they dispose of pharmaceutical
waste through the normal waste bins which end up in the landfills or dump sites.
25
The researcher finds this dangerous especially where there is no proper disposal
of pharmaceuticals as these may accumulate and stay active for a longer time in
environment and at the end causing serious health risk.
As discussed by Abbas, H., et al (2013) in their research study, that hospitals have
three main reverse logistics activities namely “Reuse”, “Recycle” and “Disposal”
which should be applied on the basis of the integrity of medicines. They further
discuss how important Reverse logistics is in the pharmaceutical industry from the
economic, environmental as well as regulatory point of view. Some important
considerations are: the security of the returned goods; keeping the cost low with
the help of automation; traceability of the goods returned from the customer to the
final stage of disposition.
Reverse Logistics, if managed well can help improve supply chain efficiency.
Reverse logistics is a vital part of maintaining the value of supply chain and
therefore hospitals and institutions should dedicate equal resources to both
keeping inventory clear of damaged or defective products and getting products to
store on shelves.
Proper storage of pharmaceuticals in hospitals is required, in order to maintain
shelf life of products by following the best storage conditions. For instance, storing
machines or TV set is totally different from medicines as they would require proper
storage temperature in order to survive. Kabir (2013) emphasizes the importance
of proper storage to minimize expiries of medicines by maintaining specific range
of temperature. He further points out that any temperature excursion can reduce
drug potency, reduce shelf life or alter a drug so it becomes harmful. Some
researchers also agree with Kabir on the importance of pharmaceuticals requiring
great handling care in storage and transportation.
26
2.3 Malawi Supply Chain System
While the Ministry of Health’s medicines budget has not ably met the
pharmaceutical needs for the country, the sector has received various support in
various health conditions. For example, The Global Fund (GF) has provided
support acquisition of HIV related commodities and anti-malaria’s; USAID and
UNFPA/DFID have supported with family planning commodities; GAVI, KfW have
supported the country with vaccines and DFID, Norway and KfW pulled together
funds to procure other essential medicines in a project that commenced in 2012
and ended in 2014, just to mention a few. In view of this, it is imperative to put in
place proper health forward and reverse pharmaceutical supply chain systems,
besides engaging appropriate human resource to manage the drugstore.
In response to the partners’ generosity, Ministry of Health has since made several
reforms including the establishment of Logistics and Supply Chain Unit that
coordinates pharmaceutical supply chain activities including monitoring the flow of
pharmaceutical products from the supplier to the end user as well as information
from end user to the supplier in the country. The Logistics Unit’s mandate is to
ensure clients/patients are optimally served by delivering: Right quantities of the
medicines & related pharmaceutical supplies. The Unit also ensures that these
medicines are delivered to the Right health facility for use by the Right clients at
the Right time and at the Right cost, Logistics Handbook (2011)
In the Malawi Health pharmaceuticals supply chain system, regulations for
management of expiries, overstocks and damages are conspicuously vague.This
forces hospitals to do their own way, which is hazardous to the surrounding
community. This has inverse repercussions towards health as improperly disposed
medicines may land in markets, or in rivers where community draws water for
drinking. Sharp projects can be harmful to people if not properly disposed of.
27
Management of expired medicines in Malawi starts with health facilities removing
expired products from the shelf, quantify and sending them to the district hospital
for disposal. The district hospital compiles the list for all expired medicines and
sends a request to the Ministry’s pharmaceutical section seeking authorization to
dispose the products,(Pharmacy Manual 2012). However, documentation of the
disposed products is not stored in a proper way such with visibly no central
databank.
On the other hand, the current Health Commodities Management SOP provides for
an opportunity for districts to loan other districts some products that might be
requested by the lender. The lender is later expected to give back the same
product or another product of the same value to the lending facility. The
instructions on redistribution are not included. However, the Ministry of Health’s
HIV/AIDS Department developed a system of managing overstocks and expiries of
ARV products at facility level, and the following is the process as outlined in the
ART/PMTCT Guidelines (2014). When expiries or overstocks have been identified,
expiries are separated from the usable stock while the overstocks are counted for
further redistribution or reallocation. Then the HIV Logistics section is notified to get
an authorization code for relocation to other facilities or proper disposal. The
District Pharmacy personnel are informed in order to arrange for transfer of expired
medicines for controlled destruction, HTC skills Intensive Training Presentation
(2013).Facilities to which ARVs have been redistributed to are not expected to give
back to the source facility. This is possible because the Department of HIV and
AIDS is currently managinga full supply system with support from The Global Fund.
UNICEF supported redistribution of essential medicines twice in 2014. The idea
was to reduce risks of expiry of primary health commodities that were distributed
through a push kitting system. Overstocked health commodities were moved from
the health centres to the district hospital pharmacy ready for redistribution. The
challenges that affected immediate redistributionis that same product types where
28
overstocked in almost all the health facilities in a district. This meant not health
facility within the district would need any of the overstocked commodities. This
meant that the district pharmacy keeps the commodities for a longer time. Most of
the district pharmacies were further challenged with insufficient space to store the
overstocks. This undoubtedly led to some medicines expiring before use.
A commodity relocation assessment was conducted by O&M (2014). Two options
were then recommended to the Ministry of Health. The first option was that health
workers send short text messages indicating the expired or overstocked
commodities to the district pharmacy, assuming all of them have access to mobile
phones and again that they know how to send such information. This also
assumed a currently existing community LMIS platform would be extended to
accommodate this since it is also short message based. The second option was to
use paper based reporting on expired and overstocks. However the process has
not been concluded yet.
Lack of a proper and efficient reverse logistics system has contributed to
insufficient space in drug stores in Malawi, as there has been a significant delay in
removal of expiries and stockpiles in most of the facilities.
An assessment done in January 2014 in Mwanza, Chikhwawa and Thyolo districts
by Chirwa et al revealed that an amount worth $28,370.75 was lost through expiry
among thirty health commodities assessed. This, extrapolated to all the twenty-
nine districts for sixty-one primary healthcare commodities, means a total of
$1,286,868.21 was lost through expiry.
29
Figure 2. 1: Cost of expiration in Mwanza, Chikhwawa and Thyolo among 30 commodities
While Figure 2.1 above depicts huge sums lost due to expiration of medicines, no
clear procedures have been put in place to manage reverse logistics.
Therefore, management of expired pharmaceuticals needs a close monitoring to
ensure they were handled properly after leaving their control and ensure secure
chain of custody (Kabir, M. 2013).
Donations to referral hospitals in Malawi have also contributed to lots of expiries
because most of them are donated with short shelf-life that they could hardly be
consumed before expiry. Malikwa, M. (2014), reports about a referral hospital in
Malawi, Queen Elizabeth Central Hospital (QECH) that most drugs that were
donated by various partners between 2012-2013 expired, causing the hospital to
divert money meant for other hospital services for disposal. She further reports that
in 2012, the same hospital had discarded expired drugs worthy MK 62 million
(~US$138,085 at an exchange rate of $1 equal MK449) while Central Medical
Stores Trust (CMST), had similar exercise in April 2013 with drugs worthy MK 1
billion (~US$2,227,172 at an exchange rate of $1 equal MK449)discarded.
30
Mwanza Distric
t
Chikhwawa Distric
t
Thyolo Distric
t
TOTAL$0.00
$5,000.00$10,000.00$15,000.00$20,000.00$25,000.00$30,000.00
$2,196.26 $1,392.42
$24,782.07$28,370.75
Fig 1: Loss by District
Amou
nt to
be
lost
2.4 Why Consider Reverse Logistics?
In some industries, reverse logistics has elevated corporate image of the
companies practicing it. For instance, a customer procures a product only to note
at home that the product is malfunctioning. Companies with a client-oriented
reverse logistics would accept returning the product and provide an opportunity to
the client to make another choice. This gives an edge, a competitive advantage to
that company as most clients would opt to trade with it as opposed to a company
with a clear mark of “goods sold are not retainable”. If reverse logistics is
implemented in a hospital setting, it can also raise corporate image among patients
and other clients by providing quality products leading to quality healthcare.
Khan, A., et al (2009) emphasizes that companies take pride in themselves if they
protect the environment and minimize the environmental impact of their supply
chains. They further emphasize on considering corporate image, as competitive
reasons cited as one of the most important reason for implementing reverse
logistics. As a part of customer service companies, they are following liberal return
policies of their competitors to stay competitive. Likewise, with inadequate drug
budget, Malawi’s pharmaceutical supply chain system ought to tap from gains of
the reverse logistics in the corporate world to reduce to the minimum possible loss
of funds due to expiration or damage of medicines.
In many cases, regulatory requirements to recover or take back items are some of
the reasons that compel companies to implement reverse logistics. For instance, if
a pharmaceutical company discovers that a certain product has a defect which is
going to be harmful to patients, avoiding legal implications, the product has to be
recalled for re-manufacturing or proper disposal. Therefore, from regulatory
perspective, any product made can be recalled due to manufacturing defects,
expiry, safe disposal or recycling. Any product made is considered for discarding
after its lifespan, and what happens afterwards is a concern for reverse logistics.
31
A wake up call was experienced by some American companies through a study
conducted by Rogers, S., et al, (1998), to define the importance of Reverse
Logistics and to determine the extent of reverse logistics activity in the United
States. The study included companies in manufacturing, wholesalers, retailers and
service firm. The study resulted in all companies paying more attention to reverse
logistics and putting systems of proper reverse logistics management in place.
Companies also realized that the reverse logistics system acts as a strategic
variable for competitive reasons.
According to Lee (2013) in his journal suggests that the following be involved in
Health care reverse logistics: mapping of the return flow, giving standard times for
the returns, defining the cost of the returns and establishing the physical inventory
locations. Like is in logistics, transportation plays vital role in reverse logistics.
Having a reliable transport, therefore, can help hospitals manage their inventory
more effectively in the sense that products that need to be returned to suppliers
can be moved quickly.
2.5 Why Are Products Returned
No pharmaceutical product can be sold on the market without being authorized by
regulatory authorities after it has passed the quality, efficacy, purity and efficacy,
Bravo, A., et al (2013). Serrato, M., et al (20) points out that there are many
reasons why products are returned, either by consumers or by companies involved
in distribution or manufacturing. In the year 2011 Malawi health supply chain
system had a recall of a confirmatory HIV test reagent by manufacturer because of
manufacturing defects.
Serious flaws in a product can lead to a recall initiated either by the manufacturer
or government agency and this appears commonly in pharmaceutical and
automotive industries. Pharmaceutical products are mainly returned when it is
expired or damaged or when the product has physical defects, or when the product
32
has failed laboratory test due to lack of some ingredients. Apart from safety issues
in such situations, getting the discredited product out of circulation and to
designated storage areas as soon as possible is a critical challenge. Olaf, S.,
(2012).
Other reasons of returning products would be due to damage in transit, or products
with short shelf life and are slow moving or for proper disposal at designated
places.
2.6 Management of Expired/Returned or Recalled Products
The Importance of effective Reverse Logistics management is obvious. The
wrongly delivered, expired and products with damaged packaging, need to be
quickly recovered and replaced with saleable product to avoid disruption in sales. It
is imperative to make sure the channel is completely cleared of all expired
medicines to avoid legal complications, Khan, A., et al (2009). However in most
public hospitals, the system is not clear as there are no standard procedures for
managing such type of products. Besides legal requirements, the other major
factors that affect the choice of medical product disposal are facility’s size, ease
and access of disposal, and cost. For example, some facilities use flushing to
sewers as a primary means of disposal since it is easy and accessible.
Medicines and medical supplies found to be defective, damaged, expired or in
excess should be quickly recalled. This will help avoid unnecessary exposure once
the problem has been detected late. Inventory control systems that track
distribution to facilities by batch number greatly facilitate product recalls, MSH
(1997). Therefore, reverse logistics concept of management of hospital solid
waste, can be applied by thinking of appropriate method of discarding of the
product to avoid damages to the environment.
33
The issue of ‘green factor’ defined as marketing of products and services based on
environmental factors, www.investopedia.com (2009), is being taken seriously
globally, so much so that manufacturers are compelled to considering
environmental issues before disposing off products. Previously manufacturers
could easily dispose of products in a landfill. Today there are strict environmental
regulations as to how much and what can be dumped. Certain hazardous materials
such as chemicals and heavy metals are banned from disposal in landfills, while
other products are banned because they can be recycled and therefore should not
take up valuable landfill space. Landfill costs have also increased steadily. These
environmental reasons along with economic considerations cause a growing
number of manufacturers’ taking their products back at the end of their lifetime,
Olaf, S., (2012).
A study conducted by Alzahrani, D., (2014), agrees that most hospitals both public
and private are suffering in Third World Countries from increasing volume of
medical waste. They are struggling to find a proper way to get rid of the size and
quantity of hazardous medical waste that is generated among health care
providers and patients in hospitals. This has the potential of causing injuries and
spread diseases due to improper disposal methods. Moreover such wastes
dumped carelessly in front of hospitals and left in the open are easily tampered
with or transfer to municipal waste into landfills. This is unhealthy and can have a
serious impact to the citizens. An important call should be made for elimination of
the problem of disposing of those hazardous waste through the advanced
technologies and special modern equipment with the need to implement integrated
environmental management of hazardous medical waste for hospitals, and safe
disposal of such waste and prevent access to hazardous chemical wastes
generated after the final treatment from penetrating the aquifer to protect the
environment and public health.
34
2.7 Waste Management Practices
Sustainable management of waste and hazardous chemical is not only a challenge
in developing countries but also in industrial countries. It is worse in developing
countries as it is not achievable at present due to limited waste management and
treatment capacity and current regulatory frame according to Burkhard, O., W., et
al, (2013). The study further recommended that to improve the current situation in
developing countries, efficient and effective regulatory framework for the
management and control of hazardous chemicals should be developed and
enforced.
It is very critical for health workers be it clinicians, nurses, support staff,
pharmacists to understand the importance of managing waste and properly
dispose them to avert inverse effects to humans and polluting environment if not
properly done. It is therefore an asset for health workers to have knowledge and
understanding on the right procedures to manage waste in their health institutions.
A study was conducted in Kenya to identify gaps that health workers had in
knowledge, attitude and practices of waste management. The study found that
health workers that were interviewed in four hospitals did not have knowledge in
health care waste management, as it was not included in their curricula for health
care training profession, Nkonge, A., et al (2012). The study concluded that it was
important that health care training curricula include issues of waste management in
order to minimize injuries from health care waste.
Another study was conducted in Sudan, Khartoum town hospitals as well as
national level to assess the management of hospital solid waste. The overall
findings were that most of the hazardous chemical materials, food, construction
debris, medicines waste were all mixed together, collected and disposed of. While
at the national level, there was no policy governing hospital waste, or even
hazardous waste. Only some federal general environmental regulations, like
35
Malawi scenario that is using a makeshift, and some procedures from town and city
localities for controlling general municipal waste exist. At the hospital level, no
policies or rules were found, except in the radiotherapy center, where they
managed radioactive wastes under the laws of the Sudanese Atomic Agency`,
Suhair, A., (2013).
The researcher finds this study in agreement with a study conducted in Limpopo
Province of South Africa on the management practices of hospital solid waste in
Limpopo Province of South Africa looking at two hospitals. The findings revealed a
major policy implementation gap between the national government and the
hospitals. While modern practices such as landfill and incineration are used, their
daily operations were not carried according to minimum standards. Incinerator ash
is openly dumped and wastes are burned on landfills instead of being covered with
soil. The incinerators used are also not environmentally friendly as they use old
technology. The findings further revealed that there is no proper separation of
wastes according to their classification as demanded by the national government,
Nemathaga, F., (2008)
2.8 Why Reverse Logistics Strategies
Reverse logistics strategies are very essential in dealing with product recalls
especially those products that pose a health and safety risk to the public, and are
required to be returned to suppliers or manufacturers. Allocating the resources to
quickly scale supply chain operations to deal with a high rate of returns, can keep
the impact of recalls to a minimum. Companies that fail to align their transportation
management strategies to handle product returns and recalls could see their
operations become overwhelmingly decreasing in productivity, Admin (2013).
A study conducted in India found that, an in-efficient reverse process might lead to
customer dissatisfaction in the context of supply chains of unused medicines if not
properly handled because this may be harmful to the living beings in the system.
Abbas, H., et al, (2013). Failure to handle returns effectively can result in delays in
36
fulfilling new orders that could cost businesses sales and customer loyalty, Admin
(2013). It is therefore important to have proper methods of disposal in order to
avoid risks of injuring human beings.
John P (2005) points out that it is the responsibility of hospital managements to
ensure that all wastes generated within their facilities is properly managed and
disposed of so as to ensure the safety of their staff, patients and members of the
public bearing in mind the environment.
2.9 Improving Process of Returns/Recalls
If companies develop standard operating processes and capabilities of managing
returns, that can be used as a competitive weapon. Companies can change the
way they manage returns by following the four key steps involved in a return
processes according to Olaf, S., (2012). These are; local screening, collection,
sorting, and disposition.
2.9.1 Local Screening
The process is done at the point of collection of returned products. For instance,
defects or expired products from the hospital are collected, effectively checked and
counted for accountability and transparency purposes.
2.9.2 Collection
After effective screening, the products are collected destined to enter the reverse
supply chain. This step is similar to “handling”, whereby waste is collected and
transported to the designated places within the facility. Pharmaceutical or medical
waste should be properly handled, stored and transported for the disposal.
However to reduce risk of infection and injury, medical waste should not be stored
for a longer period of time, Suhair, A., (2013).
37
2.9.3 Sorting
According to Suhair, A., (2013), sorting is separating waste according to type, for
instance, pharmaceutical waste and infectious waste separate dusing color coded
bags at the place where they are collected. Different companies have dedicated
central warehouse to handle their returns with numerous advantages according to
Olaf (2012). Some of the key benefits include: increase in efficiency as employees
occupy positions on full-time basis, focusing on handling returns only; experience
in the sorting process will help employees make better and quicker disposition
decisions, and cycle times will improve, resulting in better asset recovery and
higher customer satisfaction. In Malawi, sorting is done right at the hospital where
products have expired or need exchange due to overstocks. However, sorting is a
crucial step in reverse logistics as it will assist employees making decisions on
what ultimately happens with the returns.
2.9.4 Disposition
This is the last step, which should be done in the most cost effective manner. Olaf
(2012) discusses three ways to dispose of products as follows; resell, repair or
remanufacture and scrap or dispose in a secure manner. This is total elimination of
hospital waste from the health facility.
The above steps can also be applied to hospitals in disposal of unwanted products
by fine-tuning them to suit the pharmaceutical setting.
2.10 Waste Management Policy
It is very critical to prepare and have clear policy for waste management in
hospitals as Suhair, A., (2013) suggests. The policy should be clear on waste
management from waste segregation, sorting, handling and storage up to final
disposal and how each step can be handled by health care workers. This will
enable hospital implement the system.
38
Suhair, A., (2013) further suggests that in order to ease the challenges of medical
or pharmaceutical disposal, a healthcare waste management plan should be
developed, so too a relocation or redistribution plan should ensue. And all this will
materialize if there is a designated health care personnel to coordinate the
management of relocations and disposal.
A study conducted in the republic of South Africa found that waste management
sector was emerging to be key to sustainable development for effective waste
management. It further stated that in the past, the sector was dominated by private
sector with selective operations like recycling of sealable products, while the rest of
waste materials that included medicines, general and hazardous ended up in
landfills. It was in view of this that development partner’s Deutsche Gesselschaft
Fur Technische Zusammenarbeit Gmh (GTZ), Danish International Development
(DANIDA), Danish Co-operation for Environment and Development (DANCED),
and Development Bank of Southern Africa (DBSA) decided to financially support
South African government policy on waste management to reverse the trend so
that the sector is under government to enhance sustainable development, Karani,
P., et al (2007).
Another study was conducted in Botswana in particular Kanye hospital, that
wanted to examine clinical waste disposal and handling in the context of a
community home-based care (CHBC) programme, and the findings were as
follows: lack of clear policies for clinical waste management, unhygienic waste
handling and disposal by home-based care givers that included burning and
burying the healthcare waste, inadequate transportation facilities to ferry the
wastes from hospitals, clinics and then to appropriate disposal sites, lack of
storage of healthcare waste at clinics, incinerators for burning clinical waste and
high risk of contagion to individuals and the environment at all stages of managing
the clinical waste, Simon (2008).
39
Discovery of wide range of pharmaceuticals in fresh and marine waters of which
has potential to cause harm to aquatic life prompted a survey carried out in
England by Jonathan, P., et al (2006) to determine factors affecting the methods of
disposal of expired pharmaceuticals that were chosen. Findings from the survey
showed that the perceived environmental awareness had an impact on the
methods of disposal. If awareness is emphasized to public, then improper disposal
shall be minimized.
40
Figure 2.2: Conceptual Framework
41
Extent of Expired products
Management of Overstocks
Disposal guidelines
Disposal Polices and Regulations
Reverse Logistics system
Are there expired medicines in hospitals? Why do medicines expire? How are they managed when they expire? Improvements?
Why do overstocks exist in the system How are overstocks managed? Improvements?
Does the system have disposal guidelines? How is waste product disposed in hospitals? Improvements?
Are there disposal polices and regulations in the system?
Improvements?
Does the system have proper system of reverse logistics?
Are some products returned? Why? Improvements?
Importance of Reverse Logistics system in public hospitals
2.11 Chapter Summary
This chapter introduced the reverse logistics, waste and excess stock management at
service delivery points and central level in order to lay a foundation to the ensuing
discussion on the reverse logistics system in Malawi’s pharmaceutical section. Here, the
chapter discussed importance of reverse logistics; how reverse logistics in done in
corporate world; some findings from various studies on reverse logistics both at hospital
setting and in industrial companies. The chapter then discussed requirements for
establishing a vibrant reverse logistics system in pharmaceutical sector. The chapter
wound up with a section on the importance of introducing policy on management of
waste to preserve the environment
The next chapter is on research methodology, which will outline collection of data used
in the study the approach and data analysis.
42
CHAPTER 3: RESEARCH METHODOLOGY
43
3.1 IntroductionResearch methods establish the groundwork in providing the responses to the research
questions as a way of realizing the main and specific objectives of the study. This
chapter outlines the research design and strategy adopted for this study, the formulated
sampling design and sample size chosen. The chapter also identifies the data collection
and analysis techniques used a statement of reliability and validity of the data collected
and steps taken on ethical considerations.
3.2 Research PhilosophyThe term relates to the development of knowledge and the nature of that knowledge.
There are four methods that any research is designed and these are; pragmatism that
argues that the most important determinant of the epistemology, ontology and axiology
one adopts is the research question. The second one is positivism that works in the
tradition of the natural scientist, preference on this is working with an observable social
reality and end product will be law like generalizations similar to those produced by the
physical and natural scientists. The third one is the Realism that relates to scientific
enquiry. The essence of realism is that it says the senses show us as reality is the truth
and lastly Interpretivism that advocates understanding of the researcher the differences
between humans in our role as social actors.
The study took an interpretivism approach as it was seeking the views of the users of
Malawi’s health supply chain system on the current reverse logistics system, in
anticipation that the information will assist in the development of recommendations for
an ideal and proper reverse logistics system for Pharmaceutical Supply Chain in the
public health system
3.2.1 Research ApproachThe study took an inductive approach. Saunders et al. (2003) observed that the
inductive approach provides the opportunity to have more enlightenment of what is
going on. The researcher was of the view that the Malawi Public Health System
44
practices reverse logistics system in pharmaceuticals although the approaches differ
from one facility to the other.
3.2.2 Research StrategyThe research built on a case study as the researcher’s particular interest was to gain a
rich understanding and process of reverse logistics in public hospitals and its impact.
The strategy has considerable ability to generate answers to the questions ‘why’, as
well as ‘what’ and ‘how’. The strategy explores more on the subject under study,
Saunders et al (2009).
This study engaged a mixed method. This technique entails collection, analysis and
“mixing” both quantitative and qualitative data at some stage of the research process in
one study, Tashakkori et al, (2003). The approach helps to comprehend a research
problem in its entirety, Creswell, (2002). Many researchers agree that approaching a
study using one method cannot provide sufficient trends and nitty-gritty of a situation.
When quantitative and qualitative methods are combined, each method is
complimentary to the other hence allowing for comprehensive analysis, Green, et
al(1989), Tashakkori et.Al, (1998). A chief precept of pragmatism is that quantitative and
qualitative methods are harmonious.
In this regard, qualitative data from interviews was collected augmented with
quantitative data from secondary sources to help better comprehend the research
problem.
3.3Sample sizeSince supply chain management of medicines and other medical supplies is mainly
practiced by pharmacy personnel at the district and Central Hospitals, to determine
source of primary data, three pharmacy personnel were targeted at Kamuzu Central
Hospital and two at District Hospital.
45
While health centers and district hospitals are administratively divided into five health
zones, secondary logistics data was sourced from 15 district hospitals and 50 health
centers, where a random sampling was employed within each health zone. From each
zone, three district hospitals and ten health centers were identified.
The health centers were stratified into districts to which they belong, with an assumption
that within each stratum, the situation is the same from one facility to the other. After
that, random sampling was applied to facilities of each district to determine where to get
secondary data. Of the 28 districts, a maximum of two health facilities were selected
with four of the districts with smaller number of facilities represented by one health
facility.
Before applying the random selection, all facilities belonging to CHAM, NGOs, private
clinics, district hospitals were removed from the list as the data from districts was only
derived from the two hospitals where the study was taking place. The decision to
randomly select facilities within the district was in two-fold: to ensure that the sample be
representative hence to minimize bias; since stock imbalances happen in all health
facilities in the country experiences of any of the health facility was representative
enough to study reverse logistics principles. Again, to determine the need to introduce a
sound reverse logistics in the system, a randomly selected sample of twenty six
medicines was assessed in a sample of fifty health facilities to determine stock
imbalances (i.e. Overstock, under stock and stock out).
To assess the current policy on reverse logistics, interviews were conducted to the
identified three central level officials: one from the Pharmaceutical Section of the
Ministry of Health (MoH); one from Central Medical Stores Trust (CMST), and one from
partners involved in the pharmaceutical supply chain. Expert knowledge of the roles of
personnel in the identified departments was utilized to identify the three interviewees.
The reason behind was to focus on the experts who are directly involved in supply chain
management for pharmaceuticals and have knowledge and understanding on the
policies currently governing the health commodities supply chain in the country.
46
3.4Data Technique and CollectionIn order to answer research questions and allow triangulation, multiple methods and
sources of data collection were used. Both primary and secondary data was collected
and analyzed to assess the management of stock imbalances and expired medicines in
the Malawi health supply chain. The following strategies were used for data collection:
3.4.1 Document reviewThe monthly logistics Management Information System and physical Inventory reports
were assessed to verify the stock imbalances of twenty-six randomly selected sample of
medicines as experienced in 2013 and 2014 in some fifty facilities. This was to ascertain
whether the hospital was overstocked with medicines or medicines expired at some
point and how were these situations managed.
3.4.2 Expert Interview GuideThe study used primary data collection methods direct from the source through the
guided interviews that were designed to gather all elements of reverse logistics in
relation to the Malawi Supply chain system.While the policy level data was collected
from public sector departments involved in pharmaceuticals supply chain in the country.
These included Pharmacy section in the Ministry of Health, CMST and USAID |
DELIVER PROJECT.
3.5Time HorizonsEvery study has got time limit to produce results, and it all depends on the research
question and strategy as Saunders et al (2009) states. There are two time horizons,
Cross-sectional that is mostly taken for academic purpose and longitudinal that studies
change and development. Recognizing that the study was to fulfill academic purpose,
and the limited time constraint that it had to be finalized, the study was cross-sectional.
3.6Data AnalysisPrior to analysis, data was cleaned and organized for analysis. Each data collection tool
was checked for completeness, accuracy and possible errors.
47
Qualitative data was analyzed by categorizing and coding. Similar responses emerged
from the interviews and documentation reviews were summarized. Since the researcher
was looking for the views and opinion of respondents, similar responses and trends
were categorized and coded in excel, where conclusions were based.
3.7Data Validity and ReliabilityValidity is concerned with whether the findings are really about what they appear to be
about, Saunders et al (2009). In this study, validity and reliability were achieved through
the instrument used for data collection where interviews were conducted to pharmacy
personnel who manage medicines in public hospitals and those directly involved in
supply chain.
This approach maximized reliability as interviewers were able to explain clearly, issues
related to reverse logistics. In addition, secondary data came from health facilities
themselves.
3.8Ethical ConsiderationIn order to ensure integrity of the research work, some interventions were made as
follows; a letter seeking approval to conduct the study at Kamuzu Central Hospital and
Ntchisi district Hospital was sourced from the ministry of health HTSS Pharmaceuticals
directorate. The respondents were properly informed of the study objectives and their
involvement in the study as supply chain experts, but also on how the data was going to
be utilized.
Respondents were also assured of the confidentiality regardless that the study was not
sensitive. For the central level supply chain experts, appointments were made prior to
the interview.
3.9Interpretation of DataThe conclusions were based on the findings of both qualitative and quantitative data
analysis. The conclusions further guided the researcher to draw recommendations on
48
designing proper procedures for reverse logistics system in the Malawi health supply
chain system.
3.10 Chapter SummaryThis chapter outlined the research methodology that was followed in conducting the
study, this includes: research philosophy, research approach, research strategy, and
sampling size. The chapter also discussed the reasons for choosing specific sampling
methods. The chapter further discussed approaches taken in collecting primary and
secondary data from the health facilities and key informants respectively. In concluding
the chapter, data analysis methods were outlined, the actions taken to ensure the
validity and reliability of the research instrument.
The next chapter reports on the findings of the study and an analysis of the tested
variables.
49
CHAPTER 4: SURVEY FINDINGS AND DISCUSSION
50
4.1 IntroductionThis chapter presents the findings of the study after analysing primary and secondary
data from facilities and key informants. The findings have been summarised and
presented in tables, figures, graphs and charts. Such presentation of data helps to
easily analyse the data and identify trends if any. The chapter further provides an
analysis and discussion of the findings by synchronizing with the research objectives,
research questions and literature review.
4.2 Findings from primary Data
4.2.1 Reverse LogisticsA sample of five pharmacy personnel was asked if reverse logistics is practiced at their
respective hospitals. All the respondents (100 percent) indicated that they practice
reverse logistics. Asked how reverse logistics is done, only 40 percent of the
respondents was able to describe some procedures similar to reverse logistics, like
collection of expired and excess stock from the hospital wards back to the pharmacy.
However, from the 40 percent respondents who attempted to describe how reverse
logistics is done at their respective hospitals, 60 percent described the procedure for
disposal of expired medicines: health facilities remove the unwanted products from the
shelf, quantify them and send to the district hospitals. The district hospitals request from
Ministry of Health a permission to call for a Board off Committee. When granted, the
Board off Committee witnesses distraction of these health commodities and write a
report. This is only part of and not the exhaustive procedure for reverse logistics. Of
interest were two responses from two different personnel from the same hospital. It
transpired that while the responses were different among the health facilities, they were
also different between individual from same facility.
From the findings, the researcher is of the view that “reverse logistics” is not known
amongst pharmaceutical personnel. The feedback did not show the actual movement of
commodities in reverse. Malawi public health sector’s disposal system is decentralized
by district. Medicines are therefore disposed at the customer’s facility as opposed to the
51
supplier. The only clear reverse movement is when such expired commodities and
overstocks are moved from the health centers to the district hospitals to either dispose
of them or re-distribute.
4.2.2 Management of Overstocks at Hospital levelRespondents were asked whether they experience overstocks of medicines and other
medical supplies at their facility. All the five pharmacy personnel interviewed, confirmed
experiencing overstocks of different kinds of medicines. Mostly over a period of one
month, especially with those slow moving. If there are no proper procedures to manage
overstocks, the medicines end up expiring which is costly. It is even worse when facility
next is stocked out of the medicines that have expired because they were in excess and
not utilized.
4.2.3 Reasons for Overstocks in Hospital Pharmacy
Figure34.1: Reasons for overstocks
Figure 4.1 shows reasons provided by respondents as contributing to overstocks in
public hospitals; as eighty nine percent were of the view that the “push system” is the
52
Because of push system
Change in patient regimen
products are slow moving
change in disease pattern
no proper quantification
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Reasons for overstocks in Hospital Pharmacies
Percentage
main reason for overstock in hospitals. Some programs in the Ministry of Health
implement push system to ensure availability and accessibility of medicines in hospitals
and the medicines are donated to Malawi government that include; ARVs, ant malarial,
Family planning, vaccines and TB medicines.
However, due to incorrect, inaccurate and incomplete data for quantification, decisions
to procure and push medicines to hospitals are derived from as some respondents
pointed out. In addition, these medicines are sometimes slow moving and end up
expiring.
Another reason respondents provided was the change in patient’s regimen and
treatment guidelines as other contributing to overstock in the sense that, by the time the
change is effected, medicines have already been procured, distributed to hospitals and
suddenly become obsolete, and eventually they expire. For instance, the Ministry of
Health adopted World Health Organization recommendation on switching patients on
Stavudine regimen to Tenofavir regimen due to extensive side effects and this
contributed to overstocks of stavudine that became unusable and eventually expired
because the few patients that remained on the regimen would not consume all the
medicines before they expired. ART/PMTCT Guidelines (2014).
The study probed further on the measures put by various hospitals in order to manage
overstocks to minimize expiries. All the pharmacy personnel interviewed reported that
they redistribute or donate to the nearest hospital or facility that is under stocked.
While others go further in exchanging with some items with other hospital for instance,
CHAM hospitals would have some items that the hospital needs, while the public
hospital has excess. In this regard, exchange of medicines takes place and if this
initiative is not facilitated, then the medicines would end up expiring in the drug store
which is costly to hospitals that are struggling to acquire same medicines.
53
From the findings, the researcher is of the view that some reverse logistics is being
practiced at district and hospital level, while none of the respondents mentioned central
level or warehouse being involved when deciding on what to do with overstocks as a
source of supplies. Again, there are no standard procedures to guide hospitals when in
that situation. As was observed that, eighty percent of the respondents had never seen
any guidelines on the management of overstocks while twenty percent acknowledged
availability of guidelines though they were not able to describe the procedures.
4.2.4 Management of Expiries at Hospital levelThe study found out that medicines expire at hospital level. All the pharmacy personnel
interviewed acknowledged that at one point they witnessed medicines expiring due to
several reasons of which the study probed further from the pharmacy personnel and
how they manage when found in the drug store. Expiry of medicines in the supply chain
is a serious threat to the already constrained limited resource in developing countries
like Malawi where drug budgets are often insufficient.
It was noted that expiry of medicines in hospitals was common especially among
medicines sourcing from various vertical health programmes supported by donors. For
instance, expiries were seen in some essential medicines, ARVs, Anti-malarials and
Family planning commodities just to mention few. The common practice in Malawi is
that all the donated items are pushed to facilities without necessarily basing on needs or
requests from the hospitals. This practice leads into accumulation of huge quantities of
products in low volume health facilities. Some of these donations have less than six
months of shelf-life. Even if the shelf-life was over 18 months, some quantities allocated
to a facility are too huge to be consumed before they expire. Coupled by poor revere
logistics system in the health facilities, such huge quantities are prone to expiration.
Uncoordinated distribution of donated health commodities are therefore amongst the
most popular factors contributing to expiry.
54
Other reasons for the expiry of medicines are slow moving products that have short
shelf life, change in treatment policy by programmes, and hospitals not practicing first to
expire first out (FEFO) principle.
The system ends up will a good number of slow moving products due to uncoordinated
donations. However, the other more notable reasons include inadequate information on
demand for such products, and poor quantification assumptions.
While change in treatment policy is considered to be another cause, it only happens
after a reasonable period of time as treatment policies do not easily change. However,
in the event that a treatment policy is changing when the supply system still holds a
significant quantity of the affected product(s), this would pose a great challenge and
mass expiration of the product(s) is inevitable.
FEFO is a well-established principle embraced by health commodities logistics experts.
The principle demands that the medicines that expire earlier, no matter what time it
entered the drugstore, should be the first to be dispensed. To easily implement this, it
requires that the drugstore manager arrange his products such that those expiring first
are arranged in front on shelves and those expiring last are at the back. Practicing this
principle oftentimes helps to reduce expiration of medicines on shelf. However, with
inadequate supervision, some drugstore managers hardly practice the principle.
The study found out that expiries are managed differently at every hospital as figure 4.2
below shows:
55
Figure 4.2:Management of Expiries
0% 20% 40% 60% 80% 100%
Procedures for Expiries
store in a separate placequantify themseparate them dispose them off
Fig 4.2 shows different procedures followed by hospitals when they experience expiries
of medicines. Seventy five percent of the respondents dispose them off, but how,
where, when and who is responsible for the exercise was not described. While fifty
percent of the respondents separate them ready for disposal. Again procedure was not
described. Twenty-five percent quantify and store them in a separate place ready for
disposal. Respondents were not able to describe what exactly happens before the
disposal of medicines despite availability of procedures and for those that are
separated, waiting period before disposal was also not described.
The researcher is therefore of the view that, medicines expire in hospitals due to several
reasons and they are disposed of, however the procedure for disposal and how often
the exercise is done was not clear to health personnel from the findings. The researcher
went further to find out if there are any guidelines that describe procedures to follow
when medicines have expired. Eighty (80) percent of the respondents confirmed the
availability and described procedures to follow when medicines have expired while
twenty percent was not sure of the availability of guidelines because they were not
accessible. One of the respondent described expiries of medicines as a critical issue
that donors would not want to experience because organizations would not want to be
exposed. Again expiries have a negative impact on the cost and resources in a limited
resource area.
56
4.2.5 Challenges with Reverse LogisticsWhile acknowledging the possibility of some reverse logistics happening in some
hospitals, the study wanted to find out if there were any challenges that impinge the
implementation of proper procedures of reverse logistics both at central and hospital
level. The following are some of the challenges reported in fig 4.3:
Figure 54.3: Challenges with Reverse Logistics
Ltd storage
Transportation
delay of boarding off expired commodities,
donations
no policy on RL or WM at central level
high impact on cost and resources
political in nature at donors side
lack of infrastructure for disposal
wastes, experies, overstocks not reported
0% 5% 10% 15% 20% 25% 30% 35%
Challenges of Reverse Logistics (Respondents)
Source: field data, 2015
Figure 4.3 shows challenges encountered by hospitals and central level that contribute
to impingement of reverse logistics as perceived by respondents.
Among the challenges topping the list include: lack of policy on reverse logistics and
waste management at central level, donations, expiries and pharmaceutical wastes not
reported, delay in boarding off of expired medicines. Thirty one percent of the
57
respondents both at central and hospital level acknowledged the non-availability of
policy to direct and guide the issues of reverse logistics. Policy document ensures that
service providers are accountable as it stipulates processes clearly. Efforts have been
made to develop policy on supply chain that would include issues of reverse logistics,
but there has not been any commitment from the central level. Currently only guidelines
and procedures on disposal of expired medicines are available but are not backed up by
policy.
And, when disposal exercise has taken place, the only evidence available is the
certificate of disposal. The monitoring mechanism to ensure that the exercise was done
according to standard procedures is not fully functional.
Nineteen (19) percent of the respondent’s findings were of the view that donations are
contributing to challenges in the sense that they are pushed to hospitals in huge
quantities and sometimes some of them are slow moving medicines and eventually end
up expiring in facilities. While twelve percent of the respondents reported that most
donations are hardly reported when expiration occurs due to a political face this wears,
with hospitals preventing from being exposed to an investigation on why medicines
expired. This is in agreement with findings of the study conducted in Uganda by
Nakyanzi, J., et al (2008) that, the top expiring medicines in supply outlets were those
among donated medicines for vertical health programs however, decisions on what to
procure, distribute and store will also base on information of expired and excess
medicines especially where there is limited resource.
Lack of proper infrastructure to dispose expired medicines was another challenge.
Currently hospitals have their own way and designated place for disposal of
pharmaceutical waste and unwanted medicines, if not careful this can be harmful and
hazardous to the community and environment. Transport, to move products from one
facility to the other or even to recollect products from lower level for proper disposal is
another challenge. Hospitals rely on ambulances whose main role is to ferry patients
and not moving or reallocating commodities from the lower facilities to central level for
disposal or value addition. Unfortunately, government does not have separate funding
58
at central level to support movements of medicines from one facility to the other for the
purpose of reallocation, value addition or proper disposal.
Other challenges that were identified by hospitals practicing reverse logistics included,
limited space to store expired medicines. Ideally expired stock is supposed to be
removed from the drug store and quarantined, however due to insufficient spaces in
hospitals, these obsolete pharmaceuticals are usually left at a corner in the drug store
waiting for recollection, occupying valuable space which could have been utilized for
other usable medicines. Likewise, excess stocks from health facilities cannot be
properly stored in district facilities for redistribution due to lack of adequate storage
space. This is in agreement with the assessment of health commodity storage capacity
in public health facilities done by USAID | DELIVER Project, USAID I DELIVER (2014).
The assessment found that majority of health facilities did not have adequate storage
space for holding medicines and medical supplies. This provides a new challenge in the
Malawi scenario as some expired commodities stored together with usable stocks could
be mistakenly dispensed to patients. The challenge is extensively experienced due to
delay of boarding off of expired commodities because it takes long to get authorization
from the central level for disposal. This compels facilities to hold unusable commodities
for a longer period.
4.2.6 Expert interview Guide
4.2.6.1 Policy on Reverse LogisticsThe central level’s mandate is to provide overall policy direction and guidelines on the
issues of supply chain and reverse logistics. Apart from procurement, other components
of supply chain are not clearly covered by policies. However effort has been made by
MoH with support from SSDI to review the 2009 National Medicine Policy. The process
is still ongoing as the revised policy is still in draft form. However, the draft document
does not cover issues of reverse logistics. Since the revised medicines policy has not
been finalized, the researcher is of the view that the study is being done at the right time
where issues of reverse logistics can be considered and incorporated.
59
Issues of reverse logistics for instance, redistribution of excess stock, management of
expiries and proper disposal were found to be challenging, because there are no proper
procedures in place to guide so that there is, effective and efficiency operations of
supply chain. This is in agreement with the findings of study that was conducted in
Egypt, which found that, most developing countries face challenges in the sustainable
management of wastes due to limited resources and appropriate and effective
regulatory framework, Bukhard, O., et al (2013). Overall, neither investments nor
financial resources have been committed to issues of reverse logistics and waste
management for sustainable development.
Clinton Health Access Initiative (CHAI) conducted a Commodity Relocation Study
through O&M (2014). This resulted into a proposal of procedures for redistribution of
excess medicines within hospitals in order to minimize expiry of medicines, but also to
reduce drug budget that could be used to procure other essential medical items. This
has not been concluded as the government ought to make decisions on the proposals.
4.2.6.2 Role of Partners and StakeholdersPartner’s play critical role in supply chain as they support Ministry of health with
essential medicines, ARVs, Ant malarial medicines and tools for monitoring availability,
accessibility and rational use of medicines while ensuring that health workers that
manage drug stores are well equipped and are aware of various procedures of drug and
waste management in order to provide effective and efficient services. However, some
of the donated medicines are usually not based on need, or request from recipient
facilities, resulting in stock imbalances and unavailability of unneeded medicines at
different health care level. In addition, no mechanism has been put in place to support
hospitals when they are in such situations. In other words no financial resources have
been committed to support movements of overstocks back to central level or expired
medicines for proper disposal.
60
4.3Findings from secondary Date
4.3.1 Assessment of stock imbalances in fifty facilitiesA randomly selected sample of twenty six medicines was assessed in a sample of fifty
health facilities to determine stock imbalances (i.e. Overstock, under stock and stock
out). This was to determine the need to introduce a sound reverse logistics in the
system. The medicines included; Adrenaline Injection, Albendazole Tablets, Amoxycillin
tablets, Hydrochlorothiazide Tablets, Praziquantel Tablets, Promethazine
hydrochloride Tablets, Salbutamol Tablets, Water for injections, Clips, umbilical
cord, polythene Ferrous sulphate / folic acid Tablets, Magnesium sulphate Injection,
Female Condoms, Male Condoms, Oral Contraceptive tablets (MICROLUT),
Sulphadoxine/pyrimethamine Tablets, Lumefantrine/Artemether Tablets,Oral
rehydration salt, Zinc Sulphate tablets, Isoniazid Tablets,RHZ Tablets, Abacavir (ABC)
+Lamivudine (3TC) Tablets, Acyclovir Tablets, Cotrimoxazole 960mg tablet,
Doxycycline Tablets, and Erythromycin Tablets.
Out of the 26 selected medicines, sixty nine percent are distributed through ‘push
system’, while thirty one percent are pulled by facilities from the central level.
Figure 64.4: Comparative analysis of stock imbalance 2013/2014
Overstocks Understocks Stockouts0%
10%20%30%40%50%60%70%80%
comparative analysis of stock imbalance 2013/2014
2013 2014
Fig 4.4 represents the stock imbalance between the year 2013 and 2014 of the selected
products. Traditionally, Malawi pharmaceutical supply chain system implements a
maximum-minimum inventory control system of stock whereby facilities ensure that
61
quantities in stock fall within an established range of three months maximum and one
month minimum. Anything within the range of three and one is properly stocked while
outside this range is considered as stock imbalance (either overstock if above three
months of stock, or under stock if below one month of stock). It is paramount therefore
that health personnel managing medicines and other medical supplies have potential to
know their Max-Min levels in order to make helpful decisions.
The findings above show that in either 2013 or 2014 there were significant stock
imbalances. Of notable interest was the fact that while facilities were experiencing
overstocks, more and more facilities were either stocked out or under-stocked.
Comparing 2013 and 2014 trends, it is clear that the situation was worse in 2014 with
more facilities reporting overstocks, under stocks and stock-outs. This shows that there
is not enough that is being done to avert possibility of expiries on overstocks.
4.3.2 Facilities experiencing stock imbalances per month in 2014The study wanted to verify the proportion of selected facilities that experienced a stock
imbalance at some point in 2014 and what action was taken.
Figure 74.5: Facilities experiencing stock imbalances per month in 2014
57%34%
9%
Facilities experiencing stock im-balances per month in 2014
OverstocksUnderstocksstockout
62
Figure 4.5 shows the proportion of facilities with stock imbalances in any given month.
Of the 50 facilities selected, fifty seven percent experienced overstock of one or more of
the selected medicines per month. While this was so, thirty four percent experienced
under-stocks and 9 percent stock out of one or more selected medicines per month.
The challenge is, some patients are sent back without treatment because the medicine
is stocked out, yet the next facility is overstocked with same medicine that ends up
expiring on shelf.
If procedures of reverse logistics were in place and made them available to health
personnel who are managing medicines, the situation would have been managed by re-
distributing the fifty seven percent over-stocks to stocked-out or under-stocked facilities
and minimize expiry in hospitals while at the same time making the product available
where it is needed most.
4.3.3 Stock imbalance by Product
Figure 84.6: Comparative analysis of Facilities that experienced stock imbalance by product-2013/2014 amongst essential medicines, according to therapeutic use
Adrenaline 1/1000, 1ml
Albendazole 400mg
Amoxycillin 250mg
Hydrochlorothiazide 25mg
Praziquantel 600mg
Promethazine hydrochloride 25mg
Salbutamol 4mg
Water for injections, 10ml
0%20%
40%60%
80%100%
Stock imbalances by Product: 2013 - (Other Essential Medicines)
Stocked Out Understocks Overstocks
Albendazole 400mg
Amoxycillin 250mg
Hydrochlorothiazide 25mg
Praziquantel 600mg
Promethazine hydrochloride 25mg
Salbutamol 4mg
Water for injections, 10ml
0%20%
40%60%
80%100%
Stock imbalances by Product: 2014 - (Other Essential Medicines)
Stocked Out Understocks Overstocks
63
Fig 4.6 shows a comparative analysis of stock imbalances for other essential medicines
that were donated to the Government of Malawi through kit system in 2013 and 2014 by
product. The trend is similar for both years in most medicines, like Albendazole,
Promethazine Hydrochloride and water for injection whereby, 80 percent overstocks
were experienced respectively. As every medicine has expiry period, obviously from the
analysis, huge quantities must have expired if no reverse logistics was done. However,
it is worth noting that around same period of overstocks of a particular product in some
facilities, there were also other facilities with stock out and under stock of same
medicines. There was a huge stock out of Amoxycillin tablets in both years up to 60
percent, while overstock was also experienced of same product in some facilities. In
general, all the medicines were overstocked in some facilities while under stocked or
stocked out were also observed in other facilities of same products. If there are no
proper procedures for re-allocation, or re-distribution, hospitals are likely to lose huge
quantities of medicines due to expiry.
Figure 94.7: Comparative analysis of Facilities that experienced stock imbalance by product-2013/2014 amongst Anti-malarials.
0%20%40%60%80%
Stock imbalances by Product: 2013 - (Anti-malarials)
Overstocks Understocks Stocked Out
0%30%60%90%
Stock imbalances by Product: 2014 - (Anti-Malarials)
Overstocks Understocks Stocked Out
64
The next products are ant malarial medicines that also experienced stock imbalance
with similar trend to the other set of medicines as shown in Figure 4.7. The treatment
protocol for malaria changed in Malawi from use of Sulphadoxine Pyrimethamine (SP)
to Lumefantrine Artemether. Use of SP was restricted to prevention of malaria in
pregnancy every three months of pregnancy and once for prophylaxis. In view of this,
80 percent overstock is a challenge as at some point most of it will expire if no
intervention of reallocation or redistribution is considered. Worse still, some facilities
experienced a very pathetic situation of under stock or completely stocked out of the
same product.
As for Lumefantrine/Artimether which is the current first line medicine for malaria, under
stock was reported at 58 percent which is fatal to patients when they are turned back
home without the treatment due to stock out, while in some selected facilities, the
medicine was overstocked by thirty eight percent. If these were not handled properly,
obviously they were going to be lost due to expiry while patients were turned back
without medicine.
Therefore, the researcher is of the view that if proper procedures of reverse logistics are
put in place, issues of expiries will minimize as every medicine shall be managed
properly and every health personnel managing medicines shall be accountable and
responsible for proper management of overstock, under stock and expiry. The above
analysis poses as examples to express the impact of a vibrant reverse logistics in
hospitals.
4.3.4 Chapter Summary
This chapter presented findings from generated primary and secondary data collected
from health facilities. The findings have been presented mainly by using bar graphs.
The chapter also analyzed the findings according to the observed trends in the
responses to the tested items. The analysis progressed into discussion of the findings
that also involved linking relationships of the findings to the research objectives and
65
questions, and to the literature reviewed and any additional literature. Next chapter is on
conclusion and recommendations.
CHAPTER 5: CONCLUSION AND RECOMMENDATIONS
66
5.1 IntroductionThis chapter makes conclusions and recommendations from the study. The conclusions
are made on the outcomes from both the literature review and the primary study
conducted on the research respondent. Recommendations have also been made based
on the findings of the study. Both the conclusions and recommendations are made in
line with research objectives and questions.
5.2 ConclusionThe study concludes that policy on waste management and reverse logistics has
significant financial and operational advantages to the Malawi health pharmaceutical
supply chain and in public hospitals. This is very important as it will reduce expiry of
medicines in hospitals while overstocks shall be reallocated or redistributed within the
system. Medicines expire in hospitals or are overstocked at one facility while the next
facility is stocked out. This is where redistribution or reallocation is important to minimize
loss of medicines due to expiry.
Donations or push system of medicines is good when it is backed by correct data or
need for the hospital or country, otherwise issues of expiry and overstocks will never be
minimized. Moreover, there is no clear mechanism for collection of expired medicines
from the clinics, health centers to the district hospital.
There is availability of some procedures for management of expired products and
guidelines that are not backed up by policy which clearly stipulates issues of reverse
logistics, focusing on management of excess stocks, management of waste and
mechanism for collection and reporting of expiries.
The coordination between Ministry of Health and partners in pharmaceutical supply
chain can be utilized to mobilize resources for construction of infrastructure for disposal
of medicines, to avoid community poisoning, misuse or environmental damage.
5.3 RecommendationsFrom the findings above, Ministry of health needs to consider and improve on several areas of supply chain of medicines as follows;
67
1. Ministry of health and collaborating partners should consider expediting the current draft national medicines policy and include elements of reverse logistics that will mainly focus on proper management of pharmaceutical waste, proper disposal of expired medicines and reallocation/redistribution of excess medicines within hospitals to minimize expiries of medicines. The existing guidelines should include proper management of pharmaceutical waste at hospital level and be available and oriented to all hospital workers for safe handling of the waste.
2. The push system of medicines and other supplies being implemented by partners should be based on the actual needs of hospitals, and possibly compare two sets of data, logistics and morbidity in order to minimize expiries in hospitals.
3. Ministry of health and collaborating partners to consider investing in reverse logistics issues for instance; transport, supervision, within the supply chain management of medicines, in order to minimize expiry of medicines and other medical supplies in hospitals. In addition, invest in capacity building of health workers who are managing medicines, for them to be able to make quick decisions when they experience stock imbalances (overstock/under stock and stock out).
4. Ministries of Health and Environmental Affairs to consider proper infrastructure for disposal of pharmaceutical waste, general and hazardous materials to avoid risk of contagion to individuals especially children and the environment at all stages of management of waste before disposal.
5. Ministry of health and PMPB to find ways on how authorization to dispose of
expired medicines can be expedited and reduced as most spaces in the drug
stores are being occupied by expired/unwanted medicines and supplies which is
also dangerous to dispensers. In addition, there has to be a mechanism of
reporting on how the exercise was performed before the PMPB issues of
certificate of disposal.
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69
APPENDICES
70
Appendix 1: Checklist for primary data Collection
“The Impact of Reverse Logistics in Public Hospitals: A case study at Kamuzu Central Hospital and Ntchisi District Hospital, in Lilongwe.”
Introduction:
I am an MSC student in Supply Chain Management with University of Bolton. This
survey is being carried out in partial fulfillment of this degree programme. As the topic
suggests, the purpose of this survey is to find out assess the benefits of reverse
logistics in public hospitals in Malawi. The interview should take you about 20-25
minutes to complete. Please note that there are four sections and under each section
there are a set of few questions that the researcher would like you to respond to by
either ticking in one box under each statement that best suits your answer or writing
short answers where necessary
The Information You Will Provide Will Be Treated In The Strictest Confidence And Will Only Be Used For The Academic Purpose.
71
Name of Facility:________________________________
Date of Interview: ___________________________________
Designation of the interviewee: ______________________________
Interviewer:___________________________________________
No. QUESTIONSI REVERSE LOGISTICS AT THE FACILITY
1(a) Does facility practice reverse logistics? Y N Don’t Know
1(b).If Yes, what are the procedures?
.____________________________
.____________________________
.____________________________
1(c)
If Yes, are there any challenges associated with reverse logistics at this facility?
1.____________________________
2.____________________________
3.____________________________
Comments:
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2 MANAGEMENT OF OVERSTOCKS AT THE FACILITY
2(a)Do you experience overstocks at this facility? Y N Sometimes
2(b) If yes, how often
Less than one week Once a month Over a month
2(c) If Yes in 2(a), why?
2(d)Which 10 health commodities have you been experiencing frequent overstocks in the past 6 months?
2 (e) How do you manage overstocks at this facility?
___________________________
.____________________________
.____________________________
2(f) How often do you react to overstock?
2(g)Do you have reference guidelines clearly stipulated on management of overstocks?
Y N
Comments:
MANAGEMENT OF EXPIRIES AT THE FACILITY
3(a)Do you experience drug expiries at this facility? Y N
3(b) If (Yes), what are some of the causes of expiries at this facility?
1 _______________________
2.____________________________
3.____________________________
3(c)Which 10 health commodities have you been experiencing frequent expiries in the past 6 months?
3(d) How do you manage expiries at this facility?
.____________________________
.____________________________
.____________________________
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3(e) How often do you react to expiries?Once a month Any time during PI Whenever expiry has been identified
3(F)Do you have reference guidelines clearly stipulated on management of expiries?
Y N
Comments:
4 POLICY
4(a)Is there a policy to governing reverse logistics for medicines and medical supplies?
Y N
4(b) If yes, how is it done?
5 IMPROVING THE REVERSE LOGISTICS IN PUBLIC HOSPITALSIf you were to be given an opportunity to suggest strategies for proper reverse logistics system in public hospitals, how would you improve:
(a) Quantification of medicines?
(b) Storage?
(c) Logistics management information system?
(d) Procurement of medicines?
(e) Policies?
Comments:
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Appendix 2: Approval Letters to undertake the study
a) Request letter to the Ministry of Health to collect data in health facilities for academic use
75
b) Letter from Ministry of Health to Health Facilities collect data in health facilities for academic use
76
Appendix 3: List of Facilities where secondary was collected
Facility Type LocationNandumbo HC MOH Health Centre BALAKALirangwe HC MOH Health Centre BlantyreMdeka HC MOH Health Centre BlantyreNgabu Rural Hospital
MOH Com. Hospital Chikwawa
Mapelera HC MOH Health Centre ChikwawaChitera HC MOH Health Centre ChiradzuluNamadzi HC MOH Health Centre ChiradzuluKameme Health Centre
MOH Health Centre Chitipa
Nthalire Health Centre
MOH Health Centre Chitipa
Kaphuka HC MOH Health Centre DedzaMphathi HC MOH Health Centre DedzaMponela Rural Hospital
MOH Com. Hospital Dowa
Thonje HC MOH Health Centre DowaNyungwe HC MOH Health Centre KarongaWiliro HC MOH Health Centre KarongaKaluluma Rural Hospital
MOH Com. Hospital Kasungu
Mpepa HC MOH Health Centre KasunguChileka HC-LL021 MOH Health Centre LilongweChiunjiza HC MOH Health Centre LilongweChikweo HC MOH Health Centre MachingaMachinga Health Centre
MOH Health Centre Machinga
Namwera HC MOH Health Centre MangochiIba HC MOH Health Centre MangochiChipumi HC MOH Health Centre MchinjiGumba HC MOH Health Centre MchinjiNamphungo HC MOH Health Centre MulanjeMpala HC MOH Health Centre MulanjeThambani HC MOH Health Centre MwanzaManolo HC MOH Health Centre Mzimba NorthKabuwa HC MOH Health Centre Mzimba SouthMagaleta HC MOH Health Centre NenoBula HC MOH Health Centre Nkhata-BayTchesamu HC MOH Health Centre Nkhata-Bay
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Msenjere HC MOH Health Centre Nkhota-KotaMtosa HC MOH Health Centre Nkhota-KotaMbenje HC MOH Health Centre NsanjeMakhanga HC MOH Health Centre NsanjeBilira HC MOH Health Centre NtcheuBiliwiri HC MOH Health Centre NtcheuChinguluwe HC MOH Health Centre NtchisiKangolwa HC MOH Health Centre NtchisiMkhuzi HC MOH Health Centre NtchisiMigowi HC MOH Health Centre PhalombeNkhwayi HC MOH Health Centre PhalombeChisimuka HC MOH Health Centre RumphiMaganga HC MOH Health Centre SalimaMAFCO MOH Health Centre SalimaChimvu HC MOH Health Centre ThyoloMapanga Hc MOH Health Centre ThyoloMatawale HC MOH Com. Hospital ZombaNgwelero HC MOH Health Centre Zomba
Zone District Health OfficeNorthern Zone Rumphi, Karonga, Mzimba SouthCentral East Zone Kasungu, Nkhotakota, NtchisiCentral West Zone Lilongwe, Mchinji, NtcheuSouth East Zone Mangochi, Zomba, PhalombeSouth West Zone Blantyre, Chikwawa, Neno
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