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RURAL INTERNSHIP REPORT

ASSIGNMENT 2

TO STUDY THE PROCESSES INVOLVED IN THE PROCUREMENT,

STORAGE, INVENTORY CONTROL, DISTRIBUTION AND DISPOSAL

OF THE DRUGS AND MANAGEMENT OF EQUIPMENT AT PRIMARY

HEALTH CENTRE.

Submitted by Ishan Narma (M2014HE008)

Internship Coordinators

Dr. Nilesh Gawde

Dr. Matthew George

Dr. Narendra Kakade

Internship Supervisor

Mr. Amlan Majumdar

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Contents

Page No.

Introduction 3

Objectives 3

Methodology 3

Findings 4

Drug Forecasting, Demand, and Supply 4

Stock Entry 5

Drug Storage 5

Distribution of drugs and instruments 5

Stock Taking and Audits 6

Disposal of expired drugs 6

Equipment (Machines and Instruments) 6

Materials related to nonclinical services 6

Disposal of equipment/furniture 7

Role of CARE India 7

Discussion 7

Recommendations 8

Annexures 8

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INTRODUCTION

The Materials Management guidelines are not well laid-out in most of the public

hospitals whereas, in corporate hospitals, dedicated Softwares are used for inventory

management. It is a well-known fact that inconsistent supply and shortage of drugs, non-

provision of laboratory and radiological investigations leads to the underutilization of public

health services. The management of materials includes their procurement process, storage,

distribution, maintenance, and disposal. Materials in a PHC refer to a lot of things, but this study

mainly focused on management of Drugs, Equipments, Instruments and Linen as these are the

most important materials that the hospital needs for performing its primary functions.

OBJECTIVES

To study the processes involved in the procurement, storage, inventory control,

distribution and disposal of the drugs and management of equipment at Primary Health Centre.

METHODS

This study is an exploratory study to explore the processes of procurement, storage,

maintenance, distribution and disposal of materials the Primary Health Center level. The data is

collected by conducting semi-structured interviews with store keeper, accountant, clerk and

supervisor of RNTCP.

In-depth interview of storekeeper of Jalalgarh and Krityanand Nagar PHC is taken to

understand the processes involved in the procurement of the drugs from demand or requirement

calculation for procurement, storage, distribution of the materials to different departments and

disposal, if any. Information related to management of equipment and furniture is gathered from

the accountant of Jalalgarh PHC. The clerk of PHC Jalalgarh is interviewed to understand the

process associated with management of Linen. A general overview of the materials management

process was also given by the medical officer-in-charge and block health manager of Krityanand

Nagar PHC.

Data is also collected from District manager of CARE India, Purnia to know the role of

CARE India in materials management at PHC level.

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FINDINGS

Drug Forecasting, Demand, and Supply

Drugs are usually demanded at an interval of 1 to 1.5 months. Some fast moving drugs

like antibiotics, painkillers, anti-allergic and antifungals are demanded every 15 days. The

demand is calculated by taking the last month’s consumption at PHC, APHCs, and HSCs. 10%

of the last month’s consumption is added to last month’s consumption to arrive at the final figure

of demand. This 10% additional quantity is added keeping in view the increase in patient inflow

to PHC. There are some seasonal diseases for which additional 25% of drugs related to the

disease are demanded in addition to previous month's utilization. These seasonal diseases include

cough and cold in winters, dermatological problems in summers and diarrhoea in monsoons.

This demand is calculated by storekeeper and approved by Medical Officer In-charge (MOIC).

The indent is sent by MOIC of the PHC to Civil Surgeon (CS) of District Hospital, Purnia.

(Annexure 1) Civil Surgeon sends this demand to storekeeper of District hospital who supplies

the available drugs at the same time to storekeeper of PHC. The storekeeper of PHC books an

Auto to carry these drugs to PHC and gets reimbursed later by the MOIC. (Annexure 2)

The supply of the drugs is based on the availability at District hospital and not on the

demand sent. Sometimes the PHC doesn’t get all the drugs which were demanded and sometimes

the quantity supplied is lesser or greater than demanded. In some instances, even those drugs are

supplied which are not demanded. The shortfall of drugs is not supplied afterward till a new

indent is sent to the civil surgeon. In the last month, 73 drugs have been demanded by Jalalgarh

PHC but only 31 drugs were supplied.

In case of drugs under National Health Programmes, the supply is adequate and regular.

Drugs related to TB, Leprosy, Rabies and Kala Azar are supplied as per the demand sent by

PHC. RNTCP Drugs (DOTS) are supplied by Tuberculosis Center, Kasba, which acts as the

distributing center for 5 Tuberculosis Units. Whenever the available stock reaches two boxes, the

supervisor calls the Kasba Center from where the supply comes at the earliest. Anti-rabies

vaccine is supplied by the district immunization office.

Two additional PHCs that come under Jalagarh PHC have AYUSH doctors. No demand

for ayurvedic drugs is sent but if any Ayurvedic or Unani drug is supplied to PHC, the drugs are

sent to these APHCs.

On very rare occasions, drugs are purchased through Rogi Kalyan Samiti (RKS) as RKS

has very fewer funds with it, and most of this fund is used in the purchase of cartridges of

printers. In the last 1 year, no drug has been purchased with the money of RKS.

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Stock Entry

All the drugs and equipment received by PHCs are entered into the stock register. There

are two stock registers in Jalalgarh PHC, one for Drugs and another for Instrument, Linen, and

Equipment and for each item 2-3 pages are kept for entry. (Annexure 3) In Krityanand Nagar

PHC, a single stock register is used for drugs as well as instruments, linen, and equipment. To

keep the record of materials supplied within the PHC and to HSCs, a supply registered is

maintained. Whenever a material is supplied, it is entered under the name of the person who

received it. A separate list of those drugs that have expiry dates below 6 months is made, and the

medical officer is informed about these drugs. In past five years, not even a single drug has

entered its expiry date in Jalalgarh, as per the storekeeper while a few drugs expired last year in

Krityanand Nagar PHC.

Drug Storage

The space requirement for storage of materials is less for Jalalgarh than Krityanand

Nagar as Jalalgarh caters to less than half the population of Krityanand Nagar. There is one room

in the Jalalgarh PHC, which is designated to store the materials (drugs and instruments). In

Krityanand Nagar PHC, three small rooms are kept for storing materials. One room is kept for

stationary and drugs, one exclusively for drugs and the third one for instruments, linen, and

equipment. The materials are packed in a carton and kept on iron storage compartments in the

store. The Pharmacist (Store Keeper) is the in-charge of the store. There is no identification code

used for the easy identification of drugs. Drugs are kept on different shelves according to their

weight i.e. the heavy drugs like syrups, normal saline etc. are kept on the lower shelves while the

lighter one like tablets, capsules, cotton, etc. are kept on upper shelves. Although it is not

recommended to keep one box of normal saline over the other due to lack of space, these boxes

are kept one over the other. The store keeper tries to keep the similar category of drugs in the

single compartment (antibiotics, syrups, NSAIDs, etc.). The store is maintained by storekeeper

only who feels that one more person should be appointed for assistance. In the absence of store

keeper, the store is handed over to the pharmacist. Both the store were clean and well

maintained. They are cleaned every morning by a sweeper.

Distribution of drugs and instruments

Medicines and instruments are distributed within the PHC to different departments and

outside the PHC to Health Sub Centers. Weekly demand is sent by OPD, IPD, Labor Room and

Operation Theater, signed by ICMO. Drugs and equipment are supplied on the same day if

available and entered on the supply register. (Annexure 4) Drugs are distributed to HSCs after

weekly ANM meeting after entry on the supply register. From APHC, monthly demand is sent

by in-charge to MOIC and drugs are distributed as per availability by storekeeper. The monthly

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demand is sent by APHCs through indent Slip, which contains details like consumption of the

last supply, balance, and requirement.

Stock Taking and Audits

In-charge Medical Officer used to visit the store every week for inspection and a Drug

Inspector also inspects the store every 2-3 months. In the past five years, auditing took place only

once in both the PHCs. It happened 2 years back in Jalalgarh and 3 years back in Krityanand

Nagar PHC. Regional Deputy Director used to visit Krityanand Nagar PHC quarterly and do the

random physical verification. Apart from this, the storekeepers also do physical stock

verification from time to time.

Disposal of expired drugs

When the drugs have short expiry i.e. 3 months and the stock is more than required, then

it is sent to APHC or HSC if they have demanded that. In case of no demand at APHC or HSC,

the drugs are returned to the district hospital. If they refuse to take then the drugs are brought

back to PHC and in case of expiry of any drug; it is kept in a separate carton with a sticker of

“Not in Use”. These drugs are later taken to district hospital for disposal.

Equipment (Machines and Instruments)

Demand is sent by different departments to ICMO, who further sends a collective

demand to Civil Surgeon, District Hospital, Purnia. X-ray unit is provided by an NGO, who use

to look after its working and maintenance. Maintenance of computers in the offices of Block

Health Manager and Block Accounts Manager is taken care by themselves and the money spent

by them is reimbursed by the accounts section on the production of bills. The rest of the

computers are maintained by an NGO, who is paid Rs. 3000 per month as rent of

computers.There is no comprehensive annual maintenance contract of machines and equipment

given to any agency. The engineer is called only in the case of any problem in working or

calibration of equipment. Block Health Manager handles the proper working and maintenance of

equipment in the PHC.

Materials related to non clinical services

Demand of Linen is forecasted by staff members, and the demand is sent to Civil

Surgeon, District Hospital, Purnia through ICMO. The required quantity is supplied by the

district hospital. Linens are changed after every operation. These laundry services are outsourced

to a private company that is selected through tenders every three years. Every evening the used

linen is taken by the contractor for washing. The current cost of washing is Rs. 3 per cloth.

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Annually, some blankets and linen are sent by District Hospital based on the stock available

there. Biomedical Waste Management, Diet and electricity generator are also outsourced to

private companies through a tendering process.

Disposal of equipment/furniture

The materials that are not in a condition to be used are collected, and a letter is sent to the

office of civil surgeon about the disposal of this material. This material is taken by district

hospital authorities and sold as scrap through auction.

ROLE OF CARE INDIA

CARE India has developed a Facility Assessment Tool (FAT) for PHCs that can identify

gaps in the infrastructure, human resource, equipment, instruments, consumables, etc. These

gaps are discussed during Quality Improvement meetings, and funds are allotted through

Programme Implementation Plan budget that gets approved in Rogi Kalyan Samiti meeting.

The block manager also interacts regularly with block health manager and storekeeper to ensure

adequate stock of drugs and proper functioning and maintenance of equipment.

A few months back CARE organized a two-day training for the store in charge of all the PHCs

in the district. This training was conducted by officials from State Inventory Management and a

professor from IIHMR, Jaipur. The concepts like indenting, stocking, supplying, etc. were

described to the store in charges.

DISCUSSION

The public sector hospital has no strict guidelines for materials management to follow.

The demand and supply process is similar in both the PHCs but the methods of storage, and

stock entry is different. The PHCs have experienced storekeepers, and one of them was provided

training on materials management two months back. They have kept a reorder level of 50%

stock. There is no expiry of drugs in Jalalgarh PHC from past 5 years but in K.Nagar PHC,

nobody has come to take the expired drugs. The record is properly maintained. There is a weekly

inspection by MOIC. The supply of drugs related to National Health Programmes is proper.

There are some bad practices that include less space for keeping material, nonavailability of

adequate lighting and ventilation in the room. Drugs supply are not based on the demand leading

to the shortage of drugs. No material identification code is used which can help in timely

identification and appropriate storage of materials when storekeeper is not around. There is no

contract related to comprehensive annual maintenance of equipment. Also, it is seen that the

AYUSH doctors prescribe allopathic drugs in the APHCs which is unethical.

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RECOMMENDATIONS

A software should be used to calculate demand based on population growth rate, the

trend of usage of drugs, seasonal variations, etc. to make the process of demand easy for

storekeeper. There should be the use of e-supply chain to reduce the transaction cost and also

makes the record keeping by storekeeper much easier. It can also help in tracking the expiry date

of the medicines and the stock available at PHC. The expired drugs in Krityanand Nagar were

kept in a box from past few months. These expired drugs should not be kept in the store room to

avoid any confusion while distributing the drugs and should be disposed of as early as possible

according to biomedical waste management guidelines. A material identification code should be

used for proper storage as well as easily finding the drugs especially when the storekeeper is not

around. The stock taking and auditing should be more systematic. A comprehensive annual

maintenance contract should be taken for the equipment for preventive maintenance and to

reduce the breakdown of these equipment.

ANNEXURES

Annexure 1: Indent format for demand

S.No. Name of the

medicine

Opening

Balance

Received this

month

Expenditure Balance Requirement

Annexure 2: Process of demand and supply

CIVIL SURGEON, DISTRICT

HOSPITAL, PURNIA

SUPPLY

OF

DRUGS

DEMAND

FOR

DRUG

SUPPLY

MOIC, APHC

MOIC, PHC, JALALGARH/K.NAGAR

ANM, HSC

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Annexure 3: Format of stock register at Jalalgarh PHC

Name of the Item

Date Received

from

Batch

No.

Mfd

Date

Mfd

By

Expiry

Date

Quantity Signature I/C MO

Name of the Item

Date Opening

Balance

Received

this

month

Total Expendi

ture

Suppli

ed to

Balance Signat

ure

I/C MO

Annexure 4: Format of Supply Register at Jalalgarh PHC

Supplied to Mr.____ (XYZ) PHC Jalalgarh as following medicines (Indoor & Delivery) on Date

______

S. No. Medicine Quantity

Received by

Signature: