HOW MIGHT WE IMPROVE

THE PROCUREMENT AND DISBURSAL

SYSTEM OF IFA (IRON & FOLIC ACID)
SUPPLEMENTS - FOR HEALTHIER
MOTHERS & PREGNANT WOMEN IN
RURAL BIHAR?


Photo: The World Bank Group

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BACKGROUND
In 1970, the Government of India established the National Nutritional Anaemia Prophylaxis Programme
to address widespread anaemia, targeting high risk groups for iron supplementation. The programme was
expanded in 1991 to universal supplementation of pregnant and lactating women. Current
recommendations include a daily dose of 100 mg elemental iron for 100 or more days from 14 to 16
weeks of pregnancy until the 3rd month post-partum.

Unfortunately, despite these guidelines, high anaemia prevalence persists. In Bihar, only 10% of women
reported consuming IFA (Iron & Folic Acid) for at least 100 days during their last pregnancy, despite 80%
reporting registered pregnancies, implying at least one antenatal care visit.

Barriers to IFA intake by pregnant women in India and other low- and middle-income countries
have been at two levels:

1. Behavioural challenges at the beneficiary end, for instance gastrointestinal side effects, lack of
comprehensive counselling by healthcare providers, IFA negatively seen as medicine, and distrust of
government IFA or freely available IFA.

2. Supply issues (which have been recognised as the bigger barrier to IFA adherence) In Bihar,
infrastructure, personnel, and supply chain challenges have been highlighted as major constraints of
the health system. A 2009 report found Bihar’s health sub-centres to be lacking in all existing
amenities and functionality indicators measured. In 2007–08, a state-wide survey found only 56% of
primary health centres and 6% of sub-centres had at least 60% of required drugs present. In
particular, IFA had been out of stock 10 days of the previous month in 78% of surveyed health sub-
centres. More recent reports from 2014 to 2016 continue to highlight drug shortages and
procurement challenges as key issues to address in the Bihar health system.

Piramal Swasthya is working closely with central and states level government healthcare system to come
up with best practices that can be adopted, advocated at policy level to ensure provision of best
healthcare services at grass root level. This includes strengthening government’s people, policy, processes,
infrastructure and schemes. Supply Chain System plays an important role in ensuring adequate logistics,
drugs and supply at the villages level to remote vulnerable sections. A weak supply chain management
system has a potential to contribute towards infant and maternal mortality rates and poor performing
healthcare indicators through non-availability and poor accessibility of primary healthcare.

Village Health Sanitation and Nutrition Days (VHSND) are organised at village level across the country
to provide basic preventive services at grass root level. During these days, Auxiliary Nurse Midwives
(ANMs) provide Antenatal Check-ups, Immunisation services, primary care of childhood illnesses,
deworming and Vitamin A supplementation. For successful provision of these services, it is essential to
have adequate logistics in place, including adequate supply of drugs.

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In the month of September 2018, 223 VHSND sessions were observed by the Piramal Swasthya ADT
Team across 5 districts of Bihar. The following bar graph illustrates the proportion of sessions where
basic drugs were found to be unavailable:

This indicates an irregular availability of drugs across the VHSND sessions and highlights a need for
strengthening the supply chain so that basic preventive care can be provided to the intended beneficiaries.

About Piramal Swasthya:

Piramal Swasthya is a nationally recognised leader in improving primary health care, addressing health
inequities among vulnerable populations and promoting quality of care through high impact solutions:
• One of the largest partners in public-private partnerships for primary health care, partnering with
central and state Governments with 4000+ strong workforce including 580+ doctors healthcare
workers serving one million beneficiaries every month
• 34 projects spread across 19 states are making healthcare services available, accessible and affordable
for vulnerable and underserved populations
• Expertise and experience in delivering primary health care in remote rural areas, high priority districts
and tribal areas in India
• Pioneer in introducing mHealth Strategy, Telemedicine Strategy and integrated electronic medical
records platform.

The Focus (RMNCH+A, Non-Communicable Diseases - Diabetes, Hypertension & Cancer)

Piramal Swasthya is transforming towards becoming a specialist in the area of primary health care within
the maternal health, child health and non-communicable diseases arena.
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Objectives
1. To develop best practices in implementation of Public healthcare solutions for the country

2. To create and implement replicable and scalable models

- To improve maternal, child and adolescent care in tribal and high priority districts in order to reduce
maternal mortality ratio and infant mortality rate by 30% and 20% respectively, in chosen
communities within 3 years of initiation
- To prevent and manage non-communicable diseases (specifically diabetes, hypertension) to reduce
the risk of premature mortality by 25% in chosen communities over the next 5 years

3. To contribute to the transformation of 25 aspirational districts across 7 states through systems

strengthening in collaboration with NITI Aayog as part of Prime Minister’s New India mission

Piramal Swasthya – High impact Solutions

Piramal Swasthya endeavours to bridge the last mile gap in primary healthcare service delivery through its
innovative solutions:

Community Outreach Program: Mobile Health Services

Our Community Outreach Program is making primary healthcare services available, accessible and
affordable to remote and underserved population with the help of more than 452 Mobile Medical Vans
across 14 states, through a Nurse-led and a Doctor-led model.

ASARA Tribal Health Program – Ending preventable maternal deaths

This is a unique program focused on ending preventable deaths in extremely remote, hilly and difficult to
access tribal communities. The program provides specialist consultation and care to pregnant women in
remotest of the areas where there is no or limited availability of Healthcare resources.

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Remote Health Advisory and Information Services
Health Information Helpline
The Health Information Helpline (HIHL) is a health contact centre that aims to reduce the load due to minor
ailments on the public health system. HIHL provides 24×7 basic medical advice and counselling services.

Telemedicine Services
Piramal Swasthya Telemedicine Services provide specialist advice to the remotest of places through high
quality sophisticated software. It virtually connects doctor to patients and addresses the need of highly
skilled health workers where they are scarce.

D.E.S.H. Cancer Screening Program

DESH - Detect Early, Save Him/her programme was launched in November 2017, aims to screen for
oral, breast and cervical cancer through mobile cancer screening units and also to create awareness in the
communities of Kamrup, Assam. The mobile unit is provided with cutting-edge equipment, including a
mammography unit, and is staffed by doctors, nurses and radiographers.

NCD Management Program

A community based Non-Communicable Disease intervention program focused on timely screening,
identification and treatment of Diabetic and Hypertensive patients. Program also aims to reduce the
incidence of Non Communicable Diseases (Diabetes & Hypertension) through preventive, predictive and
promotive means of Healthcare service delivery.

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THE DESIGN THINKING CHALLENGE:

Context
The IFA Procurement Process is largely similar to other medicines listed on the Essential Drug List, which
are often purchased and distributed together. To our knowledge, there was no documentation which really
outlined this entire process, and it is this lack of clarity and documentation of the process that has often been
cited as a key barrier to successful medicine distribution in Bihar.

Major components of the IFA supply chain in Bihar: Flow chart showing the distribution of iron
and folic acid supplements and funds from the state level (State Health Society) to the beneficiaries
(pregnant women)

State Health Society

Based on previous consumption

BMSICL
District

Supplier District Hospital

(Civil Surgeon)

BLOCK

PHC - Primary Health Centre

(MO - Medical Officer in-charge)

Health Sub-Centre

(ANM - Auxiliary Nurse Midwife)

Accredited Social Health Activist

Anganwadi Worker

(ASHA) (AWW)

Pregnant Women

Iron and Folic Acid (IFA) Supplements

Funds for purchase of IFA supplements

Indenting Information

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Understanding the process:

Procurement begins with selection of companies and fixed rates of drugs by the Bihar State Health Society
through a competitive bidding process. Bihar government documents state that district funding is allocated
based on previous consumption.

Actual purchasing is decentralized to the district. The Civil Surgeon submits purchase orders based on State
Health Society and District Store information, which is then approved by the District Magistrate. This system
has changed slightly with the establishment of the Bihar Medical Services and Infrastructure Corporation
Limited (BMSICL), which centralized drug purchasing to a large extent. Districts now submit purchase orders
to BMSICL, who then procures drugs from suppliers and distributes it to regional warehouses. As per policy,
all districts are to purchase enough drugs for 6 months with a second order after 3–4 months to allow a 2–3
month buffer supply.

Districts are responsible for retrieving drugs from Patna-based depots with payment in hand (Cash and
Carry). Drugs should then be distributed to the blocks according to their estimated need (submitted as a
written request or ‘indent’). Indents from the block store must be approved by the Medical Officer in charge,
the Civil Surgeon, and finally sent to the District Store for fulfilment.

From the primary health centre, ANMs receive IFA to distribute at their health sub-centres and monthly
Village Health, Sanitation, and Nutrition Days (VHSNDs).

Though IFA distribution and counselling to pregnant and lactating women is clearly outlined, there is no clear
policy specifically pertaining to health sub-centre drug requests and stock management. At the village level,
ASHAs receive IFA independently through ASHA drug kits. AWWs do not receive IFA for antenatal care
distribution. All three are charged with coordinating IFA distribution to pregnant women in their coverage
areas through VHSNDs. However, specific roles and stock management between the three positions are not
clearly defined.

Key supply chain challenges:

IFA Need
- Lack of appropriate IFA need forecasting
- IFA need is most often reported as calculated based on district size with 3–3.3% of the total population
estimated to be pregnant women. Lactating women, despite being entitled to IFA by policy mandate, are not
included in this estimate.

IFA Purchasing: Late supplier deliveries resulting in inconsistent supply

Suppliers should have medicines ready within 45 days for the first order and 21 days for subsequent orders. To
increase supplier accountability to this timeline, the State Health Society established a penalty for late deliveries.

Block Requests:
- Indents not being utilized nor perceived as effective: Although the system for requesting IFA is well-
known, most health workers do not perceive indents as effective.
- Perceived or actual inability to procure IFA when needed through local purchasing: Dependency on
the district store is also emphasized, no alternative sources of IFA are perceived to be available in case of
district shortages

Buffer Stock: Lack of buffer stock use at all levels

Officials and storekeepers suggest maintaining of buffer stock to avoid stock-outs between purchases, which is
generally not practised. Some storekeeping practices also prevent others from maintaining buffer stocks.

Expiring medicines: No safe disposal plan for expired medicines and pushing of expiring drugs to patients
and frontline workers
The most common strategy reported to handle expiring drugs (IFA shelf life: 17–23 months) was increased
distribution. Some attempt at returning about-to-expire drugs to the district are also made.
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Storeroom transiency and disorder
Several district and block officials expressed concern or concessions made because there was not enough space
or no fixed location to store medicines. Medicines are seen to be stored in district hospital hallways and vacant
rooms.

Personnel & Training: Inconsistent training on IFA counselling/distribution across FLW (Front Line
Workers) types
Most health officials do not perceive supply management training as helpful. Lack of manpower for the bidding
processes in addition to shortages of doctors, pharmacists, and nurses is also a challenge.
FLWs should be conducting coordinated efforts to identify and register pregnant women, bring them to
VHSNDs, distribute IFA, and counsel on IFA consumption and benefits.

IFA supply is a public health issue in Bihar, the extent of which varies greatly across districts. Specific
bottlenecks which impact IFA forecasting, procurement, expired drugs, storage, and overall lack of personnel
needsto be identified and addressed.

In a 2006 comparative analysis, Bossert et al. found that higher performance logistics systems had decentralized
planning and budgeting. Conversely, centralization of information systems and inventory control was associated
with greater success. The typical scenarios found in Bihar are in contrast to this ideal scenario.

Program objective:
To increase the efficacy of the procurement and disbursal system
for IFA (Iron & Folic Acid) supplements in rural villages in Bihar

A few HMW starters to be explored:

How might we design a governance and co-ordination system to give the busy
Block Medical Officers more control over the IFA disbursal & procurement process?

How might we make the IFA indenting process faster, easier and more accurate
even for the lowest factor in the chain?

How might we design effective training methods to help the Medical Officer have a
more well-equipped team under him?

For further details

Students can either email their queries to [email protected]
or dial-in on Tuesdays/Thursdays from 5-6 PM to get their queries resolved.

Dial-in details are as follows:

Participant PIN: 651235#

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