high prevalence of under nutrition has existed throughout Pakistan for a long
time. The National Nutrition Surveys conducted in the last three decades depict
an alarming situation of malnutrition in Pakistan. The prevalence of
underweight in children under five years decreased from 38% to 32 %,
the prevalence of stunting increased from 37%
, and the prevalence of wasting increased from 13 % to15 %.
Recent evidence reveals that in Sindh wasting has further increased to 15.4 %.
Sindh province has one of the highest prevalence of malnourished children at 52
while 53 % of
children aged 06-59 months were Vitamin A deficient and 23 % of children less
than 5 years of age had diarrhea in the two weeks preceding the survey.
per Pakistan Demographic and Health Survey 2012-13, infant and under-five
mortality rates in the past five years are 74 and 89 deaths per 1,000 live
The concurrent vicious life cycle of malnutrition, directly or indirectly
contributes to almost 35% of all under-5 deaths in the country .
Maternal mortality ratio (MMR) in the country is also alarming at 276 maternal
deaths per 100,000 live births. Fifty-one percent of pregnant women have
anaemia in Pakistan and 59.4% in the Sindh province.
to the Multi cluster Survey Sindh 2014 results, the malnutrition levels and
micronutrient deficiency across Sindh are above the cut-off for a serious
public health problem: wasting 15.4%, stunting 48%,
iron deficiency anemia is 60 % among women & 71 % among children. In
addition, the province has slightly higher inter district variations for
example western Sindh shows districts with the highest prevalence of child
malnourishment levels that go up to 67%
(provincial average 40.5%), with district Badin having the highest stunting
rates.The poor level of health indicators are
reflective of short comings in health system in the province and indicate that
health sector in Sindh needs an urgent remedial measure for improving health
and nutrition status of women and children.
USAID Deliver Project carried out supply chain
management situation assessment for family planning commodities in Pakistan. The
assessment findings indicated various gaps in the supply chain, including the institutional
arrangement—overlapping responsibilities shared by both the Department of
Health (DOH) and Population Welfare Department (PWD). There were issues with
both the health worker capacity to keep record of commodities and with the distribution
system, for both timely availability and quantity supplied, which caused an erratic
supply patterns at various levels.
USAID’S Maternal and Child
Health Program (MCHIP) has recently done a health facility assessment (HFA) of
all 23 districts of Sindh to provide an overview of functioning health care
delivery systems and generate district and facility based information for DOH. An
important finding of HFA report related to supply chain is stock outs of
essential health and nutrition commodities in health facilities at Tehsil Headquarter
(THQ) hospitals, Rural Health Centers (RHC) and Basic Health Units (BHU) due to
poor logistics support. There are multiple factors associated with stock-outs,
which include, but are not limited to: (1) availability of quality data in
order to analyze and predict trends in demand that would contribute to accurate
commodity forecasting; (2) capacity at health facility-level to forecast and
quantify requirements; manage stock and accurately provide supply chain consumption
information; (3) Long procurement process hindering
in time distribution of commodities at different health facilities of district
and sub-district level; and, (4) no structured distribution plan of procured
nutrition commodities from provincial to district and sub district level. In
addition, limited budget is allocated for transportation of nutrition
commodities from national to district and district to sub-district level.
To support the availability and monitoring of nutrition
commodities, several system strengthening efforts are required. The flow of
commodities from central to facility level is dependent upon proper and timely
requisitioning from the districts as well as timely responsiveness and
transportation from the provincial warehouse to the districts. Innovative
solutions are needed to the commodity supply chain challenges.
As a result NI seeks to contract a consultant/consultancy
firm to conduct an assessment of the nutrition commodity supply chains in
Sukhur District under the ENRICH project. The assessment will highlight
bottlenecks and facilitators in the supply chain of the specified commodities
including, but not limited to: quantification and forecasting, procurement,
distribution and transportation, storage, inventory management and tracking
system, supply monitoring and reporting at all levels. The recommendations
should follow the health system framework and therefore be aligned to the
health system building blocks (leadership and governance, capacity, monitoring
& evaluation, advocacy and communication).
This assessment aims to gain an overall perspective of the
current supply chain management situation at the district level as it pertains
to several key areas when determining the functionality of a health system.
Duties and Responsibilities
- To understand the policies, program and supply
chain structures related to the selected nutrition commodities.
- To understand the market structure as relating to
cost structures, formulations, specifications, availability of the
commodities and local capacity for manufacturing and importation.
- Identify roles of the partners and the following
institutions in micronutrient commodity supply chain such as Nutrition
Support Program (NSP), Maternal Neonatal and Child Health Program (MNCH),
Lady Health Workers Program (LHW), Director General Health Services (DG),
District health office (DHO)
- To assess the barriers, enablers and facilitating
factors/improvement opportunities related to the components of the supply
chain system at all levels for the selected maternal, newborn and child
health and nutrition (MNCHN) commodities (Policy, Strategy,
Quantification/Forecasting, budgeting, planning, procurement,
distribution, storage, capacity-personnel and financial, monitoring and
evaluation, commodity tracking, communication, inventory management, data
management) associated with these processes.
- To assess
availability and accessibility of the MNCHN commodities by targeted
beneficiaries at primary, secondary and tertiary levels care facilities.
SCOPE OF WORK
The assessment will
target policy makers, Provincial program manager NSP,MNCH, LHW program, DG
health Services, DHOs, procurement and logistics officers selected health
facility workers (pharmacists, in-charges, in-charge of stock taking, health
records and information officers) community health workers, clients,
pharmaceutical manufacturers, pharmaceutical wholesalers and pharmacies.
The supply chain
assessment will be carried out Sukhur district. The assessment will focus on
actual realities of the supply chain system for all the commodities previously
listed, including availability of commodities and capacity of health workers
and the systems used to plan, receive, monitor and report on and manage the
The consultant’s tasks
/ scope will include but not limited to the following:
- Develop work
plan: Detailed plan
that clearly outlines key steps and timelines for completion of
deliverables as outlined in the Terms of Reference and engagement with
relevant stakeholders in the process
Desk Review: Undertake a
comprehensive desk review of key documents; in-depth interviews with key
actors (policy makers, directors of key government departments, Zonal
pharmacist/managers, stock in-charges, implementing agencies, and public
health facility in-charges), any other relevant partner and exit
interviews. The desk review should include the following:
a. Global: IFA supplements for pregnant women, Vitamin A
supplements, MNP and zinc/ORS supply
chain situation analysis highlighting best practices
b. National: Previously undertaken supply chain assessments by
government and nutrition partners. Policies and strategies for supply chain
processes as elaborated in specific objective four above, market information,
partner roles, division roles, supply challenges. The assessment will focus on
national policies affecting supply chain enabling environment.
c. Region and
district level: This is the area of
detailed analysis for current status, bottlenecks and innovative solutions with
the purpose of looking closely at the community based strategy and how the
commodities will be accessed at the selected health facilities.
NB: the global
and national piece is a desk review and background work – the Consultant will
not be analyzing this part of the supply chain for bottlenecks.
Research Protocol/Study Design: Design the supply chain assessment in line with
the objectives outlined in the TOR and the findings from the desk review.
The study design will consider the study area, sampling methods, sample
size, data collection methods, data analysis plan and ethical
Data collection tools: Develop
the data collection tools both qualitative and quantitative and document
analysis template. The consultant will ensure the tools capture data
related to all the objectives of the assessment.
the following assessments, including data analysis:
a. Supply chain situation analysis of the selected MNCHN
commodities; market survey of selected MNCHN commodities
b. Mapping of stakeholders involved in the supply chain
of the selected MNCNH commodities in the public sector.
c. Mapping of programs and supply chain structures
related to the selected MNCHN commodities
d. Assessment of the components (policy, strategy,
quantification/forecasting, budgeting, planning, procurement, distribution,
storage, capacity-personnel and financial, monitoring and evaluation, commodity
tracking, communication, inventory management, data management) of the supply
chain system at national, county, district, health facility and community
levels for the selected MNCHN commodities.
e. Assessment of accessibility in the public sector of
the selected MNCHN commodities by target populations (caregivers of newborns
and under-fives, pregnant women, health workers)
Validation Workshop: The
consultant will facilitate a validation workshop of the supply chain
assessment and recommendations for strengthening supply chain management
with key stakeholders at the provincial and district level.
strategy for strengthening supply chain management:
strategy to strengthen the supply chain management, including an implementation
plan for Sukkur district, which will serve as a case study.
system to continuous assessment of stock information (including tools
development/adaptation as needed), guideline for using the system and detailed
framework for monitoring and evaluation.
develop/modify of training curriculum, specifically looking at stock planning,
logistics, management, reporting and analysis.
8. Modify training package and conduct training of healthcare
a. Develop a system to continuously assess
stock information (including tools development/adaptation as needed), guideline
for using the system and detailed framework for monitoring and evaluation.
b. Review and develop/modify of training
curriculum, specifically looking at stock planning, logistics, management,
reporting and analysis.
Develop checklists to monitor the supply chain management of healthcare
workers during supervisory visits.
Support and coordinate with DG health office, MNCH program, Lady Health
Worker’s program, NSP, and district health office on trainings for supply chain
management, using modified training curriculum.
Develop 5 days Training of Trainers (ToT), including updated manuals,
trainer’s guide, and training materials for SCM.
Conduct 5 days training for master trainers, who are the health
personnel from DG Health office, MNCH program, Lady Health Worker’s program,
NSP, and district health office, at provincial level on modified training
package. Later these master trainers will conduct training of Health care
providers from the ENRICH project area.
Final Report: Develop a
comprehensive report of the findings of the supply chain analysis. The
report will include key recommendations to address identified barriers and
opportunities in the supply chain system for the selected MNCHN
commodities, and also recommendations on how to build on existing
achievements. The consultant should propose an effective supply chain flow
chart for all selected MNCHN commodities in this final report.
Policy Brief: The policy
brief should present the findings and recommendations of the supply chain
assessment. The brief should be no more than five pages.