TABLE 3.

The 30 Supply Chain Management Practices and Behaviors Identified in the Analysis

Facility-Level Supply Chain Function Area and Practice/Behavior	Description of Best Practices From the Literature and Observed Practices From This Study
Forecasting and Quantification
1. Calculation of minimum and maximum buffer stock	Calculation of the minimum and maximum levels of pharmaceutical stock needed over a specified time period, taking into consideration buffer stock, stock used during lead time, and order quantify for one supply period.⁵
2. Use of electronic systems	Use of electronic systems assist in the tracking of services and products delivered to patients. Furthermore, such systems also help to fulfill new monthly orders and maintain stock records, while also assisting in reporting such records to higher-level offices.
3. Use of national guidelines as reference for estimation of needs and reporting	Use of guidelines in inventory control improves poorer performance of logistic systems.³⁸
4. Order verification before submission to the central/regional level^a	A health facility staff member rechecking the ARV requisition request (verifying calculation, order, and inventory stock) before an order is sent to the central or regional level leads to fewer order verification errors.
5. Order fill rate calculation	Order fill rate should be calculated to cut down number of emergency and/or unfilled orders.
6. Late ordering of medicines	Staff should be consistently aware of order dates and treat them as a potential problem so as to avoid late orders
7. Frequency of issuing emergency orders	A study in Mali found that emergency orders of stock are required as facilities receive only about 25% of what they request.³⁹ Emergency orders were not reported as frequent or an issue.
Warehousing and Inventory Management
8. Actions taken when stock received from CMS/RMS^a	Any newly received or issued products are recorded in stock-keeping records. Entries are further updated either when stock is counted during a physical inventory, or as soon as a loss is noticed.⁵
9. Control of access to stock	Security, monitoring, and auditing are some of the methods to prevent stock-outs and losses.²⁶
10. Decision on whether to redistribute short-dated stock	Redistribution of short-dated stocks increases the complexity of the supply chain and miscommunication of stock levels between facility and central levels.
11. Location and condition of storage (whether all in one place or separate rooms)	Good inventory control includes appropriate storage space, stock rotation, stock arrangement, cleanliness, security, and fire prevention.²⁶
12. ARVs stored separately from other medicines	Due to funding requirements, many ARVs are stored in separate storage areas from other medicines. Access of staff to ARVs is limited as well to prevent theft and diversion.
13. Assigning responsibility of inventory management tasks	In most facilities, a trained nurse, pharmacy assistant, or pharmacist is assigned to manage ARVs. In some facilities a schedule and description of tasks for staff is available and implemented.
14. Frequency of balancing stocks (checking stock cards vs. physical count)	Stock status of each product in storeroom should be assessed regularly (monthly) by staff, comparing the quantities on hand with the quantities that have been entered in inventory control cards.⁵
Prescribing and Dispensing
15. Change in ARV prescription during stock-out^a	SOPs are needed for the prescribing process in the event of stock-outs to standardize actions among prescribers.
16. Change in dispensing of ARVs during stock-out^a	Written SOPs are recommended to improve consistency and quality of the dispensing process.²⁶ SOPs are needed to standardize actions during the dispensing process.
17. Actions to ensure patient adherence (e.g., pill count)^a	SOPs are needed for monitoring adherence (e.g., whether to perform pill counting) to ARVs.
Communication
18. Communication within the pharmacy team	A positive team dynamic can be achieved via regularly scheduled weekly/biweekly internal meetings.
19. Communication within the facility	Active communication between pharmaceutical and nonpharmaceutical staff regarding shortages and stock-outs is recommended to increase consistency and accurate recording of prescriptions.
20. Communication with higher-level supply chain management^a	Improved facility-level SCM performance can be achieved more easily via robust relationships with the regional and central personnel.
21. Communication with affiliated facilities^a	An increased in accurate reporting and forecasting at the main facility is a potential byproduct of positive and regular communication with any and all affiliated facilities.
22. Communication with hospital executives	Key informants report that direct lines of communication between pharmaceutical staff and hospital executives is recommended to address and avoid shortages and stock-outs.
Information Management
23. Interaction between clinical and dispensing/stock systems	Most facilities do not have linkage between clinical and dispensing information systems. Swaziland does have linked systems and key informants report frequent backlogs on prescription input.
Infrastructure
24. ARV clinic/pharmacy separate from main pharmacy	ARV clinic/pharmacy was observed to be separate from the main pharmacy in some facilities and integrated with others.
Human Resources
25. Training on stock management	An individual's technical ability, personality, and position within the supply chain had a significant impact on supply chain performance.⁴⁰
26. Leadership/management style of the pharmacy	Key informants reported multiple leadership/management styles of the pharmacies. Some were managed/led by regional and senior level pharmacists, others by pharmacists, pharmacist assistant physicians or nurses. Consistent management organization and leadership across pharmacies can improve supply chain performance.
27. Leadership management style of the clinic	Key informants reported that clinics were managed/led by physicians who attend HIV patients and other patients.
28. Attitude to workload of pharmacy staff	Pharmacist assistants and nurses in some facilities reported that workloads were too high, leading to unfinished daily activities, including those linked to supply chain management.
29. Guidelines for providers in the event of a stock-out	There are no standardized guidelines for providers for what to do in the event of a stock-out.
30. Implementation of policies on prescribing and dispensing	Some key informants reported having clear policies of not allowing patients to leave without any medicines.

Abbreviations: ARV, antiretroviral drug; CMS, central medical store; RMS, regional medical store; SCM, supply chain management; SOP, standard operating procedure.
↵a These practices and behaviors are associated with SCM more than others and are described in detail in the results section.