We aimed to specifically assess trauma care resource-related supply management structures and processes at health facilities in Ghana to inform opportunities to improve the availability of life- and limb-saving services. There were several main findings. First, stock management systems were present in all hospitals; however, high resource availability hospitals more often had frequent inspections, up-to-date stock cards, less frequent stock-outs, and shorter stock-outs. This highlights the importance of active stock management practices. Second, there was generally a low- to moderate-adherence with stock storage guidelines, which places essential resources at risk of damage, waste and stock-outs. Lastly, stock-outs of inexpensive essential trauma care resources were commonly reported, particularly at low resource availability hospitals. By highlighting specific supply chain management deficiencies and vulnerabilities, we can better inform the planning and organization of trauma care services.
Stock-outs of essential medicines at the hospital level have been widely reported in sub-Saharan Africa and represent a significant public health challenge with a recognized negative impact on morbidity, mortality and disease epidemiology.(21) Although there are a multitude of possible root causes for stock-outs (e.g., procurement financing and processes, supply capacity, communication and road infrastructure, distribution resources and planning methods, personnel staffing and training, coordination among stakeholders), hospital-level stock management is a common cause of stock-outs and readily addressable.(22) In addition to promoting compliance with existing government, USAID, and World Health Organization guidelines regarding supply chain and stock management best practices, using modeling techniques, training programs, more frequent audits, demand-side incentives, and automated logistic management information systems could markedly improve the availability of trauma resources for injured patients when needed.(21, 23) As example, an intervention study in Mozambique that included fifteen hospitals exposed to standard practice or increased frequency of audits, stock management performance reports and incentives for good performance for family planning resources demonstrated fewer and shorter stock-outs in the intervention group.(23) Accountability frameworks built into funding agreements for the management of global public health priority conditions improve stock management at the hospital level.(24, 25) Given that trauma care is planned and organized at the national, regional and/or local levels without an accountability framework, specific attention must be paid to the supply chain and stock management practices for essential trauma resources to ensure their availability when needed.
Adherence to stock management guidelines improves resource availability, reduces waste and promotes appropriate resource use.(26, 27) Further, provider concerns over stock depletion reduce the use of essential resources when needed. A case study of a tertiary hospital in India demonstrated that improving channels of communication between providers, stock keepers, and an automated vendor management system, increasing the frequency of storage audits, and establishing protocols for stock documentation improved stock management performance indicators (e.g., compliance, documentation, stock-outs).(28) Such quality improvement initiatives are inexpensive and may have a significant impact on resource availability at the hospital-level.
Some of the most common out-of-stock resources were low-cost (e.g., nasal cannulas and oxygen masks, endotracheal tubes, syringes, sutures, sterile gloves). When not due to insufficient funding, stock-outs of low-cost resources are frequently due to a lack of inventory management and procurement processes, which have been widely reported across sub-Saharan Africa.(29, 30) Establishing hospital-level low-supply alert mechanisms and real-time catalogs of government medical stores may reduce the number and period of stock-outs. SMS for Life, a public-private partnership that uses text-messaging to flag low-stocks of anti-malarial drugs, was able to reduce stock-outs from 79 to 26% at health centers in rural Tanzania.(31) Given SMS for Life costs less than US$ 80 per facility per year, similar systems for non-drug consumables could be readily implemented in LMIC hospitals and health systems.(32)
This study had a number of limitations that should be taken into consideration prior to interpreting the findings. First, the sample size for this study was small. It was our intention to demonstrate the utility of the USAID LIAT for emergency, trauma and surgical resources at the hospital level, was well as identifying specific opportunities to improve the supply chain of hospitals in Ghana more broadly. We specifically selected hospitals that represented all three levels of care (i.e., tertiary, regional, district/first-level hospitals) and extremes of resource availability to better understand the spectrum of supply chain deficiencies and vulnerabilities. Second, key informants may have over- or under-reported in their responses to USAID LIAT questions. To reduce risk of reporting bias, storerooms and stock management ledgers were systematically reviewed to verify the answers given by stakeholders. Lastly, we did not assess central ordering, procurement, or delivery to hospitals, which can add to the risk, frequency and duration of stock-outs. Although central supply chain management vulnerability and inefficiencies are important, much can be done at the hospital level to improve resource and service availability. Despite these limitations, the findings allow reasonable conclusions to be drawn regarding ways the importance of investigating supply chain management practices and opportunities to strengthen stock management practices at the hospital level in Ghana.