Solomon Islands have reached the halfway point of an ambitious Health Supply Chain reform project that will improve the quality of healthcare and supply of essential medicines for future generations to come. Led by Solomon Islands’ Ministry of Health & Medical Services (MHMS), long-term friends from Australia, BES, were engaged to deliver the reform project funded by the Australian Department of Foreign Affairs and Trade (DFAT).

NRH Pharmacy staff in Solomon Islands with BES consultant Agusto dos Santos

Solomon Islands is a 3-hour flight northeast of Brisbane. Rich in culture, natural beauty, tropical weather, and some of the best reefs and surf breaks in the world, Solomons has six major islands and more than 900 outer islands and atolls. The population of 720,000 is young, dispersed, and multi-lingual, while the majority live in rural areas and maintain subsistence livelihoods in villages of a few hundred people.

Solomon’s health supply chain was considered strong for many years compared to other low-income, low-resource countries in the Pacific. Since 2018 however, successive shocks to the system saw a regression in performance indicators. The impacts of these were felt in frequent stockouts of essential medicines in large hospitals, warehouses, and primary health clinics.

Enter the national Health Supply Chain reform project in April 2023. The 12-month project kicked off with a review and assessment – 34 senior stakeholder meetings in fact, from Government departments within the Ministry of Health and Medical Services (MHMS), the National Medical Store (NMS), and the National Referral Hospital (NRH). No stone was left unturned! More than 150 rapid interventions and upskilling with MHMS staff was planned to re-establish the once resilient national supply chain.

Hang on, what is a health supply chain?

Health supply chains are the behind-the-scenes activities taking place to stock your pharmacy with medicine and supplies for everyone. A strong supply chain involves:

• Getting the right manufacturers and suppliers through a procurement process
• Monitoring stock levels, usage and reordering to prevent stockouts
• Deliveries; in Solomons all medicine supply is centralised through the National Medical Stores (NMS) warehouse, where it’s managed and distributed nationally:
  • NMS distributes directly to the National Referral Hospital (NRH), clinics in Honiara City Council (HCC), Guadalcanal, Russell Islands, and Malaita Outer Islands, as well as every Second-Level Medical Store (SLMS)
  • Second-Level stores then distribute stock within their catchment which generally cover 10-15 health clinics, most of which are located in remote areas.
• Let’s not forget transportation! Trucks, small aircraft, boats, cars, motorbikes and sometimes even by foot! Medicine and supplies reach extremely remote provinces, and often not without complication.

Marianne Tanavalu, the National Medical Supplies Procurement Manager explains that one of the good things the reform project is doing is improving timeliness and quality control in health supply procurement evaluations.

“We have standardised manufacturer names, we introduced minimum delivery periods for all items and set mandatory expiry information from all bidders to make evaluation clearer. This helps avoid uncertainty when we compare and order medical supplies. And it can reduce waste and avoid stock-outs of medicine,” said Marianne.

Photo: Marianne Tanavalu, National Medical Supplies, Procurement Manager.

Having reached the halfway point of the project, the end of the tunnel is growing brighter. In the last 6-months, health supply chain staff in Solomon Islands have shown their appetite for change and improvement, delivering several big ticket projects already, with the support of a small team of BES project staff.

#1 – Digitising procurement

In September 2023, digital procurement software ‘the Health Supply Hub’ was launched. The Hub improves bidding processes for suppliers, increases transparency and continues to help lower the cost of medicine procurement.

Solomon Islands were the second country in the world to implement the electronic Logistics Management Information System (eLMIS) mSupply, which is now used in more than 35 countries. In 2013, Solomon Islands then became the first country to use Version 1 of mSupply Mobile! So it’s no surprise Solomons continues to be at the cutting edge of supply chain innovation. But a system is only as good as the people who use it, which leads us to the next big reform.

#2 – A plan for people and processes

The Health Supply Hub came out alongside an Annual Procurement Plan focusing on the people side of procurement. The plan coordinates processes delivered by people in multiple workplaces and locations. Through its delivery, the plan has created better clarity of roles and greater collaboration between the Ministry of Health and Medical Services and the National Medical Store teams.

#3 – Upskilling through workshops and training sessions

A priority of the project was to give everyone involved in the health supply chain a chance to upskill and learn more about specialist topics. Dozens of training sessions and workshops have already been held on procurement and health supply chain management, with many more scheduled in Honiara and the provinces. Sharing ideas and experiences between workplaces – such as learning how the digital procurement systems work – have led to requests for broader, country-wide exposure to digital procurement systems that could further improve tender approval times.

Photo: BES consultant Agusto Dos Santos runs mSupply training at the National Referral Hospital in Honiara

Workshops have also provided a space for more collaboration, where priority issues can be addressed in person; such as supporting updates to the essential medicines lists, stock distribution or revising policies and plans.

Chief Pharmacist, Solomon Bosa, thanked BES staff at the end of the National Referral Hospital training session.

“The hospital pharmacists from the Pharmacy Division have not received such comprehensive training on mSupply before. The need for data input to the supply chain systems was also useful to pharmacists working to avoid stock-outs and expiry.” said Solomon.

A long friendship

The Health Supply Chain reform project is backed by a long-held friendship between Solomon Islands and Australia. The company BES, who were engaged by MHMS and DFAT to deliver the reform project, was founded by a group of Australian pharmacists and public health experts who once called Solomon Islands home as volunteers, employees, and technical assistants. Some of the BES delivery team include former Solomons residents:

Director Michael Nunan (formerly the Chief pharmacist with the MHMS Public Pharmacy Services, and the primary healthcare pharmacy support specialist for the MHMS National Pharmacy Services, Honiara), who worked in Solomon Islands for 5 years.
Director Erin Mitchell (National training pharmacist with MHMS, pharmacovigilance pharmacist for the Solomon Islands Malaria program, and health resource officer with WHO, Honiara), who worked in Solomon Islands for 4 years.
Head of Programs Emily Porrello (Rational use of medicines pharmacist, MHMS, Honiara), who worked in Solomon Islands for 1 year.

It’s safe to say all three consider Solomon Islands a home away from home.

“It is such a pleasure to be supporting Solomon Islands again – a large piece of my heart is always there, along with many old friends and we look forward to seeing this project improve healthcare for them and all patients,” said Michael.

With five months of the Health Supply Chain reform project remaining, the foundations for reliable flows of medicines and medical supplies to healthcare facilities are being laid. Our shared aim is to see new knowledge and practices embedded for years to come, and measures such as healthcare accessibility, efficiency, and decreased stock outages increasingly seen as the norm.

BES supports health supply chains across the Pacific, helping to implement systems to improve access to medicines across all levels of each health system. The champions of those supply chains, though, are our local counterparts who work hard every day in warehouses, trucks, offices, and pharmacies to improve the lives of others. Upskilling and empowering these local counterparts brings context and sustainability that we could never hope to achieve on our own. A new initiative we are supporting are the DTAC Scholarships, awarded to Pacific Islanders based on annual applications by anyone working in a public health supply chain.

Last week we caught up with Bettina Ereinao (Honiara, Solomon Islands), one of the star recipients of the two 2021 DTAC Scholarships. Bettina has gone from strength to strength since joining the Solomon Islands Ministry of Health over 10 years ago, and we’re so proud to share a little about her recent experience.

Firstly, a little background on the project: in 2020, BES partnered with the mSupply Foundation to run the supply chain Data and Technical Assistance Centre (DTAC) across six Pacific Island Countries and Territories, with a goal to improve health outcomes in Polynesia by increasing access to quality essential medicines and strengthening supply chain systems. Funded by New Zealand’s Ministry of Foreign Affairs and Trade, DTAC aims to support member countries in setting, meeting and surpassing minimum regional standards in essential medicines access, health supply chains and digital health systems.

Last year, we announced that DTAC would support two emerging professionals in the Pacific region to undertake a health supply chain course provided by the Empower School of Health. The scholarship enabled successful applicants to complete a short course of their choice, with the opportunity to expand their knowledge in topics such as procurement, inventory management, rational use of medicines, and international career development.

After receiving one of the scholarships, Bettina selected the Certificate in PSM (procurement and supply chain management) Support Functions and Systems, which she completed in June this year.

The certificate is self-paced and entirely online, broken down into seven chapters of pre-recorded lectures and a final assessment. Students are introduced to critical functions of procurement and supply chain management, as well as learning practical approaches to pharmaceutical quality assurance, and the financial impact of PSM.

Completing this course is a real testament to Bettina’s self-discipline and drive: many of us know how learning in a virtual classroom is a challenge in itself, but Bettina was also tuning in from a remote location in the midst of a national COVID19 outbreak, and came down with the virus herself during her studies.

Since receiving the certificate, Bettina has already stepped up to a Customer Service Pharmacy Officer position at the National Medical Stores Hospital in Honiara, a vital role in the delivery of medical supplies throughout the country. “The course was timely for me,” Bettina says, “as I’ve gained more knowledge about supply chain and procurement, which will help me a lot in my work. My interest in supply chain management in medical supplies has grown.”

We extend our huge congratulations to Bettina on her amazing achievements this year, and wish her success in her new role at NMS. Watch out for Bettina’s webinar and blog post for DTAC as she shares her knowledge with colleagues across the region.

BES is working with the United Nations Population Fund (UNFPA) Pacific Sub-Regional Office (PSRO), to support the ‘Transformative Agenda for Women Adolescents and Youth in the Pacific’. The Transformative Agenda (TA) programme invests in improving sexual and reproductive health in six priority countries: Fiji, Kiribati, Samoa, Solomon Islands, Tonga and Vanuatu.

UNFPA is using Tupaia to build a real-time, regional map of reproductive health services and commodities. In Tupaia, data is coming in from multiple sources to populate visuals showing information important to planning reproductive health services. This allows regional bodies to target services and resources to the areas of the greatest need, with a focus on supply chain strengthening.

The programme seeks to reduce unmet family planning needs in the Pacific, with three identified programme outcomes: increased and improved supply of integrated sexual and reproductive health (SRH) information and services, particularly for family planning; increased demand for integrated SRH information and services, particularly for family planning; and a more conducive and supportive environment for people to access and benefit from quality SRH, especially contraceptive choice.

How does it work?

Every health facility across countries was surveyed initially to provide a baseline level of information on the availability of reproductive health commodities, equipment, medicines, human resources and services. This data was imported into Tupaia and is built upon yearly, when each facility is again surveyed during a National tour.

During these tours, our mobile data collection app Tupaia MediTrak is used to collect updated data from the health facilities, allowing graphs over time to show any progress as to the improvement of services, or to direct where further support would be of benefit. The data can be shown at facility level, or aggregated to give an overall view of how a district or province or country is tracking.

Included in this data collection process is an ongoing import of data into Tupaia on staff training. This includes information on which facilities have had staff attend trainings and what they have been trained on, to help address training gaps where they exist in provinces or facilities to ensure all women have access to a facility with sufficiently trained staff.

On Tupaia, you can see exactly what supplies each clinic has in stock

Through Tupaia, we have data coming into the reproductive health platform about family planning commodity availability for those countries that use the stock management system mSupply (Kiribati, Solomon Islands, Vanuatu, and Tonga) at the national medicines warehouse.

BES also supported the roll out of mSupply at the UNFPA central warehouse in Suva, Fiji. From this warehouse, Pacific Island Countries can order required family planning commodities, and now the warehouse is able to use the forecasting, tender and procurement functions in mSupply to ensure there is always sufficient stock to meet these needs.

What this means is that stakeholders can look at Tupaia and quickly identify the supplies that are available at each health facility across all six countries in the region. One facility may have condoms and IUDs but is running low on emergency contraceptives. Another facility nearby may have plenty of emergency contraceptives, but no services for pregnancy testing and insufficient condoms available.

The availability of country level stock status information from mSupply allows UNFPA to detect regional supply issues, country level supply issues and sub national bottle necks and provide support and advice as required. Next steps for this project include adding live information on the availability of items at the Fiji warehouse to Tupaia, so there is oversight at each country level on the availability of items within the Pacific.

In Tonga, the Reproductive Health team in the Ministry of Health can view the UNFPA reproductive health module described above, as well as other important data they need to support decision making and reporting – all within Tupaia. Tonga uses Tupaia to display Health Information System (DHIS2) data (such as contraceptive prevalence rate), and this data is captured at the facility level using Tupaia MediTrak. We thus have a growing workforce of people becoming adept at using the MediTrak data collection tool and using Tupaia to view a range of health data, so staff need only learn to navigate a single system to collect and view the data they need.

In Kiribati, the physical monitoring and the monthly review of mSupply reports have contributed to increasing the share of health facilities with no stockouts of any contraceptives from 2 per cent in 2019 to 67 per cent in 2020. Not just that, but data indicates the increased use of family planning commodities and a rise in couple-years protection.

The future of reproductive health in the Pacific

The long-term impact this project strives for is greater oversight as to the availability of reproductive health services in each of the participating countries. Countries will be able to use Tupaia to show where, for example, facilities offer family planning services, and where there are gaps in the family planning commodities available to support the offering of these services – and support Ministries of Health to plan to rectify these discrepancies.

The overall aim is to improve service availability to all women living in the 8 participating countries by ensuring they have the commodities, equipment and staff available to meet family planning and reproductive health needs.

Want to learn more about Tupaia? Visit our product page here.

Want to explore the data yourself? Check out tupaia.org

www.medqualityassurance.org

I need to preface this story by emphasising that I am a pretty poor cricketer and somewhat worse at golf, so there is a caveat over the whole analogy. Each January though, I play in an annual pharmacy cricket carnival which is weighted (at least for the Victorian team) about 90% towards good fun and 10% cricket. We do occasionally win but only because of a ruthlessly competitive streak we develop when playing NSW…

Once, a few years ago, it occurred to me that I did not have cricket boots – in fact did not usually wear them – but that we were going to be playing games on wet surfaces following a fair bit of rain. I wasn’t going to run out and buy spikes for a few semi-social games of cricket but I was conscious of embarrassing myself with acrobatic displays of falling over. What to do? I looked into the cupboard and spotted the solution! My golf shoes – rarely worn and in pristine condition – sitting buried at the back of the cupboard. Now these were the sporting variety of golf shoes, not the heavy, tan leather variety favoured by my golfing grandfather in his day… well suited to a change in sports. Not what they were intended for… but available and ideal for the job. Short story – they were perfect! Nobody noticed a thing and I played out the carnival without falling over once (well, no more than usual).

Of course, I still didn’t take any wickets or make any runs – dropped a few catches – but let’s not let my lack of cricketing ability spoil a perfectly good analogy.

Sometimes the perfect option is sitting there staring at us – we just need to think laterally.

In 2016, we were engaged by the World Food Programme (WFP) to roll-out mSupply Mobile across 100 facilities in Timor-Leste. mSupply Mobile is an Android, tablet version of the widely used mSupply software, which is used for managing stock across health supply chains in 30 countries around the world. mSupply is important for the Australian aid program; it’s used in most countries in the Pacific, as well as Timor-Leste, Myanmar, Laos and Cambodia. We have been involved in rolling out mSupply Mobile to further strengthen the mSupply medicines management architecture in 6 countries across the Pacific in the last 2 years.

The roll-out in Timor was the fastest ever roll-out of mSupply mobile with solid take-up by staff and improvements in medicines availability throughout the first year. Much of the success came down to a young local IT graduate called Agusto Dos Santos, who we employed in 2016 and embedded in the Timor national medical stores (SAMES) specifically to support mSupply and mSupply Mobile.

Agusto came to us with no experience in health but he had worked in IT and telecommunications and interviewed exceptionally well so we’d taken a chance on him above some more experienced candidates. He grasped supply-chain concepts quickly, was strong on both software and hardware and interacted very well with colleagues across the spectrum – he was the key difference in ensuring the success of the project.

Fast-forward to late 2018 and Solomon Islands proposed a roll-out mSupply Mobile to 50 facilities across the country, including full-time, in-country support for 12 months to the implementation. Now – to be blunt – the usual paradigm in development in our region is to find an available Australian or New Zealander to come in and do expensive technical assistance. Sometimes this is great and often it’s completely necessary… but could we think laterally?

We looked around the region and universally decided that the best person for the job was Agusto Dos Santos, the young Timorese guy we’d taken on with zero experience just two and a half years earlier.

Here was an opportunity for south-south collaboration in action – we were keen to trial it, the Solomon Islands Ministry of Health and the Australian Embassy in Honiara were in accord and DFAT’s innovationXchange, the project funder agreed enthusiastically.

So – we’re 4 months in. How’s it going?

Unbelievably well.

Agusto Dos Santos in Central Province, Solomon Islands

With the support of a strong Pharmacy Division in Solomon Islands, Agusto has led the implementation of mSupply Mobile in 15 facilities across 3 provinces already. They’re on schedule and under budget, with an anticipated completion date for installations by May and then 6 months of follow-up factored in. In Honiara City Council, every single public health facility is now using the system, along with every health centre in Central Province. 100% of new facilities are consistently entering data and 13/15 have completed subsequent stocktakes since implementation. Most facilities are entering data every single day.

How do we know? Well, we can see the data being entered in real-time! Because mSupply Mobile uses ‘sync’, connectivity problems do not affect data capture so there’s no excuse to not enter data. The system continues to work seamlessly, even without internet, for weeks or even months at a time.

When facilities have connection problems  staff from the National Medical Stores are responding immediately by making sure tablet sims have credit. When internet completely drops out, it’s challenging but we know that when it comes back all the information entered over that time syncs automatically, with no data loss or corruption.

A subsequent success of the new mSupply Mobile network is improved communication. We know that communication has improved because we’ve installed the Telegram messaging service on each device – a lite version of WhatsApp that sends and receives encrypted messages. Thousands of messages are being exchanged every day between staff at the National level and across facilities in moderated conversations.

See, Agusto isn’t just rolling out a token program to be forgotten about – he’s leading the implementation of cutting edge, globally recognised technology that is having immediate benefits in a tough environment.

Agusto is getting along famously with the local Solomon Islands team, finding wonderful and unexpected cultural similarities but professionally bringing his experience and IT nous to a team that benefits enormously from both. Together, they’re approaching the work with an energy that put honestly, we simply don’t see with many other consultants. Agusto is in his late 20s and goes about his work with a huge smile and an infectious enthusiasm that you simply can’t teach.

The other benefit is that when Agusto is finished, he’ll take a wealth of experience home with him, with lessons to be applied back home in Timor-Leste. We hope to identify more ‘change champions’ and from our perspective, we hope Agusto is at the vanguard of an army of change champions being deployed to support Tupaia and mSupply from the countries that most benefit from these health innovations. Moreover, the concept is winning a lot of support within DFAT and we hope it’s increasingly replicated across different programs.

Of course, we know we’re not the first ones to succeed with south-south engagement but in health supply chains and health innovation, it’s been relatively rare in our region and we’re keen to start a conversation about how to enable more of it.

So what lessons have we learnt along the way and what criticisms do we need to overcome in the future?

Agusto (far left) with WFP representatives in Timor-Leste

Talent drain

The main criticism of the model is that we risk robbing Peter to pay Paul… what’s the point of pulling out the best staff from one country if it leaves them too short on talent to realise the benefits of the original innovation we implemented? We think this argument has merit in very small ecosystems or where countries are in the absolute fledgling stages of implementation.

In the case of Agusto though, Timor-Leste had been building up a significant pool of users over several years with mSupply. Agusto is one of the best members of their team at SAMES but not the linchpin. We were confident that removing him from that environment would not leave Timor-Leste short on talent and that seems to have been borne out so far.

Visas

As Australians, we get used to turning up in a country and getting waved through the door. We have a ‘Passport Power’ rank of 7, meaning we have visa-free or visa-on-arrival entry into 161 countries around the world including nearly every country in our region. Timor-Leste? Their score is 47, with comparable easy entry into only 94 countries. Papua New Guinea fare even worse, with entry into just 78 countries – and that’s good, compared with Nepal (where mSupply started and still maintains an office), with a power score of 86 allowing them entry into just 47 countries.

That doesn’t mean staff from these countries are blocked from entry but it means they can’t nonchalantly turn up and work it all out post-arrival. In Agusto’s case, it took about a month to secure an annual working visa.

Transit visas

Gah – transit visas. These are hugely frustrating but they’re not going away. From many countries (including Timor-Leste) even if they are not leaving the airport on their way through Australia, they will need a transit visa. These are obtained via the local embassy/high commission in their home country but we’ve found them to be processed fairly quickly – within a few days.

On Agusto’s first trip with us (to Vanuatu), to help with a short-term training course, we got the rules wrong but somehow managed to get a last minute one-off exemption for him.

Accommodation

Put simply, we got really lucky on accommodation. Accommodation is not just expensive in a lot of places but it goes without saying that there are no Timorese ex-pats (that we know of) living in Honiara. We knew that finding housemates who are a good fit would set Agusto up for an enjoyable year… thanks to some planning by a friend of ours 2 months in advance, Agusto found a great room in a house shared by two Pacific Islanders and a Japanese volunteer. The combination of cultures works well and Agusto has an instant group of friends in the city.

Cash (including in transit)

International credit cards. Most of the population in low-resource countries have no access to them and without them, accessing cash quickly overseas is really difficult. Carrying wads of cash is risky and inevitably results in losing money through poor exchange rates. As soon as Agusto arrived in Solomon Islands, we arranged for him to be given some local cash by a mutual friend, to tide him over. Agusto then went with a local counterpart to a Solomon Islands bank on the first day in country to start the process of setting up a bank account (which can be laborious in some countries). Within a few days, he had a local card and we could start paying him into it. This can’t wait – everyone needs to be able to access money but we Australians can now take this for granted with international credit cards and access to ATMs in every country.

The other issue is while Agusto is in transit. Neither his accounts in Timor-Leste or Solomon Islands allow Agusto to access cash in other countries and with transits home that can be up to 24 hours, money is necessary for food and/or accommodation (as well as for unexpected baggage fees, when we accidentally booked him on a domestic Tiger Air flight from Brisbane to Darwin!). We solved this initially by arranging for him to be given cash by mutual friends – but this is not always practical or possible. We are now arranging for him to receive a ‘travel’ visa card that we can top up remotely. The fees on these cards are high but they are useful for ensuring that Agusto always has a couple of hundred dollars of emergency funds available.

Language

Unfortunately, language barriers are probably insurmountable for longer-term engagements. Whilst shorter training courses can be supplemented with translators, this is not viable over 12 months (much of it spent in the field). It was vital that Agusto was able to speak fluent English and this is an important skill to assess.

Trips home

Agusto has a wife and young daughter who have not accompanied him to Solomon Islands. Whilst they have a strong network of support around them, the separation is emotionally difficult for them. Wealthier consultants may supplement official trips with personal trips home but this is not necessarily viable for staff from lower-resource countries. We budgeted an additional trip home into Agusto’s contract to at least give him some opportunity to connect with his family. Over longer engagements, we think this is the fair and right thing to do.