Infant HIV Diagnostics: Supply Chain in Sub-Saharan Africa

Abstract

Roger Osayende, a former management consultant, must advise the Ministry of Health of Ektu, a fictional country in Central Africa, on how to implement a new point-of-care diagnostic test for infants with HIV. In Ektu, mothers often transmitted HIV infection to infants during pregnancy, delivery, or breastfeeding due to inadequate resources to invest in prevention efforts. The existing procedure to diagnose infants with HIV required collecting dried blood samples at more than two hundred healthcare facilities around the country and transporting them to a central laboratory in the capital for testing. This process was characterized by significant delays due to long transportation times, batching of samples in transportation and processing in the lab, and concomitant congestion in the lab. This delay resulted in loss to follow-up, that is, lost patients due to mothers not collecting their infants' results. A new point-of-care device was about to be introduced, which would obviate the need for this centralized processing and the resulting diagnostic delay. The key decision under consideration is where to place the devices to maximize their effectiveness.

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Resources

Exhibit 1: HIV Disease Burden for Selected Countries in Sub-Saharan Africa

Country

Disease Burden

Number of Central Labs Capable of Performing Infant DBS Testing

Botswana

33.7% of pregnant women infected in 2007

1

Kenya

> 100,000 pregnant women HIV infected/year

3

Uganda

91,000 HIV-exposed infants born per year

8

Zambia

35,374 infants were tested for HIV in 2009

3

Sources:

Botswana: William Jimbo, “Early Infant Diagnosis Data Collection, Management, and Analysis for Program Monitoring,” presented at Early Infant HIV Diagnosis Conference, Arusha, Tanzania, May 13–15, 2010.

Kenya: Shobha N. Vakil, “Early Infant Diagnosis: Improving PMTCT and Paediatric HIV Programs,” presented at Early Infant HIV Diagnosis Conference, Arusha, Tanzania, May 13–15, 2010.

Uganda: Julie Nabweteme Mugerwa, “Postnatal Followup Among HIV-Exposed Infants Whose Mothers Received ARVs During Antenatal Clinic in Mulago Hospital,” presented at 4th National Paediatric HIV Conference, Kampala, Uganda, September 28–30, 2010, http://www.upa.or.ug/dloads/E.%20Julie%20Nabweteme-%20Postnatal%20follow-up%20.pdf.

Zambia: Rokaya Ginwalla, “Zambia EID Program Overview,” presented at Early Infant HIV Diagnosis Conference, Arusha, Tanzania, May 13–15, 2010.

Exhibit 2: Summary of Dried Blood Spot Testing Procedure

Figure

Figure

Source: International Center for AIDS Care and Treatment Programs, Mailman School of Public Health, Columbia University, “Collection, Storage and Transportation of Dried Blood Spots for Infant Diagnosis,” http://www.columbia-icap.org/resources/peds/files/CollectionstoragetransDBS.ppt (accessed May 15, 2011).

Figure

Exhibit 3: Details of the Healthcare Pyramid in Ektu

Provider Level

Typical Location

Description

Example of Services

Infant DBS Testing

Infant HIV Testing Capabilities

DBS Sample Transportation

5

Capital/major city

Flagship government-run teaching hospital

Extensive services including surgery

Infant testing performed on-site

PCR machines available on-site for infant DBS testing

N/A

4

Major cities

Small hospital

Simple surgeries, moderate imaging, communicable disease treatment

DBS cards collected, but not tested on-site

None

Transported to central lab multiple times per week on a well-established schedule

3

Major cities or rural economic centers

Large clinic

Communicable disease, dental, x-rays, maternal and child health

DBS cards collected, but not tested on-site

None

Transported to central lab once per week on a well-established schedule

2

Cities or rural towns

Medium clinic

Communicable disease, maternal and child health

DBS cards collected, but not tested on-site

None

Urban: Transported to central lab using a motorbike when a large number has been collected

Rural: Transported by NGO couriers on a varying schedule, a few times each month

1

Rural areas

Small clinic

Communicable disease

DBS cards collected, but not tested on-site

None

Transported by NGO couriers on a varying schedule about once a month

Exhibit 4: Kimwame Clinic Infant HIV Test Result Storage

Figure

Exhibit 5: Timeline of Geradine's Story

Figure

Exhibit 6: Study of Dispatch of DBS Samples from Remote Clinics to the Central Lab

Clinic Number

Dispatch 1

Dispatch 2

Dispatch 3

1

6/5/2010, 4 samples

6/19/2010, 5 samples

7/3/2010, 5 samples

2

6/5/2010, 5 samples

6/30/2010, 4 samples

7/22/2010, 4 samples

3

6/13/2010, 3 samples

6/23/2010, 3 samples

7/1/2010, 3 samples

4

6/11/2010, 3 samples

6/25/2010, 3 samples

7/7/2010, 2 samples

5

6/16/2010, 2 samples

6/21/2010, 2 samples

7/3/2010, 2 samples

6

6/14/2010, 4 samples

7/3/2010, 4 samples

7/16/2010, 4 samples

7

6/10/2010, 2 samples

6/18/2010, 2 samples

7/1/2010, 2 samples

8

6/11/2010, 4 samples

7/19/2010, 3 samples

8/25/2010, 3 samples

9

6/3/2010, 6 samples

6/14/2010, 6 samples

7/1/2010, 7 samples

10

6/10/2010, 3 samples

6/23/2010, 3 samples

7/12/2010, 3 samples

11

6/15/2010, 9 samples

6/30/2010, 9 samples

7/17/2010, 11 samples

12

6/17/2010, 24 samples

7/1/2010, 21 samples

7/11/2010, 20 samples

13

6/10/2010, 3 samples

6/24/2010, 3 samples

7/10/2010, 3 samples

14

6/6/2010, 6 samples

6/10/2010, 6 samples

6/19/2010, 5 samples

15

6/17/2010, 8 samples

6/28/2010, 8 samples

7/9/2010, 12 samples

16

6/14/2010, 11 samples

7/11/2010, 17 samples

8/6/2010, 16 samples

17

6/9/2010, 7 samples

7/5/2010, 5 samples

8/1/2010, 5 samples

18

6/12/2010, 3 samples

6/18/2010, 3 samples

6/24/2010, 3 samples

19

6/12/2010, 7 samples

6/27/2010, 7 samples

7/13/2010, 6 samples

20

6/12/2010, 3 samples

6/22/2010, 3 samples

7/5/2010, 3 samples

21

6/6/2010, 6 samples

6/16/2010, 7 samples

6/30/2010, 6 samples

22

6/4/2010, 5 samples

6/19/2010, 6 samples

7/3/2010, 5 samples

23

6/6/2010, 9 samples

6/18/2010, 8 samples

7/2/2010, 8 samples

24

6/17/2010, 7 samples

7/9/2010, 7 samples

7/31/2010, 7 samples

25

6/15/2010, 7 samples

7/3/2010, 7 samples

7/16/2010, 6 samples

26

6/15/2010, 18 samples

7/2/2010, 15 samples

7/16/2010, 15 samples

27

6/10/2010, 15 samples

6/25/2010, 12 samples

7/12/2010, 12 samples

28

6/9/2010, 11 samples

6/28/2010, 15 samples

7/19/2010, 15 samples

29

6/8/2010, 23 samples

6/22/2010, 1 samples

7/11/2010, 30 samples

30

6/5/2010, 4 samples

6/15/2010, 4 samples

7/1/2010, 4 samples

31

6/10/2010, 2 samples

6/25/2010, 2 samples

7/6/2010, 2 samples

32

6/16/2010, 4 samples

7/6/2010, 4 samples

7/25/2010, 5 samples

33

6/10/2010, 3 samples

6/28/2010, 3 samples

7/15/2010, 3 samples

34

6/7/2010, 3 samples

6/26/2010, 3 samples

7/17/2010, 4 samples

35

6/6/2010, 11 samples

6/23/2010, 14 samples

7/12/2010, 14 samples

36

6/12/2010, 15 samples

6/25/2010, 15 samples

7/6/2010, 17 samples

37

6/6/2010, 9 samples

7/11/2010, 9 samples

8/18/2010, 9 samples

38

6/9/2010, 19 samples

6/26/2010, 22 samples

7/8/2010, 15 samples

39

6/16/2010, 7 samples

7/3/2010, 6 samples

7/20/2010, 5 samples

40

6/5/2010, 8 samples

6/23/2010, 7 samples

7/9/2010, 7 samples

41

6/16/2010, 5 samples

6/30/2010, 5 samples

7/19/2010, 6 samples

42

6/3/2010, 3 samples

6/22/2010, 2 samples

7/13/2010, 2 samples

43

6/12/2010, 17 samples

7/15/2010, 26 samples

8/14/2010, 25 samples

44

6/7/2010, 23 samples

6/30/2010, 26 samples

7/18/2010, 20 samples

45

6/9/2010, 30 samples

7/18/2010, 28 samples

8/27/2010, 30 samples

46

6/7/2010, 3 samples

6/20/2010, 4 samples

7/3/2010, 4 samples

47

6/12/2010, 6 samples

7/1/2010, 4 samples

7/20/2010, 6 samples

48

6/14/2010, 8 samples

7/2/2010, 11 samples

7/15/2010, 8 samples

49

6/5/2010, 23 samples

6/27/2010, 18 samples

7/25/2010, 23 samples

50

6/7/2010, 5 samples

7/2/2010, 5 samples

7/19/2010, 4 samples

Exhibit 7: Study of Transport Time Between Clinic and Central Lab

Clinic Number

From Clinic to Central Lab (days)

From Central Lab to Clinic (days)

1

5

4

2

6

5

3

4

3

4

5

6

5

3

4

6

6

5

7

3

3

8

9

10

9

5

5

10

5

6

11

5

5

12

6

5

13

4

4

14

3

3

15

4

5

16

7

6

17

8

7

18

3

2

19

6

6

20

5

6

21

6

5

22

5

6

23

4

4

24

7

6

25

6

7

26

5

5

27

7

6

28

8

7

29

6

6

30

5

5

31

5

6

32

8

7

33

6

6

34

8

9

35

7

6

36

4

4

37

12

10

38

6

5

39

7

6

40

7

6

41

5

5

42

8

7

43

9

8

44

6

6

45

10

9

46

4

3

47

6

5

48

6

6

49

8

7

50

6

6

Exhibit 8: Central Lab DBS Sample Arrival Log Book (March 2, 2010 to April 26, 2010)

Date

Clinic

Samples

3/2/2010

7

3

3/2/2010

15

4

3/2/2010

38

6

3/2/2010

46

5

3/3/2010

2

4

3/3/2010

9

13

3/3/2010

11

5

3/3/2010

14

18

3/3/2010

22

6

3/3/2010

33

8

3/3/2010

40

6

3/3/2010

42

6

3/3/2010

45

11

3/4/2010

9

8

3/4/2010

16

13

3/4/2010

17

11

3/4/2010

30

2

3/4/2010

31

4

3/4/2010

47

8

3/4/2010

48

9

3/5/2010

3

8

3/5/2010

7

9

3/5/2010

11

9

3/5/2010

15

10

3/5/2010

19

2

3/5/2010

24

7

3/5/2010

27

16

3/5/2010

34

8

3/5/2010

38

5

3/5/2010

42

7

3/5/2010

46

6

3/5/2010

50

3

3/6/2010

3

8

3/6/2010

4

2

3/6/2010

6

5

3/6/2010

13

1

3/6/2010

18

3

3/6/2010

34

11

3/6/2010

35

2

3/6/2010

37

10

3/6/2010

44

7

3/6/2010

49

9

3/9/2010

1

6

3/9/2010

3

4

3/9/2010

10

6

3/9/2010

11

11

3/9/2010

26

31

3/9/2010

32

8

3/9/2010

34

6

3/9/2010

41

9

3/9/2010

42

5

3/9/2010

43

8

3/10/2010

7

19

3/10/2010

9

15

3/10/2010

13

21

3/10/2010

38

8

3/10/2010

40

7

3/10/2010

44

3

3/11/2010

2

11

3/11/2010

4

15

3/11/2010

8

6

3/11/2010

11

2

3/11/2010

17

13

3/11/2010

30

3

3/11/2010

33

9

3/11/2010

35

3

3/11/2010

39

12

3/11/2010

41

12

3/11/2010

42

3

3/11/2010

43

9

3/11/2010

45

9

3/11/2010

48

8

3/12/2010

18

3

3/12/2010

23

9

3/12/2010

49

6

3/13/2010

3

3

3/13/2010

10

3

3/13/2010

20

3

3/13/2010

21

7

3/13/2010

34

15

3/13/2010

41

15

3/13/2010

43

8

3/16/2010

1

6

3/16/2010

8

10

3/16/2010

29

31

3/16/2010

32

6

3/16/2010

39

9

3/16/2010

41

6

3/16/2010

43

5

3/17/2010

5

4

3/17/2010

6

9

3/17/2010

16

5

3/17/2010

17

12

3/17/2010

22

10

3/17/2010

36

15

3/17/2010

37

12

3/17/2010

47

5

3/17/2010

48

6

3/18/2010

1

5

3/18/2010

3

4

3/18/2010

32

5

3/18/2010

34

6

3/19/2010

12

22

3/19/2010

28

13

3/20/2010

7

20

3/20/2010

15

22

3/20/2010

15

8

3/20/2010

18

1

3/20/2010

27

15

3/20/2010

38

3

3/20/2010

46

3

3/20/2010

46

7

3/20/2010

49

3

3/23/2010

4

12

3/23/2010

10

4

3/23/2010

15

8

3/23/2010

19

4

3/23/2010

21

13

3/23/2010

23

8

3/23/2010

25

7

3/23/2010

41

9

3/23/2010

43

12

3/23/2010

46

5

3/23/2010

50

7

3/24/2010

5

24

3/24/2010

6

5

3/24/2010

7

5

3/24/2010

20

8

3/24/2010

24

21

3/24/2010

36

11

3/24/2010

37

6

3/24/2010

38

3

3/25/2010

13

7

3/25/2010

18

3

3/25/2010

30

5

3/25/2010

44

6

3/25/2010

49

8

3/26/2010

12

21

3/26/2010

31

2

3/27/2010

4

3

3/27/2010

5

1

3/27/2010

9

5

3/27/2010

16

16

3/27/2010

18

19

3/27/2010

36

6

3/27/2010

47

5

3/27/2010

49

11

3/30/2010

2

3

3/30/2010

19

5

3/30/2010

21

6

3/30/2010

28

13

3/30/2010

30

5

3/30/2010

33

7

3/30/2010

45

10

3/30/2010

50

4

3/31/2010

4

3

3/31/2010

6

4

3/31/2010

37

15

4/1/2010

2

7

4/1/2010

8

5

4/1/2010

13

21

4/1/2010

14

5

4/1/2010

15

3

4/1/2010

33

11

4/1/2010

39

8

4/1/2010

44

4

4/1/2010

45

8

4/1/2010

46

3

4/2/2010

3

4

4/2/2010

9

17

4/2/2010

10

7

4/2/2010

26

14

4/2/2010

34

8

4/2/2010

40

5

4/2/2010

41

13

4/2/2010

43

6

4/3/2010

5

1

4/3/2010

7

1

4/3/2010

36

14

4/3/2010

38

5

4/6/2010

13

3

4/6/2010

16

5

4/6/2010

17

7

4/6/2010

44

6

4/6/2010

47

6

4/6/2010

48

7

4/7/2010

7

2

4/7/2010

25

10

4/8/2010

10

4

4/8/2010

14

4

4/8/2010

14

25

4/8/2010

18

3

4/8/2010

29

30

4/8/2010

41

6

4/8/2010

43

9

4/8/2010

49

5

4/9/2010

3

4

4/9/2010

11

12

4/9/2010

11

8

4/9/2010

12

21

4/9/2010

17

11

4/9/2010

34

9

4/9/2010

42

7

4/9/2010

42

9

4/9/2010

48

11

4/10/2010

3

3

4/10/2010

15

10

4/10/2010

26

25

4/10/2010

34

5

4/10/2010

46

5

4/13/2010

5

16

4/13/2010

14

5

4/13/2010

36

11

4/14/2010

2

1

4/14/2010

9

6

4/14/2010

10

9

4/14/2010

31

4

4/14/2010

33

6

4/14/2010

40

2

4/14/2010

41

7

4/14/2010

43

6

4/14/2010

45

9

4/15/2010

7

1

4/15/2010

17

11

4/15/2010

18

3

4/15/2010

21

15

4/15/2010

24

10

4/15/2010

48

7

4/15/2010

49

7

4/16/2010

4

5

4/16/2010

5

6

4/16/2010

7

19

4/16/2010

16

4

4/16/2010

19

8

4/16/2010

20

3

4/16/2010

35

2

4/16/2010

36

8

4/16/2010

47

3

4/16/2010

50

8

4/17/2010

1

4

4/17/2010

4

14

4/17/2010

9

7

4/17/2010

19

6

4/17/2010

29

30

4/17/2010

32

5

4/17/2010

35

3

4/17/2010

50

6

4/20/2010

6

8

4/20/2010

7

4

4/20/2010

11

11

4/20/2010

12

23

4/20/2010

20

4

4/20/2010

37

9

4/20/2010

41

12

4/20/2010

42

8

4/21/2010

1

4

4/21/2010

2

3

4/21/2010

5

17

4/21/2010

8

5

4/21/2010

18

19

4/21/2010

21

6

4/21/2010

32

4

4/21/2010

33

7

4/21/2010

36

16

4/21/2010

39

10

4/21/2010

45

7

4/21/2010

49

5

4/22/2010

1

6

4/22/2010

5

6

4/22/2010

9

6

4/22/2010

16

14

4/22/2010

27

13

4/22/2010

30

3

4/22/2010

31

1

4/22/2010

32

2

4/22/2010

36

9

4/22/2010

40

3

4/22/2010

47

5

4/23/2010

2

4

4/23/2010

33

7

4/23/2010

45

2

4/24/2010

4

3

4/24/2010

6

3

4/24/2010

8

6

4/24/2010

19

8

4/24/2010

28

13

4/24/2010

35

3

4/26/2010

37

10

4/26/2010

39

16

4/26/2010

50

7

Exhibit 9: Central Lab DBS Sample Post-Processing Log Book

Processing Complete

Results From Clinics

Date Results Ready For Dispatch

9/1/2010

7, 10, 46, 39, 38, 3, 42, 37, 25, 44, 53, 1, 47

9/3/2010

9/8/2010

1, 39, 8, 22, 23, 12, 52, 41, 27, 33, 49, 17, 16, 5, 40, 28, 47, 35, 24, 32

9/13/2010

9/22/2010

48, 8, 19, 52, 15, 46, 33, 36, 50, 18, 3, 6

9/22/2010

9/29/2010

36, 22, 25, 8, 43, 46

10/4/2010

10/6/2010

39, 27, 6, 16, 1, 31, 30, 41, 53, 3, 48, 10, 29, 51

10/8/2010

10/13/2010

29, 35, 4, 19, 32, 43, 49, 11, 18, 6

10/14/2010

10/27/2010

36, 23, 47, 43, 44, 27, 35, 46, 32, 15, 37

10/29/2010

11/10/2010

10, 47, 18, 46, 45, 49, 44, 19

11/12/2010

11/17/2010

45, 1, 21, 3, 9, 30, 28, 24

11/18/2010

11/24/2010

38, 46, 23, 14, 39, 44, 7

11/24/2010

Exhibit 10: Remote Clinics Infant HIV Sample Data

Clinic Number

Number of Infants Seen in 2010

Samples Positive

(+) Results Collected by Mother

(-) Results Collected by Mother

Infants Put on ARV Therapy

1

85

12

5

32

4

2

110

17

7

39

5

3

109

16

10

59

8

4

112

18

12

66

10

5

97

15

10

58

8

6

101

16

10

55

8

7

95

15

9

50

7

8

90

13

4

24

3

9

209

32

21

117

17

10

91

13

6

37

5

11

256

41

21

115

17

12

257

37

19

114

16

13

99

14

8

50

6

14

95

14

8

47

6

15

297

49

31

161

26

16

253

39

15

85

12

17

115

17

7

43

5

18

105

16

8

49

6

19

110

17

9

54

7

20

114

17

8

48

6

21

274

43

21

116

17

22

107

16

11

62

9

23

97

15

10

56

8

24

255

41

20

106

17

25

90

13

8

50

6

26

433

69

43

228

36

27

278

41

22

128

18

28

227

37

18

94

15

29

541

83

46

258

39

30

115

17

9

56

7

31

91

14

8

45

6

32

84

13

8

44

6

33

113

17

8

50

6

34

91

14

6

36

5

35

243

39

23

124

19

36

517

79

45

253

38

37

98

15

4

24

3

38

575

94

47

244

39

39

111

18

10

54

8

40

267

43

28

149

23

41

100

15

8

47

6

42

93

14

7

41

5

43

261

41

16

89

13

44

260

42

24

129

20

45

460

75

23

122

19

46

91

14

9

50

7

47

93

14

6

38

5

48

256

41

22

116

18

49

233

36

20

110

17

50

98

16

10

51

8

Exhibit 11: MSU POC Testing Device Details

The MSU infant HIV diagnostic test was a p24 antigen rapid lateral flow assay designed for point-of- care use in resource-limited settings. Specifically, the test measured the presence of p24 antigens rather than HIV antibodies. p24 is a core protein that surrounds the RNA genome within the HIV virus. 19

The p24 test took thirty minutes and could be used starting six weeks after birth. Similar to DBS testing, the p24 test used approximately three drops of blood from the infant. The p24 test had 95 percent sensitivity, 100 percent specificity, and was run entirely on rechargeable battery power. The price of each device was US$400–700 and the price of the consumables required for each test (lancet, filter, buffer, assay strip, etc.) was US$7–15. Consumables were sold in packages of ten or fifty and had a shelf life of eighteen months. Approximately one hundred tests could be performed on each battery charge; batteries could be recharged using a standard AC outlet.

Attribute

Description

Test duration

30 minutes

Blood collection requirements

3 drops (∼75 μL)

Blood collection

Safe-Tec MICROSAFE® collection and dispensing tube

Accuracy

95% sensitivity and 100% specificity

Cost

US$7–15 per test, US$400–700 per device

Power source

Battery

Result format

Visually read, qualitative result

Availability

2012

Figure

Source: UNITAID, “2011 HIV/AIDS Diagnostic Technology Landscape: Semi-Annual Update,” October 2011, http://www.unitaid.eu/about/MarketApproaches/Publications/2011_Update_HIV-Diagnostic-Technology-Landscape.pdf.

Figure

Exhibit 12: Ektu Stakeholder Points of View on POC Testing

Technical Working Group Member

Role

View on POC Infant HIV Testing

GOVERNMENT

Ministry of Health

Ultimate decision-making authority

The ministry was primarily concerned with maximizing the health of the citizens of Ektu given its budgetary constraints. While it was concerned about test accuracy, it was also concerned about its cost and potential impacts on the healthcare system. The ministry had to balance the clinical and economic impacts of all new therapies, products, and procedures. The ministry was also concerned that POC testing would dramatically change the workflow at local clinics and hospitals. Previously, nurses collected samples and then the infant and mother were free to leave. With this device, they would have to remain at the clinic until the specimen was processed and results given. If there were a long line, bottlenecks could result and mothers would have to wait for long periods of time. While it may not be optimal for every clinic and hospital within a country to adopt this new technology, implementing POC testing at some clinics would not impact patient load or transportation times at clinics without POC testing.

Central Lab

Provided technical expertise

The central lab was very concerned about POC testing. Specifically, it was worried that nurses and clinic staff could not be adequately trained to conduct and read the results of diagnostic testing. Incorrectly diagnosing an infant with HIV could have profound consequences. A false positive could result in infant neglect, significant emotional trauma for the mother, and unnecessary treatment. A false negative would prevent the infant from receiving life-saving treatment. Furthermore, clinics had to be able to maintain POC devices and a repair network had to be established in order to ensure prompt servicing of malfunctioning devices.

Global Center for Disease Control

Provided technical expertise

The GCDC was willing to assist with clinic trials to compare POC testing to central lab-based testing in Ektu. It saw the potential advantages of POC testing, but was concerned about the accuracy of current tests and with how Ektu would service malfunctioning devices.

NON-GOVERNMENT ORGANIZATION

President's HIV/AIDS Initiative

Negotiated low prices for HIV/AIDS drugs and consumables for Ektu and also provided expertise on PMTCT programs

The President's HIV/AIDS Initiative was primarily concerned with the potential increase in costs associated with POC testing.

Ektu Prevention, Care, and Treatment Partnership

Ran PMTCT services in the northern and central provinces of Ektu

EPCTP was excited about POC testing because it provided results quickly, but was worried about distributing supplies and testing consumables. EPCTP also shared some of the ministry's workflow concerns.

Churches Health Initiative of Ektu

Ran PMTCT services in Ektu's southern provinces

Churches Health Initiative of Ektu was excited about POC testing because it provided results quickly, but was worried about distributing supplies and testing consumables. It also shared some of the ministry's workflow concerns.

LOGISTICS PARTNERS

Supply chain management systems (SCMS)

Ordered and distributed all healthcare supplies throughout Ektu

SCMS was worried about distributing supplies and testing consumables, especially if POC testing consumables had to be maintained within a tight temperature range during shipping.

This case was prepared for inclusion in Sage Business Cases primarily as a basis for classroom discussion or self-study, and is not meant to illustrate either effective or ineffective management styles. Nothing herein shall be deemed to be an endorsement of any kind. This case is for scholarly, educational, or personal use only within your university, and cannot be forwarded outside the university or used for other commercial purposes.

2024 Sage Publications, Inc. All Rights Reserved

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