OpenLMIS Site Visits to SELV and SIGLUS

Trip Dates: 08 May 2019 - 14 May 2019

Chongsun Ahn (Unlicensed) and Sam Im (Deactivated) traveled to Maputo, Mozambique to see OpenLMIS implementations (SELV and SIGLUS) in use at the local level by end users, in order to gain insight into how the software is used and how to improve it.

Key Trip Takeaways

It was invaluable to observe the OpenLMIS software being used by end-users and encouraging to see how it helps their work.
- Conversely, bugs that exist in the system can make a significant negative impact in the user experience.
Internet connectivity and offline capability must always be considered and prioritized when thinking about non-functional requirements.
Interoperability is a recurring theme of importance when trying to achieve an efficient healthcare delivery process.
Overall, CMAM seems positive about SIGLUS/OpenLMIS and its benefits.

SIGLUS Implementer's Meeting / CMAM Presentation

Date: 09 May 2019 at 10:00am

Attendees: There were around 20 people in the room; including Felimone Amone Junior, Chongsun Ahn (Unlicensed), Sam Im (Deactivated), PSM, Program Managers.

Presentation: https://www.dropbox.com/s/9mx0ege2t7excmz/OpenLMIS_Maputo%20site%20visit.pptx?dl=0

Summary: Gave a presentation about the OpenLMIS product roadmap, OpenLMIS' vision for interoperability, its recommendations for sustainability and lessons learned from the existing implementation in Malawi. Overall, it seemed like participants were getting introduced to OpenLMIS as a whole. There were only a couple of people asking questions about the presentation, and it mostly was an introduction to logistics management information systems.

Detailed Notes

The goal of the presentation was to introduce OpenLMIS v3 to SIGLUS implementers and give an overview of interoperability, sustainability, and Malawi implementation.
The main point for interoperability was to establish no single IT system can manage the full health system/supply chain, and because of this, OpenLMIS aims to facilitate working with other systems through open standards
The main point for sustainability was to show how multiple factors affect it, not just the initial cost
We also gave lessons learned from an existing v3 implementation in Malawi and important considerations for future implementers
Although we didn't have implementers attending the meeting to ask questions about OpenLMIS, we were able to share the current capabilities of the system, and visions for future releases. Also shared means for communication via Slack (including a new Portuguese language Clack channel), the upcoming OpenLMIS 3.6 webinar, and Product Committee.
CMAM seems to be pro-OpenLMIS and pushing SIGLUS forward to more districts

Follow-up: CMAM was interested in hearing our thoughts about how the upcoming site visits will influence OpenLMIS going forward.

Centro de saúde de Sábié Site Visit

Date: 09 May 2019 around 3:00pm

Attendees: Felimone Amone Junior, Chongsun Ahn (Unlicensed), Sam Im (Deactivated), district EPI manager and Delisio Machava (Provincial EPI manager).

Summary: Visited one of the nearby health clinics while the vaccine distribution process was occurring. Toured the facility, saw the cold chain equipment, took a look at the EPI forms, and had a short discussion with the provincial EPI manager about OpenLMIS/SELV. It was an enlightening discussion and a beneficial visit to ask about the distribution process and the part that OpenLMIS/SELV plays in it.

Detailed Notes

SELV is an OpenLMIS v1 implementation that has been deployed to most provinces in Mozambique. It uses the "informed push"/distribution part of OpenLMIS v1, which is separate from the "pull"/requisition part of OpenLMIS.
We were originally going to have the site visit at the health center in Moamba; however, because of the timing of the distributions and where we were, we decided to meet the EPI managers in Sábié instead.
This was our first experience of "last mile" healthcare delivery. Because Sábié is a smaller village compared to Moamba, the roads to it are not paved. We mistakenly took a car without 4x4 and it took us 90 minutes to travel the 20 miles to Sábié. It gave us insight into the travel involved every month by the managers/field coordinators. We planned to visit at least two sites but due to the travel time, we were only able to visit one.
Once we arrived at the health center, we went to the immunization clinic, which is one small cylindrical building among several at the site. The health center closed shortly after our visit ended.
We were introduced to both the EPI district manager for Moamba and the EPI provincial manager for Maputo province. The provincial manager seems to regularly go on these trips to help facilitate the process. They had already done the distribution for Sábié earlier in the day, but came back to meet with us and show us the distribution process there.
The approval process is manually reviewed and approved on paper forms as the district and provincial managers are present. The district manager also reviews the cold chain storage to confirm it is functioning as expected by checking the temperature and vaccine storage. Not sure if this is documented anywhere for entry into SELV later.
We were not able to see the data entry in the tablet because it ran out of battery. This appears to happen often, as electricity is not available everywhere, and these distribution routes can take a long time. Once the tablet is out of battery, data is recorded on paper and then entered into the tablet once it can be turned back on.
We were able to look at a vaccine paper form used at the health center that would be entered into SELV.
Had a discussion about the "top-up" amounts (ISAs) on the form
- It was interesting to learn that the top-up amounts were sometimes based on population in a catchment area, and other times based on consumption data
- Data based on population can be outdated and not useful; this we already knew
- However, sometimes consumption data is not indicative of what amount a facility needs because of variability in population
  - Example: migration of population based on seasonality of sugar cane farming
- This is an example of where being able to override the system calculations are important. Even consumption-based data cannot take into account all of the factors.
Discussed current problems with SELV
- Syncing issues - seems to be a bug where a tablet will sync to main server, but another tablet/computer will check that distribution and find that SELV says none of that data has been synced.
- Route issues - lack of flexibility in SELV to allow different truck routing
  - Unclear about how SELV works here, but it outlines a route in a delivery zone, but because of lag time, some facilities that consume supplies quickly will run out of stock by the time the field coordinator arrives to restock, so those facilities are prioritized. However, this causes facilities that are "skipped over" to have to be handled using a new distribution?
- Connectivity is unreliable - In areas where a health clinic has limited connectivity the backup is to use paper forms. It was unclear how SELV could be improved to help with this.
- Tablet battery usage - Often, tablets run out of batteries often because of long trips; field coordinators will have to record visit info on paper and enter them into SELV later. However, this is not an issue with SELV specifically. We also need to know which tablets are commonly used and if the tablet software requirements are supported for SELV.

Follow-up: Even though there is no active development being done for SELV, it might be beneficial to look into this syncing issue to see if there is an easy fix for it, since it would have a sizable impact on end-user experience.

Marracuene District Warehouse Site Visit

Date: 10 May 2019 around 11:00am

Attendees: Felimone Amone Junior, Chongsun Ahn (Unlicensed), Sam Im (Deactivated), Dianna Lourenco (SILGUS Manager) Beneldino Mondlane (PSM IT support), district medical warehouse manager.

Summary: Visited one of the nearby district warehouses. Toured the facility, saw the cold chain equipment, took a look at the EPI forms, and had a short discussion with the district warehouse manager about OpenLMIS/SIGLUS. It was an enlightening discussion and a beneficial visit to ask about the requisition/fulfillment process and the part that OpenLMIS/SIGLUS plays in it.

Detailed Notes

SIGLUS has two parts–a Web component, which is used for viewing reports, and a custom-built Android app, which performs stock management. Both of these parts interact with the back-end system, which is using OpenLMIS v2. The Android app syncs all stock movements with OpenLMIS, and that data is viewable in real-time through reports in the Web component.
Even though OpenLMIS v2 has the capability to approve requisitions and submit district-level requisitions to a higher level, it is not used for this in SIGLUS currently.
Instead, another system called SIMAM (Sistema de Informação de Medicamentos e Artigos Médicos, Information System for Medicines and Medical Supplies), a Microsoft Access database, is used for approvals and next-level requisitions.
This warehouse also had a very active health center connected to it where a pharmacist dispenses directly to the patient.
Asked about SIGLUS' positive impact on logistics process
- Has helped greatly in real-time visibility of stock at various health facilities
- Most requisition submissions from health facilities can easily be printed from the system
  - Some facilities seem to still submit paper requisitions, and those need to be verified for accuracy
Discussed issues from current logistics process
- Because there are two systems (SIGLUS and SIMAM), and interoperability between them is low (primarily because of MS Access), syncing the data between them is time-consuming and labor-intensive
- The warehouse manager must export SIGLUS reports to CSV, make manual changes to the CSV files to match product codes, then import them into SIMAM in order to do approvals and submissions
- In this case, it would be beneficial to move to one system in order to remove this manual, error-prone process
- Additionally, this appears to be another example of why interoperability is important, as the process could have been less burdensome if both systems could interoperate well and the sync between them could have been automated more
- This is why OpenLMIS v3 needs to continue to have high interoperability as one of its priorities
One issue specifically with SIGLUS is for better offline support in reporting
- Internet connectivity was not stable at this district warehouse. That day in particular, access to the Internet was intermittent
- The warehouse manager in her workflow, tends to request the same report multiple times in a short period of time
- It would be helpful if a report that was already requested could be cached and not require Internet connectivity in order to log in and request again
- There is some complexity in solving this issue because report data is dependent on which filters are selected when the report is requested
- This functionality is something to consider and prioritize for the next release, especially if SIGLUS is to move to v3

Follow-up: It would be good to know exactly how warehouse managers use the SIGLUS reports for their work in order to know the exact benefit of adding offline support for reports. How often do they request the same report (meaning the same filters)? For how long would they need that same report? How many different reports (meaning different filters) would need to be cached?