Analysis of a health centre's monthly report and order of essential medicines

Utilisation: all ages 1,520 × 12 / 24,600 = 0.74 contacts per inhabitant per year; under 5: population 24,600 × 18% = 4,428; 640 × 12 / 4,428 = 1.73.

Maternal health: expected pregnancies per month 24,600 × 4.5% / 12 = 92.25. ANC1 78 / 92.25 = 84.6%; ANC4 31 / 92.25 = 33.6%; assisted deliveries 41 / 92.25 = 44.4% (treating expected births as equal to expected pregnancies, an assumption to be stated).

Vaccination: monthly target 24,600 × 4% / 12 = 82. Penta1 79 / 82 = 96.3%; Penta3 62 / 82 = 75.6%; dropout (79 - 62) / 79 = 21.5%.

Malaria: testing rate 610 / 690 = 88.4%; positivity 402 / 610 = 65.9%.

Interpretation: good first contact (ANC1, Penta1, adequate utilisation for under-fives), but a major loss in continuity of care: from 84.6% at ANC1 to 33.6% at ANC4, assisted deliveries at 44.4%, vaccination dropout of 21.5%, more than double the 10% threshold. Causes to explore: distance and insecurity, costs, appointments not given, stock-outs, no active tracing of defaulters. Positivity of 65.9% is consistent with the seasonal peak; 80 suspected cases were not tested (RDT stock-out?). Only one month of data: confirm the trend over three months.

The safety stock equals the AMC: 402; 610; 4,200; 6,171.

Urgent situations: (1) ACT: 60 blisters, i.e. about 4 days of consumption at the height of the malaria season, well below the safety stock: emergency order to the district without waiting for the monthly order, or a loan from a neighbouring centre, informing the district medical officer; (2) paracetamol: total stock-out; check the delivery date of the 5,000 on order; (3) amoxicillin: 0.7 months, below the safety stock, and delivery will take 2 weeks. An unadjusted AMC would underestimate needs for the products that had stock-outs (ACT: 348 instead of 402; paracetamol: 4,800 instead of 6,171).

545 treatments for 402 confirmed cases: 143 more treatments than confirmed cases. Even if all 80 untested suspected cases had been treated (which is acceptable only during an RDT stock-out), 63 treatments remain unexplained (545 - 482).

Possible explanations: treatment of RDT-negative cases (poor practice: WHO recommends parasitological confirmation before treatment); recording errors (consultation register and pharmacy register not matching); double counting; stock issued to other facilities or community health workers without being recorded as such; diversion. These issues also contributed to the ACT stock-out.

Checks: reconciliation of consultation register / prescriptions / stock card for the month; physical inventory; review of 30 files of RDT-negative cases; check of RDT stock-outs; supportive supervision of prescribers on the "test, treat, track" approach; if diversion is suspected, reporting according to the organisation's procedure.

Example: "Dear Technical Director, thank you for welcoming the team. Strengths: good attendance by children under 5 (1.73 contacts per child per year), ANC1 at 84.6% and Penta1 at 96.3%, 88% of suspected malaria cases tested. Areas for improvement: only 33.6% of expected women attend ANC4 and 44.4% give birth with skilled personnel; dropout between Penta1 and Penta3 reaches 21.5%; 545 ACTs were dispensed for 402 confirmed cases; the ACT stock (60 blisters) covers only a few days. Agreed actions: (1) emergency order of 1,146 ACT blisters and reconciliation of the September registers, by the store manager and the head nurse, by 10 October; (2) ANC and vaccination appointment book and list of defaulters sent every week to the community volunteers, by the midwife and the vaccinator, from 15 October; (3) reminder of the ACT prescribing rules at the staff meeting, by yourself, this week. We will return next month to review progress."

I cannot ignore this information: duplicated consultations distort health data and constitute financing fraud. I check factually and discreetly (sample of registers, comparison with stock cards and prescriptions, search for duplicate names and dates), while protecting the nurse who spoke up. I report the findings in writing to my manager and, according to the procedure, to the results-based financing verification mechanism and the district medical officer. I propose corrective measures (training on recording, monthly cross-checks) rather than a purely punitive approach, but without covering up the fraud.