The study's results were thoroughly explored in this section by making comparisons to other study results from around the world. Theoretical and empirical discoveries that strengthen the results were included in the discussion, as well findings that reasonably contradicted the study. Each study variable was covered in detail.
The study was attempted to assess the cold chain management practice, and operational performance in selected health centers under Addis Ababa Administrative Health bureau. Observing the demographic trend or characteristics of the sample population during data collection was useful for conclusion scientific findings. From the total of 60 study participants, 36(60%) of the respondents were male, while 24 (40%) were female. This indicates the dominance of men in managing cold chain products in health centers. Similar study reported by Mohammed et al. in 2018 indicated that the gender distribution was dominated by male employees in the health centers (39). However, the study was different from study conducted by Firomsa in which among 47 respondents 20.9%(9) and 79.1%(34) were male and female respectively(36). The difference of the finding may be the number of sample sizes, and type of facility type assessed. Additionally, the age range of the majority of respondents was < 26 years, which accounts for 32 (53.3%). From the total 60 respondents involved in the study, 30 (50.0%), 9(15.0%) and 21(35.0%) had educational qualifications of bachelor’s degree, MSc and diploma, respectively. The majority of 34 (56.7%) had work experience greater than 3 years. 26 (43.3%) of the respondents had less than 3 years of experience. This implies that the organization is in a good position in the case of cold chain product handling in the health centres in Addis Ababa. Aside from this, Nurse 12(20.0%)and midwife 5(8.3%), was mostly involved in the in-charge/coordinator/immunization focal person of the facility cold chain.
Cold chain management is a means of warranting proper cold chain maintenance, a continuous and cohesive process to ensure availability and maintain the potency of temperature-sensitive pharmaceuticals(40). Cold chain management plays a crucial role in ensuring the effectiveness of cold chain storage, handling, and stock management; rigorous temperature control in the cold chain; and adequate logistics management information systems. However, concerns over having adequate control in the cold chain are increasing in recent decades in the aftermath of an increasing volume and complexity of cold medicines and the complexity of the worldwide supply. The rapid growth of biopharmaceutical business, complex global sourcing, and distribution chain has brought global interest in the supply chain management of cold pharmaceuticals(5).
Therefore, it is better to assess the level of practice in the management of cold chain products in a given public facilities. In this study the mean of studied variables ranged from 3.52 to 4.93 respectively. Accordingly, the result indicates that, the respondents agree on SOPs are available to ensure proper cold chain storage (4.93\(\:\pm\:0.252)\). The mean scored by respondents regarding storage system and facilities were between 3.5–4.5, and above. This indicates that, the storage and facility practice in the cold chain product management in the health centres were satisfactory as per specification (37). Similar study reported from Addis Ababa that support the present study which stated that, the storage practice in cold chain management of vaccine providing immunization service is on good status(36). However, different from Tanzania were posted in which the storage practice was unsatisfactory for cold chain products particularly(41). This revealed Ethiopia followed good storage practice for assuring the cold chain products management in the public facilities.
The cold chain distribution process is the process by which cold chain products move from the point of manufacturing to the end user. Products typically move across multiple locations including manufacturing, distribution, and storage before reaching the end user. Lack of reliable transport at district level contributes to shortage of cold chain products at health facility level(38). This suggests that, good distribution system should be in place for effective and safe delivering of such products at point of interest. In this study, the mean score of the distribution system in the study ranged from 2.77 ± 0.981 to 4.62 ± 0.490. The respondents in the study were neutral on special vehicles for transportation of cold chain items (2.90 ± 0.933) and enough containers to meet demand for distribution (2.77 ± 0.981). This implies that the respondents didn’t know the distribution system of cold chain products. This means there is a chance of cold chain items being damaged during transportation because specialized vehicles and containers should be used to transport cold chain products and be fitted with monitoring devices. Similar study conducted in coast region, Tanzania, and Ethiopia showed that the main cause of delay in delivery of vaccines to the health centers was shortage or lack of transport to distribute the vaccine(36, 38). Training is a very important constraint which needs to be considered to improve the cold chain distribution plan. People involved in transportation and supply of cold chain products need to be trained and have knowledge of cold chain and how to handle breakage of cold chain(42).
Training supply chain personnel is usually focused narrowly on specific activities, such as storekeeping, maintaining cold-chain records, and providing security for commodities, rather than the higher order planning, analysis, and performance management skills needed by supply chain managers(43). In the study, the mean score of study participants regarding technical capacity ranged from 3.62 ± 0.666 to 4.93 ± 0.252. Accordingly, the respondents agree on reliable electric power supply, enough employees to handle the demand, and enough employees to handle the maintenance of equipment in the study. They strongly agree on the remaining parameters. Based on the aggregated mean score, there is satisfactory technical capacity in the health centers. The study different from Mozambique which stated that, inadequate knowledge and practices exist regarding cold chain management in primary health care facilities (43). According to study done on pharmaceutical distributors in Nairobi Country 41% of respondents have absolutely no special training in cold chain (16).
Appropriate information regarding cold chain products paramount important for effective implementation of cold chain management practice in the health facilities. In the study, the mean score of items related to information systems ranged from 3.65 ± 0.709 to 4.72 ± 0.454. As respondents responded, they agree on most information systems as their mean score is between 3.5 and 4.5, while they strongly agree that SOPs are available to ensure proper information systems and that SOPs are followed to ensure proper information systems due to their mean score being above 4.50. The parameters' averaged sum demonstrates that the health centres have an adequate information system in place. The study was different from report of Firomsa, in which respondents remained neutral on maintaining stock balance through regular recording and use of requisition forms for vaccine ordering(36). The study conducted on effective vaccine management (EVM) analysis done by WHO in 75 countries revealed that with a few exceptions, information systems are weak at each level in each region(44). The average score for each practice parameter used in the health centers was calculated, and the average was then categorized as satisfactory, unsatisfactory, and neutral. The analyzed variables' means fell between the ranges of 4.01 and 4.43. This suggests that respondents concur that elements pertinent to practice are crucial to cold chain management. This implies that, the Addis Ababa health centers satisfied the requirements for cold chain management.
Assessing factors most likely associated with cold chain management practice was important for taking intervention. Employee who has educational background highly associated with storage and facility, and distribution system both accounted (60a; 0.0001) followed with technical capacity. This implies that respondents who educated likely better engaged in the management practice of cold chain products. Experience and service year of employees positively associated in the practice of cold chain management practice. The study was different from Tiya B, reported that, information system has no significant positive effect on availability of cold chain unlike this study(45).
An empirical finding should be necessary for supply chain management practices in the assurance of cold chain product in the ware house for reliable predictors for operational performance. The study attempted to give some insights into consideration that help to improve the cold chain management performances at public health facilities in the study area and other regions with similar characteristics to the studied facilities. The average duration that the key temperature-sensitive pharmaceuticals are out of stock indicates the capacity of a system to maintain constant supply of products over time (27). In the present study, the median stock-out duration was (32/13) days for the health facilities, while the average stock-out duration was 49.23 days for the public health facility in the current study. These results show the logistics system in Health centers in Addis Ababa supplied by the Ethiopian supply chain service was not performing well. As per specification, the median stock-out duration should ideally be zero(38). The present finding different from study conducted in Tanzania which revealed the average stock-out duration of the cold chain product in public health facilities to be 15 days(46). Also the present study was higher than from study conducted in Jimma zone which revealed that, the median stock-out duration was 23.04 days for the health facilities while the average stock-out duration was 29.30 days for each public health facility in the current study(27). The present study also figures out that, 4 (20%) have good stock for temperature-sensitive products, while poor stock in 16 (80%) facilities was observed during the survey. This noted a poor product cold chain available in the stock in the health centers due to the percentage of public health funds being less/equal to/ than 80%.
Accurate inventory record keeping is essential for proper inventory management at all levels of public facilities. In the study, the inventory record accuracy rate showed that the facility mostly has poor or inaccurate stock records (85%). This study found that all health facilities, regardless of the facility type, had incorrect stock record keeping. Similar study finding reported from Jordan(47), and Ethiopia(27) that evidenced that presence of inaccurate stock record in the public health facility. The transforming cold chain performance and management in lower-income countries stressed that lack of technology to improve cold chain capacity, information, decision making, and infrastructure were some of the challenges for the cold chain management. Apart from that, less education, experience, and knowledge were established to be some of the challenges for cold chain management improvements(48).The studies indicated that the issues of stock record management are critical.
During storage and distribution, suitable procedures and equipment should be in place to check the environmental conditions of the medicinal products storage area Proper storage is vital to maintain the purity, potency, safety, and effectiveness of cold chain medicines. Cold chain storage condition performances in the study facilities were not acceptable. A significant number of PHFs were practicing undesirable storage conditions (55%). Similar report reported from Ethiopia that show inaccurate storage performance in the health facilities(27). The Cold chain medicine wastage indicates the inefficiency of logistics system management performance. The wastage rate of cold chain products were aggregated into good/low product wastage if the wastage rate is less than 25%, and poor/high wastage rate if the rate is more than 25% (27). In the study, the wastage rate of 16 health centers were more than 25% (80%). This showed that high products wastage was observed in the health centers this may be the temperature sensitivity attributed to frequent as erratic electric power supply, fueling and transport, which are necessary to ensure continuous running of cold chain equipment (49).
The multivariate logistic regression analysis revealed that, experience of respondents on cold chain management, product storage system and facility, distribution system and technical capacity of health facilities were found as significant associated factors (p < 0.05 at 95% CI) with operation performances of cold chain management. The experience level of health professionals on cold chain management showed that strong statistical association with cold chain management operation performance at their health facilities. Health workers who had more than three years work experience were about 6 times (AOR = 6.66, 95% CI: (1.29–34.36); p-value = 0.024) more likely operate the management of cold chain product and services in good manner as they compared with those who had less than or equal to three year’s work experience on cold chain management. This warranty work experience should be critical parameters in improvement of operational performance in effective cold chain management
Limitations and Opportunities for Future Investigation.
The study utilized a cross-sectional approach to gather a substantial amount of data in a short period. However, this method's limitations include the potential for different results compared to longitudinal studies. Furthermore, the use of questionnaires instead of interviews may have hindered the depth of responses. Expanding the study to various levels of cold chain management and including non-governmental health facilities could have yielded more insightful outcomes.
This study provides an opportunity for researchers and staff working in the cold chain sector to identify specific areas within the supply chain where inefficiencies may be occurring. By conducting a thorough analysis of the current processes and procedures, organizations can pinpoint areas for improvement and implement necessary measures to enhance operational efficiency. Furthermore, by continuously monitoring and evaluating the effectiveness of these measures, organizations can ensure that they are consistently improving their supply chain management practices to meet the demands of a rapidly changing industry. Ultimately, this research offers a valuable opportunity for organizations to stay competitive and meet the growing demands of the cold chain health sector.