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Supply Chain Management Design & Simulation Online

Supply Chain Case Studies

SCM Globe comes with a library of case studies that explore COMMERCIAL , HUMANITARIAN , and MILITARY supply chains. When you purchase an account you have access to all the case studies and their simulations.

The case studies range from relatively simple beginning cases like Cincinnati Seasonings , to quite challenging advanced cases such as Zara Clothing Company , or Nepal Earthquake Disaster Response .  Case studies are laboratories where you apply what you learn in lectures and readings to solve supply chain problems in highly realistic simulations. Each case has a " CASE STUDY CONCEPT " showing the supply chain principles and practices highlighted in that case.

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Case studies presently available in the online library are shown below. You are welcome to use any or all of them. You can also create your own case studies, or we can create them for you. Cases are shown in the three categories. As you work with these cases you will gain an intuitive understanding of supply chain dynamics, and develop the analytical skills for designing and managing real supply chains.

People new to SCM Globe should start with the  Cincinnati Seasonings case study . Work individually at first, not in groups. Each person needs their own account. Do the three challenges shown in the online introduction to Cincinnati Seasonings. That's how you'll learn to use the software, and how to use simulations to analyze and design supply chains. Then you will be ready to work in groups or work on more advanced cases.  Click on the case studies below to see a description and introduction to each case.

Commercial Supply Chain Case Studies

Collaborative Supply Chains

S&J Trading Company – Angola

Java Furniture Company – Indonesia

Cincinnati Seasonings

Supply Chains of the Roman Empire

Ancient Silk Road – First Global Supply Chain

Zara Clothing Company Supply Chain

Fantastic Corporation – Global Supply Chain

Fantastic Corporation – Unexpected Disruptions

Humanitarian supply chain case studies.

Disaster Response Supply Chains: Flooding Scenario

Nepal Earthquake Disaster Response Supply Chain

Humanitarian Supply Chains: Syria Evacuation Scenario (CIV and MIL)

Military supply chain case studies.

Burma Campaign – 1944 Invasion of India

Battle of Smolensk – 1941 Invasion of Russia

Alexander the Great Needed Great Supply Chains

New case studies.

New cases are added based on projects we do with instructors, students, and supply chain professionals. Here are the new supply chain models in the library:

• Local and Sustainable Supply Chains – Blue Ocean Cooperative
• Aerospace Manufacturing Cluster – Rockford IL
• Hyderabadi Biryani – Paramount Restaurant 
• Western Desert War – May 1941
• Russian Logistics for the Invasion of Ukraine

Interactive Supply Chain Case Studies

Every case study has a main theme or concept that it illustrates. You will be challenged to use knowledge acquired in lectures and readings as well as your own real-world experience to expand and re-design the supply chains in these case studies.

In the commercial supply chain cases you need to improve and expand the supply chains to support new stores and still keep operating costs and inventory as low as possible. In cases that deal with humanitarian or military missions you need to create supply chains to deliver the right supplies to the right locations when they are needed, and do so at a reasonable cost.

We are glad to provide a  free evaluation account  to instructors, students and supply chain professionals interested in exploring SCM Globe simulations — click here to request an account —  Get Your Free Trial Demo  

See SCM Globe pricing for Academic and Business versions of the software.

The best case to start with is Cincinnati Seasonings . After working through the three challenges presented in the online introduction to this case you will be ready to handle further challenges in this case or move on to more advanced cases. Get a quick introduction to working with case studies in “ Working with Case Studies “.

As problems are found in the simulations, you make decisions about how to fix them. Make changes to your supply chain model in the Edit screen. Then go to the Simulate screen and run a simulation to see the results of your changes. Depending on the changes you make, your supply chain simulation runs for additional days and other problems arise. As you address these problems you see about how supply chains work. Apply what you learn in readings and and lectures plus your work experience to solve the problems you encounter.

Keep improving your supply chain model until you get the simulation to run for 30+ days. Then download your simulation results and create a monthly Profit & Loss Report plus KPIs (as shown below). This provides an objective basis for evaluating the merits of different supply chain solutions.

Monthly Profit & Loss Reports identify areas for improvement. They help you improve your supply chain to keep it running for 30 days and also lower operating costs and inventory levels. You can work on lowering the carbon footprint of your supply chain too. These are the challenges you address in SCM Globe, and they are the same challenges people face when managing real supply chains. What works well in the simulations will also work well with actual supply chains. Skills you develop in working with the simulations are directly transferable to the real world.

NOTE: You can run simulations for longer than 30 – 60 days, but there is usually no reason to do so. This is because most companies do not run their supply chains unchanged for longer than 30 days at a time. They use a 30 day S&OP ( sales and operations planning ) cycle and these simulations correspond to that monthly S&OP cycle. These simulations focus on the tactical realities of operating a supply chain from one month to the next, and finding what works best.

Accessing the Online Library of Case Studies

As shown in the screenshots below, logon to your account and access the case study library from your Account Management screen. Click on the “View Library” button (arrow 1) in upper right corner of the Account Management screen. In the Library screen you see a list of available supply chain case studies; click “ Import ” to load a selected case study into your account; give the imported case a Name , and click “ My Account ” to go back to your Account Management screen.

You are welcome to import any or as many of the supply chain models in the library as you wish. Once you have a copy of a supply chain model in your own account you can make any changes you want to it.

In Account Management, you “ Create a New Supply Chain ” or work with an existing supply chain by clicking the “ Edit ” button (arrow 2) next to the existing supply chain you want to work on. You can also upload copies of supply chain models sent to you by other SCM Globe users (arrow 3) , and check your account expiration date (arrow 4) .

Use the Default Values or Enter New Data

When you load any of the case study supply chain models from the SCM Globe library, they come with default numbers already plugged in. You can either accept the defaults or do some research to find more current data. This data (like data and prices everywhere) changes all the time.

Look for data on products, facilities and vehicles that are used in your supply chain and see what their specifications and costs are. Costs can vary widely in different parts of the world. Go to websites of commercial real estate brokers in cities of interest and see what you can find out about rent costs:

• for cities in North America start with www.cityfeet.com
• and for cities in other parts of the world start with  www.knightfrank.com

Metric System of Weights and Measures

In the case studies all weights, volumes, distances and speeds are expressed using the metric system. The metric system is used around the world in every country except three: Liberia; Myanmar; and the United States. So it is good for supply chain professionals to feel comfortable with the metric system.

Register on SCM Globe for Access to all Supply Chain Simulations

Click the blue "Register" button on the app login page, and buy an account with a credit card or PayPal (unless you already have one). Then scan the "Getting Started" section, and you are ready to start. Go to the SCM Globe library and click "Import" next to the supply chain models you want.

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By Supplychainopz

Professionals in supply chain management use various methods to determine how to improve the performance of supply chain operations. Analysis of case study is certainly one of the most popular methods for people from business management background. In order to accelerate the learning, this article has gathered 20+ most sought-after supply chain case studies, analyzed/categorized them by industry and the findings are presented.

Boeing wants to encourage more flight frequency and direct route using a smaller capacity aircraft. Then they decide to outsource many things such as the design, testing and production of key components to key industrial partners and try to reduce number of components that go to assembly. The ultimate goal is to finish the final production process within 3 days. Airbus takes a bit different marketing approach. They want to utilize high capacity airplane to help airlines drive the operating cost down. They decide to selectively outsource the production of parts and keep the design and production of key components in-house.

Supply Chain of fashion industry involves a time based competition. Many customers have the unique product needs but a competition is very fierce because of the low barriers of entry. Many new players try to offer specialized products to customers all the time. This section features the supply chain case studies of H&M, Benetton, Zara and Adidas. –  H&M  aims to be the price leader in the fashion market.In order to materialize its vision, H&M tries to eliminate the middlemen in various stages of supply chain and consolidate the buying volumes. Product design is also the central part of its strategies. They don’t try to follow the high fashion designs but try to adopt the street trends which are easier to produce. At the end of the day, they can bring products to market within 2-3 weeks. –  Benetton , in contrast, chooses to have a full control of its production but allow its licensees to operate the stores so they can focus on production and quality control. The reason is that they would like to create the worldwide brand awareness. For fast moving products, they use the production facilities in Europe. Asian suppliers will perform production for standardized products. –  Zara  is very famous for its time based strategy. In order to launch a new product within 15 days, Zara uses a small lot production. A new product will be tested in pilot stores. If product sales is good, a larger batch will be ordered. Otherwise, remaining products will be removed from the shelves and sold as mark-down in other stores. This creates the perception among consumers that Zara’s products are unique and you have to take it while stock lasts. Vertical integration contributes to the success of Zara, they own the majority of its production facilities and stores (this is the reason why Quick Response can be effectively implemented). Its automated distribution centers are strategically located between the center of populations so products are delivered to stores quickly. Zara also works with Air France, KLM Cargo and Emirates Air in order that they can coordinate directly with the airlines to make the outbound shipments to its stores and bring back some raw materials and semi-finished materials with return legs. The last supply chain case study in the fashion retailing industry is  Adidas . In order to cope with changing customers’ demand, they decide to undertake Mass Customization strategy. The whole idea is to develop, market and deliver the product variety that most customers will find what they want. The first steps towards mass customization is to strategically offer the product choices. Too few variations will disappoint a customer but too many variations will simply postpone a buying decision. After that, Adidas asks the same key suppliers to produce custom components in order to achieve the economy of scale. In order to compensate a long waiting time, Adidas uses air freight or courier service. The reason why they can do this is that customized products are sold directly to customers so they have the higher profit margin to compensate the higher transportation cost. Supply chain strategy of the fashion retailing industry is summarized as below,

FMCG industry is typically the products sold to customers at a low cost and will be completely consumed within 1 year. The nature of this industry is the short product life cycle, low profit margin, high competition and demand fluctuation. This section will present the case studies of P&G, Unilever and Coca-Cola respectively. Forecasting and new product introduction has always been the issues for many FMCG companies,  P&G  is no exception. To cope with this, P&G conducts a merchandise testing at the pilot stores to determine the customer’s response to new product before the launch. The result is that the forecast accuracy is improved because a demand planner has an additional source data to make a better decision. Moreover, products can be shipped to stores in-time then lost sales is minimal. –  Unilever  also feels that the competition in FMCG industry has significantly increased. They have to launch the new products on regular basis but the forecasting of new product is difficult. So they create a better classification of new products (base, relaunch, repack, new) using a regression model to identify potential forecast errors for each type of new product. –  Coca-Cola  doesn’t really have many stock keep units when compared with other companies in the same industry. However, products go to over 2.4 million delivery points through over 430 distribution centers. Managing transportation at this scale is the absolute challenge. In order to streamline the delivery, Coca-Cola implemented a vehicle routing software. The reason is that is the software vendor has a very good relationship with Coca-Cola’s legacy ERP software vendor. Moreover, the vendor has a solid connection with the university who can help to develop the algorithm that fits in with the business’ needs. The result is that transportation planners at each distribution center can use the new tool to reduce travelling time/distance on daily basis.

Lean manufacturing concept has been implemented widely in the automotive industry so the case studies about lean manufacturing is very readily available. Due to the increasing competition in the automobile industry, car manufacturers have to launch a new model to the market more frequently. This section will show you how BMW manages a long term planning, how Ford applies lean concept to the new product development and how Hyundai manages the production planning and control. –  BMW  uses a 12-year planning horizon and divides it into an annual period. After that, they will make an annual sales forecast for the whole planning horizon. After the demand is obtained, they divide sales into 8 market and then select the appropriate production sites for each market, considering overall capacity constraints and total cost. As you may notice, this kind of a long range planning has to be done strategically. –  Ford  calls its product development system as “work streams” which include the body development, engine development, prototyping and launch process . The cross-functional team are the experts and their roles are to identify key processes, people, technology necessary for the development of new prototype. Each work stream team is responsible to develop timeline of each process. Detailed plan is usually presented on A3 sized paper. They clearly identifying current issues they are facing with supporting data, drawings and pictures. On weekly basis, they organize a big group meeting of all work stream team to discuss the coordination issues. –  Hyundai  deploys a centralized planning system covering both production and sales activities across the facilities and functional areas. They develop a 6-month master production plan and a weekly and a daily production schedule for each month in advance. During a short term planning (less than one month), they pay much attention to the coordination between purchasing, production and sales. Providing a long term planning data to its suppliers help to stabilize production of its part makers a lot.

Life cycle of technology products is getting shorter and shorter every day. Unlike FMCG, the launch of a new product in the hi-tech industry requires the investment in research and development quite extensively. Then, a poor planning will result in a massive loss. This section will cover JIT and outsourcing by Apple Inc, Supply Chain Risk Management by Cisco System, Technology Roadmap by Intel, Supply Chain Network Model by HP, Mass Customization by Dell and Quality Management by Sam Sung. Steve Jobs invited the Tim Cook to help to improve  Apple’s Supply Chain  in 1998. Jobs told Cook that he visited many manufacturing companies in Japan and he would like Cook to implement the JIT system for Apple. Jobs believed that Apple’ supply chain was too complex then both of them reduced the number of product availability and created 4 products segment, reduced on hand inventory and moved the assembling activities to Asia so they could focus on developing the breathtaking products that people wanted to buy. –  Cisco Systems  would like to be the brand of customer choice so they implement a very comprehensive supply chain risk management program by applying basic risk mitigation strategies, establishing appropriate metrics, monitoring potential supply chain disruptions on 24/7 basis and activate an incident management team when the level of disruption is significant. –  Intel ‘s new product development is done by the process called Technology Roadmap. Basically, it’s the shared expectations among Intel, its customers and suppliers for the future product lineup. The first step to prepare the roadmap is to identify the expectations among semiconductor companies and suppliers. Then they identify key technological requirements needed to fulfill the expectations. The final step is to propose the plan to a final meeting to discuss about the feasibility of project. Some concerning parties such as downstream firms may try to alter some aspects of the roadmap. Technology Roadmap allows Intel to share its vision to its ecosystem and to utilize new technology from its suppliers. –  HP ‘s case study is pretty unique. They face with a basic question, where to produce, localize and distribute products. Its simple supply chain network model is presented below,

From this example, only 3 possible locations result in 5 different way to design the supply chain. In reality, HP has more production facilities than the example above so there are so many scenarios to work with. How should HP decide which kind of a supply chain network configuration they should take to reduce cost and increase service to customer? The answer is that they use the multi-echelon inventory model to solve the problem. –  Dell  is one of the classic supply chain case studies of all time. Many industries try to imitate Dell’s success. The key ingredients of Dell’s supply chain are the partnership with suppliers, part modularity, vendor managed inventory program, demand management and mass customization. Also, you can find the simplified process map of Dell’s order-to-cash process as below,

–  Sam Sung  has proven to be the force to be reckoned with in the hi-tech industry. The secret behind its supply chain success is the use of Six Sigma approach. They studied how General Electric (GE), DuPont and Honeywell implemented six sigma. After that, they have created their own implementation methodology called DMAEV (define, measure, analyze, enable, verify). They use the global level KPI to ensure that each player in the same supply chain is measured the same way. Also, they utilize SCOR Model as the standard process. Any process changes will be reflected through an advance planning system (APS).

The last industry covered here is the general merchandise retailing industry. The critical success factor of this industry is to understand the drivers of consumer demand. Four case studies will be presented, namely, 7-11, Tesco, Walmart, Amazon and Zappos. –  7/11  is another popular case study in supply chain management. The integration of information technology between stores and its distribution centers play the important role. Since the size of 7/11 store is pretty small, it’s crucial that a store manager knows what kind of products should be displayed on shelves to maximize the revenue. This is achieved through the monitoring of sales data every morning. Sales data enables the company to create the right product mix and the new products on regular basis. 7/11 also uses something called combined delivery system aka cross docking. The products are categorized by the temperature (frozen, chilled, room temperature and warm foods). Each truck routes to multiple stores during off-peak time to avoid the traffic congestion and reduce the problems with loading/unloading at stores. –  Tesco  is one of the prominent retail stores  in Europe. Since UK is relatively small when compared with the United States, centralized control of distribution operations and warehouse makes it easier to manage. They use the bigger trucks (with special compartments for multi-temperature products) and make a less frequent delivery to reduce transportation cost. Definitely, they use a computerized systems and electronic data interchange to connect the stores and the central processing system. –  Wal-Mart ‘s “Every Day Low Prices” is the strategy mentioned in many textbooks. The idea is to try not to make the promotions that make the demand plunges and surges aka bullwhip effect. Wal-Mart has less than 100 distribution centers in total and each one serves a particular market. To make a decision about new DC location, Walmart uses 2 main factors, namely, the demand in the proposed DC area and the outbound logistics cost from DC to stores. Cost of inbound logistics is not taken into account. There are 3 types of the replenishment process in Wal-Mart supply chain network as below,

In contrary to general belief, Wal-mart doesn’t use cross-docking that often. About 20% of orders are direct-to-store (for example, dog food products). Another 80% of orders are handled by both warehouse and cross dock system. Wal-Mart has one of the largest private fleet in the United States. The delivery is made 50% by common carriers and 50% by private fleet. Private fleet is used to perform the backhauls (picks up cargoes from vendors to replenish DCs + sends returned products to vendors). Short-hauls (less than one working day drive) is also done by the a private fleet. For long-hauls, the common carriers will be used. There are 2 main information system deployed by Wal-Mart. “Retail Link” is the communication system developed in-house to store data, share data and help with the shipment routing assignments. Another system is called “Inforem” for the automation of a replenishment process. Inforem was originally developed by IBM and has been modified extensively by Wal-Mart. Inforem uses various factors such as POS data, current stock level and so on to suggest the order quantity many times a week. Level of collaboration between Wal-Mart and vendors is different from one vendor to the other. Some vendors can participate in VMI program but the level of information sharing is also different. VMI program at Wal-Mart is not 100% on consignment basis. –  Amazon  has a very grand business strategy to “ offer customers low prices, convenience, and a wide selection of merchandise “. Due to the lack of actual store front, the locations of warehouse facilities are strategically important to the company. Amazon makes a facility locations decision based on the distance to demand areas and tax implications. With 170 million items of physical products in the virtual stores, the back end of order processing and fulfillment is a bit complicated. Anyway, a simplified version of the order-to-cash process are illustrated as below,

Upon receipt of the orders, Amazon assign the orders to an appropriate DC with the lowest outbound logistics cost. In Amazon’s warehouse, there are 5 types of storage areas. Library Prime Storage is the area dedicated for book/magazine. Case Flow Prime Storage is for the products with a broken case and high demand. Pallet Prime Storage is for the products with a full case and high demand. Random Storage is for the smaller items with a moderate demand and Reserve Storage will be used for the low demand/irregular shaped products. Amazon uses an propitiatory warehouse management system to make the putaway decision and order picking decision. After the orders are picked and packed, Amazon ships the orders using common carriers so they can obtain the economy of scale. Orders will arrive at UPS facility near a delivery point and UPS will perform the last mile delivery to customers. Amazon is known to use Sales and Operations Planning (S&OP) to handle the sales forecast. Anyway, this must be S&OP process at product family/category level. To compete with other online retailers,  Zappos  pays much attention to the way they provide the services to customers. In stead of focusing on the call center productivity, Zappos encourages its staff to spend times over the phone with customers as long as they can so they can fully understand the customer’s requirements. They also upgrade the delivery from 3 days to 1 day delivery in order to exceed customer expectation.

All case study demonstrates that supply chain management is truly the strategic initiatives, not merely a cost cutting technique. Leading companies have a very strong customer focus because almost all of initiatives are something to fill the needs of customers. Relationship management is the unsung hero in supply chain management. It’s the prerequisite to the success of every supply chain. And at the end of the day, it comes down to the quality of supply chain people who analyze, improve and control supply chain operations. – See more at: http://www.supplychainopz.com/2014/04/supply-chain-management-case-study.html#sthash.MrnrGsyY.dpuf

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Case Study: How Should We Diversify Our Supply Chain?

• Krishna G. Palepu

A Chinese appliance maker considers expanding production to Mexico.

In the wake of Covid-19’s disruptions, Kshore, a Chinese appliance maker, is thinking of realigning its supply chain. Like many other global manufacturers, it’s being pressured by its customers, which include Walmart and other large retailers, to reduce the time, expense, and environmental impact of shipping goods between countries.

On a trip to Monterrey, Mexico, Kshore’s CEO and COO tour factories that are closer to North American markets—and are impressed by their professionalism. But questions about transportation and staffing give the executives pause. Should Kshore start production in Mexico or consider other countries? Two experts weigh in.

On the sidewalk outside the airport in Mexico City, Yun Liu and Keith Smith, the CEO and COO of Kshore, a Chinese appliance maker with $150 million in annual revenues, waited for their town car. Their journey from Guangzhou, China, had been a long one.

• Krishna G. Palepu is the Ross Graham Walker Professor of Business Administration at Harvard Business School. His research focuses on globalization, emerging markets, and strategies for multinational and local companies in those markets. He cochairs the HBS executive program Leading Global Businesses.

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Walmart: Supply Chain Management

By: P. Fraser Johnson, Ken Mark

This case focuses on the supply chain strategy of Walmart. Set in 2019, it provides a detailed description of the company's supply chain network and capabilities. Data in the case allows students to…

• Length: 16 page(s)
• Publication Date: Jul 8, 2019
• Discipline: Operations Management
• Product #: W19317-PDF-ENG

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This case focuses on the supply chain strategy of Walmart. Set in 2019, it provides a detailed description of the company's supply chain network and capabilities. Data in the case allows students to compare Walmart's source of competitiveness with those of other retailers-both online including Amazon.com and traditional brick-and-mortar retailers, such as Target-to develop insights into the management of a large, complex, global supply chain network. As competition between Walmart and its online and offline competitors heated up, a key challenge for the company's president and chief executive officer was deciding what changes made to Walmart's expanding supply chain would best support its strategic objectives. What supply chain capabilities would Walmart need as its business model continued to evolve?

Learning Objectives

This case can be used in an undergraduate or MBA course in supply chain management, operations management, business strategy, international business, logistics, purchasing, or marketing. It can provide an introduction to supply chain management using a company with which most students are familiar. In doing so, it allows students to learn how Walmart has built up its supply chain capabilities over the past five decades, and how the company leveraged these capabilities to become the world's largest retailer. Combining the Walmart case with the "Amazon.com: Supply Chain Management" case (W18451) in back-to-back classes provides a powerful illustration of the differences between two leading companies and demonstrates the importance of alignment of supply chain competencies with organizational strategy. After completion of this case, students will be able to: Assess Walmart's supply chain and identify its key competitive advantages. Quantify Walmart's ability to generate value from its supply chain. Identify potential opportunities and challenges for Walmart to improve its supply chain. Analyze the effects of the opportunities and challenges facing Walmart on its growth and evolution.

Jul 8, 2019 (Revised: Sep 9, 2019)

Discipline:

Operations Management

Geographies:

United States

Industries:

Retail trade

Ivey Publishing

W19317-PDF-ENG

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Big data and the supply chain: The big-supply-chain analytics landscape (Part 1)

Big data and the era of digital means a big analytics landscape for supply chain to work with.

Your supply chains generate big data. Big supply-chain analytics turn that data into real insights.

The explosive impact of e-commerce on traditional brick and mortar retailers is just one notable example of the data-driven revolution that is sweeping many industries and business functions today. Few companies, however, have been able to apply to the same degree the "big analytics" techniques that could transform the way they define and manage their supply chains.

In our view, the full impact of big data in the supply chain is restrained by two major challenges. First, there is a lack of capabilities. Supply chain managers—even those with a high degree of technical skill—have little or no experience with the data analysis techniques used by data scientists. As a result, they often lack the vision to see what might be possible with big data analytics. Second (and perhaps more significantly), most companies lack a structured process to explore, evaluate and capture big data opportunities in their supply chains.

In the second part of this article series, we will show how companies can take control of the big data opportunity with a systematic approach. Here, we will look at the nature of that opportunity and at how some companies have managed to embed data driven methodologies into their DNA. Exhibit 1 provides an overview of the landscape of supply chain analytics opportunities.

What is big supply-chain analytics?

Big supply chain analytics uses data and quantitative methods to improve decision making for all activities across the supply chain. In particular, it does two new things. First, it expands the dataset for analysis beyond the traditional internal data held on Enterprise Resource Planning (ERP) and supply chain management (SCM) systems. Second, it applies powerful statistical methods to both new and existing data sources. This creates new insights that help improve supply chain decision-making, all the way from the improvement of front-line operations, to strategic choices, such as the selection of the right supply chain operating models.

Let's look at each main area in turn.

A. Sales, Inventory and Operations Planning

Typically, planning is already the most data-driven process in the supply chain, using a wide range of inputs from Enterprise Resource Planning (ERP) and SCM planning tools. There is now significant potential to truly redefine the planning process, however, using new internal and external data sources to make real-time demand and supply shaping a reality.

We can think about managing inventory in a supply chain similar to the way electricity is managed: Storing electricity is expensive and difficult; power companies bring in additional consumers or start and stop plants to ensure a balanced power grid. Retailers now have the opportunity to use a similar approach. Visibility of point of sale (POS) data, inventory data, and production volumes can be analyzed in real time to identify mismatches between supply and demand. These can then drive actions, like price changes, the timing of promotions or the addition of new lines, to realign things.

Retailers can also use new data sources to improve planning processes and their demand-sensing capabilities. For example, Blue Yonder has developed data intensive forecasting methods now deployed into retailing where 130,000 SKUs and 200 influencing variables generate 150,000,000 probability distributions every day. This has dramatically increased forecast accuracy; enabled a better view of the company's logistics capacity needs; and reduced obsolescence, inventory levels, and stockouts. The recent growth of third party cloud-based services like Blue Yonder is making such activities more accessible for other retailers, too.

Similarly, IBM has helped develop links between production planning and weather forecasts for bakeries. By incorporating temperature and sunshine data, baking companies are able to more accurately predict demand for different product categories based on factors that influence consumer preferences. Amazon, meanwhile, has patented an "anticipatory shipping" approach, in which orders are packaged and pushed into the delivery network before customers have actually ordered them.

Having truly mastered big-data forecasting, the next level of sophistication is to start actively shaping demand. Leading online retailers, for example, use big data analytics, inventory data, and forecasting to change the products recommended to customers. This effectively steers demand towards items that are available in stock.

B. Sourcing

In many companies, data on procurement volumes and suppliers are only gathered for few activities in the sourcing process. However, supply data goes beyond the classic spend analysis and annual supplier performance review. On a transactional basis, supply processes can be sensed in real time to identify deviations from normal delivery patterns. Firms are also finding opportunities for predictive risk management. By mapping its supply chains and using "Google trend"-style information and social data about strikes, fires, or bankruptcies, a firm can monitor supply disruptions in transportation, or at 2nd or 3rd tier suppliers, and take decisive actions before its competitors.

Data analysis can also drive strategic decisions. In recent years, one pharmaceutical company has created a database with all bids submitted for packaging. The data has been evaluated to fully understand the cost structure of those suppliers and to create detailed cost models for different types of packaging. Using updated information on commodity prices, factor costs, and plant utilization, these models can be used to aid the selection of the most appropriate suppliers for new packaging projects. Similarly, Caterpillar has initiated a contest on the crowd-data science website Kaggle to model quoted prices for industrial tube assemblies.

These "clean sheet costing" bottom-up calculations can also be applied in the purchase of transportation and warehousing. By exploiting data on the cost breakdown of operations of trucks and warehouses across the globe, companies do create a powerful fact base to challenge carriers and Logistics Solution Providers (LSPs), and provide real insight into "should cost" during negotiations.

C. Manufacturing

Big data and analytics can already help improve manufacturing. For example, energy-intensive production runs can be scheduled to take advantage of fluctuating electricity prices. Data on manufacturing parameters, like the forces used in assembly operations or dimensional differences between parts, can be archived and analyzed to support the root-cause analysis of defects, even if they occur years later. Agricultural seed processors and manufacturers analyze the quality of their products with different types of cameras in real-time to get the quality assessments for each individual seed.

The Internet of Things, with its networks of cameras and sensors on millions of devices, may enable other manufacturing opportunities in the future. Ultimately, live information on a machine's condition could trigger production of a 3D-printed spare part that is then shipped by a drone to the plant to meet an engineer, who may use augmented reality glasses for guidance while replacing the part.

D. Warehousing

Logistics has traditionally been very cost-focused, and companies have happily invested in technologies that provide competitive advantage. Warehousing in particular has seen many advances using available ERP data. One example are "chaotic" storage approaches that enable the efficient use of warehouse space and minimize travel distances for personnel. Another are high-rack bay warehouses that can automatically reshuffle pallets at night to optimize schedules for the next day. Companies can track the performance of pickers in different picking areas to optimize future staff allocation.

New technologies, data sources and analytical techniques are also creating new opportunities in warehousing. A leading forklift provider is looking into how the forklift truck can act as a big data hub that collects all sorts of data in real time, which can then be blended with ERP and Warehouse Management System (WMS) data to identify additional waste in the warehouse process. For example, the analysis of video images collected by automated guided vehicles, along with sensor inputs including temperature, shelf weight, and the weight on the forklift, can be used to monitor picking accuracy, warehouse productivity and inventory accuracy in real time. Similarly forklift driving behavior and route choices can be assessed and dynamically optimized to drive picking productivity. The data can also be used to conduct root-cause analysis of picking errors by shape, color, or weight, to help to make processes more robust.

New 3D modelling technologies can also help to optimize warehouse design and simulate new configurations of existing warehouse space to further improve storage efficiency and picking productivity. German company Logivations, for example, offers a cloud-based 3D warehouse layout planning and optimization tool.

E. Transportation

Truck companies already make use of analytics to improve their operations. For example, they use fuel consumption analytics to improve driving efficiency; and they use GPS technologies to reduce waiting times by allocating warehouse bays in real time.

Courier companies have started real-time routing of deliveries to customers based on their truck's geo-location and traffic data. UPS, for example has spent ten years developing its On-Road Integrated Optimization and Navigation system (Orion) to optimize the 55,000 routes in the network. The company's CEO David Abney says the new system will save the company $300 million to $400 million a year.

Big analytics will also enable logistics providers to deliver parcels with fewer delivery attempts, by allowing them to mine their data to predict when a particular customer is more likely to be at home. On a more strategic basis, companies can cut costs and carbon emissions by selecting the right transport modes. A major CPG player is investing in analytics that will help it to understand when goods need be shipped rapidly by truck or when there is time for slower barge or train delivery.

F. Point of Sale

Brick and mortar retailers—often under heavy pressure from online competitors that have mastered analytics—have understood how datadriven optimization can provide them with competitive advantages. These techniques are being used today for activities like shelf-space optimization and mark-down pricing. Advanced analytics can also help retailers decide which products to put in high value locations, like aisle ends, and how long to keep them there. It can also enable them to explore the sales benefits achieved by clustering related products together.

Search engine giant Google has acquired Skybox, a provider of highresolution satellite imagery, that can be used to track cars in the car park in order to anticipate in-store demand. Others have explored the use of drones equipped with cameras to monitor on-shelf inventory levels.

A topic that is still a challenge for many retailers is out-of-stock detection and prevention. In developed markets, manual inspections are expensive, while RFID tags still cost too much to be applied to individual grocery items. Instead, retailers are now monitoring sales activity for out of stock indicators. If an item that usually sold every few minutes does not appear at the tills, an alert is triggered to have person check if the item is out of stock at the shelf. Other innovative technologies are also being tested, including the installation of light or weight sensors on shelves as well as the use of in-store cameras to monitor on-shelf stock levels.

Similar technologies can be applied directly at the point of use. Amazon's Dash service, for example provides consumers with wireless buttons that can be used to reorder domestic products with a single push, like washing powder or razor blades. Ultimately, stores may be able to link to data gathered from consumer's Internet-connected refrigerators to forecast demand in real time.

As the examples in this article show, big data is already helping leading organizations transform the performance of their supply chains. Today, such approaches are the exception rather than the norm, however. Lack of capabilities and the lack of a structured approach to supply chain big data is holding many companies back. For big data and advanced analytical tools to deliver greater benefits for more companies, those organizations need a more systematic approach to their adoption. Part 2 of this series will address that topic in detail.

About the authors: Knut Alicke is a master expert in the Stuttgart office, Christoph Glatzel is a director in the Cologne office, and Per-Magnus Karlsson is a consultant in the Stockholm office. Kai Hoberg is an associate professor of supply chain and operations strategy at Kühne Logistics University, Germany.

Supply Chain Analysis: Data Analysis Case Study Using Excel

A supply chain analysis project using microsoft excel and microsoft power bi..

Supply chain analytics plays a crucial role in driving data-driven decision-making across industries, including manufacturing, retail, healthcare, and logistics. In this report, I presented an analysis of a Fashion and Beauty startup’s supply chain data, specifically focused on the movement of makeup products. By collecting, analyzing, and interpreting this dataset, I aim to gain insights that can inform strategic decisions and optimize supply chain operations.

Dataset Overview

The dataset comprises various features related to the fashion and makeup product supply chain. These features provide valuable information for understanding the flow of products from suppliers to customers. The following features include:

Product Type

Availability

Number of products sold

Revenue generated

Customer demographics

Stock levels

Order quantities

Shipping times

Shipping carriers

Shipping costs

Supplier name

Production volumes

Manufacturing lead time

Manufacturing costs

Inspection results

Defect rates

Transportation modes

Supply Chain Analysis using Excel

The supply chain represents a network of interconnected processes involved in the production and delivery of goods to customers. Analyzing the various components of a supply chain is crucial for identifying opportunities to enhance its effectiveness and generate greater value for customers. In this report, I conducted a supply chain analysis using Excel and gave valuable insights into optimizing supply chain operations.

Dataset Source

To perform a supply chain analysis on this company, it is crucial to gather data related to various stages of the supply chain. This includes information on sourcing, manufacturing, transportation, inventory management, sales, and customer demographics.

Fortunately, I have come across this excellent dataset that provides comprehensive data about the supply chain of a Fashion and Beauty startup.

In the following section, I will guide you through the process I use to conduct a supply chain analysis using Excel.

Dataset from Github

Dataset Analysis using Excel

The first step is to import the file into Excel.

After importing the file, the next task is to remove any duplicate entries. To do this, I selected all the data by clicking on cell A1 and then pressed Ctrl+A. Then click on the “Data” tab and choose “Remove Duplicates” under the “Data Tools” section. Once duplicates are removed, the next step is to filter the data to identify any spelling errors or unwanted names. To do this, I can click on the “Filter” tool under the “Sort & Filter” section. While filtering, I noticed that some entries under the “Customer Demographics” category are labelled as “Unknown” instead of specific demographics like Male, Female or Non-Binary. Since I won’t be using this data, I proceeded with the existing information. At this stage, the data cleaning process is considered complete, and I have moved on to the next steps.

To facilitate further analysis, I converted the data into a table. I achieved this by selecting the entire data range (Ctrl+A) and then pressing Ctrl+T to convert it into a table. The next step is to create a pivot table. Navigated to the “Insert” tab and select the “PivotTable” tool. Choose the location for the pivot table (such as a new worksheet) and specify the data range (Table 1 or the relevant table name). Once the pivot table was created, I formatted the numbers to display as whole numbers and removed any decimal places for better readability.

A. Now, I’m ready to analyze the data and provide insights based on the following requirements or objectives.

I begin the analysis of the Supply Chain by examining the correlation between product prices and the corresponding revenue they generate.

Therefore, the company generates a higher revenue from skincare products, and there is a positive relationship between the price of skincare products and the revenue they generate.

B. Now, I examined the sales based on different product types.

Skincare products account for 45% of the company’s business, while haircare products contribute to 29.5% of the revenue, and cosmetics make up 25.5% of the total sales.

C. Now, I analyzed the total revenue generated from shipping carriers.

The company utilizes three shipping carriers for transportation, and among them, Carrier B contributes significantly to the company’s revenue generation.

D. Now, I examined the average lead time and average manufacturing costs for all products of the company.

Analyzing SKUs

In the dataset, there is a column labelled SKUs, which stands for Stock Keeping Units. SKUs are unique codes assigned to products to facilitate inventory management and tracking. They serve as a means to identify and differentiate individual items, ensuring accurate monitoring of stock levels. For instance, in a toy store with a diverse range of toys, each toy would be assigned a unique SKU as a secret number known only to the store, enabling efficient inventory control.

A. Now, I analyzed the revenue generated by each SKU.

Another column in the dataset is labelled Stock levels. Stock levels indicate the quantity of products available in a store or business’s inventory at a given time

B. Now, I examined the stock levels of each SKU.

C. Now, I analyzed the order quantity of each SKU.

Cost Analysis

A. Now, I analyzed the shipping costs associated with different carriers.

The above visualizations revealed that Carrier B contributes significantly to the company’s revenue. However, it is also the most expensive carrier among the three options.

B. Now, I examined the distribution of costs by transportation mode.

The company allocates a larger portion of its transportation expenses to the Road and Rail modes for the transportation of goods.

Analyzing Defect Rate

The defect rate in the supply chain refers to the percentage of products that are found to have issues or are damaged after being shipped.

A. Now, I analyzed the average defect rate across all product types.

Haircare products have a higher defect rate compared to other product types.

B. Now, I examined the defect rates based on the mode of transportation.

Road transportation exhibits a higher defect rate, while Air transportation demonstrates the lowest defect rate. This showcases how Excel programming language can be utilized to analyze a company’s supply chain.

I successfully created a dashboard using Power BI that presents the insights mentioned earlier. The dashboard effectively highlights essential revenue-related information, including:

1. Revenue generated from each supplier. 2. Revenue generated from each location. 3. Revenue generated from each company product. 4. Total products delivered by each carrier.

These insightful visualizations offer valuable data-driven perspectives, enabling informed decision-making and strategic planning.

Supply Chain Analysis involves examining different aspects of a supply chain to identify areas for improvement and enhance the overall efficiency of the supply chain, ultimately delivering greater value to customers. This report provided an overview of conducting a supply chain analysis using Excel, highlighting key steps and techniques and revenue generated.

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Creating an omnichannel supply chain: a macy’s case study.

In February 2020, Macy’s announced their Polaris plan , a three-year strategy created to stabilize profits and create growth. This plan included closing 125 underperforming stores and consolidating offices. It also included a major overhaul of their supply chain model.

But, of course, Macy’s had to close their doors less than 6 weeks later due to COVID-19. As their online presence was the only presence available, their longstanding supply chain strategy, which was already starting to cause major issues within the company, needed immediate attention.

Macy’s CEO Jeff Gennette stated in September 2020, “Everything on the digital agenda has been accelerated. We’re optimizing inventory placement to meet customer demand wherever and however they shop in our store.”

What’s so bad about Macy’s supply chain model?

Customers expect a strong omnichannel experience — one that integrates both the online and offline world of the retailer, enabling a frictionless shopping experience.

For retailers, the goal is to take the retailer’s replenishment cycle from days to hours and reduce inventory at stores. This way, retailers expand their use of stores to fulfil online orders and hold less inventory altogether, allowing them to dedicate more room for digital fulfillment.

Omnichannel shopping is the baseline expectation for customers, as companies such as Gap, Target, and many others have upped their omnichannel game.

And Macy’s is, er, behind.

Macy’s way of viewing their supply chain in the past was traditional: Move products from point A to point B and optimize costs at each stop along the way. Each delivery channel has its own transportation plan and technology stack, siloing all distribution and fulfillment centers.

This supply chain method was acceptable 10 years ago, but to stay afloat in the in-store and online retail spaces, Macy’s needed to make a change. Silos created major cost issues, not to mention slow speed and service in today’s two-day-delivery age.

The company’s supply chain model operated two separate warehouse networks, one for stores and the other for direct customer (online) orders. This system made rebalancing inventory nearly impossible, among other issues.

Macy’s supply chain also lacked a central platform for locating inventory at the SKU level across the chain, and the cost of goods were high compared to competitors since each private brand sold at May’s was sourced independently.

Creating a better supply chain

In 2019 Macy’s hired Dennis Mullahy , the first ever Chief Supply Chain Officer, to transform the supply chain into one that supports an omnichannel strategy.

Since then, Macy’s has made leaps and bounds in optimizing their supply flow, with COVID expediting the process.

The company is transitioning to a centralized warehouse model, implementing a flow and fold design, meaning a light initial allocation to stores and flexible replenishments. Multipurpose warehouses hold inventory, which can both replenish stores and fulfill e-commerce orders.

By having a centralized inventory, the retailer is better able to strengthen its margins and fulfill orders quicker and in the ways customers want.

“Our new model will leverage all of our assets much more productively and improve customer satisfaction by increasing speed of delivery as well as generate efficiencies in our operations and inventory utilization.” Dennis Mullahy wrote.

In addition, Macy’s is getting on board with using data and analytics to not only get items to customers faster, but also improve inventory forecasting and allocation and package consolidation.

The company plans to increase drop-shipping to boost margins in e-commerce, where delivery costs have been the largest drain on profits. They’ll also renew their efforts into Macy’s Backstage operations in order to compete with other off-price companies such as Nordstrom Rack and TJMaxx.

Behind the curve

And while these improvements are giving Macy’s the help it needs, they should’ve seen the warning signs sooner. Retailers of equal size have been making moves to change their supply chain for years now, and Macy’s is just catching up.

For example, Kohls has been working to integrate e-commerce and brick and mortar stores since the beginning of 2018. The company worked to change its purchase and inventory management system by starting with the smallest stores and working their way up.

Nordstrom has been working on omnichannel fulfillment for over 3 years, and brought in tech consulting firm Opex Analytics to help.

Walmart unveiled plans this month to install a high-tech automation system across 25 Walmart regional distribution centers through their partnership with Symbotic, a robotics and automation company — something they’ve been working toward since 2017. This system will digitize and modernize Walmart’s current supply chain facilities to enrich customer experience and support evolving demand.

But even though Macy’s may be a few steps behind, true omnichannel is a journey — and a difficult one at that. It requires a lot from the supply chain, especially in terms of speed, complexity, and efficiency. The global retailer is making strides in executing their Polaris plan by focusing more on the integrated fulfillment strategy and alternative fulfillment options and listening to what their customers want.  

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Supply Chain Management—A Case Study of Huawei’s Supply-Chain Chip Shortage

• Conference paper
• First Online: 08 October 2023
• Cite this conference paper

• Jiangke Chen 7  

Part of the book series: Applied Economics and Policy Studies ((AEPS))

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• International Conference on Business and Policy Studies

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Today’s business environment is more competitive and complex. Decreased trade barriers and more developed countries promoting businesses bring more businesses into the market. There is also more competition among organizations because businesses are introducing newer and cheaper innovations at a faster rate Innovation in organizational processes can make significant changes in the product output. Supply chain management is a potential area for technological innovations. Therefore, this paper will focus on the extent to which automation technology and blockchain technology support modern supply chains, and take Huawei as an example to study how Huawei’s global supply chain provides it with a competitive advantage. And makes a study on the current supply chain dilemma faced by Huawei and puts forward feasible solutions. The study found that automation can benefit enterprises by achieving faster and more efficient operations in inventory management and warehouse management. However, enterprises also need to be aware of the high cost of using automation. Blockchain technology can improve supply chain stability and security through smart contracts and shared ledger management. But there are also problems, such as a lack of laws and regulations that reduce the overall efficiency of the supply chain. Huawei’s use of reverse logistics and management of distribution channels have enhanced its supply chain’s competitive edge, but now it faces a chip shortage. For the current Huawei, finding backup suppliers, stabilizing consumer confidence, and maintaining investment in chip research and development are feasible ways to solve the existing problems.

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Mcdonald, J.: Huawei revenue sinks as smartphones hurt by US sanctions. Huawei revenue sinks as smartphones hurt by US sanctions - ABC News (go.com) (2021)

Berning, S.C.: The role of multinational enterprises in achieving sustainable development-the case of Huawei. European J. Sustainable Dev. 8 (3), 194 (2019)

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Health workers’ adherence to malaria case management protocols in Northern Sudan: a qualitative study

• Sahar Khalid Mohamed 1 , 2 ,
• Duha Khalid Mohamed 1 ,
• Khansaa Ahmed 1 ,
• Fadwa Saad 1 &
• Dejan Zurovac 3  

Malaria Journal volume  23 , Article number:  170 ( 2024 ) Cite this article

Metrics details

Nonadherence to national standards for malaria diagnosis and treatment has been reported in Sudan. In this study, qualitative research examined the clinical domains of nonadherence, factors influencing nonadherent practices and health workers’ views on how to improve adherence.

In September 2023, five Focus Group Discussions (FGDs) were undertaken with 104 health workers from 42 health facilities in Sudan’s Northern State. The participants included medical assistants, doctors, nurses, laboratory personnel, pharmacists and public health officers. The FGDs followed a semi-structured guide reflecting the national malaria case management protocol. Qualitative thematic analysis was performed.

Nonadherent practices included disregarding parasitological test results, suboptimal paediatric artemether–lumefantrine (AL) dosing, lack of counselling, use of prohibited artemether injections for uncomplicated and severe malaria, artesunate dose approximations and suboptimal preparations, lack of AL follow on treatment for severe malaria; and rare use of primaquine for radical Plasmodium vivax treatment and dihydroartemisinin-piperaquine as the second-line treatment for uncomplicated malaria. Factors influencing nonadherence included stock-outs of anti-malarials and RDTs; staff shortages; lack of training, job aids and supervision; malpractice by specialists; distrust of malaria microscopy and RDTs; and patient pressure for diagnosis and treatment. Health workers recommended strengthening the supply chain; hiring personnel; providing in-service protocol training including specialists; establishing external quality assurance for malaria diagnosis; and providing onsite supportive supervision and public health campaigns.

Conclusions

This study revealed a broad spectrum of behavioural and systemic challenges in malaria management among frontline health workers in Northern Sudan, including nonadherence to protocols due to resource shortages, training gaps, a lack of supportive supervision and patient pressure. These insights, including health workers’ views about improvements, will inform evidence-based interventions by Sudan’s National Malaria Control Programme to improve health systems readiness and the quality of malaria case management.

Malaria, a significant public health concern, continues to cast a shadow over Sudan’s healthcare landscape. The malaria burden in Sudan was estimated to be 3.7 million cases, and 1760 deaths accounted for 17.0% of the number of outpatients admitted and 14.7% of the total number of hospital admissions in 2021 [ 1 , 2 ]. Plasmodium falciparum accounts for 87.6%, Plasmodium vivax accounts for 8.1%, and other Plasmodium species account for approximately 4.3% of malaria infections [ 2 ]. The country’s struggle with malaria is further complicated by the COVID-19 pandemic [ 3 ], the persistent spectre of war [ 4 ] and the ensuing internal displacement of populations [ 5 ]. In this fragile environment, effective evidence-based management of malaria cases is paramount, safeguarding the well-being of communities and alleviating the economic burden associated with the disease. Sudan malaria case management standards reflect the WHO 2010 “test and treat” recommendations [ 6 ], and promote a shift from presumptive treatment of fevers to confirmed malaria diagnosis with either malaria microscopy or rapid diagnostic tests (RDT) and targeted treatment with artemisinin-based combination therapy (ACT) with appropriate weight-based dosing, drug dispensing and patient counselling [ 7 ]. Artemether–lumefantrine (AL) and dihydroartemisinin–piperaquine (DHAP) are the recommended first- and second-line artemisinin-based combinations for both P. falciparum and P. vivax uncomplicated malaria, while patients with P. vivax should also receive radical primaquine treatment. Regarding severe malaria management, the 2023 protocols have unambiguously recommended the use of artesunate injections and reserved parenteral quinine only when artesunate is contraindicated or unavailable [ 8 ]. Injectable artemether has been policy discontinued and banned since 2017 due to its prior irrational use [ 7 , 9 ].

Despite evidence-based policies and recommendations, health worker adherence to national guidelines is the key factor determining the real-world cost-effectiveness of the “test and treat” policy for malaria [ 10 ]. Improved adherence to malaria guidelines decreases malaria mortality [ 11 ] and highlights the importance of poor quality of care as a major contributor to mortality in low- and middle-income countries [ 12 ]. The levels, trends and factors of healthcare providers’ adherence to national malaria guidelines have been studied across Africa [ 13 , 14 , 15 , 16 ]. Despite some improvements, adherence was found to be insufficient in many settings [ 17 , 18 , 19 , 20 ] with series of studies evaluating outpatient malaria case management and observing deviations from testing indications [ 21 , 22 ]. Additionally, a tendency to prescribe non-recommended anti-malarials even for confirmed cases [ 23 , 24 ] and provide irrational anti-malarial treatments to patients who test negative for malaria has commonly been reported [ 25 , 26 ]. Furthermore, a number of studies highlighted missed opportunities in delivering timely anti-malarial treatment at healthcare facilities [ 27 , 28 ]. With respect to inpatient management, suboptimal quality-of-care has also been observed. Specifically, low testing rates of febrile patients on admission, persistence of presumptive anti-malarial treatment without testing or despite negative malaria tests, lack of parasitological monitoring, use of non-recommended anti-malarials and incomplete treatments are only few of the clinical deficiencies observed [ 29 , 30 , 31 , 32 , 33 ].

In Sudan, the quality of malaria case management, characterized by health workers’ adherence to national protocols, has been a challenge [ 2 ]. Nonadherence to standards for diagnosing and treating uncomplicated and severe malaria has been reported in different settings [ 9 , 34 , 35 , 36 ]. For instance, despite the availability of test and treat commodities for malaria, a national outpatient survey revealed that 67% of febrile patients tested, 64% of confirmed cases treated with ACT, 17% of test-negative patients treated for malaria, 6% of prescribed ACT patients weighed, 3% promptly administered the first ACT dose and 87%, 61% and 3% of patients, respectively, counselled on dosing, treatment completion and vomiting [ 9 ]. Inpatient management of severe malaria was less commonly evaluated, however a 20-hospital survey in Gezira State suggested that only 54% of severe malaria patients received the correct dose and dosing regimen [ 36 ].

Quantitative research can estimate the magnitude of the problem, but there is a need for qualitative research to understand the subtle factors and provide more nuanced recommendations for policy implementers to improve adherence. In the absence of such data in Sudan, this qualitative study embarks on an exploration of nonadherence among healthcare providers to malaria case management protocols in the Northern State of Sudan. Delving into the intricate web of healthcare practices, this research endeavours to unearth factors undermining adherence, as perceived by the very individuals entrenched in the frontline of healthcare delivery. Furthermore, it seeks to harness their collective wisdom by capturing their recommendations, thereby paving the way towards enhanced adherence.

Study design

This study utilized a qualitative research design with focus group discussions (FGDs) to explore healthcare providers’ adherence to national malaria case management protocols, specifically to identify nonadherent practices, factors influencing such practices, and gather health workers’ views on how to improve adherence to national protocols.

Northern State, one of Sudan’s 18 states, covers 348,765 km, with Dongola as its capital. Comprising seven localities, it is home to an estimated population of 1,511,442 primarily residing in rural areas along the River Nile [ 37 ]. Malaria transmission is hypoendemic, and the Sahara Desert is constrained, with an estimated incidence of 175 cases per 1000 population [ 37 ]. The selection of Northern State for the study area involved the delivery of in-service malaria case management training for health workers, an implementation platform conveniently used for the conduct of FGDs prior to training sessions. The state hosts 314 health facilities and 2345 healthcare providers distributed across various levels of care, including family health units, primary health centres, primary hospitals, and secondary and tertiary facilities [ 38 ]. At primary healthcare (PHC) facilities, RDTs serve as the exclusive diagnostic method, especially at the family health units, where the lower PHC level is operated by medical assistants (clinical practitioners with basic medical training). Health centres, representing the higher PHC levels, provide malaria microscopy services conducted by medical laboratory technologists and outpatient services provided by medical doctors. Malaria microscopy is also available at laboratories in local, general, referral, and teaching hospitals, encompassing secondary and tertiary levels of care, where outpatient and inpatient curative services are overseen by medical doctors [ 39 ]. Malaria services are supervised by the Federal and State Ministries of Health, which also oversee tasks such as updating protocols and providing training on them. The Ministry of Health also ensures the provision of essential supplies, including malaria RDTs and anti-malarial medications, most of which are free of charge. However, malaria microscopy services are still subject to charges. In 2023, a significant increase in population and healthcare providers occurred with the influx of internally displaced people, many of whom were originally from regions with high malaria transmission [ 40 , 41 ].

Study participants

A total of five FGDs were held at Primary Health Care Directorate venues in five out of seven localities within Sudan’s Northern State in September 2023. Healthcare providers from 42 health facilities participated in the FGDs (Fig.  1 ). The participants, who had diverse professional backgrounds, were chosen by the state and locality malaria control programmes to attend orientation training sessions (total of 8 training sessions for 200 health workers) on the updated malaria case management protocol [ 8 ]. The FGDs included all health workers attending an orientation session, and all study participants provided informed consent. The point of saturation through iterative data analysis after each FGD was reached after the completion of five FGD sessions, which included 104 participants in total (Fig.  2 ).

Map of Sudan showing Northern State and participant’s health facilities along the River Nile

Schematic flow of the sampling process

Data collection

At the initiation of the orientation sessions, the collection of demographic data were collected, encompassing participants’ occupations, gender, and workplace locations. FGDs were purposefully directed toward understanding healthcare providers’ adherence to the national case management protocol, unravelling factors influencing nonadherence, and soliciting recommendations to enhance adherence. Each session of these FGDs was conducted in the Arabic language, spanning approximately 2 to 3 h, punctuated with breaks and composed of a total of 104 healthcare providers and 19 to 25 participants at each FGD. The manuscript author (SKM), following semistructured guide tailored to reflect on the study objectives on adherence to malaria case management protocols, factors affecting adherence, and recommendations to improve adherence [ 8 ], moderated the discussions. The guide, with respect to the management of uncomplicated malaria, included inquiries into participants’ knowledge regarding malaria symptoms, diagnostic procedures, first- and second-line treatments, dosage specifics, and patient counselling. Regarding severe malaria management, the guide comprised inquiries on symptoms, signs, laboratory findings, diagnostic criteria, initial management strategies, treatment locations, dosage calculations, drug preparation and administration techniques, treatment duration, discharge protocols, and second-line management. Additional questions delved into the diagnosis and management of malaria in pregnant women. Prior to its use, the guide was pretested with health workers not involved in the study (Additional file 1 ). Finally, participant responses prompted exploration of the underlying causes of nonadherence to the protocols, eliciting valuable suggestions to improve the training at which focus group discussions were conducted and to provide potential improvement recommendations to the Federal Ministry of Health. During the discussions, the moderator preserved neutrality and ensured that all participants felt comfortable and similarly engaged. Simultaneously with discussions, notes were taken in Arabic language, which subsequently underwent dual forward translation by two investigators (SKM and DKM) into English and transcription for comprehensive analysis.

Data analysis

Qualitative thematic analysis was conducted [ 42 ]. It comprised seven sequential stages leveraging transcripts from FGDs and handwritten notes. Initially, all transcripts and notes were collected. Subsequently, the researcher thoroughly reviewed sample files, identifying words, phrases, or sentences pertaining to adherence to malaria diagnosis and treatment protocols. Following this, coding categories were developed using a deductive approach, with the protocol serving as the analytical framework. The fourth stage involved the coding of all files and text. The fifth stage encompassed scrutiny of the consistency in code, subthemes, and theme utilization. The sixth step entailed the interpretation of themes, drawing inferences from observed patterns, relationships, and codes, subthemes, and theme attributes. Finally, the seventh stage encompassed the presentation of findings, complemented by supporting quotes and verbatim quotes. A total of four to five themes was identified answering the research questions on healthcare providers’ adherence, factors and recommendations (Additional file 2 ).

Characteristics of participants

Of 104 participants across five FGDs, most of them were males (68.2%) and most worked at the primary health care facilities (75.5%). The number of participants ranged between FGDs from 19 in Al-Golead to 25 in Dongola locality (Table  1 ). Healthcare providers from various backgrounds participated in the study, most commonly medical assistants (59; 56.7%), followed by doctors (13; 12.5%), public health officers (13; 12.5%), nurses (9; 8.7%), laboratory personnel (7; 6.7%) and pharmacists (3; 2.9%).

Nonadherence to national malaria protocols

Four main themes reflecting health worker clinical practices nonadherent with national malaria case management protocols were identified in the analysis (Table  2 ). These included malaria diagnosis practices based on parasitological tests and clinical practices related to the treatment of uncomplicated malaria, severe malaria and patients harbouring P. vivax and mixed malaria infections.

Nonadherence to malaria diagnosis based on parasitological tests

Universal testing of fevers and targeted anti-malarial treatment is the backbone of malaria case management in Sudan. Healthcare providers reported common ordering of a parasitological test upon suspecting malaria but highlighted distrust in the test results and many reported practicing presumed malaria diagnosis. Specifically, regarding uncomplicated malaria, several health workers reported that patients with negative test results are still diagnosed presumptively and treated for malaria:

“Sometimes the test result comes negative for malaria, I test other causes of fever, and if all of them come negative I presume that patient has malaria” (Medical assistant)

Higher cadres of health workers also reported presumptive treatment practices, as medical officer managing hospital outpatients similarly observed.

“After excluding other causes of fever, even if the parasitological test is negative I treat patients as malaria and prescribe Coartem” (Medical doctor)

Regarding the management of severely ill patients, most health workers did not mention parasitological testing and reported that anti-malarial treatment is the standard management for severe disease, as observed by medical officer working at a secondary hospital.

“Febrile comatose patients are treated with broad spectrum antibiotic, antiviral therapy and anti-malarial treatment usually quinine, this is an umbrella approach commonly used” (Medical doctor)

Nonadherence to uncomplicated malaria treatment

The AL treatment of uncomplicated malaria was highly accepted by health workers, and most participants were knowledgeable about adult doses and schedules, particularly about the importance of the second dose administration 8 h after the first dose and the third dose administered 24 h after the first dose. However, some healthcare providers have shown little knowledge about paediatric dosage schedules potentially resulting in the underdosing and overdosing of malaria patients, as demonstrated by medical assistant practicing at outpatient health centre.

“From five to ten kilograms that is one tab of Coartem, from ten to twenty that is two tabs of Coartem, from twenty to thirty that is three tabs of Coartem” (Medical assistant)

Most health workers during the FGDs acknowledged a lack of AL dispensing and counselling knowledge on the administration of the first dose under observation, AL dosing with a fatty meal, repeating the dose if the patient vomited within 30 min and stressing the point of taking the dose as prescribed. Some, however, highlighted that forgetfulness and unclear counselling responsibilities between different health worker cadres encountering malaria patients within health facilities contribute to poor practices. Hospital doctor and pharmacist echoed these observations.

“I try my best to counsel all the patients but sometimes I forget” (Medical doctor). “Usually we do not counsel patients and we presume that their doctor told them how to take the drug” (Pharmacist)

Oral administration of dihydroartemisinin–piperaquine is the recommended second-line treatment for uncomplicated malaria in Sudan. However, its availability is scarce, dosing knowledge is low and health workers do not prescribe it. A healthcare provider humorously remarked on DHAP:

“DHAP (dihydroartemisinin–piperaquine) is as rare as gold (referring to the literal meaning of Dhap in Arabic), and it is nowhere to be found” (Medical assistant)

In this context, patients considered to have AL treatment failure are often prescribed artesunate injections reserved for severe malaria—the practice justified by the scarcity and unavailability of DHAP in the public and private sectors, as highlighted by the hospital doctor:

“Patients may present with recurrent malaria even after taking Coartem, DHAP is not available, we have no other choice but to prescribe artesunate injections” (Medical doctor)

Finally, despite high acceptance of AL by health workers, healthcare providers at lower levels of care (PHCs and family health units) reported the use of artemether injections as a treatment for uncomplicated malaria upon patient request:

“Sometimes the patient refuse it when I prescribe them tabs and insist that they want the oily injections (known name for artemether injections in Sudan) and I have no other choice but to prescribe it to them” (Medical assistant)

Nonadherence to severe malaria treatment

Health workers reported several treatment practices nonadherent to protocols for the management of severe malaria. Such practices spanned from the selection of non-recommended parenteral anti-malarial treatments to the lack of weight-based dosing; poor parenteral solution preparation, administration and disposal; and compromised completion of follow on ACT treatment after parenteral therapies. Participants acknowledged the frequent use of artemether injections, partly due to the patients’ pressure but also due to a lack of understanding of why artemether was prohibited while remaining available on the market. Most significantly, continued artemether use by consultants and specialists acting as supervisors and role models for front-line clinicians further undermined the treatment policy, as clearly stated by several participants of different cadres:

“I know we should not use artemether injections, but I should do what my boss says” (Medical doctor)

A medical assistant added,

“When a specialist prescribes artemether injections, I find myself wondering, who am I not to do the same?”

Most participants acknowledged not weighing adult patients but uniformly administering a 120 mg dose corresponding to a single vial of artesunate, which in turn, based on artesunate dosing recommendations of 2.4 mg/kg, results in dosing needs for patients weighing 50 kg. A lack of weighing practice in adults was well observed by the hospital doctor:

“Usually we prescribe 120 mg to all adults, we don’t weigh them and calculate the dose accordingly, weight dependant dosage are common in paediatrics but not the common in adults” (Medical doctor)

While weighing was probably more common in children, some healthcare providers acknowledged that the lack of weight-based artesunate dosing may also occur among paediatric patients:

“I usually weigh the child before prescribing any medication not just malaria medications, but sometimes, when the load is heavy in the ER or the clinic I just estimate the child’s weight” (Medical doctor)

Most participants reported uncertainties about how to prepare and administer injectable artesunate, particularly clinicians whose responsibility was related to prescribing artesunate but not to the preparing and administering of parenteral therapy:

“We don’t prepare artesunate since it’s a nurse responsibility, but when we find ourselves in a position to do this, when nurses aren’t available, we check the directions in the box, but we weren’t trained on this before” (Registrar)

Nurses were, however, less comfortable with IM artesunate preparations as well as with determining the number of vials needed for preparation, preparing solutions other than 120 mg for adults and disposing of unused solutions. The following remarks from hospital nurses illustrate these concerns:

“We usually prepare IV artesunate solutions but we are not familiar with IM preparations” (Nurse) “We are used to a standard dose of 120mg of artesunate injection, mixing vials to accommodate it to the patient needed dose isn’t a regular practice for us” (Nurse) “We usually use the remaining solution for the next dose, we don’t dispose it and we think it will be better to save it in the refrigerator” (Nurse)

The full course of AL should follow on IV artesunate treatment, which is administered to severe malaria patients upon admission, repeated minimally at 12 h and 24 h, and thereafter once a day until the patient can tolerate oral medicines and be discharged on oral AL therapy. Most participants, however, expressed a lack of awareness about AL follow on treatment, as clearly noted by the medical doctor:

“I didn’t hear about this before, but if it’s in the protocol then I will do it” (Medical doctor)

Moreover, incompletion of three minimally required IV artesunate doses at the hospital was common and discharge on injectable artesunate treatments for home administration was commonly reported:

“I’m used to neighbours knocking my door asking me to give a patient artesunate injections at home” (Medical assistant) “It’s true, I get the same neighbours asking for similar favours, and to be honest, if the patient is vitally stable we discharge him on artesunate at home” (Medical doctor)

Nonadherence to P. vivax and mixed infection treatments

While most participants were aware of radical P. vivax treatment with primaquine, the scarcity of primaquine on the market contributed to the low number of prescriptions. When primaquine is prescribed, health workers often have limited knowledge about primaquine doses, glucose-6-phosphate dehydrogenase (G6PD) risks, and adjusted dosing schedules for G6PD-deficient patients, as shown below:

“If a patient has P. vivax I prescribe them with 15 mg primaquine tabs twice daily for 2 weeks, I don’t ask specific questions to get a clue if the patient has G6PD honestly” (Medical assistant) “I didn’t know about the contraindication of primaquine with G6PD, even the paediatric weight dependant dose, I’m used to prescribe 7.5 mg tabs once per day for 14 days to all paediatric patients” (House officer)

Moreover, heath workers were less familiar with the possibility of mixed infections, particulary with test result interpretations, as observed by medical assistant below:

“Sometimes the RDT shows both P. falciparum and P. vivax, I don’t know what the meaning of this is, I presume that the RDT is not working well and I diagnose the patient with having P. falciparum infection” (Medical assistant)

Factors influencing nonadherence to protocols

Four broad themes describing factors influencing nonadherence to case management protocols were identified (Table  3 ). These included lack of commodities and shortage of human resources, poor knowledge of health workers about case management protocols, distrust in parasitological test results and patient pressure on modalities of clinical malaria management.

Lack of commodities and shortage of human resources

The absence of diagnostics and medicines precludes adherence to case management protocols. Common stock-outs of anti-malarials and RDTs at public health facilities, the reliance upon the private sector for costly purchases and the nearly universal absence of primaquine and DHAP from the market have been commonly reported by most participants, as illustrated by the hospital doctor:

“Malaria medications and RDTs aren’t always available in the hospital, most can be found in the private pharmacies and laboratories, except for primaquine and DHAP, they are hard to find” (Medical doctor)

The lack of commodities is limited not only to medicines and diagnostics but also to basic facility equipment, such as weighing scales, which are required to implement appropriate weight-based dosing of patients. The majority of participants seconded the frustrations highlighted by the medical assistant:

“I don’t have a weight scale in my centre, how am I supposed to adopt a weight dependent approach?!” (Medical assistant)

Moreover, even when commodities are available a major effort may be required to adhere to the protocols due to high patient workloads in the face of staff shortages, as also well observed by the hospital nurse:

“Now I understand I should prepare quinine dose just before administration, but I’m working alone and usually I have many patients to observe, this will definitely be a challenge” (Nurse)

Lack of training and lack of continuous support for protocol adherence

Participants commonly attributed nonadherence to a lack of knowledge and information transfer through interventions such as regular in-service training and supportive supervision, including the delivery of reminders about good practices. For instance, the role of job aids such as poster wall charts and protocol booklets was repeatedly emphasized by the participants:

“If I have a poster in my centre it will remind me if I forget” (Medical assistant)

This was similarly echoed by medical doctors in hospital settings:

“Posters help us train our house officers and as he said it helps reminding us if we forget” (Registrar)

With respect to more formal capacity building, in-service training has been acknowledged as a valuable intervention in transmitting knowledge and enhancing case management readiness for all health workers, however, it appears that consultants and specialists have not been sufficiently reached:

“When prestigious consultants treat malaria differently than us, we lose patients trust” (Medical assistant)

Finally, most participants acknowledged that the lack of supportive supervision to address the availability of commodities and provide on-job support and problem solving for front-line health workers may further facilitate nonadherent practices:

“You ask us to do things but at the same time you don’t avail the needed requirements for us, why don’t you come and see the setting at which we are practicing first?” (Medical assistant)

Distrust in parasitological test results

Treatment nonadherent to malaria test results due to the distrust of malaria microscopy and doubtful quality of laboratory services was a recurrent theme among the participants:

“Sometimes a patient presents with fever, we exclude all other causes, but if the microscopic test results come back negative from the lab, we do not trust, we manage as malaria, and we observe dramatic improvement in patients.” (Medical officer)

Notably, clinicians’ distrust in malaria microscopy has been exclusively directed towards negative test results, as well remarked by laboratory specialist:

“If I provide a negative result, the healthcare provider will not trust me, and they will send the patient to another lab that gives them positive results” (Laboratory specialist)

Discontinuation of external quality assurance systems for laboratories and a lack of recent refresher training for malaria microscopists does not mitigate the distrust in test results:

“Previously the program used to take slides from our lab for verification and provide training if the staff is giving wrong readings, but now this is not happening!” (Laboratory specialist)

Finally, similar levels of distrust were reported with respect to malaria RDT results. Furthermore, much of the confusion was reported in the PHC facilities with regard to the appropriate performance and interpretation of RDTs produced by different companies:

“The RDTs I have only gives me a negative result no matter what, I suspect it might be due to storage conditions” (Medical assistant) “I don’t understand how to use RDTs, some companies require waiting for 15 min, some for more or less, having RDTs from different companies each time is tiring and exhausting because I’m already overworked” (Medical assistant)

Patient pressure

In addition to health worker and health system factors, patient pressure may also influence health worker adherence to malaria case management protocols and alter health worker clinical practices. For instance, some health workers illustrated how patients may influence diagnosing practices for malaria:

“When you ask the patient what are you complaining from he says malaria! And when I try to explain that I’m asking about the symptoms he says I know my malaria just order me the test” (Medical doctor) “Patients insist it’s malaria even if the test is negative” (Medical assistant)

The other participants illustrated how patients may influence treatment practices:

“Patients insist its malaria even if the test is negative, they insist on being treated for malaria and if I didn’t write the drug they will buy it themselves” (Medical assistant) “Sometimes the patient have malaria but he demands injectable treatment although they should just take tabs, some insist on taking artemether injections even after I counsel them about it” (Medical doctor)

Health worker recommendations to improve adherence

The participants provided valuable insights into what could be done to address the identified challenges and improve adherence to malaria case management protocols, as summarized in Table  4 .

Ensuring the availability of case management commodities

Health workers emphasized the responsibility of the Ministry of Health to strengthen the effective supply chain for malaria commodities and ensure the universal, continuous and affordable availability of malaria diagnostic and treatment commodities. Such steps would present a basic prerequisite for adherence improvements:

“If RDTs are free and available we can take a step towards accurate diagnosis of malaria” (Medical assistant) “I don’t prescribe primaquine for patients with P. vivax because it’s not available, same goes for DHAP” (Medical assistant)

Improving the balance between human resources and workload

Quality of care is dependent on adequate human resources and calls for additional personnel to balance heavy workloads were the theme of transpiring discussions across the cadres of participants:

“Now I understand I should prepare quinine dose just before administration, but I’m working alone and usually I have many patients to observe, this will definitely be a challenge, I need more people to work with me” (Nurse) “Being overworked and not have much sleep can alter your cognitive skills! This is scientifically proven! The Ministry of Health should decrease our workload because this isn’t just affecting malaria management, this is affecting all patient’s health outcome” (Medical doctor)

In-service training on case management protocols

Participants emphasized the importance of continuous training for all health workers. Recognizing the influential role played by specialists and consultants in hospital settings, they also underscored the importance of targeted training and interventions for these professionals:

“Now, I know the updated protocol, but my boss doesn’t, I may adhere to it in my private outpatient clinic but in the hospital it’s the consultant’s decision, not mine, you have to orient him too with the protocol” (Medical officer)

Moreover, whether implemented during training or through separate communication channels, health workers expected clarifications about the reasons for artemether injection prohibitions:

“The consultant in my unit is prescribing artemether injection, I do too since I don’t understand why is it prohibited at the first place, if you are afraid of the resistance because of the mono-therapies, why would you put artesunate injection in the protocol?” (Medical doctor)

Quality assurance for malaria diagnosis and supervision activities

Most of the participants called for external quality assessments at public laboratories through onsite supervisory visits for malaria microscopy and RDTs:

“I don’t trust the lab results, supervising the lab and making sure it’s well equipped and its staff is qualified will be great” (Medical doctor) “The RDTs I have only give a negative result, I would like if the Ministry of Health came and saw if it’s working or not or if its storage is well or not” (Medical assistant)

Some hospital clinicians further emphasized MoH supervision at public pharmacies and laboratories with respect to the enforcement of free policy for government procured RDTs and artesunate vials:

“When artesunate is available in the hospital, only the first dose is free, the patient has to buy other doses from the private pharmacy, you should talk to them to make sure they provide all doses for free” (Medical officer)

Finally, participants highlighted the importance of extending supervision to the private pharmacies to ensure the delivery of quality products and compliance with artmether injection prohibition:

“If artemether is prohibited then why the government doesn’t enforce its prohibition by law? Supervise the private pharmacies!” (Medical assistant) “Artesunate injection isn’t available in the public hospital, patients buy it from the private pharmacies and the quality of the drug available isn’t good” (Medical doctor)

Health promotion campaigns

Participants emphasized that public campaigns are necessary to promote malaria diagnosis based on parasitological test results and to increase the understanding of the rational use of anti-malarial medicines:

“Patients and co-patients don’t trust the parasitological test and insist on the malaria diagnosis, the concept “I know my Malaria” needs to be fought” (Medical assistant) “Patients insist on being treated for malaria even they don’t have malaria, and if they do they insist on being treated through injections rather than tabs, let alone those who request artemether injections” (Medical doctor)

Sudan health workers from Northern State revealed a broad spectrum of protocol nonadherent malaria case management practices, factors influencing such practices and recommendations of relevance for policy implementers to improve the adherence to and quality of malaria care. The problem of malaria diagnosis transpired throughout the study. Stock-outs of diagnostic commodities such as RDTs, distrust of malaria microscopy, but also RDTs, limited in-service training and lack of supportive supervision for laboratories and clinicians have been highlighted in this study, as similarly observed in various settings across Africa [ 26 , 27 , 28 , 29 , 43 , 44 ]. More recently, compliance with test negative test results and the rational use of anti-malarials have improved in other countries [ 14 , 25 ], and many of these achievements have been attributed to the implementation of quality assurance programmes for malaria diagnosis supported with systems readiness and case management monitoring [ 15 , 45 ]. In Sudan, as also suggested by the study findings, the quality assurance programmes traditionally targeting malaria microscopy should be re-established but also expanded to include RDTs through the onsite supervision of non-laboratory personnel, in line with recently developed quality assurance guidelines [ 46 ]. To mitigate human resource issues, outpatient use of RDTs for initial febrile visits should be promoted at all levels of care, including hospitals, while complex to perform malaria microscopy should be reserved for follow-up of treatments and monitoring of parasitaemia for severely admitted patients [ 47 , 48 ].

Another quality of care aspect severely compromising the effectiveness of malaria case management is nonadherence to treatment recommendations [ 47 ]. Health workers revealed several suboptimal treatment practices. First, lack of patients’ weighing and the practice of dose approximations, the clinical deficiencies not unique to Sudan [ 29 , 33 ], are widespread and inevitably result in overdosed and underdosed treatments. Although the lack of weighing scales may provide a plausible explanation, uniformed artesunate prescriptions for adults based on a single 120 mg vial may also reflect cost considerations, ease of administration and waste minimization. Second, paediatric anti-malarial misdosing reported by health workers may not only be due to the absence of weighing scales but also due to deficient dosing knowledge. Third, suboptimal counselling practices, as similarly observed for outpatients in other settings [ 9 , 28 , 34 ], are important components of malaria case management, compromising the promptness of the treatment, patient adherence, cure rates, and follow-up needs [ 49 , 50 ]. While acknowledged in the protocols, patient counselling has been a neglected topic and has indeed not been addressed during case management in-service trainings for health workers in Sudan [ 51 ]. Fourth, while the first-line treatment recommendations for uncomplicated malaria are highly accepted by health workers, the use of injectable artemether due to patient pressure seems to compromise the implementation of the treatment policy. This irrational treatment pattern was observed during earlier national surveys [ 9 , 40 ], raised concerns about drug resistance and ultimately led to the prohibition of injectable artemether in Sudan [ 7 ]. Although the findings of this study suggest persistent artemether use for uncomplicated malaria, quantitative assessments are required to estimate the scale of this malpractice. Fifth, regarding the treatment of severe malaria, the widespread use of injectable artemether, the inferior anti-malarial choice for this category of patients, as well as incomplete ACT follow on treatments are the nonadherent aspects of care described previously [ 29 , 30 ], and are perhaps the most concerning since they directly compromise patient outcomes [ 52 , 53 ]. Artemether preferences, especially common among role model cadres such as consultants and specialists, might reflect a lack of updates about treatment effectiveness but also weak regulatory enforcements given the banned status of the product on the market. Finally, the recommended management of the treatment failures and radical treatment of P. vivax infections is uncommon in Sudan due to the very low availability of respective treatments for these special patient groups, DHAP and primaquine.

Quality improvement initiatives targeting the readiness of health systems and the adherence of health workers to evidence-based case management protocols are malaria control priorities in Sudan [ 36 ]. Reinforcement of the test and treat practices is important not only for delivering quality of care and curbing malaria mortality but also for establishing reliable disease surveillance and malaria elimination foundations to which the country, and in particular the northern states of Sudan, are aspiring to. The study health workers in the Northern State suggested several valuable interventions that concur with broad strategic plans of the National Malaria Control Program (NMCP) [ 37 ]. Quality assurance for malaria diagnosis, the programmatic intervention mentioned earlier, is one of the control priorities. Regarding the initiatives targeting clinicians, only smaller-scale, multifaceted projects have been piloted [ 54 ], while programmatic interventions focusing mainly on supply, protocols and training have had limited reach [ 2 ]. In the following years, the Sudan NMCP plans to implement a package of multifaceted, evidence-based, country-adapted, quality improvement interventions focusing on the provision of diagnostics and medicines; supportive supervision, including audit, feedback and mentorship; and in-service training coupled with monitoring and group problem solving, interventions that have been shown to have significant positive effects [ 55 ]. Clinical algorithms in the format of job aids will be integral components of the multifaceted training and supervision interventions, required to remind health workers but also policy makers about key case management standards. However, it should be emphasized that improved performance through health worker supportive interventions such as job aids, training and supervision can be realized only if basic prerequisites are in place, i.e., universal and continuous availability of “test and treat” commodities and services for malaria [ 56 ]. Finally, regular assessments of the quality of care will be established to provide reliable quantitative indicators to inform progress in health system readiness and adherence to outpatient and inpatient malaria case management protocols [ 9 , 33 , 57 ].

In addition to health system interventions, health campaigns have been suggested for Sudan’s Northern State to mitigate patient pressure by increasing public awareness of parasitological diagnosis and decreasing demand for injectable medicines, especially for artemether injections. Other countries reported differing effects of patient pressure on anti-malarial prescriptions [ 58 ]. In Sudan, further quantitative research is needed to assess relation between appropriate counselling, patient pressure and patient satisfaction level. Finally, while staff shortages are a pertinent health system problem in Sudan and additional hiring, as requested by health workers, is a long-term solution, more effective use of available resources such as task shifting of RDT performance is a more realistic palliative solution in the short term.

Several study limitations should be acknowledged. First, while the study findings represent Northern State health workers, they may not be generalizable to other parts of Sudan. Second, the study did not include policy makers and implementers what limited insights into adherence factors only to the recipients of the case management interventions. Third, while the social desirability bias in reporting clinical behaviour cannot be excluded, this bias appeared to be controlled given the extent of reported nonadherent practices. Finally, the identification and exploration of nonadherent topics were guided by case management protocols and not by quantitative adherence data in the study area. Future studies exploring adherence to protocols should deploy mixed methods designs.

This study revealed a broad spectrum of behavioural and systemic challenges in malaria management among Northern Sudan’s frontline health workers, including nonadherence to protocols due to resource shortages, training gaps, lack of supportive supervision and patient pressure. These insights, including health workers’ views about improvements, will inform evidence-based interventions by Sudan’s National Malaria Control Programme to improve health system readiness and the quality of malaria case management.

Availability of data and materials

The datasets used and analysed during the current study are available from the corresponding author upon reasonable request.

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Acknowledgements

The authors would like to thank all the health workers who participated in the study. The authors are grateful to Dr. Mujahid Abdin for the creation of the study area map and Dr. Mariam Adam Babiker for comments on the manuscript. The authors express their sincere gratitude to the Primary Health Care Directorate which funded orientation training for health workers which were used as operational avenues for the study FGDs. Special thanks to the Federal Ministry of Health, the Northern State Ministry of Health and the National Malaria Control Programme for continued study support.

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SKM conceived and designed the study, collected the data, performed the analyses, interpreted the study findings and wrote the first draft of the manuscript. KA, DKM, FMS and DZ contributed to the interpretation of the study findings and revision of the manuscript. All the authors have read and approved the final manuscript.

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Khalid Mohamed, S., Khalid Mohamed, D., Ahmed, K. et al. Health workers’ adherence to malaria case management protocols in Northern Sudan: a qualitative study. Malar J 23 , 170 (2024). https://doi.org/10.1186/s12936-024-04998-9

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Sustainable Lean Procurement and Contract Management in Oil and Gas Industry

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Lean methodologies have enabled numerous businesses to enhance their processes, reduce inventory levels, and improve ergonomics. Additionally, lean has allowed organizations to adapt their technologies and keep pace with necessary advancements. However, despite the numerous benefits it offers and the implementation of lean thinking and procurement in the oil and gas industry, companies have frequently encountered challenges related to the timely delivery of materials and services.

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