Health and Humanitarian, April 2016 by Pamela Steele Associates Ltd

Health & Humanitarian

the supply chain review

Photo courtesy of VillageReach

Issue 1 April 2016

Produced by PSA, in conjunction with the Oxford University Internship Programme

Contents 5

Editor's Note Comments from the editorial team

Spotlight on Innovation: Part One Extremis Technology

VillageReach Pioneering a new approach to supply chain management

ANDREW BROWN Professionalising Health Supply Chain Cadres A Must for the Sustainable Development Goals and Health Equity

Interview with Pamela Steele Insights and guidance from an industry leader

17 Staying in the loop

Useful agencies and networks for the health supply chain professional.

7 Habits of the successful health supply chain professional

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24 27

Leading the way ... Taking a closer look at Sudan's National Medical Supplies Fund

Insider Information

5 Things the health and humanitarian supply chain can learn from FMCG.

33 Counterfeit Drugs

Spotlight on Innovation: Part Two TransAid

Old Enemy, new solutions: how innovative tech is leading the fight. Article by Oscar Boyd

CHRIS WRIGHT Making Sense of ... Supply Chain Integration Comment Piece by Chris Wright

35 Mainstreaming gender in health supply chains A moderated discussion

Internal Affairs Oxford University interns share their experiences after a week working at PSA.

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Health & Humanitarian the supply chain review

EDITOR IN CHIEF

Pamela Steele

EDITORIAL TEAM

Editor Yuna Chang Editor Philip Matthews Editor Ross King

HOW TO REACH US MAIN OFFICE Pamela Steele Associates Ltd. Prama House, 267 Banbury Road, Oxford, OX2 7HT, UK PHONE NUMBER +44 (0) 1865 339 370 WEBSITE www.pamsteele.co.uk

From the Editors

upply Chain

Management. Since the Management. Since the term was coined in the 1980s, it has become a new buzz-phrase in both new buzz-phrase global economic discourse, and the professional management sector. The three words describe a vast and complex industry, comprising the myriad Yuna Chang, Ross King, Pamela Steele, Philip Matthews (Photo: PSA) systems of organisation, people, activities, However, to view these for professionals in the information and resources aspects as the only side of development sector, both involved in moving a global supply chain strategists and implementers, product from supplier to management would be seeking information on all customer. misleading; in fact, supply aspects of the humanitarian chain management plays a supply chain. All too often, perhaps, the crucial role in both the term supply chain development and Our hope is that Health and management prompts humanitarian sectors, Humanitaian will provide a connotations associated enabling people in the platform for the discussion of with the darker-side of developing world to access the challenges involved in the capitalism. Indeed, the conventional medicine and sector, will act as a billboard most obvious fruits of other vital resources. for exciting developments, and global supply chains are will also foster connections coffee, cheap clothes and between different projects and the raw materials utilised parties.â&#x20AC;? in modern technology - the It is on this humanitarian aspect of the supply chain exploitative systems network that this publication, involved in the Editorial Team a fore-runner in its field, procurement of such items Yuna Chang wishes to focus. Health and is well known. Philip Matthews Humanitarian is a magazine Ross King

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Spotlight on: Part One Extremis Technologies A feature length insight into design innovation

Article by Philip Matthews In each edition, ‘Humanitarian Supply Chain’ takes a closer look at the work of two organisations we feel are doing particularly interesting and effective work in the health and humanitarian sector. The aim is to better understand their operations, the challenges they face and how they are connected to the larger development sector supply chain. This Quarter, we are throwing the spotlight on… Extremis Technology and TransAid.

Image : The HuSh shelter can be assembled in under 30 minutes, housing 4 to 6 people.

portable shelters. The focus is not on immediate aid in the aftermath of natural disaster - whether earthquake, hurricane or flood but on providing relief in the transitional period, Extremis technology is between emergency response and a private sector permanent humanitarian settlement. Water, organisation, sanitation, education, established in the health services – all wake of the 2010 of these are made Haiti disaster, which easier and more seeks to give sanctuary to displaced possible with safe, people throughout the secure and robust shelter, built around world through the the family unit. provision of robust,

Photos: Extremis Technologies

Extremis is a prime The most notable feature of Extremis Technology example of how the Seed Enterprise Investment is its groundbreaking approach to providing Scheme is being shelter, designing a harnessed to back range of revolutionary innovation, and as an new forms of shelters export business in the specifically for disaster engineering and relief. Extremis manufacturing sector, Technology’s flagship Extremis is a great product is the ‘Hush1’, a example of what new portable fold-flat shelter that can be erected in businesses in the UK can achieve." an almost pop-up fashion without the need for tools, additional Chancellor of the parts or skilled labour. Exchequer, George Osborne Crucially, they can be erected in approximately thirtyminutes, rather than

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taking days or weeks to assemble. The shelters can be mounted onto seismic isolators to provide some protection in earthquake zones, and there are opportunities to add further technologies for water capture or energy generation. Extremis Technologies has, moreover, branched out from the original ‘Hush 1’ design to create the ‘Hush 2’, a more robust shelter capable of withstanding category 5 hurricanes, and also the ‘Push’, a more sophisticated temporary accommodation equipped with electricity panels, waste management, a toilet, shower, bed and work table.

put up by 3-4 people in less than two minutes”.

Speaking to the Health and Humanitarian, CEO of Extremis Technology Julia Glenn outlined the distribution process of the shelters: “We increasingly rely on local manufacturers (in country) to manufacture and distribute our HuSh shelters. That way we can use local factors of production and stimulate overseas economies, especially where this stimulation is most needed. Our shelters can be transported on the back of a flat-bed lorry, and once offloaded, can be

The UK Chancellor George Osborne was quick to realise the potential of Extremis Technology, praising the organisation as a “great example of what new businesses in the UK can achieve”. In terms of complementary technology, Extremis works alongside GravityLight, an innovative off-the-grid lamp, which produces light energy simply through utilising gravity and weight, thus eliminating need for the expensive and polluting kerosene lamps used by 1.1 billion people globally. Interestingly, a large proportion Extremis Technology’s funding - £280,000 - is entirely ‘crowd-sourced’ from charitable individuals, and much of the rest is raised in the form of angel investment. If you would like to support the work of Extremis Technology, one can make a donation through their website: http://www.extremistechnology.com/

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Feature Article

VillageReach:

Pioneering a new approach to supply chain management Article by Yuna Chang

Immunization at a Mozambique clinic ( Immunization at a Mozambique clinic (Photo: VillageReach)

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n 2002, Cabo Delgado was the first province in Mozambique to

implement the ‘Dedicated Logistics System’ (DLS), a new model for vaccine distribution, born from a comprehensive approach to immunization supply chain (iSC) system design, incorporating transport loops, level jumping, direct data collection and utilization, and dedicated logisticians to create a more efficient vaccine supply chain. The results from an independent evaluation completed at the end of the pilot in 2008 revealed dramatic improvements. The DLS and the management approaches accompanying it played a significant role in the marked improvement in immunization coverage with a reduction in vaccine stockouts from 80% to regularly about 1% per month, increased coverage of DTP-3 immunization rising from 70% to 95.4%, [1] and greatly improved the supervision and training of health facility staff. From its roots in Cabo Delgado, the DLS has been rolled out to four additional provinces, and currently covers

500 rural health centers serving a population of more than 8 million.[2] On-going monitoring of logistics data indicates a continued and sustained high level of iSC performance with stockouts regularly less than 5% percent across all provinces. Dr. Francisco Mbofana, National Director of Public Health in Mozambique,

Emilia Albino Chilaule a health worker who vaccinates children at clinic served by the DLS. (Photo: VillageReach)

[DLS] has made a direct impact (where implemented), resulting in an increase in immunization coverage - Dr. Francisco Mbofana praised the implementation of DLS, noting that it has made a direct impact (where implemented), resulting in an increase in immunization coverage and fuels greater efficiency of the vaccine supply chain. Not only has the DLS improved the immunization supply chain in Mozambique where implemented, but it also has implications for a whole new way of thinking about supply chain logistics and planning. Key to

VillageReach’s innovation is applying a holistic, comprehensive approach to supply chain design. It’s not just about patching up holes; it’s about taking the supply chain system as a whole to solve logistics problems, utilizing an ‘end-to-end perspective'. This is where the approach of system design comes in.

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As with many private sector approaches to supply chain, the DLS is based on efficiency. It uses an approach of streamlining, professionalization and continuous improvement to produce the most efficient supply chain. The DLS can be characterized by three key components: 1. STREAMLINED DISTRIBUTION PROCESS. This involves re-assignment of tasks, level jumping and optimized delivery routes. Supply chain management functions are focused as high up in the supply chain as is geographically possible at the provincial level, consolidating responsibilities and focusing limited resources. Dedicated logisticians are trained for and take on multiple supply chain responsibilities, including basic maintenance of equipment (see #3 below) which is integrated into delivery to save time and resources. 2. DATA VISIBILITY. An open source information management system, OpenLMIS (locally referred to as SELV) provides real time data for more accurate data collection and utilization. Distribution is demand-driven, based on delivery-level consumption data from health facilities analyzed by dedicated logisticians. The data is used for regular follow-up sessions to assess where improvements can be made, which logisticians then implement in a cycle of continuous improvement.

Inspecting a vaccine refrigerator at a Mozambique health center. (Photo: VillageReach) equipment, collects and reports data, and provides active and ongoing supportive supervision and training, allowing frontline health workers to focus on patient care. The infographic below illustrates how key elements of DLS differ from the multi-tier approach typical in many low- and middleincome countries, and the impact of these changes on vaccine availability and cost in Mozambiqueâ&#x20AC;&#x2122;s provinces who use the DLS:

3. CONSOLIDATION OF LOGISTICS TASKS. A specialised Field Coordinator delivers vaccines and supplies, repairs cold chain

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DLS is not just a stopgap measure in supply chain management, as it goes far beyond improvement to a single component of the supply chain. VillageReach has worked closely with the Mozambican Ministry of Health, especially at the provincial level, to ensure it is appropriate for the context and managed by the provincial government. Originally 100% NGO-funded, the DLS now operates on a cost-share model between the government (DPS) and VillageReach, both contributing to the operational costs of distribution. Although VillageReach continues to provide technical support, vaccine delivery is government-run and managed, ensuring its long-term sustainability by allowing it to adapt to shifts in political realities. Bertur Alface, Medical Chief of Gaza Province noted that DLS â&#x20AC;&#x2DC;gives us more visibility into the data coming from the health centers with improved frequency, regularity, and quality. And this has made the data credible, creating more confidence in the distribution system and in the government

and providing more evidence for decision-makingâ&#x20AC;&#x2122;. In fact, this level of leadership and ownership by Ministry of Health was one of the key contributing factors to the DLS winning an award for supply chain excellence at the 2015 Global Health Supply Chain Summit. The award recognized the Ministry of Healthâ&#x20AC;&#x2122;s willingness to question the status quo in terms of supply chain logistics, and its ability to drive decisions based on evidence to ensure vaccines are available to all children in Mozambique. Fittingly, a Ministry of Health representative was there to accept the award on stage.

when driven by champions of change at the country level as illustrated in the progression of the DLS expansion from pilot to current day (see timeline) Evidence-driven, flexible and efficient, the DLS is an example of next-generation iSC. It deserves to be recognized as a crucial game-changer, proof of the importance of system design and its impact to improve supply chain performance. It is time to move away from single issue improvement and focus on a more holistic, comprehensive approach to immunization supply chains.

Change leadership is key to the scale and sustainability of successful innovations like the DLS. Creating an enabling environment and generating political will for change takes time and is most successful

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Professionalisation Corner...

This issue, from ANDREW BROWN, Health Systems This issue, from ANDREW BROWN, Health Systems Strengthening Consultant: Strengthening Consultant:

Professionalising Health Supply Chain Cadres – A Must for the Sustainable Development Goals and Health Equity A Must for the Sustainable Development Goals and Health Equity Although it is 2016, one third of the world’s population is still without access to essential life-saving medicines. As we usher in the era of the Sustainable Development Goals, there has never been a more important time to renew our focus on developing the health supply chains in countries with the greatest health needs. These health supply chains are the ‘arteries’ of health care, without which the health products needed by health workers could not flow to the patients who need them. Many of these patients are currently dying from illnesses such as malaria that are treatable by modern medicine. Many clients are in need of reproductive health commodities to achieve their family planning goals. Many men, women and children need continuous supply of ARVs for HIV/AIDS treatment. The list goes on. We understand that health supply chains are complex systems that need infrastructure, products, data, systems and people. Health Supply Chain professionals in sufficient numbers, at the correct places, with the competencies to manage, develop, and sustain these systems. Although

significant progress has been documented against the Millennium Development Goals, a lot remains to be done. In 2011, The People that Deliver (PtD) Initiative was born with a ‘vision of a world where national supply chain workforces are planned, financed, developed, and supported in a way that ensures equitable and sustainable access to the medicines and other commodities needed for optimal health outcomes.’ As the ‘PtD Evidence for Impact Brief’ notes, PtD has succeeded in bringing the need to do more to systematically improve and professionalise cadres involved in health logistics and supply chain activity to the front and center of supply chain capacity development. PtD has published a strong evidence base, has made tools and guidance available from its in-country experiences, and has equipped supply chain professionals with advocacy tools to further engage in local contexts. 11

Supporting the professional development of health logistics and supply chain cadres is a key leaver of change if health supply chains are to be developed and sustained to deliver the health products required for health professionals to deliver the care patients need. Particularly in developing country contexts. The International Association of Public Health Logisticians (IAPHL www.iaphl.org ) is an open access association actively engaging health supply chain professionals globally. Their mission is to support the professionalization of supply chain managers and others working in the field of public health logistics and commodity security, with particular focus on developing countries, equipping individuals to strengthen the health systems in which they work. IAPHL has a membership of more than 3500 from 135 countries, across academia, country governments, UN organisations, private sector and technical partners. As a member you can engage in active discussions on supply chain topics, ask questions of experts and share your stories. IAPHL is also a hub for e-learning opportunities, job opportunities and sharing details of global projects and best practices. I place where you can learn, share and grow as a health supply chain professional.

I would encourage individual health logistics and supply chain workers and organisations to engage with both PtD and IAPHL. To both take advantage of the resources they offer and to connect to the global supply chain community so that together we can work to make medicines availability for patients a reality for everyone.

AN INTERVIEW WITH...

Pamela Steele

Pam Steele delivers a training course (Photo: PSA)

In this issue, the â&#x20AC;&#x2DC;Health and Humanitarianâ&#x20AC;&#x2122; team spoke to Pamela Steele, founder and CEO of Pamela Steele Associates, the leading international development supply chain consultancy. Pamela was born and educated in Kenya, and holds an MSc in Business Administration and an MBA in Supply Chain Management. Before founding PSA, she worked for World Vision International, the International

Committee of the Red Cross, Oxfam Great Britain, UNFPA and UNICEF. Q. What was your motivation for founding Pamela Steele Associates? A: After over twenty-five years of work in Logistic and Supply Chain Management - including work for leading NGOs and the UN - I asked myself the question: what next? I decided that I wanted to go into consultancy and use what I had learned

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in the field to help health and humanitarian organisation operate more effectively. I was itching to help without feeling restricted by organiation's bureacracies and too much talk even when lives were at risk. I had witnessed a lack of supply chain competence and a weak workforce in the frontline. There were people always willing to help, but they didn’t have the knowledge or tools to do their job or lacked leadership and supervision. Developing professional people is vital - that’s why we offer training courses in health and humanitarian supply chain management. Also, having come from Kenya and worked internationally, I felt this was the best way to give something back to my beloved continent whilst also being fully valued for my skills and experience.

We live in an incredibly volatile world today...We need people who are ready.

collaboration really frustrated me. During the tsunami the weaknesses were fully exposed and the international community let down the affected population which led to the set up the 'Cluster' system to improve coordination but this is still a work in progress. Q: What is special about PSA? A: The fundamental difference between PSA and many other aid organisations is our attitude. Let’s go and do it is our guiding mantra. We just plant, we don’t care whether the rain will come or not; we have less time to waste, we react to what we see when we see it. We live in an incredibly volatile world today. Natural disasters have increased over the years, and insecurity is also increasing. One event in the corner of the globe can tilt everything. That is why we need people who are ready. We should all be ‘first-aid trained’ and ready to 'make it happen'! We need agile people who are able to change gear, not people operating in only one compartment.

Q: What did you learn from your work with NGOs and the UN - what did these organisation do well, and what aspects could be more effective? A: I am immensely proud of my time at the NGOs and UN. There is nothing like going out into the field and seeing how your work is having a direct impact on people’s lives, and I enjoyed being part of a larger project. That said, there are many areas where the UN and other organisation can, and must, improve. Emergency responses are often chronically uncoordinated, resulting in competition between aid agencies and a fragmented approach. If UNICEF and Oxfam are both providing water, for example, who is providing other vital resources such as medical supplies, shelter or food? Lack of coordination and

Q: Tell us about a particularly exciting project that you are currently working on. A: We are going to be an implementing partner for the Bill and Melinda Gates Foundation’s project in Nigeria. I love the thought-process behind the project, taking a

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holistic approach and trying to really analyse the roots of supply chain bottlenecks, a process entirely owned and led by government change team, with the Gates Foundation supporting on the side. You canâ&#x20AC;&#x2122;t just arrive in the field and tell people what to do because you have the funds. The Gates Foundation is committed to working with anyone who is willing to work with them and contribute meaningfully. PSA is a small company, not one of the regular names chosen for such projects, but they have faith and trust in us and we can't wait to unleash our hidden talents! Q: One of PSAâ&#x20AC;&#x2122;s core services is its training courses - why is education so important? A: Health and humanitarian contexts are very complex. Things you learn through formal education give you general knowledge. However, when you move into practice particulalry the humantarian context, it demands certain skills in how you deal with vulnerable people and help preserve their dignity, how you manage operations in complex environments with weak infrastructures and limted resources, or corrupt systems. You need strong people skills, and well-developed people. Knowledge of culture, political situations, and religious practises and interpersonal skills are all key to effective health and humanitarian supply chain management. Q: What are your thoughts on being a woman in supply chain logistics? Does the sector have far to go in terms of addressing its gender imbalance? I believe that everyone should have equal

opportunities. Having said that, I realise that often certain genders face specific challenges. Fortunately, I see women breaking barriers in the field all around me, many of whom have gone further than me in very remote areas. I want to make this known: give me a vuvuzela! I have always Knowledge of culture, political situations, and religious practises are all key to effective health and humanitarian supply chain management.

been a strong advocate in encouraging more women to join the sector. Q: How do you envisage a sustainable future for the humanitarian supply chain? A: Three things are vital. Firstly, we need a well-trained workforce. Secondly, they must be well equipped with the tools and resources they need to do the job. Thirdly, they must be led, supported and continously developed. We need people operating on the same page, quickly and easily transferring knowledge.

Pam Steele (Photo: PSA) 15

STAYING IN THE loop In order to better understand the challenges tackling the global community and truly professionalise as an industry, it is important for us to help each other. Here are some useful agencies, global actors, and other contributing members doing just that.

The International Association of Public Health Logisticians (IAPHL) is a professional association dedicated to improving public health supply chain management by promoting the professional development of those who work with health supplies, including nurses, pharmacists, and others carrying out logistics tasks. IAPHL supports supply chain professionals by providing them with access to resources, job listings, and facilitated listserv discussions related to public health supply chain management. The HLA is an individual membership association for humanitarian logistics professionals. It has been established as a neutral interface between aid organisations, the private and academic sectors, and other interested parties and aims to manage a wide spectrum of issues: advocating professionalism, harnessing innovation, establishing standards ... The People that Deliver (PtD) Initiative is a broad coalition of organizations from around the world that strives to improve the health supply chain workforce in developing countries. It is based on global recognition that without trained professionals to manage the health supply chains, drugs and other health supplies do not reach the patients who need them.

Pamela Steele, CEO of PSA shares her ‘7 habits’ of highly successful health supply chain professionals. Crucially, for Pamela, habits are more than simple repeated actions - they are an overlapping combination of knowledge, skills and attitudes which empower you to move forward in the direction you wish, rather than reacting to events. Through these habits you realise your potential to become a leader and inspiration to your employees and colleagues…

7 Habits of the Successful Health Supply Chain Professional Insights into the field

BE PROACTIVE A successful professional in the health and humanitarian field must anticipate the future, doing whatever is in their power to improve the situation for stakeholders. Central to this is good research, of potential risks, of the unique situation of the supply chain in question, and of overall supply chain effectiveness.

KEEP YOUR END GOAL IN MIND

Of course, the ‘end goal’ of humanitarian work is almost always to save lives. This mission must be at the heart of every decision you make as a humanitarian professional. It is no use, for instance, for resources to arrive to where they are needed, if they are damaged and cannot be used. Always aim to produce the best value for customers and patients.

3. LISTEN FIRST

For best outcomes, supply chain professionals must always stay in tune with workers and recipients on the ground - what challenges do they face, and how can you help them?

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4. PRIORITIZE EFFECTIVELY

It is vital, in the interests of saving time and making effective decisions, that you plan and prioritise. You must move quickly and be bold, yet also stay flexible. For example, you must ensure that commodities which expire fast are delivered first.

As any successful health and humanitarian supply chain professional will tell you, 1+1 = 3.

EMBRACE INNOVATION

Effective humanitarian organisations must always balance experience with new talent, and keep abreast of the latest developments in the field. One step towards this is to ensure that all staff continuously receive fresh training and supervision.

6. ENCOURAGE DIVERSITY AND COLLABORATION As any successful health and humanitarian supply chain professional will tell you, 1+1 = 3. By this they mean that more can be achieved in a team oriented organisation which values relationships and where colleagues are motivated and conflict is dealt with swiftly. After all, human resources are the most important aspect of any company

7. CONSIDER STAKEHOLDER NEEDS

No organisation can last long without prioritising the needs of its various stakeholders. This requires high emotional intelligence and an eye for quality. Tips include putting faces to data, and presenting information in an accessible form which is more likely to spur decisionmakers into action.

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LEADING THE WAY... â&#x20AC;&#x2DC;Supply chain managementâ&#x20AC;&#x2122; may be the current buzzword in private sector industries, but it is a concept that is severely underused by governments in their logistical roadmaps. Yet in a world where highquality health care increasingly relies on teams, collaboration, and interdisciplinary work, supply chain leadership is essential for optimising health system performance. There is growing appreciation for the fact that supply chain leadership engagement and focus drives improvements in health care delivery quality, reduces patient harm and contributes to better health impacts. Sudanâ&#x20AC;&#x2122;s Ministry of Health has been one of the first government departments to recognise the importance of supply chain performance in

improving the provision of vital services. In a bold investment for the future, the National Medical Supplies Fund (NMSF) has foregrounded the training and professionalization of supply chain strategists and implementers in its policy. In this article we examine how this has led to the creation of an innovative and effective method of national health provision in Sudan. The NMSF was founded in 1991 as the Central Medical Supplies Public Corporation (CMS), before being renamed in 2015. As a parastatal organisation, it was designed to work within the government of Sudan while exercising a degree of discretion and autonomy in how it operated. It is rare that supply chain concerns are represented in the boardroom, but under the 19

Sudan senior managers at training run by PSA in Sep leadership of the Director General Dr. Gamal Khalafalla Mohamed Ali, the NMSF has been forging new paths in the area of national supply chain management. This is not an easy task given the lack of hard cash and the proliferation of sanctions, which has severely affected the supply of medicine to ordinary people in Sudan who have no connection to politics.

...Sudan's National Medical Supplies Fund 75% of its sales (the rest comes from private sector enterprises). Others include the Ministry of Finance and National Economy, the Central Bank of Sudan, the Directorate of Customs, and the United Nations Development Programme. These bodies provide specialised staff, funds for procurement, and budgets for distribution, depending on their area of expertise.

pt, Dubai 2015 (Photo: PSA) The NMSF derives its vibrancy from its multiple stakeholders, each of which makes a unique but essential contribution to the running of the corporation. NMSF stakeholders operate on a principle of continuous involvement, allowing them to discern exactly what is needed for its improvement. The Ministry of Health is the biggest player, providing NMSF with around

Instead of being tied down by generic government policies, the NMSF decides its own workforce policies, and this is a crucial aspect in how it is able to constantly reform and improve its operation. To prevent stagnation, the Director General leads an annual update of the supply chain strategy. NMSF is not just about 20

simplistic cost efficiency. In fact, it recently shifted from a policy that emphasizes cost as the primary consideration when choosing between competing producers, to a policy of qualityassured medicines.

There are 400 employees currently working for the NMSF, who are all part of a Continuous Development Programme (CPD) funded by NMSF itself. Director General Gamal Khalafalla wants to make sure that senior directors, middle-line managers and tactical staff were all trained to

Sudan sponsored 5 of its staff to attend health supply chain management courses in Dubai, 2016 (Photo:PSA)

be speaking the same vocabulary and operating on the same wavelength, in order to optimize supply chain performance at all levels. The annual number of trained employees has increased from only 10 in 2010 to more than 580 and the training budget increased from less than US$40,000 to US$670,000 in 2014. The building of a new National Training Centre in time for December 2016 is designed to bridge the gap between education and training, with a particular emphasis on managerial roles. Courses include Medicine Supply Management, Drugs and Therapeutics Committees and Pharmacoeconomics, as well as more general training in topics such as

Human Resources Management or Leadership and Organisational Change Management. This is in addition to engaging external firms to provide fresh perspectives on management. In September 2015, Pamela Steele Associates, a Supply Chain Capacity Development Company, delivered a five-day training course to eleven Ministry of Health officials. It focused on key topics such as leading strategy, leading change, and leading and developing others, for supply chain directors who operate in difficult situations where resources are scarce. In February 2016 they again sent 5 of their state and head office

staff to train in health supply chain management, and 13 of its second line managers to train in leadership and human resource management. NMSF has supported this general push for the professionalization of supply chain management by funding solid investments in infrastructure, tools and supervision, to create an enabling working environment for all. NMSF employees are encouraged to network with professionals such as Sudan Pharmacist Union and the National Institute for Medical Specialisation, in a system of active mutual support. Employees also have free access to more than 13,000 electronic journals and 25,000 electronic books, and frequently participate in workshops and conferences. The results are clear;

(Photo: PSA)

Director General Gamal Khalafalla reported that ‘the annual number of trained employees increased from only 10 in 2010 to more than 580 and the training budget increased from less than US$40,000 to US$670,000 in 2014. Pamela Steele, CEO and Founder of Pamela Steele Associates, commented that ‘having spent five rewarding days with them, I now know how committed the directors from Sudan’s Ministry of Health are to improving the lives of the people of Sudan’. Without a doubt, Sudan’s long-term investment in human resources through training, resources and continuous improvement stands out as a blueprint for future models of national supply chain management.

Spotlight on innovation: Part Two TransAid

A feature length insight into design innovation Article by Philip Matthews

TransAid is an international charity that identifies, champions, and implements local transport solution in the developing world. It was founded in 1980 because of a recognition that logistics and transport skills, something taken for granted in the UK’s commercial sector, was desperately needed to improve the efficiency with which humanitarian aid was being delivered globally. TransAid is focused on longterm development rather than disaster relief. This includes getting medicines to rural dispensaries, ensuring ambulance services operate effectively, supporting farmers to reduce their transport costs and training truck drivers to handle their vehicles safely. One of the main challenges faced by TransAid is that, due

CEO Gary Forster

to the nature of its work, the organisation must often reach communities in extremely isolated locations, the distance and harsh terrain making supporting such communities very difficult. However, as Gary Forster, CEO of Transaid, points out, “if it is hard for us to get to them, it’s even harder for them to access health facilities”. This point is brought home by a story Gary tells of TransAid's work in Madagascar: “Our greatest success? I can point to individual women, who were transported more than 40km by a bicycle drawn ambulance in rural Madagascar, and reached healthcare just in time to save their lives and that of their unborn baby”. Anecdotes such as these are indicative of a wider picture: reliable transport infrastructure is essential for ensuring access to medical care, and TransAid is leading the way.

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Indeed, the World Bank estimated 75 percent of maternal deaths can be avoided through timely access to essential childbirth-related care. Responding to this crisis, TransAid have introduced many innovative and community-led emergency transport interventions, which have enabled people to reach medical help. These include bicycle ambulances, ox and donkey carts, and motorcycle ambulances. In Nigeria, to pick a notable example, TransAid implemented an Emergency Transport Scheme to help transport pregnant mothers experiencing complications. To date over 10,000 women have been transferred to health facilities and in many cases those interventions were life saving for mother and child. An exciting current project for TransAid is called â&#x20AC;&#x2DC;MORE MAMaZ (Mobilizing Access to Maternal Health Services in Zambia). This aims to increase the use of maternal and newborn health services among rural communities in Zambia. The project is achieving transformational change for women and girls, particularly those who are under-supported at household and community level, by supporting government partners to scale up community engagement. Under MORE MAMaZ, rural communities are empowered to increase maternal newborn health awareness, address access and affordability barriers, and tackle underlying social problems that contribute to negative health outcomes, such as gender-based violence.

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However, despite TransAidâ&#x20AC;&#x2122;s achievements, there are still major challenges facing the health and humanitarian supply chain, a fact Gary Forster enthusiastically concedes: â&#x20AC;&#x153;In many cases the challenges facing health supply chains haven't changed all that much in the last 25 years. While governments have got better at managing their own medicine supply chains there is still high demand for skillsâ&#x20AC;?.

Looking to the future, Gary believes that the most pressing issues in need of reform are skills development and greater maintenance for equipment and vehicles in the health and humanitarian supply chain. If you want to discover more about the work of TransAid, visit their website at: http://www.transaid.org/.

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making sense of...

SUPPLY CHAIN INTEGRATION CHRIS WRIGHT, Senior Technical Advisor at John Snow, Inc., unpacks this innovative approach to supply chain logistics A strong health system cannot function without a well-designed, well-operated, and well-maintained supply chain management system. Supply chain industry research shows that the best commercial sector supply chains evolve through stages of maturity and improved performance (Lockamy and McKormack, 2004). Research on public health supply chains in developing countries illustrates that they also evolve through stages of maturity towards an integrated supply chain that links all people, information, and activities from the top-end (source of supply) to the bottom-end (customers seeking health services) of the supply chain (McCord and Olson 2011). The greater the maturity, the more agile and resilient supply chains are to respond to change, including the stresses of unexpected eventsâ&#x20AC;&#x201D;disease outbreaks, conflicts, environmental disasters, etc.â&#x20AC;&#x201D;that drive (and can disrupt) humanitarian response.

Figure 1: Supply Chain Maturity Framework (John Snow, 2012)

Integration can be viewed from different perspectives. Vertical integration considers the supply chain end-to-end; all actors, processes, assets, etc. Horizontal integration involves grouping products across health programs (HIV, reproductive health, maternal and child health, immunization) and commodity types (essential medicines, vaccines, injection devices, contraceptives, diagnostics) into common supply chain channels. Vertical integration provides greater visibility and data-driven 26

decisionmaking to analyze and optimize supply chains, guiding horizontal integration, product segmentation, network optimization, business process reengineering, and other performance improvement strategies.

Vertical Integration A vertically integrated health supply chain has visibility of information and activity up and down the chain, fewer steps in its processes, and greater coordination and predictability of demand between all the levels and

or distributing products together on the same truck; it can be a framework to characterize supply chain improvements within public health. However, focusing on the integration of supply chains for different programs will not automatically improve performance; ultimately, a more systemic approach is required. Furthermore, integration of products must be considered within the context of product characteristics. The most obvious characteristics are shelflife and special handling or storage requirements, such as cold chain. Therefore, any attempt to integrate products must also segment them according to common characteristics.

actors in the system. This includes linking all the actors involved in managing essential health commodities into one cohesive supply chain management organization. The organization can oversee all functions, levels, and partners, ensuring an adequate supply of essential health commodities to the clients who need them (John Snow, 2012). Drawing on commercial and public health experience, the supply chain evolution framework can help countries determine their current level of maturity and make a plan to strengthen their operations to achieve and track progress along the evolutionary trajectory (ibid).

Segmentation Segmentation

Horizontal (Product) Integration Horizontal (Product) Integration

Public health supply chains are not only growing, they are becoming more complicated. Current systems are less and less able to cope with the growing complexities. Supply chain segmentation offers a good solution for managers who want to streamline and consolidate program-specific supply chains, and who also understand that there is no one-size-fitsall solution in public health. Supply chain segmentation, a strategic tool, manages a wide range of products and improves efficiency by identifying similar characteristics in the products and/or its customers, who, in this case are the service delivery points. Products are placed into segments, which can then be managed as separate supply channels, based on the criteria and priorities within each segment. Cold chain products, short shelf-life products, bulky products, and fast moving products are common segmentation groups that are typically managed in separate

Horizontal or product integration combines the management of some or all logistics functions (e.g., procurement, storage, distribution, and logistics management information systems) for different commodity categories (e.g., family planning, HIV, malaria, and tuberculosis) into one shared supply chain. The most commonly merged functions are those of storage and distribution. The starting point for this type of integration is the assumption that disease- or program-specific supply chains are inherently wasteful and inefficient (USAID | DELIVER PROJECT 2011). As health care facilities increasingly offer integrated health care packages, all the products required for provision of these services need to be available. Historically, this has contributed to an understanding of integration as putting all products together on one truck. However, integration is not only about providing holistic health services 27

FURTHER READING:

supply channels. Vaccines are sometimes segmented into routine immunization and supplemental (campaign) logistics channels.

John Snow, Inc. January 2012. Getting Products to People: The JSI Framework for Integrated Supply Chain Management in Public Health. Arlington, VA.: John Snow, Inc.

Benefits of Integration Benefits of Integration Integrated supply chains have collateral benefits for a health system. A cohesive, well-performing public health supply chain helps build the foundation for a strong pharmaceutical management system, provides essential information for managing health programs and financing mechanisms, and helps to achieve the level of accountability exemplified in the commercial sector. An integrated supply chain management organization has the capacity to learn from errors, selfassess, and adapt through continuous improvement processes. It leverages resources from all parts of the supply chain and enables rational implementation of innovative new technologies.w technologies.

Lockamy III, Archie, and Kevin McCormack. 2004. â&#x20AC;&#x153;The Development of a Supply Chain Management Process Maturity Model Using the Concepts of Business Process Orientation.â&#x20AC;? Supply Chain Management: An International Journal, vol. 9 no. 4: 272-8. 2 McCord, Joseph and Nadia Olson. 2011. Supply Chain Evolution: Introduction to a Framework for Supply Chain Strengthening of Developing Country Public Health Programs. Arlington, VA.: USAID | DELIVER PROJECT, Task Order 4. USAID | DELIVER PROJECT. 2011. Supply Chain Integration: Seamlessly Linking the Pieces. Arlington, VA.: USAID | DELIVER PROJECT, Task Order 1.

Insider Information 5 Things the Health and Humanitarian supply chain can learn from FMCG Article by Ross King

How is it then, where medicine is involved, there is still a 75 day delay between a manufacturers' production and its delivery?

Thanks to modern economies of scale and highly efficient supply chains, the developed world now benefits from almost instant gratification. A customised computer from Japan takes only a week to be assembled and arrive on the other side of the world; clothes from Vietnam are made, shipped and sold globally in the same breath. In order to buy local food, it has become necessary to buy from a special range of organic or locally sourced produce instead of the now common-place imported variety. How is it then, where medicine is involved, there is still a 75 day average lag time between production and delivery to the developing world? Demand for medicinal aid is high, owing to new and extant international crises like the Zika Virus and Ebola, yet despite these pressures, the global health and humanitarian supply chain remains clunky and inefficient. In order to better serve people in need of support, here are 5 lessons we can learn from the world of Fast Moving Consumer Goods.

1. Segmentation

By effectively splitting up the different available markets and goods into more specialised categories, supply chain inefficiencies can be reduced by segmentation according to the characteristics of products and the requirements of customers.

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Agility

The ability to change and respond quickly to emerging crises or changing consumer demand is crucial for humanitarian agencies. Therefore, building an operating model that can better respond to demand shifts and customer wishes is paramount.

3. Measurement

Consumer-goods companies use metrics such as the manufacturingfrequency index to measure the share of SKUs that are produced with high frequency. This is something that could be implemented by healthcare providers to increase supply chain efficiency and cut down on costs.

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Alignment

In order to build a cost-effective supply chain, the health-care sector needs to adopt practices already found in the FMCG sector. Global standards can be created and implemented (such as international barcodes) to facilitate data interchange, processes and capabilities. These global standards may also help to reduce the circulation of counterfeit medicines and thus improve quality of care.

5. Collaboration

Barriers to effective communication and partnerships are often cultural as opposed to technical. However, for any mutually beneficial partnerships to emerge, all parties must share a common set of values and goals including a long-term vision, willingness to share information, and work as a team.

By working to improve both individually and collectively, these 5 key elements can be put to good use in order to radically change the way the health and humanitarian supply chain works, and help those who need it most.

Sources: McKinsey online articles / HLA / PSA blog. .................................................................................................................................................................................................... 31

Counterfeit Drugs: old enemy, new solutions. article by Oscar Boyd

Tech leads the way in the fight against counterfeit medicine: An email pings into your inbox promising untold riches. A member of west-african royalty is in need of your assistance, just transfer him ÂŁ100 and the money will be yours. It is clear that this is a fake, a ruse designed to trap the most gullible. Trash it, and no harm is done.

When it comes to medicine, however, fakes are rather more difficult to spot. For someone with technical knowledge and a mind for crime, substances such as chalk, flour and starch can be shaped to imitate any pill on the market. Labelling and packaging are likewise copied to create a product that looks, in every way, identical to the real thing. Without specialist equipment, there are few means of telling the real from the counterfeit, until people fall sick or die from untreated illnesses. The ease with which copying can take place has allowed the counterfeit industry to thrive across African nations, where it is now a multi-billion dollar industry. The World Heath Organisation estimates that in some regions of Africa, over 30% of the

medicines on sale are counterfeits, a figure that applies to both branded and generic varieties of medicine. The International Policy Network, a British think-tank, estimates that globally, 700,000 deaths a year are caused by fake malaria and tuberculosis drugs, with approximately 100,000 of these deaths in Africa alone. In an especially tragic case in November 2008, children in Nigeria started to die following unexplained fevers and vomiting. Three months and 84 deaths later, officials traced the illness to a medicine called My Pikin Baby Teeth Mixture, a painkiller syrup not dissimilar to Calpol. The cause of these deaths was simple, but disastrous. An unlicensed chemical vendor in Lagos had sold My Pikin counterfeit propylene glycol - a common medical solvent - which was then added to batch 02008 of the Baby Teething Mixture. Instead, the chemical was diethylene glycol, which, whilst similar in look and smell to propylene glycol, is used as an industrial solvent to make antifreeze and break fluid. When ingested, diethylene glycol attacks the nervous system and causes liver damage and kidney failure. In this case, three-quarters of the children made sick by batch 02008 of My Pikin Baby Teething Mixture eventually died. Illness and death are not the only consequences of counterfeit medicines, bacterial resistance is also emerging as a serious threat. A study published by the International Journal of Tuberculosis and Lung Disease found that 9.1% of drugs sampled worldwide failed basic quality control tests. The failure rate in Africa was 16.6% or about one in every six pills. Poor quality pills are less effective when combatting common bacterial infections such as tuberculosis, contributing to the dramatic rise of resistant strains in Africa and Asia. A crucial issue in the fight against counterfeits is weak enforcement. A lack of training, manpower and issues with corruption have crippled national enforcement agencies and allowed for the proliferation of counterfeits. Whilst some progress is being made at the government level - such as Nigeria and Cameroonâ&#x20AC;&#x2122;s counterfeit drugs cooperation agreement - it has been left to enterprising start-ups to fill the regulatory void. Start-ups such as mPedigree Network and Sproxil have designed systems that allow legitimate drug manufacturers to label their packages with encrypted codes. To verify a medicineâ&#x20AC;&#x2122;s legitimacy, consumers simply scratch off the label on the package and text the code free of charge - to the company that maintains the system. If legitimate, the company will then send a confirmation to verify the medicine. These start-ups are proving revolutionary. Clients of mPedigree include the drug companies AstraZeneca, Roche and Sanofi and the company has offices in Egypt, Ghana, India, Kenya, Nigeria, and Tanzania. With over three quarters of the worldâ&#x20AC;&#x2122;s population owning a mobile device - a figure likely to rise - smart-verification options have huge potential to reduce the trade in counterfeit drugs and the deaths and illness associated with them. 33

Mainstreaming Gender: Health and Humanitarian Supply Chains

Women in the aftermath of the 2005 Tsunami (Photo: UNFPA) Last December, PSA initiated and moderated an IAPHL online discussion entitled ‘Mainstreaming Gender in Health Supply Chains’. Here we see an exclusive report on the results of these discussions.

individuals who occupy a range of positions within health supply chains including pharmacists, programme managers, senior advisers, supply chain consultants and programme directors.

The discussion was carried out in three sessions, including ‘The impact of gender on health supply chain delivery’, ‘Mainstreaming gender in health supply chains’ and ‘The impact of HR policies on gender balance in health supply chains’. With a total of 32 responses from 13 different countries, this online discussion captured a variety of viewpoints from

The question of why there are so few women in health supply chains and humanitarian logistics has recently risen to prominence within the health logistics literature. There continues to be relatively few female humanitarian logisticians in health supply chains, and this is particularly worrying given that responding to the gender-specific 34

requirements of end beneficiaries is central to the overall humanitarian aim. The role of a humanitarian logistician starts with evaluating the requirements of both male and female beneficiaries, ensuring goods are delivered to address those needs, and guaranteeing all beneficiaries access. An example of gender insensitivity in humanitarian logistics was seen in the aftermath of the Indian Ocean tsunami of 2004 where the distribution of sanitary items was controlled by male officials who gave them out one at a time, forcing women to go back repeatedly to ask for more (Steele, 2014). Further, and a particularly striking example of a gender insensitive response to a humanitarian disaster, was the purchase of poorly designed items such as translucent tents which showed when females were inside alone, thus heightening the risk of sexual violence (WISE, 2006). In short, gender sensitivity remains a challenge in humanitarian logistics and it is argued that this situation would be ameliorated by the presence of female logisticians who would be better placed to anticipate and meet the needs of female beneficiaries. So why are there fewer female logisticians in supply chain provisions? The second moderated discussion sought to untangle the reasons for this. Participants suggested several factors, including the difficulty of combining work and family life, as well as the maledominated image of the logistics industry. This points to a wider issue of the underrepresentation of women in logistics education. In a study conducted by Euphoria Consulting (2009), less than 30% of logisticians regard schools and universities as supportive in encouraging women to join the industry. Once they do enter the industry, women are less likely to achieve managerial

roles. Many industry codes of conduct, even those that deal specifically with gender issues, fail to address deeply embedded structures of inequality such as low wages and the designation of females to the lowest paid, most insecure jobs. A study of 20 workplace codes conducted by Person and Seyfang (2001) found that only a third related to sexual harassment, a tenth covered reproductive health and all were poorly monitored and inspected. This may seem to paint a rather gloomy picture about the state of gender in health supply chains. However, the third moderated discussion led to some exciting suggestions for how to change the perception of the logistics industry, as well as its practices. It was agreed that female workers should be consulted with at each stage of the design and implementation of codes if they are to be truly gender-sensitive Indeed, individual organisations need to assess how to reduce any barriers women may face to employment, including soft solutions. For example, different wording of a recruitment ad might attract more women to apply. Once in employment, one participant pointed out that men are promoted on their potential whilst women are judged primarily on their performance, and identified the need for a more rigorous standardisation of practices. Companies should provide women with good maternity allowances including observing the mandatory maternity period and helping with the costs of childcare; and organisations should award women deserved managerial positions. There is still much work to be undertaken in order to change attitudes and see more women as humanitarian logisticians but it is suggested that, through cooperation and over time, this goal is not completely out of reach.

UNICEF Logistics Specialist Silvia Uneddu inspects supplies. (Photo: UNICEF)

Internal Affairs

Oxford University interns share their experiences from a week working at PSA. Pamela Steele Associates (PSA) is carving out a niche in the Oxford area for its international development training schemes. However, this small company is also offering opportunities for local growth in the form of its internship programmes. programmes PSA, in conjunction with Oxford University, offers 2 different kinds of internships: a full summer at the company or a ‘micro-internship’ for just one week. Either way, new recruits are thrust into the heart of operations from day one, and can be seen working alongside staff on major projects from the outset, helping to manage sponsored events, or even heading up their own programs. One recent intern, Rishan de Silva, single-handedly produced a strategy for PSA’s branding and marketing, coordinating the business’ growing online presence and resources with existing models.

(Photo: PSA) We started out cautious, thinking about articles we could write and tentatively emailing small companies in the hope they would get back to us. A meeting with Pam completely blew this out of the water. She listened to our ideas and encouraged us to be bolder in our vision, to not only broaden our scope of articles, but also to approach experts in the field for both content and sponsorship. Armed with suggestions for contacts and a host of new ideas, we got to work. We were amazed at the response we got: people were extremely encouraging and generous with their time and efforts, and this in turn inspired us to push for a higher quality in our work. Pam constantly checked up on us and sent us new ideas and avenues to pursue, so that the project was developing right up until the last minute.

So, while the average internship can sometimes offer little more than an excel spreadsheet masterclass and other lessons in copy and paste, PSA takes an entirely different approach. At the beginning of our week here, we were presented with a task that may have seemed gargantuan in its scope and ambition to be completed in less than 5 days: organise, create and source the content for a new magazine. Not only this, but we would have to design the layout ourselves, find funding from sponsors, advertisers and donors, assess the potential for printing and distribution in the UK and internationally, all by the end of the week.

This week has been a whirlwind. We’ve been mastering completely unfamiliar 37

topics to turn into articles, taught ourselves how to use a formatting and design programme for the magazine layout, as well as conducting sustained correspondence with some extremely inspirational people from the field. The PSA micro-internship has taught us how much can be achieved if the right kind of positive pressure is applied, and that is something that will remain with us for much longer than this one short week. We hope you enjoy the magazine, and look forward to future publications from Pam and her growing team!

Philip Matthews: Philip is a second year History student at Exeter College. Originally from Scotland, he enjoys debating, squash and playing guitar. Yuna Chang: Yuna is a third year History student at Wadham College. Ross King: Ross is a third year student at Pembroke College, specialising in Arabic and Islamic Studies. He has recently undertaken a year-abroad in the Middle East, during which he played rugby with the Jordanian national team.

Intern team with PSA Programme Support Officer, Anna Tighe. (Photo: PSA)