HEALTH & HUMANITARIAN The Supply Chain Review Issue 5, January 2018
Published by Pamela Steele Associates
ABOUT US EDITOR IN CHIEF Pamela Steele Sara A. Khan
Table of
Contents
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PROFESSIONALISATION CORNER with Joanie Robertson, PATH Continuous Improvement in Action, Vaccine Distribution in Equateur, DRC Procurement Reforms in Timor-Leste Yeksi Naa, the Informed Push Model
Training Health Care Workers in the use of new Technologies Blog: Strong collaboration and knowledge-exchange
Photo © Depositphotos
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Pamela Steele Associates Ltd. Prama House 267 Banbury Road, Oxford PH NUMBER +44 (0) 1865 339 370 OX2 7HT, United Kingdom www.pamsteele.co.uk info@pamsteele.co.uk
Editor’s Note Some would say that global health supply chains are becoming increasingly complex as the global market is changing and demand from developing economies is creating a sector that is hard to navigate. This is resulting in fragmented and weak public health supply chains, putting lives at risk for millions. With a growing number of disasters in the world, relief efforts are making humanitarian logistics and supply chain in humanitarian settings a complex venture as well and reaching those in need has proven to be difficult, putting added pressure on those who are trying to meet the critical challenges of an emergency. As we have stepped into 2018, we join the sector in asking what can be done to really improve global health and humanitarian supply chains, so that quality products can reach even the most difficult to reach communities? Many would argue that the answer often lies in implementing new technologies for a stronger and better performing supply chain. Progress is being made and organisations are using various supply chain models to make their supply chain successful. However, by bringing together new technical solutions with innovative practices, one may see a more rapid improvement in global supply chains. Technology can play a major part in ensuring better data visibility, end-to-end tracking of products and sharing of information among stakeholders for a significant impact on health outcomes.
RPAs, drone technology. These terms and better technology awareness may soon be something most supply chain professionals will have to know well as partners, donors and governments are pushing for stronger use of technology. Especially the use of UAVs or unmanned drones have proven to be an effective and cost-saving way to reach remote communities. UAVs for medical products have been tested in countries such as Rwanda and Vanuatu with the support from major donors1. However, the successful use of technology is only possible when people and processes are supporting the change and one looks at the supply chain system in a more holistic way. In this issue, we highlight people and systems that are making a difference in supply chain management. Whether it is the “Yeksi Naa” project in Senegal or the implementation of the mSupply system for SAMES in Timor-Leste, they are all part of a larger global effort to make sustainable improvements to health and humanitarian supply chains. With qualified and talented professionals in the field such as Joanie Robertson, featured in the ‘Professionalization Corner’, we are confident that new technical solutions combined with innovative practices will lead the changes in the supply chain sector in the future. We would like to thank all the contributors for this issue. Without their support and willingness to share their stories, this would not have been possible.
The terms are many and can be confusing to the layperson: mobile technology, SCMIS, eLMIS, UAV,
We hope you enjoy the issue!
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or http://unicefstories.org/2017/07/28/drones-for-good-
https://www.technologyreview.com/s/608034/blood-fromthe-sky-ziplines-ambitious-medical-drone-delivery-in-africa/
participants-in-vanuatu-drone-trial-take-vaccines-to-theskies/
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PROFESSIONALISATION CORNER A conversation with Joanie Robertson Joanie Robertson is a Senior Program Officer with international non-profit PATH. She is an engineer by background, but has now a successful career in global health working with supply chains. Her expertise has especially been within the use of technology to strengthen and improve immunization supply chains.
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background, my international travel experience, and my work in health system project management were the three legs of the stool that made a good support for my entry into PATH’s work on appropriate technologies for public health”. Joanie is now based in Seattle, USA at PATH’s headquarters, but her career has given her the opportunity to travel and work with talented colleagues across the globe. “I had the great fortune of living in Vietnam for four years, where I worked with colleagues at PATH and in the Ministry of Health to explore the impact of innovative technologies in the immunization supply chains”. Her work in Vietnam gave her an in-depth knowledge of health supply chain issues and challenges for LMICs, knowledge that she still relies on today in her projects with PATH.
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rofessionals in the development sector often claim that they have landed in this profession in an unexpectant and indirect way. It holds true for Joanie Robertson as well, who started her career as an aeronautics engineer. “Out of high school, I followed my interest in airplanes and applied my strengths in math and science to a degree in aeronautics and astronautics engineering, and later even got a private pilot license! But my career in engineering was short-lived, as I was drawn to work that focused more on people than on machines.”
What drives Joanie’s work with global health supply chains? The complex nature of health supply chains has kept her engaged in the sector. She is still challenged by the fact that there are never any easy answers to the challenges you face in global health. These days Joanie is focusing on the use of drone technology for health supply chains, a topic that has received much attention recently. She feels that; “there are a lot of unanswered questions about the appropriateness of drones and whether they can bring sustainable improvements to health supply chains”. She is confident that PATH can play an important role in this development by
“…I was drawn to work that focused more on people than on machines.” In 2001, Joanie started her career in global health and immunization supply chains with the international non-profit organization, PATH. Her interest in global health was triggered after working within healthcare administration and travelling through Asia and Africa. “The combination of my technical engineering
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“It’s easy to focus on technologies, but technologies by themselves are not enough to improve health supply chains” researching and evaluating drone technologies to explore whether they can add real value to health supply chains and thereby improve health outcomes for people. She points to an important fact; “It’s easy to focus on technologies, but technologies by themselves are not enough to improve health supply chains. They need dedicated and well-trained workers, strong management with clear protocols and procedures, careful planning, and reliable physical and information infrastructure to work right”. This way processes, technology and human resources, all critical parts of a single system, come together to support the supply chain system. Joanie believes that success stories in the sector are often seen where a highly motivated and committed individual, who understands the system is making things work based on his/her experiences and skills. Joanie wants organisations to “pay attention and learn from those people” as these individuals are making a true difference for public health.
“We all have a role to play in recognizing where there is gender imbalance” 6
Joanie realises that, much like other sectors, there is still a gender imbalance within the more technical components of the health supply chain, such as cold chain technologies. “If I look at the colleagues I interact with, including country cold chain managers and cold chain technicians, colleagues who work on equipment prequalification, and colleagues who work for the companies that design and build cold chain equipment, I see mostly men”. However, change is taking place and more women are entering the field of health supply chain. She gives us an
example of a programme in Uganda, where the manager for the cold chain team for Uganda’s National Expanded Programme on Immunization is a woman and has several female technicians and colleagues on the team along with her. Joanie emphasizes that; “we all have a role to play in recognizing where there is gender imbalance, and doing what we can to encourage women into the field, hire women when we have open positions, and develop women who are already in these careers. A little bit of awareness, and a commitment to change at an individual level, can make a big difference”. PSA would like to thank Joanie Robertson for taking the time to speak with us and we wish her well as she continues her journey in public health. Photo © PATH & depositphotos/mipan
Looking for a resource on Supply Chain Capacity Development? This is your answer. "Theory of Change for Supply Chain Capacity Development" By Pam Steele and Andrew Brown The book describes a holistic and practical approach to formulating strategies for strengthening nationallevel supply chain systems in a sustainable manner.
Available online through www.amazon.com.
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Continuous Improvement in Action Vaccine Distribution in Equateur, DRC By Clement Ngombo, VillageReach
By boat and motorcycle, it took almost an entire day to travel the 90km from Mbandaka to Bokolomwaki Health Center in the northeastern corner of the Democratic Republic of Congo. Bokolomwaki was one of the first stops on a ten-day loop to distribute vaccines to 30 storage facilities and the 58 health centers relying on them. Beginning of July 2017, the Equateur Division Provinciale de la SantĂŠ (DPS), with the support of VillageReach, began vaccine distributions in three health zones. Optimal routing was determined based on computer models and in consultation with health officials. In this new approach, two logisticians deliver vaccines and family planning products directly to health centers with sufficient cold chain storage as well as zonal warehouses. The zonal warehouses hold the stock needed for nearby health centers that are too costly to reach directly or do not have cold chain equipment for storing vaccines. The VillageReach team joined the distribution in December of 2017 to provide supportive supervision and mentorship to health care workers. Training and support during each distribution is important for the continued improvement of the supply chain. Over the last year, the DPS and VillageReach provided training on supply chain
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management, and we joined this distribution to reinforce best practices. We used “zapp theory,� which is focused on giving positive energy, so people feel respected and encouraged. We also helped the health workers give and receive constructive feedback. In this way, we celebrate their work and support them to do better than before. Many health workers had never received training on supply chain, so this supervision was also a boost to their confidence.
Vaccines are delivered to Lolanga Health Zone on motorbikes over difficult terrain.
longer have to close their clinics and travel long distances to pick up vaccines and family planning products; they can now spend time vaccinating more children. The new delivery system has brought relief to facilities that were unable to conduct clinics because of stockouts. We also found solar refrigerators provided by Gavi and other donors in these remote health centers. The vast majority of refrigerators were fully functional when we delivered vaccines and cold boxes were available for storage and delivery to even more remote facilities.
A mother travels to the health center on a small traditional boat in order to vaccinate her child.
We have learned a lot over the past several months, and have been able to constantly improve our approach. Data quality was suffering in part because health facilities had run out of logistics management forms. Logisticians began carrying extra forms on future distributions and reviewed these forms with health care workers to reinforce data use at the lowest levels of the supply chain. These distributions have also provided an opportunity to understand the “why” behind stockouts – focusing on collecting the data that will tell us where the breakdowns occur. One challenge we recognize is the need for better outreach – it is not realistic in these areas to wait for children to come to the health center.
As 2018 gets underway, we are reflecting on our experience gained during the past six months. We will continue focusing on improving the culture of data use from data collection to analysis and sharing our successes. We will also work with health officials and health workers to ensure that every child, wherever he is, is reached by vaccines. What we learn in DRC will contribute to VillageReach’s work to create more efficient supply chains, and ultimately more reliable access to health products.
On the positive side, health workers are excited by this new system because they no
The VillageReach team traveled with Dr. Joel Bompongo, Head of the EPI in Equateur Province, to Konongo Health Zone on a vaccine distribution.
Photo © VillageReach
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Procurement Reforms in Timor-Leste Large savings and improvement in quality
By Alexander Bongers, Sustainable Solutions
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ubstandard and falsified medicines affect every country in the world, but in particular low to middle income countries. In 2017, Timor-Leste’s Medical and Pharmaceutical Supply Agency (Serviço Autónomo de Medicamentos e Equipamentos de Saúde - SAMES) in partnership with the World Food Program (WFP) has introduced a more cost-effective procurement system, whereby suppliers are selected based on their ability to provide a selection of low-cost and
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high quality medicines, from a list of essential and non-essential medicines. WFP is supporting SAMES to improve its procurement process, and previously supported the implementation of an online tracking system of medical and nutritional supplies called mSupply for health facilities in Timor-Leste’s capital Dili.
mSupply is a stock management software designed for health commodities. It is currently used in many countries around the world, including Africa and Asia-Pacific. SAMES and WFP have supported the implementation of mSupply mobile in referral hospitals, district warehouses and health centres in Timor-Leste. Timor-Leste is now the largest user of mSupply mobile in the world with 100 active sites. The system allows facilities to order stock electronically, issue stock to patients and complete stocktakes. The new system has reduced lead times from months to weeks and allowed donors to track stock as well as producing usage data to improve the procurement process.
difficult, increase prices and reduce supplier performance in major contracts. Implementation of the line-by-line tendering has improved the average purchase price of each medicine by 30-50% and saved SAMES substantial cost in procurement of medicines. To facilitate line-by-line tendering, SAMES used the mSupply online tender module. This module allows SAMES to accurately evaluate the prices of medicines submitted by suppliers. The savings made on these annual tenders has allowed SAMES to purchase more critical medicines as well as speed up the procurement process. The successful implementation of the procurement system has required engagement with multiple stakeholders. Surveys and site visits were completed at health facilities in multiple districts to determine which software and hardware would be most appropriate for the needs of each facility. Training was conducted for pharmacists and directors from each health facility on mSupply mobile and supply chain management. To complete the process, on-site implementation and follow up training was completed at all health facilities.
As part of the procurement reform, SAMES completed their first round of prequalification last year and are now working with 10 prequalified companies from Portugal, Australia, India and the Netherlands for all major medicine and consumables tenders. For Timor-Leste, prequalification has proven to be a highly effective intervention to ensure SAMES is working with reliable suppliers who can provide high quality medicines. The improvements in the procurement process has meant that SAMES has moved to a “lineby-line� tendering system. Previously, SAMES procured all health commodities by purchasing medicines in lots or groups. This method of procurement can make the evaluation process
Through the use of online web dashboards, a range of data can be shared with any number of stakeholders and has resulted in greater transparency between SAMES, the Ministry of Health and donors working in Timor-Leste.
Photo Š Sustainable Solutions and depositphotos/Iconcept
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Photo Š Depositphotos
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Yeksi Naa The Informed Push Model - lessons from Senegal by Modibo Dicko, Consultant, Health Supply & Solar Systems
In 2012, Senegal had a high unmet need for family planning equalling more than one-fourth (29%) of women. Similarly, the modern contraceptive prevalence rate (mCPR) was a mere 12%. Recognizing the critical impact of family planning on maternal mortality, the government of Senegal committed at the 2012 London Summit on Family Planning to increase the country’s mCPR from 12% to 45% by 2020.
A baseline survey conducted in 2011 by Senegal’s Urban Reproductive Health Initiative (ISSU), a project funded by the government of Senegal’s Ministry of Health and Social Action (MoHSA) and the Bill and Melinda Gates Foundation (BMGF), with technical support from IntraHealth International (IHI), found that sizeable proportions of urban publicsector facilities regularly experienced stockouts of key contraceptive methods. Stockouts, a key barrier to family planning access and often a sign of a broken health supply chain, were frequent in Senegal’s public-sector health facilities, where 85% of Senegalese women seek reproductive health
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services. There was in fact inventory housed in central warehouses at the national level bus last-mile distribution seemed to be the problem. And it was threatening to undermine Senegal’s commitment to reducing maternal mortality. Senegal’s supply chain used a highly complex order-based “pull” system. “Pull” supply chain strategies are driven by customer demand but tend to minimize stock on hand. Senegal’s system relied on health workers—who typically lack sufficient logistics management training—to accurately forecast, track, and order contraceptives and who then must travel monthly to regional or district warehouses to pick up supplies. However, these logistics duties impeded health workers’ ability to focus on their primary role, namely, providing highquality health and family planning services to clients. To address these problems, the ISSU Project implemented a pilot, an innovative distribution system called the “Informed Push Model” (IPM) in two Senegalese districts adapting principles used in the commercial sector to address common supply chain obstacles of transportation, quantification, availability of data, and financial flows. To this end, thirdparty logistics operators (3PLs) engaged through performance-based contracts collect facility-level consumption data and distribute contraceptives to facilities in a timely, consistent manner. Over a period of 6 months they completely eliminated stockouts of contraceptives in the two pilot districts. After such a successful implementation of the pilot, the MoHSA and their partners – IHI, BMGF and MSD for Mothers (MfM) – committed in November 2012 to a three-year, phased national expansion of IPM. The IPM was scaled up over a two-year period (2013– 2015), to 1,404 health facilities in all 14 regions of Senegal.
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Whereas the previous pull system required upfront payment, the IPM charges facilities postconsumption. Facilities are charged only for the stock that was consumed, and only after it has been consumed. An electronic logistics management information system (eLMIS) allows for mobile data collection and real-time data on deliveries, consumption, and costrecovery. The data is uploaded to a web platform and made available to managers at central, regional and district levels. In the entire country, contraceptive consumption increased by 32.5% from April 2015 to July 2017. This new IPM-3PL system reconfigured the flow of goods, money and information, boosting performance while reducing costs. With this shift, IPM eliminated the main causes of stockouts. After the IPM-3PL was extended to serve all 1,400 health facilities across the country, consumption jumped 48% over one year nationwide. Meanwhile the system was extended to about 100 health products that,
according to the national primary healthcare policy, go up to peripheral health facilities incl. products of public health programs (Malaria, TB, AIDS), UN lifesaving commodities and essential generic products. Senegal has integrated the IPM 3PL system into the country’s central purchasing department, renaming it ‘Yeksi Naa’ (“I have arrived”). The integration of the Yeksi Naa system has led to an increase in availability products at the service level; and their availability is fuelling consumption that is rising while getting closer to real needs of the population. The success of the project is due to the implementation of many different innovations and strategies; The very idea of implementing an “Informed Push Distribution Model” represented a major innovation in Senegal's healthcare supply system, as well as in most—if not all— countries in Africa. The phased approach to the IPM project succeeded to enrol Regions in a gradual way, while adapting approaches to local contexts in a participative process involving health system staff members at all levels. By doing so, the
Project secured a quality implementation of project activities across all Regions. Leveraging public-private partnerships with 3PLs makes it possible to reduce the publicsector needs in terms of staffing and investment, while promoting private-sector job creation and added value. From the start, the Project decided to hire existing cadres of health workers and to provide them with solid training and coaching in health supply chain management. This facilitated relationships between Project staff members and their counter-parts of the health system. A better healthcare supply chain integration was a key factor for the success of Yeksi Naa project as well. The integration of several health supply chains into one, helps strengthen not only the health supply system, but also the health system as a whole. The Yeksi Naa system is designed in a sustainable manner with strong political by-in so and will have a positive impact on the Senegalese population. Photo © Depositphotos
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Training Health Care Workers in the use of new Technologies By Shubha Varma, Nexleaf Analytics and Denisse Ruiz, Nexleaf Analytics Integrating new technology is often key to modernizing health supply chains. However, introducing new devices and protocols to healthcare workers can present many challenges. Workforce ability to interact with and respond to new technology is often the missing link between innovation and impact. Nexleaf has deployed over 14,000 devices in 8 countries in the health and climate change sectors and has trained many professionals on managing technology and responding to data. Based on this experience, Nexleaf suggesst best practices for technology training to avoid common pitfalls and ensure successful uptake of new technologies. Technology trainings should offer more than rote lectures on the features of a new gadget. Rather, they should emphasize how the technology is intended to serve healthcare workers and health systems goals. Focusing on people rather than the technology leads to greater personal investment from workers, increased technology uptake, and better outcomes.
importance, and it is also useful if trainees have questions beyond the scope of the technology.
Before Training
Conduct a Trainee Pre-Assessment Assess trainee language preference, educational profile, cultural sensitivity, and exposure to other technologies.
Ensure the technology training component has an adequate, designated time frame If the technology is being rolled out as part of a larger program, it is critical to ensure that a clearly delineated time slot is allocated for training workers on the technology specifically. Involve the Ministry of Health (MoH) Encourage MoH personnel to attend trainings. The MoH’s presence conveys the project’s
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Provide adequate accommodations and resources for trainees Group sizes should be limited to 25 to 30 health workers. Workers traveling to attend trainings should be fully informed of accommodations and logistics plans beforehand.
Generate a clear curriculum and print materials Prepare a training complete with any visuals (slides, videos) customized for the group. Plan to distribute materials for trainees to keep and reference in the future.
Arrange video-recording Plan to video record trainings to help mitigate the impact of any health worker turnover after the session. During Training Present clear objectives for the training session at the beginning Explain the material that will be covered and what the trainees will be expected to know by the end of the session. Acknowledge apprehensions Reassure trainees that the new technology will help them and is not intended to replace their jobs, get them in trouble, or make their jobs more difficult. Provide context Explain why the Ministry of Health chose to implement this specific technology and how it relates to larger country goals. Link the technology to everyday tasks and decision-making. Explain how the technology relates to and integrates with the trainees’ day-to-day responsibilities. Draw analogies between the new technology and devices trainees already use, such as cell phones.
After Training Iterate on the curriculum and training materials Each round of trainings will reveal shortcomings of the current materials and generate insights for improvement. Incorporate results from the assessments into this process. Conduct refreshers Refresher trainings several months later provide an opportunity for personnel to ask about problems they cannot solve independently, relearn concepts they may have forgotten, and share positive stories about the technology. Train in-country staff to troubleshoot Train a group of healthcare workers in the country to perform advanced troubleshooting support. Provide greater detail about the hardware, functions, installation, and maintenance. Build community Encourage the use of communications tools after trainings end. For example, set up WhatsApp groups for trainees to foster group problem solving and using one another as a resource.
Demonstrate the technology in small groups. Small group sessions (6 to 7 people) ease anxiety by allowing trainees to touch and interact with the technology and to ask questions outside the larger group setting. Recognize trainees that are comfortable with the technology and encourage them to lead others Empowering quick learners during the training gives those individuals a sense of investment in their peers’ comprehension as well as the technology’s long-term success. Conduct End-of-Training Assessments Keep the questions simple, and ensure they reinforce the most important concepts.
This is not an endorsement by PSA of any training offered by Nexleaf Analytics. Please enquire directly with Nexleaf Analytics for more information.
Photo © Nexleaf Analytics and Depositphotos
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Strong collaboration and knowledge-exchange - the way to successful learning BLOG by Sanjay Saha, Head of Training, PSA
The training room, ‘Kifaru’, was finally set late in the evening for the Health Supply Chain Training to start the following day. The folders were arranged as per the training language; English and French. The environment of the room was ideal for a crosslanguage and cultural exchange for the next five days. The next morning, the participants started to arrive by 8am for registration and first session of the training. The participants were surprised to learn that the opening session of both classes will be in the same room. The training on this occasion was designed in a way that participants from both groups, English and French, learn from the facilitators during the sessions and then share each other’s perspective during the breaks and the evening meals. The opening session started with introductions of the program, the trainers, the schedule and finally the trainees themselves. It was encouraging to see that a few trainees tried to introduce themselves in both languages, and it showed that they welcomed our idea of taking the training together and were ready to learn and get to know each other during the coming days. The first day of the training is theoretical, where we are trying to make the participants think in a logical and structured manner about the concepts of supply chain and how to apply them for health commodities, and thus using the framework approach is useful. However, being didactic in nature, it always slows the trainees down after a couple of sessions and hence the last session of first the day was to test the framework approach with the trainees. The participants were asked to sketch the supply chain of their country. Some of the trainees were overwhelmed with the task as they had never done this kind of an exercise before. However, once they started to draw their public supply chains, they realized the relevance of the exercise where they could see various stakeholders and complexities involved in the supply chain. Once the diagrams were drawn and everyone could see the supply chain design of each other’s countries, they realized that they had lots to learn from each other.
As a trainer and Head of the Training Department, it was quite pleasing to see that the next morning the participants arrived much earlier than expected and discussed the topics taught on Day 1, especially the supply chain diagrams. This made me realize how the first day of the training is important as the foundation of the course. Over the next few days, I saw a group of like-minded people in the training room rather than candidates from nine different countries, learning, laughing exchanging knowledge with each other. While handing over the certificates to the trainees on the last day, I could sense the joy and happiness they felt for each other’s accomplishment as they were trying to capture those moments on cameras and phones. However, I also sensed that the candidates felt saddened by the fact that the training was over, and they would have to go back. After the successful training, I recognized that our goal of creating a bond between these professionals was achieved and they have come together as one group united for the sake of seeking knowledge and strengthening their supply chain management knowledge. Photo © PSA
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Health & Humanitarian
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