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Health System Challenges of Broken Supply Chains Don de Savigny Aliya Karim

Health Systems & Policies Research Group Department of Epidemiology and Public Health. Health System Challenges of Broken Supply Chains Don de Savigny Aliya Karim Swiss Tropical and Public Health Institute University of Basel d.desavigny@unibas.ch.

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Health System Challenges of Broken Supply Chains Don de Savigny Aliya Karim

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  1. Health Systems & Policies Research Group Department of Epidemiology and Public Health Health System Challenges of Broken Supply Chains Don de Savigny Aliya Karim Swiss Tropical and Public Health Institute University of Basel d.desavigny@unibas.ch

  2. Are essential medicines supply chains relevant to value for money? Yes: Follow the money…. Where does most public health funding go? • To essential medicines and other health commodities: drugs, vaccines, diagnostics, etc. • Only valuable if delivered…. • Largest single cost center in the health system. • Usually 40-60% of total health expenditure of low income countries • Typical example: Tanzania, pop 45 million • Total expenditure for essential drugs in 2012 was $199.7 million USD • Expenditure sources: • Printz, Naomi, Johnnie Amenyah, Brian Serumaga, and Dirk Van Wyk. 2013. Tanzania: Strategic Review of the National Supply Chain for Health Commodities. • USAID | DELIVER PROJECT, Task Order 1. 2011. Tanzania: 2020 Supply Chain Modeling—Forecasting Demand from 2020–2024. Arlington, Va.: USAID | DELIVER PROJECT,

  3. ESSENTIAL MEDICINES ARVs MALARIA TB OI ARVs Ped REAGENT Blood safety (+ HIV test) VACCINES CONDOMS CONTRACEPTIVES MEDICAL SUPPLIES GOVERNMENT BILATERAL DONOR MULTILATERAL DONOR NGO/PRIVATE GLOBAL FUND C S S C S I D A N O R A D C I D A UN I TA I D H A V A R D P E P F A R A X I O S P F I Z E R J ICA C D C G A V I C U A M M U N I C E F U S A I D W B CL I NTON GOVERNMENT C O L U M B I A A B B O T T W H O Source Of Funds Procurement Agent/Body C L I N T O N H A V A R D E G P A F A X I O S U N I C E F A B B O T T C U A M M C O L U M B I A U S A I D TEC & CCT MEDICAL STORE C R S S C M S MOH & SW J I C A G A V I CROWN AGENTS T M A P C D C Point of 1st warehousing TEC &CCT HOSPITAL CRS IMA MEDICAL STORE AXIOS COLUMBIA CUAMM HEALTH FACILITY HOSPITAL Point of 2nd warehousing REGIONAL/DISTRICT VACCINE STORE TEC &CCT ZONAL MEDICAL STORE HEALTH FACILITY HOSPITAL TEC &CCT Point of Distribution HOSPITAL ZONAL BLOOD SAFETY CENTRE DISTRICT STORE HEALTH FACILITY PRIMARY HEALTH CARE FACILITY PATIENT But expenditure enters a highly fragmented scene Medicines & Technologies supply chain complexity – Tanzania 2007

  4. Let’s briefly look at a specific case … Anti-malarial drugs in Tanzania

  5. mHealth supply chain monitoring of anti-malarials Real-time monitoring Source: SMS for Life Tanzania

  6. and the stockouts persist: Last week’s situation…. Real-time monitoring Red if stock- out this week Green if stock in Grey if no report yet Source: SMS for Life Tanzania

  7. ACT total stock-outs this week in Tanzania National Average 13% of health facilities have no first line antimalarial treatment in stock Regional Range: 1% in Dodoma Region to 38% in Mara Region. District Range: 0% in Kongwa District to 75% in Ukerewa District Source: SMS for Life Tanzania

  8. Tanzania in 2012 Malaria prevalence by region Anti-malarial stock-outs by region Data source: Tanzania Malaria Indicator Survey 2011-12 Data Source: Tanzania NMCP SMS for Life 2012

  9. Pharmaceuticalavailability: • Not just Tanzania … • Not just antimalarials … • OECD countries availability > 90% • Low income countries public sector ~ average 38% • Low income countries private sector ~ average 60% But national averages mask a worse condition for the poor and most rural populations

  10. In-country supply chains are the weakest link in the health system • GLOBAL SUPPLY CHAIN • Global demand supply planning • Voluntary pooled procurement • Price negotiation • Shipment coordination • IN-COUNTRY SUPPLY CHAIN • Quantification and forecasting • Procurement • Warehousing • Distribution to providers Manufacturers Patients Prashant Yadav www.globalhealthmagazine.com

  11. In-country procurement and supply management cycle Logistics Management Information System Source: Modified from Rima Shretta

  12. The private supply chain paradox

  13. Contrasting public and private logistics approaches Private supply chains for Coca Cola, beer, soap, shampoo and cell phone cards are incredibly efficient in Africa.

  14. Important structural contrasts between public and private supply logistics Public sector …… • Highly regulated • Lack of systematic information collection tools • Central assumption based supply chain planning • Higher need for traceability and security • Limited competition in distribution segment • Poor “contract” compliance on e.g. delivery lead time, etc. • Limited ability to create incentives • Completely different logistics systems • E.g. CMS cf. Cross docking

  15. Supply chain systems: a neglected issue • What typologies of supply systems are used in Africa? • Are there standard indicators of supply chain performance (incl. Stock-outs)? • Is there a logistics performance index best? What incentives would help? • How can costs and spending be better tracked, benchmarked and used? • What should an effective supply chain cost in relation to the commodities bill? • Why do public sector supply chains fail and private sector systems do not? • What can we learn from private professional logistics systems? • Should we privatize public sector supply and which parts? • How can we get a deeper structured understanding of issues affecting supply chains?

  16. Some recentinitiatives • Village Reach, Mozambique: creative bundling • Affordable Medicines Facility AMFm (Global Fund): • ADDOs (Tanzania, Ghana, Zambia): Accredited Drug Dispensing Outlets • ACT Watch (Multi-country): third party market data • Missing medicines campaign (Malawi): Civil society mobilization • ColaLife (Zambia): secondary distribution channels for ORS & zinc supplements • Outsourcing public health logistics; 3rd party logistics (South Africa) • Bar codes for stock tracking, management and logistics (GAVI) • New tools (PSM Toolkit) • Capacity support (GF RBM LMIS; Empower Health; UNITAID ESTHERAID, UNICEF) • Dedicated programmes (MIT-Zaragoza International Logistics Programme; Kuehne Institute for Logistics Management; USAID DELIVER; SCMS; GF P4i, RBM PSMWG)) • Stock-out hotline (GF) STOCKOUTS@theglobalfund.org

  17. Who is accountable to ensure zero-stock out performance? Addressing supply chain failure is a system-wide issue What Procurement and Supply Management design works best? What stock-out and other supply chain performance indicators need to be tracked? Civil society and media must be enabled to exert pressure for performance; Public access and data visualization What percent of the essential medicines cost should be devoted to ensuring delivery? What incentives are missing and what disincentives are obstructing supply chains? Stock outs at front line facilities are the face of a failed system for providers and the public; with fatal consequences

  18. Summary point Value for money in results based financing? Re-double efforts to approach zero stock-outs

  19. No excuse for stock-outs Thank you

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