Logistics

A short update on the interception by Dutch authorities of raw materials for generic drugs.

Health Action International (HAI) has filed a request under the “Wet Openbaarheid van Bestuur” (the Dutch version of a Freedom-of-Information act) to obtain all documents related to the seizure. According to HAI:

We hope to obtain documentation that will help to identify the operating procedures or events that allowed these seizures to occur and to determine why these seizures continued to occur over a period of time.

We hope that by exercising the right to access the public documents related to these cases, it will finally become clear how and why vital medicines were prevented from reaching patients and consumers in developing countries.

And in a related development: IDA Foundation, which is possibly the largest wholesale supplier of medicines to aid agencies, has sent letters to all relevant ministers and European commissioners (apparently no less than five ministers and two commissioners are involved…) expressing its concerns and asking for steps to avoid similar issues in the future. As IDA is based in the Netherlands and is a not unsizable employer themselves, their influence might help a bit as well.

I will keep following this closely. In the mean time: if you are based in the EC, or especially if you live in the Netherlands, or your organisation has strong ties there, please exert any influence you might have. This is an important issue that could have a serious impact on global health.

(Image: Freedom of Information? by Ian Parks.)

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Vaccination; 041028-N-9864S-021 Yokosuka, Japan (Oct. 28, 2004) - Hospital Corpsman 3rd Class Tiffany Long of San Diego, Calif., administers the influenza vaccination to a crew member aboard USS Kitty Hawk (CV 63). Currently in port, Kitty Hawk demonstrates power projection and sea control as the U.S. Navy's only forward-deployed aircraft carrier, operating from Yokosuka, Japan. U.S. Navy photo by Photographer's Mate Airman Joseph R Schmitt (RELEASED)

“That would never work here.”

I have had to listen to this reply more times than I can easily remember. It will usually come up when I propose to put procedures into place instead of continous ad-hoc decisions, standardisation instead of reinventing the wheel time after time, or proven solutions from other places in a new setting. There is a little devil in all of us that tells us that we are unique, that what works there will never work here, that every little decision we take needs our 100% attention.

Reality is different, and we only need to look at our daily lives to see everyday proof. Do you agonise daily which to put on first, your socks or your shoes? Do you feel that, in your case, it really is a good idea to keep on breathing while you swallow your soft drink? Do you try to walk through closed doors, just to see if that might lead to better results? Or will you today drive to work in reverse, just to see whether that will work better? Of course you don’t; you are aware of best practice from a lifetime of experience and from the example set by peers (classmates, siblings, friends…) and authority figures (parents, teachers, driving instructors…), and you do not go about testing those practices every day again.

Perhaps more pertinently, most of us would really not appreciate if our doctor or dentist would start experimenting with new procedures or home-made drugs when we go to our next appointment (at least, not while there are other, proven possibilities to use first). We really don’t want our electrician to try out a revolutionary new insulation method he recently thought up. Yet when it comes to aid logistics, suddenly there is no such thing as received wisdom, because “every situation is different.”

What causes this behaviour? Why do we behave so differently when it comes to aid logistics?

I think there are a number of issues here:

  • Everybody is a logistician. Or at least, everybody thinks they are. “Just get the bloody stuff here when we need it, can’t be that hard cannit?” Unlike medicine, dentistry, or electrical engineering, the complexities of logistics are much further beneath the surface — so it is not as clear to the average aid worker that logistics management sometimes requires a bit more than just common sense.
  • Unlike many other areas, our daily logistics experiences are not scalable. Logistics routinely deals with complexities of scale: techniques that can be used at small scales will break down at the large scale. Vaccinating one patient is not much different from vaccinating 10,000: draw up, check, swab, inject, discard — and then times 10,000. However, the logistics of a 10,000 person vaccination campaign is many times more complex than those for a one-patient ‘campaign’. A vaccination nurse would have experience organising the logistics for a one-patient (or perhaps 10- or 100-patient) vaccination, but not a 10,000-patient campaign; and consequently would not realise how much more complex the issues become. I will write more about complexities of scale in an other post.
  • The evidence base for much of aid logistics’ best practices is comparatively sketchy. Unlike e.g. medicine, we do not have a history of formal trials; most of our evidence is based on case descriptions and anecdotal evidence. There is a small base of formal trials in logistics in corporate settings, but there results can only be applied very tentatively to aid work. As a result, those techniques that do have a base in evidence are usually not accepted as authoritative by aid workers because they are applied to logistics. No doctor would deny the usefulness of treatment protocols; the advantages of protocols (or procedures, or algorithms, or whatever you would like to call them) have been amply demonstrated, but apply this to logistics and people will loudly complain about imposed bureaucracy.
  • There are no recognised degrees for aid logisticians. Doctors need to pass medical exams. Electricians need to sit for their tests. Drivers need to pass a driver’s test before they get their licence (well, in most developed countries anyway). We expect a degree in public health from a public-health specialist. But aid logisticians come in all kinds and shapes, some with more logistics knowledge and skills than others. There are now a couple of specialised aid logistics master’s degrees, but as they are very new there are hardly any graduates in the field yet. The results are double-edged: on the one hand, not all aid logisticians have the knowledge to recognise the importance and usefulness of standard logistics operational solutions and methods; and on the other hand logisticians do not get recognition as specialists in their own right, and hence their authority is not recognised or accepted.
  • Aid logisticians tend to be an unruly, desk-hating lot. We come from all walks of life, but especially amongst field aid loggies there is an over-representation of people with backgrounds that pre-dispose them against accepting anything remotely smelling of authority, or of desk work[1]; and that includes things like procedures, administration, standardisation, etcetera. In this sense we are our own worst enemies, and tend to sabotage our own systems.

So what can we do to improve on this? How can we change this behaviour from logisticians and other aid workers alike? More in my next post, after Easter.

(Images by the US Navy and Martin Deutsch.)

Footnote

[1] Or as one colleague once told me, with obvious pride: “We are the last adventurers — and the rest of them are just pale bureaucrats.”

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Visibility, transparency, and some sunshine

by Michael Keizer on April 9, 2009

Lockheed SR-71 Blackbird strategic reconnaissance aircraft taking on fuel from a USAF KC-135

One of the hotly discussed topics in logistics management is supply chain visibility. In a nutshell, you have a visible supply chain if your supply chain processes are measured and controlled on a fairly detailed level — often up to the level of the individual item. The big impetus for supply chain visibility has come from the advent of third party logistics or 3PL — the outsourcing of parts of the logistics process to specialised contractors, in an effort to gain economies of scale as well as economies of specialisation[1]. Outsourcing is basically an external version of delegation, and as any management textbook will tell you, there can be no delegation without verification; hence the need of a more visible supply chain. Good examples of extremely visible parts of logistics chains are the track-and-trace systems that are offered by most couriers.

An offshoot of supply chain visibility, supply chain transparence, has also gained a lot of traction over the last couple of years. Unlike supply chain visibility, which concentrates on supplying information to those using the supply chain, supply chain transparency concentrates on the ultimate buyer of the products supplied. A good example here is Icebreaker’s baacode, which gives customers an idea about the origins of their woollen undies and what happened to them during the production process.

I think both visibility and transparence will gain in importance in health and aid. Like I wrote before, any medical supply chain needs at least a modicum of visibility to be able to react effectively and efficiently to e.g. recalls; and transparence will undoubtedly become more important as we move towards more accountability to our customers, i.e. the populations we try to aid, our donors, and the general public.

However, there is more to this: I think we will also move more and more to 3PL (stay tuned to read about the whys and wherefores); and like the corporate sector, we will need more and more visibility in able to do so while still keep control of our supply chains. Whether we like it or not, we will need to invest more in systems[2] that make supply chain visibility possible; and as these systems take time to design and implement, we need to invest now.

We should be able to learn from systems that are being used in the corporate world. However, it will probably not be possible to use solutions from a corporate setting unaltered in (health) aid settings. Issues like insecurity, lack of instant telecommunications, etcetera, will mean that adaptations are necessary. This is why the Fritz Institute’s Helios system is such a great step forward: it offers the base for humanitarian supply chain visibility, packaged in a way that is suitable for many aid organisations. This is not to say it is without its problems; it isn’t, and it some organisations will find it more useful than others (e.g., it is tailored towards humanitarian aid, and might not be particularly suitable for developmental organisations), it is as yet incomplete in some aspects — but it is a step in the right direction.

high visibility clothingTime for a mea culpa. Some years ago, I was asked to advise on the choice for logistics management software for a large aid organisation. At that time, I advised against Helios (or the HLS as it was known back then) because I thought that its foreseen development trajectory was unfounded and too optimistic. I think I had good reasons for that recommendation, but I was also very wrong: Helios has been developed into something that is a model for supply chain visibility in aid.

Is your organisation thinking about supply chain visibility? Perhaps you are already implementing solutions? Share your best practices (and your mistakes — we can learn from those as well!) here.

(Images by James Gordon and Leo Reynolds.)

Footnote

[1] This will definitely be the subject of a future posting.
[2] No, systems are not just computer systems. When I write about a system, I refer to a coordinated whole of human resources, material resources, and procedures[3, 4], aiming towards a common goal. Cf. e.g. “the humanitarian system”, “the supply system”, etcetera.
[3] And yes, a computer program is no more than a fancy procedure, a.k.a. an algorithm.
[4] Don’t you hate footnotes in footnotes?

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Latest job opportunities (5 April 2009)

by Michael Keizer on April 5, 2009

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Five things not to do during a rupture

by Michael Keizer on April 1, 2009

So all your planning has gone for nothing, and for whatever reason you have a rupture in your supply line. What should you not do?

  1. Don’t panic. Take a deep breath. Take your own pulse. Stare at the ceiling. Kick the wall — hard. Kick your supply manager. Kick yourself. But for the sake of whatever you hold holy DO NOT PANIC. Yes, you have your medical director to one side screaming that people are dying and that you NEED! to take ACTION! NOW!, while to your other side your purchaser explains that the only ready source of paravenozole is highly suspect and in any case asks a prohibitive price. And yet you know that if you give in to your first instincts and do whatever can be done as quickly as possible, you will make costly and (more pertinently) dangerous mistakes. Keep that in mind and take some time to work out the possible options and what there results would be.
  2. Don’t play the blame game. Analyse later what went wrong and what can be learned, but for now don’t start blaming people (least of all yourself). The only result will be a lack of cooperation and an atmosphere of distrust that will prevent you from taking decisive and effective action.
  3. Don’t double-order. The temptation to put in an emergency order of paravenozole to get things in fast. However, it will probably mean that you will end up with overstocks once the previous order comes out of your pipeline (unless it has a very long expiry). Instead of double-ordering, first try to expedite the orders that are already in your pipeline. Talk with your suppliers and see what they can do, and how much extra it is going to cost; this is where your previous investments in a good relationship with your suppliers will pay off. Only double-order as a last resort, when nothing else works and it is clear that people will die or suffer if you don’t; but be clear about the likely consequences, which will include expiries and cost.
  4. Don’t change protocols. Discuss with your program managers what temporary changes can be implemented to circumvent or at least mitigate the rupture; but don’t change protocols because your staff will assume that it is permanent and will not thank you when they need to change back again.
  5. Don’t neglect to learn. Remember what I said about the blame game? However, that should not stand in the way of a thorough analysis of the reasons and causes of the rupture, and what can be learnt from them. Should your systems be changed? Should staff get more training? Or more supervision? What went wrong in your communications? Is your supply line as transparent as it should be? All valid and important questions, which (together with many others) you should ask yourself and your co-workers after the rupture has been resolved. If you don’t, you are on your way to the next one.

(Image: the weakest link by Darwin Bell. Some rights reserved.

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Over the last couple of weeks, a lot has been said about the interception by Dutch customs of raw materials for a generic version of the drug Losartan. Although the materials were released in the end, Dutch authorities have refused to say whether this could happen with future shipments as well.

The interception was based on European Union legislation, which requires member countries to seize counterfeit brand products as well as raw materials for their production. However, it was far from clear that the generic drugs were counterfeit under the directive in question, and it was very clear that they were not under the TRIPS agreement and the DOHA declaration, which provide for compulsory licensing of patented drugs. In any case it is clear that an incident like these could seriously endanger the flow of generic drugs to developing countries, possibly endangering public health in those countries.

For many, it looks like the Netherlands caved in under pressure from pharmaceutical companies. Merck & Co, the patent holder in Losartan, maintains a large distribution hub in the coastal town of Haarlem, and is an important employer for the region.

Schiphol Amsterdam Airport is an important logistics hub for generic drugs and their raw components as they move from (mainly) India to Africa and Latin America. This behaviour by Dutch customs could imperil that position and the Netherlands’ position as a transit hub. Perhaps that is something for the Dutch minister of Economic Affairs to mull over before deciding to let something similar happen again.

(Picture: generic drugs by Wendy House. Some rights reserved.)

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Latest job opportunity (31 March 2009)

by Michael Keizer on March 31, 2009

UNICEF is looking for a logistics specialist for Sudan. Note: closing date this Thursday!

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Some humourless links

by Michael Keizer on March 26, 2009

Some jottings that have been sitting in my to-do stack for too long.

  • Alanna Shaikh discusses the mechanics of getting rid of HIV/AIDS, and rightly flags the impossible logistics of such a plan. Be sure to scroll down to the comments section for a chuckle and an occasional blood pressure spike.
  • GlaxoSmithKline offers to make drugs more accessible for the world’s poor. It always surprises me that some think that making drug prices lower will automatically dramatically cut total cost. Just calculate the cost of getting a tablet of paracetamol to an Ethiopian patient, and you will see where the it actually is being incurred. Small hint: it is not the amount received by the manufacturer.
  • The European Union allocates an extra EUR 27 million ‘to strengthen global humanitarian preparedness and the response capacity of international organizations’. One of the purposes would be to improve international coordination and integrated logistics. More to come on integration of logistics, courtesy of a very interesting recent doctoral promotion (don’t touch that dial!), but it is already interesting to note how more and more donors see the importance of earmarking funds for logistics.

(Picture: Liquid Links by Desirae. Some rights reserved.)

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Latest job opportunities (26 March 2009)

by Michael Keizer on March 26, 2009

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The latest professional reading: Marie Claire on HAS

by Michael Keizer on March 23, 2009

I never thought I would ever feature an article from Marie Claire, but maintaining a blog takes you places. In a recent issue, they interviewed Danielle Aitchison, a pilot for the UN’s Humanitarian Air Services. Anybody who has ever worked in humanitarian hotspots will know how important UNHAS’ services are for logistics operations, and even though I have some reservations about the content and general tone of the interview, it still well worth reading. Enjoy!

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