In this second interview in the series on the Zambian supply chain pilot, A Humourless Lot talks with Prashant Yadav, professor of supply chain management at the MIT-Zaragoza Logistics Program.

AHL: Could you tell us a bit more about your role in the project?

PY: I had conducted research on the medicines supply chain in Zambia in 2006 funded by the UK DFID which highlighted deficiencies in the system. After conducting the study to diagnose the supply chain problems, one of my specific mandates from DFID and the World Bank was to come up with four of five options that could possibly solve the issues that were identified in the earlier reports. A second task was to give input on measurement and the metrics to measure success vs. failure: what indicators to use and how to measure them in such a way that we could draw scientifically valid conclusions. We wanted to integrate monitoring and evaluation into the project from its earliest stages.

AHL: You say you came up with four or five options, but only two were in the end tested. What were the others and why weren’t they incorporated into the pilot?

PY: One option that was brought up by some stakeholders but did not make it was to transport the commodities directly from the central warehouse to the facilities, using a fleet of smaller vehicles. One key issue with this option was that it was difficult to quantify costs in advance, and we believed that direct distribution to clinics would become very expensive from a transport cost standpoint. Also, it would not be technically feasible in some areas that are hard to reach.

A second option involved regional medical stores that each would service a large chunk of the country and supersede the district stores. The issue with this model was that it would become too big to pilot: to be able to make any analysis, we would need to include a number of regional warehouses that would in the end encompass a very large part of the country. We agreed that this is something we can pursue at a later stage using a simulation model.

A third and final option that was not selected for the pilot was to outsource transport to the facilities. This was dropped just due to practical aspects: we found out that we could probably only find transporters on the high-frequency routes, and many facilities are not located anywhere near those routes.

AHL: How about measurement? Can you tell a bit more about your analysis of the results?

PY: Demand for some of the 25 tracer drugs that were analyzed under this pilot was not very stable. We had thought that the results for commodities with stable demand will show that the cross-dock model [where supplies were pre-packed at the central level – MK] performs better, and the results for those items were clearly statistically significant. However, to our surprise, even for the items with large variations in demand, the results for the cross-docking model were still significantly better than either the original situation or the first model. Seasonality in demand, time of conducting the data collection, quantifying the outcomes all made the analysis fairly challenging. However, working together with Jed Friedman at the World Bank’s research group and Jérémie Gallien, a colleague at MIT, we found some robust ways to quantify the impact.

Another issue is that both models presuppose that there are no stock-outs at the central stores. We don’t know how robust the models will be if stock-outs would occur at the central store.

AHL: How about the future? What is happening next?

PY: We are now involved in the progressive roll-out of the model to the whole of Zambia. Together with the government of Zambia and cooperating partners, we are discussing various options to scale up the cross-docking model. We are also thinking about how to handle clinics that are cut-off during the rainy season under the cross-docking model.

We are also exploring some options with primary health center kits. This is an alternative model, more push-based than the normal fulfilment models and fairly rigid; consequently, it sometimes leads to more excess and wastage than might be necessary, but is robust to events such as the clinic not placing an order. We are looking at possibilities for customised kits, e.g. on a regional basis, depending on the specific circumstances and needs.

Finally, we are still collecting data and updating our evaluations. We will also use the data to feed a parameterised model that should enable us to simulate other solutions. One example is the regional-store model that was discarded at the outset for practical purposes; once we have sufficient data, which I expect to be the case in a few more months, we should be able to simulate what would happen if regional stores were to be implemented.

AHL: How well could this model be ‘exported’ to other countries?

PY: I can think of two or three countries that have a similar setup as Zambia and suffer from similar issues. They would be good candidates for a similar model, but spatial distribution of facilities could make a big difference and could in the end mean that the model would be less effective there. Even where a direct verison of this may not be applicable, there are learnings which can improve the distribution systems in many other countries. We are in discussion with several countries and large donors on how to disseminate this to a wide group of public health specialists.

AHL: Finally, what was your experience with the cooperation with so many and various partners?

PY: From my perspective, things went quite well. The collaboration offered something unique to each of the partners. For instance, for MIT/Zaragoza it offered the opportunity to use our academic knowledge for a practical improvement in the lives of Zambians. Similarly, for the World Bank and USAID it offered the possibility to show that these two organisations, who have not always cooperated smoothly, could partner closely and productively.

Likewise, each of the partners brought an important aspect into the project: the World Bank delivered funding, and impact evaluation knowledge; the USAID/Deliver project brought local presence that delivered some economies of scope; MIT/Zaragoza contributed academic knowledge; and so on.

Of course things did not always work smoothly. For instance, it was hard work to convince everyone in the joint team that it was acceptable to do a quasi-randomized trial instead of agreeing with the stakeholders on what is the one ‘best’ solution and then implementing it. Similarly, there were discussions about the profile and reporting structure of the commodity planners stationed in the districts vis-à-vis the district pharmacists who were already present in some of them.

However, in the end we were able to overcome all our differences of opinion, and I think the result shows how well we were able to work as a group.

[Image: Fight the Bite by Zelda Go Wild @ flickr. Some rights reserved.]

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1. The Zambian logistics pilot project (I)

The World Bank, The UK Department for International Development, and USAID recently released the results of a logistics pilot project in Zambia, in which the availability of various medical supplies was improved. This is the first of a three-part series in which I talk with two of the team members and finish with some personal reflections. In this first article in the series, I interview Monique Vledder, senior health specialist at the World Bank and supervisor of the project.

AHL: Could you tell us a bit more about the background of this project? Why was it initiated?

MV: We have been involved in supporting the government to implement malaria prevention programmes like bednet distribution in Zambia since 2005. However, over the course of our programmes we realised that, although the government was quite successful in preventing malaria, the people who still were infected could not get adequate treatment due to a lack of malaria treatment drugs at the rural health centres. Our analyses showed that those drugs were available at the central level and district level; but somehow they did not arrive at the health centres. Clearly, there was an issue with the supply lines between MSL (the central medical store), the districts, and the centres. We partnered with other major donors like the UK and US governments as well as JSI and Crown Agents as implementers, and with MIT to ensure academic support. Our joint analysis pointed towards placing commodity planners at the district level as the most promising option. When we discussed this with the Zambian government, we were given a strong commitment for for a pilot project to try this out.

AHL: So what exactly did the pilot entail?

MV: The pilot included 24 districts, 8 of which were used as controls (continuing the use of the ‘old’ system), and in 16 districts we implemented either of two models. Those 24 districts represent about a quarter of the whole country, so especially for a pilot project we had very good coverage. Model 1 involved the placement of a commodity planner at each of the districts. Their tasks were to facilitate communication with the health centres about commodity needs and levels and to prepare orders to MSL. Once the orders were filled and had arrived at the district warehouse, they would also be responsible for packing and dispatching the orders to the health centres.

Model 2 was very similar to model 1, but in this model the separate orders for the health centres would already be collated at the central level and would arrive pre-packed at the district level; the commodity planner was only responsible for preparing the order and for forwarding the packed order to the health centres.

AHL: And the results?

MV: They were spectacular, especially in the districts that used model 2. For example, availability of the main drugs for artemisin-based combination therapy (ACT) improved from an average of about 50 per cent to nearly 90 per cent. If we would extrapolate this to the whole country, this alone would prevent more than 16,000 deaths a year. But, of course, the effects have been much wider than just ACT; although the commodity planners concentrated on malaria supplies, availability of other supplies like antibiotics and contraceptives has increased as well.

When I started on this project, I did not know much about the logistics side of public health, but these results have made it very clear to me how important supply chain management really is for the people’s health.

AHL: So what do these results mean for other programmes? And perhaps other countries?

MV: Of course you cannot translate the results one-on-one to other programmes or settings, but what this trial has made clear is that a relatively modest investment in supply lines can deliver spectacular results. In most developed countries, supply chain management takes up more than ten per cent of the cost of the supplies themselves; in Zambia this was less than half that percentage. Whether you should aim for a similar proportions as in developed countries remains an open question, but it seems to be clear that a modest increase could lead to greatly improved health outcomes. However, I must say that we have not yet finalised our cost-effectiveness analyses; although it was fairly easy to to quantify the extra costs involved, it was not so easy to calculate cost savings, e.g. in model 2 the cost of labour that was no longer needed for repacking at the district level. Nevertheless, even if the cost savings turn out to be very modest, we expected that the improved access to medication and the resulting lives saved would make it more than worthwhile.

I think it is important in this sense to think of integrated supply lines. Although this project was initiated as part of the malaria support, the focus was on supporting the supply of all essential drugs.The results for other pharmaceuticals as for example antibiotics or contraceptives was positive as well. I think that shows that we could make even more gain if we could move away from the disease-based silos and work on approaches to strengthen an integrated supply chain

AHL: What happened after the trial ended? Are the commodity planners still active?

MV: Yes, they are; and, in fact, the districts that were not included in the trial as well as the model 1 districts were so impressed with the results that they are now requesting the country-wide implementation, and the Ministry of Health now has committed to a phased roll-out across all districts.

AHL: This project involved a large number of partners: besides the World Bank, people from DFID, USAID, JSI, Crown Agents, MIT, and of course the Zambian national and district governments were involved. Was it difficult to coordinate such a big group of actors?

MV: I think we were lucky in that that Zambian government gave us a clear commitment and took ownership of the pilot. What also helped was that we all had fairly clearly defined and complementary roles with a minimum of overlap. Thirdly, sufficient funding for the whole project duration was safeguarded from the start. And finally, monitoring and evaluation were integrated into the trial from the start, making it possible to present a result that could be accepted by all parties. All this meant that we could work very well together with a minimum of conflicts; it also meant that we could draw upon each other’s strengths to get things done.

[Image: Malaria dreams by Ashley Jonathan Clements. Some rights reserved.]

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1. The Zambian logistics pilot project (II)
2. How to get things done: more on the logistics of logistics

• Remember my post on how to get patients and health care together? It turns out that I had forgotten one major factor: legal bickering. At least, in Australia.
• Yet another idea to combat counterfeit medicine. Not a bad one as things go, but again missing the poorest. Not that I would know how to do better.
• The UNDP has put out an RFP for ‘the Provision of Services to Strengthen the National Supply Chains for HIV/AIDS, TB and Malaria Programmes in Northern Sudan’. Section 8 can lead to some interesting issues.
• This year’s Aid & International Development Forum seems to have a lot of logistics subjects, starting with the first session: “Transport – How to achieve effective transport with smaller NGOs”. Could be very interesting if you are anywhere near. If you do go there, please post some feedback here.
• Fast Company showcases eleven designs for when disaster strikes. Unsurprisingly, logistics figures prominently.
• The International Transport Journal writes about aid logistics. It paints an overly rosy picture, but overall it is not a bad introduction into international emergency aid logistics.

[Image: Liquid Links by Desirae; some rights reserved.]

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1. Humourless links for May 8, 2010
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3. Humourless links for March 1, 2010

• Crown Agents are looking for senior procurement specialists for their office in Arlington VA (USA) and Malawi; procurement specialists for Mongolia and Malawi; an ARV logistics officer for Botswana; a procurement consultant for Tanzania; a supply chain operations manager for Malawi; an SCMS deputy country director for Rwanda; a logistics assistant for their office in London (UK); public procurement advisors for several countries; and a team leader for Malawi
• Save the Children is looking for an operations director, a senior procurement specialist and two roving logistics specialists for Haiti; a senior manager procurement, contracts and compliance for the West Bank/Gaza; and two senior logistics specialists to be based in Washington DC (USA).
• Maxwell Stamp is looking for a project costing and procurement specialist for Laos
• UNICEF is looking for a procurement assistant for their office in Geneva (Switzerland), a contracts officer for their office in Copenhagen (Denmark), and a supply and logistics specialist for North Korea. Sorry, no links, they still hide their vacancies behind a registration process.
• DanChurchAid is looking for a field logistics officer for Katanga (Congo DRC).
• Merlin is looking for deputy logistics coordinators for Côte d’Ivoire and Congo (DRC); a logistician for Congo (DRC); logistics managers for South Sudan, Kenya, Pakistan, Congo (DRC), and the Central African Republic; a logistics/administration officer for Gode (Ethiopia); senior logisticians for Grand Kru and  Montserado (Liberia); and a surge logistics officer for South Sudan.
• JSI is looking for a deputy chief of party SCMS for Nigeria.
• Concern Worldwide is looking for a transport manager for Haiti; an assistant country director systems for Afghanistan; and a general systems manager and a logistics and administration coordinator for Zambia.
• The IRC is looking for logistics managers for Congo (DRC) and Haiti.
• The IFRC is looking for a trainee logistics delegate for based in Kuala Lumpur (Malaysia), an operation coordinator for Guatemala, a head of support services based in Panama City (Panama), a procurement delegate for Haiti, and a senior procurement officer based in Geneva (Switzerland).
• MSH are looking for a senior program associate – supply planning/MIS/M&E for Bangladesh.

[Image: Job opportunities by Coffeechica. Some rights reserved.]

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1. Latest job opportunities (May 4, 2010)
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Ordering systems come in two basic flavours: push and pull, plus any number of hybrid systems. All have pros and cons, and each is most appropriate for a specific situation. In this first article in a miniseries on push and pull systems, I will discuss the basics: what exactly are pull and push systems and when would you use either.

Push versus pull

In the push model, “higher”, central levels decide on supply allocation for “lower”, local levels; these decisions are typically based on supply at hand and in the pipeline, and on calculated expected consumption – the latter often approximated, based on (in the case of medical supplies) patient numbers or population data. In the pull model, “lower” levels decide on the necessary supplies for the next supply period, which are then either procured independently or obtained/ordered from the “higher” level.

The basic difference between the two models is the responsibility for timely, complete, and accurate initiation of distribution: in the push model this is the “higher” level, in the pull model the “lower” level.

From this table, it will be clear that push systems are best used when pipeline fluctuations and interruptions are rife and unavoidable, when funds tied up in buffer stocks are not an issue, and when expertise is too scarce to be decentralised; and that pull systems come into play in the opposite situation.

Hybrid models: the best of both worlds?

Many commercial manufacturers use a hybrid system. E.g. when you order a Dell computer, your sparkling new machine does not come from stock but will be newly assembled; however, the parts (which are fairly generic and can be used for a variety of different models) are not ordered as your order comes in, but come from a pre-determined stock, the size and composition of which is calculated using expected overall numbers of orders for various models. Dell can do this exactly because many different models can be made from various parts.

We rarely use hybrid systems in global health and aid. In the next post in this series, I will look at the reasons why, and offer some ways in which hybrid models can help us solve some of our most pressing problems.

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You have designed and implemented a pretty good logistics system and are proud of how effective and efficient your aupply line provides your programmes with any materials they need. Transport and administration cost are now at their minimum, fulfilment rates are close to 100%, and you process and fill almost every order within set timeframes. You feel pretty good about yourself (and not without reason), and are ready to hand over the system to your successor with justifiable pride.

And then the ministry of trade announces that as of tomorrow, clearing rules will be changed, adding three weeks to the current four to five days it takes you to clear your goods. Suddenly things look a lot less optimistic: your carefully balanced and trimmed-down supply chain is strained to the snapping point, and you are looking at having some of your key operations suspended. Even worse: one of those is a treatment programme for TB patients, and suspension of treatment might cause resistance to the drugs involved – making a bad situation suddenly look catastrophic.

What has gone wrong here? Of course, the ministry of trade is partly to blame here: changing rules on a day’s notice is bad governance any time. But a large part of the blame also lies with you: in your push for a lean, mean machine of a supply line, you neglected to take into account your environment and the risks it posed. In short, you built a fragile supply line.

Robustness of supply lines is generally important, but even more so when it comes to global health and aid: a supermarket might take the risk of an empty shelve, but an empty shelve in our case could cost lives. This is an important consideration when you build your risk management plan (which you did of course last year, immediately after reading my post on supply chain risk management): where a supermarket might choose to retain or transfer the risk, we will often have reduce it. Reduction strategies almost inevitably cost money: cost for storage, more expiries, more staff, and many other costs. A well worked-out risk management plan will help you explain why these costs are necessary, and that they do not mean that your supply line is in any way inefficient.

[Image: Crate containing Leg Lamp by J Stewart]

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1. Do you see? Technology aiding supply lines – or not
2. Supply chain risk management
3. The ways and means that divide: parallel supply lines for medical supplies

• Mary’s Meals are looking for a logistics manager for Malawi.
• Oxfam GB is looking for a logistics coordinator and a procurement manager for Haiti; and an HSP supply and logistics coordinator (based in their HQ in England).
• IMC is looking for a logistics manager for Haiti, an operations manager for Sudan, and a logistics coordinator for Congo (DRC).
• UNICEF is looking for a logistics manager for Haiti.
• MSH are looking for a technical deputy director for Bangladesh.
• UNFPA is looking for a humanitarian logistics specialist, based in their HQ in New York (USA).
• ACTED is looking for a country logistics manager for Sudan, country logistics & security managers for Chad and Iraq, a logistics intern for Chad, and a pharmaceutical procurement manager for their HQ in Paris (France).
• JSI is looking for a deputy chief of party SCMS for Nigeria, and a supply chain advisor intern.
• Solidarités are looking for a logistics coordinator for Kenya/Somalia; a logistics support officer and a logistician for Haiti; and a flying logistician based in their HQ in France.
• Merlin is looking for a supply chain manager for Pakistan.
• Creative Associates International is looking for a procurement manager for Sudan.
• The British Red Cross is looking for logistics and procurement delegates for Bangladesh and Haiti.
• PSI are looking for an associate procurement & logistics officer, a procurement & logistics officer, and a voluntary pooled procurement & logistics officer, all for their HQ in Washington, D.C. (USA)
• The PNG Advisory Support Facility is looking for a procurement manager and operations advisor.

[Image: Job opportunities by Coffeechica. Some rights reserved.]

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1. Latest job opportunities (February 28, 2010)
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• An analysis by Alanna Shaikh of how we tend to react to critics. Of course it is easy to take down an ill-conceived initiative like 1millionshirts, but it is important to reflect on whether we react much better when we are the focal point of criticism.
• Wired Magazine writes about the logistics of the Haiti response as a spring board for a wider discussion of disaster response logistics. It’s a bit overly endowed with ‘human interest’, but on the whole I would say that it is a very good introduction. “Organizing Armageddon”, though? (H/T Cynan Houghton.)
• Alex de Waal writes a great article on the ‘humanitarians’ tragedy’: the inescapable cruelties that come with our work. Sadly, it is hidden behind a paywall, but I recommend it highly if you do have access.
• The Royal Geographical Society is holding a conference on how to improve the response to natural disasters. I would expect that logistics will be an important part (although sometimes that sort of expectations are incorrect).
• I am trying to find somebody who can tell me more about the cooperation between Handicap International and Atlas Logistique. Email to their general address goes unanswered. So if you work with/for them or know somebody who does, could you please ask that somebody in the know contacts me?
• Texas In Africa writes an excellent post on how to go from saviourism to empowerment (but seriously, Laura: Barbra Streisand lyrics for a title?). On a related note, Linda Raftree writes about community dialogue, which in turn leads to some interesting discussion over at Tales From the Hood.
• According to Scott Gilmore, mercenaries, missionaries, and madmen should not work in aid.
• A video from MSF showing how bad logistics can cost lives.
• Aid logistics is getting more and more serious attention from universities. The Hanken School of Economics will organise an external course in supply chain management in development aid at the University of Manitoba (Canada).
• How a simple legal mistake by a national mail carrier can cost lives.

[Image: Liquid Links by Desirae; some rights reserved.]

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1. Humourless Links for June 13, 2010
2. Humourless links for March 1, 2010
3. Humourless links for March 3, 2010

• UNDP is looking for a supply chain management consultant and a procurement advisor, both based in their HQ in Copenhagen (Denmark); and for a procurement specialist for Sudan.
• The Mine Advisory Group is looking for a support services manager for Iraq.
• MERLIN is looking for a deputy logistics coordinator for Congo (DRC); logisticians for Haiti and Congo (DRC); and logistics managers for the Central African Republic, Pakistan, Haiti, and Congo (DRC).
• Marie Stopes International is looking for a senior procurement and logistics manager for their HQ in London (UK).
• Crown Agents are looking for a procurement coordinator and a procurement specialist for the USA; an ARV logistics officer for Botswana; a procurement specialist and a senior procurement specialist for Malawi; a procurement consultant for Tanzania; a supply chain operations manager for Malawi; and an SCMS deputy country director for Rwanda.
• A non-specified global health charity is looking for a finance & operations director for the UK.
• ShelterBox is looking for an operations manager for the UK.

[Image: Job opportunities by Coffeechica. Some rights reserved.]

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1. Latest job opportunities (June 11, 2010)
2. Latest job opportunities (May 12, 2010)
3. Latest job opportunities (January 11, 2010)

• Regular readers know about my preoccupation with duct tape. I am happy to say that I am not alone.
• Dilbert’s view of pandemic contingency planning. I wish.
• I recently have become a member of the International Association of Public Health Logisticians (IAPHL). Highly recommended for the very interesting discussions going on in their (closed) forums.
• Emerald will start publishing the Journal of Humanitarian Logistics and Supply Chain Management next year. The blurb looks highly promising. The editors have issued a call for papers.
• Analytics Magazine published a short article with ten recommendations to improve humanitarian logistics. Sadly, they are so thin on how to implement their recommendations that they could just as well have given only one: ‘improve humanitarian logistics’.
• A guide to NGOs for the military. I wonder how many NGOs for the military need a guide. (H/T Chris Albon.)
• An interesting application of standard logistics risk management on very large systems – like whole societies. (H/T Chris Watkins a.k.a. @chriswaterguy – there seems to be a Chris-thing going on here).
• FAILfare: learning from failure. A great idea – anybody in to organise something similar for health/aid logistics? (H/T Suzanne Rainey)
• Stop Stockouts seemed a great idea, but is now totally abandoned. Too bad.
• WHO finally published a procurement guideline for antimalarials. Let’s hope they will do something similar for other health commodities.
• After my earlier negativity on gifts in kind, now a story about an organisation that seems to do it right. Any reader who has first-hand experience with this outfit?
• I have been on Twitter for some time now (you can follow @Michael_Keizer for regular updates), but more recently I started a Facebook page. It’s a great place for discussions with like-minded people and allows for a bit more two-way communication than the blog.
• I have also been working on a bibliography on logistics for global health and aid, using a Zotero group. The bibliography is open for everyone, but Zotero users can import and use it directly into their own libraries. I would appreciate any additions: it is a living document and suggestions for additions and improvements are more than welcome.

[Image: Liquid Links by Desirae; some rights reserved.]

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