Public health

Humourless links for November 14, 2009

by Michael Keizer on November 14, 2009

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A tale with a tail: why logistics should be integrated into your planning

by Michael Keizer on November 1, 2009

Poster for vaccination against smallpox.Logistics is so often an afterthought.

All you programme managers, country directors, and other people managing aid programmes out there: how often do you integrate logistics planning into your planning from day 1 of your design phase? (And if any of you say: “always”, please let me know when you need an experienced logistics manager – I would just so love to work for you. Not that I would believe you, of course, unless you are a logistician by background yourself – and even then I would be sceptical.)

An old post by Diane Bennett on the Aid Watch blog tells a cautionary tale of what happens when you don’t integrate logistics into your planning. It is a seven-year history of how a lack of logistics planning caused thousands of deaths in remote South Sudan; not because the logistics weren’t thought of, but because they weren’t integrated into the programme from the start.

A medical NGO who wants to support a vaccination will have to take into account how to get the vaccines on the spot – and finding out much later that “… vaccines were available … at a regional distribution center, a $5000 air charter flight away” is too late. If UNICEF and WHO want to ensure vaccination on the spot, they will also need to ensure transportation to it, and possibly refrigeration there. All these should be planned from the start, because this tale clearly demonstrates how taking logistics on at a later stage will only lead to disaster.

But possibly the biggest issue here is that none of the three organisations involved really did their homework. Measles vaccines are fairly heat tolerant. If they would have been transported to the site in a cold box, and then used within a couple of days or even weeks (depending on the ambient temperature), no refrigeration at all would have been necessary. This technique, known as the ‘fast chain’, has been in use for some time and is endorsed by WHO; but apparently nobody managed include this in the planning.

The tale shows only one thing: include logistics and logisticians in your planning from the start, and you will sleep a lot better at night. And don’t we all want that?

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Supply chain risk management

by Michael Keizer on May 25, 2009

A lot has been written about how to deal with logistics disasters, or how to avoid specific types of mishaps. Much less attention is given to the process of managing those risks.

Risk management for the supply chain is not really different from generic risk management. Like all risk management processes, you start by making an inventory of possible risks, based on your environment, the programmes that you try to support, possible future scenarios, etcetera. This inventory includes the nature of the risk, its likelihood of occurrence, as well as its possible and likely impact. The result should be an overview of the possible extent of risk for each of the risks that you list. Some examples:

  • If a meteorite would hit your main logistics hub, you would be in dire straits indeed. However, the likelihood of this happening is vanishingly small. As a result, the extent of your risk is still very low.
  • If one of your 15 drivers would fall ill, it would probably not pose much of a problem; however, the likelihood of this happening in any given year approaches certainty. Still, because of its low impact, the extent of the risk would be low.
  • Having your one and only purchaser fall seriously ill would not be a big problem in a well set up system, in which everything is well documented. The likelihood of this happening is also quite small, so the extent of the risk here is very low.
  • However, if documentation is sketchy and most of the knowledge about markets and suppliers is locked up inside the head of your purchaser, the impact of this happening would be a lot bigger. Suddenly, the extent of your risk is now medium or possibly even high.

This last example points to the importance of the risk environment when performing your risk analysis. (It also points towards a possible way of dealing with it, about which more later.)

The next step is to design a strategy to deal with the risks. All risk strategies can be divided into four basic categories: avoid, reduce, transfer, and retain. In our example, this would mean:

  • Avoid: an avoidance strategy could take the form of not doing any local purchasing, or perhaps withdrawing from the programme. This illustrates that avoidance strategies are rarely feasible in the environments in which we work, but nevertheless they should be considered.
  • Reduce: ways in which we could reduce the extent of the risk include hiring a second purchaser (reducing the likelihood of being marooned without a purchaser) or ensuring good systematic registration and documentation (reducing the impact of the purchaser falling ill).
  • Transfer: we could outsource our purchasing to an external company, using service level agreements to ensure that they deliver what we we need, when we need it. This is not a very likely scenario for most of us, but it is something that we often do with e.g. air transport: we transfer the (very real) risks linked to these operations to e.g. a charter company.
  • Retain: we could decided that the extent of the risk is so small (e.g. because we hardly do any local purchasing anyway), that we take no action and leave things as they are. In other words: grit your teeth and suck it up.

A risk management plan basically consists of the risk analysis, with the appropriate strategy for each of these risks. Risk management plans for multinationals often comprise whole volumes (or, more and more often, many Gigabytes of documentation, code, and data), but for most field operations there is no need to go to that length: two to five pages would normally be enough. On an organisational level, it will obviously depend on how big your organisation is as well as its nature: the risk management plan for a two-project, one-country educational organisation will probably be not much more than the one-page result of a day’s hard work, but WFP’s risk management plan will more likely resemble that of a big multinational company.

However, whatever the size or nature of your organisation: you cannot afford to go without some form of risk management; organisations that think they can tend to be unpleasantly surprised at some stage.

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Go and be enlightened![1]

by Michael Keizer on May 18, 2009

"Coca-Cola Morocco" by 'ciukes' @ Flickr I am going to do something that I will not do too often: I am going to tell you to read a post about health supply chains on another blog, and not add anything to it. Over at the global health blog at change.org, Bryn Mawr student Mara Gordon just wrote an absolutely fabulous post on Coca-Cola and public health, explaining how it is around the corner from anywhere and what we can learn from that in public health. She is not the first to make the comparison, but it definitely is one of the most tasteful and refreshing ones I have read: good till the last drop.

(Image: Coca-Cola in Morocco by ciukes @ Flickr)

Footnote

[1] If you like a little puzzle: how many Coca-Cola slogans have I used in this posting? No prize, but an honourable mention for the first to post the right answer. But only after you have read Gordon’s post.

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My little sideline

by Michael Keizer on May 13, 2009

'Global Health' by Daneel Ariantho

A Humourless Lot clearly is a blog on logistics for health and aid, and even though I very occasionally make small excursions, I try to keep it tightly focussed on that subject. However, even though I am professionally specialised in it, my interests in (global) health range much wider than ‘just’ logistics – interests that I have not been able to really express here.

So you can imagine how chuffed I was when Alanna Shaikh, the ‘guide’ for one of the most widely read and accessible blogs on global health, asked me to become a regular guest blogger. I have started last Monday with a series on global health and human rights, and will post on a weekly schedule. I am not yet exactly sure where my posts will take me, but I am sure it will be an interesting ride.

So if you are interested in my interests outside of logistics, have a look at the global health blog at change.org – or go there anyway, as it is definitely one of the best blogs on the subject you can find.

(Image courtesy of Daneel Ariantho.)

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On ya bike![1]

by Michael Keizer on May 8, 2009

In some ways, this post wants you to consider the opposite of my previous post (on the use of airships in aid logistics). Don’t ever let it be said that I am not a fence-sitter.

Airships are great at integrating what was a multimodal[2] (part of a) supply chain into a monomodal one: instead of using various transport means, they could in many cases deliver from origin to destination in one go where before we would have to use several transport means.

However, the use airships for aid is still some time away, and even when it finally arrives there will still be destinations that will be very hard for airships to reach. The most apparent of these are dense urban settings: a large airship, although it needs less landing space than a wide-body plane, still needs considerably more space than e.g. a helicopter. As a large part of aid work takes place in these dense urban settings, we will need to look at other solutions for the last mile. This is all the more true for health logistics: as populations urbanise, more and more of the health effort will need to be concentrated in the cities and towns – and in most developing and middle-income countries these are very densely built up.

The easy solution is of course the tried and true combination of truck and car. However, for various reasons this is actually not appropriate in many settings:

  • Cars and trucks are relatively expensive means of transport: not so much in purchase cost (although those are not negligible), but especially in running costs and maintenance.
  • Maintenance might not always be possible: especially in developing countries it is at times difficult to find the necessary spare parts or the skills to maintain cars[3].
  • Trucks and cars add significantly to air pollution, which is already a problem in many cities in developing and (especially) middle-income countries.
  • In the most densely built-up areas, even cars can be impossible to manoeuvre.

So what solutions can we look at?

By far the oldest one is the use of raw manpower: human porters that carry goods wherever they are needed. Obviously, they can get anywhere where people can go, and where labour is cheap this is often the most economical way of transport. However, unless managed very well, porting can be punishing for the people involved, and lead to serious long-term health problems.

A much better solution is the lowly bike[4]. Like porters, it can get almost anywhere  where there are people; if not by riding it, then at least by pushing. It can bear much larger loads (more about that later) but with negligible stress on the body of the biker. And finally, bikes can be repaired by almost any technician worth their salt[5].

New developments in bike design mean that they can be used for much heavier and bulkier loads. A good example is the Big Boda load-carrying bicycle, a design from Worldbike. Bikes like this can successfully compete with cars and trucks in many settings, and should be considered seriously when designing logistics systems for health or aid.

(Images by Kees van Mansom and Worldbike.)

Footnotes

[1] If you wonder what I am talking about: have a look at this list of Australian English vocabulary.

[2] Multi-modal transport in this sense refers to transport using more than one means, e.g. train and truck, or ship-train-truck, etcetera. Strictly speaking, the term is reserved for when we have only a single transport contract, but I will use it in a slightly looser sense here.

[3] This is becoming a serious issue as cars are ‘computerised’ and more and more models cannot be maintained without expensive diagnostic machinery and specialised skills and knowledge.

[4] Yes, I am originally Dutch. Why do you ask?

[5] Obviously, I am not talking about your Bernard Hinault Special.

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The importance of contingency planning

by Michael Keizer on April 29, 2009

Slightly over a week ago, I was trying to write an article for this blog about how health issues could impact logistics. I just could not make it work: the main health impact on logistics would be from a pandemic, and although that seemed pretty realistic to me, I also felt that my readers would probably not see it as realistic enough to spare it a second thought. That was a real issue for me, because the main reason why I wanted to write the post was to get people thinking about logistics contingency planning for a pandemic.

Of course, I am now kicking myself for not have written what would have been a fairly prophetic post – and perhaps have influenced one or two people to take some action.

So my apologies for being late – let’s just say that this is a mistake I will not make very soon again.

The impact

Let’s just assume for the moment that swine flu will go pandemic. What effects will this have on our supply chains?

The most obvious one is that it will put severe demands on it. We will need to have massive amounts of medical goods at the right spot, at the right moment. How to deal with this issue merits a separate post, which you can find here.

Perhaps more insidious is the fact that every supply line depends on people – and in case of a flu pandemic, many of those people will be incapacitated (by illness or death), or be subject to isolation or quarantine. This will mean a severe blow for many of our supply chains: without truck drivers, store managers, clerks, and purchasers, our supply lines will soon break down.

Furthermore, quarantine measures might also mean that transport will be infinitely more difficult: if we can’t have trucks or planes come into the country where we work, goods will not come in either.

How to deal with it

So how to deal with this? At this stage, preparation would include four steps.

The most important issue, which needs immediate action, is to prioritise our logistics: which goods for which programmes are most needed. I would suggest to divide them into three to five groups, ranging from “immediately indispensable” to “doesn’t matter if it’s a couple of months late”. Note that we are not talking about articles here, but about article/programme groups: article 1 for programme X might be in a different group than the same article for programme Y. This needs to be done now: you do not want to have these discussions while you are in the middle of a crisis.

A second issue that needs to be dealt with concurrently with the prioritisation, is a sensitivity analysis of our supply chains: which parts our supply chains will be most vulnerable to disruption? It could be very helpful to develop a couple (not too many) scenarios and see how they impact our supply chains. When doing this, don’t forget that our supply chains extend beyond our own organisation: include the possibility that e.g. your main supplier will be severely impacted, or that your main transporter will be knocked out. Also look outside the logistics departments, e.g. by taking into account that your programme staff might be so severely overburdened that they will no longer be able to make forecasts or report regularly.

Based on the prioritisation and the sensitivity analysis, prepare contingency plans that deal with the various scenarios in such a way that (as far as possible) goods from the highest priority groups will be where they are needed, when they are needed. These contingency plans could include e.g. stockpiling (explicitly taking the risk of increased expiries), already hiring extra staff, and many other possible actions. What it exactly will entail for your organisation will depend on many factors, and there is definitely no one-size-fits-all solution. It will be important here to think laterally and come up with creative solutions: this is an extraordinary situation, and will need extraordinary solutions.

The fourth and last step is resourcing and communication: make sure that you have the (financial) resources to implement your contingency plans – which will mean that you will need to ‘sell’ your plans now to senior management of your organisation – and communicate the plans to all people involved, which would include practically everyone within your organisation, and quite a number of people outside it.

I can hardly stress enough that these steps need to be taken now: if and when the crisis arrives, it will be too late. You might counter that nothing ever goes according to plan, and that the crisis that will really happen is unlikely to be the one you planned for; that might be true, but having these plans and resources at the ready will give you an enormously increased resiliency that will enable you to cope much better than otherwise. To quote general Dwight D. Eisenhower: “plans are nothing; planning is everything”.

A call for action

Go now to the person(s) responsible for logistics planning in your organisation, and ask them whether they have prepared contingency plans for a severe pandemic impacting on your supply chain. And don’t let them get away with generalities; things are much too serious for that. And if you yourself are responsible: did you do your homework? Finally: please come back here and let us know what you did: at this stage, we should all learn from each other.

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How to get things done: more on the logistics of logistics

by Michael Keizer on April 16, 2009

In my previous post on why logistics seems to be so prone to “herding cats” problem (thanks, Laura Walker Hudson!), I suggested five  reasons:

  • The complexities of logistics are “deep” complexities, and are not readily apparent.
  • Daily logistics experiences are not always applicable to large-scale logistics.
  • Our evidence base is sketchy, which has a ‘halo’ effect on all logistics activities.
  • There are hardly any aid logisticians with a recognised advanced degree in the field.
  • Aid logisticians are not the biggest fans of systems or administration themselves.

So what to do about his?

1. Work on the evidence

This is easier said than done. However, we will need something more than our gut feelings and personal experience to be able convince our colleagues. Other areas in aid routinely publish about lessons learned — why don’t we do so in logistics?

  • If you have seen (or developed) a particularly successful technique or method, or seen a received one wreak havoc in a particular setting, don’t keep it to yourself: write an article for an appropriate journal.
  • Think how you can incorporate research in your daily practice and do so. Most aid organisations, and defintely most health organisations are open to facilitate research as long as it does not inconvenience their programs too much. Health and humanitarian disciplines routinely do research within programmes, but logistics rarely does.

2. Explain, explain, explain — and learn

Too often, we do not explain why we want to do certain things a certain way: why is it necessary to fill in that request form, why can’t we just go to the pharmacy and take what is needed, why do we need to make consumption forecasts? Be didactic; and be proactive about — don’t wait for your colleagues to ask, because they will only do so when their irritation level is already high. And if you feel that you cannot explain, rethink — perhaps we are on the wrong track.

This holds true the tactical planning level as well: why do you elect to go for six-monthly order cycles and not three-monthly ones? Why do you select these suppliers and not those? Why do you procure your drugs in Europe and not locally? Include in your explanations why logistical solutions that work at the level of one patient, one time, will not work at the level of a large-scale intervention.

Make sure that everybody understands (or at least has a chance to understand) what you are doing and why, and you will see that it will suddenly is much easier to implement your systems. You will also get much better feedback — and who knows, that feedback might lead you to reconsider your plans and improve them beyond recognition.

3. Get a recognised qualification

Get that master’s degree in aid or health logistics, and see how much more recognition you suddenly get (and how much deeper your understanding of what you do will be).

I am working on my second master’s degree now (in public health, specialising in health logistics for develing countries), but my first one was only sidewise related to aid/health logistics. Already I notice that people take more account of what I am saying, just because they feel that I somehow ‘earned’ that by studying the field. Utter nonsense, of course, but it is how the game plays — and you’d better play along if you want to have the impact you know you can.

Working on my MPH has also given me an opportunity to better integrate my knowledge. It haven’t yet learnt much that was completely new to me, but I am now better able to put things in their context, and to see links between seemingly disparate pieces of knowledge that I did not see before. It also enables me argue more convincingly (not necessarily better, but definitely more convincingly) because it has given me better knowledge of the language of health and health professionals. And finally, it has enabled me to expand my network in global health, which means that I know who to call next time I have a problem that I don’t have a good solution for, or when I think that I need specialist input for.

Get that qualification — it’s worth it.

4. Don’t undercut yourself

When the unexpected happens, don’t throw your logistics systems overboard and get into emergency mode. First think how you can accommodate the issue within your existing systems. By giving the right example, you can show the importance of those systems and that they are not just impediments to getting our work done.

Don’t change systems without in-depth understanding. Many logistics managers in aid, especially in emergency aid, have very clear ideas about how things should be run and do not hesitate to change things in the first couple of weeks (or sometimes even days) after they have arrived. However, your predecessor probably was not a fool either, and would have had reasons to implement the systems the way they did — based on what they knew after having worked for some time in that particular setting. Don’t change systems before you have been in the programme at least six weeks to two months — and for developmental programmes even longer. Changing things too fast, too soon, will only serve to undercut yourself and future logisticians.

And finally: follow the systems yourself. Nothing will undercut your authority as quickly as a ‘do what I say, not as I do’ attitude.

(Image by Todd Lappin)

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How to get health care and patients together

by Michael Keizer on April 14, 2009

Bicycle ambulance

As I have written before, health logistics as a discipline tends to ignore the impact of the logistics of daily life on health. Possibly the clearest example is how physical access to primary health care impacts on health.

What do you do when you are seriously sick? Well, most of us in the developed world would go to a doctor. But what if that doctor is a four-hour trip away? Even here in Australia, a developed country by any account, access to health care is much worse in remote and rural areas than in the cities, and the health outcomes are as can be expected. Similar results have been shown in studies in other developed countries.

Obviously, things are much worse in developing countries. That four-hour trip suddenly translates in four days (or more) on the road, or rather, on a muddy track, on your own feet or bumping along on the back of some animal instead of a smooth ride in a car or train. The health outcomes are horrifying. For instance, a recent study in Ethiopia suggested that urban elderly Ethiopian women had about a 1.6-1.8 times longer life expectancy than rural ones. Or this one: the rural areas around Kunming (China) suffer from 50% more premature deaths than the city itself.

Solutions obviously need to be found, and some are already being implemented. Foremost, we need to concentrate more of our preventative efforts on less accessible areas. Of course, that is easier said than done: the same issues confronting a patient searching medical treatment, are hindering outreach and health education efforts — and when it comes to e.g. water and sanitation efforts, the logistics issues are even worse.

Another way to deal with these issues is by decreasing the distance between patient and health care. There are basically two ways of doing so: by bringing access points to the patients, or by bringing patients to the access points.

The former can be done by more dispersed access points, or by mobile clinics. Both have some serious drawbacks. Peripheral health access points are either unable to cope with more serious complaints, or would have to be impossibly well-equipped in a setting that is resource poor — you cannot put a secondary hospital in every hamlet, definitely not in a resource-constrained setting like a developing country. Mobile clinics can be slightly better equipped and resourced, but are only occasionally available to any given population and hence cannot deal with e.g. many emergencies, simply because they are not there when the emergencies occur; moreover, they are a shocking waste of time for the health care professionals, who spend much of their working hours trekking from one place to the next instead of on patient care.

Patient transportBringing patients to the health care settings is something that is rarely done. In developed countries we do so using individual patient transport (e.g. ambulances or commercial patient transport), but that is not an option for developing countries. Another way would be to use communal patient transport. Imagine a bus (or animal-drawn cart, or a caravan of donkeys or camels…) making scheduled rounds along a number of reasonably short circuits, picking up patients and delivering them to the nearest health care facility, and returning them on the next round after treatment. It would still not solve the problems of emergency care, but for the less acute cases it would bring patients possibly faster and more comfortably, but definitely at less cost for them to the care they need — without wasting a valuable and scarce resource, health professionals’ time.

Obviously there are issues around it that need to be solved, but it seems to be a intriguing possibility with many possible advantages. I know it has been done at very small scales, e.g. in refugee camps and in the immediate surroundings of some health posts here and there, but as far as I know it has never been tried in a larger area (but I would be chuffed to be corrected). High time for a trial, I would say.

(Images by Aaron Wieler and Shawn Alladio.)

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Interception of generics in the Netherlands: latest developments

by Michael Keizer on April 12, 2009

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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