Public health

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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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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The unanswered questions of aid and health logistics

by Michael Keizer on March 22, 2009

'Small Talk' by xkcd

Some of the issues that I think should be in the forefront of aid and health logistics discussion:

  1. How should we ensure adequate logistics input in the planning phase of aid projects?
  2. Will medical professionals and health logisticians ever be able to talk each other’s language? Will non-logisticians ever feel that they own the process too?
  3. Are cold chains unbroken? Do we really vaccinate, or just administer useless stuff? (This is actually the subject of my thesis research project, so you can imagine that it is a question that is close to my heart.)
  4. What are reasonable goals when it comes to logistics efficiency in aid operations? Is it really possible to determine a minimum level of efficiency? And if not, how can we be accountable? And how about effectiveness? And the balance between the two?
  5. How much of health budgets in developing countries should be devoted to logistics? In developed countries it is often more than 80% (including procurement cost), but is that reasonable or necessary in a developing country?
  6. When should the supply chain stop being flexible (supply rubber bands?) and determine operational options instead of vice versa?
  7. Why does large-scale aid logistics seem to deliver so few economies of scale? How can we improve?
  8. How can we improve the level of logistics knowledge and skills in health systems in developing and middle-income countries? What are the determining factors for health logistics in these settings?
  9. Could health logistics be a determining factor in developing new drugs or techniques? E.g. less heat-sensitive vaccines, reagents with longer shelf lives, etcetera.
  10. Pull or push? And in which settings?
  11. Has the kit system had its time? Should we move on to less wastage-prone systems?
  12. How can we improve on training and mentoring of new health and (especially) aid logisticians? Isn’t it about time that we stop to just turn them out to swim or drown?
  13. Third-party logistics: a viable alternative in which contexts?
  14. Are logistics consultants actually worth what we pay them?
  15. Six sigma, lean, kaizen, SPC: what can we learn from them?
  16. Isn’t it time that we stop setting up parallel logistics systems for aid, instead using the ‘normal’ channels? Or is that just a pipe dream?
  17. Is it in any way possible to stop creating new patients by the environmental damage due to inefficiency of supply lines in developing countries?

Any other issues? What logistics issues keep you awake at night?

(With thanks to Alanna Shaikh for inspiring the form of this posting.)


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Sometimes I really wonder why we haven’t seen Madoff coming. Harvard Business School is one of the most high-profile business universities, and when a Harvard assistant professor of organisational behaviour talks about business ethics, you pay attention; so it should be no surprise that a recent interview with Michel Anteby, in which he seemed to support various sorts of fraudulent behaviour, drew quite some attention. His argument is that ‘leniencies’ are part of the standard managerial toolkit and that they are necessary to be able to our work well.

So let’s have a look at some of Anteby’s examples, try to find equivalents in health and aid logistics, and see how this works out.

Managing the store manager

[An] employee setting aside a clothing item in a storage room to later purchase for himself when the item will be deeply discounted is a gray zone as well. In high-end department stores such practices are often tolerated. This leniency when moderately exhibited is widely seen as “good” practice, a small favor done to reward deserving employees, and as such qualifies as a moral gray zone.

The equivalent here seems to be the store manager who ‘sets aside’ spare parts until the equipment for which they are used is superseded, and then buys them at a discount; or the medical store manager who ‘sets aside’ materials until they are almost expired in the knowledge that they will be donated to a befriended charity to prevent expiration. Is this acceptable? Not in my view — but the parallel with Anteby’s example is striking, and suggests that ‘business ethics’ would endorse acceptance of these practices.

Pulping the punch card

… a student who worked in the U.S. pulp industry was asked by his co-workers to punch them out later than they actually finished work. Management apparently was aware of this practice and allowed it.

I dont think I will need to spell this one out.

Medical paras

Paramedics are supposed to bring patients to attending physicians (most often in emergency rooms) and are not supposed to perform many medical acts. Officially, attending physicians are the ones performing the acts. Yet in some instances, to save “crashing patients” (meaning patients who seem about to die), paramedics will perform acts that they are not officially allowed to perform. Not all paramedics, however, are given such leeway—only the trusted ones. When physicians are aware of these breaches, yet remain silent, we are in the midst of a moral gray zone.

A logistics equivalent here would be to allow a storekeeper in an emergency to circumvent certain procedures so the program does not get bogged down in bureaucracy. Seems a good idea, doesn’t it? My view, however, would be that there is no need for it: include an emergency clause in your process description that allows your logistics manager to give dispensation of certain rules, but only after approval from another line manager, only for a limited period, and stipulating that this has to be formalised in writing or an email message. No need to break the rules: the rules should be flexible enough to deal with these situations — most definitely in aid organisations.

… by allowing trusted paramedics to “save lives” even if this means bending the rules a bit, physicians cater to the paramedics’ occupational identities. Paramedics become who they aspire to be, namely “saviors.” These paramedics are also more likely to cooperate with the physicians in the future. Thus, moral gray zones enable both managers and workers to perform their roles.

Anteby himself points the way here to a much better solution. In many countries, paramedics have a much larger role in patient management, in which they are allowed to and have received the training to be able to cope with crashing patients; e.g. in some countries paramedics can intubate, defibrillate, administer certain lifesaving drugs etcetera, and all this at their own initiative. Similarly, store managers who have received adequate training, tools, and discretionary authority, should be able to deal with almost any emergency while staying within the set procedures.

Upping the ante

Two broader implications can be drawn from this example. First, leniencies are part of the managerial toolkit. They allow for “local regulation”: in other words, they allow work to be done.

… Obviously, some level of organizational control is lost because “control” now occurs at the field level between the physician and the paramedic. In a way, top management loses power over its employees. In gray zones involving material pursuits—such as when a clothing item that could have been sold at a higher price to a customer is kept hidden until it becomes deeply discounted—direct losses can be calculated. At the same time, managers gain the employees’ engagement, and perhaps, more importantly, managers get to decide who benefits from its leniencies.

Anteby’s conclusion seems to be a total non-sequitur: as his own examples illustrate, work can be done without breaking the rules, without his ‘leniencies’; and employees can be engaged by other means, e.g. by sufficient training , remuneration, and career options. The telling point seems to be his last clause: power to the managers, whatever the cost.

And in the next episode…

My current project focuses on potentially contested practice where few norms seem to prevail. Whole-body donations for medical education and research provide the setting for this project. The goal is to understand how individuals and organizations operate in this context.

Right, everybody, hold on to your kidneys…


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The new pirate threat: germs

by Michael Keizer on March 5, 2009

If you are interested in logistics, health, and aid, the United States Naval Institute (USNI) blog is a wonder. Really.

The more-or-less recent attention in military circles for soft power means that the USNI is also more and more interested in how the Navy can be involved in aid, in order to win hearts and minds (force multipliers[1], anyone?). Of course, the US Navy is also one of the biggest logistics operations in the world (hey, logistics originally is a military science). So of course the USNI can be a source of fascinating stuff about the two.

One of those little gems was published a couple of weeks back. As the Navy is actively involved in catching those elusive Somalian pirates, some people are getting worried what an outbreak of e.g. MDR-TB, brought across by captured pirates, could do on a closely-packed military vessel. The stuff of nightmares, apparently, and they even quote MSF to support that. Luckily a commenter makes clear that TB is not that easy to transmit, but still…

My first posting ever on this blog was about the threat to aid (and hence to population health) posed by Somalian pirates. Apparently that threat goes further than that, and Navy sailors can be threatened by more than bullets.

(Picture: Arrrgh! | Pirates by Joriel “Joz” Jimenez. Some rights reserved.)


[1] I find it curious that nobody noticed that Powell used the term ‘force multipliers’ routinely — he even had a personal rule: “[p]erpetual optimism is a force multiplier.” So his description of aid organisations as force multipliers might actually have been a lot less meaningful than it has been described. Still not a smart thing to say, though.


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Lack of logistics planning: 7 million at risk

by Michael Keizer on March 4, 2009

An interesting article in the Ugandan newspaper The Daily Monitor, warning for a possible new polio outbreak. The most interesting part came almost at the end:

Dr Zaramba [the Director General of Health Services; MK] said the health ministry has enough vaccines to roll out an emergency vaccination exercise for children below five years later this month and in April. …

However, Dr Mbabazi [a risk analyst at the WHO country office; MK] said there are “serious health system and bureaucratic problems” that have led to the re-emergence of polio in the country that need to be fixed “real fast”. He cited bureaucratic delays that stopped the government from responding quickly to the WHO warning.

He said, “They are now talking about this upcoming emergency vaccination but as far as I know, there is no money for logistics to do it on a massive scale. Yet it is the best that can be done under the current circumstances.”

Let me reiterate this:

  • Seven million Ugandans are at risk of contracting polio
  • There are sufficient vaccines to vaccinate all of them
  • But: there is no money to arrange the logistics of a vaccination campaign.

Yet another example of how ignoring health logistics will lead to disastrous consequences. When will we start to integrate logistics in our health planning?

(Photo: Polio immunisation in Jinja, Uganda. Courtesy of Richard Franco. Some rights reserved.


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Your fundamental rights

by Michael Keizer on March 3, 2009

Transport of artillery early 17th century (Jean Théodore de Bry, 1614)

(This is the first article about the fundamentals of logistics in health and aid. A number of the issues that I outline here will come back in future postings.)

The health of a supply line is often measured by the ‘five rights’:

  1. Are the right goods (including in the right quality[1]) being delivered?
  2. Are they delivered in the right quantity?
  3. Are they delivered to the right location?
  4. Are they delivered at the right time?
  5. Are they delivered at the right price?

Of course, these same five rights are important in health and aid logistics as well, but the emphasis will often be different from ‘normal’, commercial logistics settings.

Starting with health logistics, it will be clear that the first four rights will get much more emphasis than in a commercial setting. E.g., a supermarket chain can decide not to sell lettuce for a day if the lost profit margin would be less than the extra cost of getting it to its stores; ethically, a hospital cannot easily weigh the lives and health of its patients against the costs — and in any case such a trade-off would make an interesting PR exercise. In other words: the constraints in medical health are mainly in the first four rights, and are much more rigid than in most (but not all) commercial settings. However, in resource-constrained settings (like in most developing countries), a lack of efficiency can mean that we have less resources to purchase life-saving supplies: health logistics in developing countries is a constant balancing act, where each error in either direction can mean loss of life or increased suffering.

In emergency aid, this holds true to an even greater extent: ‘the right quantity’ often will be massive, ‘the right quality’ is often not easy to determine in the hectic environment of an aid operation (hence often large amounts of supplies arrive that are in the end not used), and ‘the right location’ more often than not is extremely difficult to access due to shattered infrastructure, natural obstructions, or security issues, and will often be far away from the origin of the goods. This does not leave much space to experiment with ‘cheap’ alternatives. However, that does not mean that we should ignore efficiency: if gains can be made without endangering the effectiveness of our aid, why not use them? This will be the subject of a future posting — for now, let me just make the observation that I feel that we sometimes too easily allow ourselves to forget efficiency in our struggle for aid effectiveness.

In developmental aid[2], we are much more able to emphasise the cost side of logistics. Yes, our target areas still are often to access, and yes, the scale still often is massive, but we now can plan and forecast more easily (allowing to determine the right goods, the right quantity, and the right time more accurately), and hence we can plan our procurement and transport activities much further in advance. This implies that we can also procure much closer to our target areas, which by itself will already help decreasing cost. Most excuses for inefficient logistics that we see in emergency aid do not exist in development aid, and hence inefficient supply lines are a lot less acceptable.


[1] Especially in medical logistics, sometimes a sixth ‘right’ is added: are the goods delivered in the right condition. However, this is arguably included in the first right: e.g. expired drugs will definitely not have the required quality.
[2] Yes, I am aware that this is an artificial distinction and that there is a continuum from emergency to developmental aid. However, please humour me and allow me to use this divide for our analysis.


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Latest job opportunities

by Michael Keizer on February 28, 2009


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Smallest-scale logistics

by Michael Keizer on February 26, 2009

Talking about health logistics, we tend to concentrate on heath systems logistics, i.e. the logistics of the health system. What we ignore is the logistics of daily life and its impact on health.

To give one example: obesity is linked to the way our communities are designed and how long we spend in our cars each day. More dramatic examples include how distance from a source of clean drinking water impact on water use, or how transport and in-house storage of that same drinking water can make all the difference between clean or contaminated water.

An even more direct link between smallest-scale logistics and health are the risks that many women and girls in developing countries (especially in refugee settings) run when collecting firewood. Here it is not even the logistics that impact on the product (firewood) and hence on health, but the logistic activity (collection) itself that endangers people’s life and health (although there is also an indirect link: the use of firewood as fuel causes air pollution).

UNHCR and the Women’s Refugee Commission recently started the Get Beyond Firewood initiative, which is trying to find safe alternatives for firewood. This is a good example of how improvement of the smallest-scale logistics can improve life and health of people in developing countries.


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Blindly optimistic or blindingly obvious?

by Michael Keizer on February 25, 2009

Oxfam recently released a report that basically claims that the only way to get health systems in developing countries on track is using a mainly public-sector approach. Of course,they hedge their position by including a disclaimer that “[t]he private sector can play a role in health care”,  but that is about the only nod they give to any merits of the private sector.

Obviously, not everybody agrees, and reactions have been swift and, at times, scathing; in fact, I have not been able to find any positive comments from non-Oxfam-related sources (but that might be due to the normal bias: it is always easier to be critical than to support somebody without appearing sycophantic).

The rational approach, of course, is: whatever works. Both Oxfam and its detractors seem to have been caught up in old-style ideology. The only rational response that I have seen up to now has come from CGD‘s April Harding: she points out that there might not be any convincing evidence for a blanket private-sector approach, but neither is there one for a similarly blanket public-sector one. Kudos to Harding.

I think it should be clear that every health system is unique, with its own setting, history, and constraints; and that consequently every system has its own optimum mix of public and private sector support. The art is to find that balance in each individual case, which is one of the central issues in public health economics. Blanket statements on which approach works best don’t do anybody any favour.

(Update 16 May 2009): See my recent post on pharmacies for more info on the public/private mix for health logistics.


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