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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The logistics of logistics, or: why logistics solutions never work here

by Michael Keizer on April 10, 2009

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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Latest job opportunities (10 April 2009)

by Michael Keizer on April 10, 2009

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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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The aid logistics drinking game

by Michael Keizer on April 9, 2009

Michael Kleinman, you are dangerous.

Over at his blog at change.org, Michael started a new trend: humanitarian drinking games. After Michael himself put up the first of those, TransitionLand and Harry Rud soon followed. Time for a logistics version, methinks — after all, loggies need to keep up their reputation as the hardest-drinking, loudest-talking hardasses of humanitarian work.

  1. Every time somebody talks about “the logistics of this-or-that” when they are just thinking of normal organisational tasks, take a drink.
  2. Every time somebody changes a protocol without thinking of the consequences of the supply line, take a drink.
  3. Every time your organisation starts a new program without thinking of logistics, empty your bottle.
  4. Every time somebody complains about not receiving the wine and cheese that they ordered, take another glass from the bottle that you confiscated from their care package.
  5. Every time somebody asks how many logisticians it takes to screw in a light bulb (none — the bulb is stil in transit, haw, haw, haw), empty your bottle over their head.

Remember: if you see a bunch of drunk aid workers weaving across the streets of  Monrovia, Yangon, or Medellin, don’t blame me — blame Michael Kleinman.

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Latest job opportunities (5 April 2009)

by Michael Keizer on April 5, 2009

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Comment spam

by Michael Keizer on April 2, 2009

I am getting lots of comment spam at the moment, and not all of it is being intercepted by Akismet. I try to check often, but I cannot be online continously — so I am afraid the occasional piece of spam will remain on the site for a couple of hours. Bear with me please.

(Image: SPAM by Yonezawa Yamagata. Some rights reserved.)

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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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