A Humourless Lot» Logistics for health and aid: A Humourless Lot. Tag page for Evidence

The Zambian logistics pilot project (II)

Michael Keizer — Sat, 31 Jul 2010 09:47:38 +0000

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.]

The Zambian logistics pilot project (I)

The Zambian logistics pilot project (I)

Michael Keizer — Mon, 19 Jul 2010 12:02:00 +0000

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.]

Research wanted! A call for papers

Michael Keizer — Sat, 18 Apr 2009 06:00:04 +0000

No sooner had I finished my post calling calling for more evidence on what works (and what doesn’t) in health/aid logistics, than an email message arrived from the HUMLOG institute, alerting me to an excellent opportunity to do so. The Supply Chain Forum, a professional journal on logistics, supply chain and operations management, will publish a special issue on humanitarian supply chains. Please see their call for papers for more information.

Now get those keyboards clicking!

(Image by Nic McPhee.)

No related posts.

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

Michael Keizer — Thu, 16 Apr 2009 04:13:53 +0000

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)

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

Michael Keizer — Fri, 10 Apr 2009 05:24:18 +0000

“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.”