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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.]

Humourless links for March 1, 2010

Michael Keizer — Mon, 01 Mar 2010 02:28:00 +0000

Yet another scholarship from the awesome Zaragoza Logistics Center.
The British Red Cross combines fundraising and teaching people about the logistics realities of a disaster in a hands-on, weekend-long exercise. Looks very appealing. The BRC has been raising its logistics profile over the last year or so in some very interesting ways.
Forward Accountability: the best new development in development since the air-conditioned Landcruiser.
Well, well, well. The UN waking up to the importance of logistics for peacekeeping.
Sigh. Condoms costing lives? Hardly.
I have said it before and I will say it again: aid is complex and trying to simplify it does not help. Luckily I am not the only one to say so.