CLICK TO ADD
TITLE
The 6th Global Health Supply Chain Summit
Seeking the Transformative in Supply Chains for
Public Health: Informed Push as a Case Study
[SPEAKERS NAMES]
November 18 -20, 2013
Addis Ababa, Ethiopia
[DATE]
Ellen T. Tompsett
Sr. Programme Officer, Reducing Stockouts
Addressing challenges of data capture and
trained HR
Informed Push Model
• Last mile distribution model
• Adapts the principles used in commercial sector distribution
• Uses teams of trained staff to visit health facilities, review
inventory, and restock shelves from truck
Implementations over last decade
•
•
•
•
Zimbabwe DTTU and ZIP (USAID|DELIVER)
Mozambique DLS (VillageReach)
Senegal Informed Push (Intrahealth)
Nigeria DDIC (USAID|DELIVER)
Producing dramatic results – Zimbabwe &
Mozambique
DTTU
• Average stockout rates dropped from 20% to 2%
• 95% availability across 99% SDPs
ZIP
• Average stockout rate fell from 30-100% to 5%
DLS
• Increased vaccine coverage rate to 92.8%
• Incidence of stockouts dropped from 80% to 1%
• Cold chain uptime increased from 40% to 96%
Dramatic results – Nigeria and Senegal
DDIC
IPM
• Decreased stockout rates in Ebonyi from 85% to
5%
• Increased facility reporting rates to 100%
• Stockout rates for Jadelle and Depo from 86%
and 57% to 0% respectively
• Increased consumption by 38%
Zimbabwe
Alan Bornbusch
Public Health Adviser
DTTU – The Basics
Product availability > 95%
Facility coverage > 98%
DTTU team calculates
consumption and stock
on hand; tops up to
maximum stock level
Truck loaded with
products; quantities based
on previous quarter
consumption data
Truck drives with
stock to facility
Cost effectiveness
8
Cost Drivers
DTTU
• Fleet management
costs
• Truck capacity / size of
the trucks used
• Drivers per diem
• Number of staff in the
truck
• Time counting and
picking products at the
facility
EDS
• Number trained staff
system-wide
• Staff turnover
• Supervision costs
• Ensuring orders are
placed
• Time managing stock at
facilities
Scalability
10
Sustainability
Adequate, secure financing; human resources;
infrastructure … i.e., as for any model
Not appropriate for all products
Part of a larger segmentation strategy
Apply to a limited set products with shared
characteristics that lend themselves to informed push
Mozambique
Wendy Prosser
Program Manager
Dedicated Logistics System (DLS)
streamlines vaccine distribution
Provincial
Storage
3. Return to provincial level
office:
- input data
- analyze information
- address problems
- prepare for next trip
District
Storage
1. Leave provincial
level with:
- medical supplies
- equipment, parts
- information
Health
Centers
2. Site visit (in coordination
with district level):
- record & stock inventory
- service equipment
- supportive supervision
- collect data
13
Level jumping * Task shifting * Data use * Optimized transport loops * Supportive supervision
DLS is more cost-effective and efficient
than diffused distribution
DLS province in Mozambique
Non-DLS province in Mozambique
17% more cost-effective
21% more efficient
Pilot resulted in 93% coverage rate for
all childhood vaccines
$5.03 - - - - - - - - Cost per child vaccinated - - - - - - - $6.07
$1.18 - - - - - - - - Cost per dose delivered - - - - - - - $1.50
27%
20%
54%
Cold Chain
10%
16%
14
10%
Personnel
Transport
Vaccines &
Supplies
27%
8%
17%
48%
Process to sustainability and to scale
2015 ???
2011: Operating in
four provinces
2006: Expansion to
one more province
2002: One province
Phase 1: NGO
pilot providing
staff, budget,
infrastructure &
management
15
Phase 2:
Government
staff; NGO
budget,
infrastructure &
management
Phase 3:
Government staff
& management;
50/50 shared
budget &
infrastructure;
technical support
from NGO
Phase 4:
Completely
government
managed &
financed;
national policy
adopting this
system
Root causes of the challenges to reach
sustainability
Implementation
Issues
Funding
Leadership
Lack of dedicated and
accessible funding stream
Insufficient capacity
and motivation to
use data
Lack of alignment
with national
priorities
Environmental
Factors
Budget shortages (fuel, per
diems, vehicle and cold chain
maintenance and repairs)
Insufficient commitment
to consistent
implementation
Inconsistent
Implementation
of DLS
Insufficient
personnel for fully
implementing DLS
Insufficiently
trained & managed
distribution team
Human
Resources
16
Data
Insufficient use
of data for
decision-making
Poor quality of
data collected at
health centers
Transport
Lack of dedicated
and available
vehicles
Poorly managed
vehicle fleets and
maintenance systems
Poor Vaccine
Supply Chain
Performance
Senegal
Leah Hasselback
Project Director
Orders
Informed Push Model
Proceeds recovery
Product retrieval
Delivery
Difficulties encountered
Pull flow with orders
Informed Push Model: push flow without orders
Regional Supply
Pharmacy
Regional Supply
Pharmacy
3PL
▪
▪
▪
Poor
forecasting
of needs
Cash flow
problems
Etc.
▪
District
Retrieve
products with
own means
(e.g., rental,
taxi)
▪
▪
SDP
Payment for
quantities
consumed (not
quantities
delivered)
Margins
maintained
Information
District
▪
▪
Systematic delivery to
restore stock levels
Order-delivery form
signed with proceeds to
recover and quantity of
delivered products
SDP
1
Scalability and Sustainability
Sustaining
Scaling
2012 –
July 2013
August 2013 –
July 2014
6-month pilot in 2
districts. Expansion to
cover the regions of
Dakar (12/12),
Kaolack (1/13), and
Thiès (4/13). SaintLouis managed by
PNA.
559 SDPs
Expansion to the
regions of
Diourbel, Fatik,
Kaffrine, Matam,
Louga.
Adopted as national
FP strategy and MoH
requested national
expansion. Decision
for PNA to sustain the
system.
Explore the
integration of other
products, PNA
management test,
sustainability
planning.
1000 SDPs
Geographic
Coverage
Region covered by IPM
19
IPM managed by the PNA
August 2014 –
July 2015
Expansion to
the regions of
Tambacounda,
Ziguinchor,
Sechiou, Kolda,
Kedougou.
1367 SDPs
PNA takes over
management of
Dakar, Kaolack
Thiès.
August 2015 –
July 2016
Full
integration of
the model in
the health
system. All
regions
managed by
the PNA.
Costs & Sustainability
Cost Recovery Model
• Total estimated annual
costs at scale for family
planning: $500,000
• Total expected annual costs
recovered at scale:
$1,040,000
• Division of Reproductive
Health and Child Survival to
commit 50% of cost
recovery ($520,000) to
IPM logistics costs
Open Questions
• 3PLs in rural regions?
• PNA to manage 3PLs?
• Cost of PNA
management?
• Cost of integrating other
products?
– Other finance sources:
program fees, high margin
products, line in state
budget, donors
• Cost-effectiveness
analysis of the IPM
Nigeria
Emmanuel Ogwuche
Direct Delivery and Information
Capture (DDIC) Model
Logistics data
available for
decision making
Visibility in
the supply
chain
Increased product
availability
Health workers focused
on providing services
Scalability
Improved Commodity Availability in
Ebonyi
Malaria Commodities
90.00%
80.00%
Percentage Stockout
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Period
1
Period
2
Period
3
Period
4
Period
5
AL 1x 6
77.05%
1.64%
0.93%
1.52%
0.49%
AL 2x 6
78.69%
1.64%
2.80%
3.03%
2.46%
AL 3x 6
78.69%
1.64%
2.80%
5.56%
3.94%
AL 4x 6
77.05%
1.64%
1.87%
1.52%
1.48%
RDTs
80.33%
1.64%
2.80%
5.05%
2.46%
• Scaled from 61 to 204 health facilities in 4 runs in Ebonyi
• Scaled from 79 to 116 health facilities in 2 runs in Bauchi. Will reach 165
HF’s in November 2013
• In 2014 will scale up to 2 additional states and Federal Capital Territory
Cost-Effectiveness Study 2014
• Questions
– Can the DDIC effectively ensure the delivery of
commodities to facilities, as well as effectively capture key
commodity availability information?
– Is the DDIC system affordable?
• Strategy
– Data Quality Audit
– Costing survey to include average cost effectiveness:
• Total annual costs
• Total annual operating costs
– Compare multiple distribution models in Nigeria including
DDIC
– Compare across states and within states
Country Ownership/Sustainability
•
•
•
•
Engagement with Nigeria government at all levels
Use of public sector personnel as DDIC Team Leaders
Collaborative efforts with various agencies in the country
Integrating commodity distribution for different health programs