E-DRUG: Logistics systems in the less developed world (4)
Tony Odendaal and Marita van Rooyen offer a depressing view of healthcare
supply chains in Africa, where lazy, dishonest workers and organized
gangs stealing medicines predominate with an uninterested majority unwilling or unable to do anything about it. I have no doubt that their views are formed through real experiences, and I have seen similar things in my 10plus years working in this field but I can say with certainty that the scenarios they describe are not representative of all African countries, and I dare say not even of the majority. My bigger disagreement with their prognosis however, is their main proposed solution – an auditing function to make suremedicines are all accounted for.
(Full disclosure I am probably one of the "so-called logisticians" they
refer to: we either have an academic perspective or we have fixed views
on paper systems or we have a first world computerized perspective. This
pretty much covers everything since the solutions needed include all of
the above. I happen to believe we need more academic research to inform
our work, I believe passionately in the need for automation and IT, but I
also believe there is a huge role for strong paper systems to complement
IT, at least until we have harnessed IT completely.)
On to my response: I am currently working in a country where diversion
is not a significant problem and have worked in several others in the
past where you could say the same thing. Yet these countries do often
suffer from weak, inefficient supply chains where visibility of data on
supply of and demand for medicines is limited, compromising all supply
chains functions including quantification. I would argue medicine
diversion is more a symptom of weak systems and less a cause. I strongly
believe the best solution to diversion is data or to be more technical, a
strong Logistics Management Information System (LMIS). Diversion
information is anecdotal, and so unfortunately are other datadriven
processes like quantification because systems are incapable of generating
quality reliable and timely data on medicine use and demand. Investing in
an audit function does absolutely nothing to solve this problem. It says
we don’t care about how weak your system is, whether or not people can
get medicines when they need them, all we care about is that all the
medicines you receive are accounted for.
So what is the answer: The simple answer is data, data, data. Of
course it’s more complicated than that but that’s the best place to
start. Data visibility, in as close to real time as possible (weeks or
even months is probably good enough) at all levels of the supply chain.
Quantification is not that hard if the manager at a CMS can routinely see
what the demand for medicines is in health facilities. And if he knows
how many of those health facilities were stocked out last month and for
how long. Procurement is much easier if you have accurate forecasts. It’s
much easier for district managers to make sure their facilities are
ordering sufficient medicines if they have their consumption and stock
data in front of them. And diversion (and indeed waste due to expiries)
can be more easily managed if there are systems to monitor stock
movements throughout the system with built in checks and balances. It
would also help if we brought more “supply chain professionals” into the
mix to work alongside pharmacists and healthcare personnel to managethe
warehouses, and distribution schedules, and IT systems, and dare I say
it do some of the quantification. And yes you may probably also need an
audit function but if that’s the main solution we have to offer then we
truly are“so-called logisticians”.
Creating these kinds of systems needs automation, computerization and IT
but of course they can’t on their own be the entire solution. Paper
systems will also continue alongside IT for the foreseeable future. But
automated solutions need to be appropriate, they need to be flexible and
adaptable for resource constrained settings, and they need to be
accompanied by strong supportive supervision, system upgrades, SOPwriting, and capacity building so they are sustainable. That kind of support takes time and resources. And resources should be allocated and decisions made
rationally – which I would argue means looking at your entire
healthcare supply chain holistically and making decisions not based on a
particular donor program of interest but rather based on product
characteristics and the needs of users. That means strengthening the
entire supply chain, delivering some medicines together (but may be not
all), forecasting some medicines using different criteria to others,
using private and NGO sector partners where appropriate, monitoring
performance and taking corrective actions as needed and it probably
means a single LMIS but with a commitment to transparency and sharing
data among all.To me that’s an integrated system – its not one size fits all but it’s a system where decisions are made rationally, where there is end to end data visibility,where supply chain functions from
quantification to procurement to distributionare seamless, and the
system can react quickly to changes in supply or demand, where partners
trust each other and share their data, and where roles and responsibilities are clearly defined. I believe that the country
where I currently work, Ethiopia, is moving in the direction of a truly
integrated supply chain, with automation, paper-systems, training, SOPs,
warehouse constructions, and policy reform creating an autonomous but
accountable CMS,and I also believe several other African countries
including some in Southern Africa, are doing the same thing.
Paul Dowling
Country Director,
JSI Ethiopia
Paul_Dowling@jsi.com