1. CLICK TO ADD TITLE [DATE][SPEAKERS NAMES] The 5th Global Health Supply Chain Summit November 14 -16, 2012 Kigali, Rwanda Managing Supply Chain Risk in Complex and Difficult Situtations: A Practioner’s Perspective Dr. T U Wushe

2. Agenda Introduction- Setting, Supply Disruptions & Justification of the presentation Defining Difficult Environment Difficult Situations and Health Supply Chain Management The Zimbabwe Case 2000-2009 Case study Conclusions and Recommendation

3. Introduction Setting WHO target of 10.5 lives saved every day Drugs availability at facility level is the MOST important element Unreliable or Supply Chain disruptions is a key barrier Therefore the supply chain is a mission critical element of a health program (Shawkey 2000)

4. Supply Chain Disruptions/causes Supply Chain disruptions causes Stock outs Poor Quality products Damaged product Leakages Examples Include Normal Disruptions- fuel, vehicle breakdown, labour issues, global shortages Complex and Difficult environment- Civil strife, Political interferences, temporal closure of facilities, cross purpose goals and objectives

5. Defining Difficult Environments No universally accepted definition Torres and Anderson (2004, p.5-6) propose a difficult states taxonomy along the following categories: –State collapse: the central state ceases to function –Loss of territorial control: contested or partial loss of authority –Low administrative capacity –Political instability –Neo-patrimonial politics, or clientism –Conflict –Repressive government –Difficult Partnership countries –Low income countries

6. Difficult Situations & Health Supply Chain Management Influenced by the Health Systems strengthening framework Options - Humanitarian: Saving lives - Developmental: Strengthening public systems In practice it is a continuum and the position of operation forms a foundation for building Public Health supply chains

7. Characteristics of a Health Supply Chain in Complex Environment Lack/Poor infrastructure Multiple and at times Dysfunctional supply chains lacking coordination and oversight Lack of equity in drug availability Poor and inadequate logistics information system Poor management capacity Expired drugs, surpluses and stock outs Weak institutions the government medical stores are just a warehouse and not involved in the purchasing and supply plans Displaced or weak country systems

8. Common Sources of and risks in Complex Environments Stakeholder goal divergence. Government, civil society and donors Poor ICT knowledge and resources in government Dysfunctional competition for channel members and staff Low level of commitment by government employees Secondment positions in government creating dysfunctional working relationships Vertical programs, TB, Malaria etc. Reduced/limited access to rural health facilities Political grandstanding Protests/lawlessness/ illegal road blocks and hijackings

9. The Zimbabwe 1999 – 2009 Case study Transformed from one best in sub sahara health sysytems to one of the worst. Findings -Complex relationship matrix with partners leading to aid adjustments causing an adjustment vicious circle -No longer meet its public health obligation to almost 100% donor reliant -Critical shortage and stock outs -Deterioration of infrastructure -Skills flight to neighboring countries, NGOs & Funded vertical programs

10. The Supply Chains The Delivery Team Top Up, (DTTU) based on a pull system. This is funded by GOZ, USAID and DFID. The ARV supply system funded by USAID. Cold Chain supply system NGO led supply network. NatPharm Distribution System which is based on a pull system The Zimbabwe Informed Push system In my 2010 study Products that were allocated and distributed from the central medical stores had a higher product availability rate that those that were ordered by health facility level staff.

12. How did Zimbabwe Manage its Risks Stock outs of Commodities – The DTTU integrated logistics system In 2003 DTTU was approved, piloted and rolled out country-wide. Reporting increased from 30% to 100% and stock outs reduced from 40% to less than 5%. CPR rate one of the highest in Sub-Saharan Africa at 65% 2007 – Medicines delivery systems ground t a halt More products were subsequently added to DTTU in 2007, 2009 and 2011.

13. Resilient People

14. Risk Management Strategies Postponement Strategic Stocks Buffer Stocks Flexible Supply Base Dynamic Demand Management Robust Transportation

15. Capacity Building

17. Challenges of Implementation Cost vs. Benefits Strategic Fit Capacity

18. Conclusions Build robust and resilient supply chains that less vulnerable to disruptions- contingency planning Understand the context first then structure SCRM system Design and Application of SCRM is a process based on action more than theory SCRM in difficult and complex environment is a SCM sun discipline requires more practitioner and academic research

19. The right product at the right place and in time

20. With the Right Attitude It is Possible

21. The Reality Check VICTORY“The problems of VICTORY are more agreeable than those of defeat but they are not less difficult” (Sir Winston Churchill 11.11.42) I acknowledge that doing well in difficult and complex environment comes with its own set of challenges. Therefore supply chain managers should always be ready to seize the current opportunity and organise on the fly to deliver undisputed value to clients. SCRM is a contact sport. Be ready to play the game.