1. CLICK TO ADD TITLE [DATE][SPEAKERS NAMES] The 6th Global Health Supply Chain Summit November 18 -20, 2013 Addis Ababa, Ethiopia Seeking the Transformative in Supply Chains for Public Health: Informed Push as a Case Study

2. Ellen T. Tompsett Sr. Programme Officer, Reducing Stockouts

3. 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)

4. Producing dramatic results – Zimbabwe & Mozambique Average stockout rates dropped from 20% to 2% 95% availability across 99% SDPs DTTU Average stockout rate fell from 30-100% to 5% ZIP Increased vaccine coverage rate to 92.8% Incidence of stockouts dropped from 80% to 1% Cold chain uptime increased from 40% to 96% DLS

5. Dramatic results – Nigeria and Senegal Decreased stockout rates in Ebonyi from 85% to 5% Increased facility reporting rates to 100% DDIC Stockout rates for Jadelle and Depo from 86% and 57% to 0% respectively Increased consumption by 38% IPM

6. Zimbabwe Alan Bornbusch Public Health Adviser

7. DTTU – The Basics Truck loaded with products; quantities based on previous quarter consumption data Truck drives with stock to facility DTTU team calculates consumption and stock on hand; tops up to maximum stock level Product availability > 95% Facility coverage > 98%

8. Cost effectiveness 8

9. 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

10. Scalability 10

11. Sustainability Adequate, secure financing; human resources; infrastructure … i.e., as for any model Not appropriate for all productsPart of a larger segmentation strategy Apply to a limited set products with shared characteristics that lend themselves to informed push

12. Mozambique Wendy Prosser Program Manager

13. Dedicated Logistics System (DLS) streamlines vaccine distribution 13 District Storage Provincial Storage Health Centers 1. Leave provincial level with: - medical supplies - equipment, parts - information 3. Return to provincial level office: - input data - analyze information - address problems - prepare for next trip 2. Site visit (in coordination with district level): - record & stock inventory - service equipment - supportive supervision - collect data Level jumping * Task shifting * Data use * Optimized transport loops * Supportive supervision

14. DLS is more cost-effective and efficient than diffused distribution 14 $5.03 - - - - - - - - Cost per child vaccinated - - - - - - - $6.07 $1.18 - - - - - - - -Cost per dose delivered - - - - - - - $1.50 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 54% 10% 16% 20% 27% 48% 8% 17% 27%

15. Process to sustainability and to scale 15 Phase 1: NGO pilot providing staff, budget, infrastructure & management 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 2006: Expansion to one more province 2002: One province 2011: Operating in four provinces 2015  ???

16. Poor quality of data collected at health centers Insufficient use of data for decision-making Root causes of the challenges to reach sustainability 16 Lack of dedicated and accessible funding stream Insufficient commitment to consistent implementation Lack of alignment with national priorities Insufficient capacity and motivation to use data Insufficiently trained & managed distribution team Budget shortages (fuel, per diems, vehicle and cold chain maintenance and repairs) Lack of dedicated and available vehicles Insufficient personnel for fully implementing DLS Poor Vaccine Supply Chain Performance Funding Leadership Human Resources Transport Poorly managed vehicle fleets and maintenance systems Implementation Issues Environmental Factors Inconsistent Implementation of DLS Data

17. Senegal Leah Hasselback Project Director

18. Informed Push Model 1818 Pull flow with ordersInformed Push Model: push flow without orders 3PL Orders Product retrieval Difficulties encountered Delivery Proceeds recovery Regional Supply Pharmacy SDP Regional Supply Pharmacy District SDP ▪ Systematic delivery to restore stock levels ▪ Order-delivery form signed with proceeds to recover and quantity of delivered products ▪ Payment for quantities consumed (not quantities delivered) ▪ Margins maintained Information ▪ Retrieve products with own means (e.g., rental, taxi) ▪ Poor forecasting of needs ▪ Cash flow problems ▪ Etc. District

19. Scalability and Sustainability 19 6-month pilot in 2 districts. Expansion to cover the regions of Dakar (12/12), Kaolack (1/13), and Thiès (4/13). Saint- Louis managed by PNA. Explore the integration of other products, PNA management test, sustainability planning. 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. Full integration of the model in the health system. All regions managed by the PNA. 2012 – July 2013 Geographic Coverage August 2013 – July 2014 August 2014 – July 2015 August 2015 – July 2016 IPM managed by the PNA Region covered by IPM Expansion to the regions of Tambacounda, Ziguinchor, Sechiou, Kolda, Kedougou. PNA takes over management of Dakar, Kaolack Thiès. Scaling Sustaining 559 SDPs 1000 SDPs 1367 SDPs

20. 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

21. Nigeria Emmanuel Ogwuche

22. Direct Delivery and Information Capture (DDIC) Model Increased product availability Visibility in the supply chain Health workers focused on providing services Logistics data available for decision making

23. Improved Commodity Availability in Ebonyi Scalability 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

24. 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

25. 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