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The potential of next-generation supply chains to ease DRCs “Casse-tête”

Friday, 31st of March 2017

Vaccine

Volume 35, Issue 17, 19 April 2017, Pages 2105–2106

Commentary

The potential of next-generation supply chains to ease DRCs “Casse-tête” ^☆

Felix Kabange Mukwapa Numbi,
Blanchard Mukengeshayi Kupa^,
Ministry of Public Health, The Democratic Republic of the Congo

Available online 30 March 2017

http://dx.doi.org/10.1016/j.vaccine.2016.11.096

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Under a Creative Commons license

Open Access

Highlights

•The challenges of vaccine delivery in the DRC today.

•Why a new or “next-generation” immunization supply chain is needed, what it might look like, and its potential benefits.

•The need for political commitment, collaboration, and change management to help ensure success.

•Commitment to the future in the DRC.

The Democratic Republic of Congo (the DRC) has rapidly improved the quality of social services and infrastructure in general, and the health sector in particular in recent years. It is not always easy to know if the changes generated by the many initiatives that are taking place now will meet the needs of future generations of Congolese. However, uninterrupted access to vaccines and other essential medicines is among the changes certain to have a lasting and positive impact on the health of the population. That is why the DRC is committed to reforming its supply chains.

Assuring delivery of health products to the entire population without distinction will require significant planning, coordination and resources. The DRC constitutes an enormous logistical challenge simply by its geographic, demographic and cultural diversity. It is the largest country in sub-Saharan Africa with 2.3 million km² mainly covered by a humid tropical forest. The DRC is also one of the most populous countries in Africa with 77 million inhabitants who predominantly live in rural, geographically dispersed areas. Vaccines and health commodities are delivered from Kinshasa, often by air, which is extremely expensive. Besides the costs, it can take weeks to deliver health products to nearly 9000 active health centers, and sometimes deliveries are not made at all. As a result, many health facilities lack the products to ensure positive health outcomes.

A second challenge is that there are dozens of supply chains in the DRC managed by many different programs. Coordination between these various programs is limited, increasing the burden on health workers while rendering the management of supply chains very difficult.

Finally, there are program-specific challenges. For example, the immunization program lacks adequate and sufficient chain equipment to meet vaccine storage requirements. Even with the recent acquisition of 1600 refrigerators through Gavi funds, only 50% of health facilities have functioning cold chains, leaving a major gap to address. These reasons are why the health supply chain in DRC has been described as a “casse-tête,” literally, a “head-breaker.”

The immunization supply chain in the DRC has not changed much in several decades. While an excellent fit for distributing the first available vaccines, the supply chain has become outdated. It is simply unreasonable to expect the original design to meet the latest requirements to reach every child in the country, especially with the addition of many new vaccines. And the volume and value of vaccines will continue to grow – quadrupling or quintupling by the end of this decade according to recent estimates.

At the 2016 Ministerial Conference on Immunization in Africa, ministers of health and finance committed to addressing the persistent barriers in our vaccine and healthcare delivery systems as part of a strategy to improve immunization equity and coverage. The focus on reaching more children with a full schedule of immunizations demands that we try a different approach.

New or “next-generation” supply chain designs across a number of African countries are demonstrating the flexibility to address current and future requirements facing immunization programs. For example, independent analysis in Northern Mozambique showed a drop in stockouts from 80% to less than 1% [1]. This resulted in a 25% increase in the DTP3 coverage rate in the province, which reached 95% [1]. A second study showed the new design reduced government operating costs by 20% [2]. Similar supply chain redesign efforts have increased immunization supply chain performance and decreased operating costs. Modeling work across Gavi-eligible countries reinforced these findings by showing that redesigning supply chains to minimize administrative levels and consolidate warehousing and transport led to decreased operating costs regardless of the country characteristics [3].

Recognizing opportunities to optimize its supply chain, the DRC launched a 2020 Vision which will fundamentally improve the principles and operation of supply chains to help reach public health goals. Working with Gavi, the DRC is constructing hubs serving as regional warehouses so vaccine deliveries do not depend only on Kinshasas central warehouse. Professionals working across the supply chain at central, provincial and health zone levels have been invited to identify the current weaknesses of various health supply chain systems and to propose concrete actions to make these systems more efficient and contribute to the improvement of the health of our population.

Officials in Equateur province are already working to identify alternatives to the current immunization supply chain. As part of a program called NGCA (in English, a new generation of supply chains for health products) a system design approach is underway to explore new solutions. NGCA extends beyond incremental improvements to reconsider the entire supply chain system. It incorporates a set of characteristics, similar to other successful new or “next-generation” immunization supply chain designs. They include:

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A streamlined and efficient supply chain that decreases wastage and logistics costs.

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Clear data visibility of vaccine availability and quality all the way to the point of delivery, through appropriate information technology solutions.

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State-of-the-art cold chain equipment with ongoing monitoring and maintenance.

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A professionalized logistics workforce with authority to make supply chain decisions based on data and actual, on-the-ground circumstances.

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Key performance indicators (KPIs) to promote evidence-based decision-making, evaluate system performance and guide continuous improvement.

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Reliable funding and financial flows throughout the supply chain to enable routine, reliable deliveries of commodities.

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Leadership and political will prepared to initiate and support change.

To implement this type of “next-generation” supply chain requires a number of bold actions. It starts with a fierce commitment to a vision of what can be accomplished, similar to what has been articulated in the DRC with Vision 2020. In our country we are working to embrace a new type of collaboration – one that cuts across familiar national, public–private, and industry-sector boundaries. Political commitment will help maneuver within decentralized administrative systems, where authority and financing straddle multiple levels of government. Human resource and accountability structures that reinforce and incentivize efficient system design must be put in place and supported. Throughout the entire design process, strong communication and transparency with stakeholders are essential.

Another key factor is for health authorities, donors and implementing partners to be open and enthusiastic regarding the exploration of innovative strategies that ensure that essential medicines and vaccines reach those in need. All the actors must work together to look for efficiencies in the mobilization of these resources for successful implementation of changes. For example, the DRC government is welcoming the chance to opportunistically share resources and integrate with other programs to achieve higher impact on the health of our population. This synergistic approach may involve incentives for health actors and partners to make the entire health supply system effective.

Finally, we must tackle the significant resource gap to support the expected doubling of non-vaccine costs associated with delivering routine immunization programs in countries like the DRC. Although all countries have a budget line for funding vaccines, only a fraction have a line for the supply chain in their immunization budgets. Further, sub-national financing of vaccine distribution traditionally has received modest attention from donors and policymakers, leading to under-investment and lack of efficiency. In order to maintain the gains we have made in immunization coverage while simultaneously adding new vaccines and reaching more children, this must change.

Supplying vaccines to nearly three million children born each year in the DRC will not be easy. However, we are steadfast in our commitment because investing in the human potential of our youngest children is one of the best ways to move the country forward. Today we face a stark choice: maintain the status quo as things change around us, or roll up our sleeves and put in the resources and hard work to make sure we will be able to reach all children with safe, effective vaccines far into the future. In the DRC, we have made our decision.

Acknowledgements

Thank you to the staff in the immunization program in the DRC, and to VillageReach staff working in the DRC for their contributions to this article.

References

[1]
Kane Mark. Evaluation of the project to support PAV (expanded program on immunization) in Northern Mozambique, 2001–2008: an independent review for VillageReach with Program and policy recommendations; 2009.
[2]
VillageReach. Comparison of costs incurred in dedicated and diffused vaccine logistics systems, cost-effectiveness of vaccine logistics in Cabo Delgado and Niassa Provinces, Mozambique; June 2009.
[3]
B.Y. Lee, D.L. Connor, A.R. Wateska, et al.
Landscaping the structures of GAVI country vaccine supply chains and testing the effects of radical redesign
Vaccine, 33 (36) (2015), pp. 4451–4458
Article