WDI Paper: Unclogging Finances, Improving Vaccine Flow

A supply chain is only as effective as the last mile. That’s why an adequate and reliable flow of funding all the way to the point of care, also known as the “last mile,” is vital to an effective immunization supply chain. A new WDI policy paper examines how financial structures can impact vaccine supply chains and also highlights tools for improvement.

U.S. Army medical researchers take part in World Malaria Day in Kenya in 2010.

The paper, “Delivering the Money: The Importance of Efficient Financial Flows for Vaccine Distribution,” complements a new study by VillageReach and UNICEF identifying key financial barriers preventing or delaying vaccines from reaching the last mile. Because of WDI’s broad experience in global supply chain issues from its work on many projects around the world, VillageReach asked if the Institute would conduct a full review of the literature and desk research for a policy paper to accompany its study, which focuses on conditions in Mozambique.

The paper is the sixth in a series produced by VillageReach to develop intellectual capital for increased access to essential medicines, vaccines and other health technologies in developing countries. Additional papers in this series consider the different components of the supply chain, the challenges faced at the last mile for distribution, and examples of innovative approaches to address those challenges.

“The purpose of our policy paper is to take some of the work they’re doing in Mozambique and apply a more global context to it,” said author Michael Krautmann, a WDI research associate specializing in healthcare supply chains. “Are other countries experiencing similar problems as well? What are other countries doing to address these issues within the context of global health?”

Krautmann, along with Maria Joachim, a PhD candidate at the University of Michigan School of Public Health and WDI research assistant, extensively reviewed the literature on public financial management as a concept from sources such as the World Bank and the International Monetary Fund. But when it comes to how public finance successfully intersects with public health, the team discovered a dearth of research.

“We focused on condensing the literature that was available to provide a realistic path forward for these vaccine managers in the districts, the ones who face these issues,” Krautmann said. “We tried to address what vaccine managers can do to improve the flow of funds for vaccines in spite of whatever financial management issues they may face.”

A couple of recommendations include advocating at all levels of government for distribution support and budget clarity, and measuring and tracking distribution costs.

In addition to targeting the on-the-ground managers, Krautmann said the paper’s other audience includes global and national-level donors and policymakers, “who may be focused on problems higher up in the global health supply chain.

“This paper hopes to highlight the issue of efficient last-mile financial flows so it can be put on the global healthcare agenda and ultimately addressed,” he said.

Photo courtesy of U.S. Army Africa Public Affairs.

WDI’s Healthcare Research Initiative recently successfully completed a project with the government of Mozambique’s Ministry of Health (MOH) and VillageReach to establish better ways to measure performance at all levels of the vaccine supply chain and create better accountability structures. WDI and VillageReach also started a discussion with the MOH about sustainability of the project and shifting management of it to the government.

 Vaccines save millions of lives annually and are among the most cost-effective health interventions available. But immunization coverage worldwide has stalled at about 80 percent, leaving one in five children susceptible to permanent disabilities from vaccine-preventable diseases such as diarrhea and pneumonia.

Improving access to lifesaving vaccines begins with a well-functioning supply chain. In Mozambique, VillageReach introduced a streamlined logistics system called the Dedicated Logistics System, or DLS. The system assigns logistics tasks to field coordinators in each province – there are usually two to four per province, integrating supervision and data collection into a system design, and leveraging existing transport infrastructure. It has been successfully scaled in four provinces, but questions remained about its sustainability. A performance management system could create better accountability and increased scrutiny within the DLS, leading to better outcomes, VillageReach believes.

For this project, DLS data was collected, reviewed and analyzed for two years. For the second year of the project, monthly performance reports were collected from each health facility and reviewed, and monthly meetings were held using root cause analysis tools to identify and solve problems.

The project team of WDI – which included two WDI summer interns the past two years – VillageReach and MOH researchers established two interventions in two study provinces, Maputo and Gaza.

The first intervention was implementing performance management tools. This included field teams routinely documenting challenges and sharing them with provincial health officials and other senior management at monthly meetings where corrective measures were discussed.

The second intervention was the recognition of top performers. The province showing the most improvement was awarded $4,000 to be spent however the provincial health officials determined.

A significant result of the project was that it led to a culture of problem resolution where none had existed before. Also, providing a forum to plan the next month’s distribution cycle and discuss problems with top health officials will lead to performance improvements in the long term, as the performance management tools become more routinely utilized within the provincial vaccine supply chain organization.

The interventions improved planning for the next distribution cycle to reduce things such as stockouts, and increased the ability to address issues encountered at the province, district and health unit levels. Another result is that the financial incentive was shown to be less important than increased accountability.

Of the improvements, a medical chief in the Gaza Province said: “We discuss some solutions and register these in a document. For instance, when mobile brigades weren’t carried out due to fuel, coordinators requested district to reach out to NGOs, like WorldVision.”

A medical chief in Maputo Province said: “We have the meeting notes from VillageReach and the reports help evaluate change between past and present; field coordinators are obliged to do a report after distribution.”

VillageReach will now work with the government to move it away from partner support and gain autonomy in addressing issues that impede distribution. This will include promoting distribution teams’ autonomy in solving challenges and increasing the government’s focus and awareness.

VillageReach improves access to healthcare for remote, underserved communities worldwide. It partners with governments, businesses, non-profits, and other organizations to improve the performance and reliability of health systems in the most inaccessible and isolated communities. Student intern Zaina Awad laid the groundwork for a monitoring framework to help ensure the effective delivery of immunization services including vaccines throughout the country.

The Washington, D.C.-based Grassroots Business Fund (GBF) is a not-for-profit organization that uses a venture capital approach to support businesses in developing countries that provide sustainable economic opportunities to thousands of people at the Base of the Economic Pyramid. Student intern Owen Henkel worked with one of GBF’s portfolio companies, Corredor Agro, to implement a cost effectiveness analysis for a new capital expenditure, and also created a baseline survey regarding crop yields.

VillageReach improves access to healthcare for remote, underserved communities worldwide. It partners with governments, businesses, non-profits, and other organizations to improve the performance and reliability of health systems in the most inaccessible and isolated communities. Student intern Lilly Connett implemented a comprehensive study documenting the range of challenges in the delivery of vaccines, diagnostic test, and medicines to rural communities in Mozambique.

Over the past seven years, Supply Chain Management System (SCMS) has been the backbone of HIV/AIDS programs worldwide, distributing over USD $1 billion worth of essential medicines (e.g., antiretrovirals) and other health commodities to various countries around the world. In fourteen African countries, SCMS has contracted local vendors to supply commodities valued over USD $100 million. The WDI helped document the impact of the SCMS program on local business and economies in four countries — Mozambique, Tanzania, Kenya, and Ethiopia — and developed a white paper on lessons learned and accomplishments achieved thus far.

Vaccines save millions of lives each year and are among the most cost-effective health interventions available. However, one in five children are still without access to vaccines, resulting in an estimated 1.5 million child deaths each year and tens of thousands of permanent disabilities from vaccine-preventable diseases such as diarrhea and pneumonia. WDI is partnering with VillageReach to understand how the implementation of a mechanism to improve accountability of vaccine program staff in three provinces in Mozambique can help enhance vaccine supply chain performance. This project will be used to inform and improve public sector vaccine delivery in other regions of Mozambique, as well as other countries.

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