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Catalyzing the Improvement of Immunization Supply Chains through System Design

By Sid Rupani  April 26, 2019

Lessons from Immunization Supply Chain System Design Summit, Abidjan, February 27 – March 1, 2019

I had the privilege of representing LLamasoft as a participant and presenter at the Immunization Supply Chain System Design Summit held in Abidjan from February 27 – March 1, 2019. The summit was organized by UNICEF’s Supply Chain Strengthening Centre and was a fruitful and productive event.

One of the highlights was that this was the first year that the summit directly included many representatives from country governments and immunization departments (as opposed to only donors and implementing partners). In my view, the discussions benefited by having a high level of pragmatism and direct links to action.

Overall – I emerged optimistic that the summit generated substantial momentum and follow-up actions will drive movement on immunization supply chain system design activities in the coming year.

1. The value of “Maturity Levels” as an organizing framework for the supply chain system design process

The UNICEF team this year introduced the concept of system design “maturity levels”. From the discussions at the conference, my read was that these maturity levels are very useful as an organizing framework. Each level reflects a different phase of design, and each has a substantial hurdle to cross before getting to the next. It therefore requires countries to have an explicit strategy to move from one level to the next. Evidence, advocacy, and funding are some key levers that help countries move from one maturity level to the next.

I particularly liked that the maturity levels also conveyed the message that system design is an ongoing process and not a one-off exercise. Maturity level 5 is explicitly about ongoing redesign. This important message is core to LLamasoft’s view as a company. Your supply chain design is not a static “done deal”, there is always room and need to keep improving!

I liked the maturity levels enough to suggest to the organizers that they could consider structuring the next summit’s agenda around the maturity levels. That could mean:

  • having presentations from countries at each maturity level
  • arranging groups by maturity levels to strategize together
  • pairing countries with other countries 1-2 levels ahead of them to get advice and suggestions on how to continue their journey

For each maturity level we could ask the questions:

  • What were the key valuable outputs generated from activities at this level?
  • What are the key challenges to get to next level?
  • What is a menu of possible options to tackle or address the hurdles to get to the next level?
  • What is typical time, effort, and cost requirement to do a “good job” at this level?

Countries answers to these questions would help build a collective body of knowledge that is practical, pragmatic, and actionable. In my view this would be of tremendous value.

It would also allow countries to take an informed path through the maturity levels and allow us as a community to exceed the modest Gavi targets for 2020. Gavi’s targets for system design exercises for 2020 is for only 10 countries to have completed system design exercises. I say that is a modest target, because for other high-priority interventions, they have targets for 40-50 countries by 2020. Why should we have so few countries for system design? There are legitimate reasons in the difficulty of generating political will for change and implementation difficulty of system design recommendations. However, as a community if we structure our efforts using the maturity levels as outlined above, I think we can exceed the modest target and meet more ambitious targets in years ahead!

We all drew great inspiration from stories of successful change told by countries such as Ethiopia and India. We need more of these stories! And as the maturity level 5 implies, even for those countries that have successfully implemented change, the road doesn’t stop here! Just like the world’s leading private sector supply chains, we should adopt Amazon’s Day One mentality and seek continuous Improvement.

2. The twin challenges of linking supply chain outcomes to health outcomes and designing supply chains to meet multiple objectives

One challenge I identified, even from the inspirational successful cases presented, is that the linkage of supply chain system design activities to improvement in health outcomes is still weak. Making that link strong, visible, and explicit is essential to the success of system design. Our primary goal of course is to improve health outcomes, so we can only judge if our efforts are helping if we clarify the linkage between our efforts and health outcomes.

One example of this was from India’s presentation. The immunization program in India has done a tremendous job of improving their supply chain by deploying data systems and temperature monitoring at truly mind boggling scale. These changes have resulted in clear improvement in supply chain outcomes such as reduction of stock-out events and stock-out duration and temperature excursion events and their duration. India should be lauded for these substantial achievements. However, in terms of the important health outcome of immunization coverage, the immunization program could not clearly show that the supply chain improvements had led to an improvement in coverage. This is because coverage depends not only on supply chain outcomes (such as availability i.e. reduction in stock-outs) but can sometimes be driven by demand-side issues such as vaccine hesitancy. In India, demand-side issues were identified as the main reason for current coverage gaps.

What does that say to us as supply chain designers? Should we just accept that as a limitation, wait passively for demand to materialize and react then? In my view, we should not. Supply chain design is the art of matching supply to demand. We should be actively engaging with the parties responsible for demand creation. We should design our supply chains to be ready to respond to demand improvements (what if there’s a surge in demand?) and we should also we should be able to conclusively show that our supply chain is performing to its maximum potential and filling all the demand that it possibly can.

Another limitation in the system design case studies presented was that there was still weak linkage of system design activities to the community’s agreed objectives 1) Availability, 2) Efficiency (Cost), 3) Potency/Risk, 4) Coverage, and 5) Equity.

At the summit we talked about a number of system design activities – but for many of them, the activities were not linked to whether or how they led to improvement on the objectives. My suggestion to the organizers for the next summit is for every activity discussion, through templates or suggestions, we should attempt to consciously link back to “how did this activity change performance of the SC on each of the objectives above?” We could arrange discussions by case studies of countries that had success in improving on one of the objectives, or a pair of them.

This will likely require us as a community to come up with standardized ways to measure each of the objectives. That will be a good thing. With standardized measurement, there could be country indicator dashboards performance on each of the objectives. Countries could then plan their system design activities and interventions based on which objectives or set of objectives they’re seeking to improve and by how much.

If we consistently measure and start tracking across countries, we can start getting to useful discussions like:

  • What are the best set of activities to improve one particular objective?
  • What’s the typical investment to improve an objective by a certain percentage?
  • Where are there clearly hard tradeoffs between objectives and where are there clearly easy win-wins on multiple objectives?

A great example of tracking supply chain performance on multiple objectives in commercial supply chains is analyst Lora Cecere’s work.

Imagine if we could do this for country immunization supply chains, and create our own country “immunization supply chains to admire”? I think that would be very useful!

3. The role of optimization software in the system design process

Summit participants identified two of the biggest hurdles or barriers in moving through the system design journey from one maturity level to another as:

  • Lack of political will/fear of change, and
  • Complexity and time to generate insight and evidence of value at each stage of the system design journey

It is my firm belief that system design software tools are well-positioned to address both of those challenges.

With system design and optimization software, we can reduce fear of change and generate the political will by asking and answering lots of “what-if” questions. Asking and answering “what-if” questions is at the core of the value of design software. The goal of running these “what-if” analyses is not just to reduce fear of change by testing the changes in a simulated “digital-twin” of the real supply chain, but also to generate political will by showing the size of potential benefits. This allows evidence-based advocacy to generate political will.

One area of improvement for us software providers is in improving the user-friendliness of our tools and reducing the complexity presented to users. Improvements in these areas would reduce time-to-insight and help accelerate the journey of countries through the maturity levels.

At LLamasoft, we’re very excited to support countries for the path ahead in their System Design journeys. We’re looking forward to improving together!