Improvement of the last mile distribution in Cote d’Ivoire

Integrated Health Supply Chain Technical Assistance Program (IHSC-TA)

Phase III – Preparation of last mile distribution pilots

1 REMINDER – Context and objectives ▪ The country aims to achieve a 95% availability of health products at the last mile by 2020 ; a National Strategic Supply Chain Plan (PNSCA) 2016-20 and a PNDAP Roadmap (2017-19) have been developed to achieve this objective ; 2 pilots are being launched to test a new distribution model between districts and the ESPCs ▪ As part of the PNDAP roadmap, Phase I of the study, conducted in January-February 2018, consisted of a supply chain diagnosis - mapping, evaluation of the operational and financial performance, strengths and challenges - with a focus on the last mile ▪ Phase II of the study, conducted in March-April 2018, aimed, on the basis of this phase I, to: – Define the major improvements to last-mile supply regarding identified challenges – Suggest various alternative supply models implementing these changes, and decision criteria to choose between these models – Propose improvements to the planned pilots and / or a new pilot to test certain improvements ▪ In Phase II of the study, improvements to the last mile supply chain were proposed on operational and catalytic dimensions, including : – Operational dimensions of the chain : ▫ Optimized portfolio (products to be continuously available) to be dynamic and adapted to real needs Context and ▫ Transition to an institutionalized delivery system across all segments objectives ▫ Maintain a monthly delivery target at all levels, with harmonization with NPSP order cycles and immediate eSIGL reporting ▫ Formalization and systematization of reverse and transverse logistics, and integration into the distribution system, with dedicated financing – Catalytic dimensions of the chain : ▫ Clear support by a central entity for monitoring and management of last mile performance and clarification of the scope of action of all stakeholders along the chain ▫ Transfer to a professional (private operator or PGP from the district) of part of the last mile logistic tasks carried out by the medical staff of the ES (e.g. inventories, determination of the quantities to be delivered) ▫ Culture change in the system via financial and non-financial incentives (e.g. performance-based financing), training and reinforcement of exemplarity ▫ Adoption of an integrated information system including ordering and inventory management ▫ Digitization up to the last mile allowing real-time data access at all levels ▫ Increased self-financing with a more systematic and sufficient collection of sales margins at the relevant level and financial support dedicated to last-mile logistics

2 SUMMARY – Main questions of phase III ▪ Based on Phase II recommendations, Phase III aims to prepare for the launch of two last mile distribution pilots: a pilot based on district resources and a pilot based on the capabilities of private operators. The main questions that Phase III seeks to answer are the following: – What is the operating model of the public pilot and private pilot? – Which districts will be part of the two pilots? – What is the “product portfolio” to be continuously available at the ESPC level? – Which digital application to use to collect the data when visiting the ESPC? – How to monitor and evaluate the pilots? – What are budget will be needed to fund the two pilots? – How to prepare the national rollout of the two last mile distribution models?

Main questions

3 REMINDER – Diagnosis ▪ Product availability is generally still well below the 2020 target of 95% at the peripheral level, with a performance ranging from 50% to 80% on average depending on the level of the chain.

▪ Several chains coexist in parallel or autonomously - e.g. autonomous chains for PNMTN, blood transfusion products or vaccines, NGO parallel chains on a large number of products

▪ Significant funding is being committed on all these channels despite their performance - estimated at XOF25+ billion / year for all supply chains, of which XOF15+ billion / year for the last mile; Self-financing through profit margins is limited - from 0% to 9-15% of the last mile logistics costs according to the chain under consideration

▪ 10 major problems hinder last mile supply chain performance on operational and catalytic dimensions : – Operational dimensions of the chain : ▫ 1) Quantitative and qualitative deficiencies of storage spaces at district and ESPC levels ▫ 2) Insufficient compliance with the delivery schedule by the NPSP and low order satisfaction rate ▫ 3) Insufficient implementation of the guidelines for the management of the stocks (e.g. respect of the Reminder of thresholds) the main ▫ 4) Collection of products by the ESPC instead of delivery by the districts - inadequate transport conclusions conditions and additional costs, limited quantity transported of the ▫ 5) System entirely based on orders with risks of errors, non-compliance with thresholds, product diagnosis preferences of the nurse vs. preferences of the patient ( for paid products) – Catalytic dimensions of the chain : ▫ 6) Incomplete integration of the chain (e.g. CNTS, viral load, PNN, MTN), resulting in additional costs and replication of inefficiencies ▫ 7) Logistics managed by medical staff in many cases (e.g. CSR) ▫ 8) Insufficient performance incentives or accountability systems at all levels ▫ 9) Prevalence of manual tools and insufficient information flow (stock status, consumption) between all levels ▫ 10) Lack of financial sustainability mechanisms, e.g. margin recovery - and limited financing of the last mile distribution

4 REMINDER – Pilots improvement and potential new pilot ▪ Among the improvements proposed (strong convictions and dimensions to be arbitrated) some can be tested, either by improving existing pilots or by designing new pilots ▪ Potential improvements to dimensions already covered by the planned pilots can be implemented:

– SWEDD & PARSSI pilots: Strengthening performance monitoring (e.g. weekly reporting, immediate communication at regional level in case of problems) – Pilot SWEDD : Indexation of penalties on the seriousness of the operator's failures (vs. fixed penalty); PGP participation in deliveries to coach and supervise ESPC staff Potential – Pilot PARSSI : District performance incentive mechanism to ensure accountability improvement New dimensions can also be tested by the planned pilots, e.g.: s of planned ▪ pilots – Allocation on site with stock replenishment at the time of delivery according to the level of stock observed and consumption since the last delivery – Transfer of inventory ownership to the ESPC and increase their accountability by moving to a cash sales system with initial inventory financing – Appointment of a governance structure responsible for the day-to-day monitoring of operations and key performance indicators – Digitization of data collection and feedback from ESPC – Financial and/or non-financial incentive to the performance of the logistics personnel involved

▪ To test solutions adapted to the root causes of underperformance in an even more integrated model, an additional pilot can be considered ▫ Use of the current route but delivery to the ESPC by an operator (public or private) ▫ Establishment of a decision system on quantities delivered based on the principle of replenishment of stocks during delivery according to stock levels and consumption since the last delivery ▫ Possible presence of the district PGP at the time of delivery for logistical supervision of the ESPC Definition of a ▫ Operator or PGP responsible for digital data collection and immediate data feedback at all levels (e.g. new pilot tablet), with integration of the IT system into existing systems (e.g. eSIGL) ▫ Implementation of a governance structure responsible for the daily monitoring of operations and key performance indicators (e.g. availability rate, sales volumes) ▫ Financial or non-financial incentives for managers' performance ▫ Financial autonomy of the districts and the ESPCs (cash sales, own bank account, setting up an initial product stock and repurchase of products thanks to sales)

5 SUMMARY – Preparation of last mile distribution pilots (1/4) ▪ Following the recommendations of Phase II, it was decided to adapt the two existing last mile distribution pilots to address the challenges identified during the diagnosis. Thus, two last mile distribution models will be implemented ; (i) one based on the district's distribution capacities, (ii) the other experimenting with the outsourcing of distribution to a private service provider. Increasing product availability is based on 5 dimensions : – The definition of an optimized product portfolio to be available at the ESPC level; – “Push” model for product flows (delivery) and harmonized frequency for all products: deliveries take place once a month, from the districts to the ESPC according to an established distribution schedule – "Requisition": In this process, the PGP/district pharmacist or PGP of the private provider will coach the ESPC agent on good practices for storage, inventory, and order preparation. The determination of the quantities of products to be ordered for the next delivery will be carried out jointly between the PGP or pharmacist and the nurse of the ESPC at the time of delivery ; Pilot models – Governance will be led by the regions and by the PNDAP to monitor operations and performance ; – Digitization of last mile distribution data collection : ▫ Implementation of digital data collection and performance monitoring tools with data being digitally collected by the PGP/ district pharmacist or private operator during requisitions ; ▫ Maintaining paper bases monitoring tools at ESPC level for certain tools such as stock cards, inventory registers, return claims book… ; – In order to minimize operational costs, push delivery and requisition will be carried out at the same time. Delivery and requisition will be made by the district PGP/pharmacists or by the private provider PGP, who will travel to each of the district ESPC with a driver-conveyor

▪ 5 districts were selected to be part of the pilots project of the distribution model using the capacities of the district, and 5 others were selected to be part of the private pilot, according to the following defined criteria : – Respect for SWEDD beneficiary regions ; – Comparability of the size of districts in terms of number of ESPC between the 2 models tested ; District – Representativeness in relation to the average distance between ESPC within each district choices – Comparability of district activity on the basis of average turnover per delivery per ESPC between the 2 models tested. ▪ Districts selected for the public model : Bouna, Nassian, Tanda, Sinfra and Zuenoula ▪ Districts selected for the private model : Ferkessedougou, Ouangolodougou, Issia, Minignan, and Touba 6 SUMMARY – Preparation of last mile distribution pilots (2/4) ▪ At the time of delivery and requisition, data will be collected digitally on a tablet that will be given to the PGP/Pharmacist coach of the district or private provider. This application will be chosen to achieve two objectives : – Ease of use for the coach: data collection must be made intuitive by the application, even without internet connectivity – Easy reporting : ▫ Recovering collected data must be intuitive Identification Ideally, automatic reports can be generated to reduce manual work time of a data ▫ collection ▪ The methodology of choice of the digital application application – Search for popular solutions or solutions used in similar contexts – Filtering solutions based on 5 criteria (price, offline operation, export/viewing results, ease of form construction, and technical flexibility (e.g., GPS, image, signature, logic, etc.)) – Testing of prototypes of selected solutions (4 applications were tested) – Creating the final form ▪ The application Social Corps was chosen to collect data at the time of delivery and requisition

▪ A budgeting exercise was conducted to estimate pilot implementation costs. This budgeting includes the costs of pilot preparation, operations (pilot delivery and requisition), as well as costs related to monitoring, follow-up and evaluation. ▪ It was therefore estimated that the public pilot would cost XOF129 Million and the private pilot would cost XOF133 Million

Budgeting

7 SUMMARY – Preparation of last mile distribution pilots (3/4) ▪ “Push" delivery and requisition will be made at the same time each month. Delivery and requisition will be made by the PGP or pharmacists of the district in the case of the public pilot and by the PGP/pharmacist of the private provider in the case of the private pilot, who will travel to each ESPC in their district with a driver-conveyor. ▪ The driver-conveyor will be responsible for bringing their pharmaceutical orders to the ESPC ; ▪ After receipt of delivery by the ESPC manager, PGP or district pharmacists in the case of the public pilot and the private provider's PGP/pharmacist in the case of the private pilot will proceed to the "requisition" with the ESPC officer. The requisition will consist of coaching on good practices of storage, inventory and order preparation ; Pilots ▪ Finally, PGP or district pharmacists in the case of the public pilot and PGP/pharmacist of the private provider in the procedures case of the private pilot will collect the data through an electronic form. ▪ Activities will be conducted according to a schedule predefined by the district.

▪ The performance of the last mile delivery model will be monitored at three levels: – By district managers who will receive the data collected digitally and thereafter will have to compile orders and data from the ESPC, analyze and verify them (through phone calls/on-site visits) with the ESPC managers; – By regional pharmacists, who will be responsible for collecting monthly data from the districts and monitoring district distribution activities. Monitoring – The PNDAP/NPSP will ultimately be in charge of gathering performance evaluation elements from the and regions in order to write monthly summary reports. evaluation ▪ In the case of the private pilot, NPSP will also be in charge of collecting district data in order to monitor the activities of private providers in order to make payments. ▪ At the end of the pilot, an evaluation will be conducted by central level teams and by regional pharmacists using an evaluation grid across the districts involved in the pilot, as well as some ESPC in each district.

8 SUMMARY – Preparation of last mile distribution pilots (4/4) ▪ At the end of the pilot project, it will be necessary to evaluate each of the two models and decide which model(s) to deploy on a national scale, based on 3 criteria (cost/impact ratio, feasibility of potential rollout on a national scale, financial sustainability of the models) ▪ It will also be necessary to make adjustments to the operating models during the scale up, in order to capitalize on the lessons learned from the pilots and streamline the monitoring procedures used during the pilots ▪ It is important to stagger the scale-up (in 3 waves separated by 4 months) of the last mile distribution models at the national level to ensure successful implementation ▪ The funding of the model will require additional resources:

National – Total cost of last mile distribution estimated between XOF 2.0 and 4.4 billion per year on average rollout depending on the selected model (e.g., private model or public model) – But self-financing at district level only generates XOF 180 million each year – Hence the need to explore several internal and external financing levers ▪ A simplified governance structure should be put in place (e.g., maintenance of the DS - region - central level hierarchy and monitoring of activity and performance indicators) ▪ At the organizational level, the rollout of the model will require ensuring the availability of human resources at all levels of the chain (i.e. central analyst, PGP in the DS…) ▪ In the medium term, it will be necessary to think about the convergence between last mile distribution models and other initiatives currently ongoing (i.e., eLearning, empowerment, etc.)

9 1. Context 2. Pilots description

10 Context and objectives of the study Focus on the document

Context Objectives of the study ▪ The National Strategic Supply Chain Plan (PNSCA) 2016-2020 ▪ The purpose of this study is to solve the last mile aims to make 95% of health products accessible at all levels of the drug availability problems in Côte d'Ivoire health pyramid by 2020 ▪ In order to achieve this objective, the study aims to: ▪ Substantial progress has been made over the last decade with the progressive modernization of the supply chain, but 1▪ Carry out a factual diagnosis of distribution at the distribution down to the last mile remains problematic : last mile, in particular through a detailed inventory – Product availability at the distribution / dispensing points, and of existing supply chains and an estimate of their overall order satisfaction remain low for many product families current costs – A majority of ESPC ensure their own supply of medicines with expensive district travel and by means not adapted to the 2▪ Develop 2-3 integrated supply chain transformation transport of health products (public transport, motorcycles) options up to the last mile: – There are several parallel distribution chains leading to – Detailed assessment and budgeting of options, dispensation points and therefore potentially operational and including reverse logistics, and feasibility of financial inefficiencies private sector involvement ▪ Initiatives related to last mile distribution have recently been – Development of a reading grid to arbitrate launched, including: between the different options – The development of a national roadmap to which many stakeholders have committed to: PNDAP, NPSP, USAID, 3▪ Identify the organizational implications of the UNFPA, World Bank selected transformation option, prepare and launch the distribution pilots if necessary and/or – Preparation and imminent launch of pilots of new last-mile accompany the current pilots delivery models by SWEDD and PARSSI projects – However, a diagnosis of last mile distribution and an assessment of distribution patterns have not yet been made

SOURCE: Protocol document of the study 11 Key messages related to the context and objectives of the pilot 1 ▪ Unsatisfactory last mile supply chain performance in terms of product availability and costs – Product availability between 50% and 80% depending on data sources and products – Total cost of the NPSP chain between XOF18 and 20 billion per year 2 ▪ On the last mile supply chain in particular, identification of 10 major problems affecting the operational and catalytic dimensions of the chain 3 ▪ Launch of 2 last-mile supply pilot projects to improve drug availability and reduce PPIs – Choice to test two different models: ▫ A “public” pilot based on the logistical capacities of the districts, deployed in 5 districts ▫ A “private”1 pilot using service providers, deployed in 5 other districts with comparable characteristics (i.e., scope) – Operationally, pilot projects based on: ▫ District “push” delivery to the ESPC at monthly intervals ▫ A “requisition” (e.g. coaching) made at the time of delivery ▫ Digital data collection to monitor stock levels and compliance with good practices in the field 4 ▪ 10 questions were addressed to prepare the pilots 5 ▪ Governance of the pilots at three levels: district, region, and central, to ensure the proper functioning of pilots from their preparation to their evaluation 6 ▪ Several actions to be taken in the very short term to ensure the proper launch of pilots

1 also referred to as « PPP model» 1212 1 DIAGNOSTIC REMINDER– Supply chain service level performance by data source

Results obtained for the 3 key service level performance indicators according to the different data sources used

SARA PMP e-SIGL NPSP Survey Field Survey Database Data

Product Availability ▪ Availability at the last ▪ Availability at the last ▪ Availability of the ▪ Availability of the Average on all mile: ~50% mile: ~80% extended list from extended list at the products monitored – Tracers: 53% ▪ Availability to NPSP customers NPSP: 80% – Extended list1: districts: ~78% – Health districts: 56% 59% – Dispensation points: 61%

Order Satisfaction ▪ Satisfaction rate at ▪ Satisfaction rate of ▪ Satisfaction rate of Rate the last mile: ~65% NPSP clients allocations between the Average on all orders ▪ Satisfaction rate at – Exact satisfaction: plant and the agency n/a districts : ~69% 31% – Vital products: 78% – Satisfaction in – Other references: quantity: 35% 82%

Respect of delivery ▪ Compliance with ▪ Compliance rate with deadlines delivery times at the delivery times of Average on all orders last mile : ~48% NPSP's direct n/a ▪ Respect of order n/a customers delivery deadlines to – Abidjan: 47% districts: ~50% – Inside: 54%

1 Extended list = List of tracer products present in SARA + other non-tracer products present in SARA and e-SIGL SOURCE: SARA survey (WHO, 2016); PMP field survey (PNDAP, 2017); Performance indicators (NPSP, 2017); e-SIGL (NPSP, Jan-Dec2017) 13 1 DIAGNOSTIC REMINDER – Financial performance of the supply ESTIMATIONS chain

Parallel chains Vaccine chains Blood products Viral load reagent (MTN, NGOs and NPSP Chain (PEV only1) chains chains PMOs) 18-20

Total cost of the chain, Bn XOF/year

Cost of the last mile, 9-10 ~2,7 ~1,5 ~0,5 >0,9 Bn XOF/year 1,3 (including ~5.6Bn (the whole chain is (the whole chain is (the whole chain is XOF of salaries) last mile) last mile) last mile)

Cost of last mile/ value ~30% ~11% ~140% ~15-25% n/a of products (including ~5.6Bn (the whole chain is (the whole chain is (missing data) XOF of salaries) last mile) last mile) Last mile profit margin, Bn XOF/year 0,9-1,8 0 1,1 0 0 (free products) (free products) (free products) Self-financing of the logistics cost of the last 10-20% 0% 0% 0% 0% mile (including salaries) (free products) (revenues <50% (free products) (free products) logistics costs) 25-45% (without salaries)

1 Data not available at the time of the study for INHP vaccines SOURCE: NPSP accounts; CNTS account; GAVI; cost estimation models 14 2 The diagnosis revealed 10 major supply chain performance problems at the last mile

Operational dimensions of the chain :

1 Quantitative 2 Insufficient 3 Insufficient 4 Collection of 5 System entirely and qualitative adherence to implementation products by based on shortfalls in delivery of stock ESPCs instead orders, with district and schedule by management of delivery by risks of errors, ESPC storage NPSP and low guidelines (e.g. the districts - non- space order compliance inadequate compliance satisfaction with stock transport with thresholds, rate availability conditions and product thresholds) additional preferences of costs, limited the nurse vs. quantity patient (paid transported products)

Catalytic dimensions of the chain :

6 Incomplete 7 Logistics 8 Insufficient 9 Prevalence of 10 Lack of integration of managed by performance manual tools financial the chain (e.g. medical staff in incentives or and insufficient sustainability CNTS, viral many cases accountability information mechanisms, load, PNN, (e.g. CSR) systems at all flow (stock e.g. margin MTN), resulting levels status, recovery - and in additional consumption) limited costs and between all financing replication of levels dedicated to inefficiencies last mile distribution

15 3 In view of the problems identified during the diagnosis, two pilots to fulfill 2 key objectives

Improve the availability of drugs ▪ Ensure that all ESPCs can respond in real time to the demand for drugs (reduce stockouts, etc.) Reduce the rate of unusable drugs ▪ Ensure the integrity of drugs and reduce losses (expiry date, damage, etc.)

16 3 Two pilot models of last mile distribution were selected to Models selected during address the identified issues the GTT on May 15th Models Advantages Inconveniences Constraints Model 1 ▪ Possibility of testing the ▪ Delivery to a limited ▪ Need to break the delivery entire capacity of public number of ESPCs every circuits (developed by the operators to run the day districts for the initial pilots) Delivery and requisition pilots made by districts in a single ▪ Increase logistical resources loop (delivery of the previous ▪ Least expensive model month’s order at the time of ▪ Upgrading of all ESPCs in requisition) ▪ Sustainability of the terms of inventories, etc. model

Model 2 ▪ Ability to test the full ▪ Delivery to a limited ▪ Need to break the circuits ability of private number of ESPCs during (developed by the districts operators to run pilots the day for the initial pilots Delivery and requisition ▪ Operational complexity ▪ Upgrading of all ESPCs in made by private operators in ▪ Viable alternatives for terms of inventories, etc. a single loop (delivery of the resource-limited districts previous month’s order at the ▪ Availability of private time of requisition) ▪ Possibility to visit multiple operators ESPC in parallel

Model 3 (not selected) ▪ Availability of private ▪ High costs ▪ Need to break requisition operators to ensure the circuits (developed by the ▪ Limited value of testing delivery districts for the initial pilots) private operators on their ▪ Delivery by a private ability to only deliver drugs ▪ Upgrading of all ESPCs in operator terms of inventories, etc. ▪ Operational complexity - ▪ Requisition made by the less than model 2 district (coordination between several stakeholders)

SOURCE: GTT 17 3 Pilots have been developed to address these problems Dimension concerned by the pilot Retention of the current model Design dimensions Choice in the pilot Rational

Definition of a portfolio of ~100 products to be Focusing efforts on high value-added drugs for a Product portfolio continuously available communities

Delivery from the districts to the ESPC, with Better control of the follow-up of the chronogram b Product flow dedicated vehicles

c Frequency Monthly frequency Monthly frequency Trans- portation Operat- A d Pathway Shorter daily routes Integration of requisitioning ional

Delivery Public & private operators, with clear roles (transport, Test the ability of both operators to address the e operator requisition, data collection, supervision) challenges of last mile distribution

Method for determining Requisition (coaching in good storage practices, and Ensuring proper inventory management and good f quantities inventory and ordering practices) estimations of requirements while empowering ESPCs

Reverse and transverse g NA Dimension addressed independently of the pilots logistics

a Integration Incomplete integration of the chain Not addressed in the pilot models given the level of complexity generated by the integration of the chains

Pyramidal performance management (from districts to Ensure effective performance monitoring Gov. Gov. central level) b and HR PGP carry out deliveries with the service provider; Ensure that each stakeholder is responsible for the tasks Cataly- Human B performance management by pharmacists that depend on its area of competence tic Resources

Use of digital tools (e.g. digital form + tablets) Ensure the effectiveness and relevance of performance c Tools and IT systems monitoring

Externally funded pilots without questioning the current d Financing Actual model funding model

SOURCE: TDR 18 3 General description of the delivery and requisition process

Description of the delivery process and requisition

Coaching on Preparation 1 2 Loading 3 Delivery 4 good of the order practices of storaget

TRANSPORTATION REQUISITION Resources District Pharmacist : Driver/Conveyor : Driver/Conveyor : PGP/Pharmacist : mobilized : Preparation of the Verification and loading Deliveries made to the Coaching on the follow- ▪ Logistic order placed by the of packages and ESCP and signature of up of good storage means ESPCs departure with delivery tools, in the practices and stock ▪ Fuel PGP/District Pharmacist presence of the management ▪ Driver / PGP/pharmacist conveyor ▪ PGP ▪ Tools

Coaching on Coaching 8 Return 7 Data 6 good 5 on good Collection practices of practices of Next tour order inventory preparation DATA MANAGEMENT

Driver/Conveyor : PGP/Pharmacist : PGP/Pharmacist : PGP/Pharmacist : Return to district and Collection of product Coaching of the Coaching of the ESPC transmission of delivery delivery and coaching ESPC nurse on the nurse on product and requisition data identification of the inventory best documents and data quantities to order practices

SOURCE: GTT 19 3 The two pilot models of last mile distribution will be implemented on a selection of districts in 5 regions Private pilot Public pilot

Poro-Tchologo- Bagoue Kabadougou Bafing-folon Model 2: Delivery Model 1: and requisition Boukani Delivery and made by private Gontougo requisition made operators in a Worodougou Hambol by districts in a single loop Bere single loop (delivery of the (delivery of the previous month’s Gbeke previous month’s order at the time of Tonkpi order at the time requisition) of requisition) Haut Indenie Sassandra Marahoue Belier N’ZI-Ifou Cavally Djuablin Guemon

GOH Agneby-Tiassa- Me LOH Djiboua Gbokle-Nawa Abidjan 2 Sud Comoe San Pedro Abidjan 1-GP

SOURCE: TDR 20 4 10 elements to address in order to achieve the defined objectives

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation criteria 4.1 National rollout plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

21 5 Three-level governance of the pilots: district, region, and central, to ensure the proper functioning of pilots … Stakeholders Roles

➢Final evaluation of pilots ➢Monitoring pilots activity and PNDAP/ performance at the global level NPSP/ IHSCTA ➢Pilots preparation

➢Monitoring pilots activity and Regions performance at the regional level

➢Monitoring pilots activity and Districts performance at district level

22 5 … from preparation to evaluation Update according to the ANO

May JuneJuly Aug. Sept.Oct. Nov. Dec. Jan. Feb Mar AprilMay JuneJuly

Pilot preparation

Implementation of preparatory activities

Pilot launching

Public pilot launching

Private pilot launching

Operations

Public pilot operations

Private pilot operations

Monitoring and evaluation

Public pilot monitoring mission

Private pilot monitoring mission

Final evaluation

National rollout

Generalization to other districts of the country

23 6 Checklist of actions to be taken before launching the pilots (1/2) Ideal time before pilot Activity to be carried out launch Ask each district to send 3 resumes for each driver-conveyor position to Should be done already be filled Hiring the drivers- In coordination with SWEDD, select drivers-conveyors ~3 weeks before conveyors Sign tripartite employment contracts (between the selected driver- 4 to 1 week(s) before conveyor , SWEDD and the RS)

Purchase the tablets (with support from IHSC-TA) and make the tablets 4 weeks before available at PNDAP headquarters

Install and configure the data collection application on each tablet 3 weeks before Equipment purchase Purchase 11 SIM cards that will be issued to PGP and will be credited with 1 week before XOF5,000 per month

Ensure receipt of 11 coolers and 11 x 20 = 220 cold accumulators are ~1 month before sent to the districts

Contract signed between NPSP and UCP ASAP

Selection of private Publication of the call for tenders ~6 weeks before providers

Conclusion of contract with service providers ~3 weeks before

SOURCE: TDR, team retro planning 24 6 Checklist of actions to be taken before launching the pilots (2/2) Ideal time before pilot Activity to be carried out launch

Make fuel cards 1 month before

Before they are transported, place the following items in each of the vehicles : ▪ 1 x cooler

▪ 20 x cold accumulator 2 weeks before

Transportation ▪ 1x tablet with the data collecting application of vehicles ▪ 1 x SIM card

Transport the 4x4 vehicles to the districts 2 weeks before

Conclude contract with a flatbed truck transport service provider 3 weeks before

Have tricycles transported by the transport provider in a flatbed truck 2 weeks before

In the digital application, create administrator accounts for each district 2 weeks before and regional pharmacist affected by the pilot 1 week before the Print and bind the Procedures and Good Practices Manual (PGPM) Preparation of training the 1 week before the Purchase participants kits (notepad, pens, flap folders) presentation- training training day 2 weeks before the Communicate the date of the training sessions to all participants training 1 week before the start of Conduct training sessions each pilot

SOURCE: TDR, SOURCE: TDR, team retroplanning 25 1. Context 2. Pilots description 2.1 Preparation 2.2 Operations 2.3 Performance monitoring 2.4 Rollout plan

26 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation criteria 4.1 National rollout plan

Product portfolio Performance 1.2 2.2 Pilots Procedures 3.2 identification monitoring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

27 1. Context 2. Pilots description 2.1 Preparation 2.2 Operations 2.3 Performance monitoring 2.4 Rollout plan

28 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation Criteria 4.1 National Rollout Plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

29 Proposed amendment to the number of districts to be part of the pilots

Current situation Proposition

▪ Scope : ▪ 18 districts / 600 ESPC (~1/3 ▪ Scope : ▪ Reduction to 6 or 10 districts of the country) – Representative of all CIV ▪ 5 regions districts in terms of density ▪ Approved budget of XOF~260 – Comparable in size Mn – Aligned with partners' geographical requirements ▪ Evolutions ▪ Enlargement and improvement (coverage of the 5 selected of the perimeter of the pilots regions) (assisted requisitioning, performance monitoring, IS, etc.) to address identified challenges beyond delivery ▪ Rationales : ▪ Improved pilots performance challenges management ▪ Refinement of initial budgeting ▪ Respect of the budget initially estimated for the pilots ▪ Constraints ▪ Difficulty of managing the pilots ▪ Better interpretation of pilot ▪ High budget due to model results changes with no possibility of budget increase ▪ Results potentially biased by Consequence Necessity to communicate exogenous factors ▪ developments to SWEDD and the regions

30 Methodology : Criteria for selecting districts to include in the pilots

Criteria Description Rationale ▪ Representation of the 5 pre- ▪ Alignment with SWEDD Coverage of all A selected regions in the initial requirements regions pilots

+ District size ▪ Number of ESPCs per district ▪ Comparison of pilots under B comparability (# of close to national average (20- comparable conditions ESPCs per district) 30) + ▪ 3 types of districts by ▪ Selection of a representative geographic density (average sample from all districts Representativeness distance between ESPCs): C of all districts – Dense (density) – Moderately dense – Scattered + Comparability of ▪ Revenues per district ▪ Exclusion of very special D district ▪ Revenues per ESPC cases of very low activity/ESPC ESPC/district activity (Revenue) 31 Details of the 10 districts selected for the pilots Main Districts selected on May 15th Optional Districts selected on May 16th Monthly C Geographic density D distance to B Number travel all of ESPCs Mileage per Medium- Revenue Revenue circuits in the in the ESPC in the Dense dense Scattered per district, per ESPC A Region District district, km district district district district district ‘000 XOF ‘000 XOF Boukani Bondoukou 1870 55 34,0 … … 12850 234 Gontougo Bouna 4781 31 154,2 … … 7663 247

Nassian 510 8 63,8 … … 2662 327 Pilot 1 – Public Tanda 1708 57 30,0 … … 6379 112 operator Marahoue Bouafle 765 35 21,9 … … 15059 430

Sinfra 316 8 39,5 … … 8283 1135

Zuenoula 336 23 14,6 … … 8688 378

Poro- Boundiali 1046 42 24,9 … … NA NA Tchologo- Bagoue Ferkessedougou 792 22 36,0 … … 6145 279

Korhogo 4150 104 39,9 … … NA NA

Ouangolodougou 1120 19 58,9 … … 8726 459

Tengrela 355 13 27,3 … … NA NA Pilot 2 – Private Haut Daloa 836 51 16,4 … … NA NA operators Sassandra Issia 840 30 28,0 … … 9270 309

Vavoua 1050 25 42,0 … … NA NA

Kabadougou- Minignan 1310 20 65,5 … … 6500 325 Bafing-Folon Odienne 1648 52 31,7 … … NA NA

Touba 1119 30 37,3 … … 14200 473

The 10 districts were selected to be part of the last mile distribution pilots 32 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation Criteria 4.1 National rollout Plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

33 Methodology for developing the priority reference basket (the “product portfolio”)

1 2 Identification of existing 3 priority lists Streamlining the list Manual adjustments Simplification of the NPSP continuous Product reference basket availability list (65 portfolio according to two Additions or references) validated by filters: withdrawals of ✓ PNDAP ✓ Deleting products on a case by case basis by Dr. ✓ NPSP Programs list – products that do not have Hodjo, Béché and ✓ PN “traceurs programmes” Kouassi according to (44 references) authorization level « D » (not their expertise authorized at Captures products with high ESPC level) criticality, high rotation and high ✓ Disposal of financial attractiveness products not available at national level

34 Contents of the priority basket (1/5) Legend storage conditions Inflammable Temperate Zone Cold chain

Special storage Program Reference Counting unit conditions? ARTEMETHER 20 mg bulb inj. box/10 Bulb

ARTEMETHER 80 mg bulb inj. Bulb

ARTESUNATE 120MG powder injectable suspension + SOLVANT FL/10ML BOX/1 Boxes

DELIVERY KIT Kits

GTC PARACETAMOL 100 mg bag box/12 Boxes

PARACETAMOL 300 mg bag box/12 Boxes

QUININE RESORCINE 200 mg / 2 ml bulb inj. box/100 Bulb

QUININE RESORCINE 400 mg / 4 ml bulb inj. box/100 Bulb

QUININE SULFATE 500 mg tablet box/9 Boxes

ALBENDAZOLE 400 mg tablet Tablets

AMOXICILLINE + CLAVULANIC ACID 100 / 12.5 mg drink. sus. powder bottle/60 ml Bottles

AMOXICILLINE + CLAVULANIC ACID 500 / 62,5 mg tablet box/16 Boxes

AMOXICILLINE 1 g powder injectable suspension bottle box/50 Bottles

AMOXICILLINE 250 mg drink. sus. powder bottle/60 ml Bottles NPSP AMOXICILLINE 500 mg gel Platelets

ARTESUNATE 120 mg powder inj. suspension . + SOLVANT bottle/10 ml box/1 Bulb

MICROPERFORATED ADHESIVE TAPE 5 m X 0,18 m ROLL Rolls

CREPE BAND 4 X 0,10 m ROLL Rolls

BENZYLPENICILLINE + BENZATHINE 2,4 MUI pow. inj. suspension bottle box/50 Flacons

SOURCE: Ivorian priority reference basket 35 Contents of the priority basket(2/5) Legend storage conditions Inflammable Temperate Zone Cold chain

Special storage Program Reference Counting unit conditions? SHORT PERIPHERAL CATHETER 22 G pack/100 Units

NON-STERILE GAUZE PADS 40 X 40 pack/100 Units

HYDROPHILIC COTTON 1 kg ROLL Rolls

DEXAMETHASONE 4 mg / ml injectable bulb box/100 Bulb

DICLOFENAC 50 mg tablet box/1000 Platelet

ECONAZOLE 150 mg ov. box/150 Platelet

ETHANOL 96 % CODEX 1 L Flacons Inflammables

FER III + FOLIC ACID caps. box/40 Boxes

FER III bottle/120 ml pack/30 Bottles

NPSP RESORBABLE WIRE SYN. N°2/0 1/2C NEEDLE 30 mm TRIANGULAR TRESSE Wire Temperate zone POLYGLYCOLIC ACID + LACTIC ACID

STERILE SURGICAL GLOVES T. 7,5 PAIR Pairs

LATEX EXAMINATION GLOVES MM pack/100 Pairs

GLUCOSE 5 % 250 ml inj. sol. UNIT Pockets

GLUCOSE 5 % 500 ml inj. sol. UNIT Pockets

MAGNESIUM HYDROXIDE bag 15 ml drinkable suspension box/30 Bags

METOPIMAZINE 10 mg / ml inj. box/10 Bulb

METRONIDAZOLE 125 mg / 5 ml susp. bottle/100 -120 ml Bottles

METRONIDAZOLE 500 mg tablet box/1000 Platelet

SOURCE: Ivorian priority reference basket 36 Contents of the priority basket(3/5) Legend storage conditions Inflammable Temperate Zone Cold chain

Special storage Program Reference Counting unit conditions? NECESSARY FOR ADULT INFUSION pack/25 Units

OCYTOCINE 5 UI amp. inj. Bulb Cold room

PARACETAMOL 500 mg tablet PLAT/10 Platelet

PHLOROGLUCINOL 150 mg supp. box/10 Boxes

PVP IODEE DERMIQUE 10 % bottle/125 ml Bottles

NPSP PYRANTEL PAMOATE susp. 125/2,5 ml bottle/30 ml Bottles

RINGER LACTATE 500 ml . inj. sol. UNIT Pockets

SYRINGUE 10 ml 3 PIECES STERILE AVEC AIGUILLE pack/100 Units

SYRINGUE 5 ml 3 PIECES AVEC AIGUILLE pack/100 Units

ANTITETANIC SERUM 1500 UI inj. box/10 Bulb Cold room

SODIUM CHLORURE 0,9 % 500 ml inj. sol. UNIT Pockets

RAPID DIAGNOSTIC TEST FOR MALARIA KIT/25 Tests

RECTANGULAR ADULT IMPREGNATED MOSQUITO NETS BALLS/50 Units

PNLP AMODIAQUINE/ARTESUNATE 50/135 MG CHILD (1-5ANS) PLT/3 CP BOX/25 Platelet

ARTEMETHER/LUMEFANTRINE 20/120 MG ADULT PLT/24 CP BOX/30 Platelet

PYRIMETHAMINE/SULFADOXINE 25/500 MG TABLET Platelet

ABACAVIR / LAMIVUDINE 60/30 MG PLATELET BOX/60 Boxes

PNLS BD FACSPRESTO CD4/CD4 % /HB CARTIDGE KIT/100 Tests COBAS TAQMAN/AMPLIPREP HIV 1 QUAL TEST KIT/48 Tests

SOURCE: Ivorian priority reference basket 37 Contents of the priority basket(4/5) Legend storage conditions Inflammable Temperate Zone Cold chain

Special storage Program Reference Counting unit conditions? COTRIMOXAZOLE 960(TRIMETHOPRIME + SULFAMET. 160/800 MG) PLT Platelet

DETERMINE HIV TEST KIT/100 Tests

EFAVIRENZ/LAMIVUDINE/TENOFOVIR 600/300/300 MG PLT BOX/30 Boxes

FACSCOUNT REAGENT CD3/CD4 %, 50 TESTS KIT Tests Cold room

LATEX EXAMINATION GLOVE MM PACK/100 Pairs

GUAVA AUTO CD4/CD4%, 100 TESTS KIT Tests Cold room

LOPINAVIR/ RITONAVIR 80/20 MG DRINKABLE SOL. PACK/5 Flacons Cold room PNLS LOPINAVIR/RITONAVIR 200/50 MG PLT BOX/120 Boxes

NEVIRAPINE 10 MG / ML Bottle 240 ML Bottles

NEVIRAPINE 10 MG/ML Bottle/100 ML Bottles

PIMA CD4 REAGENT, 100 TESTS KIT Tests

STAT PAK HIV1/2 TEST KIT/20 Tests

TENOFOVIR /LAMIVUDINE 300/300 MG PLT BOX/30 Boxes

TRITEST WITH TRITOUNT TUBE TEST KIT/50 Tests Cold room

PNN Plumpynut, bag 92 g Pouches

SOURCE: Ivorian priority reference basket 38 Contents of the priority basket(5/5) Legend storage conditions Inflammable Temperate Zone Cold chain

Special storage Program Reference Counting unit conditions? MICROGYNON 0.03/0.15 MG BOX / 3 CYCLES Platelet

DEPO PROVERA/PETOGEN 150 MG / 3ML INJ BOX/25 Bulb

JADELLE (IMPLANT + TROCAR) 150 µG BOX/10 Sticks

PNSME MALE CONDOM BOX/144 Condoms

IMPLANON IMPLANT 68 MG BTE/1 Sticks

MOTHER AND CHILD'S HEALTH BOOKLET Booklet

MEDROXYPROGESTERONE (SAYANA PRESS) 104 mg / 0,65 ml inj. UNIT Bulb

SOURCE: Ivorian priority reference basket 39 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation criteria 4.1 National rollout plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

40 Refurbishment of stocks – Decisions taken in GTT

01 Information and training for district pharmacists to the use of the product portfolio

Decisions Encourage district pharmacists to order products from the product 02 portfolio (higher chance of selling the products given the planned taken delivery and requisition during the pilots)

Refurbishment of stocks at the next NPSP delivery (quantities of free 03 products determined with national programs, and quantities of paid products according to district orders)

41 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation criteria 4.1 National rollout plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

42 Methodology : Need to select a solution that allows data collection in "field" conditions and easy analysis of results

On the field In the ESPC, regions and PNDAP

Data collection to be made ▪ Recovering collected data must intuitive by the application, even be intuitive without internet connectivity ▪ Ideally, automatic reports can be generated to reduce manual work time1

1 Either with the selected solution or with Excel files prepared in advance 43 However, there are dozen of solutions on the market - which one to choose ?

Examples of data collection applications

SOURCE: Google Search 44 Methodology : Choice of a solution following a 4-step Detailed in the selection process next pages

1 2 3 4 Search for reference solutions or solutions used in similar Filtering solutions according Testing of prototypes of Creating the contexts to 5 criteria selected solutions final form

Pre-selection by 5 filtering criteria: Creation of simplified Creating the McKinsey’s - Price prototypes to enable final form in Research Dpt. of : - Offline operation concrete decision-making close - Reference - Export / view results depending on the ease and collaboration solutions in this - Ease of form construction quality of use with the field - Technical flexibility (e.g., PNDAP, as - Solution used for GPS, image, signature, well as off-line data logic) analysis tools collection in for the data developing collected countries

1 Excluding capex for FAT and equity investments 45 1 8 solutions identified thanks to McKinsey's internal expertise and discussions with PNDAP members

Solution Comment

Google Sheet + Internet reference solution + solution to make it a mobile AppSheet application

Social Cops Indian field data collection company with previous involvement in very large scale projects

McKinsey's experts looked for solutions Magpi US-Kenyan company working primarily for NGOs known as:

▪ Reference in the Harvest Your Data Recommended solution on specialized forums, with an data collection industrial focus and some case studies for education field ▪ And/or used in similar contexts Survey Monkey + Internet reference solution + solution to make it a mobile Discussion with Quick Tap survey application PNDAP to identify solutions already Device Magic Offline data collection solution recommended on specialized known forums, highly industry-oriented and for recent tablets/smartphones

PushForm Offline data collection solution recommended on specialized forums, apparently highly industry-oriented and for recent tablets/smartphones

SurveyCTO Offline data collection solution used by the World Bank (a tutorial is available on the WB website)

SOURCE: McK digital, interviews with the PNDAP 46 2 Analysis of solutions on 5 criteria FOR DISCUSSION Unattractive aspect highlighting four high potential Applications to test with Highly attractive applications prototypes aspect 4) Ease to 1) Price for 11 users 2) Works build the 5) Technical Solution (USD / month) offline? 3) Results as… form flexibility Conclusion

Google $55 Google Sheet Form + AppSheet

Social $200 Dashboard, Cops CSV, API

Survey $129 Dashboard, CSV CTO

Magpi 0 à $500 Dashboard, Excel

PushForm $100 Excel, XML, PDF, API

Harvest $90 CSV, SPSS, Your Data PDF, API

Survey $430 Excel, PDF, API, Monkey + Zapier1, Quick Tap SurveyMonkey survey

Device $330 Excel, PDF, API, Magic Zapier1

SOURCE: McK digital, desk research | Note 1 : Zapier is a solution that allows to redirect data to many other supports (i.e., DropBox...) 47 2 Details of the analysis of the solutions on 5 criteria ZOOM

1) Price for 11 users (USD / 2) Works 4) Ease to build the Solution month) offline? 3) Result as… form 5) Technical flexibility

Google $55 Yes, as an Google Sheet Easy (from a Google Native fields, advanced fields (GPS, picture, Form + Android app sheet file) signature), workflow, interface customization, AppSheet fluidity

Social $200 Yes, as an Dashboard, Easy (intuitive drag- Native fields, advanced fields (GPS, pictures, Cops Android app CSV, API and-drop, possibility of signatures, barcodes), logic, search within the (Collect) massive update) form, fluidity

Survey $129 Yes, as an Dashboard, Easy (intuitive drag- Native fields, advanced fields (GPS, pictures, CTO Android app Excel and-drop, possibility of signatures, barcodes), logic, pre-validation (surveyCTO) massive update) limited customization, fluidity

Magpi 0 à $500 Yes, as an Dashboard, Average (drag-and-drop Advanced fields (GPS, pictures, signatures, Android app Excel not very intuitive, possi- barcodes), logic, workflow (Magpi+) bility of massive update

PushForm $100 Yes, as an Excel, XML, Average (no drag-and- Native fields, advanced fields (GPS, pictures, Android app PDF, API drop option, possibility signatures, barcodes), logic – but frequently (pushForms) of massive update) reported slowness

Harvest $90 Yes, as an CSV, SPSS, Average (drag-and- Native fields, advanced fields (GPS, pictures, Your Data Android app PDF, API drop not very intuitive) signatures, barcodes), logic, workflow, interface (droidSurvey) customization

Survey $430 Yes, as an Excel, PDF, API, Not tested Native fields, advanced fields (pictures, QR Monkey + Android app Zapier, codes), logic Quick Tap (QuickTap SurveyMonkey survey Survey offline)

Device $330 Yes, as an Excel, PDF, API, Easy (intuitive drag- Native fields, advanced fields (GPS, pictures, Magic Android app Zapier and-drop) signatures, logic), workflow, – but frequently (Forms) reported slowness SOURCE: McK digital, desk research 48 2 Details on the “technical flexibility” criteria ZOOM

Technical flexibility defined as the existence of … Description Illustration / useful to …

Native fields support Common data formats are managed in a simple and Make typing easier. For example, enter a number or phone intuitive way (according to Android standards) number with a "number" keypad displayed.

Support for GPS The application records GPS coordinates when the ▪ Know the exact location of ESPC advanced form is validated ▪ Verify that the form has been completed in the reported ESPC fields and The application allows to answer certain fields by ▪ Motivate the PGP and nurse at the ESPC to follow good data types Picture taking a photo practices (opportunity to verify image) ▪ Generate evidence in the event of litigation ▪ Taking pictures of paper documents

Signature The application collects signatures drawn on the Increase the sense of responsibility of the stakeholders involved screen

Barcode/ The application allows to scan barcodes Could be used (later) in stock level survey QR code

Possibility to add logic to The form flow adapts to the previous answers (for Hide unnecessary questions based on previous answers to the the form example: if answer to question A ="Yes", then hide form / adapt the form to the situation, even offline question B)

Workflow management Existence of workflow management functionality after Alerts team members automatically and in real time when function data collection thresholds are exceeded (automatic email or SMS with differentiated access levels)

Possibility to customize the Possibility to change colors and logos within the app Make the application more natural for users interface

General fluidity of the form The application remains fluid even when long forms Avoid inconvenience due to slow / frozen interface to users are loaded

Pre-validation User entries can be reviewed by a supervisor before Ensure the quality of data collection being added to the DB

49 3 The data collection form was prototyped and tested on FORM ONLY 4 different applications

Solution Status Instructions for accessing the prototype

Survey Test form 1. Install the « Survey CTO » app (Android only) CTO created 2. Request an email invitation 3. In parameters, indicate "pndap2" as server name and indicate the login details 4. On the home page, click on "download blank form" and download the available option

Google Test form 1. Install the « AppSheet » app Form + created 2. Follow the link : https://www.appsheet.com/newshortcut/57d43c19- AppSheet 471e-47a0-bf79-673d64dcf707 3. Install the new app suggested on the page

Social Test form 1. Install the « collect » app (Android only) Cops created 2. Provide phone number to JB to receive the invitation 3. Connect to the home page 4. In "settings", click on "Refresh forms" (the interface is in English but can be translated later)

Magpi Test form 1. Install the « Magpi+ » app created 2. Ask JB to send the email invitation 3. Login 4. Login to the application 5. In the menu, click on « synchronization »

50 3 Similar form structure was used for each of the 4 NON-FINALIZED FORM – ONLY applications, in order to test all the functionalities FOR APPLICATIONS TEST

Sections of the form Questions in the form (~85 questions)

Current location Structure of the form allowing Name of the ESPC to proceed with the test: About the Name of the ESPC manager ESPC ▪ The way the navigation is Phone number of the ESPC manager done between the different questions and sections Arrival time at the ESPC ▪ Ease of entering various data Have all the packages been delivered ? types (e.g., GPS location, number, multiple choice lists, Are all packages in good condition ? Good single choice lists, phone delivery Main causes of degradation number, photo, signature, text, practices star rating) Compliance with good practices ▪ The fluidity of the End time of delivery application despite a large number of questions (the form Temperature in the main storage area contains ~85 questions in all) Good The cold chain is respected ▪ The possibility to hide or storage show certain questions practices The cold chain has not been interrupted during the previous month according to the answers to If the cold chain has been interrupted during the previous month,, please add more details the previous questions (see the question "if the cold chain Respect of the good storage practices was interrupted during the previous month...", whose Recommen- Recommendations for the next visit dations display depends on the How well have your recommendations from the previous time been implemented? answer to the previous question) AMOXICILLINE 500 mg gel Stock levels ▪ The possibility to insert (… 57 other references listed…) explanatory comments under each question Would you like to attach a picture to this form ? Conclusion End time of assisted requisition Signature of the ESPC manager

51 4 « Social Cops » was selected to perform data collection during the delivery and requisition

At district, regional and central levels: During the requisition: collection of data analysis of collected data through the Web offline with an Android tablet interface

Partially automated Excel and Word reporting using pre-designed templates

52 1. Context 2. Pilots description 2.1 Preparation 2.2 Operations 2.3 Performance monitoring 2.4 Rollout plan

53 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation Criteria 4.1 National rollout plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

54 Two pilot models of last mile distribution were selected to Models selected during address drug distribution challenges at the last mile the GTT on May 15th Models Advantages Inconveniences Constraints Model 1 ▪ Possibility of testing the ▪ Delivery to a limited ▪ Need to break the delivery entire capacity of public number of ESPCs every circuits (developed by the operators to run the day districts for the initial pilots) Delivery and requisition pilots made by districts in a single ▪ Increase logistical resources loop (delivery of the previous ▪ Least expensive model month’s order at the time of ▪ Upgrading of all ESPCs in requisition) ▪ Sustainability of the terms of inventories, etc. model

Model 2 ▪ Ability to test the full ▪ Delivery to a limited ▪ Need to break the circuits ability of private number of ESPCs during (developed by the districts operators to run pilots the day for the initial pilots Delivery and requisition ▪ Operational complexity ▪ Upgrading of all ESPCs in made by private operators in ▪ Viable alternatives for terms of inventories, etc. a single loop (delivery of the resource-limited districts previous month’s order at the ▪ Availability of private time of requisition) ▪ Possibility to visit multiple operators ESPC in parallel

Model 3 (not selected) ▪ Availability of private ▪ High costs ▪ Need to break requisition operators to ensure the circuits (developed by the ▪ Limited value of testing delivery districts for the initial pilots) private operators on their ▪ Delivery by a private ability to only deliver drugs ▪ Upgrading of all ESPCs in operator terms of inventories, etc. ▪ Operational complexity - ▪ Requisition made by the less than model 2 district (coordination between several stakeholders)

SOURCE: GTT 55 General description of the delivery and requisition process

Description of the delivery process and requisition

Coaching on Preparation 1 2 Loading 3 Delivery 4 good of the order practices of storaget

TRANSPORTATION REQUISITION Resources District Pharmacist : Driver/Conveyor : Driver/Conveyor : PGP/Pharmacist : mobilized : Preparation of the Verification and loading Deliveries made to the Coaching on the follow- ▪ Logistic order placed by the of packages and ESCP and signature of up of good storage means ESPCs departure with delivery tools, in the practices and stock ▪ Fuel PGP/District Pharmacist presence of the management ▪ Driver / PGP/pharmacist conveyor ▪ PGP ▪ Tools

Coaching on Coaching 8 Return 7 Data 6 good 5 on good Collection practices of practices of Next tour order inventory preparation DATA MANAGEMENT

Driver/Conveyor : PGP/Pharmacist : PGP/Pharmacist : PGP/Pharmacist : Return to district and Collection of product Coaching of the Coaching of the ESPC transmission of delivery delivery and coaching ESPC nurse on the nurse on product and requisition data identification of the inventory best documents and data quantities to order practices

SOURCE: GTT 56 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation Criteria 4.1 National rollout plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

57 PUBLIC PILOT Delivery procedure

Preparation Operations Monitoring and evaluation

Requisition Back to Delivery Storage Inventory Order District

Where? Who? District Level ESPC Level Stakeholders Quoi? 1 Receive the report order from ESPC District Managers 2 Process ESPC orders

District 3 Verify qualitatively and quantitatively the packages Managers and Driver

4 Loading packages into the vehicle

5 Conveying packages to ESPCs Driver

6 Unload the vehicle

7 Receive packages ESPC Manager

ESPC 8 Verify qualitatively and quantitatively the package, fill Managers in and sign the related tools and Driver

9 Coaching in good delivery practices Coach and ESPC Digital collection of delivery data manager 58 PUBLIC PILOT Requisition procedures - storage

Prepara- Monitoring and Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district Where? Who? ESPC Stakeholders What 1 Check the storage conditions of the ESPC pharmacy and observe compliance with good practices Coach

2 Coaching on the application of good practices relating to storage conditions Coach

3 Carry out the arrangement of the products received at the time of the delivery ESPC Manager

4 Coaching on the storage of products received during delivery Coach

5 Fill in the digital form with the storage data Coach

6 Write the recommendations provided by the coach on the correspondence booklet ESPC Manager

7 Implement the coach’s storage recommendations ESPC Manager

59 PUBLIC PILOT Requisition procedures - inventory

Prepara- Monitoring and Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district Where? Who? ESPC Stakeholders

What?

1 Take inventory of products in stock ESPC manager

2 Conduct coaching sessions on the inventory of products in stock Coach

3 Complete the digital form with the inventory data Coach

4 Write the recommendations provided by the coach on the correspondence booklet ESPC manager

5 Implement the coach’s recommendations regarding the inventory ESPC manager

60 PUBLIC PILOT Requisition procedures - order preparation

Prepara- Monitoring & Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district Where? Who? ESPC Stakeholders What? Coach and 1 Initiate the ESPC manager to prepare the order manager of the ESPC

Manager of the 2 Place an order ESPC

3 Observe the transmission of the command Coach

4 Coaching on the calculation of quantities to order Coach

5 Fill in the computer form with the order data Coach

Manager of the 6 Note down the coach provider's recommendations on the correspondence booklet ESPC

Manager of the 7 Implement the coach provider's recommendations regarding the order ESPC 61 PUBLIC PILOT Requisition procedures – return to the district

Prepara- Monitoring & Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district

Where? Who? ESPC District Stakeholders What?

Coach, manager of the ESPC and 1 Check that all tools are filled in and driver signed

2 Receive the filled in and signed tools at the District manager time of the delivery and requisition

3 Coach Share digitally collected data

62 PRIVATE PILOT Delivery process

Prepara- Monitoring & Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district Where? Who? District Level ESPC Level Stakeholders What? 1 Receive the report order from ESPC District managers 2 Process ESPC orders

District 3 Verify qualitatively and quantitatively the packages managers and driver

4 Loading packages into the vehicle

5 Convey packages to ESPCs Driver

6 Unload the vehicle

7 Receive packages ESPC manager

ESPC Verify qualitatively and quantitatively the package, fill 8 managers & in and sign the related tools driver

9 Coaching in good delivery practices Coach & ESPC Digital collection of delivery data manager 63 PRIVATE PILOT Requisition procedures - Storage

Prepara- Monitoring & Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district Where? Who? ESPC Stakeholders What? Check the storage conditions of the ESPC pharmacy and observe good compliance with good 1 practices Coach

2 Conduct coaching sessions on the application of good practices relating to storage conditions Coach

ESPC manager 3 Carry out the arrangement of the products received at the time of the delivery

4 Conduct coaching on the storage of products received during delivery Coach

5 Fill in the digital form with the storage data Coach

ESPC manager 6 Write the recommendations provided by the coach on the correspondence booklet

ESPC manager 7 Implement the coach’s storage recommendations

64 PRIVATE PILOT Requisition procedures – Inventory

Prepara- Monitoring & Operations tion evaluation

Requisition Return to Delivery Storage Inventory Order district

Where? Who? ESPC Stakeholders

What?

1 Take inventory of products in stock ESPC manager

2 Conduct coaching on the inventory of products in stock Coach provider

3 Complete the digital form with the inventory data Coach provider

4 Write the recommendations provided by the coach on the correspondence booklet ESPC manager

5 Implement the coach’s recommendations regarding the inventory ESPC manager

65 PRIVATE PILOT Requisition procedures - order preparation

Prepara- Monitoring & Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district

Where? Who? ESPC Stakeholders What? Coach provider & 1 Initiate the ESPC manager to prepare the order ESPC manager

2 Place an order ESPC manager

3 Observe the transmission of the command Coach provider

4 Coaching on the calculation of quantities to order Coach provider

5 Fill in the digital form with the order data Coach provider

6 Write the recommendations provided by the coach on the correspondence booklet ESPC manager

7 Implement the coach’s recommendations regarding the order ESPC manager

66 PRIVATE PILOT Requisition procedures – return to the district

Prepara- Monitoring & Operations tion evaluation

Requisition Back to Delivery Storage Inventory Order district

Where? Who? ESPC District Stakeholders What?

Coach, manager of the ESPC and 1 Check that all tools are filled in and driver signed

2 Receive the filled in and signed tools at the District manager time of the delivery and requisition

3 Coach Share digitally collected data

67 1. Context 2. Pilots description 2.1 Preparation 2.2 Operations 2.3 Performance monitoring 2.4 Rollout plan

68 Procedures of the pilots

1 2 3 4 Performance Preparation of the pilot Operations National deployment monitoring

National Deployment 1.1 District selection 2.1 Pilot models 3.1 Evaluation Criteria 4.1 Plan

Product portfolio Procedures of the Performance mo- 1.2 2.2 3.2 identification pilots nitoring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

69 The monitoring and evaluation of the pilots will take place at several levels

Description Criteria Indicators Rational (why?) 1 ▪ Monitor the proper ▪ Conformity to ▪ Proportion of ESPCs delivered ▪ Performance application of the delivery plan by the District in one month evaluation of procedures put in place ▪ Conformity of ▪ Proportion of ESPCs delivered stakeholders (schedules, proper data delivery to order by the district on time according collection, coaching, etc.) (satisfaction rate) to the district distribution Activity ▪ Report on the proper ▪ Execution of the schedule monitoring conduct of pilot activities coaching ▪ Order satisfaction rate

During 2 the pilot ▪ Track the pilot’s ▪ Product availability ▪ Availability rates of the products ▪ Pilot effectiveness and impact ▪ Product expiration from the programs performance on improving last mile and loss ▪ Availability rate of recoverable evaluation distribution ▪ Compliance with products and “targeted free-of- – Improved product good practices charge” products availability ▪ Payment collection ▪ Proportion of ESPCs with at least Impact – Reduction of one health product is out of stock monitoring expiration dates of ▪ PPI rates over the period ; products ▪ Proportion of ESPCs with well maintained storage space ▪ Direct product sales recovery rates

3 ▪ Evaluate which model ▪ Last mile distribution ▪ Comparison of impact indicators ▪ Decision on to deploy to scale and models performance between the two models which model to At the under what conditions ▪ Actual cost of ▪ Comparison of activity indicators deploy at scale Evaluation end of distribution between the two models of the pilot the pilot ▪ Model sustainability ▪ Comparison of monitoring and ▪ Ease of setting up evaluation reports the model

70 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation criteria 4.1 National rollout plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

71 PUBLIC PILOT Monitoring and evaluation procedure – public

Monitoring Preparation Operations and evaluation

ESPC Level District Level Region Level Central Level

District Manager / Departmental Regional A Coach B Management C Pharmacist D Central level

Analyze regional Analyze district Do the coaching Analyze ESPC data distribution synthesis distribution reports reports

Monitor the implementation of good practices done by the ESPC manager Elaborate the monthly Monthly distribution Elaborate the monthly distribution reporting summary report distribution summary report Collect data (including issues and (including issues and – regional level litigation) – district level litigation) – central level

Report problems back to the district

Carry out monitoring and evaluation missions

Take corrective action Take corrective action Elaborate the final pilot on identified on identified evaluation report deficiencies deficiencies 72 PRIVATE PILOT Monitoring and evaluation procedure – private

Monitoring Preparation Operations and evaluation

ESPC Level District Level Region Level Central Level

District Manager / Departmental Regional A Coach B Management C Pharmacist/NPSP D Central level

Analyze regional Analyze district Do the coaching Analyze ESPC data distribution synthesis distribution reports reports

Monitor the Elaborate implementation of good monthly practices done by the Make the Distribution ESPC manager monthly Elaborate monthly Elaborate monthly Summary distributio distribution summary distribution reporting Report, n report (including issues Collect data (including issues and including summary and litigation) – central litigation) providers’ report level payment (region) Report problems back notices to the district (NPSP)

Carry out monitoring and evaluation missions

Take corrective action Take corrective action Elaborate final pilot on identified on identified evaluation report deficiencies deficiencies 73 Pilots procedures

1 2 3 4 Performance Pilot preparation Operations National rollout monitoring

1.1 District selection 2.1 Pilot models 3.1 Evaluation Criteria 4.1 National Rollout Plan

Product portfolio Procedures of the Performance moni- 1.2 2.2 3.2 identification pilots toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

74 Budgeting carried out on 5 categories of expenditure taking into account all pilot project costs

Costs included in this category for public Costs included in this category for the Category of expenditure model private model

▪ Acquisition of vehicles N/A (vehicles supplied by private Acquisition and allocation of distribution ▪ Sending vehicles to their respective service providers) vehicles districts

▪ Sending a team of trainers from the central level to each region Organization of a kick-off and training ▪ Holding of a 2-day kick-off meeting and training meeting attended by stakeholders ▪ Transport to their regional headquarters of 2 people from each pilot's DS

▪ Fuel costs Fixed price invoiced by the private ▪ HR expenses service provider, estimated on the basis Pilot Implementation of its operational costs

Costs related to a field mission consisting in sending 2 people from the central Monitoring the delivery and requisition level and the pharmacist from each region to monitor the operations of each process district + 2 ESPCs in each district

Costs related to a field mission consisting in sending 2 people from the central Performance evaluation of the stakeholders level and the pharmacist from each region to evaluate the impact of the pilot in and the distribution model each district + 2 ESPCs in each district

SOURCE: TDR, budgeting model 75 METHODOLOGY Use of 5 key assumptions in estimating the budget of the different options

Total estimated working time required assuming delivery and requisition will be 01 possible in 1 to 2 ESPCs / day / district

Estimate of the fixed price invoiced by the private sector based on a 02 reconstitution of the costs incurred by the private sector, increased for administrative costs (20%)1 and the commercial margin (25%)

Taking into account the fleet of vehicles already available in Key the districts, in order to be able to distribute the three 4x4s and 03 the eight tricycles already acquired so as not to have to buy Assumptions new vehicles

Budgeting for performance monitoring in order to capture all costs 04 related to the pilot (e.g. monitoring and evaluation missions)

05 Mobilization of partnerships (e.g., IHSC-TA) in the budgeting

1 Average percentage of overheads in turnover for the 20 largest Ivorian companies : 16% of turnover, i.e. a 20% increase in the cost base SOURCE: GTT (discussion of structuring assumptions), annual reports (for margin and administrative fee levels), desk research 76 METHODOLOGY Pilot budget estimate was based on a top-down and bottom-up approaches

Preliminary and non-binding discussions with a “Top-down” private provider (ESD) to ensure the feasibility of the approach to private model and to confirm the order of magnitude confirmation of its cost

Estimate provided by the EDD provider

Budget

Granular Reconstitution of the cost based on assumptions: “bottom-up" fuel cost, distance from each circuit, hourly wages, Approach to cost of a tire change... Cost Reconstitution Estimate made on Excel file

77 Estimate of a required budget of XOF~130 million for the Contribution SWEDD public pilot and XOF133 Million for the private pilot Contribution IHSC-TA Costs included in this Costs included in this category for public category for private Expense category models, XOF Million models, XOF Million Over the duration of the pilot (6 months), the public and private models have Acquisition and allocation of distribution resources 86 2 88 0 almost at the cost (XOF~130 million each) ▪ Cost of the public model driven by Organization of a kick-off and 10 investment in vehicles 10 7 training meeting ▪ Cost of the private 0 model very largely dominated by the fees charged by the private Pilot Implementation 23 1 24 117 operators In the public model, possibility for IHSC-TA to pay XOF17 Million Monitoring the delivery and corresponding to the requisition process 4 4 5 routing of the vehicles, the initial training of the stakeholders, and the monitoring of the pilot Performance evaluation of the process stakeholders and the distribution 3 3 4 model

Total 112 17 129 133

SOURCE: TDR, budgeting model 78 HYPOTHESIS DETAILS Budgeting hypothesis (1/5)

Category Cost Unit Value Driver’s salary XOF / month 150 000 Driver’s salary including expenses XOF / month 277 500 Driver’s salary including expenses EUR per month 423 Driver’s salary XOF / h 938 Driver’s salary including expenses XOF / h 1 734 Driver’s salary including expenses & commercial margin XOF / h 2 783 PGP salary (pritave sector) XOF / month 300 000 PGP salary (pritave sector) including expenses XOF / month 555 000 PGP salary (pritave sector) including expenses EUR per month 846 Hypothesis Overnight stay (PGP and driver public and private) XOF / night 15 000 linked to HR expenses Dinner Expenses (PGP and driver public and private) XOF / dinner 7 000 Minimum motivation for travel XOF / day 5 000 PGP per diem (excluding hotel) XOF / day 10 000 Legal working hours h / week 40 Legal working hours h / month 160 Legal working hours h / day 8 Working days per month j / month 20 Daily care for a central level participant on the move XOF / day 60 000 Transport support XOF 15 000 Contribution rate on gross salary % of salary 85%

SOURCE: TDR budgeting model 79 HYPOTHESIS DETAILS Budgeting hypothesis (2/5)

Category Cost Unit Value Consumption of a 4x4 or pickup truck l / 100 km 15 Consumption of a 4x4 or pickup truck l / km 0,15 Consumption of a 4x4 or pickup truck XOF / km 91,5 Consumption of a tricycle l / 100 km 8 Consumption of a tricycle l / km 0,08 Consumption of a tricycle XOF / km 48,8 Purchase cost of a 4x4 or pickup type vehicle XOF 20 000 000 Cost of buying a tricycle XOF 3 000 000 The private sector uses tricycles True / false FALSE The private sector uses tricycles True / false TRUE Hypothesis linked to vehicles Distance after which 4x4s must undergo maintenance km 10 000 Distance after which tricycles must undergo maintenance km 1 125 Cost of a maintenance operation for a 4x4 XOF 165 000 Cost of a maintenance operation for a tricycle XOF 50 000 Number of tires to change on each 4x4 during the pilot km 5 Distance after which the tricycles must undergo a tyre change km 4 Cost of a tire change for a 4x4 XOF 120 000 Cost of a tricycle tyre change XOF 25 000 Cost of a 4x4 tire change XOF 120 000 Cost of a tricycle tyre change XOF 25 000 Cost of fuel XOF / l 610

SOURCE: TDR budgeting model 80 HYPOTHESIS DETAILS Budgeting hypothesis (3/5)

Category Cost Unit Value Cost of making a batch of fuel cards XOF 15000 Number of batches of fuel cards required per pilot # 1 Daily price of renting a 4x4 XOF 90 000 Depreciation period of a 4x4 Years 2 Depreciation period of a tricycle Years 1 Hence daily amortization of a 4x4 XOF / day 27 397 Hence daily amortization of a tricycle XOF / day 8 219 Cost of liability insurance for 4x4s XOF / year 73 415 Cost of liability insurance for tricycles XOF / year 22 920 Cost to purchase a smart padlock to secure 4x4s XOF 250 000 Hypothesis linked to vehicles Smart Padlock Monthly Subscription XOF / month 50 000 Number of locks by 4x4 # 1 Number of locks by tricycle # 1 Increase in transport times to take account of hazards and breaks % 10% Number of 4x4s already acquired # 3 Number of tricycles already acquired # 8 Cost of the toll on the northern ring road XOF / trip 1 250 Cost of a service of transport of vehicles by flatbed truck between XOF 300 000 Abidjan and Bouaké Distance between Abidjan and Bouaké km 347 Maximum number of tricycles transported in each flatbed truck # 6

SOURCE: TDR budgeting model 81 HYPOTHESIS DETAILS Budgeting hypothesis (4/5)

Category Cost Unit Value Time required to prepare a delivery (packaging...) h 0

Time required for delivery h - Time required for requisition h - Cost of a monthly telephone plan allowing communication before XOF / month 5 000 the PGP arrives in the district Cost of purchasing a large size cooler XOF 150 000 Cost of purchasing a cold accumulator XOF 5 000 Hypothesis linked to Number of coolers per driver # 1 deliveries Number of cold accumulators by cooler # 20 (equipment, Distance beyond which the transport of a vehicle generates a km 350 preparation…) night of accommodation Monthly cost of a 3G card for tablets XOF / month 10 000 Cost of a tablet XOF 100 000 Share of working days requiring a hotel night % 67% Private sector overhead costs % of turnover 20% Private sector margin % of turnover 40% Number of ESPC visited per day (assumption used in simplified # 1,5 calculations) Pilot Duration month 6 Assumption of cost mark-up to create the high estimate % 30% Stuctural Assumption of increase of the distance of each circuit % 50% hypothesis linked Bank charges XOF / month 20 667 to the pilot as a whole Of which balance communication costs XOF / year 50 000 Of which online bank account consultation fees XOF / month 11 000 Of which account maintenance costs XOF / month 5 500

SOURCE: TDR budgeting model 82 HYPOTHESIS DETAILS Budgeting hypothesis (5/5)

Category Cost Unit Value Number of people per district sent to the launch day (excluding # 2 driver) Participants from each district at the launch day are accompanied True / False FALSE by a driver? Hence the total number of people on the move from the central # 3 Hypothesis for level launch and Duration of training in each district days 2 training days Hence the number of treatments required per person # per person 3 Number of coffee breaks per day # 2 Cost of printing a colour page XOF / page 150 Cost of binding a document XOF / document 350 Cost of a participating kit (notepad, pen) XOF 1500 Number of inspection(s) to be carried out (e.g. number of visits to # 1 all pilot districts) Number of ESPC to visit when visiting inspected districts # 2 Cost hypothesis for district to district inspection Duration of an inspection in a district or in a ESPC h 1 5 team Average travel speed km / h 41 Number of inspectors # 3 Total time spent at each district days 2 Duration of training in a district h 16 Cost hypothesis Number of times a region receives training # 1 for decentralized training Number of trainers sent to districts # 2 Number of participants from districts # 3

SOURCE: TDR budgeting model 83 1. Context 2. Pilots description 2.1 Preparation 2.2 Operations 2.3 Performance monitoring 2.4 Rollout plan

84 Pilots procedures

1 2 3 4 Performance Pilot preparation Operation National rollout monitoring

1.1 District selection 2.1 Pilots models 3.1 Evaluation criteria 4.1 National rollout plan

Product portfolio Performance moni- 1.2 2.2 Pilots procedures 3.2 identification toring procedures

Refurbishment of 1.3 stocks

Identification of the digital data 1.4 collection application

Budgeting

85 Four main questions to address to prepare the national rollout of last mile distribution models

How to decide which distribution model to deploy in each district

What adjustments should be made to the models before national rollout?

At what pace should distribution models be deployed at the national level?

What future improvements can be made to the distribution models?

86 DISTRIBUTION MODEL ALLOCATION During the national rollout, a distribution model – public or private – will be allocated to each district based on a three-steps process Detailed in the next page Processus d’attribution d’un modèle de distribution au dernier km à un district

2. Identification of the performance of each 3. Allocation of a model 1. Districts segmentation model per type of to each district district

Classification of district Identification of the Allocation of a distribution per type based on the relative performance of model (private or public) average distance the private model adapted to the district between the ESPCs compared to the public according to the criteria of ▪ Dense districts (low model based on the pilots ▪ Sustainability of the distances between results model ESPCs) ▪ Comparison of product ▪ Ease of implementation ▪ Moderately dense availability improvement of the model districts rates ▪ Model performance ▪ Fragmented / distant ▪ Comparison of loss districts (high distances reduction rates and between ESPCs) product expiration rates

87 DISTRIBUTION MODEL ALLOCATION Three main questions to address in order to select which model to deploy at each district

Models identification process

By default : rollout of the public model ▪ The last mile public Is the private model feasible ? distribution model (Availability of the private sector is used as the operators) default model since it is always possible to deploy it by mobilizing Is the cost/impact ratio for the private sector sufficient resources higher than in the public model ? (Use of the ▪ The feasibility and composite impact indicator) sustainability analysis of the Rollout the private model are public model required prior to the selection of the Rollout the Is the private model sustainable ? private model public model (Given the funding available)

Rollout the Rollout the public model private model

88 Prior to the rollout, it will be probably necessary to make adjustments to the operating model based on the key learnings from the pilots

▪ potential operational constraints might be identified during the pilots Need to adjust the last mile ▪ Pilot procedures and tools distribution models tested in the developed centrally were tested pilots prior to the national rollout once in the field (during the to capitalize on key learnings field visit on Tuesday, July 19th) from the pilots

89 ADJUSTMENTS TO BE MADE TO THE MODELS 6 dimensions to be potentially adjusted during national rollout Dimensions that can potentially be adjusted Adjustment criteria ▪ To be adjusted according to the references actually consumed at ESPC level: Product – Simplification of products presented in several dosages portfolio – Withdrawal products not unused by 80% of ESPCs – Addition of products used by 80% of ESPCs but not part of the product portfolio ▪ Deploy the tool used during the pilots until the implementation of the new tool Data collection connected to e-SIGL tool ▪ Update the data to be collected (i.e., list of districts...) ▪ Potentially extend the scope of digitization to other tools ▪ Update the target duration of visits based on the average duration observed during Duration the pilots of visits ▪ Update the target visit duration taking into account the learnings from the pilots (e.g., more and more efficient requisitioning) ▪ Simplify best practices based on the results of monitoring and analysis of blocking Good practices in points and challenges encountered by the different players involved in the in distribution distribution process ▪ Lighten good practices by removing irrelevant ones Set up non-financial incentives (i.e., equipment made available, training) following Incentives to ▪ monitoring and evaluation insights performance

▪ Integrate the procedures under development by UNFPA Procedures

SOURCE: Team analysis 90 ADJUSTMENTS TO BE MADE TO THE MODELS During the pilot, there are three ways to identify potential adjustments

Means to be used during the pilot Description

Analysis of data to calculate indicators that may indicate that an adjustment is 1. Analysis of collected necessary (e.g., average length of visits, data level of satisfaction, level of monitoring of good practices)

During the pilot, 3 ways to identify the Monitoring mission (3 months after the start 2. Interviews with adjustments to of the pilot) to gather qualitative feedback participants during the be made to the from participants in the pilot model during monitoring mission rollout

Final evaluation mission to gather qualitative 3. Interviews with feedback from participants in the pilot (i.e., participants during the suggestions for improvement...) final evaluation mission

9191 ROLLOUT PLAN Need to stagger deployment of last mile distribution models nationally to ensure successful implementation Potential phasing of national rollout of last mile distribution models

Phase 3 Phase 2 Phase 1

Number of 33% of the districts that are 33% of the following districts Last 33% of the districts not part of the pilots districts Launch of delivery and Rollout of the third of districts Rollout of last third of requisition process for 4 following four months after the districts four months after Description months before launching the first phase (a priori, private phase 2 next deployment phase (pubic model) model mainly)

▪ Allows to prioritize the ▪ Allows to identify and ▪ Allows to better control model whose operations select potential and monitor the first are more controllable (no providers at the central rounds of data call for tenders, etc.) level (during the roll out collection and the first ▪ Allows to better control of the first phase) rounds of regular and monitor the first ▪ Allows to better control operations Rationale rounds of data collection and monitor the first and the first rounds of rounds of data collection regular operations before and the first rounds of expending the model to regular operations more districts before expending the model to more districts 92 FUTURE IMPOROVEMENTS Several model improvements are possible in the short, Short term (0-1m) Mid term (6m-1year) medium and long term Long term (>1year)

x Responsible entity

Arbitration of Product portfolio Review of the quantity Route optimization / operational adjustment ("ESPC determination system load break points plotters") dimensions PNDAP PNDAP PNDAP DPML NPSP NPSP

Implementation of Operational an integrated Integrated reverse reverse logistics logistics system system integration PNDAP NPSP

Integration of parallel Integration of blood Continuation and Viral load chain chains, e.g. PNN, reagents and Vaccine integration acceleration of the integration PNMTN consumables integration process PNS , PTF PNLS CNTS PEV, INHP NPSP Retroci NPSP NPSP

Strengthening Strengthening Governance and Transformation of HR Implementation of governance and pharmacists’ and HR Transformation culture, e.g. incentive eLearning at the last coordination between PGP’s logistical Agenda systems mile DGS DGS entities PNDAP competencies PNDAP PTF PTF

Catalysts Systems integration, Integration and NPSP and eSIGL e.g. eSMT, eSIGL, Digitization of the last digitization of IT control cycle MedTic, quantif. km tools and systems harmonization PNDAP software PNDAP PNDAP NPSP NPSP NPSP

Review of the Increased self- financing system District empowerment financing (diagnosis and PRSSE solutions) DGS DGS 93 Kate Woods [email protected]

Simplice Kamdem [email protected]

This presentation was produced for review by the United States Agency for International Development. It was prepared by McKinsey&Company under sub-contract with Chemonics International Inc. for the Integrated Health Supply Chain – Technical Assistance Activity, Contract number AID-624-TO-17-00003.

94