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Last Mile Delivery Improvement in Côte D'ivoire

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Last Mile Delivery Improvement in Côte D'ivoire Last mile delivery improvement in Côte d’Ivoire Programme Integrated Health Supply Chain Technical Assistance (IHSC-TA) Deliverable # 3: Mapping of current last-mile supply chains 1 3. Supply chain mapping of health products 3.1. Actors of the chain and consolidated view 3.2. Detail of product, information and financial flows on the different chains 4. Supply chain performance and costs 4.1. Service level performance 5. Supply chain diagnosis 5.1. Performance levers of a supply chain 5.2. Bottlenecks and strengths of current chains at the last mile 2 3 KEY MESSAGES – Supply chain mapping (1/2) ▪ More than 10 stakeholders intervene on the different functions of the supply chain, often on a single function (quantification, purchase, financing, storage, distribution) ▪ To date, 5 main types of supply chains coexist in Ivory Coast – NPSP Main Chain: delivery of NPSP to Direct Clients (Districts, Hospitals and some HC) and delivery or collecting from districts to other HC, with a parallel chain for MTNs – Some parallel chains on program products operated by DPs, on a continuous or ad hoc basis, with different Players and storage points from the NPSP chain general – Vaccines: 2 autonomous and parallel chains operated by PEV and INHP organization – Blood products: 1 CNTS chain – Viral load test reagents: 2 autonomous and parallel chains operated by Retro-CI / CDC and by the OPP-ERA project ▪ Community-level supply is generally limited to products from 3 programs (malaria, MTN, TB for irregular patients - with some localized exceptions for ARVs) and, in some cases, some EGDs (antibiotics, analgesics, antipyretics) ▪ A majority of the product families are integrated in the NPSP main chain - with a tendency to abandon vertical and independent product chains – ex. PNN integration in progress). The chain of MTN products is an exception with a chain comparable to the NPSP chain in its design but totally independent Integration of ▪ Some NPSP chain segments are themselves parallel – ex. in Abidjan, delivery of some products (e.g. ARVs) to the the NPSP districts and the delivery of other product families to the HC chain ▪ Attempts to integrate NPSP and blood products into the procurement functions have not been sustainable; an integration for distribution has not been attempted; an integration of the viral load test reagent chain is planned for the coming months ▪ In the NPSP chain – The NPSP delivers its direct clients (districts, hospitals, some HC mainly in Abidjan) in Abidjan and via a private Product flow operator outside Abidjan, at a monthly frequency until the last – 35-45% of the HC are delivered by their district while 55-65% collect their own products from the districts, mile also monthly; CHWs collect their products from hospitals or HC, usually monthly also – Emergency deliveries are operated by the customers themselves or by the various IPs 3 3 KEY MESSAGES – Supply chain mapping (2/2) ▪ The inputs for blood products are collected by 27 sampling sites (5 SP, 18 ATS, 4 CTS) from the CNTS in Abidjan at the frequency of their choice; blood bags are collected by CNTS clients (hospitals, private clinics) by Product flow their own means at the frequency of their choice to the last ▪ The vaccines are delivered by the INHP ​​to the regional offices, then collected by the vaccination centers by mile (2) their own means quarterly. ▪ The viral load reagents are delivered quarterly by the IPs to the 16 laboratories from the central level ▪ The requisition model has a vast majority on the chains and at all levels, including the last mile, the exceptions generally concern campaign activities (e.g. vaccination) or one-off DP activities. ▪ In the NPSP chain – With the exception of some TB and nutrition products still distributed by allocation, all products are operated on requisition Information – Direct NPSP clients send their orders monthly; orders from non-direct HC clients are aggregated by the flow district prior to transmission to the NPSP ▪ Blood sampling sites (SP, ATS, CTS) order their inputs according to their needs – ex. depending on sampling campaigns; it's the same for the end customers of blood bags ▪ Vaccine quantities are allocated without orders from health structures ▪ Viral load reagents are also delivered on order ▪ Funding and procurement is fragmented and shared between the NPSP, donors and their central procurement bodies ▪ Once in the NPSP chain, the products remain theoretically the property of the NPSP until the sale to the patient – Program and GTC products are provided to direct and other HC customers free of charge; the State is supposed to pay them a margin corresponding to the logistics costs (rarely implemented) Financial – For recovery products, the HC pays the districts after recovery in the majority of cases (~ 90% - ~ 10% of flows districts in tight financial situation pay in advance); direct customers then pay the NPSP (one month post delivery delays), which gives them a margin of 8% (rarely implemented) ▪ CNTS blood product inputs are provided free of charge to SP / ATS / CTS; 60-70% of blood bags are donated to hospitals (theoretically sold at lower cost for reimbursement of these by the state under the GTC), and 30-40% are sold to private clinics ▪ Vaccines and viral load reagents are provided free of charge to all health structures that use them 4 3.1 10 actors are involved in the Ivory Coast supply chain Participants Role ▪ Proposal and promotion of the national drug policy PNDAP / CNCAM– National ▪ Coordination of the implementation of the national pharmaceutical policy Pharmaceutical Activity ▪ Supply coordination and tracking of activities related to logistics management of health target Development Program products ▪ Quantification related to different health programs through technical committees NPSP – New Public Health ▪ Acquisition of pharmaceuticals as the sole national public procurement center Pharmacy ▪ Answer 100% of public structures' orders for vital products and 60% in EGD ▪ Coordination of the technical and financial partners’ efforts National Health Programs ▪ Quantification of each program’s disease-related pharmaceutical needs (PNLT, PNLS, PNLP, ▪ Supply and Distribution Monitoring by the NPSP PNSME/PNN, Others) ▪ Follow-up and recommendations to regional directorates and HC CNTS – National Blood ▪ Product selection, forecasting, supply planning, and blood product purchases Transfusion Center ▪ Distribution of blood transfusion related products to the establishments of the CNTS network ▪ Vaccine Supply Selection, Forecasting and Planning with the Expanded Program on INHP – Public Hygiene Immunization Coordination Directorate (DC-PEV) National Institute ▪ Chat in coordination with the State, UNICEF, and the NPSP for the purchase of vaccines ▪ Storage and distribution in public health facilities DSC – Community Health ▪ Coordination of community activities; promotion of local medicine Directorate ▪ Monitoring the activities of NGOs and other civil society organizations working in the health sector ▪ Promotion of health and public hygiene policy in the region Health & Public Hygiene ▪ Monitoring and evaluation of health activities Regional Directorates ▪ Appui technique aux districts Health Districts ▪ Coordination of health activities Health Facilities ▪ Making medicines available to the population ▪ Financial support for the purchase of pharmaceutical products, e.g. Global Fund, USAID, PEPFAR Technical & Financial ▪ Coordination with central procurement bodies Partners1 ▪ Support to the supply chain CBO et CHW – Community ▪ Supply to the furthest location particularly in remote areas Based Organizations and CHW ▪ Basic care provided in community-based health facilities (ESCOM) Agents Private logistic operators ▪ Delivery NPSP-districts out of Abidjan for NPSP products and transportation of tubes to be tested between ATS and CTS for blood products 1 Multilateral Institutions (e.g.: WHO, World Bank, UNFPA, UNICEF, ONUSIDA, FDA…) and implementation projects (e.g.: SCMS, MSF…) SOURCE: Supply chain map(WHO/PNDAP 2016), interviews with PNS & DP 5 3.1 Integrated main chain, a few parallel minor chains, and 4 autonomous chains for vaccines, blood and viral load reagents Product chain integrated into the national chain? Minor parallel chain? Recoverable drugs & Occasional supply in the private & GTC illicit sector Malaria Campains (e.g.: LLIN) Direct supply by MSF and small NGOs HIV (Basic tests & Emergency direct procurement by treatments) IP (e.g.. ICAP) NPSP Chain EGD, program Campains; persistence of the PNN Nutrition Products Direct procurement by PAM and products & GTC warehouse other partners Occasional donations from Mother & Child Health Pathfinder, Save, MSF, and small & FP NGOs Tuberculosis Neglected Tropical Diseases Autonomous chain Chain Autonomous chain; Integration for PEV Chain storage at regional INHP antennas, Vaccines but separation in progress Autonomous chain INHP Chain Blood CNTS Chain Autonomous chain Transfusion Autonomous chain - Integration to Retro-CI Chain the NPSP chain intended for 2018 Reagents viral load test OPP-ERA Chain Autonomous chain SOURCE: Supply chain map (2016), interviews with PNS & DP 6 MAPPING 3.2 Supply chain of recoverable essential drugs and GTC products Direct flow of product Paid allocation Free allocation Paid requisition Free requisition XX Purchase value (XOF, billion)) Transpor- Transpor- Transpor- Funding Quantifica- Procure- Central Intermediate Final Community tation/ tation/ tation/ tion/Planning ment storage storage storage based
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