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 storage distribution distribution distribution

NPSP Districts Health according to HC the means or ~6,91 Districts HC State for the NPSP NPSP NPSP NPSP GTC UH, RHC, (reimbursement RH, GH, other National network National NPSP) 2 direct clients ~5,2 N/A N/A Districts Health according to HC Districts the means or Private HC Private Private Private Private wholesaler wholesalers wholesalers wholesalers carriers stores Private UH, RHC, Private carriers or RH, GH, other Private Private network pharmacies health ~0.83 direct clients facilities CHW only distributes free products

Strengths and pain points: ▪ The majority of purchases are imported from abroad resulting in high costs, a lack of flexibility on orders and returns, and exclude the possibility of direct distribution by producers ▪ Possibility of improving the choice of products and suppliers at the NPSP - need to strengthen the capacity of the procurement unit ▪ Low recovery rates and significant delays in payment of health facilities ▪ Insufficient funding of the public system - and especially of free delivery - leading to high costs of products for sale to patients (sometimes the only source of funding for some institutions) ▪ Worrying magnitude of the illicit market - estimated at about one-third of the drug market1 - competing with public and private sector prices with serious public health consequences (therapeutic failures, intoxications, etc.)

1 Estimated data NPSP 2016 2 Estimated data NPSP 2016 on the basis of ~10mds XOF purchase of drugs GTC+ARV distributed at ~50%/50% according to NPSP 3 Cartography database 2015 SOURCE: NPSP interview; Supply chain mapping (WHO 2016); Evaluation of the supply chain (USAID 2015); NPSP accounts (NPSP 2016) 7 MAPPING 3.2 Supply chain of antimalarial products

Paid allocation Free allocation Paid requisition Free requisition XX Purchase value (XOF, billion))

Funding Quantification/ Central Transportation/ Intermediate Transportation/ Final storage Transportation/ Community Procure- Planning storage distribution storage distribution distribution based storage ment

Global funds Districts Health districts according to the HC 1 PNLP with means or HC 1,8 Central technical RTD, LLIN, CTA, RTD, mosquito nets, Community procurement NPSP NPSP CHW assistance from laboratory inputs, laboratory inputs, SP organizations PMI (entry in body of donors SP 2018) donors UH, RHC, RH,

GH, other direct National National network ~4,62 clients

Quantification/3 Regular stock Requisition for all Large storage at the Delivery rarely Limited storage, CHW screen and distribute ACT years on shortages products except district or RH or RHC supported by the regular supply, Support from TGF/UNICEF (bike, training consumption history, allocation for RTD, or UH run by trained district managed by the etc.) and Save the Children annual review SP, lab inputs, pharmacists prescribers mosquito nets

Global 3 PNLP with 19,5 Central Distribution Fund technical Health districts Private carrier Community procurement Private carrier Private carrier sites, ex. HC, CHW gns assistance from organisms PMI schools, etc.

Campai body of donors nd donors LLIN campaign UNICEF completes e.g. Bolloré until Local carriers from districts to every 3 years all purchases the districts distribution sites

MSF Districts nd No systematic or integrated Health districts according to the HC Community NGO NGO stores Private carrier CHW quantification means or HC NGO NGO Small UH, RHC, RH, organisms

network nd NGOs GH, other direct clients

Strengths and pain points: ▪ Close monitoring of the chain by the PNLP, through regular collection of performance data and diagnosis of obstruction points during quarterly validation sessions ▪ Global chain integrated around the national chain, but multiple small direct donations from local NGOs and large ad-hoc donor campaigns – which increases distribution costs and creates a lack of transparency about needs ▪ Recent evolution towards an allocation system for some products (diagnostic tests, SP, laboratory reagents and mosquito nets) as a result of misuse of RTDs and overstocks – even if allocations are considered suboptimal due to lack of data

1 ‘Grant Statement’ Data from Global Funds 2016 communicated by PNLP 2 FY2017 budget of PMI accessible online 3 UNICEF data from LLIN campaign 2017/18 purchase of 15 018 250 mosquito nets SOURCE: Interview with PNLP and UNICEF; Supply chain mapping (WHO 2015); Evaluation of the supply chain (USAID 2015) 8 MAPPING 3.2 Supply chain for HIV products

Paid allocation Free allocation Paid requisition Free requisition XX Purchase value (XOF, billion))

Funding Quantifica- Procure- Central Transporta- Intermediate Transporta- Final Transporta- Community tion/Planning ment storage tion/ storage tion/ storage tion/ based storage distribution distribution distribution

State Districts IDA / PPM for 1 Health according to 5,9 HC the donors NPSP (or IP districts the means or such asICAP, Global fund PNLS with the HC EGPAF, Ariel HC, RH, support of NPSP CHW 1 for urgent and RHC, UH 6,6 IHSC-TA transverse NPSP for the PEPFAR orders) RH, RHC, UH state ) ) (CD4, tests and 5,91

ARV Not allocated Quantification on All products • Delivery of Large storage at Delivery rarely Limited storage, • CHW mainly involved in to a donor for morbidity data stored at the monthly orders the district or RH supported by regular supply, sensitization – rare cases of

biochemistry, hematology) hematology) biochemistry, 2018: ~9,3 and NPSP except • Allocation or RHC or UH the district managed by the dispensation (ex. MDM network) Drugs ( Drugs detected/tested from viral load during run by trained prescribers on medical prescription using tools inputs overstocks at pharmacists • Associations, ex. RIP+, follow up (Forelab, the NPSP on chain performance Quantimed) 1 State 0,6 1 Retro-CI Retro-CI Retro-CI IP HC TGF 0,4 Reagents21 Lab HC, Sampling N/A N/A CDC 2,01 Platforms relay RH, RHC, UHtubes UH, RHC, 2 OPP-ERA OPP-ERA OPP-ERA 3PL RH, GH, other UNITAID 0,3 direct clients Retro-CI supported viral load reagents for 19 IP = HAI, • IP transports the Retro-CI tubes from the relay labs Absence of community involvement

Viraltests load platforms in 13 labs, by OPP-ERA for 2 platforms EGPAF, CFC, to the platforms and consumables by the NPSP funded by the sate Ariel, Aconda • Compensated relay laboratories for the transport of tubes by OPP-ERA

Strengths and pain points: ▪ Unreliable data leading to overestimation of targeted populations (ex. pediatric ARVs, opportunistic infections) ▪ Significant Gap in the supply plan (~ 30% in 2017 and 2018), and share of the state that is not purchased or delayed, leading to shortages on products de-prioritized during purchases (ex. laboratory inputs) and reducing staff training opportunities ▪ Delays in delivery by DP procurement units (ex. following withdrawal of SCMS) ▪ Occasional ad hoc donations not agreed with the public sector, especially OIs (ex. cotrimazole) ▪ Parallel chain on the viral load, (reagents and tubes) not yet integrated into the NPSP chain (for reagents) leading to additional costs

1 Supply chain PNLS 2018 (IHSCTA) 2 Cost of purchase of products (500k euros / year); Interview Expertise France SOURCE: Interview with PNLS, CDC, and Expertise France; Supply chain mapping (WHO 2015); Evaluation of the supply chain (USAID 2015); Supply chain PNLS 2018 (IHSCTA) 9 MAPPING 3.2 Nutrition Products Supply Chain

Allocation for purchase Free allocation Requisition for purchase Free requisition XX Purchase value (XOF, billion)

Funding Quantification/ Procure- Central Transport/ Intermediate Transport/ Final Transport/ Community Planning ment storage distribution storage distribution storage distribution based storage

State Central Districts Health according to 0,11 procureme HC districts the means or PNN with nt of DP NPSP NPSP HC support from UH, RHC, UNICEF Routine UNICEF for 2 1 NPSP RH, GH, other ~0,6 years and N/A N/A direct clients IHSCTA for 1 Districts year Central Health according to National Circuit National Others PNN HC Private the means or 1 procureme warehouses districts ~0,1 carriers UH, RHC,

nt of DP in Treichville HC RH, GH, other Punctual Annual NPSP for the direct clients UNICEF finances Products used for punctual Hospital and district requisitions but Only MUACs (not requiring 75%, state 10% quantification products actions (40% of the PNN product for 2 years financed by the district allocations for HCs medical expertise) are made an others (PAM, value) are stored and distributed available to CHW PEPFAR, C2D, state by the PNN using private carriers No support for CHWs or World Bank, UNICEF for food, community intervention at PNN MAP) <5% each2 some medical material. product level

PAM Health 1 out of 3 districts with 3 PAM PAM Central store districts ~0.06 Private carrier financial HC N/A N/A

NGO NGO PAM Circuit support

Strengths and pain points: ▪ UNICEF chain integrated to the national network/NPSP end 2017 – with convention UNICEF/NPSP/PNN – previously direct deliveries ▪ 2 parallel chains persist in addition to the NPSP chain – PNN punctual actions with storage by the PNN and parallel costly distribution by 3PLs financed by the DP & the state – Direct delivery PAM – no PAM/PNN/NPSP agreement yet ▪ Use of management tools, monitoring not yet mature and training needed, PNN integrated in ESIGL by mid January 2018 ▪ Annual quantification realized since 2 years only, no quarterly validation session due to lack of funding

1 PNN data, Supply chain plan 2016; 10% of procurement parts for the state based on the PNN interview 2 PNN interview 3 PAM interview, 2017 data (drastic decrease of purchases from>3m to 0.1m since 2015 – currently present in 3 districts) SOURCE: PNN, UNICEF, & PAM interviews ; Supply chain map (WHO 2015); Evaluation of the supply chain (USAID 2015) 10 MAPPING 3.2 MCH & FP products supply chain

Allocation for purchase Free allocation Requisition for purchase Free requisition XX Purchase value (XOF, billion)

Funding Quantification/ Procure- Central Transport/ Intermediate Transport/ Final Transport/ Community Planning ment storage distribution storage distribution storage distribution based storage

UNFPA _ entirety Districts until 2016 Health according to HC PNSME UNFPA – districts the means or ~1.81 assisted by even for HC UNICEF ~0,312 regional products NPSP NPSP N/A N/A pharmacists financed by and donors the state UH, RHC,

State RH, GH, other National network National ~2,613 direct clients

Annually as a The PNSME Lack of involvement from CHW – result of a data also stores a ongoing pilot for Sayana Press collection on small amount of Toumodi, Dabakala, and Blolequin distribution - products on its and premises for the progressive fairgrounds integration of consumption Districts Donations from No systematic Health according to HC other partners or integrated districts Community Huts, CBO, (MSF, Save, quantification NGO NGO stores Private carrier the means or NGO NGO UH, RHC, organizations CHW Circuit HC Pathfinder) RH, GH, other nc direct clients Strengths and pain points: ▪ Durability of the chain guaranteed by the sale of all PNSME products (products donated to the state by UNFPA, USAID/Deliver but sold to the patient); revenue saved by the state for future purchases ▪ Global chain integrated around the national chain, but many NGOs directly distributing family planning products ▪ Overstocks of some PNSME products, because their price is higher than the market’s and the same products are often distributed free of charge by the NGOS ▪ Lack of availability of less well sold products because they are not controlled by HE since they are recoverable ▪ Lack of involvement of community health workers compared to other program products, only one product (Sayana Press) has been piloted for distribution in a region by CHWs

1 PNSME 2018 supply chain (IHSC-TA) 2 Supply plan mentioning Amoxicillin, ChloRHCexidine, & SRO Zinc; no data for ophthalmic ointment, vitamins & misoprostol that is said to be fully financed by UNICEF 3 MSHP procurement & NPSP procurement SOURCE: PNSME, UNICEF, & IHSC-TA interviews; Supply chain map (WHO 2015); Evaluation of the supply chain (USAID 2015) 11 MAPPING 3.2 Tuberculosis products supply chain

Allocation for purchase Free allocation Requisition for purchase Free requisition XX Purchase value (XOF, billion)

Funding Quantification/ Procure- Central Transport/ Intermediate Transport/ Final Transport/ Community Planning ment storage distribution storage distribution storage distribution based storage

Global Fund Districts Global Fund 1 Health according to CDT2 & CT2 ~3.2 procurement districts the means or within HC central (GDF) Lab inputs, State HC Health huts kits, Community

l networkl PNLT NPSP NPSP Community spittoons organizations ~0.81 CDT dans les organizations NPSP for GH, RH

UNION – state-funded Nationa technical 4 side effects CAT2, PPH2 assistance Lab inputs, kits, spittoons Annual • Ordering from Supervision of • HE order using a formula based • Quarterly CHW distributes NGO Alliance quantification PNLT in DP the orders on the number of detected cases supply for the 25 front-line ensures the by PNLT on • Products delivery by the and available stock CAT & the 3 products (e.g. follow up for screening data procurement PNLT from GDF • For some products (lab inputs, PPH Rhze) only in irregular patients for normal by GDF through a kits, spittoons etc.) the PNLT • Quarterly cases of stock + 6 • Validation of forwarder to the makes allocations based on supply for the irregular patients months safety the order after NPSP consumption data reported by the 244 CDT stock control by the HE –products not integrated with PNLT eSIGL

Strengths and pain points: ▪ Strong integration of donors (80% coming from the Global Fund & 20% from the state, & the UNION on quantification) without parallel chains, except for some PEPFAR donations on laboratory reagents ▪ Significant delays in GDF deliveries– Global Fund procurement unit - causing delays to NPSP ▪ Difficult transition to a new requisition system : institutions quantify their own needs based on the number of cases - but orders are not or incorrectly filled indicating a need for training and follow-up of the staff in charge (55 centers out of a sample of 127 do not place their order yet on Esigl3) ▪ Limited tracking of the chain by the PNLT : lack of performance data and limited data on consumption

1 Financing hypothesis of 80% & 20% of tuberculosis spending for the Global Fund and the State (PNLT interview) on data from the report Evaluation of the chain 2015 2 Treatment and Diagnosis Center (CDT), Treatment Centers (CT), Anti-tuberculosis Centers (CAT), Department of Pneumology and Phtisiology of a UH (PPH) 3 PNLT interview 4 Starting 2019, the state will start buying some anti-tuberculosis drugs through the NPSP SOURCE: PNLT interview; Supply chain map (WHO 2015); Evaluation of the supply chain (USAID 2015) 12 MAPPING 3.2 MTN1 products supply chain

Allocation for purchase Free allocation Requisition for purchase Free requisition XX Purchase value (XOF, billion)

Funding Quantification/ Procure- Central Transport/ Intermediate Transport/ Final Transport/ Community Planning ment storage distribution storage distribution storage distribution based storage

Pfizer / USAID Districts ITI2 FHI360 Health according to HC 16,13 0,0033 PNLMTN-CP districts the means or for all Private carrier HC Health huts GSK Merck Pharma firms products Community PNLMTN-CP financed by Community via WHO except organizations 3 3 donors organizations 0,5 27,4 Azithromycin UH, RHC, at NPSP RH, GH, other National network National IP (Sigh-tsaver, SCI4) direct clients

All products Detailed maps Orders are Lack of funding • No continuous supply, all products are distributed • Strong involvement of CHW are donations of 4/5 forwarded to the for storage at for annual campaigns for each of the 5 pathologies (35400 in total) in the mass from pharma pathologies WHO which NPSP • IP (e.g. USAID, SCI, ITI, Sightsaver) fund the distribution firms except for from primary sends the transport of pharmaceuticals in the various endemic • e.g. FL-ONCHO (Ivermectin and tetracycline data collection information to health districts targeted for mass distribution Albendazole) in 2017 in 74 HD – funded by in sentinel sites the pharma two campaigns funded by USAID USAID firms. and Sightsaver

Strengths and pain points: ▪ Sophisticated quantification informed by detailed maps for 4 of the 5 pathologies covered by the PNLMTN-CP (a cartography still to be completed) and the collection of primary data in sentinel sites, resulting in few stock shortages during annual campaigns ▪ Significant fragmentation of DP (ITI, SCI, Sightsaver, USAID, donations from pharmaceuticals manufacturers) resulting in high transaction costs and significant coordination issues ▪ Own storage and distribution system parallel to the national chain / NPSP for all products except Azithromycin : – Stock kept under suboptimal conditions in unventilated premises of the PNLMTN-CP ; lack of funding for storage at the NPSP – Costly distribution by 3PLs paid by donors from PNLMTN-CP premises to districts

1 5 molecules supported (Ivermectin, Albendazole, Praziquantel, Azithromycin comp., And sPPS, and Tetracycline) and the Alere test for 5 pathologies (Lymphatic Filariasis, Onchocerciasis, Geohelminthiasis, Schistosomiasis, Trachoma 2 International Trachoma Initiative 3 PNMTN 2017 data; Merck for Ivermectin and Praziquantel, Glaxosmithkline for Albendazole, Pfizer / ITI for Azithromycin comp and sPPS, and Tetracycline 4 schistosomiasis Control Initiative SOURCE: PNMTN interview; Supply chain map (WHO 2015); Evaluation of the supply chain (USAID 2015) 13 MAPPING 3.2 Supply chain for vaccines INHP DATA NOT AVAILABLE

Paid allocation Free allocation Paid requisition Free requisition XX Purchase value (XOF, billion))

Funding Quantification/ Central Trans- Inter- Transpor- Inter- Trans- Final Storage Transpor- Community Procure- Planning storage portation mediate tation / mediate portation / tation / based storage ment /Distribu- storage Distribution storage Distribu- Distribution tion tion

State for traditional PEV at Districts vaccines National INHP Health according to ~4,72 Forecasting HC PEV PEV regional Vac- Districts the means or Workshop with UNICEF HC

Routine antennas cines UNICEF central 1 Gavi deposit forecast tool procurement ~14,72 (PEV of PEV office at Copenhagen PEV and antennas Health UH, RHC, Campaigns INHP in in Districts RH, GH, other UNICEF quantified by PEV an ad progress) direct clients 2 ~0.03 DP hoc

Campaigns manner Donations from Annual All • 10 cold rooms • Delivery every 9 antennas Collected Collected Quarterly N/A N/A Gavi are mostly quantification purchases of 40m3 in three months to the planned for monthly by monthly by HE allocation from UNICEF based on target (state positive antennas PEV; 4 district from districts population and included) are • 1 cold room of • 6 refrigerated under antennas with with vaccine use of loss data made by 40m3 in trucks and 6 PEV construction, coolers carriers and national UNICEF negative utilities 250m3 in targets • INHP solicited for total campaigns

State 1 nd INHP and Regional antennas

INHP NPSP in ad INHP INHP ;Vaccination Non

PEV 4 Other - nd hoc manner centers

2 cold rooms INHP had 5 18 regional dedicated to non- refrigerated antennas INHP PEV vaccines trucks

Strengths and pain points: ▪ Major delay in the release of funds by the State for the payment of vaccines which led to long-term stock outs3 ▪ Considerable delays in the clearance of consumables (2 to 4 months)3 ▪ Lack of adequate peripheral equipment in INHP antennas and district depots; 40% of existing rolling stock is to be reformed3 ▪ Lack of adequate equipment and lack of maintenance of peripheral structures, ex. cold rooms and not all refrigerators have 30-day continuous temperature recorders3, no emergency plan in case of failure, lack of maintenance of buildings3 ▪ Lack of storage space for non-PEV vaccines in positive- the INHP has 10.5 m3 of net capacity while 50 m3 is needed ▪ Lack of training and supervision, ex. agents don’t master the shake test

1 Vaccines from the expanded program (PEV) are administered free of charge to the target population (0 to 59 months) and « non-PEV » vaccines are sold to the population. 2 PEV 2017 Data : Funding from the State and partners on behalf of PEV 3 GEV Report 4 3 Community vaccination centers and 3 international vaccination centers SOURCE: Interview with PEV and UNICEF; Supply chain mapping (WHO 2015); Evaluation of the supply chain (USAID 2015); GEV Report (OMS 2015); Vaccine supply chain technical committees (PNDAP 2016) 14 3.2. Supply chain for blood transfusion products1

Paid allocation Free allocation Product flows generated in the periphery Paid requisition Free requisition XX Purchase value (XOF, billion))

Funding Quantification/ Procure- Central Transporta- Intermediate Transporta- Final Transporta- Community Planning ment storage tion storage tion Storage tion based storage /Distribution /Distribution /Distribution

State ~3.62 18 ATS CNTS Consumable reagents Sampling GH, UH, Health C2D tubes GH, UH, CNTS with trainings CTS, ATS, Health ~0,43 the support of CNTS 4 CTS N/A N/A and SP trainings and IHSC-TA private clinics Blood NPSP for Sampling bags

National network National WHO some non- tubes blood Ad-hoc4 products 5 SP in Abidjan Private clinics

CTS, ATS go CTS perform HE go get blood 162 hospital get the inputs, diagnostic tests bags in an deposits consumables; on tubes routed ambulance, in Structures need CNTS has only by ATS and SP an ad hoc to pay for the one truck by a 3PL manner blood bags that are consumed

Pain points: ▪ Absence of a formalized system and monitoring for product selection and unsystematic and manual quantification, based on approximate distribution data ▪ 3 interdependent chains not integrated in the national chain: reagents and consumables, sampling tubes, blood bags ▪ Chain is structurally unsustainable financially (much higher costs than revenues) and dependence on state subsidies ▪ Lack of donor support (>90% financed by the State) limiting the purchases of reagents and consumables and resulting in a suboptimal logistic (no organized delivery, multiple collection flows), leading to a satisfaction of about 70% of national blood requirements

1 Reagents and consumables used in the collection, biological qualification of blood donations, and the production of labile blood products and their distribution 2 Total budget of the CNTS chain estimated at 4 billion XOF, of which 90% is covered by the state; CNTS interview 3 Contract of 2 billion over 4 years; CNTS interview 4 For example, 4000 blood bags were given in 2017 – 0,5% of CNTS’s need in the Muskoka/H4+ project; CNTS and WHO interviews SOURCE: CNTS interview; Supply chain mapping (WHO 2015); Evaluation of the supply chain (USAID 2015) 15 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

16 4/5 METHODO – Supply chain diagnostic framework

Performance Performance key dimensions indicators Performance levers

Operational functions Product availability rate at each point in Quantif. / procurement the chain Planning

Order satisfaction Storage & Transport & Service level rate at each point of storage distribution the chain management

Average delivery time at each point Supply chain in the chain performance Catalysts

Governance Tools & IT Cost per unit of & HR systems distributed product value Costs Financing

Self-financing rate

17 4.1 KEY MESSAGES – Supply chain performance – Service level

Data sources

▪ The service level was estimated using 3 key performance indicators (product availability rate, order satisfaction rate and respect of delivery times) with 4 data sources (SARA Survey, PMP field survey, e-SIGL & NPSP data) ▪ The product availability generally decreases with distance from the central level : ~80% at NPSP level , ~60% for direct NPSP clients & General ~50% at last mile conclusions ▪ There are a few performance variations between regions – which suggests systemic challenges rather than geographical or individual ones ▪ Products from major programs generally have a better level of service throughout the chain – for example smaller programs (e.g. FP, nutrition, blood) and EGDs have low availability rates at all levels

▪ Field survey conducted by WHO in July 2016 in ~ 1000 health facilities which are dispensing points with a majority of HC (~85% of the sample) SARA survey ▪ Low average last mile availability for tracer products and an extensive list of products (~53-56%) with consistent results across regions, but large disparities across products - ~80-90% for vaccination products and malaria, ~55-65% for tuberculosis, HIV & the mother & child health products, <45% for FP products, the recoverable/GTC & blood transfusion products

▪ Field survey carried out in December 2017 in 57 health structures at all levels according to a list of 33 products – Lower availability at the GH level (79%) than at the HC level (86%) – Uneven availability of products by family, > 75% for tuberculosis, vaccines, HIV, malaria and recoverable < 75% for the mother and child health and GTCs – total shortage for PNN PMP field survey – Extremely long shortage periods, 65 to 74 days on average depending on supply chain levels and 25 to 110 days on average depending on programs – ~ 64% average order satisfaction rate - 85% non-response rate for HC due to lack of data – Average delivery delay rate of ~ 50% with an average delay of 11 days compared to the NPSP schedule ▪ Order history for NPSP customers in 2017 ▪ NPSP direct customer availability is slightly higher than last mile results in SARA survey – Average availability of ~ 60% for sanitary districts and NPSP client dispensing points e-SIGL database – At dispensing points, only HIV products have an availability rate > 73%, alarming availability for the PNSME (36%) – Malaria & HIV availability > 75% in sanitary districts, < 60% for FP, tuberculosis, recoverable & PNSME ▪ According to the order reports, the number of orders exactly fulfilled and the average share of satisfied orders at NPSP direct customers are both <50% in all regions for all product families – except for tuberculosis ▪ Product availability at the NPSP with an average of ~ 80% is greater than availability at secondary / primary level – Availability is homogeneous across product families, ranging from ~ 73% for FP to ~ 92% for tuberculosis – These results are in line with the NPSP’s 80% product availability goal, but below its 100% goal for tracers NPSP data ▪ NPSP direct customers must order via e-SIGL on a fixed date; the NPSP only takes these orders into account later, according to its own timetable; it also requires 42 days to complete a full monthly delivery cycle – The NPSP estimates the average duration of its deliveries to 7-9 days after processing the order depending on the location of the customer and the rate of compliance with delivery times to 47-54% 18 4.1 Synthetic view of supply chain service level performance by data source

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

PMP SARA e-SIGL NPSP on the field study Database Data study

Product availability ▪ Last mile availability ▪ Last mile availability: ▪ Extended list ▪ Availability of the Average on all products ~50% ~80% availability for NPSP extended list to the tracked – Tracers: 53% ▪ District availability: clients NPSP: 80% – Extended list 1: ~78% – Sanitary districts: 56% 59% – Dispensing points: 61%

Order satisfaction ▪ Last mile satisfaction ▪ NPSP customer ▪ Satisfaction rate of rates rate: ~65% satisfaction rate allocations between the Average on all orders ▪ District satisfaction – Exact satisfaction: central procurement n/a rate: ~69% 31% store and the agency – Satisfaction in – Vital products: quantity: 35% 78% – Other references: 82%

Respect of delivery ▪ Respect of delivery ▪ On-time delivery rate times times at the last mile: for NPSP direct Average on all orders ~48% customers n/a ▪ Respect of delivery n/a – Abidjan: 47% times to districts: – Interior: 54% ~50%

1 Extended list = List of tracer products present in SARA + other non- tracer products present in SARA and e-SIGL SOURCE: SARA study (WHO, 2016); on the field study - PMP (PNDAP, 2017); Performance indicators (NPSP, 2017); e-SIGL (NPSP, Jan-Dec 2017) 19 4.1 Last mile availability by region of tracer products

Number of health facilities considered, N2 = 963 Availability1: <50% 50 - 80% >80% Santé de la Recoverable & Malaria Tuberculosis HIV/AIDS Vaccine- Blood reproduction GTC preventable transfusion FP MCH diseases

# references or categories considered3 2 4 6 9 4 0 2 0 ABIDJAN 1 6% 82% 65% 78% 77% 94% ABIDJAN 2 18% 83% 56% 82% 75% 96% AGNEBI-TIASSA-ME 2% 91% 76% 77% 60% 92% BELIER 3% 87% 38% 75% 89% 99% BOUKANI-GONTOUGO 4% 86% 13% 54% 45% 98% CAVALLY-GUEMON 7% 88% 87% 72% 75% 84% GBEKE 3% 83% 64% 76% 83% 82% GBOKLE-NAWA-SAN PEDRO 8% 80% 62% 74% 61% 83% GOH 1% 88% 88% 60% 51% 82% HAMBOL 1% 89% 26% 70% 52% 79% HAUT SASSANDRA 1% 74% 73% 69% 60% 92% INDENIE-DUABLIN 3% 82% 83% 69% 63% 76% KABADOUGOU-BAFING-FOLON 2% 96% 95% 60% 55% 78% LOH-DJIBOUA 2% 86% 59% 60% 56% 93% MARAHOUE 1% 78% 50% 66% 60% 95% NZI-IFOU 3% 90% 59% 71% 68% 94% PORO-TCHOGOLO-BAGOUE 3% 86% 73% 63% 49% 66% SUD-COMOE 4% 89% 32% 70% 68% 91% TONKPI 3% 85% 95% 69% 57% 91% WORODOUGOU-BERE 3% 87% 50% 61% 65% 70% TOTAL 4% 86% 62% 69% 63% 87%

▪ Health facilities considered by the SARA survey cluster the different types of dispensing points (HC, RHC, medical center, etc.) with a majority of HC (85% of the sample) ▪ Low average availability of tracer products at the last mile with a homogeneous situation on a regional but a very strong disparity on a product level – Good availability of vaccination products and paludism – Availability ~ 65% for FP, tuberculosis and HIV products – Alarming situation for recoverable products in tracer products

1 Computed from a field survey conducted in July 2016. During each visit, the interviewer noted the availability or not of each medication followed on the day of the visit (particular case of vaccines where the availability corresponds to whether or not the establishment has experienced a stock-out in the last 3 months) 2 Number of health structures considered. This includes HC and public and private sector hospitals 3 According to the list issued in September 2017 by the PNDAP (71% of these products are present in the SARA survey) SOURCE: SARA survey (WHO, 2016) 20 4.1 Last mile availability by region of an extended list of products

Number of health facilities considered, N2 = 963 Availability1: <50% 50 - 80% >80%

Recoverable Malaria Tuberculosis HIV/SIDA Reproductive health Vaccine Blood and GTC preventable transfusion FP MCH diseases

# references or categories considered3 57 14 13 75 8 4 4 4 ABIDJAN 1 21% 77% 65% 67% 56% 48% 88% 40% ABIDJAN 2 28% 81% 56% 70% 56% 51% 83% 56% AGNEBI-TIASSA-ME 22% 88% 76% 69% 39% 63% 90% 36% BELIER 18% 83% 38% 64% 53% 54% 99% 59% BOUKANI-GONTOUGO 22% 85% 13% 50% 29% 60% 98% 31% CAVALLY-GUEMON 29% 89% 87% 63% 52% 78% 82% 54% GBEKE 20% 82% 64% 66% 58% 64% 90% 51% GBOKLE-NAWA-SAN PEDRO 21% 73% 62% 59% 43% 51% 85% 37% GOH 16% 85% 88% 64% 28% 52% 83% 25% HAMBOL 19% 81% 26% 63% 34% 83% 84% 42% HAUT SASSANDRA 13% 67% 73% 64% 41% 39% 90%0% 50% INDENIE-DUABLIN 17% 79% 83% 67% 37% 40% 73% 38% KABADOUGOU-BAFING-FOLON 20% 93% 95% 53% 33% 67% 16%84% 56% LOH-DJIBOUA 17% 84% 59% 51% 34% 51% 21%93% 16% MARAHOUE 18% 75% 50% 53% 41% 46% 89% 21% NZI-IFOU 23% 87% 59% 58% 45% 60% 94% 35% PORO-TCHOGOLO-BAGOUE 21% 86% 73% 59% 31% 54% 67% 55% SUD-COMOE 23% 89% 32% 56% 44% 49% 91% 48% TONKPI 16% 87% 95% 51% 40% 43% 92% 50% WORODOUGOU-BERE 18% 83% 50% 55% 35% 47% 79% 75% TOTAL 20% 83% 62% 60% 41% 55% 87% 44%

▪ There is a low general availability in the last mile of products in the extended list – Average availability< 65% for all product families, with the exception of malaria and vaccines with an average availability of ~83% and ~87% – The availability of recoverable products and GTC, FP and blood transfusion is alarming, with an average availability of less then 50% – Availability of vaccines > 85% on average in the country and > 80% in 17 regions out of 20 – The availability from one region to another is globally homogeneous; except for tuberculosis ranging from 13% in Boukani-Gontougo to 95% in Tonkpi

1 Calculated from a field study conducted in July 2016. At each visit, the interviewer noted the availability or not of each medication followed on the day of the visit (particular case of vaccines where the availability corresponds to whether or not the establishment has experiences a break in the last three months). 2 Number of health facilities considered. This includes HC and public and private hospitals 3 Extended list = List of tracer products present in SARA + other non- tracer products present in SARA and e-SIGL SOURCE: SARA study (WHO, 2016) 21 4.1 Last mile availability by region of vaccine products

Availability1: <50% 50 - 80% >80% Number of health facilities considered, N2 = 796

DTP Vaccine - Oral polio Measles vaccine BCG Vaccine HepB-Hib vaccine

ABIDJAN 1 92% 96% 76% 86% ▪ Average availability rate for each type of ABIDJAN 2 94% 97% 44% 97% vaccine at the national level is between 81% for the measles vaccine and 93% AGNEBI-TIASSA-ME 90% 94% 86% 91% for the DTP - HepB - HiB vaccine which are the two EPI tracer products BELIER 97% 100% 100% 97% ▪ Strong regional disparity BOUKANI-GONTOUGO 96% 100% 100% 96% – The Poro-Tchogolo-Bagoue region CAVALLY-GUEMON 82% 85% 82% 79% has an availability <70% on each vaccine considered GBEKE 67% 97% 97% 100% – The regions of Belier and Boukani- Gontougo have availability> 95% GBOKLE-NAWA-SAN PEDRO 76% 90% 84% 89% for each vaccine considered

GOH 67% 96% 80% 90% ▪ We notice that all the regions were out of at least one type of vaccine during HAMBOL 69% 89% 93% 85% the 3 months considered. HAUT SASSANDRA 83% 100% 78% 99%

INDENIE-DUABLIN 66% 85% 70% 69%

KABADOUGOU-BAFING-FOLON 66% 90% 92% 87%

LOH-DJIBOUA 85% 100% 93% 93%

MARAHOUE 89% 100% 81% 84%

NZI-IFOU 91% 97% 94% 94%

PORO-TCHOGOLO-BAGOUE 63% 69% 65% 69%

SUD-COMOE 91% 91% 89% 91%

TONKPI 84% 97% 96% 89%

WORODOUGOU-BERE 47% 93% 93% 83%

TOTAL 81% 93% 84% 89%

1 Percentage of establishments that have not experienced a product shortage in the past 3 months prior to July 2016 2 Number of health structures considered. This includes HC and public and private sector hospitals SOURCE: SARA survey (WHO, 2016) 22 4.1 ~80% of tracer products were available on the day of the survey

Survey of 57 facilities of all levels of the health pyramid1 Facilities average Share of products2 available on the day of visit by type of facility Share of products available on the day of visit by product family

PNLT 95 % UH 87 % PEV 94 %

HC 86 % PNLS 92 %

Recoverable 81 % GH 79 % 64% shortage rate on PNLP 80 % Implanon 68mg

PNSME 67 % RHC 73 % 51% shortage rate on GTC 65 % Amoxicilin 250 mg

3 District 78 % PNN NA4 100% shortage rate on Plumpy Nut in the HE where the product is managed Ø 77% Ø 79% ▪ Lowest availability at RHC level (79%) than HC level (86%) –due to the greater number of references being at the secondary level ▪ Uneven availability of products by family (e.g. PNLT, PEV, PNLS higher than PNN, GTC, PNSME etc.) –mainly explained by their varying ability to attract funds from DP

1 13 RHC/UH, 14 GH, 15 SD, 13 HC in 14 regions 2 33 products considered in the analysis - an average of 3 per product family 3 SDs are not dispensing points to patients - and therefore are not last mile facilities 4 Limited sample: a single tracer product (Plumpy Nut) and 3 facilities managing the product SOURCE: PMP Survey (PNDAP, 2017) 23 4.1 The average duration of a tracer product stock shortage is 70 days

Average of institutions x Number of shortage episodes Survey of 57 institutions at all levels of the health pyramid1 Average duration of a stock shortage3 by type of Average duration of a stock shortage by product structure category Days Days

PEV n/a4 - RHC 76 PNSME 89 7

GH 70 PNLT 85 1

GTC 74 7 HC 69 PNLP 73 2

PNN 68 2 UH 60 Recoverables 64 4

District2 65 PNLS 25 2

69 70 ▪ Extremely long shortages (~2 to 3m), and homogeneous by type of institution: longest being at RHC (76d) and shortest at Districts (65d) – potentially linked to more proactive district management (ex. emergency orders and security stocks) by professional managers ▪ Uneven shortage times according to the products, ex. 4 times shorter for PNLS than for PNSME – illustrating the prioritization and better management of the distribution of certain products 1 13 RHC/UH, 14 GH, 15 SD, 13 HC in 14 regions 2 The SD are not dispensing points to patients- and are therefore not last mile institutions. 6 months of reporting from April to September; reported data greater than 6 months have been replaced by 182 days 3 On 6 months, april to September – values greater than 6 months replaced by 182 days 4 limited sample, 2 marker products (VAR and DTC HepB) and 1 health center handling product in sample SOURCE: PMP study (PNDAP, 2017) 24 4.1 According to the survey, ~ 60% of shortages in health facilities are related to shortages at the central level All facilities Survey of 57 facilities of all levels of the health pyramid1 ESPC Stock shortage reason % of shortages

Shortage on a 60 national level 44 ▪ For health facilities, shortages in NPSP Distribution 14 are the main reason timeline not for their shortages respected 1 (60% on average, 44% for HC) 10 Did not order ▪ For the HC, district this month 17 shortages are the second cause of 9 shortage (34%) and Others 17% of shortages are 4 due to order problems - suggesting an order Shortage on a 7 management problem district level 34

1 13 RHC/UH, 14 GH, 15 SD, 13 HC in 14 regions SOURCE: PMP Survey (PNDAP, 2017) 25 4.1 ~ 40% of products ordered by health facilities are not delivered by the NPSP Survey of 47 facilities of all levels of the health pyramid1 Facilities average

Satisfaction Rate2

HC 75 % direct clients3 ▪ HC have a higher satisfaction GH 60 % rate than tertiary and secondary health facilities - for two potential reasons: Limited sample for the HC - RHC 60 % – only 3 are direct customers – More references to be delivered at tertiary and UH 57 % secondary level

District3 69 %

Ø 64%

1 13 RHC/UH, 14 GH, 15 SD, 3 HC direct clients in 14 regions 2 Average number of references/lines of tracer products received divided by the number of references/lines tracer products ordered over 6 months of reporting 3 Sample of 3 HC direct clients of the NPSP 4 SDs are not dispensing points to patients - and therefore are not last mile facilities SOURCE: PMP Survey (PNDAP, 2017) 26 4.1 Delivery times are not respected for ~ 50% of health facilities

Survey of 47 facilities of all levels of the health pyramid1 Facilities average 58,3 % 48,8 % 48,4 % 49,9 % Share of Ø 49% facilities for 25,0 % which delivery times are not respected ▪ ~ 50% of health facilities state that delivery times are 13,9 12,5 not met - this is the case for 11,0 10,5 10,3 60% of the HC Average time Ø 11.8 between placing ▪ The average time between an order and ordering and receiving is ~ receiving 12 days, with a low variance products of +/- 1.5 days depending on the types of facilities 14,4 When the deadlines set by 10,7 11,4 ▪ 8,4 9,8 Ø 11.1 the timeline are not respected, the average Average delay of delay is ~ 11 days deliveries2 ▪ The average delay is lower HC RHC GH UH District4 for the HC (~ 8 days) direct eventual sign that the clients3 blocking point is upstream of the district

1 13 RHC/UH, 14 GH, 15 SD, 3 HC direct clients in 14 regions 2 Average time between the delivery date in the NPSP schedule and actual receipt of goods 3 Sample of 3 HC direct clients of the NPSP 4 SDs are not dispensing points to patients - and therefore are not last mile facilities SOURCE: PMP Survey (PNDAP, 2017) 27 4.1 Last mile availability by region at SDPs that are NPSP clients

Number of health facilities considered, N2 = 228 Availability1: <50% 50 - 80% >80%

Recoverable Malaria Tuberculosis HIV/AIDS Reproductive health Vaccine Blood and GTC preventable transfusion FP MCH diseases

# references or categories considered3 57 14 13 75 8 4 0 0 ABIDJAN 1 50% 63% 82% 77% 67% 30% ABIDJAN 2 54% 61% 74% 71% 65% 23% AGNEBI-TIASSA-ME 69% 70% 70% 74% 72% 44% BELIER 58% 68% 44% 70% 65% 37% BOUKANI-GONTOUGO 70% 62% 82% 79% 51% 28% CAVALLY-GUEMON 66% 78% 67% 80% 83% 61% GBEKE 63% 65% 72% 73% 66% 30% GBOKLE-NAWA-SAN PEDRO 66% 63% 50% 71% 64% 31% GOH 65% 65% 48% 77% 54% 32% HAMBOL 76% 71% 86% 82% 63% 14% HAUT SASSANDRA 73% 69% 89% 78% 60% 57% INDENIE-DUABLIN 64% 74% 36% 71% 86% 24% KABADOUGOU-BAFING-FOLON 47% 66% 51% 65% 54% 39% LOH-DJIBOUA 61% 69% 62% 77% 58% 34% MARAHOUE 61% 75% 65% 65% 60% 44% NZI-IFOU 67% 59% 69% 70% 59% 50% PORO-TCHOGOLO-BAGOUE 73% 65% 86% 68% 61% 44% SUD-COMOE 68% 64% 48% 70% 65% 32% TONKPI 68% 74% 80% 82% 62% 63% WORODOUGOU-BERE 69% 68% 75% 77% 58% 34% TOTAL 62% 65% 68% 73% 64% 36%

▪ The availability of products at dispensing points that are directly NPSP clients is slightly higher than that found with the SARA study – The majority of the SARA surveyed facilities are HCs and therefore most often located at an additional stage in the supply chain ▪ Only HIV products have an availability > 73% ▪ Alarming availability of maternal and child health products ▪ Availability of around 60% for recoverable products, malaria, tuberculosis and FP ▪ Strong regional disparity in tuberculosis products 1 Calculated from share of facilities with stock shortages for each health product tracked by orders placed each time on e-SIGL 2 Number of health facilities from the e-SIGL base that are dispensing points. This includes UHC, RHC, GH and HC 3 Extended list = List of tracer products present in SARA + other non- tracer products present in SARA and e-SIGL SOURCE: Orders made by NPSP clients on e-SIGL (NPSP, 2017) 28 4.1 Availability by region at district deposits

Number of health facilities considered, N = 83 Availability1: <50% 50 - 80% >80%

Recoverable Malaria Tuberculosis HIV/AIDS Reproductive health Vaccine Blood and GTC preventable transfusion FP MCH diseases

# references or categories considered3 57 14 13 75 8 4 0 0 ABIDJAN 1 56% 74% 40% 79% 56% 0% ABIDJAN 2 73% 76% 77% 62% 8% AGNEBI-TIASSA-ME 61% 81% 91% 81% 69% 24% BELIER 66% 86% 29% 68% 65% 67% BOUKANI-GONTOUGO 43% 81% 80% 75% 53% 18% CAVALLY-GUEMON 67% 78% 61% 75% 64% 33% GBEKE 56% 88% 56% 81% 65% 25% GBOKLE-NAWA-SAN PEDRO 67% 76% 61% 75% 54% 21% GOH 36% 66% 100% 70% 57% 0% HAMBOL 59% 85% 45% 78% 60% 16% HAUT SASSANDRA 62% 83% 52% 69% 56% 39% INDENIE-DUABLIN 69% 78% 37% 78% 61% 24% KABADOUGOU-BAFING-FOLON 54% 81% 35% 74% 54% 21% LOH-DJIBOUA 39% 77% 30% 68% 40% 35% MARAHOUE 58% 87% 54% 84% 60% 35% NZI-IFOU 61% 74% 66% 66% 59% 11% PORO-TCHOGOLO-BAGOUE 69% 72% 30% 75% 55% 28% SUD-COMOE 51% 78% 94% 75% 66% 73% TONKPI 68% 83% 51% 76% 70% 39% WORODOUGOU-BERE 48% 73% 92% 68% 47% 65% TOTAL 59% 79% 54% 75% 60% 28%

▪ Product availability at the health district level is slightly higher than availability at last mile with the SARA study ▪ Results are relatively homogeneous from one region to another, but with a large disparity in product families – Availability > 75% for products against malaria and HIV – Availability < 60% for products against FP, tuberculosis, recoverable and health products for mothers and children – Very high regional disparity for tuberculosis products

1 Calculated from share of facilities with stock shortages for each health product tracked by orders placed each time on e-SIGL 2 Extended list = List of tracer products present in SARA + other non- tracer products present in SARA and e-SIGL SOURCE: Orders made by NPSP clients on e-SIGL (NPSP, 2017) 29 4.1 NPSP direct customer satisfaction rating – share of orders satisfied

Number of health facilities considered, N2 = 311 Satisfaction rate1: <50% 50 - 80% >80% EGD Malaria Tuberculosis HIV/AIDS Reproductive health Vaccine Blood preventable transfusion FP MCH diseases

# references or categories considered3 57 14 13 75 8 4 0 0 ABIDJAN 1 25% 19% 65% 20% 25% 16% 57% 57% ABIDJAN 2 23% 24% 61% 27% 30% 20% 63% 63% AGNEBI-TIASSA-ME 24% 21% 61% 25% 31% 23% BELIER 26% 23% 69% 26% 30% 20% 59% 59% BOUKANI-GONTOUGO 26% 25% 72% 32% 34% 10% 67% 67% CAVALLY-GUEMON 24% 21% 74% 22% 22% 21% 80% 80% GBEKE 22% 29% 54% 34% 38% 12% 68% 68% GBOKLE-NAWA-SAN PEDRO 27% 18% 43% 23% 29% 18% GOH 27% 20% 92% 26% 24% 17% 59% 59% HAMBOL 33% 23% 72% 28% 29% 16% 78% 78% HAUT SASSANDRA 30% 20% 76% 22% 22% 21% INDENIE-DUABLIN 23% 25% 68% 28% 31% 7% 54% 54% KABADOUGOU-BAFING-FOLON 28% 22% 46% 23% 16% 10% 68% 68% LOH-DJIBOUA 32% 22% 65% 25% 24% 17% 42% 42% MARAHOUE 26% 19% 65% 24% 23% 11% 55% 55% NZI-IFOU 22% 27% 47% 30% 27% 15% PORO-TCHOGOLO-BAGOUE 27% 26% 92% 30% 26% 16% 64% 64% SUD-COMOE 19% 25% 57% 28% 35% 15% TONKPI 30% 20% 65% 24% 23% 12% 55% 55% WORODOUGOU-BERE 25% 19% 85% 28% 30% 20% TOTAL 26% 22% 66% 26% 27% 16%

▪ The satisfaction rate was calculated by considering that a product order from a district is satisfied if the quantity received is greater than or equal to the order ▪ The satisfaction rate of orders made by districts remains a challenge – On average, 30% of the orders are satisfied according to the quantity demanded, which can be the cause of overstocks when the deliveries are too important at the district level and then the cause of stock shortage when these are not realizes or in low quantity – The satisfaction rate for tuberculosis products, 66%, is the highest and can be explained by different control mechanisms with a product allocation to the districts according to the number of tuberculosis cases identified and not according to historical consumption data (recent move to a system by requisition)

1 Calculated based on whether or not the quantity received is equal to the quantity ordered 2 Number of health facilities from the e-SIGL base. This includes UHC, RHC, GH and health districts. 3 Extended list = List of tracer products present in SARA + other non- tracer products present in SARA and e-SIGL SOURCE: Orders made by NPSP clients on e-SIGL (NPSP, 2017) 30 4.1 NPSP direct customer satisfaction rating– share received from quantities ordered

Number of health facilities considered, N2 = 311 Satisfaction rate1: <50% 50 - 80% >80% EGD Malaria Tuberculosis HIV/AIDS Reproductive health Vaccine Blood preventable transfusion FP MCH diseases

# references or categories considered3 57 14 13 75 8 4 0 0 ABIDJAN 1 30% 25% 71% 28% 31% 21% 57% 57% ABIDJAN 2 30% 28% 70% 35% 35% 20% 63% 63% AGNEBI-TIASSA-ME 32% 25% 65% 32% 36% 26% BELIER 33% 28% 69% 33% 35% 21% 59% 59% BOUKANI-GONTOUGO 34% 27% 73% 38% 39% 10% 67% 67% CAVALLY-GUEMON 32% 26% 75% 30% 28% 23% 80% 80% GBEKE 29% 31% 59% 39% 40% 16% 68% 68% GBOKLE-NAWA-SAN PEDRO 34% 24% 49% 31% 34% 20% GOH 35% 27% 92% 34% 31% 20% 59% 59% HAMBOL 41% 27% 77% 35% 32% 18% 78% 78% HAUT SASSANDRA 40% 25% 85% 31% 28% 21% INDENIE-DUABLIN 33% 30% 72% 35% 33% 7% 54% 54% KABADOUGOU-BAFING-FOLON 34% 25% 50% 27% 20% 13% 68% 68% LOH-DJIBOUA 38% 28% 71% 31% 27% 17% 42% 42% MARAHOUE 34% 25% 68% 31% 29% 14% 55% 55% NZI-IFOU 28% 29% 55% 35% 32% 17% PORO-TCHOGOLO-BAGOUE 37% 29% 95% 36% 30% 17% 64% 64% SUD-COMOE 25% 30% 59% 34% 39% 19% TONKPI 38% 25% 69% 30% 29% 22% 55% 55% WORODOUGOU-BERE 30% 26% 85% 35% 33% 29% TOTAL 33% 27% 67% 33% 32% 19%

▪ The satisfaction rate was calculated based on the share received vs the quantity ordered for each district product order ▪ The satisfaction rate of orders made by districts remains a challenge – On average, 35% of the quantities ordered are delivered on the expected date, which can be the cause of overstocks when the deliveries are too important at the district level then of stock shortages when these are not realized or in a low quantity – Satisfaction rate for tuberculosis products, 67%, is the highest and can be explained by different control mechanisms with a product allocation to the districts according to the number of tuberculosis cases identified and not according to historical consumption 1 Calculated based on the ratio of the quantity received to the quantity ordered the previous month, for each health product monitored. 2 Number of health facilities from the e-SIGL base. This includes UHC, RHC, GH and health districts. 3 Extended list = List of tracer products present in SARA + other non- tracer products present in SARA and e-SIGL SOURCE: Orders made by NPSP clients on e-SIGL (NPSP, 2017) 31 4.1 Availability at central level (NPSP data)

# references Availability1 <50% 50 - 80% >80% or categories Availability1 considéred2 Data not available for Product availability at NPSP EGD 57 ▪ calculation during the study level is higher than at the secondary and primary Malaria 14 82% levels with an average availability of 80% – The availability rate is Tuberculosis 13 92% homogeneous according to product HIV/AIDS 75 76% families ranging from 73% for FP to 92% for tuberculosis Reproductive FP 8 73% These results are in line health – with the 80% NPSP 4 MCH 79% target for continuously available products but Vaccine preventable are still far from the diseases - 100% target for tracer products (~ 100 products) Blood transfusion n/a – products stocked at - CNTS

1 Average number of references considered present at the NPSP at the end of the month between January and December 2017 – no data available on the number of days out of stock 2 Extended list = List of tracer products present in SARA + other non- tracer products present in SARA and e-SIGL SOURCE: End of month inventory (NPSP, 2017) 32 4.1 Satisfaction rate~80% at agency level by comparing the number of complete deliveries with planned allocations

Satisfaction rate of the allocation of vital products Satisfaction rate % of deliveries in quantity ≥ planned allocation, 2017 Min target 95% 100%

80% 78% ▪ Satisfaction rate represents whether or 60% not deliveries are 40% greater or equal to the original planned 20% allocations 0% ▪ Satisfaction rate of Jan. Feb. Mar. Apr. May June Jul. Aug. Sept. Oct. Nov. Dec. the allocations from the plant to the agency is ~ 80% on Satisfaction rate Satisfaction rate of the allocation of non vital products average for vital and % of deliveries in quantity ≥ planned allocation, 2017 Cible min 80% non vital products 100% – Initial target of 95% 80% 82% for vital products 60% – Initial target of 80% for non vital 40% products 20% 0% J Feb. Mar. Apr. May June Jul. Aug. Sep. Oct. Nov. Dec.

SOURCE: Performance indicators (NPSP, 2017) 33 4.1 Average delivery time of NPSP remained up to 100% higher than targets in 2017

Average delivery time1 – Abidjan Deliveries Abidjan # average days for all orders of the month, 2017 Max. target 5 days 10 ▪ Performance below 8 targets 8-10 months Ø 7,2 j. out of 12 in the 6 country 4 ▪ Strong correlation 2 with respects of delivery times 0 ▪ National annual Jan. Feb. Mar. Apr. May June Jul. Aug. Sept. Oct. Nov. Dec. average2: 9,1 days

Taking into account Average delivery time– Inside Deliveries Abidjan the order date of the # average days for all orders of the month, 2017 Max. target 7 days NPSP chronogram 15 variable, using the direct customer as a 10 base point – whereas Ø 9,3 j. e-SIGL required a fixed order date for 5 all direct customers, hence a longer 0 delivery time in Jan. Feb. Mar. Apr. May June Jul. Aug. Sept. Oct. Nov. Dec. reality (1-42 days, NPSP delivery cycle 1 All direct clients of NPSP time) 2 Weighted by the number of regions SOURCE: Performance indicators (NPSP, 2017) 34 4.1 For all products and regions, on-time delivery rates are below targets in 2017

Rate of compliance with delivery deadlines1– Abidjan Deliveries Abidjan % of the total month’s orders, 2017 Target 90% 100% ▪ Performance below targets 8-9 months 80% out of 12 in the 60% country Ø 47% 40% ▪ Very low performance (<50%) 20% ~ 50% of the months 0% ▪ National annual Jan. Feb. Mar. Apr. May June Jul. Aug. Sept. Oct. Nov. Dec. average2: 53%

Taking into account Rate of compliance with delivery deadlines1– Interior Deliveries Inside the order date of the % of the total month’s orders, 2017 Target 90% NPSP chronogram 100% variable, using the 80% direct customer as a base point – whereas 60% Ø 54% e-SIGL required a 40% fixed order date for all direct customers, 20% hence a longer 0% delivery time in Jan. Feb. Mar. Apr. May June Jul. Aug. Sept. Oct. Nov. Dec. reality (1-42 days, NPSP delivery cycle 1 All direct clients of NPSP time) 2 Weighted by the number of regions SOURCE: Performance indicators (NPSP, 2017) 35 4.1 The satisfaction rate of demand for blood transfusion product varies by year and remains below 100%

Estimated need (CNTS objectives) 1 Blood bags given vs. estimated demand in blood bags Real production (bags given) ‘000 bags, 2015-2017

248

236 231 -7% -23% 219 -18%

192 189

2015 16 2017

1 CNTS objective: production of 10 blood bags per 1000 inhabitants/year SOURCE: CNTS 36 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

37 5 METHODO – Evaluation of the performance drivers of the current supply chain Performance Performance key dimensions indicators Performance levers

Operational functions Product availability rate at each point in Quantif. / procurement the chain Planning

Order satisfaction Storage & Transport & Service level rate at each point of storage distribution the chain management

Average delivery time at each point Supply chain in the chain performance Catalysts

Governance Tools & IT Cost per unit of & HR systems distributed product value Costs Financing

Self-financing rate

38 5.1 Last mile performance depends mainly on 5 of these levers and some key factors of success

Operational Functions Catalysts

Storage & Governance & Quantification/ Transport & Tools & IT Procurement inventory Human Funding Planning distribution systems management resources

Adequate Availability of Transparency Delivery Coordination methodology Choice of space and of decision- IT architecture assured at and alignment based on suppliers and quality of making and systems each stage of of donors with epidemiologic products storage processes at integration the chain needs al data conditions national level

Coordination Supervision Optimization between Inventory mechanisms of distribution Preparation, stakeholders management along the Adequacy methods Financial follow-up and and at the pyramid with the needs (frequency, sustainability revision of the consolidation reception, (availability and skills of allocation / mechanisms quantification of volumes organization and quality of supply actors requisition and and provision pharmaceutic etc.) processes als)

Coordination between Optimization stakeholders of the chain Staff trained and (number and and dedicated harmonization location of to logistics of processes intermediary management between warehouses) products

Performance incentives

39 5.2 KEY MESSAGES– 10 major problems hindering the performance of supply chains at the last mile

Operational functions Catalysts Storage and Transport. Quantification/ Governance Tools and IT Procurement inventory and Funding Planning and HR systems management distribution

▪ Insufficient ▪ Collection of ▪ Incomplete ▪ Prevalence of ▪ Lack of financial storage space products by HC integration of manual tools sustainability in district and – inadequate the chain (ex. and poor mechanisms, HC transport CNTS, viral information flow ex. margin conditions and load, PNN, (inventory status, recovery – lack additional costs, MTN) consumption) of dedicated limited quantity between all levels logistics funding Low NPSP ▪ transported at the last mile adherence rate on delivery ▪ Logistics timeline and low managed by order fulfillment medical staff ▪ System entirely in many cases based on (ex. RHC) orders, with risks of errors, ▪ Insufficient not respecting implementation thresholds, of of guidelines for product ▪ Lack of inventory preferences from performance management (ex. nurses vs. incentives or compliance with patient (paid accountability thresholds) products) systems at all levels

SOURCE: Interviews with stakeholders 40 5.2 Key performance drivers were assessed for the 4 types of supply chains

Operational Functions Catalysts

Quantification/ Storage & inventory Recoverable drugs & GTC Procurement Transport & distribution Governance IT systems Funding Planning management

Adequate Availability of Transparency of methodology Choice of Delivery assured at IT architecture and Coordination and space and quality decision-making Malaria based on suppliers and each stage of the systems alignment of of storage processes at epidemiological products chain integration donors with needs conditions national level data HIV (Basic tests/treatments) Coordination Optimization of Supervision Inventory EGD, Program between distribution mechanisms along Preparation, follow- management at the Adequacy with the Financial stakeholders and methods the pyramid up and revision of reception, needs and skills of sustainability NPSP chain consolidation of (frequency, (availability and the quantification organization and supply actors mechanisms volumes and allocation / quality of provision I products & Nutrition products processes requisition etc.) pharmaceuticals)

Coordination Optimization of the between Staff trained and chain (number and stakeholders and dedicated to GTC location of harmonization of logistics Mother & Child health & FP intermediary processes management warehouses) between products Tuberculosis Performance Neglected Tropical Diseases Chain incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Procurement Transport et distribution Governance Tools & IT systems Funding Planning management

Adequate Availability of Transparency of methodology Delivery assured at IT architecture and Coordination and Choice of suppliers space and quality decision-making based on each stage of the systems alignment of and products of storage processes at epidemiological chain integration donors with needs conditions national level PEV Chain data

Coordination Optimization of Supervision Inventory between distribution mechanisms along Preparation, follow- management at the Adequacy with the Financial stakeholders and methods the pyramid up and revision of reception, needs and skills of sustainability consolidation of (frequency, (availability and the quantification organization and supply actors mechanisms volumes and allocation / quality of provision II Vaccines processes requisition etc.) pharmaceuticals)

Coordination Optimization of the between Staff trained and chain (number and stakeholders and dedicated to location of harmonization of logistics intermediary processes management warehouses) INHP Chain between products

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Adequate Availability of Transparency of methodology Choice of Delivery assured IT architecture and Coordination and space and quality decision-making based on suppliers and at each stage of systems alignment of of storage processes at epidemiological products the chain integration donors with needs conditions national level data

Coordination Optimization of Supervision Inventory Preparation, between distribution mechanisms along management at Adequacy with the Financial follow-up and stakeholders and methods the pyramid the reception, needs and skills of sustainability revision of the consolidation of (frequency, (availability and organization and supply actors mechanisms Blood quantification volumes and allocation / quality of provision III CNTS Chain processes requisition etc.) pharmaceuticals)

Coordination transfusion Optimization of the between Staff trained and chain (number and stakeholders and dedicated to location of harmonization of logistics intermediary processes management warehouses) between products

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Adequate Availability of Transparency of methodology Choice of Delivery assured IT architecture and Coordination and space and quality decision-making based on suppliers and at each stage of systems alignment of Retro-CI Chain of storage processes at epidemiological products the chain integration donors with needs conditions national level data

Coordination Optimization of Supervision Inventory Preparation, between distribution mechanisms along management at the Adequacy with the Financial follow-up and stakeholders and methods the pyramid Reagents viral reception, needs and skills of sustainability revision of the consolidation of (frequency, (availability and organization and supply actors mechanisms quantification volumes and allocation / quality of provision IV processes requisition etc.) pharmaceuticals) load test Coordination Optimization of the between Staff trained and chain (number and stakeholders and dedicated to location of harmonization of logistics intermediary processes management warehouses) OPP-ERA Chain between produ

Performance incentives

41 5.2 Evaluation of key performance drivers for the NPSP chain

Operational Functions Catalysts

Quantification/ Storage & inventory Recoverable drugs & GTC Procurement Transport & distribution Governance IT systems Funding Planning management

Operational Functions Catalysts

Quantification/ Storage & inventory Procurement Transport et distribution Governance Tools & IT systems Funding Planning management

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Adequate Availability of Transparency of methodology Choice of Delivery assured IT architecture and Coordination and space and quality decision-making based on suppliers and at each stage of systems alignment of Retro-CI Chain of storage processes at epidemiological products the chain integration donors with needs conditions national level data

Performance incentives

42 5.2 I 4 key bottlenecks on the last mile of the NPSP chain: insufficient storage, lack of distribution optimization, weak governance, and unsustainable financing

Positive points Improvement points

Operational Functions Catalysts

Quantification/ Storage & storage Transport et Tools & IT Procurement Governance Funding Planning management distribution systems

Adequate Availability of Transparency Delivery Coordination methodology Choice of space and of decision- IT architecture realized at and alignment based on suppliers and quality of making and systems each stage of of donors with epidemiologica products storage processes at integration the chain needs l data conditions national level

Supervision Coordination Optimization of mechanisms between Inventory distribution Preparation, along the Adequacy with stakeholders management at methods Financial follow-up and pyramid the needs and and the reception, (frequency, sustainability revision of the (availability skills of supply consolidation organization allocation / mechanisms quantification and quality of actors of volumes and and provision requisition pharmaceutical processes etc.) s) Coordination between Optimization of stakeholders the chain Staff trained and (number and and dedicated harmonization location of to logistics of processes intermediary management between warehouses) products

Performance incentives

SOURCE: Interviews with stakeholders 43 5.2 I Our field trips and interviews revealed positive points and improvement points on the last mile of the national chain

Positive points Improvement points

Upstream of the ▪ Difficulties of quantification and procurement, and insufficient storage upstream of last mile the chain (NPSP, districts) resulting in high costs and delays and shortages at last mile ▪ Ongoing efforts for the deployment of an early ▪ Inadequate pharmacy infrastructure and storage equipment at the last mile and warning system in some programs to mitigate deteriorating as we go down the sanitary pyramid the phenomena of shortages / overstocks - e.g. 70% do not have a storage area that meets their needs, 22% are equipped to national standards - e.g. infrastructure compliance rate of 60% for RHC, 45% for GH, 39% for HC) sign of decreasing resource allocation from central level to HC ▪ Product reception best practice not respected– especially in the HC: the receipt of the products is not carried out under the responsibility of a pharmacy manager in ~ 60% of the HC, 56% of the HC have a space arranged to receive the products, 25% of the stock cards are missing in the HC Storage & ▪ Uneven application of good storage practices by facilities at the last mile – especially inventory in HC: e.g. cleaning programs are not followed and ~ 60% of HC suffer from insects and management rodents ▪ Uneven application of inventory best practices by facilities at last mile – especially in the HC: e.g. ~ 25% of missing stock cards ▪ Non-monitoring of national prescription guidelines and protocols leading to a divergent consumption of orders when the prescriber is not the stock manager and shortages / overstocks ▪ CHW not always taken into account when ordering and deprioritized during sub-stocks, leading to a limited availability of products for CHW at HC

▪ Relatively good quality road network, with ▪ Delivery not assured by the Districts for ~ 2/3 of the HC (with strong regional disparities paved roads facilitating the accessibility of the – operational and financial burden for HC staff diverted from care activities to collect territory products, and duplication of costs (lack of shared pathways); the presence of a vehicle for logistics in the district does not guarantee the delivery of the HC Transport & ▪ District collection made by public transport (31%), and by motorbike (28%) increasing distribution the risk of damage or loss (breakage, cold chain, theft etc.) ▪ Delivery / collection on order only – lack of ability to adapt supply based on consumption or to rectify errors during the distribution phase ▪ Complexity and high cost of collecting by the CHW at HC

SOURCE: PNS, institutes and NPSP interviews; review of existing studies 44 5.2 I On each of the 3 catalysts of the national chain, our field visits and interviews revealed positive points and improvements

Positive points Improvement points

▪ Importance of community relays in the management ▪ Multiplicity of flows and lack of coordination between stakeholders lead to additional costs and of public health facilities (ex. COGES co-directing the duplication of efforts at the last mile districts with the executive team) ▪ Tension between free and paid products, with free products sometimes not a priority for distribution ▪ Numerous skills building activities supported by - and distortion of market prices Governance and DPs– ex. SIGL and E-SIGL trainings ▪ Lack of supervisory mechanisms between the different levels of the pyramid with respect to the availability of HR drugs and quality standards checks at the last mile ▪ Absence of incentive systems for logistics performance at all levels ▪ Training and knowledge of limited best practices in logistics - most of the distribution is provided by health professionals and not logisticians at the last km

▪ Recent integration on e-SIGL of the main vertical ▪ Multiplicity of tools and IS currently used but with gaps in their supply chain coverage: programs and plans of continuous integration for the – Each tool / IS used for a single activity (ex. clinical follow-up, orders), technical limit of some of these IS management of orders (ex. e-SIGL is a tool for reporting and not for 'live' tracking of stocks) ▪ Implementation plan for an integrated e-SMT system – Absence of a large scale inventory management IS - various systems tested but not for inventory management harmonized and deployed nationally ▪ DCII is willing to move towards a greater – Incomplete product integration of e-SIGL (tropical diseases, reagents and consumables) dematerialization of health logistics data ▪ Minimum IS penetration at the last mile - paper hand tools used in almost all HC, with need for data capture and compilation (risk of error) in the district Tools and IT systems ▪ Low availability of IS and tools for recoverable products and GTC products ▪ Weaknesses in the IT capabilities of medical staff (e.g. seizure errors, poor understanding of use) and heavy need for IS training, especially at the last km – ex. retention of paper use habits and seizure instead of direct entry by health staff on existing ISs ▪ DIIS not associated with all IS activities - ex. choice or development

▪ Strong mobilization of DP with financial and in-kind ▪ Lack of systematic public funding or DPs for logistics on the last mile - ad hoc in-kind support in support at each level of the pyramid certain geographies Funding ▪ World Bank / PRSSE pilot projects underway to test ▪ Margin system not functional and districts do not receive a management fee nor 10% margin from the NPSP the impact of the transfer of ownership of stocks ▪ Lack of financial ownership of inventory by pharmacists at the HC level, which reduces liability

SOURCE: Interviews with PNS, institutes and NPSP; review of existing studies 45 5.2 Evaluation of key performance drivers for the vaccine chain

Operational Functions Catalysts

Quantification/ Storage & inventory Recoverable drugs & GTC Procurement Transport & distribution Governance IT systems Funding Planning management

Operational Functions Catalysts

Quantification/ Storage & inventory Procurement Transport et distribution Governance Tools & IT systems Funding Planning management

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Adequate Availability of Transparency of methodology Choice of Delivery assured IT architecture and Coordination and space and quality decision-making based on suppliers and at each stage of systems alignment of Retro-CI Chain of storage processes at epidemiological products the chain integration donors with needs conditions national level data

Performance incentives

46 5.2 II 3 bottlenecks on the last mile of the vaccine chain: lack of optimization of the chain, no delivery, unsustainable financing

Positive points Improvement points

Operational Functions Catalysts

Quantification/ Storage & storage Transport et Tools & IT procurement Governance Funding Planning management distribution systems

Performance incentives

SOURCE: Interviews with stakeholders 47 5.2 II Our field visits and interviews revealed positive points and improvement points at the last mile of the vaccine chain

Positive points Improvement points

Upstream of the ▪ Difficulties of quantification and procurement, and insufficient storage upstream of last mile the chain (INHP/PEV, antennas) resulting in high costs and delays and shortages at last mile

▪ Two private agencies contracted to follow the ▪ Recently split chain in two (PEV, INHP) and not part of the NPSP chain limiting preventive and curative maintenance of economies of scale / integration on storage equipment Lack of storage space for vaccines and consumables at all levels2, e.g. 10,5m3 at Storage & ▪ INHP but 50m3 are necessary1 inventory ▪ Physical inventories of vaccines & consumable 1 Lack of adequate equipment and lack of maintenance at the antenna and district management regularly made ▪ level, e.g. cold rooms and refrigerators do not all have continuous temperature recorders ▪ Young and functional2 last mile cold chain type 30 days3, missing emergency plan in case of breakdown, lack of maintenance of equipment buildings3

▪ Extension plan and replacement of rolling ▪ Recently split chain in two (PEV, INHP), not part of the NPSP chain, and ad hoc stock financed to up to USD 7m mostly by Gavi campaigns conducted in parallel limiting economies of scale / integration on transport Transport & ▪ Lack of adequate rolling stock in the periphery INHP antennas and district warehouses; distribution 40% of existing rolling stock is to be reformed3 ; hence the collection system by the districts and the HC

▪ Training provided by INHP during the ▪ Lack of training and supervision, e.g. agents do not master the shake test, the formative Governance & introduction of new vaccines (e.g. DTC-HepB- supervision is insufficient, supervision visits are rarely performed1 HR Hib & PCV 13)1 ▪ Lack of formal training module in PEV logistics1

▪ Migration towards electronic tools (e.g. SMT) ▪ Multiplicity of tools with three electronic tools filled in parallel (SMT, SIG Inventory, IT Systems DVD MT) and numerous manual paper tools (records, stock sheets, purchase orders and delivery, etc.)

▪ Strong cross support from Gavi in the purchase ▪ Strong dependence of EPI on external support (~75%) due to a weak contribution from of vaccines, the assumption of operational costs the state (~30%) Funding and the strengthening of the health system for ▪ Need to prepare for the exit of the country from the Gavi eligibility (~60% of PEV vaccination funding)3– by sustaining the chain and budgeting the necessary contributions from the state ▪ Major delay in the release of funds committed by the State for the payment of vaccines 1 1 GEV report , 2015 data 2 PEV 2017 Rehabilitation plan leading to long-term shortages at the last mile 3 Chain evaluation, 2015 data 4 PEV 2016-2020 Complete Multiannual Plan SOURCE: PEV, UNICEF, CNCAM interviews; PEV 2016-2020 Complete Multiannual Plan (MSHP 2015) ; Supply chain map (WHO 2015); Evaluation of the supply chain (USAID 2015) ; GEV Report (WHO 2015) ; Rehabilitation, expansion and extension plan for the cold chain and rolling stock (PEV 2017) 48 5.2 Evaluation of key performance drivers for the blood products chain

Operational Functions Catalysts

Quantification/ Storage & inventory Recoverable drugs & GTC Procurement Transport & distribution Governance IT systems Funding Planning management

Operational Functions Catalysts

Quantification/ Storage & inventory Procurement Transport et distribution Governance Tools & IT systems Funding Planning management

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Adequate Availability of Transparency of methodology Choice of Delivery assured IT architecture and Coordination and space and quality decision-making based on suppliers and at each stage of systems alignment of Retro-CI Chain of storage processes at epidemiological products the chain integration donors with needs conditions national level data

Performance incentives

49 5.2 III 3 main bottlenecks on the last mile of the CNTS chain: lack of optimization of storage points, parallel transportation and distribution, unsustainable financing

Positive points Improvement points

Operational Functions Catalysts

Storage & Quantification/ Transport & Tools & IT Procurement inventory Governance Funding Planning distribution systems management

Adequate Availability of Transparency Delivery Coordination methodology Choice of space and of decision- IT architecture assured at and alignment based on suppliers and quality of making and systems each stage of of donors with epidemiologica products storage processes at integration the chain needs l data conditions national level

Performance incentives

SOURCE: Interviews with stakeholders 50 5.2 III Our interviews revealed positive points and improvement points at the last mile of the CNTS chain

Positive points Improvement points

Upstream of ▪ Difficulties of quantification and procurement, and insufficient storage the last mile upstream of the chain (CNTS, CTS) resulting in high costs and delays and stock shortages at the last mile

▪ Study carried out and ongoing reflection in ▪ Lack of deposits at the CTS level for ATS and SP inputs (limited means of Storage and partnership with SCMS to deconcentrate transport for ATS and CTS, need to come and get supplies in Abidjan) inventory the storage of blood products ▪ Unsatisfactory storage conditions, especially on inputs requiring a cold chain management

▪ Three interdependent chains managed by the CNTS are not integrated into ▪ Responsiveness of the CNTS in the national chain entailing high costs and difficulties of storage and distribution: emergency situations with for example the - Inputs and consumables: CTS, ATS / SP collect them in an ad hoc way from use of its heavy equipment truck, or truck the CNTS, which has only one truck; improper storage conditions on reagents Transportation borrowing at the NPSP requiring a cold chain and - Diagnostic tests: 3PL carry them from ATS / SP to CTS at high costs distribution - Blood bags: health institutions get them on their own and in an ad hoc manner (no allocation or chronogram)

Governance ▪ Lack of precise knowledge of the storage conditions required for blood and HR transfusion products

Tools and IT ▪ Integration in progress at e-SIGL ▪ No IT inventory management tool (pilots in progress at two sites for a tool not systems harmonized with the national chain)

▪ Initiatives launched to encourage hospital ▪ Chain structurally unsustainable financially (costs much higher than revenue) payments with one invoice per month and dependent on state subsidies ▪ Lack of support from donors (> 90% financed by the State) limiting purchases of reagents and consumables, and resulting in sub-optimal logistics (no organized Funding delivery, multiplicity of collection flows), leading to the satisfaction of around 70% of national blood requirements ▪ Difficulties to generate revenue - partial recovery especially at UH level

SOURCE: PNS, institutes et NPSP interviews; review of existing studies 51 5.2 Evaluation of key performance drivers for the viral load test products

Operational Functions Catalysts

Quantification/ Storage & inventory Recoverable drugs & GTC Procurement Transport & distribution Governance IT systems Funding Planning management

Operational Functions Catalysts

Quantification/ Storage & inventory Procurement Transport et distribution Governance Tools & IT systems Funding Planning management

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Performance incentives

Operational Functions Catalysts

Quantification/ Storage & inventory Tools & IT Procurement Transport & distribution Governance Funding Planning management systems

Adequate Availability of Transparency of methodology Choice of Delivery assured IT architecture and Coordination and space and quality decision-making based on suppliers and at each stage of systems alignment of Retro-CI Chain of storage processes at epidemiological products the chain integration donors with needs conditions national level data

Performance incentives

52 5.2 IV 3 bottlenecks in the viral load chain: lack of storage space, lack of optimization of transport flows, lack of clear and effective governance

Positive points Improvement points

Operational Functions Catalysts

Quantification/ Storage & storage Transport & Tools & IT procurement Governance Funding Planning management distribution systems

Adequate Availability of Transparency Delivery Coordination methodology Choice of space and of decision- IT architecture assured at and alignment based on suppliers and quality of making and systems each stage of of donors with epidemiologica products storage processes at integration the chain needs l data conditions national level

Coordination Optimization of between the chain Staff trained stakeholders (number and and dedicated and location of to logistics harmonization intermediary management of processes warehouses) between produ

Performance incentives

SOURCE: Interviews with stakeholders 53 5.2 IV Our interviews revealed positive points and improvements points on the viral load chain

Positive points Improvement points

Upstream of the ▪ 2 players, making quantification and procurement more complex; insufficient storage at the central level (Retro-CI) last mile

▪ Direct supply by private providers of OPP- ▪ Lack of consolidation of storage spaces : ERA platforms to save storage costs – Retro-CI buys and stores in Abidjan the reagents for its 19 parallel platforms of the national chain; lOPP-ERA does not store ▪ Plan to integrate reagent storage and centrally but ensures the direct supply by private suppliers of its 2 platforms in parallel of the national chain distribution at the NPSP in 2018, potentially – NPSP stores some state-funded consumables for all platforms Storage and with a pilot phase inventory ▪ Quarterly delivery to the interior and lack of storage space for large quantities of reagents in the CDC laboratories – e.g. management stored at Yamoussoukro or Bouaké CNTS ▪ Uncertainty about NPSP's ability to resume DP activities and contain large volumes of input necessary for the viral load, as well as ensure adequate storage conditions (need close monitoring, cold room at -20°)

▪ Costs / means of transport provided on the ▪ Multiplicity of transport flows and distribution methods leading to additional costs and duplication of activities : 3 products by multiple logistic actors (3PL or – Reagents : The 19 Retro-CI platforms get their reagents supply at central level with the support of IP operating in IP), without collection by the health personnel geographic and logistics silos (Ariel, EGPAF etc.) every 3 months; 2 OPP-ERA platforms are directly supplied from Transportation and ▪ Good delivery functionality on reagents and suppliers twice a month distribution tubes – Consumables : All platforms are supplied by the NPSP monthly - without coordination with Retro-CI and OPP-ERA – Tubes : Operational IPs in geographic and logistic silos transport the tubes

▪ Recent trainings carried out at relay ▪ The multiplicity of actors on the viral load leads to a lack of transparency and coordination of activities, and to a lack of laboratory level leading to a significant ownership of the chain by the state / PNLS and thus sustainability : drop in the rate of rejection of samples – Near-absence of state intervention with full DP support Governance and – PNLS non involved and thus not playing its role of coordination and supervision for HIV activities HR – TWG on viral load does not meet at the agreed frequency (1-2 meetings in 2017) ▪ Crucial need for training on viral load : few staff trained in this fledgling activity leading to rejection of samples (15 to 20% initially)1 and damage / expiration of reagents

▪ Need to integrate inputs with eSIGL Tools and IT ▪ Erroneous information transfer from HE and technical platforms – contradictory data shared by IPs in the field and not systems corresponding to central level data

▪ Supported provided from DPs at all levels ▪ Need for funding to scale up existing storage and distribution structures that are undersized and under-equipped to cope with of the chain: on procurement, storage, future viral load test volumes distribution and capacity building – Current limited coverage (entire regions not served) and extension plan not yet validated by the PNLS Funding – Estimated needs in viral load tests will double by 2020 – in the OPP-ERA coverage areas – Viral load tests use 6 to 10 times more inputs and require a sophisticated supply chain (e.g. storage at -20°C) ▪ Deadlines for release of funds for state-financed consumables and stored at the NPSP and for the reagents financed by the donors (3 months shortage in 2017) 1 Interview Expertise France, project OPP-ERA SOURCE: Interview with PNLS and the project OPP-ERA; interview with the CDC; document review 54 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.