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Skip to 0 minutes and 11 seconds SPEAKER: People who work with supply chains or those who study them are constantly faced with the effects of system complexity. A group of researchers studied the supply chain of Antiretroviral Therapy, ART, in Uganda a few years after these drugs began to be widely distributed for treating HIV. The need for rapid scale-up of ART meant that there was a strong demand from public and private facilities for these drugs and a number of different donors providing funding and drugs. The government ART supply chains at the time were inefficient, inflexible, and required long lead times for procurement.

Skip to 0 minutes and 47 seconds This was partly due to a lack of well-trained staff and good information systems and governance in the supply chain, a great opportunity for strengthening the health system. Private organisations were faced with a dilemma. They could use the government supply chains and risk delays and stock-outs or they could set up their own parallel systems and have more control. Many private organisations set up parallel procurement and supply lines for ART, nine different lines for the same drugs. Although some actors tried to strengthen the government system or intended to integrate their system with others at a later point, this mostly did not happen.

Skip to 1 minute and 26 seconds Instead, private organisations became increasingly dependent on their own supply systems and their increasing complexity and differences made them more difficult to integrate with each other. In an example of emergent behaviour, focus on short-term achievements on individual program performance meant that there was resistance to integration or systems strengthening efforts that might have been beneficial to national ART supply in the long term. A negative feedback loop was set up where investment in private supply chains drew expertise, finances, and power away from government supply chains, which, in turn, made it more difficult for these supply chains to improve and be attractive to private organisations.

Skip to 2 minutes and 8 seconds The result of this fragmentation was high degrees of inefficiency, with frequent stock-outs and examples of duplication, like two organisations supplying the one provider. What could be done? The authors found that many of the efforts to strengthen supply chain management focused on simplistic assumptions about this complex system, only focusing on one or two aspects, like staff training or information systems, which did not have sustainable impact. They said, ‘The term “system strengthening” is largely misused for interventions which continue to have fragmenting effects.’

Skip to 2 minutes and 44 seconds Simplistic interventions that don’t address the complex determinants of poor function and parallel solutions that avoided addressing systemic bottlenecks were not likely to provide long-term improvements compared to approaches that engaged private and public actors and simultaneously addressed issues of coordination, governance, financing, and information systems.

Supply chain management and health system complexity

When watching this video you may be struck by the fact that the government of Uganda and each of the different donors were all working to achieve a similar goal. Everyone wanted to increase the proportion of people having access to anti-retroviral therapy (ART). Everyone wanted to reduce the burden of HIV in Uganda. So, what went so terribly wrong with the supply of ART, given that everyone was working to the same purpose? One aspect that is not captured in the video is the fact that each stakeholder was working to their own targets and milestones for rolling out ART. Yet these targets were dependent on weak systems in the country.

The stakeholders faced a difficult choice. They could either meet their donor targets for ART roll-out by developing their own independent strategies to overcome the system weaknesses, (and not worry about any of the unintended consequences) OR they could decide to try and improve the health system, and as a result risk not complying with donor requirements, and perhaps losing their funding.

It is striking, but not that surprising, that the response of most stakeholders was to create their own workarounds, which in turn led to the duplication and the knock-on effects described in the case study.

Put yourself in the position of an implementing agency fulfilling a global donor’s commitment to ART delivery – reflect on what your response would be.

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Health Systems Strengthening

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