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Skip to 0 minutes and 8 seconds SD GUPTA: Welcome to Health Commodity and Logistics Management. Without logistics, health programs would not have the commodities they need to provide clients with lifesaving services. Learning objectives are as follows. Describe the importance of logistics management to public health programs. Explain common logistics management challenges and reasons of those challenges. Describe the best practices for cold chain management, storage, and distribution. Apply knowledge gained to solve management and order chain logistics problems at national and subnational levels. Logistics and supply chain in any health program, and particularly immunization program where logistics and supply is quite complex, there is a phrase, which was used very early by leaders in a management program. No product, no program.

Skip to 1 minute and 12 seconds So for the success of the program, it’s important that we have a regular supply, continuous supply, all the vaccines, and other commodities. This phrase, no product, no program, underscores the important role of a strong supply chain in a successful health program. There is a second [INAUDIBLE] impact of logistics on health programs. Effective supply chains help ensure commodity security and have determined the success or failure of any public health program. Well functioning supply chains benefit public health programs in important ways by logistics, increase its program impact. A very logistic system provides a reliable supply of commodities. More people are likely to use health services. It enhances equality of care. Well-supplied health programs can provide superior service, while poorly supplied programs cannot.

Skip to 2 minutes and 10 seconds It also improves cost efficiency and effectiveness. And effective supply chain pays off by reducing product losses due to overstock, waste, expiring, damage, and pilferage. And the whole idea for logistics, supply chain is more data security. And it means that persons or the users can obtain, choose, and use health commodities they require. So this commodity security is an important idea that it has to be insured to ensure equity in health care. Now I have a video for you to watch. Please, watch it carefully, and then we can talk about it. [VIDEO PLAYBACK]

Skip to 3 minutes and 3 seconds [NON-ENGLISH SPEECH] - To parents, it didn’t make much difference, the switch from one type of oral polio vaccine to another wasn’t a big issue. But to public health professionals, the switch was a carefully timed global feat in April, 2016. Trivalent oral polio vaccine, or tOPV, contains weakened forms of the three types of polio virus. Over four decades, its use had been very successful in eliminating most polio in the world. It also eradicated type 2 polio virus. However, very rarely, the type 2 vaccine strain could circulate and change into a form that caused polio disease.

Skip to 3 minutes and 44 seconds To end that risk, the use of type 2 had to end globally at the same time, and every vial was switched with a new bivalent OPV. - With the end game, we’re not just eradicating the polio virus itself. We’re also managing the circulating vaccine-derived polio virus. - An initial challenge was timing. The Philippines had already planned to use tOPV in 2016. But the secretory of health decided to make the switch on the recommended global schedule. With that decision, the immunization department went into action. - When we were informed of the switch, we immediately informed also our local government units. - Another challenge, using up the extra stocks of tOPV so they wouldn’t go to waste.

Skip to 4 minutes and 33 seconds This involved an intensive February, 2016 outreach tOPV campaign in communities with lower vaccine coverage. Next, the logistics of ordering, storing, and delivering 3 million doses of bOPV from warehouses to health posts across the country. The new vaccines came just in time. - We went to the Provincial Health Office on April 26 because they asked us to come on that date. So we were given the 66 bivalent OPV in time for the switch the next day, which is Wednesday, of course, the immunization session day and switch day. - After the switch, the Red Cross helped to monitor health posts checking for any remaining tOPV. Vials were gathered and safely disposed.

Skip to 5 minutes and 20 seconds Health leaders attribute a smooth switch to efficient step-down training, involving thousands of health staff from provincial capitals to the villages. - We invested a lot in the training. That was the key, I think, that everyone involved in this switch should be aware of it. So we were able to do all of that in just barely a month. - Health workers knew the switch had to work well. Putting a final end to polio was simply too important. - If we continue to improve our program, I think we can continue to make this country a polio-free country, and, of course, the rest of the world a polio-free world. Hope that will be soon.

Skip to 6 minutes and 12 seconds [END PLAYBACK]

Skip to 6 minutes and 13 seconds SD GUPTA: One successful immunization program that built on functional end-to-end supply chain and logistics systems. The role of supply chain is to ensure effective vaccine storage, handling, and stock management, vigorous temperature control in the cold chain, and maintenance of adequate logistics management information system. What is logistics? It is important to understand. This means the process of planning and executing the efficient transportation and the storage of goods from the point of origin to the point of consumption. And the whole of logistics is to meet customer requirements in a timely, cost effective manner. Now, we’ll go through logistics management. You see this graphic.

Skip to 7 minutes and 5 seconds So this logistics management is all about procuring, producing, storing, distributing the material or vaccine to the proper place, and a proper quantity for [INAUDIBLE]. So this vaccine supplies, as I said earlier, is a complex kind of logistics because you’ll protect the quality and efficacy of the vaccine. We need a bold chair. And that has made it more complex. We have to maintain such temperatures. But essentially, what logistics management would mean, you will receive vaccine at the port from the manufacturer, or the deliverer who is supplying it. But you receive the vaccine from the port. Once it is received, the vaccine is stored in the central warehouses. And then this vaccine is supplied to regional warehouses or the estate warehouses.

Skip to 8 minutes and 4 seconds And probably the state warehouses, the vaccine has to go to the district hospitals directly, or it can go to district warehouses. In most countries, including India, or big countries, they are [? the strict ?] level warehouses where this vaccine is stored. And according to that supply plan, this is distributed through the health post or health centers. This is given to the health workers and dictate the supply and take it to the health facility who will be given to the children, who are the end user of this vaccine. So this health worker and the community level through primary health centers or subsectors. This vaccine is delivered to the clients. And who are our clients?

Skip to 8 minutes and 54 seconds These are the children who need to get the vaccine. So there are different ways of supplying vaccine or giving immunization to children. It could be at a fixed facility, like health facility at primary health center, or it could be through campaign or camp approach. A vaccine is delivered to a particular site. This is done mainly because people do not come for vaccination to the health facility. So the camps had to be organized at the village level and when the vaccine is made available. So you’re going to see right from the port where we will see the vaccine.

Skip to 9 minutes and 33 seconds Putting it into the central warehouse and then transporting include regional warehouses, and then to the district warehouses or district hospitals, and then going to health [? workers ?] through the transportation system from district to the health facilities. And then it is collected by community health workers or health workers who are responsible to give vaccines to the children. They are [? on trains. ?] So this is for the whole logistics management is carried out, now a very important component is what is the timeliness, what is the right quantity, at what time it should be reaching the health facility, at what time it should be reaching the vaccination site in cold chain.

Skip to 10 minutes and 24 seconds That is the vaccine carriers of cold vaccines to maintain the temperature. So there’s a whole sequence. But it is important to understand what do we want to achieve with this. With good logistics management, what we want is uninterrupted availability of quality vaccines from manufacturers, who service delivery levels so that opportunities to vaccinate are not missed because of the vaccines that are another level. This requires a system to achieve the seven rights of supply chain management. What are those seven rights? Right product. Right product means the vaccine. Does it meet the specification? What are the quality of it? And does it have the potency, right potency? This is very much required. We decide what is the right product?

Skip to 11 minutes and 21 seconds What is the right commodity we are working on? So who does it? What is right? This is done at the policy level or national levels. What is the right product that needs to be procured? And what is the right quantity? In what quantities these commodities we procure? How do we decide what is the right quantity? We do forecast. We prepare supply chain plans. We estimate the demands based on a monthly consumption of the vaccine. And the users of the vaccine. Based on that, we focused the quantity of the vaccine that would be required. The right quantity has to be assessed for supply to a particular health facility.

Skip to 12 minutes and 8 seconds So the next important right is the right quantity, right amount of the vaccine will be procured and supplied to the health facilities at the right time. And then comes the right quality. The vaccine should be important for the commodity that we are talking about should be a good quality. That means it meets the specifications and standards of the product. And then its potency and safety is maintained during the transportation and distribution. And then what is the right place? Very important component of logistics commodity supply. Is it reaching the right place? Where is the end user of the commodity? In case of immunization, it is at the health facility level.

Skip to 12 minutes and 58 seconds It is mainly at the village level, where we are organizing immunization camps. But it should reach the right place where the users are going to use that commodity. So we had to work on where this vaccine has to reach again, next, in right time, between a right place at right time. So we have two things, session planned for vaccination, and also supply plan distribution of that particular commodity. Once we have the times, the dates, when the camps will be organized, or when the immunization sessions will be had at the health facility. Vaccines should be available at that point of time. So supply chain has to synnergize or integrate with the session planning at the health facility level.

Skip to 13 minutes and 53 seconds And on the next right is level right six, the right customer. Right customer means the commodity for which is procured for whom is the right person who gets it. So where in case of, say, polio vaccine, this was a [INAUDIBLE] post-polio program. It was to be given to all the young children below the age of five years, irrespective of the fact whether they received it earlier or not. So they are our customers. And they come to the health facility, or brought to the health facility, or to the campsites. We have to decide what are customers. But we need to do a [INAUDIBLE].

Skip to 14 minutes and 32 seconds We had to do listing and invite them to attend a health facility on that particular day and time. The right customer is very, very important, and they should come and, of course, the right price. So we need to understand this, the corrective supply chain is important for saving cost and avoiding this. So how can we get the commodities at right price at lower cost but with the same efficacy and quality? The right price at the commodity, again, who procures it decides what should be the price of this. And you all know the rates are decided, the procurement is on the basis of quality as well as cost. And then procurement, the season has taken at a national level.

Skip to 15 minutes and 24 seconds My national program managers and policymakers. So these are these seven rights, which are very, very important that determine the quality of logistics supply set. Having talked about these seven hours of logistics, I’d like to share with you what are the health commodities for polio program? Most important, of course, is the vaccine, oral polio vaccine, which we used. As you know, this vaccine has to be procured in right quantities, we cannot over-procure these vaccines because they are expired, and we require specific storage and transportation for vaccine to maintain the temperature. And that is what the cold chain is. So maintaining cold chain during storage, transportation, distribution. And at the end user level at the health facility is important.

Skip to 16 minutes and 22 seconds So cold chain supplies include mainly the vaccine carriers. All of these vaccine carriers, vaccine carriers are usually double deckered boxes where the temperature is capped at low level. And this is then such a way that these carriers, to keep the temperatures low, there is something called ice packs. And ice packs lying around within this carrier, for them, the temperature is maintained. We need freezers, freezers for storage of the vaccine. And then there’s electricity. Sometimes there is disruption or electricity. So there has to be standby generators to supply. There are specialized refrigerators or freezers. We call them ice-lined [INAUDIBLE] vectors. They were required.

Skip to 17 minutes and 16 seconds So the electricity goes off, still, you can maintain temperature for maybe 12 hours or 24 hours with the ice lines that are created around it. However, if the electricity is out for a longer time, would require generators. And by running generators, we need a [INAUDIBLE],, more diesel, whatever. This fuel is required to run the generator. Sometimes these freezers that also run by generators only places that are electric are primarily these generators are used for maintaining temperatures. And then we need transport for transportation of a vaccine. From different storage sites, we saw that it came to port and then to central warehouse, and the regional warehouse, then district, and then down the line to the health facility.

Skip to 18 minutes and 12 seconds At every point, we needed transportation on the vaccine. Now, this is very, very important. Having worked in immunization programs for several years, this is now the important thing, which sometimes failed us because of the failure of the transportation available for timely distribution of a vaccine to the vaccination sites, either the health facility or [INAUDIBLE]. Another important commodity, which requires the cold chain, for surveillance for stool samples. We want to know, once the cases are reported, as [INAUDIBLE] as polio cases are reported so immediately, within 24 hours or so, the stool samples are collected. And these are then sent to central laboratory, or regional laboratory, for virological testing.

Skip to 19 minutes and 2 seconds But these samples have to be, again– it would require a cold chain system. So that is what reverse core chain is for [INAUDIBLE] surveillance, acute flaccid paralysis surveillance, [INAUDIBLE] And this was a very important component of polio eradication program. Once the case is found, the stool samples are collected and tested for evidence of the virus or polio virus and which strain of polio virus. And then it was communicated back. It was positive or negative, or whatever, and appropriate measures would be taken. So this reverse cold chain is also very, very important. And it took long time fixing transportation of the stool samples to the laboratories from the field.

Skip to 19 minutes and 51 seconds And then environmental surveillance commodities, like vaccine temperature monitors, selecting [INAUDIBLE] monitors, and many other things related to, important is communication, to require communication material, and this communication material leads to for you as a disease, and then communication related through informing people where there’s the next session and then telling them that they should come on this particular time on that date. That’s very important. If the communication is weak, if the community doesn’t have any information about your session, your session will not be attended well by the children. And in that case, you will be wasting not only the vaccine, but the time and other resources. So communication materials are very, very important commodities for the successful programs.

Skip to 20 minutes and 47 seconds Another thing is polio workers, all the human resources and their supplies. They need, to have the bags, tally sheets, they need to have uniforms, and also training material, they need to have. But these are important health commodities in polio programs.

Introduction to Health Commodity and Logistics Management

Dr. S.D. Gupta, M.D, Ph.D, FAMS Chairman, IIHMR University, India

In this lecture, we briefly review the seven key components or ‘rights’ that are essential to a well functioning health commodity supply chain.

Before we delve into challenges faced in getting each component just right as well as innovative strategies developed globally, please take a moment to review Chapters 1 and 10 in the reading Introduction to Logistics and Logistics System Design.

Can you think of two potential logistical barriers, not mentioned in the lecture, in delivering vaccines to every corner of the world?

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Planning and Managing Global Health Programmes: Promoting Quality, Accountability and Equity

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