In this second interview in the series on the Zambian supply chain pilot, A Humourless Lot talks with Prashant Yadav, professor of supply chain management at the MIT-Zaragoza Logistics Program.

AHL: Could you tell us a bit more about your role in the project?

PY: I had conducted research on the medicines supply chain in Zambia in 2006 funded by the UK DFID which highlighted deficiencies in the system. After conducting the study to diagnose the supply chain problems, one of my specific mandates from DFID and the World Bank was to come up with four of five options that could possibly solve the issues that were identified in the earlier reports. A second task was to give input on measurement and the metrics to measure success vs. failure: what indicators to use and how to measure them in such a way that we could draw scientifically valid conclusions. We wanted to integrate monitoring and evaluation into the project from its earliest stages.

AHL: You say you came up with four or five options, but only two were in the end tested. What were the others and why weren’t they incorporated into the pilot?

PY: One option that was brought up by some stakeholders but did not make it was to transport the commodities directly from the central warehouse to the facilities, using a fleet of smaller vehicles. One key issue with this option was that it was difficult to quantify costs in advance, and we believed that direct distribution to clinics would become very expensive from a transport cost standpoint. Also, it would not be technically feasible in some areas that are hard to reach.

A second option involved regional medical stores that each would service a large chunk of the country and supersede the district stores. The issue with this model was that it would become too big to pilot: to be able to make any analysis, we would need to include a number of regional warehouses that would in the end encompass a very large part of the country. We agreed that this is something we can pursue at a later stage using a simulation model.

A third and final option that was not selected for the pilot was to outsource transport to the facilities. This was dropped just due to practical aspects: we found out that we could probably only find transporters on the high-frequency routes, and many facilities are not located anywhere near those routes.

AHL: How about measurement? Can you tell a bit more about your analysis of the results?

PY: Demand for some of the 25 tracer drugs that were analyzed under this pilot was not very stable. We had thought that the results for commodities with stable demand will show that the cross-dock model [where supplies were pre-packed at the central level – MK] performs better, and the results for those items were clearly statistically significant. However, to our surprise, even for the items with large variations in demand, the results for the cross-docking model were still significantly better than either the original situation or the first model. Seasonality in demand, time of conducting the data collection, quantifying the outcomes all made the analysis fairly challenging. However, working together with Jed Friedman at the World Bank’s research group and Jérémie Gallien, a colleague at MIT, we found some robust ways to quantify the impact.

Another issue is that both models presuppose that there are no stock-outs at the central stores. We don’t know how robust the models will be if stock-outs would occur at the central store.

AHL: How about the future? What is happening next?

PY: We are now involved in the progressive roll-out of the model to the whole of Zambia. Together with the government of Zambia and cooperating partners, we are discussing various options to scale up the cross-docking model. We are also thinking about how to handle clinics that are cut-off during the rainy season under the cross-docking model.

We are also exploring some options with primary health center kits. This is an alternative model, more push-based than the normal fulfilment models and fairly rigid; consequently, it sometimes leads to more excess and wastage than might be necessary, but is robust to events such as the clinic not placing an order. We are looking at possibilities for customised kits, e.g. on a regional basis, depending on the specific circumstances and needs.

Finally, we are still collecting data and updating our evaluations. We will also use the data to feed a parameterised model that should enable us to simulate other solutions. One example is the regional-store model that was discarded at the outset for practical purposes; once we have sufficient data, which I expect to be the case in a few more months, we should be able to simulate what would happen if regional stores were to be implemented.

AHL: How well could this model be ‘exported’ to other countries?

PY: I can think of two or three countries that have a similar setup as Zambia and suffer from similar issues. They would be good candidates for a similar model, but spatial distribution of facilities could make a big difference and could in the end mean that the model would be less effective there. Even where a direct verison of this may not be applicable, there are learnings which can improve the distribution systems in many other countries. We are in discussion with several countries and large donors on how to disseminate this to a wide group of public health specialists.

AHL: Finally, what was your experience with the cooperation with so many and various partners?

PY: From my perspective, things went quite well. The collaboration offered something unique to each of the partners. For instance, for MIT/Zaragoza it offered the opportunity to use our academic knowledge for a practical improvement in the lives of Zambians. Similarly, for the World Bank and USAID it offered the possibility to show that these two organisations, who have not always cooperated smoothly, could partner closely and productively.

Likewise, each of the partners brought an important aspect into the project: the World Bank delivered funding, and impact evaluation knowledge; the USAID/Deliver project brought local presence that delivered some economies of scope; MIT/Zaragoza contributed academic knowledge; and so on.

Of course things did not always work smoothly. For instance, it was hard work to convince everyone in the joint team that it was acceptable to do a quasi-randomized trial instead of agreeing with the stakeholders on what is the one ‘best’ solution and then implementing it. Similarly, there were discussions about the profile and reporting structure of the commodity planners stationed in the districts vis-à-vis the district pharmacists who were already present in some of them.

However, in the end we were able to overcome all our differences of opinion, and I think the result shows how well we were able to work as a group.

[Image: Fight the Bite by Zelda Go Wild @ flickr. Some rights reserved.]

The World Bank, The UK Department for International Development, and USAID recently released the results of a logistics pilot project in Zambia, in which the availability of various medical supplies was improved. This is the first of a three-part series in which I talk with two of the team members and finish with some personal reflections. In this first article in the series, I interview Monique Vledder, senior health specialist at the World Bank and supervisor of the project.

AHL: Could you tell us a bit more about the background of this project? Why was it initiated?

MV: We have been involved in supporting the government to implement malaria prevention programmes like bednet distribution in Zambia since 2005. However, over the course of our programmes we realised that, although the government was quite successful in preventing malaria, the people who still were infected could not get adequate treatment due to a lack of malaria treatment drugs at the rural health centres. Our analyses showed that those drugs were available at the central level and district level; but somehow they did not arrive at the health centres. Clearly, there was an issue with the supply lines between MSL (the central medical store), the districts, and the centres. We partnered with other major donors like the UK and US governments as well as JSI and Crown Agents as implementers, and with MIT to ensure academic support. Our joint analysis pointed towards placing commodity planners at the district level as the most promising option. When we discussed this with the Zambian government, we were given a strong commitment for for a pilot project to try this out.

AHL: So what exactly did the pilot entail?

MV: The pilot included 24 districts, 8 of which were used as controls (continuing the use of the ‘old’ system), and in 16 districts we implemented either of two models. Those 24 districts represent about a quarter of the whole country, so especially for a pilot project we had very good coverage. Model 1 involved the placement of a commodity planner at each of the districts. Their tasks were to facilitate communication with the health centres about commodity needs and levels and to prepare orders to MSL. Once the orders were filled and had arrived at the district warehouse, they would also be responsible for packing and dispatching the orders to the health centres.

Model 2 was very similar to model 1, but in this model the separate orders for the health centres would already be collated at the central level and would arrive pre-packed at the district level; the commodity planner was only responsible for preparing the order and for forwarding the packed order to the health centres.

AHL: And the results?

MV: They were spectacular, especially in the districts that used model 2. For example, availability of the main drugs for artemisin-based combination therapy (ACT) improved from an average of about 50 per cent to nearly 90 per cent. If we would extrapolate this to the whole country, this alone would prevent more than 16,000 deaths a year. But, of course, the effects have been much wider than just ACT; although the commodity planners concentrated on malaria supplies, availability of other supplies like antibiotics and contraceptives has increased as well.

When I started on this project, I did not know much about the logistics side of public health, but these results have made it very clear to me how important supply chain management really is for the people’s health.

AHL: So what do these results mean for other programmes? And perhaps other countries?

MV: Of course you cannot translate the results one-on-one to other programmes or settings, but what this trial has made clear is that a relatively modest investment in supply lines can deliver spectacular results. In most developed countries, supply chain management takes up more than ten per cent of the cost of the supplies themselves; in Zambia this was less than half that percentage. Whether you should aim for a similar proportions as in developed countries remains an open question, but it seems to be clear that a modest increase could lead to greatly improved health outcomes. However, I must say that we have not yet finalised our cost-effectiveness analyses; although it was fairly easy to to quantify the extra costs involved, it was not so easy to calculate cost savings, e.g. in model 2 the cost of labour that was no longer needed for repacking at the district level. Nevertheless, even if the cost savings turn out to be very modest, we expected that the improved access to medication and the resulting lives saved would make it more than worthwhile.

I think it is important in this sense to think of integrated supply lines. Although this project was initiated as part of the malaria support, the focus was on supporting the supply of all essential drugs.The results for other pharmaceuticals as for example antibiotics or contraceptives was positive as well. I think that shows that we could make even more gain if we could move away from the disease-based silos and work on approaches to strengthen an integrated supply chain

AHL: What happened after the trial ended? Are the commodity planners still active?

MV: Yes, they are; and, in fact, the districts that were not included in the trial as well as the model 1 districts were so impressed with the results that they are now requesting the country-wide implementation, and the Ministry of Health now has committed to a phased roll-out across all districts.

AHL: This project involved a large number of partners: besides the World Bank, people from DFID, USAID, JSI, Crown Agents, MIT, and of course the Zambian national and district governments were involved. Was it difficult to coordinate such a big group of actors?

MV: I think we were lucky in that that Zambian government gave us a clear commitment and took ownership of the pilot. What also helped was that we all had fairly clearly defined and complementary roles with a minimum of overlap. Thirdly, sufficient funding for the whole project duration was safeguarded from the start. And finally, monitoring and evaluation were integrated into the trial from the start, making it possible to present a result that could be accepted by all parties. All this meant that we could work very well together with a minimum of conflicts; it also meant that we could draw upon each other’s strengths to get things done.

[Image: Malaria dreams by Ashley Jonathan Clements. Some rights reserved.]

Update July 4: Andrew points out a linguistic complication: in English, the adjective professional has a much wider meaning than the noun professional; in other words, one can be a professional without acting professionally. So please, read the article with this in mind and replace ‘a professional’ with ‘acting professionally’ where appropriate.

The ever-excellent Linda Raftree recently wrote an article about amateurs, professionals, innovations and smart aid. In it, she sketches in its extreme form two diametrically opposed views of volunteers and professionals: on the one extreme, volunteers are seen as well-meaning but utterly useless do-gooders who potentially do more damage than good, while on the other hand professionals are seen as useless ballast who are in no way capable of doing what they claim to do and who weigh down agile, smart new initiatives from volunteers.

I think that one of the big issues here is the conflation of amateur and volunteer, and of salaried aid worker and professional. In my view, being a volunteer does not automatically imply that you are an amateur, and some of the salaried aid workers out there are not professionals at all. I would say that there probably is a correlation between your contract status and your position on the amateur-professional continuum (although I have no evidence to back that up – just personal observation), but there is definitely no hard-wired link.

So what makes a professional?

When I worked in a large international consultants’ firm, I used to teach introductory courses that included professional ethics to first-year associates. We would usually spend some time on working out what exactly makes a professional, what we understand by ethics, and what is the importance of ethics for professionals. Over the years, there was a remarkable constant set of traits that almost always were seen as central to being a professional.

I post two lists here: one with traits that were almost universally recognised as being essential to being a professional, and one with some statements that would usually lead to some more disagreement and discussion. Both sections are tailored towards professionals in other settings than aid work, but read ‘users’ instead of ‘clients’ and they are totally applicable to our sector too. I copy and paste it here unchanged (with many thanks to the participants of my courses who have helped to construct this list), because some of the wording might lead to interesting discussions.

Elements of professionalism

True professionals:
• are competent;
• know their limitations, and are willing to push these back continuously;
• are discreet and respect confidentiality;
• stick to promises and agreements;
• are loyal and honest towards clients and colleagues;
• practice what they preach;
• are strongly motivated by ethical values;
• are rational and objective, but respect their partners’ emotions;
• are creative;
• are independent, but communicate well;
• are willing to be held accountable and to explain their actions, and report unasked;
• are willing to share knowledge and skills;
• foster professionalism in others, wherever they find it.

Some statements for discussion about professionalism

• “True professionals never declare their professionalism; they demonstrate it”.
• “Amateurs don’t have any room for true professionals, especially in recognised professions”.
• “Volunteers are often more professional than the professionals”.
• “True professionals respect their partners’ time schedule”.
• “True professionals strive to minimize bureaucracy, but respect the rules; they try to change (and minimize) the rules, not to ignore them”.
• “Anyone can be a professional. In fact, most professionals work outside recognized professions”.
• “A bureaucrat can’t be a professional”.
• “A true professional is almost always a good teacher and mentor. However, not every good teacher is also a true professional”.

Are you a professional?

It should be noted here that one can be a professional in one role but a rank amateur in another. I think (hope?) that I am a professional aid and global health logistician, but I am aware that as a musician I am as amateur as they go. I think that most salaried aid workers are professionals in their jobs, but a sizeable minority isn’t. I also think that many volunteers are professionals, although many aren’t; but that being a short-term volunteer will almost always mean that you cannot be a professional in that role.

So what do you think? Do you think that these lists are a fair representation of what is a professional? Are you an aid professional? Do you think that volunteers can be aid professionals, or that the reality is that they hardly ever are? I am looking forward to your comments.

Update November 5: This article was was meant to put a bit of pepper in a long and still ongoing debate about the role of professionals and amateurs in aid; I am happy to say that this discussion has really taken off since then (although I probably have to admit that some posts from people like Nick Kristof, with a slightly wider audience than I have, probably have contributed more to that than this post). Good Intentions prepared a link list and a synthesis of the consensus up to now. Recommended reading.

Kathleen McDonald asks for my views on INGOs who set up their own (parallel) supply lines for medical supplies, as opposed to using the country’s normal supply lines.

Let me start with a truism: horses for courses. When deciding to use the local supply chain or set up your own, you will need to take into account your programme needs as well as your environment; and that means that it is impossible to make any sweeping statements about which way to go is better.

Reasons to set up a parallel supply chain

Some of the reasons that INGOs give for setting up a parallel supply chain:

• Specific supplies are not locally available. Some programmes are so far ahead of what happens locally, that they use supplies that cannot be gotten through the national supply chain. This happened quite a lot in the early years of the international HIV response, when it was hardly ever possible to source antiretrovirals locally. It is still a consideration in some programmes.
• Local supplies are of unproven quality. An INGO that takes its duty of care towards its patients seriously, will want to ensure that medications and other medical supplies qualitatively sufficient. This is not always easy: local producers and distributors are not always open to audits by customers, especially not if they cannot be guaranteed a certain minimum amount of custom. National regulatory agencies in ‘weak’ nations often lack the means to adequately ensure quality.
• Local suppliers cannot scale up sufficiently. This can be a consideration in very large programmes or responses, especially in case of outbreaks/epidemics.
• Local supply chains have broken down (temporarily). This will often be the case after large disasters or areas that are prone to violent conflict.
• Local supplies are (much) more expensive than imported ones. It might be surprising, but in quite a number of cases imported supplies – even factoring in transport, taxes and import duties, clearing costs, and other incidental costs – can be cheaper than locally bought ones, sometimes by a large margin. This usually happens when only a small number of suppliers have a stranglehold on the market.

Reasons not to set up a parallel supply chain

Of course, there are some very good reasons not to set up a parallel supply chain too:

• Parallel supply chains damage local structures. If local suppliers are pushed out of business due to our parallel supply chain, the long-term damage to the health of the population might actually be worse than what is gained by our programme.
• Parallel supply chains send the wrong message. In the long term, the goal of every INGO should be to restore the population’s own capacity. Note that I am not saying here that every organisation, even emergency responders, should do developmental work – but I do maintain that we should always do our best to keep that long-term goal in mind and should select solutions that (at the very least) damage it as little as possible. Parallel supply chains send a message that is diametrically opposed to this: ‘only what comes from abroad has sufficient quality’.
• Using local supply chains is a great way to find out where and how to help. If we know first-hand what are the strength and weaknesses of the local supply line, we are in a prime position to offer support to address those weaknesses.
• Local suppliers can be great sources of information. Any supplier worth their salt (in fact, any entrepreneur worth their salt) knows their markets well. Build up a good and lasting relationship with your supplier, and they might be the first one to flag that sales of ORS in a certain district have gone through the roof – your first indication of that cholera outbreak that the local government desperately wanted to keep under wraps. Do you think you would ever get that information if you are undermining their position?
• Local supplies sometimes are more appropriate. Your European-made oxygen concentrator might work perfectly well in a hospital in Berlin, but will it work in the hinterlands of whatever dusty, hot, voltage-challenged country you find yourself in? You are more likely (although by no means certain) to find something that works at your friendly local medical supplies salesman.

So what’s best?

As always, you will need to weigh the pros and the cons as they apply to your situation. There is no set ‘best’ model that is valid always and everywhere, and you will need to do some serious and active fact-finding to be able to find what’s best in your situation. It will probably mean that you will need to set up more than one supply chain, procuring some supplies locally while importing others. And what’s worse: you will need to do so again and again as circumstances change: in many developing countries, local markets can change dramatically over the course of as little as a year. But then, nobody said our work was easy.

Having said all this: many INGOs do not do their due diligence and set up parallel supply chains by default, without considering whether this is the right thing to do. While this is perfectly reasonable in an emergency response situation in which we don’t have time to research all pros and cons, and could even be acceptable in the first phases of a project while we scope out the local situation, I would say that this is not acceptable in the long term. If you work in one of these organisations, or in a programme in which these decisions are not regularly examined and re-examined, you could do worse than to start a discussion whether you are really doing the right thing.

[Image: Skies 1 (& visitor) by B Cleary]

• Remember my post on how to get patients and health care together? It turns out that I had forgotten one major factor: legal bickering. At least, in Australia.
• Yet another idea to combat counterfeit medicine. Not a bad one as things go, but again missing the poorest. Not that I would know how to do better.
• The UNDP has put out an RFP for ‘the Provision of Services to Strengthen the National Supply Chains for HIV/AIDS, TB and Malaria Programmes in Northern Sudan’. Section 8 can lead to some interesting issues.
• This year’s Aid & International Development Forum seems to have a lot of logistics subjects, starting with the first session: “Transport – How to achieve effective transport with smaller NGOs”. Could be very interesting if you are anywhere near. If you do go there, please post some feedback here.
• Fast Company showcases eleven designs for when disaster strikes. Unsurprisingly, logistics figures prominently.
• The International Transport Journal writes about aid logistics. It paints an overly rosy picture, but overall it is not a bad introduction into international emergency aid logistics.

[Image: Liquid Links by Desirae; some rights reserved.]

• Crown Agents are looking for senior procurement specialists for their office in Arlington VA (USA) and Malawi; procurement specialists for Mongolia and Malawi; an ARV logistics officer for Botswana; a procurement consultant for Tanzania; a supply chain operations manager for Malawi; an SCMS deputy country director for Rwanda; a logistics assistant for their office in London (UK); public procurement advisors for several countries; and a team leader for Malawi
• Save the Children is looking for an operations director, a senior procurement specialist and two roving logistics specialists for Haiti; a senior manager procurement, contracts and compliance for the West Bank/Gaza; and two senior logistics specialists to be based in Washington DC (USA).
• Maxwell Stamp is looking for a project costing and procurement specialist for Laos
• UNICEF is looking for a procurement assistant for their office in Geneva (Switzerland), a contracts officer for their office in Copenhagen (Denmark), and a supply and logistics specialist for North Korea. Sorry, no links, they still hide their vacancies behind a registration process.
• DanChurchAid is looking for a field logistics officer for Katanga (Congo DRC).
• Merlin is looking for deputy logistics coordinators for Côte d’Ivoire and Congo (DRC); a logistician for Congo (DRC); logistics managers for South Sudan, Kenya, Pakistan, Congo (DRC), and the Central African Republic; a logistics/administration officer for Gode (Ethiopia); senior logisticians for Grand Kru and  Montserado (Liberia); and a surge logistics officer for South Sudan.
• JSI is looking for a deputy chief of party SCMS for Nigeria.
• Concern Worldwide is looking for a transport manager for Haiti; an assistant country director systems for Afghanistan; and a general systems manager and a logistics and administration coordinator for Zambia.
• The IRC is looking for logistics managers for Congo (DRC) and Haiti.
• The IFRC is looking for a trainee logistics delegate for based in Kuala Lumpur (Malaysia), an operation coordinator for Guatemala, a head of support services based in Panama City (Panama), a procurement delegate for Haiti, and a senior procurement officer based in Geneva (Switzerland).
• MSH are looking for a senior program associate – supply planning/MIS/M&E for Bangladesh.

[Image: Job opportunities by Coffeechica. Some rights reserved.]

Ì have been posting for a while now, and I think it’s time that I start to listen instead of blathering on. So, here are some questions for you, my readers.

1. Should I expand the series on push versus pull supply lines? Almost all my points have already been pre-empted by Dennis Bours’ comments on the first posting in the series, so there it might not be much use to just rehash what’s already there. On the other hand, the comments might be a bit cryptic for non-insiders. So, it’s up to you: expand and explain, or go on to the next subject?
2. Are there any specific subjects that you would like me to write about? No, don’t worry, I have definitely not run out of ideas for future posts, but I might very well have overlooked some issue or idea that is very much alive amongst you.
3. Any other ways in which I can improve the blog and make it more helpful or interesting to you, or more attractive to new readers? E.g., I have been toying with the idea to introduce the occasional podcast or video – would that be a good idea, or definitely not? Other ideas?

So, this is your turn. Let me know what you think. The ball is in your court.

[Image: Tennis ball by Michal Ufniak]

The 1 million T-shirts saga goes on.

I really, really would wish that we could all just say that the T-shirt guys learned from what happened and we could move on to more rewarding issues. In fact, I thought exactly that had happened, and hadn’t spent even the shortest tweet on it for several weeks – and then they posted this blog post. Go and read. And cry.

Yes, that is right. They want to support what is probably the most badly conceived anti-child-trafficking initiative ever. I am not going to tire you here with why it is such a bad idea (others have done an admirable job on that, e.g. this post by Amanda Kloer, which was written well before the T-shirts ever came up). What I do want to draw attention to is that, evidently, Jason still has not learnt that it might be a good idea to stop and think before jumping off –  and preferably only do so while being informed by best practice and evidence.

Obviously, he was taken aback a bit by the criticisms and quickly took the post down, tweeting that he did so for ‘due diligence’. Perhaps it should be pointed out here that ‘due diligence’ is normally understood as something done before the proverbial shit hits the proverbial fan. If you do this afterwards, it is more properly known as ‘negligent laziness’.

And then Jason and Stephen write a follow-up post in which they try to explain why they posted their first one. And fail miserably. What they do bring across is that they feel that it’s all about them. Take this sentence, for instance: “It’s frustrating and disheartening when individuals with a great deal of experience in various efforts seem to get pleasure in crushing the energy and desire of people who want things to be better in the world.” Seriously? You think that people get a kick out of kicking you? Is that why so many people who can use their time in ways that are much more gratifying to themselves insist in trying to explain to you again and again (and again, and again) that it would be a good idea to ask questions before you go off on your next hare-brainwave? I mean, of course I have nothing better to do than spend an hour on writing this blog.

“The story we shared was simply that… a story. … We simply shared a story that we heard and wanted to pass it on.” Again, really guys? So I guess that’s why you decided to donate those t-shirts to ‘Bob’, because it was simply… a story. That you wanted to pass on. Without any suggestion that you thought it was a good idea. Tell me, what exactly is the level of stupidity you expect from your readers? And while you’re at it, if you only wanted to share a story that should not have any impact, could you please explain why you did not keep it for your next session with your drinking buddies?

This post is a serious break from what I have written before on gifts in kind in general and on the t-shirt saga in particular; both in content and in tone. First, I don’t only write about the issues any more, but also about the people behind it; simply because I think the people have now become the issue. A mistake can happen, and the people who make it usually go through it growing a bit wiser and more knowledgeable – and get my full kudos for learning from their mistake. You can even make multiple mistakes and still get my support – if you learn from it and don’t make the same mistake over and over again. However, you lose it if you don’t learn from your mistakes and not only insist on making us all go through the same sorry arguments over and over again, but in addition make clear that you haven’t even tried to understand the central issue: that it is not about you, but about the people that you say you want to help, and that consequently you have a duty to do your due diligence – and yes, that implies thinking and asking questions before you do something stupid.

Secondly, up to now I have tried to write in a fairly dispassionate voice. I have left that behind me too, because I have started to realise that Jason et al. are apparently more reactive (if not receptive) to snark than to reasonable discourse. Yes, they go through the motions of being nice, reasonable people who listen to what is being said, but this latest little jaunt shows that it is a front. They don’t listen, not even to the people they asked themselves to advise them, unless the message is hammered home with a sledgehammer. So I guess that is what we need to do. Sad.

[Image: Dollar Origami 4 by Piotr Bizior – www.bizior.com]

Ordering systems come in two basic flavours: push and pull, plus any number of hybrid systems. All have pros and cons, and each is most appropriate for a specific situation. In this first article in a miniseries on push and pull systems, I will discuss the basics: what exactly are pull and push systems and when would you use either.

Push versus pull

In the push model, “higher”, central levels decide on supply allocation for “lower”, local levels; these decisions are typically based on supply at hand and in the pipeline, and on calculated expected consumption – the latter often approximated, based on (in the case of medical supplies) patient numbers or population data. In the pull model, “lower” levels decide on the necessary supplies for the next supply period, which are then either procured independently or obtained/ordered from the “higher” level.

The basic difference between the two models is the responsibility for timely, complete, and accurate initiation of distribution: in the push model this is the “higher” level, in the pull model the “lower” level.

From this table, it will be clear that push systems are best used when pipeline fluctuations and interruptions are rife and unavoidable, when funds tied up in buffer stocks are not an issue, and when expertise is too scarce to be decentralised; and that pull systems come into play in the opposite situation.

Hybrid models: the best of both worlds?

Many commercial manufacturers use a hybrid system. E.g. when you order a Dell computer, your sparkling new machine does not come from stock but will be newly assembled; however, the parts (which are fairly generic and can be used for a variety of different models) are not ordered as your order comes in, but come from a pre-determined stock, the size and composition of which is calculated using expected overall numbers of orders for various models. Dell can do this exactly because many different models can be made from various parts.

We rarely use hybrid systems in global health and aid. In the next post in this series, I will look at the reasons why, and offer some ways in which hybrid models can help us solve some of our most pressing problems.

You have designed and implemented a pretty good logistics system and are proud of how effective and efficient your aupply line provides your programmes with any materials they need. Transport and administration cost are now at their minimum, fulfilment rates are close to 100%, and you process and fill almost every order within set timeframes. You feel pretty good about yourself (and not without reason), and are ready to hand over the system to your successor with justifiable pride.

And then the ministry of trade announces that as of tomorrow, clearing rules will be changed, adding three weeks to the current four to five days it takes you to clear your goods. Suddenly things look a lot less optimistic: your carefully balanced and trimmed-down supply chain is strained to the snapping point, and you are looking at having some of your key operations suspended. Even worse: one of those is a treatment programme for TB patients, and suspension of treatment might cause resistance to the drugs involved – making a bad situation suddenly look catastrophic.

What has gone wrong here? Of course, the ministry of trade is partly to blame here: changing rules on a day’s notice is bad governance any time. But a large part of the blame also lies with you: in your push for a lean, mean machine of a supply line, you neglected to take into account your environment and the risks it posed. In short, you built a fragile supply line.

Robustness of supply lines is generally important, but even more so when it comes to global health and aid: a supermarket might take the risk of an empty shelve, but an empty shelve in our case could cost lives. This is an important consideration when you build your risk management plan (which you did of course last year, immediately after reading my post on supply chain risk management): where a supermarket might choose to retain or transfer the risk, we will often have reduce it. Reduction strategies almost inevitably cost money: cost for storage, more expiries, more staff, and many other costs. A well worked-out risk management plan will help you explain why these costs are necessary, and that they do not mean that your supply line is in any way inefficient.

[Image: Crate containing Leg Lamp by J Stewart]