Thanks very much to Liz Igharo for organizing this blog and to Carolyn Hart (one of the people who formulated the initial concept for International Association for Public Health Logisticians (IAPHL)!) for kicking us off with some great reflections on the IAPHL community! In this second edition of the IAPHL blog, we would like to take a step back for some “big picture” thinking.
Under Administrator Mark Green’s leadership, the U.S. Agency for International Development (USAID) has embarked on a “Journey to Self-Reliance.”
“To end the need for foreign assistance, we must focus on building self-reliance — defined as the ability of a country, including government, civil society, and the private sector, to plan, finance, and implement solutions to solve its own development challenges.”
— Mark Green, Administrator, USAID
We see this as not only the current lens that USAID is taking in its development approach, but a framework that applies to what all of us, IAPHL members and the public health community at large, are collectively trying to achieve in our supply chain and logistics work. This is what we’d like to explore a bit further in this quarter’s edition of the IAPHL blog series.
The theory of change that underpins USAID’s Journey to Self-Reliance approach is based on two factors: commitment and capacity. Commitment is “how well a country’s laws, policies, actions, and informal governance mechanisms — such as cultures and norms — support progress towards self-reliance.” Capacity is “how far a country has come in its journey across the dimensions of political, social, and economic development, including the ability to work across those sectors.”
USAID developed this approach as a guide to envision the journey forward and inform strategic decisions. Likewise, this thinking can be informative and useful for supply chain managers and practitioners. But what do these elements mean in the context of public health supply chain and logistics?
If you were to ask yourself whether “commitment” is being demonstrated or achieved in the supply chain(s) you are working on – where would you even begin? Would you know how to answer that question?
We suggest you consider both: (1) domestic resource mobilization — meaning is the national and/or sub-national government contributing an increasingly more significant portion of the public health commodities and supply chain operating budget? and (2) governance — in this case, how the supply chain is governed (across the commodity procurement and delivery cycle), and what position supply chain operations hold within the broader public health sector.
Domestic resource mobilization is about whether public health commodities — and their delivery to clients — are prioritized when it comes time for a government to make decisions about resource allocation. This could look like specific budget lines for health commodity procurement, or including coverage for medicines in public insurance schemes. But we cannot forget that funding the purchase of medicines does not necessarily cover the cost of the work it takes to get them to the point of delivery. Every IAPHL member probably understands very well the costs of operating a supply chain AND that the public health supply chains in low- and middle-income countries (whether publicly-operated, outsourced to the private sector or some combination of the two) are often underfunded. True self-reliance requires that countries have the means and the mechanisms in place to direct necessary resources toward ensuring adequate quantities of medicines and public health commodities are consistently accessible and available.
Governance is really an issue that relates to both commitment and capacity. What truly matters is how oversight of supply chain operations — and ultimately supply chain performance — is positioned within the national public health administration. The capacity of a government to operate effectively in so doing is a key metric in measuring a country’s progress toward self-reliance. Both the commitment to and the capacity for good stewardship and management by the government are critical signals as to whether a country is becoming more self-reliant in regards to its public health supply chains. And the lack of either is a key red flag that more focus on governance is needed.
The Journey of Self-Reliance talks about capacity as a country’s ability to define and manage its own development journey. UN agencies similarly describe capacity development as a process through which countries obtain, strengthen and maintain the capabilities to set and achieve their own development objectives. Both of these visions empower countries and country systems by putting them in the lead, rather than seeing capacity as something “built” by external actors. Both visions also recognize that capacity development must occur at different levels (e.g., individual, organizational and societal levels) and across different sectors (public sector, commercial sector, civil society, etc.) to be successful.
Are these broader notions of capacity relevant to global health supply chains? We think that the global health supply chain space has made impressive progress in this area. In the supply chain space, we identify and address our supply chain challenges through comprehensive strategic plans for the whole supply chain system (we could do more to implement and monitor them effectively). We have moved beyond one-off training as the primary approach to overcome capacity gaps among staff, and instead strengthen the supply chain workforce from a human resource systems perspective. We use non-traditional mechanisms like IAPHL to share knowledge and build each other’s capacity. We go beyond treating symptoms of deep-rooted supply chain challenges with more inputs (e.g., build more storage space if there isn’t enough warehousing; set up a vertical information system if we aren’t getting the data we need through the national system) and instead attack the root causes that lead to those symptoms (e.g., increasing the speed of products moving through the supply chain to reduce inventory holding; changing incentives and improving usability of information systems to facilitate data reporting and use).
For sure, there is much more we can do. Many of these advances have occurred in some countries, but not all; we are still guilty of having a very public-sector focused approach; we often look at supply chains as separate from the rest of the health system; sometimes the supply chain-perspective loses sight of the client and patient perspective. But, with the commitment and cooperation of key stakeholders and with motivated champions like the IAPHL members, we will see that more and more countries with the capacity successfully ensure access to medicines and other health products for all.
WHAT DO YOU THINK?
Do you think self-reliance is an important objective for public health supply chains? What specific metrics might measure progress along the Journey to Self-Reliance for a public health supply chain?
Bridget McHenry and Kevin Pilz are advisors in the Commodities Security and Logistics Division in USAID’s Office of Population and Reproductive Health. Click here to see how USAID’s supply chain heroes are making a difference for the lives of women and girls in Rwanda and further that country’s Journey to Self-Reliance.