On March 12th, 2014 IAPHL launched a moderated discussion on the challenges members face related to rural transport logistics. The difficulties associated with managing vehicles in rural areas were considered, along with personal experiences and best practices. This discussion was facilitated by Matthew Hahn of Riders for Health. A summary of the discussion is below:
Original message: Improving access to health care (or any service) in the most rural communities of Africa is an important area of work for many of us. Much of the current debate centers around how we can use cell phone technology. While this has a crucial role to play, the one are that is always left out of the debate is how you actually run vehicles in a reliable and well maintained way so people in remote places can always be physically reached.
Riders for Health works with ministries of health and local and international NGOs to manage and maintain vehicles, especially those used in rural areas to deliver health care. Managing vehicles in this way has been our focus for over 20 years.
We are very interested to hear of other organizations’ experiences in running vehicles, especially in rural areas. To start the discussion I would just like people to share their experiences of how you and your organizations use transport in your daily work.
- How much of your work is dependent on transport?
- What are the vehicles used for?
- To what extent does the transport you use run in urban, peri urban or rural areas, and which of these provides the greatest challenge
“Transportation to the most peripheral facilities in the least populated/low volume areas is generally more costly per unit or unit-value shipped, and these types of destinations usually have the fewest options in terms of transport. In addition, these kinds of destinations are more likely to have seasonal transportation disruptions like flooded roads in rainy season as well as other infrastructure issues like weak telecommunications service. And the sites themselves generally have the fewest staff and the smallest budgets so they may be the least equipped to manage their own transport. On the other hand they also generally, have a more restricted range of services. I’d be interested to hear what people have to say about delivering goods to this critical but particularly hard to reach segment. “
(John Durgavich, USA)
“While rural transport is more difficult for the reasons already discussed in this forum, in my experience what’s more important than rural versus urban is vehicle management. Where there are strong management systems and managers, transportation systems are worse. Additionally, the lower in the health system the transport needs are, generally there are fewer resources available and more diffused management structures. One strategy to deal with this is to centralize vehicle management in strategic locations. This doesn’t work for all activities for which vehicles are needed, but where it does make sense it offers the possibility of stronger management systems and dedicated resources. Several of the examples Caroline cited use this strategy.
This is the strategy I am using in my current work with the Informed Push Model (IPM) in Senegal. Additionally, the project outsources the transportation to 3PLs who deliver family planning products to all health service delivery points – urban and rural. Currently they are delivering to 1,000 service delivery points in 7 of Senegal’s 14 regions. Interestingly, in this strategy the rural regions are not always the most expensive on a per service delivery point basis as the cost relies on the service providers available and their cost structures. Using the 3PLs allows us and the Ministry of Health to be free from time-consuming operational activities such as route planning, procuring fuel, maintaining vehicles, etc. However, outsourcing does require a management and supervision structure to maintain the quality of services and ensure that performance based pay clauses are followed. Centralizing the transport activities at the regional level simplifies the required management and supervision and helps keep the costs low, and in the case of family planning product distribution this centralization makes sense.”
(Leah Hasselback, Sénégal)
“I think a contributing factor to the reluctance to use 3PLs is that using 3PLs moves people away from an area they are more comfortable or more experienced (managing a fleet of vehicles) into an area where they are less comfortable or less experienced (managing a performance-based contract). A solution to this would be education as to what 3PLs are and what benefits they provide, but also education on how such arrangements need to and can be managed.
A good analogy, I think, would be a child’s education. Parents are usually comfortable sending their children to school where the teacher (a “3PL” whose core business is teaching/education) educates the child, yet the parents do not (or at least should not) completely ignore any aspect of their child’s education: they check in with their children to see what they are learning, they check in with the teacher/school to see how their child is doing, etc. In the same way, the MOH would supervise, monitor and constantly assess the performance of the 3PL, ensuring that they are meeting their obligations and fulfilling their responsibilities.”
(Gregory Roche, Zimbabwe)
“Although it’s not a solution in all cases, outsourcing transportation is like hiring a specialist to do a task where I don’t have the skills or a constant requirement for a particular type of equipment. Let’s say my job is to move a total of 75 cubic meters once per quarter from a central store to three regional stores. I’d need an 8 ton truck to haul a 20′ container for two weeks to move my three 25 cbm loads. I don’t need to own an 8 ton truck or have a FT driver to work for 9 days and idle for 35 days. If I want my teeth cleaned every six months, I’m going to go see a dental hygienist -not buy a set of dental picks and a sterilizer. If I need a course of cotrimoxazole, I’m not going to compound it myself using a recipe off the internet.
However, the decision to outsource (or not) should not be based on preference or intuition, but on an analysis of the requirements and intended benefits, the funding, the human resources and other costs associated with the transportation to be managed. “
(John Durgavich, USA)
“Some observations that many will find familiar:
Separate fleets and limited coordination across supply chain levels Transport fleets operate independently at national, provincial, district levels. The operational budgets and assets are unique to each layer. Freight carrying at the upper levels of the supply chain (CMS ->provincial depots) typically involves 10-20 ton vehicles, while most district trucks are no more that 2 tons.
Provincial and district fleets operate at less than official capacity. There are significant differences between current official book values of transport assets (which includes dead, parked vehicles) vs. values based on functioning vehicles. In a number of cases we saw actual fleet capacity at 15-25% of the official capacity. The districts do not own the expired vehicles so they can’t sell for others to repair or for scrap.
Rolling fleet capacity is being limited by delays in funding approvals for both regular scheduled maintenance and repairs. This is not a small problem … delays in release of funds may be as much 3+ months. The lower down you go in the supply chain, the more chronic a problem this seems to be.
CAPEX not available for province, district fleet development The addition of new/used vehicles to provincial and district fleets is very rare. There are few examples of capex budgets being allocated for provinces or districts. Many districts are only seeing new vehicles as a result of new program initiatives – the aging fleets inevitably result in higher costs of maintenance.
As a result of the above pointing to limited fleet capacity, province->district & district->health center distributions are often conducted on request-basis only. In these circumstances, non-freight vehicles – ambulances – are used to carry commodities.”
(John Beale, USA)
“Across this tapestry of different experiences and capacity, we do however find a few constants when we look at outsourcing. We have come across multiple consultant reports (and we may have been guilty of this historically) which focus on the economic and operational argument for outsourcing but provide little or no advice on how the process of outsourcing should be undertaken. This process needs to be considerate of how countries should offload/transfer their transport assets, relocate/reallocate staff (which can be difficult in civil services anywhere), pilot specific routes to get experience before diving in to a national change etc. We regularly face directors from central medical stores who fully understand the economic argument, but are at a loss as to how to start the outsourcing process. (We should also recognise that no matter how accurate the consultant’s models the cost-saving estimates are still estimates and need to be calibrated through pilots).
There is a lot of pressure to get medical stores to outsource transport, and to do it quickly. In our opinion a good approach is for medical stores to start trialling outsourcing on specific routes in order to gain experience around costs, service levels, contract management etc. This would be in-line with how large western retailers transitioned to using outsourced transport in the 90’s. This would be better than advocating for “all or nothing” which we sometimes see.”
(Caroline Barber, UK)
“Almost everyone mentioned that transport in rural areas was more challenging than anywhere else, which was exacerbated by the fact that the further down the chain vehicles were needed, the less resources they had. My colleague from Lesotho pointed she finds it challenging when people begin projects in rural areas want to see quick results, and reach many people within a short time, despite the fact that it could be more expensive and time consuming to reach a smaller number of people in rural areas.
Several contributors reported that vehicles in rural areas were more likely to suffer mechanical breakdown and downtime, and that it was often the case that there were often far fewer vehicles actually in operation than officially listed, or vehicles such as ambulances had to be diverted to act as delivery vehicles. This is something that we have routinely come across.
Several contributors went on to look at the merits of outsourcing transport to 3PL providers, who are able to bring vehicles management skills and allow ministries of health to focus on the delivery of health care, and there was some good advice for how we can best market these services to organisations who might be reluctant to consider outsourcing.
But I think the most important point raised was that whatever vehicle is being used, and whatever system for managing them, the thing that underpins any successful programme is adherence to the principles of basic maintenance, financial management and operational management. Unfortunately, in our experience while there is a growing acceptance that vehicles need to be purchased, these underpinning management structures are forgotten, which results in the failure of vehicles mentioned above.
(Matthew Hann, UK)
“Invariably when a local 3PL looks to take on this type of operation, it involves more work. Consequently they need more labour/drivers. An obvious area to explore is the transfer of staff across to the 3PL company. I appreciate that T&C’s can be an issue but it is an option to look at. In the respect of the remaining assets, a lot will depend on the state of the vehicles. They could be considered as part payment against the costs to be presented to the customer. This would allow the transport company to expand their fleet on a structured repayment plan that is agreeable to both parties. This can be a win-win scenario, with both parties achieving their goals painlessly. It is often the case of looking for options outside of the box. Often is the case that mainstream commercial solutions have to be considered in order to get the answer you often seek.”
(Paul Forbes, UK)
“In many cases, outsourcing is implemented without consideration to TCE as this might not work effectively due to the exigencies at the local level ie available range of vehicles an expertise.
Organizational structure as to the placement of the transport function is very crucial in this situation. To effectively realize the gains in a structures SC, transport is a key function that must come under the SC Manager. In most national organizational structures, transport is seen as a separate function from SC and which makes it difficult for SC Managers to perform their roles effectively. That is, the warehouse manager now has to virtually in some instances ‘beg’ transport managers fir vehicle to move supplies. As it’s been said by a colleague, that the vehicle has been given out for another assignment which may not in anyway relate to movement of goods or even official duties.
Yes, we can use 3PL in addressing some of these issues, but this should be done on country-by-country basis. Some countries with good fleet of vehicles can be urged to merge SC and Transport in order to make some progress. Countries less endowed can therefore use 3PL as their systems are not well developed.”
(David Duke Nyarko, Ghana)
“It is worth noting however that the more money is spent on preventive maintenance the less money will be spent on repair (breakdown) maintenance. So if our finances fail to meet the PPM obligations then they fail far too much to meet the repair maintenance obligations. So the situation seems hopeless……..!
If there can be consistent flow of adequate financial resources, PPM schedule can be well followed which in turn will reduce the costs of repairs. We thus conclude that having adequate finances helps reduce costs.”
“In Mozambique, we are working with the Ministry of Health for vaccine distribution. Previously, distribution followed administrative tiers, from national to provincial level, then to the districts, which then had the responsibility to deliver to the health centers. This means that in a province with 10 districts, for example, they would need 10 vehicles for delivery to the health centers. This system faced all of the challenges each of you has pointed out with vehicle maintenance and funds availability for fuel.
Now, in four provinces with an optimized distribution system, the government uses three dedicated vehicles and personnel in each province to deliver from the provincial level directly to the health centers. Each province is divided into three zones, following more efficient transport loops that ensure delivery to the most rural areas. This has reduced the number of vehicles, maintenance and fuel required to reach the last mile of service delivery.
Of course, maintenance is still required and financial flows continue to be a challenge. But this is one way Mozambique has found to minimize those challenges.”
(Wendy Prosser, IAPHL member)
“I think for the long lasting solutions we need to have alternative approaches in conducting our businesses for instance nowadays we are advocating Cascade supervision in which the team from the District headquarters uses a vehicle to supervise the people at the Health center who in turn supervises the people at the Dispensary using motorcycles. This somehow reduces a cost by having minimal mileage for vehicles and also cheap to have PPM for motorcycles. Although the challenge behind this model is that; you need skilled health care personnel at each level of health care.”
(Ntuli Kapologwe, Tanzania)
I want to give two examples of where we have been able to work with partners to implement successful vehicle management systems for health providers.
Where Riders for Health is proving a full service leasing model in The Gambia, we are showing that ministries of health can provide a more reliable service to their whole population, based on a fully managed and reliable vehicle fleet. It allows us to carry out outreach, emergency transfers, logistics and deliveries. Since 2009 our fleet there has travelled over 10m KM with no preventable breakdowns. The mix of motorcycles and emergency referral ambulances and trekking vehicles mean that each health centre has the mix of vehicles appropriate to them.
In Lesotho we worked with partners to develop a system of motorcycle couriers for medical samples in rural areas. This system has now been successfully replicated in several other countries. Both of these examples are based on systems of preventive maintenance, and outreach servicing – taking our technicians to the places where vehicles are operating, rather than needing them to visit a central workshop.
You can find out more about Riders for Health and the different systems we are implementing with our partners on our website, http://www.riders.org/what-we-do/our-services.
Riders’ work has been featured in several academic publications and in research case studies and we have presented our monitoring and evaluation data at a number of conferences. You can download these case studies and abstracts here: http://www.riders.org/research.”
(Matt Hann, UK)