On April 14th, 2014, IAPHL members discussed human resources (HR) as a barrier to effective health supply chains. This conversation was facilitated by Pamela Steele, director and principal consultant at Pamela Steele Associated (PSA) Ltd, a consultancy specializing in supply chain management in the international development and humanitarian sectors. This discussion served as the first in a series of three on HR as a barrier to supply chain management effectiveness, existing solutions, and potential educational approaches.
Original Message: “The discussion for week one focuses on the challenges faced by the public health supply chain workforce. We will take an in-depth look at how your greatest SCM workforce challenges impact the functioning of health supply chains and ultimately health programs. During week two and three of our discussion, we’ll consider ways to address these challenges in a systematic way.
It will be good to know your general thoughts on this topic from your contributions to the discussions. The question for today is:
*WHAT WORKFORCE ISSUES AFFECT YOUR PUBLIC HEALTH SUPPLY CHAIN AND HOW DO
THEY IMPACT THE AVAILABILITY OF GOODS?*
Please *read the attached one page background document* before you contribute your own thoughts.”
“One thing to add on the performance aspect is the motivation of health workers to engage in supply chain management activities. For example, in consumption-based distribution systems that we have seen, health workers will complete requisition forms to submit to the higher distribution level, but then will receive only a fraction of what they requested without any explanation of the reason why. This results in deprioritizing quality data for requisitions as the information is not actually used at higher levels of distribution.
Another thing to consider is the system in which the health worker is working and how his/her terms of reference fit within that system. A specific example is of a distribution system that is designed to follow administrative tiers for distribution–from the national level to the province/state, then to the district/county. At that point, it becomes the district’s responsibility to deliver to the health centers. Oftentimes, the district does not have the resources (personnel, vehicle, fuel, per diem) to ensure the commodities are delivered to the health centers. In this situation, the system becomes more ad hoc, depending on the motivation of the health worker to arrange transport and time away from the health center to fetch medicines from the district level. Fetching medicines from the district is out of the scope of work for the health worker but is necessary for the functioning of the health center. Consequences are more frequent and severe stock-outs, lost opportunities for care when a nurse is fetching commodities, and even less supervision at the health center level as no one from the district is visiting for distribution.”
(Wendy Prosser, U.S.)
“The paradigm shift of the health supply chain from a small store room management to a supply chain management concept introduces a new dimension of management challenges. The focus is to ensure sustainable and stable supply system and the components of SCM strengthening is the whole purpose of the existence of this forum. The SCM concept has diversified the need of specialized skills and knowledge to manage it effectively in the public health sector system. It is no longer the role of a pharmacist but a SCM expert.
The SCM expert needs to be professionalized to ensure that its existence in the system carries value therefore impact the health outcomes…
Pharmacists can provide the technical assistance to the SCM to ensure compliance to the regulation however the right to manage SCM needs to be left with the qualified SCM.”
“If we look at the supply chain management that covers 4 principle phases from USE —>SELECTION—>PROCUREMENT—>DISTRUBUTION—->USE. This drug management functions are undertaken in four principal phases, which are interlinked and are reinforced by appropriate management support systems. One of the management support systems which strengthen this process is HR.
There is a serious shortage of health workers across the world and has been identified as one of the most critical constraints to the achievement of health and development goals. The crisis is impairing provision of essential, life-saving interventions such as childhood immunization, safe pregnancy and delivery services for mothers and access to prevention and treatment for HIV/AIDS, malaria and tuberculosis and other chronic/complicated diseases. This links this discussion to the availability, affordability, and accessibility of medical supplies. When there are no medical supplies, there is no programme and no services.
There is a general lack of adequate staffing and adequate training provided to staffs to make them competent in the area of SCM. To add further pressures, country priorities focus more on disease programs leaving SCM to lower priority. The pull of higher salaries in industrialized countries and the push of poor working conditions at home drive thousands of health workers to jobs abroad each year hence leaving a vacuum on SCM role for that respective countries. Yet developing countries face an escalating double burden of both infectious and non-communicable diseases and are in need of massive scale up of training and retention interventions and adequate staffing.
Moreover, the unfavorable working conditions, widespread shortages and large scale migration of health workers are the challenges we face today. How can we give people the care they need if we don’t have enough health workers to take care of an effective SCM that will supply them will safe, quality and effective medical supplies?”
(Azalea Raikabakaba, Fiji)
“In addition to the several key issues raised in the attached useful article, I think that the evolution of the supply chain function in many countries, especially in the so-called resource-poor settings, has been such that the function is seen almost entirely as an administrative one, requiring little or no specific training and, therefore, further HR investment is needed.
Unfortunately, the rate at which it has been shown, through research and hard evidence, that inefficiencies in the health system can be significantly attributed to leakages in the supply chain, has been much faster than the rate at which steps have been taken to strategically and operationally correct the above fallacy that SCM is simply an administrative matter…The bottom line seems to be that the more we as a community are able to document and show that SCM brings value, and that only with appropriate training and experience can performance charters be delivered upon, the more the future will hold bright for our contribution to service delivery generally.”
(Murtada Sesay, Sierra Leone)
“In a consumption-based system, you need to have not only staff commitment but also qualified staff and in the required number to be involved in supply chain activities. At the regional or district level where you have pharmacist or pharmacist-assistant you can be assured at least that the order will be more accurate as they are trained… I think to have pharmacist-assistant at primary health care will help improve the supply chain.”
“Today we move on to question two, referring still to the same background summary document which was sent with the first question and the question for today’s discussion is:
WHO ARE RESPONSIBLE FOR SUPPLY CHAIN FUNCTIONS AND FOR DECISION MAKING AT EACH LEVEL OF YOUR PUBLIC HEALTH SUPPLY CHAIN?”
(Pamela Steele, U.S.)
“While there are individuals and departments responsible for supply chain functions and decision-making at the various levels of public health supply chains, I’m also curious to know: *Who is responsible for the overall functioning of your public health supply chain? Is there anyone who is responsible for ensure that the entire supply chain system is functioning adequately?*”
(Bridget McHenry, U.S.)
“In my opinion, one of the major reasons for erratic supply of health commodities in many developing countries is due to lack of adequately trained human resource on health supply chain management. In Ethiopia, pharmacists are highly involved in the management of health commodities. Nine years back graduates of the school of Pharmacy had no courses directly addressing health SCM in their curriculum but now attempts are being made to include SCM courses with reasonable credit hours in the harmonized curriculum in the country. As a result, I am observing improvements in the health SCM practice but I feel that the course coverage is still insufficient. Besides, it lacks hand on experience; getting the right experts (academicians) who specialized on health commodities and SCM, and retaining these highly trained academicians is also a big challenge.
Recently, the quantity, value, and complexity of health commodities flowing through public health supply chains in Ethiopia have increased more than ever. I believe this trend will continue for the subsequent years too. Partners and government have also been trying to fill gaps of their employee through in-service training but it rarely includes academicians. This ignorance to the academic sector contributes for the disconnection between the pre-service training and the real practice on the ground leading academicians to be theoretician than problem solvers.”
(Dawit Teshome, Ethiopia)
“In developing countries like here in Papua New Guinea (PNG), where supply chain functions are still very much labor intensive, from top to bottom, the placement of appropriately trained supply chain individuals at critical points of the supply chain becomes very necessary.
Many countries within the region and maybe elsewhere, do not necessarily think this is a priority and focus mostly on investing in other cadres of health workers, nurses, doctors etc. Maybe because those of us responsible for flagging this important agenda, are not doing enough to get this agenda on the table for deliberation and pushing it to policy and decision makers… One point that comes out very clear from this is that, we have been spending too much money and time on training the wrong cadres of health workers such as nurses, who have other primary duties and spend very little to no time on supply chain management.
The results of this approach, is that we continue to have issues with inventory management, ordering, storage, and ultimately stock outs and or expiries.
Although, we may not be able to place pharmacists and logisticians at all points where we want them to be, at the Central Level, the Department of Health has begun talks with a local university here to develop curriculum for the training of Pharmacy Technicians and Logisticians. It is anticipated that, when these people get trained, they will be posted to lower level health facilities, alongside nurses to perform supply chain functions. Meanwhile, the Central level here is hard at work with provincial authorities to map out requirements and create positions for these graduates. Though this approach is still in the pipeline, we are very optimistic that, if all goes to work, we may see positive results in the long term.”
(Graham Wavimbukie, Papua New Guinea)
“I found that adding the reporting of last’s month usage to the stock replenishment requisition, therefore having a 2-in-1 form for 1/ requisition (supply chain) and 2/ usage (M&E), helps staff to think again about the direct “linkage” of both, and increase work quality and prevent mistakes. It is also a huge incentive for on-time reporting of M&E data.
Task segregation (supply chain vs. M&E staff at the local and central levels) has de-linked them unfortunately. The fact that the GFATM has 2 segregated PSM and M&E hubs and therefore 2 sets of specialists does not help either.
It is controversial as well, but there is obviously a chain of supply for data (often, in the reversed direction of the chain of supply for products – a good example is stock replenishment requisition). Why could not it be included in the task of supply chain staff ? In 2006 at the MBA of Supply Chain in Michigan State University, this concept was already being thoroughly discussed for the service industry (therefore without chain of supply for products).”
(Pierre de Vasson, Canada)
“The solution does not only lie in creating a new SCM cadre outside the pharmacy framework. Pharmacists can still form the pivot point around which SCM professionalization is centered. Whereas SCM does not equal pharmacy practice, the practice of pharmacy should not be immune to change.”
(Dr. Lloyd Matowe, Program Director, Pharmaceutical Systems Africa)
“Indeed a supply chain operation has internal and external stakeholders, and various activities going on within different supply chain elements. Supply chain does not happen by itself, it has to be directed, for a lack of a better word….or ‘orchestrated’ (by) a conductor, what is known as ‘coordination’. Unfortunately not everyone who is involved in part of supply chain realizes that they are part of a whole. Also many who should be part of a national supply chain resort to silo systems that do not communicate with each.”
(Pamela Steele, U.S.)
“Whatever responsibility one assumes or is assigned to us, we should always ensure this is clearly documented in a job description, and aligned with the overall organizational goals and related work plans. This also means that we should be ready to account for that responsibility within an appropriate appraisal framework, usually on annual basis”
(Murtada Sesay, Sierra Leone)
“One way could be to simply train them in short trainings to make them aware of the complexity of these supply chains, and of the impact they as decision takers have on these supply chains. It would be quite easy to show a number of cases of how different decisions at Government and Donor level have had impacts which really was very costly or problematic.
The purpose of such short trainings should not be to make them professionals in two days in the field – but to make these officials from government and donor side better decision takers, as they would have an improved insight in the implications of their decisions, and a better understanding of why professionalism is needed.
It would be possible to give them an idea of the bigger picture – effect of procurement process, lead times, policies when choice of drugs are changed, the effect of variations in funding. We have been drafting such a training.”
(Per Kronslev, IAPHL Member)
“In my view, having the right professional merely doesn’t guarantee for effective execution of the required responsibilities. Here, it is customary to recruit and employ fresh university graduates for health supply chain activities in majority of governmental health facilities. Obviously this would take some time to train and bring them to the desired perfection in executing their responsibility. Once they become experienced and well equipped, retaining them for long and plan strategically is the most difficult task. Unattractive salary, high brain drainage, and lack of incentives and double standard among professional are some of the reasons.
In short, public health facilities are almost becoming a training center staffed with either inexperienced or less competent persons.”
(Dawit Teshome, Ethiopia)
“We all agree that ‘One size fits all’ approach would not work to address this Global HR issue in EPI as it requires identifying EPI background within that Country (as per maturity/focus level), level of Operational issues due to Logistics / SCM trained persons, existing process flow to propose customized solution to Govt. in a phase-wise manner.
Existing adhoc mechanisms of managing SCM by Pharmacy / Nursing professionals may not be sustainable as SCM too is a science hence short term methodology could be to have regular trainings & recognition of existing staff (including incentivisation & freeze role), long term could be to add SCM topic in Pharmacy / Nursing courses.
The Ministry officials of Country need to be sensitized on how ‘this Operational gap’ is affecting overall coverage and then customized solution needs to be designed as per priority.”
(PRASHANT TEWARI, India)
“We have been investing billions of money in improving availability and access to essential drugs and commodities by procuring these, but putting peanuts for its management including that of investing in strengthening warehouses and strengthening HR component (training & capacity building on SCM, strengthening monitoring mechanism, creation of special cadres of SCM professionals, attractive package etc.).
As per my experience in PSCM in the context of India, this area has always been a neglected area due to lack of politico bureaucratic interests, lack of accountability in the part of people managing SCM and good leadership. Now there is a significant shift in the approach. After decentralization of procurement & SCM, various state Governments are pushing forward to strengthen their Procurement & supply chain management (PSCM) system by establishing Medical corporations, creation of special cadres for handling PSCM at state level (though on contractual mode) bringing in more professionalism, development of infrastructure including warehouses, strengthening LMIS to give information on real time basis and integration of PSCM with prescription practice.
It needs a systematic approach. At the moment even though these cadres are being created at state level….it could be further strengthened by engaging young pharmacy graduates/Science graduates etc. with proper training on PSCM & QA to manage the district stores including managing forecasting, storage, distribution, ensuring QA, rational use, etc. and needs to be supervised on a regular basis to further strengthen the SCM. Apart from this, they need to be well paid including provision of performance based incentives, training for upgrading their skills, promotions etc. This is more so important because at the moment there is no special cadre on PSCM except store officer/store in charge (either pharmacist/general undergraduate/graduates) who have been managing the stores for a long time without any formal training on PSCM including that on forecasting, procurement, supply chain etc. which leads to poor management of essential drugs and commodities which often leads to stock outs, overstocking, expiry etc.”
(Nilakantha Bhoi, New Delhi)
“I have seen a common topic on the lack of skills and inadequate training and the differences between the experiences of SCM experts and those of pharmaceutical experts doing SCM jobs. I have found from my experience that being a recent graduate and wanting to start a career in SCM, it’s very difficult given that many of the organizations want/need the experience that only fieldwork can bring and not necessarily the research at universities. However there is a lack of programs for graduate students to transition into the field and thus be able to contribute to the need of skills and capacity in the field.
Providing effective training it’s an important change; moreover, it is the need to expand opportunities for new generations to learn and thus utilize the skills from school into the field and improve in a sustainable manner the current needs and future needs of SCM.”
(Tatiana Viecco, United Kingdom)
“A lot of issues have come out of this touching on SCM organization and those responsible. We have learnt that some set-ups are divided into central, provincial or district roles, and further into different functions such as procurement, etc. Some have no SCM department while in other set-ups the Central Medical Stores are responsible for distribution of health commodities up to the facility level. In some countries supply chain functions are located in various departments regardless of whether they have anything to do with it.
A contributor raised the issue of responsibility and accountability and wondered who has oversight of supply chain operations at all, be it at national, provincial and or even at district level who can be held accountable but also to ensure operations are going according to plan, supply chain departments/units or functions are working in tandem and communicating with each other-charring relevant and timely information.
Someone in charge of supply chain team performance but above all one capable to represent supply chain interests at a strategic level, like at board level.
We’ve learnt that in some countries it’s the pharmacists or their assistants or nurses who are responsible for supply chains activities and that many do not think that supply chain is important to warrant attention.
Another contributed raised a very important point that SCM cadre should be created outside pharmacy framework, to which another contributor added that it is important to have a good balance of those qualified and skilled for different levels (strategists and doers)- citing that professionalizing supply chain should not aim only at creating high level courses to Msc levels in SCM, rather that it should encompass all chores along the chain from central to the periphery ( lower qualification cadres)-meaning that they should not all be at a ‘captain’ levels but to include ‘foot soldiers’ or ‘front line level’ staff who can be relied on to make things happen.
I’m sure we can go on discussing this question until the cows come home, so I will put a stop to it. If you have any more to contribute to it then send them directly to me I will include them in the final summary of all the discussion for from this week.
Today I want us to discuss our third question which is:
*HOW ARE THOSE WITH RESPONSIBILITY WITHIN THE PUBLIC HEALTH SUPPLY CHAIN EQUIPPED TO FULFIL THEIR SUPPLY CHAIN RESPONSIBILITIES?*
(Pamela Steele, U.S.)
“Currently, people who are responsible from national to central store to hospital to health center and to nursing station in my context are deficient with the competencies I.e. Skills, knowledge, resources, time, numbers, consistency. Why? The system lacks to recognize that the current people (and number) that manages it (nurses, pharmacist, Dr, Lab tech, biomedical technicians, etc ) their role and scope of services to be responsible for has increased due increased universal attention to public health programs.
The shift of the responses to the public health needs have somehow increased triple fold (understatement) with focus more on the technical competency such as up skilling of Drs, nurses, improve facility, strengthen health promotion and so on. A successful public health program for any settings must depend also on a competent and effective logistics system which are currently lack universally.
They are not equipped with the right numbers.
They are not equipped with the right attention from the executives because executives are not equipped with the right understanding of SC.”