The latest piece in our thought leadership series – Stronger together: Health supply chain voices – comes from Rebecca Alban, senior manager and team lead at VillageReach. She explains which investments represent best value for money for countries and donors.
In this period of aid reduction we – VillageReach – like many organisations and donors, are pivoting our ways of working to ensure the initiatives we support are catalytic, impactful, cost-effective and can be sustained by country-level partners or governments (not by VillageReach).
Which approaches offer countries the greatest impact and donors the best value for money? Which initiatives work but are not viable for scale? Based on these reflections here are our top recommended supply chain investment areas for donors and governments to prioritise. Our recommendations consider cost, potential and demonstrated impact on supply chain processes and effectiveness, as well as practical considerations of government ownership and stewardship.
Based on VillageReach’s extensive experience with governments, the private sector and other implementing partners on various supply chain integration efforts across Africa, we suggest the following supply chain investment areas be prioritised to yield strong, people-centred, sustainable supply chains:
- Engage the private sector to improve efficiency
- Increase supply chains to extend beyond health facilities and reach CHWs
- Enable data visibility and use across the supply chain
- Facilitate thoughtful, deliberate transition of supply chain initiatives to governments
The role of an adequately-staffed, skilled and motivated workforce is crucial to health supply chains that deliver for patients. Investments in workforce development will be needed to sustain advances that have been made in supply chain performance and to make gains in the areas below; workforce capacity is integral to outsourcing and improving data quality, while effective leadership is needed for governments to take ownership of supply chain initiatives. As for community health workers (CHWs) – we need to ensure they are salaried, skilled, supervised and supplied.
- Integrate outsourced transport into public health supply chains
Successfully managing public health supply chains (PHSCs) requires developing and expanding government-run logistics units. This means hiring and retaining specialist staff, investing in IT systems for supply chain visibility and making large capital investments in vehicles, warehouses and cold chain infrastructure. This in-house approach not only requires significant resource mobilisation; it also requires significant time to create new positions in ministries of health (MoH) and to attract and maintain specialised talent. Sustaining such systems without consistent donor support has proven challenging in many LMICs.
Government collaboration with the local private sector offers significant potential for sustainable development in Africa. Private sector companies have expertise in areas such as data analytics, transportation and warehousing operations, and cold chain maintenance. They hire and train people with these specialised skills and they invest in the infrastructure to maintain vehicles, IT systems and tools. Additionally, when governments leverage the local private sector to provide these types of products and services for public systems they are also contributing to the growth of their economies. When African governments strategically plan and manage outsourced logistics for PHSCs, we see improved performance, efficiency and sustainability.
But outsourcing only yields results if governments have the capacity to manage, contract and ensure accountability from providers. Donor and government collaboration is required to catalyse successful private sector engagement. Recommended areas for catalytic investment include:
- Encouraging public-private collaboration and competition through catalytic funding
- Building government contracting and oversight capacity
- Attracting local logistics providers through improvements such as including clear service standards and contract expectations using available tools such as the Global Fund Outsourcing Guidance
- Adopting digital tools for logistics performance management. Governments can begin with simple dashboards or open-source platforms to monitor delivery performance, costs and stock availability, and scale up as resources allow
- Leverage existing guidance and resources on outsourcing in PHSCs from People that Deliver (PtD), ARC, Gavi, USAID and VillageReach’s Outsource Transport Resource Center (OTRC)
- Support the development and maintenance of digital systems (eLMIS) to provide timely and accurate supply chain data
Introducing or enhancing an eLMIS in a country’s health supply chain is critical to improving the collection, analysis, communication and use of accurate data for effective decision-making. Without visibility into essential data elements such as product location and movement, the rate of consumption and use, and stock levels throughout the system, countries are blind to the risks of stockouts or expiry. eLMIS data are the “source of truth” that governments and partners depend on to make decisions and are essential for quantification processes and for planning distribution along the supply chain. This visibility helps ensure the timely delivery of essential medicines and supplies, and leads to better patient outcomes. eLMISs improve efficiency by automating manual tasks and can reduce costs by improving supply planning, thus reducing overstocking, holding costs and wastage.
While many countries’ systems are supported at least partially by donor funding, efficiencies from the systems, streamlined processes, new revenue streams and cost-conscious operational support structures can ensure systems are affordable. Local operation and ownership is feasible and is happening in a number of countries.
An evaluation in Tanzania and Guinea found that eLMIS routine operating costs were lower or comparable to paper-based systems, though a large initial investment was required. It also showed that systems were affordable and that significant cost savings would be possible with the reduction of duplicative processes/systems and full scale up. The study also noted improved vaccine management and perceived data quality.
Investments in an electronic vaccine logistics system in Mozambique improved data visibility, forecasting and distribution decisions, and reduced vaccine stockouts. In Nigeria data visibility provided by OpenLMIS saved over 850,000 doses of vaccine from expiry.
Recommended areas for catalytic investment include:
- Implementation and maintenance of eLMIS systems:
- Add automation features for data analysis, visualisation and workflow support (alerts, automated calculations, barcode scanning, automated report generation)
- Streamlined processes, adequate support for users, reinforcement by programme managers/MoH and use of data to maximise uptake and sustained use
- Capacity building for governments to manage and sustain digital solutions and leverage the data from these systems in their planning and resource allocation to increase efficiencies
- Enhance eLMIS data analytics and visualisation alongside data-use initiatives and capacity building for data-driven supply chain decisions
- Integration of eLMIS into other information systems, such as DHIS2, and community health information systems (CHIS) to facilitate supply chain visibility down to the community level
- Improve commodity availability for community health workers (CHWs): Strengthen CHW supply chains and integrate them into national supply chain systems
Community Health Workers (CHWs) are the backbone of responsive primary health care systems, bridging the gap between hard-to-reach areas and essential health services. CHWs have consistently demonstrated cost-effectiveness across a broad spectrum of health interventions. However CHWs can only be effective in these roles if they have the necessary commodities to serve their communities. Unfortunately CHW stockouts are quite common and occur at a higher rate than at associated health facilities, indicating specific challenges with the community-level supply chain. Research shows that CHWs globally are stocked out of medicines one-third of the time. Integrating the CHW supply chain with that of the national upstream supply chain is a recommended approach to improve CHW product availability. This approach requires working across MoH departments (community health and supply chain) to ensure that the policies, financing, HR capacity, logistics and data for community level supply chains are integrated into already existing supply chain infrastructure.
In Kenya, working in partnership with Lwala Community Alliance and the CHU4UHC, we have improved the coordination between the Department of Community Health and the Department of Health Products & Technology (which manages the supply chain) to align on policies and processes to manage the community level supply chain. This has led to more streamlined county supply chain policies, SOPs, quantification process, data management and CHW capacity building initiatives at the county and national level.
Through our work in Liberia, working in partnership with Last Mile Health and the Liberia MoH, CHWs were officially integrated into the National Public Health Supply Chain Master Plan in 2023. We also introduced a new CHW kitting system in five counties to routinely get health products to CHWs via kits, which was expanded by the Liberian government to a national initiative in 2024.
The application of PtD’s Building HR for supply chain management Theory of Change to CHWs in Liberia showed that a consideration of the four pathways – skills, staffing, motivation and working conditions – is necessary if commodities are to be available in the most cost-effective way possible and to improve health outcomes. This work showed that, in particular, the motivation of CHWs often suffers.
- Facilitate thoughtful, gradual, transition of supply chain initiatives to governments
We will continue to see an increased focus on government ownership of supply chain initiatives, but does the supply chain community understand the key ingredients to a successful transition?
After many years of crafting and refining the VillageReach Transitioning Well approach, we recommend that all donors, governments and implementing partners draw from our key guiding principles. Transition to government isn’t simply about stepping away; it’s a carefully planned and executed transfer designed to strengthen programmes and facilitate local ownership of health systems. Now is also the time to think critically about how partners provide technical assistance and support governments, and pivot our approaches to focus on enabling governments rather than directly implementing programmes in perpetuity.
Recommended areas for catalytic investment and government cooperation include (these elements should be integrated into funding for programmes, not standalone):
- Putting governments in the driver’s seat from the beginning: support co-development of a solution based on a problem identified as a priority by the government (rather than a problem prioritised by a donor or partner)
- Conducting evaluations to determine whether the solution is effective and therefore worth transitioning to government
- A costing exercise to understand the operational costs that will need to be absorbed by government, and help plan for financing
- Jointly planning for and implementing a transition plan, including capacity building initiatives to ensure required technical and soft skills for impactful implementation of the solution
In summary our recommendations are to prioritise donor and government coordination to:
- Engage the private sector to improve efficiency
- Increase supply chains to extend beyond health facilities and reach CHWs
- Enable data visibility and use across the supply chain
- Facilitate thoughtful, deliberate transition of supply chain initiatives to governments
These insights and recommendations can support donors in their prioritisation of various supply chain initiatives and inform country decision making as MoH's pivot their systems to do more with less. These are all recommendations that we believe, with the collaboration and support of donors and national governments, can yield strong, self-reliant, people-centred supply chains in LMICs.
Rebecca Alban is a global health professional and senior manager and team lead, Human Resources for Health at VillageReach
