NOTES FROM THE FIELD

Sharing what we've learned—one voice at a time

MACEPA staff report back from bednet logistics workshop

MACEPA intervention planning and distribution expert Paul Libiszowski blogged from Nairobi, Kenya, where he worked with Malaria No More, the Alliance for Malaria Prevention (AMP), and others to support a logistics workshop on scaling up long-lasting insecticide-treated bednets (LLINs) to universal coverage. Thirty national malaria control logisticians from 27 countries attended the workshop, with the goal of strengthening the planning skills needed for countries to reach the Roll Back Malaria 2010 targets.

Strong partnerships benefit workshop participants and facilitators

Posted by Paul Libiszowski, MACEPA Project Implementation Specialist

About the blogger Paul Libiszowski (center) has over 20 years of experience in development assistance, including 13 in Africa and 8 in management positions in the US and Europe. He supports commodity distribution, micro-planning and budgeting for MACEPA project implementation at the country level.

September 11, 2009, Nairobi, Kenya—Yesterday was the last day of the LLIN logistics workshop, and participants are now packing up and getting ready to return home. The workshop went smoothly and was pretty basic for the International Federation of the Red Cross (IFRC). It also served a useful and unique purpose for MACEPA: In the past we have piloted tools for helping to jump-start scale-up of LLIN deliveries, but it has not always been clear how best to share these tools with those who will benefit most from their use. During this workshop we were able to reach out to some of the key players and country programmes involved in LLIN logistics and to interact with some of the leading logisticians of the IFRC. I’m feeling confident that the tools are now well tested and ready to be further adapted and used in-country by these individuals.

IFRC has a very logistics-intensive focus in its malaria activities and beyond, so for MACEPA, their staff are key reference points when defining what is needed, logistically speaking, for LLIN campaign support. With MACEPA and IFRC conducting this week’s workshop together, we were able to integrate our approaches and methodologies, resulting in a cohesive and fairly seamless presentation of the range of options available for the delivery of LLINs. This may sound fairly straightforward, but such partnering doesn't always result in smooth integration that ends up benefitting the participants. But this week it did – at one point I started to prepare a separate exercise for applying MACEPA’s methodologies in direct delivery but it soon became clear that the joint exercise developed by Doug and Alain easily incorporated the points I was going to make. And the participants got it.

I suppose, when I think about it, that this is a tribute to the IFRC logistician facilitators, who both know their disciplines well and proved very accommodating of new ideas and methodologies. Cheers to Doug and Alain!

—Paul

Boats, trucks and trains—optimizing net delivery

Posted by Paul Libiszowski, MACEPA Project Implementation Specialist

September 10, 2009, Nairobi, Kenya—Thursday was the final day of the four-day training in LLIN logistics. A long exercise developed jointly by Alain and Doug brought together many of the concepts presented in earlier sessions. Participants had to apply these concepts in developing a delivery and distribution plan using a scenario provided by the trainers. As I mentioned in prior blog entries, with direct delivery of containers now an option, the exercise not only tested the participants’ sequential application of classic logistics approaches, but also offered the possibility to explore in-country intermodal container shipment options.

To digress and pontificate a bit (sorry) – intermodal freight shipping of containers has been a boon to international trade in the last 30 years. (Intermodal shipping means transporting containerized cargo – like bednets – with more than one type of vehicle, i.e., trucks, trains, and boats.) But the potential of container shipments may not be fully exploited in the interior of Africa due to an enduring – and almost always false – perception that containers are required to be unloaded in the capital. Keeping the nets inside the containers until they are as close to the delivery location as possible offers many advantages: they remain safely locked and insured, and the time and labor involved in unloading and reloading them into vehicles is minimized. The opportunity for secure container shipping within Africa is only beginning to be realized as traditional approaches to centralized control begin to give way to more efficient decentralized delivery mechanisms. Thus, workshop participants had before them an array of delivery and distribution options that allowed them to creatively consider the best alternatives in each scenario.

Yemaneberhan Tadesse, Director of the Central Pharmacy in Ethiopia, manages health commodities in his country and has a firsthand understanding of the complexities of shipping mass quantities of bednets. According to Mr. Tadesse, delivering bednets presents a particular logistics challenge for several reasons: They are bulky. They are less time-sensitive than other commodities. They take a lot of time to manage. And they require more planning and are costly to deal with. As Mr Tadesse said, there is a need to “address special agendas” with malaria commodities, referring to the peak activity levels around campaigns. So the issue of proper planning is important. You have to have a plan for warehousing, for example, and for handling the peaks in activity. Mr. Tadesse said he does not increase staffing for these peaks but instead stretches his own staff. Mr. Tadesse told me that he appreciated the reinforcement of the basic logistics concepts presented in the workshop, as well as their application to malaria commodity logistics.

Stay tuned for my workshop blog epi-LOG!

—Paul

The "rough stones" of malaria control

Posted by Paul Libiszowski, MACEPA Project Implementation Specialist

September 9, 2009, Nairobi, Kenya—The third day of the log training is over. There was a recurring theme underlying many of the discussions today: Participants feel that what they are learning is applicable for mass campaigns with 2010 targets, but are wondering what is going to happen after mass distribution is over. At one point today we discussed tracking the nets from the time they are stored in-country to the time they need to be trucked to a "distribution point," and the interim warehousing required. While routine distributions might not vary too greatly, I asked the participants what changes they thought would be needed in the proposed system in order for it to become routine – just to inspire thinking. I had to leave to facilitate a French session but hope to have planted the seeds for a future brainstorming. Maybe maintaining buffer stocks and reorder points would be a start.

Several determined people argued that nets targeted for specific groups like kids under age five should not be included in calculations for quantifying universal coverage requirements. I guess I don't agree, but at the end of the day perhaps it is less important to come to consensus on a single universal coverage quantification than to continue keeping track of the pool of nets in the country – nets of all origins that contribute to universal coverage under a mix of multiple distributions.

MACEPA-sponsored workshop participants

Today was also my day for presenting to participants from French-speaking countries on the direct delivery model. There was lots of interest, although DRC clearly felt it was not for them. But other countries saw it as an important opportunity and asked many relevant questions. It is not for all countries, and I hope I've laid it out as a possibility to be considered and researched, rather than a holy grail for rapid scale-up.

Sometimes, our malaria community discusses how refined malaria control tools must be in order for them to be shared and be useful. It is clear that workshop participants favor using tools that are still considered “rough stones,” rather than “polished jewels.” My fellow facilitators recognize this and have presented several of these “rough” tools but also continually underline the need to be able to understand the tools and adapt them to specific situations. It is hard to develop a tool that is universally applicable to all country settings right out of the box. Thus, the tools presented today are not intended to be ready-to-use, but are good, basic, and well-adapted tools nevertheless – just what seems to be needed!

—Paul

Using communities to reach—and maintain—universal coverage?

Posted by Paul Libiszowski, MACEPA Project Implementation Specialist

September 8, 2009, Nairobi, Kenya—Great discussions at the workshop today. Clearly, the question of how to transition from mass distribution of LLINs to sustained coverage is on peoples' minds. Until now, logistics planning has focused on the initial stage of scale-up to ensure that a high percentage of a country’s population receives nets. It is interesting that thoughts are now moving toward maintenance systems. That is, after most or all of the country’s population has nets, how do you make sure that they keep having them every year?

Countries are increasingly moving away from integrated campaigns (in which, for example, net distribution is combined with measles vaccination – both of which target children under age 5) in favor of mass distribution campaigns for universal coverage. But what happens after everyone who needs a net has one? Establishing routine, community-based systems seems to be the winning response. But this means knowing when nets are needed, where, and how many, throughout the country on an ongoing basis. Is it feasible to expect that community health workers, who are often overburdened and undercompensated, would be willing and able to take on that responsibility? I saw some consensus, some denial, and some skepticism.

There was much discussion today of how to determine how many nets are needed. National census statistics are often old and projections are unreliable. District figures risk being inflated because the higher the estimated population, the more nets you receive. Local surveys are perhaps the best option, but they are costly and difficult to carry out. Maybe this too points to community health worker structures as a viable solution for regular monitoring.

—Paul

The importance of logistics—managing millions of bednets

Posted by Paul Libiszowski, MACEPA Project Implementation Specialist

September 8, 2009, Nairobi, Kenya—It’s the second day here at the Logistics ('Log') training and we've moved more into exercises, following yesterday's flurry of country presentations. Participants continue to be very engaged, although there is clearly a range of interests and experience.

Many discussions have led to further consideration of the direct delivery option. Participant Cretus of Nets for Life volunteered that in Ghana they had tendered for nets. Two suppliers responded. One supplier offered the nets for $4.00 per net delivered to the port; the other offered $4.50 per net delivered to locations in the interior. After calculating and comparing the costs, they determined that the direct delivery option by the shipper was less expensive than doing it themselves. This could be evidence that having commercial transporters do in-country transport of loaded containers has become a compelling option, rather than having to coordinate all the mobilization required for locally-organized transport of bales unloaded at central locations in the countries.

One fact offered today by Doug of the International Federation of the Red Cross underlined the relevance of the logistics exercise. Nigeria needs 60 million nets to achieve universal coverage. This represents 2200 40-foot containers that, if lined up end-to-end, would extend 27 kilometers!

One issue that we keep coming back to is waste disposal, which seems to be a broad-based concern among all the participants. Whether it’s the nets or the bags they come in, countries are concerned about what will become of the eventual waste generated by mass distribution campaigns. We can only say that WHO recommends following national policy and not collecting used nets unless mandated to do so. It would be good to have a handle on the latest information on this since there are rumors of the development of biodegradable bags and incinerator trials.

Log on,
Paul

Getting the nets out

Posted by Paul Libiszowski, MACEPA Project Implementation Specialist

September 7, 2009, Nairobi, Kenya—I arrived a few days ago in Nairobi, where a group of logistician/facilitator types have come together to prepare documents and sessions for the LLIN logistics workshop this week. It’s been great to spend some time working closely with bednet distribution experts from the International Federation of Red Cross. Discussion is rich, as this has also been a rare opportunity for us to come to a consensus face-to-face on logistics approaches. Regular conference calls spanning three continents only scratch the surface.

Words mean a lot when planning something as complex as getting nets to millions of households over a period of weeks. We’ve already decided to clarify our terms: the word distribution will refer to the process of handing out the nets locally; delivery will refer to the initial phase of getting large quantities of nets into the country and to the distribution location.

One of my favorite issues we’ve addressed thus far is decentralized versus centralized distribution of LLINs. There is some debate surrounding this question. Is it better to deliver nets from the production source directly to districts or to bring them first into the capital city? Personally, I am encouraged that the decentralized approach is gaining recognition as an alternative along a spectrum of approaches that may be applied, depending on the country’s geography and its capabilities. This approach worked in Zambia as a scale-up surge mechanism and it can benefit other countries as well. Zambia saved a considerable amount of money and time by initially delivering nets from the port directly to the districts. Logisticians here report that countries are increasingly asking about decentralized distribution. And we have aligned on how logisticians talk about it – so this is all good knowledge creation and dissemination going on…

Meanwhile, being on a non-secure internet line, I’ve already won millions through e-mail spam in my first day here! If only they were nets.

—Paul