HHL Conference Series: Developing Global Health Supply Chain Capacity in Frontier Or Low-Middle Income Countries

In the lead up to our annual Health and Humanitarian Logistics Conference, 16 & 17 November, we hear from key people from around the HLA's network and the humanitarian aid sector.

In this guest blog, Pamela Steele considers the steps needed to develop capacity in health supply chains, and the challenges faced by low-middle income countries.

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In 2014, West Africa was the epicenter of the Ebola outbreak. The Mano River Union (MRU) countries, Sierra Leone, Guinea, and Liberia were hit by almost 99% of the total Ebola cases. Sierra Leone and Liberia themselves faced particularly unstable conditions as they had just emerged from deadly civil wars that had devastated their economies and health systems. These countries all faced significant challenges when battling the disease due to health systems lacking in basic supply chain infrastructure.

It’s not only the West African countries have fragile health systems. Most Low and Middle-Income Countries' health infrastructures were implemented by colonial administrations in prior decades and today are considered to be dilapidated. These health systems remain weak despite billions of dollars invested by western donor countries. When the devastating Covid-19 pandemic struck, there was a huge fear that they could not withstand the pressures. Africa was fortunate that, while the impact of Covid-19 was strongly felt globally and locally, it did not kill as many people as had been envisaged (although it did lead to a high level of economic suffering in its aftermath).      

This poses a significant question - will these countries be lucky again, given that no-one knows when the next pandemic will kick in? And has Africa learned its lesson on the need to strengthen its weak health systems, particularly the health supply chain system? 

The pandemic put great strains on existing health systems. It challenged in-country health supply chains, significantly impacting the delivery of essential care to those in need up-to-and-including today, two years after! Poor infrastructure that currently supports the delivery of health products, inadequate funding, parallel supply systems, insufficient local manufacturing capabilities, high prices, are some of the critical weaknesses exposed by both Ebola and the Covid-19 pandemic. 

This situation urgently calls for building efficient supply chain connections that focus on identifying locally sustainable and globally enabled supply chain management approaches, adaptable to complex and challenging environments. Thus, the need to develop innovative solutions that meet markets local, regional, and global needs.

Governments Leading The Way

Unreliable access to medicines and other health supplies remains one of the leading causes

of preventable deaths and poor health outcomes, particularly in Africa. One third of lives are at risk because of irregular access to medicines. While many factors affect the availability of drugs, the capacity of a country's supply chain to ensure access to health supplies can be a significant constraint. As mentioned earlier, although western donors have been investing heavily in strengthening health systems and, recently, supply chain capacity development, we have seen little progress being made. What can be done to ensure their investments lead to sustainable improvements that reduce dependency on external assistance? I think that the model for capacity development is archaic, often driven by donors with little commitment from national governments, and where implementing partners do the job through embedded staff instead of genuinely building the capacity of government staff to act autonomously. It's time to take a performance-based approach, because it should not be dependent on donors to come up with a plan for strengthening a country's health system; rather, it should be government leaders leading their health system strengthening by taking the driver's seat and driving development. 

The parallel systems, although created with good intentions, weaken government systems, including poaching the few capable workforces, thereby weakening the same governments they have come to help, thus the need to integrate those systems and take a whole-system perspective. 

The Right People and the Right Skills

But let's face it, strengthening health supply chains is complex and costly. 

According to (Kaplan, 1999), capacity development is "the ability [of an organization] to function as a resilient, strategic and autonomous entity" or, as defined by United Nations Development Programme, the process through which individuals, organizations, and societies obtain, strengthen, and maintain the capabilities to set and achieve their development objectives over time. In addition, the Paris Declaration on Aid Effectiveness states that capacity development is essential for sustainable development. Supported by strengthening and using national procurement and supply management systems, they are crucial elements of scaling up for more effective aid. 

Health supply chain capacity development requires the rare skills of planning, execution, monitoring, and fully understanding supply operations. Reforms can be driven by national-level stakeholders through internal and external political channels, but also by interest groups with a narrow focus on a specific commodity (e.g. vaccines) or a specific part of the supply chain (e.g. cold chain or procurement). Developing meaningful supply chain capacity improvements involves governments, the private sector, non-profits, and international organizations, as well as funds and collaborative initiatives. Some of these entities enjoy political clout, visibility, and attractive funding facilities, while others have gained credibility with niche expertise, unique tools, or in-country presence. In addition, many of these entities collaborate. Yet often, many technical implementers tend to lack the capacity and capability to develop systems that would reduce a government's dependency on external expertise.

Six Steps to Sustainable Development

Supply chain capacity development is complex. It is not an intervention; and is not as simple as providing technical assistance or training, although these are essential elements in operationalizing capacity development strategies. Meaningful development involves managing change and strengthening the enabling societal environment and the organizational levels, as well as the capacity of the individuals working in the supply chain. The aim is to make such improvements sustainable. 

Here are a few guiding principles one could take into consideration when embarking on health supply chain capacity development: 

1. Context: ensure the context is considered holistically linked to governance, financing, workforce, and information systems, and is aligned with the national development plans and strategies. 


2. Ownership: health supply chain capacity development efforts reside with those who "own" the supply chain(s), as only those in charge of the systems can change them and influence the enabling environment. Third parties can advocate for and facilitate the process; however, no third party can promise to ensure, guarantee or lead such reforms.


3. Partnerships: Supply chain capacity development must be approached in collaboration with all stakeholders that operate or depend on the system, or can otherwise be supported. This includes aid agencies, local NGOs, civil societies, faith-based organizations, and the private sector. Inclusion and early stakeholder engagement lays the foundation for the sense of ownership, benefiting implementation. Although forging a broad stakeholder base is time-consuming, this consultation process can serve as a form of capacity development. The partners work through a process that can later be emulated in similar contexts.


4. AS-IS before TO-BE: Country contexts vary; Supply chain capacity development advice and action are based on facts, logic, and evidence. Despite the money and time investment, robust systems assessments and root cause analyses are critical stages to precede remedial action. If the reform is not anchored in a solid foundation (the objectives and critical issues), the likelihood of failure increases.


5. Commitment and Sustainability: Supply chain capacity development is a long-term commitment. At the onset, it is agreed with the stakeholders what success will look like and how it is articulated as longer-term goals and shorter-term milestones that can be monitored. 


6. Capacity to help: Navigating the process of forging partnerships, establishing strategic frameworks, and contributing to assessments and root cause analyses as part of supply chain capacity development is demanding and time-consuming. It requires broader skill sets that differ from those required for technical assistance. Third parties making supply chain capacity development commitments do so with a pragmatic view of what they can do and where their relative strengths lie. 

Governments need to get into the driver's seat to make capacity developments happen, and they need to take a systematic approach to address health system strengthening and coordination of partners as a foundation for improving health care. Indeed, this will be required to achieve sustainable development goals on health and for universal health coverage to become a reality.

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Our 2022 Health and Humanitarian Logistics Conference is taking place on 16 & 17 November at the Aidex Expo, Brussels. The theme for this year is 'Strengthening Local Crisis Preparedness and Response Plans through Effective Logistics Networks', where challenges and potential solutions will be discussed over two days.

Register now for free in-person or online access