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Strengthening public health supply
chains in Ethiopia: PEPFAR-supported
expansion of access and availability
Daniel Taddesse, David Jamieson & Logan Cochrane
Published online: 02 Sep 2015.
To cite this article: Daniel Taddesse, David Jamieson & Logan Cochrane (2015) Strengthening
public health supply chains in Ethiopia: PEPFAR-supported expansion of access and availability,
Development in Practice, 25:7, 1043-1056, DOI: 10.1080/09614524.2015.1069794
To link to this article: http://dx.doi.org/10.1080/09614524.2015.1069794
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Strengthening public health supply chains in Ethiopia: PEPFAR-supported
expansion of access and availability
Daniel Taddesse*, David Jamieson, and Logan Cochrane
(Received October 9, 2014; accepted June 22, 2015)
When the US President’s Emergency Plan for AIDS Relief (PEPFAR)-supported Supply Chain
Management System (SCMS) programme began working in Ethiopia in 2006, the estimated
population of people living with HIV exceeded one million, while only 24,000 were on
treatment and only 50 treatment sites were in operation. SCMS and other key partners
entered into this context to support the Ethiopian government in significantly strengthening
the public health supply chain system, with the aim of increasing the availability and
accessibility of pharmaceutical products. The country now has 1,047 treatment sites and is
nearing complete treatment coverage. This article discusses how priorities were set among
many competing challenges from 2006 until 2014, and how the four-step strategy of build,
operate, transfer, and optimise has resulted in a successful partnership.
Lorsque le programme Supply Chain Management System (SCMS —Système de gestion des
chaînes d’approvisionnement) soutenu par l’Emergency Plan for AIDS Relief (PEPFAR —
Plan d’urgence pour l’aide à la lutte contre le sida) du président des États-Unis a commencé
à opérer en Éthiopie en 2006, la population estimée de personnes séropositives dépassait un
million. Or, seulement 24 000 suivaient un traitement et on comptait seulement 50 sites de
traitement opérationnels. Le SCMS et d’autres partenaires clés sont entrés dans ce contexte
pour aider le gouvernement éthiopien à renforcer considérablement le système de chaîne
d’approvisionnement en matière de santé publique, dans le but d’accroître la disponibilité et
l’accessibilité des produits pharmaceutiques. Le pays compte maintenant 1,047 sites de
traitement et approche d’une couverture de traitement presque complète. Cet article traite de
la manière dont les priorités ont été établies dans un contexte de nombreux défis concurrents
de 2006 à 2014, et du fait que la stratégie en quatre étapes consistant à construire, opérer,
transférer et optimiser a abouti à un partenariat réussi.
Cuando en Etiopía empezó a funcionar el Sistema para la Administración de la Cadena de
Suministro (SCMS) impulsado por el Plan Presidencial —de EE.UU.—de Emergencia para
el Alivio del SIDA (PEPFAR por sus siglas en inglés) en 2006, la población de seropositivos
excedía el millón de personas. Sin embargo, solo 24 mil de éstas recibían tratamiento y
únicamente funcionaban 50 centros de tratamiento. El SCMS y otros importantes socios
ingresaron a este contexto con la intención de coadyuvar a que el gobierno etíope
fortaleciera significativamente el sistema de la cadena de suministro de la salud pública,
orientado a elevar la disponibilidad y el acceso a productos farmacéuticos. Ahora el país
cuenta con 1,047 centros de tratamiento, acercándose a alcanzar una cobertura de
tratamiento del 100%. El presente artículo analiza cómo se establecieron las prioridades en
un contexto de múltiples retos en competencia durante el periodo 2006-2014, y la manera
en que la estrategia de cuatro pasos —construir, operar, transferir y optimizar—dio lugar a
esta alianza exitosa.
© 2015 Taylor & Francis
*Corresponding author. Email: dtaddesse@et.pfscm.org
Development in Practice, 2015
Vol. 25, No. 7, 1043–1056, http://dx.doi.org/10.1080/09614524.2015.1069794
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Keywords: Aid –Capacity development; Civil society –Partnership; Methods; Social sector –
Health; HIV/AIDS and sexual health; Sub-Saharan Africa
Introduction
This article presents the experiences, successes, and challenges of a large-scale donor-funded
project that sought to build and strengthen the public healthcare system of Ethiopia, and specifi-
cally in response to HIV/AIDS. As a several hundred-million dollar project implemented over a
ten-year period, the activities and impacts were wide ranging. Many singular initiatives are ana-
lysed in the academic literature, however far fewer examine long-term and large-scale projects.
This article aims to fill this gap, and in doing so presents many of the larger activities that
were conducted. The authors recognise a large amount of information is presented and hope
that the inclusion of multiple activities, as opposed to fewer activities, provides unique insight
into how projects of this scale, complexity, and duration can function, the challenges that may
be experienced, and the successes that can arise from sustained and scaled interventions.
The first two sections present an overview of HIV/AIDS globally and nationally. This is fol-
lowed by an overview of the first phase of the project, lasting from 2006 to 2009. The third section
details the activities conducted during the second phase, from 2010 to 2014, emphasising the
model of build, operate, transfer, and optimise. The article concludes with lessons learnt and
reflections for donors and implementing organisations working on and/or considering projects
that strengthen public systems and operate at this scale.
HIV/AIDS: the global context
The US President’s Emergency Plan for AIDS Relief (PEPFAR) was launched in 2004 to address
the global pandemic of HIV/AIDS. When PEPFAR started, many countries did not have the infra-
structure and systems to ensure that needed health commodities and pharmaceutical products,
such as test kits and anti-retroviral (ARV) treatments, reached their destinations in the correct
quantity and at the right time. Supply chain systems needed to be developed and strengthened
to meet the scale that the HIV/AIDS pandemic demanded.
In response to this need, PEPFAR launched Supply Chain Management System (SCMS) through
the US Agency for International Development (USAID) in 2005. The aim of this initiative is to
provide a reliable, cost-effective, and secure supply of products for HIV/AIDS programmes.
SCMS operates in 22 countries. In partnership with the Government of Ethiopia, SCMS has contrib-
uted to major improvements in the country’s health sector, including supporting the rapid expansion
of health facilities and ARV treatment sites throughout the country, provision of prevention of mother-
to-child transmission (PMTCT) services, and national anti-retroviral therapy (ART) coverage.
HIV/AIDS in Ethiopia: the national context
With approximately 90 million people, Ethiopia has the second-largest population in Africa (CSA
2007; UNDESA 2009). The growth rate of 3.2%, combined with 46.3% of the population being
under the age of 15, contributes to projections that the country’s population will expand to 119
million by 2030 (Evans 2012; UNFPA 2008). About 80% of the population lives in rural
areas, which poses a number of challenges for the provision of healthcare services and commod-
ities. However, Ethiopia is rapidly urbanising, with one-third of the population projected to be
living in urban areas by 2030 (Evans 2012).
At the beginning of 2006, an estimated 24,400 people in Ethiopia were on ART (Raman
et al. 2012). At the time, more than a quarter of a million people required ART and coverage
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was only 8.8% (HAPCO 2006). In addition, only 21% of women were accessing PMTCT ser-
vices (Asrade and Amanuel 2014), while there were over 75,000 women living with HIV giving
birth annually and almost 900,000 children orphaned due to HIV/AIDS (National AIDS
Resource Center 2007). Free government-provided treatment for HIV was not available until
2005, in limited quantities, while payment-based ARV treatment was available only as of
2003; internationally, however, the first approved ARV became available in 1987. The
number of treatment sites in Ethiopia was expanding, from 25 in 2005 to 50 in 2006, but cover-
age was still insufficient for a population of 75 million (in 2005). Systems to support diagnosis,
treatment, and logistics were absent in much of the country (Raman et al. 2012; SCMS 2012).
These challenges were compounded by a shortage of skilled healthcare workers, the unavailabil-
ity of data to make informed forecasting and procurement decisions, inadequate infrastructure
for storage and distribution, and insufficient health commodities and pharmaceutical products
(HAPCO 2006).
From an estimated 4.4% in 2003, national prevalence of HIV has dropped to 1.5% of the adult
population; approximately 800,000 people (HAPCO 2012). Generalised trends include higher
prevalence rates in urban areas (4.2%) compared with rural areas (0.6%) and in specific popu-
lations, such as widowed individuals (more than 10%) and commercial sex workers (CSA
2012). Significant regional differences are found in Ethiopia, with prevalence above 6% in Gam-
bella and below 1% in Southern Nations, Nationalities, and Peoples’Region (CSA 2012).
Phase I: responding to the crisis (2006–09)
The initial response to the grim reality in Ethiopia in 2006 was broad and urgent, focused on
addressing the critical needs of the population. The Government of Ethiopia and its public and
private health sector partners agreed that diagnosis and treatment of HIV/AIDS would be
provided at no charge. The Federal Ministry of Health (FMOH) and the National HIV/AIDS Pre-
vention and Control Office (HAPCO) worked to ensure that the systems, skills, and capacity
needed to provide the required services were being put in place. This process included scaling
up voluntary counselling and testing services, ARV treatment provision, and prevention of
mother-to-child transmission (PMTCT) services (HAPCO 2006).
Compliance posed a logistical challenge: once a person was diagnosed with HIV, he or she
needed to visit a treatment site monthly for the first six months, and then quarterly after that.
The limited number of treatment sites in operation were largely urban, while most Ethiopians
resided in rural areas. Although higher prevalence rates existed in urban areas (10.5%) compared
to rural ones (1.9%), the large proportion of the population living in rural areas meant that nearly
half (48%) of all infections were in rural areas (HAPCO 2006). Getting treatment to those who
needed it required much more robust distribution, and necessitated the development of systems
for quantification, procurement, warehousing, distribution, and training.
A diversity of donors and implementing partners during the early years brought logistical and
supply chain problems, resulting in an unsustainable reliance on costly emergency orders of pro-
ducts. In an effort to address this challenge, the Government of Ethiopia centralised all stake-
holders under the FMOH. While improvements occurred, coordination and collaboration
challenges continued –particularly as expansion was sometimes directed by donors and imple-
menting partners based on their own plans and priorities.
A master plan for distribution
To expand distribution, in 2006 SCMS, USAID|DELIVER PROJECT, UNICEF, the World
Health Organization (WHO), and other stakeholders worked with the Ethiopian FMOH to
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develop a Pharmaceutical Logistics Master Plan. This led to the creation of the Pharmaceuticals
Fund and Supply Agency (PFSA), which would become the sole distributor of all health-related
commodities for the public sector throughout Ethiopia, including all pharmaceuticals as well as
related health commodities, such as medical equipment, test kits, laboratory equipment, and
reagents.
Significant challenges included product shortages at diagnosis and treatment sites. If, for
example, testing kits were not in stock, those who had made the important, yet difficult, decision
to take an HIV test –often facing stigma and discrimination –would be redirected. In addition,
those receiving ART needed a continuous and consistent supply of ARVs to maintain their per-
sonal health and to ensure that viral mutations were not facilitated due to inconsistent treatment.
The myriad of products required for diagnosis and treatment, many new to Ethiopia, brought new
forecasting, procurement, and distribution challenges.
A sustainable strategy
SCMS led efforts to create a system for overseeing activity expansion and ensuring that all
required products were available and accessible. Doing so required prioritisation of the main
areas for intervention, some of which would entail redesign of entire systems. SCMS set out to
address these challenges in a more sustainable and coordinated fashion than the initial response
to the crisis. A four-part process was designed to make lasting improvements: build, operate,
transfer, and optimise. This included shifting from an activity-focused management system to a
results-based one, changing a supply-driven system to a demand-driven one, and developing
and expanding human and physical capacity. At the same time, information systems would
need to be scaled-up to meet the maximum expanded coverage at the facility level, increasing
the quantity and quality of available data for information-based decision-making, forecasting,
procurement, and distribution. Warehouse management systems would be developed and
implemented for all regional warehouses and the warehouses themselves would transition from
leased facilities to purpose-built pharmaceutical warehouses equipped by SCMS with appropriate
technologies and tools, such as vertical racking, forklifts, and cold rooms. The distribution system
would be expanded with SCMS-provided transport vehicles. Seconded staff, training, technical
assistance, and supportive supervision would be provided to facilitate the capacity building, tran-
sition, and transfer process.
Dramatic improvements
As a result of SCMS establishing systems for forecasting, procurement, warehousing, and
distribution as well as direct support to health facilities, by the end of 2009 the total
number of treatment sites supported had increased from 25 in 2005 to 412. Half of these
were located in rural areas (Raman et al. 2012). Over this period the number of people receiv-
ing ART jumped from 24,400 to 155,000. The number of products managed rose from just a
few to 588.
Multiple challenges remained, however. Implementation plans of individual stakeholders and
of the collective partnership lacked detail, due in part to a continued lack of coordination and har-
monised planning. Physical infrastructure, information systems, and human resources were not
adequate for the size of the operations at the time, nor the speed of expansion necessary to
meet the expected need. Many stakeholders, including SCMS, were working toward transferring
activities and responsibilities to PFSA, but the process was slowed due to limited capacity and
resources at PFSA. New programmes, such as food by prescription (FBP), were planned, but
due to limited storage capacity had not begun in earnest.
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Phase II: advancing the response (2010–14)
SCMS continued to pursue the build, operate, transfer, and optimise model in supporting the
Ethiopian FMOH. The challenge it faced was how to determine the most effective ways to
provide this support and establish appropriate, viable, and sustainable systems.
Build
Designing a workable information system
Effective supply chain management required a robust data collection system, which would enable
data-driven decision-making, improve service coordination, facilitate scale-up, and enhance pro-
curement and distribution of pharmaceutical products. SCMS, along with partner organisations,
such as USAID | DELIVER, supported the design of the Integrated Pharmaceutical Logistics
System, the roll-out of which in all regions and city administrations in the country was conducted
by PFSA with the support of SCMS. Soon thereafter, the Health Commodities Tracking System
(HCTS) –a web-based application with an offline option and a synchronisation tool –was designed
to track and report on inventory. Because some regions lacked computers and internet connectivity,
a paper-based system was used in tandem, which was then coded at regional warehouses.
Expanding warehousing capacity
In Ethiopia, the governmental agency PFSA operates a central warehouse, which supplies
regional warehouses that distribute products to hospitals and thousands of health facilities
throughout the country. Launched in 2007, PFSA is a relatively young organisation, and the diver-
sity and volume of its pharmaceutical products continues to grow. In the past, physical capacity
held back supply chain development. To address this issue, SCMS supported a major warehouse
expansion initiative to meet immediate and anticipated needs of the expanding patient population
by temporarily leasing regional warehouses, while USAID and the Government of Ethiopia co-
funded the construction of 10 permanent and purpose-built regional warehouse facilities. For
these sites, SCMS provided technical assistance with designing the warehouse network, develop-
ing warehouse layouts and structural designs, and outfitting the warehouses with vertical racking
and materials handling equipment.
Multi-level racking systems, which SCMS introduced,allowed for vertical storage to maximise
use of available space and prevent product damage, as boxes are stacked according to capacity
(Figure 1). The racking system includes a location-based storage system, which improves product
organisation by ensuring that products nearest to expiry are used first. Because the central and
regional warehouses have an improved ability to quantify and locate stock, product shortages and
overstocking have been reduced, which has resulted in cost savings as fewer emergency orders
are required and product expiry has almost been eliminated due to improved management.
At one of the sites, located in Adama, vertical racking led to an increase in warehouse capacity
of more than a third, to 880 pallets, which was increased exponentially to 5,160 pallet spaces in
the new warehouse. Across the 10 new warehouses, the introduction of SCMS-provided vertical
racking raised pallet capacity from 6,039 to 30,340 pallet spaces, a more than five-fold increase.
Building distribution and procurement capacity
To ensure that products reached their destination promptly, efficiently, and cost-effectively, SCMS
provided 74 delivery trucks (19 of which are fitted with mobile cold rooms), five field vehicles,
and five motorbikes. This support saved a significant amount of money that PFSA spent on rental
trucks for delivering commodities to health facilities. These funds can now be used to procure
Development in Practice 1047
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essential lifesaving medicines. Vehicles and motorbikes also support ongoing data collection,
monitoring and evaluation, and emergency deliveries. SCMS also provided mobile offices with
10 rooms, 355 refrigerators, and six cold rooms.
SCMS has played an important role in ensuring the required pharmaceutical products are
available within and throughout the country. In 2009 SCMS procured more than US$38.5
million of commodities, up to US$31 million from 2010 to 2013, and US$19 million in commod-
ities in 2014. The reduced usage of SCMS for procurement reflects the transition to governmental
ownership, as governmental procurement steadily rose during these years and the government is
increasingly procuring commodities that SCMS had previously procured.
An essential component of expanding access to healthcare is ensuring facilities have the
equipment they require. For example, the safe delivery of infants requires hospital beds, sterilising
equipment, infection prevention materials, delivery equipment, and surgical tools; SCMS has pro-
cured and supplied health facilities with more than US$10 million worth of such equipment.
Service expansion
The construction of new hospitals and health facilities was conducted by the Ministry of Health,
the rapid growth of which demonstrates the commitment and leadership of the Government of
Ethiopia in taking the initiative to bring about these successes. SCMS supported the development
of forecasting, procurement, warehousing, and distribution systems that underpinned the expan-
sion of health facilities and provided direct support (equipment, training, technical assistance, and
supportive supervision) to health facilities to expand the services offered. The number of public
health facilities expanded rapidly, reaching 1,463 in 2012, 2,028 in 2013, and 3,447 in 2014. ARV
treatment sites increased from 412 in 2010 to 1,047 in 2014. Sites providing PMTCT services
expanded significantly, with 646 in 2012 and 2,495 in 2014, most of which are located in rural
areas. ART lab monitoring sites also expanded from 2011 onward. Figure 2 illustrates the
growth in number of total sites, as well as ART, PMTCT, and ART lab monitoring sites, from
January 2005 to April 2014.
Operate
Practical knowledge and skills building
Newly introduced technologies and procedures required new knowledge and skills. During the
life of the SCMS project, almost 9,000 people have been trained in different aspects of supply
Figure 1. Left: Warehouse, Ethiopia (before) Right: Warehouse, Ethiopia (after).
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chain management, ranging from forklift operations, to defensive driving, to the logistics manage-
ment information system. SCMS has sent 40 staff from PFSA and SCMS to South Africa for
warehouse operations and management training. As a result of this training, each warehouse,
on average, implemented at least 23 improvements and the participants gained first-hand experi-
ence working in a world-class facility as they learnt best practices (Cochrane 2013). The leased
warehouses were not purpose-built pharmaceutical warehouses, resulting in some limitations in
what could be done within them. Since the newly constructed warehouses were completed and
transition into them began in 2014, improvements continue to be seen. The enhancements
include space utilisation and commodity management, as the purpose-build warehouse layouts
were designed with commodity flows in mind. Additionally, PFSA and SCMS recognise that
international training is not a sustainable option for all current and future personnel, and therefore
a domestic facility with customised curricula is being developed, which will be used for ongoing
training.
Figure 2. Expansion of service provision.
Notes: * Based Ministry of Health (2014) for recent data, and HAPCO (2014) for 2006–13.
** Based on SCMS data.
Development in Practice 1049
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Quantification and procurement
Quantification of commodity demand is crucial to ensuring that required pharmaceutical products
are where they need to be, when they are needed and in the correct quantity. Taking into account
the country’s current, expected, and changing pharmaceutical needs, SCMS supported quantifi-
cations that were conducted in 2008, 2010, 2012, 2013, and 2014. These are national-level plan-
ning exercises that enumerate the country’sfinancial needs and help to develop national
procurement plans. As a primary partner of the FMOH and PFSA, SCMS was asked to coordinate
donor partners and the quantification workshops, for which it also provided technical and finan-
cial assistance.
New financial and accounting software
PFSA’s procurement budget is several hundred million US dollars. However, the account closing
process, which was largely manual, took months. A high error rate, due to manual data entry,
added to the processing time. This was the case until 2012, when SCMS provided software
and training on financial and accounting software. This resulted in a number of efficiencies;
the time it took to reconcile accounts was reduced from two to three months to one week;
bank reconciliation time was reduced from one month to three to five days; staff bookkeeping
time reduced from 80% of staff time to 10%; and reporting time reduced from nine months to
one month, with reporting errors reduced by 75%. Following the training, PFSA staff also
cleared a three-year backlog (2009–12). These achievements were accomplished while also redu-
cing payment processing staff and inventory management staff by 50%.
A new electronic system for all health commodities
As the quantity and number of healthcare products expanded, improved systems for data collec-
tion were required. The existing data collection system, HCTS (discussed above), was specifically
designed for HIV/AIDS-related commodities. To make the system more inclusive, PFSA and
SCMS developed the Pharmaceuticals Logistics Information Tracking System (PLITS) that
included all health products. PLITS further enhanced supply planning, quantification, distri-
bution, and decision-making across the country. Starting in 2013, SCMS supported the rollout
of PLITS into 900 ARTsites and 300 PMTCT sites. As a further means of enhancing data collec-
tion, quality and availability, SCMS collaborated with the USAID|DELIVER PROJECT to inter-
face data collection systems, ensuring all data collection mechanisms automatically interact and
share data as a single application. This integration process was designed to prevent the duplication
of data entry.
A new workflow management system
Currently, 19 products are being procured that have a shelf-life under six months, the shortest of
which is only 16 days upon arrival in the country. These products are required for machine cali-
bration, to test machine functionality, and for performance tracking. SCMS developed a workflow
management system, called the Short Shelf Life Product Management System (SSLPMS) to track
commodities movement and the distribution process, as well as to reduce expiry. This electronic
system replaced a paper-based one and uses a 16-step standard operating procedure developed for
distribution. The SSLPMS ensures that all people involved in distributing short shelf-life products
are updated on product movement and are automatically alerted to their responsibilities. In the
case of delays, supervisors are automatically notified. The introduction of this system has
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eliminated product expiry, which had been a problem in previous years. It has also ensured
optimal service provision, as the products required for testing lab machines are available when
needed.
Health systems strengthening in human capacity and data quality
The health systems strengthening field support (HSS FS) team came together in 2010, joining
smaller teams working on commodity and lab support. Their objectives are to: (1) build the
capacity and capability of coordination at the lower levels, from the regional level to the district
level; (2) gain accurate, timely and quality data; and (3) build the capacity of regional, zonal, and
district-level health offices.
To ensure regional ownership of supply chain activities, SCMS supported the development
and implementation of regional intervention plans that addressed identified gaps. SCMS
ensured the required capacity was present by training PFSA and SCMS staff as well as 800 per-
sonnel at the regional, zonal, and district levels. As a result, regionally developed intervention
plans have been institutionalised for continuous improvement of supply chain management.
SCMS also provided training and support to all regions so that monitoring and evaluation
plans could be developed and implemented throughout the country. The approval of these
plans at the regional level results in dissemination and adoption throughout the lower levels of
the healthcare system within it.
In collaboration with PFSA, the USAID | DELIVER PROJECT and other partners, SCMS
conducted training at more than 2,000 health facilities to improve product management, data col-
lection, and reporting. Following the training, supportive supervision was provided to more than
500 sites to ensure that implementation is performed correctly and efficiently. Standardised forms
are now being used at all facilities and are distributed along with pharmaceutical products within
the healthcare system supply chain.
Health facilities do not operate in isolation, nor do they directly communicate with the federal
authorities. In order to ensure that all levels of the supply chain system are managed appropriately
and undertake their respective activities, SCMS provided orientations to staff at the regional,
zonal, and district levels. In anticipation of continued staff turnover, SCMS also developed a
skills and knowledge transfer system so that new staff are prepared to undertake their responsi-
bilities. The transition of task responsibility from the implementing organisation and seconded
staff to PFSA and its personnel was facilitated with supportive supervision. As a result of
these activities, PFSA has improved qualitative and quantitative data for information-based
decision-making on procurement, distribution, and resupply of products at the health facility
level –significantly reducing the potential for shortages and emergency orders. PFSA has also
successfully taken ownership of these tasks, ensuring the sustainability of these improvements
beyond the life of the SCMS project.
Transfer
Skills transfer, in the form of training, technical assistance, and job support supervision, is
essential if the improvements and successes described above are to be sustained. Long-term
planning between PFSA and SCMS regarding the transfer of tasks and responsibilities
allowed for sufficient transfer planning and time for both parties. The smooth transition that
has been experienced to date is one the greatest successes of the project. Of note is that through-
out the building, operating, and transitioning processes there was not a single ARV treatment
interruption. The size and distribution of the population in Ethiopia make this particularly
noteworthy.
Development in Practice 1051
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PFSA has the sole responsibility for ARV procurement and all healthcare commodity deliv-
eries, with support from SCMS through seconded staff, training, mentoring and, when needed,
emergency orders. SCMS continues to procure certain products for PEPFAR-supported national
health programmes, which are distributed mainly through PFSA. Locally produced products save
time and cost while supporting the expansion of local capacity and boosting the local economy. To
shift to local suppliers, SCMS assessed local importers and manufacturers to ensure that they met
country as well as USAID requirements. One local manufacturer was approved initially, and the
first order of 310,000 bottles of Co-trimoxazole suspension was placed in 2012. Initially, the
quality of imported and locally manufactured products was ensured by batch testing internation-
ally; however, with SCMS support, product testing has begun in Ethiopia, saving time and cost
while expanding local capacity.
From the more than 70 SCMS seconded staff in place as of 2010, less than one-third remain,
following one-to-one task transfer from SCMS seconded staff to PFSA permanent staff. This
process will be complete by the end of 2015. In a few locations, such as the Adama and
Jimma warehouses, most HIV/AIDS commodities management and distribution-related tasks
have been fully transferred to PFSA. Most warehouse and transport supervision activities are
also entirely handled by PFSA.
Optimise
Optimising SCMS and Government of Ethiopia efforts relied on several key factors for success
including planning, coordination, and communication.
Planning
To ensure that the network is optimised and that distribution is managed efficiently, distribution
planning is essential. SCMS conducted a distribution route analysis to enable route optimisation
even though only half of the health facilities were geo-coded. The distribution optimisation plan
improves distribution efficiency, maximises resource use, and supports the development and
enhancement of other projects, such as the lab referral network and efforts to geo-code all
health facilities. The map will include locations, distances, and road conditions to improve distri-
bution planning and make the distribution process more efficient and cost-effective.
Detailed planning is essential for optimisation, in particular for larger projects such as ware-
house development, software development, procurement planning, maintenance, waste manage-
ment, and security. Planning of this nature enables accurate timetable estimation, tasks to be
appropriately scheduled, resources used accordingly, and facilitates accurate costing. Detailed
planning processes were integrated into joint work plans with government partners, which clari-
fied expectations, responsibilities, and management for all parties.
Coordination and communication
Early in the project a major challenge for SCMS, as one partner to the Government of Ethiopia
among many, was a lack of coordinated, and therefore strategic, action. This lack of coordination
also affected planning activities, resulting in different stakeholders simultaneously engaging in a
particular activity, often in different ways. Creating and supporting platforms to increase coordi-
nation, collaboration, and communication has been a key factor in enabling more strategic
implementation. SCMS has taken a lead role in coordination activities, such as managing
bimonthly logistics partners meetings, government-led bimonthly Pharmaceutical Logistics Part-
ners Meetings, Supply Coordination Group meetings, and regular warehouse transition meetings.
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Lessons learnt
Government leadership is the foundation for success
The successes achieved since 2006 are built on a foundation of leadership and support from the
Government of Ethiopia and its commitment to strengthen the national pharmaceutical supply
chain. In making the public health supply chain a priority and actively supporting public
health expansion plans, the federal government has played a major role in the successes achieved
to date. Government leadership facilitated the rapid expansion of treatment coverage and the
vastly expanded public healthcare system.
Appropriate technology is important
A large number of laboratory machines were procured for installation and use at health facilities
throughout the country. Several factors resulted in delayed installation, including inadequate
assessments of the readiness of health facilities for the installation, limited capacity of local con-
tractors, and an insufficient assessment of contractors’capacity to handle the expected workload.
Similar projects ought to include more thorough assessments and be phased in line with the
capacity of all parties.
Equipment and training go hand-in-hand
To improve waste management and prevent infection as a result of mishandled waste, SCMS pro-
cured waste segregation bins of different volumes, and distributed them to health facilities in part-
nership with PFSA. Although distribution efforts achieved high coverage, implementation was
low. Most facilities did not receive assembly manuals, many did not have a focal person respon-
sible for managing the introduction of waste bins and as a result many were not aware of their
correct use. In similar projects, when new systems and/or products are introduced, they should
be accompanied with clear instructions, and assembly directions if required. If the distribution
is large, a delegated person ought to be identified for coordination, and training or orientation pro-
vided if needed. Where training is needed, an assessment should be made, including represen-
tation from different levels of health facilities, and from all regions of intended distribution.
The key lesson is that providing new equipment must be part of a greater change management
process, it cannot be assumed that new processes will be implemented automatically with the
arrival of the equipment.
Real-time data are essential
In the past, quantification and procurements managed by SCMS were based on information and
recommendations from experts and field-level practitioners. This was partly due to necessity, as
consumption data were not readily available. The result was overstocking, product expiry, product
shortages, and emergency orders. The issue was addressed by improving data collection systems,
and now forecasting and procurement are based on actual consumption data. In turn, overstock-
ing, expiries, shortages, and emergency orders, and their respective costs, have been significantly
reduced.
Capacity building is key
Building and expanding local capacity –from the central offices to the health facilities –is the
foundation for Ethiopia’s achievements. Capacity building includes training and job support
Development in Practice 1053
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supervision. It also incorporates the creation of robust systems and structures, the provision of
information systems, expanding physical capacity, such as shelving and materials handling
equipment, and introduces new processes and policies, such as standard operating procedures.
Capacity building enables service provision to expand geographically, increase beneficiaries,
and handle rapid growth in volume and quantity of pharmaceutical commodities to provide the
required services and products.
Newly established capacity can also facilitate the creation of new projects. For example,
although the need and interest in having a FBP programme existed in Ethiopia, the capacity
did not. As a result of enhanced capacity, improved efficiency and the development of new
systems, the FBP programme was started in 2009. It has two main implementing partners,
Save the Children US and the World Food Program (WFP), while SCMS supported it with logis-
tics, quantification, procurement, storage, and distribution of nutritional products. As of 2014, the
FBP programme operated at 568 sites and the success of the programme is founded upon the
expanded healthcare system described in this article, as it utilises the public health supply
chain and distribution network to operate.
Reflections
Less than a decade ago, PFSA began the daunting task of procuring and delivering healthcare pro-
ducts to a large, and mostly rural, population. The estimated population of people living with HIV
at that time exceeded one million, while only 24,000 were on treatment (8.8% of those requiring
it). SCMS and other key partners entered into this context to support the government in signifi-
cantly strengthening the public health supply chain system. SCMS followed a four-step process:
build, operate, transfer, and optimise. Systems were put in place for forecasting, procurement,
logistics management, warehousing, distribution, workflow management, accounting, and other
related areas.
This four-step process has reached its final stage and SCMS is moving towards project
phase-out (in 2016). The systems established, in collaboration with PFSA, have laid the foun-
dation for delivering HIV/AIDS commodities to patients and have made significant progress
toward addressing the critical need that existed in 2006. After systems were built and oper-
ational, the long-term local capacity building initiative began, with the aim of transferring oper-
ations to governmental partners. As the government took ownership, SCMS worked to ensure
that systems were operating as efficiently and effectively as possible, based on continuous
improvement that optimises capacity and capability and can respond to changes in the public
healthcare supply chain systems.
From 8.8% in 2006, ARV treatment coverage is now 80%, the number of people on ART
has risen from 24,400 to over 344,000, and the percentage of women accessing PMTCT
services has increased from 21 to 57% (Ministry of Health 2014). From an estimated
4.4% in 2003, national prevalence of HIV is currently 1.5% of the adult population, approxi-
mately 800,000 people (HAPCO 2012). During the life of the project, the total number of
healthcare sites increased from 775 to 3,447, PMTCT-providing sites from 500 to 2,495,
ART-providing sites from 25 to 1,047, and ART lab monitoring sites from 106 to 326.
The expansion of the healthcare system, service provided, and treatment coverage is
remarkable.
SCMS Ethiopia, as one of the largest operations of its kind globally, has played an important
role in supporting the Government of Ethiopia to achieve these successes. Although many suc-
cesses have been realised, other challenges remain. Ongoing SCMS plans include ensuring a
smooth transition of all activities, continuing to optimise the supply chain, supporting
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procurement planning and donor coordination, and institutionalising supply chain management
training at educational institutions throughout the country. These activities are planned to be com-
pleted before the project closes out in 2016.
Many government and non-government bodies seek to partner with governmental entities
to create and/or develop stronger public systems, from healthcare to education and security.
This article provides a practical example of how one such partnership formed, thrived, and
managed the many challenges it faced in enabling the government to meet its targets for
those living with and affected by HIV/AIDS. The activities presented in this article ought
not be understood as a prescription for other programmes, rather they should serve as
examples for building, operating, transferring, and optimising large-scale and long-term pro-
jects. The challenges presented should be understood as general lessons, considered within
other contexts, and incorporated where appropriate. The successes experienced in Ethiopia
demonstrate that donors can play an important role in creating and developing effective
public systems.
Disclosure
Two of the authors are employed by Management Sciences for Health in Ethiopia, which is the implementing
partner for SCMS Ethiopia, which is funded through PEPFAR.
Funding
This paper describes work supported by PEPFAR and administered by USAID.
Notes on contributors
Daniel Taddesse is Deputy Country Director of Supply Chain Management System, Partnership for Supply
Chain Management, Addis Ababa, Ethiopia.
David Jamieson is Deputy Director of Supply Chain Management System, Partnership for Supply Chain
Management, Addis Ababa, Ethiopia.
Logan Cochrane is a Consultant for Supply Chain Management System, Partnership for Supply Chain Man-
agement, Addis Ababa, Ethiopia.
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