Presented at Africa Healthcare Delivery Conference, Abuja, Nigeria, June 26, 2018. (https://ahdconference.org) Public health supply chains tend to be limited in human capacity, where the management capacity of health workers at the last-mile delivery points is inadequate. Supervisory bandwidth of district-level health officials is also limited. Accountability can be low and workers are not always motivated to perform. Consequently, problems or risks in the supply chain are not resolved in a timely fashion leading to poor service quality or higher costs. Our objective is to improve supply chain performance by driving timely actions by health workers at the last mile. We aim to achieve this through a combination of demand-driven monitoring of critical events by supervisors, and motivating health workers using a “social” approach, where supervisors can “like” or “appreciate” good performance. We empower a supervisor with an application on a mobile phone, which presents critical supply chain events that he/she needs to act up on, whenever downstream actions are delayed beyond a reasonable duration. Examples of such events include unattended stock outs over an acceptable duration, cumulative high/low temperature exposure of fridges, or no data entry within expected times. The supervisor is also shown “good performance” events over a 3 month period, such as “good stock availability”, “no temperature excursions in fridges” or “consistently good data entry”, which he can “like” or “appreciate”. This, in turn, triggers a notification of “appreciation” to health workers, and enables a relatively frictionless channel for motivating them towards sustained performance.

1. June 26, 2018
Arun Ramanujapuram
CTO, Logistimo
Ensuring timely actions in public
health supply chains using mobile
phones
Co-authored by Kaushal Shukla
Africa Healthcare Delivery Conference, Abuja, Nigeria, June 26-27, 2018

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Open source platform for supply chain &
logistics in low-resource environments
Overview
Principle of bottom-up empowerment
Built on
Supply chain
management
Cold-chain
Monitoring
Transportation
Management
Since 2010

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Human-centered technology
Robust
Any phone or computer Any network or medium
VoiceGPRS SMSOffline
Scalable
Smart
Thousands of nodes, Millions of transactions, Terabytes of data
Machine and social intelligence
For low-resource environments

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India
Immunization, drugs SC
11,270 facilities
14,500 refrigerators
Myanmar
Reproductive health
2700 facilities
Indonesia
Immunization SC
100 facilities  3000+
100 refrigerators  3000+
Zambia
Immunization SC
150 facilities
16 refrigerators
Uganda
Immunization - SC & Fleet
30 facilities  185
30 refrigerators  200
Mozambique
Diagnostics logistics - Fleet
2 districts
Supply chain and cold-chain logistics across 15,000 facilities
400 districts, 22 states, 6 countries
In 6 countries

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Partners
Investors

6. Challenge

7. Low resource environment
Low human resource capacity
Limited infrastructure
3-6 level supply chain
National Store
State Store
Regional Store
District Store
Sub-district Store
PHC
Varies by country and supply chain verticals
Inventory management
Ensure availability, minimize wastage
Cold-chain management
Ensure storage within 2-8 degrees
Key responsibilities

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Cold-chain handler or pharmacist capacity is limited
52% passed 12th grade
67% > 46 years
Never used a mobile app.
Limited logistics training
Study Uttar Pradesh, India

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Multiple responsibilities
On the move
Minimal support staff
Frequent transfers
Supervisory bandwidth at district is limited too

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Last-mile human capacity challenges
Facility health worker or Pharmacists
• Inconsistent data entry
• Limited inventory discipline
• Unaware of degrading storage conditions
• Low accountability
• Minimal recognition
District Officials
• Limited management bandwidth
• Limited review or oversight procedures
• Low culture of data use
• Reactive risk management
Leads to stock outs, wastage, less motivated workforce

11. Solution

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Enters:
- issues
- receipts
- stock counts
- discards
- transfers
- orders Gets:
- real-time stock views
- alerts on low stock/expiry
- delivery status
- optimal stocking recommendation
- consumption patterns
- product information
GPRS and/or SMS
Inventory on a mobile phone
For the pharmacist at the health facility
Health worker is empowered to manage inventory with decision support

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Remote temperature data loggers
Sending temperature samples once an hour over GPRS or SMS
Inside the vaccine refrigerator

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Dashboards on phone and television monitors
For District Health Officials
District official is empowered to monitor and manage anytime, anywhere
Interactive inventory and temperature dashboards

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Monitoring principles
• Escalate risks on a “need to know” basis
• Highlight good performance
• Enable “appreciation” in a frictionless manner
Enable risk detection and “social” recognition in a frictionless manner
• Critical indicators
• Good performance indicators
• Social “Like” option
For District Health Officials

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Critical event indicators
• Stock outs not resolved over 7 days
• 15 days of stock expiring in 2 months
• Cumulative heat exposure of >24
hours in 4 days
• Cumulative cold exposure of >6 hours
in 2 days
• No data entry since 7 days
Surfaces risks automatically, enables instant action

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Good performance indicators
Enables a frictionless channel to “recognize” and “socialize”
• Good stock management
• Stock of all items available 100% of the
time since last 3 months
• Excess stock no more than 15% of days
• Good asset management
• No excursions since last 3 months
• Good data entry performance
• Data entered within 24 hours of
dispensing since last 3 months
• Good supply performance
• >90% of last-mile stores have >90%
availability with 1 supply per month
since last 3 months
Option to “Like” good performance indicator

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Phone apps. in 370+ districts, 11500+ stores
India
Zambia
97% stock availability
12 states
11,270+ facilities
14,500+ refrigerators monitored
90% stock availability
10 provinces
150+ facilities
16 refrigerators monitored
2M transactions/month, 30M temperatures/month, 1 TB of analytic data
Population: 661 M, Birth cohort: 17 M
Population: 17 M, Birth cohort: 7 M

19. Initial results

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Initial findings – methodology and adoption
• App. usage data was collected over 5 months – Jan-May 2018
• 22 district officials were interviewed across 16 districts in 4 states of India
• Key questions:
• What actions were taken on reviewing critical indicators?
• How were good performance indicators utilized for improving performance?
Mobile app. adoption since Jan 2018 (# of users)
Steady usage by >250 district officials on an ongoing basis

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Initial findings – critical indicators
Risks detected early Coordinated actions pro-actively
7 near-expiry stock events Saved costs
Actions: Redistributed thousands of SKUs
12 cumulative heating/freezing exposure Prevented wastage through coordinated
and timely actions
Actions: power backups reassured, faster time
to repair, timely shifting of vaccines, proactive
replacement of fridges, maintenance practices
reinforced (e.g. defrosting)
5 delayed data entry events Improved worker capacity
Actions: Retrained at the site
District officials intervened immediately to resolve these risks:
(which they would otherwise remain unaware or know much later)
Risks that officials would otherwise be unaware of were acted on immediately,
leading to improved service and cost savings

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Initial findings – good performance
406 “likes” were given to facilities for good performance in 14 of 16 districts
(over 3 months of the study period)
• In 13 districts, “likes” were given to varying number of facilitis, with 34
facilities being liked on the average
• Officials made independent choices on: (a) whether to like a facility repeatedly or
once in a while, (b) give a like per good indicator or on a combination of indicators.
• In 3 districts, a new practice was initiated by the district officials to
recognize facilities with “likes” in monthly Medical Officer meetings
• In 4 districts, screenshot of stores “liked” were shared on the district’s
WhatsApp group, which motivated pharmacists to sustain performance
• In most districts with consistent “like” activity, respondents confirmed
that pharmacists were motivated to strive for better performance
“Social” pressure works to drive performance –
Creative practices emerged, people felt motivated, others strived to raise the bar

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Summary
• Mobile app. was more strongly adopted compared to a web interface
by most district officials, who had little supervisory bandwidth or were
on the move
• District officials were able to pro-actively mitigate supply chain risks,
which would otherwise have not come to their attention in time
• Notification of good performance promoted new behaviors for
recognition of pharmacists/medical-officers in the district, that were
otherwise non-existent
• Social pressure worked, where receiving “likes” lead to improved
motivations, and bottom-up efforts to improve performance
The monitoring app. enabled a frictionless channel for coordinating
timely actions to improve supply chain performance and efficiency

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Be the change you wish to see
– Mahatma Gandhi
You cannot do great things.
You can do small things with great love.
– Mother Teresa

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Thank you! arun@logistimo.com