For the past month, I’ve been in Democratic Republic of Congo working to further establish and expand VillageReach’s presence in the country. I’ve also been preparing for a workshop to present the preliminary results of a supply chain modeling exercise that will help key stakeholders identify opportunities for improvement. In the process, I’ve been making the rounds to all our partners, and a key question about our work keeps coming up:
What is taking so long?!?
It’s true: VillageReach began work here in 2015 with an evaluation of the health supply chain in Equatuer and Tshuapa Provinces, and we have been studying the public health supply chain ever since. We aren’t expecting to implement any on-the-ground activities to improve supply chain performance for another six months, when we will begin with a small-scale pilot. So what have we been doing here for the past year and a half? Great question.
We’ve been using a system design approach to identify and understand the persistent challenges that prevent vaccines and medicines from getting to patients at the right time, in the right quantity, and in good condition. System design is a process which creates the plan, or blueprint for how a supply chain should run and how all of its components fit together and interact. Predictably, it takes time to collect and analyze all the information necessary to develop such a blueprint, not to mention getting all the decision-makers to come to a consensus and sign off on the plan. The modeling exercise is an important tool that provides insights into how various configurations of the supply chain might perform, and requires a significant investment of time to build an accurate model.
But there’s another reason that system design cannot be rushed. Improving supply chain performance often means changing systems that have been in place for 40 years or more. Huge investments have been made in these systems. Public health officials and healthcare workers have dedicated their careers to improving supply chain system performance – and there are success stories. In the DRC, coverage of the pentavalent vaccine, which protects against five common childhood diseases, has increased from 44% in 2002 to 81% in 2015.
However, nation-wide statistics can hide inequities in health care coverage. From 2015 to 2016, the number of children who did not have access to vaccines in Equateur province actually increased by over 13% while in the neighboring province of Tshuapa, the number of unreached children was halved. These inequities will likely be exacerbated as vaccine supply chains become more complex as new vaccines are added and populations continue to grow. This challenge is seen worldwide. In their current configuration, most vaccine supply chains are not meeting performance standards necessary to get vaccines to points of care in good condition (see the graph below). As the Gavi 2015 Annual Progress Report lucidly explains, “[b]ecause the remaining pockets of unimmunised children tend to be those that are hardest to reach, coverage improvements slowed during the 2011–2015 period…A ‘business as usual’ approach will not be sufficient to reach these children.” 
To jump-start progress and reach every child with vaccines, existing systems must be carefully analyzed and updated appropriately so that they can respond to current, and future, challenges. That’s where system design comes in.
The engine driving the system design process is the willingness of engaged stakeholders to look very critically at the status quo – not just during the initial design process, but continuously finding ways to improve the system. An effective way to open hearts and minds to a new approach is to identify champions – people who have a solid understanding of the challenges and who are motivated to work toward change. We work with these champions to really dig into what isn’t working, what is working, and why. In many ways it’s like a puzzle, and system design is about figuring out how to put the puzzle back together to improve system performance. We also give these champions a platform to advocate and convince others to look critically at the current system, and to acknowledge that while painful at times, change is necessary. Building momentum and support for a new approach requires time to build a strong base of support in order to drive change forward.
So what has VillageReach done over the last year and a half? We’ve started the process of asking the hard questions. We’ve built an accurate model of the existing supply chain. We’ve engaged champions. We’ve created platforms for the advocacy that will lead to change. The next six months will show the culmination of these efforts. Presenting the model to stakeholders is the beginning of the next phase: creating an action plan to improve the supply chain and ultimately, to reach children even in the most remote regions of the DRC with lifesaving vaccines.
 . EVM (Effective Vaccine Management) Assessments – Average score of Principal, Sub-National, Local District and Service Point Level
 DRC Expanded Programme on Immunization. 2016 Operational Action Plan.
 Gavi (2016). Keeping Children Healthy: The Vaccine Alliance Progress Report 2015.