Products to People: Episode 1 – Strategy & Stewardship

Transcript

Tiwonge Mkandawire: I am your host, Tiwonge Mkandawire, bringing you guests from the health sector to discuss the importance of integration for building equitable, people-centered, resilient, and sustainable public health supply chains. So, during this episode, we are going to talk a bit more broadly about integration. What is it? Why is it important?

At VillageReach, with support from The Bill & Melinda Gates Foundation, we’re implementing the Supply Chain Integrators Grant. And this investment enables us to partner with governments, funders, to build public health supply chains that have those attributes that we want – equitable people-centered, resilient, and sustainable.

In order to guide this work, we’ve developed an Integration Framework, which offers a pathway to achieving these high-performing supply chains. Our framework consists of components and cross-cutting elements to achieving integration. Some of these are relatively well-known. Talking about data integration, so making sure that systems that enable the generation, correlation, analysis, and use, for decision-making of good quality data across the supply chain are things that we’ve been talking about for a while. Product integration is another one. Finding opportunities to consolidate the flow of products through the supply chain when the right segments are applied.

This podcast, however, will focus on new opportunities for integration, such as leveraging private sector capacity to better improve the performance of not only the supply chain, but ultimately, of patients’ or clients’ health outcomes, and also, opportunities that exist to enable the delivery of supplies beyond the health facilities.

In most of the countries where we work, the traditional way of doing things is that products are distributed and they are taken to health facilities, and the patients have to make their way to these centers. What we are proposing is a change from that norm. We would like to get products to the people. Get the products beyond the health facilities, to those places that are more convenient for the patients – whether it’s in their homes, the local pharmacy, or somewhere else.

So, join me as we continue this conversation today with Kelly Hamblin, from The Bill & Melinda Gates Foundation, to get us started on this very crucial conversation about supply chain integration.

Can you tell us a little bit about yourself, and your experiences in this exciting space of healthcare supply chain?

Kelly Hamblin: Yeah. Thanks so much, Tiwonge, and I’m so happy to be here. So, I’ve been a Program Officer at The Bill & Melinda Gates Foundation for about four years now, and I’ve had the pleasure of working in supply chain throughout that time. And honestly, even throughout my career. So, it’s been a passion of mine since I’ve entered into the field of global health. And so, prior to joining the foundation, I was actually a Supply Chain Advisor at two different USAID missions in Sub-Saharan Africa, and then had actually been an Implementing Partner, working in supply chain prior to that. So, I’ve basically spent, I guess nearly 15 years thinking deeply about supply chain and then being interested in it, prior to that.

So, this is something that I’ve thought a lot about and thought a lot about how we can make things better, and easier for healthcare workers, and more convenient for patients and clients who are coming to access the health system. So, happy to be talking about this today.

Tiwonge Mkandawire: Thanks for that, Kelly. You know, I’m so glad you mentioned 15 years to be thinking deeply about, you know, things related to the supply chain to health, it’s a lot of time. So, when you think about Supply Chain Integration generally, as well as the framework, as I described it a little earlier, what are your thoughts? What are the things that come to your mind?

Kelly Hamblin: First of all, I really appreciate how the framework actually really breaks things up into chunks that are easy to understand, and also calls out some areas that we’ve already been talking a lot about I think, as an ecosystem for a while, but then also highlights areas that we’ve neglected historically. So, thinking about it in that way, and kind of asking ourselves to be like, “Okay, so like we’ve thought a lot about data, but where we probably need to be a bit more purposeful is thinking of like the overall strategy, or how our workforce is being supported.” And I think that that’s a really great way to think about it.

I’d say that in general, when we’re talking about integration, the strongest argument that I’ve seen in favor of moving to that model is that it’s much more convenient for healthcare workers, because it’s how they are providing services, right? Or at least in a system that’s kind of not skewed by significant amounts of donor funding. You’ll see a healthcare worker or provider who is providing all sorts of services to their clientele. And so, I think it’s really important to remember that form should follow function, that supply chain should be designed to mirror and support the services that are being offered. And so, when you think about it in that way, it seems like a very obvious statement that then we should be ensuring that we’re treating our products in a way that they are easily and conveniently being provided to the facility or the location where those services are being provided. And I think that that’s what this framework is kind of getting at by highlighting those other areas where that could be the case.

Tiwonge Mkandawire: You know, that is absolutely the point. Ultimately, this is about getting products to the people at that point of care where those products are needed. And I find it really fascinating how you point out the parallels with the way that services are provided. So, thanks for pointing out that parallel.

I can’t resist asking you to unpack a little bit more your comment about how sometimes donor funding can skew things a little bit, or skew the system a little bit, maybe a little bit away from that model. Can you unpack a little bit about that? What is it about the donor funding models, or approaches that have been there in the past, or maybe still exist, that have made this a little bit challenging, made providing an integrated service, or an Integrated Supply Chain challenging?

Kelly Hamblin: Yeah. So, I might be getting myself in a little bit of trouble here, because I’ll back myself into a corner. But I do think that it’s something that we should be really upfront to talk about, even as a funder, historically in various different roles.

Again, often what we see is that supply chains are designed to reflect the services that are being provided. And without purposefulness in countering that or kind of thinking through, does this make sense or should I be treating this differently, if there is a program that is stood up that is dedicated to a particular service, or, and thus the product that’s associated with that service, the movement of the products are going to reflect that.

And so, we see this a lot in outreach campaigns, we see it when we’re– I think that’s like where it might feel the most obvious. Say, we’re doing a distribution of bed nets, or a campaign to respond to an outbreak and to provide vaccines to prevent illness. Or if we’ve identified that there is an at-risk population for HIV, and we want to make sure that we have an outpost to make sure that that population is getting the right services. Often, the money that is associated with those kinds of targeted interventions is funded out of a pot of money that’s very specific to reach that objective. And then, they will bring in people who are very focused on that objective as well. And that makes a lot of sense. Like when you’re thinking about just that product, or just that service, it is natural to then design the way that products are getting there with that in mind.

But if we kind of open that aperture up a little bit, and reflect on, “Okay, but today, or this week, we’re going to be providing this very targeted service. But next week that same provider is going to be providing a whole different set of services.” Maybe, they’re going to do like a Maternal, Newborn and Child Health Day, or maybe they’re going to have their routine vaccine clinic at their outpost. It’s important to remember that often, we’re asking the same healthcare workers to do these services, to do it themselves as a provider of the health system.

And so, thinking through, “Okay, if we had provided this service that we want to target, but then also complemented it with others, we might have gotten more reach, there might have been more interest. It certainly would’ve been more efficient as we were moving products from point A to point B.” And so, the important thing to remember is that the supply chain to provide those services is going to reflect the services. And so, I think it’s really important to remember when we’re talking about Supply Chain Integration, that it’s not even possible to talk about it alone if we’re not talking about the services that are being provided, also being integrated.

And that’s a long way of saying, I think that the funding environment has historically– and I think we’re moving away from this right now – has historically been very focused on providing kind of one-off services– not one-off, that may not be fair, but like is focused on ensuring that the services that they’re funded to do are being provided primarily. And so then, the supply chain will reflect that. If we start thinking about service delivery being holistic and being client-centered, then we’ll naturally have a distribution system and a supply chain that is also more integrated and holistic. And that’s what gives me energy right now. That’s what I think I’m really excited to see as we’re seeing the way that funders are funding, as we’re seeing the voice of healthcare workers being more highlighted in how they are thinking about how services should be provided, we’re, I feel like beginning to move in that direction.

Tiwonge Mkandawire: Thanks for that, Kelly. There’s so many rich bites in there. I feel like I’m in a candy store, and I don’t know which one to go after first. But I can’t agree with you more about how, you know, we can’t really get to a point where we have a properly integrated supply chain that meets the needs of the health system until the service delivery is also fully integrated. And for me personally, that’s part of why I am so passionate about that strategy and stewardship arm, or the strategy and stewardship element of the framework. Because in order to get the kind of shifts that you mentioned in the way in which donors are funding, in order to make sure that the voices of healthcare workers are actually coming through– and I would take that a bit further and say, maybe the voice of the patients also needs to be coming through, informing not only how the services are delivered, but also how the supply chain then responds to that, and is, yet, responsive and agile enough to meet the need. At the heart of it is that strategy and stewardship.

So, I’m going to ask you this question, but if you can try and answer it, maybe putting on a different hat to the one that you normally wear. So, you mentioned that you did have experience as an Implementing Partner before, and you know, as a donor, and Implementing Partner, I’m sure you’ve had a lot of opportunities to interact with governments. What are the things that you think as players, as key stakeholders in this space, we need to change? Either in our approaches, or just in the way we think about things, and just looking at it from an Implementing Partner experience, or what should implementing partners do more of or less, and the same for governments, in your opinion?

Kelly Hamblin: I think the opportunity that implementing partners have is, often, they will get funding that is associated with a particular program, or work stream, or funding color, for lack of a better term. And how they use that money, how they propose an intervention to respond to that, can really shape whether the response is holistic and integrated, or whether it’s very targeted. And it’s natural, in particular, for implementing partners to– you know, they’ve often been asked by a funder to deliver on a specific objective, and kind of bringing in all these other like sub-objectives or externalities, and trying to address them, makes the problem they’re trying to address, or the program they’re hoping to improve, it makes that all the more complicated.

But they have the opportunity to do that if they’re willing to kind of take the time, and structure their response and their strategy to be holistic. And I often feel like if they are– say, you’re speaking to your primary counterpart within a Ministry of Health, and it’s the Chief Pharmacist. Their day-to-day operations are integrated. If you’re talking to the Head of the Reproductive Health program, then it’s not. And I think it’s important to make sure, as an implementing partner, that we’re talking to a breadth of stakeholders within the Ministry of Health, and that we balance kind of funding stream or programmatic-focused objectives, and the counterparts associated with that, with also the cross-cutting partners and counterparts within the Ministry of Health that are looking at it more holistically.

I think if that’s the primary starting point, then often we will see more opportunities for design of a program to reflect a strategy of the Ministry of Health holistically and not an individual program. And it doesn’t mean you need to ignore the unique characteristics of a specific program that perhaps some products are at higher risk of counterfeit, or of diversion of moving outside of the intended system that they’re supposed to be in. But it does mean you don’t have to ignore that. Like you can address the specific characteristics of that program or product, but also factor in the overall strategy and design simultaneously.

Tiwonge Mkandawire: You know, that’s really brilliant. I think when you talk about how, as implementing partners, and we are interfacing with stakeholders within the government, we are coming in, usually, with that lens of, “I am here to do this program or this priority. The person we’re speaking to is dealing with a multitude of things.” And you know, I think there’s a real lesson, or a reminder of a lesson there for a lot of us – to be more open to not only having those conversations that are a bit broader, a little bit more holistic, and really allow the opportunity to create new things. And I think for me, that really drives home the real definition of an Implementing Partner. You know, we are meant to be partners in this journey, and we need to be bringing our contributions, and our thoughts and our ideas to help shape future changes in the program. So, thanks for that.

Maybe just pivoting back to the perspective of government. So, from the implementing partner side, yes, be a better partner. Be a bit more flexible in how you’re thinking about solutions and structuring your responses, so that it creates an opportunity for those more holistic implementations. What needs to change, or what changes could help move the needle from a government perspective?

Kelly Hamblin: The first response that comes to mind for me is ensuring that our government counterparts are first in designing what that strategy should look like. I think it’s very easy, especially in the way that implementing partners are funded, and the way that often, donors kind of structure– the way they provide funds, is that much of the plans or, like a high-level objective, or strategy, have already been formed before we have a conversation with our counterparts within the government, and trying to refrain from that– I realize you just asked me what the role of the ministry would be, but I think this is kind of coming back to what the role of the implementing partner is a little bit – is just making sure that they have an opportunity first, to say how a program should be designed so that that’s kind of factored in.

I would encourage– and certainly, in my roles, when I was a funder located in countries in Sub-Saharan Africa and had the opportunity to have direct counterparts with Ministries of Health, I definitely would’ve welcomed pushback. And I think sometimes, that feels scary from the perspective of a government counterpart, to tell an Implementing Partner, or certainly, a funder, “No, you’re wrong,” but I would’ve been thrilled to– let me be clear. In some cases, I was told,” I disagree with you. Do this differently.” But it probably should have happened more than it did. And so, I would encourage our government counterparts to say, “What I think is best is this, because this reflects–” and then back it up with the reasoning, with the structure that your own program has, that makes that important.

So, I think that’s what I would’ve loved to see more. I’m thinking, actually in particular, in the last couple of years, in thinking through how services and supply chains for vaccines have been rolled out in response to the COVID pandemic. And there were probably times when our government counterparts should have said, “No, I don’t want that product.” Or, “This is not the right time for me to be receiving these vaccines.” Or, “I don’t want a vaccine that requires -70 temperature control.” And those voices should be taken seriously, and valued, and we should be adjusting our response according to that voice. I feel like having a– the COVID example was tough, right? Like, there was so much that was outside of our control as funders, as recipient countries. I feel like all partnership tends to break down when we’re in crisis mode, or it can, and so, you have to be very proactive to protect against that.

But I think the most critical thing that I would like to see moving forward is, that there is more voice from ministries, that they have the opportunity to design– and also patients. Because it’s important to remember that not all patients are getting their services from just the public sector, but knowing that like a response is designed with the holistic public health system in mind, and then also how clients are receiving services, what their preferences are in mind as well.

Tiwonge Mkandawire: What you’ve just said there, I think absolutely resonates with me. I think hopefully, that it also aligns with what we consider the call to action that’s in the white paper on Supply Chain Integration, where our framework is described. And specifically, for governments, what we are encouraging is that governments should take the lead in that integration process. They need to have those clear supply chain strategies, which can then guide the contributions from partners– and by partners, I mean both implementing partners, and donors alike, as well as the private sector. So, those strategies should be providing that guide on how all of those contributions are being made to help the country meet its needs.

And also, you know, the second call to action is really around establishing a way for coordinating all of those inputs. So, I think what you described there about encouraging our government counterparts to have that voice and make sure it’s heard very strongly, is something that’s very close to my heart.

Pivoting a little bit, I hadn’t planned on talking about COVID, but it really is hard to not talk about it when I think about all of the investments, all of the lessons learned as a result of the COVID pandemic, and how we responded to it. So, when we look at the COVID pandemic, and streamlining or integrating into the mainstream health system, what are some of the elements that you think we need to make sure we do not lose, that we gained from the pandemic that we need to make sure we’re finding ways of incorporating in how we do business, how services are provided on a day-to-day basis, going forward?

Kelly Hamblin: You know, one of the things as a public health professional that I found so fascinating, especially in the very, very early stages of the pandemic, was how forthcoming everybody was with data. You know, you had these portals where– you know, whether it was journalists, or academics, who were pulling together all the data that they could find, and making it into a visual so that access to information was democratized, and it was such a powerful piece of information, or sets of information for just civil society, for me, you know, sitting at home, like in March and April in the US with the instructions of, you know, “Don’t go to the grocery store if you can avoid it.”

To be able to look at evolution of case numbers, and the progress of treatment and vaccine development, all very democratized. And that was something that was very unique to the response, and has in some ways, continued, but in some ways, it has also backed off some. I think the competition across countries and across counties or states have actually led to people starting to close up and hold their data more closely because there were fears that if you shared how many doses you had of a vaccine that you hadn’t used yet, that perhaps you would be deprioritized. And often that was not the case, but there was this perception that I think led to people not being as transparent with their information.

And so, that was something that– it was very energizing to see, and I would love to see it continue moving forward. I think that there’s also, you know, there was this move towards like global partnership, and of course, we just got done talking about the importance of voice of our government counterparts, and I think that really came through a lot in the COVID response, how important that was over the course of the last two years or three years, I guess now, I think that ensuring that we’re factoring in the preferences of recipient countries has been really highlighted, and I would love to see that continue moving forward.

And then finally, I think that it was a bit of an all-hands-on-deck, and so we began to see this emerging conversation around integration as part of the response. You saw that there was a clear statement from WHO, that cold chain space originally intended for immunization, should perhaps be made available for treatment or diagnostics, even if they required cold chain, and that’s a great example of kind of– there was a general movement in that direction, and actually, WHO had already said that about other products, but then it was like a really kind of clear message that we shouldn’t be thinking about one service separate from the other, that we need to be able to diagnose whether somebody has COVID, and then immediately follow up with treatment, and those should be together. And if they do require cold chain, we should be making the cold chain that is available for that.

And so, those are the types of things that I loved in the COVID response, that I would hope that can continue moving forward. I think that there was great innovation in information systems as well in kind of tracking service delivery. There was some great innovation in cold chain during that time. Lots of new players in the kind of like cold chain and temperature monitoring space, that I think became more aware of the global health space and hope that they continue to be engaged moving forward. So, it’s easy to talk about how challenging that time was, or how things didn’t go as planned, and there’s lots of those, but there’s also a lot of really exciting progress that was made that I hope we can maintain as well.

Tiwonge Mkandawire: Oh, Kelly, thank you so much. You know, I think that is the first time when I’ve been able to fully grasp how the COVID response was a really good example of integration. I’m talking to you from South Africa, and I was amazed at the level of, not only transparency in information from the government on what was going on, but also seeing how they were actively engaging with their Scientific Advisory Board to make sure that the decisions that they were making were evidence-based, and very much informed by the trends in data that they were seeing. So, it goes back to that strategy and stewardship component.

Kelly, thank you so much that you’ve been absolutely amazing. I can’t agree with you more on just how many opportunities there are out there in how we can better use the private sector to make sure that services are being provided in a way that offers the client, the end beneficiary, that additional convenience, that additional reliability, and things like that. So, thanks for pointing that out.

Just very quickly, I’m mindful of the time, do you have any other thoughts related to Supply Chain Integration in general that maybe we haven’t talked about that you’re yearning to share?

Kelly Hamblin: In thinking through our health workforce, and the workforce of staff that are delivering products to service providers, but then also the staff who are providing those services, I think being purposeful about what we’re asking of service providers to do, as often, they are managing the stock that they’re distributing, is also a really important element of thinking through integration. And so, I think when designing a system and thinking about what information you need to get out of that system, being purposeful about what the interactions are with getting that information, is with the other things that that service provider is being asked to do. You know, deliver immunizations or counsel patients– it feels a little softer, but it’s also an important way to think about it.

And then maybe one other thing that I’ve been thinking a lot about is when we’re thinking about integrating a supply chain or integrating services within a health system in general, it’s so important to remember that it’s often a zero-sum game in terms of finances and budget, and we can’t separate out the decisions that are being made for distribution, and decisions that are being made around finances. The biggest drivers of the health system costs are your workforce, and then the products that you’re buying, right? And those are really big cost drivers.

Tiwonge Mkandawire: Kelly, thank you so much. I think if there’s one thing I’m going to take away from this conversation, is that we all need to be more purposeful. Need to be more purposeful in every aspect of how we are thinking about our approaches and how we are implementing.

You know, from a government perspective, be more purposeful in making sure that we are thinking, as you’ve just said, a little bit broader. Thinking about the funding, thinking about the bottom line, and the real changes that are happening in the system and then demand brought on by the additional funding, as well as trends in the client’s needs. So, just being more purposeful in making sure that they understand those changes, they understand those trends, so that they are designing their strategies accordingly.

For partners, be more purposeful about presenting and designing interventions and solutions that are holistic. Let’s not be bogged down with, you know, “I am funded for this. I am doing HIV, I am doing COVID, I’m doing immunization.” Whatever it is that you’re funded for, be purposeful about thinking holistically, be purposeful about pushing for an integrated approach to not only service delivery, but how supply chains are designed and implemented.

For the donors, to be more purposeful about finding and exploring new opportunities, or new ways of funding that help encourage the movement of some of those solutions that are being thought about by partners, or the strategies that are coming through from the governments.

And for all of us in this community, to be more purposeful about leveraging some of the opportunities that we see that maybe we didn’t utilize fully, like the potential that’s there in the private sector, like being purposeful about how to maximize on the supply chain workforce, so that they are, you know, allocated, and well, just staffed in a way that meets the needs and helps us move forward to an Integrated Supply Chain.

Kelly, you have been absolutely fantastic. Thank you so much, and I look forward to more conversations as we move to getting products to people. Thanks.