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Medicines and health products must be available at service delivery points for health programs to effectively serve patients. Yet regular availability of such supplies is often not guaranteed in developing countries due partly to a lack of well-performing supply chain systems. The particularly challenging economic situation in Zimbabwe in recent years called for an innovative solution to ensure availability of key health products where and when clients could access them.
In 2003, the Delivery Team Topping Up (DTTU) system made its first deliveries to bring supplies to public sector health facilities. The system has since proven itself an effective and robust supply chain solution. With very little interruption, DTTU trucks have made deliveries to the country’s more than 1,600 public sector, NGO and private sector facilities (under a public/private partnership). Throughout its expansion, the system has maintained high reporting rates and delivery coverage, and low stockout rates. Return on investment is measured in terms of the Zimbabwe National Family Planning Council (ZNFPC) achieving its goals of reducing maternal and child morbidity and mortality.
Specifically, condoms and contraceptives distributed by DTTU from 2004-2013 had the potential to meet the needs of more than 15 million couples in Zimbabwe. These condoms and contraceptives had the potential to prevent an estimated 4.9 million unintended pregnancies, 700,000 induced abortions, 193,000 infant (under age one) deaths, 68,000 child (under age five) deaths due to improved birth spacing, and 18,000 maternal deaths.
During this time, by avoiding the direct costs of unintended pregnancy and delivery care, and of treating complications from unsafe abortions, Zimbabwean families and the public health system saved an estimated $334m in direct healthcare spending.
Well-performing supply chains, including effective in-country distribution systems, are critical to ensuring product availability and accessibility, says Dr. Abdourahmane Diallo of the U.S. Agency for International Development (USAID). Yet designing, building and operating health supply chains can be especially challenging in countries in which a variety of disruptive forces – in the case of Zimbabwe, a challenging socio-economic environment – makes operation of normal public sector systems difficult. Transport systems are especially vulnerable.
In Zimbabwe, years of hyperinflation negatively affected public health system capacities, and poor conditions led to an exodus of trained staff members, especially in rural areas. The economy also affected financing for donor-funded projects and programs, and caused fuel shortages.
These factors contributed significantly to specific system failures. For instance, in 2002 a year’s supply of donor-funded contraceptives and condoms were available in central warehouses in Harare and Masvingo, yet were unavailable to be dispensed to clients in many rural clinics. An HIV/AIDS commodities transport assessment conducted the same year concluded that under the country’s fragile health system, the public sector supply chain could not provide the required services.
In response, USAID, through its DELIVER project and with its partners, supported the ZNFPC – the body responsible for public sector condoms and contraceptive supplies – to design and implement the Delivery Team Topping Up system to ensure availability of condoms and contraceptives. Other key partners included the UK Department for International Development and its technical assistance providers, Crown Agents. Collaboration among partners to operate, expand and improve DTTU has continued in subsequent years.
DTTU is a “rolling warehouse,” truck-based inventory control system. It's adapted from vendor-managed inventory principles used in the commercial sector, notably the soft-drink industry.
With DTTU, facility staff members do not place orders. Delivery trucks are loaded with products based on past consumption. The delivery team (a team leader and a truck driver) travels to health facilities to “top up” each facility with the products needed to meet the next period’s requirements. The delivery team questions facility staff about losses and adjustments and days out of stock, carries out physical counts of commodities, calculates the average monthly consumption, calculates the maximum quantity for the facility and tops up the facility to maximum quantity level. Damaged or expired products also are recovered.
Two delivery teams operate in each province at one time. SDPs are resupplied every three months and are “topped-up” to a maximum stock level of six months’ worth of products. It takes two to four weeks to complete all deliveries in a given province.
The DTTU design also involved streamlining distribution into fewer tiers: the central warehouses in Harare and Masvingo, and the service delivery points. SDPs include health centers, district council clinics, hospitals at all levels, nongovernmental organizations and community-based distributors. The two-tier system has the added benefit of shortening the lead time between the central warehouse and the SDP and reduces the overall quantities of stock that the system needs to hold, thereby reducing inventory costs.
Estimated annual operating costs for DTTU were approximately $1.5m, as of 2012.
The system was first pilot tested in Masvingo and Mashonaland West provinces in 2003. Results from the pilot indicated stockouts of condoms at facilities in the two provinces fell to an average of two percent, from 20 percent prior to implementation. Based on these findings, DTTU was implemented nationally in 2004.
An evaluation in 2007 also showed remarkable results. Focusing on condoms and contraceptives, the evaluation found that throughout the nation, the DTTU system achieved 99 percent coverage of all service delivery points – more than 1200 clinics at the time. On the same national scale, it achieved more than 95 percent availability of contraceptives and condoms. The evaluation also determined that
the cost of delivery from the two central warehouses to health facilities was about $0.02 per unit, where unit is defined as one male or female condom, one vial of Depo-Provera, or one cycle of pills. This cost is equivalent to 12 percent of the total value of all products.
DTTU began with distribution of condoms and contraceptives. Based on the successful reduction of stockout rates, and the benefits of having national-level data for consumption and stock on hand, other programs became interested in the DTTU system. In 2007, HIV rapid test kits, syphilis rapid test kits, and nevirapine for the prevention of mother-to-child transmission of HIV were included. In 2011, CD4 point-of-care commodities, and commodities required for early infant diagnosis of HIV were also included.
Based on the success and customer satisfaction associated with DTTU, other programs in Zimbabwe, and in other countries, have considered adopting or adapting the system for their needs.
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