Background
Public health supply chain ensures integration, coordination and control of all resources, tools and processes required to ensure availability of commodities to beneficiaries in a timely and cost-effective manner. It is believed that to be effective, a public health supply chain must have a master plan centered on addressing the key objectives of a country’s health system through commodity availability interventions. The master plan serves as a blueprint for future expansion of the supply chain, while addressing the challenges of the current environment and providing a strategic approach to addressing the needs for a foreseeable future.
Beyond planning for the future, the recent supply chain challenges created by the disruptive nature of the Covid-19 pandemic, have enhanced the significance of a country’s need for a public health supply chain master plan. It has underscored the critical requirement of having a robust master plan to establish mechanisms and interventions that support a dynamic and resilient supply chain that can withstand the impacts created by disruption challenges. Ghana was fortunate to have had an operational and successful master plan that was established by the Ministry of Health (MoH) and its agencies chiefly the Ghana Health Services (GHS) and facilitated by development partners.
The Ghana Supply Chain Master Plan (SCMP) was developed in 2011. It was born out of the ever-changing supply chain demands and the desire to develop a foresighted approach to address siloed initiatives into an integrated outlook centered on tangible interventions and aligning them to both country health sector development framework and global development sustainable standards. The focus of the master plan included streamlining procurement processes, improving commodity financing and resource utilization, optimization of distribution and warehousing network, improving coordination mechanisms, and establishing a platform for end-to-end visibility and providing real time data to inform decision making. Prior to the 2011 master plan initiative, attempts to address all these interventions had not yielded any notable impact on the supply chain. Therefore, the ministerial decision in 2011 marked the turning point for Ghana’s public health commodity supply chain revolution.
Drivers for Change, Ghana’s context
Driven by poor performance, fragmentation and inability to sustain implementation objectives, the Ghana MoH undertook a holistic system evaluation and established that the lack of governance, including clarity of roles and responsibilities among key actors contributed significantly to poor performance. Additionally, absence of a platform and tools to provide end to end visibility across the value chain, lack of real time and quality data to support decision making and a challenged distribution and transportation mechanism especially to the last mile played a significant role in hindering the attainment of the health intervention objectives. These issues coupled with sub-optimal warehouses across the major streams of the supply pipeline, poor storage conditions at service delivery points (SDPs), unclear distribution networks, inadequate workforce, and capacity, created significant issues and interruptions to commodity availability and overall service delivery. The challenges had far reaching consequences including frequent stockouts at service delivery points, wastage due to commodity expiries, poor product quality, high operational cost, gross supply chain operational inefficiencies, lack of accountability, absence of decision-support systems and ultimately poor client’s satisfaction.
The Ghana Supply Chain Master Plan (SCMP)
On identification of the supply chain root causes, the MoH with the collaboration of key stakeholders, developed a 5-year Strategic Supply Chain Master Plan (SCMP) 2012-2018, to address all notable challenges and establish both strategies and mechanisms to optimize the public health commodity supply chain. The SCMP was anchored on the mission of “Ensuring quality health commodities are available, accessible, and affordable to all, supported by a sustainable, reliable, responsive, efficient and well-coordinated supply chain”. It was organized along seven (7) major thematic areas that impact on a high-performing supply chain.
These included the following:
- Organization (i.e. institutional capacity and roles) and coordination, human resources, and supervision.
- Financing, resource mobilization, and commodity pricing.
- Procurement.
- Distribution (i.e. storage, inventory management, transport, and waste management.
- Information systems and processes (including Logistics Management Information System [LMIS]).
- Quantification and product selection, and
- Policy, legal, and regulatory environment.
Key to this development, was the collaborative effort by key in-country supply chain actors and support from developing partners. This ensured a holistic buy-in from all key actors from inception to post implementation evaluation. Since 2012, the SCMP has provided Ghana with the right framework and the foundation for all successful supply chain interventions implemented across the country.
The 2015 Central Medical Store (CMS) unfortunate fire incidence prompted a revision to the developed SCMP (i.e. Ghana Supply Chain Master Plan [SCMP], 2015-2020 Revised Edition) to accommodate the disruption occasioned by the loss of the CMS. The existence of the SCMP provided the impetus and the rallying point for cost recovery agreement entered into by the Global Fund and GoG for the implementation of high impactful interventions which has propelled the revolution in the public health commodity eco-system. The successful implementation of key interventions in the SCMP and the benefit realization since its development has necessitated the MoH to kick-start processes aimed at revising the current version of the SCMP which elapsed in 2021. It is the expectation of the MoH and its Agencies that, the current SCMP and the follow-on version of the SCMP will continue to remain the “go-to” transformational guide for the country to sustain gains made and to strive for the attainment of commodity security for the Country.
The Master Plan Development Approach and Implementation
To effectively achieve the objectives of addressing the Ghana MoH public health supply chain challenges, and develop transformational interventions to address the limitations, the MoH developed a dynamic long-term planning document that provided a conceptual layout to guide interventions to current challenges including strategies for future growth and development. The approach included analysis, recommendations, and proposals for operational improvements, focusing on four (4) critical phases:
- Holistic systemic diagnosis
To identify the challenges and develop a more in-depth understanding of complex supply chain environment, a holistic system diagnosis must be undertaken. This evaluation helps in identifying interventions for future sustainable solutions with an innovative and transdisciplinary approach, aimed at promoting a horizontal dialogue among all key stakeholders and entities involved. In case of Ghana, the MoH commissioned a comprehensive assessment of the public health supply chain including a strategic review of all available documented previously conducted assessment reports on the performance of the Ghana public health system. This was supported and guided by a dedicated technical assistance provider and the involvement of critical supply chain players that ensured proper diagnosis of the supply chain. The outcome presented stakeholders with the strengths and limitations of the existing supply chain., afforded stakeholders the opportunity through several engagements to thoroughly diagnosis the situation, reviewed assessment findings, obtained and built consensus on the limitations identified, and at the same time examined and established the strengths of the public health commodity supply chain. Key outputs informed objective setting and the establishment of related best practices leading to the formulation of strategic interventions as contained in the SCMP.
- Establishment of Governance Framework and mechanism
The existence of a well-resourced, dedicated and empowered governance mechanism is critical to providing required leadership and guidance for any successful implementation, it facilitates the identification of key resources, its mobilization and effective utilization. Proper governance arrangement creates the enabling environment for performance monitoring and monitoring, builds confidence in established processes whilst ensuring accountability. In Ghana’s case, the MOH, established a well-structured governance mechanism with multi-sectoral/agency membership which included both implementing and development partners. There was the over-arching Supply Chain Steering Committee, chaired by the Minister of Health, that provided oversight, resource and support for the focused Technical Working Group (TWG) and other several Sub-Committees such as the IT/Logistics Management Information System (LMIS), Risk and the Public Private Partnership (PPP). The framework also established an Operational Unit under the direct supervision of the Supply and Procurement Directorate of the MOH with dedicated technical lead supported by USAID. The framework allowed for a bottom-up approach that ensured that the Operational Unit functioned to provide technical inputs for the other structures to effectively operate and engaged and also to provide leadership. Routinely, all establishments within the governance arrangement meets to review implementation progress and ensure alignment of priorities and undertake resource rationalization as part of the process.
- Stakeholder involvement
The successful implementation of any intervention requires inputs from key stakeholders or end-users without which intended benefit realization and impact will be a mirage. Constant engagements and involvement of the right stakeholders from inception to post implementation evaluation is critical. The MOH in the bid to ensure total buy-in, through the functions and operations of the established governance structures involved and engaged with all relevant stakeholders on regular basis, developed and implemented a comprehensive stakeholder management plan following a thorough Stakeholder’s analysis. The plan directed and informed which stakeholder to engage, what information to engaged on, the engagement media to leveraged on and the frequency of engagements. This approach allowed for a continuous review and adaptation to ensure total reach across the entire supply chain eco-system.
- Political support and alignment with Government vision
The alignment of a major reform or intervention to national priority plays a critical role in guaranteeing implementation success. This is usually the case in most resource constraint settings, where there is the need to ensure that political leadership is aware of such major reforms as it may resource commitment at the government level. In the case of Ghana, following the development of the SCMP and the endorsement by the Minister of Health, the MOH ensured that Cabinet Memo was developed and submitted for Cabinet approval. The MOH also ensured the inclusion of the SCMP and its implementation plan in the Ministry’s annual Program of Work (POW), Aid Memoirs and highlighting of same in several State of Nation addresses (SONA) to the Parliament of Ghana as a pivotal document for the nation’s public health supply chain reform in achieving the MOH vision of expanding access to health to all living in Ghana.
The Impact
The successful development and implementation of the SCMP, significantly transformed Ghana’s public health supply chain, establishing operational efficiencies leading to increased availability of commodities, addressing challenges, reducing overall supply chain costs, and establishing mechanisms that facilitated resilience and agility during the pandemic. Notable improvements included commodity distribution optimization that leverage private sector expertise through the last mile distribution (LMD) initiative from the central tier to the last mile of the value chain, collaboration with the Public Procurement Authority (PPA) to review existing procurement regulations that facilitated framework contracting for commodity procurement to drive down cost of commodity and the implementation of the Ghana Integrated Logistics Management Information System (GhiLMIS) which leveraged Information technology (IT) to improve business and operational processes for commodity management. Additionally, the MOH in collaboration with GHS implemented warehouse improvement interventions at the mid-stream of the supply pipeline to assure product quality and reduce wastage during storage.
The coordinated LMD initiative at the central tier has improved coordination among supply chain entities, reduced warehouse holding and operational cost. It has contributed to product availability at the SDPs. At the regional or mid-tier of the supply pipeline, beyond streamlining distribution processes and improving product availability, it has contributed to reducing level of effort (LOE), reduced order turn-around time and cycle-time. It has also improved internally generated funds (IGF) for both the regional warehouses and the SDPs and has ensured patient satisfaction as a results of improved service provision.
The GhiLMIS implementation has provided near real-time data availability, end-to-end supply chain visibility, reduced order cycle time, reduced LOE, reduced operational inefficiencies and improved business operations across the value chain. The agile, responsive, scalability capability of the GhiLMIS provided just-in time system for the Ghana to respond to the emergency situation as a result of the COVID-19 pandemic. The MoH/GHS utilized the GhiLMIS for all transactions, recording and reporting of all COVID-19 related activities. As a national tool and system for commodity management the GhiLMIS continue to play a vital role in the performance and management decision-making for the country.
Since 2019, Ghana has successfully utilized framework contracting (FWC) mechanism for the procurement of selected high-cost and high-volume driving commodities, critical but hard to procured essential public health commodities primarily to achieve price reduction and economy of scale. The FWC since its implementation has contributed to improved IGF for the regional warehouses and also procurement of quality health commodities.
Warehouse improvement initiated as part of capacity improvement and operational efficiencies over the years has ensured that warehouses across the country especially mid-stream of the value chain have been renovated to improve condition of storage, capacity increased to accommodate inventory throughputs and provision of basic warehouse material handling equipment. Quality of commodities stored and managed in these warehouses have been maintain both in storage and in transit.
Lessons learned and recommendations
Ghana’s journey towards the development and implementation of the 5-Year Strategic SCMP was all-inclusive backed by ministerial commitment. The developmental process and the implementation of the SCMP encountered several challenges. However, the aggressive stakeholder engagement, establishment of process ownership, honest review and buy-in by all underpinned the success of the Ghana approach.
Country context, drawing on in-country expertise, learning from other country’s experiences, fused with overall country’s vision and objectives were crucial in ensuring the successful development and subsequent implementation of the sustainable MoH’s SCMP that has guided all reforms implementation and has stood the test of time.
By Adolf Antwi, Philip Lule, Dr. Mrs. Joycelyn Azeez
