1. 1 Informed Design: Supply Chain Costing for Policy Decision Making Cost-Effectiveness of Vaccine Supply Chains in Mozambique USAID | DELIVER PROJECT Critical Issues Series Washington DC, July 30, 2012 Leah Hasselback

2. 2 2 Why do supply chain costing? Costs of getting commodities to health facilities is often overlooked or unknown Knowledge of operating costs and cost drivers should be used to make decisions about: Supply chain design Implementation Performance Advocate for funding supply chain Align pricing policies with actual costs Improve efficiency and effectiveness of the supply chain

3. 3 3 Project History 5-year supply chain redesign pilot project implemented in Cabo Delgado province (Dedicated Logistics System) Old: Collection-based, ad hoc system New: Delivery-based, vendor managed inventory with level skipping Included supportive supervision and information system Conducted impact evaluation in Cabo Delgado, using neighboring Niassa province as a comparison Mozambique Cabo Delgado Niassa Nampula

4. 4 Impressive results…but at what cost? 4 IndicatorBaselineResult Coverage Rates (DPT-Hep B3)68%95% Vaccine stock outs80%1% Cold chain functioning~40%96% DPT1-3 Dropout Rate12%3.8% Trust in the public health system 91% visited in last month despite : 47% of families living over two hours away; 85% of them having to walk to get there ; and most common reason for vaccination failure being “place of immunization too far.”

5. 5 Cost Study Objective – Compare the costs of vaccine logistics in the pilot province and a control province. Challenges – Haphazard nature of supply chain in Niassa. – Wide variety of activities, participants, frequency, and costs. – Lack of cost records. – Sufficient recall. Methodology – Excel-based cost model Transport, personnel, cold chain, vaccine & supplies Immunization portion only – Niassa as comparison province – Niassa 10% random sample using PPS 10 health centers in 8 districts Surveys at health centers, districts, and province & national transport & maintenance staff Total 42 surveys

6. 6 Description of Logistics System Assessed Cabo Delgado – Project system – Active logistic delivery system – Vaccines reliably delivered to health facilities each month Niassa – Mixed & inconsistent – Collection & distribution – Varies by location & month Mozambique

7. 7 Cabo Delgado: Dedicated Logistics System 7 District Storage Provincial Store Health Centers Outreach Teams 4. Field coordinator office - input data - analyze information - prepare for next trip - training 1. Leave with: - medical supplies - propane - equipment, parts - knowledge 2. Site visit: - record & stock inventory - service equipment - collect data - supportive supervision 3. Return with: - data

8. 8 Niassa: Old System

9. 9 Results Characteristic / ComparisonNiassaCabo Delgado Difference Niassa – Cabo Delgado Absolute Costs Population1,178,1171,632,809-454,692 Total Vaccine Logistics Costs (1 yr)$266,563.04$305,418.80-$38,855.76 Transport$ 35,968.39 (14%)$ 55,234.48 (18%)-$19,266.09 (-4%) Personnel$75,482.23 (28%)$ 35,376.00 (12%)+$40,106.23 (16%) Cold Chain$31,306.42 (12%)$27.191.82 (9%)+$4,114.60 (3%) Vaccines & Supplies$123,806.00 (46%)$187,616.51 (61%)-$63,810.51 (15%) Costs Controlling for Population Differences Population of Children U5179,892303,007-123,115 Total Cost Per Child U5 (1 yr)$1.48$1.08$0.40 Relative Cost-Effectiveness DPT3 2008 Coverage Rate among children aged 24-35 months 70%95.4%-25.4% Total Cost Per Child Receiving DPT-Hep B3 (1 yr) $6.07$5.03$1.04 Relative Cost-Efficiency Number of Vaccine Doses Delivered (1 yr) 498,624889,152-390,528 Total Cost Per Dose of Vaccine Delivered $1.50$1.18$0.32

10. 10 Results: Breakdown of Costs Conclusion: The Dedicated Logistics System (Cabo Delgado) is more cost- effective and efficient, which leads to government savings.

11. 11 Using the Results Results were used to advocate for expanding the Dedicated Logistics System to other provinces, building on 15 months of advocacy with impact results. 3 months later expansion approved by the Minister of Health. Today 4 of Mozambique’s 10 provinces implement the Dedicated Logistics System, which now extends to over 445 health centers.

12. 12 Thank You www.villagereach.org Leah Hasselback Mozambique Country Director leah@villagereach.org Tel: +258 827324196 Av. 25 de Setembro, 1123-11º. E Maputo, Mozambique Tel: +258 21326446 Fax: +258 21326448