Interview Main Topic Pharma Supply Chain
15/10 2018 // International
Pharma Supply Chain and its impact on Global Health 2020 and beyond
Interview with Maeve Magner
Forward-thinking health systems, governments, and other stakeholders are taking a critical look at ways to improve healthcare. Governments have been joined by a long list of private donors (the Bill & Melinda Gates Foundation, etc…) thanks to whom funds have been made available for health spending, and many organizations (NGOs, public & private organizations, humanitarian groups …) are willing to spend them. With this kind of cash flowing into this field, do you believe we are seeing the desired results? What is your opinion of the progress that we have seen to date, and what are the challenges that still exist?
Indeed, given the funds invested in global health, a market which amounts to ~ USD 37.6 billion annually1, I don’t believe we are seeing the returns. However, we do need to acknowledge that progress has been made. Over the past 20-25 years, for instance, we have seen the maternal mortality ratio (MMR) decline by 44%, mortality rates for the under 5s have declined from 180.5 to 75.5 per 1,000, while Aids-related deaths have fallen by 51% since their peak in 2004.
However, there is still a lot more work to do regarding the new HIV 90/90/90 targets, the SDGs, the fact that people are living longer and the burden of disease is increasing, especially for NCDs2, and progress on malaria and immunization coverage is stalling in some regions. To add to this, many developing countries are transitioning from low to middle income status and donor funding and have tough decisions to make on resource allocation.
There are still many inefficiencies across the public health system with challenges driven by poor demand data, challenging infrastructures, and high cost to serve. But, as we know, turning supply chains around takes time and commitment, and we are starting to see some changes. There is also a willingness to adopt innovation which will enable many countries to leapfrog traditional routes.
Much too often aid is tied to short-term numerical targets, like increasing the number of people who receive specific drugs, etc… Very few understand that it will take a full generation or two to improve public health in developing countries. Efforts should focus less on a particular disease than on broad measures that affect the population’s general wellbeing. What is your take on this?
Global health is a very complex space, with many actors, donors and UN agencies, such as the Global Fund, GAVI, UNICEF and UNFPA which are funded by public funds from governments around the world (i.e. UK, Sweden, US, Japan, etc.) typically on a 5-year cycle, which can drive the short-term focus. Organizations such as TGF and GAVI then disburse these funds to UN agencies, NGOs and recipient governments which add another layer of oversight and management requiring evidence of impact.
Speaking from a procurement and supply chain standpoint, the metrics used 11 years ago when I first worked in development were not focused on long-term, system-wide change, due in part to the lack of procurement and supply chain expertise, but also due to the difficulty in gathering evidence of impact.
Things are now changing following recognition that longer-term approaches are needed for sustainability, which are supported by investments, strengthening the health system, harmonizing supply chains, capacity development for people and organizations, improving data quality and use for decision making, innovating for impact, and strengthening private health care.
The initial emergency response to diseases like HIV required a very focused approached which resulted in vertical supply chains, but now other disease programmes are benefiting from the success of these supply chains.
While there will continue to be challenges in securing longer-term funding from global governments, other funding sources are becoming available, ranging from the Global Financing Facility, ADB loans, to increased domestic financing and health insurance.
There are three issues we would like to address which, if taken care of, could have a massive impact on improving the global health system. We would like to hear your thoughts on:
1. Building up medical skills
The World Health Organization says that there is currently a global shortage of more than seven million health workers and that number could rise to nearly 13 million by 2035. Millions of people lack access to essential health services. Providing universal health coverage (UHC), worldwide – which could be a reality in the coming years – is for many experts the key to providing a solution.
Can you elaborate on this? Based on your experience, especially in Africa, do you see any progress? Any significant results? And if so, what would they be?
To achieve UHC globally will require a big change from how we do things today, and we are starting to see those changes already. i) More healthcare workers are being trained and recruited. But to qualify as a nurse, doctor or pharmacist takes a long time, and often they move abroad for better pay and conditions. Other approaches like that of the BMGF is to focus on investing in health system managers working at district, facility or community level, while countries like Ethiopia rely heavily on their Community Health Workers Network. ii) Task shifting is another key area where logisticians and data entry clerks are freeing up pharmacists and nurses to do the work they were trained to do, while some warehousing and distribution functions are being outsourced to the private sector. iii) However, I feel the biggest change of all is and will continue to be in technology at all levels, which will improve the overall medical capacity in the health systems.
From the technical training of staff using technologies like VR and the use of tele-medicine and tele-diagnostics. In working with governments across Africa, Zenysis makes it easier to aggregate and analyse data across multiple systems, while consumers are leveraging technology platforms like Kasha to become more knowledgeable about managing their health. And finally, from the supply chain, both Zipline and Wingcopter are delivering health commodities via drones in Rwanda and Tanzania. It is still too early yet to see significant results. However, to date the trends are good, so stay tuned.
2. Increasing access to medicines
Almost two billion people cannot access medicines (according to the WHO)
Increasing access to medicines has to take many forms – there is no simple one-size-fits-all solution.
What is currently being done in this direction? Which major success stories do you know of?
Affordability and accessibility in both the private and public health systems is important in improving access to medicines. However, this is such a big topic, I am not sure I can answer it all here.
To ensure an adequate and consistent supply of affordable drugs for low- and middle-income countries, global development agencies continue to work with the pharma industry to introduce new innovative drugs and to shape markets, with a recent example being the $75 DTG single pill HIV treatment. With Governments now having to self-fund their health programmes, we are seeing huge demand for branded generics and an increase in local manufacturing on the continent of Africa.
With increased focus on NCDs, we have also seen several initiatives focused on improving access to medicines and technologies for NCDs, including the American Cancer Society and CHAI for cancer drugs, the Coalition for Access to NCD Medicines and Technologies for Hypertension, Diabetes and Dyslipidemia, and the Defeat NCD Partnership. The latter two initiatives bring together governments, the private sector and academia amongst others.
In private health systems, we see the advent of technology companies like Maisha Meds, MyDawa, Connectmed, mPharma and mClinica, among others, providing independent pharmacies with more opportunities to access quality medicines at affordable prices.
Last mile distribution continues to be a challenge both in terms of physical access, especially during the rainy season, but also a challenges in terms of cost to serve, which makes it unattractive for commercial organizations to distribute. Innovation such as drone deliveries are being considered, while NMS in Uganda is working with international and regional 3PL and temperature monitoring capacity to pilot last mile distribution. CHWs3 are increasingly being leveraged to provide services at the community levels, taking with them some commodities for the communities.
3. Improve Medical Information
Quite a few healthcare experts perceive access to medical information as low. We see two major issues here.
First of all the lack of access to medical information – Data… Demand, patient data, etc. What are the good initiatives you are aware of?
The BMGF, along with other agencies, in-country governments and the private sector have developed a Visibility and Analytics (VAN) blueprint similar to SC Control Towers, which is being adopted in several countries across the continent. This enables better visibility of the data, but also focuses on a process of continuous improvement. There is also an initiative of better data use, which focuses on changing the culture around global health data, and GS1 is being adopted as a standard and a requirement for commodity procurement.
Various LMIS systems like eLMIS and One Network are used to collect supply chain data, typically for replenishment orders, while systems like DHIS are used to collect HMIS data. Tableau in conjunction with PATH are providing visuality solutions, while organizations like Zenysis are focusing on data aggregation and advanced analytics across many of these systems.
The second issue we see is the reliability of information.
Indeed, data quality is a challenge, in terms of availability and accuracy of the data, and then again the ability to aggregate and analyse that data is limited. However, aggregating data from multiple sources and over longer periods of time allows us to see trends and identify and prioritize areas of focus pretty quickly.
What can be done internationally in the aid space in order to recognize what is accurate and reliable? What is your point of view on an international standard?
As I mentioned previously, the VAN blueprint was co-developed by a multi-stakeholder group and is being adopted in country, while donors and governments are also standardizing on GS1. Common SC KPIs, SC assessments and a maturity model have been agreed across the donors and governments to help standardize around data and data use, reducing the burden and increasing the accuracy of reporting, while gaining visibility across the whole SC to enable more timely and better decision making.
Thanks, Maeve, for your time and for sharing your expertise with us!
It is always an honour to talk to you.
Thank you, it has been a pleasure.
The interview was held by Silva Certan-Mallmann, BME
About Maeve Magner
Maeve Magner is a supply chain professional with over 30 years of experience largely in high tech global health, having worked for organizations such as Dell Computers and the Clinton Health Access Initiative. A former CEO for Africa’s largest privately owned 3pl for the past 5 years, Maeve has been working as an independent advisor to global health organizations such as the Bill and Melinda Gates Foundation and GAVI, commercial investors Tencent and SOSV, and start-up companies such as Zenysis. Maeve serves on the board of several organizations, leads the supply management stream for the Coalition for Access to Medicines, and is an advisor for the MMV access programme, while serving as a mentor to multiple start-ups.
Between 2014 and 2016, TGF has invested ~$5bn in the procurement and management of health products, and the number of malaria cases and deaths has halved in Asia in less than 15 years (TGF website). Incidences of HIV (as % of the uninfected population) fell from .78% in 1995 to .21% in 2015. In the past 15 years, there are now 21.7 million living with HIV on ARV, new HIV infections have declined by 47% since the peak in 1996. Three out of four people living with HIV know their status (UNAIDS website)
 SOURCE: http://vizhub.healthdata.org/fgh/
 Noncommunicable diseases
 Community health workers