Sinette Goosen World Malaria Day 2018: Reflecting on the public health supply chain with a focus on IRS

Globally, the efforts to end malaria in endemic, high-burden countries are vast and ongoing.

The fight against malaria brings together thousands of entities, from researchers, manufacturers, governments, and funders, to humanitarian groups and non-government organizations (NGOs). Supporting these institutions in their work is a myriad of interwoven service providers (SPs), executing many unseen tasks.

Among these SPs is the public health supply chain, working diligently to ensure:

    • Best value and quality products are procured to make available funds go further.
    • Commodities reach the point of care, on time and in full.
    • Infrastructure, such as storage facilities, are developed along the supply chain to ensure compliant pharma-grade storage of products.
    • Chain of custody is enforced through technology that captures information about shipment location, product integrity, and patient consumption.

On World Malaria Day 2018, the Partnership for Supply Chain Management (PFSCM) reflects on some of its most recent successes achieved in sourcing and moving complex and sensitive malaria commodities to some of the hardest-to-reach places on earth.



Sourcing and moving malaria commodities: IRS focus

PFSCM has been procuring and delivering malaria commodities for the Global Fund to Fight AIDS, Malaria and Tuberculosis since 2009.

Since then, more than 1,600 shipments of malaria commodities, worth more than $527 million, have been delivered to more than 45 countries for the Global Fund.

Commodities include artemisinin-based combination therapy (ACT), malaria rapid diagnostic tests (MRDTs), insecticide-treated bed nets and indoor residual spraying (IRS) products.

In recent years, PFSCM has refined and streamlined processes for the procurement and delivery of IRS products specifically.

IRS in a nutshell
Indoor Residual Spraying (IRS) is the application of long-acting chemical insecticides on the walls and roofs of all houses and domestic animal shelters in a given area, in order to kill the adult vector mosquitoes that land and rest on these surfaces.

The primary effects of IRS toward curtailing malaria transmission are:

  • To reduce the life span of vector mosquitoes so that they can no longer transmit malaria parasites from one person to another;
  • and to reduce the density of the vector mosquitoes.

In some situations, IRS can lead to the elimination of locally important malaria vectors. Some insecticides also repel mosquitoes and, by so doing, reduce the number of mosquitoes entering the sprayed room, and thus human-vector contact.

In terms of IRS, PFSCM mostly procures and ships a World Health Organization Pesticide Evaluation Scheme (WHOPES)-approved long-lasting microencapsulated formulation of the organophosphate insecticide, pirimiphosmethyl. The product is specifically designed for use in IRS programs to provide up to one year’s residual control of mosquitoes and other public health pests. It is effective against pyrethroid resistant Anopheles, Aedes, and Culex species.

PFSCM Senior Procurement Specialist Martin Mugisha says the procurement and shipping of IRS products comes with unique challenges, especially for public health supply chains.

“The sensitivities relating to IRS products are intertwined. These include complex sampling; pre-shipment inspection and quality control testing processes; relabeling; multiple shipments owing to the hazardous classification of products; limited delivery periods to various developing countries; constraints in order placement; and a lack of awareness and education about the role supply chains play in supporting IRS programs.”

Quality control testing, sampling, and pre-shipment inspection: Product quality is of utmost importance to PFSCM, and quality control batch testing is continuously undertaken.

PFSCM works with a WHO-prequalified laboratory in Belgium to execute the critical batch testing, which is especially important for pirimiphosmethyl — although pirimiphosmethyl is a trusted product, quality testing is done on each batch, owing to the hazardous classification of the product.

Further, quality assurance measures include sampling and pre-shipment inspections often undertaken by renowned inspection, verification, testing, and certification company Standard Global Services (SGS).

Sampling and/or pre-shipment inspections may be pursued at SGS’s own discretion, or as a result of a client request or a specific country requirement.

These safety measures are essential in safeguarding humans and the environment. By managing the quality testing process firmly and partnering with world-class laboratories, PFSCM reduces the cost and lead time of quality testing.

Relabeling for country-specific languages: Another important IRS supply chain activity is the translation of user directions and relabeling of the products. This ensures that country-specific language pairs — such and English and French, and English and Portuguese — are clear and accurate for safe and easy use by spray operators and others involved.

This process requires specialized outsourced services, which are undertaken at the manufacturing facility and coordinated by the procurement agent.

Moving hazardous products: The WHO has classified pirimiphosmethyl as a Class U product, meaning it is unlikely to present acute hazard to humans and the environment. Pirimiphosmethyl presents no significant risk to spray operators or householders when used as directed.

However, for the shipment of large quantities of the product, regulations pertaining to the shipment of hazardous cargo need to be followed. These requirements increase the complexity of the shipping procedure and may result in several vessels being used per order to comply with the allowable amount of dangerous goods per ship.

PFSCM has longstanding agreements with reputable freight forwarders who have extensive experience in managing hazardous cargo in a safe and cost-effective manner.

Time-sensitive products: IRS products need to be delivered before the spraying seasons start. Spraying usually occurs before the rainy seasons, and provisions for the in-country distribution and spray operator training need to be made.

PFSCM actively engages with stakeholders to align processes for smooth delivery of goods.

Constraints in order placement: Forecasting and order placement at the in-country level can be challenging, especially when data is in short supply and resources limited. Accurate forecast data plays a crucial role in manufacturer production scheduling and stockholing.

Improved forecasting data generates market confidence and encourages vendors to enter into long-term agreements with SPs, thereby also ensuring that recipients can enjoy better product pricing and stable supply.

The procurement agent and supply chain SPs need to be flexible and agile in responding to the consumption patterns of public health supply chains in developing countries, and need to drive advancements in this area for optimized spend.

Lack of awareness about the role of supply chains: Stakeholders need to be educated on the importance of collaboration, especially where roles start overlapping. Quick execution of waiver applications, accurate monitoring of warehouse capacity, and attention to details such as the availability of staff for unloading cargo can make a significant impact on a project.

In the public supply chain space, PFSCM often acts as advisor and educator, traveling to engage with stakeholders in person, to ensure all parties understand their roles and are equipped to fulfil their responsibilities.

“Having navigated these challenges and barriers for some years, PFSCM has become an expert in the field of IRS procurement logistics,” notes Mugisha.

Adapting to an ever-changing malaria environment
The malaria landscape is evolving, with drug and pesticide resistance, diminishing funding, environmental concerns, counterfeit and stolen goods, and a need for increased supply chain efficiencies driving new treatment innovations.

With new innovations, the supply chain will need to adapt and gear up for temperature-controlled conditions for new vaccines, while contemplating how new biomedical nanotechnology drug delivery systems will impact on the future of public health supply chains and patient care.

Working with SGS

PFSCM and SGS have a well-established business relationship, with SGS playing a key role in PFSCM’s operations for over a decade now.

SGS facilitates the pre-shipment inspections and sampling of IRS products as per client or country requirements.

In 2018, PFSCM and SGS again had the opportunity to share knowledge and engage about ways of streamlining quality assurance systems in the unique IRS environment.

The collaboration has proven exceptionally fruitful ahead of a major consignment of IRS products due for delivery to Mozambique by mid-2018.

Mugisha explains that stakeholder engagement such as this has been essential in orchestrating complex IRS deliveries.

“IRS shipments comprise many individual processes and products, and therefore the harmonious alignment of QC testing and pre-shipment inspection is critical to ensure the order not only arrives on time, but also in its entirety,” stresses Mugisha.

He adds that direct insight into the specialized tasks managed by SGS, as well as continuous interaction, has helped PFSCM simplify quality assurance procedures to reduce lead time, proactively manage risks, and, ultimately, ensure that the most critical logistics step is well executed.

Further, the efficiency of the quality assurance process is also accelerated by reputable vendors offering excellent quality products.

“The outstanding track record of the pirimiphosmethyl we procure is a contributing factor to the success we have had in reducing quality assurance lead time,” notes Mugisha.

Proactive approach in harmonizing major 2017 IRS deliveries to Mozambique

In 2017, PFSCM made inroads in engaging with IRS program stakeholders and aligning various parallel processes for the shipment of IRS products to Mozambique.

In August 2017, PFSCM orchestrated the delivery of a large consignment of IRS commodities to be used in the Mozambique Ministry of Health’s IRS campaign, which took place around October 2017.

The milestone consignment of 33 containers was shipped via 3 ports of entry, across more than 2,000 km, to 7 regional warehouses in Mozambique.

PFSCM Senior Logistics Services Specialist Jerome Sabatier says it was critical that the shipments were delivered on time, that sufficient compliant storage was available in all seven regions, and that the quality sampling and logistics was done in a cost-effective manner.

“This shipment entailed many complex facets. To save time and money, we conducted the product quality testing early in the preparation phase and tendered part of the shipment to save about $50,000. Apart from this, we anticipated that poor infrastructure, language barriers, and bureaucracy would likely attribute to the complexity of distribution.”

Sabatier explains that PFSCM took a proactive approach to solving the logistics challenges and visited several of the designated warehouses, ports, and in-county stakeholders to ensure all requirements were met before the 33 containers of IRS were delivered.

Further, PFSCM also greatly improved supply chain communication channels by building rapport with in-country stakeholders, such as the logistics SPs, agents, warehouse managers, and other institutions.

“Through the in-country groundwork, we avoided many pitfalls, such as incorrect delivery addresses, availability of labor for offloading at warehouses, and import waiver delays.”

The team not only succeeded in ensuring successful deliveries, but also managed to create awareness about the importance of this malaria prevention project and the shipment of commodities that make it possible.

By sharing their expertise and conveying a genuine sense of responsibility, the PFSCM team motivated the various stakeholders to uphold the same level of ownership.

Price reduction to yield future savings

Meanwhile, earlier in 2017, PFSCM negotiated a 17% price reduction on pirimiphosmethyl. Prior to these negotiations, the pricing for this IRS commodity had remained the same since 2014.

The price reduction is expected to yield significant savings on future procurements and will contribute to saving more lives.

Applying refined strategies for IRS to Mozambique in 2018 and expanding into Zimbabwe

In 2018, PFSCM will again deliver a large consignment of IRS products to Mozambique.

In total, 27 containers will be delivered to 3 provinces in preparation for the spraying season, which is again due to start in October.

In addition, an order of 10 containers will also be delivered to Zimbabwe.

For these shipments, PFSCM will leverage the groundwork done and relationships built in 2017 and will again:

  • Actively engage with stakeholders; and
  • Reassess warehouses inspected in 2017.

This year, PFSCM has already achieved major successes by saving $133,000 on ocean freight cost through spot-bidding and strategizing with SGS.

Navigating the Sahel region with SMC products
At the start of 2018, PFSCM received a large order for seasonal malaria chemoprevention (SMC) commodities to be delivered to Africa’s Sahel region between July and September 2018. SMC is a relatively new, highly effective intervention to prevent malaria in children under five years of age, those most vulnerable to the disease’s effects.

SMC is a complete treatment course of amodiaquine plus sulfadoxine-pyrimethamine (AQ+SP), which is administered in up to four monthly doses to children aged 3 to 59 months during the peak malaria transmission season (July to December) in the Sahel region.

The $5 million project will see 15 million co-blisters of AQ+SP procured and distributed to three African countries: Burkina Faso, Chad, and Nigeria. More than 3 million infants and children will likely benefit from this preventive treatment in these regions in 2018.

PFSCM Senior Client Account Manager Eva van Tol says this is an exciting and challenging project for PFSCM. In Burkina Faso and Chad, products will be delivered to a central location, from which further distribution will be undertaken by PFSCM partners, such as CAMEG. In Nigeria, PFSCM will leverage its in-country expertise to assist the Malaria Consortium with in-country distribution. The products are procured as part of the ongoing ACCESS-SMC prevention program, which is a UNITAID-funded project led by the Malaria Consortium in partnership with Catholic Relief Services.