Delivery Team Topping Up: Bringing about reliable distribution of health supplies in difficult environments: Zimbabwe

The term “fragile state” is often used to describe countries wherein a variety of disruptive forces makes operation of normal public sector systems impossible. The causes vary and are not new. They include warfare, civil strife, general economic failure, or especially poor governance. In a fragile state, public health transport systems are particularly vulnerable. In response to these shortcomings, the USAID | DELIVER PROJECT and its predecessors, collaborating with their in-country partners, have adopted an approach used successfully in the commercial sector— notably the soft drink industry—called the Delivery Team Topping Up (DTTU) system to ensure the availability of condoms for the prevention of HIV and AIDS and of contraceptives in Zimbabwe.

In any country, a key step in ensuring the availability of public health supplies is the assembly and maintenance of reliable supply chains with effective in-country distribution systems. Reliable transport is essential for operating such distribution systems, which means that, without intervention, supply chains within ‘fragile state’ countries are drastically weakened by failed systems and unreliable infrastructure.

So, how can international development efforts best design a reliable, well-functioning supply chain when the public sectors of ‘fragile state’ countries cannot provide the necessary infrastructure to support it?

The DTTU system, implemented in Zimbabwe by JSI through the USAID | DELIVER PROJECT, is one solution to this challenge. DTTU systems are distribution paradigms in which special investments are made to ensure that reliable vehicles, drivers, technical staff members, or a combination of these will directly provide or “top up” facilities with the health products that they need.

Under a DTTU system, delivery trucks are filled with a predetermined quantity of a product—usually based on past consumption patterns— and the product is driven to health facilities. The drivers or other staff members who are part of the delivery team have the responsibility of calculating current consumption and re-supply quantities, and they reconcile inventory deficits at each facility visited. Thus, they “top up” the inventory of each facility with quantities needed to meet the next period’s requirements.

The USAID | DELIVER PROJECT and its predecessor projects, Family Planning Logistics Management (FPLM) and DELIVER, also managed by JSI, have been working with DTTU systems for many years, successfully employing the system to ensure reliable supply chains in areas that present logistical challenges.

As defined earlier, DTTU has three main characteristics: (a) specially trained drivers (or other accompanying technical staff members); (b) reliable transport; and (c) adequate operating funds. In situations where options for transport within the public and private sectors are not available or reliable, this approach means in practice that the DTTU will have to acquire and maintain its own fleet of trucks. This necessity creates a major start-up cost, but in some fragile state situations, donors recognize the need and are prepared to cover this expense. The recurrent costs of fuel, maintenance, and staff travel expenses also must be covered. However, in terms of effectiveness, the results have been good.

The Case of Zimbabwe

The implementation of the DTTU system in Zimbabwe to supply health facilities with contraceptives and condoms for HIV and AIDS prevention serves as a good example of DTTU in practice. The DTTU system was implemented in Zimbabwe in 2004 and is still operating effectively.

The public health care system in Zimbabwe operates in a difficult economic environment; hyperinflation has had a very negative effect on program capacities and high unemployment has led to an exodus of trained staff members. The effect has been most severe in rural areas where many vacant positions have remained unfilled, and rotations through posts are frequent. These factors have contributed significantly to specific system failures, including the supply chain.

Widespread fuel shortages caused by the country’s economic instability have further stymied aid efforts to overcome distribution challenges in Zimbabwe. When there is fuel, it is only obtainable in urban centers meaning that there are no opportunities to refuel in rural areas.

Through the USAID | DELIVER PROJECT, JSI and its implementing partners carried out a pilot test of the new DTTU system first in Masvingo and Mashonaland West provinces in 2003 and then nationally in 2004. In 2003, before implementation, stockouts of condoms in the two provinces occurred at an average of 20 percent of all facilities. After the pilot had been implemented, that rate fell to an average of 2 percent.

The partners decided to streamline actual distribution into two tiers only: (a) the central warehouses in Harare and Masvingo; and (b) the service delivery points (SDPs). SDPs include Ministry of Health health centers, district council clinics, hospitals at all levels, nongovernmental organizations, and community-based distributors.

In each ZNFPC provincial office, the Nurse-in-Charge/Community, the Service Delivery Coordinator, the Stores-in-Charge, and the Provincial Accountant have been trained in how to carry out deliveries. In addition, all truck drivers received training so that they can perform stock accounting and reporting tasks during deliveries. Two teams operate in each province at one time, and it takes two to four weeks to complete all deliveries in a given province.

DTTU systems have yielded positive results in increasing the availability of a products in difficult environments by guaranteeing direct delivery to health facilities and creating systematic accountability at all points of procurement, delivery, and receipt of commodities.