泰国免疫计划的供应链管理外文文献Optimizing national immunization program supply chain management in Thailand an economic analysis

Original Research Optimizing national immunization program supply chain management in Thailand an economic analysis A Riewpaiboon a C Sooksriwonga N Chaiyakunaprukb c d e P Tharmaphornpilas f S Techathawatf K Rookkapang A Rasdjarmrearnsook f C Suraratdechah a Division of Social and Administrative Pharmacy Department of Pharmacy Faculty of Pharmacy Mahidol University Bangkok 10400 Thailand b School of Pharmacy Monash University Malaysia Selangor Malaysia c Center of Pharmaceutical Outcomes Research CPOR Department of Pharmacy Practice Faculty of Pharmaceutical Sciences Naresuan University Phitsanulok Thailand d School of Pharmacy University of Wisconsin Madison USA e School of Population Health University of Queensland Brisbane Australia f Bureau of General Communicable Diseases Department of Disease Control Ministry of Public Health Nonthaburi 11000 Thailand g Department of Pharmacy Administration Faculty of Pharmaceutical Sciences Prince of Songkla University Songkhla 90112 Thailand h United States Agency for International Development Washington DC USA a r t i c l e i n f o Article history Received 27 October 2014 Received in revised form 6 April 2015 Accepted 22 April 2015 Available online 28 May 2015 Keywords National immunization program Logistics Cost analysis Thailand a b s t r a c t Objectives This study aimed to conduct an economic analysis of the transition of the conventional vaccine supply and logistics systems to the vendor managed inventory VMI system in Thailand Study design Cost analysis of health care program Methods An ingredients based approach was used to design the survey and collect data for an economic analysis of the immunization supply and logistics systems covering pro curement storage and distribution of vaccines from the central level to the lowest level of vaccine administration facility Costs were presented in 2010 US dollar Results The total cost of the vaccination program including cost of vaccine procured and logistics under the conventional system was US 0 60 per packed volume procured cm3 and US 1 35 per dose procured compared to US 0 66 per packed volume procured cm3 and US 1 43 per dose procured under the VMI system However the fi ndings revealed that the transition to the VMI system and outsourcing of the supply chain system reduced the cost of immunization program at US 6 6 million per year because of reduction of un opened vaccine wastage Corresponding author Faculty of Pharmacy Mahidol University 447 Sri Ayutthaya Road Ratchathevi Bangkok 10400 Thailand E mail address arthorn rie mahidol ac th A Riewpaiboon Available online at Public Health journal homepage public health 129 2015 899e906 http dx doi org 10 1016 j puhe 2015 04 016 0033 3506 2015 The Royal Society for Public Health Published by Elsevier Ltd All rights reserved Conclusions The fi ndings demonstrated that the new supply chain system would result in effi ciency improvement and potential savings to the immunization program compared to the conventional system 2015 The Royal Society for Public Health Published by Elsevier Ltd All rights reserved Introduction Universalvaccinationprogramhasplayedanimportantrolein disease prevention The program success is greatly based on effective and effi cient supply chain and logistics system Criteria for good supply chain management comprises of six rights i e product correct product as per request quantities correct as per request place sent to requested organization time timely supply quality no damage or with appropriate condition e g temperature and costs appropriate service charge or cost World Health Organization WHO has launched the Effective Vaccine Management EVM Initiative focusing on key concepts on lower stock levels reduced wastage accurate forecast of vaccine requirements and pre vention of equipment break downs 1WHO and PATH imple mented a collaborative project called Optimize from 2007 to 2012 aiming to develop immunization systems and technolo gies including conducting studies and analysis on outsourcing ofvaccinesupplychainandlogisticstoprivatesectorinseveral countries including Thailand 2Zaffran et al provided the evi denceofimportanceofvaccinesupplyandlogisticssystemsin the recent review of studies in Senegal and Tunisia under projectOptimize 3Thereviewindicatedthatinsomecountries eitherun openedoropened vialvaccinewastagewas accounted for 50 Most un opened vaccine wastage can be attributed to supply chain process Stockouts are also caused by inappropriate supply chain system It is recommended that immunization supply system may increase effi ciency and effectiveness by outsourcing certain function of private or parastatal agency which is corresponding to the Thai policy Information technology and human resources may also pose concerns for supply chain systems Thailand is one of the countries that have demonstrated the importanceof optimizing national immunization program supply chain management Prior to 2009 the Thailand Department of Disease Control DDC managed the vaccine supply chain and logistics system the conventional system The vaccine logistics systems started with the delivery of vaccines from the producer importer to the central ware house of the pharmacy unit located in the DDC Vaccines were transported to 12 disease prevention and control regional offi ces then to 76 provincial health offi ces to district health offi ces and fi nally to about 10 000 health service fa cilities including hospitals and health centers Fig 1 To streamline the vaccine supply and logistics system and improve information fl ow the National Health Security Offi ce NHSO and DDC launched a pilot project in 2009 to outsource vaccine supply management to the Government Pharmaceu tical Organization GPO a state enterprise under Thailand MinistryofPublicHealth Aspartoftheoutsourcing arrangement the GPO introduced and managed a vendor managed inventory VMI and contracted a private logistics company to distribute vaccines and related commodities in 28 of 76 provinces Since 2010 the NHSO has been solely in chargeofprocuringanddistributingvaccinesforthe Expanded Program on Immunization EPI and has continued to outsource its procurement and distribution functions to the GPO Fig 2 In late 2010 the VMI system was expanded to the whole country VMI is a streamlined approach for inventory management and order fulfi llment One of key features of VMI involves collaboration among suppliers and customers which changes thetraditionalprocurementanddistributionprocesses Instead of sending purchase orders indicating the types and dosesrequired customerselectronicallysendinventory Fig 1 e Conventional vaccine supply chain distribution system GPO Government Pharmaceutical Organization DDC Department of Disease Control PCU Primary care unit public health 129 2015 899e906900 information to the supplier The supplier generates replen ishment orders for the customer based on the inventory level demand The process is guided by objectives that are mutually agreed upon for the customer s inventory levels fi ll rates and transaction costs 4Waller et al described the main advantages of VMI on cost reduction and customer service improvement 5 In Thailand the VMI system starts at the central ware house and vaccines are supplied directly to the hospitals in each district designated as district warehouses Vaccines and related commodities are then distributed from the district warehouses to primary care units PCUs i e sub district health centers or hospital immunization clinics The vac cine inventory is managed at the central warehouse through the secure internet portal VMI webpage The information regarding the present stock of vaccines at the district ware house is collected and recorded by the hospital pharmacy department and submitted to the central warehouse on a monthly basis The central warehouse then prepares and de livers the vaccines according to the demand Anecdotal evidence suggests that VMI offers higher man agement effi ciency for the vaccine supply chain system and will reduce unopened vial vaccine wastage 6However there is no empirical evidence to support the benefi ts of VMI for vaccine products in the public sector Therefore this study aimed to conduct an economic analysis of the supply chain systems of the national immunization program NIP in Thailand The study was supported by the project Optimize a collaboration between the World Health Organization and PATH http www path org publications detail php i 2019 Methods Study design This study was designed as a post implementation economic analysis We employed a micro costing and ingredients based approaches from the government perspective Costs were calculated from a summation of costs of all system levels or components of the program The study compared the total costs and unit cost of two vaccine supply chain systems outsourcing and transitioning to VMI vs conventional Due to limitations in data collection process the analysis did not includethecostsfromsupportingunits forinstance administration department of hospital hidden costs of in ventory for instance excessive inventory and stock outs and start up costs for instance training on introduction of VMI system All costs were presented in 2010 US dollar ex change rate US 1 31 69 Thai baht THB 7 Study sites data sources and data collection The study sites included the central level vaccine manage ment unit at NHSO and DDC and 12 health management re gions covering 76 provinces 878 districts of Thailand to ensure national representative samples For each of 12 health management regions one province was purposely selected For the VMI system the study coveredthe NHSO 12 provincial hospitals 12 district hospitals and 24 health centers For the conventional system the study sites covered the central warehouse at the DDC 12 disease prevention and control regional offi ces 12 provincial health offi ces 12 district health offi ces and 24 health centers In both conventional and VMI system health centers are the only common study site so the data from both systems were collected from the same health centers Data collection forms were developed specifi cally for con ventional and VMI systems and for each facility type and were fi eld tested for content validity by researchers prior to use The data collection forms contained the following sec tions 1 key activities and workfl ow 2 resources used 3 costing information for each type of resource and 4 quanti ties of vaccine supply Logistics activities of both systems weredefi ned for all levels and included activities of estimating target quantities preparing and submitting request forms Fig 2 e VMI vaccine supply chain distribution system NHSO National Health Security Offi ce GPO Government Pharmaceutical Organization PCU Primary care unit public health 129 2015 899e906901 collecting or receiving vaccines completing inventory regis tration storing vaccines and monitoring temperature The total logistics costs at each level included cost of purchasing cost of storage and inventory management vaccine storage and cost of transportation vaccine distribution The number of doses and packed volume of the vaccine procured were collected for each vaccine type Data were collected through face to face interviews with health staff at sampled health facilities between July 2010 and January 2011 Quantities of vaccine supply and costing information were retrospectively collected for a period of four months from the interview date for the VMI system to capture vaccine information prior to the transition to VMI For the conventional system data were also collected for the period of four months in the fi rst half of 2009 before the transition took place in 2010 The data collected from four months period was at least six months before the date of transition to VMI in 2010 Similarly data of logistics system are from 4 month period which was at least six months after the date of transition to VMI Costing methods Cost data included labor cost material cost and capital cost of cold chain and logistics systems At each study site resources usedwerequantifi edandunit costwas identifi ed todetermine the total cost At each system level mean median and stan darderror oftotal costsand costper dose werecalculatedwith respect to each cost component i e labor cost material cost and capital cost The unit cost of the whole system was the summation of the unit cost mean of all facility levels The total logistics cost of the country was derived from multi plying the unit cost by the total number of doses for all vaccines The cold chain and logistics equipment included cold containers computers and printers The capital costs were estimated usinga 3 discountrate 8Thecostsofcapitalassets shared by other activities were allocated on the basis of per centage use Labor cost was estimated from the product of time spent on each activity by each staff worker minute per activity per month and worker hour wage rate calculated from average monthly salary adjusted by 22 working days per month and six productive hours per day Material costs included offi ce supplies electricity costs for cold chain and transportation Thetransportationcostwaseitherthe outsourcing fee in the VMI system or the estimation of dis tance and fuel costper kilometer in the conventional system Outsourced logistics costs of the vaccine supply chain system were at 5 of the vaccine cost based on the NHSO offi cial rate Reference costs for transportation by motorcycles and cars were US 0 063 and US 0 126 per kilometer respectively Electricity costs were estimated from electricity units kilo watt hour and the cost per electricity unit Electricity units were calculated by multiplying compressor wattage by the compressor s estimated running time 8 h per day The refer ence cost of electricity was US 0 091 per unit Salary refer ence costs and vaccine prices used for both systems were that of 2010 value Therefore infl ation or discounting was not applied We also estimated the marginal cost required for scaling up the supply chain systems of the EPI program The cost per one additional vaccine was calculated based on the number of doses packed volume and unit price of an additional vaccine and obtained from the average of the current EPI vaccines Table 1 The staff time and use of offi ce materials were assumed to be about the same for both systems Outsourcing costs were assumed to remain the same at 5 of the value of additional vaccines procured Capital costs of additional cold containers and electricity costs were estimated The number of additional cold containers was determined by the differ ence between the available space of the containers and the space needed for additional vaccine taking into account the total volume of the cold container ft3 percentage of volume sharing to other purposes of using of the cold container the volume used by the existing vaccines and the volume needed for additional vaccine estimated from the average packed volume per dose 2 73 cm3 and total number of doses of additional vaccine Data analysis The cost of vaccine logistics per dose and per cm3of packed vaccine supplied were computed for each level and then summed to derive the unit cost for the whole system The total annual vaccine logistics cost of the national immuniza tion program was derived from the overall unit cost for the whole systemmultiplied by the totalnumberofvaccinedoses The cost of the logistics system and the cost of vaccine products were added to represent the cost of the program The Table 1 e Expanded Program on Immunization EPI vaccines in Thailand VaccineVial size dose vial Packed volume per dose cm3 Price per vial US at 2010 prices BacilleCalmette Gu erin103a2 21 Diphtheria tetanus toxoid1031 74 Diphtheria tetanus pertussis1033 04 Diphtheria tetanus pertussis hepatitis B10314 18 Diphtheria tetanus pertussis hepatitis B21 52 73 Hepatitis B21 52 73 Japanese encephalitis21 53 91 Measles1035 11 Measles mumps rubella106a18 13 Measles mumps rubella13a2 81 Oral polio201 54 87 a Included diluents although diluents do not require cold chain in practice they are kept in the cold chain public health 129 2015 899e906902 marginal cost per dose was calculated as the total incremental logistics cost divided by the number of doses of additional vaccine Due to limitation of sample size probabilistic sensi tivity analysis was conducted to explore variability of the re sults Capital labor and material costs of all levels were randomly selected by MS Excel function gamma distribution Simulation was iterated 1000 times The results were unit cost total cost and difference between the systems Results Costs of logistics systems vaccines procured and overall savings Overall the total logistics cost per health center district distributor and central supply of the VMI system was higher than those of the conventional system Table 2 which resulted in a higher cost per dose procured Labor was a major cost component of logistics costs at all levels of both systems except at the provincial and central level The cost per dose procured at health center was the highest compared to other facility levels for both systems A total of 26 6 million and 20 6 million doses of vaccines were procured by the conventional system in 2009 and by the VMI systemin 2010 respectively Table 3 As a result the total costs of vaccines procured for the conventional system US 22 976 732 washigherthantheVMIsystem US 18 055 517 The total logistics costs of the VMI system however were US 1 637 390 less than the conventional sys tem Table 3 reports the total and average logistics costs of the conventional and VMI systems including the savings from changing to the VMI system For the VMI system the logistics costs were based on the outsourcing cost of 5 of the cost of procured vaccine The unit cost of procuring vaccines under the VMI was slightly higher than that of conventional system at US 0 55 per dose and US 0 26 per cm3for the VMI and US 0 48 per d