How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

doi:10.1136/bmjgh-2019-001609

. 2019 Sep 5;4(5):e001609.

doi: 10.1136/bmjgh-2019-001609. eCollection 2019.

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

Bruce Y Lee^{1

2}, Patrick T Wedlock^{1

2}, Elizabeth A Mitgang^{1

2}, Sarah N Cox^{1

2}, Leila A Haidari^{2

3}, Manoja K Das⁴, Srihari Dutta⁵, Bhrigu Kapuria⁶, Shawn T Brown^{3

7}

Affiliations

¹ Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.
² Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA.
³ HERMES Logistics Team, Pittsburgh, Pennsylvania and Baltimore, Maryland, USA.
⁴ INCLEN Trust International, New Delhi, India.
⁵ UNICEF India, New Delhi, India.
⁶ UNICEF Regional Office for South Asia, Kathmandu, Nepal.
⁷ McGill Center for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada.

PMID: 31565408
PMCID: PMC6747917
DOI: 10.1136/bmjgh-2019-001609

How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

Bruce Y Lee et al. BMJ Glob Health. 2019.

. 2019 Sep 5;4(5):e001609.

doi: 10.1136/bmjgh-2019-001609. eCollection 2019.

Authors

Bruce Y Lee^{1

2}, Patrick T Wedlock^{1

2}, Elizabeth A Mitgang^{1

2}, Sarah N Cox^{1

2}, Leila A Haidari^{2

3}, Manoja K Das⁴, Srihari Dutta⁵, Bhrigu Kapuria⁶, Shawn T Brown^{3

7}

Affiliations

¹ Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA.
² Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA.
³ HERMES Logistics Team, Pittsburgh, Pennsylvania and Baltimore, Maryland, USA.
⁴ INCLEN Trust International, New Delhi, India.
⁵ UNICEF India, New Delhi, India.
⁶ UNICEF Regional Office for South Asia, Kathmandu, Nepal.
⁷ McGill Center for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada.

PMID: 31565408
PMCID: PMC6747917
DOI: 10.1136/bmjgh-2019-001609

Abstract

Introduction: Coping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping.

Methods: We developed a computational simulation model of Bihar, India's routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping.

Results: Coping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08.

Conclusion: Our results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.

Keywords: health systems; vaccines.

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Conflict of interest statement

Competing interests: None declared.

Figures

**Figure 1**
Diagram of the universal immunisation programme supply chain in Bihar, India.

**Figure 2**
Change in key supply chain metrics under different coping scenarios.

**Figure 3**
Average time out of stock and trips taken under different coping scenarios.

See this image and copyright information in PMC

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References

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1. Lee BY, Connor DL, Wateska AR, et al. . Landscaping the structures of GAVI country vaccine supply chains and testing the effects of radical redesign. Vaccine 2015;33:4451–8. 10.1016/j.vaccine.2015.07.033 - DOI - PubMed

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[1] Arndt BG, Beasley JW, Watkinson MD, et al. . Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017;15:419–26. 10.1370/afm.2121 - DOI - PMC - PubMed

[2] Arndt BG, Beasley JW, Watkinson MD, et al. . Tethered to the EHR: primary care physician workload assessment using EHR event log data and time-motion observations. Ann Fam Med 2017;15:419–26. 10.1370/afm.2121 - DOI - PMC - PubMed

[3] Sinsky C, Colligan L, Li L, et al. . Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016;165:753–60. 10.7326/M16-0961 - DOI - PubMed

[4] Sinsky C, Colligan L, Li L, et al. . Allocation of physician time in ambulatory practice: a time and motion study in 4 specialties. Ann Intern Med 2016;165:753–60. 10.7326/M16-0961 - DOI - PubMed

[5] Diarra A, Ousseini A. The coping strategies of front-line health workers in the context of user fee exemptions in niger. BMC Health Serv Res 2015;15 10.1186/1472-6963-15-S3-S1 - DOI - PMC - PubMed

[6] Diarra A, Ousseini A. The coping strategies of front-line health workers in the context of user fee exemptions in niger. BMC Health Serv Res 2015;15 10.1186/1472-6963-15-S3-S1 - DOI - PMC - PubMed

[7] Abimbola S, Topp SM. Adaptation with robustness: the case for clarity on the use of ‘resilience’ in health systems and global health. BMJ Global Health 2018;3 10.1136/bmjgh-2018-000758 - DOI - PMC - PubMed

[8] Abimbola S, Topp SM. Adaptation with robustness: the case for clarity on the use of ‘resilience’ in health systems and global health. BMJ Global Health 2018;3 10.1136/bmjgh-2018-000758 - DOI - PMC - PubMed

[9] Lee BY, Connor DL, Wateska AR, et al. . Landscaping the structures of GAVI country vaccine supply chains and testing the effects of radical redesign. Vaccine 2015;33:4451–8. 10.1016/j.vaccine.2015.07.033 - DOI - PubMed

[10] Lee BY, Connor DL, Wateska AR, et al. . Landscaping the structures of GAVI country vaccine supply chains and testing the effects of radical redesign. Vaccine 2015;33:4451–8. 10.1016/j.vaccine.2015.07.033 - DOI - PubMed

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How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

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How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India

Authors

Affiliations

Abstract

Conflict of interest statement

Figures

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References

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