Hi, 

I'm a pharmacist from the Netherlands, currentlly working in Viet Nam
as an advisor to the Ministry of Health. We are looking at the
national supply system for antiretroviral medicines. As these
medicines are very expensive, at risk of expiry and as the programs
are still scaling up to larger patients numbers, with changing
treatment regimens. A stock out is disasterous as patients health is
immediately affected and drug resistance may develop.
I am proposing the following:
A simple supply system with stock kept at one place the National level
and at about 200 health facilities, which are supplied by the central
level with new drugs on a monthly basis, based on their consumption
and expected new number of patients for the following month. Safety
stock is needed at cenral and (to a lesser extent) at facility levels.
The government prefers a system in which stock is passed 1 x per year
from the national level to the 64 provincial levels, which then supply
to the >1000 districts, which then supply to >1000 health facilities.
Safety stock will need to be kept at each of the levels.

Now the question: 
I am looking for a convincing tool (preferably an illustration or
ideally an animation) that can help showing the difference between
these two approaches in terms of total amount of drugs needed to fill
the supply pipeline.
We have a language barrier and the decision makers do not have much
time to read lengthy calculations. It should be very graphically
visible and it would be fantastic if we could make it interactive so
can enter data like frequency of resupply or number of facilities at
each level.

---

Clarification of Question by phasuma-ga on 03 Jun 2006 22:33 PDT

Dear all, 

Please let us focus on the original nature of the question: How to
visualise the impact of basic supply system parameters on total stock
required. 2 or 3 levels of storage? Monthly, quarterly or annual
distribution? How much safety stock at each level? The same questions
would apply for any other medicine, food or indeed bedsheets.

roxrox-ga: 
My description was indeed not clear at all. It is like this:
There are 64 provinces and about 600 districts in total in the country
A single district has 1 or more facilities. At this moment, not all
districts offer the treatment but the goal is to offer universal
access in all districts.

It is also good to realise that need for the medicines differs from
province to province (due to population density and prevalence of
infections).
Let us assume that the top 6 provinces with highest need together
require 50% of all supplies and the top 20 provinces with highest need
account for 75% of supplies.

Is this sufficient information? For now, a simple animation would be fantastic! 
At a later stage we could think about including the possibility to
change parameters.

check out this list of sites, might be a gem in there that you could use...

http://www.enre.umd.edu/tools/log.htm

let me know if I helped

Well this is pretty much the standard 'nick it, hoard it, ration it' setup.

Sun and satellite distribution system versus satellite <-> satellite
or sun <=> sattelite

However, it would be discourteous to suggest that local stocks would
be stolen, so you might as well have a 'sun and satellite' drawing
that shows a number of thin blue arrows going out, and another that
has one fat blue arrow going out, and a number of thinner red arrows
going back in - and round the block.

You could (for the audience) quip about the air miles that the drugs would acquire.

If your audience is about 100 people, then use a paper flip chart and
wax crayons. Sketch the diagrams in light pencil - it makes you deft.

Use a pointer, something like a short billiard cue, you can magnetize
an audience with a stick of wood.

People are bored with powerpoint, OHPs, slides and whiteboards, crude
visual presentation grabs their interest - I was taught this in 1982
by someone who learnt it in rather unusual areas - it works.

Personally I don't think much of what you are up to, every live HIV+
human is a carrier, you are delaying a 'burn out'
- also increasing the likelihood of a more virulent mutation.

Let me understand the numbers
Knowing each provence is a little different
but for the purposes of making an aimation for you
Their plan
64 Provences
A single Provence has 1,000 Districts
A single District has 1,000 health facilities

Meaning 
1,000 districts * 1,000 Health facilities = 100,000 Health Facilities per Provence

64 Provences * 100,000 Health Facities Per Provence = 6,400,000 that
sure seems like a lot.

Or is it more like
There are 1,000 Health Districts in total, spread between 64 Provences.
Each Provence has about 16 Health Districts (1,000/64 = 15.62)
And each Health District has 1,000 Health Facilities
1,000 Districts * 1,000 Health Facilities = 1,000,000 Total Health Facilities

Please provide better numers

Your system, 1 HQ then 200 Super Centers suppling XXX??? Number of Health Facities.

Would be happy to do a nice animation for you but need clarification first.

Thankfully people such as frde-ga are in the minority. My son is in
Africa in the Peace Corps as a non paid volunteer for 28 months doing
AIDS prevention education.

I also agree with you that an animation will make the point really really well.

@roxrox-ga

I think you misunderstand my point.
- your son is doing a worthwhile job doing AIDS prevention education.

My point is rather different - artificially healthy carriers are
working directly /against/ prevention of transmission.

@phasuma-ga 

I suggest that you avoid illustrating the number of 'depots' at each level
- there are two points to get across
 a) the more stocks held in different locations, the higher the theft rate
    those drugs have a high market value
 b) with the government's preferred approach, you risk having two way 
    novements of stocks as incorrect long term estimates are inevitable.
    1) there is always a tendency to overestimate
    2) there is always a tendency to hoard
    3) clawing back stocks is difficult and inefficient

This is actually very similar to a problem that the UK hospital system
has with the distribution of bed sheets.

You also have an audit problem.

Normally I dislike JIT distribution, but in this case it looks like
the solution least likely to go wrong.

Incidentally bulk CD production is inexpensive, you could provide a
'book of the film' for your audience.

I would look at the approach taken by maps of military movements.

With something like this one can only make a first guess (sorry 'estimate')
- you don't currently know the usage otherwise you would not be asking the question

A system like this starts off by 'filling the cistern' 
eg: the supply of a large quantity of stock
after that you normally replenish, ie: top up 
- and occasionally you just reduce or increase stocks at levels
- the system is 'balanced' when you only need to replenish

The drugs are light and not particularly bulky, so they should be
relatively easy to transport. I'm not sure what transportation is like
in Vietnam, probably it is pretty good.

If that is the case then the safety stock can be fairly low
- one month's supply at each sub-level would be more than adequate
Assuming the system looks like this :-

  Base -> Provincial * 64 -> District * 1000 -> Health Facility * 1000

The actual number of Provinces, Districts and HFs is irrelevant
One simply looks down one strand from top to bottom
- each strand looks identical 
- also each strand is from Base to just one Patient  <== that is important

If you have 3 levels each holding one month's supply, then you really
have 3 month's supply in the system - and that is excluding Base

Digressing entirely, I assume that these drugs come in blister packs,
I would insist on those getting passed up the line and 'standard
replenishment' only being issued against those tokens.  It will not
avoid theft, but it will make it a little more difficult.

The key is to estimate the number of patients for each health facility
- everything else depends on that

This gives me an idea for your presentation:

  Aircraft to Base, Truck to Province, Van to District, Motorcycle to HF