Zimbabwe
Ouganda
Togo
Afrique du Sud
Nigéria
Niger
Namibie
Mozambique
Mali
Ghana
France
Tchad
Bénin
Polio
Rougeole
Distribution system
Post00319 TRANSPORT MANAGEMENT PROJECT 6 February 2001
CONTENTS
1. GAVI TRANSPORT MANAGEMENT PROJECT
2. TRANSPORT MANAGEMENT FOR SERVICE DELIVERY STATUS SUMMARY AND PLANS
3. CONDUCTING A TRANSPORT SITUATION ANALYSIS
4. POWERPOINT PRESENTATION: TRANSPORT MANAGEMENT FOR SERVICE DELIVERY
1. GAVI TRANSPORT MANAGEMENT PROJECT
John Lloyd, PATH-CVP, kindly posted this interesting update on the GAVI
Transport Management Project in December 2000. It is posted at this time to
ensure wider readership.
The full text of the e-document "TransportStudySummary" and the
Powerpoint presentation "TransportProject" is posted below. To see the
graphics and Graphs download the files
The files TransportStudySummary.pdf and TransportProject.zip are available
on the web for download at:
ftp://ftp.acithn.uq.edu.au/Technet/1-
ClickHereForTECHNETfiles/TransportProject/
TransportProject.zip [810kb]
TransportStudySummary.pdf [45kb]
To get the files by email - sen and email to:
[email protected]
with the message:
get technet TransportProject.zip
get technet TransportStudySummary.pdf
Discussion, comments and additions please: [[email protected]][email protected][/email]
or use your reply button
___________________________________________________________________________
From: "John Lloyd"
To: Technet Moderator
Subject: Transport Management Project
Date: Wed, 13 Dec 2000
Dear All,
Last week at the Taskforce on Immunization, Pretoria, we presented country
reports to Ghana, Cote d'Ivoire, South Africa and Zimbabwe, I made the
attached presentation and distributed a short summary report which is also
attached.
You will see from the presentation and report a significant shift in our
plans for the next phase, compared to our discussions at the DC meeting. We
have abandoned the idea of a multi-country meeting next year because we do
not believe that the human resources exist at this time to offer support to
multiple countries for the reform of their entire health transport
management system. Instead, we prefer a country by country approach to
support transport systems, specifically focussed on service delivery and
service delivery support in the following types of countries:
1) countries where WHO/PE is outsourcing surveillance transport to Riders
for Health: in these countries we would wish to facilitate an extension of
these contracts to cover routine outreach services for immunization and
other interventions. Nigeria, DRC, Zimbabwe and Chad. We met with the Chad
delegation and agreed a joint meeting with WHO and CVP/West Africa early in
the new year.
2) countries where WHO/UNICEF are running the 'pilot' Sustained Outreach
Services projects (SOS): here we would hope to review and improve the
transport management and to extend the reach of these projects to a national
scale as quickly as possible. These countries are: Mozambique, Chad, Uganda
and Mali
3) countries where Village Reach intends to establish outsourced cold chain:
we would seek the appropriate transport management human resources and
partners for the projects. These countries are, provisionally, Mozambique,
Togo and Benin.
4) countries which are to receive GAVI GFCV support for immunization
services: these countries will be in a better position to sustain reforms in
transport management for service delivery with the investments made by GAVI.
Particular attention will be paid to countries whose immunization
assessments specifically cite transport as being a factor limiting the
achievement of higher coverage.
5) countries prioritised for CVP support by the West African office of PATH-
CVP in Abidjan: Cote d'Ivoire, Togo, Burkina and Ghana.
Several countries appear on two or more of these preference lists, Chad
being the first to be approached by both WHO and CVP. Country proposals will
be developed with the appropriate transport management organisations to
assure that:
- fleet management
- operations management
- information systems and
- national policy
...can all be tackled in a systematic manner. The first step to achieve this
will normally be the situation analysis.
We will keep you informed of developments: in the meantime, we send you the
warmest wishes for Christmas and the New Year!
John Lloyd
Lionel Pierre
Marie Miller
PATH-CVP
Ferney Voltaire
France
____________________________________*______________________________________
2. TRANSPORT MANAGEMENT FOR SERVICE DELIVERY STATUS SUMMARY AND PLANS
___________________________________________________________________________
TRANSPORT MANAGEMENT FOR SERVICE DELIVERY
STATUS SUMMARY AND PLANS - DECEMBER 2000
During 2000, a study has been carried out in Cote d'Ivoire, Ghana, South
Africa and Zimbabwe as the first phase of a project by GAVI Partners. The
project aims to remove transport as a major obstacle to reaching children
with immunization and other primary health services who live outside the
reach of fixed health facilities. The project aims to achieve this objective
by applying the principles of effective transport management that have been
found to be effective in African countries, according to the findings of
this study.
The study sought to identify the key components that must be in place for a
cost effective transport system to support the delivery of health services.
It aimed to quantify the impact of each component on the final transport
equation.
Methodology
The research tested a hypothesis that an effective management system
required the following components:
* policy
* operational management
* fleet management
* management information
and that these components should be supported by a clear definition of
current and future transport requirements and a competent committed
workforce. To investigate the hypothesis, a team was assembled to apply
three questionnaires:
* economic cost analysis
* transport management procedures
* knowledge, attitude and practices (KAP)
The questionnaires were applied to a sample of approximately eight health
facilities in four districts, in two regions of each country, the results
were analysed and reports prepared for each country. The overall results
will be consolidated into a composite report by the end of January 2001.
RESULTS
Overall, the study has proved the hypothesis. It has shown that
improvements to fleet management, underpinned by a complete and timely
information system, will result immediately in higher vehicle availability
and a lower overall cost per kilometre. These improvements will however,
only have impact on the utilisation of transport and therefore impact on
health service delivery, if attention is paid to operational management by
public health managers. Impact on access and higher efficiency will not be
sustained unless policy is clearly established and the financing of vehicle
replacement is planned and budgeted. A trained, motivated and adequately
paid workforce is vital for the project to succeed.
Fleet management
* Vehicles can and should be run without breakdown and remain
available for use for more than 90% of their lives. The study shows that
motorcycles should run for at least 60,000 km, and vehicles for at least
180,000 kilometres. (The study suggests that these ages can be significantly
exceeded in the correct fleet management environment). Usable, vehicle life
should be prolonged where running costs are minimised and replacement costs
and depreciation are high.
* Long economic life depends on a rigorous regime of preventive
maintenance by a high quality maintenance provider from new. Long life also
depends on appropriate choice of vehicles. Preventive maintenance virtually
eliminates repair work and results in at least 20% higher availability.
* Out-sourcing demonstrated particularly high scores for fleet
management and for availability of vehicles, but only when the whole fleet
management process was included in the out-sourcing contract. This
demonstrated that attention to all aspects of fleet management is required
to achieve results, whoever provides the management infrastructure.
* The appropriate mix of types of vehicle according to task and
terrain was a particularly significant factor in assuring impact and
efficiency. Motorcycles emerged as particularly effective and appropriate
choice for many outreach service situations and have proved both less costly
and better utilized than 4 wheel vehicles for this purpose.
Operational management
* Good fleet management leading to high vehicle availability does not
translate to improved service delivery unless action is taken on operational
management, management information and human resources.
* Whether out-sourced or managed by the government, the allocation of
transport to routine service delivery and service delivery support must be
pre-planned and controlled. High utilization rates were achieved by
countries and areas that achieved high scores for operation management and
specifically, trip planning and control. Effective planning and scheduling
created improvements in a number of areas
* Improving the kilometres travelled per vehicle per month by 20%
* Improving individual vehicle utilisation leading to a smaller
vehicle fleet, requiring a lower capital investment
* In conjunction with prioritisation, causes an improvement in use for
service delivery
* If fleet management is fully or partially out-sourced, the
government needs to monitor and supervise the transport contract and manage
the relationship with the third party provider. A system of performance
measurement, contract review and quality control is essential but was found
to be lacking in the countries studied where out-sourcing was an important
component. Transport management interventions can only be sustained if
performance is regularly reviewed and remedial actions taken.
* The creation of a transport charging system on a kilometre used
basis gives a strong base for effective transport management. Funds are
then readily available for fuel and planned preventive maintenance, and
transport budgeting for a programme is made much easier. If the charge
includes depreciation then the requirement for capital investment in
transport is eliminated. This system of charging for transport is equally
effective for an in-house or out-sourced solution.
* The implementation of fuel controls can improve fuel utilisation by
38% and therefore reduce costs.
Transport Policy
* A strong policy leads to the long-term consolidation of
interventions in transport. In particular it assists in the conversion of
improved availability to improved service delivery. It also provides a
strong base for operational management. The most effective policies were
those that had been well disseminated and updated frequently.
* Critical policies on replacement, planning and budgeting for
transport renewal were seen to be problems in most countries in the study.
Even where policies and plans are established, they are frequently not
followed due to lack of financing and a universal reluctance to take
vehicles out of service when they can no longer be run economically and
effectively.
* A key specific finding was that kilometres travelled should always
be used in preference to age in years for vehicle replacement planning
* Policies on the operation and utilisation of vehicles depend for
their implementation on monitoring and supervision. The information systems,
including log-books that enable the use of vehicles to be tracked, are
seldom given sufficient priority but when monitoring is good, the study
shows that vehicles are both available and well utilised.
Next steps
The principles of effective transport management which have been established
on the basis of evidence of performance in the study will be applied by the
collaborators with GAVI partner funding in countries:
* where weak transport system remains a major barrier to coverage with
immunization and other services,
* where there a clear commitment to reform of transport management is
evident and
* that are eligible for GAVI immunization systems support.
The project will focus on transport systems for service delivery and service
delivery support, mainly at the district and facility level. Particular
emphasis will be laid on the managed utilisation of motorcycles for the
personal mobility of health workers, supervisors and repair technicians at
the peripheral level.
Selecting countries for support
Among the countries eligible for support, priority will be given to the
following three situations:
* Expansion of existing or planned WHO out-sourcing contracts for
polio surveillance transport to include transport for routine outreach
services
* Strengthening existing or planned WHO/UNICEF/UNFoundation projects
for Sustained Outreach Services (SOS) or Child Health Days.
* Assistance to initiatives targeted at the out-sourcing of part or
whole of vaccine cold chain systems in countries.
Nature of support
Support will be offered, within budgetary possibilities of PATH-CVP and
initially over a period of two years, through selected collaborators to
reform transport management systems for service delivery in the following
ways and in agreement with country governments:
* Situation analysis: consultants will be made available to assess the
current transport situation, focussing on service delivery and following the
outline protocol attached as Annex 1. In general, this will be the essential
first step for all forms of support. Evaluations will also be made in the
later stages of implementation.
* Training: training may be organised, funded and facilitated for
transport managers and training of public health managers in transport
management
* Out-sourcing: transport management systems may be established by
third party providers.
* Information systems technology: consultants will be made available
to advise on computer networks and on telecommunications for the management
and performance monitoring of transport systems
* National policy workshops may be organised, funded and facilitated
in countries with on-going reform of transport management systems and where
a situation analysis has been conducted.
* Vehicles and hardware will not be provided by PATH-CVP but support
may be given to prepare the necessary long term replacement plans and to
assemble the documentation to apply for bi-lateral partner funding.
John Lloyd
Resident Adviser
PATH-CVP, Ferney Voltaire, France
[email protected]
____________________________________*______________________________________
3. CONDUCTING A TRANSPORT SITUATION ANALYSIS
___________________________________________________________________________
ANNEX 1: CONDUCTING A TRANSPORT SITUATION ANALYSIS
A transport situation analysis comprises of four steps. These steps take us
through from identifying the current situation through to developing the
actions required to move towards a well managed, correctly resourced, and
properly utilised transport system.
The four questions are
* What have we got?
* What do we need?
* What can we afford?
* What steps must be taken to move from what we have got to what we
need?
Each of the above questions must be answered in terms of the 5 key elements
of an effective transport management system:
* Policy
* Operational management
* Fleet management
* Management information
* Human resources
KEY STEPS TO BE TAKEN
What have we got?
Some of the data required at this stage (particularly the inventory) can be
gathered before the consultancy either by the Ministry or by a locally
employed consultant. If time permits it is better for the Ministry to do
the data gathering.
- Policy
All existing documented transport policy should be collated. This includes
government circulars, Ministry documentation and any other relevant
information. Knowledge of policy should be tested at all levels of the
organisations and information gaps identified
- Operational management
Current operational management systems should be identified. Knowledge of
these and quality of implementation should be tested by interview at all
levels. Particular attention should be paid to the authorisation of vehicle
use, the allocation of vehicles and the management structure.
- Fleet management
This requires the completion of an inventory. The elapsed time normally
required for completing this means that it is often best for the data to be
gathered in advance and spot-checked by the consultant. A typical data-
gathering tool is attached in attachment 1. The age, condition, allocation
and use profile of the fleet can be calculated from the inventory
information. The inventory must include 4 wheeled and 2 wheeled transport,
motorised and non-motorised.
A review of existing maintenance procedures should be carried out. This
includes inspection of workshops used and existing alternatives. Information
should be gathered such that true labour costs per hour can be calculated
and compared. Care must be taken to look at maintenance facilities outside
the main cities.
An analysis of effective vehicle makes and models for the conditions should
be undertaken. This should include availability of spares, mechanics
knowledge, durability and the experience of other agencies.
- Management information
Usually in a situation analysis much of the management information must be
gathered from first principles. This requires the analysis of logbook
information (if it exists), fuel records, accounts, health data and
anecdotal evidence. Information is required to calculate the basic key
performance indicators for the fleet eg kilometres travelled, fuel
utilisation, running costs, availability and utilisation. In addition the
consultant should try to establish how much work couldn't be carried out
because of transport constraints
- Human resources
During discussions with individuals at all levels in the health system an
opinion should be formed of the level of knowledge and understanding of all
aspects of transport. This should include drivers and riders, transport
officers, mechanics and health managers.
What do we need?
Policy, operational management, management information, and human resources.
The shortfalls of the current system can be identified against the
components of an effective system. The steps required to move from the
existing situation towards the implementation of an ideal system should be
identified, scheduled and costed. These are likely to include training of
transport staff, managers, drivers, riders, mechanics, the development and
implementation of a management information system, and the development of a
comprehensive transport policy.
Transport needs and ideal fleet profile
The process of identifying needs should be carried out at the same time as
the identification of what we have got. This requires the consultant to
identify the required elements of work at various levels that require
transport support. The methodology for this phase is attached as attachment
2. It is important that this is carried out with a consistency of approach
and that stated vehicle needs are tested by comprehensive questioning. It
is vital that the consultant identifies needs in terms of days (or half
days) of use and not in terms of vehicles. Consideration must be given at
this stage to the use of bicycles and motorcycles. The number of
kilometres to be travelled by mode, at each level should be identified.
Fleet management
The consultant must review the fleet management options available that will
allow cost-effective management of the full life of the vehicle from
procurement to disposal. The purpose of fleet management is to ensure the
availability of vehicles and their operation at the lowest cost per
kilometre over the full life of the vehicle (including depreciation). The
outsourcing of fleet management in its entirety is likely to be the most
cost-effective solution for a health department. Other options include
vehicle leasing or the outsourcing of the maintenance function. The
availability and cost structures (including set up costs) of service
providers in this area must be reviewed as part of the situation analysis.
The cost and vehicle availability of the current structure should be
compared against that of any potential system. The cost (and training
requirements) of establishing the structure within the health department to
manage the outsourced activity must also be identified
The consultant should draw on the information gathered in the identification
of transport needs and the ideal fleet profile to assist the department in
the development of an invitation to tender document and a draft contract for
services to be outsourced. The contract should include a service level
agreement, a system of measurement and performance review, and should
clearly outline the responsibilities of both parties.
What can we afford?
The major constraint on the transport system tends to be the availability of
funding, particularly capital to replace vehicles. The consultant should
identify all current sources of funding for the transport system, including
donor funds. A review should then be carried out to identify the costs
associated with the operation of the required fleet. Any potential
shortfall should be identified and the impact on fleet size and/ or
kilometres to be travelled calculated and estimation made of impact on
health service delivery. Meetings should be held with relevant donors, the
Ministry of Finance and other relevant parties to establish potential levels
of support for system reform.
What steps must be taken?
Using the data gathered above the consultant should work with key people in
the Ministry to develop and cost an action plan to move towards an effective
transport system to support health care. The elapsed time required for
change should not be underestimated and support should be provided over a
period of at least two years.
RESOURCES REQUIRED FOR CONDUCTING A SITUATION ANALYSIS
This can vary slightly dependent on the size of country and fleet but should
be completed within four weeks of consultancy input. Gathering of the
inventory information prior to the consultancy visit enhances the efficiency
of the process
Inventory compilation:
Health department official to compile. Transport costs and per diems for up
to one month dependent on collection method.
Consultancy
24 days consultancy, return flights. 10 - 14 days in the field, 6 - 10 days
at headquarters, 4 days analysis and write up. Per diems required for full
period, transport whilst in field. Typical distance covered 2000 - 3000km
(Namibia 6,000km).
If possible the consultant should be counterparted by the individual in the
Ministry with responsibility for transport as this gives best scope for
skills transfer. If this is the case then counterpart local costs should be
included
A one day workshop should be held with Ministry staff (and potentially
donors) to discuss and refine findings
____________________________________*______________________________________
4. POWERPOINT PRESENTATION: TRANSPORT MANAGEMENT FOR SERVICE DELIVERY
___________________________________________________________________________
1. Transport management for service delivery
"By 2005, 80% of developing countries will have routine immunization
coverage of at least 80% in all districts"
2. Transport critical to GAVI goal
* Half countries eligible GFCV are in Sub-Saharan Africa
* One third of these countries are under 50% DTP3 coverage...
* One tenth are unable to provide any vaccine to 50% of their children
* About half of these populations cannot be reached by fixed facilities
BUT
* Availability of transport is low
* Vehicle life is short and costs are high
* Vehicles not utilised for service delivery
* Partners reluctant to supply vehicles
3. Study in four AFR countriesWHO and PATH/CVP
Objectives:
* Identify the major components of effective transport management
* quantify the benefits in terms of cost, transport availability and service
delivery
* Countries:
Cote d?Ivoire
Ghana
Rep. South Africa
Zimbabwe
Sample:
Two regions
Four districts
Eight facilities
+ Comparative systems
4. Study methods
Three elements of the study:
* Cost and cost-effectiveness of transport
* Appraisal of transport management system against main components
* Knowledge, attitudes and practices (KAP) survey of managers, drivers,
mechanics and clients
Team:
Economics - Abt Associates, USA
Management - Transaid Worldwide, UK
Knowledge, attitude and practices (KAP): CVP and local
Collaboration: Riders for Health, UK
4. 3 main findings
5. Finding 1: Fleet management increases availability, reduces cost
* Regular preventive maintenance reduces whole life cost
7. Finding 1: Fleet management increases availability, reduces cost
* Regular preventive maintenance reduces whole life cost
* Increases availability
8. Finding 1: Fleet management increases availability, reduces cost
* Regular preventive maintenance reduces whole life cost
* Increases availability
* Outsourced fleet management can be cost effective
9. Finding 1: Fleet management increases availability, reduces cost
* Regular preventive maintenance increases availability
* High availability results in lower cost
* Outsourced fleet management can be cost effective
* Motorcycles reduce cost, better utilized
10. Finding2: Operational management is vital to obtain impact
* Good fleet management does not guarantee impact
11. Finding2: Operations management is vital to obtain impact
* Good fleet management does not guarantee impact
* Good operations management is
* Planning and scheduling the use of transport
* Prioritisation of transport needs according to health priorities
* Authorisation and monitoring of vehicle movements
* Management responsibility for transport
* Pooling of vehicles
* Scheduling of maintenance
* Effective controls on fuel, use, keys etc
12. Finding2: Operations management is vital to obtain impact
* Good fleet management does not guarantee impact
* Operations management is
* Good operations management coincides with high immunization coverage
13. Finding 3: Policy development and replacement planning key to
sustainability
* Transport policy barriers: vehicle replacement
* Country A planned replacement, budgeted for replacement but failed to
replace
* Country B does not replace govt vehicles, will not amortise replacement
of out-sourced vehicles
* Country C planned replacement, but could not find the budget
* Country D received unsuitable vehicles for their purposes
* Budgeting by the km, establishing a transport trading account
* Information systems, including log-books, are critical to improve both
availability and utilisation
14. Conclusion
* Better management increases availability, improves utilisation, reduces
capital and recurrent costs, raises confidence of investors
* Critical success factors for transport management include
* rigorous fleet management assures efficiency,
* systematic operational management assures impact,
* complete and timely information system and
* clear, consistent policy assures sustainability
* Financing the routine replacement of vehicles and controlling the choice
is critical
* Paid, committed, trained health and transport staff.
15. Strategy
* Expand out-sourced fleets managed by WHO for polio eradication to cover
service delivery - but strengthen operational management & policy
* Rationalise fleet and operations management of Sustained Outreach services
(SOS) and replicate
* Merge the operational needs of measles control strategies with those of
SOS
* Expand the managed use of motorcycles for outreach
* Advocate for GAVI partner policies on transport management
16. Next steps
Relative to the needs of service delivery:
* Situation analysis
* Training
* Outsourcing
* National policy workshops
* Rationale, plan for vehicle needs
___________________________________________________________________________
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---
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____________________________________*________________________
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