Best Practices in Supply Chain Preparedness For Public Health Emergencies - January 2018 - English Ecaterina Marshall

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BEST PRACTICES IN SUPPLY

CHAIN PREPAREDNESS FOR
PUBLIC HEALTH EMERGENCIES
Technical Report
USAID | Global Health Supply Chain – Technical Assistance Multi Award IDIQ
(GHSC - TA) Contract No. AID OAA I 15 00030
Francophone Task Order Contract No. AID OAA TO 17 00006
DISCLAIMER. This publication was produced for review by the United States Agency for International Development. It was prepared by
Chemonics International Inc. and McKinsey & Company.
Disclaimer. The views expressed in this publication do not necessarily reflect the views of the United States Agency for International
Development or the United States government.
TABLE OF CONTENTS
List of acronyms ......................................................................................................................................................................................................... 2
Executive summary .................................................................................................................................................................................................. 3
1. Landscape assessment ................................................................................................................................................................................ 6

1A Stakeholder Assessment.............................................................................................................................................................. 7
1B Hazard Assessment ..................................................................................................................................................................... 10
1C Current State Emergency Supply Chain Capability Assessment .................................................................. 13
2. Governance, financing, and personnel .......................................................................................................................................... 16

2A Organizational Structure and Designation of Authorities ................................................................................. 17
2B Financing of Emergency Supply Chain ............................................................................................................................ 20
2C Personnel Training and Readiness...................................................................................................................................... 23
3. Emergency protocols................................................................................................................................................................................ 26
3A Trigger Definition .......................................................................................................................................................................... 27
3B Separation of Emergency and Routine Supply Chain........................................................................................... 28
3C Emergency Supply Chain Protocol.................................................................................................................................... 30
4. Emergency procurement and supply chain ............................................................................................................................... 32

4A Commodity Planning .................................................................................................................................................................. 33
4B Quantity Forecasting ................................................................................................................................................................... 35
4C Procurement and Sourcing of Emergency Health Commodities................................................................. 37
4D Stockpiling........................................................................................................................................................................................... 39
4E Emergency Response Warehousing and Storage ................................................................................................... 41
4F Transport............................................................................................................................................................................................ 43
4G Waste management .................................................................................................................................................................... 45
4H Logistics Management Information System ................................................................................................................. 47
Bibliography ................................................................................................................................................................................................................ 49
Experts consulted ................................................................................................................................................................................................... 52
BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 1

LIST OF ACRONYMS
ACCEL Academic Consortium Combating Ebola in Liberia
CDC Centers for Disease Control and Prevention
CMS Central Medical Stores
EOC Emergency Operations Center
ERP Emergency Preparedness and Response Plan
ERW Ebola Response Workers
ESC Emergency Supply Chain
FAO Food and Agricultural Organization
JEE Joint External Evaluation
IHR International Health Regulations
LCA Logistics Capacity Assessment
LMIS Logistics Management Information System
LMU Logistics Management Unit
LWSC Liberia Water and Sewer Corporation
MOH Ministry of Health
MSF Doctors Without Borders (Médecins Sans Frontières)
NERC National Ebola Response Center
OCHA United Nations Office for the Coordination of Humanitarian Affairs
OCV Oral Cholera Vaccine
OPALS Operational Planning Application for Logistics and Supply
PEPFAR President’s Emergency Plan for AIDS Relief
PIP Pandemic Influenza Preparedness Framework
PPE Personal Protective Equipment
PSCN Pandemic Supply Chain Network
SKU Stock-Keeping Unit
SOP Standard operating procedure
UNCTAD United Nations Conference on Trade and Development
UNDP United Nations Development Programme
UNISDR United Nations Office of Disaster Risk Reduction
UNHRD United Nations Humanitarian Response Depots
UNICEF United Nations Children’s Fund
WBPEF2 World Bank Pandemic Emergency Financing Facility
WFP World Food Programme
WHO World Health Organization
WTO World Trade Organization
2 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

EXECUTIVE
SUMMARY
When it comes to emergency supply chain referenced under the “Resources” section of each
management, a little preparedness will go a long chapter in this document.
way. Investing relatively small amounts of time and
resources up-front to reach a minimum level of The supply chain fits into a broader topic of emer-
preparedness can significantly improve outcomes gency preparedness planning. Each country should
for vulnerable populations when an epidemic oc- have its own comprehensive emergency prepared-
curs, minimizing the impact on people and infra- ness and response plan, which includes critical
structure. The same set of supply chain prepared- elements such as surveillance. The emergency
ness activities are applicable across most infectious supply chain recommendations in this document
threats and many resources are available to help are intended to be part of a broader emergency
countries prepare. preparedness agenda at the country level.
This document compiles best practices in emer- These recommendations are based on a One
gency supply chain preparedness so that countries Health approach to emergencies that complements
can respond rapidly and effectively to epidemic and the all-hazards approach that some partners have
pandemic threats. Such a response requires a well- adopted. One Health is an approach that takes a
functioning supply chain. However, the inherent holistic view of human, animal, and environmen-
unpredictability of an emergency poses particular tal factors in disease preparedness and response.
challenges for the supply chain – visibility into both This document focuses specifically on supply chain
demand and supply is limited, and involvement of preparedness for a set of infectious diseases and
multiple stakeholders requires significant coordina- zoonotic hazards that developing countries com-
tion. Investment in preparedness combats these monly face. However, almost all of the practices in
challenges by planning for a range of possible sce- this document are also applicable to non-zoonotic
narios and outlining stakeholder roles to mitigate infectious hazards and many are relevant to non-
the impact of these “unknowns”. infectious disease emergencies.
We take a country-centric approach to emergency Many existing resources are available to aid pre-
preparedness, focusing on what governments paredness efforts. Local and international stake-
themselves can do to strengthen their capacity holders have developed a number of materials to
to respond to public health emergencies. Other support emergency supply chain preparedness and
organizations, such as the Pandemic Supply Chain response. These include sophisticated tools and
Network, have already done significant work on guidance covering steps that require deep technical
ways the international community (including private expertise. The gap that remains for most countries
sector) can collaborate on emergency prepared- is to adapt and apply these tools to their own
ness. This document complements those ongoing settings. For most countries, this will require a
efforts by outlining the country’s own role in pre- sustained initial effort by a small team, followed by
paredness efforts. This intended audience of this lighter-touch annual updates in subsequent years.
document includes both international organizations Activities can be summarized across three themes:
(donors and NGOs) and developing country gov- • Clarifying governance of the emergency sup-
ernments and public health practitioners. A closely ply chain. Clearly identifying who has authority
related publication is the country-facing Emer- and accountability for the emergency supply
gency Supply Chain Playbook, which translates chain overall and the key sub-components
the lessons from this document into a package of within it will help countries mobilize rapidly
action-oriented user guides, management tools, and effectively in the event of a disease out-
templates, and job aids suitable for in-country use break. In addition, identifying potential partners
for emergency supply chain preparedness and re- across each of the emergency supply chain
sponse. The relevant sections of this Playbook are components and opening consistent channels of

communication will further bolster KEY COMPONENTS OF EMERGENCY SUPPLY CHAIN
countries’ ability to respond to MANAGEMENT AND PREPAREDNESS
emergencies
• Identifying disease threats and 4
needed commodities. Developing Emergency procurement
and supply chain
an initial understanding of a coun-
try’s specific threats and potential • Commodity planning
• Quantity forecasting
• Stockpiling
• Emergency response
• Transport
• Waste management
resources to leverage in an emer- • Procurement and sourcing of
emergency health commodities
warehousing and storage • Logistics management
information system
gency is essential to preparedness
because of variation in country
1 2 3
contexts across multiple dimen-
Landscape Governance, financing, Emergency
sions (hazards, geography, existing assessment and personnel protocols
capacity). These dimensions inform • Stakeholder assessment • Organizational structure & • Trigger definition
• Hazard assessment designation of authorities • Separation of emergency
countries’ decisions on how they • Current state emergency • Financing of emergency and routine supply chain
supply chain capability supply chain • Emergency supply chain
design their emergency supply chain. assessment • Personnel training and protocol
readiness
Understanding disease threats will
also allow countries to identify the
types and quantities of commodi-
ties that should be stocked in the
emergency supply chain in the event
of an emergency, as well as deciding The best practices in this document were gathered
whether to stockpile some of these from review of existing literature in the fields of
commodities in advance supply chain management and emergency re-
• Planning storage, transport, and logistics in sponse, as well as interviews with interdisciplinary
the event of an emergency. In the event of experts. Experts consulted for this study include
an outbreak, containing the threat is greatly staff from leading international organizations (e.g.,
aided by simple advance planning steps such as WHO, UNICEF, WFP), public health and supply
identifying potential storage sites and logistics chain staff in developing countries, non-govern-
providers mental organization, and private sector partners.
A full list of sources and experts consulted can be
This document is organized into four sections: (1) found in the document’s bibliography.
Landscape Assessment; (2) Governance, Financ-
ing, and Personnel; (3) Emergency Protocols; and
(4) Emergency Procurement and Supply Chain.
Each section is further divided into individual
chapters covering recommendations for discrete
topics. These recommendations are not intended
to be exhaustive; rather, they represent an effort
to synthesize the significant amount of existing
literature on each topic into a core set of imple-
mentable best practices. Each chapter also includes
a case study highlighting an instance that illustrates
some element of the recommendations, and many
chapters also identify a set of common pitfalls to
be avoided.

1. LANDSCAPE
ASSESSMENT
1A | STAKEHOLDER • Military
• Multi-national organizations (e.g., WHO)
ASSESSMENT • International and local NGOs
• Functional sectors (e.g., Logistics Cluster)
Map the local and international players
• Private sector organizations (e.g., local busi-
in a country’s emergency supply chain nesses, international businesses with in-country
(ESC) to understand their roles, respon- operations
sibilities, and capacities in an emergency. • Universities and centers of excellence
The ESC team, or in its absence the Ministry of

Definition Health (MoH), should list the organizations that fall
A stakeholder assessment is a thorough mapping under each of these categories to develop a sense
of all local and international organizations that of which sectors will play major roles. The United
could play a role in a country’s ESC in the event Nations Office for the Coordination of Humani-
of an outbreak. The assessment should not only tarian Affairs (OCHA) provides a good starting
identify the stakeholders but also determine their point for locating this information, as it supervises
capacity to provide supply chain support, and what different programmatic and technical clusters and
their roles could be. can help countries understand the overall stake-
holder landscape by sector. The Logistics Cluster’s
Logistics Capacity Assessments (“LCAs”; to be
Why this is important addressed in greater detail under “Current state
Understanding the roles played by different stake- capacity assessment”) also list relevant stakehold-
holders ahead of time will enable the strongest ers, along with the logistical capabilities that each
response from Day 1 of an emergency, with clear, provides. .1 Countries should supplement these
coordinated involvement from all stakeholders. An sources with their own research, however, as
accurate identification of the capabilities that each country contexts change rapidly.
stakeholder will bring to the emergency supply
It is important to identify specific focal person(s)
chain enables coordination and planning ahead of
within each of the stakeholder organizations with
time. This will reveal overlaps and gaps in capacity,
whom the country will discuss supply chain logistics
which the country and its partners can then plan
and capabilities. Some of these organizations (likely
to bridge ahead of an actual outbreak. the international organizations, NGOs, and func-
tional sectors) will have a local director of supply
Mapping chain or logistics.2
Every organization that could be a stakeholder Role identification
in a country’s emergency supply chain should be
“mapped” ahead of time. Mapping involves listing Once the ESC or MoH has identified relevant
the names of relevant organizations and individuals, stakeholders, they should determine what roles
contact information, roles and responsibilities, and these stakeholders typically play to design ap-
geographic location. The mapping should include propriate coordination structures, as well as to
the following types of institutions: understand the organizations’ impact on their ESC
• National and local governments capacity.
• Emergency operations centers
• Local authorities and communities
1 Pandemic Supply Chain Network Project: “Project Report” (2017)


The country’s government, and likely its MoH paredness trainings Identifying which stakeholders
in particular, will play the lead role as much as performed well along the value chain shows who
possible, shaping the ESC response organization, can lead certain parts of preparedness exercises.
developing regulations, coordinating across other
actors, and leading on communications. The typical Not only will past disaster response case studies
groups of actors are: show which organizations participated in sup-
• Local authorities and communities, which supply chain response, but also provide information
port the policies and communications developed on partner timelines. Information on historical
by central structures response time by partner (e.g., time required to
• Coordinating mechanisms, such as Logistics mobilize commodities from United Nations Hu-
Clusters or Logistics Management Units (LMUs), manitarian Response Depots (UNHRD) regional
which hold meetings across local and interna- stockpile to point of service) will provide an impor-
tional actors tant input to plan resupply and identify bottlenecks
• International organizations, which provide to simplify, such as customs protocols.
technical programmatic activates, along with
tactical logistics, operational, commodity, and The ESC team can use existing assessments as
funding support starting points to identify the historical roles
• Local NGOs, which have varying roles depend- stakeholders have played. LCAs include a country-
ing on the community, but generally serve to specific section on humanitarian background, which
support activities in specific communities and outlines past emergencies and historical responses.4
build trust International organizations with in-country mis-
• Private sector organizations, which provide sions (e.g., WHO) that were involved in previ-
both physical assets, goods, and services as well ous outbreaks will provide useful case studies
as potential collaboration in preparedness in on operations in previous outbreaks as well that
response planning3 illustrate how partners have coordinated in past
emergencies.5
The ESC team should look to past emergencies to
better understand the roles that each stakeholder Partner capacity assessment
plays in specific contexts. Though there are typical Understanding the capacity that each partner
sectoral roles in ESCs, the degree of each sector’s brings to the ESC is essential to identifying gaps
influence, as well as the roles of specific organiza- that a country should fill ahead of an emergency.
tions within each sector, vary by country and by Stakeholders will have different capacities based on
emergency. Past emergencies provide useful infor- the country environment. These capacities range
mation on past behavior that can help countries from physical capacity such as warehouses and
develop realistic expectations for roles that each supplies to informal capabilities such as community
partner will play in the supply chain. trust.
Understanding what elements of coordination Ministries involved in public health emergencies,
worked well and what worked poorly between such as the ministries of Health, Livestock, and
stakeholders in the ESC is an important input for Agriculture, should work with their point people in
countries to establish appropriate organizational partner organizations to assess each partner’s ma-
structures and partner coordination mechanisms terial capacity, as well as technical expertise, across
for the future. An examination of past partner the following dimensions:
responses also helps countries plan for ESC pre-
3 Pandemic Supply Chain Network. “Downstream Logistics in Pandemics,” Logistics Cluster (2017).
4 Logistics Cluster Website: http://dlca.logcluster.org/display/public/DLCA/LCA+Homepage
5 World Health Organization. “Joint External Evaluation Tool,” (2016).

• Personnel
• Stockpiled commodities
• Warehousing and storage space CASE STUDY –
• Cold chain capacity THE PHILIPPINES
• Transport
• Funds 6
Sometimes capacity can come from innovative

sources, so countries should think outside the box
– e.g., private sector businesses that deal with food
refrigeration could serve as backup cold chain stor-
age capacity in an emergency.
It is important to note partners’ capacity by geo- The Philippines’ effort to identify and coordinate
graphic presence, as resources may vary across with partners shows the powerful role that stake-
regions. holder assessment plays in emergency response.
During Typhoon Haiyan in 2013, private sector re-
Process covery efforts were helpful – companies with local
The ESC team should refresh this stakeholder presence served as first responders, donors, logisti-
assessment on an annual basis or more frequently cal aids, and in some cases, technical experts. But
if possible, as part of their routine ESC mainte- these efforts were uncoordinated, intermittent, and
nance processes. They should ensure that the list largely separate from government recovery initia-
of organizations and point people for each orga- tives. However, the Filipino government recognized
nization remains current, and that when there is the important role private sector could play in
staff turnover (both at the government and at the augmenting response efforts. After the crisis ended,
partner organization), they reestablish contact with the Philippines proactively worked to engage the
the newest stakeholders as soon as possible. This private sector to contribute to future ESC, setting
way, all stakeholders will be integrated into the ESC up partner coordination mechanisms to ensure a
coordination mechanism, and countries can ensure coordinated response. The government now holds
their participation in trainings and simulations, such a monthly multi-sectoral meeting among national
as table-top exercises to practice the execution of and international key stakeholders such as gov-
a country’s Emergency Preparedness and Response ernment agencies, NGOs, and private sector-led
Plan. organizations to prepare for potential emergencies.
These meetings, which include representatives for
hundreds of groups, address coordination issues
and policy discussions, and promote an inclusive,
synchronized approach toward disaster manage-
ment. By identifying relevant stakeholders and
focusing on areas where collaboration is beneficial,
the country can better understand the capabilities
at its disposal, and how it can leverage those tools
to improve operations ahead of future emergen-
cies.7

7 Mercado et. al. “Advances in Civil-Military Coordination in Catastrophes: How the Philippines Turned Lessons Learned from Super Typhoon
Haiyan (Yolanda) Into Best Practices for Disaster Preparedness and Response,” Center for Excellence in Disaster Management (2015); Brown,
Serena. “The Private Sector: Stepping Up,” Humanitarian Practice Network (2015).

Potential pitfalls to avoid Knowing the diseases themselves enable commod-
ity forecasting by dictating which commodities are
• Letting stakeholder contact lists get out of date
necessary, and knowing potential outbreak tar-
• Overestimating partner capacity and failing to
gets provide estimates on what quantity could be
plan for a gap
required. This forecasting, in turn, has implications
• Not fully incorporating private sector interest on storage and transport needs (e.g., cold chain
and capacity by not acknowledging them as capacity). Diseases’ threat profiles also prescribe
stakeholders in assessment process considerations for waste management. Under-
standing the likelihood of different outbreaks helps
countries calculate the risks to mitigate when put-
1B | HAZARD ASSESSMENT ting in place preventative measures, which they can
weigh against the potential costs of putting those
Identify the range of potential threats measures in place.
facing the country and prioritize them
for preparedness efforts based on the Risk identification and prioritization
potential severity and likelihood of each The Ministry of Health, in partnership with Minis-
tries of Livestock and Agriculture, should identify
and prioritize the diseases they are susceptible
Definition to and use that list to guide their ESC planning
Hazard assessments build out the range of poten- activities. A country’s starting position should be
tial threats facing the country and prioritize them that it is at risk of all the Integrated Disease Surveil-
for preparedness efforts based on the potential lance and Response (IDSR) list of priority diseases
and zoonotic diseases. Countries can prioritize
severity and likelihood of each. For hazards that
their risks by drawing from existing exercises and
countries identify as priorities, they should identify
resources. Existing exercises include the CDC
the hazard-specific variables that have implications
One Health Disease Prioritization workshop,
on the ESC planning process (e.g., likely geographic
the WHO’s list of priority pathogens, and any
spread and commodities required) and establish other locally relevant prioritization exercises.8 The
routine monitoring protocols. responsible ministries covering infectious diseases
and zoonoses should hold workshops that gather
Why this is important these medical experts to check whether there are
additional diseases to add as potential threats (e.g.,
Hazard assessment is essential to ESC prepared- emerging diseases not yet codified into IDSR).
ness, as it provides most of the inputs required
for emergency planning across the value chain. Those responsible for planning the risk assess-
Through a hazard assessment, a country will ment can leverage the WHO’s Risk Assessment
understand the range of scenarios it should Framework, which provides a useful methodology
prepare for, as well as the likelihood of each of to identify the potential risk posed by each disease.
those scenarios. When planning for epidemics and The framework identifies impact and likelihood
pandemics, the hazard assessment should consider as the primary axes on which to map diseases. A
all possible disease outbreak scenarios, assess their disease’s impact depends on its transmission (how
relative likelihood, and develop a threat profile for infectious and contagious it is), as well as its viru-
each potential disease. Nearly all logistics plan- lence (how severe the disease caused by it is), and
ning flows from an understanding of what the the effect it would have on a country’s infrastruc-
threat profiles for a country’s specific diseases are. ture (healthcare facilities, workers, etc.).9
8CDC: “One Health Zoonotic Disease Prioritization Workshop” (2016); World Health Organization: “Blueprint Priority Diseases,” (2017)
9World Health Organization, “Rapid Risk Assessment of Acute Public Health Events,” (2012); World Health Organization: “Emergency Response
Framework,” (2017)
Risk depends on the likelihood of a disease as well. detailed profiles. Some elements of the threat
Countries should leverage in-country expertise, profile are especially important inputs to the ESC
as well as expert third parties and international planning process, such as:10
partners, to determine the likelihood of these • Transmission mode: How the disease travels
diseases. Factors such as local conditions, historical from host to host, which will have an impact on
outbreaks, and neighboring countries’ susceptibility the type of personal protective equipment (PPE)
all impact the likelihood of a given disease. required, security precautions for emergency
supply chain operations, and waste management
Once countries have assessed the likelihood and protocols
impact for each priority disease, they will be able • Expected rate of disease spread (based on
to plot diseases on a matrix to develop a priori- reproductive number and average generation
tized list for monitoring and ESC planning. length): Will have implications for quantity fore-
casting and resupply planning of commodities
The ESC team should refresh this hazard assess- • Geographic and demographic patterns:
ment on a regular basis, as disease threats evolve Where outbreaks are most likely to begin
over time. After an initial hazard assessment is (based on ecological, climactic, vector, human,
complete, updating the hazards list in subsequent or other factors within the country), and most
years will require significantly less time and re- likely patterns of spread, which will determine
sources. which areas the supply chain must target, and
therefore will have implications for warehous-
Some governments may choose to employ an
ing and storage locations and transport route
all-hazards approach to supply chain preparedness,
mapping. Demographic information will provide
through which they would plan for natural and
guidance on which populations are most vulner-
humanitarian emergencies using the same systems
able, so countries can calculate low and high
and processes as for infectious threats. However,
estimates of populations at risk for each disease
the scope of this document includes only supply
to guide commodity forecasting.
chain preparedness for infectious threats.
Surveillance capabilities
Regardless, the ministries tasked with emergency
preparedness and response should ensure they are The Ministry of Health will need to monitor the
proactively taking a holistic approach to not just priority diseases they identify during their risk map-
assessing risk but actively managing it. This includes ping. This will require basic surveillance capabilities
conducting numerous risk assessments for given for monitoring, such as collection mechanisms and
situations, linking them to operational capacity and laboratories for testing samples. Since many pub-
supply chain risk management. lished frameworks already address this topic exten-
sively, this document does not detail best practices
Key elements for planning in surveillance, noting only that surveillance systems
should be optimized to provide timely information
When a country has prioritized which diseases
on all threats prioritized through the supply chain
they ought to plan for from an ESC perspective,
planning process.
they should develop detailed threat profiles for the
highest-priority diseases. The Ministry of Health
and other responsible ministries should work
with epidemiologists, who are experts in mapping
disease outbreak and evolution, in building these
10 World Health Organization, “Rapid Risk Assessment of Acute Public Health Events,” (2012); World Health Organization: “Emergency Response
Framework,” (2017); Pandemic Supply Chain Network. “Downstream Logistics in Pandemics,” Logistics Cluster (2017).

Potential pitfalls to avoid
• Failing to consider the full breadth of diseases
CASE STUDY – (including zoonotic diseases) as threats
KENYA • Not linking the output of the risk prioritization
exercise to a monitoring and surveillance system
• Not refreshing the assessment on a routine basis
to ensure threats accurately reflect the current
context
Resources
• The ESC Preparedness Playbook discusses how
Kenya’s approach to hazard assessment illustrates
to conduct a hazard assessment in the “Triggers”
how understanding risk and prioritizing among
section and provides logistics checklists and
hazards can support emergency supply chains. In
worksheets to support execution
recent years, the Kenyan government has worked
• Governments cancan request the CDC’s One
with international and local stakeholders – in-
Health Zoonotic Disease Prioritization Work-
cluding government ministries and departments,
shop support to help identify the top 5 zoonotic
development partners, civil society organizations,
diseases they are at risk for by reaching out
local leaders, and community representatives – to
to [email protected] and working with their
produce comprehensive national hazard assess-
CDC country offices.
ments. These reports have recorded past incidents
• For countries that have completed the Joint
of disaster by category and scale to quantify which
External Evaluation (covered in more detail in
challenges are most pressing. Moreover, Kenya
the following chapter), reference the mapping of
has developed plans for action in concert with
International Health Regulations (IHR) relevant
the UN’s Hyogo Framework for Action, identify-
hazards and priority risks as a starting point.12
ing key resiliency goals and tracking core indicators
• Reference the WHO Emergency Risk Frame-
to measure its progress. Thus far, the government
work to map diseases based on impact and
and WHO have identified inadequate financing
likelihood. According to WHO Emergency Risk
and poor utilization of existing supply chains as
Framework, all member states should have sur-
critical weak points in disaster preparedness. The
veillance systems that detect outbreaks of infec-
government has also prioritized addressing high-
tious diseases as a result of the IHR’s emphasis
risk environmental factors, such as lack of access
on strengthening these capabilities.13
to clean water, and certain high-risk diseases, such
as HIV and influenza. Kenya’s hazard assessment is
not comprehensive; the country could benefit from
further risk prioritization and improving surveillance
capabilities. But the government’s overall approach
to hazard assessment provides a framework that it
can use to prioritize its investments in supply chain
capabilities toward where they have the highest
impact.11
11 Kenya Ministry of Devolution and Planning, “National Progress Report on the Implementation on the Hyogo Framework for Action,” World
Health Organization (2015).
12 World Health Organization, “Joint External Evaluation Tool,” (2016); International Health Regulations website: http://www.who.int/topics/
international_health_regulations/en/
13 World Health Organization: “Emergency Response Framework,” (2017)

1C | CURRENT STATE standards on emergency preparedness. It assesses
“country capacity to prevent, detect, and rapidly
EMERGENCY SUPPLY CHAIN respond to public health threats.”14 The JEE covers
CAPABILITY ASSESSMENT several areas relevant to emergency supply chain
preparedness, which countries who have com-
Assess the current state of emergency pleted the assessment should use to assess their
supply chain preparedness to under- starting point:
• Procedures and regulations governing sending,
stand baseline capacity and identify
receiving, and distributing medical countermea-
potential pain points sures for emergencies
• Resources dedicated toward the logistics of
Definition medical countermeasures
• Thoroughness of a country’s pandemic plan’s
An emergency supply chain capability assessment consideration of medical countermeasures
will provide a country with an understanding of its • Cold chain capacity for vaccine delivery
“starting point” in terms of both emergency pre-
paredness and emergency supply chain capabilities. However, the JEE and other types of existing as-
sessments focus primarily on medical and scientific
Why this is important elements of preparedness, rather than logistical and
supply chain elements. Organizations are hopeful
If a government understands its current state of that future versions of the JEE may incorporate
ESC preparedness, it will be able to identify both additional logistics-specific components into their
strengths to leverage and weaknesses to bolster in assessment of country preparedness.
its emergency supply chain. With this knowledge, it
will be able to better prioritize its own investments The governmental team conducting the ESC pre-
of resources and efforts, and understand where paredness capacity assessment should ask itself sev-
it should seek to leverage partner capacity when eral high-level questions to understand its degree
possible. of emergency supply chain preparedness, such as:
• Does a national disaster preparedness plan exist,
and does it consider logistics?
Preparedness efforts
• Are surveillance capabilities linked to logistics
The ESC team (likely within the Ministry of Health) and response plans??
should understand what initiatives they have • Are there roles and structures identified in the
already put in place for emergency preparedness plan to govern the emergency supply chain?
across all areas, from surveillance and monitor- • Are initial protocols to govern the emergency
ing to overall supply chain and logistics capacity- supply chain drafted?
building. The most efficient way to review existing • Has any planning on type, quantity, and source
preparedness efforts is to leverage assessments of commodities occurred, and are any of those
that have already been conducted on these efforts, commodities stockpiled?
to avoid rework and identify the areas that do
require additional focus and investment. Supply chain capabilities
The ESC team requires an end-to-end understand-
The Joint External Evaluation (JEE) is a framework
ing not only of its planned supply chain activities for
that the WHO introduced to assess a country’s
emergency preparedness, but of its routine supply
progress toward International Health Regulations
chain capabilities, as the latter impacts a country’s
14 World Health Organization, “Joint External Evaluation Tool,” (2016)

ability to implement the former. Again, countries infrastructure as well, such as:
should leverage existing assessments where pos- • Types and numbers of healthcare facilities
sible to identify any potential pain points. One • Local drug production, quality, and vulnerability
existing assessment is the Logistics Capacity Assess- • Vaccination campaigns
ment (LCA), which assesses tactical elements of • Clinical waste management collection and de-
infrastructure and services that impact the supply struction capabilities
chain’s ability to function in an emergency. Any pain
points identified here should be accounted for and Looking at past emergencies can be especially
planned for in the emergency preparedness plan. useful for governments to understand both the re-
Generally, LCAs focus on infrastructure, suppliers, silience of their country’s supply chain and potential
services, and landscape, with particular attention breakage points. Countries may be more suscep-
on any shortcomings that might complicate logistics tible to some emergencies rather than others (e.g.,
planning in an emergency. A detailed overview floods), and will have developed specialized meth-
of each section of the LCA can be found in both ods of leveraging supply chain capabilities to an-
the PSCN’s Downstream Logistics Guide and the swer those emergencies, such as alternative means
Logistics Cluster’s website.15 of transport. The ESC team can identify and build
on these points of strength to improve their supply
For some countries, LCAs either do not exist or chain’s responsiveness to future outbreaks. If some
are out-of-date. As these assessments do not map aspects of the supply chain broke down in past
the supply chain from end-to-end, the ESC team emergencies, countries should identify those bottle-
should undertake a high-level assessment to iden- necks or pain points as the priority capabilities they
tify their supply chain’s core competencies and look should invest in. For example, if in a past outbreak
at past outbreak responses to identify emergency- a country experienced significant vaccine wastage
specific capabilities. Some high-level questions to from a lack of adequate cold chain capabilities, the
guide early understanding of the supply chain are: country should either prioritize investment in cold
• Is it centralized or decentralized? chain capabilities or identify local partners who can
• Is it government-run or privately controlled? bolster that portion of the supply chain and plan
• How resilient has it been in the face of past the most efficient ways to partner with them.
crises (outbreaks or other disasters)?
• Are there shortages or stockpiles?
The Logistics Cluster has developed a tool for

quick logistics assessment in emergency situations:
the Rapid Logistics Capacity Assessment Tool,
which countries can leverage.16
Most governments have conducted more detailed

assessments covering some or all of the following
topics: forecasting and quantification, procurement,
storage and inventory management, governance
and capabilities, financing, and LMIS & data man-
agement. This existing data should be reviewed
and deepened or refreshed in areas relevant to
the emergency supply chain. In addition, countries
should understand the current state of healthcare
15 Pandemic Supply Chain Network. “Downstream Logistics in Pandemics,” Logistics Cluster (2017).
16 ibid

Potential pitfalls to avoid:
• Failure to adequately learn from prior outbreaks
in identifying strengths and weaknesses in the
emergency supply chain
• Assuming that routine supply chain capabilities
will be sufficient to implement emergency supply
chain plans in the event of an emergency
• Creation of “double work” by failure to suf-
ficiently leverage existing assessment, or not
linking existing assessments to action plans
Resources
• For countries that have completed the Joint Ex-
ternal Evaluation, reference the “Preparedness”
and “Medical Countermeasures and Personnel
Deployment” chapters17
• For countries with up-to-date Logistics Capacity
Assessments, they should use these LCAs as a
means to review tactical elements of infrastruc-
ture and services18
• For countries without an updated LCA, they can
utilize the Rapid LCA toolkit.19
17 World Health Organization. “Joint External Evaluation Tool,” (2016).

18 Pandemic Supply Chain Network. “Downstream Logistics in Pandemics,” Logistics Cluster (2017); Logistics Cluster Website: http://dlca.logcluster.
org/display/public/DLCA/LCA+Homepage
19 Logistics Cluster Website: http://www.logcluster.org/rapid-assessment-toolkit

2. GOVERNANCE,
FINANCING, AND
PERSONNEL
2A | ORGANIZATIONAL Key organizational roles and supply chain
partners
STRUCTURE AND
There are two key aspects of organizational design
DESIGNATION OF needed for emergency preparedness: (1) the desig-
AUTHORITIES nation of a single national emergency supply chain
lead and a clear chain of command for mobilization
Clearly define roles and responsibilities of emergency supply chain resources, and (2) the
for developing and maintaining an emer- identification of all relevant partners that could be
gency supply chain, and establish how mobilized toward emergency response.
key stakeholders will interact during an National emergency supply chain lead for health
emergency and Ministry of Health organizational structure
for emergency supply chains
Definition A single position should be designated as the
government’s lead responsible for the emergency
Emergency supply chain organizational structure supply chain in the event of an epidemic. Appoint-
and designation of authorities means defining who ing one lead role minimizes confusion by providing
is responsible for developing and maintaining an a single point of contact for coordination across a
emergency supply chain, both between emergen- range of both internal governmental functions and
cies and in times of crisis. A clear organizational external partners. The key considerations in select-
structure will also streamline the interaction being the lead are:
tween different Ministries, the Emergency Opera- • Technical background to understand logistics of
tions Centers, and relevant partners. supply chain function
• Strong leadership and coordination skills since
Why this component is important he/she will have to work closely with logistics
operators from different entities
A clearly defined organizational structure for an • Solid working relationships with health centers
emergency supply chain is essential to ensure ef- and connections with distributor networks, as
fective execution in a high-intensity, time-critical there will not be time in the midst of surge ca-
situation. Predetermined plans allotting responsi- pacity to build these relationships from scratch
bility for supply chain decisions enable the emer-
gency structure to be operationalized immediately. The degree of separation between the emergency
Predefined roles simplify coordination in complex, and the routine supply chain will vary based on
multidimensional emergency environments. The context (covered more in “Separation protocol”),
range of stakeholders involved – governments, but each should have its own designated lead. The
partner NGOs, and donors – creates a risk over- emergency supply chain lead should be able to re-
lapping roles or gaps in responsibilities. Clarifying quest additional resources from the routine supply
who owns decisions and how decision-makers chain during an emergency.
will interact limits leadership voids or competing
mandates. This ensures that the supply chain can The emergency supply chain lead will need a team
get the maximum value from different resources (“ESC Team”) to support them, with technical ex-
that stakeholders bring to bear. pertise on forecasting, procurement, storage, trans-
port, and human and animal medicine. This team
should be interdisciplinary to ensure a One Health
approach (e.g., should include individuals from
Ministries of Livestock/Agriculture). Each member

of the ESC team should be responsible not only for ensure that all stakeholders are able to effectively
the initial implementation of preparedness, but the contribute to the planning and response in an
ongoing maintenance of all preparedness-related emergency.
activities.
The MoH should use the inputs from their
The emergency supply chain should have a report- stakeholder mapping to determine how best to
ing structure extending from the national to local coordinate the multiple partners involved in the
levels. The central government should designate emergency supply chain. Understanding the roles
a lead at each of these levels of government (i.e., played by different actors will help identify the best
national, regional/state/province, and district). The organizational structure and partner coordination
same skills as above should be sought for emer- mechanisms to put in place ahead of an emergency
gency supply chain focal points at each level of the (Refer to stakeholder mapping section).21
supply chain. The role may be filled by a “roster”,
(e.g., responsibility rotates across individuals based Each contributing organization, whether public
on a calendar), but the roster must be filled by sector, private sector, or international organiza-
specific names. tion, should designate an emergency supply chain
point of contact at the national level and for each
The emergency supply chain lead for health should sub-national and local hub. In the event of an
report in to the logistics lead of the national emergency, this will be essential to understand-
Emergency Operations Center (EOC). If an EOC is ing on-the-ground supply and demand of needed
already in place in a country, then this reporting re- commodities. Where local authority is less clearly
lationship should be in place permanently. If EOCs defined, the lead should interact with local partners
are only stood up in the event of an outbreak, then such as local NGOs, which can be an important
the reporting mechanism should be documented source of early-on needs assessment and distribu-
in a country’s Emergency Response Protocols.20 tion support in affected communities.22 These indi-
Clearly outlining the interaction between the lead viduals will work closely with the national emergen-
and the EOC is especially important since during cy supply chain lead to ensure a single, coordinated
an outbreak, the EOC will be the lead’s link to the emergency supply chain effort.
broader emergency response efforts, including
coordinating with such entities as the military, in- Codification and performance management
frastructure officials, communications staff, interna- In order to ensure that all needed roles are prop-
tional organizations, and private sector. erly defined and filled, countries should maintain
a status tracker covering the status of filled and
Relevant partners and designation of points of
vacant positions and which staff have been trained
contact
in emergency preparedness. For some positions,
The MoH should map the full set of partners such an official authorization may be required from the
as international organizations, NGOs, and key Minister of Health to formally create and staff new
private sector organizations (e.g., major businesses positions in ESC. The MoH and other ministries
with significant supply chain networks) that could involved in ESC should also establish a roster moni-
be mobilized in the event of an emergency. A clear toring which staff are responsible for mapping of
organizational structure identifying the roles and partners and identification of leads and for ensuring
points of contact at each organization helps to that training is conducted.
20 World Health Organization, “Framework for a Public Health Emergency Operations Centre,” (2015); World Health Organization, “A Systematic
Review of Public Health Emergency Operations Centres (EOC),” (2013).
21 World Health Organization, “Emergency Response Framework,” (2017).
22 Pandemic Supply Chain Network Project: “Project Report” (2017), pg 71

Pitfalls to avoid
• Some common pitfalls that countries have en-
countered in the past include CASE STUDY –
• Not designating a specific individual in a clear SOUTH SUDAN
enough manner, so that in the time of crisis,
there is ambiguity over who owns authority
• Designating an individual but then undermining
their authority when an epidemic begins
• Designating an individual who lacks the op-
erational skills to obtain the necessary level of
respect from those they must interact with,
both internally and externally (e.g., with EOC
and partner organizations) The successful prevention of the spread of cholera
• Maintaining non-emergency reporting lines (e.g., in South Sudan through the use of Oral Cholera
emergency supply chain lead from Ministry of Vaccine (OCV) reflects how clear organizational
Health continues to report to head of national structure and authority support effective contain-
supply chain rather than to the EOC) ment of an outbreak. Due to conditions in Protec-
tion of Civilian (PoC) sites and internally displaced
persons (IDP) camps, the Ministry of Health (MoH)
Resources of South Sudan, WHO, and other partners pre-
pared in advance for the possibility of a cholera
• The ESC Playbook contains a chapter on
outbreak. Two elements of governance played an
“Governance and organizational structure” that important role in ensuring success when the dis-
provides guidance on how to develop an ESC ease hit – predetermined organizational structures
team, map stakeholders, and set up trainings, and strong leadership. Preexisting coordination
with a suite of supporting tools, templates, and structures (e.g., the UN Health Cluster) were put
training materials in place ahead of the possible emergency, which
allowed the agencies to operationalize their struc-
ture. While authority was clearly vested in one
director and agency, international agencies were
able to collaborate within the cluster system to ef-
ficiently vaccinate a quarter million South Sudanese,
preventing the spread of an outbreak. The MoH
and WHO played strong leadership roles, which
minimized confusion across the diverse agen-
cies and actors contributing to the supply chain
process. Clear direction from these expert actors
enabled even those partner agencies that were
not medically focused and lacked OCV experi-
ence to contribute effectively as part of a broader
coordinated response effort. South Sudan’s success
has important implications for future emergency
responses – if the right structures and leaders are
in place, then it is possible that a broader range of
actors with diverse field experience can successfully
contribute to future emergency response efforts.23
23 Abubakar et al. “The First Use of the Global Oral Cholera Vaccine Emergency Stockpile: Lessons from South Sudan,” PLOS Journal of Medicine
(2015)

2B | FINANCING OF Preparedness ESC budget
EMERGENCY SUPPLY CHAIN The budgeting of ESC inventory and prepared-

ness costs should be incorporated into the routine
Determine how the ongoing mainte- supply chain budgeting process, since the costs
nance and response functions of the are ongoing/annual. The preparedness ESC budget
should include funds for:
emergency supply chain will be financed • Expenses for warehouses designated for emer-
gency storage
Definition • Payroll and administrative costs for emergency-
specific staff
ESC financing entails identifying the funding
• Inventory management of emergency supplies
amounts needed on an ongoing basis to maintain
(e.g., cost of rotating out old stock) for any
requisite levels of emergency preparedness, as well
national stockpiles
as funding amounts needed for response in the
• Routine preparedness training
event of an emergency. Governments should also
define the sources of these funds and the proce- These costs should be included in the routine
dures to access and disburse them. supply chain’s strategic planning, product forecast-
ing, allocation, and procurement processes. This
Why this component is important budget planning should take place on an adhered-
to calendar basis. The resulting budget for ongoing
Setting a clear budget for ESC maintenance allows emergency supply chain maintenance should be
governments the financial resources to prepare derived from the priorities outlined in the country’s
for emergency situations, and identifying sources Emergency Preparedness and Response Plan (ERP).
of and procedures to access response funding
in advance of emergencies allows them to move Response reserve fund
quickly to contain and hopefully stop outbreaks.
Though allocating funds towards preparedness The budget needed for response should be
can be very difficult for countries to do, it has calculated as an incremental cost to the prepared-
tremendous impact on the efficacy of response: a ness ESC budget. This incremental cost should
UNICEF/WFP study found that all preparedness be calculated as a weekly budget for operating an
investments examined saved significant time and/ emergency supply chain across the entire country.
or funds in the event of an outbreak, and 64% of A rough rule of thumb is that when an epidemic is
geographically restricted, the country can propor-
investments saved both. 24
tionally adjust the budget (e.g., if it covers one-
quarter of the country’s population, it will cost ap-
Budgeting proximately one-quarter of the calculated amount).
The Ministries of Health and Finance should main- The size of the response reserve fund should be
tain two categories of budgets: the preparedness based on the country’s risk assessment of likely
ESC budget and the response reserve fund. The threats, commodity planning, and quantity fore-
preparedness ESC budget covers the cost of main- casting exercises. While an estimate can be made
taining an ongoing level of emergency prepared- ahead of time based on commodity forecasting and
ness, while the response reserve fund covers the logistics requirements assumptions for each poten-
costs of responding to an epidemic. tial threat, the estimate must be revisited when an
24 Meerkatt et al. “UNICEF/WFP Return on Investment for Emergency Preparedness Study,” (2015)

actual outbreak occurs. The main drivers of cost beginning of an emergency could result in the haz-
are typically: ard becoming more severe and potentially miss the
• Types and quantities of commodities necessary opportunity to stop the threat before it becomes
(based on commodity list required for the set of an epidemic.
hazards the country faces)
• Transport required to move predicted volume. In an epidemic, both international and national
Note that transportation costs often spike dur- financing will likely be necessary. International
ing emergencies organizations have set up emergency response
• Capabilities required to store predicted volume funds (e.g., WB PEF2, WHO contingency fund).25 It
(e.g., cold chain) is important to be aware of these funds ahead of
• Incremental staff needed to man supply chain time, and know how the country will access them
(e.g., district store leads, additional cold chain when the emergency triggers are activated. A gov-
officers to travel with commodities) ernment could also set up its own rapid response
fund, or a country-specific public-private donor
This budget should be revisited annually and partnership that could be specifically used to fund
updated with the latest surveillance data informing the supply chain in an emergency. Multiple different
which threats are most likely, as well as the latest players could pay into the fund, which would then
assumptions on inflation and population growth. be managed by the emergency supply chain lead
in an emergency to operate the emergency sup-
Sources of funds ply chain. The mix of funding sources will vary by
The preparedness ESC budget and response country, but every country should clearly identify
reserve fund will likely require multiple funding which funding sources will be used in the event of
mechanisms (national funds, international funds, an emergency.
or donor funds). For example, in some countries,
It is important to note that these sources of
national budgets support ongoing preparedness,
emergency funds are not always distinct from one
whereas emergency response funds are provided
another, nor are they always sufficient. Alternative
by international organizations and donors.
funding mechanisms are currently being explored,
Since the costs of ongoing emergency prepared- such as bonds tapping into capital markets, insur-
ness are predictable and will show relatively little ance products, and third-party financing.
variation from year-to-year, the country should
Fund release processes
either dedicate a portion of its resources toward
this on an annual basis, or work with partners to Governments should develop expedited processes
fund this maintenance annually. and protocols for release of funds ahead of time.
The key considerations are to ensure efficiency in
For the response reserve fund, the Ministry of accessing funds during an emergency and maintain-
Finance should clearly identify where the funds ing proper documentation for credibility and future
will come from in the event of an emergency. A planning.
government’s’ funding plan should have a first-level
component for a smaller or early-stage events and Some traditional invoicing practices may be too
a larger source of funds in the event of an epidem- time-intensive for emergency situations, so the
ic. The first-level funding component is especially MoH should work with suppliers ahead of time to
critical because delays in disbursing funds at the establish expedited invoicing process. One way
25 World Health Organization, “Emergency Response Framework” (2017); World Health Organization Contingency Fund website: http://www.who.
int/about/who_reform/emergency-capacities/contingency-fund/en/ ; World Bank Website: http://www.worldbank.org/en/topic/pandemics/brief/
pandemic-emergency-financing-facility

this could work is to have suppliers keep logs on
a preapproved template as proof of activities and
CASE STUDY – invoice the government against these activities on a
weekly basis.
SIERRA LEONE
Independent verification will be helpful to make
sure that deliveries are actually occurring as they
are being reported. This verification will build a
record of all emergency spend that should be used
not only in donor reporting, but also as an input to
the incremental emergency supply chain budgeting
process that occurs every three years.
Sierra Leone’s response to the Ebola epidemic It may be beneficial to provide up-front payments
demonstrates the importance of proper docu- to suppliers when a pandemic emergency is trig-
mentation in emergency supply chain financing. In gered. Suppliers will likely have to pull vehicles from
the early phases of Sierra Leone’s Ebola epidemic, routine business and ramp up hiring to fulfill surge
fund utilization was not documented and spend- capacity, and having capital on hand ensures that
ing could not be accounted for. Inadequate control suppliers are sufficiently liquid to do so.
of financial resources diminished public trust and
inhibited proper supply chain management. How- The MoH, as well as other ministries involved in
ever, in later phases of the response, the National emergency preparedness and response from a
Ebola Response Center (NERC) developed an One Health approach (e.g., Ministries of Livestock
effective system of financing and documenting the and Agriculture), should collaborate to create an
payment of Ebola Response Workers (ERWs). expedited process to input and update suppliers in
They used mobile phones to transfer salaries to the master vendor file rapidly, since the MoH/EOC
ERWs, which not only increased transaction speed, will likely have to contract with additional suppli-
but also allowed the NERC to track payments. The ers to meet surge capacity. The national ESC lead
NERC, with UNDP support, collected the names should have enhanced authority to approve ad-
of the beneficiaries, contracted with mobile phone ditional expenses and suppliers, but these instances
service providers to execute cash transfers, and should be documented clearly.27
worked with vendors to provide the actual cash
to beneficiaries. The NERC recorded these cash
transactions online, and included them in their
published financial report. Sierra Leone’s move
toward proper documentation thereby enabled
rapid dispensation of funds while ensuring that the
funds were appropriately documented. These two
elements together – enhanced liquidity and appro-
priately dispensed funds – preserved public trust at
a time when community support was essential to
the emergency response effort.26
26 National Ebola Response Center. “Lessons From the Response to the Ebola Virus Disease Outbreak in Sierra Leone, May 2014-November 2015:
Summary Report,” (2015).
27 World Health Organization, “Emergency Response Framework” (2017).

Pitfalls to avoid Why this is important
• Some common pitfalls that countries have en- Effective emergency response depends on having
countered in the past include: capable, well-trained staff and partners that un-
• Lack of funds in early phases of emergency, derstand how to respond to a crisis. Since emer-
which will prevent the purchasing of supplies gency response efforts are different from routine
necessary to stop the outbreak before it spreads procedures, it is important to make sure staff have
• Reallocation of ring-fenced funds to other priori- the capabilities and knowledge to properly support
ties ESC functions ahead of time. Personnel train-
• Inefficient fund- release policies that stall re- ing programs and other readiness initiatives (e.g.,
sponse efforts simulations) help staff develop the right skills to
fulfill their roles and support effective emergency
responses.
Resources
• The ESC Playbook contains a chapter on
Training programs
“Financing” that provides guidance on how
to calculate and allocate ESC preparedness Governments should use training and readiness
and response budgets. It also lists out multiple programs as an integral component of their ERPs.
examples of existing funding mechanisms and Training programs are one of the most high-impact
some initial guidance on how to access them in activities a government can support, when there
the event of an outbreak is no crisis at hand. By developing expertise and
understanding among staff and partners, train-
ing programs lay the groundwork for a successful
disaster response. Governments can use these
2C | PERSONNEL TRAINING initiatives to invest in human resource capabilities
AND READINESS across the supply chain.
Develop trainings and simulations to An effective emergency preparedness training pro-

prepare staff for emergency response, gram should possess the following characteristics:
• The training program should cover existing plans
and ensure staff are consistently trained and all ESC protocols
on them • Training should exist at the national, regional,
and district level to facilitate readiness at all
Definition levels of government
• Trainings should be held on a routine basis for
Personnel training and readiness refers to activities all departments involved in emergency supply
for key staff and stakeholders involved in emergen- chain, such as MoH, Ministry of Agriculture, Min-
cy preparedness to increase their understanding istry of Livestock, or other government agencies,
of ESC operations and build capabilities. Simula- and with external parties involved in emergency
tions involve real-time training exercises for ESC response, including partners, NGOs, and medi-
stakeholders to identify weaknesses and areas for cal suppliers. Other stakeholders that may need
improvements. training include civil society organizations, local
leaders, and community representatives

The officials responsible for designing and leading Pre-emergency: Results from the drills, simula-
training should ensure that such programs are up tions, and training programs will inform current
to date. Programs should therefore be updated state capacity assessments. Instructors should be
in tandem with preparedness plans (usually on a careful to record areas of confusion and identify ar-
3-year basis), or in light of new information that is eas for improvement in training programs. Simula-
relevant to emergency response. Program directors tions should be used by country officials to identify
should also seek out best practices and partners to which weaknesses may impact the effectiveness
make training programs responsive to stakeholders’ of its supply chain in an emergency. Results from
needs. simulations should be used to supplement training
programs. Areas of particular weakness should be
Simulations regularly drilled and tested.
Realistic simulations based on the country’s ESC
Post-emergency: After every emergency, govern-
are useful for two reasons: (1) for identifying pain
ments and their partners should engage in a com-
points in a response plan, and (2) to provide train-
prehensive debrief to identify areas for improve-
ing on preparedness and response for in-country
ment. Officials should solicit feedback from diverse
staff.28 Because simulations provide an opportunity
sources, including experts and individuals on the
to test a response plan in real time, they often
ground, in the form of an After-Action Review and
reveal valuable information about supply chain
the debriefing should take place with key individuals
processes and uncover potential weaknesses. In ad-
involved in the ESC response. It is critical that these
dition, since outbreaks are infrequent and country
debriefs identify “lessons learned” which must then
staff involved in the ESC spend most of their time
be used to update the Emergency Preparedness
in nonemergency jobs, simulations provide valuable
and Response Plans. Training programs and drills
opportunities for country staff to practice skills and
should be updated also to reinforce the ERP.
decision-making needed for emergency situations.
Tracking
To maximize the effectiveness of simulations, drills
should involve individuals from all levels of govern- As listed in “ESC Protocols” chapter, it is important
ment and representatives from all partners that to track whether all individuals involved in ESC
would be involved in responding to an emergency. have been trained. Officials should also record the
Simulations should mirror realistic conditions as date in which an individual last received training so
much as possible. Exercises can be targeted to test as to ensure that members of the supply chain are
individual aspects of the supply chain response kept up to date on new procedures and practices.
process, but officials should strive to undertake
comprehensive simulations when possible.
Incorporating lessons learned

Officials should design personnel training programs
to incorporate feedback from prior crises, staff,
and stakeholders. To ensure programs are effective,
they should incorporate information from both
pre-emergency training scenarios and post-emer-
gency assessments.
28 Pandemic Supply Chain Network. “Project Report,” (2017). pg 76

Pitfalls to avoid
• Emphasis on training attendance rather than
mastery of content CASE STUDY –
• Failure to capture lessons learned during NIGERIA
outbreaks and use them to update plans and
trainings
• Focus on “traditional” training formats (e.g.,
lecture) at the expense of more innovative and
engaging formats
Resources
• The ESC Playbook chapter on “Governance and
In the past decade, Nigeria has effectively lever-
Organizational Structure” provides guidance on
aged personnel training to improve supply chain
how to set up trainings on ESC P&R. It includes
preparedness for influenza epidemic. After a small
a modular set of materials to conduct trainings
avian flu outbreak in 2007, the Nigerian govern-
on ESC preparedness and response, including
ment began testing its pandemic response plans in
several customizable scenarios, a detailed facilita-
simulations on a semiannual basis. These simula-
tor guide to inform how trainings should be led,
tions were conducted in 2007, 2009, and 2011; the
and a participant workbook for trainees.
latter exercise was the largest government exercise
• JEE’s “Medical countermeasures” chapter
in the nation’s history. These training exercises,
contains information on country trainings and
carried out jointly with the US Department of
simulations29
Defense, help educate healthcare professionals
• CDC’s Division of Strategic National Stockpile
and ready staff in the case of an eventual outbreak.
(DSNS) has conducted in-country Emergency
Observers say that the simulations effectively
Preparedness and Response simulations30
transmitted important information to healthcare
• WHO “Simulation Exercise Manual” provides
professionals, key stakeholders, and the public,
practical guidance on simulation exercise design
while allowing the government to proactively invest
and execution for public health emergencies in
in improving logistical planning to ensure adequate
particular31
emergency preparedness. Nigeria has kept the
damage from influenza outbreaks low over the
last decade, suggesting that the MoH’s simulations
and training programs are working to improve ESC
readiness.32
29 World Health Organization. “Joint External Evaluation Tool,” (2016), pg 64

30 Center for Disease Control. “Preparing Global Responders,” (2017) https://www.cdc.gov/phpr/stockpile/ghsastockpilesupport.htm
31 World Health Organization. “WHO Simulation Exercise Manual,” (2017).
32 Sellwood, Chloe and Jonathan Van-Tam, Pandemic Influenza: Second Edition. (2013); Nigeria Ministry of Health: “National Pandemic Influenza
Preparedness and Response Plan,” (2013).

3. EMERGENCY
PROTOCOLS
3A | TRIGGER DEFINITION is especially important to ensure that the emer-
gency response process itself is apolitical, which
Pre-establish protocols for what types encourages national and international cooperation
of alerts trigger the activation of the and facilitates a swift response.
ESC to reduce difficulties in decision- External triggers
making
National triggers should link to external emergency
evaluation systems, such as the WHO’s grading sys-
Definition tem. Country governments should establish how
different grades correspond with the activation of
Trigger definition is the establishment of thresholds
their ESC protocols, with defined actions for the
that “trigger” the activation of the ESC. The activa-
supply chain identified in the case of each grade.
tion of the ESC means that a country will move
Linking to international definitions of emergen-
from employing routine protocols to following its
cies facilitates collaboration and planning between
emergency protocols.
the government and third-party stakeholders, as
they operate under a consistent framework. For
Why this is important example, if a country activates its protocols in a
consistent manner with the WHO, then its stream-
Trigger definition is particularly important because
lined emergency customs protocols will already be
of the difficulties involved in both identifying and
in place to facilitate the import of WHO’s essential
escalating disease-driven emergencies. Failure to
commodities shipments. International organizations
identify and treat epidemics early on increases the
also offer support in assessing and grading poten-
risk of their escalation into full-blown epidemics.
tial emergencies, which countries should leverage
Given the risks of delayed action, and the potential
when they are uncertain about the status of an
for politics to enter the decision-making process,
outbreak (e.g., the Rapid Response Assessment
it is best to rely on a predefined set of criteria that
from WHO).33
trigger escalation.
Internal triggers
Trigger criteria Governments may also choose to define their own
Governments should pre-defined, documented de- internal triggers for ESC activation.. These could
scription of all triggers that will activate the use of be local (e.g., a single case of a particular threat
ESC and logistics protocols. These triggers should might trigger internal emergency) or global (e.g.,
cover at least all the threats that they prioritized declaration of influenza in nearby country). Coun-
for monitoring in their hazard assessment. Where try governments might choose to establish more
possible, the triggers should be tied to specific, proactive triggers than those identified by external
quantifiable benchmarks. Typical triggers are pre- countries if they wanted to prevent lag time from
defined numbers of suspected cases, confirmed impeding the emergency response. Governments
cases, or even types of diseases themselves. can also explore more innovative trigger models
such as social media trends, big data assessments,
All triggers that require an emergency response probabilistic risk assessments, or progressive type
should not only be predefined, but also be trans- systems.
parent and public to garner national trust. Defining
apolitical triggers can be particularly challenging, but
33 World Health Organization. “Technical Guide to Rapid Assessment and Response,” (2003); World Health Organization, “Rapid Risk Assessment of
Acute Public Health Events,” (2012).

CASE STUDY – Resources
DEMOCRATIC • The ESC Playbook chapter on “Triggers” pro-
REPUBLIC OF THE vides guidance on trigger definition
• The WHO Emergency Response Framework
CONGO details the WHO emergency grading process
extensively.35
3B | SEPARATION OF
EMERGENCY AND ROUTINE
SUPPLY CHAIN
The Democratic Republic of the Congo’s response Develop protocols for how the emer-
to its 2017 Ebola outbreak demonstrates how
clearly defined trigger mechanisms can facilitate an gency and routine supply chains should
effective disaster response. Having dealt with Ebola interact
outbreaks before, including in 2014 – officials, lo-
cals, and politicians agreed that a rapid response to
Definition
any outbreak would be critical to preventing a simi-
lar outbreak within national borders. The confirma- Separation of emergency and routine supply chains
tion of the first positive case of Ebola triggered an will allow a government to develop protocols for
immediate response plan. The government notified how these two supply chains should interact in
international stakeholders in order to obtain capital the event of an emergency. Once the emergency
and technical assistance. It also triggered the swift protocol is triggered, the ESC should become as
implementation of emergency protocols, putting stand-alone as possible, and should be managed by
into place an ESC and logistics protocols to cope a different individual than the routine supply chain.
with the disease. The response included rapid
identification of individuals who may have been
Why this is important
infected and treatment for those with the disease.
Observers noted that the response was “fast, By clearly establishing the separation of emergency
decisive, and coordinated,” cutting off the potential and routine supply chains and defining their inter-
for the disease to spread. The DRC managed to action, governments will be able to better prior-
end the outbreak in just 42 days; it resulted in only itize the maintenance and functionality of the ESC
four deaths. Without a predefined, clear, and public in response to an emergency. This will enable the
trigger, the toll could have been much worse.34 ESC to function as rapidly and effectively as possi-
ble in response to an outbreak. There is a concern
Potential pitfalls to avoid that merging the emergency and the routine sup-
ply chains would lead to a reallocation of resources
• Failure to link national triggers to internationally-
defined grading systems from the ESC to potentially undersupplied routine
• Slow triggering of emergency protocols due supply chains, which should be avoided.
to desire to avoid the appearance of crisis and
avoid impact on the economy
34 Yong, Ed. “How the Democratic Republic of the Congo Beat Ebola in 42 Days.” The Atlantic (2017). CDC, “Ebola Outbreak Democratic Republic
of the Congo 2017,” (2017).
35 World Health Organization, “Emergency Response Framework,” (2017)

Prioritization
Successful operation of the ESC in a crisis situation
will rely on multiple levels of prioritization. Dur- CASE STUDY –
ing an outbreak, the functioning of the ESC should HAITI
take priority over the functioning of the routine
supply chain. This does not mean that the routine
supply chain should cease to function in an emer-
gency; to the contrary, wherever possible it should
function as normal so that nonemergency health
commodities remain in circulation. However, if an
epidemic or disaster becomes acute enough, some
of its resources may need to be diverted into the
ESC. In fact, during the most severe outbreaks, the
Haiti’s experience in dealing with a cholera out-
routine supply chain may need to be completely
break in 2010 was unsuccessful in many respects.
dedicated to emergency usage for a period of time.
However, the government’s response shows how a
nation can use routine supply chains to supplement
In addition to the prioritization of the ESC over
an ESC without compromising the functioning
the routine supply chain, prioritization within the
of either. In the early stages of the cholera out-
routine supply chain itself should occur during an
break, the disease’s rapid spread caught authorities
outbreak. This way, if repurposing from the routine
off-guard and outpaced the nation’s public health
supply chain to the ESC must happen, lower-
response. To compensate, Haiti tapped into the
priority efforts can be diverted to support the
existing HIV commodities supply chain to facilitate
ESC. In the case that a country has multiple parallel
the distribution of essential supplies. These efforts
supply chains (e.g., vaccines, HIV commodities), the
were supplemented with additional emergency
ESC team should establish an order of precedence
funds from the CDC. MSPP and additional PEPFAR
on how assets from the non-emergency supply
partners received $14 million to expand treat-
chains would be repurposed into the ESC (e.g.,
ment and prevention efforts. These funds helped
repurposed vaccine cold chains). In this way, the
ensure that the emergency supply chain did not
most important parts of the routine supply chain(s)
jeopardize operation of the routine supply chain.
can be preserved even while the ESC is being
PEPFAR clinicians received supplemental trainings
prioritized. Moreover, this partial preservation of
to help with cholera treatment and prevention
the routine supply chain should seek to minimize
efforts. Importantly, PEPFAR continued to perform
wastage of nonemergency commodities wherever
its normal duties with respect to HIV care. In this
possible.
way, even though Haiti’s response to the outbreak
One preparedness-specific interaction between was too slow to contain the disease, its experience
the emergency and routine supply chains will be demonstrates that well-defined coordination of
the rotation of emergency stock into the routine emergency and existing supply chains can augment
supply chain. The protocols surrounding this will be an emergency response effort.36
further elaborated in the “Stockpile” chapter. An-
other point of interaction may be in the last mile, Resources
where in practice, the ESC may leverage aspects of
routine supply chains. • The ESC Playbook contains a customizable “Re-
sponse Quick Guide” in which ESC teams can
36 Tappero, Jordan and Robert Tauxe. “Lessons Learned During the Public Health Response to the Cholera Epidemic in Haiti and the Dominican
Republic.” Accessed via National Institute of Health (2011).

document their ESC protocols, including those operator (e.g., district warehouse managers, health
on the separation between the routine and facility staff). Protocols should also be designed to
emergency supply chain ensure staff safety, as items being transported may
• CDC’s Division of Strategic National Stockpile be biohazardous. These protocols should cover of
(DSNS) provides country governments with the following areas:
support in developing detailed Emergency • Organizational structure and financing
Response Plan for Medical Countermeasures in • Commodity forecasting and quantification
which governments can document protocols37 • Stockpiling
• Procurement and sourcing
• Storage and warehousing
• Transport and customs
3C | EMERGENCY SUPPLY • Waste management
CHAIN PROTOCOL • Data visibility
Establish protocols to govern the ESC’s Effective ESC protocols should be governed by
readiness in between emergencies and “no-regrets principles” prioritize efficacy over
resourcing concerns prioritizing agility and allowing
to manage how the ESC will function in for flexibility (e.g., rapid incorporation of new ven-
an emergency. dors). However, this flexibility should not come at
the cost of appropriate documentation. Protocols
Definition should clearly identify which forms of documenta-
tion are essential for each stage of the emergency
Protocols are rules that describe how processes supply chain.38
should function under an emergency, and who
should run those processes. They should be incor- Customs protocols
porated into a government’s Emergency Prepared-
ness and Response Plan. Before an emergency occurs, countries should
review and document customs protocols to speed
the entrance of supplies through their borders
Why this is important once emergency status is triggered. Customs
The establishment of protocols in advance of an protocols will cover how goods pass through ports
outbreak creates a clear set of guidelines that can and airports in an expedited fashion (e.g., blanket
be activated immediately once emergency status duty waivers, temporary exemptions). In addition,
is triggered. When protocols are developed in ad- countries should arrange for tax and duty exemp-
vance, they can be employed in training stakehold- tions for the transport of health emergency com-
ers to ensure all partners are adequately prepared modities into the country prior to an outbreak.
to perform their roles in the event of an outbreak. These agreements are backed by signed documents
where possible to prevent renegotiation.39 Finally,
governments should adopt the following external
Characteristics of effective ESC protocols best practices where possible:
Effective ESC protocols should have delineated • OCHA, UNCTAD, and World Customs Orga-
responsibilities for actors on every level. At every nization/WTO have developed customs proto-
level of the ESC, protocols should clearly articu- cols that should be put in place upon declaration
late the responsibilities of each type of individual of an emergency. These should be deployed

38 World Health Organization, “Emergency Response Framework,” (2017)
39 “Emergency Response Supply Chain Assessment,” Australian Council for International Development’s Humanitarian Reference Group (2007)

during pandemic responses to alleviate bottle-
necks40
• Customs IT systems have also been developed CASE STUDY –
(ASYCUDA, ASYREC) to interact with existing
customs IT systems and speed processes during NIGERIA
an emergency41
Metrics
Countries should track indicators to monitor
the current state of preparedness on an ongo-
ing basis, as part of performance management of
the ESC. A short list of helpful metrics should be
established. In selecting metrics, countries should
Nigeria’s clear delineation of ESC protocols facilitat-
balance between minimizing additional work while
ed an effective response to a 2014 Ebola outbreak.
also ensuring visibility into the current state of ESC
Adopting infrastructure from its past responses to
preparedness. These include:
epidemics, Nigeria used its Polio Emergency Op-
• Number of ESC roles filled out of total roles
erations Centre and its experience and resources
needed, with a roster of names
with prior epidemics as a springboard for an Ebola
• Share of ESC operators trained in ESC protocols
response. The EOC was divided into six functional
and frequency of simulation exercises
units, each tasked with managing a separate part
• Stockpile levels
of the response plan. The agency bypassed routine
bureaucracies to coordinate real-time responses
Resources to local officials and international stakeholders, al-
lowing it to quickly build technical knowledge and
• CDC’s Division of Strategic National Stockpile
distribute supplies. According to the World Bank,
(DSNS) provides country governments with
roles within the EOC were clearly defined, making
support in developing detailed Emergency
it possible for leadership to hold individuals ac-
Response Plan for Medical Countermeasures in
countable for specific results. Team managers were
which governments can document protocols42
granted a degree of autonomy with resource allo-
• The ESC Playbook contains a customizable
cation and personnel management. The EOC also
“Response Quick Guide” in which ESC teams
leveraged Nigeria’s previous investments in front-
can document their essential ESC protocols for
line health workers and facilities to mobilize against
emergency response across each element of the
the Ebola threat. In these ways, the existence of
ESC (e.g., transport, waste management)
well-established ESC protocols as part of broader
• WHO has a set of SOPs that should be activat-
EOC protocols allowed Nigeria to quickly mobilize
ed within 24 hours of emergency grading out-
lined in its Emergency Response Framework43 to fight the spread of Ebola.45
• The JEE assesses countries’ plans to address
regulatory concerns in the event of an emer-
gency44
40 Pandemic Supply Chain Network. “Project Report,” (2017). Pg 75

41 Ibid. Pg 76
43 World Health Organization, “Emergency Response Framework,” (2017). Pg 34
44 World Health Organization. “Joint External Evaluation Tool,” (2016)
45 Odutolu, Ayodeji Oluwole. “Nigeria’s Seven Lessons from Polio and Ebola Response,” World Bank (2016)

4. EMERGENCY
PROCUREMENT
AND SUPPLY CHAIN
4A | COMMODITY PLANNING The ESC team can use hazard assessments as the
first indicator of what types of commodities they
Determine essential commodities to should plan for, and hazard assessments may al-
stockpile and procure based on poten- low countries to “cross off” several commodities
based on the absence of a particular disease threat.
tial epidemics Once governments identify relevant threats, they
should build on established resources to determine
Definition which specific commodities they need. Various
organizations such as the PSCN, Food and Agricul-
Commodity planning for potential epidemics refers tural Organization (FAO), and WFP have already
to the identification of the types and specifications worked on identifying lists of commodities needed
of commodities required to combat an outbreak. by disease type for the most common infectious
diseases. ESC teams should leverage these existing
lists by cross-referencing them against their own
hazard assessments and working with experts to
A predetermined and specified list of commodities further specify any additional commodity needs46
provides countries with critical information to plan
across the supply chain. Compiling this can signifi- Commodity specifications
cantly slow down the early phase of a response, Specifications for emergency commodities should
so developing an initial list is essential in increasing be identified ahead of time as much as possible
response efficacy. Creating a defined list enables to enable the most effective planning. If countries
countries to forecast needed quantities, identify can identify technical specifications down to the
suppliers and negotiate agreements, determine SKU level by defining elements such as size, color,
storage needs, plan for transport, and develop packaging, and shape, they will be able to identify
protocols on inventory management as well as suppliers accurately and put contracts in place
waste disposal. before a crisis begins. This can be a labor-intensive
process, and experts from organizations like the
WHO and UNICEF should be involved in defining
Types of commodities the commodity specifications early on. This ensures
Determining the types of commodities needed they reflect WHO standards to ease the procure-
in the event of an outbreak is the first step in an ment process and facilitate collaboration with
effective commodity planning process. The ESC international stakeholders.
is responsible for several categories of supplies:
medical and nonmedical consumables, PPE, phar- Supply kits
maceuticals or vaccines directly relevant to specific The ESC may use pre-configured supply kits in the
diseases, health facility infrastructure and equip- early phases of an emergency response to ac-
ment, and emergency response logistics equipment. celerate supply chain operations. These kits vary
The majority of supplies that countries will need based on the response scenario, and are designed
during an emergency, such as PPE and emergency by professionals to be modular. However, several
response equipment, will be consistent regard- downfalls can come from the over-reliance on kits,
less of a country’s hazard profile. Other specific such as a lack of proper forecasting and planning of
items will vary based on the types of disease risks a specific needs, a lack of visibility and validation, and
country faces. significant lead times when purchasing from popu-
lar basic aggregators. Potential use of these kits and
their composition should both be accounted for in
the commodity planning process

its vaccine stores to rapidly halt an outbreak of foot
and mouth disease. These achievements reflect
CASE STUDY – the important role that commodity planning can
play in preparing for and addressing outbreak of a
BOTSWANA disease.47
Prioritization
If resources are limited, governments will need to
prioritize which commodities they purchase. This
choice should be informed by several consider-
ations:
• Risk level posed by absence of commodity
Over the past decade, Botswana’s Ministry of • Number of emergencies and scenarios that
Health has reformed its Central Medical Stores commodity can be used for
(CMS), a government agency responsible for sup- • Complexity of acquisition and management, e.g.,
plying drugs and medical supplies, with the aim of sourcing, shelf life, cold chain requirements
promoting 97% commodity availability. Although • Relative cost
not specifically focused on ESC, Botswana’s supply • Frequency of resupply necessary
chain reform experience highlights the benefits of
improved supply planning and management. The Pitfalls to avoid:
MoH’s reforms included transforming CMS into a
• Insufficient planning of commodity specifications
semi-autonomous agency (parastatal). In concert
• Oversight of basic commodities that may be es-
with these efforts, the government released a
sential during an emergency response
strategic plan designed to estimate the country’s
• Assumption that another stakeholder will be
needs in different crisis situations. CMS categorized
responsible for identification of commodities
drugs into vital, essential, and nonessential items,
• Lack of prioritization amongst commodities
specifying target procurement and storage rates
leading to shortages of important goods
for each category. Botswana also assessed methods
to ensure that these drugs could be made avail-
able in different regions. Strategies included reas- Resources
signing management responsibilities within CMS,
• The ESC Playbook contains a “Commodity fore-
revising performance indicators, and streamlining
casting” section that contains guidance and tools
internal administrative practices. CMS also worked
on identification and quantification of commodi-
to refocus its procurements programs to minimize
ties. It contains commodity lists for ~20 priority
rates of drug expiry and work with partners to
infectious diseases and zoonoses in the form of
limit supply constraints. Though Botswana still faces
Disease Job Aids for ESC staff48
challenges with respect to stock outs and sup-
• PSCN has created detailed commodities lists for
ply chain management, the country’s commodity
several common diseases that WHO is in the
planning efforts have shown benefits. Commodity
process of refining49
planning has helped promote widespread access to
HIV/AIDS medicines, and the government has used
47 Thomson et al. “Central Medical Stores Botswana: 2010 – 2012 Strategic Plan,” USAID; Muzulu, Paidamoyo. “Botswana donates foot-and-mouth
disease vaccines to Zim,” Newsday (2017); African Health Observatory. “Analytical summary – HIV/AIDS: Botswana,” World Health Organization
(2017)
48 USAID. “Emergency Supply Chain Preparedness Playbook: Disease Job Aids,” (2018).

4B | QUANTITY required for pandemic response. While OPALS
was designed for H1N1, PSCN is working to
FORECASTING expand the tool to forecast commodities for the
ten diseases that its commodities list covers
Determine the quantity of essential
• UNICEF’s Emergency Supplies Calculator helps
commodities required in an emergency countries identify quantities required and costs
during an epidemic based on several demo-
Definition graphic factors, such as population at risk.
• PSCN’s list provides maximum monthly quanti-
Quantity forecasting is the process of calculat- ties for each of its commodities list items50
ing the quantities of key commodities that will be
necessary to deliver care in the event of a public How to create quantity forecasts
health emergency.
Before a crisis emerges, countries should work to
estimate overall likely demand for key commodi-
Why this is important ties in the event of disease outbreaks. At the very
Shortages in key commodities can cripple an least, the MoH should engage experts from WHO
emergency response and limit a country’s ability to to develop a rough estimate of the consumption
slow the spread of disease, while over-purchasing ratios by disease for each of the critical commodi-
wastes precious resources. By determining how ties identified (e.g., # number of units per 100 pa-
much of certain goods they will need in a crisis, tients). Several critical considerations can affect the
countries can lay the groundwork for an effective severity of an outbreak and a country’s response
response and reduce supply shortages in the event needs. These include:
of an outbreak. Quantity forecasting also allows • Demographic data (e.g., number of children,
countries to begin establishing supply agreements population size)
and logistics protocols in preparation for out- • Geographic factors, including the fraction of the
breaks. population living in urban vs. rural areas and the
types of ecosystem present
• Timeframe of response, along with consumption
Tools for quantity forecasting patterns and continuity of demand
The process of quantity forecasting is highly techni- • Patterns from prior epidemics of likely patho-
cal. It requires modeling specific commodity needs gens
under different outbreak scenarios. Countries • Epidemiological behavior of pathogen
should leverage partner expertise and existing
By entering data for each of these factors into a
tools for supply estimates while they develop their
digital model, such as the ones listed above, coun-
own capacity. Working with experienced partners
tries can retrieve detailed estimates for both the
helps countries access sophisticated modeling tools
quantity of supplies needed and their costs. These
and expertise that can help improve the accuracy
estimates will provide countries with baseline
of predictions.
scenarios of their commodity needs in the event of
Existing tools for quantity forecasting include: an outbreak. In addition, countries can modify each
• Operational Planning Application for Logistics of these assumptions to identify their needs under
and Supply (OPALS) is a tool developed by the different outbreak scenarios. For instance, countries
WHO to help gauge quantities of critical items can identify how their quantity demands in an epi-
demic with an aggressive clinical course rate versus
50 Pandemic Supply Chain Network. “Project Report,” (2017), pg 33; Pandemic Supply Chain Network website: https://www.pandemicsupplychain.
org/information-platform/

risk or high-likelihood in their hazard assessments.
Countries should also create quantity forecasts that
CASE STUDY – reflect all major feasible outbreak possibilities.
GHANA Factors to consider
Accurate quantity forecasts require a holistic
understanding of crisis scenarios. Therefore, when
testing different models, countries must pay par-
ticular attention to how their quantity demands
might vary during different stages of the outbreak
and across regions.
Regional variation: Commodity demands can vary

Ghana has effectively used quantity forecasting in
significantly across subnational regions and deliv-
preparation for numerous emergency situations.
ery centers in the event of an outbreak. As such,
During the Ebola crisis, the Ghanaian govern-
countries must identify potential demand at both
ment responded to the possibility of an outbreak
the national and regional level in their forecasts.
by having the MoH assess the country’s ability to
In general, regional demand can be calculated as a
respond to an epidemic. Using outbreak scenarios
population-weighted fraction of national demand.
with different projections of how rapidly the
However, areas with different geographic and
disease could spread, the government undertook
demographic characteristics may have significantly
a comprehensive risk and vulnerability assessment.
different challenges in the case of an outbreak.
For each scenario, the government estimated its
Therefore, national-level forecasters should consult
needs for drugs and non-drugs consumables, gaps
with regional experts such as state- or provincial-
in current stock levels, and procedures to distribute
level health officials to identify any factors that may
commodities to sites. As part of this effort, Ghana
affect local quantity needs. Countries should also
partnered with the WHO to conduct monitoring
project the maximum demand a given region could
and supervisory visits to local health sites to review
have in the event of a severe outbreak. Together,
epidemic preparedness at the local level. The gov-
these subnational forecasts will provide countries
ernment also worked to identify potential sources
vital context for their transport and logistical plans.
of medical goods from both internal and external
suppliers. Though Ghana never faced an outbreak Stages of the crisis: Commodity demands will vary
of Ebola, it has been well-stocked with emergency in different stages of a crisis. In the earlier stages
supplies during outbreaks of cholera and yellow of an outbreak, countries may opt to use greater
fever, reflecting the important role quantity fore- quantities of pre-configured medical supply kits,
casting plays in maintaining stable levels of essential whereas in later stages, demand may shift toward
commodities.51 individual items. Therefore, countries need to ac-
count for both the number of kits needed at the
a relatively mild one. By adjusting these assump- outset of a crisis and the transition to a piecemeal
tions in the model, countries will be able to create ordering system. Countries should also plan for
response plans for outbreaks of varying severity. frequency of resupplies, which will depend on the
When testing these scenarios, countries should doubling rate of the epidemic, and for the need to
place particular focus on diseases identified as high- restock the stockpile after an emergency ends.52
51 Ghana Ministry of Health: “National Preparedness and Response Plan for the Prevention and Control of Ebola Viral Disease,” (2014); Ohene et al.
“Assessment of the response to cholera outbreaks in two districts in Ghana,” Journal of Infectious Diseases of Poverty (2016)
52 Expert interviews

Forecasting at the onset of an outbreak 4C | PROCUREMENT AND
Initial data to inform quantity forecasting should SOURCING OF EMERGENCY
be gathered as part of the preparedness agenda to
give countries a solid understanding of how they HEALTH COMMODITIES
will quantify needs under different emergency sce-
Identify suppliers that will be responsible
narios. However, quantity forecasting for a specific
outbreak must occur at the outset of an outbreak, for providing emergency commodities
as countries will use outbreak-specific data, such and determine their capacity to meet
as location and size of an initial outbreak, to define emergency needs
their quantity forecasts. If the ESC team chooses
to do so, it should utilize the above models and
considerations to ensure accurate predictions. Definition
Procurement and sourcing involves obtaining es-
Pitfalls to avoid sential commodities from local and international
• Not applying “no-regrets principles” and instead suppliers in preparation for and during an emer-
prioritizing resources over preparation, leading gency response.
to being undersupplied at the outbreak of an
emergency Why this is important
• Lack of forecasts for multiple outbreak scenarios
• Failure to account for how needs may change Bottlenecks for essential commodities can inhibit
over the course of an outbreak an emergency response even when other areas
of the supply chain are functioning effectively. For
each essential commodity, countries need to know
Resources not only how much they need, but also a clear
• The ESC Playbook contains a “Commodity sense of where they will source these commodi-
forecasting” section that contains guidance and ties from. Countries should also have mechanisms
in place to obtain those commodities so that a
tools on identification and quantification of com-
response can begin as soon as a crisis hits. This
modities
requires building and maintaining a list of potential
• Operational Planning Application for Logistics
suppliers and their capacity, and putting agree-
and Supply (OPALS)53
ments in place with suppliers beforehand about
• UNICEF’s Emergency Supplies Calculator54
exactly what they will provide during an out-
break.55
Identifying sources of supplies

Countries should have a comprehensive list of
potential sources for all essential commodities.
First-line suppliers should be pre-identified, vetted,
and contracted ahead of time to limit lead times.
Suppliers should also be diversified to limit risks
such as long production lead times or local factory
shutdowns due to the spread of infection.
53 Pandemic Supply Chain Network: “Supplies,” https://www.pandemicsupplychain.org/supplies/ (2017)

54 UNICEF: “Emergency Supply Calculator,” https://www.unicef.org/cholera/Chapter_10_UNICEF/14_Supply_calculator/WebCalculation.htm
(2016)
55 Pandemic Supply Chain Network. “Project Report,” (2017), pg 37

crisis, they demonstrate the importance of effec-
tive procurement and sourcing strategies for ESC
CASE STUDY – management.56
LIBERIA
Local, regional, and national suppliers each can play
a unique role in the procurement process:
• Local suppliers: Countries should build out an
inventory of in-country sources to supply com-
modities in the short term. Local suppliers can
provide rapid access to essential commodities,
but can be susceptible to slowdowns because of
a widespread epidemic. The Ministries of Health,
During the 2014 Ebola crisis, Liberia created and along with any other national procurement
implemented new procurement and sourcing functions, should develop quality standards and
processes as part of the emergency response. Initial accreditation processes for working with local
responses to the outbreak were focused on setting suppliers. They should also leverage technical
up Ebola treatments centers, and as a result, the experts and international organizations to en-
ESC initially received inadequate attention. For in- sure quality control through regular monitoring
stance, healthcare workers lacked access to proper programs
PPE that could help ensure their own safety. To • Regional stockpiles: Existing strategic reserves
compensate, Liberia’s government, in concert with located in major regions (e.g., west Africa) can
the Academic Consortium Combating Ebola in play a pivotal role in providing expensive and
Liberia (ACCEL), created new procurement and hard-to-access supplies during an emergency.
sourcing processes to improve drug and equipment Countries should work with regional suppli-
availability. Local procurement was used when pos- ers (e.g., UNHRDs, WHO, FAO stockpiles) to
sible to create a rapid, cost-effective supply pro- determine which commodities could be sourced
cess. ACCEL worked with a local medical school from each during an emergency response, but
to make the process auditable and ensure quality in countries should plan with the expectation
line with the government’s standards. International that they would not be able to rely on strategic
procurement and partnerships with NGOs also reserves alone in the event of a multi-country
played a major role in the supply chain and allowed outbreak
Liberia to leverage international suppliers to fulfill • International sources: Where possible, coun-
unmet needs. The Liberian government also estab- tries should work to establish standby agree-
lished a streamlined process for customs clearance ments with global stakeholders and suppliers
to expedite drug imports. When these steps were because they are less likely to experience down-
put into action, supply chain performance rapidly time during an epidemic. Because organizations
improved. The revamped Liberian supply chain have diverse strengths and capacities, countries
procured and delivered more than 70 metric tons should aim to pre-determine the different roles
of supplies within a twelve-week period. Moreover, organizations would play in a sourcing strategy
operational efficiencies from the new procure- (e.g., UNICEF procures pharmaceuticals, WFP
ment process helped reduce transportation costs, procures logistical supplies)
and ACCEL used those savings to fund deliveries
to previously unreached hospitals. Though Liberia
and ACCEL’s efforts emerged in the midst of a
56 Goentzel, Jarrod and Ian Heigh. “Supply Chains in Crisis,” Inside Logistics (2015)

Procurement procedures • The LCAs provide a preliminary list of in-coun-
try suppliers with estimated capacity, though
After identifying potential suppliers, the ESC team
these must be updated and maintained regu-
should put in place contracts and agreements with
larly58
suppliers and plan the procurement process ahead
• The UN Global Marketplace lists international
of time. Because crises can affect many countries at
and local suppliers59
once, procurement strategies should be designed
to ensure that countries can meet their commod-
ity needs in a time of high demand. Contracts
should specify the procedures by which countries 4D | STOCKPILING
will receive the goods from their suppliers, identify
potential risks, specify transport methods, and out- Pre-purchase and store emergency sup-
line the amount of essential commodities they will plies to have in reserve short term in
receive from each supplier. This information will
the event of an emergency
help countries avoid bottlenecks in procurement
due to limited inventory during an emergency. The
MoH and other relevant ministries should establish Definition
processes and protocols for regularly reviewing and
Countries should have ready access to a critical
updating the lists of their suppliers as well as their
quantity of essential commodities on hand for the
contracts and standby agreements with those sup-
initial period of an epidemic to enable an effective
pliers. They should also update contracts to fit with
response before regular resupply is established.
changing needs and health priorities. In particular,
Earmarked regional stocks or virtual stocks, as well
the MoH should modify existing contracts to put in
as national stockpiles, can provide ready access.
long-term agreements for surge capacity fulfillment
where possible. Moreover, countries should con-
tract new providers (after vetting and quality assur- Why this is important
ance) to meet additional capacity as necessary.57
Effective stockpiling and stockpile management will
strengthen countries’ capacity to handle emergen-
Potential pitfalls to avoid
cies by enabling an immediate response in the first
• No quality assurance tests conducted for identi- phase of an emergency.
fied suppliers
• Reliance on regional and international stockpiling
mechanisms without pre-established agreements International versus national stockpiles
in place Commodities can be stockpiled either interna-
• Lack of diversification of sources leading to tionally (usually in a regional logistics hub such as
bottlenecks Kenya for east Africa) or nationally. Appropriately
managed national stockpiles reduce the need for
cross-border imports of essential emergency com-
Resources
modities. However, international stockpiles can be
• The ESC Playbook contains a “Procurement more cost effective because they cover several
and sourcing” section that provides guidance countries and can be a stopgap if local capacity is
and tools on obtaining essential commodities not sufficient.
from suppliers, as well as a database in which to
record suppliers and their potential capacity
57 Pandemic Supply Chain Network. “Project Report,” (2017), pg 37-39

59 United Nations website: https://www.ungm.org/

The ESC function of a country should hold a work-
ing session with experts and partners to determine
CASE STUDY – whether a regional or a national stockpile is most
MOZAMBIQUE appropriate for the country context. Choosing
what to stockpile locally requires understanding
the cost of being short on a product versus the
cost of being long (e.g., expired product, inventory
holding). Considerations for international versus
national stockpiling for each commodity are:
• Demand considerations: Likelihood of use, sub-
stitutability (e.g., can another product or method
be used for the same effect?), consumption pat-
terns, existing stock levels in routine supply chain
Mozambique’s government has used stockpiling • Ability to manage inventory locally: Lifecycle,
effectively to prepare for potential cholera epidem- complexity of management, cold chain capabil-
ics. A consistent challenge in stockpiling medical ity required, storage capacity available/affordable
goods is minimizing risk of loss while maintaining a locally
stable supply of goods. Mozambique’s government • Ease of import: Ease of passing customs, risk
undertook a comprehensive analysis of records level posed by travel time61
from neighboring countries to assess its needs with
respect to cholera prevention and treatment. The Locally-held stockpiles
Mozambique government took concrete steps
to ensure that its stockpiles would remain well- If stockpiles are held locally, the commodities
supplied without wasting resources. In particular, should be purchased and stored separately, and
assigning co-shared responsibility to the MoH the country should develop a system for rotating
and a separate agency helped promote sensible supply through routine supply chain while regularly
management of the drug stockpile. Because using replenishing emergency stocks to prevent expiry.
goods from the stockpile required joint authoriza- Best practice would be to pre-position stocks at
tion from two agencies, Mozambique was able to strategic storage locations based on the geographic
ensure that goods were only used in response to likelihood of key threats. This system should include
an emergency, rather than to supplement routine both stock rotation and stock monitoring. Stock
medical supply chains. The system is not without rotation should be done in a scheduled manner:
flaws, as stock outs are still a common problem in the ESC should not be “raided” when the rou-
certain areas of the country. But the use of dedi- tine supply chain is stocked out, and needs to be
cated, well-run stockpiles in planning for potential preferentially in stock at all times. Stock monitoring
cholera epidemics helped to lay the groundwork should occur at regular intervals (at least quarterly)
for efficient ESC management.60 to avoid product expiry and misappropriation of
commodities.62 Finally, protocols codifying inventory
management and appropriate use of stockpiled
supplies should be documented, shared, and fol-
lowed in nonemergency situations.
60 Wagenaar et al. “Stock-outs of essential health products in Mozambique-longitudinal analyses from 2011 to 2013,” Journal of Tropical Medicine
and International Health (2014); expert interviews
61 Pandemic Supply Chain Network: “Project Report,” (2017), pg 46-51
62 Emergency Response Supply Chain Assessment,” Australian Council for International Development’s Humanitarian Reference Group (2007).

Pitfalls to avoid Definition
• Poor visibility into stockpile stock levels and Preparing storage infrastructure to manage inven-
expiry dates tory involves mapping existing storage infrastruc-
• Loose restrictions ring-fencing stockpiled com- ture and creating external partnerships prior to
modities emergencies to build up extra capacity.
• Failure to restock commodities after an out-
break
Effectively preparing storage infrastructure ensures
Resources that countries have sufficient warehousing to store
• The ESC Playbook contains a “Stockpiling” sec- the quantity and volume of essential commodities
tion that provides guidance on how to identify forecasted.
stockpiling needs and resources
• If countries have completed the JEE, they can
Positioning of warehousing and storage
reference the “Preparedness” section on map-
ping of national stockpiles to identify current The number of warehouses required in a country
capabilities and gaps63 depends upon the quantity and volume of essen-
• The UNHRD are a global network of strategi- tial commodities, population distribution, physical
cally located depots managed by WFP. Together, characteristics, infrastructure quality, and particular
they form a preparedness tool that supports the threats faced. The ESC function should understand
strategic stockpiling efforts of the wider humani- warehousing and storage specifications for each
tarian community. UNHRD provide a range of essential commodity (shelf life, temperature, vol-
services, including management of emergency ume, weight, demand) to inform how much total
relief stocks (pre-positioning, storage, and storage capacity they need, as well as what type of
handling of emergency supplies and support management is appropriate. The ESC team should
equipment)64 review existing warehouse and storage facilities to
understand current capacity available and clear out
wasted capacity (e.g., space taken up by expired
goods). Finally, warehousing and storage consid-
4E | EMERGENCY RESPONSE erations for each emergency commodity should
WAREHOUSING AND be codified into an inventory management section
for the warehousing and storage protocols, and
STORAGE managers should be trained on them.
Prepare storage infrastructure to man-
Building up external capacity
age inventory of essential commodities
If capacity is not sufficient to store essential com-
during an epidemic
modities between resupplies, the government
should build or rent additional capacity. To do so,
they should enter into negotiations and discussions
with partner agencies and private sector actors on
the cost and availability of potential storage facili-
ties.65 During these negotiations, countries should
63 World Health Organization. “Joint External Evaluation Tool,” (2016)

64 For more information, please see: http://unhrd.org/

keep in mind that certain commodities may require
additional capacity or resources in terms of:
CASE STUDY – • Loading and unloading of supplies
• New equipment
EL SALVADOR • Warehouse labor
• Delivery site setup
• Security
• Temporary warehousing is another alternative
for emergency response storage if owned, part-
ner, and private sector capacity is insufficient.
The ESC team can work with routine supply
chain storage and warehousing staff to identify
strategic locations where temporary storage
El Salvador’s response to an earthquake in 2001 could be set up (e.g., lots near airports/seaports,
shows the important role that well-designed stor- centrally located sites). These sites should be
age and warehousing plays in emergency response. documented ahead of time.
El Salvador operates an integrated storage system
in which medicines and supplies are primarily Pitfalls to avoid
distributed from central warehouses to local stor-
• Even if storage capacity exists before an emer-
age areas and organizations. When the earthquake
gency, staff may not be prepared for a scale-up67
hit, the design of El Salvador’s system allowed the
country to access stored goods rapidly. El Salvador
used an inventory tracking management system Resources
designed in partnership with the Pan American
• The ESC Playbook contains a “Storage and
Health Organization to register goods coming in
warehousing” section that provides guidance on
and out of government warehouses. The system
storage and warehousing, and provides tools
kept track of existing stores and goods received
and templates to support a warehousing and
from donors, storage capacity at the local level,
storage assessment
and local inventory. Quick distribution, effective
• Countries can reference the CDC Strategic Na-
use of existing capacity, and access to an interna-
tional Stockpile guidelines to understand proto-
tional airport also allowed El Salvador to quickly
cols around warehousing and storage68
access and stock international aid in its central
• The LCAs provide a preliminary list of in-coun-
warehouses. Moreover, the accountability provided
try warehousing and storage with estimated ca-
by the warehousing management system attracted
pacity and guidance on sources of information69
positive press attention, which promoted public
trust. El Salvador’s storage system is not perfect:
its costs could be lower and it occasionally suffers
from stock outs. Nonetheless, in the case of the
earthquake, effective management, accessibility, and
sufficient capacity helped facilitate an accountable,
streamlined emergency response.66
66 Tomasini, Rolando, and Luk N Van Wassenhove. “Coordinating Disaster Logistics after El Salvador’s Earthquakes using SUMA’s Humanitarian
Supply Management System.” Harvard Business Review (2003). Alliance for Health Logistics Systems. “Characterization of the Supply Chains for
Medicines and Medical Supplies in Latin America.” USAID (2015)
68 CDC Website: https://www.cdc.gov/phpr/stockpile/index.htm

4F | TRANSPORT Mapping transport routes and identifying trans-
port options
Determine how commodities will flow For each threat, the ESC team should identify
from stockpiles and storage facilities to service delivery points close to where the threat
service delivery points is most likely to occur and in areas accessible to
end users. In addition, countries should identify
any commodity-specific considerations (e.g., cold
Definition
chain required). Finally, countries should map out a
Making a transport plan involves liaising with range of potential options for likely service delivery
customs officials, identifying transporters, writ- points.
ing transport protocols, and mapping transport
routes. Mapping transport routes should consider Building on the supplier list from the commodity
the existing transport infrastructure, the physical forecasting step, the ESC team should understand
characteristics of the commodities transported the logistics capability of each potential commod-
(and any special constraints they require, such ity provider. For example, some suppliers are able
as cold chain), seasonality, and the locations of to deliver products directly to the central medical
the country’s stockpiles, warehouses, and service store, whereas others require the use of third-
delivery points. party logistics companies to deliver products into
the country. Properly documenting this information
Why this is important in advance of an emergency will allow countries
to quickly understand lead times for ordering and
Effective transport plans enable countries to de- resupply in the event of an emergency.70
liver vital emergency goods in a time-efficient man-
ner. Proper planning is required for countries to In addition, the ESC team should maintain an
dispatch needed commodities across a wide range updated list of logistics providers for each region
of terrain inside their borders and to avoid wast- and/or district that could be mobilized in the event
age of commodities through improper handling of an emergency. These include MoH vehicles, and
during transport. Moving commodities down from should also include private sector options such as
the central level to the point of care can be very third-party distributors. In many countries, military
challenging, and early mapping and identification of
vehicles could also be mobilized. The team should
transport mechanisms and routes can save valu-
document the types of vehicles available and pre-
able time in an emergency.
vet all logistics providers for quality.
Liaising with customs officials Where possible, countries should negotiate

contracts for transportation that can be activated
To prepare their transport operations, the ESC
when an emergency response is triggered.71 Pay-
function should determine whether each com-
ment structures for transport vary: some organiza-
modity will come from within national borders
tions, such as the WFP, pay transporters based on
or internationally. For imported commodities, the
ESC should establish a point of contact within the weight, while others pay based on distance trav-
national customs agency prior to an emergency eled.
to establish expedited processes and tariff-free
treatment of emergency commodities (outlined in
Section 3C of this document). This area has been a
particular challenge in several recent epidemics.
70 Pandemic Supply Chain Network: “Project Report,” (2017). pg 50


Writing transport protocols
Governments should draft additional protocols to
CASE STUDY – streamline and safeguard the transport process and
GUINEA the commodities transported. First, these protocols
should specify procedures for handling receipt of
each type of vehicle, especially noting where special
machinery is required (e.g., forklifts). Second, these
protocols should specify safe handling procedures
to protect staff involved in transport and logistics.
In addition, countries should create protocols to re-
deploy regular SC transport or other MoH vehicles
to be used when necessary in an emergency.73
Guinea’s mass campaigns with a two-dose OCV
Transport planning at the time of an outbreak
demonstrate effective use of transportation plan-
ning in ESC management. The country’s vaccination Immediately after an emergency is triggered, the
efforts faced significant challenges, as the cholera ESC team should make a transport plan to provide
epidemic affected a large, difficult-to-access area needed logistics to the site of the outbreak. Some
with a highly mobile population. Moreover, the key considerations in developing the plan include:
campaign had little time to prepare and mobilize • This plan should ideally be nimble and adaptive,
the public to respond to the outbreak. Yet effective responding quickly to changing geographies as
transportation planning allowed Guinea to deliver an outbreak begins or spreads from one area to
high volumes of cold-chain vaccines in resource- another. Using the LCA in conjunction with local
limited settings. Vaccines were transported from knowledge of transportation infrastructure will
a central supplier in India to the national airport, allow countries to pre-identify potential bottle-
where they were then taken to district capitals in necks and to create new emergency transport
refrigerated trucks. From the capitals, vaccination routes
teams used cars and boats to transport vaccines at • This plan should take into account frequency
an ambient temperature to final vaccination sites. of resupply depending upon the consumption
These vaccination sites, chosen in concert with patterns of the commodity in question. For
community leaders, were designed to be easily example, certain emergency commodities are
accessible and centrally located. Despite having meant for one-time use (e.g., vaccine) whereas
to transport logistically difficult goods such as others represent a repeat need (e.g., medication
water, the design of the supply route meant that or medical supplies). In addition, the frequency
the government was able to effectively interface of distribution will be a function of the burn rate
with at-risk populations. Guinea’s model also kept of supplies
delivery costs low, at only $1 per vaccine. Guinea’s
model thereby shows that efficient use of trans- A number of external considerations exist as well,
portation can improve the reach and efficacy of an including environmental, political, and demographic
ESC without raising costs.72 factors. Environmental conditions such as severe
weather may restrict the viability of using certain
routes in the transport plan. Political decisions such
as travel bans add another dimension of complex-
ity. Population movement or quarantines represent
72 Ciglenecki et al. “Feasibility of Mass Vaccination Campaign with Oral Cholera Vaccines in Response to an Outbreak in Guinea,” PLOS Journal of
Medicine (2013)
73 Timoleon, Chaliamalias. “The Logistics Chain of Emergency Supplies in Disasters,” Athens University: School of Medicine (2012)

a third constraint, which should also be factored Why this is important
into the route planning.74
Without effective sorting of waste, cross-con-
tamination of nonhazardous waste could occur,
Pitfalls to avoid
increasing the quantity of waste that needs to be
• Reliance on verbal rather than written contracts disposed of and increasing the risk of further infec-
• Assumption that suppliers will also act as dis- tion.
tributors
• Not incorporating commodity-specific consider-
ations (e.g., cold chain) into transport plan Categorization of medical waste
The ESC should sort each of the commodities
they use in a given emergency into one of several
Resources
discrete categories, each requiring a different set of
• The ESC Playbook contains a “Transport and disposal practices. The appropriate type of trans-
waste management” section that provides guid- port and storage capacity will vary depending upon
ance on transportation which category of commodity is being disposed of.
• UNHRD and WFP have developed downstream Countries can then use this categorization to calcu-
logistics kits ready for deployment within 24/48 late the required resources for safe disposal. Once
hours, with ready-to-deploy logistics hub (has this calculation is complete, all personnel operators
mobile storage, offices, generators, etc.), and involved in waste disposal should be trained on the
WFP has developed designs and modules for different category-specific protocols.77
how to build logistics bases75
• The LCAs provide an overview of national infra- Procedural considerations
structure as well as transportation providers76
Countries should identify where supplies are be-
ing used (clearly demarcating them when toxic)
and implement receptacles in these areas. The
4G | WASTE MANAGEMENT bulk of these receptacles will be at health facilities,
but others might be at waste disposal sites or in
Plan on how best to dispose of contam- warehouses. Where possible, countries should use
inated commodities during an epidemic existing waste management protocols from their
routine supply chain. For special categories such
as highly toxic waste (see below section), special
Definition containers should be provided. Disposal will vary
Waste management involves creating plans for the depending on the type of waste (e.g., recycled, bur-
safe disposal of contaminated commodities during ied, incinerated, chemically treated), and countries
an epidemic. This involves establishing protocols to should ensure proper facilities and transport for
categorize contaminated commodities and outlin- each type of disposal procedure.78
ing specific requirements for each type’s disposal.
74 Timoleon, Chaliamalias. “The Logistics Chain of Emergency Supplies in Disasters,” Athens University: School of Medicine (2012)
77 Pandemic Supply Chain Network. “Downstream Logistics in Pandemics,” Logistics Cluster (2017)
78 ibid

Categories of waste
Contaminated commodities can be divided into
CASE STUDY – three categories:
LIBERIA • Sharps waste includes syringes, needles, scal-
pels, and other sharp objects, and thus proper
disposal of sharps waste necessitates the use
of special, puncture-proof containers. These
specialized containers should be procured prior
to an emergency, and their quantity should be
proportional to the amount of sharps com-
modities the country requires
• Non-sharp infectious waste includes both
pathological waste (human tissue and fluids) and
Disposal of toxic and contaminated waste posed
infectious waste (such as medical devices) which
a critical challenge for Liberia during its recent
has been contaminated by pathological waste.
Ebola crisis. The Liberian government was able to
This category of contaminated waste should
meet that challenge by partnering with UNICEF to
remain separate both from other categories of
develop comprehensive safety guidelines for waste
contaminated commodities, and from non-con-
disposal. The government and its partners worked
taminated, non-infectious waste (e.g., cardboard
to promote awareness of safe disposal meth-
boxes) and human waste. Keeping these sepa-
ods, build technical capacity, and transport waste
rate reduces the possibility of further contami-
without jeopardizing sanitation workers’ safety. In
nation, thereby lightening the load on the overall
addition, a Liberian government agency (LWSC)
supply chain by minimizing the total amount of
was tasked with the process of desludging Ebola
contaminated waste that must be transported80
contaminated sewage in Monrovia. Among other
• Highly toxic waste includes genotoxic, carcino-
responsibilities, the LWSC worked with communi-
genic, radioactive, and chemical waste, as well
ties to maintain direct supply of chlorine solutions
as unused or expired pharmaceuticals. Because
and septic tanks. The government supplemented
of the increased level of severity of contamina-
these efforts with multi-sectoral monitoring pro-
tion, protocols enforcing stricter PPE should be
tocols, including members of the local and national
codified and enforced, and special containers
ministries, and with engagement of civic leaders at
should be used to reduce exposure. This extra
the local level. The Liberian government’s strategy
equipment, like the puncture-proof containers
prioritized dissemination of technical knowledge
for sharps waste, must be procured prior and in
and awareness, while strategically allocating the
proportional quantity to the projected amount
tools needed to dispose of waste. Put together,
of highly toxic waste81
these efforts ensured safe disposal of contaminated
items and limited spread of the disease.79
79 Simen-Kapeu et al. “Strengthening health systems to restore and sustain child survival gains in the context of Ebola: Case studies from Liberia,”
UNICEF (2015)
80 This does not include human remains burial, which can be extremely challenging during an outbreak.
81 Pandemic Supply Chain Network. “Downstream Logistics in Pandemics,” Logistics Cluster (2017). Pg 135

Cultural considerations ple Excel-based trackers or clearly-defined paper-
based systems may be more appropriate.
Countries should include the expertise of local
authorities in the planning process to ensure that
waste management procedures align with local Why this is important
cultural practices. Civic leaders and community
LMISs serve both as a check on the supply chain
leaders can also be helpful in communicating safe
(to make sure the commodities are in fact reach-
waste management procedures to affected com-
ing the projected destination in the quantity and
munities during an outbreak.82
frequency they were planned) and a tool to
Pitfalls to avoid improve the supply chain (identifying gaps or inef-
ficiencies). However, using LMISs with ESCs is not
• Using improper waste disposal materials for a widespread practice in developing countries, and
sharps or toxic waste its implementation should be considered in the
• Mixing hazardous and nonhazardous waste at context of broader ESC priorities.
receptacle site
• Failure to incorporate regional cultural customs
for waste management in disposal plan System viability
Countries should evaluate the existing LMIS for
Resources their routine supply chain on its system viability. For
a LMIS to be viable from a systems perspective, it
• The ESC Playbook contains a “Transport and must be reliable and accessible. An assessment of
waste management” section that provides guid- LMIS reliability should include both the reliability
ance on waste management of the tool or software used and the reliability of
the network. An assessment of LMIS accessibility
should include data quality and accessibility. In addi-
4H | LOGISTICS tion, the LMIS should be user-friendly and easy to
maintain and update.
MANAGEMENT
INFORMATION SYSTEM Preparing an emergency LMIS
Countries should take the following steps to pre-
Where possible, utilize Logistics Man- pare an emergency LMIS:
agement Information Systems (LMIS) or • Countries should ensure that the LMIS tracks
other data systems for effective man- stock levels of at least a subset of all commodi-
ties from the emergency stockpile and from
agement of ESCs warehouses on the national, regional, and sub-
regional level
Definition • Countries should ensure that all emergency
commodities suppliers and product specifica-
When used well, LMISs track the correct and
tions are preloaded into this system to allow for
timely delivery of all elements of the supply chain
rapid ordering and tracking
and allow for data-driven decision-making about
• Countries should ensure that the lead time
supply chain management. However, in developing
of the largest supplier for each commodity is
countries with poorly functioning LMIS for routine
preloaded into the LMIS so that the appropriate
supply chains, it may not make sense to rely on
re-order timing and quantity can be calculated
these systems for the ESC. In these situations, sim-
82 Pandemic Supply Chain Network. “Downstream Logistics in Pandemics,” Logistics Cluster (2017). Pg 136

• Countries should ensure that any extra stock
pushed from national to regional or sub-regional
CASE STUDY – warehouses in consultation with experts is
noted in the LMIS
TANZANIA • All individuals involved in ESC management
(including national, provincial, city, and country
government officials) should be pre-trained on
the LMIS
• Countries should define protocols on how to
use the LMIS during an emergency (e.g., how
often to update, persons responsible for tracking
specific data). A two-tiered, weekly or bi-weekly
system in which a national point person calls
LMIS improvements in Tanzania have improved regional managers for stock levels and each re-
the country’s health care system and its readiness gional point persons call sub-regional managers
for emergency health situations. Over the past is best practice during an emergency
decade, Tanzania has partnered with international
stakeholders and local care delivery organizations
to implement widespread use of LMIS technology. Resources
As a result, data accuracy and access have im- • The ESC Playbook contains a “Data visibility”
proved, helping to promote well-informed decision section that provides guidance on inventory
making across the supply chain. These programs management and tracking systems
have also helped ensure that hospitals and caregiv-
ers have access to critical medical products. Stock
outs have decreased by over 20%, and quality data
is continuing to improve forecast accuracy rates.
Tanzania’s advancements in LMIS use have laid
the groundwork for a response in the event of a
health emergency. The country’s efforts to create a
fully integrated LMIS for all commodity groups has
streamlined preparedness efforts and helps ensure
proper access to necessary care in the event of an
emergency.83
83 USAID: “Health Logistics in Tanzania: Timeline of Accomplishments for Supply Chain Interventions” (2016)

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EXPERTS CONSULTED
Organization Name
AL ANaid Kathy Fulton
Bill and Melinda Gates Foundation Prashant Yadav
CDC Michael Ayers
CDC Tom Jackson
FAO Severin Loul
GHSA Olga Bassong
Harvard Humanitarian Initiative Dr. Stephanie Kayden
IFRC Amanda McClellan
IMC John McGhie
MIT Jarrod Goentzel
MSF Stefaan Phlips
Liberia Public Procurement and Concessions Commission James Dorbor Jallah
OFDA Linda Mobula
OFDA Robert Sepe
OFDA Giselle Zimmerman
PSCN; Henry Schein Allison Neale
PSM Scott Dubin
UNICEF Stephane Arnaud
UNICEF Carol Kungu
UNICEF Jean Cedric Meeus
UNICEF Benjamin Schreiber
University of Minnesota Dr. Amy Kircher
US Dept of Health & Human Services Stephen Curren
US Dept of Health & Human Services Laura Wolf
USAID Marilyn Crane
USAID Lindsay Parish
USAID Wendy Taylor
WEF Ryan Morhard
WFP Shilpa Anjali
WFP Stephen Cahill
WFP Konjit Kidane
WFP Bruno Vandemuelebrocke
WHO Michael Griffin

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BEST PRACTICES IN SUPPLY

Executive summary .................................................................................................................................................................................................. 3

1. Landscape assessment ................................................................................................................................................................................ 6

2. Governance, financing, and personnel .......................................................................................................................................... 16

4. Emergency procurement and supply chain ............................................................................................................................... 32

Experts consulted ................................................................................................................................................................................................... 52

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 1

2 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

4 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 5

The ESC team, or in its absence the Ministry of

1 Pandemic Supply Chain Network Project: “Project Report” (2017)

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 7

8 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

Sometimes capacity can come from innovative

6 Pandemic Supply Chain Network Project: “Project Report” (2017)

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 9

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 11

12 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

14 World Health Organization, “Joint External Evaluation Tool,” (2016)

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 13

The Logistics Cluster has developed a tool for

Most governments have conducted more detailed

14 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

17 World Health Organization. “Joint External Evaluation Tool,” (2016).

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 15

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 17

18 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 19

EMERGENCY SUPPLY CHAIN The budgeting of ESC inventory and prepared-

20 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 21

22 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

Develop trainings and simulations to An effective emergency preparedness training pro-

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 23

Incorporating lessons learned

28 Pandemic Supply Chain Network. “Project Report,” (2017). pg 76

24 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

29 World Health Organization. “Joint External Evaluation Tool,” (2016), pg 64

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 25

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 27

28 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 29

37 Center for Disease Control. “Preparing Global Responders,” (2017) https://www.cdc.gov/phpr/stockpile/ghsastockpilesupport.htm

30 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

40 Pandemic Supply Chain Network. “Project Report,” (2017). Pg 75

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 31

46 Pandemic Supply Chain Network. “Project Report,” (2017). Pg 119

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 33

34 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT 35

Regional variation: Commodity demands can vary

36 BEST PRACTICES IN EMERGENCY SUPPLY CHAIN MANAGEMENT

Identifying sources of supplies