Collaborating with Karuna Trust

Activists have been strengthening communities and improving Karnataka’s public health system for decades. Now Logistimo has entered the story, leveraging technology to better empower those leaders. We see this as just the beginning of a new chapter. As with all positive sustainable change, getting it right, and ensuring it persists, takes time. Since we’ve been working on this for over a year, we thought it would be a good time to start sharing…

Karnataka context

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Karnataka is a southern Indian state steeped in a rich and complex history, scattered with the ruins of ancient and medieval capitals – the dynastic remains of the Kadamba and Chalukya to Vijayanagar and Adil Shahi. She boasts an extraordinarily diverse terrain – a long coastline on the Arabian Sea, stretching across the thickly forested and bio-diverse Western Ghat range, through the lush Malnad, and onto the increasingly arid Deccan plateau. The folks you encounter from village to village are warm, welcoming, and resilient.

Home to more than 60 million people representing roughly 4% of India’s citizenry, Karnataka’s population is comparable to Italy or Thailand. Reflecting the diverse ecology and history of the region, she contains some of the most socioeconomically developed districts of India (with respect to literacy and other human development indices), as well as a few below the national average. 23.6% of Karnataka’s population falls below the poverty line – for rural dwellers, this means earning less than USD $7.50 per month.

In 2011, Maternal Mortality Ratio stood at 178 per 100,000 live births (MMR measures number of women aged 15-49 years dying due to maternal causes), and the Infant Mortality Rate (number of deaths of children less than one year of age) was measured at 35 per 1000 live births – ranking 19th in India. Among those that survive, 40% of children under 3 years of age are underweight or stunted. Yet, Karnataka ranks 7th in India with respect to life expectancy at birth (67.9 years), just above the national average (65.5 years).

Karnataka is not just an exotic place – its also home to Logistimo. There are clearly many problems to solve in our backyard.

Why supply chains matter

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Rural health system performance across the state depends partly on strong supply chains – to ensure medicines and supplies are reliably available at the point-of-care, exactly when needed. Today logistics is constrained by lack of real‐time visibility of inventory and demand across the network – these data are essential for appropriate decision making at all levels of the value chain. But minimal connectivity with remote sub-centers and only periodic visibility of primary health center (PHC) conditions limit the efficacy of the system – culminating in unreliable availability of medicines, excessive waste and underserved communities.

Ground realities also contribute to this – poor road infrastructure means long delivery lead times, the absence of computerized systems result in major information delays, and people generally operate without deep visibility into what else is happening along the supply channel. These obstacles magnify uncertainty, and manifest boom & bust cycles of stock availability – or what operations researchers call the “bullwhip effect“.

Karnataka’s State Government has begun to step in the right direction. The official policy is to establish 1 PHC for every 20,000 to 30,000 people (rural and urban contexts respectfully) , and approximately 6 sub‐centers for each PHC. Today there are over 2000 PHCs in Karnataka, and the government is busy establishing more. This will improve geographic proximity to underserved communities.

Yet these health facilities – especially rural PHCs and sub-centers – find it difficult to maintain appropriate staff (of doctors, nurses and pharmacists). Such constraints to human resources, plus the inherent disconnectedness to urban hubs, create a challenge to adequately stocking medicines and other consumable items at the point-of-care. This is not a unique problem – across the developing world, public health logistics remains a challenge; it has been deeply researched at universities, and it remains a focal point of advocacy and development aid .

These harmful conditions plague practically all verticals of the health system; including vaccines, essential medicines, malaria, HIV, tuberculosis, emergency drugs, diagnostics, family planning & reproductive health commodities. To alleviate these problems and to properly inform upstream decision‐making, quality data must be shared through reliable coordination mechanisms. Yet electricity is periodic, wired- and wireless- networks are unreliable, human resources are scarce, and roads are long and bumpy. Coordinating agile and efficient logistics in these environments requires a novel approach.

How Logistimo helps Karuna Trust

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In May 2012 the Bill & Melinda Gates Foundation sponsored Logistimo to raise the bar of vaccine supply chain performance through Grand Challenge Explorations. They focus on immunization because preventing diseases is the most powerful investment in the health system. The Foundation wanted to test if our agile mobile & cloud platform could create appropriate information symmetry to improve the operational and tactical decisions that health workers face – thereby improving vaccine availability, expanding immunization coverage, and reducing wastage.

We saw this as an opportunity to put Karnataka on the cutting edge of last-mile vaccine logistics. But we realized early that it would be impossible without the help of folks deeply embedded in the health system. We were lucky to meet Dr. H. Sudarshan, a high‐profile tribal rights activist, seasoned social worker, clinician, and winner of the Padma Shri award. In 1981 he founded Vivekananda Girijana Kalyana Kendra (VGKK) to work with the Soliga Tribals, and established Karuna Trust in 1986 to expand their activities in integrated rural development. He views health as an integral part of socio-economic development. Their proven approach is to integrate preventive, promotive, curative and rehabilitative health services. Moreover, Dr. Sudarshan stands firmly by principles of equal distribution, community participation, and making health services accessible and available to people universally. Those principles resonated with our mission, so the partnership between Logistimo and Karuna Trust was born.

Karuna Trust manages 65 PHCs across Karnataka, Odisha, Arunachal Pradesh, Meghalaya and Manipur.  Of these, 29 PHCs are in Karnataka – one in each district – through a public-private partnership (PPP) with the Department of Health and Family Welfare. Logistimo was initially deployed in July 2012 across the 29 Karnataka PHCs, and also at the headquarters in Bangalore, to better manage 8 vaccines – Bacillus Calmette‐Guerin (BCG), Diphtheria, Pertussis and Tetanus (DPT), Japanese Encephalitis (JE), Tetanus Toxoid (TT), Hepatitis B Vaccine, Measles Vaccine, Rabies Vaccine and Polio Vaccine; and later they added Pentavalent Vaccine. The aims of the deployment were these:

    • Real‐time visibility of stocks, consumption & demands at all facilities
    • Logistical agility via enhanced coordination between district health office (DHO), supervisors, pharmacists and other health workers
    • Data‐driven decision support extended to all participants through SMS alerts and other notification channels
    • To ultimately ensure reliable availability of vaccines, essential medicines, and other health commodities at the point‐of‐care.

What happened next was a pleasant surprise. The pharmacists and supervisors liked it because it empowered them to do their jobs better, and to monitor the workforce in realtime. They asked to expand the use of Logistimo across as many items, facilities and activities as possible. Today Karuna Trust uses Logistimo across 29 PHCs to manage 135 items – including vaccines, essential medicines, emergency drugs, diagnostic kits, surgical items, tuberculosis drugs, mental health drugs, family planning & reproductive health commodities.

Armed with evidence accumulated from the experience, Dr. Sudrashan’s powerful support, and explicit approval from the Karnataka Department of Health and Family Welfare – we got an opportunity to partner with Chamarajanagar District Health Office (DHO) to implement the system in March 2013 across 104 facilities – PHCs, community health centers (CHCs), mobile immunization units, hospitals, hospital departments, stockrooms, and taluk health offices (THOs) – covering every single public health facility for this rural, tribal and naxal district. Chamarajanagar facilities manage 140 items of the same categories described above.

Emerging impacts

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Today there have been over 250,000 transactions and events triggered through the platform, and user adoption continues to grow and improve. This presents a robust dataset to explore for insights on the nature of these rural supply chains, and deeper understanding of how to improve logistics.

From what we have observed, many PHCs do not yet have adequate or timely stock of vaccines and medicines. Materials frequently stock-out, leading to poor treatment. It appears the problem mostly stems from [a] inaccurate procurement at the central-level, [b] reactionary delivery patterns, and [c] insufficient staffing at rural PHCs, diminishing visibility of PHC conditions for upstream decision making. However, these challenges are surmountable if appropriate systems are in place.

The quality of data coming from pharmacists is of course crucial to making the best decisions. We’ve seen strong data entry behaviors from the majority of pharmacists, especially when there is careful supervision in the early stages of adoption. Achieving strong data quality across all pharmacists with minimal supervision remains an important challenge. Users typically report heavy workloads and lack of network infrastructure – obstacles we have addressed in the platform design. Despite the obstacles, Karnataka health workers have often gone out of their way to achieve health-related goals. This gives us confidence in achieving universal data quality and optimal stock management over the next several months.

Many overarching improvements are already surfacing. Across the total 133 sites and roughly 150 health commodities, responsiveness to bottlenecks (stock-outs, or dangerous level stocks) have improved more than 10-fold, and vaccine availability hovers around 94%. Although these are self-reported numbers, in the section below you will read about the independent 3rd party who is rigorously auditing and evaluating the impacts.

What does it all mean for mothers and children? Vaccines and medicines are becoming reliably available when they visit government health centers – and this translates into better treatment and prospects for life.

What comes next

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Our clients continue to expand their use of Logistimo across various dimensions. They continue to broaden the scope of items being managed on the platform, they continue to expand geographically to more facilities, and they continue to avail more useful functions. The roadmap for the next 3 months includes geo-tracking of all mobile health units (using GPS devices inside tablet computers), expansion to 9 Arunachal Pradesh PHCs, and training users to enter indents (orders) at the PHC-level so that fulfillment accuracy by upstream warehouses can be monitored (and this will perhaps better inform central procurement).

Dr. Sudarshan has also approved a radically progressive concept: absolute transparency. In the next several weeks, Karuna Trust will share publicly all inventory and logistics events at every PHC managed by Karuna Trust. It is only a matter of time before citizens begin using that information to plan PHC visits, which are sometimes far away from them.

Towards gathering evidence, we have partnered with Dr. Prashant Yadav of the William Davidson Institute at the University of Michigan to research what is happening. Dr. Yadav is a thought-leader in the sphere of pharmaceutical supply chains in the developing world, and is best positioned to ask pertinent questions and draw insights that would inform policymakers in India and beyond. His team have begun their own journey to examine the data. What they learn will likely reveal itself after months, and take even longer to be peer-reviewed and published. This effort will surface benchmarks about the performance of Karnataka’s healthcare supply chain, and also to help us understand the impact Logistimo might be making.

Provided the impact evidence is strongly positive, we’ll aim to win the support of National Rural Health Mission (NRHM) to expand usage across the whole of Karnataka. Towards evolving the technology towards social engagement and self-governance for health workers, we will also persuade the Bill & Melinda Gates Foundation to continue their generous investments for this program.

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Stay tuned for updates!