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Research
How coping can hide larger systems problems: the routine immunisation supply chain in Bihar, India
  1. Bruce Y Lee1,2,
  2. Patrick T Wedlock1,2,
  3. Elizabeth A Mitgang1,2,
  4. Sarah N Cox1,2,
  5. Leila A Haidari2,3,
  6. Manoja K Das4,
  7. Srihari Dutta5,
  8. Bhrigu Kapuria6,
  9. Shawn T Brown3,7
  1. 1Global Obesity Prevention Center (GOPC), Johns Hopkins University, Baltimore, Maryland, USA
  2. 2Public Health Informatics, Computational, and Operations Research (PHICOR), Baltimore, Maryland and New York City, New York, USA
  3. 3HERMES Logistics Team, Pittsburgh, Pennsylvania and Baltimore, Maryland, USA
  4. 4INCLEN Trust International, New Delhi, India
  5. 5UNICEF India, New Delhi, India
  6. 6UNICEF Regional Office for South Asia, Kathmandu, Nepal
  7. 7McGill Center for Integrative Neuroscience, McGill University, Montreal, Quebec, Canada
  1. Correspondence to Dr Bruce Y Lee; bruceleemdmba{at}gmail.com

Abstract

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

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

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

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

  • health systems
  • vaccines

This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.

https://doi.org/10.1136/bmjgh-2019-001609

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    Footnotes

    • Handling editor Stephanie M Topp

    • Contributors BYL and STB conceptualised the study and wrote the draft report. PTW, EAM, SNC and LAH conducted the simulations and analyses, managed the data, and wrote and critically revised the draft report. MKD, SD and BK collected data and critically revised the draft report.

    • Funding This work was supported by the Bill and Melinda Gates Foundation, the Agency for Healthcare Research and Quality (AHRQ) via grant R01HS023317, USAID System and Complexity Monitoring, Evaluation, Research, and Learning (System and Complexity MERL) via AID-OAA-A-15-00064, and the Global Obesity Prevention Center (GOPC) at Johns Hopkins and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) via grant U01HD086861 and 5R01HD086013-02 and NICHD and the Office of the Director, National Institutes of Health (OD) under award number U54HD070725. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

    • Competing interests None declared.

    • Patient consent for publication Not required.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.