Humanitarian Supply Management And Logistics In The Health Sector

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Humanitarian SupplyManagement and Logisticsin the Health SectorEmergency Preparednessand Disaster Relief ProgramDepartment of Emergency and Humanitarian ActionSustainable Development and Healthy EnvironmentsPan American Health OrganizationWashington, D.C., 2001World Health Organization

Cover photographs: PAHO/WHOPAHO Library Cataloguing in Publication Data:Pan American Health OrganizationHumanitarian supply management in logistics in the health sectorWashington, D.C.: PAHO, 2001189 p.ISBN 92 75 12375 6I. PLANNINGDISASTER EMERGENCIESEQUIPMENT AND SUPPLIESINTERNATIONAL ASSISTANCEHV553.P187 2001 Pan American Health Organization, 2001A joint publication of the Emergency Preparedness and Disaster Relief CoordinationProgram of the Pan American Health Organization (PAHO) and the Department ofEmergency and Humanitarian Action of the World Health Organization (WHO).The views expressed, the recommendations formulated, and the designationsemployed in this publication do not necessarily reflect the current policies or opinions of PAHO or WHO or of its Member States.The Pan American Health Organization and the World Health Organization welcomerequests for permission to reproduce or translate, in part or in full this publication.Applications and inquiries should be addressed to the Emergency Preparedness andDisaster Relief Coordination Program, Pan American Health Organization, 525Twenty-third Street, N.W., Washington, D.C. 20037, USA; fax: (202) 775-4578; email: publication has been made possible through the financial support of theInternational Humanitarian Assistance Division of the Canadian InternationalDevelopment Agency (IHA/CIDA), the Office of Foreign Disaster Assistance of theU.S. Agency for International Development (OFDA/AID), the Department forInternational Development of the U.K. (DFID), the Swedish InternationalDevelopment Cooperation Agency (SIDA) and the Italian Ministry of Foreign Affairs.

CONTENTSPageAcknowledgements.viiPreface .ixIntroduction.xiChapter 1 – The Context .1Disasters – General Aspects .1Main Effects of Disasters .3Chapter 2 – Logistics.9Logistics and Emergencies.9Logistics Planning and Preparedness.9Supply Chain Logistics .13Chapter 3 – Assessing Logistical and Supply Needs.15The Importance of Needs Assessment .15Assessment of Local Capacity.17Factors That May Restrict or Facilitate Relief Efforts .18Social, Environmental and Cultural Featuresof the Affected Population and Region.19Chapter 4 – Coordination .21Coordination Structures .21Cooperation Agreements .24Requests for Humanitarian Assistance .25Annex.30Chapter 5 – Key Characteristics of Emergency Supplies .35What Are Emergency Supplies? .35Categories .35Human Resources .37The Standardization of Emergency Supplies.37Hazardous Materials.38Specialized Materials.39Annex .40Chapter 6 – Procurement .43Sources and Procurement of Emergency Supplies .43Requisitions .45Sending Supplies .46iii

ivHumanitarian Supply Management and Logistics in the Health SectorAnnexes .52Chapter 7 – Receiving Supplies.55Arrival of Supplies .55Receiving International Shipments .56Receiving Local Shipments .62Annexes .64Chapter 8 – Record-Keeping, Control, and Monitoring of Supplies.69Arrival and Recording of Supplies.69Control, Monitoring, and Follow-up Systems .71Dealing with Non-Priority Items and Other Supplies .76Annex.78Chapter 9 – Storage .83Types of Warehouse .83The Choice of Storage Site.84Estimating Storage Needs and Capacity.85Alternative Storage Sites .89Staff Required .89Equipment and Material Required in the Warehouse.90Warehouse Sectors.91Storage and Internal Distribution of the Supplies.94Procedures for Arrival and Dispatch .96Control and Monitoring Systems .98Occupational Health and Safety in the Warehouse .99Maintenance and Sanitation Measures .100Hazardous Materials .101Annexes .105Chapter 10 – Transport .109Types of Transport and Their Characteristics .109Determining the Type of Transport Needed.114Vehicle Control.115Transporting Supplies.119The Transport of Hazardous Materials .120Convoys or Caravans .121Management of Air Operations .124Annexes .127

ContentsChapter 11 – Distribution .131Key Principles.131Responsibilities and Criteria for Distribution .132Distribution Systems .133Monitoring and Control .137Annexes .139Chapter 12 – Managing Medical Supplies .143Selection .143Programming Acquisitions.146Reception and Evaluation of Acquisitions.147Donations .147Storage Systems.150Controlling and Monitoring Products in the Storage Centers .153Distribution .154Discarding Pharmaceutical Products .155Annexes .156Chapter 13 – Transparency and Informationin Emergency Supply Management.159Transparency.159Information .159Chapter 14 – Telecommunications .163The Communication Strategy .163Telecommunications Systems .164Basic Procedures.167Chapter 15 – The Application of New Technologiesto Emergency Logistics.169Bar Codes .170AMS Laser Cards .172Radio Frequency Identification Tags and Labels .173References.175v

Acknowledgementshe Pan American Health Organization, Regional Office for theAmericas of the World Health Organization (PAHO/WHO) wouldlike to express their special gratitude to the chief author of thishandbook, Gerardo Quirós Cuadra, an expert on the subject and a frequent collaborator of FUNDESUMA. We would also like to thank the outstanding support provided by FUNDESUMA and the technical contributions it has made to the handbook.TOther especially significant contributions came from Dr. María MargaritaRestrepo, of the Faculty of Chemistry and Pharmacy of the University ofAntioquia, Medellín; Gérard Gómez of the Latin American EmergencyRelief Office of Médecins sans Frontières; Dr. Edgardo Acosta Nassar,Jerónimo Venegas and Víctor Martínez of FUNDESUMA; GlaucoQuesada of the German Red Cross; Alvaro Montero, consultant forUSAID/OFDA and FUNDESUMA; John Price II of the U.S. DefenseLogistics Agency; and Sandra Salazar Vindas. Their suggestions, recommendations, documentary contributions and conceptual support havemade it possible to offer a more comprehensive approach to the subjectscovered in the book.The first draft of this work was widely disseminated among logistics andsupply management organizations and experts around the world.Hundreds of comments were received and taken into account in the finalversion of the text. We wish to recognize all those individuals who, in apersonal capacity or in the name of the organizations they work for,made valuable suggestions and comments that have enriched this effort.They include Katarina Toll, Isabelle Demuyser-Boucher, GerhardPutnam-Cramer, and Hans Zimmerman of the U.N. Office for theCoordination of Humanitarian Affairs (OCHA); Rod McKinnon, ofEmergency Management Australia; Gregorio Gutiérrez, Project Impact,the Dominican Republic; Luis Campos Cerda and Luis Felipe PuelmaCalvo, Emergency and Disaster Program of Maule, Chile; G. Kipor, AllRussian Center for Disaster Medicine; Sonja Nieuwejaar of the U.S.Federal Emergency Management Agency (FEMA); Alfonso Vaca Perillaof Colombia’s Civil Defense; Luis Wintergest Toledo of Mexico’s CivilProtection Agency; Javier Olaya of the Colombian Red Cross; Steven DeVrient of PAHO/WHO Nicaragua; the Nicaraguan Red Cross; AlessandroLoretti of WHO; Martin E. Silverstein of the Uniformed ServicesUniversity of Sciences; Peter Manfield of Cambridge University; Judithvii

viiiHumanitarian Supply Management and Logistics in the Health SectorThimke of the World Food Program; Róger Barrios Chica of theUniversidad Nacional Autónoma of León, Nicaragua; José GómezMoncada; Tony Joe; Raúl Talavera Benavente and Vicente Bruneti.Many others enriched this text with their commentaries and recommendations. To all of them, our thanks.

Prefacemergencies and disasters place exceptional demands on the logistical and organizational skills of the affected country. This challenge is felt with particular intensity in the health sector, wheredeficiencies in the flow of supplies may have dire consequences. Theproblem does not merely lie in the procurement of emergency goods andequipment. Special attention must also be paid to the management ofthose supplies already at hand or in the pipeline. Supplies may be pilingup at the central level while acute shortages are painfully evident at theemergency site. Unsolicited—and often inappropriate—donations alsocompete for storage and transport facilities that may be in short supply.EHumanitarian personnel may be unfamiliar with standard accountingand stock-control procedures. Alternatively, these procedures may beoverlooked under the pressure of the emergency. Accountability and athorough paper trail are likely to fail at exactly the moment when themass media are most eager to find evidence of misappropriation ofexternal assistance, and thus perpetuate the myth of local incompetenceor, worse still, corruption.Since the publication in 1983 of PAHO’s handbook, Medical SupplyManagement after Natural Disasters, and particularly over the lastdecade, considerable progress has been made worldwide toward theeffective management of humanitarian supplies, proper accountability,and greater transparency. The development by the Pan American HealthOrganization of the SUMA emergency supply management methodologyhas helped to place the effective and accountable control of the supplychain high on the list of priorities of both governments and nongovernmental organizations.This handbook aims to present the most basic concepts of humanitariansupply management and logistics. Although the handling of medical andpharmaceutical supplies is given special attention, the logistics principlesdescribed here have multisectoral applications, not only in emergencysituations, but also in the day-to-day operations that must be a part ofdisaster prevention and preparedness.ix

xHumanitarian Supply Management and Logistics in the Health SectorThroughout this manual, a basic premise is maintained: that disastermanagement is primarily a national responsibility. While the massiveinflow of donations may occasionally exceed the capacity of the affected country to absorb them, the most effective and appropriate responseby the international community and humanitarian organizations is tocontribute to capacity building at the national level. This manual isdirected at those who are locally responsible for managing the flow ofsupplies and ensuring the timely delivery of emergency supplies to disaster victims—from civil protection experts to custom officers, and fromministry of health and social security professionals to the dedicated volunteers of humanitarian organizations.It is our hope that this publication will contribute to greater effectiveness and accountability in the process of providing humanitarian assistance to the victims of disasters, and therefore to more equitable accessto health by the affected population.Dr. Claude de Ville de GoyetChief, Program on Emergency Preparednessand Disaster Relief,Pan American Health OrganizationWashington, D,C.

Introductionrocurement, storage, mobilization, distribution—these and otheraspects of providing material assistance to people affected by disasters, and the handling of those supplies employed by relieforganizations in their aid operations, require an organizational structureto ensure the efficient management and utilization of resources that inemergency situations, almost by definition, tend to be limited.PThis structure is provided by logistics, the art or strategy of achievingpractical objectives as promptly and methodically as possible while making the most effective use of available resources.Two basic premises are addressed in this handbook:1.Humanitarian supply logistics cannot be improvised at the time ofthe emergency. Countries and organizations must see it as a cornerstone of emergency planning and preparedness efforts. Employingresources appropriately, and being able to secure those that are notat hand, depends on first identifying their availability and location,as well as the sources for obtaining them. All those activitiesdemanded by logistical deployment during an emergency—themechanisms for standardizing the various processes and all the necessary documents for recording information and controlling, monitoring and following up on the flow of supplies—must be prepared,understood, and tested in advance.2.The various stages in the flow of supplies from their point of originto the moment they reach their recipients—whether they be theorganizations managing the emergency or the actual beneficiaries ofthe assistance—are a chain made up of very close links. How any oneof these links is managed invariably affects the others. Supply management must therefore be the focus of an integral approach thatlooks at all the links in the sequence and never loses sight of theirinterdependence. This is known as supply chain logistics.This handbook is intended as a guide to certain basic aspects of emergency supply logistics and as reference material for all those involved inxi

xiiHumanitarian Supply Management and Logistics in the Health Sectorthe management of humanitarian supplies. It describes a series of procedures for the correct handling of supplies at each of the stages of thelogistics chain. Some of these procedures reflect the standards of international organizations involved in disaster response. Many others, however, are the distillation of concrete experiences by those in the field.While no guidelines can be universally applicable, the techniques andprocedures proposed here should be of some value in almost all circumstances involving emergency operations.The manual is aimed at all those who work in emergency management,whether government officials or members of nongovernmental organizations; the procedures outlined should be applicable in both cases. Thecontent has been organized in such a way that those who are alreadyexperts in the field can use it as reference material, while those who wishto learn about the subject will find a systematic presentation of the mostrelevant aspects of the logistics of managing humanitarian supplies.This is a new contribution by the Pan American Health Organization andthe World Health Organization to national efforts to strengthen operational capacity, particularly in those aspects related to the managementof humanitarian assistance. It expands and updates information inPAHO/WHO’s Scientific Publication Medical Supply Management afterNatural Disasters (1983).

Chapter 11The Contexthe purpose of this chapter is to provide a general context for themost common scenarios that would call for an intervention byhumanitarian organizations, as well as for those recurring conditions in which these organizations must act to meet the needs of the victims of disasters.TDisasters – General AspectsThe term “disaster” is usually applied to a breakdown in the normalfunctioning of a community that has a significant adverse impact onpeople, their works, and their environment, overwhelming local responsecapacity. This situation may be the result of a natural event—say, a hurricane or earthquake—or it may be the result of human activity.Some organizations make a distinction between “disasters”—the result ofnatural phenomena—and “complex emergencies” that are the product ofarmed conflicts or large-scale violence and often lead to massive displacements of people, famine, and outflows of refugees. Examples wouldinclude the Balkan crisis, the Ethiopian, Somali and Sudanese famines,the genocide in Rwanda and the violence in East Timor.Each disaster is unique—its effects not only have to do with the type ofnatural or man-made phenomenon, but also with the economic, health,and social conditions of the area. However, there are common features,and identifying them can help improve the management of humanitarian assistance and the use of resources. The following aspects should betaken into account when considering the nature of a disaster (see alsoTable 1.1):1.1There is a correlation between the type of disaster and its impact onhealth, particularly the occurrence of injuries. For instance, earth-This chapter was originally written by Dr. Edgardo Acosta Nassar and partially modified to meet theneeds of this handbook. Dr. Acosta is Executive Director of FUNDESUMA, a foundation dedicated tomaintaining and disseminating the SUMA humanitarian supply management methodology. Dr. Acostahas extensive international experience in disaster preparedness and management.1

2Humanitarian Supply Management and Logistics in the Health Sectorquakes cause many traumas that demand medical attention, whilefloods tend to produce relatively few injuries;2.Some of a disaster’s effects do not have an immediate impact onpublic health, but pose a potential threat. Population displacementsand environmental changes may increase the risk of a spread incommunicable diseases. In general, though, epidemics are notcaused by natural disasters;3.Immediate and potential health hazards in the aftermath of a disaster seldom materialize simultaneously; they tend to strike at different times, and with variable intensity within the affected area. Thus,injuries tend to happen at the time and place of the impact, demanding immediate medical attention, while the risk of an increase incommunicable diseases evolves more slowly and reaches maximumintensity with overcrowding and breakdowns in hygiene;4.After a disaster, the need for food, clothing, shelter, and primaryhealth care is rarely absolute; even the displaced often have theresources to satisfy some of their own basic needs. Moreover, it iscommon for the victims of a disaster to recover quickly from the initial shock and participate spontaneously in search and rescue effortsand other relief initiatives, such as the storage and distribution ofemergency supplies;5.Wars and civil conflicts generate a particular set of health problemsand operational obstacles. Overcoming them requires dealing withmany political, social, ethnic and geographical issues.Effective humanitarian relief management is based on anticipating problems and identifying them as they arise, and providing specific suppliesat the right time where they are most needed.

Chapter 1: The contextMain Effects of DisastersThe various effects of disasters on the population and its surroundingsgenerate different kinds of needs and require different approaches tomeet those needs. It is therefore important to have a general sense ofwhat these effects are, and which systems are most commonly affected.However, experience shows that the effects in question cannot be takenas absolutes, since the impact and form a disaster takes depends on thespecifics of the affected region. Bearing this in mind, the following is anoverview of some basic characteristics of these effects.Social ReactionsThe behavior of disaster victims rarely explodes into general panic orsinks into stunned apathy. After the initial shock, people tend to startacting positively to meet well-defined personal goals, leading to anincrease in individual activities that, in spite of being spontaneous,quickly self-organize into collective endeavors. Earthquake survivors, forinstance, are usually the first to engage in search and rescue efforts,often within minutes of the impact; in a matter of hours, self-organizedgroups have already assigned themselves specific tasks that play a keyrole in relief and recovery.It is only in exceptional circumstances that actively antisocial behaviorsuch as looting takes place. However, sometimes individuals’ spontaneous reactions, while perfectly rational from the point of view of selfinterest, can prove detrimental to the community as a whole, as whenpublic utility employees do not show up at the workplace until they havetaken steps to ensure the safety of their family and possessions.Since rumors abound after a disaster, especially concerning epidemics,the authorities may face tremendous pressure to adopt emergency measures, such as massive vaccination campaigns against typhoid or cholera,without there being solid public health evidence for doing so. Moreover,many people are reluctant to apply the measures considered necessaryby the authorities.After an early warning has been issued concerning a major risk, andeven after a disaster has actually taken place, many are reluctant to be3

4Humanitarian Supply Management and Logistics in the Health Sectorevacuated, although their homes may no longer be safe or, quite simply,may no longer exist.Communicable DiseasesNatural disasters do not cause massive outbreaks of infectious diseases,although in some circumstances they may increase the odds of theirspreading. In the short term, the increase in morbidity is frequently theresult of fecal contamination of drinking water and food, causing gastrointestinal diseases.The risk of epidemic outbreaks of communicable diseases is proportional to the density and displacement of the population, since these factorsdegrade living conditions and substantially increase the demand fordrinking water and food, which tend to be scarce in such circumstances.In the immediate aftermath of a disaster, the risk of contaminationgrows—as in the case of refugee camps—as existing sanitation servicessuch as water supply and sewerage systems break down and it becomesimpossible to maintain or restore public health programs.In the case of complex disasters, malnutrition, overcrowding, and thelack of basic sanitary conditions are frequent. In such circumstances,outbreaks of cholera and other diseases have occurred.Population DisplacementsWhen large population displacements take place, whether spontaneousor organized, humanitarian assistance becomes crucial—and urgent.People tend to flock to urban areas, where public services do not havethe capability to handle sudden, very large increases in the populationserved, leading to increased mortality and morbidity rates. If the disaster destroys most homes in a given area, large local “migrations” maytake place within the same urban environment, as victims look for shelter in the homes of relatives and friends.In situations in which large numbers of the population flee their homesdue to war or other forms of violence, and the threat to life is imminent,organized reactions are much less likely, since the chief priority of the

Chapter 1: The contextvictims is to get away from the danger as quickly as possible. In thesecases, the timely intervention of international aid organizations can stillmake the difference between life and death. Even so, these agencies mayfind among these populations attitudes of mutual assistance and organized response that can maximize the effectiveness of the intervention.Exposure to the ElementsHealth hazards associated with exposure to the elements are not common in temperate zones, even after a disaster, as long as the displacedare kept in dry places where they can remain sheltered from the windand cold. However, in other climates with significant extremes in temperature, whether too hot or too cold, proper shelter can be vital. Hence,the need to provide emergency shelter should not be seen as

The first draft of this work was widely disseminated among logistics and supply management organizations and experts around the world. Hundreds of comments were received and taken into account in the final version of the text. We wish to recognize all those individuals who, in a personal capacity or in the name of the organizations they work for,

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