to facilitate effective operation of the MDR TB SLD supply chain. The question of structure and governance to oversee this particular supply chain was, in turn, informed by a discussion among workshop participants about the extent to which the SLD supply chain shares characteristics of other supply chains. This discussion was framed by Salmaan Keshavjee, Harvard Medical School, who remarked that notwithstanding similar challenges (e.g., manufacturing complexity, limited market size, supply chain and access problems), strategies applied to other markets to improve their systems do not seem to work in the MDR TB context.

Olusoji Adeyi, World Bank, and several others expressed skepticism that the MDR TB market is in fact unique, arguing instead that more precise definition of the specific problems in the market could aid development of effective solutions. Other participants offered thoughts on ways that the MDR TB SLD supply chain could be viewed as unique. David Ripin, CHAI, noted that the MDR TB market faces a unique type of fragmentation among customers because the middle-income countries that represent large portions of demand are more difficult to aggregate effectively than, for example, the pediatric HIV market.

Nina Schwalbe, GAVI, suggested that the crux of the difference between MDR TB and other markets is its organizational and institutional establishment, which, she argued, needs significant restructuring. She cautioned that internal politics among the key players in the existing supply chain could impede effective reform and exhorted workshop participants to address and resolve those issues. Keshavjee added that complications and barriers that arise out of the present structural configuration of the supply chain justify the need for restructuring. He maintained that effective restructuring needs to be prefaced by properly examining and aligning the interests of all parties involved in the current system of SLD procurement. Amy Bloom, Acting Chief, Infectious Diseases Division, USAID, suggested that an evidence-based analysis of the hosting arrangements among GDF, the Stop-TB partnership, and WHO be conducted, noting that USAID is currently supporting such an analysis.

The remainder of this section reports individual participants’ suggestions about the issue of the responsibility and accountability for a potential restructuring.

Consideration of WHO/GDF Hosting Arrangements

Participants considered the implications of GDF being hosted by WHO and the potential consequences of GDF’s removal from WHO. In this discussion, individual perspectives were offered on the structural advantages and disadvantages of having a centralized supply chain mechanism like GDF, successes achieved by GDF, and needs for improvement if the centralized



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