Thoughts from the Last Mile Welcome to the VillageReach Blog
04.28 2015

Five Lessons For Closing the Immunization Gap

For the last fifteen years, VillageReach has been working to help ensure all children have access to vaccines. I have had the opportunity to spend time in rural health facilities across sub-Saharan Africa, talk with hundreds of healthcare workers, and meet with numerous leaders of health ministries. Through our daily interactions with health workers and government partners, I’ve seen first-hand the challenges to achieving immunization equity, especially as new vaccines are being added to already strained systems.

Following are five important lessons I’ve learned which I believe will help close the immunization gap:

1. Guesswork can be minimized through modeling
A new refrigerator here, a new warehouse location there… tweaking immunization supply chains to improve performance and costs can be a challenge for government staff when accountability, costs, and data are widely decentralized.  Used extensively by private sector supply chains, computer simulated modeling is a low-cost, and low-risk way for the public health sector to determine how the different components of a system can be arranged to produce optimized results. We’ve found that using these tools with our ministry of health partners can help eliminate uncertainty in the face of new vaccine introductions and investment decisions. In Benin, a modeling exercise showed that the improved plan would save $500,000 in total costs while improving vaccination rates.

2. People in the right places get more vaccines to the right places 
The shortages in the health workforce – particularly in rural areas – are well known.  Yet, as a sector, we continue to push health workers to do more tasks that take health workers away from their core business of administering life-saving vaccines, treating patients, and educating the community.  Having dedicated logisticians to manage stock, distribution, and data collection allows health workers to focus on their key tasks of caring for patients. This saves money in personnel and reduces the logistics cost per dose of vaccine delivered. It alsoimproves vaccine availability.  In Mozambique, this model has decreased average stock outs to less than 3%.

Immunization Supply Chain Graphic

See the Immunization Supply Chain Infographic

3. Hidden costs can make or break the immunization supply chain
The trivial expenses we take for granted– fuel, transport fares, phone calls — add up in low-income countries.  Sometimes these costs aren’t even known because hardworking healthcare personnel step in – for instance taking the local bus to collect vaccines from the district.  Unfortunately these routine expenses are often overlooked in government budgets and not commonly covered by donors.  In many of the places where VillageReach works, only a fraction of the budgeted funds reach local governments, and even then, funding is often delayed by three or four months. Budgeting for these expenses and ensuring money is distributed in a timely way can be the difference between a closed health center and one that’s vaccinating kids every day.

4. When it comes to data, visibility and analysis are equally important
Access to data is, of course, important.  Yet in the places where VillageReach works, data are primarily managed through paper-based systems.  The need to have the right amount of data to manage health delivery and supply chain has led to a proliferation of too much data. And most of that data are not used regularly to drive decisions, inform programs, or raise questions about effectiveness or efficiency. In Mozambique, we’ve been working with local government officials to ensure that data is both available and utilized. For example, monthly review meetings discuss not just immunization system performance, but also the timeliness of vaccine distributions.  The information system is designed to provide data visibility in a way to ensure that decision-makers understand not just the data, but also the reasons behind the data.  If vaccine distributions did not happen on time, decision-makers know the reason; whether it was a lack of funds to purchase fuel, a problem with vehicles, or weather prohibiting travel or access. This ability to have and use data has been transformative to optimizing vaccine availability.

5. Maintenance Matters 
A lack of working vehicles for just one or two days can have a domino effect that causes vaccine delays of more than two weeks.  Similarly, refrigerator uptime in rural health clinics is typically less than 80%, putting vaccine quality at risk. Budgeting for spare parts and time for both preventative and corrective maintenance can ensure vehicles are up and running and increase refrigeration uptime to more than 90%, without investments in new cold chain equipment.  This focus on maintaining what’s already in place means getting quality vaccines to reach more children.

There are other, less quantifiable lessons I’ve learned, such as the benefits of having national leadership involved in prioritizing immunizations, and the importance of building trust in the health system.  But maybe the most helpful bit of knowledge I’ve gained is that no one strategy alone will close the immunization gap.  Ensuring vaccines are available at immunization posts is where VillageReach is putting its emphasis, but our efforts will only be successful when paired with innovative strategies for improving vaccine product profiles, creating demand within the community, and ensuring vaccines are affordable to low- and middle-income countries. A large number of people across countries and are designing, experimenting, innovating and simply doing their part.  I’m just proud to be one of them.

ABOUT THE AUTHOR
Emily Bancroft is Vice President at VillageReach where she is responsible for the strategy, oversight and management of all VillageReach programs.  The organization’s Final 20 Project responded to the call made by the Global Vaccine Action Plan (GVAP) to improve immunization supply chains.  In Mozambique, resources and technical assistance helped provincial governments redesign the management of their immunization supply chain leading to remarkable improvements — all without investments in new equipment. The successful results in Mozambique have provided a model for other countries and have led to improvements in other countries including Senegal, Benin, Tanzania, and Nigeria.

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