Understanding and addressing contraceptive stockouts to increase family planning access and uptake in Senegal.

BACKGROUND: Senegal's government has pledged to reduce contraceptive stockouts, which have been frequent in public sector health facilities. An innovative distribution system called the Informed Push Model (IPM) addresses supply chain obstacles through direct regional-to-facility delivery of contraceptives and use of private sector logistics operators. Following promising pilot results, Senegal's Ministry of Health and Social Action committed to a three-year (2013-2016) expansion of IPM to all public health facilities nationwide. METHODS: From August 2014-July 2016, IPM's six logisticians made 29,319 visits to restock public sector health facilities. During these regular facility visits, the logisticians conducted a physical inventory to flag contraceptive stockouts (no usable stock of any single method available) and asked facility staff to identify the primary reason for documented stockouts. Our descriptive study examines stockout trends over the course of IPM scale-up. We also describe trends in contraceptive consumption over the three-year period using facility-level data collected by the logisticians. RESULTS: Contraceptive consumption rose by 91% over 35 months in the first three IPM regions, and by 118% in the next five regions (over 26 months). After scale-up to 1,394 health facilities, nationwide consumption rose by 48% over one year. On average, logisticians documented stockouts at fewer than 2% of facility visits. In comparison, two pre-IPM studies in 2011 identified stockouts of selected modern contraceptives at 60-70% of facilities visited, with 84% of clients reporting stockouts in the past year. Six factors (including consumption spikes, IPM-preventable causes, and community outreach) explained most remaining stockouts. CONCLUSIONS: IPM has been highly successful in ensuring full availability of contraceptives across regions and health facilities. The model also has facilitated the flow of essential data on consumption and stockouts from facilities up to district, regional, and central-level managers. These achievements highlight the relevance of professionalizing supply chain management while continuing to mitigate stockouts through enhanced stakeholder communication and improved training, coaching, and supervision of third-party logistics operators. Supply reliability is critical in shaping demand for and regular use of contraception. The government is transitioning the IPM to full management by the National Supply Pharmacy.

Decision making process, programmatic and logistic impact of the transition from a single-dose vial to a multi-dose vial of the 13-valent pneumococcal vaccine in Benin.

BACKGROUND: Benin, a country eligible for Gavi support, changed the presentation of the 13-valent pneumococcal vaccine (PCV13) from the single-dose vial (SDV) to the multi-dose vial (MDV). The present work aims to evaluate the process of making this decision as well as programmatic and logistic impacts. METHODS: WHO protocol for post-introduction evaluation (PIE) was used. Programmatic impact was evaluated by comparing PCV13 coverage and dropout rates with a comparator vaccine administered simultaneously over similar 6-month periods prior to and after the transition. This impact was also appreciated from observation of multi-dose vial management practices during immunization sessions. Logistic impact was measured from the analysis of storage capacities, waste management and vaccine losses. RESULTS: Decision to move to PCV13 MDV was taken at EPI level. Activities planned to support this switch were partially implemented. Impact on vaccination coverage and PCV13 dropout rates in relation with the transition to PCV13 MDV was not detected. The study found that 63% of the health staff surveyed knew and applied WHO's multidose vial policy (MDVP). Vaccines opened vials were found in 83% of health facilities visited. PCV13 MDV (37%) was one of the 3 main vaccines found with open vials in health facility refrigerators. Vaccination risky practices were observed during immunization sessions in 83% of health facilities. The main risky practice was the lack of indication of the date and hour of opening vials (56%). There was a reduction of the volume occupied by vaccines at central store by 47%. Net storage volume per fully immunized child (FIC) decreased from 69.5 to 41 m3. PCV13 MDV allows for 40% reduction in the amount of waste produced by vaccination. PCV13 open vial loss rate has increased from 3 to 7%. CONCLUSION: Benin's experience in transition to an MDV presentation of PCV13 reveals the need for better preparation and planning.

Interventions to increase the distribution of vaccines in Sub-Saharan Africa: a scoping review.

Achieving universal access to immunization, as envisioned in the global vaccine action plan continues to be a challenge for many countries in Sub-Saharan Africa. Weak immunization supply chain (iSC) has widely been recognized as a key barrier, hindering progress towards vaccination targets in this region. These iSCs, which were designed in the 1980s, have become increasing fragile and are now considered outdated. The objective of this review was to assess the effectiveness of system redesign and outsourcing to improve outdated iSC systems in sub-Saharan Africa. We searched the following electronic databases from January 2007 to December 2017: Medline, EMBASE (Excerpta Medica Database), the Cochrane Library, Google Scholar, CINAHL (Cumulative Index to Nursing and Allied Health Literature), WHOLIS (World Health Organization Library Database), LILACS (Latin American and Caribbean Literature on Health Sciences) and contacted experts in the field. Our search strategy yielded 80 records and after assessment for eligibility, seven papers met the inclusion criteria. Five studies evaluated the experiences of system redesign in three countries (Nigeria, Benin and Mozambique), two assessed outsourcing vaccine logistics to the private sector in Nigeria and South Africa. According to these studies, system redesign improved vaccine availability at service delivery points and reduce the cost of distributing vaccines. Similarly, outsourcing vaccine logistics to the private sector reduced the cost of vaccines distribution and improve vaccine availability at service delivery points.

When technical achievements aren't enough: Lessons learned from efforts to catalyze policy action on supply chain in Senegal.

Before 2013, Senegal public health supply system was pull-based and fully public-run. Lengthy and recurrent stockouts of essential health products (incl. contraceptives) were the rule, not the exception as they used to strike more than 80% of public service delivery points (SDPs). Following a successful pilot in two districts in 2012, the Senegalese Ministry of Health and Social Action (MSAS) implemented the Informed Push Model (IPM) Project (2013-2016). In its first two years, IPM bridged key gaps and expanded the distribution of contraceptives by private third party logistics operators to all public SDPs in Senegal and nearly eliminated stockouts. However, the MSAS was slow to take ownership of the project. Understanding the roots of this reluctance, executing a range of targeted communication and advocacy efforts and preparing a strong transition plan are succeeding to push Government toward full ownership to enable the National Supply Pharmacy to distribute all health products going to SDPs, including vaccines, consistently with their Strategic Plan 2014-2018.

Integration of vaccine supply chains with other health commodity supply chains: a framework for decision making.

One of the primary objectives of National Immunization Programs is to strengthen and optimize immunization supply chains so that vaccines are delivered to the end recipients effectively, efficiently and sustainably. As a result of larger investments in global health and a wider portfolio of vaccines, global agencies are recognizing the need for vaccine supply chains to operate at their most optimal levels. Integration with other supply chains is often presented as a strategy to improve efficiency. However, it remains unclear if the proposed benefits from integration of vaccine supply chains with other supply chains will outweigh the costs. This paper provides a framework for deciding where such integration offers the most significant benefits. It also cautions about the pitfalls of integration as a one size fits all strategy. It also highlights the need for systematic collection of cost and efficiency data in order to understand the value of integration and other such initiatives.