Uncovering the Drivers of Childhood Immunization Inequality with Caregivers, Community Members and Health System Stakeholders: Results from a Human-Centered Design Study in DRC, Mozambique and Nigeria.

BACKGROUND: The importance of immunization for child survival underscores the need to eliminate immunization inequalities. Few existing studies of inequalities use approaches that view the challenges and potential solutions from the perspective of caregivers. This study aimed to identify barriers and context-appropriate solutions by engaging deeply with caregivers, community members, health workers, and other health system actors through participatory action research, intersectionality, and human-centered design lenses. METHODS: This study was conducted in the Demographic Republic of Congo, Mozambique and Nigeria. Rapid qualitative research was followed by co-creation workshops with study participants to identify solutions. We analyzed the data using the UNICEF Journey to Health and Immunization Framework. RESULTS: Caregivers of zero-dose and under-immunized children faced multiple intersecting and interacting barriers related to gender, poverty, geographic access, and service experience. Immunization programs were not aligned with needs of the most vulnerable due to the sub-optimal implementation of pro-equity strategies, such as outreach vaccination. Caregivers and communities identified feasible solutions through co-creation workshops and this approach should be used whenever possible to inform local planning. CONCLUSIONS: Policymakers and managers can integrate HCD and intersectionality mindsets into existing planning and assessment processes, and focus on overcoming root causes of sub-optimal implementation.

A Tale of 2 Countries: Implementation of the Cold Chain Equipment Optimization Platform in Guinea and Kenya.

In 2016, the Gavi Cold Chain Equipment Optimization Platform (CCEOP) was approved and launched in recognition of the fact that functional cold chain equipment (CCE) is essential to strengthening vaccine supply chains and ultimately achieving Gavi's immunization equity and coverage goals. Through CCEOP, Gavi committed to investing US$250 million between 2016 and 2021 to commission CCE in more than 63,000 facilities to upgrade and expand their CCE footprint while stimulating the market to provide affordable, technologically advanced, and accessible equipment. We present case studies from Guinea and Kenya, both of which received CCEOP support, that highlight 2 ways for countries to prioritize investments and implement activities through a large funding and support mechanism. The studies explore the different ways that each country implemented CCEOP and consider how aspects of leadership and technical capacity influence country priorities and results. They also uncover key lessons on sustainability of a large immunization supply chain effort. The experiences of Guinea and Kenya can help other countries embarking on similarly large health system interventions, especially related to supply chain strengthening and immunization programs. In particular, these experiences offer important lessons in leadership, processes and systems, country ownership, technical capacity, and sustainability.

The value of tailoring vial sizes to populations and locations.

BACKGROUND: Frequently, a country will procure a single vaccine vial size, but the question remains whether tailoring the use of different size vaccine vial presentations based on populations or location characteristics within a single country could provide additional benefits, such as reducing open vial wastage (OVW) or reducing missed vaccination opportunities. METHODS: Using the Highly Extensible Resource for Modeling Supply Chains (HERMES) software, we built a simulation model of the Zambia routine vaccine supply chain. At baseline, we distributed 10-dose Measles-Rubella (MR) vials to all locations, and then distributed 5-dose and 1-dose MR vials to (1) all locations, (2) rural districts, (3) rural health facilities, (4) outreach sites, and (5) locations with average MR session sizes <5 and <10 children. We ran sensitivity on each scenario using MR vial opening thresholds of 0% and 50%, i.e. a healthcare worker opens an MR vaccine for any number of children (0%) or if at least half will be used (50%). RESULTS: Replacing 10-dose MR with 5-dose MR vials everywhere led to the largest reduction in MR OVW, saving 573,892 doses (103,161 doses with the 50% vial opening threshold) and improving MR availability by 1% (9%). This scenario, however, increased cold chain utilization and led to a 1% decrease in availability of other vaccines. Tailoring 5-dose MR vials to rural health facilities or based on average session size reduced cold transport constraints, increased total vaccine availability (+1%) and reduced total cost per dose administered (-$0.01) compared to baseline. CONCLUSIONS: In Zambia, tailoring 5-dose MR vials to rural health facilities or by average session size results in the highest total vaccine availability compared to all other scenarios (regardless of OVT policy) by reducing open vial wastage without increasing cold chain utilization.

System redesign of the immunization supply chain: Experiences from Benin and Mozambique.

INTRODUCTION: Evidence suggests that immunization supply chains are becoming outdated and unable to deliver needed vaccines due to growing populations and new vaccine introductions. Redesigning a supply chain could result in meeting current demands. METHODS: The Ministries of Health in Benin in Mozambique recognized known barriers to the immunization supply chain and undertook a system redesign to address those barriers. Changes were made to introduce an informed push system while consolidating storage points, introducing transport loops, and increasing human resource capacity for distribution. Evaluations were completed in each country. RESULTS: Evaluation in each country indicated improved performance of the supply chain. The Effective Vaccine Management (EVM) assessment in Benin documented notable improvements in the distribution criteria of the tool, increasing from 40% to 100% at the district level. In Mozambique, results showed reduced stockouts at health facility level from 79% at baseline to less than 1% at endline. Coverage rates of DTP3 also increased from 68.9% to 92.8%. DISCUSSION: Benin and Mozambique are undertaking system redesign in order to respond to constraints identified in the vaccine supply chain. Results and learnings show improvements in supply chain performance and make a strong case for system redesign. These countries demonstrate the feasibility of system redesign for other countries considering how to address outdated supply chains.

Re-designing the Mozambique vaccine supply chain to improve access to vaccines.

INTRODUCTION: Populations and routine childhood vaccine regimens have changed substantially since supply chains were designed in the 1980s, and introducing new vaccines during the "Decade of Vaccine" may exacerbate existing bottlenecks, further inhibiting the flow of all vaccines. METHODS: Working with the Mozambique Ministry of Health, our team implemented a new process that integrated HERMES computational simulation modeling and on-the-ground implementers to evaluate and improve the Mozambique vaccine supply chain using a system-re-design that integrated new supply chain structures, information technology, equipment, personnel, and policies. RESULTS: The alternative system design raised vaccine availability (from 66% to 93% in Gaza; from 76% to 84% in Cabo Delgado) and reduced the logistics cost per dose administered (from $0.53 to $0.32 in Gaza; from $0.38 to $0.24 in Cabo Delgado) as compared to the multi-tiered system under the current EPI. The alternative system also produced higher availability at lower costs after new vaccine introductions. Since reviewing scenarios modeling deliveries every two months in the north of Gaza, the provincial directorate has decided to pilot this approach diverging from decades of policies dictating monthly deliveries. DISCUSSION: Re-design improved not only supply chain efficacy but also efficiency, important since resources to deliver vaccines are limited. The Mozambique experience and process can serve as a model for other countries during the Decade of Vaccines. For the Decade of Vaccines, getting vaccines at affordable prices to the market is not enough. Vaccines must reach the population to be successful.