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Vaccine Logistics and Supply Chain | ITSU

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The Immunization Supply Chain and Logistics (ISCL) systems, which were designed in the 1980s, have supported the achievement of acceptable vaccination, Vaccine Logistics & Supply chain assessment in Bihar, MP & UP. The success of global immunization since the launch of the Expanded Programme on Immunization.

Vaccine logistics & supply chain, Immunization Policies and Guidelines, Immunization Technical Support Unit, Ministry of Health and Family Welfare, UIP in India, Mission Indradhanush, MoHFW, Universal Immunization Program in India, Child Vaccination program in India, Routine Immunization Program in India, NTAGI and STSC secretariat, GAVI HSS Secretariat, National Health Mission
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Vaccine Logistics and Supply Chain | ITSU

  1. 1. Vaccines logistics and supply chain assessment in Bihar, MP and UP Diagnostic findings November 2012 ITSU - PHFI
  2. 2. Content – – – – Context & assessment design Assessment results: Severity of stock-outs Issues and root causes for stock-outs Recommendations for the States ITSU - PHFI 2
  3. 3. Context and objective of the vaccines supply chain assessment Context  Public Health Foundation of India (PHFI) and the Ministry of Health & Family Welfare have entered into an Memorandum of Understanding to implement activities to strengthen India’s  UIP/RI programme    Regular supply of vaccines (diluents and syringes) has been identified as one of the key issues impacting the Routine Immunization programme    Preliminary diagnostics on supply chain security have been conducted but gaps remain in understanding the root causes and potential solutions  Objectives of the assessment Against this backdrop, ITSU team conducted a deep-dive assessment of logistics and supply chain of vaccines and syringes in Bihar, UP and MP with the aim to:  Understand if issues exist in regular availability of vaccines, diluents or syringes to the ANMs    Understand issues in the end-to-end vaccines (with diluents and syringes) supply chain and root causes for the stock-outs  ITSU - PHFI 3
  4. 4. We selected 2-3 districts in each state for detailed visits Regional warehouse Criteria for shortlisting districts for deep-dive ▪ Combination of poor and good current BCG coverage (representative of access issue) ▪ Combination of districts which are near and far from regional warehouse ▪ Districts from different regional warehouses in the State Bihar: Jamui & Saharsa districts Madhya Pradesh: Guna & Tikamgarh districts Uttar Pradesh: Agra, Shrawasti & Allahabad districts SOURCE: Census 2011; DLHS-3 ITSU - PHFI
  5. 5. We visited all stores involved in supply chains of selected districts/blocks Bihar Madhya Pradesh Uttar Pradesh ▪ Patna ▪ Bhopal ▪ Lucknow State/ Regional ▪ Gwalior ▪ Varanasi ▪ Agra ▪ Bhagalpur ▪ - ▪ Faizabad Divisional ▪ Purnia ▪ Allahabad ▪ Jamui ▪ Guna ▪ Shravasti District ▪ Saharsa ▪ Tikamgarh ▪ Allahabad ▪ Etah ▪ Jamui-Sadar ▪ Aron ▪ Hariharpurrani Block ▪ Giddhor ▪ Beenaganj ▪ Ikauna ▪ Salkhua ▪ Niwari ▪ Koraon ▪ Simri Bakhtiyarpur ▪ Jatara ▪ Mauiama ▪ Aliganj ▪ Jalesar ITSU - PHFI 5
  6. 6. We talked to ~200 persons across Centre, suppliers and states (1/2) Centre ▪ Dr Ajay Khera (DC, CH & Immunisation) ▪ Dr Pradeep Haldar (DC, Immunisation) ▪ Dr MK Agarwal (Assistant Commissioner, Immunisation) ▪ Dr Balwinder (Senior Technical Consultant, Immunization) ▪ Mr Saumitra Sahar (Section Officer, Immunisation) ▪ Mr Paritosh Panigrahi (Cold Chain Consultant, Immunisation) ▪ Mr YK Pathak (Director, Procurement) ▪ Mr Sushil Kumar (Section Officer, Procurement) Suppliers ▪ Mr S K Bahl (Director-Business Development, Serum Institute of India) ▪ Dr Daksha Yani (Director, Green Signal Bio Pharma Ltd) ▪ Mr Jeevan Kumar (Vice President, Biological E Ltd) ▪ Mr Dheeraj M (Biological E Ltd) Partners ▪ Dr Hemant (Regional Team Leader ▪ Dr Arun Kumar (SMO-RI, Bihar) ▪ Dr Deepak Kumar (SMO,NPSP Saharsa) ▪ Dr Ujjawal Sinha (WHO/NPSP) ▪ Dr Anand SMO, Bhagalpur ▪ Dr Narendra Beena (SMO, Jamui) ▪ Dr Ravi (UNICEF) ▪ Mr Mukeshwar Rawat (State task force, UNICEF) ▪ Mr Shamik Trehan (CARE) ▪ Mr Parveen Bhalla (CARE) ▪ Mr Amit Trivedi (District Child Health Coordinator, UNICEF) ▪ Mr Vishwanath G (Consultant, UNICEF) ▪ Mr Dharmender Raghuvanshi (MCH Monitor, Guna, UNICEF) ▪ Dr Gura (State SRTL NPSP) Bihar ▪ Mr Sanjay Kumar (Executive Director, NRHM, Bihar) ▪ Dr NK Sinha (State Immunisation officer ▪ Dr MP Sharma (State cold chain officer, Bihar) ▪ Mr Ram Ratan (SPO, RI & Polio) ▪ Mr Suraj Nandan Sinha (Store keeper, PHI) ▪ 7 refrigerator mechanics ▪ Mr Abhijit Kumar (Store keeper) ▪ Dr B N Mishra (DIO, Saharsa district) ▪ Dr Anjani Kumar Sinha (Acting DIO, MOIC) ▪ Mr Ranvir (Store-keeper, Jamui district) ▪ Mr Pankaj Kumar (Data assistant, Jamui district) ▪ Mr Ajay Kumar Singh (Store-keeper, Jamui-Sadar block) ▪ Mr Promod Kumar (Cold chain officer, Saharsa district) ▪ Mr Sant Kumar (Data assistant, Saharsa district) ▪ Dr Azad Singh (CS, Saharsa district) ▪ Mr Sanjeev (Administrative Assistant to SRTL Bhagalpur) ▪ Mr James Besra (Store-keeper, Jamui-sadar block) ▪ Mr Ashok Kumar Sinha (Health Educator, Jamui-sadar block) ▪ 44 ANMs & 52 ASHAs ITSU - PHFI 6
  7. 7. We talked to ~200 persons across Centre, suppliers and states (1/2) Madhya Pradesh Uttar Pradesh ▪ Mr Santosh Shuka (Deputy Director Immunization) ▪ Dr Ashwin Bhagwat (RI Co-ordinator, UNICEF) ▪ Mr V K Srivastav (State Cold Chain officer) ▪ Mr Neeraj Shukla (Vaccine & Logistics Manager) ▪ Mr M I Qureshi (Division Technician) ▪ Neeraj Narang (Divisional Logistics Manager, Gwalior) ▪ Abhay (Store-keeper, Gwalior) ▪ Dr Nidhi (NRHM) ▪ Dr D K Bhargav (CMHO, Guna) ▪ Dr P K Sharma (DIO, Guna) ▪ Dr G B Paliwal (DPM) ▪ Dr O P Gautam (CMHO) ▪ Dr P K Jain (DIO, Tikamgarh) ▪ Chandrasekhar Tiwari (Store in-charge & Technician, Tikamgarh) ▪ Dr K K Srivastav (MOIC, Aron) ▪ Dr B S Raghuvanshi (Cold Chain and RI Ic) ▪ Mr Krishangopal Sharma (Vaccine, Cold Chain and Logistics Handler`) ▪ Mr Pradeep Sharma (Block Program Manager, Aron) ▪ Shaikh Jalaluddin (Block Medical Officer, Beenaganj) ▪ Kamlesh Kabir Panthi (Computer Assistant, Beenaganj) ▪ Mukesh Kansotiya (Cold Chain Technician, Beenaganj) ▪ Ms Pamila (BPM, NRHM, Beenaganj) ▪ Mr Raghuveer, Supervisor, Cold Chain handler ▪ Dr L C Chanderia (Block Medical Officer, Jatara) ▪ Dr Amit Chourasia (Block Immunization Officer, Jatara) ▪ Mr. Ajit Jain (Multi Purpose Worker and Cold Storage Handler, Jatara) ▪ Dr Bajpaye (Block Medical Officer, Niwari) ▪ Mithilesh Shrivastava (LHV, Niwari) ▪ No of ANMs: 15 ▪ No of vaccine couriers: 7 ▪ Dr Vedprakash (GM Immunization, NRHM) ▪ Mr Amit Kumar Ghosh (MD, NRHM) ▪ Dr Bharat Ram (AD, UIP) ▪ Dr Poornimal Verma (JD, EPI) ▪ Mr Shashank (Assistant cold chain officer, Lucknow) ▪ Mr Nigam (Store keeper State) ▪ Mr Ramesh Gupta (State Refrigerator Mechanic) ▪ Mr O P Kueeil (Admin officer, Nadarganj) ▪ Dr D K Dubey (Additional Director, Varanasi division) ▪ Mr Gupta (Operator/ Cold-chain handler, Varanasi regional store) ▪ Dr Padmakar Singh (CMO Allahabad) ▪ Capt Ashutosh Srivastav (DIO, Allahabad) ▪ Mr P K Anuragi (Cold chain handler, Allahabad district store) ▪ Mr Rajkumar (Refrigerator Mechanic, Allahabad district store) ▪ Dr A K Sing (Block Medical Officer, Koraon PHC) ▪ Mr Anurag Mishra (Cold-chain handler, Koraon PHC) ▪ Dr Ashok Singh (Store-keeper, Agra warehouse) ▪ Mr Rakesh Kumar (Cold-chain incharge, Agra warehouse) ▪ Dr Manju Sharma (CMO, Agra) ▪ CMO, Etah ▪ Cold-chain handler, Etah ▪ Store-keeper, Etah ▪ Cold-chain technician/ store-keeper, Aliganj ▪ Dr Rajesh Sharma (MOIC, Aliganj) ▪ Dr R P Gupta (CMO, Sharawasti) ▪ Dr Ashok Kumar Sant (DIO, Sharawasti) ▪ Dr Praveen (Chief Pharmacist, Shrawasti) ▪ Mr G N Yadav (DHNTC) ▪ Dr M L Verma (BMP, Hariharpurrani) ▪ Mrs Lalita Devi (LHV/ Cold-chain handler, Hariharpurrani) ▪ Mr Ramanand Prajapati (Record keeper) ▪ Dr Rajat Singh (BMO, Ikuana) ▪ Mr R K Tyagi (AD, Faizabad) ▪ Mr Jagdish Malhotra (Refrigerator Mechanic, Faizabad) ▪ Mr Vinay Kumar (WIC attendant, Faizabad) ▪ Dr Chitranshi (Joint Director) ▪ Dr V Pandey (Joint Director) ▪ Dr Padmakar Singh (CMO, Allahabad) ▪ Mr Harish Singh (Cold-chain handler, Allahabad division) ▪ Ms Sonal Rai (DHNTC) ▪ Dr U B Singh (MOIC, Suraon) ▪ Mr Pankaj Singh (Health Education Officer, Suraon) ▪ Mr Keshav Pandey (Cold-chain officer, Muaiyama) ▪ Mr Pramesh Kumar (Health Education Officer, Muaiyama) ▪ Prema Devi (LHV) ▪ 10 ANM/AWW/ASHAs ITSU - PHFI 7
  8. 8. Content – – – – Context & assessment design Assessment results: Severity of stock-outs Issues and root causes for stock-outs Recommendations for the States ITSU - PHFI 8
  9. 9. 10-15% sessions were stocked out of vaccines in Bihar & UP; tOPV most stocked out Conducted sessions in last 12 months* stocked-out of vaccine (per cent) Bihar Madhya Pradesh Uttar Pradesh Instances of ANM not taking vaccine despite vaccine being available at PHC due to lower anticipated demand at session (especially in UP) Data not NA noted * For Bihar: Apr 2011-Mar 2012 from all 4 blocks visited; For MP: Aug 2011-Aug 2012 (except for Beenaganj & Aron, it is Aug 2011-Mar 2012); MP TT stock-out data is for Aron, Jatara and Niwari blocks only; For UP, Apr 2011-Mar 2012 for Hariharpurrani & Ikuana, Oct 2011-Oct 2012 for Jalesar, Feb 2011-Jul 2012 for Aliganj, May 2011-Apr 2012 for Mauiama and Oct 2011-Mar 2012 for Koraon SOURCE: Block stock registers ITSU - PHFI 9
  10. 10. Content – – – – Context & assessment design Assessment results: Severity of stock-outs Issues and root causes for stock-outs Recommendations for the States ITSU - PHFI 10
  11. 11. Five root-causes leading to supply chain issues Four key Issues in supply chain… A. Irregular and sometimes short supply of vaccines at regional warehouses B. Poor distribution practices followed at regional/ division/ district warehouses C. High vaccine wastage at session sites D. Issues in cold-chain space and maintenance … caused by five key root-causes 1. Delay in procurement and loosely defined delivery schedule 2. Poor staffing and training of personnel involved in supply chain 3. Poor session planning and/or adherence of roster 4. Poor documentation of current stock and information sharing across levels 5. Insufficient and/or delay in release of funds ITSU - PHFI 11
  12. 12. 1. Irregular and sometimes short supply of vaccines at regional warehouses A Uneven vaccine supply to regional store: Patna example Assumptions ▪ Ideal supply calculated as total supply in the year to be distributed equally in 6 bi- monthly intervals ▪ Total supply includes opening stock in April and delivery from suppliers and GMSDs Bi-monthly supply of vaccine to Patna Lakh doses; FY12 BCG DPT TT SOURCE: PHI ITSU - PHFI 12
  13. 13. 1. Irregular and sometimes short supply of vaccines at regional warehouses A Uneven vaccine supply to regional store: Gwalior example Assumptions ▪ Ideal supply calculated as total supply in the year to be distributed equally in 6 bi- monthly intervals ▪ Total supply includes opening stock in April and delivery from suppliers and GMSDs Bi-monthly supply of vaccine to Gwalior Lakh doses; FY12 tOPV BCG TT Hep-B SOURCE: PHI ITSU - PHFI 13
  14. 14. 1. Irregular and sometimes short supply of vaccines at regional warehouses A Uneven vaccine supply to regional store: Agra example Assumptions ▪ Ideal supply calculated as total supply in the year to be distributed equally in 6 bi- monthly intervals ▪ Total supply includes opening stock in April and delivery from suppliers and GMSDs Bi-monthly supply of vaccine to Agra Lakh doses; FY12 tOPV DPT TT Measles SOURCE: PHI ITSU - PHFI 14
  15. 15. 1. Irregular and sometimes short supply of vaccines at regional warehouses A tOPV and TT supplied to Patna were 25% and 7% short of demand estimated by Centre respectively Demand and supply of vaccines to Patna from suppliers Lakh doses; FY12 tOPV TT 25% 7% SOURCE: UIP Programme division ITSU - PHFI 15
  16. 16. 1. Irregular and sometimes short supply of vaccines at regional warehouses A Hep-B supplied to Agra, Lucknow and Gwalior were 60-70% short of order placed by Centre Order placed and actual supply of Hep-B vaccine Lakh doses; Aug 2011-Jan 2012 Gwalior Lucknow Agra 63% 63% 77% SOURCE: UIP Programme division; Stock registers at Agra, Lucknow and Gwalio ITSU - PHFI 16
  17. 17. 2. Poor distribution practices followed by regional/ divisions/ districts B Issues in supply chain & distribution practices in States Supply chain structure Safety/ buffer stock Basis of distribution Pick-ups by blocks Description ▪ Instances of defined supply chain structure not being followed making demand estimation difficult ▪ Concept of safety/ buffer stock non known to most people or not being implemented ▪ Vaccines are distributed on the basis of number of beneficiaries without consideration of actual consumption/ current stock ▪ In some places, blocks distant from the district store delay pick-ups of vaccines to optimize mobility fund Examples ▪ Allahabad district takes JE and Hep- B vaccines from Lucknow and all other vaccines from Varanasi ▪ Blocks in Guna re-order when 1 week stock is remaining ▪ Observed in all 3 states ▪ - SOURCE: Interviews with supply chain personnel ITSU - PHFI 17
  18. 18. 3. High vaccine wastage at blocks and session sites C Vaccines wastage is higher than assumed in demand estimation leading to shortage of vaccines Key assumptions made by Centre in annual demand estimation ▪ Target population: – Number of beneficiaries as provided by State – Coverage as per UNICEF Coverage Evaluation Survey ▪ Wastage: 25% ▪ Buffer: 25% Wastage observed from randomly selected sessions (Percent) Bihar Madhya Pradesh Uttar Pradesh UNICEF study (42 sessions) (~180 sessions) (88 sessions) (5 states*, 2010) Data not noted * Includes Uttar Pradesh, Assam, Maharashtra, Tamil Nadu and Himachal Pradesh SOURCE: Tally sheets of ANMs; Vaccine Wastage Assessment, April 2010 (UNICEF); ITSU - PHFI 18
  19. 19. 4. Issues in cold-chain space and maintenance D Issues in cold chain space and maintenance Cold storage capacity Delay in installation Quality and maintenance of equipment Vaccine vans Store location Description ▪ Insufficient cold storage capacity to store 2-3 months on vaccines demand ▪ Equipment delivered to stores but not installed ▪ Frequent performance issues with Haier equipment and Chint stabilizers ▪ Vaccine vans are not available at all districts, or are very old ▪ Store location small, inconvenient or inappropriate Examples ▪ Patna & Purnia have WIC capacity to store only one month requirement of vaccines of state and division respectively ▪ Bhagalpur has capacity to store only half month’s tOPV requirement ▪ Bluestar WICs at Agra and Faizabad not installed for last 2 years ▪ WIC at Saharsa not installed for last 6 months ▪ Sickness rate in Guna district excluding Haier equipment is 3.9% but the same including Haier is 11.7%; ▪ Tikamgarh Haier DF installed in 2009 and has been non functional for last 6 months ▪ Shrawasti does not have a van ▪ Tyres of Faizabad division’s van are damaged and hence not functional ▪ Allahabad’s van is very old (condemned on paper) ▪ Lucknow syringes and vaccines stores are 25- 30km far, making pick-up of material difficult ▪ Tikamgarh vaccine store is located in Nurses Training Center SOURCE: Interviews with supply chain personnel; Field observations ITSU - PHFI 19
  20. 20. 4. Issues in cold-chain space and maintenance D Insufficient WIC capacity at Patna Key assumptions ▪ Storage capacity at Patna: – 3 WIC with capacity of 2.5, 2.5 and 2 lakh vial – 2 WIF with capacity of 2.5 and 1.2 lakh vial ▪ Monthly demand (as per State) estimated based on – BCG: Number of sessions planned – Other vaccines: Number of live births; 100% coverage; 33% wastage; 25% buffer ▪ Storage guidelines: – tOPV in WIF only – DPT and TT in WIC only – BCG and Measles in WIC, however can be stored in WIF if lack of space in WIC tOPV DPT, TT & Hepatitis- B BCG & Measles Cold storage capacity (actual and required) Lakh vial WIC WIF Patna has WIC capacity to store only one month’s vaccine requirement (ideally should be able to store up to 3 months requirement) SOURCE: PHI Store-keeper; SIFHW; UIP Programme division ITSU - PHFI 20
  21. 21. 4. Issues in cold-chain space and maintenance D Insufficient WIF capacity at Purnia and Bhagalpur tOPV DPT, TT & Hepatitis- B BCG & Measles Key assumptions ▪ Storage capacity at Purnia division: – 1 WIC with capacity of 1.2- 1.5 lakh vial – 1 WIF with capacity of 1.5-2 lakh vial ▪ Storage capacity at Bhagalpur: – 2 WIC with capacity of 2- 2.5 lakh vial each – 1 DF with capacity of 0.05 lakh vial ▪ Monthly demand (as per State) estimated based on – BCG: Number of sessions planned – Other vaccines: Number of live births; 100% coverage; 33% wastage; 25% buffer ▪ Storage guidelines: – tOPV in WIF only – DPT and TT in WIC only – BCG and Measles in WIC, however can be stored in WIF if lack of space in WIC Cold storage capacity (actual and required) Lakh vial WIC WIF PURNIABHAGALPUR ▪ Purnia has capacity to store two months’ vaccine requirement for the division (ideally should be able to store upto 3 months’ requirement) ▪ Bhagalpur does not WIF/DF capacity to store even one months’ tOPV requirement for the division SOURCE: PHI Store-keeper; SIFHW; UIP Programme division ITSU - PHFI 21
  22. 22. Five root-causes leading to supply chain issues Four key Issues in supply chain… A. Irregular and sometimes short supply of vaccines at regional warehouses B. Poor distribution practices followed at regional/ division/ district warehouses C. High vaccine wastage at session sites D. Issues in cold-chain space and maintenance … caused by five key root-causes 1. Delay in procurement and loosely defined delivery schedule 2. Poor staffing and training of personnel involved in supply chain 3. Poor session planning and/or adherence of roster 4. Poor documentation of current stock and information sharing across levels 5. Insufficient and/or delay in release of funds ITSU - PHFI 22
  23. 23. A. Delay in procurement and loosely defined delivery schedule 1 Delays in placing purchase orders gives insufficient lead time to suppliers, leading to erratic supply Lead time to suppliers < 90 days Percentage of total annual order placed (Lead time given to suppliers*) FY12 Jan Feb Mar Apr May Jun Jul AugSep Oct Nov Dec Jan 2011 2012 BCG 17% 37% 46% (63d) (58d) (80d) tOPV 69% 31% (162d) (72d) DPT 38% 54% 8% (60d) (162d) (54d) TT 84% 16% (85d) (53d) Measles 100% (80d) * Time between date of issuing purchase order and deadline for supplying first “lot” SOURCE: Procurement division ITSU - PHFI 23
  24. 24. A. Delay in procurement and loosely defined delivery schedule 1 Procurement has been on time in FY13 Lead time to suppliers < 90 days Percentage of total estimated demand ordered (Lead time given to suppliers*) FY13 Jan 2012 Feb Mar Apr May BCG 80% (145d) tOPV 100% (150d) DPT 46% 54% (240d) (113d) TT 76% 23% (NA) (NA) Measles 100% (146d) * Time between date of issuing purchase order and deadline for supplying first “lot” SOURCE: Procurement division ITSU - PHFI 24
  25. 25. A. Delay in procurement and loosely defined delivery schedule 1 Delivery schedule is weakly defined allowing suppliers to supply 3-4 months stock at a time (instead of desired 2 months) Delivery schedule needs to be tightly defined. Currently it allows 2 supply chain issues to occur: ▪ Supplier can supply 2 months stock in start of Aug and another 2 months stock in end of Nov causing shortage of vaccines in Oct and Nov ▪ Supplier can supply 2 months stock in end of Nov and another 2 months stock start of Dec causing cold storage capacity shortage with 4 months stock at warehouse SOURCE: Procurement division ITSU - PHFI 25
  26. 26. B. Poor staffing and training of personnel involved in supply chain 2 Manpower & training issues Lack of appropriate manpower Lack of training Examples ▪ At various places in UP, mechanics and cold chain Regional Director, who handlers were staffed through contractual staff or manages the divisional through “attached” (additional) duty and are not capable warehouse, relies on of their responsibilities: CMO’s office for hiring of – Lack technical knowledge (i.e. data to be recorded, support staff i.e. cold preventive maintenance, no temperature recording at chain handlers at Lucknow) divisional warehouse. It ▪ – No knowledge of funds/ TA/DA available often gets de-prioritized Second ANM not hired at large blocks or delayed at CMO office ▪ Of 7 mechanics in Bihar, only 1 is fully trained and capable of handling requests stand-alone; team has requested for training multiple times in past one year ▪ Technicians in MP not trained for digital and non-CFC equipment ▪ Store in-charge at blocks not trained (or monitored) for recording returned vaccines and syringes ▪ Store in-charge in all states not trained on how to distribute based on number of beneficiaries and actual consumption/current stock SOURCE: Interviews with supply chain personnel; Team analysis ITSU - PHFI 26
  27. 27. B. Poor staffing and training of personnel involved in supply chain 2 Only 30-40% supply chain personnel trained in UP and Bihar HW trained (2011, Percent) Cold chain handlers trained (2011, Percent) Medical Officers trained (2011, Percent) SOURCE: National Institute of Family & Health Welfare ITSU - PHFI 27
  28. 28. 3. Poor session planning and/or adherence of roster All three states have a high dependence on outreach sessions Place of immunization Potential reasons for high dependence on outreach  Largely rural  Demand primarily through ASHA/AWW mobilisation  People used to being serviced closer home due to polio? SOURCE: UNICEF CES 2009 survey ITSU - PHFI 28
  29. 29. 3. Poor session planning and/or adherence of roster 3 Under current guidelines, minimum wastage for outreach sessions likely to be 30-40% (up to 70% for BCG) Key assumptions in theoretical wastage assessment for Simbi Bakhtiyarpur block ▪ Assessment includes 265 villages ▪ Frequency of sessions as per MoHFW guidelines i.e. – 1 session/2 months if injection load < 25 – 1 session/month if injection load >25 & <50 – 2 sessions/month if injection load >50 – Does not factor in a compulsory session at AWC every month ▪ Injection load per infant is 11: – BCG: 1 – DPT: 4 – Measles: 1 – Hepatitis-B: 3 – TT: 2 ▪ A vial is opened for even one infant Estimated (theoretical) wastage Percent Theoretical wastage would be higher, if the guideline about a compulsory session every month at AWC is also factored in SOURCE: Immunization handbook; Team analysis ITSU - PHFI 29
  30. 30. 3. Poor session planning and/or adherence of roster 3 Moreover, ANMs are not following planning sessions as per guidelines(1/2) ANMs has visited the village once a month though micro-plan requires her to visit twice/ month ANM has visited these villages twice in 2 months whereas the micro-plan requires her to visit it once in two months Software calculates frequency of sessions for various villages PHC prepares actual schedule SOURCE: ANM Roster (Simbi Bakhtiyarpur) ITSU - PHFI 30
  31. 31. 3. Poor session planning and/or adherence of roster 3 Moreover, ANMs are not following planning sessions as per guidelines(2/2) ANM: Prema Kumari Plan made on dummy date (holidays or 4-week month not accounted for). Sessions planned for holidays are re-scheduled without proper intimation to AWC leading to poor turnout at new date An ANM is planned to conduct two sessions in different villages on same day Software calculates frequency of sessions for various villages PHC prepares actual schedule SOURCE: ANM Roster (Simbi Bakhtiyarpur) ITSU - PHFI 31
  32. 32. 4. Poor record keeping of stock and sharing across levels 4 Poor record keeping observed across states ▪ No records found for syringes or vaccines returned at block ▪ Batch number of diluents not recorded at most levels (especially on distribution vouchers) ▪ Tally sheets not being filled regularly. When filled, they are not being used to match the number of returned vials ▪ Vaccines and syringes stock data not maintained online, disabling region and district to distribute as per past consumption/ current stock Reasons for not maintaining proper records: ▪ No standard templates for data recording ▪ No standard training module for data operators and hence lack of proper training ▪ No enforcement for updating stock information in HMIS SOURCE: Team analysis ITSU - PHFI 32
  33. 33. 5. Insufficient funds and delay in release of funds 5 Insufficiency or delay in release of funds causes issues in maintaining a regular cold chain Insufficient funds Delay in release of funds Examples ▪ Divisions fuel fund – UP: No division fund at all – Bihar: Sufficient only to make one trip whereas multiple trips required because of large volumes involved ▪ Funds budgeted for Bhopal electricity and generator fuel insufficient ▪ No fund budgeted for labour to load/unload vaccines ▪ AVD stipend not sufficient for long distance session sites, especially in districts like Tikamgarh where an AVD is allocated one site only ▪ Mechanics in Patna not “excited” about outstation requests – Travel allowance: Rs 150/ day (was Rs 400/day with UNICEF) – Night stay: Rs 500/night against hotel bill; many hotels do not give bills ▪ Annual fund shortage from April-July due to delay in finalization and approval of PIP which impacts payments to AVD and ANM ▪ Electricity bill at Faizabad not paid for last 2 years (Rs 3.5 lakh) ▪ Electricity bill at Lucknow due for Rs 1.7 lakh SOURCE: Interviews with supply chain personnel; Team analysis ITSU - PHFI 33
  34. 34. 5. Insufficient funds and delay in release of funds 5 POL for vaccine delivery insufficient for divisions to pick-up vaccines for entire division from Patna ESTIMATES Assumptions Bhagalpur Purnia ▪ POL for Vaccine Delivery from State to Bhagalpur Division/ Annual: Rs 100,000 Annual: Rs 100,000 district and PHC/CHC: Monthly: Rs 8,333 Monthly: Rs 8,333 Fund available ▪ POL for vaccine delivery from Bhagalpur to PHC/CHC: – Number of blocks in the district 16 14 – Monthly budget allocated for each block Rs 300 Rs 300 – POL for vaccine delivery from district to PHC/CHC Rs 4,800 Rs 4,200 ▪ POL for vaccine delivery from Patna to division Rs 3,533 Rs 4,133 ▪ Monthly vaccine demand for division 32,563 vials 60,612 vials Fund required ▪ Banka: 7,200 vials ▪ Araria: 9.954 vials ▪ Bhagalpur: 10,756 vials ▪ Katihar: 10,882 vials ▪ Jamui: 6,232 vials ▪ Kishangarh: 5,998 vials ▪ Munger: 4,820 vials ▪ Madhepura: 7,075 vials ▪ Lakhisarai: 3,555 vials ▪ Purnnia: 11,614 vials ▪ Saharsa: 6,731 vials ▪ Supaul: 7,908 vials ▪ Number of trips required – Capacity of a van: 30,000 vials (with diluents) 30,000 vials (with diluents) 30,000 vials (with diluents) – Number of trips for vaccines pick-up 1.1* 1.1* – Number of trips for syringes pick-up 1 1 ▪ Cost of one trip – Distance between division and Patna 250 km 307 km – Per km cost of van Rs 6 Rs 6 – Round-trip cost Rs 3,000 Rs 3,000 ▪ POL for vaccine delivery from Patna to division required > Rs 6,000 > Rs 11,000 * Assumes all vaccines are available at the time when van goes for pick-up SOURCE: Team analysis ITSU - PHFI 34
  35. 35. Content – – – – Context & assessment design Assessment results: Severity of stock-outs Issues and root causes for stock-outs Recommendations for the States ITSU - PHFI 35
  36. 36. Recommendations for Bihar Manpower & 1 training 2 Lack of funds 3 Session planning 4 Cold chain equipment 5 Data recording Key issues ▪ Hire and train cold chain staff where required; training must include technical (including distribution on basis of past consumption/ current inventory) and financial aspects (i.e. funds available for various activities) ▪ Team of 7 refrigerator mechanics currently placed in Patna must all be trained and relocated to divisions (to help solve machine break-downs faster) ▪ Hire buffer ANMs to cover for absent ANMs (so that no planned sessions are cancelled/postponed) ▪ Mobility fund must be reviewed for sufficiency, especially at division level ▪ Mobility fund must be distributed amongst districts and blocks based on their distance from the warehouse (instead of current practice of distributing it equally) ▪ Explore mobility support to ref mechanics and vaccine store keepers at district level for preventive maintenance ▪ MOIC must support ANMs in making micro-plans and improve session planning such that: – ANMs conduct vaccination sessions at villages/sites as per frequency recommended by guidelines based on injection load – No ANM conducts more than one session in a day – Micro-plan is planned on actual calendar dates so that holidays (and other foreseeable events i.e. polio campaigns) are accounted for ▪ Order and install new WIC capacity at Patna and WIF/DF at Bhagalpur ▪ Cold chain in-charges be trained to record batch number of diluents, syringes received/distributed and vaccines returned from outreach sessions ▪ All stock data must be entered in an online system .Visibility into stock information at higher level will help in raising indents and at lower level will help in allocation of stock SOURCE: Team analysis ITSU - PHFI 36
  37. 37. Recommendations for Madhya Pradesh Manpower & 1 training 2 Lack of funds 3 Session planning 4 Cold storage space 5 Data recording Key issues ▪ Hire and train cold chain staff where required; training must include technical (including distribution on basis of past consumption/ current inventory and maintenance of safety stock) and financial aspects (i.e. funds available for various activities) ▪ Refrigerator mechanics must be trained for digital and non-CFC equipment ▪ Review sufficiency of funds, especially for electricity & generator at Bhopal ▪ Mobility fund must be distributed amongst districts and blocks based on their distance from the warehouse (instead of current practice of distributing it equally) ▪ Review AVD policy in Tikamgarh (one AVD per session) leading to low incentive for AVDs covering far-away sessions to return vaccines at end of session ▪ MOIC must support ANMs in making micro-plans and improve session planning such that: – ANMs conduct vaccination sessions at villages/sites as per frequency recommended by guidelines based on injection load – No ANM conducts more than one session in a day – Micro-plan is planned on actual calendar dates so that holidays (and other foreseeable events i.e. polio campaigns) are accounted for ▪ Identify space and build the Tikamgarh vaccine store in an appropriate area ▪ Cold chain in-charges be trained to record batch number of diluents, syringes received/distributed and vaccines returned from outreach sessions ▪ Train ANMs to fill tally sheets and ensure compliance ▪ All stock data must be entered in an online system .Visibility into stock information at higher level will help in raising indents and at lower level will help in allocation of stock SOURCE: Team analysis ITSU - PHFI 37
  38. 38. Recommendations for UP Manpower & 1 training 2 Lack of funds 3 Session planning 4 Cold chain equipment 5 Data recording Key issues ▪ Review of vaccine supply and distribution ▪ Hire and train cold chain staff where required; training must include technical (including basis of distribution being past consumption/ current inventory) and financial aspects (i.e. funds available for various activities) ▪ Hire buffer ANMs to cover for absent ANMs (so that no planned sessions are cancelled/postponed) ▪ NRHM to ensure timely dispersion of funds for issues identified (example, electricity bill, generator fuel, vaccine van fuel) ▪ Explore mobility support to ref mechanics and vaccine store keepers at district level for preventive maintenance ▪ MOIC must support ANMs in making micro-plans and improve session planning such that: – All villages are assigned to an ANM – ANMs conduct vaccination sessions at her villages as per frequency recommended by guidelines based on injection load – No ANM conducts more than one session in a day – Micro-plan is planned on actual calendar dates so that holidays (and other foreseeable events i.e. polio campaigns) are accounted for ▪ Explore shifting of vaccine storage close to syringes store ▪ Review and rationalize flow of vaccines and syringes from regions to divisions and districts ▪ De-bottleneck new WIC installation at Agra and Faizabad ▪ Ensure vaccine van available at every district: ▪ Cold chain in-charges be trained to record batch number of diluents, syringes received/distributed and vaccines returned from outreach sessions ▪ All stock data must be entered in an online system .Visibility into stock information at higher level will help in raising indents and at lower level will help in allocation of stock SOURCE: Team analysis ITSU - PHFI 38
  39. 39. Backups ITSU - PHFI 39
  40. 40. BCG: ~7% of sessions were stocked out, primarily in Salkhua Estimated percentage of sessions without vaccine Jamui district Saharsa district Giddhor Jamui-Sadar Salkhua Simbi Bakhtiyarpur Vaccineavailable Vaccine availabl e NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared session-wise vaccine distribution data for 4 months only ITSU - PHFI 40 SOURCE: Block stock registers
  41. 41. tOPV: ~45% of sessions were stocked out, across all 4 blocks Estimated percentage of sessions without vaccine Jamui district Saharsa district Giddhor Jamui-Sadar Salkhua Simbi Bakhtiyarpur NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared session-wise vaccine distribution data for 4 months only ITSU - PHFI 41 SOURCE: Block stock registers
  42. 42. DPT: ~16% of sessions were stocked out, primarily in Giddhor & Jamui-Sadar Jamui district Giddhor Jamui-Sadar Salkhua NA NA NA NA NA NA NA NA NA NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared session-wise vaccine distribution data for 4 months only ITSU - PHFI 42 SOURCE: Block stock registers Saharsa district Simbi Bakhtiyarpur NA NA NA NA NA NA NA NA Estimated percentage of sessions without vaccine
  43. 43. TT: ~10% of sessions were stocked out, primarily in Giddhor & Salkhua Jamui district Giddhor Jamui-Sadar Salkhua Vaccineav ailable NA NA NA NA NA NA NA NA NA NA NA NA NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared session-wise vaccine distribution data for 4 months only ITSU - PHFI 43 SOURCE: Block stock registers NA NA NA NA NA Saharsa district Simbi Bakhtiyarpur Estimated percentage of sessions without vaccine
  44. 44. Measles: ~9% of sessions were stocked out, primarily in Giddhor, Salkhua & Simbi Bakhtiyarpur Jamui district Giddhor Jamui-Sadar Salkhua Vaccineavail able NA NA NA NA NA NA NA NA NA NA NA NA NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared session-wise vaccine distribution data for 4 months only ITSU - PHFI 44 SOURCE: Block stock registers NA NA NA NA NA Saharsa district Simbi Bakhtiyarpur Estimated percentage of sessions without vaccine
  45. 45. BCG: 20-25% of sessions were stocked out across all districts Estimated percentage of sessions without vaccine Etah district Shrawasti district Allahabad district Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ITSU - PHFI 45 SOURCE: Block stock registers
  46. 46. DPT: No significant supply issue observed for DPT except in Mauiama district (10-15%) Estimated percentage of sessions without vaccine Etah district Shrawasti district Allahabad district Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ITSU - PHFI 46 SOURCE: Block stock registers
  47. 47. tOPV: 15-30% sessions were stocked out in Ikuana, Mauiama and Koraon blocks Estimated percentage of sessions without vaccine Etah district Shrawasti district Allahabad district Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ITSU - PHFI 47 SOURCE: Block stock registers
  48. 48. Measles: ~30% sessions were stocked out in Mauiama Estimated percentage of sessions without vaccine Etah district Shrawasti district Allahabad district Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ITSU - PHFI 48 SOURCE: Block stock registers
  49. 49. TT: ~10% sessions were stocked out in Mauiama Estimated percentage of sessions without vaccine Etah district Shrawasti district Allahabad district Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA NA ITSU - PHFI 49 SOURCE: Block stock registers

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