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Preliminary Results from Direct-To-Facility Vaccine Deliveries in Kano, Nigeria

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Preliminary Results from Direct-To-Facility Vaccine Deliveries in Kano, Nigeria Preliminary results from direct-to-facility vaccine deliveries in Kano, Nigeria Muyi Aina Uchenna Igbokwe Solina Center for International Development and Research Rabiu Fagge Kano State Primary Health Care Management Board Presentation at the Health and Humanitarian Logistics Conference, Copenhagen June 8, 2017 CONFIDENTIAL AND PROPRIETARY Any use of this material without specific permission of Solina Health is strictly prohibited Content Background Methods Results Learnings Conclusion 2 General information on Kano state, Nigeria Kano at a glance Kano State has 44 LGAs ▪ 11 Million (2011) Population1 Makoda Kunchi Dambatta GDP per ▪ $1,288 USD Tsanyawa Bichi 2 Minjibir Gabasawa capita Dawakin Tofa Bagwai Ungogo Tofa Dala Gezawa Shanono Rimin Gado Tarauni Ajingi KumbotsoWarawa ▪ 0.44 Million Gwarzo Kabo No. of Madobi Dawakin Kudu Kura Gaya children <1 Wudil Karaye Bumkure Albasu Kiru Garun Mallam Garko Rogo Bebeji Rano ▪ 50 deaths per 1,000 Kibiya Takai Infant mortality rate3 children Tudun Wada Sumaila ▪ BCG: 27.5% Immun. ▪ DPT3: 18.9% coverage rate4 Doguwa ▪ Fully immunised: 13.2% ▪ 1,300 PHCs;, 1,142 0 50 100 Km Healthcare facilities providing RI services SOURCE: 1. City population statistics; 2. Canback Dangtel C-GIDD, 3. MDG 2014; 4. Nigeria Demographic and Health Survey, 2013 3 Historically, a weak vaccine supply chain system significantly contributed to poor immunization coverage rates in Kano Key supply chain bottlenecks resulted in …and contributed to the poor vaccination inadequate supply of vaccine for RI sessions… coverage in Kano and other northern states DPT3 coverage by state (NDHS 2013) 1 Inadequate cold chain and poor maintenance limiting vaccine availability at service points 2 Complex and ineffective distribution architecture causing frequent stock outs 3 Inadequate and ad-hoc funding for vaccine transportation across all levels 4 Faulty vaccine forecasting and allocation which did not adequately reflect demand 5 Weak data management systems resulting in ineffective management decision making 6 Lack of proper supportive supervision due to 1. ‘Baseline’ Kano RI coverage survey conducted in 2014 showed a DPT3 coverage of 38% funding limitations and capacity gaps 2. This reflected the vaccination coverage status as @ Jan 2012 – May 2013 4 SOURCE: Kano RI program diagnostics; NDHS 2013; KanRICS 2014 A tripartite MoU to strengthen RI, enabled Kano state to embark on the ambitious transformation of its vaccine supply chain 1 Kano state, BMGF and Dangote Deployed weekly dashboard Foundation executed an MOU in on vaccine stock performance Nov 2012 to strengthen RI The MoU supported interventions 2 across core RI thematic areas: Strengthened cold chain . Governance (PHCUOR policy infrastructure at facilities and implementation) satellite stores . Service delivery 3 Re-designed the vaccine . Vaccine supply chain distribution architecture and . Supportive supervision engaged private vendor . Data management and use 4 . Community engagement and Set-up working group to social mobilization manage the transformation 5 The re-designed architecture delivered vaccines directly to equipped health facilities from state satellite stores Vaccines delivered Vaccines picked-up A. Previous vaccine distribution B. Re-designed vaccine distribution architecture architecture National cold stores National cold stores Quarterly Quarterly State store (x1) State stores (x1) Monthly Monthly LGA stores State satellite (x44) stores (x5) Bi-weekly/ As needed Monthly Cold chain- Cold chain- equipped equipped facilities (x484) facilities (x484) Weekly Weekly CCE-unequipped CCE-unequipped Facilities (x628) Facilities (x628) 6 The new system utilized both insourced and outsourced approaches LGAs covered by state LGAs covered by private vendor # satellite # primary and Primary to Description stores cascade facilities cascade ratio State-run: Insourced Primary ▪ Deliveries carried out 2 Cascade 1 : 1.5 by state drivers using 212 state delivery trucks, 354 and coordinated by 142 state delivery manager Private vendor-run: Outsourced ▪ Vehicles and drivers 4 1 : 1.8 provided by private vendor; deliveries 248 454 702 coordinated by vendor delivery manager Total Note: 6 1 : 1.7 All inventory management and 390 666 1,056 warehousing is managed by the state 7 SOURCE: KSPHCMB, Solina analysis Content Background Methods Results Learnings Conclusion 8 We conducted a retrospective review of program data to understand the effects of the direct deliveries on stock performance and vaccinations . To describe the preliminary Quantitative . Vaccine stock data obtained Objective results from Kano’s direct data through physical stock counts delivery operations at equipped facilities during deliveries . Retrospective review of data . Vaccination data obtained Approach on the performance of the directly from immunization tally program sheets at health facilities . Cost data was obtained from expenditure reports, market . 20 months of implementation survey and interviews Duration (June, 2014 – January, 2016 - Capital costs were amortized to reflect annual . All equipped health facilities costs Sampling included in study sample for vaccine stock performance Qualitative . Targeted key informant . 30 representative facilities data interviews and focus group selected through a multistage discussions with relevant stratified random sampling stakeholders using structured included in the vaccination questionnaires analysis 9 Content Background Methods Results Learnings Conclusion 10 There was a significant reduction in stock outs at CCE equipped facilities following the implementation of direct deliveries Legend Stock-outs Below buffer Adequate Stock xx No. of cold chain-equipped facilities 90 178 275 346 361 377 387 408 10% 19% 17% 22% 17% 17% 19% 41% 22% 22% 23% 22% 24% 22% 25% 5% 68% 61% 61% 54% 57% 55% 60% 56% Q21 Q3 Q4 Q1 Q2 Q3 Q4 Q12 2014 2015 2016 11 Stock out rates have declined across facilities receiving vaccines through both insourced and outsourced models Percentage of antigens stocked out at primary facilities receiving direct deliveries in Kano (%) Actual Moving average (Interval = 12) State-wide N=390 Outsourced N=248 Insourced N=142 Clearer, more 35 consistent trend -4% -2% of stock out 30 decline observed for 25 insourced facilities 20 -10% 15 10 5 0 2015 2016 2015 2016 2015 2016 . Greater ownership and accountability for stock performance results by LGA CCOs (who participate more regularly on vaccine deliveries to insourced facility) is driving the consistent stock out decline . It will be critical to ensure LGA CCOs take full ownership of deliveries from inception regardless of the model deployed 12 SOURCE: Kano stock performance dashboard, Team analysis Delivery delays and increasing numbers of cascade facilities negatively impacted the stock performance a. Impact of cascade facilities on stock-out rates No cascade Stock-out rate (%) 1 or 2 cascade facilities 3 or more cascade facilities 50 p < 0.0011 40 30 20 10 0 Delivery cycle 9 11 13 15 17 19 21 23 25 27 29 31 b. Impact of delivery delays3 on stock-out rates Stock-out rate (%) 80 60 R = 0.9352 40 20 Delivery delays 0 (days) 0 1 2 3 4 5 6 7 8 9 10 13 There was a 1-year lag before a corresponding increase in vaccinations (all vaccines except HepB) was observed Penta3 BCG Measles Average combined OPV3 Yellow fever HBV 0 monthly vaccinations 787 1,000 437 +80.1% 900 837 538 +55.6% 800 591 732 700 +23.9% 600 786 554 +41.9% 500 819 629 +30.2% 400 300 505 354 -29.9% 200 Jan ’13 - Apr ’13 - Oct ’13 - Apr ’14 - Oct ’14 - Apr ’15 - Oct ’13 - Oct ’14 - Mar ’13 Sep ’13 Mar ’14 Sep ’14 Mar ’15 Sep ’15 Sep ’14 Sep ’15 14 Beyond improved stock performance, direct deliveries yielded additional benefits for the RI program More focus on service delivery: Health worker spend more time delivering services to clients. Other benefits . Distribution of other PHC items Improved stock data management: The model e.g. data tools created visibility into facility stock levels through onsite information capture . Regular monitoring of CCE functionality Additional opportunities for supervision: . Retrieval of Logisticians mentor facility personnel on vaccine safety boxes management, handling and CCE maintenance on delivery visits 15 Vehicle depreciation, personnel and vaccine distribution to unequipped facilities were responsible for the bulk of direct delivery costs Summary of annual program costs of Kano’s direct vaccine delivery program1 (US$, 000) Vehicle depreciation 34 69 103 Insourced Outsourced Cold chain equipment 7 10 CapEx 4 Communication 4 4 Furniture 1 Personnel 12 72 84 Cascade deliveries 22 48 70 Trainings 1 1 OpEx Vehicle maintenance 17 35 52 9 Vaccine insurance 9 19 24 Office overhead 4 27 Total 104 268 372 1. Bi-weekly delivery costs for a year. Costs of insourced and outsourced not comparable as they are not on the same scale | 16 The annual cost of vaccine distribution per child < 1 in Kano was US$0.74 Summary of annual program costs of Kano’s direct vaccine delivery program1 Overall Insourced Outsourced # primary facilities (#) 390 142 248 # cascade facilities (#) 666 212 454 Annual cost 0.76 0.6 0.8 per child3 Bi- weekly Unit cost per 36.76 28.1 41.6 deliveries ward4 (US$2) Unit cost per 29.76 22.0 34.1 delivery5 1. Bi-weekly delivery costs for a year. Costs of insourced and outsourced not comparable as they are not on the same scale 2. Naira value converted to USD @197NGN/USD 3. Annual cost of vaccine distribution per child 4. Unit cost of distribution per ward – includes cost of cascade deliveries 5. Unit cost per health facility receiving vaccines annually 6. Cost are weighted insourced and outsourced scale SOURCE: Team analysis | 17 Content Background Methods Results Learnings Conclusion 18 We have learnt some lessons from Kano direct delivery experience (1/2) 1. Private vaccine distributors need an upstream role in health facilities stock allocations for outsourcing to be maximally effective. 2. Scale matters; so better to run either a outsourced model or an insourced system for economies of scale 3. Fewer deliveries result in higher per-delivery costs but lower total program costs.
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