, AID fliaternal and Child FROM THE AMERICAN PEOPLE / Survival Program

What to Know about Your CCEOP Application and Deploying Cold Chain Equipment: Lessons from Tanzania and Mozambique December 2018 mcsprogram.org

INTRODUCTION With one in fve children in low- and To address these issues, Gavi, the Vaccine PROCESS FLOW FOR CCEOP middle-income countries (LMICs) still not Alliance (hereafter referred to as Gavi), has fully vaccinated and thus at risk of prevent- invested in ensuring equal access to new Organize and prepare application able life-threatening illnesses, immunization and underused vaccines in LMICs.To ad- and accompanying documents programs are under pressure to increase dress the iSC challenges, Gavi developed its coverage and improve performance and immunization supply chain strategy in 2015 Submit complete application effciency.Adding to this challenge, the to increase attention on the importance number of vaccines available has grown of an effcient and effective iSC to ensure from the original six recommended by the vaccine potency and increased availability Respond to any clarification request World Health Organization (WHO) three of vaccines to improve coverage and equity. by Gavi decades ago to 12 or more, depending Gavi’s Cold Chain Equipment Optimization on the country.At the same time, pop- Platform (CCEOP), established in 2016, ulations are growing, and immunization addresses a fundamental part of this strat- Received approval from Gavi supply chains (iSCs) are facing constraints egy.The CCEOP is a funding mechanism in reliable, optimal, and suffcient cold for which countries can apply to procure Prepare Year 1 Operational chain equipment (CCE) and transport to optimal WHO performance, quality, and Deployment Plan (ODP) accommodate ever-increasing volumes and safety (PQS)-approved CCE that is re- varieties of vaccines, vial presentations, and quired to maintain the ideal temperature cold chain requirements. range to keep vaccines potent.Together Revise ODP based on UNICEF procurement process and any updated with new temperature-monitoring devices prices/expenses (improved over simple thermometers), this PQS-approved equipment will ensure Deployment of new equipment WHAT IS THE IMMUNIZATION adequate storage for current and planned conducted by service bundle providers SUPPLY CHAIN? vaccines, fewer maintenance requirements, and lower running costs.The CCEOP ad- The immunization supply chain en- dresses the supply and demand for optimal Received approval from Gavi compasses all the equipment, activ- CCE, generation of demand by countries ities, tools, resources, and planning for technologically innovative and appro- necessary to ensure that vaccines priate CCE, and stimulation of the market Prepare ODP for Year 2 stay safe and effective and reach all to respond to that demand with affordable those who need them.This can in- and accessible equipment.2 With improved clude, for example, the cooling equip- CCE in LMICs, immunization programs can not fnancially support other components, ment the vaccines are stored in, the increase and sustain immunization cov- such as operationalizing the maintenance routes through which they are dis- erage and equity by ensuring that potent plan or strengthening human resources. tributed, the data collected to track vaccines are more available. The country must support, with separate and evaluate the distribution, and the funds, costs associated with components people who manage the systems. The CCEOP jointly invests with countries outside the purchase, deployment, and in the purchase, deployment, and installa- installation of CCE. For the manufacturer’s — Gavi Alliance, Strengthening the tion of higher performing CCE.The plat- warranty to be eligible for the platform, Immunisation Supply Chain11 form links to Gavi’s overall immunization the CCEOP requires that the manufac- supply chain strategy to strengthen all as- turer contract with local service bundle pects of the immunization system, but does providers to deploy and install the CCE

1 Gavi Alliance. 2016. Strengthening the Immunisation Supply Chain. Geneva, Switzerland. https://www.gavi.org/library/publications/gavi-fact-sheets/gavi-supply-chain-strategy/ 2 The CCE demand is expected to increase with the implementation of the CCEOP, particularly for ice-lined and solar direct drive refrigerators/freezers, which make up 80–90% of annual CCE expenditures according to the 2014 UNICEF Supply Division procurement data. Gavi’s market-shaping strategy aims to ensure that suffcient supply of high-performing CCE is widely available from many suppliers at sustainable prices. Countries must submit a comprehensive ment beyond repair, and obsolete equip- multi-year plan (cMYP), an updated CCE ment (more than 10 years old or CCE inventory, a cold chain rehabilitation and using absorption technology that relies on expansion plan, and a CCE maintenance gas or kerosene, which are unreliable) to plan with their application (Annex 1). 3 receive new equipment through CCEOP. These processes, such as developing the The initial application requested 5,640 maintenance plan or updating the CCE pieces of CCE (Table 1), consisting of solar inventory, are done in preparation for direct drive (SDD) equipment as well as the application and can be supported by equipment that runs off the electrical grid. in-country partners. Although Gavi did not initially provide a ceiling for allowable funding requests, it The United States Agency for International asked IVD to reduce its request by about Development’s fagship Maternal and Child half, citing budget expectations. Following Survival Program is providing technical some questions from Gavi for additional assistance to the ministries of health in information, the IVD’s application was Tanzania and Mozambique in the applica- approved in October 2017. tion processes.These two countries are at different stages of the CCEOP applica- In February 2018, the country submitted its tion, approval, and equipment deployment operational deployment plan (ODP), detail- process.This document aims to highlight ing the frst year plan of deployment for the experiences in both countries in an effort new equipment, with details about facilities to provide insights and lessons learned for and sites to receive the new equipment, other countries eligible for CCEOP. specifc locations (GIS coordinates), access information, type of structure or roof (rel- evant for SDDs and in determining where solar panels could be installed), and contact The district immunization vaccine offcer at a information for each site. UNICEF, as the health facility in Morogoro district,Tanzania. COUNTRY OVERVIEW: procurement agent, provided updated Photo credit: Ian J. Connors/John Snow, Inc. TANZANIA prices to IVD.There was a small increase in the price for equipment (expected, since there was a year between the CCEOP ap- at the facility or warehouse. In addition The Immunization and Vaccination De- plication and equipment procurement) and to delivering and installing the equipment, velopment (IVD) Program of Tanzania a larger and surprising increase in the cost these service bundle providers will train submitted its CCEOP application and all of the service bundle provider. Because this health care workers and technicians on corresponding documentation to Gavi in was the frst time using service bundle pro- basic maintenance.The service bundle pro- May 2017.All partners involved in immuni- viders, the original cost estimates provided viders provide maintenance for any broken zation activities collaborated in developing by the manufacturers dramatically changed equipment under the warranty but do not the application and preparing the required during the process and upon fnalizing the provide ongoing maintenance beyond the documentation, such as updating the CCE contracts.As such, IVD had to reduce the warranty’s expectations. inventory and developing the maintenance number of units for procurement by 25%. plan. No external support was provided As of mid-2018, IVD is in fnal negotiations Application for the CCEOP requires thor- to prepare the application.The country with Gavi on the type and quantity of ough preparation, analysis, and planning. prioritized newly opened facilities, equip- equipment it will receive.

Targeted segment Equipment model Manufacturer Vaccine capacity (L) No. of units District vaccine store TCW 4000 AC B Medical 240 140 District vaccine store VLS 400A Vestfrost 145 254 Health facilities (on grid) VLS 200A Vestfrost 60 1,015 Health facilities (on grid) BFRV55 SDD SunDanzer 56 2,149 Health facilities (on grid) VLS 054 SDD Vestfrost 55.5 2,082 Total 5,640

3 Guidance for the CCEOP application process can be found on the Gavi website: www.gavi.org/support/process/apply/cceop/. COUNTRY OVERVIEW: MOZAMBIQUE

Mozambique began its process about a year later than Tanzania.The initial workshop for preparation of a CCEOP application in Mozambique was held in March 2018, facilitated by a con- sultant from UNICEF.This consultant sup- ported the Ministry of Health Expanded Program on Immunization (EPI) and part- ners through the application process and preparation of the required documenta- tion. Partners had previously contributed Photo credit: Ian J. Connors/John Snow, Inc. to preparing the documents required to accompany the application—for example, Village Reach supported updating of the their ODP, a few lessons from Tanzania and • Fully understand the application process cold chain inventory and the Clinton Mozambique may help them to streamline from the beginning. Both Tanzania and Health Access Initiative supported the process and more effciently prepare Mozambique recommend having a team development of the CCE maintenance for eventual equipment deployment. of committed and capable people re- plan. Gavi did not provide guidance on sponsible for developing the application, allowable funding requests.The country • Clearly document the CCE selection and seeing it through approval, and ensuring submitted its application in June 2018, priority locations. Both Mozambique and a country-owned process. In Mozam- and it was approved at the end of July, Tanzania followed a thorough process bique, UNICEF provided a consultant pending a few clarifying questions from to identify the most appropriate CCE as who worked with the Logistics Techni- Gavi, such as ensuring consistency well as priority sites for deploying new cal Working Group to ensure under- throughout the application in terms of equipment, based on analysis of need, standing of the application process, pose equipment requests and priority areas. coverage, and equity. For CCE selection, clarifying questions to Gavi, and ensure The country has prioritized fve provinces one criterion is to request equipment that all accompanying documents were (Nampula, Zambezia,Tete, Manica, and that is the same or similar to equipment included.This facilitated adherence to Sofala) that are geographically remote the country already has, and thus lever- the application timeline.Tanzania did and have low coverage and many poor age technicians’ expertise for ongoing not use an external consultant, but the communities with high numbers of maintenance. Both countries used Gavi’s process was led by a group of commit- unvaccinated children. CCE technology guide4 to identify the ted people from EPI and partners. It was specifc PQS-approved equipment for useful in both countries to have docu- The CCEOP application forecasts a total this funding platform. Because the CCE ments such as CCE inventory and main- of 997 units of CCE as follows: market is fuid and is still being shaped tenance plans updated and prepared • 361 on-grid ice-lined refrigerators by the CCEOP, UNICEF must negotiate before starting the CCEOP application, with-out a freezing compartment the best price, which means the country which also promoted country owner- • 118 on-grid freezers might not receive its preferred equip- ship of the process. Using WHO tools • 128 off-grid SDD refrigerators without ment.As seen in Tanzania, however, with such as the Cold Chain Inventory and freezers proper documentation and justifcation, the Vaccine Volume Calculator helped • 390 off-grid SDD refrigerators with a a country is better placed to make the the teams to determine the necessary freezing compartment argument for its preferred selection. size of the equipment by location. The next steps include the UNICEF pro- curement process, followed by updating • Double-check for consistency in the appli- • Plan for service bundle providers. Using the ODP based on any required changes cation. The application is lengthy and it the manufacturer’s designated service due to fuctuation in prices and service often duplicates requested information, bundle providers to install equipment bundle requirements. such as number of equipment units is a new approach that Gavi included requested or priority sites. Providing in the CCEOP to see if installation can consistent information and completing be made more effective and effcient. KEY LESSONS LEARNED the required forms fully (with accom- The Mozambique EPI sees this as a As other countries prepare their CCEOP panying signatures) will avoid additional beneft as it had challenges in the past application, develop a cold chain mainte- questions from Gavi that may delay the with ensuring that CCE installation at nance plan, update CCE inventory, or approval process. subnational levels was completed in a revise 4 Gavi Alliance. 2018. Cold Chain Equipment Optimisation Platform. Geneva, Switzerland. https://www.gavi.org/library/publications/gavi/cold-chain-equipment-technology-guide/ timely manner.The Tanzania group has a change. In Tanzania, the average cost per MOVING FORWARD different view, however, as IVD has the equipment unit increased 33% between Gavi is already addressing several issues technical capacity to install and manage application and time of procurement, coming out of the f rst years of this expe- the CCE and has transport available for including the service bundle provider rience. In line with reshaping processes to delivering the equipment to the sites. costs.As such, IVD had to reduce the ensure better outcomes, Gavi has already From IVD’s perspective, the service number of CCE units in its plan by 25%, changed some of the application proce- bundle providers are expensive—more and, subsequently, revise the ODP. dures to reduce the approval time, and than the cost of the equipment itself— consultants are providing support to en- as they charge a standard rate regard- • Understand the true costs. Different sure that the application is complete, thor- less of site location for a job that IVD is equipment will require different mate- ough, and appropriate to avoid extensive equipped to do. Regardless, because this rials and will have different costs. For back-and-forth questions and clarifca- is currently a Gavi requirement, both example,Tanzania was surprised to tions. Gavi is committed to ensuring that countries are preparing to use a service discover the price difference between immunization is available to all and that bundle provider. solar CCE that requires poles for the the CCEOP is fulflling its goal of adopting solar panels and the same equipment more reliable and effcient equipment. • Plans will change. Despite Gavi revising using the rooftop for the solar pan- These lessons learned can help countries some aspects of the application to els—a distinct requirement for certain leverage this platform as CCEOP expands quicken the approval process, the time facilities but with a surprising additional and improves its processes. between the application and equip- cost.An additional mandatory cen- ment deployment is still lengthy, and tral-level training was also included in factors, such as equipment and service the ODP, cutting into funds that could bundle provider prices, will inevitably be available for equipment procurement.

Annex 1: Mandatory documents to accompany the CCEOP application No. Strategy/plan/document 1 Signature sheet for the ministers of health and fnance, or their delegates 2 Minutes of the coordination forum meeting (National Inter-Agency Coordinating Committee, Health Sector Coordination Committee, or equivalent) endorsing the proposal 3 National health sector development plan/strategy (or similar) 4 National comprehensive multi-year strategic plan 5 Effective vaccine management (EVM) assessment 6 EVM improvement plan 7 EVM annual work plan and progress report on EVM improvement plan 8 WHO Cold Chain Equipment Inventory Tool, PATH Cold Chain Equipment Manager Tool, or other tools to help assess targeting of equipment 9 Inventory report and facilities segmentation 10 Comprehensive document on cold chain equipment (CCE) needs: Chapter 1: Cold chain rehabilitation and expansion plan Chapter 2: Projected coverage and equity improvements Chapter 3: Operational deployment plan, including deviation plan to account for any last-minute changes in the deployment plan during installation Chapter 4: Equipment selection 11 Maintenance plan with fnancing and source(s) 12 Proof of status for CCE tariff exemptions waiver

This brief is made possible by USAID and the Maternal and Child Survival Program and does not refect the views of USAID or the United States Government.