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Performance Management of Last Mile Vaccine Distribution

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Nov. 2015 Performance Management of Last Mile Vaccine Distribution Brittany G. Johnson, Ekta Jhaveri, Wendy Prosser, Aida Coehlo, Prashant Yadav ACKNOWLEDGMENTS This work could not have been possible without the tireless work of the VillageReach team in country and Seattle. Particularly Ruth Bechtel and Tatenda Mutenga who provided regular follow-up and support. Of course, the research would not have been possible without the distribution teams’ willingness to participate and be available for follow-up. In Maputo, Margarida Matsinhe. In Gaza Alberto Mabota. In Niassa Gregorio Júnior, and EPI teams in all 3 provinces. Sarah Alphs Mwenda provided direction and momentum in the development of this study. Leila Yosef provided initial follow-up transcription and translation for the first six months of study implementation. About VillageReach VillageReach work with their partners to deliver vaccines to the last mile. Through this mission they research the dependencies within complex systems and identify the requirements for new solutions to thrive in sub-Saharan countries. VillageReach provides the data, tools, learning and support to empower key institutional stakeholders, including governments and global health partners, to implement change and take innovation through to scale and sustainability. About the Healthcare Initiative at the William Davidson Institute WDI’s Healthcare Initiative develops intellectual capital that helps increase access to essential medicines, vaccines and other health technologies in developing countries. We do this by helping create scalable and sustainable models for supply chains and delivery in healthcare. We help stimulate stakeholder discussions around new solutions to the many problems affecting global healthcare and explore new ideas through models, field experiments, and pilot implementations. Through this research, the initiative supports policymakers in philanthropic organizations, developing country governments, bilateral and multi-lateral agencies, pharmaceutical and vaccine manufacturers, and healthcare investment firms. 1 Contents Acronyms ...................................................................................................................................................... 3 Executive Summary ....................................................................................................................................... 4 Introduction .................................................................................................................................................. 6 Study Background ..................................................................................................................................... 8 Consideration of Study Findings ............................................................................................................... 8 Experimental Design ................................................................................................................................... 10 Analysis Methods ........................................................................................................................................ 16 Analysis of MIS Data................................................................................................................................ 16 Root Cause Analysis ................................................................................................................................ 22 Results ......................................................................................................................................................... 30 Conclusion ................................................................................................................................................... 32 Annex .......................................................................................................................................................... 34 2 Acronyms CMAM Central de Medicamentose Artigos Médicos (Central Medical Store) DPS Direcção Provincial de Saúde (Provincial Health Management) DLS Dedicated Logistics System EPI Expanded Program on Immunization LMIS Logistics Management Information System MISAU Ministério de Saúde (Ministry of Health) NGO Non-Governmental Organization PAV Programa Alagado de Vacinação (see EPI) SELV Sistema Electronica de Logistica de Vacinas (see LMIS) WDI William Davidson Institute VR VillageReach 3 Executive Summary Since 2011, VillageReach has implemented a Dedicated Logistics System (DLS), whereby the provincial Expanded Program on Immunization (EPI) delivers vaccines directly to health facilities on a monthly basis, skipping the district level and streamlining distribution. This program has successfully increased vaccine coverage in the provinces where it operates and with a higher cost-efficiency. However, to achieve these results, VillageReach has provided continual managerial support with a cost-share approach to government distribution teams, with the occasional additional financial support. Between March 2014 and 2015 VillageReach in collaboration with the William Davidson Institute analyzed a strategy to shift accountability for vaccine distribution to the government. They implemented a control match study considering the impact of private sector management strategies. The research team selected three provinces, Gaza and Maputo were intervention sites and Niassa a control site. Intervention sites held monthly meetings with senior leadership to review and resolve distribution issues. These monthly meetings reviewed distribution issues charts which the distribution team tracked over the course of the month. EPI chiefs held discussions according to the structure of a resolution report to work through root causes of distribution issues and potential resolutions. Additionally, the province that showed the greatest delta in change over the baseline received a financial award for performance improvement. All provinces showed improvement in vaccine delivery and availability over the course of the study. Gaza and Maputo showed marginal significance that was attributed to the tools introduced. Additionally, a similar intervention was leveraged by the VillageReach Mozambique office in conjunction with a new logistics information management system to review DLS data gathered on a monthly basis with all provinces, leading to additional noise in the data. Personnel changed in the control province over the course of the study, contaminating the control. Based on baseline and endline study results, the monthly meetings had significance in ensuring that responsibilities of the distribution team were fulfilled. Additionally, these meetings provided timely feedback and support from supervisors. Based on the written monthly resolution reports, creative problem solving took place to resolve issues within the control of the distribution team. Nonetheless, distribution teams felt that without VillageReach asking for these reports on a monthly basis, it would be unlikely that they will continue to meet. This suggests that a required management directive is necessary in maintaining good practice. Monthly resolution reports provided a continual resource for root cause identification, making it feasible to consider key impact areas for engagement among government and outside actors. For instance, through these reports the research team discovered that of the deliveries made over the course of the study, 20% more would have been possible had refrigerators been functional. This provides evidence for future work by government and other vaccine supply chain stakeholders to identify key strategic areas for interventions and resolve the most pressing bottleneck issues. 4 5 Introduction Vaccines save millions of lives each year and are among the most cost-effective health interventions available. While immunization coverage has dramatically increased over the last three decades, the coverage rates have plateaued at 80%. One in five children are still without access to vaccines, resulting in an estimated 1.5 million child deaths each year and tens of thousands of permanent disabilities from vaccine-preventable diseases such as diarrhea and pneumonia. Improving access to lifesaving vaccines starts with a well-functioning supply chain which is essential for ensuring the availability of quality vaccines in the right quantities and at the required time to populations in need. VillageReach is a social enterprise that supports supply chains and last mile delivery across Africa. Since 2002, VillageReach has worked to build the capacity of provinces and districts in Mozambique to carry out health logistics activities to improve immunization coverage rates. Their work has highlighted a number of factors contributing to the current inefficiencies and ineffectiveness of the vaccine supply chain including Information deficits due to poor communication and reporting infrastructure Deficient financial resources and unpredictable financial flows Poor quality of infrastructure (e.g. electricity, roads, warehouse facilities) Inadequate human resources in terms of number, capacity and performance due to lack of accountability structures These gaps increase the costs of vaccine delivery and create large disparities in the quality of the immunization system across geographies. In partnership with the Direcção Provincial de Saúde (DPS) in four provinces, VillageReach has been engaged in an approach to accelerate access to vaccines and improve supply chains through
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