Immunization Supply Chain Improvement Roadmap for Pakistan TABLE OF CONTENTS Acronyms....................................................................................................................................................... 2 Executive Summary ....................................................................................................................................... 3 Introduction .................................................................................................................................................. 7 Background and Project Overview ................................................................................................................ 8 High-Level Recommendations For Pakistan to Move to a Next-Generation Immunization Supply Chain ... 15 Streamlined and Efficient supply chain, not based on administrative levels ........................................... 15 Equity Lens for Supply Chain Improvement ............................................................................................. 16 Professional Logistics Workforce, Saving Staff Time for Service Delivery ................................................ 16 Clear Data Visibility .................................................................................................................................. 17 Leadership Using Data for Management and Decision-Making ............................................................... 17 Modelling Results, Recommendations and Next Steps ............................................................................... 19 Federal EPI ............................................................................................................................................... 19 Punjab ...................................................................................................................................................... 23 Sindh ........................................................................................................................................................ 30 Khyber Pakhtunkhwa ............................................................................................................................... 36 Tribal Areas (formerly Federally Administered Tribal Areas [FATA]) ........................................................ 44 Balochistan .............................................................................................................................................. 46 Gilgit-Baltistan ......................................................................................................................................... 53 Azad Jammu & Kashmir ........................................................................................................................... 58 Integrating supply chain design into existing mechanisms .......................................................................... 61 Equity .......................................................................................................................................................... 64 Potential Partners ........................................................................................................................................ 67 Conclusion ................................................................................................................................................... 71 Appendices .................................................................................................................................................. 73 Appendix I: Gavi Immunization Supply Chain Process Scorecard............................................................. 73 Appendix II: Supply Chain Equity Metrics Definitions and Benchmarks ................................................... 74 Appendix III: Data collected on Pakistan’s Immunization Supply Chain ................................................... 75 1 ACRONYMS 3PL Third Party Logistics AJK Azad Jammu & Kashmir BCG Bacille Calmette-Guerin, a vaccine for tuberculosis disease BMGF Bill and Melinda Gates Foundation bOPV Bivalent Oral Polio Vaccine (protects against poliovirus type 1 and 3) CCE Cold Chain Equipment CCEOP Cold Chain Equipment Optimization Platform CDA Capital Development Authority of Islamabad CES Coverage and Evaluation Survey CMYP Comprehensive Multi-Year Plan DLI Disbursement Linked Indicator DPT3 Diphtheria, pertussis (whooping cough) and tetanus vaccine DRAP Drug Regulatory Authority of Pakistan EOC Emergency Operation Centre EPI Expanded Program on Immunization EVM Effective Vaccine Management EVMA Effective Vaccine Management Assessment FATA Federally Administered Tribal Areas FIC Fully Immunized Child FR Frontier Region Gavi The Global Vaccine Alliance GB Gilgit-Baltistan GHSC Global Health Supply Chain GoP Government of Pakistan HPV Human Papillomavirus HR Human Resource iSC Immunization Supply Chain JA Joint Appraisal KP Khyber Pakhtunkhwa MOU Memorandum of Understanding NISP National Immunization Support Project NLWG National Logistics Working Group NVI New vaccine introductions OpenSRP Open Smart Register Platform PC-1 Planning Commission Form - 1 PCV-10 Pneumococcal conjugate vaccine, 10-valent PSLSM Pakistan Social and Living Standards Measurement survey RI Routine immunization SOP Standard Operating Procedures SOLVE Supply Optimization Through Logistics Visibility and Evolution STEP Strategic Executive Leadership Programme TCS Tranzum Companies and Services TT Tetanus Toxoid UNICEF The United Nations Children’s Fund UPS United Postal Service USAID United States Agency for International Development vLMIS Vaccine Logistics Management Information System WHO World Health Organization WFP World Food Programme ZM Zindagi Mehfooz 2 EXECUTIVE SUMMARY Resilient, high-performing and efficient immunization supply chain (iSC) is a foundation for reaching global and national immunization coverage and equity targets. Many approaches towards iSC improvements at global and country levels tend to focus only on incremental changes in individual components of supply chain performance (e.g., better cold chain equipment or improved data systems). Whilst these initiatives are important, often, the supply chain structure, set-up and network itself hinder transformative and long- lasting changes and limit programmatic goals. Pakistan is experiencing expansion in its immunization services through rapid new vaccine introductions (NVI) into its routine immunization systems, is transitioning from Gavi funding, and has an increased focus on reaching every child with vaccines for preventable diseases with over 80% coverage in all antigens in every district to equitable distribution of immunization services across all population. The system design approach is part of larger efforts to strengthen the immunization supply chain (iSC) structure in Pakistan for efficient service delivery and to accommodate the rapid changes in the immunization system. This approach will build on the 2014 EVM (Effective Vaccine Management) assessment which identified distribution among other weaknesses at all levels of the supply chain structure and demonstrated high inequities in vaccination across provinces and districts. A system design approach was therefore used to assess changes needed to optimize Pakistan’s network, distribution and related functions. Though additional supply chain investments are being made throughout the country, the continuous expansion of immunization services and renewed drive for equitable service delivery to underserved population will further tax the country’s supply chain system. The system design study is therefore aimed at identifying bottlenecks in the iSC structure and set-up, and suggest ways to ensure that the structure is robust enough to stand the changing needs to deliver services efficiently. This system design analysis aimed to contribute to continuous improvement of the iSC through systematic changes, and not a one-off approach. The implementation of the outcomes from the analysis should be adjusted to conform to realities and could take several years for full implementation, evaluation and expansion. Below is a graphic illustration that guided system design optimization approach. At the start of the project, provincial EPI teams identified 14 potential scenarios that could be modelled to provide insights into how best to improve the current immunization supply chain. The proposed scenarios fell loosely into one of these categories: ● Changing point-of-entry for vaccines and dry goods ● Changing delivery routes and optimize the use of the divisional warehouses. 3 ● Implementing direct delivery to lower levels of the supply chain, especially in hard-to-reach areas ● Sourcing vaccines and dry goods across provincial administrative boundaries To guide decision making and ensure an evidence-based approach, data was collected across all levels, documenting current supply chain practices, inputs and costs. This was followed by data analysis using LLamasoft’s Supply Chain Guru® software tool to provide a picture of how the current system operates and generate insights into potential ways to improve availability, reduce risk, increase equity and reduce costs. This report summarizes the results of the Immunization Supply Chain System Design and Optimization project, including recommendations from the analysis, decisions taken at the results workshop in July 2018, and next steps towards implementation endorsed by the Provinces and Areas. As system design