vaccine logistics and supply chain

Vaccines logistics and supply chain assessment in Bihar, MP and UP

Diagnostic findings

November 2012 ITSU - PHFI

Content

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Context & assessment design

Assessment results: Severity of stock-outs

Issues and root causes for stock-outs

Recommendations for the States

ITSU - PHFI 2

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

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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

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

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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

https://www.itsu.org.in/

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

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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

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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

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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


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-


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


https://www.itsu.org.in/


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-


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



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

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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

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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

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https://www.itsu.org.in/itsu-overview

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);

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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

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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

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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

PU

RN

IA

BH

AG

AL

PU

R

▪ 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

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

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


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


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

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

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

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


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


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


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

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

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

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

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ITSU - PHFI 35

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

Recommendations for Madhya Pradesh


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



▪ 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


ITSU - PHFI 37

Recommendations for UP


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



▪ 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


ITSU - PHFI 38

Backups

ITSU - PHFI 39

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

Va

ccin

e a

va

ila

ble

Vac

cin

e

avai

labl

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

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



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



Saharsa district

Simbi Bakhtiyarpur

NA

NA

NA

NA

NA

NA

NA

NA


TT: ~10% of sessions were stocked out, primarily in Giddhor &

Salkhua

Jamui district


Vac

cin

eav

aila

ble

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA



NA

NA

NA

NA

NA

Saharsa district

Simbi Bakhtiyarpur


Measles: ~9% of sessions were stocked out, primarily in Giddhor,

Salkhua & Simbi Bakhtiyarpur

Jamui district


Vac

cin

eava

il

able

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA

NA



NA

NA

NA

NA

NA

Saharsa district

Simbi Bakhtiyarpur


BCG: 20-25% of sessions were stocked out across all districts


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

DPT: No significant supply issue observed for DPT except in

Mauiama district (10-15%)




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


tOPV: 15-30% sessions were stocked out in Ikuana, Mauiama and

Koraon blocks




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


Measles: ~30% sessions were stocked out in Mauiama




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


TT: ~10% sessions were stocked out in Mauiama




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


vaccine logistics and supply chain

Documents

mr dheeraj

supply chain of vaccines

syringes supply chain

bihar dr deepak kumar

unicef mr dharmender

regional warehouse districts

supply chain security

states itsu phfi