Post00271 TECHNET STRATEGIC FRAMEWORK - PART 1 08 August 2000 CONTENTS 1. TECHNET '99 DRAFT RECOMMENDATIONS The agreement of a Technet Strategic Framework is an essential task that we must complete to enable the institutionalization of the Technet within the WHO. As an aid to this development process the Technet Forum is posting the recommendations and action points resulting from the Technet Consultation Meetings. This posting is the first in a series that should help us to formulate and agree on a strategic framework. " These are the recommendations that were agreed upon in a plenary session of the Technet members meeting in Harare in December 1999. They grew from recommendations suggested by those that made and heard presentations during the five technical sessions, by the sub-groups that met during Session 6, and at other times through the meeting. Most of the recommendations are presented under the session headings, except for those that are more general in nature, which are placed at the end". The text below is an extract of the Draft TECHNET MEETING REPORT, prepared by Kristina Engstrom, WHO/V&B, Meeting Rapporteur, with the guidance of John Lloyd, formerly of WHO and now PATH/CVP. Our thanks to Kris and John for making this material available. The moderator apologizes for the delay in posting these recommendations and action points. * The posting of these recommendations is to inform our discussions and to enable the development of the Technet Strategic Framework. * Technet'98 Recommendations will be posted soon, with the earlier recommendations to follow as we convert them to plain text. Presentation Topic: Organizational Culture Adapted from: http://mba98.vanderbilt.edu/Derrick.Mic ... urefinal2/ 1. What Is Organizational Culture? (A Textbook Definition) Organizational Culture: The Set of Shared Values and Norms that Control Organizational Members? Interactions with each Other and with other People outside of the Organization. It is Composed of: * Values - Terminal (Desired Outcome) - Instrumental (Desired Behavior) * Norms 2. Culture: A Manager?s Definition "Culture is what?s sane, according to your company?s definitions." - Madelyn Jennings, Vice-president, Personnel, Gannett Company, Inc. Frameworks for Organizational Culture Understanding and diagnosing organizational cultures is a very subjective process Frameworks exist for guiding you through the process --- MGT 441 - Organizational Design, Terry Noel Content Team Seven: PJ Dempsey, Amelia Koonce, Derrick Mickle, Stefanie Schweigler, Jim Willis ___________________________________________________________________________ TECHNET '99 DRAFT RECOMMENDATIONS These are the recommendations that were agreed upon in a plenary session of the Technet members meeting in Harare in December 1999. They grew from recommendations suggested by those that made and heard presentations during the five technical sessions, by the sub-groups that met during Session 6, and at other times through the meeting. Most of the recommendations are presented under the session headings, except for those that are more general in nature, which are placed at the end of this chapter. SESSION 1: REACHING THE UNREACHED Technet members have learned that failure to reach remote populations that is attributed to lack of transport is usually not lack of vehicles per se but lack of transport management. Management tools exist and are in use but not nearly widely enough. Experience with transport management systems needs to be collated, adapted, and disseminated; cost studies must continue; and operations managers need management skills, as recommended below. R 1. A Technet Transport sub-group should be established by March 2000 to: * Collect and evaluate existing transport management tools, modify them where necessary, and disseminate them to Technet members and national managers. * Document experience in using these tools and disseminate achievements and problems. * Prepare transport system indicators and a survey instrument that can be used on its own and also be integrated into the new Immunization Services Assessment Guidelines for those instances where an in-depth transport assessment is warranted.Conduct transport availability and cost studies in areas of different population density, both for routine outreach and supplementary immunization activities, to better define the basis for transport infrastructure budgeting. SESSION 2: LOGISTICS OF DISEASE CONTROL Experience with Acute Flaccid Paralysis (AFP) surveillance has underscored the principle that support for logistics is more likely to be obtained when there is a surveillance system. Much of that system relies on logistics, including: * Storage of vaccine in appropriate cold chain conditions at all levels * Distribution of vaccine, syringes, and other equipment and materials * Collection and transport of specimens (reverse cold chain) Planners and policy-makers hope that the investments made and experience gained in polio eradication will contribute to other disease control activities control. One benefit that could be realized relatively quickly is to expand surveillance supervisory visits to include logistics activities. R 2. The WHO Vaccines and Biologicals Department and the Secretariat for Technet should prepare a simple checklist to be used during supervisory visits for AFP, neonatal tetanus, or measles surveillance for the assessment of vaccine supply and cold chain in health facilities. This checklist should be disseminated to countries for their review and adaptation. SESSION 3: SAFETY OF INJECTIONS Safety of injections is a growing concern for the public, as well as for health care providers and those who advise and support them. Among the many technical and management issues that need further work before injection safety can be ensured are: * Development of effective, yet inexpensive equipment for disposal and destruction of sharps and other infectious waste * Development of decision-making tools for selection of injection technologies * Evaluation of sterilization practices * Research and development of auto-disable syringes for curative use Technet members agreed that the Safe Injection Global Network (SIGN) should play the major role in co-ordinating research, promotion, and planning on injection safety in curative as well as preventive settings. It should participate in or take the lead in implementing the four Technet recommendations below. R 3. Technet endorses the recommendations of the Almaty Technet sub- committee, 28-30 April 1999, on the disposal and destruction of sharps and other infectious waste. R 4. On the basis of the WHO three-country study (Ekwueme, Larsen, et al.), the Technet secretariat should develop, field test, and disseminate a generic protocol for countries to use to compare the cost-benefit of available injection technologies. R 5. The prevalence of the use of time-steam-temperature (TST) sterilization indicators and of adequate sterilizer maintenance in each country using sterilizables should be urgently evaluated. The evaluation should identify the causes of good and bad performance and should be followed by plans of action to ensure sustainability of injection safety. R 6. SIGN should convene a working group to define specifications for auto- disable (A-D) syringes for curative injections and then evaluate the potential of A-D syringes for curative settings in two stages: * First, studies should be conducted under ideal circumstances to evaluate the safety and effectiveness of A-D technology for curative syringes in these settings. * Subsequently, A-D syringes should be evaluated in the field to evaluate their effectiveness in preventing re-use where resources and supplies are limited. SESSION 4: THE COLD CHAIN Policies concerning the cold chain, cold chain supplies and equipment, and tools for the management of vaccine supply, distribution, and storage continue to be topics of discussion for Technet members. As with transportation, injection safety, and other logistics issues, the technology may be available but the execution is not. In their recommendations for the cold chain, Technet members focussed on filling gaps in technology and management tools and in providing training that ensures high quality performance. Problems of implementation are addressed more globally in the last section on Other Recommendations. R 7. The current guidelines on the introduction of CFC-free refrigerators into the cold chain should be revised to include HFC and HC gases, which are now more widely used. R 8. Technet and PAHO should convene a working group to guide the revision of the commodities and logistics management software (CLM), including the transition to the Windows platform by March 2000. R 9. WHO should prepare a guide on the management and supervision of vaccine distribution using Vaccine Vial Monitors (VVMs) by July 2000. Existing training materials should be included in this guide as appropriate. Special efforts should be made to disseminate these materials widely and to promote their use in training. R 10. Technet should conduct more country studies on the integration of the distribution of drugs and vaccines by the end of 2000. SESSION 5: INTEGRATION OF HEPB, HIB & VITAMIN A Just as decision-making tools are needed for the selection and implementation of transport systems, waste disposal systems, and injection equipment, they are needed for the selection of vaccines and different renditions of the same vaccine, especially when new vaccines are becoming available for integration into immunizations services. Technet recommendations focussed on these needs. R 11. Technet should produce guidelines for managers that will help them compare advantages, disadvantages, and costs of different vaccine products. Guidelines should include information on monovalent and polyvalent presentations, single- and multi-dose presentations, requirements for syringes, training needs, and cold chain requirements at each level. R 12. By June 2000, a Technet sub-group should be prepared to advise WHO and UNICEF on procurement specifications for different vaccine presentations. WHO and UNICEF should work with vaccine manufacturers to optimize the storage volume and packing of vaccine. R 13. By June 2000, WHO and UNICEF should request vaccine manufacturers and National Regulatory Authorities to include data in their inserts on the shelf life at designated tropical temperatures for the more stable vaccines that are supplied with VVMs. OTHER RECOMMENDATIONS Technet members made other recommendations that apply generally to all of the topics of interest or that address Technet itself. R 14. A Technet sub-group should be formed to develop a strategic plan for Technet activities, linked to the WHO/V&B strategic plan, and to identify the appropriate process and modalities of engagement with GAVI by the end of February 2000. R 15. GAVI should consider forming a Logistics Task Force to complement the work being carried out by its other Task Forces (currently, on financing, advocacy, and country coordination). The Logistics Task Force would focus on the revitalization of immunization services, participating in design, field-testing and implementation of country assessments and introducing new vaccines. R 16. Technet should set up a sub-group to collaborate on the development of the instrument for GAVI country assessments by February 2000. R 17. Technet recognizes the importance of training in improving service performance and introducing new policies, strategies, technologies, and vaccines. Considering the poor record of previous training efforts, new training strategies that assure quality and are targeted to those who need the training to do their jobs should be designed, implemented, and evaluated. R 18. Extending the scope of the recommendation of the 2nd Technet meeting, Technet should request Ministries of Health to allow national logisticians and managers to communicate with Technet members and the Technet secretariat on technical issues. Official communications would continue to be conducted through normal channels. ___________________________________________________________________________ ___________________________________________________________________________ ACTION POINTS During the sub-group meetings in Session 6 and thereafter in plenary, participants agreed on actions that they could undertake to support the implementation of the 1999 (or previous) recommendations and to contribute to the improvement of primary health care operations. Some of these actions are new; those that have been brought forward from earlier Technet meetings are so indicated. 1. INJECTION SAFETY Injection safety continues to be of major concern to Technet members and others working in the health sector. 1.1 NATIONAL INJECTION SAFETY PLANNING In 1998, the Copenhagen meeting of Technet included as a priority activity that: Every country should devise or update a national plan of action for injection safety aimed at achieving 100% safe injections by 2000. WHO will continue to monitor the status of these plans and will report to Regional EPI Managers' meetings and the next Technet consultation. At the end of 1999, it was clear that many countries were still not treating injection safety as a high priority. They had not implemented safety measures, e.g., ensuring that re-usable needles and syringes were sterilized, had not developed injection safety plans, and were not monitoring injection and syringe disposal practices. ACTION POINT 1.1. Technet members should continue to remind their colleagues, partners, and clients of the importance of this activity, promote plan development, and provide assistance in monitoring of plan implementation. 1.2 INTEGRATED APPROACH TO SOLVING THE INJECTION SAFETY PROBLEM Although auto-disable syringes offer close to 100% protection against re- use, this protection can never be totally guaranteed. This and other considerations (such as that re-usable syringes will continue to be needed) mean that the provision of auto-disable syringes alone will not work. Health workers need to integrate safe practices into their daily behavior. They must have adequate supplies of auto-disable syringes at all times. They must have adequate disposal facilities to ensure that syringes are rendered harmless after use and then completely destroyed. These points, made in 1998 and earlier, must be continuously emphasized. ACTION POINT 1.2. Technet members should help national managers and partners understand that no guarantees can be made against re-use of auto- disable syringes. Members should help managers plan to provide good training and supervision for health workers, to monitor needle and syringe use, to install adequate storage and disposal facilities. 1.3 EXTENDING THE LIFE OF STERILIZABLE SYRINGES In a study in Zambia, where 50% of injections are given with sterilizable syringes, the life of syringes was significantly lengthened when a vapor purifier filter was used. Hard water pads were useless. TST spots were enthusiastically received because they helped prove that leaking sterilizers were not sterilizing the equipment. ACTION POINT 1.3. Technet members should encourage sponsors to continue the trials of the filters and should continue to promote the use of TST spots and monitor sterilization in practice. 1.4 TECHNOLOGY TRANSFER Availability of funds and technical assistance will not guarantee successful transfer of syringe production to new manufacturers any more than they guaranteed problem-free transfer of vaccine production. Regulation of production and continuing monitoring of product quality are also needed. ACTION POINT 1.4. Manufacturers of auto-destruct syringes, such as Becton- Dickenson should provide information about what is needed to transfer syringe production technology and what assistance they can provide in setting up the production process itself and in dealing with connected issues, such as waste management. 2. INDICATORS OF LOGISTICS PERFORMANCE WHO and UNICEF staff, national staff, and international partners have been conducting assessments, evaluations, and reviews of logistics, the cold chain, and other aspects of immunization operations for many years; and good assessment tools have been developed. Now, new tools are needed to examine the impact of changes in technology and the introduction of new vaccines as well as to continue the review of the performance of health workers in meeting existing standards. They have also called for a common tool that all staff and partners can use. This tool, which includes indicators for all aspects of immunization operations, is now under development. In keeping with Recommendation 16 (see Chapter 3), Technet members have played and will continue to play a role in this development. 3. TRANSPORT FOR OUTREACH Most people involved in the planning and provision of health services are now convinced that it is not how many vehicles you have that counts but how you use them. Recognizing that help in transport systems development is widely needed, participants in this Technet meeting recommended that a working group be formed to select the best management systems tools and disseminate them, with recommendations for technical assistance and training, to national managers. See Recommendation 1 in Chapter 3. 4. INTRODUCTION OF NEW VACCINES With the availability of new vaccines (hepatitis B and Hib) and revived interest in old ones (yellow fever), national managers are faced with new kinds of decisions: Should we put our resources into improvements in the existing immunization programme or into the introduction of new vaccines? To make these decisions, managers need to know: * The extent of improvements that are needed * The capacity of the existing programme to integrate a new vaccine * The operational requirements of the vaccine, e.g., how it is administered and what its storage requirements are. The new Immunization Service Assessment Guidelines will help managers assess their programmes' performance and capacity for expansion. Manufacturers of new vaccines can help by providing information about the new vaccines. WHO, in turn, can continue to collect this information from manufacturers and from regional offices such as PAHO, organize, package, and disseminate this information to national managers. ACTION POINT 4.1: WHO should ask manufacturers of new vaccines to provide the following: * For each vaccine and diluent and each presentation, the size of box in which it comes and its volume in refrigeration. * For each vaccine and each presentation, the number of vials included in the inner package and the number of inner packages in each box. Description of diluent packaging - included in the vaccine box or packed separately? * Photocopies of the labels that the manufacturers place on vials, ampoules, diluents, and boxes. * Photocopies of inserts. 5. INTEGRATION OF VACCINES AND DRUGS In some countries, vaccines and drugs are now being stored, packed, and shipped from a single central-level store. Similarly, integrated transport management is being re-instituted or tried for the first time. Other aspects of operations are also being considered for integration. Logisticians can help managers examine the benefits and constraints of integrating other operational functions, such as maintenance and repair of equipment and supervision, in their efforts to improve services. Technet members particularly, because of their knowledge, experience, and ubiquity, are in an excellent position to provide this assistance. ACTION POINT 5.1: Technet members should help managers systematically consider the short-term and long-term impacts of decisions to integrate and decentralize operational functions. 6. COLD CHAIN The cold chain recommendations of the 1998 Technet addressed requirement for refrigerators to be used for vaccine storage and the activities that were needed to plan for the purchase or repair of equipment that met these requirements. Most of these activities are long-term and were endorsed again in the 1999 meeting. Renewed emphasis was placed on facilitating the integration of VVMs and the multi-dose vial policy (aka opened-vial policy) into daily practice by health workers and managers. Technet members can help by promoting their use and providing training and technical assistance. ACTION POINT 6.1: Technet members should take every opportunity to explain how VVMs work and describe their benefits to health workers, managers, and the public. Similarly, the multi-dose vial policy needs to be explained and promoted. In addition, Technet members should monitor the use of VVMs and the application of the policy in health facilities. ___________________________________________________________________________ The Draft report is now available for download in Adobe acrobat format: Technet1999-MeetingDraftReport4-2000.pdf (9kb) Go to the website ftp://ftp.acithn.uq.edu.au/Technet/1-ClickHereForTECHNETfiles/Technets Then double click on the file: Technet1999-MeetingDraftReport4-2000.pdf to start the download. or Send an email to: [[email protected]][email protected][/email] with the message: get technet Technet1999-MeetingDraftReport4-2000.pdf and the file will be emailed to you