TechNet-21 - Forum

This forum provides a place for members to ask questions, share experiences, coordinate activities, and discuss recent developments in immunization.
  1. Jay Rajgopal
  2. Supply chain and logistics
  3. Friday, 12 February 2016

This is motivated by John Lloyd's recent post about a supply chain for outreach immunization, which I found very interesting. My question is somewhat peripherally related though. As some background, I am an academic who focuses on supply chain analysis, and in particular, I have worked a fair bit on the WHO-EPI vaccine distribution chain over the last few years (I was part of the original HERMES team with Bruce Lee, Shawn Brown, Bryan Norman and others). My interest is mainly in the modeling (via mathematical models or via computer simulation) and analysis aspects, and I have developed a particular interest in outreach since very little seems to have been done in systematically modeling this aspect of vaccine delivery. However, I am having a very hard time understanding the modalities of outreach operations since these seem to be highly variable depending on which country we are talking about! From e-mail exchanges and conversations at meetings (such as the Global Health Supply Chain Summit) with professionals in the field, there seem to be no standard modes for outreach - unlike the overall distribution chain, which typically have a standard 4-level hierarchical structure with fairly standard equipment and vaccine replenishment times. For example, the way I was told outreach is conducted in India (Bihar state) is quite different from the way I was told it is handled in parts of Africa (Mozambique, I believe?).

Which brings me to my question. Is there any publication - paper, article, book/monograph - that describes how outreach immunization is conducted across the world? I'm not talking about planned campaigns, but rather, routine EPI vaccine delivery at remote locations via outreach. If there is no such publication, I was wondering if people in this forum who are involved in outreach would be willing to share how exactly outreach is done in their neck of the woods - just a two to three paragraph summary? For example, how frequently does it happen, whether outreach locations are repeated in some cyclic fashion over time, whether each outreach trip is a single point-to-point visit or whether multiple locations are covered in one trip, whether it occurs from IHCs or from higher levels such as a district facility, whether vaccine supplies for outreach are included as part of routine orders placed upstream, what kind of personnel and equipment constraints one needs to worry about, what are the main metrics used to assess performance of outreach, etc. etc. etc. I suspect the answers to these types of questions will vary quite a bit from place to place, but I'm just looking for the most common processes in use. It just seems that I need to understand the main aspects of outreach and how it relates to the overall EPI supply chain in order to make sure that any models I attempt to build are grounded in reality! I honestly believe that this aspect of immunization has not been studied enough and that there is much room for improvement.

If a few kind souls in this forum could take a few minutes to provide a brief overview of outreach at their location I would really appreciate it...

Cheers

Jay

John Lloyd Accepted Answer
Dear Shamsuddeen!

Its good to hear that via  DHIS one can separate immunization given through outreach from those given at fixed sessions. Perhaps many other countries with DHIS could do the same thing? At the risk of showing my ignorance and naivety, I believe we need to answer the following questions with data to support the answers:
who are the physically ‘hard to reach’? Total no. of infants under 1 yr in areas more than 5-6kms from nearest health facility and percentage of all <1yrs in same zoneApprox % of zone land area that could be classified into, say, a)rural with roads, b)rural no roads c)forest, d)mountain, e)urban and peri-urban <5kms from a health facility: Use ‘HERMES’?how much will it cost to reach them per zone per year?density of population per zone, per classification % assign cost rates for each classification cost per FIChow much time/manpower will the service demand per zone, per  classificationassess the service to be provided (frequency of visits, range of interventions - Use ‘SOS’ WHO/UNICEF as bible!)how many staff person days per year will be used for the servicewhat vaccines, supplies and equipment/transport are needed (capital/maintenance cost)assign vaccine utilization rates per zone, per classificationassess vaccine carriers/coldchain and transport needs
Are these the kind of questions that have already been answered? If not, if the kids are the ‘last 20% un-immunized’ and if we need global funding on the scale of PEI, then we should start now! With this level of data, before micro-planning fills in the details, we can create a global resource to reach the last kids by, say, 2025? No?
  1. more than a month ago
  2. Supply chain and logistics
  3. # 1
Jay Rajgopal Accepted Answer

Thanks everyone for the responses thus far in this thread. I'm going to take some time to digest the various points made and check out some of the links provided - once I do that, I'm sure I'll have more questions!

cheers

Jay

  1. more than a month ago
  2. Supply chain and logistics
  3. # 2

Hi, Jay Rajgopal. Good afternoon from Dar es Salaam, Tanzania?

Concerning the routine EPI vaccine delivery at remote locations through a) stand alone vaccination OS at planned sites – nearby villages, harmlets or site normally situated at around 5 km radius and b) an integrated mobile clinic – where OS and other health interventions are practiced by a big team of health professionals (nurses, clinicians, public health officers etc) are travelling by cars long distances to rural areas with multiple locations along the way, these sites are normally more than 15 kms. For integrated mobile visits, the district hospitals or health centers are the ones responsible because they have 4WD vehicles (ambulances normally)

In most parts of my country, OS are conducted in a cyclic mode of monthly or quarterly depending on the number of children available, remoteness of the area, seasonal variation – e.g., heavy rains; vacccinator availability during planned dates, vaccines availability or other logistics etc. It should be noted that, immunizing health facilities have prepared an annual visit dates plan which is shared to every village/streets (the lowest government administrative body) and communities

The OS vaccine supplies are part of the routine stocks delivered at the facility(ies) every month by the District Medical Officers’ office i.e., there is no separate supply of quantities.

Regards

  1. more than a month ago
  2. Supply chain and logistics
  3. # 3
Shamsuddeen Sani Accepted Answer

Hi Jon,

I think we can very well compute coverages attributable to outreaches at least in my location. We have a data platform using DHIS (distric health information system) which disaggregates EPI data. In this case, all vaccinations from outreach , fixed or mobile sessions can be easily segregated and downloaded.

Thanks

Shamsuddeen

  1. more than a month ago
  2. Supply chain and logistics
  3. # 4
  4. View last reply:
Shamsuddeen Sani Accepted Answer

Hi Jay,

Greetings from Kano, Nigeria. I would like to describe to you a typical outreach strategy where I am currently based. The outreach strategy stipulates that settlements beyond 2km radius from the health facility should be served by outreach services. Note that, the globally accepted standard is 5km but looking at the reality on ground its practically impossible to implement so in certain locations.

The EPI servce provider develops a quarterly microplan that stipulates the settlements to be served by fixed session, outreach and mobile. In the microplan, the person responsible for the conduct of outreach is clearly identified, as well as target population, and resources needed. Typically, a leading community mobiliser at those outreach sites will be identified as well. A day before the outreach day, a town announcer goes to the settlement and inform them about a routine immunization session the following day. Normally, one outreach session is held every week in addition to one or two fixed sessions. All health facilities muct have a session plan that outlines the settlements and the specific days for their outreaches (if they are at all to be covered by outreach sessions).

In terms of logisctics, we have an informed push system for vaccine supply. It typically provides a month stock of vaccine to all equipped health facilities. In a situation where a health facility doesnt have a functional cold chain equipment, they will have to receive direct vaccine delivery from a nearby health facility that has a functional cold chain equipment. In such facilities, vaccine commodities are supplied twice a week( during outreach and fixed session days).

Hope this helps in kick starting further discussions and I will be very happy to answer questions.

Shamsuddeen

  1. more than a month ago
  2. Supply chain and logistics
  3. # 5
James Cheyne Accepted Answer
Hello Jay and thank you for your interest in outreach.  As more people get interested in existing outreach practises we will be able to better understand why some places have very effective outreach programmes and other places have little or no outreach services.  If we can document what usuall works and what usually doesn't we will be a better place encourage and support what works and discourage what doesn't.

My guess is that for every ten health centres that operate with high quality outreach sessions there will be at least twelve or more ways to manage them.  These will be based on a host of highly specific and local opportunities and constraints that change regularly and sometimes at short notice.  Where there are skilled and motivated staff with good support from 'above' they usually manage to find a way.

A common model is for the health worker to travel out from her/his health centre for just one day, partly because this health worker in the only person in the health centre trained to give injections and the local people in that village don't want their health centre closed for more than a full day.  The heath worker may walk and at the end of the day take the vaccines back to the health centre before retuning home.  Or in some cases, return home with the remaining vaccine and take them back to the health centre refrigerator the following morning.

In some societies women are discouraged from staying away from home for more than a day and women are also discouraged from using motorcycles but are still able to use step-through scooters where they are available - which in turn limits where they can go where the roads roads are bad.  If the health worker has access to public transport s/he will need a reliable way to have the fare refunded without too much delay: not always available.

The health worker may visit one, two or three immunisation sites during the one-day trip.  About ten years ago I followed an Auxiliary Nurse Midwife on a three-session one-day walk in the forest area of Srikakulam District in India. She was a very tough and determined lady.

In the absence of widely available support from above and tough and determined workers throughout the health service there is an urgent need to move on from current 'ad hoc'ism' and develop some tried and tested strategies for outreach that are two, three and four days away from the nearest fixed health post.  Routine monthly polio campaigns may have some lessons for the routine services. 
 
Perhaps you, Jay, can help model some options that are based on near-outreach from the health posts and far-outreach options based on the District stores.  I hope so.

Unless the health workers can reliably reach these distant locations, not only with vaccines but also with other medicines, some areas will be stuck with unacceptable low standards of health services for a long time to come.  Do we want that?  I think not.


James Cheyne
Health Service Logistics
james@cheyne.net;
H: +41 22 776 0885; M: +41 78 845 3090
Skype: jamescheyne;
Sowing seeds

  1. more than a month ago
  2. Supply chain and logistics
  3. # 6
Narayana Holla Accepted Answer

Dear sir Please do read the post - link is given below. If it interests you we can communicate further to scale-up the programme to other planning units of the Block. http://www.technet-21.org/en/forums/miss-mission-indradhanush-simulation-study-sampaje-case-reporting

References
  1. http://www.technet-21.org/en/forums/miss-mission-indradhanush-simulation-study-sampaj
  1. more than a month ago
  2. Supply chain and logistics
  3. # 7
  4. View last reply:
John Lloyd Accepted Answer

Hi Jay!

Yes, I agree that we need more feedback on 'lessons learned' on successful and failed outreach strategies. And I agree that it is very hard indeed to find such stories - not surprising considering that EPI never encouraged countries to keep track of immunizations conducted during outreach separately from fixed sessions. Although the data exist by analysis of daily tally sheets, they are then aggregated in reporting. So how do we know what proportion of our coverage is achieved by outreach v. fixed sessions?

PEI has a better history of reaching populations through outreach than EPI! In many countries the children under 5yr reached by PEI exceed the number declared in the census and the estimates of LB rates by as much as 20%! But in the 90s we tried to theme two TECHNET meetings on outreach operations. Unable to get a single document from the Americas' experience, we managed to focus discussion on country presentations.

What did we learn? First, we definitely need to track performance and costs of outreach immunizatiions separately because:

  • managers will be able to see demand hotspots and budget for them,
  • their micro-planning of outreach will become as effective as PEI,
  • they will appreciate and use vaccine wastage data (both administrative and VVM),
  • they will be able to take vaccine to the limits of VVM stability and
  • they will see coverage rise!

Jay, before we ask everyone for information, should we develop a rational list of what info would be the most helpful?

  1. more than a month ago
  2. Supply chain and logistics
  3. # 8


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