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  1. James Cheyne
  2. Supply chain and logistics
  3. Wednesday, 05 September 2018

Dear Colleagues,

You are invited to contribute to a new discussion on 'When should Ministries of Health use refrigerated vehicle to deliver vaccines?'.

Discussion co-moderated by James Cheyne and John Lloyd:

There are at least four good reasons for using refrigerated vehicles to replace the classic pickup trucks loaded with cold boxes:

  1. The number of vaccines used in national immunization programmes has roughly doubled over the past 20 years and the number of new vaccine introductions is likely to increasing at a similar rate over at the next ten years. Larger volumes of vaccines will need larger vehicles.
  2. Refrigerated vehicles with three or four times the carrying capacity cost about the same as a typical pickup truck including the cost of the cost boxes and ice packs.
  3. Refrigerated vehicles eliminate the need to freeze hundreds of ice packs for each trip. Furthermore, continuous temperature monitoring in refrigerated vehicles is likely to reduce the amount of vaccine frozen in transit
  4. Larger capacity vehicles are better adapted to make round trips to deliver vaccines to several remote stores, saving both fuel and time.

There are also at least four reasons for retaining pickup vehicles that deliver the vaccine in cold boxes and not investing in refrigerated vehicles:

  1. Existing delivery routes can continue to be used without the need for new route planning and new training for drivers and heath staff.
  2. Refrigerated vehicles can be difficult to maintain and spare parts for both the vehicle and the refrigeration unit are not always easy to source.
  3. Even with good maintenance and repair services available a backup refrigerated vehicle is needed to keep the deliveries moving when the first vehicle is being serviced or repaired after an accident.
  4. When not needed for vaccine deliveries pickup vehicles can be used more economically for non-vaccine deliveries.

The world is not this simple, though. 

We would like your thoughts and opinions on when you think refrigerated vehicles can be more effective and also when pickup trucks with cold boxes on the back can be the better option. 

Or, of course, we would like to hear of any other options you know about to delivering large volumes of vaccines simply and reliably.

Finally, if you are already using refrigerated vehicles, please have a look at WHO’s survey of refrigerated vehicles.  The purpose of the survey is to gather information on the performance of refrigerated vehicles that are three years old or older:   https://www.surveymonkey.com/r/PQSrefrigeratedvehicle

The information will be used to help PQS develop standards for refrigerated vehicle meet the needs and operating environments of immunization programmes. Your help will be extremely valuable to WHO PQS and the WHO Expanded Programme of Immunization (EPI).

Best regards from John and James.  We are both looking forward very much to debating your thoughts, ideas and suggestions.  Many thanks.

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Dear Sir,
The use of refrigerated vehicle in vaccine distribution helps a lot in eliminating
vaccine exposure to freezing temperature. Here in the Philippines specifically
Central Visayas ,we use conditioned packs and EPS boxes from the National Cold 
Store (Manila) to our Regional Cold Store (Cebu City) via air transportation (24 hours
duration). My distribution to Provincial and City Health Offices (District Cold Store) is using cool water packs and EPS boxes. Right now, the National Cold Store is using Credo boxes with usb data logger for vaccine distribution to Regional Cold Store and this will be return  after storage.
No more EPS boxes for distribution and the cold boxes which is available in the District Cold Store
cannot accomodate large quantities of vaccines. So, the best option is to have refrigerated vehicle
for vaccine distribution compared to purchasing EPS boxes and water packs.

This is my  thoughts. Thank you.

Arnulfo E. Lavares
Regional Cold Chain Manager
Department of Health-Regional Office VII
Osmeña Blvd., Cebu City
Philippines 6000
  1. more than a month ago
  2. Supply chain and logistics
  3. # 1
James Cheyne Accepted Answer
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Dear TechNet members,

Thank you for following and contributing to the TechNet discussion on refrigerated vehicles. Here is an interim summary of the discussions so far:

Nine people joined the discussion with one person contributing seven times sharing his thoughts and opinions on how refrigerated vehicles are being used and how they could be used differently. A big thank you to each of you, with a special mention for Alain Blaise Tatsinkou who contributed more than anyone else.  

Our vision was to find ways to be sure that refrigerated vehicles are available when they are needed, that they are expertly specified and procured, that they are used most effectively, and that they are maintained to a high standard. 

Your posts exposed a number of important issues to understand the issues better and to think about for the future:

  • Refrigerated vehicles can be particularly useful to delivering the large quantities of supplies needed for routine campaigns, for meningitis or measles control, for example, and campaigns to control outbreaks.
  • Refrigerated vehicles are most useful at the higher end of the supply chain. That is, either from the manufacturer or the airport to the central store, then to the regional stores and to the larger district stores. 
  • Some refrigerated vehicles can be fitted with a partition dividing a cold storage area from a second storage so that other supplies that don’t need to be kept cold, syringes, bed nets, etc. can be delivered at the same time as the vaccines. Specifications exist for moveable partitions; another option is to specify fixed partitions – currently used in Turkey, for example.
  • One contributor suggested that vehicles with both cold and ambient compartments could be used as a mobile clinic to reach distant populations with a wide range of health services.
  • Delivering supplies reliably from different ministry departments can be hard to manage in practice. One comment was that delivering supplies reliably from several different ministry departments has been successful in a number of places when the delivery service was outsourced to a third party contractor. 
  • Refrigerated vehicles are significantly more complicated to service that normal road vehicles so outsourced maintenance was also suggested as an option.
  • A WHO-led questionnaire on the strengths and weaknesses of existing refrigerated vehicles was promoted several times: https://www.surveymonkey.com/r/PQSrefrigeratedvehicle this survey is still open for more contributions, please.
  • One frequently mentioned problem was vehicles that do not have good systems for securing the vaccine load during transport. For example, shelves that don’t have nets to prevent the vaccine boxes falling off the shelves, nor stackable boxes or roll cages and straps to stop the load shifting during the trip.
  • Fifteen countries were listed during the discussion as already using refrigerated vehicles to deliver vaccines.
  • Interestingly, there were no comments of the advantages of real-time temperature monitoring and alarms during the delivery trips.
  • Finally, please note that the International Association of Public Health Logisticians (IAPHL) is just opening a new moderated discussion on refrigerated vehicles for October (now): https://community.iaphl.org/iaphl/discussions/list. We hope you will contribute to these discussions as well as continuing your valuable and lively contributions to TechNet.

James Cheyne

  1. more than a month ago
  2. Supply chain and logistics
  3. # 2
James Cheyne Accepted Answer
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Hello Serge,

Thank you for this important observation.  This issue has come up before but now we all know about it and that's a good start to getting it fixed.

The current new draft specifications for qualified refrigerated vehicles has the following two paragraphs on packing vaccines in a vehicle:

Paragraph: 5.1       Body structure to be rigid and capable of withstanding vibrations and shocks from rough roads while keeping the driver and load safe. Load tie-down eyes, hooks or rails fitted and two ratchet straps for each metre length of the vehicle body. I.e. 14 straps for a seven-metre length body. The straps to be the hook type 5 cms wide.

Paragraph 5.15     Foldable stacking boxes, rolling cages or ventilated pallets available.  No mention of shelves.

For example for stackable or folding boxes, see: http://www.plastor.co.uk/catalog/euro-stacking-containers-and-without-lids-folding-containers

For Roll cages, frequently used in supermarkets for delivering many small items see: https://www.google.ch/search?q=supermarket+roll+cages&rlz=1C1CHWA_frCH567CH567&tbm=isch&tbo=u&source=univ&sa=X&ved=2ahUKEwjjzKWw5ufdAhWlx4UKHUPiAzsQsAR6BAgBEAE&biw=1422&bih=646

The new specifications will be published shortly by WHO-PQS.

Following up on Joel's comment of "...we have 2 refrigerated trucks here in Madagascar ... [that] are used as traditional transport trucks. Vaccines are always transported by PQS certified cold boxes with cold ice packs."  I can think of two reasons why the refrigerated vehicle could be used to carry cold boxes with vaccine and icepacks:

  1. If the delivery trip is likely to be longer than the cold life of the cold boxes in the local ambient temperature;
  2. If the refrigerated vehicle doesn't have backup facilities in the event of a breakdown or during overnight parking. In the case of a breakdown, this backup is typically a generator with a fuel tank large enough fixed in the vehicle to keep the refrigeration unit running for 24 hours. For overnight parking, an extension wire is needed to plug into a local socket of the correct voltage.

If neither of these conditions exist the cold boxes loaded with vaccine and ice could be taken on a pickup truck with a shaded load area.  Or, have I missed something?

Finally, you say: "The only good experience I saw was in Uganda."  Could you describe this for us please?  Many thanks. I have heard that the vehicles in Uganda are well managed but I have nor seen them for myself.

Many thanks Serge and Joel for stimulating this discussion.  I hope it's useful.

James

  1. more than a month ago
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  3. # 3
Serge Ganivet Accepted Answer
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Hi,

From my few experiences in Liberia, Mali, Burkina Faso and Senegal, the main issue is how to pack the vaccines in the refrigerated truck.

The shelves are not appropriate because the cartons fall easily, there is no effective net, etc... so most of time the vaccine / store managers prefer to put the vaccine boxes in insulated boxes and more with cool packs in each of these cold boxes. The only good experience I saw was in Uganda.

Do we have refrigerated truck with appropriate equipment to avoid the use of containers to pack the vaccines, as mentioned also by Joel?

Thanks!

  1. more than a month ago
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  3. # 4
James Cheyne Accepted Answer
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Dear Paul,

You say "In my experience, maintenance is by far the biggest issue. Not just maintenance but also proper commissioning of refrigerated vehicles."

I couldn’t agree more!  Put in order of what needs to be done from procurement to use, WHO has been working on two of the three most important steps to ensure that refrigerated vehicle continue to run as promised - and for a long time:

  • Careful and thorough initial specification for procurement. WHO has a specification document that will shortly be posted on the WHO-PQS website.
  • Thorough commissioning that includes an inspection when the vehicle is delivered to be sure that it meets the specifications and that everything works, static testing of its refrigeration unit and its controls during daytime and night time temperatures, and close monitoring during the vehicle's first three months of routine use to correct problem quickly and to have the evidence needed to claim repairs thought the guarantee. When agreed, this document will also be posted on the WHO website.
  • Guidance on vehicle servicing is still weak, however, other than frequent discussions on whether servicing should be outsourced or carried out by the Ministry concerned. The best information I know of on servicing options come from NGOs and the private sector. Sorry I can't help further.

Concerning any poor training of drivers, this is clearly an important issue. Standard operating procedures and effective supportive supervision might help here too.

Your next point about 4X4 drive refrigerated vehicles: feedback from several experienced users of refrigerated vehicles has led to the most recent specification proposing that all refrigerated vehicles have a 4X4 drive option. Concerning damage due to poor roads depends also on skilled and experienced drivers, of course, plus extra protection for the refrigeration unit that is fitted high up on the front of the body.  The driver may not notice low hanging branches that can do serious damage to a refrigeration unit.

Finally, please note, for your information the IAPHL ListServe is starting a moderated discussion on Monday 1st October that will also cover these issues, and others, in more details.

Many thanks for your helpful and useful comments.

  1. more than a month ago
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  3. # 5
James Cheyne Accepted Answer
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Dear Dr. Chandralal Mongar,

Your post is realy helpful, thank you.  You are clearly well-organised in Thimpu.

James

  1. more than a month ago
  2. Supply chain and logistics
  3. # 6
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Dear Dr. Chandralal,

Thank you for your post. It is also describing the mode of operation of the refrigerated vehicles that I am familiar with and aware of.

Best regards,

Alain

 

Quoting Dr Chandralal Mongar

"Dear James,

Bhutan uses refrigerated vehicles for transporting vaccines from the airport to the national EPI store. The two regional EPI stores - Gelephu (central) and Mongar (eastern) - use their refrigerated vehicles to collect vaccines from the national EPI store and to distribute them to their catchement districts quarterly. There are three refrigerated vehicles in total, one for the national EPI store and one in each of the regional EPI stores. Beyond district level, vaccines are transported in cold boxes/vaccine carriers using conditioned ice packs once a month. 

With best regards, 

Chandralal"

 

  1. more than a month ago
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  3. # 7
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Hello Joel,

Thank you for your confirmation, I guess James saw your message.
Best wishes for you and your team.

Regards,

Alain

Quoting Joel Coddet:

"Dear Alain Blaise Tatsinkou,

I can confirm that we have 2 refrigerated trucks here in Madagascar. For your information, these 2 refrigerated trucks are used as traditional transport trucks.
Vaccines are always transported by PQS certified cold boxes with cold ice packs.

Best regards,

Joel Coddet

Logistics, Vaccines management and cold chain officer

WHO Madagascar"

 

 

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

Bhutan uses refrigerated vehicles for transporting vaccines from the airport to the national EPI store. The two regional EPI stores - Gelephu (central) and Mongar (eastern) - use their refrigerated vehicles to collect vaccines from the national EPI store and to distribute them to their catchement districts quarterly. There are three refrigerated vehicles in total, one for the national EPI store and one in each of the regional EPI stores. Beyond district level, vaccines are transported in cold boxes/vaccine carriers using conditioned ice packs once a month. 

With best regards, 

Chandralal

  1. more than a month ago
  2. Supply chain and logistics
  3. # 9
Paul Dowling Accepted Answer
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A few observations:
In my experience, maintenance is by far the biggest issue. Not just maintenance but also proper commissioning of refrigerated vehicles. Cold room maintenance is challenging enough for most programs, refrigerated vehicle maintenance adds a level of complexity to your supply chain. Even if private sector maintenance capacity exists many programs are reluctant to outsource maintenance, often because they simply don’t have the budget. Refrigerated vehicles can also create a false sense of confidence, “oh it’s a refrigerated vehicle so we just put the vaccines in and we are good to go”. This creates a lot of risks for product quality. Cold boxes may not perform as well as a functioning refrigerated vehicle but they need a lot less maintenance.

I’m not sure the space thing is a big factor. Obviously it depends on a particular country/system setting including the volumes of products, how dispersed delivery sites are and how many can be visited in a single run, but in a lot of cases the volumes of products going to a single site are quite low, and refrigerated vehicles tend not to be used at full capacity, even if syringes are included. Then it can become a rationale of loading more in, so delivery cannot be made within the delivery window – drivers must make an overnight stop and quality is compromised. I am not saying this should happen, and I’m not sure any program manager would ever admit to this, but sadly it can and does happen.

An exacerbating factor is that drivers are often not trained in correct operation of these vehicles, including simple practices like keeping doors closed to more complex things like not adjusting thermostats. We seem to do a better job in training people to prepare cold boxes than we do in operating refrigerated vehicles.

Another issue is the use of refrigerated vehicles makes integrated delivery (e.g. vaccines with other medicines that don’t require refrigeration) and thus efficiency harder. Not impossible, but harder. Against that, there are other medicines that require or prefer cold chain (some test kits, oxytocin) but they are few and usually low volume. In my experience, most countries have moved or are moving towards integrated (for program-based essential medicines) delivery (or integrated pick up).

The introduction points out that a refrigerated vehicles can cost as much as a single 4WD pick up, but remember most refrigerated vehicles can't make deliveries through difficult off-road terrain or dirt roads. And while I have seen refrigerated 4WD vehicles, I really don’t know how the refrigeration units stand up to rough terrain, or how much they cost.

While this may sound obvious, I think what gets forgotten is to analyse and make evidence-based decisions. Don’t simply say "oh, refrigeration is better". Look at the levels of your supply chain, volumes of products for each level, how dispersed are delivery sites, what the road conditions are, whether or not capacity exists to do routine maintenance and funding is available to pay for it. And when you buy vehicles, make sure they are properly commissioned before using, and there is a training program for both warehouse staff and drivers on how to operate them. At the end of the day, most supply chains will use both, with refrigerated vehicles operating from central warehouses down to regions or provinces, 4WDs doing last mile deliveries, and with a mix in between.

  1. more than a month ago
  2. Supply chain and logistics
  3. # 10
Joel Coddet Accepted Answer
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Dear Alain Blaise Tatsinkou,

I can confirm that we have 2 refrigerated trucks here in Madagascar. For your information, these 2 refrigerated trucks are used as traditional transport trucks.
Vaccines are always transported by PQS certified cold boxes with cold ice packs.

Best regards,

Joel Coddet

Logistics, Vaccines management and cold chain officer

WHO Madagascar

  1. more than a month ago
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  3. # 11
Abdul Aziz Sediqi Accepted Answer
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This is very nice idea actually if possible to replace the refrigerators with refrigerated vehicles. But I am still confuse of how the vaccines could be delivered to the health facilities from the regional or provincial cold chain. Can you help me understand how it works?

Second question: is it possible to use this method for all over the world? I am not sure it is doable, because for example in my country Afghanistan, there are around 429 districts ,34 provinces, 8 regions with 2021 HFs with EPI services. Also most of the districts are insecure and a lot of people that live in those districts do not have access to health services. What could be possible to do in this insecure country to deliver vaccines by refrigerated vehicle?

 Thanks for your help!

  1. more than a month ago
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  3. # 12
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Hi James,

Thank you for sharing with us the experience in Turkey.  I believe that a good use of refrigerated vehicles provides many advantages and opportunities for the EPI and other health interventions. I know two more countries using refrigerated vehicles.

  • Niger 
  • Senegal 

Best 
Alain

 

  1. more than a month ago
  2. Supply chain and logistics
  3. # 13
James Cheyne Accepted Answer
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Hello again Alain!

Thank you so much for your reply with the list of seven countries using refrigerated vehicles.  In the meantime we have learned that one province in Turkey with a total population of about three million people is now using refrigerated vehicles to deliver vaccines.  This shows that these vehicles can be useful in areas where there are relatively few people to reach.

Thank you (again).

James Cheyne,

  1. more than a month ago
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  3. # 14
James Cheyne Accepted Answer
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Hello Abebe,

Thank you for your really interesting reply.  Would you have a few minutes to give us some more details on how your refrigerated vehicles operate in Ethiopia?

First, WHO published a survey recently on how well refrigerated vehicles perform after three years' use.  Your experience in Ethiopian is valuable for others if you could complete the survey which can be accessed at:

 https://www.surveymonkey.com/r/PQSrefrigeratedvehicle 

The survey has 36 questions and may take 20+ minutes or so to complete but your experience will be valuable to help WHO to develop strong specifications for new refrigerated vehicles that need to operate in tough conditions. 

Secondly, WHO and I have some questions that will help us to understand better how your vehicles are use and managed:

  • How many small / medium / or large refrigerated vehicles do you have in use?
  • How many deliver vaccines / other temperature-sensitive pharmaceuticals / other health service supplies (syringes, safety boxes, etc.)?
  • How many are they based in: Addis Ababa / the Regions or chartered cities / zones?
  • If possible can you share other documentation on the performance of the vehicles? If possible a typical vehicle logbook, typical service history, a typical regional delivery route and other information that could help other Ministries to re-plan their delivery schedules.  In case you do not want to share these details with the whole TechNet community you are welcome to send these details directly to my email (james@cheyne.net) and I will ensure that they are not shared beyond the WHO community. 
  • I will be happy to have a Skype call also if this would be easier for you to reply: 'jamescheyne'.

Thank you again and I, and WHO, look forward to hearing from you again.

Best regards.

  1. more than a month ago
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  3. # 15
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Good morning James,
From my peers, I do have some information for countries that are using refrigerated vehicles, mainly for EPI.

  • Burkina Faso
  • Cameroon
  • Côte d'Ivoire
  • Madagascar
  • Mali
  • Nigeria
  • Tchad

Best

Alain

  1. more than a month ago
  2. Supply chain and logistics
  3. # 16
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Hi James,

 

Ethiopia is also using refrigerated vans to deliver vaccines from the central store to sub-national stores and then to districts. We have experiences in the out-sourcing preventive maintenance of the cooling units to the third party, training the drivers on how to operate the vehicles and other best practices to keep the cold chain effective.

 

Abebe

  1. more than a month ago
  2. Supply chain and logistics
  3. # 17
James Cheyne Accepted Answer
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Good morning refrigerated vehicle specialists.

During this discussion I have been asked how many Ministries of Health are already using refrigerated vehicles to deliver vaccines or other temperature-sensitive pharmaceuticals.

I now that Uganda, DR Congo and one province in Turkey are using vehicles but I'm sure that are many more Ministries with useful experience, both good and bad, with these vehicles.

Question:

Could you please post the names of the countries or regions that you know are already using refrigerated vehicles?

This will be helpful for us to reach out to compile the experience from the people who really know: the people who use them

Many thanks.

James Cheyne.

 

  1. more than a month ago
  2. Supply chain and logistics
  3. # 18
James Cheyne Accepted Answer
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Hello Alain, thank you for your useful comments and suggestions. 

I agree wholly that managers and policy makers should think about integrated deliveries and that refrigerated vehicles might be useful as mobile clinics for remote areas.

Many ministries of health could make huge leaps forward in their supply chain management if products from different department could be delivered in the same vehicle. The problem seems to be that no department wants to use their vehicles to deliver another department’s product while the other department continues to use their vehicle for some other trips. Also, the department that manages the common deliveries may prioritise their products for delivery while other department reasonably believes that their products are equally important and need priority delivery.

One solution might be for the ministry to contract a third party to deliver products from different departments that recognise the advantages joint deliveries. Ram, DHL, Fastway, and other similar companies already operate in several African countries. These companies charge a fee based on the volume or the weight of what needs to be delivered and the distance to the destination. Refrigerated vehicles could be a good place to start with the departments of vaccines and drugs collaborating on joint deliveries. Success would depend on a clear and comprehensive contract initiated by the office higher up than the departments responsible for vaccine and drug deliveries and of course on time payments to the company.

Refrigerated mobile clinics for remote areas: I don’t have any experience with this idea and I’m sure that there are conditions where refrigerated vehicles could extend vaccine and drug deliveries to underserved populations. I have however attached a picture of a vaccine delivery being made to an area where the road gets really bad.

Thank you again Alain.  Does anyone else on TechNet have any suggestions to add, please, on how refrigerated vehicles could be used?

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  1. more than a month ago
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  3. # 19
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Hi James,

The truck transverse movable partition for transporting goods and even large objects with a separate door is a good idea, that makes the truck really useful not only for immunization activities like syringes boxes and safety boxes transportation, but also for other appropriate items needed in health care facilities and districts, you have already mentioned bednets. If adequately used, I can foresee big savings on Ministries of Health's budgets with integrated deliveries, which is something managers and decision makers should have in mind when planning to acquire such vehicles for their health system.

Another thing that we have experienced is the use of the refrigerated vehicle (pick-up) to conduct successfully immunization outreach activities in remote areas with no health care facilities nor adequate power supply at all. The vehicle was then used by the team as a mobile cold room for vaccines and icepacks storage during these few days. It is a long and nice story.

Thanks. 
Alain

  1. more than a month ago
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  3. # 20
James Cheyne Accepted Answer
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Hello Alain,

Thank you for your helpful reply. I especially appreciate a reply from someone who has obviously had many years of experience.

Concerning your comment "One of the disadvantage of using these [refrigerated] vehicles is that they cannot be used for other material delivery such as syringes etc...", it is possible to procure refrigerated vehicle that can be used to deliver supplies at ambient temperatures at the same time as supplies at cold temperatures.

The WHO draft specifications for procuring refrigerated vehicles include a clause that says:

" 5.14     For vehicles that can accommodate a transverse moveable partition for transporting goods at ambient temperatures a side door for access to refrigerated compartment should be provided." (The final WHO specifications for refrigerated vehicles will be posted to the WHO-PQS website shortly.)

The front part of the body is kept cool by the refrigeration unit in the front of the body, and the rear part of the body can be used to deliver other produce, bednets, syringes, etc. As noted in the specification, a separate door is needed in the side of the body to access the cold area. The other products are loaded and off-loaded through the rear doors. This is a convenient configuration since larger vehicles can also be specified with a tail lift to help loading and unloading heavier objects - bednet, for example. The picture in my earlier post showed a refrigerated vehicle that has a side access door to reach the cold storage area.

Your thoughtful comments in your last paragraph are also very helpful. Thank you. Would you have time to comple the WHO survey (if you haven't already)? Please see:

 https://www.surveymonkey.com/r/PQSrefrigeratedvehicle 

This survey is rather long but your expertise will be a valuable contribution to WHO's work to ensure that vehicles bought to carry vaccines are produced to a high standard. 

Best regards,

James Cheyne.

  1. more than a month ago
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  3. # 21
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To respond to your question, yes I will definitely agree that ministries of health should have refrigerated vehicles for vaccines delivery in their parking. This is particularly useful when countries are conducting mass immunization campaigns and they are helpful for vaccines distribution from the central store to regional and district stores, but not for health care facilities. During immunization campaigns, in terms of quantity, the resources for the activity are always more important than they are for routine activities and thus, using these vehicles for vaccines delivery is an advantage for the program.

One of the disadvantage of using these vehicles is that they cannot be used for other material delivery such as syringes etc..., so, ministries of health would also need trucks for other material delivery and to deliver 

However, using the refrigerated vehicles for these important volumes of vaccines is a very good investment for the program, assuming that these vehicles are also included in the maintenance plan of the program.

Thanks.

  1. more than a month ago
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