TechNet-21 - Forum

This forum provides a place for members to ask questions, share experiences, coordinate activities, and discuss recent developments in immunization.

Discussions tagged Optimize

How Private Sector Solutions Can Strengthen Supply Chains for Public Health

Dear Colleagues,
JSI is pleased to announce a new publication in the Getting Products to People series: How Private Sector Solutions Can Strengthen Supply Chains for Public Health For years, experts in the field working on strengthening supply chains to support public health programs have emphasizedthe importance of the private sector role in extending the reach and improving the performance of the supply chainsthat serve the public with the health products they need. The private sector has often been deemed thesolutionto efficiency challenges and improving value for money.JSI has extensive experience working on designing private sector solutions that work in both low and middle income countries. We have found that although the private sector is definitely part of the solution, there are many models that work and extensive privatization is not necessarily always the panacea to our supply chain problems.We determine it will take anuanced approachto building agile supply chains and strong and sustainable healthcare marketplaces to meet our universal health coverage goals. This will include the private sector but does not presuppose full health sector privatization. The public will always need to serve as a good steward for public health and equitable access to products and services.It is strong, visionary supply chain leaders who will design and oversee supply chains that work and leverage the capacity of the private sector to help in these endeavors.

Expanding Digital Immunization Registry in Vietnam

PATH has been collaborating with Vietnam National EPI to pilot the Digital Immunization Registry in one district in a Southern province under Optimize Project since 2012. In 2014, this system was expanded in all 164 Commune Health Centers in that province. It can help to reduce workload burden, increase data accuracy and more importantly increase on-time vaccination rates. This intervention has been awarded the Health Innovation Award, a partnership between GSK and Save the Children in 2015. PATH is working closely with Ministry of Health and the local biggest telecom company to integrate this system into national health information system and scale up nationwide. Please find more information via the link below
http://www.technet-21.org/en/resources/technet-resource-library/2742

Supply Chain 2035: Preparing for the Next 20 Years

Over the last two decades, increased investments in health have yieldedsignificant gains in health outcomesfor tens of millions of people around the world. At the same time, economic growth has raised hundreds of millions out of extreme poverty and helped fuel a vast expansion in information technology that has revolutionized the way people communicate. Inspired by the 20th anniversary of the first World Development Report to focus on health,the Lancet Commission on Investing in Health releasedGlobal Health 2035: A world converging within a generationin 2013. This visionary report asserts that we can achieve significant health gains in low- and middle-income countries (LMICs) by 2035, thus achieving agrand convergence. These gains are predicated on three key assumptions:

Continued economic growth in low- and middle-income countries will enable increased investment in health.
Insurance will be a primary tool in achieving universal health coverage (UHC) in low- and middle-income countries.
Non-communicable disease (NCD) will dominate disease burden.

Butachieving the grand convergenceand theSustainable Development Goals for healthdepends on a profoundevolution in the supply chainsthat deliver the medicines, vaccines, and other commodities required to maintain and improve health and well being. With large-scale investments in health programs, a widening portfolio and volume of products, and expansion of services to new populations, supply chains must be more flexible, efficient, and responsive. Here are just a few of the scenarios that will require new approaches to health supply chains in LMICs:

Universal health coverage insurance schemes and continued economic growth will foster a more robust marketplace, encouraging the private sector retail pharmacy market to expand. But insurance schemes must be designed to assure quality products in ahealthier marketplace, and to promoteequitable access to productsand services for people—especially in rural areas—whom the private sector do not serve. Thefull cost of supply chainsmust be factored into insurance payment mechanisms.
As more countries achieve middle-income status, donor funding will phase out, creating risks as graduating countries take full stewardship of their health systems including the cost of ensuring access to health commodities.Supply chain stewardsmust focus on maintaining and extending equitable access while managing risks of disruptions at every level of the supply chain. Atotal market approachthat embracesmultiplicity and redundancyin the supply system is essential.
Continued advances in technology and information systems will enable greater end-to-endsupply chain data visibility. Supply chain data will be integrated with patient records and financial systems, automating resupply and payments, while biometrics will be used to validate client identities, improve adherence, and promote rational use. But greater visibility must be combined with the capacity of supply chain managers at every level of the health system toanalyze data and take effective action, within an institutional culture that values data quality and use.
Storage and transportation systems will routinely leveragealternative energy technologiesas well asautonomous vehiclesfor reaching remote locations. These technologies will require management systems and skilled personnel dedicated to keeping them running, maintaining and replacing equipment and vehicles as they near the end of their usable life, and staying abreast of technology upgrades and innovations.
Human resources for supply chain management will still be a challenge, as it is currently throughout the public andthe commercial supply chainsectors, but outsourcing, vender-managed inventory, and direct delivery from venders will be commonplace and will mitigate the HR challenges. Supply chain stewards must embraceprofessional competenciesand promote career paths andperformance-based incentive mechanismsto recruit and retain supply chain talent today.

The grand convergence predicted for 2035 will require universal access to health supplies, and the range of skills and knowledge required to achieve that goal is more diverse than ever before. We require a command of health financing, insurance formularies, health informatics, risk management, business reengineering, market segmentation, pharmaceutical markets and regulation, and human resource management. Supply chain simulation technologies and costing applications are now essential tools in system design, optimization, and market segmentation. Career development and incentive mechanisms are as important as training curricula in preparing and retaining a capable supply chain workforce and leadership.
In order for public health supply chains to evolve, the people who support and work within them must also evolve. There will be many different models and many innovative approaches, and JSI will continue to help envision, design, and build supply chains for the future to meet Global Health demands in 2035.
Chris will lead a discussion on this topic onIAPHLin the coming weeks. This post was originally published on JSI's The Pump.

Next Generation Supply Chains – A Dialogue with EPI and Child Health Managers

Reposted from JSI's The Pump Jeff Sanderson,Senior Technical Advisor African immunization supply chains need to be transformed. Between 2010 and 2020, new vaccine introductions will quadruple the volume of vaccines per immunized child. The number of vaccine doses that health workers will administer is increasing six-fold. Evidence fromEffective Vaccine Management(EVM) assessments in70 developing countriesfound that in nearly all countries, immunization supply chains are not functioning well enough to ensure vaccine availability and potency and to meet coverage targets. Worse, only a few countries have prioritized supply chain strengthening as a strategy to strengthen immunization program performance. The future of immunization supply chains was the topic of an evening dialogue at the January 25-29, 2016 “Exchange of best practices workshop on Reaching Every Community (REC); Equity and Integration of Child survival interventions in East and Southern African Countries” in Cape Town, South Africa. The key theme of the meeting was to support the increase of coverage for immunization and child survival interventions through the reaching every community/child approach. This evening session, organized by John Snow, Inc. in collaboration with PATH, featured a panel of EPI officials from four African countries that aretransforming their public health supply chainsto accommodate the increasing demands on these supply chains from immunization and other health programs. Each of the four panelists discussed ongoing changes in their country supply chains; their key points are in the full blog post here.

Cold Chain Policy vs. Cold Hard Reality: Thinking Inside the Box

Recently, I was sitting with the Expanded Programme on Immunization (EPI) Manager, his senior staff, and technical assistance (TA) partners in an African country, discussing support for better visibility and analysis of immunization supply chain data. The EPI Manager was willing to listen, but wasn’t sure his team needed help in data analysis. As for visibility, that was already being addressed: they using a web-based inventory management system that, among other things, providecold chain volumetric data (total capacity and used capacity). As we discussed plans to deploy the online tool at the district level and in facilities with internet connectivity, I asked if data was also collected on the other, non-EPI commodities that we know are often stored in the cold chain: some lab reagents, certain antiretroviral medicines, oxytocin, insulin, etc. The team seemed surprised by the question; “those aren’t our commodities,” the program logistician explained. True, I replied, but they do frequently take up room in the fridges (even if only in the short-term), so if it isn’t captured as part of inventory, then your volume data won’t give you the true picture of what percentage of capacity is really being used... Read the complete blog post here

Optimize wraps up collaborations in six countries

by Dan Brigden, WHO Over the last five years, project Optimize has worked closely with national immunization programs to explore innovative solutions to supply chain challenges. Each project has attempted to solve a particular immunization challenge—from an electronic immunization registry in Albania to a moving warehouse in Senegal, and from remote temperature monitoring in Vietnam to web-based stock management in Tunisia. The results of these projects have now been collected, analyzed, and published on the PATH and World Health Organization (WHO) Optimize websites. “Optimize has learnt many things during its five years of existence,” observes project director Michel Zaffran. “We’ve seen successes and failures, and our efforts have contributed to catalyze efforts to explore innovative solutions to supply chain challenges. Now we need to share the lessons we have learnt so others can make use of them and continue the effort.” Optimize collaborated with national immunization programs to demonstrate innovative solutions in six countries: Albania, Guatemala, Senegal, South Sudan, Tunisia, and Vietnam. Detailed information on the projects undertaken by project Optimize can be found in a set of country-specific Optimize reports available on the PATH and WHO Optimize websites. Also available is a set of evidence brief reports that provide brief summaries of key findings in particular areas. Albania In Albania, Optimize collaborated with the Albanian Institute of Public Health to help transform the way immunization data and vaccine stock are managed. The collaboration attempted to evaluate the benefits of two demonstration projects: 1. Immunization Information System (IIS). The project developed and implemented an online immunization information system that can record immunization data and manage vaccine stock. The new system—named IIS—can schedule and record child immunizations, as well as manage vaccine stock and storage. The aim of the project was to measure the impact of accurate and timely immunization data on immunization and vaccine stock management. 2. Remote temperature monitoring. The project tested a short message service (SMS, or text message)-based system to monitor and log temperature conditions in peripheral cold chain equipment. The aim was to assess whether these remote alarm systems facilitate better vaccine and cold chain management than non-connected temperature loggers. The Optimize Albania Report. http://www.who.int/entity/immunization_delivery/optimize/Optimize-Albania_report.pdf Senegal In Senegal, Optimize collaborated with the Senegalese Ministry of Health to demonstrate innovations in the supply chain that can help the national immunization program to increase efficiency and improve performance, preparing the country for the introduction of new vaccines in the future. The following demonstration projects were undertaken: 1. Supply chain integration. This included integration of public-sector vaccine, drug, and other health product supply chains. 2. The moving warehouse. Specially equipped trucks are being used to deliver vaccines and other health products from the regional level directly to health posts. The Optimize Senegal Report. http://www.path.org/publications/detail.php?i=2272 Tunisia In Tunisia, Optimize and the Tunisian Ministry of Public Health collaborated on three demonstration projects to explore new logistics and supply chain solutions that can optimize the vaccine supply chain: 1. Streamlined and integrated supply chain. This project demonstrated the benefits of streamlining and integrating the storage and delivery of vaccine products with that of other public-sector health commodities that require refrigeration. 2. Net-zero energy supply chain. This project demonstrated an environmentally friendly vaccine supply chain at subnational levels using solar energy to achieve zero net energy consumption. 3. Computerized logistics management information system (LMIS). A computerized LMIS demonstrated tracking and tracing vaccines in real time throughout the supply chain, mitigating the risk of overstocking, expiry, and vaccine wastage. The Optimize Tunisia Report. http://www.who.int/entity/immunization_delivery/optimize/optimize_tunisia_report.pdf Vietnam In Vietnam, Optimize collaborated with Vietnam’s National Institute of Hygiene and Epidemiology to demonstrate new technologies and software systems that could be used to improve the performance of the vaccine supply and logistics system: 1. VaxTrak—a computerized system for tracking vaccine stock and reporting aggregated monthly immunization data. 2. ImmReg—a paper-based and computerized system for aggregated reporting of fee-based immunization services. 3. Computer- and mobile phone-based technologies for tracking children due for immunization and recording the immunizations given to them on an individual basis. 4. A new passive cooling device for storing vaccines in commune health centers. 5. New direct-drive solar refrigerators for storing vaccines in district health centers. The Optimize Vietnam Report. http://www.path.org/publications/detail.php?i=2269

ICT Toolkit goes online

An online version of the ICT Toolkit developed by project Optimize has been published on the TechNet-21.org website.

http://ict.technet-21.org

The original document, entitled Planning an information systems project: A toolkit for public health managers, is available as a PDF on the PATH and WHO websites, and provides guidance to public health managers planning the implementation of information and communications technology in health information systems. It draws on lessons learned by project Optimize, a five-year collaboration between the World Health Organization and PATH, to help optimize the vaccine supply chain.


An online version of the ICT Toolkit has just been released. Photo: WHO.

The ICT toolkit focuses on the planning phase of an information systems project. It proposes an eight-step process that can help managers:


Choose the solution that best fits their needs and context.
Obtain the external help and expertise they need.
Develop, scale, and then sustain their chosen solution.


The online version of the toolkit provides links to internet content such as documents, websites and YouTube movies that the PDF was not able to include. It also enables registered TechNet users to comment on and rate individual pages.

Visit the online version of the ICT Toolkit today.

How can information systems help to improve the performance of immunization programs?

by Jan Grevendonk, WHO Project Optimize has worked closely with national immunization programs throughout the world to demonstrate innovative solutions to supply chain challenges. Many of these demonstration projects have involved the use of information systems to help improve the performance of immunization programs. The results of these information and communications technology (ICT) projects have now been collected, analyzed, and published. In addition, Optimize has also published several other resources that can help public health managers to plan for the implementation of information systems projects. The results of these ICT projects have now been collected, analyzed, and published on the PATH and World Health Organization (WHO) Optimize websites. In addition, Optimize has also published several other resources that can help public health managers to plan for the implementation of information systems projects. A summary of Optimize ICT publications is provided below. For a list of all Optimize publications, visit the PATH and WHO Optimize websites. For further information on all Optimize ICT demonstration projects, please contact Jan Grevendonk (grevendonkj@who.int). Planning an Information Systems Project: A Toolkit for Public Health Managers This toolkit can help public health managers plan for the implementation of ICT projects in health information systems. It focuses on the planning phase of an information systems project and proposes an eight-step process that can help decision-makers: -Choose the solution that best fits their needs and context. -Obtain the external help and expertise they need. -Develop, scale, and then sustain their chosen solution. http://www.who.int/immunization_delivery/optimize/resources/en/index5.html Information Systems Used in National Immunization Programs This series of short videos describes the impact of different information systems projects on the performance of national immunization programs. Each video explains the context in which a particular system was deployed, how it works, and what the impact has been. Videos on IIS in Albania, ImmReg in Vietnam, Logistimo in South Sudan, VaxTrak in Vietnam, wVSSM in Tunisia, and vrMIS in Mozambique have been published. To view the latest videos, visit the PATH Programmatic Videos YouTube channel. A Case for Better Immunization Information Systems This evidence brief discusses the rationale for improving immunization information systems and describes user experiences with different types of systems. It also provides advice on feasibility in different contexts. It draws on evidence gathered during project Optimize demonstrations in Albania, Guatemala, Senegal, South Sudan, Tunisia, and Vietnam. http://www.who.int/immunization_delivery/optimize/resources/en/index5.html Keeping Track of Vietnam’s Vaccines This fact sheet describes how project Optimize worked in Vietnam with national, regional, and local partners to help introduce VaxTrak, a software program that allows users at various levels of the health system to track vaccine stock and report monthly immunization activity. http://www.path.org/publications/detail.php?i=2225 Vietnam’s Immunization Registries Go Online This fact sheet describes how project Optimize worked with government and software partners in Vietnam to introduce a digital immunization registry named ImmReg. This registry allowed the health system to better track children due for vaccination and shortened the time required for recording and reporting immunizations, compared to the existing paper-based registry. http://www.path.org/publications/detail.php?i=2273 Before and After: How an Online Immunization Registry Has Benefitted Health Workers in Albania Starting in 2009, the Albanian Institute of Public Health collaborated with project Optimize to implement an online immunization information system (IIS) that can schedule and record all child immunizations in the country, as well as manage vaccine stock and storage. It was first implemented in one district in 2011 and will be gradually deployed to all other districts over the next three to five years. This photo set illustrates how the new system has benefitted health workers in Albania. The “Before” pictures describe how health workers used the previous paper-based registry, while the “After” pictures describe how they are now using IIS. http://www.who.int/immunization_delivery/optimize/albania/en/" target="_blank">http://www.who.int/immunization_delivery/optimize/albania/en/ Albania Pilots an Immunization Information System The Albanian Ministry of Health, in collaboration with project Optimize, developed a registry-based immunization information system named IIS. This fact sheet illustrates how the data the new system produces has been used to improve the management of the country’s vaccination program, how it is changing the way people collaborate, how it ensures timely and equal access to immunization for all children, and how it reduces the administrative burden on staff. http://www.path.org/publications/detail.php?i=2253

Closing the book on project Optimize

by Michel Zaffran, WHO In December 2007, a team of talented individuals from PATH and the World Health Organization (WHO) came together to form project Optimize, a five-year collaboration to identify ways in which supply chains can be optimized to meet the demands of an increasingly large and costly portfolio of vaccines. Our goal was to help define an ideal vaccine supply chain that can be used to develop stronger, more adaptable, and more efficient logistics systems, extending the reach of lifesaving health technologies to people around the world. We decided to put our energy into three parallel streams of work: 1. Innovate—create an environment more conducive to innovation in both products and processes. 2. Demonstrate—generate more evidence on new ideas about supply chains and how they work. 3. Facilitate—inspire partner organizations and governments to invest in supply chain improvements over the long term. As we look back, we can point to important achievements in each of these areas. Innovate In the area of innovation, Optimize played a role in reestablishing the Vaccine Presentation and Packaging Advisory Group. Optimize also contributed substantially to the first generic preferred product profile for vaccines as well as to WHO’s Programmatic Suitability for Prequalification guidance on vaccine products. We supported innovation in the cold chain equipment industry by issuing challenges for industry to develop new equipment such as battery-free solar refrigerators, long-life cold boxes, and large-capacity cold boxes. We also worked closely with WHO to help develop specifications for the prequalification of these new types of products and field-test new products in different countries around the world. Demonstrate In our collaborations with countries, we sought to document country experiences with innovative processes and systems including integrated supply chains, mobile warehouse delivery systems, a controlled-temperature chain for last-mile delivery of certain vaccines without ice, carbon-neutral supply systems, and several different types of immunization information systems. Facilitate We have facilitated the development of a multi-partner vision for vaccine supply and logistics systems in 2020 and a plan of action for its implementation. These efforts have generated momentum toward longer-term commitments from partner agencies and governments to invest in supply chain system improvements and product innovations over a longer time horizon. For example, the GAVI Alliance is working on an end-to-end supply chain strategy to complement new vaccine introductions. WHO and United Nations Children’s Fund (UNICEF) have also started working together on a major project to help countries make informed operational and strategic decisions about their supply chain systems following Effective Vaccine Management assessments. Nonprofit, government, academic, and industry partners, including PATH, Agence de Médecine Préventive, People that Deliver, the Bill & Melinda Gates Foundation, the Clinton Health Access Initiative, John Snow Inc., the University of Pittsburgh, VillageReach, Logistimo, OpenLMIS, and the Developing Countries Manufacturers Network, as well as UNICEF and WHO, have ongoing programs to tackle issues related to vaccine products, supply system design, information systems, human resources, and equipment. As Optimize closes its books this month, we are happy to see that work in these areas will continue and that countries will be supported as they strive to manage larger and more complex immunization programs. At the global level, and in partnership with the vaccine industry, stakeholders are now shifting their focus from the procurement price of vaccines to the development and licensing of products that minimize total system costs and complication at the country level. At the regional level, partners are working hard to help countries choose the right vaccine and cold chain products and make strategic decisions about how their supply chains are designed and managed. At the national level, governments and immunization partners are beginning to invest in systems, processes, equipment, and professionals to ensure that newer vaccines are handled properly and reach the people who need them. The immunization supply chain is the backbone of immunization programs and can also become a backbone for other health interventions. It can support successful health interventions and help ensure that more people live a healthier life. We are grateful to all those who have contributed to the Optimize effort: Ministry of Health colleagues in Albania, Guatemala, Senegal, South Sudan, Tunisia, and Vietnam, as well as the many colleagues in the public and private sectors who have helped to create the momentum for improved immunization supply and logistics systems. Last but not least, we are grateful to the Bill & Melinda Gates Foundation for making this enterprise possible.

Four videos on Logistics Information Management Systems from PATH

VaxTrak in Vietnam VaxTrak helps health workers keep track of vaccine stock. In 2011, the Vietnamese National Expanded Programme on Immunization introduced VaxTrak in the provinces of Phu Tho, Quang Tri, and Ben Tre. This short video shows how VaxTrak works and examines the impact it has had. [youtube]zbYuN9OXV4c[/youtube] Logistimo in South Sudan Logistimo is a cloud-based logistics management information system that can help immunization health workers keep track of vaccine stock. In May 2012, the Government of South Sudan deployed Logistimo in the national store, the ten state stores, and all six counties of Central Equatoria State. This short video shows how Logistimo works and examines its impact. [youtube]Sr7rCnpLWyM&list=PLYNXI1NRQQ-AFEa6PaFxPplrvyZvChKwX[/youtube] Immunization Information Systems (IIS) in Albania In 2011, the Albanian Institute of Public Health deployed IIS in the northern Albanian district of Shkoder to record child immunizations and manage stock. This short video shows how it works and examines the impact it has had in Albania. [youtube]dczmp7JsIr4&list=PLYNXI1NRQQ-AFEa6PaFxPplrvyZvChKwX[/youtube] ImmReg in Vietnam ImmReg is a digital immunization registry that uses mobile phones to track children due for vaccination and record their vaccinations. In 2011, the Vietnamese National Expanded Programme on Immunization introduced ImmReg in the district of Mo Cay Nam in Ben Tre province. This short video shows how ImmReg works and examines its impact. [youtube]59gGuyFHle0&list=PLYNXI1NRQQ-AFEa6PaFxPplrvyZvChKwX[/youtube]

Project Optimize in transition

by Bjorn Melgaard, Judy Roberts, Prashant Yadav, Anup Akkihal, Robert Steinglass, and Gisele Corrêa Miranda, Optimize Project Advisory Group members Following the 2013 TechNet Consultation in Dakar, Senegal, members of the Optimize Project Advisory Group (PAG) met for the last time to discuss progress made over the past five years and to learn about plans going forward as key areas of work on vaccine supply chains begin to transition to partners. Looking back The meeting began with a presentation by Optimize staff to summarize the results and achievements of the last five years. What became clear as the presentation unfolded was that many of the goals Optimize set out to achieve have now been realized. For example, new pathways to innovation have been established through the Vaccine Presentation and Packaging Advisory Group and through product-development “challenges” for cold chain manufacturers. These efforts have resulted in the development of new vaccine presentations and formulations, new cold chain equipment, and vaccination policies better suited to developing-country contexts. In addition, new equipment, information systems, technologies, and operational models have been demonstrated, generating case studies and evidence that are sorely needed in the field. Last, but not least, Optimize and its partners have successfully elevated the discussion of vaccine supply systems to the global stage, and consensus is beginning to emerge on the priorities for supply chain enhancements over the next decade. Looking forward To partially answer the question of what comes next, PAG members and relevant partners were invited to speak about their core competencies and plans for improving vaccine supply and logistics systems over the next five to ten years. These presentations are available for viewing and downloading on TechNet-21.org. Perhaps the most significant change in the supply chain landscape is the emergence of the GAVI Alliance as a major influencer in the area of vaccine supply chain and logistics work. As GAVI continues its work to introduce new and underused vaccines in eligible countries, it has pledged to develop a supply chain strategy by the end of 2013. This strategy will help clarify ways in which countries can solicit support from the Health Systems Strengthening funding window and how partners can provide tools and technical assistance to countries that are building more responsive and robust supply chains. The World Health Organization (WHO) and United Nations Children’s Fund (UNICEF) have also started working together on a major project to help countries make informed operational and strategic decisions about their supply chain systems following Effective Vaccine Management assessments. The Bill & Melinda Gates Foundation, too, will continue to help shape the global agenda in this area. Other nonprofit, government, academic, and industry partners, including PATH, Agence de Médecine Préventive, People that Deliver, the Clinton Health Access Initiative, John Snow Inc., the University of Pittsburgh, VillageReach, Logistimo, OpenLMIS, the Developing Countries Manufacturers Network, UNICEF, and WHO plan to continue and grow their work in specific areas of expertise, including vaccine products, supply system design, information systems, human resources, and equipment. In addition to work in specific technical domains, some organizations are also focusing their efforts in specific countries. Parting thoughts Clearly, the vaccine supply and logistics field is evolving with many competent partners eager to play a role in the future. The 2020 Global Vision for Vaccine Supply and Logistics Systems Action Plans may provide a starting point for partners as they determine where to direct their efforts. Questions still remain about how various partners can maintain the cohesion and momentum that was enabled by project Optimize. Importantly, there is no clear mechanism to hold institutions accountable and on track. Will major partners like WHO and UNICEF be able to support countries with limited staff? Will eligible national immunization programs be able to access support from GAVI’s Health System Strengthening funding window, and will they spend it on supply system strengthening? Will we see a major change in the way countries manage their vaccine supply systems? Or will countries default to minor repairs of what seems to be a broken system? The answers to these questions will become clearer in the coming years. In the meantime, the PAG wishes to congratulate project Optimize and its partners for strengthening global vaccine supply chains and sharing their insights over the past five years. The PAG also wishes success to those who will continue to work in this area over the next five years. On all counts, the work to improve vaccine supply systems is just beginning, and our collective success will be judged by the number of children that countries are able to immunize with an increasingly powerful set of vaccines.

Tanzania leading the way with barcodes on vaccine packaging

by Daniel Thornton, GAVI; Henry Mwanyika, PATH; Drew Meek, WHO; Ulrike Kreysa, GS1 A project in Tanzania is exploring how best to implement barcodes on vaccine packaging. By adding barcodes to the shipping containers and secondary packaging used to transport vaccines, project organizers hope to learn how barcode technology can improve supply chain management and vaccine safety in developing countries. Over the last 40 years, barcodes have transformed global supply chains in the packaged food and consumer products industries. Most supermarket chains around the world use barcode scanners at the checkout counter, and most smartphones can now scan barcodes. Barcodes make it easy to track the flow of goods from their point of origin to their final destination, to recall products that may pose a safety hazard, to detect counterfeit or fraudulent goods, and to link a product with information such as where it was made, where it has been, ingredient lists, and instruction manuals in multiple languages. The global immunization community has recently started to explore the potential of using barcodes in vaccine supply chains. In fact, some countries have already begun to establish and mandate their own barcode standards. But with developing-country immunization programs lacking the infrastructure required to scan and use barcode information, and without a global barcode standard to follow for vaccine products, the use of barcodes on vaccine products destined for developing countries is happening much more gradually. Electronic health information systems are becoming increasingly pervasive in developing countries, especially at the central warehouse level. This has reduced some of the barriers to the use of barcodes and at the same time made the need to establish global standards more pressing than ever. Such standards would make it much easier to correctly implement and interpret barcodes coming from different suppliers around the world. In March 2013, a working group of the Vaccine Presentation and Packaging Advisory Group (VPPAG) met in Brussels, Belgium, to identify the challenges and set out a long-term vision for the adoption of barcode technology in developing-country vaccine supply chains. The meeting was hosted by GS1, the nonprofit global supply chain standards organization, and was attended by representatives from the United Nations Children’s Fund, the World Health Organization (WHO), PATH, the GAVI Alliance, and several vaccine manufacturers. The group concluded that: -There are no longer any major obstacles to the introduction of barcodes on secondary packaging[sup]1[/sup] and packaging containing secondary packaging. -Adding barcodes with lot number and expiry date information to primary packaging (the vaccine vial or ampoule) poses a technical challenge that may take several years to overcome. -Overall agreement exists on standards for the type of information that should be included in barcodes, the type and format of barcode to use, and the levels of packaging on which it should be included. -Online databases need to be established where barcode information can be retrieved (for example, for a logistician to find out that the item he has just scanned is a box of 25 vials of measles, mumps, and rubella vaccine that needs to be stored between 2°C to 8°C). An existing WHO vaccine product database can potentially be adapted to serve this purpose. -The planned project in Tanzania presents a great opportunity to evaluate the benefits of using barcodes on vaccine packaging. For the project in Tanzania, collaborating manufacturers will add barcodes to the shipping containers used to transport vaccines to Tanzania. Encoded in each barcode will be a serial shipping container code, an 18-digit number used to identify individual containers and provide dispatch information. In parallel to the shipment, an advanced shipping notice will be sent. Upon arrival, the barcodes will be scanned by logisticians to automatically generate key sections of the vaccine arrival report. Collaborating manufacturers will also add barcodes to secondary packaging to enable staff to keep track of vaccines as they move further down the supply chain from the national to the regional and then to the district level. Encoded in these barcodes will be the product’s global trade item number, as well as the lot number and expiry date of the vaccines contained in the secondary packaging. This will enable Tanzanian logisticians to keep better track of vaccine stock movements. Because the benefits of barcodes to vaccine supply chains is becoming increasingly evident, and interest among developing-country governments in barcodes continues to grow, it will be critical for vaccine products with barcodes to be ready in the public-sector supply chain. For this to happen, both global- and national-level decision-makers can take positive steps toward a future where barcodes are an essential component of vaccination programs. To learn more about the work of the VPPAG barcode working group, please contact Daniel Thornton (dthornton@gavialliance.org), Henry Mwanyika (hmwanyika@path.org), Drew Meek (meekd@who.int), or Ulrike Kreysa (ulrike.kreysa@gs1.org). To read more about the need for global barcode standards and the readiness of developing countries to introduce barcodes, please read the article “Is it time to start barcoding vaccine labels” in the July 2011 edition of the Op.ti.mize newsletter. [size=10]1. Secondary packaging includes the primary packaging (the vaccine vial or ampoule), the packet containing the vaccine vial, and any intermediate packaging.[/size]

Vietnam’s transition from paper-based to online vaccine tracking

by Dao Ding Sang and Vu Minh Huong, PATH Over the last three years, Optimize has been working with Vietnam’s National Expanded Programme on Immunization (NEPI) to pilot a new computerized logistics management information system. The new system, named VaxTrak, is designed to help immunization health workers keep track of vaccine stock as it is received and dispatched, and to facilitate aggregated monthly reporting on immunizations given. The goal is to increase the accuracy and timeliness of vaccine inventory and immunization reports, to reduce the amount of time health care workers spend on reporting duties, and to increase the availability of data, especially at national and regional levels. Vietnam’s paper-based vaccine stock-management and reporting system In Vietnam, storekeepers use a paper-based stock ledger to record information on vaccine stock transactions, such as when and where vaccines were received or dispatched, the number of doses involved, the expiration date, and the lot number. These vaccine registers are kept at every level of the health system, and are updated as vaccines move from national to regional, provincial, and district levels, on their way to the commune health center where immunizations are administered. Compiling the monthly immunization report on vaccine use can be complicated. Health workers must pore over the vaccine register, previous immunization reports, and receipt and distribution vouchers to try to reconcile the data in order to provide an accurate report. Using this paper-based system, recording vaccine-related data is an administrative burden. The work is tedious and can easily lead to inaccuracies. In addition, there are often delays in making the completed reports accessible to national level authorities who have oversight of the entire vaccine supply chain. Managing information in VaxTrak With VaxTrak, information about vaccine stock is managed in a computer database. When dispatching a shipment of vaccines, users at the point of departure enter information into the system about the products and quantities being dispatched. When the vaccines arrive, users at the destination can find the shipment in the system and confirm receipt. Then the vaccines are automatically added to the inventory at the destination location. The system also allows users to enter aggregated data on immunizations administered in the user’s territory. At the end of the month, reports on both vaccine stock and immunizations given can be easily generated by the system without the need for health workers to painstakingly review the paper records. VaxTrak benefits Once in the VaxTrak system, information is available in real-time via the Internet to staff of the immunization program at all locations with proper authorization. Health workers can access up–to-date information about vaccine stock, such as the number of doses distributed or in stock. They can also view expiry and lot number information on vaccines. This can help with planning the amount of vaccine to order and allocating available vaccines among different locations. Better planning can help to avoid stockouts that can result in missed opportunities to vaccinate, as well as over-ordering, which can result in vaccines being wasted. NEPI and Optimize first introduced VaxTrak in the national store, three regional stores, and three provincial stores (one in each of the three regions). After six months, Optimize collected data to evaluate the system’s performance. By comparing actual vaccine stock quantities with the quantity recorded in the paper registry and in the VaxTrak database, we found that VaxTrak significantly increased the accuracy of vaccine data: the number of lots with matching data went from 77 percent before VaxTrak to 100 percent after using the software for several months. The number of lots counted before and after implementation was 39 and 40, respectively. The assessment also showed that using VaxTrak reduced the time burden of reporting. In provinces, the average amount of time needed to complete the monthly immunization report changed from 22 minutes to 16 minutes. Likewise, the average amount of time needed to complete the vaccine register decreased from 88 minutes to 43 minutes. The users’ perspective VaxTrak users have expressed satisfaction with the system because it enables them to access data whenever and wherever they have an Internet connection, it has an easy-to-use interface in Vietnamese, and they feel it helps them to manage vaccine stock more accurately. They are pleased with the ease of reporting, since the software automatically compiles and aggregates data. For users at higher levels, seeing the real-time balance of the vaccine stocks not only at their own facility store but also at lower level stores is extremely helpful for management and planning. Despite its impressive performance, users faced some challenges with the VaxTrak software. First, the development and introduction of VaxTrak took significantly more time than originally planned. As a result, users did not have much time to become familiar with the software and help detect defects that needed revision. In addition, outside of Optimize’s intervention, NEPI was also testing other software applications; evaluating multiple programs at once overburdened some health workers. Scaling up the system presents another challenge, as managers need to address shortages of human and financial resources to provide technical support for facilities, as well as sufficient training for users. The latter is a particular problem, given the high rate of staff turnover at lower levels. Looking to the future Based on the strong performance, useful functions, and good acceptability of the VaxTrak system, NEPI is interested in exploring avenues for scaling up the system to additional provinces following the close of project Optimize. If funding can be identified, NEPI would like to take these additional steps: [indent][/indent]- Reinstate monitoring and evaluation, especially at district level, to identify all [indent][/indent] issues that need to be resolved in the next stage. [indent][/indent]- Work with software developers on improvements to the system and ensure that [indent][/indent] software design allows for the proposed increased number of users in the system. [indent][/indent]- Develop a plan to progressively implement the system in new sites and ensure that [indent][/indent] adequate training and technical support are available for all users on an ongoing [indent][/indent] basis. In 2013, Optimize will publish comprehensive information on the demonstration projects and other initiatives it has been involved in, including VaxTrak. To view a full list of the resources that Optimize has published to document its work in Vietnam, please refer to the Vietnam resources page of the Optimize website.

Newsletters du projet Optimize au Sénégal: des solutions innovantes

Depuis fin 2009, le projet Optimize et le Ministère de la Santé du Sénégal travaillent en étroite collaboration afin d’identifier et de tester des innovations qui permettront d’apporter à la chaîne d'approvisionnement des produits de santé (vaccins, médicaments et autres) des gains d'efficacité et de performance.   Depuis deux ans, des démonstrations sont en cours sur le terrain dans le but de mettre en relief les avantages d'une chaîne d'approvisionnement en vaccins qui : · est intégrée aux chaînes d'approvisionnement d'autres produits de santé ; · tire profit d'un « entrepôt mobile » pour rationaliser la distribution des vaccins et autres produits de santé aux niveaux local et régional ; · est gérée à l'aide d'un système d’information de gestion logistique (SIGL) informatisé; · respecte l’environnement en recourant à l’énergie solaire pour produire l'électricité nécessaire à la chaîne du froid et en contribuant à la gestion des déchets biomédicaux.   Depuis le mois de juillet 2011, Optimize produit un bimestriel (newsletter) qui a pour objectif d’informer les parties prenantes de l’évolution du projet.   L’ensemble des newsletters sont téléchargeables à l’adresse suivante: http://www.technet21.org/index.php/documents/76-general/view-category.html Pour plus d’information sur le projet Optimize Sénégal: http://www.who.int/immunization_delivery/optimize/senegal/fr/index.html Bimestriel Optimize: Mai-Juin 2011 Bimestriel Optimize: Juillet-Aôut 2011 Bimestriel Optimize: Sept-Oct 2011 Bimestriel Optimize: Nov-Dec 2011 Bimestriel Optimize: Jan-Fev 2012 Bimestriel Optimize: Mars-Avril 2012 Bimestriel Optimize: Mai-Juin 2012 Bimestriel Optimize: Juillet-Aôut 2012  

EVM assessment highlights supply chain improvements in Vietnam

by Nguyen Van Cuong, NEPI, and Vu Minh Huong, PATH

Earlier this year, Vietnam’s National Expanded Programme on Immunization (NEPI) conducted an Effective Vaccine Management (EVM) assessment to evaluate the country’s immunization logistics systems. The results reveal that key improvements have been made since the previous assessment was conducted in 2009.

The EVM assessment and planning tool was developed by the World Health Organization to provide countries with the means to systematically assess their vaccine management processes. This can enable them to identify areas that need to be improved and focus their resources accordingly. An EVM assessment uses a structured questionnaire to evaluate a country’s supply chain at different levels using specific criteria based on good storage and distribution practices. The EVM assessment is just the beginning of a continuous process of improvement, and the assessment tool can also be used as a supervisory aid to monitor and support individual facilities on a regular basis.

The 2009 EVM assessment in Vietnam, conducted by NEPI with the help of project Optimize, highlighted several areas for improvement in the country’s vaccine supply chain. These included recommendations to improve vaccine arrival procedures, prioritize and strengthen standard operating procedures (SOPs) for vaccine management, and put in place a preventive maintenance plan for refrigerators. Since then, NEPI has worked hard to strengthen these areas and the findings of the 2012 EVM assessment indicate that these efforts have paid off. They also demonstrate the effectiveness of the EVM assessment and planning tool as a means for countries to improve their vaccine management practices.



Comparing results of the 2012 and 2009 assessments, we see that the national store has made significant improvements in establishing procedures for vaccine arrival, stock management, and distribution. The national store now meets the 80 percent target in all criteria, compared to just 18 percent in 2009. At the provincial level, results have been improved in most criteria, notably in vaccine management and storage capacity. Many of these improvements are due to the efforts that NEPI has made to strengthen and reinforce SOPs in various functions within the EPI. The EVM assessment has been a useful tool to identify these problems, enabling NEPI to prioritize and direct resources and training to resolve them.

Key recommendations of the 2012 EVM assessment include the following:
? Integrate the EVM assessment tool into regular EPI supervision at all levels, and urge managers to reinforce and regularly review areas identified in the assessment as needing strengthening.
? Improve temperature monitoring by upgrading the monitoring equipment for vaccine refrigerators, cold rooms, and refrigerated trucks at the national, regional, and provincial levels with devices capable of continuous temperature monitoring.
? Work to raise awareness of the importance of preventing vaccines from freezing, retrain staff to use the “shake test” to detect freeze-damaged vaccines, and provide freeze indicators for district-level refrigerators and for transport between province and district.
? At the district level, improve the time it takes to repair broken cold chain equipment.
? Disseminate SOPs widely to all levels so that staff are provided with specific and clear guidelines for vaccine management practices.

For more information, or to request a copy of NEPI’s 2012 EVM assessment report (available in English and Vietnamese), please contact Nguyen Dac Trung (dactrungn@gmail.com).

We encourage your questions or comments. Please click reply at the bottom of the page.

South Sudan deploys new mobile phone-based stock management tool

by Morris Gargar, Consultant; Elly Tumwine, UNICEF; and Ryan McWhorter, Logistimo The Government of the Republic of South Sudan is working with the United Nations Children’s Fund (UNICEF) and project Optimize to test a cloud-based logistics management information system (LMIS) that uses mobile phones to manage vaccine stock. The new system, named Logistimo, was deployed in May 2012 and is now being used in the central store, the ten state stores, and all six counties of Central Equatoria State. So far, the response from Expanded Programme on Immunization (EPI) staff to the new tool has been positive. “The procedure is very simple and it helps to accelerate our work, with timely response from national level,” says Teresa Adams Deng (EPI Manager, Jonglei State). In recent years, the EPI in South Sudan has made substantial progress in increasing vaccine coverage rates. However, a serious barrier to further progress is the lack of reliable information on stock levels and consumption rates at all levels of the supply chain below the national level. Without this information, stockouts frequently occur because health centers are not resupplied in time. The Logistimo demonstration project in South Sudan aims to evaluate the benefits to immunization programs of more reliable and up-to-date information on stock levels and consumption rates, as well as the feasibility of implementing a mobile-phone based LMIS in remote locations. As part of the demonstration, county stock managers have been provided with mobile phones they can use to register stock transactions and submit orders for additional stock. National or state managers can then use this information to track stock and demand in real-time and analyze consumption patterns. There are several potential benefits to this approach. Being cloud based, the new system does not require investment in computer servers and other information technology infrastructure. This removes logistical barriers to implementation such as purchasing cost and equipment maintenance. Instead, the Logistimo LMIS is hosted on a remote server that can be accessed by a web browser or a mobile phone using general packet radio service (GPRS) or short message service (SMS) technology. Because of this, the system can be quickly scaled up to support additional users, new facilities, or increased stock with minimal additional work or equipment. The Logistimo mobile phone application (LogiMobile) can be used on widely available, low-cost mobile phones, while the application itself requires only two hours of training for the operator to become proficient. Navigating a simple set of menus, county stock ­managers can record vaccine stock levels using only their mobile phone keypad. They can enter how much stock they have at that moment, how much they have issued to patients or to other clinics, or how much has been damaged or expired. The stock update is then sent from the mobile phone to the Logistimo LMIS using a GPRS connection or by SMS text message if GPRS is unavailable. Although it requires a network connection for the operator to register an update, LogiMobile can also work in offline mode by storing updates and sending them as soon as a connection becomes available. It is just as easy for county stock managers to order vaccines. Requests for vaccines are immediately recorded in the Logistimo LMIS for national or state managers to review and approve. To help ensure the request is dealt with promptly, Logistimo can also be configured to automatically send an SMS message to the manager to provide notification of pending orders. When an order is received, state managers can validate and ship those orders using LogiMobile or the browser-based component of Logistimo, named LogiWeb. The system can then notify the county stock manager by sending an SMS text message with details of the manager’s response (for example, “Your order has been processed and will be delivered on 12/12/2012”). When the shipment arrives, the county stock manager can then record the arrival on the mobile phone. Each stage of the process is recorded in the Logistimo system. As well as being used to record stock levels and the progress of orders, the Logistimo LMIS can also be used to guard against stockouts. Should stock levels fall below a minimum level without the county stock manager ordering a new shipment, the Logistimo system can be configured to automatically warn county stock managers of low stock levels. For example, it can send an SMS message to the user with a warning that new stock needs to be ordered. LogiWeb contains all the functionality of LogiMobile, but can also be used to report on stock availability and consumption in real-time across the country. Users can manage their orders, track inventory problems throughout the country, and report on consumption trends to aid in forecasting and procurement. A cloud-based LMIS that uses mobile phones to register stock transactions and submit orders for additional stock has the potential to simplify stock-ordering, saving time currently spent by stock managers preparing and sending paper orders. It also has the potential to make stock data more accessible, enabling state managers to make ordering or dispatch decisions according to reliable and easy-to-understand data in real-time. During the last two months, more than 400 transactions have been entered using the Logistimo system and the project will soon begin collecting data on stockouts, wastage, and service levels across the country. Project Optimize will publish a progress report on the project in early 2013. For more information, please contact Jan Grevendonk (jgrevendonk@path.org). To show the Logistimo LMIS at work in South Sudan, Op.ti.mize has created a photo set on Flickr. View the slideshow here. We encourage your questions or comments. Please click reply at the bottom of the page.

In Pictures: Online immunization registry transforms work in Albania

To accompany the article “Online immunization registry transforms the work of health staff in Albania” in this month’s newsletter, project Optimize has publishedhttp://www.flickr.com/photos/projectoptimize/sets/72157630314080396/" target="_blank"> a photo set on Flickr that reveals how the new tool has benefitted health staff in the pilot region of Shkoder. The photo set is divided into two: “Before” and “After.” The “Before” photographs describe how health workers used the previous paper-based registry, while the “After” photographs describe how they are now using IIS, a computerized immunization registry. The photo set includes several screenshots of the IIS tool itself. http://www.flickr.com/photos/projectoptimize/sets/72157630314080396/show/" target="_blank">Access the photo slideshow directly. Click “Show info” in the top-right corner to view/hide photograph descriptions, and click the following button in the bottom-right corner to view the slideshow in full-screen mode: To comment, make sure you are logged in and click Reply.

Online immunization registry transforms work in Albania

An interview with Silvia Bino, Albania Institute of Public Health The Institute of Public Health in Albania recently developed an online immunization registry to replace their existing paper-based system. In May 2011, the new system—named IIS—was piloted in Shkoder district. One year later, Op.ti.mize talks to Silvia Bino about how it has transformed the way vaccinations are scheduled and recorded. Before IIS was launched, how were immunizations scheduled? Nurses and the district head of vaccinators worked together using a paper-based system to make sure that all children received the vaccinations they required. Each month, the nurse made a list of all the children due to be vaccinated that month in her health center by carefully going through the health center’s immunization and cohort registries. She used this list to schedule each vaccination, notify parents, and work out how much vaccine to order. She did all this using pen and paper. Were immunization records kept in the same way? Yes. The nurse had to record the details of every child vaccinated on up to six forms and registers. At the end of each quarterly period, she had to review this information to produce a vaccination coverage report. This report was compiled by hand and compared the number of children scheduled for vaccination with the actual number of children vaccinated. The nurse would then send this report to the district head of vaccinators, who would review and aggregate the figures. What problems did nurses have with this system? The nurses spent a lot of time recording and reviewing immunization data. And despite their hard work, some errors in data collection and reporting were inevitable. We needed to automate as much of this administrative work as possible and help them get on with the more important parts of their jobs. Were there any other problems? The lack of detailed data was another big problem. At the national level, we only received aggregated data that wasn’t helpful to manage or improve the program. For example, we only received coverage estimates by district, when we needed to know the vaccination coverage by community, who the unvaccinated children were, where they lived, and why they had not been vaccinated. The old system could not give us this information. Other problems were that we could not control the distribution of vaccines in the way we needed to and that there was no easy way to keep track of children who moved to another part of the country. How has the work of health staff changed? A lot of the nurses’ work has been automated. For example, as soon as children are born, the maternity nurse enters their data into a central database. A schedule of their future immunization appointments is then automatically generated. When the appointments are due, the children are automatically included in their local health center’s monthly plan. The nurses no longer need to go through the immunization registries to find the children who need to be vaccinated. Instead, they use the monthly plan to organize their vaccination schedules. The monthly plan also calculates the total number of vaccine doses required, and this information helps nurses to determine the exact vaccine quantities to order. I have to say that IIS has also improved the quality of nurses’ work. For example, they can spend more time with parents and caregivers to answer questions or address any concerns they may have. And with IIS they are now better able to access and share information. Has the new system improved stock management? Absolutely. As children are vaccinated, nurses with access to a computer can update their immunization status directly into the monthly plan by entering the vaccination date and the vaccine lot they used. Because IIS is used for stock management, the system can show which vaccine lots are stored at every health center and can deduct their balance every time a nurse uses a certain lot for immunization. With IIS, the district head of vaccinators prints out a monthly plan for every health center and health post and distributes them to nurses together with the vaccines. In this way, he can easily make sure that the requested amounts are correct. Village health nurses who don’t have access to a computer can use the paper plan to organize their work and report back on the vaccinations they have administered by taking note of the vaccination date and the lot they used in the columns provided on the form. What are the main benefits? IIS simplifies the monthly planning and reporting that nurses need to do. But there are other benefits to tracking individual children. Firstly, IIS doesn’t just generate coverage reports automatically by comparing actual vaccinations with planned vaccinations, it can also show exactly which children have not been vaccinated—those who have been registered but have not received all their doses yet. This enables nurses to quickly identify any defaulters and to check that access to vaccination is equitable across communities. IIS also manages the stock of vaccines and consumables which allows the Institute for Public Health to monitor the expiry date, distribution, and usage of ever more expensive vaccines. By linking the vaccine lots to the individual child records, lots can be traced through the stores and eventually to any children who have received a dose from a particular lot. This is essential for vaccine safety. Are there any benefits for parents? Parents will shortly be able to access IIS themselves to view their child’s vaccination history and download a vaccination certificate for their child, required for school and visa applications. Are there plans to scale up the pilot? Yes. We plan to start using the system in other districts in Albania later this year. If all goes well, we will be able to implement IIS nationwide by the end of 2014. In the meantime, we are also adding new features to IIS, such as the tracking and reporting of adverse events following immunization. In May this year, we also hosted a workshop for the countries of the South East European Health Network. We hope to collaborate further with these countries in the future as we are all looking to improve our health information systems. For more information on Albania’s implementation of IIS, please contact Silvia Bino. Note: Optimize will provide a full report on the implementation of IIS in 2013. To comment, make sure you are logged in and click Reply.

Going digital: Upgrading Vietnam’s paper-based immunization registry

by Dr. Nguyen Van Cuong, NEPI and Joanie Robertson, PATH Vietnam’s National Institute of Hygiene and Epidemiology is collaborating with project Optimize to demonstrate the benefits of a computerized immunization registry. In January 2012, a new computerized immunization registry was piloted by Vietnam’s National Institute of Hygiene and Epidemiology. Dr. Nguyen Van Cuong of Vietnam’s National Expanded Program on Immunization (NEPI) and Joanie Robertson of PATH provide an update on its performance. Think for a moment of the information associated with a child’s immunization. Who is the child? Where does she live? When was she born? Who are her parents? What vaccine will she receive? When and where will she be immunized? Did she actually receive the vaccine? And did she suffer any adverse reactions as a result? Now multiply this information by one and a half million—the number of children born in Vietnam every year. Next, add the five visits each child must make to fulfill the dozen-dose immunization schedule of Vietnam’s NEPI, administered at more than 11,000 commune health centers throughout the country. At this point, you begin to understand just how much data are captured and reported in the immunization program. In Vietnam, all of these data are meticulously recorded by hand in special notebooks. The country’s immunization registry is composed of thousands of such books, each containing a list of children born in the catchment area of a particular commune health center. Every child is recorded by name, along with their gender, date of birth, address, and the name of their parents. When a child receives an immunization, the date of that immunization is recorded in the book. Every month, health workers painstakingly flip through the pages of the book and count the immunizations delivered at the health center that month. This is the only way to obtain the aggregate number of immunizations delivered for each vaccine. Once these statistics have been gathered, they are passed on to the district health center, which aggregates the numbers for all of its communes. The district health center then passes these figures on to the province, which in turn aggregates the data and reports to the regional and national level. What if this information was digitized? If immunization data were kept in a database rather than a book, the computer could do all the counting and aggregating, leaving the health workers with more time to care for patients. And instead of waiting for the paper reports to come to them, the district, province, and national program staff could use a web-based interface to access the data at any time. This would help program staff to monitor, supervise, and plan immunization activities. Vietnam’s National Institute of Hygiene and Epidemiology is collaborating with project Optimize to start making this happen. In November 2010, an experienced local software developer was hired to build the system. It was important to work with a local developer who could speak the language of the NEPI administrators and commune health workers to understand their requirements, processes, and priorities. Working closely with NEPI and Optimize, the developer built the four components of the digital immunization registry: -A database to securely hold information on each child. -A mobile phone application that can download and upload data to/from the database, such as information about immunizations administered and aggregated report information on key indicators. -A desktop PC application that Expanded Programme on Immunization officers at district, regional, and national levels can use to generate reports from the database. -A short message service (SMS) feature to send text messages to parents of children with scheduled immunizations. In January 2012, the new immunization registry was piloted in Mo Cay Nam district in Ben Tre province. Health workers from all 17 communes in Mo Cay Nam came to the provincial health center for two days of training. The software performed well, but some health workers unfamiliar with computer programs and mobile phone applications found it difficult to use. And with only one day a month to practice (immunization days occur only once a month in Vietnamese communes), it was noted that becoming proficient in the new tool would present a challenge to such health workers. With further support, users are now beginning to enjoy the benefits of the new system. Assessment data are still incomplete, but it is already clear that in communes where health workers are successfully mastering the immunization registry, the system is helping to increase data availability. It is also helping to reduce the time needed not only for reporting, but also for immunization day planning and preparation. In particular, the new system has shortened the time needed to screen patients prior to vaccination because health workers have access to more information about each child. Additionally, the relationships between health workers and children’s parents have benefitted, since the parents are impressed with the reminder SMS they receive from the system prior to immunization day. All of these things are having a positive effect on the immunization program in the community. A small pilot such as this cannot answer every question that needs to be asked when designing a national immunization registry. However, the findings add further weight to the case for harnessing the power of digital technologies to track and store immunization data. The lessons learned in this demonstration will help to increase the strength and robustness of future computerized registry systems. Optimize will publish an evaluation of the immunization registry demonstration in Vietnam later this year. For more information, please email [email=jrobertson@path.org]Joanie Robertson[/email]. To comment, make sure you are logged in and click Reply.

wVSSM goes online in Tunisia

by Mojtaba Haghgou, consultant, and Ramzi Ouichi, WHO A web-based version of the Vaccination Supply Stock Management (VSSM) tool has been successfully deployed in Iran. Now, project Optimize is collaborating with the Tunisian Ministry of Health to field-test wVSSM in Tunisia. VSSM is an open-source software application developed by the World Health Organization (WHO) to enable immunization program managers and vaccine store staff to manage vaccines and related supplies. It is based on existing WHO and UNICEF policies on vaccine management, with consideration for common field practices in developing countries. Although the focus is on vaccines, the application can be used to manage health supplies, particularly those provided through primary health care services. First deployed in 2006, VSSM is now available in ten different languages and used by immunization programs in more than twenty countries. The web-based version of VSSM, named wVSSM, has all the features of the standalone version. Being web-based, wVSSM is simple to use and easy to access. Inventory data are stored on a central server that can be viewed by anyone with a wVSSM account, a computer, and a working Internet connection. Once connected, staff can view the total current stock of any item up to the country level. In 2009, the Iranian Ministry of Health and Medical Education deployed VSSM in the national vaccine store and three regional stores. In early 2011, Iran moved from VSSM to wVSSM, starting at the national level and then going to the regional, provincial, and district levels. Today, all 6 regional, 46 provincial, and approximately 350 district stores in Iran are connected to wVSSM, and all vaccine stock management is done with wVSSM. (wVSSM has not been deployed below the district level). In November 2011, in collaboration with project Optimize, the Tunisian Ministry of Health began field-testing wVSSM in Tunisia. The goal of this testing was to demonstrate the benefits of moving away from a paper-based system to a computerized, networked information system that links national, regional, district, and health center levels. This will enable the exchange of real-time data on vaccine forecasting, stock management, and order status information, ensuring that the right quantities are distributed to the right place at the right time. It is expected that this ability to track and trace vaccines throughout the supply chain will reduce the risks of overstocking, expiry, and high vaccine wastage. As Tunisia begins to introduce new and more expensive vaccines, reducing these risks is becoming increasingly important. Although wVSSM is a comprehensive stock management solution, some modifications were needed to accommodate the local context in Tunisia. In particular, some Arabic and French text was modified to make it more easily understood by Tunisians. Relevant forms for ordering vaccines also needed to be added. Once the wVSSM tool was updated for use in Tunisia, over the course of 2011, the team conducted a series of induction and refresher workshops. In parallel with the training activities, the required computer hardware was purchased and installed. A wVSSM server was set up at the Informatics Centre of the Tunisian Ministry of Health in Tunis, and IT equipment such as computers and printers were installed at the ten pilot sites selected to use wVSSM. The team also worked to ensure that the pilot sites had the Internet connectivity required to communicate with the wVSSM server. In the three months since field-testing began, moving from a paper-based system to a computerized one has worked well, and health workers are pleased with the change. Currently, the national, regional, and district levels of the system have all been linked, and complete stock management information for vaccines can be seen in real time at each level. Although the initial experience has been positive, it has not been free of challenges. Without a reliable Internet connection, wVSSM cannot function. In the more remote areas of Tunisia, where connectivity cannot be guaranteed, this has made it difficult for health workers to use the new system. It has also taken time for health workers to adapt to the new tool. A demonstration version of wVSSM is available online. Contact Mojtaba Haghgou ([email=mojtaba@wvssm-demo.com]mojtaba@wvssm-demo.com[/email]) to receive a username and password. To comment, make sure you are logged in and click Reply.

Albania pilots electronic immunization registry

by Erida Nelaj, Albania Institute for Public Health and Jan Grevendonk, PATH In May 2011, the Albanian Institute for Public Health (IPH) launched a new web-based immunization registry and vaccine ordering system in the district of Skodra. Based on the acceptability and success of the system in Skodra, the government is deciding when and how to roll out the software nationwide. After an initial training with nurses, the system appears to be working well, and acceptability is high. [Click photo to enlarge] The project began in 2009 when IPH asked project Optimize to help develop a strategy for an electronic immunization registry and vaccine stock management system. Working with a local software developer, IPH and Optimize documented the key processes and requirements for the system and referred to them throughout the development process to ensure the project was on track. A year later, after several rounds of preliminary testing with users, the software and training materials are complete and have been deployed at 24 health centers in Skodra. In many ways Albania is a difficult place to deploy a web-based information system. Few health centers are equipped with computers, electricity is unreliable in many areas, Internet access is limited, and even mobile networks do not reach the more remote areas of the country. However, the system was designed to work around these issues by providing access through mobile phones and, when needed, paper-based reporting systems to complement online access. After a month of use in the district, IPH and Optimize staff checked in with nurses in health centers across the district to learn how they liked the new system. They found that nearly everyone understands the system and finds it highly functional. Despite some frustrations with Internet access and electricity, nurses clearly see the value in the system, noting that it will save them a tremendous amount of time creating their monthly plans and make it easier for them to track and monitor vaccinations, even among families that move to and from other districts. For now, nurses are simply playing with the system, and data are not being collected for use. In September, the system will be used for actual data collection, monitoring, and ordering. Over time, additional features and capabilities will be added to the system, including the mobile-phone component that will allow nurses to download immunization schedules for children associated with their health post, find any child in the database, and register the vaccinations they administer from any location with connection to a mobile SMS (short message service) network. Nurses have also requested that the system be expanded to include additional functionality such as adverse events reporting and disease reporting. As the Government of Albania prepares for nationwide introduction in the coming years, neighboring countries, too, are taking an interest in the system. In the fall, representatives from these countries will be invited to visit health centers in Skodra to understand how the system works. Optimize will monitor the system for up to a year and conduct multiple evaluations, including a functional evaluation of its use and acceptability, impact on supply chain performance, and cost. For IPH, the success of the pilot will be measured by how well it can improve the quality of the monitoring system for immunization coverage, increase ordering accuracy, and decrease the administrative burden on health workers. [Click photo to enlarge] For nurses who currently record each vaccination session on five different paper records, the benefits of the system are obvious. After completing the first training session, one nurse asked, “okay, just tell me when it is going to start.” For administrators, the system will also bring value. Not only will coverage data be more accurate, but the data are disaggregated, which means that district officers and nurses can see that not only do five percent of children need vaccination, but they can see the individual names and locations of children who are due or overdue for vaccination. Combined, these benefits will accrue to families whose children will receive all the vaccines they need right on schedule. To learn more about the software system or comment on its use in Albania, please click reply at the bottom of the page.

Your phone rings; it’s the freezer calling

by Olivier Ronveaux, WHO, and Mojtaba Haghgou, Vaccine Management Consultant Maintaining required temperatures in vaccine refrigerators and freezers is one of the more thankless tasks of a cold chain manager as it requires painstaking manual recording of the temperature of each piece of equipment twice daily. Despite the monotony, temperature monitoring is a crucial task, especially in central stores at the national level where millions of doses of costly vaccines are at stake. A 2004 study of vaccine freezing in Indonesia, for example, found that freezing temperatures were recorded in 74% of shipments. Without careful temperature monitoring, accidental freezing or overheating of certain vaccines can reduce their potency to levels that render them ineffective against disease. Several countries, among them Sudan and Iran, have found a way to automate the temperature monitoring system saving both time and money while increasing the accuracy and reliability of the monitoring system. While Sudan is a bit smaller in population than Iran, the two countries have a similarly sized number of surviving infants (1,086,000 in Sudan and 1,300,000 in Iran) and handled an almost identical number of doses of vaccines in 2007/2008 (about 108.8 million doses). Sudan automated its temperature recording system with financial and technical support from the World Health Organization (WHO) Regional Office for the Eastern Mediterranean (EMRO) in 2007. A United Kingdom-based company was contracted for the design, assembly, and installation of the system which cost about £52,000 at the time. The system includes a network of gas-type temperature sensors (Figure 1) in each cold and freezer room that measures the internal temperature and transmits it wirelessly via a transmitter installed on the roof of each cold and freezer room to a hub. The hub is connected to a computer for saving data. The store manager can also view the data on a monitor in his office (Figure 2). When temperatures exceed 10[sup]o[/sup]C or fall below 0[sup]o[/sup]C, an alarm system sounds a siren in the store and calls the mobile phones of the store staff and the Expanded Programme on Immunization (EPI) manager. The system also sends a short message service (SMS) text to the mobile phones providing information about the specific cold or freezer room and its internal temperature at the time of breach. The system has functioned continuously since February 2007 without interruption or malfunction. A manual system is maintained for backup purposes and is kept on file. Iran's system is older (2005) and perhaps more impressive because it was manufactured, designed, assembled, installed, and maintained entirely by local companies. Although the cost of the system is unknown, it is likely to be the less expensive of the two systems since it involved no international travel or foreign labor costs. The system is similar to the Sudanese system with the following differences: local products and labor, the connection between the temperature monitor and the modem is wired (not wireless), the connection between the modem and the computer is wireless, and the temperature sensors are digital, rather than gas type. EPI staff members from many other countries in the region have already toured Sudan to learn about its system, and there is great interest globally in replicating the concept. Since 2007, WHO has established specifications for performance, quality, and safety (PQS) for temperature monitoring systems and protocols for testing such systems. To support decision-making, Optimize is working to establish minimum criteria under which countries should consider installing automatic temperature recording systems. The type of recommended system will depend on the size of the stores, the number of vaccine doses handled per year, and the importance and location of the store. Download a copy of a recent Optimize report on temperature monitoring systems in Sudan and Iran.

Albania explores computerized immunization registries

Albania explores computerized immunization registries by Jan Grevendonk, PATH, and Olivier Ronveaux, WHO In early 2009, the Albanian Institute for Public Health (IPH) asked Optimize, a WHO-PATH collaboration, to develop a strategy for a computerized national immunization registry and vaccine ordering system. Working with IPH and other large stakeholder groups, Optimize assessed the existing paper-based system this summer and developed a strategy for implementing a small-scale pilot under IPH management in one district (Skodra). In Albania, health workers are expected to record vaccinations for children in their catchment area on five different paper records. In order to determine vaccine orders, these records are compiled at the end of each month into two different reports that are aggregated at the district and national levels. The existing system, while functional, places a tremendous administrative burden on health workers and does not provide enough detail about populations that could be falling through the system’s cracks. The benefits of an online centralized registry linked to vaccine ordering are potentially enormous. Most importantly, a central registry would allow health workers to accurately track each child’s vaccinations even if that child moves between catchment areas. The system could also facilitate more accurate forecasting and improved inventory records of the vaccines needed in each area of the country. The success of the pilot will be measured by how well it can: • Improve the quality of the monitoring system for immunization coverage by providing access to more accurate and more relevant disaggregated data at the central level in a more timely fashion. • Increase ordering accuracy—using the information collected through the immunization registry, vaccine inventory and wastage can be better assessed enabling the right quantity of vaccines, diluents, syringes, and safety boxes to be available at each level of the system. This could possibly reduce the need for buffer stocks. • Decrease the administrative burden on health workers. The proposed system will integrate the immunization registry with the functionality of the basic logistics management information system. In the future, the two functions can be integrated further and expanded to accommodate other applications such as disease and adverse events following immunization surveillance. Albania, like many lower-resource settings, has varying levels of access to consistent electricity, internet access, and mobile-phone service. The pilot will therefore use a combination of three modes of communication: internet access with personal computers at the national and district levels as well as in large health centers; mobile phone access in other health centers and village outposts; and paper-based access in areas without access to mobile technology. The pilot system will role out in mid-2010 with the goal of expanding the program nationally after evaluating and revising the pilot system. We invite you to comment on or post a question relating to this article by clicking the “post reply” button on this page. You will have to log in or register; the process is very simple. To link back to the Optimize e-newsletter, click here.

Vietnam To Assess and Evaluate Opportunities To Optimize

Vietnam To Assess and Evaluate Opportunities To Optimizeby Joanie Robertson and James Cheyne, PATH Optimize is drafting a memorandum of understanding with the Ministry of Health, National Institute of Hygiene and Epidemiology (NIHE), in Vietnam to possibly implement two phases of work. The first, an assessment phase, will evaluate opportunities for supply chain system improvement and identify cold chain technology requirements required to optimize supply systems. The second, a demonstration phase, will implement technologies and system interventions that can improve the vaccine supply chain and establish a long-term vision for the evolution of immunization services and support systems. During the assessment phase, NIHE, PATH, and WHO staff will conduct an Effective Vaccine Managementstudy, which will help highlight areas needing improvement in the vaccine supply chain. The team will also discuss future vaccine introduction plans, review, and document potential approaches for information systems strengthening, as well as potential areas of collaboration with fee-based immunization services. Based on the assessment results, the team will craft a vision for an optimal supply chain that can be compared to the existing public sector supply chain. In phase two, Vietnam and partners will begin to demonstrate new approaches and technologies on a pilot scale in three provinces. Those approaches and technologies that prove successful can then be scaled-up nationwide, potentially serving as a model to other countries wishing to implement similar interventions. We invite you to comment on or post a question relating to this article by clicking the “post reply” button on this page. You will have to log in or register, but the process is very simple. To link back to the Optimize e-newsletter, click here.

Why Optimize?

Why Optimize?by Daisy Mafubelu, Assistant Director General, WHO Family and Community Health Cluster,and Chris Elias, President and CEO, PATH In 2007, the World Health Organization (WHO) and PATH jointly launched Optimize, a five-year effort to help countries anticipate and manage the growing complexity of the logistics of immunization programs. The project draws strength from WHO’s expertise in setting norms and standards, establishing policies, and developing guidelines and from PATH’s 20 years experience in improving vaccine transport and storage and advancing appropriate technologies to deployment in developing-country immunization systems. The collaboration, funded by the Bill & Melinda Gates Foundation, is not exclusive: national governments, UNICEF, donors (including the GAVI Alliance), industry, and many others have critical roles to play in shaping logistics systems of the future. In contrast to supply chains that simply react to ongoing logistical problems, Optimize and its partners envision supply chains that actively predict, propose, and meet the needs of rapidly changing immunization programs, so that as vaccination products, schedules, and policies evolve, so do the logistics systems that bring those services to people in need. There are three dimensions to this effort. One is to create an enabling environment for innovation. This means creating preferred product profiles for new vaccine, device, transport, and refrigeration technologies so that the needs of developing countries are considered in the earliest stages of research and development. It also means creating an enabling policy environment—one that ensures that new technologies, systems, and processes are safely assimilated into country programs within a reasonable time frame. For example, a policy that allows relatively heat-stable vaccines to be used in a controlled environment, but not necessarily in the “cold chain,” could free up limited space in refrigerators and cold rooms that make up the vaccine supply chain. When coupled with a policy that requires vaccine vial monitors on these vaccines, health personnel can ensure that each individual vaccine vial has not been ruined by exposure to heat. A second dimension of the project is to demonstrate the utility of new management processes and technologies that may improve the efficiency, flexibility, and cost-effectiveness of the supply chain. For example, the integration of the storage and distribution of vaccines with other heat-sensitive products canreduce redundancies in storage and transport equipment. Similarly, the introduction of computerized monitoring and tracking systems can help countries move beyond paper-based systems and make vaccine management and ordering more accurate and efficient. A third dimension to the project is to share our findings and observations in real time, allowing the global community to participate in and influence discussions on future supply chain designs. The result we seek is a globally accepted supply chain model that meets the ever changing needs of populations in low- and middle-income countries. We invite you to comment on or post a question relating to this article by clicking the “post reply” button on this page. You will have to log in or register, but the process is very simple. To link back to the Optimize e-newsletter, click here.

The Battery-Free Solar Refrigerator Challenge

by Joanie Robertson, Technical Officer, PATH

In March 2009, six companies submitted designs to PATH in response to its Battery-Free Solar Refrigerator Challenge. Product designs that meet desired specifications will receive financial assistance to cover the cost of third-party testing required for consideration under the World Health Organization's Product Quality and Service (PQS) process.

The purpose of the Battery-Free Solar Refrigerator Challenge is to encourage the development of new products in the solar refrigeration category for use in developing-country immunization programs. Solar-powered refrigerators are an attractive alternative to gas- and kerosene-powered absorption devices: they are environmentally sound, provide an alternative to grid electricity where it is unreliable, and can be produced affordably. However, most existing solar refrigerator products are inadequately designed to meet the needs of developing-country immunization programs. The main issues relate to the lack of or inappropriate replacements for exhausted batteries, inappropriate system sizing, and poor installation work.

The Battery-Free Solar Refrigerator Challenge is designed to help address the first of those issues. By providing clear specifications to known solar refrigerator manufacturers and helping facilitate the PQS testing and submission process, Optimize hopes to reduce some of the market barriers and spur innovation and growth in this important refrigeration category.
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