RI strategic initiative

RI strategic initiative orking Retreat Pre-reads/handouts I BILLetMELINDA GATESfradad- 1 EFTA01072417 RI Retreat agenda CI= 11154:45 a amain( evattabIo 540630 fro 41304,10 an, 4146-104) am Welcome. overview or the day and contend Introchralon to 'WON a' strategy refresh process How RI lean gallon the soon of thalr program • One ortvotnol deInnon moo (Mate non may cosh** Mallon of RI • Dissamiga.MIOch toads me mai catIcal la tons/di Fstaloj7 VIO Mitchell John *IWO MItchMI and Malt Manton 10:30410)am Brag 11.00.120)pm How RI Ste Into founctabon's Melon for WHAM • Moore ttol Ponoon tootkm and obi natuuom Maw Ctrs RI anatla prograMgOals of (1004010 IMml enhIVCOTVOS to RI ca/0 twee a trzroknmMw moor,Matt Hansen and Molly AbblULZOI4 12:0012:4S pm Mach 12:45.2:30pen RI currant and future pnoblVr. klenlincation • Manley MOW gaps that Oolong* louniatIon ablIM 10 reel gods • °mow= hch Spa sooti4 be 10P pn00y IV he glotol comely-0y 10 oddrem, ThyCore team My I000)" Strategy 23043/0 an Ore* 100430 ph 416620 ph WIMAII tlW leunceselon could and should engage Whallit team NS rowdfrom fr-may • woo am C moose.] Rots tor to 5.10. 25 'MU Talk • QYuMpr Mimeo IVCci0 fink tho kordotoo Provo/ engem. • RrM'Olo•m GeMaW b-ndalloo ammo:mom VloMllonMi and Skye Gilbert VI* Mitchel Recap al the day and not slope 2 2 EFTA01072418 RI team charter EFTA01072419 Project Charter (I) Routine Immunization Steering Group: Global Development Program Team Name Work Group Goal The goals of the RI Steering Group are as follows: - Develop routine immunization strategy; - Identify resources that can be employed toward RI goals (potential partners, catalytic funding, voice); — Identify strategic opportunities for future RI Investments; — Monitor initial implementation of RI strategic initiatives. GD Goal this effort relates to Strong routine immunization systems are the core of our Vaccine Delivery goals (as listed on the Scorecard I: — Eradicate Polio — Prevent re-emergence of polio from either wild or vaccine-derived viruses — Reduce measles morbidity and mortality (from 2000-2008, 2/3 of reduction in measles mortality due to RI' — Save 6.0M lives in 69 high burden countries over 2010-2019 with currently available (DTP Measles, Nib, pneumo, rota) and new vaccines (malaria) — Reach 90% of the children n the poorest countries with sustained coverage of vaccines nationally and no district <80%. — Achieve the DoV effort. Work Group Executive Sponsor Steve Landry Work Group Lead: Acting DD, RI Violaine Mitchell Time Frame Eleven Months: February 1, 2012 — December 31, 2012 Updated on April 30, 2012; and August 31, 2012 4 EFTA01072420 Project Charter (II) Opportunity Ratemen& Justification Summary Assumptions and Risks • Wattehraa twine an . pa, .1 ratan.. rerbdtv reciartvebtad wt., w fre,entall, 015215r. • WmManRrwnru,rn-unuuo+evRrlbwlxnnLaMGaWrUl4lryvrytlnmuyanohteunnnavllorlof role 414.1401, rif e 'ha to0r an vier. end Ilan pixy ity ljart.K.Jalve w1o+r0✓nc 02..ntrat end thaw within kn[atashed traliMs9.0 ,2 • yrient routine Demtnitabe WAtera.122 46O A. Attest!, e1,2.222. e)she.lit ma. 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StItage.0.2.a.41ereili te intustallafte EFTA01072421 Project Charter (III) >fcctesta Objectives Success Measures • Articulate RI goals — Within global context — Specific to the foundation — Specific to key geographies • Mmdmize RI resources — Identify key partner strengths — SUategiae as to potential external partnerships — Coordinate with other Internal efforts • Outline Strategic Initiative In RI — Identi Investments • Ultimately, to achieve the new DoV goals • Shorter-term Increase in RI coverage in key geographies fic success measures 7B13 on a initiative basis 6 EFTA01072422 Project Charter (IV) a nt.,,,, s .. Core Steering Group members and their s Pr/ Division • RI leans Voters* Mitchell Man Hanson Rap Rao Molly Abbrunese • INDIA TEAM Devendra Mandan • ()then IN) in-country prese • None Codaboration with other foundation terns (CD &FM Steering Group Memberare expected to coordinate across the foundation Gobal Health teams, and vitth the Gbbal Development out as appropriate. Partite • F MOH In key countries • Bilateral Donors, such as: USAID. UK/DrID. and Norway • Other Partners: GAVI Secretariat, UNICEF, WHO. World Bank Role of team members / staff manning sPecifIc activities with MOH • Violaine Mitchell, Acting DD for RI, will serve as the key contact person for FMOMs in key geographies • Steering Group Members will advise the Acting DD of new opportunities and topics under discussion with partners • Acting DD and RI Program Officer(s) will be available to pm/support these discussions with internal staff and external partners, as requested or appropriate , ,,.,,,,,,,,,,, o. <., ,, ,..., i 7 EFTA01072423 Project Charter (V) Proposed Timeline and Deliverables: 1 year High-level Milestones for Year One of Routine Immunization Steering Group Date Complete Review and adoption of RI Steering Group Charter 2/01/2012 Development of Year One Work Plan 2/01/2012 Meetings with External Advisors 06/2012, 09/2012 Development of Metrics for Project See Scorecard Initiation of 3 RI Emblematic Grants Ql, Q2 2012 8 EFTA01072424 Project Charter (VI) IVOPOINIA010tilt0 R0k$10414$0300001Ple Cieung 6,04 StEns-te - Chris Oa% Presibtm.Glabal DeallOPmait Po Steed,. 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ICIN:01P140 Ca ha.. a; ..... rt ans eh gr man ProgramOf/kir nosiorling bSt.11,10.u. p ird plain On.n,..* oC, OfCalntugc pWel (WINN/ 'not-% ityors ..,r., navy ups( et • tgot af.lyits 'Moto Presort/ St narn(uvelo.p,00. plse cats itowasitts B4000 wn. .ten. rde.artt4n9.t• (0.01.”,514W00/(01. 45,41.0 9 EFTA01072425 10 EFTA01072426 Global Immunization 1980-2009 - DTP3 coverage 100 80 Ecn 60 4.) 40 20 feeigg slgiwggeleigg ggiegg Global —Eastern Mediterranean —European — Western Padfle —American —South East Asian SwevYMOVNCEFixwiseatliVeon0,209.4.0y2M 11 EFTA01072427 DPT3 coverage levels in key geographies OTP3 covetage (a) 12 EFTA01072428 Trends in DTP3 Coverage in Nigeria, 1980 - 2010 EPI re-launched. UCI implemented EPI initiated 07 70 CO 50 140 20 10 a 1970 1975 UCI 5$ end 1990 1995 ton 2000 1980 1985 EPI renamed NPI. made a paraslatal Sone' 1 WHON/1020:40mol 0a 10/01/2010 ha. tmLappau tigunanmni.”1.:tnoltocres.012221/enn- 2.N800.1111 Immuntalen paler Survey MUGS). 2010. MOH and teHODA NPI 4NPHCDA Key Afti, Nig I. WHO/ UNICEF 2. NICS 2010 2005 2010 2015 EFTA01072429 Coverage and risk comparison of DTP3 shows that hardest to reach are those most in need of intervention Compared coverage rates and risk by wealth quintile • Using child mortality rates (1- 59 months) as a proxy for risk of vaccine preventable disease • Each line represents a single country. with individual points for each wealth quintile For most vaccines and most countries, lower wealth quintiles have higher mortality risks and lower coverage rates — however the pattern differs between countries • Assuming infections targeted by new vaccines are distributed similarly to child mortality. existing programs may miss substantial fraction of high risk children ■ a • • 100% icrft 10% o a 100 I50 20) Vida 50V) irCenno Each Nom represents one county. ladWdual point, miasma each wealth quintile =IIIMMEMe tad Four graphs of coverage by quintile for all countries, recent year. BCG, DPT2, Polio 2, Measles. Like tableau lower left, but only most recent year 14 EFTA01072430 Case-study of impact of equitable distribution with Rotavirus Estimated distributional effects of totavirus vx Rotavirus mortality and coverage curves mortality reduction and cost effectiveness et • • • 1 It i• an.. man. Each lino represents a county: Individual points represent each wealth quintile Coverage decreases and deaths from rotavirus ;x.c ny atilt lower wealth NM. mi.*. caul Mown. I.......1. anew. tawdry linos nes Nan PpLinna SS *NOS as wand ~nal non,. Mame .P.A4 MIMS VO3 la INS WM 4...~ M Car WI lille an 44.1 >754 Rent MO) IN • a in as 21•1 • 5. MS IIan OS Mn 544 4/0 :MI PM )110 04 4.14 110m1 1e11. .01.11 In 2n ran.. Itei PM 147 249 MT TI 1414 pp 2M 251 PI MIS 14 00 I•15 2/1 )70 M IMO 00 10 Ill I Oa 121 Plemi PM Mn 10 10 aa is tie MOM ten I M ill 5740 Ma I SY i PO >at) ini I M I le I re, Well I N I 11 N4 MO 0 le Me Me as MP UM no 1M sie IMO KM 215 SW ON MY 2L •44 2n Pal. NM co ova Innen miennlina coal 4•0 • a+.. tim.4.7.40 newly ...no, Wen tmeni• 444.4.644 Nan &NA retell Fa • IMNIMOMMSYMMISMOT ant---D=wir /MSC 15 EFTA01072431 Countries with DTP3 coverage below 70% 40 countries in 1990 37 countries in 2000 20 countries in 2009 © 2010 Bill & Melinda Gates Foundation 16 EFTA01072432 Demands on vaccine delivery systems are rising dramatically Demands on delivery systems are vowing dramatically Cumulus -4w nulae and volume q vorrines used An imam.- childhood Amenummlion [Myopia lalanket Rib 10000/0.11 OR KO 101,00.X.1 Total Valw, OW USD) I1 1012 1954 1986 191% 1990 19W II% In 19% 200) 1001 133. 1006 MOS 1010 IOW 20% Mintz %MSS. Caw Onl Swim Welds,/ lelfsels Odom?: el ant aloleesimmallaw. 17 EFTA01072433 Health worker shortfall is affecting immunization coverage Immunization coverage improves with increased density of vaccinators 90 - 80 - O-4 70 - a) 60 - - O 0 30 - 20 - 10 - 0 ••• Ilurrenmearc:e3 to -• Doclorg NJIOS 10 Density (per 100 000) 100 WHO esthrolas Vat Inns then z . MISICOrOpOleeekeelli:traic ,-,- rases. end RiclatgOOPer100,cr ,. 0:0111400 a dal tiberlaCt, 18 EFTA01072434 57 countries are facing a critical shortage of health workers ft 4 iri 1 c eh vall 1 - Abt ti ralli y Canines tort Crital 'Notate of health torten Countries...ghoul cnbcal shortage <IMAM wodtn Reaching target levels of health worker availability would roquir 2.4 million additional health workers in critical countries 19 EFTA01072435 Tech wrovelc , Many technological innovations could improve RI supply-chain, but need to be effectively implemented/deployed Temperature monitoring innovations: e.g. VVIA. freeze-tags. 30-day temperature recorders IT systems innovations lutuwadiva..• azis • 42)::"Zilleth IR,' re:. et...44esS HERMES: supply-chain modeling tool EVM+: next generation EVM toc RFID tags: inventory monitoring too' Others... 20 EFTA01072436 New touchpoints for vaccination (e.g. schools) have been deployed effectively in developed world Comparison of school-based versus health- facility touchpoints in developed world Coverage raon fat 3 deo:G.11)V ICO 40 UK swan relied as Ngh- atorellmata h '<boob s -7---- AV* UK anal USA eau Mawr corforteowato noes • UK 213 Fe UK 4-18 Feteeth.° 0:1,70 CI US 3.1irti 32 In developing world. greater proportion of out-of-school children can be a barrier to school-based immunizations of school alien:lance I UK 3 Ocoee USA 3 eases Pray Low .00:01INAIMIO Pray Law iffiX•040,116. Panty Isar 14.444.0W9Ity UK:HA/vaccine LISA:WV...wane dawn:demo", school' Sherpa Mrouell regutor hoavn North Amence Women EU SubStoran Meta SouthandYAW Asia Chennets, 21 EFTA01072437 Other services often integrated with routine immunization Health Facilities Integrating Services with Routine Immunization In 2007 RED evaluated countries) 0 OR POW) •CcadtN-133I Wiftn-fl I h i€ -1 Integrated service • The RI infrastructure provides a platform for the delivery of additional services during fixed and outreach vaccination sessions • In both fixed and outreach sessions. the services combined with immunization varied, even within the same country (see figure above) • Health facilities report that services are more frequently combined at fixed sites than during outreach sessions In addition to straining delivery system with new vaccines. health workers are also providing multitude of additional services with each interaction I 22 EFTA01072438 Our initial thinking on barriers to successful immunization 23 EFTA01072439 State of routine immunization today We have achieved significant Impact • In 2010. 109 million infants worldwide receive DTP3 vaccinations each year • 130 countries met the 2010 target of z90% national coverage of DTP3 • More than 2.5 million deaths are averted per year of children <5 years of age However, an unfinished agenda remains • In 2010. 19.3 million (-20%) children did not receive some or all of the routinely recommended childhood vaccines • DTP3 coverage was below 70% in 18 countries in 2010. only 59 countries (31%) achieved ≥80% coverage of DTP3 in every district • --2 million additional child deaths could be avoided if we can reach GIVS target of immunizing 90% of children < 5 years of age We cannot afford to be complacent in addressing these key gaps • RI coverage fell. or remained stagnant in 22 low-income countries between 2005 and 2009 • Hardest to reach children are those most in need of intervention and represent the most potential lives saved 24 EFTA01072440 Initial framework for thinking about components of routine immunization Data for decision•making For routine immunization to occur. three processes must be successful: • Demand: Individual must be present at the point of interaction where they can receive a vaccination • Snonly: The vaccine needs to anive at a designated point of i-iteraction where it can be administered to an individual • At the point of vaccination a health worker must actively identify an individual's vaccination needs and follow the right steps to administer and record the vaccination In addition, one enabler of routine immunization must be in place: • Data for decision-making must be collected, analyzed, and used. The data includes disease surveillance, coverage rates, and other metrics around the RI process 23 EFTA01072441 Demand barriers (I) Demand Barrier Rationale, evidence, assumptions ill pEdUall1011y 111 orwooen Slalus. • Niemen with low educational ilaltr3 may have less aCals 10 eseciad information. as well as lesser degree of socio-economic (mothers. caregivers) independence. Nils nate,' relates to decisimmialting power) • Evidence: Often correlated with chid health indicators. cited as risk factor for lack of vaconation Political banters • Chicken who he in conflict-affected areas. or who have recently migrated from those areas are less 'hely to be vaccinated. Reasons may range from lack of personal financial lemmas. lack a service delivery systems. and lack of trust in 'authority.' • Evidence: TBD Tech- nology Opera- tions Lack of caregiver education • Rationale: Some caregivers may not realize (or may not have been about vaccination told) linen to come back for subsequent doses. and villy* is important to do so • Evidence: Cutts S Eliellik (e.g. t0SURS of PaleiMan studyusing home' based education: study usng redesign c4 ot card to hilllight return dates and education on importance of full series) Lack of inkrmatico /Anti- • Rationale. May stem from misenformation: or from a lack of vaccine movements int:malice) regarding AtiFts • Caregivers may • Some indications that anti-vaccinahon movements are growing with choose not to have coverage rates increase as people see less evidence of trzEii. child vaccinated • Evidence: TBD Cultural / religious beliefs • Cultural or religious resistance to receiving vaccination, • Evidence: TBD 26 EFTA01072442 Demand barriers (II) IM= Opera tionS Cont.) Demand Barrier Rationale, evidence, assumptions Geography • Distance to point of vaoariation is a border (often related to line and finance, but also in its own righl) • Some geographic areas. we 'off the grid' (e.g. urban slums). and not accounted for n a designated service delivery area • Evidence: Cuttstieild pacer; Walt Orensteinn and Stanley Flotiliin Lack of financial resources • Delivery system does not account fee the cost and opponunily cost of binreang to a vaccination of waiting, and of any 'Unofficial' charges • Evidence: TED Lack of rpm/van:on • If no other services are offered at the same silelsame lime. it not be perceived as weer the cost & time • Evidence:TED Lack of btasernaliChld • Chidren been at home I without a skated birth attendant are les: lleallh Service UUizalion likely to be vaccinated • This priori lack of service uttizadon. presumably for similar operational reasons. spits over into lack of senuse utlizaticei for imrnortirdtion • Evidence: TBD Poo service deivery • Missed opporkwities. whereby 'lockouts. concerns of wastage rhos no opening of a new multi-dose vial). or other cancellation of vaccination discourage completion of a series • Evidence: TBD • Drepouts can also be caused by someone having a bad priori experience at a health censer - ride trealment by a healthcare worker. unexpected Sees. local vaccine ranchero, ex. • Evidence: TBD Bad experience 27 EFTA01072443 Surveys in Nigeria and Ethiopia shows that majority of un- vaccination driven by lack of awareness or willingness Total patient pool IIIIWN gram 1111/11 Main reasons C44•0 BY ratter for chid n04 recemnp vaccine' : • • Nigeria size of unAinder vaotinaied (All vaccines? 100% • Ohio& size ohm. vactinslims (Measles vaccines) Demand Compliance Total untunder vaccinated' • La:444i* • fee, ado .6140 • Post too fa. • blew.. mc • Foordikluagte Clik wasobsent Own wok Seam • UnelatabAlvel • RAMS note • Lac* mamma e3.4 04% et BO% 4, Lifer nearn A nib 69% e=1 31% 306 18% 12% WA ”-02%rt i.88% 47•-• 04% 41Th. St% II Su, 41% 23% 18% 18% WA 1.4ajOnty of unrunder• Smni8cani source of VaCCII130011 unAmder vaccination 28 EFTA01072444 correlated to mothers education schooV9 Primer/ Inforceoalalo Sezenenr Unwise,• 40 60 BO ICO % Coverage Mothers education appears to be a positive factor for immunization Coverage in Khartoum, Sudan Key findings on education from other studies • Generally. the studies reviewed suppore“ the conventional wisdom that education. particularly mothers education, is a positive factor for immunization • However, the relationship is not always dean and consistent • e.g. in one Kenya study fathers education correlated well with vaccination in urban areas and mothers education in rural areas • In Nigeria. educated people were less likely to immunize their children than illiterates 29 EFTA01072445 Lack of information on vaccination presents a barrier Country examples • Liberia: Over 1/3 of mothers said they were not informed about the return date • 2008 EPI review in Benin found that one d the pincipal reasons for non-vaccination was mothers being unaware of the need to return or when or where to return • In Mozambique. 3/4 of health workers said they always write the return dates on the child's card, but only 1/4 of the cards actually had the return date written • However..-i Uganda. 80% of parents claimed that health staff advised them to retsn for more vaccinations • In one area of Bangladesh. with a 30% dropout rate. 63% of mothers claimed they were not informed about the time and place of EPI sessions 30 EFTA01072446 Case study: addressing demand in rural India has more impact than addressing supply-issues only Note: This is a controversial issue( Immunization rates by type of immunization camp in rural India Fuly immunized 1%) so 30 20 0 %coverage 6% Avg cost! child Note. CCTs • ;34 novas temente/ me mee room •el+ dewed meoleaten nem epos 6.5x Control Reliable Incentives' + camps only reliable camps 18% 39% 555.83 527.94 V TOD Key findings Demand Improving reliability of services improves immunization rates by -3x. but adding small incentives improves uptake of by -6.5x • Primary impact of incentive is to increase full compliance Offering incentives proves to be more cost effective than purely improving supply • Average cost 1 child is actually lower when offering incentives - since daily fixed cost (mainly health worker salary) is spread over more children Study indicates that size of incentive does not matter beyond the fact that a positive incentive is offered However. coverage still remains very low despite interventions 31 EFTA01072447 Epidemiology of unimmunized child — access Impact of distance in Khartoum State. Sudan Impact of distance in Senegal lip Ici-clale irmnunizabon (%) 40 78 60 20 o ..— WO ire 4 GO inns Atilt hire a GO mns 40 Full imrriunizalica (%) so ro 60 40 93 0 10 Um wain i0 ims Welk awe a 30 32 EFTA01072448 Nigeria: Closer look at disparities by wealth quintile Methods • 2003 and 2008 data • Analyzed by region. wealth, vulnerability (nutritional status) and time • BCG. DPT1. DPT2. DPT3. Polio 0. Polio 1. Polio 2. Polio 3. Measles Table show coverage rates of different vaccines by wealth Quintile Key findings • Children in poorer households are less likely to be vaccinated • Disparities in coverage for all vaccines 100% 90% 80% >0% 00% 40% 30% 20% 10% 0% Penegi Pvcrtc ‘1019 fbc/Ro linen< Vaccination coverage rates by wealth quintile: Nigeria DHS 2008, children 12-23 months BOG —OPTI 0012 -OPT, Polo 0 —Polo, Polo 2 —Polo Mooth•• 1 figure (most recent year) with multiple vaccines coverage rates by quintile (national) 33 EFTA01072449 Epidemiology of unimmunized child Demand Barriers Utilization difficulties: country examples Lack of motivation • In Dhaka. 21% of mothers in one study stated that immunizations were not necessary for thee children Previous use of health • Studies in West Africa. India. and Ecuador found that services families with a history of using health services for other reasons had a much higher chance of having their ch Jr vaccinated Poor service delivery • In Liberia. 30% of mothers commented on the inconvenience of long waiting times Bad experience • In Uganda. only a minority (13%) complained about being treated rudely or badly • After some mothers lose their immunizationThealth cards. they are scared to go back to the health centers for fear of being yelled at by the health staff. made to pay for a new card. and/or asked to return home for the forgotten card I saINIMMI 34 EFTA01072450 Epidemiology determinants of unimmunized child: summary of major Demand Major RIM Factors (secondary factors) ConespendingfrolnforcIng - Place of residence (rucal cistant front a health faddy) (family factor) Insufficient facift es. truela:se selvicer..routreach. restncledincorivenew servire hours (sernce factorS1 Poverty gamily Ham) Health marker attitudes and behavior. charges (official tad unaided (service factors) Mothers' education (family factor) (Although mothers' education was commonly associated viith ithiHren's immurization status. some studies found little or even a reverse correlation) Inthdficienthneffective IEC. engagement with commtably leaders and groups (service factors) Majer Causal Faders (primary factors) Cenuperbelna RaInferekia faders Bad experiences at health facittWoutreach. leadng to fears. negative expectations. and lack of bust ((amity fader) Health uerker &dudes and behavior. aide effects. stock Calls (service factors) Competing priorities (too busy) gamily Wei) Restridedfmconvenient hours. difficult access. unreliable serene, (service factors) Missed opportunities to immunize (sentry factor) Parents' altitudes and fears (e.g. to have sick chid immunized). although in most cases parents accept heath staffs recommendation Feardrumors (Ian* factor) Insufficienthnertedive IEC. engagement milk community leaders and groups (service factors) Lack of appreciation of ba.Oc benefit of vaccination ((amity factor) InthdficienVnertedive IEC. engagement milk community leaders and groups (service factors) Lack of understanding of need for multiple doses. when and where to return. That immunization protects against certain specific diseases (family factor) Poor health worker communication; insufficient/ ineffective IEC. engagement with community leaders and grows (service factors) 4>Nute• s volt!. 0tlel f won, I 35 EFTA01072451 Summary of papers reviewed shows a significant impact can be achieved by addressing demand generation barriers COUrIlly (Reg Veile) brarohn 19911191 8de< deStriptiOn OutcomeS Demand Moss .90:nation compagro: stainnary anke ara niobto ~ca Wite or eritioul bW sakmonialon as an ereceelbe 1201 Zlekla 19911161 En ya 1998 122) Mån 1997 Ota~ kame. ~rem:Ses (Frør b Semi elias ~ul anta)) 'noble kre 'henne« reernateltros 9wri grem atemprtsans.anotersnt ol~n~pbetial vahnloors !rc« grass »is 0(2.1~1kX4 IDOCt»400t <anwasirs Trea ~44n.le (Ara ot p» campaien was Mord,- Segl 1990 kcesed on kor N. fam ~e. and pfinfed ode wl rendnders el nar~ øy end *nem *meina Propan ol bre veds ()urne~ proerot sen Mad to 11"0 be oblaten lone eat Scinic ot tolt obo«, and wfl e roten* ~e ror the okt 1400 pmuoø ol smal colaVatoo mol tøsod CM!. 0111630101110id kir Ia-born va/x*1~ data. elabfreon 2006[171 2009 LSI 'Smie' Su« corroncelon togrem Modedm men/ ot Vanen) boalinn›LHaimossages (09. MCH.FP. vaconation) Tre ~au. «odla includod eapboards, enensian døme sen* telciame abedisemenee ~e spa. pre* a& in naseapen and local Trne elrechfied Statene binonen mb, kn thourand roande«. 1) CleCUPStn indros +avl ~nov**. bom ommuenney 2) Focusod on ad als andasns ol acnatIon 3) FOCUS00 on hal aztr‘ plan :Muting Øens tor eir, ~la and chtehoad °oste Ftogu1atmoela.63.3% 1~ raca," carrpapla: 77.1% Solony vatm ta rnerow.94.1% ',lobb vatn bod inconat 99.3% Men*, v.:floa 935-19 Bota (I% ~oase) enroene 11" nole~ Tete 122% ~ess) ~nano131K napm) Notes Ditto.« lo tak study n ~Ila 2000 53.9% Meie)» 64.5% 11993) Inler~~ ~se 59ntol93% [onkel grip: excoaso 1~ 60.7%lo 93" Total aro.112A Ond! poren 67.6% noteromber 68 e% ~tatten anaa 494% Monen wlio asen" meny Smeng Sen prabancel «anal bon) moro lloly tron noe bro db nol lo ~pleie OPT ~net», (90Ins499.1 Note:~ pilstat rorob:61.1kcitio •111.1991.11 ~ia nimm: 20%.~..e efter knoin~-trensfer OPT: 28.5%inercazo stor knoncer3aoSanster 61~re COVIMILI 811/10.., 36 EFTA01072452 Point of Vaccination barriers (I) Polic Tech nology Barrier Health worker shortage Geer/seeing health worker ptiodliss Policies can result in missed • oppccturiliss to vaccinate (e.g. wastage. oren-vial) • Recordng name-based data • on •vaccina:ions is lime consuming. prone to ems. • and often nsukident to allure backing of chicken in the community Rationale, evidence, assumptions • Critical shortages and a high turnover of service delivery and supply Chain health workers in the poorest counties: ccenpouncrir by poor motivation and undemerfcemanse—leave poorest areas most underserved • Evidence: Stale of wono's niceness • Opportunity cost associated with screening la immirrization. administering a vaccination. and recording the information con 1 outweighed by need for another competing health service • Evidence:Stu:0hs showing decrease or vaccinationsduring curahve care Mils Include poides against wastage. lack of Wits. facilitating open.v policies. and lackof clarity at cortdintications Evidence: Observation and status of VVMs on new vaccines Difficult to ID patient quickly al health facility if home-based vaccinatcm card is unavailable Evidence: DOA and DOS assessments. RED ovals EFTA01072453 Point of Vaccination barriers (II) Barrier Missed opporltnities due lo stock•outs cc nadequale tinning leading to concerns about wastage or lane contraindications Civic operations discourage parents ken attending Rationale, evidence, assumptions • Evidence: RED evais: presentations by WHO iesnonsi EPI advisors to SAGE sneering,: Re:Mum on mined opportentes • Inadequate explanation to parents of hie need to return or when to MUT • Negative family experience al a previous health center or outreach alteManoe • Evidence: same as above 3 EFTA01072454 57 countries are facing a critical shortage of health workers 4Ia - Canines with cella shortage of health Wattn - Countries settent touch shortage of heath *odes Reaching target levels of health worker availability would roquir 2.4 million additional health workers in critical countries 39 EFTA01072455 Health worker shortfall is affecting immunization coverage Immunization coverage improves with increased density of vaccinators 100 90 80 - 70 - ) 60 50_ 40 - 30 _ 20 - 10 - 0 10 lc° -0- Maas -~',Asses Density (per 100 000) 40 EFTA01072456 a, ,-.3 i: , • 'afar-. ., 4,770, C". =4'7 re, "1"Niv . vl *n. IIII31,1,r,1-"loill i , p 11Data accuracy is difficult to achieve on health facility-based primary records Records include registers, tally sheets^ clinic copy of health card or family record etc Barriers to data accuracy include: • Poor form design (e.g. lack of space: outdated records meaning improvisation is needed for new vaccines) • Lack of writing tools (e.g. pencil blunt: biro runs out of ink) • Mistakes in recording data (e.g. wrong vaccine dose. wrong date. inclusion of children outside — the target age group etc) • Deliberate falsification of records. e.g. due to real or perceived pressure to meet targets • Poor storage leading to lost or damaged (e.g. by rain, rats. etc) records and egisters Oa MEMO 1 75.4r. I •••••••••••• 41 EFTA01072457 -60-70% of all opportunities for valid vaccination were missed in CAR study Frequency of missed opportunities for vaccination, by antigen, among the study sample of 12-23-month-olds. Central African Republic. 1990 % of visits 100 80 40 0 Con DIM 70 1~ is.,COrtgi VISis aero vs OCe.“, elgen • A missed opportonRy for yearn/ben was defined as a VateirtaliOn visit or other health mite visit by a child wnr, ud not receive arraccinatian for which he or she was eligbie • Immunization policy in the CentralAfrican Republic encourages the immunizattn of all age-eligible ehildten. unless they are sick enough to wattanl hosutalitalion (study assumes no hospdatirarpms) I 42 EFTA01072458 Study suggests that by using all opportunities to vaccinate, full coverage rates could be raised to 65% Some opportunities were missed even when another vaccine was given 54o missed oppaturolies OPT' OPTS Limas Antigen MI % (NSW *two no atiar vocal. was ahem %ffisr.o3 nennl motor vocal. an' flan Potential increase in coverage by avoiding missed opportunities during other vaccination -visits or all visit % emiage 03 80 0 OPTS Menke Al .,.J:rc4 Sesalne noted onyx w0 PCONtlal vrafated dins .003 und PCONtlal vias wan wad 43 EFTA01072459 Other studies showed % of missed opportunities varied widely 4 by country but generally higher in curative than preventive visits Prevalence of missed opportunities in Key findings from missed opportunity preventive and curative visits in ten countries studies Cameroon (2.35 nos) CM (12-23 meal ..nores 023 noel 06464410.23 ,4461 2466640-23n -4cl r —t ...ea (12.23 f.>41 y44460494'441 PA4zarn0oue (12-23 fru) IDPualo Ro2(2.6006441 Vs6-64.4016 (023 two AO courdrw• (01 O 20 40 60 SO 100 % missed oppedtmilies Screening for immunizations at curative visits important • Studies showed that 'Never immunizec' children were identified at curative services but were less likely to be seen at preventive services Alternatively, health facilities should increase the number of days that immunizations are offered • Studies in Gabon showed a 2- to 3-fold increase in missed opportunities on days when immunizations were not scheduled • In Burundi. missed opportunities were lowest in facilities that immunized at every health contact (15%), compared with facilities that immunized every day but not at every contact (21%), or facilities that immunized fewer than 4 days/ wk (30%) EFTA01072460 Five major reasons for missed opportunities highlighted by studies Major reasons for missed opportunities Conclusions Medan % acrass dudes analyzed (ranee in patendeses) Failure to administer immunizations simultaneously False contraindications Negative health•worker attitude eg Ani, e.,reie are n:o ant.% atul <v wewomo ftv vt Logistics problems aP vv MOIWO. poor COW orpmeanan oathaentorternang parental refusal 3 11%1 22 t7-35% 19(648%) 16(146%) 10(481%1 O 5 la IS 20 25 Medan %el missed opportunities Initiatives to eliminate missed opportunities can have significant impact: • Missed opportunities were reduced by 8-69% • Immunization coverage was increased by 10-145% Recommendations include: • Use missed opportunities survey: routinely • Screen and immunize at every contact • Administer vaccines simultaneously • Emphasize true contraindications • Provide continuing education on immunization • Reduce fear of vaccine wastage 45 EFTA01072461 Supply barriers (I) Policy Barrier Rationale, evidence, assumptions Health worker shortage Inadequate training Poo- demand forecasting at al levels Strateges not context spectec • Critical shortages and a high ttrnover of service delivery and supply chain health workers in the proofed Quintiles; compounded by poor supervision and support often resultng in absenteeism and underperformance —leaves poorest Weft most underserved • Evidence: State of worlds mothers • Little upitoidate pre-service training for immunization services. in- senice training is lime-consuming to devebp. thus is ftecroieney out- of-date. Few a-Learning or text messaging systems avedatle • CPI managers' meetings are useful for exchanging ink:motion at the policy level but rarefy provide updates to stall al the lower levels • Unclear protocols and inadequate training of staff for appropriate data collection and utilization • Evidence: TOD • Vaccine demand brocading is often based on old census data an last years procurement • It is rarely matched to end-user consumption • Eindenca TBD • Countries and districts face challenges in adapting program strategies to specific contextdroeds • Evidence: TBD 46 EFTA01072462 Supply barriers (II) Barrier Rationale, evidence, assumptions Policy (cost.) S Built in buffer stocks are if* large Parallel systems Lack o( optimally designed systems liatenal and nternabonal relicts are being very slow to adapt to the heal-stabrIty of new vaccines • Current irefficiericies are overcome by maintaining high stock levels and tolerating high wastage rates • andence: TBD • Many vertical meditine supply Chains (vx cold chains). ART. RH. operating in parallel • There are also significant management deincentives to init.-gin', • Evidence:TOD • There are onty rare projects 01 aitntry policies to demonstrate efficient and effective vaccine supply chains optrnized for high performance and low cost rather. current systems follow administratrae sructures • E odenct• TOO • HBV. TT. conjugate bacterial, and pentavalent vaccines (minus pedussis) can be heabslable . but polities constiain vaccination to sites with functionng cold chain . increasing costs of cold-chain • Assumption . Abifty to distribute. store and deliver vaccines under mere flexible singe condticns • Eodence: Multiple references on heal-stability and heeze-sensitrahe Project OM:nixie work? 47 EFTA01072463 Supply barriers (Ill) Barrier Lack of reliable funding Donor dependency Pore financial management. parlicubdy at lower levels Lack of discretionary funds at operational boos to solve ombems locally Routine nvounbarion lacks priority al global level Rationale, evidence, assumptions • Inadequate. unpredictable. and delayed release of designated funds from governments and damn to central and district levels affects abiley of program lo an and implement RI services • Evidence Nigeria national stock oul of pad vx in 2011 due lo late disbursement of funds. Lydon - report on Laos financial suslainablity pan • Many countries depend opal outside donors bond the goo's share of NIP • Evidence: country share of Funding • With lore or no budget oversight and accOuntatilly thee, is hale understandng of the cost drivers of the program and potential efficiencies • Evidence: TBD • E.g. Lady authority or petty cash to subcontract to a local sourt, of transport • Evidence: RED teals. personal experience • Evidence No RI position funded at UNICEF HO through regular resources. <2% of AFRO's immunization budget goes to RI. much or WHO's immunization program funded through GAtil Rusin< tt PLUM 48 EFTA01072464 Supply barriers (IV) Polley (cont.)Barrier Lack of information used to guide country dedsion making e around new product introductions) Inadequate guidance provided for some new votaries Inadequate vaccine safety guidelines Inadequate waste deposes guidance SE= Rationale, evidence, assumptions • Ladled country access to up-to-date information on product presentation and future pricing trajectories • GAVI-elgible countries have Mlle choice over vaccine peesertat- • No detailed mapping of is available of areas with tow coverage with high drop-oul rates. Opguide and diced irdensifed activities • Evidence TBD • Many national immunizalko programs lack policies. guidance strategies lo deliver vaccines that do not readily lit into arrant Muth! EPI schedule or louchpoints • Evidence: Hec,B brth dose should be given within 24 hours of birth. Men A is largeled to 1.29 year olds n campaign settings. HPV is targeted to school age population • Guidance on AEFI training and capaccy needs in countries is weak and yet wen the advent of newer vaccines (some introduced for the first lime ei develop-fly countries. given at different age groups. and through Sins.) AEFI stereillance and response is critical - esoecially with increasing pressure from anli-vaocire movement • Evidence: TBD • No dear policy recommendations on njedicei material waste disposal • Evidence: TBD 49 EFTA01072465 Supply barriers (V) Tech- nology Opera lions Barrier Convicting and inadequate information systems Lack of reliable ccovnuncation between layers of health system Lack of information systems Suboptimal product profile Infrastructure in place does not match current need Outreach sessions frequently cancelled or delayed Supply Rationale, evidence, assumptions • Different systems for lopstics and supply chain. stock management. immunization records. performance monitoring and surveillance • Lack of birth registry to track unvaccinated children • Evidence: RED swats; SAGE reports ARISE. Cuttsainth report • Fixed posts were built decades earlier and population has mount: subsequently or posts were organized for pontosl reasons rather than need • Evidence: personal experience. • Current information systems to monitor and trap*. vaccine and irtecton supply stocks from arrival to point of use or disposal are not being ate not pale or are not being used lo back and mentor vaccine supplies and utilization from national to peripheral levels • Evidence: Optimize • packaging. presentaticn. thermostablity. and dosage regimen could be inproved for the developing world supply chain • Evidence: Project Optimize • Mismatch between ih the ntrnber of vaccination points anditor they are distributed in a manner oral does riot match up with popidation needs and the requiernents of the heath service • Evidence: personal experience. data on WHO heath systems site • Owing to a lack of funzing or procedures in place to refund out-of- pocket expenses of health staff iwnunization entrench is often delayed or Cancelled • Evidence: TBD 50 EFTA01072466 Supply barriers (VI) Opera tions (cent.) Barrier Rationale, evidence, assumptions Inadequate cold-chain • Al ✓ub national levels in Wieder capacity • Evidence: WHOWNICEF data; Project Optimize Inadequate temperature monitoring and reporting Inadequate maintenance Suboptimal power supply Serious transportation issues at peripheral points Supply Chao evaluation • Significant variability et the use of supply chain and cold chain variability assessment tools leading to vanable measured costs across countries and data gaps • Endence TOO • There is an absence of data compled centrally on V3CCitte heat exposure and no routine data is available at al on freeze exec:sena al any level of the system Mils indicate heat exposure localy • Evidence: Optimize • Cold Ch9in ethipment maintenance lends to be poor feeerythitie from not wiping down solar panels to hang an effective maintenance organization with skiled staff. transport and spare parts • Evidence: TBD • Poor and inxosistenl power supply at planet:anal levels • Evidence: LARI 2011 • The last 10K are the most dello-ill • Evidence: TBD 51 EFTA01072467 WHO Immunization schedule al friiiri• ............, -i r-ez.. , ...wean Lea ,. 1....7. ”ft... ••••,“0••• isimidooen anan• KO ,.... 4.,...to• ay an, 4...0 vft. ' ., ...,..saira nion, .,....ftioftebanoft I I •...room Ms .. ...cm; 'WWI ......i....fri.. annowom noein,.. , one 0 hN MP. On.afte e,..... 1..• ..4".”1"ftlf ihnftss ...V..) p..... .Z..... f%, IN ...so. oen •4e,....i, .•••••• a ....n.. nre •4 4 ••••••• • ... .t....!•. 4 a.m. I 4 en•nr.f...•.• 4o. Oft•O on ..v.. cc, -••• •••••Th,...ft...., ...oft. I teitroliortnri 4.10,ffeby OM •.,..it”nesii • ••••• P.. n""I ter.......01.1 .0,40 &rat On.; ,,.....ftHa I. a,. raY... 10. g.......... ....p.m. on OM. 1".."..." I ......roi.. OM 4 ......... re ......e. 0774 ...ft,..,. , Pt," curb. II.. non "gat ' o non ne a ...win, caw 0.0...*,.,,.." ......, te,I anus.. 2..... ........ F.., tool.. it 0,.....el• • .... ft... in. l nern ne polo'*. — f.,,,,,,.... non. ''''' n. ....... ,.... .,.... in, en nor won, • one.. Fr no . en ---,on t en..., nonnt= none.. , to.,....nen— ,, I.. •ore .... •.I•• ,in•enn ee rDo e.i eine on mein 2t...1 e en en •o Fel ',soon.. nen, 1..1 ens eltaftr— ...L..... fa ftn ...Z... 1.....,.... ...,..... •......... ........, .-. ...,s,.........•,..... ,.-..............., .. . . .. „.... aftw..0.....ionromwt. .................. Owes ft.% z"" iv,. t011nwliolle•Sallulall 52 EFTA01072468 Country schedules AnOfien not (countries with vaccine Introduced I (of 1931010 slaps' .cciarnenclagons Medi &AIWA.. WA 177 102%1 00130%Y WA 173 M0%) 88 (45%10 39120%) 139122Y% 45(23%) acocoel(COniugele v. PIN Reeernmendeffern kir caddren residing M cedOn miens Japanese Encephalon. Yellow rove, lecar mrntla tux., /0, chsidten ewne1001-n*acP0P0460^5 Typhoid Chokra 012%) 33O2%) WA WA 0,000014 32 (17%) 125%) t A WA .,,nendallons for chill, n receiving vs from ,,zatton ptogtom wish WIJ/di CILitaCICYJOICS Wattreasell 120162%) 131165% 106166%) • • 1510%) 0 of country vaccine introductions (for WHO tracked vaccines') e counties per vaccine a • •.iC •MCV2 ❑ Piwro ps III IF Maras cos !Slane • HepA L. Pans • vans • nere E HPV -11 lance M Retahln, dd. (Wef 0 WmV raw 0 rent.** I W Iv wane ,.. • won. atelt.OJelisealia aryl,* ifrvaXcps I•I••tIlI••tO20,t•-.r.s pro won sea peva amuses.. cfranrittx it Seta two ow Di EFTA01072469 Average Annual Immunization Program Cost per Year (2009 $USD) $100.000.000 $90.000,000 $80.000,000 $70.000.000 $60.000.000 $50.000.000 $40.000.000 $30.000.000 $20.000.000 $10.000.000 $0 2004 2005 2006 2007 2008 20092010 2011 201220132014 2015 —Routine —Campaign Shared —Imm Specific Total 34 EFTA01072470 Human resources costs a large part of non-vaccine costs Source: Lydon P, et al. 2009 r1 Human Resources MCold Chain Transport (Surveillance Training Social Mobilization Other SOttON UOM BMW POION016.041.2011 55 EFTA01072471 Proportion of government funding increasing slowly Deno 1,1 governmen; tund.ng for •,‘accines and To o!ine Immunization in 185 WHO Member States-2610-2005 %Vaccinc cvcodehect teamed *.Roumw imenuninton cp;mblain I)) th 'ben crtuncom 0mm[d In thc mcntmcni I00% 90% 60% fe% g 1 I 0—Sanplc A‘Cl2gC Popu • wash:.: Maar'. I 56 EFTA01072472 Half of countries financing less than 50% of total needs Government financing is 42% of total financing 100". 57 EFTA01072473 Today's vaccine supply chain A network of people and equipment and well established procedures stivo(t vesc" PAIL,* RECORD ANNUAL STATISTICS ItStouiryS ANALYSIS RIONTIII.T REPORT CloZil KIIIOUNIS Ate • 7:2* .0 411 VACCINATOR/ NOON. MOORED KOREN CENTRE MANUFACTURER REQUEST FORSUPPLY fate,mil- AIRPORT Fri% 1;1M wawa STORE DOTRICT/ REGIONAL STORE Simple, precise & standardized 58 EFTA01072474 Supply system architecture follows administrative/ political structure —fr Al pots Pier.ify SIure —. National $ 0-natio al I - SI34.7 late --• Sub-national 2 "K - to- C.4. II•ofth Centel NoahCaren C SONCO Calvary 5— Oalhory I - 111=1:isi EFTA01072475 Vaccine storage recommendations Primary vaccine store Up to 6 Months Intermediate vaccine store Region- up to District- up to 3 months one month Health centre Up to one month Health post Up to we month OPV -WC to -WC BCG Measles. MR. MMR YF Mb freeze-dried Meningococcal AMC HepB 2°C to +8°C (-WC lo-WC oho (*WWI IPV DT DTP. DTP Hep B Hb liquid Td TT +2°C to +8°C Never Freeze ! +2°C to +8°C EFTA01072476 Data suggests that vaccine effectiveness is impaired by age as well as logistics issues MCVI Vaccine Effectiveness by age of administration and select WHO region 1E0 77 1• •96 192 92 77 1 1 AFR SEAR EUR GUDE 4 92%. >12 ma a vo 1- Generally lower VE estimates in AFR and SEAR hale been 'Orbited by studies to pagearmialle differences including cdd chin Sues. eadeepate vaccine handing. pow vacdne stooge. ad inadequate wain* adriiristralion Age a: altnnistraton apmars to have signfloant inosel an MCVI VE 9411 moneys 3.12mouge 61 EFTA01072477 Legacy from the early EPI days: arr Focus on enforcing standard practices in a robust infrastructure • SOPs for all aspects of the programmes - Simple rules and procedures/guidelines - Easy to convey through cascade training - Easy to remember and monitor • Training large numbers of staff Training materials, large numbers of training courses, cascade training - Focus on mid level managers and health workers - All partners engaged in supporting/conducting training sessions • Health Care workers trained to follow SOPs not to make decisions - Keep vaccines cold ! (freezing occurring with TT and DTP but because freezing point> were low, freezing was not a real concern until Hep B was introduced) Vaccine management rules: Discard vaccines vials open at the end of the session Discard vaccine vials taken for outreach and returned unused Open a 10 dose vial even if only one child comes to the session to avoid missed opportunities High rates of vaccine wastage was encouraged (acceptable for penny vaccines but is no longer) WM can help change paradigm - this is still not exploited in an optimal manner to move towards a more flexible and efficient supply chain EFTA01072478 Changing environment - More vaccines with diverging storage requirements Heat sensitivity Most sensitive 2 LOBS sent:!Days 7 at 37°C 14 30 Traditional cold chain u) ca a, -J Soutec hfiltben. J. TechN6421 ConsOation • 2006 Freeze sensitivity EFTA01072479 Prices and packed volume pre dose have been increasing ov