Logistics in developing countries are often perceived as insolvable nightmares: structural barriers such as vast territories, limited infrastructure and hot climates often come with inadequate processes. Implementing simplified routines and ensuring continuous improvement through the use of basic digital tools can help increase traceability, accountability and efficiency.
One of the first steps in redesigning a vaccine distribution system is to understand the existing bottlenecks, flaws and inefficiencies that prevent it from being functional. In Chad, for example, access to vaccines throughout the country was limited due to several factors:
- Delivery cycles were not synced, meaning delivery to the sub-national level would happen once every quarter and further delivery to the districts were happening every second month. This prevented the logistics team from building strong and consistent routines and made vaccine availability unclear
- Push and pull modes coexisted1, sometimes at the same level and within the same area. This led to redundancy of vaccine deliveries and poor updates of stock management tools.
- There was no clear process, nor established budgets and procedures, to ensure vaccines were actually delivered and communication between the different levels was not effective.
- Finally, there wasn’t any kind of performance indicator for logistics either, excepted from the number of stockout days at the central level, which was easily manipulated.
Clarifying and enforcing a single vaccine delivery system for the whole country was therefore critical:
- Vaccines go through four steps from the central level down to the health center
- Each sub-national depot is responsible for a set of districts, and each district is responsible for a set of health centers
- Push delivery is enforced down to district level every second month and progressively down to health center every month.
- Processes and tools are standardized to prepare each delivery including delivery plan, payment lists, contracts with external providers, needs assessments and delivered quantities calculators
1Push delivery is when the upper level delivers a product to the lower levels, on a regular schedule and based on information that comes up from the lower levels. It ensures full pyramidal control and products tracking provided the communication between levels is effective. Pull delivery, on the other hand, means the lower levels will have to go and pick up the products directly from the upper level warehouses. This usually fosters a better adequation between delivered products and actual needs but makes the system far less predictable.
A 4-step, pyramidal vaccine delivery system facilitate access to all areas
PEV resources and contracted services are mobilized to ensure a push distribution every two months to districts
Acasus app is used to collect data on each delivery
Systems are only as good as those who work them. That is why the key to the success of the vaccine delivery was to ensure continuous training and improvement of the logisticians on the ground.
All logisticians have been equipped with a phone loaded with the Acasus app. It allows them to capture data from the field, included in zones deprived of the internet. Among data collected are stocked and delivered quantities of vaccines, availability and functionality of the cold chain, availability of vehicles and motorcycles. All reports are geolocated which helps ensure that deliveries have indeed taken place. The app also facilitates:
- The tracking of vaccine delivery day by day to identify issues from the ground (e.g. stuck vehicles during the rain seasons, breakdowns, stockouts, etc.)
- On the go training of district-level managers
- Identification of improvement areas after the delivery
To do so, the data collected is leveraged in a comprehensive logistics report for each delivery and each sub national depot. The reports are shared and discussed at the end of each delivery to identify key improvement actions.
Post-delivery reports allow quick identification of improvement areas as well as financial justification thanks to data geolocation
The reports focus on a limited number of indicators that summarize the state of the logistics in the country:
- Vaccines, inputs and vaccination cards availability at sub-national and district levels
- Functionality of cold chain at the district level
- Time to deliver compared to previously set standards
Each indicator is furthermore broken down for sub-national depot and analyses are available at the district level to identify areas of attention during the following delivery. For example, districts where ILRs encounter functionality or temperature-tracking issues are clearly identified, together with a first diagnosis of the fault.
These reports would however be nothing if there were no routine to discuss them: the whole logistics crew gathers once every second month to review performance and identify key pragmatic actions that can be taken to improve delivery. Best practices are shared within the team. A good example of this is how Sarh sud-national depot shared how to spread near-shortage vaccines evenly between all districts thanks to careful successive planification.
The introduction of regular distribution and digitized supervision has significantly improved the monitoring of operations and increased efficiency
In Chad, logistics redesign and continuous improvement routines dramatically improved access of all districts to vaccines, inputs and vaccination cards:
- Stock-outs have been divided by 2.5 over a year across antigens, inputs and cards
- Share of sufficiently-supplied districts have risen to ~90% for vaccines and 75% for vaccination cards