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1. CLICK TO ADD TITLE The 6th Global Health Supply Chain Summit November 18 - 20, 2013Addis Ababa, Ethiopia GAVI Alliance immunisation supply chain strategyDaniel Thornton, GAVI Secretariat [SPEAKERS NAMES] [DATE]

2. Overview Introduction to GAVI Issues with the immunisation supply chain Introduction to the strategy development process Next steps

3. GAVI Alliance: a public private partnership

4. GAVI supports immunisation in the world’s poorest countries Click to add text

5. Overview Introduction to GAVI Issues with the immunisation supply chain Introduction to the strategy development process Next steps

6. Manufacturer Immunisation supply chains: backbone of national immunisation programmes Shipments (air & sea) Ordering Forecasting Vaccine Arrival Analysis National Store Reports Sub-national Stores Records Health Centers Service Delivery Waste management 6

7. Value, volume and complexity have grown rapidly

8. Compare 1980s to 2010

9. Challenge of reaching effective vaccine management standards No country meets all minimum standards for all criteria, at all levels of the supply chain

10. A GAVI Alliance immunisation supply chain strategy is required • Recognition that stronger immunisation supply chains are needed to achieve the GAVI Alliance mission • Agreement that this topic requires more attention at all levels in order to: • improve the effectiveness and efficiency of immunisation supply chains • increase the resources for immunisation supply chains • enhance collaboration across the Alliance (e.g. WHO/UNICEF immunisation supply chain Hub) • leverage expertise and knowledge from other health sectors and the private sector

11. Overview Introduction to GAVI Issues with the immunisation supply chain Introduction to the strategy development process Next steps

12. GAVI Alliance immunisation supply chain strategy timeline Cold chain work transferred to taskforce Board discusses supply chain Taskforce established Presentation to Board Taskforce reset Q4 2012 Q1 2013 Q2 2013 Q3 2013 Q4 2013 Q1 2014 Q2 2014 Q3 2014 Q4 2014 Framework to PPC Strategy to PPC SAGE discussion (1/2) Landscape analysis findings SAGE discussion (2/2) GAVI immunisation supply chain strategy Phase 1: Landscape analysis Phase 2: Consultations & framework developed Phase 3: Strategy development Phase 4: implementation planning GAVI 2016-2020 strategy Board Jun 18-19 EC 4 Mar SAGE 1-3 Apr PPC5-6 May

13. Identified challenges were prioritised into four working groups • Global • Data discrepancy country vs. global Priority working groups for approaching challenges • Multiple signals of demand received by manufacturers. Limited opportunity to reconcile • Lack of total cost perspective on portfolio and SC decision • Long lead times for approval • Product specifications impact SCM Vaccine Products • Timing of approval • Interface • Poor quality of short-term country forecasts • Vx intro decisions and scheduling are not robust enough and change frequently People and practices • Frequent updates of forecast to manufacturers • Missed return on investment from money on “Procurement Accounts” • Last minute sharing of procurement plan • Identified challenges • Long lead-times and delays in getting shipment clearance Data for management • Delay of co-funding • Delivered products don’t match preferred specification • Lack of transparency into shipment data Cold chain strengthening • In-country • Multiple levels of supply chain holding inventories • Limited expertise to operate and oversee SC processes • Insufficient or non-functional cold chain equipment • Ad-hoc delivery schedules • Insufficient transportation resources System optimisation • Suboptimal cold chain equipment selection • Limited transparency on demand frequency, size and location • Poor equipment repair and maintenance • Lack of SC processes / not well implemented 13

14. Priority working groups • Support access for quality pre-service and in-service training health supply chain training • Advocate for recognition of supply chain management as a profession • Strengthen management structures and systems People & Practice Data for management • Capture and share information about on-going projects • Identify gaps where funding should be targeted to help, and encourage scale up of information systems identified as most likely to succeed in range of countries Cold chain strengthening • Define target specifications for better projects • Improve global guidance to countries • Set up feedback mechanisms for buyers and manufacturers. • Explore market shaping options System optimisation • Support countries to streamline network designs in order to increase their efficiency, agility and effectiveness. • Focus on transportation systems, synergies with private sectors and other health commodity supply chains 14

15. Insufficient high performing human resource with appropriate expertise at global and local levels Who is managing the immunization supply chain in Benin (2012) ? Challenge Causes Lack of sufficient expertise in existing staff Insufficient high performing HR w/ appropriate expertise at global/ regional level Insufficient overall number of staff Insufficient high performing human resources with appropriate expertise in countries “When you use a nurse or a physician as a logistician, you lose the nurse or physician and you don't get a good logistician!” Dr. Saracino, former Minister of Health, Côte d'Ivoire TFI members briefing, Harare, Oct.2006. Lack of proper incentives and performance management Source: AMP LogiVac Project 15

16. Previous generation of GAVI health systems funding had little focus on supply chain training DRC Ghana Nigeria Of 3 countries, only Nigeria provides logistics training, and at time of evaluation, training had not yet been implemented 16 Source: HSS Evaluations

17. Significant barriers to implementation of new tools and technology Despite the promise of some existing tools and new technologies... ...systems improvements are often challenging to implement in countries • Countries have a lack of choice and access to information on potential solutions • Costs of licensing and contracting are high • Country MoH have limited capacity to develop contracts with information system providers • Cost and complexity of developing custom-made software • Lack of connectivity, reliable electricity and capacity to maintain systems at peripheral level imply that typical commercial systems are often not suitable • Lack of technical expertise at central levels needed to run and maintain systems once they are acquired. • Stock Management Tool (SMT), District Vaccine Data Management Tool (DVD-MT) • Microsoft Excel-based tools for monthly reporting, developed by WHO • Vaccination Supplies Stock Mgmt (VSSM) • Access based tool developed by WHO • Supports warehouse management • Used for central/large subnational stores • Open LMIS • Freely available resources for electronic logistics management information systems • and other tools • Commercially available systems developed by profit and non-profit organisations Mobile Phones and Networks Cloud Computing 17 Source:, Project Optimize: Information Systems Action Plan, Expert Interviews, Village Reach: The framework for open LMIS

18. There are four critical cold chain equipment gaps at the facility level • ~134,000 • Many facilities that should have cold chain equipment (based on government plans) are not equipped today • Nigeria: <20% of 11,500 target facilities currently equipped • Unequipped facilities 17% • Non-functional equipment • Much of equipment which does exist is non-functionalor not installed (e.g., due to poor maintenance) 17% • Significant portion of installed base is absorption, solar with battery, or domestic refrigerators with significant issues: • Expensive to run • Unreliable • Inadequate holdover • Risk to efficacy of vaccines due to poor temperature control (e.g., freezing, etc.) • Undesirable technology 42% • Smaller portion of installed base are ILRs and SDDs that: • Do not meet facility needs (e.g., 50% of facilities need <15L capacity, but most too large) • Are of some risk to efficacy of vaccines (risk freezing if user does not pack refrigerators correctly) • Acceptable, but sub-optimal technology 24% 1 Extrapolated data from 7 countries representing >50% of GAVI birth cohort 18 SOURCE: CCEM data; country data; WHO/NPHCDA

19. Example of system optimisation from India: milk run Bhagalpur division Bihar Baseline: each district pays average INR 4200 to book separate trips Solution: round trip milk run reduces distance, saves ~INR 100,000 (~$1500) per year 19 SOURCE: Public Health Foundation India

20. Overview Introduction to GAVI Issues with the immunisation supply chain Introduction to the strategy development process Next steps

21. Next steps • Continue to engage with countries, stakeholders, experts, throughout this process • Draw upon existing knowledge and expertise, especially in the prioritised areas • People & practice • Cold chain strengthening • Data for management • System optimisation • Launch request for expressions of interest to better understand the landscape of existing service providers and technical partners

22. Thank you