Deep Dives

Supply Chain Transformation Through System Design

Transformational change is needed for supply chains to meet the demands of growing vaccine programs.

An uninterrupted supply of vaccines is critical to achieving immunization goals, yet it continues to remain elusive in many parts of the world. New evidence from several countries published in Vaccine shows that streamlining the in-country vaccine supply chain increases efficiency, reduces stockouts, and saves money and lives.

In most countries, vaccines travel from a central warehouse—or “cold store”—to regional stores, often making additional stops along the way before reaching the district store where health workers must travel to collect them. In light of immunization program growth, this delivery system design has proven to be often inefficient and burdensome to health workers who spend time traveling to receive vaccines from the district stores when they could be treating patients.

To get to more places effectively and efficiently, traditional immunization supply chain processes may need to be streamlined to reduce operating costs and redundancies. Dedicated logistics personnel should also be charged with managing them. By asking questions such as where, how frequently, and by whom vaccines should be delivered, and who is responsible for logistics data, system design can help determine where data and supplies must flow to best reach people in need of vaccines.

Starting in 2013, the Nigerian government and its partners embarked on a pilot project to transform Nigeria’s immunization supply chain by investing in the people, processes, and equipment required to deliver vaccines.

Prior to the start of this pilot project, the vaccine supply chain in Nigeria, Africa’s most populous country, directed all supplies through the National Strategic Cold Store (NSCS) in Abuja. NSCS supplied six zonal warehouses throughout the country. Each zonal warehouse then went on to supply central warehouses in each of the six states within a zone. The country’s 774 Local Government Authorities (LGAs) each had its own warehouse and traditionally collected vaccines from the state warehouse. Finally, the primary health care centers in each LGA collected the vaccines from their corresponding LGA warehouse to be administered in their communities.

As part of the vaccine transformation project, Nigeria made changes to the supply chain design at the federal and state levels. It also invested in cold chain equipment and data visibility and use. At the federal level, instead of receiving all vaccines through the NSCS and then sending them through one of the six zonal warehouses, a three-hub system was designed. By receiving vaccines directly from suppliers at zonal stores in Kano, Abuja, and Lagos, the burden on NSCS is reduced and storage needs are reduced by 30 percent. This change will also result in significant future cost savings—between US$3 and $4.5 million in capital investments.

At the state level, the system was streamlined by delivering vaccines directly from the state warehouse to health facilities using cold chain equipment and therefore bypassing the LGA warehouse completely. This approach, called PUSH Plus, no longer requires health officers to collect vaccines from the LGA, but rather relies on direct delivery according to customized schedules. As more health facilities are equipped with cold chain equipment, the program will be rolled out further.

These system changes had a direct impact on vaccine availability in Nigeria. In Lagos State, stockout rates dropped from 43 percent to none, and immunization coverage increased from 57 percent to 88 percent. Health care workers are able to devote an additional 1 to 6 hours each week to patients—time that had previously been spent on supply chain logistics. In Kano State, stockouts decreased from 41 percent to 10 percent even as the number of health facilities served increased from a quarterly average of 90 to 408.

In neighboring Benin—a smaller country whose population is half of that of Nigeria—an overhaul of its supply chain launched at the same time that Nigeria began its efforts. The country focused on vaccine delivery in the Comé Health Zone within the district of Mono in southern Benin. After a thorough evaluation using the Effective Vaccine Management (EVM) assessment tool, the government consolidated all sub-district warehouses to a single district store and redesigned the delivery system. Other system improvements included new cold chain equipment and staff trainings.

As a result of these changes, vaccine distribution, vaccine management practices, and infrastructure all improved to meet targets set by the EVM tool. Benin’s government is now applying this approach of supply chain redesign to all districts in the country as part of a four-year action plan.

A similar supply chain transformation effort occurred in Mozambique’s Cabo Delgado province. Previously, the vaccine distribution system in Mozambique relied on both air and ground transport, and both delivery and pickup to move vaccines from the central warehouse in Maputo to the 1300+ health facilities throughout the country.

Cabo Delgado, Mozambique’s northern-most province, furthest from the capital of Maputo, implemented a top-to-bottom overhaul of its supply chain in a five-year pilot effort. The district warehouses were eliminated as distribution points, new equipment was procured and installed, transportation routes were redesigned, and dedicated staff were assigned to manage logistics.

The effort reduced stockouts at health facilities from 79 percent at the start of the action plan to less than 1 percent at its conclusion. Coverage rates of the DTP3 vaccine increased from 69 percent to 93 percent during this same period. All but one of the 27 facilities in Cado Delgado had a working refrigerator one year after the pilot ended, a significant development. In addition to the improved service levels, the pilot proved to be 17 percent more cost-effective than the system in the control province. The success of the pilot spurred system design efforts in other provinces as well, and the government of Mozambique is now evaluating the system design country-wide to identify additional efficiencies.

Incremental change will not be enough to transform the supply chains of 30 years ago to meet the needs of today’s immunization programs and the demands of tomorrow’s. As shown in these examples, sustained commitment to and investment in thoughtfully designed immunization supply chains can significantly improve stock availability and immunization coverage.