I recently returned from a week in Mozambique with a goal of learning about new immunization supply chain models and observing their impact. I also wanted to better understand opportunities and constraints for taking this work to scale -- in Mozambique and across other Gavi-eligible countries.
In 2013, the Gates Foundation began working with five provincial governments in Mozambique, the national ministry of health, and VillageReach on a new system for delivering vaccines. The new system represented big changes over their current design. It takes a holistic approach – reconfiguring the transport system, re-assigning roles and responsibilities of personnel, obtaining and using data differently, and integrating supervision and cold chain maintenance into monthly vaccine distributions. I was able to get a first-hand view and see some impressive results of this “next-generation” system while in southern Mozambique’s Gaza Province. In Gaza, there’s now a much better chance that when children show up at a health center for immunizations, the vaccines will actually be there. Vaccine stockouts have dropped from 43% in 2012, before the province revamped their system, to routinely less than 3% today.
Getting the “last mile” part of the system to work is one of the biggest obstacles many countries face whether for vaccines or other health commodities. In a pull system, the health centers manage inventories and overburdened health care workers are tasked with arranging deliveries to their facilities from higher levels in the system based on requisition forms they fill out on a monthly basis. However, often resources such as personnel, vehicles, and fuel are not available to ensure distribution. And even when stockouts are reported, it can take weeks to get more vaccines. When this happens, the system collapses into an ad hoc approach, where health workers arrange for third party transport and can spend a day or more away from the health center to fetch needed supplies themselves. Or they will provide a partial vaccination session based on vaccines that are available, asking caregivers to come back later for the missing vaccines. These and other stopgap measures are required for health centers to function, even though they are inefficient and can compromise care in remote locations.
Next-generation supply chains help overcome these problems. Unfortunately, routine expenses for the final steps are often overlooked in government budgets. In Mozambique’s emerging model, the province manages the distribution directly to the health facilities, while funding is still split between the province and the district. So funds are not always available in the right places, or for the right amounts, for fuel, staff per diems or vehicles – and when they’re not, deliveries grind to a halt. Even with the next-generation system, about 10 percent of the time, vaccine deliveries aren’t made due to lack of operational funding from the province.
This issue is not unique to Mozambique. Many country policies and corresponding financial flows still follow a traditional supply chain model that adhere to rigid government administrative structures, which are not always the most effective or efficient way to deliver health commodities. Eventually, however, countries will need to allocate more government resources at the right levels for these systems in order to reach the final 20% of children who still do not receive a basic set of immunizations.
One thing that struck with me from the visit is how important it is that consistent and reliable funding is available so vaccines can be delivered monthly all the way to each health facility. This is no small feat and a big difference from how things work currently. I also realized addressing such issues will require the Gates Foundation, along with other donor and implementing partners, to play a stronger leadership role in helping countries assess the tradeoffs given funding and capacity constraints. It may include looking at other ways to increase efficiencies, such as the integration of vaccines with other health commodities.
Finally, I was left from the trip with the realization that lasting system transformation is not as straightforward as I naively once believed. It involves fundamental changes to the health system, specifically changes to the administrative, policy and financing channels. It will require global donor engagement and increased country government commitments. It will require stronger partnerships with our colleagues in the countries in which we work. And it will require some additional learning on our part.
After observing the progress and challenges in Mozambique, we are better positioned than ever to take on these challenges. And a big thank you to Village Reach and the government of Mozambique for making the trip possible.