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Skip to 0 minutes and 8 seconds SD GUPTA: Now, the next issue is vaccine supply. What are the challenges in vaccine procurement and supply? You see these round circle.s They have the main issues– availability and accessibility of vaccine, shortage of vaccine, and vaccine management, and availability of finance, and then political will or support, and then capacity-building of human resources. I would say that availability and accessibility of vaccine was one of the major challenges in vaccine supply, because if this is not available, then you cannot run sessions. Timely availability at the right place in the session is very, very important. And we have to really see the access issue. So we have to go nearer to the people so that they are able to attend the vaccine sessions.

Skip to 1 minute and 5 seconds So right from– so that’s at the field level this happened. But there were challenges, and at the national level, there were problems. And they said there were stockouts. Vendors were changed, and there were breakdowns at some points of time, But. These were not very frequent. But down from the national to the state level, the of delays in supply that happened, so because the storage facilities were required to keep the vaccine inventory for their future two months of three months, the right expiry date of the vaccine. That is, vaccine management was required, first in first out, first expiry, first out. All that was– inventory management systems were involved.

Skip to 1 minute and 52 seconds But there was issues again, around the storage and, we have discussed earlier, from where the money should come. In a big way, some donor partners participated in financing the programs. No program would succeed without political will, policy support. You know, in a country like India– huge country– a large number of infants and under-five children to be vaccinated every month or during the post-polio sessions and then mobilizing. So this political commitment was very, very important. And due to the strong political commitment, no [INAUDIBLE] country could really eradicate polio from. The support is very, very necessary from the political circles, as well as from the bureaucracy. This is very, very important.

Skip to 2 minutes and 45 seconds And then, on a larger scale, capacitative building of human resources was required. It provided a lot of time to build capacity of the human resources, especially for maintenance of [INAUDIBLE],, then planning for immunization sessions, and then the distribution and delivery of the vaccine and organizing vaccination tests at the vaccination sites on the given dates and times regularly. So these procurement issues were also there. Then there was an issue, shall we do centralized or decentralized procurement? No, this is a policy issue, whether this has to be centralized or decentralized. In India, and in most countries, this was centralized [INAUDIBLE].

Skip to 3 minutes and 36 seconds We had to work on the quality of the vaccine, the specifications we required, and the cost considerations, and the finance– all that. Therefore, it was preferred, at most places, to procure centrally, or at the federal level. And then, there’s also a big question– which brand of the vaccine should be used? Which meets your requirement? Which is more cost-effective? Are the funds available? Can you negotiate prices with them? Can you assure them a supply of the vaccine? That is very, very important.

Skip to 4 minutes and 15 seconds So these challenges were there, but I’m very delighted to share with you that most countries under the supervision and coordination of the World Health Organization, and some donor organizations such as the Rotary International and Bill and Melinda Gates Foundation, to name a few, who weren’t always with the program with the support. So that would happen.

Skip to 4 minutes and 56 seconds As I said, normal challenges in India– we have a huge population– 1.3 billion people now. And we required about $2 billion for the entire country and procurement of about$2 billion. And if you procure, then where to store the vaccine? From where the funds will come to get those large quantities of the vaccine? This was an important issue. So 2 billion doses of the vaccine is a huge amount of the vaccine that was required. And it is a huge population, and then multiple stakeholders. And strengthening health systems and bringing in various stakeholders was very, very important and a challenging issue. And of course, there’s policy and adaptability. It was very, very important, like FDA in the US.

Skip to 5 minutes and 55 seconds So regulatory authorities at the national level, [INAUDIBLE] policy and adaptability to the government regulation and procurement that may affect the diseases and the procurement. Now, as I said in the beginning, once this was declared eradicated in 2012, shall we continue with the oral polio vaccine? What was our purpose for the oral polio vaccine? Well, there are two reasons. We wanted to do away with disabilities caused by poliomyelitis, and second, the big role that the polio vaccine played was creating herd immunity. As oral polio vaccine excreted in the students and contaminating the water supply around that, you get natural closing of the vaccine. And that created herd immunity, and then large coverage, huge coverage, with the vaccine created herd immunity.

Skip to 6 minutes and 55 seconds So this was the advantage with oral polio vaccine. But once eradicated, shall we go forward with the vaccine, oral polio vaccine, or switch to inactivated polio vaccine, or IPV? Many countries adopted. This was in Indonesia. So there is a global shortage and local shortages. And how Indonesia dealt with these challenges. So when you introduce a new variant of the vaccine, in case of a polio vaccine, we needed, first of all, maintenance of the cold chain to the end user level. Now, the logistics and supply chain of this injectable vaccine, this was a new vaccine. So where to get it? What is the cost of it?

Skip to 7 minutes and 45 seconds So initially, when the countries decided to go for IPV, [INAUDIBLE] the case, they decided to go for IPV, and they had initial shortages at the national level as well as at the [INAUDIBLE] level. So an important issue with vaccine programs was demand estimation. and stockouts. How do you measure whether this logistics supply chain management is performing very well. This can be measured by a very available indicator. That is stockouts– at the health facility level, especially. So what is the average duration of stockouts of the vaccine at the storage level, as well as at the health facility level? And that was a big challenge for demand estimation of the vaccine.

Skip to 8 minutes and 37 seconds And how do you estimate the demand, how much vaccine will be required? So delayed logistics supply due to natural calamities, violence-struck areas, disturbed countries where violence was taking place so the logistics, right from procuring, down to distribution to the facility level. And then, on booth days or session days, shortage of vaccine would occur if there was a delayed logistics and breakdown of the logistics. And this happened in Afghanistan and Nigeria because of the violence and conflicts in those countries. There are, also, issues related to countries where people did not accept vaccine for different reasons. So there are countries where there are small pockets of polio myelitis cases. Especially Afghanistan and Nigeria, they still have new cases of polio myelitis.

Skip to 9 minutes and 37 seconds Because of acceptance and difficulty in logistics and supply and difficulties for health care workers to go to the field, where security is very, very important. In India, it was a difficult time, because all of the flights– India, Bangladesh, and many other countries, the vaccine supply was disrupted and the vaccine sessions could not be organized because of the calamities– flooding and other disasters. So measures were adopted. And you can see an interesting picture here of the health worker. He’s using this improvised fry pan, or whatever you want to say– so using it to ferry the health worker across the flooded area. And there were many innovations.

Skip to 10 minutes and 31 seconds And you see on your right the health worker carrying the vaccine, within, going through the riverine areas.

Skip to 10 minutes and 42 seconds So the health facility staff and their program managers evolved the ways or improvised the ways how the vaccine distribution could be managed in unreached areas. There was at least two pictures that you see are from Afghanistan. And it was really difficult. Terrains in Afghanistan are difficult. They are difficult. They’ve got no roads, no transportation off to go into the interior areas. There are only two or three airports. The vaccine would not be supplied. So these were the real issues. But hats off to our health workers, who managed to distribute the vaccine in unreached areas. So therefore, it is very, very important that we need talented people to achieve the goals of the.

Skip to 11 minutes and 31 seconds Program So good logistics supply plan requires there are many stakeholders and players, and a good logistics system provides a reliable supply of commodities. More people are likely to use health services. Customers feel more confident, customers means you end users, I would like to say, confident about the health program, and cost and supply of commodities. It motivates them to seek and use services and the constant supply, and regular supply, and a continuous supply of health commodities. Supply is not effectively accomplished with a single unit or entity. We have to engage multiple stakeholders and actors in the supply of health commodities, and they are the key to success. Now, my stakeholders may be many. They may be government agencies.

Skip to 12 minutes and 28 seconds They may be donors. There may be noncommittal organizations. So there may be internal stakeholders and external stakeholders. The government agencies, the transportation and communication facilities, shipping lines, airlines, ground transport, storage facilities, government agencies, ministries of health, finance, transportation, customs, service delivery points, health facilities, centers, health posts and clinics. They are all government systems– the health system, basically, and the governance of this system. And many levels, and many stakeholders within my government, different departments who needed to coordinate on the procurement and supply of the vaccines. And then, external stakeholders. These donors with the funding agency, or you can say “development partners.”

Skip to 13 minutes and 20 seconds And then manufacturers, suppliers, wholesalers, and then transporters, and communication facilities, and storage facilities– as I said, warehouses and hubs, [INAUDIBLE] many private warehousing facilities and agencies. And, of course, we should always remember the main stakeholder is our end user, the household having children, where our customer– let us say, customer satisfaction is very, very important. They need to be engaged. The communities must be engaged. They should be part of decision-making and organizing sessions. They should own this. So their role as external [INAUDIBLE] we have mentioned within the last. I would have done it earlier in the beginning. So the users are ultimate in success of the program.

# Vaccine Supply

Dr. S.D. Gupta, M.D, Ph.D, FAMS Chairman, IIHMR University, India

The reading Vaccination: rattling the supply chain discusses the advantages and disadvantages of changes in vaccine packaging policies (i.e. newer vaccines are in single or double-dose packages and vaccines are now required to have more sophisticated packaging), which has resulted in the need for additional space for cold storage.

Drawing on the reading and the lecture, respond to the following:

What considerations need to be taken into account when balancing the need for sufficient stock and necessary changes in packaging with the need for additional space going forward? Create a list of at least 3 considerations, drawing on the lecture and the reading.

Post your list in the discussion. Then respond to another’s post and order their list from the highest-priority to the lowest-priority considerations, and explain your ranking.