NextBillion - An Initiative of the William Davidson Institute at the University of Michigan

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.