The Immunization Supply Chain and Logistics (ISCL) systems, which were designed in the 1980s, have supported the achievement of acceptable vaccination, Vaccine Logistics & Supply chain assessment in Bihar, MP & UP. The success of global immunization since the launch of the Expanded Programme on Immunization. Vaccine logistics & supply chain, Immunization Policies and Guidelines, Immunization Technical Support Unit, Ministry of Health and Family Welfare, UIP in India, Mission Indradhanush, MoHFW, Universal Immunization Program in India, Child Vaccination program in India, Routine Immunization Program in India, NTAGI and STSC secretariat, GAVI HSS Secretariat, National Health Mission Source by : https://goo.gl/HXZNZD

1. Vaccines logistics and supply chain assessment
in Bihar, MP and UP
Diagnostic findings
November 2012 ITSU - PHFI

2. Content
–
–
–
–
Context & assessment design
Assessment results: Severity of stock-outs
Issues and root causes for stock-outs
Recommendations for the States
ITSU - PHFI 2

3. Context and objective of the vaccines supply chain assessment
Context

Public Health Foundation of India (PHFI)
and the Ministry of Health & Family
Welfare have entered into an
Memorandum of Understanding to
implement activities to strengthen India’s

UIP/RI programme



Regular supply of vaccines (diluents and
syringes) has been identified as one of
the key issues impacting the Routine
Immunization programme



Preliminary diagnostics on supply chain
security have been conducted but gaps
remain in understanding the root causes
and potential solutions

Objectives of the assessment
Against this backdrop, ITSU team
conducted a deep-dive assessment of
logistics and supply chain of vaccines and
syringes in Bihar, UP and MP with the
aim to:

Understand if issues exist in regular
availability of vaccines, diluents or
syringes to the ANMs



Understand issues in the end-to-end
vaccines (with diluents and syringes)
supply chain and root causes for the
stock-outs

ITSU - PHFI 3

4. We selected 2-3 districts in each state for detailed visits
Regional warehouse
Criteria for
shortlisting districts
for deep-dive
▪ Combination of
poor and good
current BCG
coverage
(representative of
access issue)
▪ Combination of
districts which
are near and far
from regional
warehouse
▪ Districts from
different regional
warehouses in the
State
Bihar: Jamui & Saharsa districts Madhya Pradesh: Guna & Tikamgarh districts
Uttar Pradesh: Agra, Shrawasti & Allahabad districts
SOURCE: Census 2011; DLHS-3 ITSU - PHFI

5. We visited all stores involved in supply chains of selected
districts/blocks
Bihar Madhya Pradesh Uttar Pradesh
▪ Patna ▪ Bhopal ▪ Lucknow
State/ Regional ▪ Gwalior ▪ Varanasi
▪ Agra
▪ Bhagalpur ▪ - ▪ Faizabad
Divisional ▪ Purnia ▪ Allahabad
▪ Jamui ▪ Guna ▪ Shravasti
District ▪ Saharsa ▪ Tikamgarh ▪ Allahabad
▪ Etah
▪ Jamui-Sadar ▪ Aron ▪ Hariharpurrani
Block ▪ Giddhor ▪ Beenaganj ▪ Ikauna
▪ Salkhua ▪ Niwari ▪ Koraon
▪ Simri Bakhtiyarpur ▪ Jatara ▪ Mauiama
▪ Aliganj
▪ Jalesar
ITSU - PHFI 5

6. We talked to ~200 persons across Centre, suppliers and states (1/2)
Centre
▪ Dr Ajay Khera (DC, CH & Immunisation)
▪ Dr Pradeep Haldar (DC, Immunisation)
▪ Dr MK Agarwal (Assistant Commissioner, Immunisation)
▪ Dr Balwinder (Senior Technical Consultant, Immunization)
▪ Mr Saumitra Sahar (Section Officer, Immunisation)
▪ Mr Paritosh Panigrahi (Cold Chain Consultant, Immunisation)
▪ Mr YK Pathak (Director, Procurement)
▪ Mr Sushil Kumar (Section Officer, Procurement)
Suppliers
▪ Mr S K Bahl (Director-Business Development, Serum Institute
of India)
▪ Dr Daksha Yani (Director, Green Signal Bio Pharma Ltd)
▪ Mr Jeevan Kumar (Vice President, Biological E Ltd)
▪ Mr Dheeraj M (Biological E Ltd)
Partners
▪ Dr Hemant (Regional Team Leader
▪ Dr Arun Kumar (SMO-RI, Bihar)
▪ Dr Deepak Kumar (SMO,NPSP Saharsa)
▪ Dr Ujjawal Sinha (WHO/NPSP)
▪ Dr Anand SMO, Bhagalpur
▪ Dr Narendra Beena (SMO, Jamui)
▪ Dr Ravi (UNICEF)
▪ Mr Mukeshwar Rawat (State task force, UNICEF)
▪ Mr Shamik Trehan (CARE)
▪ Mr Parveen Bhalla (CARE)
▪ Mr Amit Trivedi (District Child Health Coordinator, UNICEF)
▪ Mr Vishwanath G (Consultant, UNICEF)
▪ Mr Dharmender Raghuvanshi (MCH Monitor, Guna, UNICEF)
▪ Dr Gura (State SRTL NPSP)
Bihar
▪ Mr Sanjay Kumar (Executive Director, NRHM, Bihar)
▪ Dr NK Sinha (State Immunisation officer
▪ Dr MP Sharma (State cold chain officer, Bihar)
▪ Mr Ram Ratan (SPO, RI & Polio)
▪ Mr Suraj Nandan Sinha (Store keeper, PHI)
▪ 7 refrigerator mechanics
▪ Mr Abhijit Kumar (Store keeper)
▪ Dr B N Mishra (DIO, Saharsa district)
▪ Dr Anjani Kumar Sinha (Acting DIO, MOIC)
▪ Mr Ranvir (Store-keeper, Jamui district)
▪ Mr Pankaj Kumar (Data assistant, Jamui district)
▪ Mr Ajay Kumar Singh (Store-keeper, Jamui-Sadar block)
▪ Mr Promod Kumar (Cold chain officer, Saharsa district)
▪ Mr Sant Kumar (Data assistant, Saharsa district)
▪ Dr Azad Singh (CS, Saharsa district)
▪ Mr Sanjeev (Administrative Assistant to SRTL Bhagalpur)
▪ Mr James Besra (Store-keeper, Jamui-sadar block)
▪ Mr Ashok Kumar Sinha (Health Educator, Jamui-sadar block)
▪ 44 ANMs & 52 ASHAs
ITSU - PHFI 6

7. We talked to ~200 persons across Centre, suppliers and states (1/2)
Madhya Pradesh Uttar Pradesh
▪ Mr Santosh Shuka (Deputy Director Immunization)
▪ Dr Ashwin Bhagwat (RI Co-ordinator, UNICEF)
▪ Mr V K Srivastav (State Cold Chain officer)
▪ Mr Neeraj Shukla (Vaccine & Logistics Manager)
▪ Mr M I Qureshi (Division Technician)
▪ Neeraj Narang (Divisional Logistics Manager, Gwalior)
▪ Abhay (Store-keeper, Gwalior)
▪ Dr Nidhi (NRHM)
▪ Dr D K Bhargav (CMHO, Guna)
▪ Dr P K Sharma (DIO, Guna)
▪ Dr G B Paliwal (DPM)
▪ Dr O P Gautam (CMHO)
▪ Dr P K Jain (DIO, Tikamgarh)
▪ Chandrasekhar Tiwari (Store in-charge &
Technician, Tikamgarh)
▪ Dr K K Srivastav (MOIC, Aron)
▪ Dr B S Raghuvanshi (Cold Chain and RI Ic)
▪ Mr Krishangopal Sharma (Vaccine, Cold Chain and
Logistics Handler`)
▪ Mr Pradeep Sharma (Block Program Manager, Aron)
▪ Shaikh Jalaluddin (Block Medical Officer, Beenaganj)
▪ Kamlesh Kabir Panthi (Computer Assistant, Beenaganj)
▪ Mukesh Kansotiya (Cold Chain Technician, Beenaganj)
▪ Ms Pamila (BPM, NRHM, Beenaganj)
▪ Mr Raghuveer, Supervisor, Cold Chain handler
▪ Dr L C Chanderia (Block Medical Officer, Jatara)
▪ Dr Amit Chourasia (Block Immunization Officer,
Jatara)
▪ Mr. Ajit Jain (Multi Purpose Worker and Cold
Storage Handler, Jatara)
▪ Dr Bajpaye (Block Medical Officer, Niwari)
▪ Mithilesh Shrivastava (LHV, Niwari)
▪ No of ANMs: 15
▪ No of vaccine couriers: 7
▪ Dr Vedprakash (GM Immunization, NRHM)
▪ Mr Amit Kumar Ghosh (MD, NRHM)
▪ Dr Bharat Ram (AD, UIP)
▪ Dr Poornimal Verma (JD, EPI)
▪ Mr Shashank (Assistant cold chain officer,
Lucknow)
▪ Mr Nigam (Store keeper State)
▪ Mr Ramesh Gupta (State Refrigerator Mechanic)
▪ Mr O P Kueeil (Admin officer, Nadarganj)
▪ Dr D K Dubey (Additional Director, Varanasi
division)
▪ Mr Gupta (Operator/ Cold-chain handler,
Varanasi regional store)
▪ Dr Padmakar Singh (CMO Allahabad)
▪ Capt Ashutosh Srivastav (DIO, Allahabad)
▪ Mr P K Anuragi (Cold chain handler, Allahabad
district store)
▪ Mr Rajkumar (Refrigerator Mechanic,
Allahabad district store)
▪ Dr A K Sing (Block Medical Officer, Koraon PHC)
▪ Mr Anurag Mishra (Cold-chain handler, Koraon
PHC)
▪ Dr Ashok Singh (Store-keeper, Agra warehouse)
▪ Mr Rakesh Kumar (Cold-chain incharge, Agra
warehouse)
▪ Dr Manju Sharma (CMO, Agra)
▪ CMO, Etah
▪ Cold-chain handler, Etah
▪ Store-keeper, Etah
▪ Cold-chain technician/ store-keeper, Aliganj
▪ Dr Rajesh Sharma (MOIC, Aliganj)
▪ Dr R P Gupta (CMO, Sharawasti)
▪ Dr Ashok Kumar Sant (DIO, Sharawasti)
▪ Dr Praveen (Chief Pharmacist, Shrawasti)
▪ Mr G N Yadav (DHNTC)
▪ Dr M L Verma (BMP, Hariharpurrani)
▪ Mrs Lalita Devi (LHV/ Cold-chain
handler, Hariharpurrani)
▪ Mr Ramanand Prajapati (Record keeper)
▪ Dr Rajat Singh (BMO, Ikuana)
▪ Mr R K Tyagi (AD, Faizabad)
▪ Mr Jagdish Malhotra (Refrigerator Mechanic,
Faizabad)
▪ Mr Vinay Kumar (WIC attendant, Faizabad)
▪ Dr Chitranshi (Joint Director)
▪ Dr V Pandey (Joint Director)
▪ Dr Padmakar Singh (CMO, Allahabad)
▪ Mr Harish Singh (Cold-chain handler,
Allahabad division)
▪ Ms Sonal Rai (DHNTC)
▪ Dr U B Singh (MOIC, Suraon)
▪ Mr Pankaj Singh (Health Education
Officer, Suraon)
▪ Mr Keshav Pandey (Cold-chain officer, Muaiyama)
▪ Mr Pramesh Kumar (Health Education
Officer, Muaiyama)
▪ Prema Devi (LHV)
▪ 10 ANM/AWW/ASHAs
ITSU - PHFI 7

8. Content
–
–
–
–
Context & assessment design
Assessment results: Severity of stock-outs
Issues and root causes for stock-outs
Recommendations for the States
ITSU - PHFI 8

9. 10-15% sessions were stocked out of vaccines in Bihar & UP;
tOPV most stocked out
Conducted sessions in last 12 months* stocked-out of vaccine (per cent)
Bihar Madhya Pradesh Uttar Pradesh
Instances of ANM not
taking vaccine despite
vaccine being available at
PHC due to lower
anticipated demand at
session (especially in UP)
Data not NA
noted
* For Bihar: Apr 2011-Mar 2012 from all 4 blocks visited; For MP: Aug 2011-Aug 2012 (except for Beenaganj & Aron, it is Aug 2011-Mar 2012); MP TT stock-out data
is for Aron, Jatara and Niwari blocks only; For UP, Apr 2011-Mar 2012 for Hariharpurrani & Ikuana, Oct 2011-Oct 2012 for Jalesar, Feb 2011-Jul 2012 for Aliganj, May
2011-Apr 2012 for Mauiama and Oct 2011-Mar 2012 for Koraon
SOURCE: Block stock registers ITSU - PHFI 9

10. Content
–
–
–
–
Context & assessment design
Assessment results: Severity of stock-outs
Issues and root causes for stock-outs
Recommendations for the States
ITSU - PHFI 10

11. Five root-causes leading to supply chain issues
Four key Issues in supply chain…
A. Irregular and sometimes
short supply of vaccines
at regional warehouses
B. Poor distribution practices
followed at regional/
division/ district warehouses
C. High vaccine wastage
at session sites
D. Issues in cold-chain
space and maintenance
… caused by five key root-causes
1. Delay in procurement and
loosely defined delivery schedule
2. Poor staffing and training of
personnel involved in supply chain
3. Poor session planning and/or
adherence of roster
4. Poor documentation of current stock
and information sharing across levels
5. Insufficient and/or delay in release
of funds
ITSU - PHFI 11

12. 1. Irregular and sometimes short supply of vaccines at regional warehouses
A Uneven vaccine supply to regional store: Patna example
Assumptions
▪ Ideal supply
calculated as total
supply in the year
to be distributed
equally in 6 bi-
monthly intervals
▪ Total supply
includes opening
stock in April
and delivery
from suppliers
and GMSDs
Bi-monthly supply of vaccine to Patna
Lakh doses; FY12
BCG DPT
TT
SOURCE: PHI ITSU - PHFI 12

13. 1. Irregular and sometimes short supply of vaccines at regional warehouses
A Uneven vaccine supply to regional store: Gwalior example
Assumptions
▪ Ideal supply
calculated as total
supply in the year
to be distributed
equally in 6 bi-
monthly intervals
▪ Total supply
includes opening
stock in April
and delivery
from suppliers
and GMSDs
Bi-monthly supply of vaccine to Gwalior
Lakh doses; FY12
tOPV BCG
TT Hep-B
SOURCE: PHI ITSU - PHFI 13

14. 1. Irregular and sometimes short supply of vaccines at regional warehouses
A Uneven vaccine supply to regional store: Agra example
Assumptions
▪ Ideal supply
calculated as total
supply in the year
to be distributed
equally in 6 bi-
monthly intervals
▪ Total supply
includes opening
stock in April
and delivery
from suppliers
and GMSDs
Bi-monthly supply of vaccine to Agra
Lakh doses; FY12
tOPV DPT
TT Measles
SOURCE: PHI ITSU - PHFI 14

15. 1. Irregular and sometimes short supply of vaccines at regional warehouses
A tOPV and TT supplied to Patna were 25% and 7% short of demand
estimated by Centre respectively
Demand and supply of vaccines to Patna from suppliers
Lakh doses; FY12
tOPV TT
25% 7%
SOURCE: UIP Programme division ITSU - PHFI 15

16. 1. Irregular and sometimes short supply of vaccines at regional warehouses
A Hep-B supplied to Agra, Lucknow and Gwalior were 60-70% short of order
placed by Centre
Order placed and actual supply of Hep-B vaccine
Lakh doses; Aug 2011-Jan 2012
Gwalior Lucknow Agra
63% 63% 77%
SOURCE: UIP Programme division; Stock registers at Agra, Lucknow and Gwalio ITSU - PHFI 16

17. 2. Poor distribution practices followed by regional/ divisions/ districts
B Issues in supply chain & distribution practices in States
Supply chain
structure
Safety/ buffer
stock
Basis of
distribution
Pick-ups
by blocks
Description
▪ Instances of defined supply chain structure
not being followed making demand
estimation difficult
▪ Concept of safety/ buffer stock non known
to most people or not being implemented
▪ Vaccines are distributed on the basis
of number of beneficiaries without
consideration of actual consumption/
current stock
▪ In some places, blocks distant from the
district store delay pick-ups of vaccines
to optimize mobility fund
Examples
▪ Allahabad district takes JE and Hep-
B vaccines from Lucknow and all
other vaccines from Varanasi
▪ Blocks in Guna re-order when 1
week stock is remaining
▪ Observed in all 3 states
▪ -
SOURCE: Interviews with supply chain personnel ITSU - PHFI 17

18. 3. High vaccine wastage at blocks and session sites
C Vaccines wastage is higher than assumed in demand estimation leading
to shortage of vaccines
Key assumptions made
by Centre in annual
demand estimation
▪ Target population:
– Number of
beneficiaries as
provided by State
– Coverage as per
UNICEF Coverage
Evaluation Survey
▪ Wastage: 25%
▪ Buffer: 25%
Wastage observed from randomly selected sessions (Percent)
Bihar Madhya Pradesh Uttar Pradesh UNICEF study
(42 sessions) (~180 sessions) (88 sessions) (5 states*, 2010)
Data not
noted
* Includes Uttar Pradesh, Assam, Maharashtra, Tamil Nadu and Himachal Pradesh
SOURCE: Tally sheets of ANMs; Vaccine Wastage Assessment, April 2010 (UNICEF); ITSU - PHFI 18

19. 4. Issues in cold-chain space and maintenance
D Issues in cold chain space and maintenance
Cold storage
capacity
Delay in
installation
Quality and
maintenance of
equipment
Vaccine vans
Store location
Description
▪ Insufficient cold storage capacity
to store 2-3 months on vaccines
demand
▪ Equipment delivered to stores
but not installed
▪ Frequent performance issues
with Haier equipment and Chint
stabilizers
▪ Vaccine vans are not available at
all districts, or are very old
▪ Store location small,
inconvenient or inappropriate
Examples
▪ Patna & Purnia have WIC capacity to store only
one month requirement of vaccines of state and
division respectively
▪ Bhagalpur has capacity to store only half
month’s tOPV requirement
▪ Bluestar WICs at Agra and Faizabad not installed
for last 2 years
▪ WIC at Saharsa not installed for last 6 months
▪ Sickness rate in Guna district excluding Haier
equipment is 3.9% but the same including Haier is
11.7%;
▪ Tikamgarh Haier DF installed in 2009 and
has been non functional for last 6 months
▪ Shrawasti does not have a van
▪ Tyres of Faizabad division’s van are damaged
and hence not functional
▪ Allahabad’s van is very old (condemned on paper)
▪ Lucknow syringes and vaccines stores are 25-
30km far, making pick-up of material difficult
▪ Tikamgarh vaccine store is located in Nurses
Training Center
SOURCE: Interviews with supply chain personnel; Field observations ITSU - PHFI 19

20. 4. Issues in cold-chain space and maintenance
D Insufficient WIC capacity at Patna
Key assumptions
▪ Storage capacity at Patna:
– 3 WIC with capacity of
2.5, 2.5 and 2 lakh vial
– 2 WIF with capacity of 2.5
and 1.2 lakh vial
▪ Monthly demand (as per State)
estimated based on
– BCG: Number of sessions
planned
– Other vaccines: Number
of live births; 100%
coverage; 33%
wastage; 25% buffer
▪ Storage guidelines:
– tOPV in WIF only
– DPT and TT in WIC only
– BCG and Measles in WIC,
however can be stored in
WIF if lack of space in
WIC
tOPV
DPT, TT & Hepatitis-
B BCG & Measles
Cold storage capacity (actual and
required) Lakh vial
WIC WIF
Patna has WIC capacity to store only one
month’s vaccine requirement (ideally should
be able to store up to 3 months requirement)
SOURCE: PHI Store-keeper; SIFHW; UIP Programme division ITSU - PHFI 20

21. 4. Issues in cold-chain space and maintenance
D Insufficient WIF capacity at Purnia and Bhagalpur
tOPV
DPT, TT & Hepatitis-
B BCG & Measles
Key assumptions
▪ Storage capacity at Purnia
division:
– 1 WIC with capacity of 1.2-
1.5 lakh vial
– 1 WIF with capacity of 1.5-2
lakh vial
▪ Storage capacity at Bhagalpur:
– 2 WIC with capacity of 2-
2.5 lakh vial each
– 1 DF with capacity of 0.05
lakh vial
▪ Monthly demand (as per State)
estimated based on
– BCG: Number of sessions
planned
– Other vaccines: Number of
live births; 100% coverage;
33% wastage; 25% buffer
▪ Storage guidelines:
– tOPV in WIF only
– DPT and TT in WIC only
– BCG and Measles in WIC,
however can be stored in
WIF if lack of space in WIC
Cold storage capacity (actual and required)
Lakh vial WIC WIF
PURNIABHAGALPUR
▪ Purnia has
capacity to store
two months’
vaccine
requirement for
the division
(ideally should be
able to store upto
3 months’
requirement)
▪ Bhagalpur does
not WIF/DF
capacity to store
even one months’
tOPV requirement
for the division
SOURCE: PHI Store-keeper; SIFHW; UIP Programme division ITSU - PHFI 21

22. Five root-causes leading to supply chain issues
Four key Issues in supply chain…
A. Irregular and sometimes
short supply of vaccines
at regional warehouses
B. Poor distribution practices
followed at regional/
division/ district warehouses
C. High vaccine wastage
at session sites
D. Issues in cold-chain
space and maintenance
… caused by five key root-causes
1. Delay in procurement and
loosely defined delivery schedule
2. Poor staffing and training of
personnel involved in supply chain
3. Poor session planning and/or
adherence of roster
4. Poor documentation of current stock
and information sharing across levels
5. Insufficient and/or delay in release
of funds
ITSU - PHFI 22

23. A. Delay in procurement and loosely defined delivery schedule
1 Delays in placing purchase orders gives insufficient lead time
to suppliers, leading to erratic supply
Lead time to suppliers < 90 days
Percentage of total annual order placed (Lead time given to suppliers*)
FY12
Jan Feb Mar Apr May Jun Jul AugSep Oct Nov Dec Jan
2011 2012
BCG 17% 37% 46%
(63d) (58d) (80d)
tOPV 69% 31%
(162d) (72d)
DPT 38% 54% 8%
(60d) (162d) (54d)
TT 84% 16%
(85d) (53d)
Measles 100%
(80d)
* Time between date of issuing purchase order and deadline for supplying first “lot”
SOURCE: Procurement division ITSU - PHFI 23

24. A. Delay in procurement and loosely defined delivery schedule
1 Procurement has been on time in FY13
Lead time to suppliers < 90 days
Percentage of total estimated demand ordered (Lead time given to suppliers*)
FY13
Jan 2012 Feb Mar Apr May
BCG 80%
(145d)
tOPV 100%
(150d)
DPT 46% 54%
(240d) (113d)
TT 76% 23%
(NA) (NA)
Measles 100%
(146d)
* Time between date of issuing purchase order and deadline for supplying first “lot”
SOURCE: Procurement division ITSU - PHFI 24

25. A. Delay in procurement and loosely defined delivery schedule
1 Delivery schedule is weakly defined allowing suppliers to supply
3-4 months stock at a time (instead of desired 2 months)
Delivery schedule
needs to be tightly
defined. Currently it
allows 2 supply chain
issues to occur:
▪ Supplier can supply
2 months stock in
start of Aug and
another 2 months
stock in end of Nov
causing shortage of
vaccines in Oct and
Nov
▪ Supplier can supply
2 months stock in
end of Nov and
another 2 months
stock start of Dec
causing cold storage
capacity shortage
with 4 months stock
at warehouse
SOURCE: Procurement division ITSU - PHFI 25

26. B. Poor staffing and training of personnel involved in supply chain
2 Manpower & training issues
Lack of
appropriate
manpower
Lack of
training
Examples
▪ At various places in UP, mechanics and cold chain
Regional Director, who
handlers were staffed through contractual staff or
manages the divisional
through “attached” (additional) duty and are not capable
warehouse, relies on
of their responsibilities: CMO’s office for hiring of
– Lack technical knowledge (i.e. data to be recorded, support staff i.e. cold
preventive maintenance, no temperature recording at chain handlers at
Lucknow) divisional warehouse. It
▪
– No knowledge of funds/ TA/DA available often gets de-prioritized
Second ANM not hired at large blocks or delayed at CMO office
▪ Of 7 mechanics in Bihar, only 1 is fully trained and
capable of handling requests stand-alone; team has
requested for training multiple times in past one year
▪ Technicians in MP not trained for digital and non-CFC
equipment
▪ Store in-charge at blocks not trained (or monitored)
for recording returned vaccines and syringes
▪ Store in-charge in all states not trained on how to
distribute based on number of beneficiaries and actual
consumption/current stock
SOURCE: Interviews with supply chain personnel; Team analysis ITSU - PHFI 26

27. B. Poor staffing and training of personnel involved in supply chain
2 Only 30-40% supply chain personnel trained in UP and Bihar
HW trained (2011, Percent) Cold chain handlers trained (2011, Percent)
Medical Officers trained (2011, Percent)
SOURCE: National Institute of Family & Health Welfare ITSU - PHFI 27

28. 3. Poor session planning and/or adherence of roster
All three states have a high dependence on outreach sessions
Place of immunization
Potential reasons
for high
dependence on
outreach

Largely rural

Demand
primarily
through
ASHA/AWW
mobilisation

People used to
being serviced
closer home
due to polio?
SOURCE: UNICEF CES 2009 survey ITSU - PHFI 28

29. 3. Poor session planning and/or adherence of roster
3 Under current guidelines, minimum wastage for outreach
sessions likely to be 30-40% (up to 70% for BCG)
Key assumptions in theoretical
wastage assessment for Simbi
Bakhtiyarpur block
▪ Assessment includes 265 villages
▪ Frequency of sessions as per MoHFW
guidelines i.e.
– 1 session/2 months if injection
load < 25
– 1 session/month if injection
load >25 & <50
– 2 sessions/month if injection
load >50
– Does not factor in a compulsory
session at AWC every month
▪ Injection load per infant is 11:
– BCG: 1
– DPT: 4
– Measles: 1
– Hepatitis-B: 3
– TT: 2
▪ A vial is opened for even one infant
Estimated (theoretical) wastage
Percent
Theoretical wastage would be higher, if the
guideline about a compulsory session every month
at AWC is also factored in
SOURCE: Immunization handbook; Team analysis ITSU - PHFI 29

30. 3. Poor session planning and/or adherence of roster
3 Moreover, ANMs are not following planning sessions as per
guidelines(1/2)
ANMs has
visited the
village once a
month though
micro-plan
requires her
to visit twice/
month
ANM has
visited these
villages twice in
2 months
whereas the
micro-plan
requires her
to visit it once
in two months
Software calculates frequency of sessions for various villages PHC prepares actual schedule
SOURCE: ANM Roster (Simbi Bakhtiyarpur)
ITSU - PHFI 30

31. 3. Poor session planning and/or adherence of roster
3 Moreover, ANMs are not following planning sessions as
per guidelines(2/2)
ANM: Prema
Kumari
Plan made on dummy date
(holidays or 4-week month not
accounted for). Sessions planned
for holidays are re-scheduled
without proper intimation to
AWC leading to poor turnout at
new date
An ANM is planned to
conduct two sessions
in different villages
on same day
Software calculates frequency of sessions for various villages PHC prepares actual schedule
SOURCE: ANM Roster (Simbi Bakhtiyarpur)
ITSU - PHFI 31

32. 4. Poor record keeping of stock and sharing across levels
4 Poor record keeping observed across states
▪ No records found for syringes or vaccines returned at block
▪ Batch number of diluents not recorded at most
levels (especially on distribution vouchers)
▪ Tally sheets not being filled regularly. When filled, they are
not being used to match the number of returned vials
▪ Vaccines and syringes stock data not maintained
online, disabling region and district to distribute as per
past consumption/ current stock
Reasons for not maintaining proper records:
▪ No standard templates for data recording
▪ No standard training module for data operators and
hence lack of proper training
▪ No enforcement for updating stock information in HMIS
SOURCE: Team analysis ITSU - PHFI 32

33. 5. Insufficient funds and delay in release of funds
5 Insufficiency or delay in release of funds causes issues in
maintaining a regular cold chain
Insufficient
funds
Delay in
release
of funds
Examples
▪ Divisions fuel fund
– UP: No division fund at all
– Bihar: Sufficient only to make one trip whereas multiple trips required
because of large volumes involved
▪ Funds budgeted for Bhopal electricity and generator fuel insufficient
▪ No fund budgeted for labour to load/unload vaccines
▪ AVD stipend not sufficient for long distance session sites, especially
in districts like Tikamgarh where an AVD is allocated one site only
▪ Mechanics in Patna not “excited” about outstation requests
– Travel allowance: Rs 150/ day (was Rs 400/day with UNICEF)
– Night stay: Rs 500/night against hotel bill; many hotels do not give bills
▪ Annual fund shortage from April-July due to delay in finalization and
approval of PIP which impacts payments to AVD and ANM
▪ Electricity bill at Faizabad not paid for last 2 years (Rs 3.5 lakh)
▪ Electricity bill at Lucknow due for Rs 1.7 lakh
SOURCE: Interviews with supply chain personnel; Team analysis ITSU - PHFI 33

34. 5. Insufficient funds and delay in release of funds
5 POL for vaccine delivery insufficient for divisions to pick-up
vaccines for entire division from Patna ESTIMATES
Assumptions
Bhagalpur Purnia
▪ POL for Vaccine Delivery from State to Bhagalpur Division/ Annual: Rs 100,000 Annual: Rs 100,000
district and PHC/CHC: Monthly: Rs 8,333 Monthly: Rs 8,333
Fund available
▪ POL for vaccine delivery from Bhagalpur to PHC/CHC:
– Number of blocks in the district 16 14
– Monthly budget allocated for each block Rs 300 Rs 300
– POL for vaccine delivery from district to PHC/CHC Rs 4,800 Rs 4,200
▪ POL for vaccine delivery from Patna to division Rs 3,533 Rs 4,133
▪ Monthly vaccine demand for division 32,563 vials 60,612 vials
Fund required
▪ Banka: 7,200 vials ▪ Araria: 9.954 vials
▪ Bhagalpur: 10,756 vials ▪ Katihar: 10,882 vials
▪ Jamui: 6,232 vials ▪ Kishangarh: 5,998 vials
▪ Munger: 4,820 vials ▪ Madhepura: 7,075 vials
▪ Lakhisarai: 3,555 vials ▪ Purnnia: 11,614 vials
▪ Saharsa: 6,731 vials
▪ Supaul: 7,908 vials
▪ Number of trips required
– Capacity of a van: 30,000 vials (with diluents) 30,000 vials (with diluents) 30,000 vials (with diluents)
– Number of trips for vaccines pick-up 1.1* 1.1*
– Number of trips for syringes pick-up 1 1
▪ Cost of one trip
– Distance between division and Patna 250 km 307 km
– Per km cost of van Rs 6 Rs 6
– Round-trip cost Rs 3,000 Rs 3,000
▪ POL for vaccine delivery from Patna to division required > Rs 6,000 > Rs 11,000
* Assumes all vaccines are available at the time when van goes for pick-up
SOURCE: Team analysis ITSU - PHFI 34

35. Content
–
–
–
–
Context & assessment design
Assessment results: Severity of stock-outs
Issues and root causes for stock-outs
Recommendations for the States
ITSU - PHFI 35

36. Recommendations for Bihar
Manpower &
1
training
2 Lack of funds
3 Session planning
4 Cold chain
equipment
5 Data recording
Key issues
▪ Hire and train cold chain staff where required; training must include technical (including distribution on basis
of past consumption/ current inventory) and financial aspects (i.e. funds available for various activities)
▪ Team of 7 refrigerator mechanics currently placed in Patna must all be trained and relocated to divisions (to
help solve machine break-downs faster)
▪ Hire buffer ANMs to cover for absent ANMs (so that no planned sessions are cancelled/postponed)
▪ Mobility fund must be reviewed for sufficiency, especially at division level
▪ Mobility fund must be distributed amongst districts and blocks based on their distance from the warehouse
(instead of current practice of distributing it equally)
▪ Explore mobility support to ref mechanics and vaccine store keepers at district level for preventive
maintenance
▪ MOIC must support ANMs in making micro-plans and improve session planning such that:
– ANMs conduct vaccination sessions at villages/sites as per frequency recommended by guidelines based
on injection load
– No ANM conducts more than one session in a day
– Micro-plan is planned on actual calendar dates so that holidays (and other foreseeable events i.e. polio
campaigns) are accounted for
▪ Order and install new WIC capacity at Patna and WIF/DF at Bhagalpur
▪ Cold chain in-charges be trained to record batch number of diluents, syringes received/distributed and vaccines
returned from outreach sessions
▪ All stock data must be entered in an online system .Visibility into stock information at higher level will help in
raising indents and at lower level will help in allocation of stock
SOURCE: Team analysis ITSU - PHFI 36

37. Recommendations for Madhya Pradesh
Manpower &
1
training
2 Lack of funds
3 Session planning
4 Cold storage
space
5 Data recording
Key issues
▪ Hire and train cold chain staff where required; training must include technical (including distribution on basis
of past consumption/ current inventory and maintenance of safety stock) and financial aspects (i.e. funds
available for various activities)
▪ Refrigerator mechanics must be trained for digital and non-CFC equipment
▪ Review sufficiency of funds, especially for electricity & generator at Bhopal
▪ Mobility fund must be distributed amongst districts and blocks based on their distance from the warehouse
(instead of current practice of distributing it equally)
▪ Review AVD policy in Tikamgarh (one AVD per session) leading to low incentive for AVDs covering
far-away sessions to return vaccines at end of session
▪ MOIC must support ANMs in making micro-plans and improve session planning such that:
– ANMs conduct vaccination sessions at villages/sites as per frequency recommended by guidelines based
on injection load
– No ANM conducts more than one session in a day
– Micro-plan is planned on actual calendar dates so that holidays (and other foreseeable events i.e. polio
campaigns) are accounted for
▪ Identify space and build the Tikamgarh vaccine store in an appropriate area
▪ Cold chain in-charges be trained to record batch number of diluents, syringes received/distributed and vaccines
returned from outreach sessions
▪ Train ANMs to fill tally sheets and ensure compliance
▪ All stock data must be entered in an online system .Visibility into stock information at higher level will help in
raising indents and at lower level will help in allocation of stock
SOURCE: Team analysis ITSU - PHFI 37

38. Recommendations for UP
Manpower &
1
training
2 Lack of funds
3 Session planning
4 Cold chain
equipment
5 Data recording
Key issues
▪ Review of vaccine supply and distribution
▪ Hire and train cold chain staff where required; training must include technical (including basis of distribution
being past consumption/ current inventory) and financial aspects (i.e. funds available for various activities)
▪ Hire buffer ANMs to cover for absent ANMs (so that no planned sessions are cancelled/postponed)
▪ NRHM to ensure timely dispersion of funds for issues identified (example, electricity bill, generator fuel,
vaccine van fuel)
▪ Explore mobility support to ref mechanics and vaccine store keepers at district level for preventive
maintenance
▪ MOIC must support ANMs in making micro-plans and improve session planning such that:
– All villages are assigned to an ANM
– ANMs conduct vaccination sessions at her villages as per frequency recommended by guidelines based
on injection load
– No ANM conducts more than one session in a day
– Micro-plan is planned on actual calendar dates so that holidays (and other foreseeable events i.e. polio
campaigns) are accounted for
▪ Explore shifting of vaccine storage close to syringes store
▪ Review and rationalize flow of vaccines and syringes from regions to divisions and districts
▪ De-bottleneck new WIC installation at Agra and Faizabad
▪ Ensure vaccine van available at every district:
▪ Cold chain in-charges be trained to record batch number of diluents, syringes received/distributed and vaccines
returned from outreach sessions
▪ All stock data must be entered in an online system .Visibility into stock information at higher level will help in
raising indents and at lower level will help in allocation of stock
SOURCE: Team analysis ITSU - PHFI 38

39. Backups
ITSU - PHFI 39

40. BCG: ~7% of sessions were stocked out, primarily in Salkhua
Estimated percentage of sessions without vaccine
Jamui district Saharsa district
Giddhor Jamui-Sadar Salkhua Simbi Bakhtiyarpur
Vaccineavailable
Vaccine
availabl
e
NA
NA
NA
NA NA
NA NA
NA NA
NA NA
NA NA
NA
NA
NA
NA
NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared
session-wise vaccine distribution data for 4 months only ITSU - PHFI 40
SOURCE: Block stock registers

41. tOPV: ~45% of sessions were stocked out, across all 4 blocks
Estimated percentage of sessions without vaccine
Jamui district Saharsa district
Giddhor Jamui-Sadar Salkhua Simbi Bakhtiyarpur
NA
NA
NA
NA NA
NA NA
NA NA
NA NA
NA NA
NA
NA
NA
NA
NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared
session-wise vaccine distribution data for 4 months only ITSU - PHFI 41
SOURCE: Block stock registers

42. DPT: ~16% of sessions were stocked out, primarily in Giddhor &
Jamui-Sadar
Jamui district
Giddhor Jamui-Sadar Salkhua
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared
session-wise vaccine distribution data for 4 months only ITSU - PHFI 42
SOURCE: Block stock registers
Saharsa district
Simbi Bakhtiyarpur
NA
NA
NA
NA
NA
NA
NA
NA
Estimated percentage of sessions without vaccine

43. TT: ~10% of sessions were stocked out, primarily in Giddhor &
Salkhua
Jamui district
Giddhor Jamui-Sadar Salkhua
Vaccineav
ailable
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared
session-wise vaccine distribution data for 4 months only ITSU - PHFI 43
SOURCE: Block stock registers
NA
NA
NA
NA
NA
Saharsa district
Simbi Bakhtiyarpur
Estimated percentage of sessions without vaccine

44. Measles: ~9% of sessions were stocked out, primarily in Giddhor,
Salkhua & Simbi Bakhtiyarpur
Jamui district
Giddhor Jamui-Sadar Salkhua
Vaccineavail
able
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA: For Jamui-Sadar, register for calendar year 2011 was locked and store-keeper did not have key; For Simbi Bakhtiyarpur, store-keeper shared
session-wise vaccine distribution data for 4 months only ITSU - PHFI 44
SOURCE: Block stock registers
NA
NA
NA
NA
NA
Saharsa district
Simbi Bakhtiyarpur
Estimated percentage of sessions without vaccine

45. BCG: 20-25% of sessions were stocked out across all districts
Estimated percentage of sessions without vaccine
Etah district Shrawasti district Allahabad district
Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon
NA NA NA NA
NA NA NA NA
NA NA NA NA
NA NA NA
NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
ITSU - PHFI 45
SOURCE: Block stock registers

46. DPT: No significant supply issue observed for DPT except in
Mauiama district (10-15%) Estimated percentage of sessions without vaccine
Etah district Shrawasti district Allahabad district
Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon
NA NA NA NA
NA NA NA NA
NA NA NA NA
NA NA NA
NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
ITSU - PHFI 46
SOURCE: Block stock registers

47. tOPV: 15-30% sessions were stocked out in Ikuana, Mauiama and
Koraon blocks Estimated percentage of sessions without vaccine
Etah district Shrawasti district Allahabad district
Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon
NA NA NA NA
NA NA NA NA
NA NA NA NA
NA NA NA
NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
ITSU - PHFI 47
SOURCE: Block stock registers

48. Measles: ~30% sessions were stocked out in Mauiama
Estimated percentage of sessions without vaccine
Etah district Shrawasti district Allahabad district
Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon
NA NA NA NA
NA NA NA NA
NA NA NA NA
NA NA NA
NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
ITSU - PHFI 48
SOURCE: Block stock registers

49. TT: ~10% sessions were stocked out in Mauiama
Estimated percentage of sessions without vaccine
Etah district Shrawasti district Allahabad district
Jalesar Aliganj Ikuana Hariharpurrani Mauiama Koraon
NA NA NA NA
NA NA NA NA
NA NA NA NA
NA NA NA
NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
NA NA NA
ITSU - PHFI 49
SOURCE: Block stock registers