Cold Chain Policy vs. Cold Hard Reality: Thinking Inside the Box

 

Recently, I was sitting with the Expanded Programme on Immunization (EPI) Manager, his senior staff, and technical assistance (TA) partners in an African country, discussing support for better visibility and analysis of immunization supply chain data. The EPI Manager was willing to listen, but wasn’t sure his team needed help in data analysis. As for visibility, that was already being addressed.

The technical advisor from one TA partner was demonstrating a dashboard of an online inventory management tool that is used to manage vaccine stocks in the central and regional cold stores, and which will eventually be deployed at lower levels. It’s a good tool–not perfect, but a solid piece of technology that provides visibility of some essential data for analysis and action.

One of the dashboards displayed volumetric data showing total cold room capacity against total volume used, with each antigen indicated as a percentage of total volume used. It is a nice piece of information; the data indicated that there was plenty of spare storage capacity in the cold chain at the central and regional levels.

As we discussed plans to deploy the online tool at the district level and even in facilities with internet connectivity, I asked if data was also collected on the other, non-EPI commodities that we know are often stored in the cold chain: some lab reagents, certain antiretroviral medicines, oxytocin, insulin, etc. The team seemed surprised by the question; “those aren’t our commodities,” the program logistician explained. True, I replied, but they do frequently take up room in the fridges (even if only in the short-term), so if it isn’t captured as part of inventory, then your volume data won’t give you the true picture of what percentage of capacity is really being used.

At this point, the EPI Manager cited the long-standing policy, first promoted by the World Health Organization (WHO) decades ago, that there should be nothing in the EPI fridges except vaccines. Period.

My response? A great idea and solid policy argument (notably to reduce the risk of vaccines being compromised), but impractical and probably unrealistic at the facility and even district level, given resource limitations and the increasing demand for fridge space for other priority health interventions. That’s the reality at the last mile, and everyone in the room knew it.

At the facility level, vaccine competes for space in refrigerators with other life-saving commodities, despite policies to store vaccines by themselves. How can program and facility managers use data to address this problem? Photo credit: Tindosolar. (2014).
At the facility level, vaccines competes for space in refrigerators with other life-saving commodities, despite policies to store vaccines by themselves. How can program and facility managers use data to better manage limited refrigerated space? Photo credit: Tindosolar. (2014).

Immunization programs are part of broader national health priorities that include diagnosing and treating HIV, treating post-partum hemorrhage to prevent maternal mortality, and, increasingly, treating diabetes and other non-communicable diseases. Some of the essential commodities for these priorities need room in the cold chain. And generally, the only fridge available at the primary health center “belongs” to the EPI program.

So what does a clinician do? Not treat diabetics? Not stock oxytocin? If a woman dies from preeclampsia or postpartum hemorrhage, her baby is at a much higher risk of dying from complications that cannot be addressed by vaccines.

I suggested to the EPI team that we want to know all of the stocks in the fridges at every level. To get that data, we would need a formal statement from the EPI program transmitted to clinicians acknowledging that the vaccines-only policy is ideal but not currently practical, and that we want them to report all commodities they are storing in their fridges or cold rooms, regardless of which program they belong to. They won’t be reprimanded for ignoring the policy, since they are doing what’s practical to provide the best possible care to their patients and clients. We’d also need to expand the list of commodities in the inventory management tool in order to accommodate these additional products and data.

Why do this? Because information is power. The only way to know what our true space availability and resource needs are is to collect stock data of everything taking up room in the fridge. Only then can we advocate for more resources. “But that’s for the facility staff to do; they need to ask their local authorities for more fridges,” replied the EPI logistician. “We are decentralized,” she said, “that’s where the resources are controlled.”

That might be, I said, but how effective do you see them being at advocating for more resources? We all know how under-resourced health facilities already are, and how disempowered frontline health care workers feel. That won’t change without strong support at the policymaking level — at the national level where budgets are developed or donors are mobilized before the funds or equipment are channeled to the local governments.

I explained that, for the EPI Manager to ensure that there is adequate room for vaccines in the cold chain, he needs to have data showing not only how much space is being used for vaccines but also for other commodities, by other programs. He needs to be able to tell his peers that their programs need to share the cost of cold chain capacity and maintenance, and how much that would cost based on how much space they are using. He can only do that if he has visibility into what is really going on throughout the supply chain, and only then if he has the people who know how to look at the data, understand what can be done with the data, and are able to analyze the data, he can ultimately determine where the problems are, and suggest solutions.

I could see that this resonated with the EPI Manager. The next day, I heard from my colleague that the EPI Manager had called him in the evening and said he wanted help to improve supply chain data visibility and to strengthen analysis among his team. He’d been given a taste of what can be done with data to address a major systemic problem, and he wanted more.

Note:

WHO and UNICEF issued a joint statement to provide guidance to country programs, excerpted here:

“WHO and UNICEF reiterate that it is permissible to use the EPI cold chain for the storage of appropriate temperature-sensitive pharmaceuticals. In particular, WHO and UNICEF recommend the following:
  • Integration and documentation. Countries and partners are urged to consider integrating temperature-sensitive health products, particularly oxytocin, into national EPI cold chains, where safe and feasible. They are also urged to document experiences as evidence for future policies and guidance. 
  • Safe storage and labeling. To keep non-vaccine products and vaccines and diluents safely distinct, leaders and health care workers must adopt solutions to quickly and clearly distinguish vaccines from other products, such as placing clear and unambiguous visual cues on external packaging.”