IntroductionCoping occurs when health system personnel must make additional, often undocumented efforts to compensate for existing system and management deficiencies. While such efforts may be done with good intentions, few studies evaluate the broader impact of coping.MethodsWe developed a computational simulation model of Bihar, India’s routine immunisation supply chain where coping (ie, making additional vaccine shipments above stated policy) occurs. We simulated the impact of coping by allowing extra trips to occur as needed up to one time per day and then limiting coping to two times per week and three times per month before completely eliminating coping.ResultsCoping as needed resulted in 3754 extra vaccine shipments over stated policy resulting in 56% total vaccine availability and INR 2.52 logistics cost per dose administered. Limiting vaccine shipments to two times per week reduced shipments by 1224 trips, resulting in a 7% vaccine availability decrease to 49% and an 8% logistics cost per dose administered increase to INR 2.73. Limiting shipments to three times per month reduced vaccine shipments by 2635 trips, which decreased vaccine availability by 19% to 37% and increased logistics costs per dose administered by 34% to INR 3.38. Completely eliminating coping further reduced shipments by 1119 trips, decreasing total vaccine availability an additional 24% to 13% and increasing logistics cost per dose administered by 169% to INR 9.08.ConclusionOur results show how coping can hide major system design deficiencies and how restricting coping can improve problem diagnosis and potentially lead to enhanced system design.
Background:
Effective immunization supply chain (iSC) is crucial for safe and timely transport of potent vaccines to the beneficiary. India’s iSC, with a network of ~29,000 cold chain points (CCP), measures its quality standards using the World Health Organization–United Nations International Children’s Emergency Fund (WHO–UNICEF) global tool on effective vaccine management (EVM). The two national EVM assessments (EVMA) were conducted in 2013 and 2018. This study helps to see the impact of policies and practices through EVMA in maintaining an efficient iSC for effective implementation of immunization program.
Materials and Methods:
We conducted a desk analysis using EVMA reports to summarize and compare the findings of the two studies. Cut-off of 80% was considered ideal for each category/criteria score.
Results:
Both EVMA 2013 and 2018 were conducted using Android-based global EVM tool, though across a wider sample of CCP. Maximum and minimum changes in scores were sub-national and lowest distribution (16% each) and national buffer stores (7%), respectively. Maximum and minimum improvements were seen in vaccine management (29%) and MIS and supportive functions (3%), respectively. The improvement was statistically significant for the overall scores (
P
= 0.02), primary (
P
= 0.01), subnational (
P
= 0.02), and lowest distribution stores (
P
= 0.03). Among the 36 recommendations of 2013 assessment, 78% and 22% were fully and partially implemented (or ongoing), respectively.
Conclusion:
Implementation of EVM recommendations has significantly led to improvement and continues to provide a benchmark for iSC and its processes. Follow-up assessments every 3–5 years can further help to evaluate iSC and ascertain the impact of recommendations.
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