Vaccine Logistics and Supply Chain

Vaccines logistics and supply chain assessment
in Bihar, MP and UP
Diagnostic findings
November 2012
ITSU - PHFI
Content
Context & assessment design

Assessment results: Severity of stock-outs
Issues and root causes for stock-outs
Recommendations for the States
ITSU - PHFI 2
Context and objective of the vaccines supply chain assessment

Context
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:
Public Health Foundation of India (PHFI)

and the Ministry of Health & Family
Welfare have entered into an
of Understanding to
Memorandum
implement activities
to strengthen Indias
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
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
We selected 2-3 districts in each state for detailed visits

Regional warehouse
Bihar: Jamui & Saharsa districts
Madhya Pradesh: Guna & Tikamgarh districts
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
Uttar Pradesh: Agra, Shrawasti & Allahabad districts
Districts from
different regional
warehouses in the
State
SOURCE: Census 2011; DLHS-3
ITSU - PHFI
We visited all stores involved in supply chains of selected

districts/blocks
Bihar
Madhya Pradesh
Uttar Pradesh
Patna
Bhopal
Gwalior
Lucknow
Varanasi
Agra
Bhagalpur
Purnia
Faizabad
Allahabad
Jamui
Saharsa
Guna
Tikamgarh
Shravasti
Allahabad
Etah
State/ Regional
Divisional
District
Block
Jamui-Sadar
Giddhor
Salkhua
Simri Bakhtiyarpur
Aron
Beenaganj
Niwari
Jatara
Hariharpurrani
Ikauna
Koraon
Mauiama
Aliganj
Jalesar
ITSU - PHFI 5
We talked to ~200 persons across Centre, suppliers and states (1/2)

Centre
Bihar
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)
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
We talked to ~200 persons across Centre, suppliers and states (1/2)

Madhya 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
Uttar Pradesh
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
Allahabad district store)
Mechanic,
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
Allahabad division)
Ms Sonal Rai (DHNTC)
Dr U B Singh (MOIC, Suraon)
Mr Pankaj Singh
Officer, Suraon)
(Health
handler,
Education
Dr A K Sing (Block Medical Officer, Koraon PHC)

Mr Anurag Mishra (Cold-chain handler, Koraon
Mr Keshav Pandey (Cold-chain officer, Muaiyama)

Mr Pramesh Kumar (Health Education
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)
Officer, Muaiyama)
Prema Devi (LHV)
10 ANM/AWW/ASHAs
ITSU - PHFI 7
Content

ITSU - PHFI 8
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
noted
NA
* 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
Content

ITSU - PHFI 10
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
1. Irregular and sometimes short supply of vaccines at regional warehouses
A Uneven vaccine supply to regional store: Patna example

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

Bi-monthly supply of vaccine to Gwalior
Lakh doses; FY12
tOPV
BCG
TT
Hep-B
Assumptions
Ideal supply
calculated as total
supply in the year
to be distributed
Total supply
includes opening
stock in April
and delivery
from suppliers
and GMSDs
SOURCE: PHI
ITSU - PHFI 13
A Uneven vaccine supply to regional store: Agra example

Bi-monthly supply of vaccine to Agra
Lakh doses; FY12
tOPV
DPT
TT
Measles
Assumptions
Ideal supply
calculated as total
supply in the year
to be distributed
Total supply
includes opening
stock in April
and delivery
from suppliers
and GMSDs
SOURCE: PHI
ITSU - PHFI 14
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%
SOURCE: UIP Programme division
7%
ITSU - PHFI 15
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
63%
SOURCE: UIP Programme division; Stock registers at Agra, Lucknow and Gwalio
Agra
63%
77%
ITSU - PHFI 16
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
Examples
Instances of defined supply chain structure
Allahabad district takes JE and Hep-
Concept of safety/ buffer stock non known
Blocks in Guna re-order when 1
Vaccines are distributed on the basis
Observed in all 3 states
In some places, blocks distant from the
not being followed making demand

estimation difficult
to most people or not being implemented
B vaccines from Lucknow and all

other vaccines from Varanasi
week stock is remaining
of number of beneficiaries without

consideration of actual consumption/
current stock
district store delay pick-ups of vaccines

to optimize mobility fund
SOURCE: Interviews with supply chain personnel
ITSU - PHFI 17
3. High vaccine wastage at blocks and session sites
C Vaccines wastage is higher than assumed in demand estimation leading

to shortage of vaccines
Wastage observed from randomly selected sessions (Percent)
Key assumptions made

by Centre in annual
demand estimation
Bihar
(42 sessions)
Madhya Pradesh Uttar Pradesh

(~180 sessions)
(88 sessions)
UNICEF study
(5 states*, 2010)
Target population:
Number of
beneficiaries as
provided by State
Coverage as per
UNICEF Coverage
Evaluation Survey
Wastage: 25%
Buffer: 25%
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
4. Issues in cold-chain space and maintenance
D Issues in cold chain space and maintenance
Cold storage
capacity
Description
Examples
Insufficient cold storage capacity
Patna & Purnia have WIC capacity to store only
to store 2-3 months on vaccines

demand
one month requirement of vaccines of state and

division respectively
Bhagalpur has capacity to store only half

months tOPV requirement
Delay in
installation
Quality and
maintenance of
equipment
Equipment delivered to stores

but not installed
Frequent performance issues
with Haier equipment and Chint

stabilizers
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
Vaccine vans are not available at

Vaccine vans
all districts, or are very old
Shrawasti does not have a van

Tyres of Faizabad divisions van are damaged
Store
Store location
location
small,
inconvenient or inappropriate
and hence not functional

Allahabads van is very old (condemned on paper)
Lucknow syringes and vaccines stores are 2530km 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
D Insufficient WIC capacity at Patna

tOPV
DPT, TT & HepatitisB BCG & Measles
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
Cold storage capacity (actual and

required) Lakh vial
WIC
WIF
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
SOURCE: PHI Store-keeper; SIFHW; UIP Programme division
Patna has WIC capacity to store only one

months vaccine requirement (ideally should
be able to store up to 3 months requirement)
ITSU - PHFI 20
D Insufficient WIF capacity at Purnia and Bhagalpur

tOPV
DPT, TT & HepatitisB BCG & Measles
Key assumptions
Purnia has
PURNIA
division:
1 WIC with capacity of 1.21.5 lakh vial
1 WIF with capacity of 1.5-2
lakh vial
Storage capacity at Bhagalpur:
2 WIC with capacity of 22.5 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
BHAGALPUR
Storage capacity at Purnia
SOURCE: PHI Store-keeper; SIFHW; UIP Programme division
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
ITSU - PHFI 21
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
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
2011
Feb
Mar
Apr
May
Jun
Jul
BCG
17%
(63d)
tOPV
69%
(162d)
DPT
38%
(60d)
TT
Measles
AugSep
37%
(58d)
Oct
Nov
Dec
Jan
2012
46%
(80d)
31%
(72d)
54%
(162d)
8%
(54d)
84%
(85d)
16%
(53d)
100%
(80d)
* Time between date of issuing purchase order and deadline for supplying first lot
SOURCE: Procurement division
ITSU - PHFI 23
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
BCG
80%
(145d)
tOPV
100%
(150d)
DPT
46%
(240d)
TT
Measles
Feb
Mar
Apr
May
54%
(113d)
76%
(NA)
23%
(NA)
100%
(146d)
* Time between date of issuing purchase order and deadline for supplying first lot
ITSU - PHFI 24
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
ITSU - PHFI 25
B. Poor staffing and training of personnel involved in supply chain
2 Manpower & training issues

Examples
Lack of
appropriate
manpower
At various places in UP, mechanics and cold chain
handlers were staffed through contractual staff or

through attached (additional) duty and are not capable
of their responsibilities:
Lack technical knowledge (i.e. data to be recorded,
preventive maintenance, no temperature recording at
Lucknow)
No knowledge of funds/ TA/DA available
Second ANM not hired at large blocks
Regional Director, who

manages the divisional
warehouse, relies on
CMOs office for hiring of
support staff i.e. cold
chain handlers at
divisional warehouse. It
often gets de-prioritized
or delayed at CMO office
Of 7 mechanics in Bihar, only 1 is fully trained and

Lack of
training
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
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
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
SOURCE: UNICEF CES 2009 survey
primarily
through
ASHA/AWW
mobilisation
People used to
being serviced
closer home
due to polio?
ITSU - PHFI 28
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
SOURCE: Immunization handbook; Team analysis
Estimated (theoretical) wastage

Percent
Theoretical wastage would be higher, if the

guideline about a compulsory session every month
at AWC is also factored in
ITSU - PHFI 29
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

SOURCE: ANM Roster (Simbi Bakhtiyarpur)
PHC prepares actual schedule

ITSU - PHFI 30
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

SOURCE: ANM Roster (Simbi Bakhtiyarpur)
PHC prepares actual schedule

ITSU - PHFI 31
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
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

Examples
Insufficient
funds
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

Delay in
release
of funds
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
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/

district and PHC/CHC:
Annual: Rs 100,000
Monthly: Rs 8,333
Annual: Rs 100,000
Monthly: Rs 8,333
POL for vaccine delivery from Bhagalpur to PHC/CHC:

Number of blocks in the district
Monthly budget allocated for each block
POL for vaccine delivery from district to PHC/CHC
16
Rs 300
Rs 4,800
14
Rs 300
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
Banka: 7,200 vials
Bhagalpur: 10,756 vials
Jamui: 6,232 vials
Munger: 4,820 vials
Lakhisarai: 3,555 vials
60,612 vials
Araria: 9.954 vials
Katihar: 10,882 vials
Kishangarh: 5,998 vials
Madhepura: 7,075 vials
Purnnia: 11,614 vials
Saharsa: 6,731 vials
Supaul: 7,908 vials
30,000 vials (with diluents)

1.1*
1
30,000 vials (with diluents)

1.1*
1
250 km
Rs 6
Rs 3,000
307 km
Rs 6
Rs 3,000
> Rs 6,000
> Rs 11,000
Fund available
Fund required
Number of trips required

Capacity of a van: 30,000 vials (with diluents)
Number of trips for vaccines pick-up
Number of trips for syringes pick-up
Cost of one trip
Distance between division and Patna
Per km cost of van
Round-trip cost
POL for vaccine delivery from Patna to division required
* Assumes all vaccines are available at the time when van goes for pick-up
ITSU - PHFI 34
Content

ITSU - PHFI 35
Recommendations for Bihar

Key issues
Hire and train cold chain staff where required; training must include technical (including distribution on basis
1
Manpower &
training
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)
2 Lack of funds
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
3 Session planning
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
4 Cold chain
equipment
Cold chain in-charges be trained to record batch number of diluents, syringes received/distributed and vaccines
returned from outreach sessions
5 Data recording
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
ITSU - PHFI 36
Recommendations for Madhya Pradesh

Key issues
Manpower &
training
2 Lack of funds
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
ANMs conduct vaccination sessions at villages/sites as per frequency recommended by guidelines based
3 Session planning
on injection load
Identify space and build the Tikamgarh vaccine store in an appropriate area
4 Cold
space
storage
5 Data recording

Train ANMs to fill tally sheets and ensure compliance
ITSU - PHFI 37
Recommendations for UP
Key issues
Manpower &
training
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)
2 Lack of funds
Explore mobility support to ref mechanics and vaccine store keepers at district level for preventive
maintenance
3 Session planning
All villages are assigned to an ANM
ANMs conduct vaccination sessions at her villages as per frequency recommended by guidelines based
4 Cold chain
equipment
on injection load
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:
5 Data recording
ITSU - PHFI 38
Backups
ITSU - PHFI 39
BCG: ~7% of sessions were stocked out, primarily in Salkhua

Estimated percentage of sessions without vaccine
Giddhor
Jamui-Sadar
Saharsa district
Salkhua
Simbi Bakhtiyarpur
Vaccine
availabl
e
Jamui district
NA
NA
Vaccine available
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
tOPV: ~45% of sessions were stocked out, across all 4 blocks

Giddhor
Jamui district
Jamui-Sadar
Salkhua
Saharsa district
Simbi Bakhtiyarpur
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
ITSU - PHFI 41
DPT: ~16% of sessions were stocked out, primarily in Giddhor &
Jamui-Sadar
Saharsa district
Jamui district
Giddhor
Jamui-Sadar
Salkhua
Simbi Bakhtiyarpur
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
ITSU - PHFI 42
TT: ~10% of sessions were stocked out, primarily in Giddhor &
Salkhua
Jamui district
Jamui-Sadar
Salkhua
Vaccineav
ailable
Giddhor
Saharsa district
Simbi Bakhtiyarpur
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
ITSU - PHFI 43
Measles: ~9% of sessions were stocked out, primarily in Giddhor,
Salkhua & Simbi Bakhtiyarpur
Saharsa district
Jamui district
Jamui-Sadar
Salkhua
Vaccineavail
able
Giddhor
Simbi Bakhtiyarpur
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
NA
ITSU - PHFI 44
BCG: 20-25% of sessions were stocked out across all districts

Etah district
Jalesar
Aliganj
Shrawasti district
Allahabad district
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
DPT: No significant supply issue observed for DPT except in

Mauiama district (10-15%)
Etah district
Jalesar
Aliganj
Shrawasti district
Allahabad district
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
tOPV: 15-30% sessions were stocked out in Ikuana, Mauiama and

Koraon blocks
Etah district
Jalesar
Aliganj
Shrawasti district
Allahabad district
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
Measles: ~30% sessions were stocked out in Mauiama

Etah district
Jalesar
Aliganj
Shrawasti district
Allahabad district
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
TT: ~10% sessions were stocked out in Mauiama

Etah district
Jalesar
Aliganj
Shrawasti district
Allahabad district
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

Vaccine Logistics and Supply Chain

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Vaccine Logistics and Supply Chain

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Vaccines logistics and supply chain assessment

Context & assessment design

Context and objective of the vaccines supply chain assessment

Objectives of the assessment

Against this backdrop, ITSU team

Public Health Foundation of India (PHFI)

Regular supply of vaccines (diluents and

Preliminary diagnostics on supply chain

Understand if issues exist in regular

Understand issues in the end-to-end

We selected 2-3 districts in each state for detailed visits

Bihar: Jamui & Saharsa districts

Madhya Pradesh: Guna & Tikamgarh districts

poor and good

Uttar Pradesh: Agra, Shrawasti & Allahabad districts

SOURCE: Census 2011; DLHS-3

We visited all stores involved in supply chains of selected

We talked to ~200 persons across Centre, suppliers and states (1/2)

Dr Ajay Khera (DC, CH & Immunisation)

Mr S K Bahl (Director-Business Development, Serum Institute

Dr Hemant (Regional Team Leader

Mr Sanjay Kumar (Executive Director, NRHM, Bihar)

We talked to ~200 persons across Centre, suppliers and states (1/2)

Mr Krishangopal Sharma (Vaccine, Cold Chain and

Dr A K Sing (Block Medical Officer, Koraon PHC)

Mr Keshav Pandey (Cold-chain officer, Muaiyama)

Context & assessment design

10-15% sessions were stocked out of vaccines in Bihar & UP;

Context & assessment design

Five root-causes leading to supply chain issues

A. Irregular and sometimes

C. High vaccine wastage

caused by five key root-causes

1. Irregular and sometimes short supply of vaccines at regional warehouses

A Uneven vaccine supply to regional store: Patna example

1. Irregular and sometimes short supply of vaccines at regional warehouses

A Uneven vaccine supply to regional store: Gwalior example

1. Irregular and sometimes short supply of vaccines at regional warehouses

A Uneven vaccine supply to regional store: Agra example

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

Demand and supply of vaccines to Patna from suppliers

SOURCE: UIP Programme division

1. Irregular and sometimes short supply of vaccines at regional warehouses

Order placed and actual supply of Hep-B vaccine

2. Poor distribution practices followed by regional/ divisions/ districts

B Issues in supply chain & distribution practices in States

Instances of defined supply chain structure

Allahabad district takes JE and Hep-

Concept of safety/ buffer stock non known

Blocks in Guna re-order when 1

Vaccines are distributed on the basis

Observed in all 3 states

In some places, blocks distant from the

not being followed making demand

to most people or not being implemented

B vaccines from Lucknow and all

week stock is remaining

of number of beneficiaries without

district store delay pick-ups of vaccines

SOURCE: Interviews with supply chain personnel

3. High vaccine wastage at blocks and session sites

C Vaccines wastage is higher than assumed in demand estimation leading

Wastage observed from randomly selected sessions (Percent)