One of the first steps in redesigning a vaccine distribution system is to understand the existing bottlenecks, flaws and inefficiencies that prevent it from being functional. 

In Chad, for example, access to vaccines throughout the country was limited due to several factors:

• Delivery cycles were not synced, meaning delivery to the sub-national level would happen once every quarter and further delivery to the districts were happening every second month. This prevented the logistics team from building strong and consistent routines and made vaccine availability unclear
• Push and pull modes coexisted¹, sometimes at the same level and within the same area. This led to redundancy of vaccine deliveries and poor updates of stock management tools.
• There was no clear process, nor established budgets and procedures, to ensure vaccines were actually delivered and communication between the different levels was not effective.
• Finally, there wasn’t any kind of performance indicator for logistics either, excepted from the number of stockout days at the central level, which was easily manipulated.

Clarifying and enforcing a single vaccine delivery system for the whole country was therefore critical:

• Vaccines go through four steps from the central level down to the health centre
• Each sub-national depot is responsible for a set of districts, and each district is responsible for a set of health centres
• Push delivery is enforced down to district level every second month and progressively down to health centre every month.
• Processes and tools are standardised to prepare each delivery including delivery plan, payment lists, contracts with  external providers, needs assessments and delivered quantities calculators

A four-step, pyramidal vaccine delivery system facilitates access to all areas

PEV resources and contracted services are mobilised to ensure a push distribution every two months to districts

A four-step vaccine delivery system was used to support regular distribution to districts. Vaccines and other inputs were first packaged and prepared for transport, before being delivered using a combination of programme and rented vehicles. At the point of delivery, teams supervised the process and recorded storage and delivery information in tracking sheets.

The Acasus app is used to collect data on each delivery

Systems are only as good as those who work them. That is why the key to the success of the vaccine delivery was to ensure continuous training and improvement of the logisticians on the ground.

All logisticians have been equipped with a phone loaded with the Acasus app. It allows them to capture data from the field, included in zones deprived of the internet. Among data collected are stocked and delivered quantities of vaccines, availability and functionality of the cold chain, availability of vehicles and motorcycles. All reports are geolocated, which helps ensure that deliveries have indeed taken place.

The app also facilitates:

• The tracking of vaccine delivery day by day to identify issues from the ground (e.g. stuck vehicles during the rain seasons, breakdowns, stockouts, etc.)
• On-the-go training of district-level managers 
• Identification of improvement areas after the delivery

To do so, the data collected is leveraged in a comprehensive logistics report for each delivery and each sub-national depot. The reports are shared and discussed at the end of each delivery to identify key improvement actions.

Post-delivery reports allow quick identification of improvement areas as well as financial justification thanks to data geolocation

The reports focus on a limited number of indicators that summarise the state of the logistics in the country:

• Vaccines, inputs and vaccination cards availability at sub-national and district levels
• Functionality of cold chain at the district level
• Time to deliver compared to previously set standards

Each indicator is furthermore broken down for sub-national depot and analyses are available at the district level to identify areas of attention during the following delivery.

For example, districts where ILRs encounter functionality or temperature-tracking issues are clearly identified, together with a first diagnosis of the fault.

These reports would however be nothing if there were no routine to discuss them: the whole logistics crew gathers once every second month to review performance and identify key pragmatic actions that can be taken to improve delivery. Best practices are shared within the team. A good example of this is how Sarh sub-national depot shared how to spread near-shortage vaccines evenly between all districts thanks to careful successive planning. 

The introduction of regular distribution and digitised supervision has significantly improved the monitoring of operations and increased efficiency

In Chad, logistics redesign and continuous improvement routines dramatically improved the access of all districts to vaccines, inputs and vaccination cards:

• Stockouts have been divided by 2.5 over a year across antigens, inputs and cards
• Share of sufficiently-supplied districts have risen to ~90% for vaccines and 75% for vaccination cards