Financing - Gavi Transition (GTR)

Problem statement:

Like most low and middle-income countries, Kenya is supported by donors to fill the gaps in the health system. This support ranges from technical and managerial assistance to finance the procurement of critical equipment, supplies, and activities for an equitable and sustainable health system. However, with Kenya's Gross National Income (GNI) per capita exceeding the current Gavi threshold of support of $1,730[1] GNI for three consecutive years, Kenya entered the accelerated phase of the Gavi transition in 2022 with the expectation of becoming fully self-financing by 2030[2]. To succeed in this transition, Kenya's immunization program must navigate several financial and programmatic risks to its sustainability.

Four major "shocks" could affect the country's ability to sustain high coverage and equity during a transition from Gavi support. These include the loss of:

1.      Gavi subsidies for vaccines, often the most significant cost driver of the immunization program,

2.      Gavi cash support for immunization system strengthening, which includes operational costs,

3.      Guaranteed access to Gavi vaccine prices and procurement channels, and

4.      Technical and managerial support; performance management incentives and support; and political support from Gavi or other partners.

If not adequately prepared, Kenya may lose the gains in strengthening immunization and the entire health system.

National: How to pay for the vaccines, especially with the approx. 15% yearly increase for vaccine procurement

How to increase Treasury visibility into the vaccine procurement process and ensure that the appropriation in aid reflects overall Gavi funding for vaccines and HSS

Sub-national: How counties manage their funds/financial independence from now on considering facility autonomy as donors transition

[1] https://www.gavi.org/sites/default/files/programmes-impact/gavi-eligibility-and-transition-policy.pdf

[2] Extended from 5 years to 8 years in transition policy

Our work thus far:

1.      Determined the process for increasing immunization funding allocation through the MTEF and helping the NVIP to cost better/quantify vaccine requirements, leading to an increase in immunization funding from $7M to $12M

2.      Conducted the mapping of funding flows and sources that led to a county successfully identifying and providing Ksh4m ($40k) for last-mile delivery from county funds

3.      Improved NVIP's capacity on market intelligence and product portfolio optimization, resulting in a PCV product switch that would yield a potential three-million dollar per year savings opportunity for the EPI post-transition

4.      Informed the Health Financing teams work on HF Financial Autonomy and governance guidelines and best practices documents

 Looking forward:

·        Improve the sustainability of immunization financing by mobilizing domestic resources for vaccine program operations and financial autonomy at the facility level through optimization of available funding pockets at both national and sub-national levels

o  Improved facility allocation and funding

·        Increase Gavi funding visibility and treasury commitment and allocation to immunization

o  Improved visibility of funding and utilization by the Treasury

·        Prioritize vaccines to be introduced both nationally and sub-nationally

·        Gavi transition plan developed that is well costed, realistic and includes projected costs for commodities and program operations (beyond the generic one that currently exists)

Service delivery

Vaccination is one of the most cost-effective interventions implemented to prevent diseases, especially among children, and is crucial to reducing infant and child morbidity and mortality. Therefore, Kenya endorsed the immunization agenda 2030 (ia2030) strategy to improve vaccination coverage inequity. To reach every district (RED), the strategy aimed to achieve the goal of 80% immunization coverage in all communities and 90% nationally. However, Kenya still falls short of these targets with 80% national coverage with a significant sub-national variation.

The latest demographic and health survey , DHS2022 demonstrated the need to optimize systems to improve immunization coverage at all levels if Kenya must achieve IA2030 goal. According to the report, 2% of children aged 12–23 months have received no vaccinations at all (Zero dose children).

The HPV vaccines coverage hit 58% in 2022 from 32% in 2021. This is still below the target of 90% coverage. To reduce cervical cancer burden, we must streamline and strengthen systems that improved HPV coverage to the target of 90%.

Our work thus far:

1.      Established the process for increasing immunization coverage through improving defaulter tracing workflows. Supported NVIP to devise defaulter tracing registers that enhance the defaulter tracing process. This will also reduce missed opportunity vaccination gaps.

2.      Optimized geospatial techniques to improve vaccine programming. Worked with MoH to improve facility catchment maps by digitizing them and increasing the mapping of vital points of interest that are useful for microplanning and vaccine campaigns. This also drew genuine appetite among the MOH colleagues for using GIS, which is expected to translate into more use cases in the future.

3.      Improved the MoH's capacity to continuously utilize their data through the data review processes by learning and re-learning better improvement mechanisms, improving data quality and completeness at all levels.

4.      For HPV, we have supported the MoH to leverage existing mechanisms to improve vaccination at the health facility. For example, we supported MoH in developing a screening tool that routinely identifies eligible girls at the health facility for vaccination. This process was determined to improve HPV coverage by at least 33%. Beyond HPV, the strategy has been utilized to screen for COVID and RI.

5.      Leveraging GIS technology, we have supported the MoH to map and link 26,000 schools with the nearest health facility. This will guide HPV microplanning, especially during school outreaches.

6.      We further continue to support the engagement of MoH with stakeholders that are vital to the success of HPV vaccination, i.e. improving engagement with the ministry of education, and religious leaders, among others. 

7.      We are also supporting the NVIP in the routinization of COVID-19 vaccination from service delivery to M&E.

 Looking forward:

1.      Improve utility and sustainability of defaulter tracing registers through capacity building and continuous monitoring

2.      Improve granular data culture use by leveraging data review sessions to optimize decision-making with data and enhance data quality and completeness.

3.      Prioritize health facility screening at all immunizing health facilities

4.      Improve the utility and scale of digital maps in all health facilities.

5.      Prioritize appropriate workflows that routinize COVID-19 vaccinations.

Supply Chain:

In order to ensure access and availability of vaccines to the last mile by averting shortage and or stock out of vaccines, the country’s immunization supply chain is organised across four levels:

·        1 –  National (Country Vaccines Store)

·        9 -   Regional Depots

·        306 - Sub- County stores

·        8200 + - Immunizing health facility (service delivery).

In order to create visibility on the movement of vaccines and ensure their equitable distribution, the program uses Chanjo.

As of December 2022:

 O·        The national stock out rate  was at 38.8% for traditional vaccines, 80% for GAVI supported Vaccines (26% excluding Rotavirus), and 22.8% HPV.

·        Turnaround time was for orders was at an average of 5 days at National, 1.78 days at regional level, 2 days at Sub- County Level .

·        Chanjo utilization rate was at average of 98% an improvement of 6% from 92% in the previous year. The increased utilization resulted in an increase of 196 users vs 185 in 2021. The total number of active users on Chanjo now stands at 916

Our work so far:

·        Supported 3 focus counties (Kwale, Kisii and Uasin Gishu) and 2 none focus counties (Laikipia and Bungoma) to include last mile distribution in their Annual Work Plan (AWP) and 3/5 counties (Kwale, Kisii and Laikipia) included it in their County Investment Development Plan (CIDP).

·        In collaboration with the counties, we leveraged on existing local resources (Services Delivery Partners) provided Technical Assistance (TA) to 10 non-focus counties on integrated Immunization data review meetings.

·        Supported NVIP in holding the first ever national data review meeting that included all 47 counties.

·        In light of capacity building MOH towards Chanjo handing over, collaborated with NVIP and 8/9 regional managers in sensitization/ training of 38/47 counties and over 150 users on new chanjo modules including Cold Chain. Involved regional managers in monthly chanjo utilization analysis they led the discussions with counties/sub-counties.

·        Supported NVIP and Department of Health Products (DHPT) waste disposal committee and in collaboration with Afya Ugavi, in compiling and analysing expired vaccines across the country with special focus COVID -19 vaccines. Supported the developed of vaccines expiry tracker.

·        In light of inclusion of Pharmacists in the immunization, collaborated with UNICEF and NVIP in sensitizing all 47 county pharmacists on immunization supply chain and collaborated with them on identification of functional incinerators in light of identification of future waste disposal sites.

·        Showcased our work at GHSC summit and CPHIA.

Looking Forward:

·        Offer TA to both NVIP & counties on best approaches on Last Mile distribution implementation.

·        Collaborate with key IPS & Donor organizations in empowering counties towards co-financing of key supply chain immunization activities such as DRM and vaccines re-distribution.

·        Continue supporting NVIP in analysing and usage of chanjo data for decision making with focus on procurement, forecasting & Quantification, distribution, and support service delivery.

·        Collaborating with UNICEF, in capacity building and inclusion of pharmacists in the immunization space through waste management, commodity management and AEFI monitoring/reporting.

·        Work closely with National Waste management and disposal committee led by DHPT & NVIP in disposal of expired vaccines and continuous monitoring and management. 

Data & data use

The targeted national immunization coverage for the country for all antigens in the routine schedule is 90% but as a country, we have stagnated at 83% (see fig 1). This number drops to 58% once you incorporate the few antigens that were stocked out over 2021 and 2021. WHO specifies the 6 rights of vaccine administration as the right product, at the right time, in the right quantity, to the right person at the right place while in the right condition. This is only achievable through consistent review of the data available leading to a consistent feedback process by the program. The vaccine program primarily collects all its logistic data through Chanjo ELMIS.

 Current data completeness on KHIS

 Our work thus far:

1.      Supported NVIP in scaling up the primary logistics management tool, Chanjo ELMIS to 98% nationwide. Higher system usage results in more accurate forecasting and a reduction in the number of stockouts.

2.      Facilitated and assisted NVIP in the inclusion of revised tools into KHIS. This way all commodities can be effectively planned and forecasted.

3.      Supported NVIP in the decentralization of vaccine distribution centers in Tana River County using geospatial analysis to establish the areas with the greatest impact.

4.      Provide TA for NVIP during routine vaccine distributions based on available consumption and logistical data. This also includes route optimization for the counties doing last-mile distribution

5.      Implementation of new modules on Chanjo ELMIS that facilitate continuous learning and onboarding for changing staff.

6.      Training the regional level users as system administrators further drove the widespread adoption of Chanjo ELMIS

7.      Increasing the visibility of GIS mapping techniques by hosting the QGIS maps on Chanjo as well as providing the program with complete shape files for the incomplete locations

8.      Increasing visibility of vaccine program data through creation of integrated immunization dashboards combining data from different source including the digital microplans. These dashboards are used to drive the discussions at the national level through the national logistics working group

9.      Integrating the Chanjo ELMIS system with the primary source of health data in the country, KHIS. This provided an additional level 

Looking forward:

1.      In collaboration with NVIP, working to integrate all immunization data through a shared repository (Kenvip). This has provided visibility on data collection systems that were previously unavailable due to their proprietary nature

2.      Incorporate digital maps into the existing platforms (KHIS and Chanjo) in order to scale the use of spatial analysis. 

3.      Leveraging AI and advanced data science techniques to drive different methods of vaccine distribution and allocation of related resources

4.   Leveraging AI and Machine learning to assess and drive the improvement of data collected by the program. The current statistics on completion are as shown below

5.      Increasing speed of delivery through sharing the proprietary codebase of Chanjo ELMIS to the greater digital health community. This way, collective development can be adopted by any other countries interested in scaling an existing ELMIS system

6.      Incorporate the digital health practitioners within the ministry in the development process and move the hosting of the ELMIS system to the government servers. This will ensure sustainability of the system as well as adhering to the national data protection act of 2018.

Cold Chain for public health

Problem statement

There is evidence of poor-quality Oxytocin, particularly resulting from storage and handling methods, in many LMICs. As with vaccines, when Oxytocin is not of sufficient quality, it will rapidly degrade, becoming ineffective. As such, effective temperature management is key in ensuring potency, with the recommendation for storage and transport at temperatures not outside the limits of 2°C - 8°C. While preliminary studies show that Oxytocin can tolerate freeze-thaw cycles, data on long-term exposure to freezing temperatures is unavailable, and thus freezing Oxytocin (<2°C) should be avoided.

A March 2016 WHO systematic review reported widespread occurrences of Oxytocin not meeting quality assurance standards; of 559 samples collected across 15 LMICs (including Kenya), unacceptable Oxytocin content was found in 36% of tested samples. 60% of samples from LMICs in Africa was inadequate according to QA standards.

The characteristics of Oxytocin storage, and similarities to vaccine handling, provide a key opportunity for integration of their storage and management within the vaccines cold chain. Past and ongoing expansions to the country’s vaccine storage volumes at all levels similarly enhance the capacity for integration; vaccines cold chain equipment at sub-county level had an average capacity utilisation of 18% (January 2023), thus allowing for significant excess capacity for storage of Oxytocin. Towards closing the gap in temperature-damage to Oxytocin:

·        Oxytocin should be stored in the same temperatures as vaccines.

·        With the expanded vaccine cold chain, the country has excess capacity of up to 80% in vaccine CCE.

·        We aim to integrate Oxytocin storage into the vaccine CCE and expand its availability to all facilities offering maternity services.

·        For a start CHAI is proposing to support development of policy to facilitate and implement integration, developing SOPs and tools to facilitate integration.

·        Develop a scale-up plan to ramp up availability of Oxytocin countrywide, as required to avert the unnecessary death of mothers.

Our work thus far.

1.      Storage volume expansion: with significant (and ongoing) investment directed towards the expansion of the country’s CC capacity, excess storage capacity is available at storage levels of the supply chain (sub-county stores and higher), with the service delivery points on track for similar expansion by 2026.

2.      Technical capacity improvement: Since 2019, county medical technical staff have been provided with knowledge capacity expansion on the public health system, with sensitisation on asset inventorying, management, and procurement, in addition to standard technical management skills, ensuring a base upon which equipment viability, and thus product potency, can be maintained and ensured.

3.      Streamlining of monitoring and reporting structures; technical staff at national and county level have been provided with effective platforms for asset management, and visibility into the supply chain, via online tools for inventorying, remote temperature visibility, and event escalation.

Looking forward

1.      Integration of Oxytocin and other temperature sensitive products within cold storage capacity, availing its effective, timely and efficient application for PPH prevention and treatment.

2.      Improvements to the CCE capacity utilisation resulting from storage integration; this rationalises equipment procurement and cuts on the financial burden of procurement of parallel storage equipment and systems.

3.      Standardisation of operating procedures for storage of vaccines and Oxytocin, with recommendations for further effective utilisation of CC capacity.

4.      Scale-up of integrated cold chain temperature monitoring and control, including further streamlining of reporting structures to improve data for decision making.