The problem:

In Sub-Saharan Africa, over 30 million children under five are affected by Vaccine-Preventable Diseases (VPDs), causing around 500,000 deaths each year. Kenya, facing high child morbidity and mortality, reports 41 per 1,000 children dying from VPDs. Presently, according to KDHS2022 80% of children receive basic immunization, but when considering the full national schedule, coverage falls to 55%. HPV vaccine coverage is at 28%, up from 16% but still short of the goal. To tackle cervical cancer, Kenya must enhance systems to reach the 90% HPV vaccination target.

SERVICE DELIVERY

In Kenya, immunization is primarily provided at fixed posts complimented by outreaches, Periodic Intensification of Routine Immunization (PIRI) and Supplemental Immunization Activities (SIAs). Challenges include:

1.   High drop-out rates (under vaccination)

a.   Poor defaulter tracking mechanism. No standard way of tracing defaulters). This has led to: i.          14% (KHIS) are Zero Dose (ZD) children which may cause high VPDs burden.

ii.      23% of children missed measles vaccine in 2023.

iii.      11% of children who receive BGC missed OPV birth dose.

iv.      9% of children do not complete their full polio vaccination schedule; 5% missed HPV second dose in 2023.

v.      HPV vaccines coverage remains sub-optimal (37% by 2023) and varies sub-nationally.

vi.      Low COVID-19 coverage: COVID-19 is still a challenge and adversely affects older population and those with underlying medical conditions.

2.   Caregiver knowledge gap

i.       Low caregiver knowledge on scheduled vaccines [~53% coverage among caregivers with no education} ii.       Insufficient awareness and prevalent myths and misconceptions adversely affect HPV vaccination rates)

3.   Missed opportunities.

i.      Vaccine Scheduling

ii.      Health Care Workers (HCWs) knowledge on open vial policy. HCWs often prefer to schedule administration of multi-dose vaccines during low session sizes; this leads to missed opportunities.

4.   Vaccines wastage

i.      Wastage – sometimes due to multi-dose vaccine vials’; low session sizes lead to vaccines wastages, impacting more need of vaccines than expected.

Our work thus far

1.   Established the process of line listing defaulters using a new defaulters tracing register that was piloted and scaled nationally.

2.   For HPV, we have supported the MoH to leverage existing mechanisms to improve vaccination at the health facility by reducing missed opportunities. 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 34%. Beyond HPV, the strategy has been utilized to screen for COVID and RI. The screening tool has been scaled in two counties (Kisii and Kisumu and awaits national rollout).

3.    We are also supporting the NVIP in the routinization of COVID-19 vaccination.

2024 plans

1.   Improve utility and sustainability of defaulter tracing tool, continuous monitoring, and capacity building. 2. Support the MoH to scale immunization screening tool in pending facilities.

3.   Conduct implementation research (IR) aimed at improving coverage, reduced missed opportunities and vaccines wastage.

a.   IR on MR/YF swich from 10 to 5 dose vials

b.   IR on HPV integration into school health adolescents’ programs

COLD CHAIN AND SUPPLY CHAIN

a)    Supply Chain.

The vaccines supply chain is split into 4 tiers with the last tier being the service delivery point. The challenges that affect our supply chain are as follows:

1.   Inequitable Vaccine Distribution: Vaccine shortages still happen at different levels of the supply chain. Pentavalent vaccine is the measure of both access and utilization making it a necessary antigen at all service delivery point s however in 2023, 53.1% of all facilities reported a stockout of the vaccine.

2.   Change in Vaccine Attributes: As the vaccines program looks to make operations more eficient, new vaccine formulations are introduced. Rotavirus Vaccine went through this change globally switching from Rotarix to Rotavac vaccine. This vaccine has different attributes ie. A higher number of doses per vial, introduced an additional dose into the schedule and is transported from the manufacturer in a frozen state. This creates logistical challenges that further aggravate the stock shortages

3.   Poor Waste Management: The program did not have clear guidelines on disposal of waste. This leads to a lack of accountability depending on the type of waste. An example of this is the expired vaccines.

Our work thus far

1.   Created visibility on stock availability and stock runway: This was done through Chanjo ELMIS.

2.   Facilitated Last Mile Distribution (LMD) scaling from 3 initial counties to 7 counties – a 133% improvement. These was achieved through mentorship/support during County Integrated Development Plan (CIDP) writing and Health Products and Technologies Units (HPTUs) forum.

3.   Supported nationwide reverse logistics for the expired vaccines in all 47 counties

2024 plan

1.   Continue to scale up LMD through sustainable channels like (HPTU) in Counties.

2.   Support creation and dissemination of Standard Operating Procedures (SOPs) for waste in the program including electronic waste

3.   Research implementation: leverage the switch from 10 dose to 5 dose MR & YF vaccines to reduce wastage in the supply chain

b)    Cold Chain.

There has been significantly increased investment in cold chain coverage in the past 2 years, culminating in ongoing deployments in expansion of service delivery points' storage capacities; 7,850 immunising sites (95% of all immunising sites, out of 8,236 inventoried) currently possess cold-storage capacity on site. This is up from 82% in 2016, and 88% in 2021. However, thepending 5%still represents approximately 436 facilities, spread within all 47 counties, and accounting for a cumulative catchment population of 1.2m, including 36,000 live births per annum. This figure is set to grow, both in population and facility numbers, because of the constant expansion of service delivery points (there were 7,720 immunising sites in 2021, and 6,199 in 2016).

•    National position: these immunising sites are currently pending funded allocations for procurements in their coverage, with the completion of the cold chain equipment optimisation platform having targeted all previously inventoried facilities prior to 2021.

•     Sub-national position: Counties are yet to fully commit to self-procurement of vaccines cold chain equipment. This is reportedly a primary consequence of national and global interventions providing significant expansion to service delivery and storage points’ cold capacities

Prevailing gaps in the vaccines cold chain stand as:

Our work thus far

1.   Post-market assessment of new equipment, a longside centralised data-use of remote temperature, has reconciled equipment choice by quality and service/maintenance burden, streamlining and guiding future procurements and deployments.

2.   Assessed and confirmed viability of PHC products’ integration within vaccines cold chain and management system.

3.   Expansion of available data and capacity for decision-making via integration of all storage points countrywide with remote temperature monitoring device (RTMD) tracking at national and county levels.

2024 plan

1.   Revision and update of previous (2016-2021) cold chain rehabilitation plan for cold chain equipment optimalisation, as well as incorporation of decommissioning (disposal) and repair/management plans.

2.   Application and procurement of final phase of cold chain equipment optimisation platform (CCEOP) to address capacity and quality gaps at service delivery points.

3.   Further streamlining and value-addition of remote-data use amongst disparate manufacturers and suppliers.

4.   Incorporation of lessons learnt from Oxytocin-integration assessment with SRH elements.

DATA AND DATA USE

The vaccines program generates a magnitude of data from the immunizing facilities, however, there still exist gaps in the data collected and reported. While the program still boasts a high reporting rate of over 98% in 2023, the following challenges still affect the data & its use in the country

1.   Inaccurate data reported: Some of the services reported to have been issued have been found to be incorrect. This can be epitomized by a survey conducted in June 2023 where HPV doses reported to have been issued between January 2019 – Dec 2023 were found to have a variance of ~7000 doses between the KHIS and the physical client registers

2.   Incomplete reports: The country still has a challenge of incomplete reports where there is limited follow-up. A good example of this is Section B of the MOH 710 ledgers which track immunization logistics. This section tends to be ignored by the records oficers for some of the routine antigens i.e. HPV, Malaria & Rota. This affects allocation since we are not able to accurately estimate the wastage and as such incorrect forecasting that further exacerbate the stock shortages experienced

3.   Inaccurate population estimates. This primarily affects forecasting of vaccines. This is best exemplified by HPV where the target populations yield the wrong coverage making it impossible to track the antigen’s accurate performance in the country

4.   Inconsistent data from multiple sources tracking the same metric: Logistic information is tracked through Chanjo ELMIS and KHIS. These figures when compared do not tally and as such leakages in the reporting system are dificult to estimate.

Our work thus far:

1.   Consolidation of all vaccines data from the primary tools in the program into a central repository. The data has been consolidated into a repository that can create a better facility picture.

2.   Began the engagement with the directorate team regarding the transition of Chanjo ELMIS

3.   Promote data use culture in multiple counties using the Data review meetings. In 2023, 20/47 counties were able to hold quarterly review meetings involving all the relevant cadres. The country was also able to update the nationally disseminated data review template incorporating the new antigens into the schedule and addressing waste disposal as a feature of the program.

4.   Supported creation of the M&E framework that will guide monitoring and evaluation framework specific to the immunization program. This encompasses not only the key indicators tracked in the program but also defines the success / failure of country operations. This should help align some of the indicators that are incorrectly tracked on the KHIS repository e.g. the incorrect population estimates for HPV.

2024 Plans

1.   Promote the scale up of the data review meetings using a co-funded approach for their sustainability 2.    Complete the transition for the available tools like Chanjo ELMIS to the government to increase

3.   Identify newer methods of triangulation to identify unseen gaps in the Kenyan context

GAVI TRANSITION

Kenya entered the Accelerated Transition (AT) phase for Gavi support in January 2022. Kenya will remain eligible for Gavi support until 31 December 2029 and is expected to be fully self-financing in 2030. Projected co-financing costs are expected to increase from $10 m in 2023 to $38 m in 2029.Whereas Kenya has not defaulted on co-financing requirements, the disbursement of funds is sometimes delayed. To mitigate this, Kenya has relied on the Vaccine Independence Initiative (VII), a collaboration with UNICEF, for credit facilities, to ensure uninterrupted supply of vaccines, with the current VII ceiling being USD 4.5 million. With the expanding needs of the immunization program, the VII will not adequately meet this need.

Key challenges include inadequate financing of operations for immunization services and delays in release of funds by both levels of government.

Our work thus far:

1.   Supported NVIP in more accurately costing and quantifying vaccine requirements and operational needs for inclusion in the NVIP Strategy and for domestic resource mobilization

2.   FPP plan completed including costs breakdown for vaccine delivery

2024 plan:

1.   Develop a Transition Roadmap (costed immunization financial sustainability plan) to plan for thelong-termneeds of the immunization programme and outline milestones and outcomes that can be monitored.

2.   Increase the visibility and ownership of Transition and domestic resource allocations within Ministries (MoH, MoF) and counties.