INVESTING IN COLD CHAIN MAINTENANCE STAFF TO ENSURE THE AVAILABILITY OF VACCINES TO THE LAST MILE

Transcription

1 VIET NAM 1 CASE STUDY: VIET NAM INVESTING IN COLD CHAIN MAINTENANCE STAFF TO ENSURE THE AVAILABILITY OF VACCINES TO THE LAST MILE ABSTRACT From 2003 to 2012, Viet Nam and the Luxembourg Development Cooperation Agency collaborated to upgrade the immunization cold chain equipment (CCE) nationwide. This intervention has been implemented through a project named VIE/025, which enabled Viet Nam to strengthen Human Resources (HR) competencies for immunization CCE maintenance. The country implemented new approaches for HR development to support the redesigning of Viet Nam s immunization CCE maintenance. This project accomplished three goals: (1) influenced the political will to reform HR policy and plan for the establishment of new specialized positions (national, regional and Provincial Equipment Managers); (2) enabled local authorities to hire dedicated CCE maintenance personnel; and (3) outsourced highly specialized cold chain corrective maintenance staff to the private sector. BACKGROUND In recent years, Viet Nam (population 91.6 million) has experienced steady rates of economic growth and social development. The country is divided into six major geographical zones, including the Red River Delta, Northern midlands and mountain areas, the North Central and Central Coastal areas, Central Highlands, the South East, and the Mekong River Delta. The country is divided administratively into four regions, 63 provinces, 704 districts and

2 2 VIET NAM 11,138 communes. Three-quarters of this land is mountainous, which requires specific attention in regard to the public health supply chain, especially the cold chain of vaccines. From 2003 to 2012, the Vietnamese Government, along with the Luxembourg Development Cooperation Agency (LuxDev) and the National Expanded Program on Immunization (NEPI), decided to invest in immunization cold chain equipment (CCE). Through the project named VIE/025, the NEPI was empowered to procure, deliver and install refrigerators, and to redesign the CCE maintenance system. Viet Nam invested in the capacity of health workforces to manage corrective and preventive maintenance at all levels of the immunization network. It is organized through four regional collaborating institutes, 63 provincial preventive medicine centres (PPMC), 704 district preventive medicine centres and 11,200 commune health stations. VIET NAM S LEADERSHIP AND INVESTMENT IN COLD CHAIN MAINTENANCE Capacity building on maintenance Lux Development project. Photo: EPI Vietnam. In Viet Nam, decisions related to human resources for NEPI are made by each health facility. In 2017, about 12,000 health workers are assigned to health commodities supply chains, which include the immunization supply chains (isc). They are mostly medical doctors, pharmacists and health technicians. Although staff are assigned to the health supply chain and logistics, there are no specialized staff with a background in health supply chain management. The Ministry of Health provides the health staff with in-service training in supply chains with the support of development partners, ingos, and donors: WHO, UNICEF, USAID, PEPFAR, LuxDev, PATH, Chemonics and the Agence de Médicine Préventive (AMP). In 2010, Viet Nam s government supported the recruitment of specialized and qualified staff for CCE maintenance. This decision was part of the investment in Performance, Quality, Safety (PQS) cold chain equipment, including cold rooms and vaccine refrigerators, and was undertaken with the financial and technical support of LuxDev through the VIE/025 PROJECT aiming to strengthen the Expanded Program on Immunization (EPI) cold chain. Two essential components of the initiative were the following: 1) Equip Viet Nam with EPI cold chain equipment and redesign the EPI maintenance system: from 2007 to 2012, 5,630 vaccine refrigerators were deployed nationwide. In 2010, Viet Nam developed its EPI sustainable maintenance programme.

3 VIET NAM 3 2) Strengthen the capacity of health manpower in regard to preventive and corrective maintenance. In order to empower EPI manpower for CCE maintenance, a training master plan was developed to strengthen skills from national to communal levels. The training master plan included international training, face-to-face and on-the-job training, and supportive supervision. Furthermore, in 2010, the national EPI recommended creating the positions of National Equipment Manager (NEM), Regional Equipment Manager (REM) and Provincial Equipment Manager (PEM). Therefore, from 2007 to 2012, about 4,200 health staff were trained to use the newly procured CCE, in addition to 128 provincial and regional staff with essential technical and maintenance management skills required for the vaccine cold chain equipment management. Trainings focused on the installation, daily maintenance and basic repairs of cold chain equipment a. For NEM, REM and PEM, the training covered: TCW Photo: EPI Vietnam. Management duties and functions CCE management (CCEM) reporting Spare-parts ordering methods The utilization of a dedicated EPI CCEM software The process of building a sustainable maintenance system In 2017, the preventive and curative maintenance services are performed by Governmental staff (EPI staff, engineers and technicians). In addition to this staff, some curative maintenance services are outsourced to qualified contractors. Human resources development for robust CCE maintenance in Viet Nam Project VIE/025, which concluded in April 2012, was significant because it enabled decision makers to invest in specialized staff within the immunization supply chain. In 2010, when NEPI proposed to hire specialized professionals as NEM, REM and PEM, this was not mandatory but only recommended. Nowadays, to perform EPI CCE preventive maintenance and repairs, there are 11,977 health technicians and six engineers. a TCW3000, TFW800, RG50 refrigerator models.

4 4 VIET NAM The engineers and technicians are in charge of corrective maintenance. Otherwise, EPI staff is responsible for cold chain management including preventive maintenance. If required, more staff with a technical capacity can be hired from the private sector, and technical providers can be contracted on an as-needed basis. At the regional level, maintenance activities are managed by an REM. Repairs will be carried out by technical staff of the institutes. At the national level, the NEM coordinates, monitors and evaluates all activities related to equipment. The NEM must have good management skills, logistics experience and sound technical understanding. This is a full-time position. The NEM will combine the reports of all regions and prepare adequate statistics including equipment data like age, number of breakdowns, maintenance performance (i.e., downtime of equipment), cost of repairs, asset data (i.e., inventory), remaining value and stock of spares. EPI Staff for CCE maintenance 2016 In 2015, the Effective Vaccine Management assessment (EVMA) demonstrated that Viet Nam achieved or exceeded WHO s recommended target level of 80 per cent for each of the nine criteria measured under the EVMA. The average maintenance performance at the primary facilities was reported at 90 per cent. Provincial store performance for maintenance criteria was equally strong at 92 per cent average across the 13 provinces assessed. District level maintenance standards were also strong at 88 per cent. Also, the EVMA reported a very low percentage (4%) of installed equipment that was not functional. This is also possibly attributed to the procurement of high-quality equipment, the robust redesigned maintenance system and the specialized manpower.

5 VIET NAM 5 CHALLENGES OF EPI MAINTENANCE MANPOWER As new CCE is procured, maintenance staff must be capable of installing it and ensuring preventive and corrective maintenance. This calls for available skilled technicians, a sufficient spare parts budget, and equipment performance monitoring so as to prevent breakdowns and to repair CCE in a timely fashion. The immunization supply chain team was entrusted with redesigning the maintenance system, as well as procuring, delivering, installing and maintaining the CCE. However, during the project, the resources allocated to improve the capacity of health workers to carry out maintenance were considered insufficient by the NEPI. Likewise, Viet Nam s EPI faces the challenge of a high turnover in provincial, district and commune facilities; indeed, trained staff leave their maintenance responsibilities to another position within the preventive medicine or curative sectors. Thus, the investment in training was wasted. Vaccine storage at Hai Duong PPMC. Photo: Dorothy Leab. Also, it is difficult to document the existing maintenance trainings across the countries. Unfortunately, after the completion of the VIE/025 project, there is no longer a training master plan to systematically reinforce the capacity of maintenance staff. The NEPI does not manage the trainings, so there is no systematic track record of training activities in CCE maintenance across the countries. After the completion of the VIE/025 project, the NEPI has continued to provide regional and provincial levels with technical learning materials, guidelines and Standard Operating Procedures (SOPs). Because of the decentralization of the health system, each health structure is responsible for assessing training needs, delivering training and supervising the work performance. The challenge of the cascade training model is that there is a need for fidelity, or the faithful replication of training. In other words, there is no evidence demonstrating that the quality of the CCE maintenance training has been upheld when the training is replicated at the lower levels. Additionally, EPI reviews and assessments highlight the low performance of the health workforce in some health facilities. Indeed, despite the reported high level of maintenance standards, a number of weaknesses were observed during site assessments. Some cases of refrigerators that were not adequately defrosted and the absence of lubrication for refrigerator hinges were observed. Similar to the training system, the supervision is also top-down, flowing from national to lower levels. However, supervision is inconsistently performed due to human and logistical limitations and the overlapping of supervisory activities.

6 6 VIET NAM LESSONS LEARNED Vaccine storage at Thanh Ha DPMC. Photo: Dorothy Leab. Dao Thi Hoi, Pharmacist at Thanh Ha DPMC. Photo: Dorothy Leab. The project funded by LuxDev to equip Viet Nam with CCE and to train health workers on preventive and curative maintenance contributed to the equitable access to life-saving medicines, vaccines and other essential health supplies, with the right products, in the right quantities, under the right conditions, at the right time, in the right place and at the right cost. This initiative generated an optimal CCE maintenance system that relies on a combination of specialized and dedicated staff with the support of technical service providers (outsourcing). NEPI fostered the collaboration with local authorities and LuxDev to identify the need for maintenance staff and to create specialized positions for corrective maintenance at regional and provincial levels. It also engaged the district preventive medicine centres to hire dedicated staff in charge of daily maintenance and temperature monitoring. For example, in the Hai Duong Provincial Preventive Medicine Centre (North Region), the supply chain department includes seven staff in charge of vaccine supply chain functions. However, in this province, the staff is expected to take over and supervise the CCE maintenance of 12 districts, including 263 commune health stations. A possible solution to address the low number of technicians for corrective maintenance would be to foster task shifting. The delegation of simple repairs could be moved to EPI staff at lower levels, that is, district health centres. They would be tasked with identifying, isolating and rectifying faults with failed equipment. Hoi is in charge of CCE preventive maintenance at the Thanh Ha District under the Provincial Preventive Medicine Centre (PPMC) governance in Hai Duong. I am in charge of checking temperature, cleaning the equipment, and reporting when there is an issue. In case of equipment breakdowns and failures, I move the vaccines to the second refrigerator, and then I report to the Director, then the Director reports to the PPMC. I could not repair by myself but wish I could be trained for basic corrective maintenance.

7 VIET NAM 7 INNOVATIVE APPROACH FOR HUMAN RESOURCES DEVELOPMENT Through the VIE/025 project, Viet Nam introduced a new strategy for immunization supply chain human resources development that relies on a set of favorable factors: The national authority s leadership to upgrade CCE for equitable coverage across the country Government engagement to reform the regulation and create an environment that enables innovation. The insufficient CCE capacity for routine immunizations and the introduction of new vaccines was an opportunity for the EPI workforce to propose redesigning the CCE maintenance system. The political will to accordingly increase manpower s technical capacity because of a new maintenance system in place: Reinforcing skills of the existing EPI staff: based on a competency framework, staff were trained at all levels of the health system to use the new equipment and to undertake preventive maintenance. Creating specialized positions: the Government created new specialized positions in the health system. Health technicians and engineers were hired to conduct preventive and corrective maintenance at the beginning. Now both personnel are mainly in charge of corrective maintenance. Outsourcing the corrective maintenance to the private sector: the Government contracted and monitored the outsourced maintenance services of 5,000 CCE, the majority of which is located in the mountainous and hard-to-reach communes of the country. Under the contract, the CCE could be maintained simultaneously at all levels. During this time, the private companies also trained the EPI staff and technicians on basic corrective maintenance. - - The local ownership to secure local buy-ins and increase local capacity. Because the innovation has become fully self-sustaining, local ownership has been observed. For example, in Hai Dung Province, the PPMC s leader decided firstly to set up a dedicated team of nine staff to address immunization supply chains, and secondly to contract a local cold chain company for outsourcing complex corrective maintenance.

8 8 VIET NAM POTENTIAL APPLICATION This CCE maintenance capacity-building initiative could be implemented in a way to continuously train health workforces in maintenance skills. The NEPI developed its Learning Management System (LMS), which could be utilized to provide e-learning modules on CCE maintenance in regard to both preventive and basic corrective maintenance. This makes the related Standard of Procedures (SoPs) and guidance documents available at all levels of the health system. Indeed, in Viet Nam all health facilities are equipped with computers and Internet access at all levels of the health system, including commune health stations. Regarding the repairing of CCE, which is currently under the responsibility of the NEM and REM, task shifting could be an additional new human resources development approach. This would consist of empowering provincial maintenance teams to enable the timely repair of equipment failures and broken refrigerators, and therefore reducing outsourcing costs. In 2017, the NEPI leaders indicated the need to intensify human resources development for maintenance because of the CCE rehabilitation and expansion plan. This will be implemented by the Government with the support of the Global Alliance for Vaccine and Immunization (GAVI), which will co-finance 1,360 new refrigerators through the Cold Chain Equipment Optimization Platform (CCEOP). NEXT STEPS The introduction of new vaccines and the expansion of the immunization programme planned by Viet Nam in the five-year period suggests that the cold chain might require substantial upgrades, since the existing cold chain capacity may become a major bottleneck in implementing proposed strategies and reaching programme objectives. Expanding the immunization programme in turn increases the vaccine volume and thus will require significant improvements to the existing storage capacity to accommodate an increased volume of vaccines. For this reason, Viet Nam applied to the GAVI Cold Chain Equipment Optimization Platform (CCEOP). The objectives of the Viet Nam CCEOP proposal are to increase vaccine storage capacity for the introduction of new vaccines, to expand immunization services to isolated and poor areas, and to replace CCE that was procured during the VIE/025 Project ( ). In this context and through the opportunity of this

9 VIET NAM 9 new funding, Viet Nam might find innovative approaches to harmonize the performance of maintenance work at all levels through high-quality training, supportive supervision and coaching, and performance auditing. RELATED LINKS < < DraftStatement_5.2.pdf> REFERENCES Ministry of Health, Maintenance and Repair Strategy for Cold Chain Expansion and Replacement Plan, Ministry of Planning and Investment, Country Report: 15 years achieving the Viet Nam Millennium Development Goals, Patro, P. K., Cold Chain Management for Cold Chain Handlers,n.d. Umar, I. A, and B. Chawaguta B. Strengthening HR for SCM in the Immunization Supply Chain in Nigeria through Stakeholder Engagement, UNICEF and GAVI, Assessment of the Human Resources Landscape for Immunization Supply Chain Management, Viet Nam National Expanded Program on Immunization, Comprehensive Multiple-Year Plan (cmyp) for Extended Program on Immunization , WHO and UNICEF, Viet Nam Effective Vaccine Management Assessment, Zaffran, M. et al., The Imperative for Stronger Vaccine Supply and Logistics Systems, 2013.

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