EFTA01072417

RI strategic initiative orking Retreat Pre-reads/handouts I BILLetMELINDA GATESfradad- 1 EFTA01072417 RI Retreat agenda CI= 11154:45 a amain( evattabIo 540630 fro Welcome. overview or the day and contend VIO Mitchell 41304, 10 an, Introchralon to 'WON a' strategy refresh process John *IWO How RI lean gallon the soon of thalr program • One ortvotnol deInnon MItchMI and Malt Manton 4146-104) am moo (Mate non may cosh** Mallon of RI • Dissamiga.MIOch toads me mai catIcal la tons/di Fstaloj7 10:30410)am Brag How RI Ste Into founctabon's Melon for WHAM • Moore ttol Ponoon tootkm and obi Matt Hansen and Molly 11.00.120)pm natuuom Maw Ctrs RI anatla prograMgOals of (1004010 IMml AbblULZOI4 enhIVCOTVOS to RI ca/0 twee a trzroknmMw moor, 12:0012:4S pm Mach RI currant and future pnoblVr. klenlincation • Manley MOW gaps that Oolong* louniatIon ablIM 10 reel gods Core team My I 00 0)" 12:45.2:30pen • °mow= hch Spa sooti4 be 10P pn00y IV he glotol comely-0y 10 Strategy oddrem, Thy 23043/0 an Ore* WIMAII tlW leunceselon could and should engage Whallit team NS rowdfrom fr-may 100430 ph • woo am C moose.] Rots tor to 5.10. 25 'MU Talk VloMllonMi and Skye Gilbert • QYuMpr Mimeo IVCci0 fink tho kordotoo Provo/ engem. • RrM'Olo•m GeMaW b-ndalloo ammo:mom 416620 ph Recap al the day and not slope VI* Mitchel 2 2 EFTA01072418 RI team charter EFTA01072419 Project Charter (I) Team Name Routine Immunization Steering Group: Global Development Program The goals of the RI Steering Group are as follows: - Develop routine immunization strategy; Work Group Goal - Identify resources that can be employed toward RI goals (potential partners, catalytic funding, voice); — Identify strategic opportunities for future RI Investments; — Monitor initial implementation of RI strategic initiatives. Strong routine immunization systems are the core of our Vaccine Delivery goals (as listed on the ScorecardI: — Eradicate Polio — Prevent re-emergence of polio from either wild or vaccine-derived viruses GD Goal this effort — Reduce measles morbidity and mortality (from 2000-2008, 2/3 of reduction in measles mortality due to RI' relates to — Save 6.0M lives in 69 high burden countries over 2010-2019 with currently available (DTP Measles, Nib, pneumo, rota) and new vaccines (malaria) — Reach 90% of the children n the poorest countries with sustained coverage of vaccines nationally and no district <80%. — Achieve the DoV effort. Work Group Steve Landry Work Group Lead: Violaine Mitchell Executive Sponsor Acting DD, RI Time Frame Eleven Months: February 1, 2012 — December 31, 2012 Updated on April 30, 2012; and August 31, 2012 4 EFTA01072420 Project Charter (II) Opportunity Ratemen& • Wattehraa twine an . pa, .1 ratan.. rerbdtv reciartvebtad wt., w fre,entall, 015215r. • WmManRrwnru,rn-unuuo+evRrlbwlxnnLaMGaWrUl4lryvrytlnmuyanohteunnnavllorlof role 414.1401, rif e 'ha to0r an vier. end Ilan pixy ity ljart.K.Jalve w1o+r0✓nc 02..ntrat end thaw within kn[atashed traliMs9.0,2 • yrient routine Demtnitabe WAtera.122 46O A. Attest!, e1,2.222. e)she.lit ma. Mum wat th•cath new nbeduchen • $0.011.:1utite ~ere Pelovn.zwe apinst Mute measse, oabreaa. sudi 'WOW t•PtAeKed a Justification 2010.2011. 4,2 vMl rare the way lor <imago. • 11 e ...pt., that e• .42Fontly sgintsunt Inancul ennerliferfeumlawne natµ taxad pole on.ohcalsen rif Summary ranvottthelrtr0'Ja11M.Mh101.2011101~ NittConite45)341., Pea> «20<et JCIMOty On, WX2et $.2521.1 Ito GAV1 • len,ntaben alw•Oalorrn up.n whaho11,e manna and c2d11 Hath trUnantnnt may tárd.rband.11,ts cen1212utárs cut halal gash • 1N>er>HOhaWnNMl5ppM11tsirorOtO,tlrSW?em>6trORa, ImlmintOmOMhatemynteUMxatxelnr nun,/ cc...num.:tom loch A, Ip.ct. to With 20111 • lbw le,datsen Nearer, ettantrehonath bur pc teen mi. as lahlrary 4 4444444 Ette.nt the *fiat GAM Scud-nil V20«, ,N220 2.11.11«.212.2»tr, .1.201htfe..22.141b2C.mentrt• As áent(Ore. • A anlega.cocedruhnl•pwait..to wan,' snmankra un bet (*Wan nr-enuagra our 'ninon • 02 4,21,^1.2. 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StItage.0.2.a.41ereili te intustallafte EFTA01072421 Project Charter (III) >fcctesta • Articulate RI goals — Within global context — Specific to the foundation — Specific to key geographies • Mmdmize RI resources Objectives — Identify key partner strengths — SUategiae as to potential external partnerships — Coordinate with other Internal efforts • Outline Strategic Initiative In RI — Identi Investments • Ultimately, to achieve the new DoV goals Success Measures • Shorter-term Increase in RI coverage in key geographies fic success measures 7B13 on a initiative basis 6 EFTA01072422 Project Charter (IV) a • RI leans nt.,,,, s .. Voters* Mitchell Man Hanson Core Steering Group Rap Rao members and their Molly Abbrunese s Pr/ Division • INDIA TEAM Devendra Mandan • ()then IN) in-country prese • None Steering Group Memberare expected to coordinate across the foundation Gobal Health teams, and vitth Codaboration with the Gbbal Development ou as appropriate. other foundation terns (CD &FM • F MOH In key countries Partite • Bilateral Donors, such as: USAID. UK/DrID. and Norway • Other Partners: GAVI Secretariat, UNICEF, WHO. World Bank • Violaine Mitchell, Acting DD for RI, will serve as the key contact person for FMOMs in Role of team key geographies members / staff • Steering Group Members will advise the Acting DD of new opportunities and topics under mann ing sPecifIc discussion with partners activities with • Acting DD and RI Program Officer(s) will be available to pm/support these discussions with MOH internal staff and external partners, as requested or appropriate , ,,.,,,,,,,,,,, o. <.,,,,..., i 7 EFTA01072423 Project Charter (V) Proposed Timeline and Deliverables: 1 year High-level Milestones for Year One of Routine Immunization Steering Group Date Complete Review and adoption of RI Steering Group Charter 2/01/2012 Development of Year One Work Plan 2/01/2012 Meetings with External Advisors 06/2012, 09/2012 Development of Metrics for Project See Scorecard Initiation of 3 RI Emblematic Grants Ql, Q2 2012 8 EFTA01072424 Project Charter (VI) IVOPOINIA010tilt0 R0k$10414$0300001Ple Cieung 6, 04 StEns-te - Chris Oa% Presibtm.Glabal DeallOPmait Po Steed, . Group - YbOlailt MOIChtll Ilan( INA IlVataltilMatinbielSen C4ocinate..1•44tiltez rant Gcts..aht T.dr.crtnpv.ans.nomtwanne.ntKeeColiltillnin..nra, bArylarrm emanil ,Cetro.ctrim Mx",,,—. :••••• whi est ro iron 11.1, 'dont law datnn:%•11•St-tarca,rm, Ludzan.in COw ns/I 'Am •cepaetneart ,,,,, • (WC., C'PAI Maio:am vs. ' ow C.Idil4020, B1 ton, in, trolAid, Ins Slitnig Cron, (44rdelatet.. pmt D.....itneie 4-oittipOlect :may. Ott, .11.1igatAlta• IA:Mtn cliabn't.........ve.. rd'S•11:1¢1.•InSevain ra •ntry *eau Imorvne .C.ron.t..,.mkt,. wt. entathid %Firm{ &imp age.an. Omen. slew lit. et It•I•gir Ifnoun rent as to'inurscnoldianiannyen0 ram' •.C.-.) oxID•unto.r. atop , .. rig ntrek rent Iran Stli Gnu: .p.4:nutz cline:we:n:4. a$ Kay.. ICIN:01P140 Ca ha.. a; ..... rt ans eh gr man ProgramOf/kir nosiorling bSt.11,10.u. p ird plain On.n,..* oC, OfCalntugc pWel(WINN/ 'not-% ityors .. , r., navy ups(et •tgot af.lyits 'Moto Presort/ St narn(uvelo.p,00. plse cats itowasitts B4000 wn..ten. rde.artt4n9.t• (0.01.”,514W00/(01. 45,41.0 9 EFTA01072425 10 EFTA01072426 Global Immunization 1980-2009 - DTP3 coverage 100 80 cn E 60 4.) 40 20 feeigg slgiwggeleigg ggiegg Global —American — Eastern Mediterranean —European —South East Asian — Western Padfle SwevYMOVNCEFixwiseatliVeon0,209.4.0y2M 11 EFTA01072427 DPT3 coverage levels in key geographies OTP3 covetage (a) 12 EFTA01072428 Trends in DTP3 Coverage in Nigeria, 1980 - 2010 EPI re-launched. EPI renamed NPI. UCI implemented made a paraslatal EPI initiated UCI 5$ end NPI 4NPHCDA 07 70 CO 50 Key 140 Afti, Nig I.WHO/ UNICEF 20 10 2. NICS 2010 a 1970 1975 1980 1985 1990 1995 2000 2005 2010 2015 ton Sone' 1 WHON/1020:40mol 0a 10/01/2010 ha. tmLappautigunanmni.”1.:tnoltocres.012221/enn- 2.N800.1111 Immuntalen paler Survey MUGS). 2010. MOH and teHODA EFTA01072429 Coverage and risk comparison of DTP3 shows that hardest to reach are those most in need of intervention Compared coverage rates and risk by wealth quintile 100% icrft • Using child mortality rates (1- ■ a 10% 59 months) as a proxy for risk • of vaccine preventable disease • • Each line represents a single country. with individual points for each wealth quintile For most vaccines and most countries, lower wealth quintiles have higher mortality risks and lower coverage rates — however the pattern differs between countries o a 100 I50 20) • Assuming infections targeted Vida 50V) irCenno by new vaccines are distributed similarly to child Each Nom represents one county. ladWdual point, miasma each wealth quintile mortality. existing programs may miss substantial fraction of high risk children =IIIMMEMe tad Four graphs of coverage by quintile for all countries, recent year. BCG, DPT2, Polio 2, Measles. Like tableau lower left, but only most recent year 14 EFTA01072430 Case-study of impact of equitable distribution with Rotavirus Estimated distributional effects of totavirus vx Rotavirus mortality and coverage curves mortality reduction and cost effectiveness NM. mi.*. caul Mown. I.......1. anew. tawdry linos nes Nan PpLinna SS *NOS as wand ~nal non,. Mame .P.A4 MIMS VO3 la INS WM 4...~ M Car WI lille an 44.1 >754 Rent MO) IN • a in as 21•1 • 5. MS I an OS Mn 544 4/0 :MI PM )110 04 4.14 110m1 1e11. .01.11 In 2n ran.. Itei PM 147 249 MT TI 1414 pp 2M 251 PI MIS 14 00 I•15 2/1 )70 M IMO 00 10 Ill I Oa 121 Plemi PM Mn 10 10 aa is tie MOM ten I M ill 5740 Ma I SY i PO >at) ini I M I le I re, Well I N I 11 N4 MO 0le Me Me as MP UM no 1M sie IMO KM 215 SW ON et MY 2L •44 2n • • 1 It i• Pal. NM • an.. man. co ova Each lino represents a county: Individual points Innen miennlina coal 4•0 represent each wealth quintile • a+.. tim.4.7.40 newly ...no, Wen Coverage decreases and deaths from rotavirus tmeni• 444.4.644 Nan &NA retell Fa ; x.c • IMNIMOMMSYMMISMOT ny atilt lower wealth ant ---D=wir /MSC 15 EFTA01072431 Countries with DTP3 coverage below 70% 40 countries in 1990 37 countries in 2000 20 countries in 2009 © 2010 Bill & Melinda Gates Foundation 16 EFTA01072432 Demands on vaccine delivery systems are rising dramatically Demands on delivery systems are vowing dramatically Cumulus-4w nulae and volume q vorrines used An imam.- childhood Amenummlion [Myopia lalanket Rib 10000/0.11 OR KO 101,00.X.1 Total Valw, OW USD) I1 1012 1954 1986 191% 1990 19W II% In 19% 200) 1001 133. 1006 MOS 1010 IOW 20% Mintz %MSS.Caw Onl Swim Welds,/ lelfsels Odom?:el ant aloleesimmallaw. 17 EFTA01072433 Health worker shortfall is affecting immunization coverage Immunization coverage improves with increased density of vaccinators 90 - 80 - O-4 70 - a) 60 - - O 0 30 - ••• Ilurrenmearc:e3 to -• 20 - Doclorg NJIOS 10 - 0 10 100 Density (per 100 000) WHO esthrolas VatInns then z . MISICOrOpOleeekeelli:traic,-,- rases. end RiclatgOOPer100,cr,. 0:0111400 a dal tiberlaCt, 18 EFTA01072434 57 countries are facing a critical shortage of health workers ft 4 i ir val 1 l c eh 1 - Abt ti r alli y Canines tort Crital 'Notate of health torten Countries...ghoul cnbcal shortage <IMAM wodtn Reaching target levels of health worker availability would roquir 2.4 million additional health workers in critical countries 19 EFTA01072435 Tech wrovelc, Many technological innovations could improve RI supply-chain, but need to be effectively implemented/deployed Temperature monitoring innovations: e.g. VVIA. freeze-tags. 30-day temperature recorders IT systems innovations HERMES: supply-chain modeling tool lutuwa diva..• az i s EVM+: next generation EVM toc 42)::"Zil eth IR,' RFID tags: inventory monitoring too' re:. et...44es S Others... • 20 EFTA01072436 New touchpoints for vaccination (e.g. schools) have been deployed effectively in developed world In developing world. greater proportion of Comparison of school-based versus health- out-of-school children can be a barrier to facility touchpoints in developed world school-based immunizations Coverage raon fat 3 deo:G.11) V of school alien:lance ICO UK swan relied as Ngh- atorellmata h '<boob s -7---- AV* UK anal USA eau • Mawr corforteowato noes UK 213 Fe I UK 4-18 Feteeth.° 0:1,70 CI US 3.1irti 40 32 UK 3 Ocoee USA 3 eases Pray Low Pray Law Panty Isar .00:01INAIMIO iffiX•040,116. 14.444.0W9Ity UK:HA/vaccine LISA:WV...wane dawn:demo", Sherpa Mrouell North Amence SubStoran SouthandYAW school' regutor hoavn Women EU Meta Asia Chennets, 21 EFTA01072437 Other services often integrated with routine immunization Health Facilities Integrating Services with Routine Immunization In 2007 RED evaluated countries) 0 OR POW) •CcadtN-133I Wiftn-fl I i€ h -1 Integrated service • The RI infrastructure provides a platform for the delivery of additional services during fixed and outreach vaccination sessions • In both fixed and outreach sessions. the services combined with immunization varied, even within the same country (see figure above) • Health facilities report that services are more frequently combined at fixed sites than during outreach sessions In addition to straining delivery system with new vaccines. health workers are also providing multitude of additional services with each interaction I 22 EFTA01072438 Our initial thinking on barriers to successful immunization 23 EFTA01072439 State of routine immunization today We have achieved significant Impact • In 2010. 109 million infants worldwide receive DTP3 vaccinations each year • 130 countries met the 2010 target of z90% national coverage of DTP3 • More than 2.5 million deaths are averted per year of children <5 years of age However, an unfinished agenda remains • In 2010. 19.3 million (-20%) children did not receive some or all of the routinely recommended childhood vaccines • DTP3 coverage was below 70% in 18 countries in 2010. only 59 countries (31%) achieved ≥80% coverage of DTP3 in every district • --2 million additional child deaths could be avoided if we can reach GIVS target of immunizing 90% of children < 5 years of age We cannot afford to be complacent in addressing these key gaps • RI coverage fell. or remained stagnant in 22 low-income countries between 2005 and 2009 • Hardest to reach children are those most in need of intervention and represent the most potential lives saved 24 EFTA01072440 Initial framework for thinking about components of routine immunization Data for decision•making For routine immunization to occur. three processes must be successful: • Demand: Individual must be present at the point of interaction where they can receive a vaccination • Snonly: The vaccine needs to anive at a designated point of i-iteraction where it can be administered to an individual • At the point of vaccination a health worker must actively identify an individual's vaccination needs and follow the right steps to administer and record the vaccination In addition, one enabler of routine immunization must be in place: • Data for decision-making must be collected, analyzed, and used. The data includes disease surveillance, coverage rates, and other metrics around the RI process 23 EFTA01072441 Demand barriers (I) Demand Barrier Rationale, evidence, assumptions il l EdUall1011 p y 111 Slalus. • Niemen with low educational ilaltr3 may have less aCals 10 eseciad orwooen information. as well as lesser degree of socio-economic (mothers. caregivers) independence. Nilsnate,' relates to decisimmialting power) • Evidence: Often correlated with chid health indicators. cited as risk factor for lack of vaconation Political banters • Chicken who he in conflict-affected areas. or who have recently migrated from those areas are less 'hely to be vaccinated. Reasons may range from lack of personal financial lemmas. lack a service delivery systems. and lack of trust in 'authority.' • Evidence: TBD Lack of caregiver education • Rationale: Some caregivers may not realize (or may not have been about vaccination told) linen to come back for subsequent doses. and villy* is Tech- important to do so nology • Evidence: Cutts S Eliellik (e.g. t0SURS of PaleiMan studyusing home' based education: study usng redesign c4 ot card to hilllight return dates and education on importance of full series) Lack of inkrmatico /Anti- • Rationale. May stem from misenformation: or from a lack of vaccine movements int:malice) regarding AtiFts • Caregivers may • Some indications that anti-vaccinahon movements are growing with Opera- choose not to have coverage rates increase as people see less evidence of trzEii. tions child vaccinated • Evidence: TBD Cultural / religious beliefs • Cultural or religious resistance to receiving vaccination, • Evidence: TBD 26 EFTA01072442 Demand barriers (II) Demand Barrier Rationale, evidence, assumptions IM= Geography • Distance to point of vaoariation is a border (often related to line and finance, but also in its own righl) • Some geographic areas. we 'off the grid' (e.g. urban slums). and not accounted for n a designated service delivery area • Evidence: Cuttstieild pacer; Walt Orensteinn and Stanley Flotiliin Lack of financial resources • Delivery system does not account fee the cost and opponunily cost of binreang to a vaccination of waiting, and of any 'Unofficial' charges • Evidence: TED Lack of rpm/van:on • If no other services are offered at the same silelsame lime. it not be perceived as weer the cost & time • Evidence:TED Opera Lack of btasernaliChld • Chidren been at home I without a skated birth attendant are les: tionS ll eallh Service UUizalion likely to be vaccinated Cont.) • This priori lack of service uttizadon. presumably for similar operational reasons. spits over into lack of senuse utlizaticei for imrnortirdtion • Evidence: TBD Poo service deivery • Missed opporkwities. whereby 'lockouts. concerns of wastage rhos no opening of a new multi-dose vial). or other cancellation of vaccination discourage completion of a series • Evidence: TBD Bad experience • Drepouts can also be caused by someone having a bad priori experience at a health censer - ride trealment by a healthcare worker. unexpected Sees. local vaccine ranchero, ex. • Evidence: TBD 27 EFTA01072443 Surveys in Nigeria and Ethiopia shows that majority of un- Demand vaccination driven by lack of awareness or willingness Total patient pool Main reasons C44•0 BY IIIIWN 1111/11 gram Compliance Total untunder vaccinated' • La:444i* • fee, ado .6140 • Post too fa. Lifer nearn A ratter for chid n04 • blew.. mc • Foordikluagte Clik wasobsent recemnp vaccine' : Own wok Seam • UnelatabAlvel • RAMS note • Lac* mamma • e3.4 04% et BO% 4, nib 69% • Nigeria size ofunAinder vaotinaied 31% 306 18% 12% e =1 WA (All vaccines? 100% ”- 02%rt i. 88% 47•-• 04% St% • Ohio& size ohm. 41Th. II Su, vactinslims 41% 23% 18% 18% WA (Measles vaccines) 1.4ajOnty of unrunder• Smni8cani source of VaCCII130011 unAmder vaccination 28 EFTA01072444 Mothers education appears to be a positive factor for immunization Coverage in Khartoum, Sudan Key findings on education from correlated to mothers education other studies • Generally. the studies reviewed suppore“ the conventional wisdom that education. schooV9 particularly mothers education, is a positive factor for immunization Primer/ • However, the relationship is not always dean and consistent Inforceoalalo • e.g. in one Kenya study fathers education correlated well with vaccination in urban areas and Sezenenr mothers education in rural areas • In Nigeria. educated people were less Unwise,• likely to immunize their children than illiterates 40 60 BO ICO % Coverage 29 EFTA01072445 Lack of information on vaccination presents a barrier Country examples • Liberia: Over 1/3 of mothers said they were not informed about the return date • 2008 EPI review in Benin found that one d the pincipal reasons for non-vaccination was mothers being unaware of the need to return or when or where to return • In Mozambique. 3/4 of health workers said they always write the return dates on the child's card, but only 1/4 of the cards actually had the return date written • However..-i Uganda. 80% of parents claimed that health staff advised them to retsn for more vaccinations • In one area of Bangladesh. with a 30% dropout rate. 63% of mothers claimed they were not informed about the time and place of EPI sessions 30 EFTA01072446 Case study: addressing demand in rural India has more Demand impact than addressing supply-issues only Note: This is a controversial issue( Immunization rates by type of immunization camp in rural India Key findings Fuly ;34 novas temente/ me mee room immunized 1%) •el+ dewed meoleaten nem epos Improving reliability of services so improves immunization rates by -3x. but adding small incentives improves 6.5x uptake of by -6.5x • Primary impact of incentive is to increase full compliance 30 Offering incentives proves to be more 20 cost effective than purely improving supply • Average cost 1child is actually lower when offering incentives - since daily 0 fixed cost (mainly health worker Control Reliable Incentives' + salary) is spread over more children camps only reliable camps Study indicates that size of incentive %coverage 6% 18% 39% does not matter beyond the fact that a positive incentive is offered Avg cost! 555.83 527.94 child However. coverage still remains very Note. CCTs • V TOD low despite interventions 31 EFTA01072447 Epidemiology of unimmunized child — access Impact of distance in Khartoum State. Sudan Impact of distance in Senegal lip Ici-clale irmnunizabon (%) Full imrriunizalica (%) 40 78 so ro 60 60 40 40 20 93 10 o ..— 0 WO ire 4 GO inns Atilt hire a GO mns Um wain i0 ims Welk awe a 30 32 EFTA01072448 Nigeria: Closer look at disparities by wealth quintile Vaccination coverage rates by Methods • 2003 and 2008 data wealth quintile: Nigeria DHS 2008, • Analyzed by region. wealth, children 12-23 months vulnerability (nutritional 100% status) and time 90% BOG • BCG. DPT1. DPT2. DPT3. 80% — OPTI Polio 0. Polio 1. Polio 2. >0% Polio 3. Measles 0012 00% - OPT, Table show coverage rates of Polo 0 40% different vaccines by wealth — Polo, Quintile 30% Polo 2 20% — Polo Key findings 10% Mooth•• • Children in poorer 0% households are less likely to Penegi Pvcrtc ‘1019 fbc/Ro linen< be vaccinated • Disparities in coverage for all vaccines 1 figure (most recent year) with multiple vaccines coverage rates by quintile (national) 33 EFTA01072449 Epidemiology of unimmunized child Demand Barriers Utilization difficulties: country examples Lack of motivation • In Dhaka. 21% of mothers in one study stated that immunizations were not necessary for thee children Previous use of health • Studies in West Africa. India. and Ecuador found that services families with a history of using health services for other reasons had a much higher chance of having their ch Jr vaccinated Poor service delivery • In Liberia. 30% of mothers commented on the inconvenience of long waiting times Bad experience • In Uganda. only a minority (13%) complained about being treated rudely or badly • After some mothers lose their immunizationThealth cards. they are scared to go back to the health centers for fear of being yelled at by the health staff. made to pay for a new card. and/or asked to return home for the forgotten card I saINIMMI 34 EFTA01072450 Epidemiology of unimmunized child: summary of major Demand determinants Major RIM Factors (secondary factors) ConespendingfrolnforcIng - Place of residence (rucal cistant front a health faddy) Insufficient facift es. truela:se selvicer..routreach. (family factor) restncledincorivenew servire hours (sernce factorS1 Poverty gamily Ham) Health marker attitudes and behavior. charges (official tad unaided (service factors) Mothers' education (family factor) Inthdficienthneffective IEC. engagement with commtably (Although mothers' education was commonly leaders and groups (service factors) associated viith ithiHren's immurization status. some studies found little or even a reverse correlation) Majer Causal Faders (primary factors) Cenuperbelna RaInferekia faders Bad experiences at health facittWoutreach. leadng to Health uerker &dudes and behavior. aide effects. stock fears. negative expectations. and lack of bust ((amity Calls (service factors) fader) Competing priorities (too busy) gamily Wei) Restridedfmconvenient hours. difficult access. unreliable serene, (service factors) Missed opportunities to immunize (sentry factor) Parents' altitudes and fears (e.g. to have sick chid immunized). although in most cases parents accept heath staffs recommendation Feardrumors (Ian* factor) Insufficienthnertedive IEC. engagement milk community leaders and groups (service factors) Lack of appreciation of ba.Oc benefit of vaccination InthdficienVnertedive IEC. engagement milk community ((amity factor) leaders and groups (service factors) Lack of understanding of need for multiple doses. when Poor health worker communication; insufficient/ and where to return. That immunization protects against ineffective IEC. engagement with community leaders and certain specific diseases (family factor) grows (service factors) 4>Nute• s volt!. 0tlel f won, I 35 EFTA01072451 Summary of papers reviewed shows a significant impact Demand can be achieved by addressing demand generation barriers COUrIlly (Reg Veile) 8de< deStriptiOn OutcomeS brarohn 19911191 Moss .90:nation compagro: stainnary anke ara Ftogu1atmoela.63.3% niobto ~ca Wite or eritioul bW sakmonialon as an 1~ raca," carrpapla: 77.1% ereceelbe Solony vatm ta rnerow.94.1% ',lobb vatn bod inconat 99.3% 1201 Ota~ kame.~rem:Ses (Frør b Semi Men*, v.:floa 935-19 elias ~ul anta)) Bota (I% ~oase) 'noble kre 'henne« reernateltros 9wri grem enroene 11" nole~ atemprtsans.anotersnt ol~n~pbetial Tete 122% ~ess) vahnloors !rc« grass »is ~nano131K napm) 0(2.1~1kX4 IDOCt»400t <anwasirs Notes Ditto.« lo tak study n ~Ila 2000 Zlekla 19911161 Trea ~44n.le (Ara ot p» campaien was Mord,- 53.9% Meie)»64.5% 11993) Segl 1990 kcesed on kor N. fam~e. and pfinfed ode wl rendnders elnar~ øy end *nem *meina En ya 1998 Propan ol bre veds ()urne~ proerot sen Inler~~ ~se 59ntol93% 122) Mad to 11"0 be oblaten lone eat Scinic ot tolt [onkel grip: excoaso1~ 60.7%lo 93" obo«, and wfl e roten* ~e ror the okt Mån 1997 1400 pmuoø ol smal colaVatoo mol tøsod CM!. Total aro.112A 0111630101110id kir Ia -born va/x*1~ data. Ond! poren 67.6% noteromber 68 e% ~tatten anaa 494% elabfreon 'Smie' Su« corroncelon togrem Modedm men/ Monen wlio asen" meny Smeng 2006[171 ot Vanen) boalinn›LHaimossages (09. MCH.FP. Sen prabancel «anal bon) vaconation) Tre ~au. «odla includod eapboards, moro lloly tron noe bro db nol enensian døme sen* telciame abedisemenee ~e lo ~pleie OPT ~net» , (90Ins499.1 spa.pre* a& in naseapen and local Note:~ pilstat roro b:61.1kcitio •111.1991.11~ia Trne elrechfied Statene binonen mb, kn nimm: 20%.~..e efter knoin~-trensfer 2009 LSI thourand roande«. OPT: 28.5%inercazo stor knoncer3aoSanster 1) CleCUPStn indros +avl ~nov**. bom ommuenney 2) Focusod on ad als anda sn s ol acnatIon 3) FOCUS00 on hal aztr‘ plan :Muting Øens tor eir, ~la and chtehoad °oste 61~re COVIMILI 811/10.., 36 EFTA01072452 Point of Vaccination barriers (I) Barrier Rationale, evidence, assumptions Health worker shortage • Critical shortages and a high turnover of service delivery and supply Chain health workers in the poorest counties: ccenpouncrir by poor motivation and undemerfcemanse—leave poorest areas most underserved • Evidence: Stale of wono's niceness Geer/seeing health • Opportunity cost associated with screening la immirrization. Polic worker ptiodliss administering a vaccination. and recording the information con 1 outweighed by need for another competing health service • Evidence:Stu:0hs showing decrease or vaccinationsduring curahve care Mils Policies can result in missed • Include poides against wastage. lack of Wits. facilitating open.v oppccturiliss to vaccinate policies. and lackof clarity at cortdintications (e.g. wastage. oren-vial) • Evidence: Observation and status of VVMs on new vaccines Recordng name-based data • Difficult to ID patient quickly al health facility if home-based on •vaccina:ions is lime vaccinatcm card is unavailable Tech consuming. prone to ems. • Evidence: DOA and DOS assessments. RED ovals nology and often nsukident to allure backing of chicken in the community EFTA01072453 Point of Vaccination barriers (II) Barrier Rationale, evidence, assumptions Missed opporltnities due lo • Evidence: RED evais: presentations by WHO iesnonsi EPI advisors stock•outs cc nadequale to SAGE sneering,: Re:Mum on mined opportentes tinning leading to concerns about wastage or lane contraindications Civic operations discourage • Inadequate explanation to parents of hie need to return or when to parents ken attending MUT • Negative family experience al a previous health center or outreach alteManoe • Evidence: same as above 3 EFTA01072454 57 countries are facing a critical shortage of health workers 4Ia - Canines with cella shortage of health Wattn - Countries settent touch shortage of heath *odes Reaching target levels of health worker availability would roquir 2.4 million additional health workers in critical countries 39 EFTA01072455 Health worker shortfall is affecting immunization coverage Immunization coverage improves with increased density of vaccinators 100 90 80 - 70 - ) 60 50_ 40 - 30 _ 20 - -0- Maas -~ ',Asses 10 - 0 10 lc° Density (per 100 000) 40 EFTA01072456 Data accuracy is difficult to achieve on health facility-based primary records Records include registers, tally sheets^ clinic copy of health card or family record etc Barriers to data accuracy include: • Poor form design (e.g. lack of space: outdated records meaning improvisation is needed for new vaccines) • Lack of writing tools (e.g. pencil blunt: biro runs out of ink) • Mistakes in recording data (e.g. wrong vaccine dose. wrong date. inclusion of children outside — the target age group etc) • Deliberate falsification of records. e.g. due to real or perceived pressure to meet targets • Poor storage leading to lost or damaged (e.g. by rain, rats. etc) records and egisters a, ,-.3 i: , • 'afar-. ., Oa MEMO 4,770, C". 1 7 5 .4 r. I =4'7 re, "1"Niv . vl *n. IIII31,1,r , •••••••••••• 1-"loill i , p 11 41 EFTA01072457 -60-70% of all opportunities for valid vaccination were missed in CAR study Frequency of missed opportunities for vaccination, by antigen, among the study sample of 12-23-month-olds. Central African Republic. 1990 % of visits 100 80 70 is.,COrtgi 40 VISis aero vs OCe.“, 0 Con DIM 1~ elgen • A missed opportonRy for yearn/ben was defined as a VateirtaliOn visit or other health mite visit by a child wnr, ud not receive arraccinatian for which he or she was eligbie • Immunization policy in the CentralAfrican Republic encourages the immunizattn of all age-eligible ehildten. unless they are sick enough to wattanl hosutalitalion (study assumes no hospdatirarpms) I 42 EFTA01072458 Study suggests that by using all opportunities to vaccinate, full coverage rates could be raised to 65% Potential increase in coverage by avoiding Some opportunities were missed even missed opportunities during other when another vaccine was given vaccination-visits or all visit 54o missed oppaturolies % emiage 03 80 0 OPT' OPTS Limas OPTS Menke Al .,.J:rc4 Antigen Sesalne noted onyx w0 MI % (NSW *two no atiar vocal. was ahem PCONtlal vrafated dins .003 und %ffisr.o3 nennl motor vocal. an' flan PCONtlal vias wan wad 43 EFTA01072459 Other studies showed % of missed opportunities varied widely 4 by country but generally higher in curative than preventive visits Prevalence of missed opportunities in Key findings from missed opportunity preventive and curative visits in ten countries studies Screening for immunizations at curative Cameroon (2.35 nos) visits important • Studies showed that 'Never immunizec' CM (12-23 meal children were identified at curative services ..nores 023 noel but were less likely to be seen at 06464410.23, 4461 preventive services 2466640-23n-4cl r —t Alternatively, health facilities should . ..ea (12.23 f.>41 increase the number of days that immunizations are offered y44460494'441 • Studies in Gabon showed a 2- to 3-fold PA4zarn0oue (12-23 fru) ID increase in missed opportunities on days when immunizations were not scheduled Pualo Ro2(2.6006441 • In Burundi. missed opportunities were Vs6-64.4016 (023 two lowest in facilities that immunized at every health contact (15%), compared with facilities that immunized every day but not AO courdrw• (01 at every contact (21%), or facilities that immunized fewer than 4 days/ wk (30%) O 20 40 60 SO 100 % missed oppedtmilies EFTA01072460 Five major reasons for missed opportunities highlighted by studies Major reasons for missed opportunities Conclusions Medan % acrass dudes analyzed (ranee in patendeses) Initiatives to eliminate missed opportunities can have significant impact: Failure to administer 22 t7-35% • Missed opportunities were immunizations simultaneously reduced by 8-69% • Immunization coverage was False contraindications 19(648%) increased by 10-145% 16(146%) Recommendations include: Negative health•worker attitude eg Ani, e.,reie are n:o ant.% • Use missed opportunities survey: atul <v wewomo ftv vt routinely Logistics problems 10(481%1 • Screen and immunize at every aP vv MOIWO. poor COW contact orpmeanan oathaentorternang • Administer vaccines parental refusal 3 11%1 simultaneously • Emphasize true contraindications O 5 la IS 20 25 • Provide continuing education on immunization Medan %el missed opportunities • Reduce fear of vaccine wastage 45 EFTA01072461 Supply barriers (I) Barrier Rationale, evidence, assumptions Health worker shortage • Critical shortages and a high ttrnover of service delivery and supply chain health workers in the proofed Quintiles; compounded by poor supervision and support often resultng in absenteeism and underperformance —leaves poorest Weft most underserved • Evidence: State of worlds mothers Inadequate training • Little upitoidate pre-service training for immunization services. in- senice training is lime-consuming to devebp. thus is ftecroieney out- of-date. Few a-Learning or text messaging systems avedatle • CPI managers' meetings are useful for exchanging ink:motion at the policy level but rarefy provide updates to stall al the lower levels • Unclear protocols and inadequate training of staff for appropriate Policy data collection and utilization • Evidence: TOD Poo- demand forecasting • Vaccine demand brocading is often based on old census data an at al levels last years procurement • It is rarely matched to end-user consumption • Eindenca TBD Strateges not • Countries and districts face challenges in adapting program context spectec strategies to specific contextdroeds • Evidence: TBD 46 EFTA01072462 Supply barriers (II) Barrier Rationale, evidence, assumptions Built in buffer stocks are • Current irefficiericies are overcome by maintaining high stock levels if* large and tolerating high wastage rates • andence: TBD Parallel systems • Many vertical meditine supply Chains (vx cold chains). ART. RH. operating in parallel • There are also significant management deincentives to init.-gin', • Evidence:TOD Lack o( optimally • There are onty rare projects 01 aitntry policies to demonstrate Policy designed systems efficient and effective vaccine supply chains optrnized for high performance and low cost rather. current systems follow (cost.) administratrae sructures • Eodenct• TOO liatenal and nternabonal • HBV. TT. conjugate bacterial, and pentavalent vaccines (minus relicts are being very slow pedussis) can be heabslable . but polities constiain vaccination to to adapt to the heal-stabrIty sites with functionng cold chain . increasing costs of cold-chain of new vaccines • Assumption. Abifty to distribute. store and deliver vaccines under mere flexible singe condticns • Eodence: Multiple references on heal-stability and heeze-sensitrahe S Project OM:nixie work? 47 EFTA01072463 Supply barriers (Ill) Barrier Rationale, evidence, assumptions Lack of reliable funding • Inadequate. unpredictable. and delayed release of designated funds from governments and damn to central and district levels affects abiley of program lo an and implement RI services • Evidence Nigeria national stock oul of pad vx in 2011 due lo late disbursement of funds. Lydon - report on Laos financial suslainablity pan Donor dependency • Many countries depend opal outside donors bond the goo's share of NIP • Evidence: country share of Funding Pore financial management. • With lore or no budget oversight and accOuntatilly thee, is parlicubdy at lower levels hale understandng of the cost drivers of the program and potential efficiencies • Evidence: TBD Lack of discretionary funds • E.g. Lady authority or petty cash to subcontract to a local sourt, at operational boos to solve of transport ombems locally • Evidence: RED teals. personal experience Routine nvounbarion lacks • Evidence No RI position funded at UNICEF HO through regular priority al global level resources. <2% of AFRO's immunization budget goes to RI. much or WHO's immunization program funded through GAtil Rusin< tt PLUM 48 EFTA01072464 Supply barriers (IV) SE= Barrier Rationale, evidence, assumptions Lack of information used to • Ladled country access to up-to-date information on product guide country dedsion presentation and future pricing trajectories making e around new • GAVI-elgible countries have Mlle choice over vaccine peesertat- product introductions) • No detailed mapping of is available of areas with tow coverage with high drop-oul rates. Opguide and diced irdensifed activities • Evidence TBD Inadequate guidance • Many national immunizalko programs lack policies. guidance provided for some strategies lo deliver vaccines that do not readily lit into arrant new votaries Muth! EPI schedule or louchpoints • Evidence: Hec,B brth dose should be given within 24 hours of birth. Polley Men A is largeled to 1.29 year olds n campaign settings. HPV is (cont.) targeted to school age population Inadequate vaccine • Guidance on AEFI training and capaccy needs in countries is weak safety guidelines and yet wen the advent of newer vaccines (some introduced for the first lime ei develop-fly countries. given at different age groups. and through Sins.) AEFI stereillance and response is critical - esoecially with increasing pressure from anli-vaocire movement • Evidence: TBD Inadequate waste • No dear policy recommendations on njedicei material deposes guidance waste disposal • Evidence: TBD 49 EFTA01072465 Supply barriers (V) Supply Barrier Rationale, evidence, assumptions Convicting and inadequate • Different systems for lopstics and supply chain. stock management. information systems immunization records. performance monitoring and surveillance • Lack of birth registry to track unvaccinated children • Evidence: RED swats; SAGE reports ARISE. Cuttsainth report Lack of reliable • Fixed posts were built decades earlier and population has mount: ccovnuncation between subsequently or posts were organized for pontosl reasons rather layers of health system than need Tech- • Evidence: personal experience. nology Lack of information systems • Current information systems to monitor and trap*. vaccine and irtecton supply stocks from arrival to point of use or disposal are not being ate not pale or are not being used lo back and mentor vaccine supplies and utilization from national to peripheral levels • Evidence: Optimize Suboptimal product profile • packaging. presentaticn. thermostablity. and dosage regimen could be inproved for the developing world supply chain • Evidence: Project Optimize Infrastructure in place does • Mismatch between ih the ntrnber of vaccination points anditor they not match current need are distributed in a manner oral does riot match up with popidation needs and the requiernents of the heath service Opera • Evidence: personal experience. data on WHO heath systems site lions Outreach sessions • Owing to a lack of funzing or procedures in place to refund out-of- frequently cancelled pocket expenses of health staff iwnunization entrench is often or delayed delayed or Cancelled • Evidence: TBD 50 EFTA01072466 Supply barriers (VI) Barrier Rationale, evidence, assumptions Inadequate cold-chain • Al ✓ub national levels in Wieder capacity • Evidence: WHOWNICEF data; Project Optimize Inadequate temperature • There is an absence of data compled centrally on V3CCitte heat monitoring and reporting exposure and no routine data is available at al on freeze exec:sena al any level of the system Mils indicate heat exposure localy • Evidence: Optimize Inadequate maintenance • Cold Ch9in ethipment maintenance lends to be poor feeerythitie from not wiping down solar panels to hang an effective Opera maintenance organization with skiled staff. transport and spare parts tions • Evidence: TBD (cent.) Suboptimal power supply • Poor and inxosistenl power supply at planet:anal levels • Evidence: LARI 2011 Serious transportation • The last 10K are the most dello-ill issues at peripheral points • Evidence: TBD Supply Chao evaluation • Significant variability et the use of supply chain and cold chain variability assessment tools leading to vanable measured costs across countries and data gaps • Endence TOO 51 EFTA01072467 WHO Immunization schedule al isimidooen friiiri• anan• ............, r-ez..-i ,., ...wean 1....7. Lea ”ft... ••••,“0••• KO ,.... 4.,...to• ay an, ., ... , ..saira nion, I ...room Ms ......i....fri.. 4...0 .,....ftioftebanoft I • .. ...cm; 'WWI annowom noein,.. , one vft. ' e,..... 0 ...so. oen a ....n.. nre 1..• ..4".”1"ftlf hN MP. .Z..... f%, •4 e,....i, •4 4 ... •.t.... !•. ihnftss ...V..) On.afte IN p..... .•••••• ••••••• 4 a.m. I 4 en•nr.f...•.• 4o. Oft•O on ..v.. cc, -••• •••••Th, ... ft...., ...oft. I teitroliortnri 4.10,ffeby OM •.,..it”nesii • ••••• P.. I ter.......01.1 .0,40 &rat On.; n"" I. a,. raY... 10. ......roi.. OM Ha g.......... ,,..... ft ....p.m. on OM. 4 ......... re ...ft,..,. , Pt," I 1" .."..." ......e. 0774 curb. II.. non "gat ' a ...win, o non ne caw anus.. 2..... 0,.....el• • .... 0 . 0 ...* , . ,, .." I ........ ......, te, F.., tool.. it ft... in. nern ne polo'*. — f.,,,,,,.... l non. .,.... en nor won, • one.. Fr ....... ,.... in, ''''' n. no . en ---,on t en..., nonnt= none.. , to.,....nen— ,, I.. •ore .... •.I•• ,in•enn ens ee e en en •o ',soon.. r Do . ei eine on mein 2t...1 Fel nen,1..1 eltaftr— ...L..... fa ft n ...Z... 1.....,.... ..., ..... •......... ........, .-. ...,s,.........•,..... ,.-..............., .. . . .. „.... aftw..0.....ionrom wt. .................. Owes ft.% z" " iv,. t011nwliolle•Sallulall 52 EFTA01072468 Country schedules not (countries with vaccine AnOfien Introduced I (of 1931010 slaps' .cciarnenclagons Medi &AIWA.. 0 of country vaccine introductions WA (for WHO tracked vaccines') 177 102%1 00130%Y e counties per vaccine WA a • 173 M0%) acocoel(COniugele 88 (45%10 v. 39 120%) 139122Y% PIN 4 5(23%) Reeernmendeffern kir caddren residing M cedOn miens Japanese Encephalon. 012%) Yellow rove, 33O2%) lecar mrntla tux., /0, chsidten ewne1001-n*acP0P0460^5 Typhoid WA Chokra WA 0,000014 32 (17%) t A 125%) WA .,,nendallons for chill, n receiving vsfrom •.iC •MCV2 ,,zatton ptogtom wish WIJ/di CILitaCICYJOICS ❑ Piwro ps III IF Maras cos 120162%) !Slane • HepA 131165% L. Pans • vans • nere Wattreasell 106166%) • E HPV -11 lance 1510%) • M Retahln, dd. (Wef 0 WmV raw 0 rent.** I W Iv wane ,.. • won. atelt.OJelisealia aryl,* ifrvaXcps I•I••tIlI••tO20,t•- .r.s pro won sea peva amuses.. cfranrittx it Seta two ow Di EFTA01072469 Average Annual Immunization Program Cost per Year (2009 $USD) $100.000.000 $90.000,000 $80.000,000 $70.000.000 $60.000.000 $50.000.000 $40.000.000 $30.000.000 $20.000.000 $10.000.000 $0 2004 2005 2006 2007 2008 20092010 2011 201220132014 2015 —Routine —Campaign Shared —Imm Specific Total 34 EFTA01072470 Human resources costs a large part of non-vaccine costs r 1 Human Resources MCold Chain Transport (Surveillance Training Social Mobilization Other Source: Lydon P, et al. 2009 SOttON UOM BMW POION016.041.2011 55 EFTA01072471 Proportion of government funding increasing slowly Deno 1,1 governmen; tund.ng for •,‘accines and To o!ine Immunization in 185 WHO Member States-2610-2005 %Vaccinc cvcodehect teamed *.Roumw imenuninton cp;mblain I)) th 'ben crtuncom 0mm[d In thc mcntmcni I00% 90% 0—Sanplc A‘Cl2gC 60% Popu • wash:.: Maa r'. fe% g 1 I I 56 EFTA01072472 Half of countries financing less than 50% of total needs Government financing is 42% of total financing 100". 57 EFTA01072473 Today's vaccine supply chain MANUFACTURER A network of people REQUEST mi l - FORSUPPLY and equipment f a te, and well established procedures stivo(t ANNUAL STATISTICS ItStouiryS v esc" ANALYSIS AIRPORT Fri % 1;1M RIONTIII.T REPORT C loZ il KIIIOUNIS wawa STORE PAIL,* A te • RECORD 7:2* .0 DOTRICT/ REGIONAL STORE 411 KOREN CENTRE Simple, precise VACCINATOR/ NOON. MOORED & standardized 58 EFTA01072474 Supply system architecture follows administrative/ political structure — fr Al pots —. National Pier.ify SIure $ 0-natio al I --• Sub-national 2 late - to- - S I3 4 7. "K C. 4. II•ofth Centel NoahCaren C SONCO Calvary 5— Oalhory I- 111=1:isi EFTA01072475 Vaccine storage recommendations Primary Intermediate vaccine store Health post vaccine store Health centre Region- up to District- up to Up to we Up to 6 Up to one month 3 months one month month Months OPV -WC to -WC BCG Measles. MR. MMR 2°C to +8°C YF (-WC lo-WC oho (*WWI Mb freeze-dried Meningococcal AMC +2°C to +8°C HepB IPV DT DTP. DTP Hep B +2°C to +8°C Hb liquid Never Freeze ! Td TT EFTA01072476 Data suggests that vaccine effectiveness is impaired by age as well as logistics issues 1 111 MCVI Vaccine Effectiveness by age of administration and select WHO region 1E0 • 96 92 92 4 92%. >12 ma a vo -1 77 77 Age a: altnnistraton apmars to have signfloant inosel an MCVI VE AFR • SEAR EUR GUDE 9411 moneys 3.12mouge Generally lower VE estimates in AFR and SEAR hale been 'Orbited by studies to pagearmialle differences including cdd chin Sues. eadeepate vaccine handing. pow vacdne stooge. ad inadequate wain* adriiristralion 61 EFTA01072477 Legacy from the early EPI days: arr Focus on enforcing standard practices in a robust infrastructure • SOPs for all aspects of the programmes - Simple rules and procedures/guidelines - Easy to convey through cascade training - Easy to remember and monitor • Training large numbers of staff Training materials, large numbers of training courses, cascade training - Focus on mid level managers and health workers - All partners engaged in supporting/conducting training sessions • Health Care workers trained to follow SOPs not to make decisions - Keep vaccines cold ! (freezing occurring with TT and DTP but because freezing point> were low, freezing was not a real concern until Hep B was introduced) Vaccine management rules: Discard vaccines vials open at the end of the session Discard vaccine vials taken for outreach and returned unused Open a 10 dose vial even if only one child comes to the session to avoid missed opportunities High rates of vaccine wastage was encouraged (acceptable for penny vaccines but is no longer) WM can help change paradigm - this is still not exploited in an optimal manner to move towards a more flexible and efficient supply chain EFTA01072478 Changing environment - More vaccines with diverging storage requirements Heat sensitivity Most sensitive 2 Days 7 at 37°C 14 30 LOBS sent: ! Traditional Freeze sensitivity cold chain u) ca a, -J Soutec hfiltben. J. TechN6421 ConsOation • 2006 EFTA01072479 Prices and packed volume pre dose have been increasing over time DTP Mesas wµ1 rm Prteumo Rots rmw• art. De< a DroDY'ReDi It wf .teans pea Pun DI a... 5 0 7D OP•MOCI Kludge (CM30016:44.1 10 ' UNICEF adPMIO - Plard sesame Nos Yon. Kenny IND ION 2000 2000 ••CMH Pilo DVD*011000) 64 EFTA01072480 Supply chain strained by new vaccines Figure 1: Demands on vaccine delivery systems are rhino dramatically.= Demotes on drWorey swami am growing onwiterkelly mart ram— sic &tomtit/1P 00 ratan inns. misfile MSS awkilbad.mwtt. oar No oar P.vaS•ft 11119113 ••••.<4•11 10.1•1•1 Voloaddlow 1101WWIIMpoll lorw*Aart Ski tom iSW NW MC IS nt• rn Iffl lfK IS WO an 2004 2000 000a 200 NW $01 • Plierad Ilipedbabi • New and inaeased•volume packaging require more storage space and baking / supervision on disposal • Hq.er cost of vaccines increases financial risk and exacerbates fled of MO wastage 65 EFTA01072481 Commodi y Logistics System in Kenya complexity 401.• let I. sn TB( Man.n. Q1A •441.1.1.11 00•••••• OnIAP A litr••7 oh, sare genres el 4 , • Fob For utacts A108. TB wsl oninmeAlina Prom••••••• ERZ C I.. AsonUnad./ S C maw t lanen=74 Amnon-ID anili MEN POPIILS Man kiCOS ••••••• I 66 EFTA01072482 Best practices: SCMS regional distribution centers run by PEPFAR SCMS regional distribution centres and coverage Management of warehousing and distribution - could be outsourced to parastatais and autonomous supply a? Uncles 67 EFTA01072483 Enduring weaknesses- EVM assessments in 24 countries lvM Ptionaty Intl EVM SubNallonal level IM 100 so so 60 60 40 40 20 0 U 12 0 14 81 C6 82 88 19 L1 L4 45 IS P to 19 1-Arrival ; 2-Temperatures: 3- Capacity: 4 Infrastructure; 5- Maintenance; 6- Stock Mgt 7- Distribution: 8- Vaccine mgt; 9-Information Sys 80 % is considered as the score of an effective system EWA Lowest Dolinglevel EVM Service Mot Level ice 100 80 so 60 60 90 l0 1 1S 20 20 T 0 fl f5 IA IS K f7 to (9 Cl to IS IS Cl 1$ EFTA01072484 Effective Vaccine Store Management metrics • primary • intermediate • service point 69 EFTA01072485 Two highlighted interventions to address issues Optimize (WHO, PATH partnership with funding from BMGF) • Since 2007 has aimed to use technological and scientific advances to guide the development of new products and ensure maximum efficiency and safety in the field • e.g. passively cooled produce-delivery carts, battery-free solar refrigerators Vaccine Presentation and Packaging Advisory Group (VPPAG) • Provides forum for representatives of UN agencies, experts involved in public sector delivery of vaccines, and industry representatives to discuss vaccine presentation and packaging issue • Originally run by GAVI in 2007 to deal with new pneumo vaccine, now run by WHO and expanded in scope to address HPV and other pipeline vaccines 70 EFTA01072486 Aspects of transportation affecting effectiveness and efficiency eri mg Waif COUP. VW* 0(101a! Iu mows. veherpt/ in mentenar03. vocreong order rep PC el *9 mxor !op/ erNo:ia•.: Avadabaity cost of ricrper. to: running Mix of vehicles Health impact Who goes [sen Lively WHIM at mimeos le • doses rm. - _ _ Noes imPrri On Man. 5t50/11I,P pled / Mingo:pre, Waite GM/aryl nITIresof in weed rrerbe, 'end mTlq the of patbeis soon in motile dole) done Sticks Witted cot rd..eled Per We edeirrerytriPine ean500e00 µ.loon$ reach defirnafon parfOrinie to Iran, • 71 EFTA01072487 Comparison of transportation efficiency measures across ea_ two countries and two vehicle types 411vDt* ■0...tr a Km Running Total cost vehicle Mgmt cost I km I km Availability Utilization month Stele 1 013 _J NO.05 006 Yinhyol 006 015 ao OW 00 01 0.2 00 05 10 0 50 100 0 50 100 0 1200 4.000 0 S S % bwlvekkblms. Mgmtscoati Ghanaian resources aro around 50% more effective than the Cote d'Ivoiro transport resources in most efficiency measures 72 EFTA01072488 Planning vaccination services and managing resources needs improvement • Emphasizing low vaccine wastage (e.g. only vaccinating one day a week: not opening a multi-dose vial for few children) may mean more missed opportunities Poor stock control and lack of transport for vaccine cksbibution meal stock-outs are common Mothers fumed away because of stock-outs. attendance on days not designated for vaccination. outreach team not arriving on time. health workers concern about vaccine wastage or false contra. indications. may be discouraged from returning • Children who are vaccinated are not always protected, as inadvertent freezing of freeze-sensitive vaccines is now more common than damage by excessive heat transport of vaccine to outreach needs to maintain appropriate temperatures for heat-sensitive and freezing-sensitive vaccines • Lack of planned preventive maintenance greatly reduces the working life of transport and cold chat equipment • Projects have demonstrated increased utilization rates of transport by improving transport police'. (e.g. using most cost-effective means of transport) and maintenance • Effective Vaccine Store management (EVSM) evaluations since 2000 constantly identify the need for more, higher-grade and better-trained logisticians to plan and implement efficient vaccine supply chain management. especially now that expensive new vaccines are being introduced. • Refresher training must be updated and repeated due to frequent staff turnover. • Governments need to create posts for logistics and transport managers • The best mix of strategies (e.g. daffy vaccination at fixed sites: reducing missed opportunities: using most cost-effective transport and human resoisces) needs to be evaluated in different settings EFTA01072489 Distribution of clinics versus population density and DPT3 vaccination coverage highlights problem areas in Nigeria Cri DPT3 Vaccination coverage Population & clinic density 74 EFTA01072490 GAVI-countries rely on GAVI for new vaccine support -r a of applications approved and recommended for approval (cumulative) 180 a 160 ■ E 140 *T„, 120 ■ FtOtavirus = °100 1M • Pneumococcal 80 a •—• — Measles 2-, dos, fit. 60 _ ■ Hib containing gm '3 I 40 MI _ MI km I I 10 0 20 F Yellow fever 0 Mil I I I • Hepatitis f. 2000 2001 2002 2003 2000 2005 2006 2007 2008 2009 Year 75 EFTA01072491 Data for decision-making barriers (I) Barrier Rationale, evidence, assumptions Inadequate IlACI (integrated • Ikta policies don't emphasize (a) need to bring health:. management of childhood card lo outpatient care. (b) need to use all opportunities t• • • ifnesses) policies chid for vx. including attendance for curative care • Evidences rthiewol NCI training No national poky of using a • Need card that captures al health services (e.g. growth =flirting. general homebased 'health vaccinations and sick visits). card* for al health • Would help reduce rested opportunities and monitor vaccination Policy interactions status of children with VPDs • Evidence: redone, experience Difliculty knowing vx status • Vaccination status of daltren who are it is often unknown for dedren who are ill (bit vx card often not bought) or not recorded (bit Poe' of health worked) • VPO surveilanoe therefore often lacks into on vx status c' which could be used to asses vx effectiveness • Evidence: personal experience Difficulty in diagnosing • Difficulty ie diagnosing aetiological agent of disease syndromes lie aetiological agent of diarrhoea. sepsis and pneumonia makes surveillance complex to disease syndromes organize; only feasible in sentinel sites Tech- • Evidence: personal experience nology Cause of death dab ere • Poetrbly need technology to improve autopsies (poletriallY Plot • very difficult to obtain in low modem detection of infectious agents) income countries • Need improved completeness and quality of death registration • Evidence: Personal experience 76 EFTA01072492 Data for decision-making barriers (II) Barrier Rationale, evidence, assumptions Improved methods are • For surreys. infer-nation is usually obtained via home-based records needed to record infamatign • For admirrstrative data. the numerator may be taken from tally on M of vaccine-dose sheets, but what is recorded on those tally sheets depends on what ccoduinatons each child was on the health card when the chid was vaccinated has receiver( • Evidence:TOD Lack of inexpensive Geld- • Needed for use in finger-prick blood spots or oral fluid reduce Vit. bendy antibody assays potential to use serosurveinance and model resulting data to Tech- estimate impact nology • Evidence:TOD (colt.) Lack of communications • Needed to track (and reduce the eminence of): 'Nor:louts' of technology vaccine. transport. fuel. or health waken • Evidence: northern Nigeria piled project? RED evaluation Lack of data toallow high- • Dab on population movements. urbanization etc not easily available level managers and policy- and not matched with data on physics infrastructure (roads. makers to plan and manage eactricity eb), communications and other planing rectrirementx vaccination points ellicieray • Evidence: Personal experience Inadequate disease • Constrained by due to Oeflicient use of tools. lack of skiled uneaten:a motivated human resources: lack of laboratory reamer:es. lack access to curative care fa sick chicken Opera • Evidence: F Cutts Landscape analysis on surveillance for EnAGI 2D:: tions Inadequate skills and • Inability to determine causes of outbreak (Wire to vaconale vs resoutes to conduct ussd vaccine failure) or root causes r rick factors outbreak investigations • Evidence: TOO 77 EFTA01072493 Data for decision-making barriers (III) Barrier Rationale, evidence, assumptions Inadequate monitoring of • For heath services metrics (e.g. infrastructure. health numbers. dianbution and workers. transport) maintenance of inputs • For vaccination program metrics (e.g. cold chain. vaccines. suppliet Opera- • Monitoring systems need to be integrated and adequately supervised tions • Evidence: IRAN retools. Cutts & O e11k report. Project Opt (coot.) Inadequate AEFI • Limited by same constraints as above as well as • ladt. , ' stemillanze dissemination of dear definitions for AEFIs • Evidence: TOO False perception • Need also to know vaccine effectiveness or surrogates of VE Ie that coverage equals vaccines stored and transported under temperatues that do population protection inactfrara them or reduce their potency Overall • riddance: TOO Inadequate skins. motivation • Inadequate combined reviesn of data on larger population. inpx. and co-ordination to relieve outputs and impact. Wadequate use of information for action and use data • riddance: TOO 78 EFTA01072494 Comparison of WHO and DHS for DPT3 Data DX 04(4400. nuMlny WHO and DHS coverage estimates for DPT3 in 11 countries Key observations • DHS coverage tends to be lower ••• • OHS not influenced by administrative data emaitn1Draw. asa,ar. 79 EFTA01072495 Advantages and Disadvantages of methods to measure Data maddtalon• vaccination coverage Disadvanuus. k: .,„„ i an cue complete and mcorme Need good eomptit': c zccc, Rased intitimumi on cumulative vaccination Need complete drib registry for we &nominal°. I electronic) claim. of individuals alb] populations Need unique In ILLUIII/Cf throllf*IIII lift fan he used to set appointment,. issue If held locally. dilficuh to track rumination of migrates reminders and recalls. If held nationally. feedbocletme at local level may b: Cre of ebb:tonic rystenw could reduce slow tinw rpm on paper registers tout am Requires adequate funding and human resources widespread in low income COnntrICI. and Need secure ploccdurerm nuMain confidentialky often not used Routine Simple in conception Population denominator.. often inaccurate coport of Continuous infomution alkros Priv me SOMIr ohm does not recur', -. accinations monaoring of cumulative coverage through Exaggeration of asses administered common le.g. delivered the year and by districhhealth facility double-counting of same child if home-based recoil! Can he used at local kcal to track mislaid. inclusion of children outside target age musk or coverage and dropout rates purpueful evEgeratioM Transenmion errors at each health system level when runcebosed wstemt. used Surveys If well conducted. can pmssate accurate ACCIOJCy of Jam depends on adequate surrey design. information training. suparbion and quality control Other indicators (e.g. missed Sampling frame often based on nutdatcd census opponunilick caretaker kw-whilst:lean be inform.uion assessed nigh rick subgroups (e.g. migrams. street children, Involvement of health woders can to nuy be missed teaming copodunity Iloarebased remit may be mitring or incomplete mil lamennetc inine)s kw multiple accuracy of verbal history of vaccination varies programs can reduce cosh. Panic ipmion rate affects reliability of mutts lot quality sample surreys can he used fallen long delays moil results arc known. to identity health facilities and low coverage Small sample sates give imprecise results: Large sample _population subunits sires arc expensive and more hmewomuntinv cm. se. 4 ...•••• onnkuono 1 80 EFTA01072496 Draft conclusions on state of coverage Dora for decision- making Ogg.: ot challenges are: • Rape ly changing population demographics. e.g. urbar zation. changing birth rates. Want survival rates. chant: jag stonily settings • Polcal context of denorninala measurement • thmsbarnts on high.qualliy survey implementation especially in politically unstable countries. conlielaffected areas. and urban slums • Increasing cornpexity of vaccination schedule inaeases chances of errors in recording 8 compting numerator de, Ways to improve coverage estimates: • New or improved siereY methods can be developed. but wil only address parts of the problem (i.e. can reduce serection bias (though security constraints may persist), can reduce but not ekrin.the observer bias. and can airwave data management). • Fuller analysis of existing data can Sao improve coverage estimates (e.g. combining data from routine reports and surveys into models (Lassie!) • Registries may be longterm solution but are CiffiClit to implement even in righinccene countnes • %Welber measured by survey or other maws. accurate completion of primary records of vaccination is assentor lit regimes strong managervant and superrocon To decide where to invest. need to determine priorities for use of coverage data: • Asa tool to estimate poputsbon protection. coverage a limited by assumptions about •vaccine effectiveness and thus a not sufficient • Triangdate data on vaccinations with data Wen effective vaccine management assessments. surveillance. outbreak iwasligatens. and special strides (e.g. case contra slides) to obtain fuller picture of program impact • Asa tool to identify under-served populations for local (e.g. district)usa. coverage is very helpful and existing methods are adequate if implemented welt • Investment in improving recording and transmission of data on vaccinations. and strengthening managerial use and feedback of data. wil improve all methods of measurement 1= 11====19= 81 EFTA01072497 Data quality audits show 48% of countries have a poor verification factor Data from Data Quality Audits (DOA') conducted between 2002.2005 in 41 countries 40% no IMgNM WM 2r%mainorniromitentireratimi ar4iniadseigiwa.=vtiutimpimpit IItn or. IIIIIIMIJIIII iiiiiJiMiliil WI II 0" lailliielS1 URIIIIIIIIii! hal ILMININIIII I IIII i 0,4 lin Mal SIM 2r4 § gi li t §g 11011101raMMICAMEJNI1 - . 5% MN/ CI INni 46% of countries obtained a VF (verification factor) below 80% (needed for continued GAVI support 82 EFTA01072498 Weaknesses in the information systems apparent at all levels WENN % of countries % of districts % of health units Immunization reporting system quality guidelines achieving achieving achieving VSO Of computers 10 manage ellMtaltann data 103a 41 Use of drawers denominatces accordng lo year to cabman DTP3 we .A 87 4, Vaunts ledgers are tp )3 clota tor TT 54 r-76 _q PubliCalkon MO immtwoz8C01 0848 B2 1 Se WA oencoiratogs for DTP3 (*Anal wading 10 WHOO8AnlhOnS 92 WA WA ',acmes ledgers are tp to date foe DIP _ .I 70 .T3 Existence of data reporting guidelines 74 89 WA reeflOsch On immunizaten laloser level it 53 t, - Integf8tOrt Min. reporting 8,18/0081 from hILIS tO fliStriCI level 61 WA Intagraton dem. reportng systems from dolma to national level 56 WA WA Existence of charnel* showing immunization partcananoe indicators -a5 4M. 63 59 Mcnaorino COPTI.3 drop cut 1810 :36 _ 46 56 EXitt8000 M OtiWolOOS 10 report AEFI 32 .) 164 C000CI OSIIM8401of vaccine wastage r31 * 32 Doncfronabrs used at national and dstncl levels woods • 14 WA WA Existence of gurdelnes to deal web laeo roponng ▪ I3 60 WA Avaltablity Of Conant taly sheet, kg OPT WA WA Avaltablity M reports WA WA E 65 Existence avaccine ledgers WA W 56 8 .. O 50 100 0 50 ID) 0 50 100 83 EFTA01072499 However. countries have demonstrated ability to improve Verification Factors Compared performance of countries that undertook two DOAs across 2-3 years VF 10) I Ikrti+af t. Carewc,), PM" 03A VF Ounoa Curregt 00A vr Nona 1 84 EFTA01072500 Indicators to monitor immunization program performance Program Indicators component % d vaccinated cisldren (if routne reports are used. OTP3 taken as proxy) ulputs % drects with >80% OTP3 coverage in infants' % districts with (390% measles vaccine coverage in infants' % of planned outreach seasons that were conducted on schedule :uluery: % of planned fixed site sessions that were conducted on schedule Access to % of chiiiren up-to-dale (BCG and DTPIn:eel) by age 2 months ,vices (lacking 'Dropper- difference in percentage receiving DTP1f0PVI and either DTP3e0PV3 or measles actenties raCtine Use of all Percentage of children receiving all vaccines for which they are elgibe al each visit opportunities Safety Proporton of districts that have been suppled with adequate (equal or more) nurribee ite AM for all routine immunizations during the yea' igistics and Proporton of districts that had no interruption in vaccine supply' iuld chain Percentage of facilities storing vaccine at recommended temperatures Vaccine effectiveness in expected range We each vaccine everualed Transport' Klometerdvehide or motorbikeirronth thigh km • high utilization) Percent use for service deivery and service delivery support (hgher•more effective) Poficy of panned preventive maintenance (PPM) & % PPM activities conducted Full cost per km (low cost • more efficient use of vehicles/instal:dies) Sumeiltance/ % expected detect disease surveillance reports recereed al national level' ron's:ring % expected detect coverage reports received at national levee Managenwnl Country has 5year immunization plan and supervision % dregs having miapplans that include immunization actreffies' % cistricis that did >t supervisory iisit to all Health facilities in last year' 2ideder Proportion of providers who know and follow recommended guidelines. inducing those on ituncedtref simultnnecus administration. contraindications, and sale injection procedures 3 ri 85 EFTA01072501 S6 EFTA01072502 For most survey respondents, goal-setting had strong coverage component Whether as a discrete strategy or coordinating entity and from your vantage point what would you propose as the overarching goal(s) of RIinvestments at the foundation? Sustainability also a recurring theme in goal-setting (but spelled in many ways() erepYt — RIB ce. . ir2,1 "-11'=-17 improv_ xis*. w *Di programs me4ff:tern::: wheave 1 plarteemr seams ell merlon 4 wrirr' eli i coverage Note: Includes surveys completed through 'Size of words correspond to frequency of use across responses 1/31; will share full version on Monday 87 EFTA01072503 Survey respondents generally set four different categories of goals Improving Coverage ©Improving the RI ©Achieving ORnating 'cyst system and data health impact Founded/an goals ,,rd 10 l'eSt P,PAII0n3 • Cantle rmmstrnerent• 61, 91 owl teensy • WHO/ ntIldbin al Performame of RI wsie-rn pe,th Wthnit an RI Vtalegy • AI;nail 9)% 41 WI pray %upon, nths Oe-,a, yriosae IndI Hixee • Baling sustainable F.x.inare Ma control PnXialles le ellen for thrower, are Palteta, • Cried pawl Wanes Ma erwing coverage al Mere enianewn *anionic., el VPOs ewmaion a,y leharin • DM In all rlistentsal Wanton SIM art RI • Innemeniwawcw. • Chicken eclat one. wren of rerun • Swat pea ennosem eNla boothg age.(ain • Greater ofitdoncy one posse,/ adalescorta) (Wanly (V • Per GAM goes audante eIwd imemaiome neon br CO. • Uninbrsal PrceraT. • CoweeesxM 1.91, infant • wero..re Caber/ OPIX080,4 whew needed =Malt/ fates de le VPDs • UpdringeroaarninnasAlem • HOnxtden. Icenerlorming armlet" • WPM'" cod <non and legelas • 'lake of be unarms onlne • Icopraed program • Achieve eeprty n *Nemec, cnanagemem • Impratd *InmatesCl • Foam on WM embed 0-9 nee waCCr415 YAM'elOn Moray • INIMOMINIO RIOr:terra Event/one wants to improve eeverege, but has Monet Ideas en Note: Includes surveys completed through where to leas 1131: will share full version on Monday 88 EFTA01072504 Internal and external interviews reveal key themes in where people think the foundation should engage External (n = 3)' Internal (n = 4) Strong alignment on foundation's role in Strong alignment on foundation's role advocacy in advocacy and supply chainllogistics The (your) voice to motivate the donor • lisc the to-ct:w voce to make RI a community to loved in systems.' priority_ for countries.' Support governments building cepaeity • 'Bring partners together to work on this (and sustaushg thin the health system.' issue. but to do so we'd need to have some help LMlCAIIfCs get enough information to skin In the game.' aegoasle effectively with menufactufen.' 'Focus on the supply chain: (2 people) Poacyrnalters !idea to (the co-charsl cOrrefenny... ITheigperspeetive is valuable Direction less clear in data andpowerful? (2 people) improvement and human resources • Improve immunization data.' ( 2 PesPle) One interviewee also highlighted • We can push others to hnorove rantrirt- foundation's intellectual leadership • ;Success of sysavn is based on human • -(BIAG') is very good a! rhattenging our management. we need to toothier whether assuatithimutttomIlhirfield.paniculasly on tie ham a fore. and if so, bow to be MSc togistics management.' initurnsannagrams.at "(2peopt) I 89 EFTA01072505 Foundation investments to date that are relevant to RI 90 EFTA01072506 Ongoing efforts at the foundation have largely focused on supply barriers 'Samoa owe -er1.9y not DB conoishenti•v Point of Systam Domand vaccination wide CWT IM Trailed nunby Ourdny Aware. Ware Mall nom MAO =Aar Mann eeMce & mama aeon ow mon SIM 54AM AIMISE•SUM PITT. .42.5B ONO 135AM ,-51.2B •OPO- 'SID • 1, pC,Si Global: Cit., ' fun <42%0) onqatogro vow M I.p••• PAGE 46 6) VINCEFit. 4,14 0•144 - Yil•On oreina m:IS0 4, M.) • WC Wry ti 35.3A 539M 58.3M 110AM Country: Ergo sk., • 69Vimv Avow*, Yr VA.C.SA %Man 'a OW Nconf Miele rem et.VOM On, eaeaftacc......e.sa • V010. WM* mar, • TrGm WI TH.I•yt Fawn; IIIII PAM:0 Local: 19.91& 'mu pm SOA5M SUM VP, Data for decision-making ohmic stineliancoll $25M 91 EFTA01072507 Summary description of PARs directly relating to RI Preliminary! Sue of °woolly Whal on Global: yranl misled le hemmer:O/d cohmry (.ante S2 An doompe. (WI Fa PO -. ,a adOreSSIM local CPRF Rivalonon lo0•MPf Firq WvpnDotvo.?.... i 2010 201 w' c.io Local NOSE Leamr, Went 0,0plite eel:ohe-4/m .>nn Phoome 2. LI gedorrnaroo of (Cele* norruniyamn venom. InNed 44 ['MO Markyra 20002012 lAaneHmom Gaol ErnbOSSUPP:CYAltin the ra..val Mmanzabon PlAnneo) & 414.1‘10 M07l0nFl trioent 32 Owl riery•WI 2011.2013 hlamr-emeM Couhry loontel Ronnalanal 024.000-200 WHO erman20501 Carmirrenl 8 01.0 )Meriulm 10 Onect Man 2011.2012 poky Meng Olowl Poem' Dowor43 a COM:e0hireno0 Han be 0 Mandna ea:ene CaTenbrool 8 .0-0 satiny revefloreg weans:IOLAand Heyde* 11 Proo Mall 20202011 pOlce seer.: n A Total funding of grants SISLIt• reeding lo Rt. -$22.7M 'Sample grants -may n0I Oe eVegeehenSite 92 EFTA01072508 Summary description of PARs indirectly relating to RI (I) Preliminary' Stu of Gently Waal on Global! grant 'elms to harnessank it country/ Smote Iron nescn0een 0441 RI PO Trawl addresses local C....fai Vao:rn. 1 um) ,, ,, „,„ ,,,, i„,„,.. , ,,,,,„. ATKI. UNICEF. Global Polo Endogan Inialha pantoWHO 2006. Rot 15573443 UNICEF it2IXIMI.anf Rotary (14061A1 122U WW1 Ten Winne SyMirrado Global ewonca1on and Heath PfoRsistognIrA and Po, RuCcfy Wm PATH Cad CARA of Ts Future 34.7 meted SIte 2007.2011 6 LCRISIICS County Peirica Aconeraffng. Wog, the WHO orequalkaion commnront /3. Ay1O Foam access to wenee for to doietoons) worl0 27.0 Mersa Want 2007/011 polcy war, Globz4 Moose SVRVAC Grant co deem. sunearco 22.0 mend Linda V. 20062014 Ravenna WA Catelytescro nfl, OK rt. gently ad poteely obtain awns 13 40140nal-PlitAILMIal biendbROS. ana adrenal Ire 62,029,00r4 of (Okay Infar.41-T.I0 2003- SupPlY RUT° PATTI nano. taxch Me clnoS ono' Ono 11.0 Metal Slew prowl A Lorin Glob! 1.140102 Roatto muslin, enonour and sustain those In/aim telucicoom la -Sturm Alma 11.0 mon Tim 2009-2011 SmtewrOto Globe) Sortx•Ing lie tobtlishenen of nion', processes to Pow& 4nranco 0•10orco.olortrod docisica meting in cotmtrront & 4149 wrifronficnespith 99 POW Vs> 20062014 polcr were Cony ()way Evaluabln of DopcoatioCoruidgo Jot Infactots. 2007- sante 6 0441 PATH Rogi4atory. Ecorpfnic and PrcgraInnalc Fonitilty 99 meted Sitio presort msnaRmon1 Local Adfocacy Of GAvi <Rum, powwow (Of FuLvnt-g 6 Sabin Sus/Anti. Prrruniff mon Financoa 92 WSW Vb 2007.2012 Pnxuanni Cony 93 EFTA01072509 Summary description of PARs indirectly relating to RI (II) Preliminary' Soo of Drodly venni on Global! rant Whsle to frsme.ork 4 country/ Want** 5hon des.:,,oto,, i 9.0 m PO Timing add,. st s local Paimar i$ACe)SirenotxresviillO'snominvean4 maw cormn, '" , 4 M40 SOON ludttlbeNSSN menulzab:41200610 68 :nitro:, S:o.o pw......, pont wen, c.4:4.ar 0:00.Ct 510 mar NnctfaChg &woolen lot MI and Firurcev E. Lon. Club Ostabula lamb PAI VIA/Whims SA Maria Michael 201/2012 PCOCUCITSII Global Eglet40 a 'MOM VOOMM kir tionnunent lognhans, to OM moneresnl end tecProial MUSLIM* capiellos la developing Gantry wain* SuIVY 6M 8 AMP loWsics (eV* cyan tromt 43 Inflect Taeleem 2011.2015 6 lo;oslics cower/ Oprobriatze poky <Mimeo No country level oackiless. town& occurala aormalon Maas* AnO - was*, co cad than Inaba erd vaccine Pnnnr0 0 temNei MONIQtasnl IS Metal Siam 20111014 menasemord County wi'0001 Ceiba. of Dowilop loan> outdo( ornoroarce WO ItYp4CI C. Lorton mews unhanorg °won niocrc. 1D In:Wed McNeal 2000-2011 Myron Giond Tog Foto. Promcrla a strong 1486orUlp torn for HOYS el Stale n kr Distal MICA In SUSialiting TO Inman:10as frogass WM PrIcalzatkn 6 Nee" ovules 050 Indeed fAchael 20091012 poky tang County 2010. &xi:4y cnon SEEDR tr4a:no cots boon lot Ina. 041;060(03d Mari 045 Insect Ppoorva prowl 6 MOM. Loco; Tolal funding Oran° Inane* f&Ming 40 RI: -$3.592M 'Sano‘e g03014 -may n0400 Cenorenen8ht 94 EFTA01072510