COVID-19 Vaccine Collaborative Supply Planning: Is This the Next Frontier for Routine Immunization Supply Chains?
Publication date: 2023
PROGRAM CASE STUDY COVID-19 Vaccine Collaborative Supply Planning: Is This the Next Frontier for Routine Immunization Supply Chains? Laila Akhlaghi,aWendy Prosser,a Avotiana Rakotomanga,b Janet Makena,c Tochukwu Azubike,d Yahaya Bello,d Samson Emelike,e Liteboho Mothetsi,f Moroke Motuba,g Victor Olayemi,h Sam Samba,h Silvestre Suh,h Stevens Ramaroson,b Fatimata dit Ngo Yarroi Key Findings n To support the COVID-19 vaccine roll-out, a collaborative partnership, the Vaccine Collabora- tive Supply Planning Initiative, developed supply planning approaches building upon experiences from other health program products to review past consumption patterns and apply them to under- standing inventory situations, requirements, and shipments. n This Initiative applied best practices for supply planning, established a collaborative model with government decision-makers and partners, and used an adaptive learning approach to respond to the challenges of rolling out the COVID-19 vaccine. Key Implication n Immunization program managers can adapt this supply planning approach for routine vaccines to improve visibility into consumption and stock status and contribute to strengthening the overall management of the immunization supply chain. ABSTRACT In response to the COVID-19 pandemic, vaccine manufacturers quickly pivoted to develop vaccines, offering limited visibility into production timelines and quantities. Low- and middle-income countries developed vaccine introduction plans within the context of constrained global supply, unknown vaccine availability or timelines, and unknown demand. The Vaccine Collaborative Supply Planning (VCSP) Initiative was established to address the gaps in visibility of supply and demand of COVID-19 vaccines for improved supply planning. The Initiative drew from experi- ences with supply planning for other health program products. The Initiative’s 2 goals for introducing COVID-19 vaccines were to: (1) incorporate the use of supply chain data for forecasting, supply planning, and resupply decisions; and (2) establish a col- laborative model for governments and partners to learn and implement. Beginning in September 2021, the Initiative was op- erational in 15 countries through strategic partnerships with gov- ernment immunization programs and 7 partnering organizations. Partners noted the Initiative offered several benefits: enabled visi- bility into stock status; provided ability to triangulate service deliv- ery and stock data; provided insight into products at risk of expiry; facilitated tracking of monthly consumption patterns to in- form decisions; offered ability to create forecasting scenarios; provided support to national logistics working groups; improved coordination at the country level; created trust through transpar- ency across global partners; and offered opportunity for real-time adjustments through adaptive learning. Partners also noted chal- lenges, including the influence of political decisions and the avail- ability of quality data. The Initiative successfully applied best practices for supply planning, established a collaborative model with government decision-makers and partners, and used an adap- tive learning approach to respond to the challenges of rolling out the COVID-19 vaccine. Lessons learned and recommendations sug- gest how this approach can be used to strengthen forecasting and supply planning for all vaccines as the COVID-19 vaccine is inte- grated into routine services. BACKGROUND The COVID-19 pandemic’s disruptive effects in early2020 prompted a global effort to both reduce the im- mediate spread of the virus and develop effective vaccines to end the pandemic quickly. Bymid-2021, preclinical and clinical development of almost 300COVID-19 vaccine can- didates was underway, with regulatory approval for emer- gency use given to 6 vaccines, which were then deployed a John Snow, Inc., Arlington, VA, USA. b John Snow, Inc., Antananarivo, Madagascar. c inSupply Health, Nairobi, Kenya. dMinistry of Health, Abuja, Nigeria. e John Snow, Inc., Abuja, Nigeria. f John Snow, Inc., Maseru, Lesotho. gClinton Health Access Initiative, Maseru, Lesotho. hClinton Health Access Initiative, Freetown, Sierra Leone. i John Snow, Inc., Bamako, Mali. Correspondence toWendy Prosser (email@example.com). Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S1 mailto:firstname.lastname@example.org aelong Underline aelong Highlight worldwide.1 However, despite significant scaling efforts, limited manufacturing production capacity and input shortages—compounded by disruption in global supply chains—resulted in an opaque land- scape for production timelines and quantities. Additionally, countries producing the vaccine prior- itized domestic use, initially restricting exports to other countries, leaving many low- and middle- income countries (LMICs) without access to the vaccines.2 The global community took several measures to address the uneven supply and distribution of COVID-19 vaccines. The Vaccine Trade Tracker was established to monitor production across all manufacturers,3 and dose-sharing commitments were made to increase the flow of vaccines to LMICs.4 Gavi, the Vaccine Alliance, created the COVAX Facility to accelerate rapid vaccine produc- tion and ensure equitable access for all countries.5 Within the facility, the Gavi COVAX Advance Market Commitment is a separate funding mecha- nism, particularly for LMICs that heavily relied on donations to obtain vaccines. COVAX initially prior- itized high-risk, vulnerable populations and essen- tial health workers due to supply constraints. They designed the allocation plan for vaccine distribution to LMICs based on population size. Country COVID-19 coordination teams in LMICs, typically led by the Essential Programme on Immunization (EPI) within the ministries of health (MOHs), prepared for the new vaccine by developing national vaccine deployment plans. These plans defined distribution and campaign strategies, identified priority populations, and set targets for coverage.6 Vaccination plansweremostly designed as large-scale campaign efforts aimed to reach hundreds or even thousands of people daily in central locations with large vaccination teams with all the required supplies. However, thenational vaccine deployment plans were developed in the context of constrained supply, unknown vaccine availability or timelines, and unknown demand for these vaccines. The unknown demand was because the target populationwas different frompopulations that traditionally access immunization programs for routine immunization, which complicated the ability to ensure the availability of adequate stock levels. Furthermore, LMICs could have received vaccines through COVAX or other donors, bilateral donations directly from manufacturing countries, and some government self-procuring of vaccines, complicating the global planning perspective. In early 2021, the global community realized that it required new coordinating and planning approaches to ensure equitable vaccine availability where needed. The Vaccine Collaborative Supply Planning (VCSP) Initiative was established to address the gaps in visibility of both the supply and demand side of COVID-19 vaccines for improved forecast- ing and supply planning. Forecasting is the process of estimating the quantities of products that will be dispensed or used. Supply planning involves determining the total quantities of products re- quired, taking into account forecasted consump- tion, existing product in the pipeline, desired stock levels, shipping lead times, and desired arriv- al dates of shipments.7We document the rationale and global best practices that drove the design of the VCSP Initiative; describe the tools and collabora- tive approach; and provide evidence of success, fea- sibility, and acceptability, and potentially its use as a foundational approach for all vaccines, as immuni- zation programs are shifting to integrate COVID-19 into routine services. VCSP INITIATIVE DESIGN AND DESCRIPTION Noting the need for more robust supply planning to be used in practicewith the evolving immuniza- tion decisions, John Snow, Inc. (JSI), as the lead partner working with MOHs, EPI, and key part- nering organizations, drew from its experiences with supply planning for other health program products in designing the VCSP Initiative, particu- larly when faced with supply constraints and the need for collaboration. The Initiative had 2 prima- ry goals for introducing COVID-19 vaccines in par- ticipating LMICs (Table 1): (1) to incorporate the use of supply chain data for forecasting, supply planning, and resupply decisions; and (2) to estab- lish a collaborative model for governments and partners to learn and implement. Achieving these goals would make the case for these approaches for routine immunization and integration of the COVID-19 vaccine services into primary health care. Incorporate the Use of Supply Chain Data to Drive Forecasting, Supply Planning, and Resupply Decisions During the design phase, the VCSP Initiative iden- tified several technical priorities for forecasting, supply planning, and resupply decisions at both the country and global levels. These priorities were informed by the Global Family Planning Visibility and Analytics Network (GFPVAN, https://www.rhsupplies.org/gfpvan/), which was In early 2021, the global community realized that it required new coordinating and planning approaches to ensure equitable vaccine availability where needed. COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S2 https://www.rhsupplies.org/gfpvan/ http://www.ghspjournal.org aelong Highlight aelong Highlight aelong Underline aelong Highlight created in 2012 to improve coordination for the supply of family planning products. The GFPVAN established a collaborative space to track and fine- tune the flow of products across multiple coun- tries and coordinate with multiple donors (i.e., to avoid last-minute requests from countries, ensure product availability at the country level, minimize overstock and expiries, and providemore stable pre- dictability of the product need for manufacturers), resulting in improved product availability, proactive supply planning and budgeting by governments, and cost savings of more than US$100million.8 Based on the experience of the GFPVAN and tracking the challenges with the introduction of the COVID-19 vaccine, the Initiative prioritized country-led decisions and insights, ensuring data visibility to support those decisions. The VCSP Initiative aimed to shift the decision-making pow- ers to country leaders having and using their own data and evidence to forecast and plan their vac- cine needs based on actual demand, experience with mass campaigns, and a clear understanding of the stock status in their countries. The VCSP Initiative achieved this by develop- ing a country-based decision tool that adjusted the data collection and analysis typically done in an immunization program to be more appropriate for the dynamic supply and demand experience of COVID-19 vaccines. The tool was designed, vali- dated with country-level stakeholders, and con- tinuously revised based on feedback to improve usability and analytics for decision-making. The country teams were initially trained on the tool, and regular check-ins reinforced its use and pro- vided an opportunity to clarify any questions and/or adapt the tool. The tool reports and uses monthly consumption, which reflects a feasible expectation for the number of vaccines adminis- tered and people reached through campaign (or noncampaign) efforts. With this insight, decision- makers can review historical patterns to estimate how long the current stockwill last (with potential expiry estimates) and when and how much new stock is required. They can also use this informa- tion to determine different scenarios for campaign efforts and better manage and prioritize stock rotations based on potential expiries. This analysis provides the ability to change and update orders and supply plans to ensure a steady and predict- able supply.9 The Initiative also prioritized creating a stan- dardized, open, and transparent process across public, private, and government stakeholders. The GFPVAN put a considerable amount of effort into creating a network of partners, redefining processes for forecasting and supply planning, and identifying governance structures that were beneficial for all stakeholders. With that in mind, the VCSP Initiative created a similar standardized process and naming convention, aligned stake- holders on data-sharing expectations, and collec- tively developed a data-sharing agreement. Data were anonymized for noncountry stakeholders, and reporting and sharing mechanisms for global partners were established for insights that should be considered for global planning. As the largest procurers of vaccines in LMICs, COVAX closely tracked country-level consumption and potential expiries, constraints, and stock-outs of vaccines they procured. However, COVAX could not account for bilateral arrangements directly be- tween countries, direct donations, or other sources such as the African Vaccine Acquisition Trust. The VCSP Initiative approach prioritized a system that reports on and tracks all COVID-19 vaccines pro- cured by or donated to countries; the aggregate data provides greater global visibility than any single donor could without collaboration. The Initiative’s approach provides country-level insight to strengthen global planning, which, in turn, benefits countries.10 TABLE 1. Vaccine Collaborative Supply Planning Initiative Participating Countries and Partner Organizations Participating Country Partner Organization Democratic Republic of Congo VillageReach Côte d’Ivoire CHAI Ethiopia JSI Kenya inSupply Health Limited Lesotho CHAI Madagascar JSI Malawi JSI Mali JSI Mozambique VillageReach Niger JSI Nigeria JSI Sierra Leone CHAI South Africa Guidehouse Tanzania inSupply Health Limited Uganda PATH Abbreviations: CHAI, Clinton Health Access Initiative; JSI, John Snow, Inc. TheVCSP Initiative aimed to shift decision-making power to country leaders using their own data and evidence to forecast and plan their vaccine needs based on actual demand, experience with mass campaigns, and a clear understanding of the stock status in their countries. COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S3 http://www.ghspjournal.org Establish a Collaborative Model for Governments and Partners to Learn and Implement The global effort to get COVID-19 vaccines to bil- lions of people around theworld required a collab- orative approach among multiple stakeholders. Such partnerships are most effective when partners who are aligned on shared goals and purpose build understanding and trust and use common planning processes while investing in connections.11–14 From the beginning, the VCSP Initiative was designed as a collaborative model that leverages the strengths, expertise, and connections of all partners, with the government immunization pro- gram in the lead. JSI worked with partners to in- troduce the project and approach, and then countries self-selected for participation based on government and in-country partner interest. The Initiative identified strategic partners in priority countries that had strong relationships and dem- onstrated trust with the MOH and the EPI supply chain team. The team, which included Clinton Health Access Initiative, Guidehouse’s Global Health Supply Chain-Technical Assistance project, inSupply Health, PATH, VillageReach, and led by JSI, worked closely with the National Logistics Working Group (NLWG) in each country as the coordinator for the vaccine supply chain. EPI largely used mass campaigns to reach the most people in an efficient way with the new vaccine. Partnershad supply chain expertise butnotnecessar- ily extensive experience with supply planning. The VCSP Initiative also prioritized building and main- taining relationships with global partners, such as Gavi, COVAX, the World Health Organization, UNICEF, and the U.S. Agency for International Development. Within 8 months of starting, the VCSP Initiative organized a retreat to build a com- munity of vested and trusted partners aligned on a common goal and purpose for the Initiative, being transparent about challenges faced by countries. A second retreat then continued the objectives to build community by increasing participation, sharing les- sons learned, and strategizing on what would be needed for the future of the collaboration.15 The VCSP Initiative established regular touch- points with and between all partners through a WhatsApp group and regular check-ins, creating a network where partners shared information and sought support from other partners directly. The Initiative designed anadaptive learning approach to facilitate continuous learning and optimize pro- gram effectiveness.16 The approach systematically collected information on the implementation process of the Initiative, collaboration aspects, and the techni- cal aspects of supply planning and vaccine introduc- tion. The VCSP Initiative shared this information with key stakeholders at the appropriate time to en- sure understanding and consideration by decision- makers and adjust the approach and tools in real time. Collectively, the project team across all coun- tries, together with government stakeholders, continuously tracked progress and documented insights into lessons learned and key success fac- tors of the decision tool and collaborative ap- proach. We present the results of demonstrated benefits as well as challenges identified since the start of this Initiative. IMPLEMENTATION RESULTS Since its inception in September 2021, the VCSP Initiative has expanded its operations from 5 to 15 countries through strategic partnerships. Six partnering organizations work closely with the EPI and other in-country partners. The decision tool used the same consumption and supply data available to in-country teams managing the COVID-19 efforts but analyzed it differently, which was more appropriate for a dynamic envi- ronment. Partners noted that the VCSP Initiative introduced several innovative ways of data man- agement and analysis that were not previously routinely used in immunization programs, result- ing in demonstrable benefits and making the case for integrating these innovativemethods of forecast- ing and supply planning into routine immunization efforts.17 Although partners noted the benefits, full adoption of the Initiative into routine immunization efforts requires longer-term effort, policy changes, ongoing technical support and capacity-building, and global guidance beyond the scope of this project. The VCSP team also noted ongoing challenges that the Initiative faced during implementation. It is important to note that the indicators and visuals presented are only simulated data and are not re- flective of any country. They are included as an example of how this approach is applied and how the data is used. Benefits Enabled Visibility Into Stock Status and Months of Stock Partners noted that the VCSP tool enabled the EPI supply chain managers to determine resupply or order quantities, monitor supply plans and supply chain status, and monitor performance at subna- tional levels. This allowed them to ensure that Partners noted that the VCSP Initiative introduced innovative ways of data management and analysis, resulting in demonstrable benefits and making the case for integrating these innovative methods of forecasting and supply planning into routine immunization efforts. COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S4 http://www.ghspjournal.org aelong Highlight aelong Highlight aelong Highlight aelong Highlight aelong Highlight aelong Highlight there was enough (but not too much) product available to meet the needwherever and whenev- er it was needed. It did this by providing visibility into the stock status as a relative measurement of the period of time that the stock would last based on average rates of most recent consumption. Decision-makers were also able to determine whether to postpone orders for the sake of avoid- ing constraints on the cold chain. Additionally, us- ing stock levels and months of stock as a metric allowed for more efficient and effective monitor- ing of the supply (Figure 1). Provided Ability to Triangulate Service Delivery and Supply Chain Data The VCSP tool combined data from both service de- livery and supply chain to provide visualizations that supported decision-making, making it a unique aspect of the tool. Service delivery data, which in- cluded vaccine consumption that is calculated using doses administered and wasted, was com- bined with supply chain data, capturing all incoming shipments with their relevant specifi- cations (e.g., expiration dates) and any adjust- ments made to the stock level (Figure 2). The decision tool documented any changes to the bal- ance, highlighting data quality issues. For exam- ple, the tool could alert users that there was no usable product available to be reported as used (circled in Figure 2). Partners reported that this feature led to careful reviews of both sets of input data and corrective action to improve data quality not just for COVID-19 vaccines but for all vaccines. FIGURE 1. Vaccine Collaborative Supply Planning Tool Dashboard Chart Displaying the Summary of Vaccine Stock Status Abbreviation: MOS, months of stock. FIGURE 2. Data Entry Example in Vaccine Collaborative Supply Planning Tool Combining Both Service and Supply Chain Data and Flagging Possible Errors Abbreviations: HIS, health information system; LMIS, logistics management information system; MOS, months of stock. COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S5 http://www.ghspjournal.org aelong Highlight Gained Insight Into Products at Risk of Expiry The process of entering data into the VCSP tool re- quired the inclusion of shipment details, such as expiry dates. The triangulation of data on con- sumption, stock levels, and estimated expiries by applying the assumption of first-expiry, first-out rules identified when and how many doses had the potential to expire (Figure 3). The analysis of these data allowed countries to prioritize certain vaccines for distribution and campaigns and/or reallocate vaccines at risk of expiry to other coun- tries that could more readily use those vaccines at that moment. Furthermore, to address the short shelf life of vaccines received in the early phases of the vaccine roll-out, countries took measures, such as setting policies for minimum acceptable shelf life from donors and manufacturers. Facilitated Tracking of Consumption Patterns by Month to Inform Decisions Related to Both Supply and Demand Other health programs routinely track monthly consumption, but this type of analysis was not standard practice in immunization programs, as monitoring tended to track coverage rates over time based on aggregate vaccine administration. However, due to the unstable context of the COVID-19 vaccine and the need to adapt process- es for the changing cohort receiving the vaccine, there was a demand for additional data to support decision-making. The VCSP decision tool addressed this need by providing monthly consumption pat- terns that included both doses administered and wasted, allowing for the identification of the effects of campaign efforts on consumption, which aided in understanding future demand, given available resources (Figure 4). This led to more effective de- mand creation, optimized vaccine distribution to sub- national levels, andadjustments to required resources. Partners noted that the tool provided the ability to ad- just supply planning in response to emerging issues with better timing of deliveries andpreferred vaccines. Offered Ability to Create Various Forecasting Scenarios Decision tool users could create various scenarios based on consumption patterns, target goals, and re- alistic expectations ofwhatwas feasible to see the ef- fect on stock status and expirations. These scenarios could be used in discussions to proactively deter- mine the quantity and timing of future orders, reject orders, review the magnitude and timing of poten- tial expiries, review changes to coverage rates, and assess the capacity of the system to provide the nec- essary vaccinations required per month to reach goals. Using the possible outcomes generated by the scenario generation feature, managers could pre- empt and mitigate potential supply chain risks for all possible outcomes. FIGURE 3. Example of Vaccine Collaborative Supply Planning Tool Dashboard Table Displaying Quantities at Risk of Expiry Given Current Average Consumption Rates a Total assumes no preference for products being administered. COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S6 http://www.ghspjournal.org aelong Highlight aelong Highlight aelong Highlight Provided Support and Reinforcement for NLWG Partners highlighted that the VCSP Initiative rein- forced the role and skills of the NLWG. The intro- duction of the COVID-19 vaccine required the NLWG to adjust its management style to respond to the complex environment that lacked both visi- bility into vaccine supply and/or demand from the new cohort of patients. The Initiative provided a structured approach for supply planning, which the NLWGs in the 15 countries adopted. In some instances, the Initiative collaborated with in- country partners to revise the terms of reference of the NLWG, clarifying roles and responsibilities for reviewing stock status. The VCSP Initiative in- troduced a draftmonthly report as part of the stan- dard processes of the NLWG, enabling the NLWGs to elevate supply chain decisions to higher-level decision-makers with the evidence necessary for optimal supply planning. One country also hired new staff for data management for the supply chain based on the new understanding of how the vaccine roll-out was progressing. Improved Coordination at Country Level Government leaders and immunization program managers engaged in-country partners to support the impressive introduction of COVID-19 vaccines. One benefit that the VCSP Initiative partners noted was the coordination effort required by the VCSP de- cision tool, which drew data from service delivery as well as supply chain actors and systems. This collabo- ration requireddifferent stakeholders towork togeth- er to input and analyze the data. The partners noted that this approach was helpful to other areas of vaccine introduction, including identifying where demand-generation activities would be beneficial andhowtobest distribute thepreferredvaccinebased on previous consumption and availability. Through this structured data review and collaborative process, trust was built across partners, contributing to more transparency, increased sharing of data, and, ulti- mately, more proactive supply planning not only for COVID-19 vaccines but for all vaccines. Created Trust Through Transparency Across Global Partners The VCSP Initiative made significant efforts to en- gage all partners in an open and transparent man- ner at the global level, providing high-level insight into global consumption and supply trends using aggregate country-level data. Country-specific data was shared only by the EPI through standard channels for donor reporting and procurement decisions and was not reported by the Initiative, which contributed to country ownership and rein- forced trust in the process and data use. Offered Opportunity for Dynamic Approaches Through Adaptive Learning The VCSP Initiative developed a self-assessment framework that tracked and measured the evolu- tion of supply planning activities. This was devel- oped through adaptation of the Supply Chain Evolution Framework.18 The country teams, which included the VCSP country lead, EPI, and partners, regularly evaluated the country’s progress FIGURE 4. Example of Vaccine Collaborative Supply Planning Tool Dashboard Chart Showing Consumption (Doses Administered and Wasted) of Vaccines Per Month With Coverage of Target Population COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S7 http://www.ghspjournal.org in COVID-19 vaccine supply planning, moving along the continuum of ad hoc to reactive to proactive response. Technical aspects of supply planning and management were assessed using aspects listed in Table 2. The self-assessment was subjective and allowed teams to critically reflect and analyze their supply planning process to iden- tify the areas that needed improvement to adapt to changing circumstances. Country teams shared their insights with all partners, creating opportu- nities for cross-country collaboration and learn- ing. Over the course of the Initiative, countries made progress along the evolution continuum to- ward more proactive supply planning by addres- sing and prioritizing the weakest technical areas. The assessment results were not used to rank countries based on their performance and were anonymized while sharing them among teams. Although all 9 benefits are notable, building capacity and providing support for the NLWG may contribute the most to stronger management of the immunization supply chain for all vaccines. This approach introduced new supply planning techniques to the NLWG, bringing in best practices from other health areas not normally considered by EPI and providing an opportunity for growth and skills development. Challenges Faced by VCSP Political Decisions Not Informed by Technical Insight Country COVID coordination teams faced political decisions, such as accepting bilateral donations, which may not have aligned with sound stock management, cold chain capacity, feasibility of large-scale campaigns, or the preference or efficacy of the vaccine. Furthermore, countries’ initial targets for COVID-19 vaccine coverage were established based on several unknowns, including unclear esti- mates of a new vaccination cohort not previously targeted for vaccines. In addition, targets were de- veloped with the assumption that the country had the ability and the capacity to implement the vacci- nation plan without commensurate support and resources. Although theVCSP tool could provide ev- idence of the impact of these politically driven deci- sions and offer scenarios to minimize risks, political considerations often overshadowed the supply chain considerations. Lack of Data Quality, Availability, and Information Management System The VCSP team observed a common issue across all countries, particularly in the initial months of the Initiative, which was lack of access to data, poor data completeness and quality, and/or delayed reporting. Specifically, unavoidable and avoidable vaccine wastages were least likely to be reported across countries. Although there has been some improvement in the quality and timeliness of reporting through structured data review, im- munization programs still face systematic and consistent challenges with access to complete, quality, timely, and disaggregated data. Moreover, immunization programs in VCSP countries expressed concerns about the VCSP tool being a separate system instead of being integrated into existing logistics management information systems or health management information systems. TABLE 2. Supply Planning and Management Technical Aspects Regularly Reviewed for Adaptive Learning for the Vaccine Collaborative Supply Planning Initiative Technical Aspects Characteristics to Rank (Ad Hoc–Reactive–Proactive) Adjustments � Communicated � Funded � Implemented Analysis � Routine assessment � Scenario monitoring � Supply plans � Updated forecasts � Vaccine expiry Data � Access � Accuracy � Reliable system � Reporting practices Commitment � Resources allocated � Stakeholder commitment � Stakeholder inclusion � Terms of reference existence Meetings � Actions reviewed � Evidence-based decisions � Flexibility ad hoc meetings � Risks addressed � Scheduled � Stakeholder inclusion � Timely decision-making The VCSP team observed a common issue across all countries: lackof access to data, poor data completeness and quality, and delayed reporting. COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S8 http://www.ghspjournal.org RECOMMENDATIONS As the urgency of COVID-19 has waned and the epidemic has become endemic, immunization programs are shifting attention to integrating the COVID-19 vaccine into primary health care and routine immunization services, with this process still in its early phase of being rolled out. The les- sons learned and benefits that were achieved through the VCSP Initiative provide a foundation for strengthening supply planning for all vaccines. Based on the insight from the VCSP Initiative re- lated to the evolution of data systems, global and country-level experiences gained from COVID-19 vaccine supply chain management, and the readi- ness and interest of immunization programs, we offer the following recommendations for applying these approaches for improved supply planning and forecasting for all routine and new vaccines. Moving forward with both country and global recommendations is integral to the success of this approach. For Country Immunization Programs � Incorporate and triangulate supply chain data with service delivery data for immunization supply chain decision-making. This reinforces the need for robust supply chain data systems, as noted by global thought leaders.10 Partners noted that the increased use of supply chain data from logistics management information systems and its triangulation with health man- agement information systems data supported strengthened logistics management information systems in immunization, both for validating the data and its use in decision-making (e.g., ensur- ing that there were sufficient supplies to meet vaccination plans). Immunization programs ac- knowledged the benefit of the VCSP approach for the COVID-19 vaccine and expressed interest in applying similar approaches to routine vac- cines and related supplies, and at the subnational level, in recognizing that the process would re- quire long-term change management to adapt to routine vaccines. The VCSP Initiative approach was foundational for strengthening supply fore- casting and planning for all vaccines, including for the integration of the COVID-19 vaccines into routine services. � Evaluate multiple forecasting methods to im- prove the validity and accuracy of the final fore- cast. The incorporation of alternative forecasting methodsusing consumptionorbottom-upanaly- sis for routine vaccines, in addition to those using demographics and coverage goals, could result in more valid and accurate forecasts for all vac- cines.19 This would be especially important for donors procuring vaccines and governments that self-finance or cofinance routine vaccines and enable them to evaluate more than 1 future scenario, resulting in increased accuracy, agility, and autonomy. � Integrate the supply planning indicators and visuals demonstrated by the VCSP Initiative into the centralized system for supply chain management of all vaccines rather than as a stand-alone tool. � Leverage existing relationships and the estab- lished trust of the collaborativemodel to continue the accelerated strengthening of supply chain management systems for vaccines. Partners who worked closelywith the EPI and theNLWG, both within countries and across countries, noted that the collaborative nature of the VCSP Initiative was among its strengths. � Enforce inventory management policies (e.g., minimum and maximum stock levels) for vac- cine supply chain management and ensure adherence at all supply chain levels. As immu- nization programs mature, it may be timely to apply this standard in a practical way, learning from the COVID-19 experience to adopt into primary health care and routine immunization services. For Global Immunization Stakeholders � Establish a global coordinating body to provide an unbiased forum for vested partners to re- view, predict, and identify potential discor- dance between vaccine supply and demand, as demonstrated by GFPVAN and the VCSP Initiative. A coordination body is instrumental in strengthening the preparedness of global supply chains to respond to our ever-changing global health environment (e.g., local manufacturing of vaccines, new vaccine introduction, shifting disease patterns, and future pandemics).11 � Establish a mechanism to gather standardized and real-time supply chain data for vaccine de- mand and supply across multiple countries. This mechanism would enable increased visi- bility, which is essential to effective and effi- cient global vaccine management (e.g., global forecasting, manufacturing, new product in- troduction, and equitable and appropriate distribution).7 COVID-19 Vaccine Collaborative Supply Planning for Routine Immunization www.ghspjournal.org Global Health: Science and Practice 2023 | Volume 11 | Supplement 4 S9 http://www.ghspjournal.org � Adapt and expand global guidance to LMICs to incorporate contextualized local needs and the ever-evolving science of supply chain manage- ment to support more agile and responsive vac- cine supply chains. CONCLUSIONS The VCSP Initiative successfully applied best prac- tices for supply planning, established a collabora- tive model with government decision-makers and partners, and used an adaptive learning ap- proach to respond to the challenges of rolling out the COVID-19 vaccine. The Initiative increased visibility into country COVID-19 vaccine supply chain data, forecasting, and supply planning, leading to evidence-based decisions by countries on vaccine shipments and demand plans. Government stake- holders provided positive feedback on the Initiative’s success, feasibility, and acceptability and expressed interest in extending the approach to routine vac- cines and to lower levels of their supply chain. Improving supply planning for all vaccines can fur- ther strengthen the overall immunization program as it continues tomature andprovidea strong founda- tion for the integration ofCOVID-19vaccines into pri- mary health care and routine immunization services. The next stepswill shift the focus to incorporating this approach to routinevaccines in a few follow-on coun- tries to show its value, engaging global partners such as Gavi, UNICEF, and theWorld Health Organization to endorse potential changes. The VCSP Initiative’s success demonstrates the potential for a data-driven approach to supply planning to support immuniza- tion programs in achieving their goals. Acknowledgments: The Vaccine Collaborative Supply Planning Initiative was a collaborative effort that was made possible only with the support and engagement of ministries of health and immunization programs in multiple countries (Cote d’Ivoire, Democratic Republic of Congo, Ethiopia, Kenya, Lesotho, Madagascar, Mali, Malawi, Mozambique, Niger, Nigeria, Sierra Leone, South Africa, Tanzania, and Uganda) and through the technical support from all Initiative partners (Clinton Health Access Initiative, Guidehouse’s Global Health Supply Chain-Technical Assistance project, inSupply Health, PATH, VillageReach, John Snow Health Zambia, and John Snow, Inc.). We would also like to acknowledge global partners from UNICEF, World Health Organization, and Gavi, the Vaccine Alliance for their participation in this Initiative. Funding: The Vaccine Collaborative Supply Planning Initiative was supported by the Bill & Melinda Gates Foundation grant #INV-036328. Author contributions: LA was responsible for the conceptualization, methodology, formal analysis, and investigation of this work and for writing and critically reviewing the article. WP led the writing of the original draft and contributed to the investigation and formal analysis. AR and JM significantly contributed to the formal analysis, investigation, and supervision of the work, as well as reviewing thewriting of the article. TA, YB, SE, LM, MM, VO, SS, SS, SR, and FY contributed to the formal analysis and investigation of the work, as well as reviewing the writing of the article. All authors reviewed and approved the final article. Competing interests: None declared. REFERENCES 1. Li Y, Tenchov R, Smoot J, Liu C,Watkins S, ZhouQ. A comprehensive review of the global efforts on COVID-19 vaccine development. ACS Cent Sci. 2021;7(4):512–533. CrossRef. 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