Knowledge Brief Health, Nutrition and Population Global Practice CHALLENGES AND OPPORTUNITIES OF SUPPLY CHAIN IN TIME OF COVID-19 Rialda Kovacevic, Marasi Mwencha, Ahmed Ouma, Moji Christianah Adeyeye, Olamide Folorunso, Ken Legins, Souleymane Kone June 2021 KEY MESSAGES: • Nonstandard operational characteristics and labeling of new vaccines pose handling and utilization challenges • The multiplicity of bilateral vaccine supports without cold chain insights created challenges for supply chains • Global coordination of different funding opportunities for cold chain equipment is recommended • Sustainable governance structures are country-driven, broadly collaborative, and coordinated across government agencies • Traceability and safety monitoring must be part of the vaccines’ supply chain • It is necessary to focus on key enablers such as capacity-building by providing training for member states to ensure resources at the country level are properly coordinated • There must be strong coordination at the continental and country-level, so all efforts are synergistic Introduction COVID-19 Vaccine Cold Chain A supply chain is an essential building block of any health system. During the COVID-19 pandemic, supply chains COVID-19 vaccines are imposing challenges on have been forced to respond with unprecedented global supply chains. The first is the vaccines current resilience, speed, and agility to cope with the situation at release under emergency use, which means vaccines’ hand. Complete, end-to-end inventory visibility is vital to formulation, labeling, and storage characteristics are still understand when vaccines, therapeutics, or diagnostics only partially understood. Further complexities are will be available for use. introduced by countries receiving multiple vaccines that As one of the seven workstreams of Access to COVID-19 have or will have different profiles for their respective Tools Accelerator (ACT-A) Health Systems Connector supply chain needs. The COVID vaccines have diverse (HSC), the supply chain workstream, and country temperature ranges, starting from ultralow at -70°C and counterparts share some insights and lessons deep freezing at -20°C, to the traditional range of 2–8°C. learned. The second level of challenge for global supply chains is the target population, which is different than the “usual” population of national immunization programs—that is, Page 1 HNPGP Knowledge Brief • children. Rather, the focus for COVID vaccine initial • There are insufficient coordination mechanisms recipients is high-risk adults with comorbidities and to ensure that parallel deals and supplies and frontline workers. Furthermore, worldwide supply chains COVAX supplies do not surpass countries’ cold are facing logistics constraints, uncertainties about when chain capacity to accommodate simultaneous the vaccines will be received and ease of access, shipment arrivals. including overcoming the burden of equitable distribution to the general population and service Lessons learned while working on the COVID vaccine providers. One of the biggest challenges is the scale of supply chain: the vaccination endeavor, as this is the first time • Global coordination of different funding vaccination interventions attempt to reach all countries opportunities for cold chain equipment is and all populations at the same time. Another big issue recommended. on the horizon is the amount of waste that will be • Upgrading recipient countries’ cold chain generated and the need for it to be disposed of safely. infrastructure is also recommended. Concerns regarding the vaccines also include their • Learning opportunity much appreciated by traceability and safety monitoring. There must be country teams regarding: coordination among all partners to undertake these • familiarization with global methods and activities. tools for cold chain assessment and gap analysis Partners, including members of the supply chain • Introduction of WHO-UNICEF cold chain workstream of the Health Systems Connector (HSC), have equipment (CCE), including new contributed to country capacity-building. This includes temperature monitoring devices at country support guidance and tools such as COVID-19 national and subnational levels supply and logistics guidance, as well as cold chain • Cold chain demand beyond the support available equipment inventory and the gap analysis tool. 1 2 from Gavi is expressed by many countries. These tools aim to provide real-time access to COVID-19 Africa Centers for Disease Control Supply Chain Strategy vaccine operational characteristics; harmonize processes Lessons Learned and methods for cold chain needs assessment across regions and countries; facilitate the provision of technical As COVID-19 first began to spread, countries of the assistance in a large number of countries; and streamline African continent came together and organized the development and review of country proposals for themselves to face the challenge of disrupted supply Gavi support. chains. Africa Centers for Disease Control and Prevention (CDC) has been at the forefront of ensuring that the Challenges countries have faced in terms of the COVID supply chain for COVID-19 commodities is uninterrupted vaccine supply chain: during the pandemic. The objective of Africa CDC is to • The multiplicity of bilateral vaccine supports ensure the flow of good quality and reasonably priced without cold chain insights created challenges for health commodities. Governments of African Union supply chains. Most lower-middle-income member states gave a clear mandate to Africa CDC to countries are receiving two or more vaccines facilitate negotiations with manufacturers to procure without relevant guidance on the cold chain. vaccines and other health commodities at best prices. Furthermore, the lack of information on bilateral The continent as a whole enjoys the comparative vaccines’ operational characteristics has been a advantage of a large market (more than 1.3 billion frequent issue. people). The decision allowed the continent to pull its • Nonstandard operational characteristics and efforts together and to approach manufacturers and labeling of new vaccines pose handling and providers jointly. The Africa CDC established the Africa utilization challenges. Medical Supplies Platform (AMSP), where other health 1 https://www.who.int/publications/i/item/who-2019-ncov- 2 https://www.technet-21.org/fr/library/main/6841-cold- vaccine-deployment-logistics-2021-1. chain-equipment-inventory-and-gap-analysis-tool. Page 2 HNPGP Knowledge Brief commodities required for the pandemic response can cross-purposes. This also requires that partners align also be sourced. Many governments on the continent do with the country plan that is proposed by the not have a high enough reach to access suppliers and government. manufacturers, which leaves them vulnerable to distributors that charge a premium in comparison to what they themselves pay to manufacturers. With the Implementing Pharmaceutical Traceability in Nigeria— creation of a medical supply platform, suppliers can National Agency for Food and Drug Administration and come directly to Africa CDC. Prices are negotiated in Control—Pilot COVID-19 Vaccines Traceability Activities advance, and all products available on the platform are African representatives of the national and vetted. On paper, many countries indicate readiness regional economic communities, development partners, regarding redistribution of commodities, but the ground and the private sector agreed to work together to create situation is different, as systems are becoming sustainable governance structures that are country- overwhelmed. driven, broadly collaborative, and coordinated across government agencies. Further, they wanted to There is a need to focus on key enablers, such as strengthen regulatory policies and procedures, including capacity-building, and to make sure there are alternate standardized health commodity labeling guidelines that systems for augmenting storage and distribution reinforce pharmaceutical traceability goals. The National capacity, as well as for building robust systems of Agency for Food and Drug Administration and Control’s governance. To avoid duplication of effort, governance (NAFDAC) objective is also to implement automatic ought to be improved by strengthening coordination at identification and data capture technologies and support the country level. The government must take leadership process improvements to advance supply chain here; if it has a strong team in place, coordination should efficiencies and invest in the underlying health systems not be an issue. Africa's medical supply platform was a infrastructure that enables verification and Track and first step, an emergency measure, to make sure good Trace of pharmaceuticals through the supply chain. quality products are available and accessible to Partnering with GS1 Nigeria lent further credence to the governments in Africa. Africa CDC has started a journey agency’s resolve to deploy the Track and Trace system in toward local production across the spectrum, from the strengthening Nigeria’s supply chain. The office at simple (e.g., masks) to the complex (e.g., vaccines). Local NAFDAC is responsible for driving the implementation of production is encouraged in two ways: First, the Nigeria Traceability Strategy and the development of governments are encouraged to provide some relief to the necessary regulatory framework. the private sector, which wants to set up manufacturing facilities for some of the commodities that are needed on COVID-19 vaccine traceability implementation included the continent. Second, the Africa CDC and the African the preparation stage, which focused on proposal Union are providing a platform for strategic discussion, development, call to action and participants resource mobilization, and coordination of who confirmation, information and requirements gathering, manufactures what, to guarantee a ready market and design and deployment of the traceability prototype avoid flooding of the market with a single item; this way platform, and approval of proposals by stakeholders. This access and the supply chain are improved in the medium stage was followed by the assembly of items and and long terms. training, which focused on protocol development, development and deployment of software/mobile apps, The continent has a range of experts in the supply chain, purchase of hardware and 2D barcode readers, collection but coordination of this expertise is still not adequate. of master data, confirmation of the presence of Africa CDC is establishing capacity-training for member traceability features on vaccines secondary packs, testing states to ensure resources at the country level are of the prototype traceability platform, and training on properly coordinated. This allows capacity-building scanning and data input. Currently, NAFDAC is in the within the country, as opposed to importing expertise deployment stage, which includes inspection of vaccines from outside and having short-term solutions. There at the port of entry and capturing event data as they must be strong coordination at the continental and country level so all efforts are synergistic and not at Page 3 HNPGP Knowledge Brief • move through the supply chain. NAFDAC is expected to analyze these results. NAFDAC is collaborating with health care supply chain actors for COVID-19 AstraZeneca vaccine (from the Serum Institute of India [SII]) in Nigeria’s 36 states plus the Federal Capital Territory (FCT) and in over 400 facilities (including national, zonal, state, and local government warehouses and health care facilities). The Track and Trace was made possible using the Global Trade Item Number (GTIN) from master data obtained from SII, locally assigned Global Location Numbers (GLNs), and GS1 standards. The port of entry for vaccines is the Abuja International Airport, from where vaccines with secondary packaging barcoding are taken to the central cold store warehouse, scanned, and transported to state warehouses, where allocated vaccines are scanned to confirm the number that left the central warehouse. Ongoing data collection and analysis of the scanned vaccines is meant to identify any potential infiltration of the supply chain and to support pharmacovigilance activities for the COVID-19 vaccine. Currently, data from scanning of the vaccine from two Nigerian states are not archived. The Health, Nutrition, and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health or disseminate new findings and lessons learned from the Regions. 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