Enhancing Immunization Data Visibility and Action at District Level in Rivers State, Nigeria

Data Visibility and Action from a District Level perspective in Rivers State, Nigeria TechNet-21 Conference Francis Ibama Akuku Toru District Level Cold Chain Officer October 18th, 2017

Nigeria is made up of 36 states across six geopolitical zones with a Federal Capital Administrative map of Nigeria showing States and the Federal Capital Nigeria operates a federal system of Governance Sokoto Katsina Jigawa Yobe Zamfara Borno 2017 Projected population 198,167,916 Kano Kebbi Kaduna Bauchi Gombe Niger Number of public health facilities offering RI = 25,350 Adamawa Kwara Plateau kkm FCT Nasawara Oyo Taraba Kogi U-5 mortality rate: 125 per 1000 live births* OsunEkiti Rivers State Benue Ondo Ogun Enugu Edo Ebonyi Lagos Cross River Abia Rivers state is located in the south- south geopolitical zone in Nigeria. Imo Delta Rivers Bayelsa Akwalbom | 2 2 SOURCE: Rivers State Logistics Working Group

Rivers state is located in the south-south zone with 23 districts Map of Rivers state showing the District and Senatorial Zone Rivers state at a glance Nyesom Wike Port Harcourt Governor Capital Governance 6,775,581 271,023 11,0777 Km2 23 319 Total population < 1yr Population Land mass No. of District No. of wards Demography1 $3,965 USD GDP per capita2 BCG: 82% DPT3: 66% Measles: 71% Immunisation coverage rates3 358 public facilities 150 private facilities Healthcare facilities 1. RSPHCMB 2013 2. World Bank Data 3. Data from NICS/MICS Survey 2016 4. Administrative Data | 3 SOURCE: Rivers State Logistics Working Group

Immunization Supply Chain in Nigeria Vaccinetravel Vaccinetravel Vaccinetravel Vaccinetravel NationalStrategic Cold Store Manufacturer District Level Cold Stores StateCold Stores HealthFacilities Zonal Cold Stores 3 2 1 Vaccines administration DATA DATA DATA 4 Mother & Child Data is generated at all levels of the immunization supply chain system | 4

Multiple systems existed but poorly coordinated and not readily translated to action Problem Description Implication Status of vaccine stock unknown at health facility and district levels High wastage rates and poor vaccine management practices across health facilities No data visibility 1 1. Inequitable allocation, distribution and prioritization of new cold chain equipment (CCE) 2. Unstructured and uncoordinated CCE maintenance 3. Recurrent vaccine stock-out including under and overstocking of health facilities No analysis carried out to inform data-driven decisions on vaccine allocation or redistribution, when required Vaccine allocation and distribution not informed by data No use of data for action 2 No governance structures to guide, inform and uphold accountability frameworks Vaccines used during immunization sessions were poorly accounted for by Health workers Poor accountability 3 | 5 SOURCE: Rivers State Logistics Working Group

Rivers state logistics working group instituted a data review system through 3 key interventions to improve data visibility Intervention Screenshot Details Provides insight into cold chain functionality status on a monthly basis. The inventory management system was deployed in 2013. Cold Chain Inventory 1 This stock management system provides a unified platform to aggregate, record, analyse and validate stock data. This stock management system was deployed in 2015 2 NLMIS Health Workers Response Management Response System Utilization and Visibility into Facility TMC Data Availability of CTMD Reporting to Higher Level Progress per KPI --------------> Temperature monitoring dashboard The excel-based dashboard allows CCE temperature readings to be documented and temperature excursions flagged. This dashboard was deployed in 2016 % HF with excursion that activated contigency plan LGAs that reported excursions and discussed at RI Review meeting? % LGAs that reported Dashboard for the month LGAs that reported Dashboard for the month % HFs reporting TMC data % HFs with Freeze Excursion LGA TMC Data was discussed at SLWG 3 Nasarawa State LGA Reporting rate % of HFs with CTMD % HFs with Excursion LGA Nasarawa State HF Reporting rate Nasarawa state HF Response rate Percentage of HFs with CTMD Management response Akwanga Awe Doma Karu Keana Keffi Kokona Lafia Nasarawa Nasarawa Eggon Obi Toto Wamba Total 50% 33% 60% 56% 100% 0% 50% 67% 50% 100% 100% 33% 20% 55% 100% 100% 80% 111% 100% 133% 100% 117% 25% 100% 67% 33% 80% 90% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 60% 6% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 100% Yes 100% 55% 90% 100% 100% 100% 100% 100% 0% 100% Tools provided enhanced visibility and improved efficiency in our vaccine supply chain process across all districts in Rivers state | 6 SOURCE: Rivers State Logistics Working Group

Data flows through multiple systems from the service delivery to the District Level and is consolidated for response and upward transmission Analytics Multiple System/Sources The Multiple data sources provide visibility for action Data Visibility The efficient system delivers: The right product in the right quantities and the right condition to the right place at the right time for the right cost Response Manual Compilation Data Visibility Program Vaccine Availability/Potency for uptake Higher level Store | 7

Although there are multiple systems and technology, the people, processes and policies remain the same Cold Chain Inventory TMC Dashboard NLMIS Health Workers Response Management Response System Utilization and Visibility into Facility TMC Data Availability of CTMD Reporting to Higher Level Progress per KPI --------------> % HF with excursion that activated contigency plan LGAs that reported excursions and discussed at RI Review meeting? % LGAs that reported Dashboard for the month LGAs that reported Dashboard for the month % HFs reporting TMC data % HFs with Freeze Excursion LGA TMC Data was discussed at SLWG Nasarawa State LGA Reporting rate % of HFs with CTMD % HFs with Excursion LGA Nasarawa State HF Reporting rate Nasarawa state HF Response rate Analytics Percentage of HFs with CTMD Management response Akwanga Awe Doma Karu Keana Keffi Kokona Lafia Nasarawa Nasarawa Eggon Obi Toto Wamba Total 50% 33% 60% 56% 100% 0% 50% 67% 50% 100% 100% 33% 20% 55% Temperature Monitoring 100% 100% 80% 111% 100% 133% 100% 117% 25% 100% 67% 33% 80% 90% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 60% 6% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 0% Yes 100% Yes 100% 55% 90% 100% 100% 100% 100% 100% 0% 100% Stock The Multiple data sources provide visibility for action CCE Data Visibility Management Monitoring Restock all facilities based on allocation plan from the NLMIS Response Prioritize the CCE for CCEM based on the analytics of the TMC Data CCE allocation & reallocation decisions are made Manual Compilation Data Visibility Program Vaccine Availability/Potency for uptake Higher level Store | 8

Case study 1 Stock Data Visibility After deploying visibility system Using the NLMIS system which includes the weekly stock balance report from the facility, I can determine when facility stock levels are at or below buffer level, and issue emergency stock before a stock out Prior to deploying visibility system There was no system in place for facility to request stock before stock outs occurred, I could only issue stock to facilities after they had reported a stock out. Impact There is availability of vaccines for uptake owing to the increased number of doses I issued the health facility. This provides evidence for me to advocate to the state government for an adjustment of target population in that catchment area. Following the introduction of the data visibility system into stock, I am now able to; Make better allocation decisions to avoid over-stocking or stock outs Hold higher level stores accountable due to visibility I now have into facility stock performance | 9

Case study 2 Temperature Monitoring with Cold Chain Equipment Maintenance After deploying visibility system Prior to deploying visibility system Now, I have insight into health facilities temperature data. Using this data, I can provide appropriate responses. I had no insight into CCE efficiency as health facilities only reported CCE break down when it happens. Impact This has helped me reduce CCE downtime in my district and ensure availability of safe and potent vaccines to mothers and children. In my resource constraint environment, this data provides evidence for me to prioritize CCEs for maintenance. With the data visibility systems into CCE Performance, I am able to; Prioritize resource allocation for CCE maintenance and repairs through interpretation of the analysis | 10 SOURCE: Rivers State Logistics Working Group

Case study 3 Closing Cold Chain gaps through Equipment allocation Prioritization After deploying visibility system Prior to deploying visibility system Impact I also advocated to the state Government for equity based allocation of CCEs My district is on track to achieve the national policy of ensuring that at least one ward has a cold chain equipment, ensuring that a mother, come what may, can walk to the nearest HF with a CCE within her ward and access vaccine. This year, 46 CCEs were allocated to my state. Of the 46, the state allocated 6 to specific health facilities in my district. This has been a norm in the past, as allocation of CCEs have been a top down approach with little focus to equity of CCE distribution Leveraging the CCE tracking system, I am able to track the availability of CCEs and prioritize allocation to wards without a functional CCE. The introduction of visibility using the cold chain inventory tracking system, I am able to: Equitably prioritize resource (new CCE allocation) to service delivery points within my district | 11

Building a Data Driven Culture Training As my understanding of the end to end supply chain system improved I became more aware of the SC gaps On the Job Mentoring Finance and Government ownership Supportive Supervision Awareness of the Gaps User Acceptance Testing Simplicity and efficiency of the data visibility systems The systems introduced were user friendly and appropriate for my environment Real Time Support Feedback Response Coordinating structures The existence of strong governing and coordinating systems such as SLWG, RIWG, MEWG, data harmonization team TORs Accountability Structures | 12

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