As we face a potential spike in COVID-19 infections between Easter and winter, especially in under-served communities, it becomes all the more important for African health authorities to master the massive logistical feat of vaccine distribution.
So, what kind of numbers are we dealing with here? A few quick calculations illustrate that the Africa Centres for Disease Control and Prevention (CDC) target of 780 million vaccinations across Africa over 12 months would require 3.5 million single dose vaccinations per day, or 437 000 an hour – if we work on 220 annual working days and 8 hours a day. Double that for vaccines that require two doses.
Now consider that South Africa wants to vaccinate about 40 million people this year. That’s 182 000 per day for single dose, or 363 000 for double dose, at 45,500 vaccinations per hour – assuming no new variants derail everything. The logistics around this will multiply significantly if COVID-19 stays with us year after year like the flu.
A very complex orchestra of demand and supply-side events need to be coordinated impeccably every day for the vaccine engine to run smoothly. I agree with experts such as Dr Phionah Atuhebwe of WHO Africa that micro-planning is the answer. I’ve seen first-hand everything that can go wrong without this approach.
At the early stage of a massive intervention like this, we tend to obsess over vaccine sourcing, but the real challenges begin when the pallets arrive at the airport. Without micro-planning, many things will go wrong, including:
- Storage: On the ground, refrigerators are often too small or full, creating massive supply chain issues and mismatches in adequate vaccine supply.
- Lining people up: Recent public health messages to avoid facilities and social distance are now creating vaccine compliance challenges. Many public health facilities do not operate by appointments and working people cannot afford to queue for long hours, while the unemployed may not be able to get there. Unpredictable demand is difficult to plan and staff against. If we implement a 15-minute observation period for adverse patient reactions, further space and management complications arise.
- Vaccine specifications: Different vaccines have different preparation requirements. Some need to be thawed for two hours before administering. So, if your clinic opens at 7am, someone must start thawing at 5am, leading to potential human resource challenges.
- Time: Unless it’s a 24-hour clinic, most clinics don’t start at 5am, so if staff arrive at 7am, vaccinations start at 9am, decreasing the eight effective working hours to six. This increases the daily country targets by 25%.
- Vaccine expiration: Once opened and mixed, vaccines must be used within short time limits, and unused doses must be discarded. If patients don’t arrive in the right volumes, there is tremendous wastage.
- Safe disposal: Vaccination at this scale produces an unprecedented amount of medical waste, such as sharps and syringes that must be disposed of safely.
- Records: Every single vaccination requires stringent documentation. Those using paper systems will need clinical stationery, immunization cards and appointment slips in unprecedented volumes, creating unprecedented supply chain challenges.
- Administration policy: Some countries have policies restricting who can give injections, often creating massive supply-side bottlenecks and requirements for ‘emergency use authorization’ for other cadres to assist.
- HR complexities: Current experience tells us that most patients want to access services before or after work and queue for the shortest possible time. Over-time requirements for staff, especially those with children, can lead to labour disputes and strikes.
- Digital Solutions: Vaccination at this scale will require a quantum leap in digital adoption, which is particularly critical if COVID-19 remains with us like the flu. In this scenario, it causes problems when staff have to use their own airtime and data for work.
On the solutions side, I believe countries could benefit from a few useful approaches:
- Public Information, Education and Communication (IEC): Widespread language and literacy-appropriate public IEC, at population-saturation levels, is vital for decreasing vaccine hesitancy and misinformation, ensuring population access and demand management, increasing adherence particularly regarding second doses, and ensuring side-effects reporting.
- Dry runs: Before the vaccines even arrive, all facilities staff need to be fully trained and have conducted dry runs that cover all micro-planning elements.
- Technology solutions: Technology is critical for managing facilities’ readiness assessments, staff training, space and equipment, stock management and visualization, vaccine documentation and tracking of performance against targets – in real-time or at least daily, to provide critical management insights for decision-making. Countries need to invest in these solutions long before a crisis hits. We don’t have to reinvent the wheel for COVID-19. The key, however, is making existing systems interoperable through the impeccable orchestration of people, processes and technology.
A control tower approach: COVID-19 ties the fates of the entire globe together. A global, technology-driven control tower approach enables us to do coherent, evidence-based supply and demand matching on the national, regional and local levels so that we can meet global targets to beat the pandemic.
We will fail if we treat COVID-19 like yet another vertical disease programme. It’s our chance to springboard to Universal Health Coverage (UHC) and do better on so many other illnesses. If 65% of populations are reached by the health system this year, we could screen them for other communicable and non-communicable diseases too. Micro-planning, combined with technology and a global control tower approach, provide the answers.
ABOUT DR ERNEST DARKOH
Dr Ernest Darkoh is one of the co-founders of the BroadReach Group, where he leads efforts to radically improve healthcare delivery and to catalyze broader healthcare sector involvement across the African continent and globally. He is internationally respected as an expert in health systems programs on the ground. He is recognised by the New African magazine as one of the 100 most influential Africans, was elected Social Entrepreneur of the Year in 2015 by the World Economic Forum and was named one of TIME Magazine’s 18 global health heroes. Dr Darkoh also serves on the board of the Schwab Foundation. He has a medical degree and Masters in Public Health from Harvard University and completed an MBA at Oxford University as a Fulbright Scholar.