The Effective Vaccine Management (EVM) initiative was launched in 2010 to raise global and national attention to immunization supply chain performance metrics and identify areas where supply chain improvements might positively impact immunization and health outcomes.¹

Since 2015, the EVM initiative has evolved to become a robust process helping countries build flexible and responsive supply chains for immunization and health programmes. There are four steps to the comprehensive EVM approach: assess, plan, implement and monitor, which repeat in a cycle of continuous learning and innovation. An evidence-based continuous improvement plan (cIP) is a new element of the revised EVM initiative. 

The plan fulfills a critical function of providing the national EPI programme with an opportunity to use the EVM initiative as it was intended—as a continuous process for iSC improvement, rather than an assessment that occurs every three to five years without influencing policies or practice. The cIP looks holistically at the six essentials of immunization supply chains and considers strategic changes that can be made to achieve greater availability, quality and efficiency of services offered in the immunization programme. By raising awareness of iSC challenges and potential solutions, the cIP can be used as an investment case to advocate for funding.

• The cIP is strategic and actionable

• The cIP is integrated with the broader health system

One of the consequences of fragmented iSC planning is that it seldom explores problems that should be addressed at a health systems level, as this often requires political collaboration with other departments (such as human resources, management information systems, and financing). Donor HSS grants targeting immunization outcomes are often planned separately from iSC until it is time to cost procurement needs for cold chain equipment and infrastructure. This leads to missed opportunities and redundant programming (for example ineffective ad-hoc training for iSC in lieu of embedding recurring iSC training needs in the HR capacity development plan for health).

The cIP development process takes an HSS perspective and ensures that planning for iSC is not carried out in isolation but in conjunction with the EPI programme and other government stakeholders at all levels, including subnational governance bodies, ministries of finance, departments responsible for human resources, and information and communication technologies. Relevant stakeholders are invited to contribute to an analysis of health systems bottlenecks that contribute to, or exacerbate, deficiencies revealed in EVMAs. This exercise builds a powerful advocacy case for systems-level support to iSC.

• The cIP is prioritized based on evidence and available funding

Many countries face considerable discrepancies between the cost of proposed interventions and available resources. When plans are not explicitly prioritized, they are implicitly prioritized when resources are insufficient. Sometimes all interventions are only partially funded (for example, at 60% of the full cost requirement) and sometimes a few interventions “win” full financing while others “lose” and receive far less support. Win/lose scenarios are often based on vested interests, status quo, or donor preferences, rather than a transparent assessment of evidence and cost-effectiveness and can undermine efforts to conduct evidence-based planning.

The cIP helps prioritize explicitly iSC investments at two levels. First, it delivers a costed annual work plan linked to the pooled funding available or anticipated (for example the specific envelope of the GAVI HSS grant in development). Second, it prioritizes strategies that address the root causes of problems identified through the EVM and function-specific assessments (for example, iSC human resources capacity assessment, iSC system design assessment, temperature monitoring studies, cold chain equipment inventory and expansion needs assessment). In addition, the EVM process has built-in continuous performance review cycles that allow flexibility to adjust the plans based on the same rigour that contributed to the initial development of the cIP.

• The cIP is focused on implementation through joint ownership

A common planning oversight is a failure to articulate how implementation will be monitored or measured. Previously, lack of attention to implementation mechanisms and limited buy-in at the managerial (national and subnational) and workforce level, have been cited as key reasons for weak implementation of many national iSC plans.

The cIP planning process is deliberately inclusive, starting with a joint review of up-to-date, locally-generated data, and a collective understanding of the contextual factors of the immunization and health system. This collaborative approach has shown to increase the likelihood that those involved will take ownership of the strategic and tactical decisions made, resulting in greater support for implementation. The EVM process also requires countries to identify coordination mechanisms (such as National Logistics Working Groups (NLWGs)) to monitor implementation along performance indicators and annual targets set by EPI and partners.

After orienting stakeholders to the EVM initiative and the EVM assessment has been carried out, the EPI, with support from the NLWG and WHO and/or UNICEF, can launch the cIP development process to address observed iSC challenges in a strategic manner (see figure below).