Effective vaccine management: how to develop a continuous improvement plan: guidance note

1How to Develop a Continuous Improvement Plan (cIP) How to Develop a Continuous Improvement Plan (cIP) Guidance Note Effective Vaccine Management (EVM) Version 1.0 February 2018 2 3How to Develop a Continuous Improvement Plan (cIP) Contents 1 Introduction 1.1 What is the Effective Vaccine Management (EVM) initiative? 9 1.2 The immunization supply chain continuous Improvement Plan (cIP) 12 1.2.1 Why develop a cIP? 12 1.2.2 Aligning EVM assessment results with the six supply chain essentials 14 2 The continuous Improvement Plan (cIP) development process 2.1 When should the cIP be developed? 17 2.2 Who is responsible for developing the cIP? 18 2.3 What is the best way to develop a cIP? 19 2.3.1 Compile and disseminate a situation analysis 19 2.3.2 Convene a cIP workshop 20 2.3.3 Align cIP goals and objectives with broader national health plans 24 2.3.4 Draft the five-year strategic cIP, including annual operational plan 27 2.3.5 Conduct a planning and budgeting exercise 28 3 The continuous Improvement Plan (cIP) content 3.1 Situation and root-cause analyses 31 3.2 The cIP strategic plan 33 3.2.1 Long-term vision for the immunization supply chain 33 3.2.2 Goals, objectives, strategies, key performance indicators, and costs 34 3.3 The cIP annual operational plan 36 3.3.1 Operational plan 36 3.4 Associated costs and sources of funding 37 4 Implementing and monitoring the cIP 4.1 Socialize and institutionalize the cIP 39 4.2 Implement the cIP 40 4.3 Monitor implementation and outcomes 41 5 Continuous learning and improvement 42 4Supplemental resources supplement 1: Establishing or strengthening a National Logistics Working Group www.technet-21.org/en/library/explore/supply-chain-and-logistics/3735 supplement 2: Situation analysis www.technet-21.org/en/?option=com_sobipro&sid=4800&pid=57&Itemid=2586 supplement 3: cIP workshop agenda repository www.technet-21.org/en/?option=com_sobipro&sid=4819&pid=57&Itemid=2586 supplement 4: Collaborative workshop techniques www.technet-21.org/en/?option=com_sobipro&sid=4801&pid=57&Itemid=2586 supplement 5: WHO Framework for National Health Policies, Strategies and Plans www.who.int/nationalpolicies/FrameworkNHPSP_final_en.pdf supplement 6: Root-cause analysis www.technet-21.org/en/?option=com_sobipro&sid=4802&pid=57&Itemid=2586 supplement 7: Human-centred design methodologies and toolkit www.hcd4i.org supplement 8: Guidance on Dashboards for Immunization Supply Chain www.technet-21.org/iscstrengthening/index.php/en/data-for-manage- ment-documents-and-downloads/guidance-on-dashboards supplement 9: Activity and monitoring plan template (cMYP Guidelines, page 69) apps.who.int/iris/bitstream/10665/100618/1/WHO_IVB_14.01_eng.pdf supplement 10: cMYP costing tool www.who.int/immunization/programmes_systems/financing/tools/cmyp/en/ supplement 11: WHO/UNICEF Joint Statement: Achieving immunization targets with the comprehensive Effective Vaccine Management (EVM) framework www.who.int/immunization/programmes_systems/supply_chain/ EVM-JS_final.pdf 5How to Develop a Continuous Improvement Plan (cIP) Acronyms and abbreviations CCE Cold Chain Equipment CCE OP Cold Chain Equipment Optimization Platform cIP Continuous Improvement Plan cMYP Comprehensive Multi-Year Plan DISC Dashboard for Immunization Supply Chain EPI Expanded Programme on Immunization EVM Effective Vaccine Management EVMA Effective Vaccine Management Assessment Gavi Gavi, The Vaccine Alliance GF Global Fund GFF Global Financing Facility GVAP Global Vaccine Action Plan HR Human Resources HSIS Health Sector Improvement Strategy HSS Health System Strengthening HSSP Health Sector Strategic Programme ICC Inter-agency Coordinating Committee for immunization IP Improvement Plan iSC Immunization Supply Chain KPI Key Performance Indicator LMIS Logistics Management and Information System M&E Monitoring and Evaluation MoH Ministry of Health NGO Nongovernmental Organization NHSP National Health Sector Plan NITAG National Immunization Technical Advisory Group NLWG National Logistics Working Group SOP Standard Operating Procedure TA Technical Assistance UNICEF United Nation Children’s Fund WHO World Health Organization 6About this Guidance Note This document provides guidance to countries on how to develop a continuous immunization supply chain (iSC) improvement plan. Its purpose is to help countries build a case for supply chain investments and develop an improvement plan that engages relevant stakeholders, thus setting the immunization programme on a path for successful implementation. This Guidance Note includes: • An overview of the continuous improvement plan (cIP) development process, including who should be involved, when the plan should be drafted, and how best to gather the required inputs and feedback. • Strategies for aligning Effective Vaccine Management (EVM) assessment outputs with national immunization and health sector planning and financing mechanisms, such as the comprehensive multi-year plan for immunization (cMYP); application for support from Gavi for health system strengthening (HSS); the national health sector improvement strategy (HSIS), and other health sector strategies and plans. • Guidance on preparing a cIP, to include a five-year strategy and a yearly operational plan that can be used to allocate responsibilities and map progress towards a common vision. • Suggestions on how to develop a budget and finance the cIP to ensure sustainability and identify resource gaps. Countries may be familiar with the previous EVM improvement plan process that immediately followed an EVM assessment (EVMA). Whereas the previous EVM improvement plan was designed to address certain short-term supply chain deficiencies, the new, continuous EVM improvement plan described here is designed to be more strategic and inclusive of a wider set of stakeholders who can help reveal the root causes of supply chain problems and mobilize human and financial resources to address them. Supplemental resources for each step of the EVM improvement planning process are also provided. 7How to Develop a Continuous Improvement Plan (cIP) Foreword In the context of renewed global efforts to increase immunization coverage and leave no child unvaccinated, the role of strong national immunization supply chains is hard to overstate. Supply chains are complex and include many elements – people, technologies, systems – that need to be brought together through a plan of continuous action. Such a plan can catalyse not only the immunization supply chain professionals working in the national Expanded Programme of Immunization (EPI), but also their colleagues from the ministries of finance, planning, human resource management departments, senior leadership, development assistance partners, funders and academia. Without this commitment and support, the immunization supply chain professionals are unlikely to succeed in addressing existing gaps in performance and setting up the programme on a path to a sustained, country-driven excellence in ensuring continued vaccine availability, quality and systems efficiency. The purpose of this guidance is to help make the plan of action robust and credible. A robust plan is based on evidence and a strong programming logic, i.e. it focuses investments on activities that together add up to a defined set of objectives and thus help realize the vision of the future and address the deficiencies of the past. The plan is credible when it responds to country needs, and represents a shared vision of the stakeholders who have bought into the plan of action and have a way to track implementation progress against predefined performance targets. These attributes elevate the plan to a powerful investment case for iSC improvement – an advocacy tool for ministries of finance to include and retain iSC activities in their national budget, and for partners to continuously support the cause. These are also the prerequisites of the “holy grail” of institutionalization: the programme putting iSC improvement activities on the radar of national leadership by linking them to the annual operational plans and budget performance metrics. 8However, even a fully funded plan is at risk of remaining a piece of paper unless it touches the hearts and minds of those whose mission is its implementation. Aligning continuous growth – continuous learning – of the EPI workforce at all levels with the process of continuous improvement of the iSC system, is the essential element that makes the coalition for sustained excellence in iSC whole. The EPI workforce is the first to learn what does not work, and often has the clearest insights on how to make it work in the programme context. Participatory models that empower and give implementers a stake in the design and implementation of iSC improvement plans are being embraced increasingly by countries, centralized and devolved contexts alike. The EVM initiative has progressed significantly from being associated with an assessment tool. It has been transformed to help national programmes make major health systems strengthening investments work as intended – to address the underlying systemic bottlenecks to iSC performance. WHO and UNICEF hope that this guidance can inspire and equip you with the knowledge and skills on how to make this initiative work for you. 9How to Develop a Continuous Improvement Plan (cIP) What is the Effective Vaccine Management (EVM) initiative? The 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 It is geared towards the six essentials of immunization supply chain: 1 In 2016, WHO and UNICEF issued a joint statement on the EVM initiative and the vital role that immunization supply chains play in achieving immunization targets set by the Global Vaccine Action Plan (GVAP). This was preceded by a Call to Action issued by the Immunization Practices Advisory Committee in 2014 that recommended a process of assessment, planning, implementation and monitoring to improve immunization supply chains. 1 1.1 Introduction Immunization supply chains are not only limited to equipment and distribution: they are dynamic systems that are flexible, adaptable to changing needs and changing contexts and reactive to ensure vaccine availability in all conditions. A well-designed strategy allows countries to holistically model their supply chains to improve supply chain performance and resilience. Reliable, well-maintained and cost-effective cold chain equipment is vital to ensure that there is adequate, sustainable vaccine storage for current and planned vaccines, that maintenance requirements are kept low, and running costs are reduced. A virtuous cold chain equipment strategy allows countries to access existing guidance and technical assistance, and allocate financial support to better plan for, select, install, manage and maintain their cold chain equipment. Vaccine quality needs to be maintained throughout the immunization supply chain to avoid vaccine wastage due to exposure to heat or freezing temperatures, whether at fixed storage location or during transport. A valuable temperature management strategy helps countries ensure good storage and distribution practices; effective, well-managed temperature monitoring and record-keeping procedures. Countries need effective transport of vaccines between each level of their supply chain to ensure vaccine potency is not compromised by a weak distribution system. A productive distribution strategy includes adequate use of passive containers, satisfactory packing practices with coolant packs, temperature indicators, and accessible transport contingency plans. s y s t e m d e s i g n c o l d c h a i n e q u i p m e n t temperature management d i s t r i b u t i o n 10 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 (see figure 1 ). As a preliminary step, Expanded Programmes on Immunization are encouraged to mobilize national commitment to continuous improvement by bringing stakeholders together to adapt the comprehensive approach to EVM and its four steps, and establish the mechanisms for continuous iSC improvement. Organizing a consultation with key stakeholders is recommended to secure commitment to the EVM initiative, assign clear roles and responsibilities, and agree on an implementation and monitoring process. If schedules allow, a short learning visit for participants to another country that has implemented the EVM process would be beneficial. The key elements of the comprehensive EVM approach are summarized in table 1 . Next generation supply chains require dedicated and competent managers as well as adequate numbers of skilled, accountable, motivated and empowered personnel at all levels of the supply chain. An efficient iSC human resources (HR) strategy helps countries strengthen and build capacity for their supply chain managers by providing access to training, encourage collaboration, positive supervision and professional development opportunities. Data are essential to supply chain managers for managing all aspects of the immunization supply chains, be they vaccine availability, or stock management efficiency. A sound iSC data strategy allows countries to align with data standards, and develop useful tools such as dashboards to monitor effectively their supply chain and make data-informed decisions. h u m a n r e s o u r c e s d ata figure 1 comprehensive approach to evm MONITOR Monitor implementation measure progress toward outcomes ASSESS Collect and review evidence to identify iSC strengths, weaknesses, opportunities, and bottlenecks PLAN Create vision, strategy and operational plan for iSC improvement IMPLEMENT Disseminate plan, ensure funding, and put plan into operation CIP C O M M I T t o c o n t i n u o u s i m p r ov e ment 11How to Develop a Continuous Improvement Plan (cIP) table 1 Suggested Timetable For The EVM Approach Step Estimated duration (in days) Process Format Cost types PREPARATION 0.5–2 Orientation of in-country stakeholders on EVM initiative Workshop Operational costs, facilitation ASSESS 5–10 Preliminary learning visit of select representatives of the Ministry of Health (MoH) and national institutions to participate in EVMAs in another country Visit Travel costs 15–20 EVM assessment planning; training and implementation; sharing and validating findings/results with EPI and MoH Workshop, Assess- ment Individual or institutional contract for EVMA management; operational costs; facilitation 5–10 Situation analysis from the EVMA, plus other assessments and studies that are available (see Table 3) Review Individual or institutional contract PLAN 1– 2 Preparation of the materials for a second workshop and explore how the six iSC essentials can be used to improve the nine EVM criteria2 Staff time 3–5 cIP development workshop: • Establish appropriate oversight and project management mechanisms (through the National Logistics Working Group (NLWG) or other continuous improvement group). • Review situation analysis and identify root-causes. • Define five-year iSC vision, strategic goals, key performance indicators (KPIs) and tactics based on evidence from the performance assessments. • Determine additional technical assistance (TA) needed to complete the cIP (e.g. for planning and budgeting or developing a monitoring and evaluation (M&E) framework). • Discuss how to achieve the three iSC objectives of availability, quality and efficiency by using the six supply chain essentials to improve the nine EVM criteria (see Figure 2) Workshop Operational costs; facilitation 5–15 Alignment with cMYP, national health sector plan (NHSP), funding proposals (e.g. health strengthening systems (HSS) and cold chain equipment optimization procedures (CCE OP). Working group Staff time 15–25 cIP drafting and budgeting: Secure endorsement of the cIP from the Inter-Agency Coordinating Committee (ICC), its development timelines, roles and responsibilities, and dissemination plan. Working group Staff time; operational costs; possibly individual or institutional contract IMPLEMENT 15–25 • Share cIP with all stakeholders, including EPI workforce at subnational level. • Ensure that national HR plans reflect the HR needs of supply chains / if no national HR plan, translate the cIP objectives/tactics into an iSC specific HR plan • Engage a national institution to support M&E • Mobilize funding sources as per your budgeting plan. Working group Staff time MONITOR On a yearly basis • Monitor implementation progress according to plan. • Evaluate key performance indicators for dynamic, data-driven management. • Ensure timely availability and use of resources. Working group Staff time 2 2 The nine EVM criteria: E1 – Vaccine arrival; E2 – Temperature control; E3 – Storage capacity; E4 – Infrastructure; E5 – Maintenance; E6 – Stock Management; E7 – Distribution; E8 – Vaccine Management; E9 – Information Systems. Further information is available at: http://www.who.int/immunization/programmes_systems/ supply_chain/evm/en/ 12 1.2 The immunization supply chain continuous Improvement Plan (cIP) 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. Why develop a cIP? Considerable progress has been made to improve EPI programmes in recent years, partly due to increased investments in supply chains. Immunization supply chain investment cases are now more likely to contain robust situation analyses, be more focused on strategic and evidence- based interventions, and more likely to be costed in a rigorous manner. The cIP builds on these developments and addresses shortcomings of previous planning requirements. 1.2.1 strategic and actionable Many countries develop multiple plans to address the iSC system at different levels, often in response to short-term funding or technical assistance (TA) opportunities and split between national budgets, donor grants, and partner commitments. The planning process may thus be reduced to annual incremental exercises at the expense of a longer-term, strategic planning effort that accounts for contextual changes and changing priorities. As a result, some highly effective (and cost-effective) interventions are neglected in favour of other interventions or may be redundant or programmed inefficiently. The cIP is part of a comprehensive EVM process that enables countries and development assistance partners (where these are present) to learn together which strategies and interventions work and do not work in the country. By using the cIP as an investment case for iSC, immunization staff can pool government and donor resources and TA from partners to address country priorities that already have strong links to multi-year national EPI programme and national health sector plans. In this way, the cIP benefits the country directly, beyond any donor-related consideration. 13How to Develop a Continuous Improvement Plan (cIP) 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. 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. 14 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. Aligning EVM assessment results with the six supply chain essentials Historically, EVM assessments have focused on performance scores organized along the nine EVM criteria. While this helps the programme to focus on discrete tasks (for example, plan to develop a standard operating procedure (SOP) where that procedure was found missing), the same EVMA data can also be analysed to determine which of the six iSC essentials require more urgent focus, as well as giving a high-level benchmark on how the programme managers can achieve the three iSC objectives (availability, potency, efficiency). These new uses of EVM assessment data make for a powerful advocacy and communication tool which helps the EPI programme “manage upwards” by making a more nuanced case for support and resources. The analysis of the data generated by EVM assessments is illustrated in figure 2 . 1.2.2 15How to Develop a Continuous Improvement Plan (cIP) 6 s u p p ly c h a i n e s s e n t i a l s 9 e v m c r i t e r i a 3 o b j e c t i v e s va c c i n e a r r i va l s1 m a i n t e n a n c e5 s to r ag e c a pa c i t y3 d i s t r i b u t i o n7 t e m p e r at u r e m a n ag e m e n t2 s to c k m a n a g e m e n t6 i n f r a s t r u c t u r e4 va c c i n e m a n ag e m e n t8 wa s t e m a n a g e m e n t9 figure 2 Aligning the six supply chain essentials with the nine EVM criteria s y s t e m d e s i g n c o l d c h a i n e q u i p m e n t temperature management d i s t r i b u t i o n h u m a n r e s o u r c e s d ata ava i l a b i l i t y q u a l i t y e f f i c i e n c y By focusing on the six supply chain essentials, countries can systematically increase scores along the nine EVM criteria, and more readily achieve the three objectives. 16 Analysis of EVM assessment data in terms of the three objectives and six iSC essentials enables the programme to frame its cIP as a roadmap to attaining not only compliance with the WHO technical standards, but also the iSC objectives. This helps the programme to build the cIP around a monitoring and evaluation (M&E) framework that measures the relative value and progress of the implementation of cIP activities in terms of their contribution to such established programme indicators as “no vaccine stock-outs at subnational level” (availability: for example, “0% health facilities reporting vaccine stock-outs”), uptime of cold chain equipment (quality: for example, “100% of facilities with functional cold chain equipment”; “100% instances of malfunctioning cold chain equipment reported within 48 hours and addressed within 72 hours”), EVM scores above 80% (efficiency), etc. Once the high-level indicators have been decided, iSC systems performance, in terms of the six essentials, represents an intuitive and comprehensive way of organizing the cIP along the six corresponding strategies that contribute to the attainment of the above-mentioned performance indicators. figure 3 illustrates this logic. figure 3 Proposed cIP framework 2016 2020 ro ad ma p f or im pr ov em en ts s u p p ly c h a i n e s s e n t i a l 1 s u p p ly c h a i n e s s e n t i a l 2 s u p p ly c h a i n e s s e n t i a l 3 s u p p ly c h a i n e s s e n t i a l 4 s u p p ly c h a i n e s s e n t i a l 5 s u p p ly c h a i n e s s e n t i a l 6 % % % % % % E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E >80% 17How to Develop a Continuous Improvement Plan (cIP) 2 2.1 When should the cIP be developed? The cIP is one component of a many-layered planning process for the immunization programme. It cannot be developed without preparation and a baseline understanding of how the supply chain operates, the status of equipment and infrastructure, and a clear understanding of the situation in which the supply chain operates. To this end, the implementation of the EVM approach should be tailored to each country context as described in table 2 . Key assessments should be used to inform the development of a cIP, including the Effective Vaccine Management assessment, system optimization studies, EPI review, and HR assessments (see table 3 ). Using available baseline assessments as a starting point, the cIP can be developed at any time. It is designed to feed into the national immunization planning process, becoming a section, for example, in the cMYP for immunization or health sector strategy. Ideally, a cIP should be developed immediately following the completion of an EVM assessment, and serve as an input to a new (or updated) cMYP or health sector strategy. The timing and format of cIPs will differ between countries according to context and familiarity with the EVM process. ( table 2 proposes several scenarios; table 4 can also be referred to for more detailed information on preparing the plan.) The continuous Improvement Plan (cIP) development process Scenario How to implement the comprehensive EVM approach When 1 Your country has been actively and successfully using a previous EVM improvement plan to determine strategy and implement improvements throughout the EVM cycle (3–5 years) Develop the following cIP based on the present Guidance Note. Socialize the next cIP with all EPI staff and embed it into the next cMYP or health sector strategy. Schedule your next EVM assessment to occur prior to the next cMYP or health sector strategy plan process, as this will allow the cIP to be integrated into the larger immunization planning process. 2 Your country has a strong iSC component already embedded in the cMYP or health sector strategy, which constitutes your country’s iSC plan Develop your next cIP based on the present Guidance Note. Design the cIP to become an annex to the health sector strategy or Section Five of the cMYP3: “Vaccine, cold-chain and logistics.” Option 1: If the cIP is being developed close to and prior to the revision of the cMYP or health sector strategy, then the cIP should be integrated and endorsed as part of that document. Option 2: If the timing of the cIP does not allow an integration into either your cMYP of health sector strategy, develop a stand- alone cIP until the next revision cycle and use it as the main iSC component for your next plan. 3 Your country has no iSC strategy or a weak iSC improvement plan. Develop the next cIP based on this Guidance Note. Mobilize technical assistance, as needed, to establish a mechanism that can manage the cIP development process. Contact your WHO or UNICEF country office to start the EVM initiative, and begin planning your next EVM assessment. table 2 implementing the evm approach in different country contexts 3 See p.28 WHO-UNICEF Guidelines for cMYP for Immunization – Update September 2013. Available at: http://apps.who.int/iris/bitstream/10665/100618/1/WHO_ IVB_14.01_eng.pdf?ua=1 18 Who is responsible for developing the cIP? The national EPI team is responsible for developing the cIP. The process, however, should be supported by a permanent subgroup of the Inter-Agency Coordination Committee (ICC) for immunization, for example a NLWG or supply chain coordinating committee. In countries lacking such mechanisms, engaging with national learning institutions (such as universities) to complement the work of or be a substitute for the NLWG is strongly recommended. Beyond the development of the document itself, the coordinating committee in your country (for example, the NLWG) will play an essential role in monitoring implementation progress and outcomes. Strong leadership from these groups has proven a key success factor for substantial improvement of national iSCs. The cIP itself should be assigned to a specific individual or a small “secretariat” responsible for drafting the plan, soliciting input, making changes, and seeing the plan through to finalization. Half-day commitment workshop. It is critical that all EPI team members, NLWG members, and ICC members understand the EVM initiative and their roles and responsibilities. We recommend that every five years the EPI team organize a half-day orientation to the EVM initiative prior to the EVM assessment. tip supplement 1 Establishing or strengthening a National Logistics Working Group www.technet-21.org/en/library/explore/ supply-chain-and-logistics/3735 2.2 box 1 Launching the comprehensive EVM approach in Sierra Leone and Nigeria In Sierra Leone, the EPI organized a half-day workshop in Freetown for national and subnational MoH and administrative chiefs from all districts. During the workshop, participants examined past EVM performance and discussed how improvements along the six iSC essentials could improve availability, quality, and efficiency of the immunization programme. In the end, participants had a clear vision and a shared understanding of the EVM approach. The decision to include administrative district chiefs was critical to onboarding them in the discussions of priorities, strategies, and performance indicators, particularly in this context where subnational EPI staff are subordinate to the administrative district chain of command. A month later, after a new EVM assessment report was presented, there was already a broad consensus – and a momentum – for developing a cIP that was subsequently linked to the Gavi HSS financing process. 19How to Develop a Continuous Improvement Plan (cIP) What is the best way to develop a cIP? 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 box 2 ). Once the cIP has been approved by the ICC and NLWG, the EPI can disseminate and socialize the plan, integrate it into the cMYP or health sector strategic plan, and begin implementation and monitoring activities. Compile and disseminate a situation analysis What: A situation analysis is a summary of the recent EVM assessment report as well as other available assessments, including the EPI review, cold chain inventory, new vaccine readiness, and HR capacity assessment. It should provide a succinct analysis of the strengths and weaknesses of the supply chain and opportunities for improvement. It should also show changes from past EVMA scores, the implementation status of previous improvement plans, and the overarching context of the immunization programme and the health system. Developing a cIP “at-a-glance” process Compile and disseminate a situation analysis • Detailed situation analysis • Broad stakeholder understanding of EVM and other assessment results • Bottleneck/root cause analysis • Vision, goals, objectives, strategies and KPIs for iSC improvement during the next five years • A list of possible interventions and solutions • Alignment between iSC goals and the Global Vaccine Action Plan/ HSS goals • Align with cMYP, NHSP and other national health strategies • Strategic plan describing vision, goals, objectives and strategies • Detailed operational plan listing activities, responsibilities, timelines, costs, sources of financing, and indicators to achieve strategic goals • ICC/NLWG meeting to endorse the cIP for implementation Convene cIP workshop Align cIP goals and objectives with the cMYP and HSIS Draft and finalize the five-year cIP outputs 2.3 2.3.1 box 2 20 Why: A situation analysis provides a starting point for discussion and ensures that all participants at the cIP workshop (described in subsection 2.3.2 ) are working with up-to-date evidence on the status of the supply chain and can devise improvement target, strategies and activities for the cIP, based on a common understanding of the current context. When: The situation analysis should be conducted after the EVMA has been completed. It should be disseminated to cIP workshop participants at least one week prior to the cIP workshop. Who: Some countries have asked the EVM assessor to summarize the situation analysis on behalf of the EPI team and the members of the NLWG. Other countries have asked a local technical assistance partner or academic institution to summarize the situation analysis, as these institutions are sometimes tapped to do the same for HSS proposals. Convene a cIP workshop What: The cIP workshop is a multi-day, interactive meeting where relevant supply chain stakeholders can collaborate to review the situation analysis in depth, conduct a rapid assessment of root causes, and define the five-year vision, goals, objectives, strategies and KPIs for improving supply chain performance to achieve broader immunization goals. Why: The workshop serves as an opportunity to align supply chain stakeholders around a common understanding of the challenges in the immunization supply chain and a long- term vision and goals for its improvement. When: The cIP workshop should occur after the situation analysis is available, and prior to the development of a new cMYP or a new national health plan. Effective collaborative workshops can be resource-intensive and time- consuming. It is therefore crucial to allocate adequate time for each session to avoid compromising the quality of collaboration, which is a predictor of the quality of the cIP. Length of cIP workshop. Many countries have reported that four days is adequate for a cIP workshop. However, some countries may require more than one workshop to agree on a vision and a set of viable goals and objectives. EPI managers should plan accordingly. tip 2.3.2 supplement 2 Situation analysis www.technet-21.org/en/?option=com_sobipro&sid=4800&pid=57&Itemid=2586 21How to Develop a Continuous Improvement Plan (cIP) Who: The EPI, with support from national institutions (such as NLWG, academia) and WHO and/or UNICEF, is responsible for organizing the cIP workshop, developing the cIP document, and monitoring its implementation. Following the cIP workshop, a single individual or “secretariat” should be assigned responsibility for drafting the plan, soliciting inputs, making changes, and facilitating the necessary buy-in and approvals. Core participants should include EPI and iSC staff representing different levels of the health system as well as regional and district administrators. If the iSC is integrated with, or overseen by, another government department, relevant staff from that department must also be involved. Stakeholders who are involved in the development of other national plans (for example cMYP, HSIS, NHSP) should be included as a priority. Representatives from other ministries, including human resources and infrastructure, as well as the National Regulatory Authority (NRA) or other regulatory bodies when applicable should be invited, as they can recommend solutions to problems that the MoH cannot solve directly, as well as champion investments in these solutions at key junctures of the political process during national budget negotiations. Other participants may be considered, and should be included based on their ability to contribute to the technical discussion on the supply chain. This includes nongovernmental stakeholders such as outside consultants, donors (World Bank, Japanese International Cooperation Agency, the Bill & Melinda Gates Foundation, the US Agency for International Development, and others as applicable), technical partners (UNICEF and/or WHO Country Offices, the US Centres for Disease Control and Prevention, International Development Research Centre, PATH, John Snow, Inc., and others as applicable). Where: Conducting workshops off-site has been shown to notably reduce distractions and elevate the engagement level of participants; however, this may not always be feasible. The location must have adequate space for both plenary and breakout discussions. Include non-supply chain experts in the workshop. By including non- supply chain experts in the workshop, the EPI team can explore a greater array of choices on how to solve supply chain problems. For example, with input from officials from ministries of finance, education, infrastructure, and the MoH department of human resources, EPI staff may suggest solutions that the EPI team had not previously considered. tip 22 How: Advanced planning is critical to ensure a productive workshop. An agenda and supporting documents must be produced and shared in advance (for example a succinct note summarizing the situation analysis and five to six strategic options to discuss). Several countries have developed cIP workshop agendas that can be followed or adapted. Most workshops start with a discussion on the status of the supply chain (situation analysis) and the ways in which the supply chain supports, or fails to support, immunization objectives. This discussion naturally brings up the question of benchmarks: what the performance should be (vision), and how it can be measured (KPIs defined for each iSC level). From there, participants can explore root causes of existing challenges and propose strategies, goals and objectives that would progress the programme to where it would like to be in five years. Output: The output of the cIP workshop should be a five-year vision, a set of six goals (one for each supply chain essential) with high-level performance indicators, and the corresponding objectives and strategies that should come out of the root-causes analysis carried out during the cIP workshop (see section 3 ). Because members of other planning groups (for example NHSP; cMYP; Gavi, the Global Fund (GF) or Global Financing Facility (GFF) grant applications; health commodity supply chain) are included in the cIP workshop, the cIP should already reflect the highest priorities of other programme and planning instruments. supplement 3 cIP workshop agenda repository www.technet-21.org/en/?option=com_sobipro&sid=4819&pid=57&Itemid=2586 Collaborative workshop techniques. Many countries have adopted collaborative workshop techniques to generate productive stakeholder conversation during the workshop (see supplement 4 ). Experience has shown that breaking cIP workshop participants into groups – with each group focused on one of the six supply chain essentials – can be highly effective. Each group then presents goals, objectives, strategies and activities, along with an estimated budget and any additional tasks required to operationalize activity. It is important, however, during this focused process to also allow for an exploration of strategies that take on a broader system view. One suggestion is to assign one group to focus on a problem that does not necessarily fit into a single strategic area (such as polio transition or staff shortages). It is also advisable to examine best practices, or examples of “positive deviance”, within the country to identify possible solutions that are already working. tip 23How to Develop a Continuous Improvement Plan (cIP) box 3 Positive Deviance EVM assessments identify the flaws of the iSC system which then become the focus of the cIP. The associated tools and processes, including the bottleneck analysis, are designed to identify and correct problems, not to identify or understand when and why things work well. The consequence is a lack of motivation and engagement from countries, who may feel threatened by the process as it highlights the deficiencies without recognizing the specific drivers of achievements. The purpose of positive deviance is to enable communities4 of practitioners to discover their successful behaviours and strategies, and transform them into plans of action to promote sustainable change. The approach is based on the following principles: • Communities of practitioners have solutions and “know-how” • Communities of practitioners can organize themselves to solve an agreed problem • Collective intelligence to solve a specific problem is more effective than solutions imposed by external experts • Sustainability is at the core of the response The methodology of positive deviance consists of five basic steps: 1. Define the problem, current perceived causes, challenges and constraints, common practices, and desired outcomes. 2. Determine the presence of positive deviant individuals or groups. 3. Discover uncommon but successful behaviours and strategies through inquiry and observation. 4. Design activities to allow community members to practice the discovered behaviours. 5. Monitor and evaluate the resulting project or initiative, which further fuels change by documenting and sharing improvements as they occur, and helps the community discern the effectiveness of the initiative. In the context of EVM, the health workforce involved in iSC would constitute communities at each iSC level. Ideally, a positive deviance approach should be an intricate part of the EVM process, reflecting itself in the additional qualitative information collected during the EVM assessment and, most importantly, in ensuring that reiterating feedback loops capture the perspectives, solutions and know-how of the iSC workforce throughout the assessment, planning and implementation processes. This approach can help ensure that the cIP is derived from local needs, contextualized through generating deviance from community. In addition, the approach can offer a reality check on the EVM assessment process, including evidence that could help improve the EVM approach in future. The recent cIP development process in Sierra Leone used elements of this approach in two ways: (i) national EVM assessors were encouraged to collect structured notes on the background to any good practices they observed during their assessment visits; and (ii) the cIP development workshop encouraged the participants – some of whom were elected district representatives who could bring in community perspectives – to discuss whether any districts may have “got it right” contrary to the nation-wide EVM assessment findings. One such conversation identified a district that paid performance-based incentives that had a positive impact on core iSC performance indicators; this was a revelation to representatives from some other districts and provoked genuine reflections on the strategies available. 4 For definitions and components of successful communities please refer to https://community-canvas.org/ 24 Align cIP goals and objectives with broader national health plans What: With cIP goals and objectives in hand, EPI staff should participate in relevant, parallel planning efforts (such as the NHSP, cMYP and HSS investment cases) and discuss how the cIP and its implementation can contribute to immunization and health system goals, EPI equity analysis, and EPI reviews. figure 4 illustrates how the cIP can be fully incorporated into broader national and other health plans, cutting across the six essentials of the immunization supply chain. 2.3.3 box 4 Nigeria Nigeria designed a four-day cIP workshop to enable EPI managers from 36 states and the Federal Capital Territory to reflect on the results from the recent EVMA and jointly examine the causes of insufficient improvement and inadequate implementation of previous plans. This event differed notably from typical training workshops and planning meetings. It was designed to be highly dynamic, iterative, and engaging to maximize substantive contributions from all participants and secure maximum buy-in for the cIP, particularly from the state-level government EPI managers. The approach enabled the new cIP to bring measurable and sustainable improvement to the country’s iSC, and ensured that the cIP was appropriate in the context of Nigeria’s devolved health sector. supplement 4 Collaborative workshop techniques www.technet-21.org/en/?option=com_sobipro&sid=4801&pid=57&Itemid=2586 25How to Develop a Continuous Improvement Plan (cIP) Why: Incorporating the cIP into the NHSP, cMYP and other relevant plans will make those plans stronger and more specific. The more integrated the planning efforts become, the easier it will be to eliminate duplicate efforts and identify opportunities for efficiencies (such as a shared set of indicators or outcomes) with other plans. Who: Key EPI staff should attend relevant planning committee meetings to present the cIP and discuss how the plan supports the NHSP, cMYP (and other relevant plans). By attending these meetings, planning participants can look for redundancies as well as opportunities for efficiencies. figure 4 integrating the cIP to broader health plan processes Immunization multi-year plan (cMYP) National health sector plan EVM cIP system design Cold chain equipment temperature management distribution human resources data 26 When: During the cIP workshop, relevant stakeholders involved in other planning processes (for example NHSP; Gavi, GF or GFF grant application, health commodity supply chain plan) should already be participating in the development of overarching goals, strategies and activities for the supply chain. After the cIP workshop, EPI staff and external planning participants should share the draft vision, goals, objectives and strategies with committees working on relevant immunization and health strategies and brief them on the cIP workshop discussions and outcomes. Output: The primary output of this step should be the welcome inclusion of the cIP into the cMYP, NHSP, and other planning documents. A secondary output could be a list of suggested revisions that will further align the cIP with other planning instruments based on discussions with relevant planning groups. As needed, these recommendations should be used to adjust the goals, objectives, and strategies developed during the cIP workshop. Making the most of HSS programming. When considering iSC improvements through the HSS lens, EPI staff should ask: which specific health systems need to be strengthened to help us resolve the most urgent iSC bottlenecks facing our programme? The answers will likely relate to the HSS “building blocks”: health sector governance, human resources, information systems, financing. Building alliances with stakeholders outside the EPI chain of command may be key to resolving problems and is a worthy investment of effort. Donors often encourage (for example through Gavi HSS grants) national EPI programmes to enlist support from other government departments to address urgent EPI problems. tip 27How to Develop a Continuous Improvement Plan (cIP) Draft the five-year strategic cIP, including annual operational plan What: The cIP should be written in two parts (see section 4 ). First, a strategic section stating the vision, goals, objectives, KPIs, and estimated costs5 for activities identified and developed during the cIP workshop. Second, the plan should include an annual operational plan with associated costs, sources of financing, and implementation indicators. Once completed, the full cIP becomes the cMYP section on cold chain and logistics (see section 5 ) or an annex to the health sector strategy. Why: The five-year cIP aligns all stakeholders, including TA providers, to a common set of goals that improves immunization efficiency, quality and availability. The cIP is a continuous learning tool that links EVMA results with the overall strategic vision for immunization. When: The time required to develop the cIP will vary by country. The EPI team should agree on a reasonable deadline, given available staff resources. If a new cMYP or NHSP are being developed, the cIP should be finalized within the development timeframe of these plans. Sufficient time should be allocated to the budgeting and financing component of the cIP, as this will improve the viability of the plan (see subsection 3.4 ). Who: The cIP should be developed by (or in close partnership with) senior EPI staff, as EPI will be primarily responsible for executing the plan. Working groups formed during the cIP workshop may be willing to draft sections of the plans relating to strategic focus areas, but the EPI team is responsible for integrating those sections into a complete plan. There may be exceptions in some contexts where cIP drafting may need to be carried out externally, particularly when there is insufficient relevant capacity in-country. Output: The cIP includes a five-year strategic plan, and an annual operational plan that can be presented to the NLWG and the ICC for endorsement. 5 WHO and UNICEF recommend conducting a full planning and budgeting exercise for the cIP, and linking it to the cMYP budget. 2.3.4 28 2.3.5 Conduct a planning and budgeting exercise What: A planning and budgeting exercise is an effort to identify all costs and sources of funding associated with activities listed in the cIP during the five-year period. Associated costs can include: • Personnel (e.g. staff assigned to reporting) • Capital expenditures on equipment and infrastructure (e.g. acquisition of vehicles, cold chain equipment) • Operational expenditures (e.g. cold chain repair or maintenance) • Transport • Outsourced services • Workshops and international exchanges • Technical assistance needs (e.g. system design technical support, NLWG set-up support) Why: As with all plans, the cIP is only useful to the extent that it is supported and funded. A planning and budgeting exercise defines the costs associated with cIP implementation and monitoring, and enables EPI managers and logistics coordinating committees to identify sources of funds to meet the needs of the programme. When: The planning and budgeting exercise should be conducted as soon as the draft cIP plan is completed and before it is approved by the ICC. Who: The EPI is responsible for completing a planning and budgeting exercise, whether by identifying a TA partner to conduct the planning and budgeting exercise or a private agency. Involve the Ministry of Finance early. Countries that involve colleagues from their Ministry of Finance during the planning and budgeting exercise generally have greater success raising funds and implementing their cIP. The presence of Ministry of Finance staff not only increases the accuracy of the cost estimates and sources of funds, but also accelerates the timeline for signing the budget and dispersing funds. tip 29How to Develop a Continuous Improvement Plan (cIP) 3The continuous Improvement Plan (cIP) content • a clear description of what the country wants to achieve: the vision, goals, and anticipated outcomes for the iSC, which can serve as a rallying point for all relevant stakeholders; • logical and strategic – answering what, why, and when specific activities should occur, who is responsible, and how progress will be measured using KPIs; • based on a systematic, evidence-based analysis of the root causes of poor iSC performance, as well as an analysis of the enablers of strong iSC performance; • created as part of a participatory planning process with relevant stakeholders from other ministries and levels of the health system so it responds to, and is supported by, broader national planning processes for immunization (such as cMYP) and health; used to raise awareness and advocate for investment and oversight from higher management levels of the MoH. • either a stand-alone document or directly integrated into existing annual work plans; • a tool to track implementation progress of the annual work plan with direct links to outcomes described in the strategic plan that can be reported during yearly reviews; • developed annually with a description of objectives and activities, timelines, responsibilities, costs, and indicators to monitor progress; • reviewed and endorsed by the ICC and a supply chain working group or committee; • reviewed at least quarterly by EPI managers and reported at least annually to the ICC and NLWG where it exists. The strategic plan should be: The operational plan should be: As previously mentioned in this Guidance Note, the cIP will consist of two main parts: (i) the strategic plan which describes the vision, goals and key strategies for the supply chain during the next five years; and (ii) the operational plan – an annual work plan detailing activities, timelines, responsibilities, costs, and indicators. 30 Suggested cIP content “at-a-glance” 1. Situation and root-cause analyses • See above subsection 2.3.1 a. Long-term vision • Describes the desired future state of the immunization supply chain • Describes how the cIP vision and goals support the objectives of the immunization programme and the health sector b. Goals, objectives, strategies, KPIs, and estimated costs • Describes high-level goals to improve availability, quality and efficiency of the iSC • Describes key objective for each goal with indicators that show progress toward them • Describes strategies based on the root-cause analysis that will move the country closer to achieving the goals within the next five years • Describes selected KPIs that will allow progress measurement throughout the continuous improvement cycle • Provides estimated costs for all activities within the five-year plan and describes possible and confirmed sources of funding (including partner- supported activities) a. Activity and monitoring plan for year 1 • Describes the key activities and progress indicators that will be used to track implementation • Describes governance of the cIP (e.g. roles of NLWG, partner, TA providers, etc.), as well as timelines, and responsibilities b. Associated costs and sources of funding • Calculates the specific costs associated with the operational plan • Identifies sources (and timing) of funding from partners, donors, and government budgets 2 . The cIP strategic plan 3. The cIP operational plan box 5 31How to Develop a Continuous Improvement Plan (cIP) supplement 5 WHO Framework for National Health Policies, Strategies and Plans www.who.int/nationalpolicies/FrameworkNHPSP_final_en.pdf Use the WHO Framework for National Health Policies, Strategies and Plans to strengthen your plan. Experience shows that the policy dialogue for building comprehensive national health policies, strategies and plans is as much a political as a technical process. It requires attention for the inspirational side of defining vision and policy; it also requires attention for operational detail. The balance between vision, policy, strategic planning and consistency in implementation varies considerably from country to country. You are encouraged to consult the WHO Framework for National Health Policies, Strategies and Plans (see Supplement 1 below) on prerequisites for sound planning documents that match your country’s overall national health strategies. tip 3.1 Situation and root-cause analyses The situation analysis (see supplement 2 ) is the first section of the cIP. It describes the status and current performance of the supply chain and its components by summarizing the key results and recommendations from the EVMA and other relevant assessments. table 3 below lists the assessments, plans and situations that may be analysed as part of the situation analysis. The right-hand column shows suggestions of where inputs, information and data can be found. 32 table 3 Assessments, inventories, and reports to include in a situation analysis Assessments, inventories and reports Where to find them National EPI review • National EPI programme EVMA reports and EVM improvement plans (IPs), including details of EVM implementation • National EPI programme, or WHO and UNICEF country offices Up-to-date cold chain equipment inventory (CCEI), including expansion and equipment rehabilitation requirements • National CCEI, if available • CCE OP application • EVMA reports • Logistics management and information system (LMIS) • Procurement plans and records New vaccine supply chain readiness assessment • EVMA reports • Applications for introduction of new vaccine to Gavi, WHO, UNICEF, etc. • cMYP • Gavi HSS applications HR capacity assessment • EVMA reports • Gavi HSS applications • cMYP • Health sector HR assessments Temperature monitoring assessment of the cold chain • Recent temperature monitoring study • Temperature monitoring system data Transportation network design assessment • EVMA reports • Supply chain assessments (USAID, etc.) and strategic plans National immunization and health sector strategies, policies and priorities • EPI annual plan • EPI multi-year plan • National health sector multi-year strategy • cMYP • Gavi HSS strategy • Other health commodity supply chains strategies/assessments Equity assessments • National EPI programme 33How to Develop a Continuous Improvement Plan (cIP) A root-cause analysis examines why supply chain performance is low in certain areas. The root-cause analysis is an opportunity to resolve challenges that result from failures. There are many ways to conduct a root-cause analysis (see supplement 6 below); the approach can be determined by the EPI team. Three components are essential to a root-cause analysis: problem statement, root-causes, and possible strategies to address the root causes. Some countries have successfully used the human-centred design methodologies toolkit (see supplement 7 below) to guide the root-cause discussion in cIP workshops. Taken together, the situation and root-cause analyses provide national policy-makers with an overview of the strengths, opportunities, weaknesses, and threats of the immunization supply chain and help prioritize activities so that investments can be focused accordingly. The cIP strategic plan The strategic plan should be concise and easy to read. It should display the long-term vision for the supply chain, and the high-level goals, objectives and strategies that have been identified for the next five years (including indicators to measure outcomes and progress toward those outcomes). A one- to two-page summary of the strategic plan should be widely disseminated and used as a tool to track progress. Long-term vision for the immunization supply chain The long-term vision should describe how the iSC supports the immunization programme: how it performs, how it is organized, and what it contributes to the immunization programme and to the national health sector. The vision should describe a resilient iSC that can accommodate changes to health system priorities (for example health security, polio transition, electronic records), as well as anticipated changes to the general infrastructure and the political climate (such as investments in rural electrification, infrastructure and roads, and increased internet access). Most importantly, it reflects the goal of supply chains to improve availability, efficiency, and the quality of vaccines and immunization supplies across the country. Example: “We envision a supply chain that reliably delivers sufficient quantities of vaccines and immunization supplies directly to all fixed immunization posts (including new posts that are opening during the next five years) and does so without compromising quality due to exposure to heat or freezing temperatures. By doing so, the supply chain will support the EPI goal of 90% vaccination coverage by xxxx, and decrease child mortality by xxx.” supplement 6 Root cause analysis www.technet-21.org/en/?option=com_sobipro&sid=4802&pid=57&Itemid=2586 supplement 7 Human-centred design methodologies and toolkit www.hcd4i.org 3.2 3.2.1 34 Goals, objectives, strategies, key performance indicators, and costs Goals describe the medium- and long-term outcomes that are necessary to achieve the vision. In the case of supply chains, goals are easy to write when they are aligned with core supply chain objectives of increasing availability, quality, and efficiency. A manageable strategic plan usually lists between three and five goals that are achievable within five years. Each goal should have at least one KPI that can be measured and reported over the course of the year. Example: Goal #1: Increase immunization coverage by ensuring all EPI vaccines and immunization supplies are available at the point of vaccination in at least 20 high-priority districts by 2023. KPI: Number of priority districts achieving 12 months of full stock availability (see below). Objectives are quantitative measures of the goals that are time-bound. They often start with the words “increase” or “decrease” or “establish”. It is a country’s discretion to select any number of objectives per goal that are realistically achievable within the timeframe and budget available. Typically, a country would select relevant iSC performance indicators from the Guidance on Dashboards for Immunization Supply Chain (DISC) (see supplement 8 below). Example: Objective #1: Increase the number of facilities in high-priority districts achieving full stock availability6 within a 12-month period. 6 Full stock availability (from DISC indicators) is the percentage of storage points with full availability of all or selected set of tracer vaccines and immunization supplies over a resupply period. Full availability is defined as no stock-out in the store or health facility at any point during the period. 3.2.2 supplement 8 Guidance on Dashboards for Immunization Supply Chain (DISC) www.technet-21.org/iscstrengthening/index.php/en/data-for-management- documents-and-downloads/guidance-on-dashboards 35How to Develop a Continuous Improvement Plan (cIP) Strategies describe the approach that will be used to achieve the goal or objective. Strategies usually answer questions that emerge when faced with choices or constraints, and for this reason, strategies can differ significantly depending on who is involved in the discussion. For example, when new refrigerators are needed, does it make more sense to buy solar-direct drive refrigerators or invest in micro-grids for rural electrification? When health workers need to be trained on basic refrigerator maintenance, would it be more effective to offer refresher training, supportive supervision, or develop and include the relevant curricula into MoH-accredited pre- service training linked to career progression of the relevant workforce? Consultations should be held with a broad range of stakeholders, not just immunization supply chain professionals, to identify the best strategic options. Depending on the situation, some countries may find it easiest to form cIP strategies around the six supply chain essentials (see subsection 1.1 ). The sample strategy below leverages two supply chain essentials: Distribution and System Design to improve overall iSC performance. Example: Strategy #1: Implement a pull-based (demand driven) distribution system for vaccine and cold chain with reliable transportation system based on efficient network design and route planning. Outcome indicator: Number of districts with a functioning pull-based distribution system based on efficient network design and route planning in [specific] districts. let availability, quality and efficiency drive your plan. Introducing the iSC objectives of availability, quality and efficiency at the start of the cIP design workshop is an excellent way to focus the conversation – and the resulting cIP – on what matters most. EVMA data can be presented graphically to show how iSC performance meets (or fails to meet) three objectives across the distribution levels. Workshop discussions can then be steered to discuss and quantify desired performance levels for each of the three objectives, which in turn would clarify investments required to meet the objectives. For example, a discussion of what it takes to assure vaccine quality at the service delivery level will lead to a discussion on two DISC indicators: (i) functional status of cold-chain equipment; and (ii) temperature alarm rate. Participants can then agree on minimum performance levels (for example, all failed cold chain equipment units are reported/logged within two days, and repaired or replaced within five days), which will clarify investments required to capture and monitor these data and to ensure compliance with the agreed performance levels. tip 36 supplementn 9 Activity and monitoring plan template (cMYP Guidelines, page 69) apps.who.int/iris/bitstream/10665/100618/1/WHO_IVB_14.01_eng.pdf The cIP annual operational plan Operational plan The operational plan is the part of the cIP that translates goals, objectives, and strategies into a set of activities that can be assigned and accomplished within a 12-month period (for example, Activity #1: “List the functional requirements for a stock management system for each major user group”). Because activity-level planning can be dynamic and dependent on external factors, it is not necessary to articulate specific activities beyond 12– 14 months. The recommendation is to develop a plan that can be used by those managing the iSC, in a format that feeds into existing EPI annual work plans. Each activity should have an associated measurable process or completion indicator and estimated cost. The activity plan also should specify the governance structure for implementation oversight (i.e. roles/responsibilities of NLWG, partner agencies, and TA providers) and a timeline for monitoring indicators. Include a monitoring process and schedule. Countries have emphasized the importance of including a schedule for monitoring (e.g. dates when the KPIs are reviewed and discussed) and indicating which person or team will be responsible for collecting and reviewing KPIs according to the schedule. tip Include partner activities in operational plan. To ensure accountability of all stakeholders, the operational part of the cIP should include both activities (and implementation indicators) supported from within the EPI programme plan, and activities (and implementation indicators) supported by TA partners. tip 3.3 3.3.1 To ensure the cIP operational plan is useful, countries are encouraged to tailor the format of the plan to match their needs, integrating it into any annual planning tool(s) the EPI is already using. table 4 below describes different scenarios and suggestions for formatting the cIP to best fit a country’s needs. 37How to Develop a Continuous Improvement Plan (cIP) table 4 Finding the appropriate format for the cIP operational plan Scenario Suggested Action Risk Mitigation 1 The EPI team has been successfully using the current EVM IP to assign activities and measure progress on a yearly basis. Use the cIP as the supply chain chapter of the cMYP and add cIP activities to the annual cMYP activity work plan template. [add link] Although the cIP work plan will be part of the cMYP, it must be socialized with all EPI as a stand-alone document. The NLWG or other EPI coordination mechanism is responsible for tracking progress on the cIP, which should be reported by the EPI every 12 months, even if it is a section in the cMYP. 2 The EPI team uses the EPI annual work plan or cMYP to assign and track supply chain improvement activities. Option 1: If the cIP is being developed close to and prior to the revision of the EPI annual work plan or cMYP, then the cIP operational plan should be integrated into the annual work plan or cMYP template. Option 2: If the timing of the cIP does not allow an integration into EPI annual work plan or cMYP, then use the annual work plan or cMYP template to develop a stand-alone cIP work plan until the next revision cycle. Keep iSC activities in one section within the EPI annual work plan or cMYP, as this will make it easier for the NLWG or the designated coordination mechanism to conduct the yearly review of the cIP. 3 The EPI team needs a stand-alone cIP work plan because no other planning tool exists or because it makes it easier to track partner support to EPI activities. Add the cIP as the supply chain section of the cMYP or health sector strategy and add cIP activities to the annual cMYP activity work plan template. Include a supply chain professional in the cMYP monitoring team to ensure that iSC activities are indeed integrated to the overall cMYP. Keep cIP activities together in the cMYP, as this will make it easier to extract iSC activities for the yearly cIP review. Associated costs and sources of funding The planning and budgeting section of the cIP plan has two parts: a cost estimate and a funding plan. cost estimate The planning and budgeting section should list a full estimate of costs associated with activities listed in the operational and strategic portions of the plan. A tool was developed for the cMYP costing exercise. Since the cIP plan was designed to become part of the cMYP, using the cMYP costing tool as a key resource is recommended. supplement 10 cMYP costing tool www.who.int/immunization/programmes_systems/financing/tools/cmyp/en/ 3.4 38 As part of the planning and budgeting exercise, researching how budgeting is carried out in your country’s immunization programme is recommended so that the cIP cost estimate is aligned with the usual budgetary cycle. If completed in isolation from other budgeting exercises, cIP costs are unlikely to be prioritized and met. Budgeting research should answer: • What is the budgeting process for the EPI, and who is responsible for it? • When are budgets allocated? Annually? Biannually? • Is it preferable to create a stand-alone cIP budget plan or to integrate cIP costs into an existing budget document? • Who should be aware of or involved in the cIP planning and budgeting exercise, and who should review drafts for feedback and validation? funding plan The funding portion of the plan should indicate possible and reliable sources of funding for those costs and the estimated timing of funds availability. Few countries will rely on a single source of funding to maintain activities. Funding diversification is essential for the long-term sustainability of any programme or organization, including the supply chain. Generating in-kind and financial support from donors and other organizations (for example the private sector) should be included among fundraising strategies. To identify possible grants and contributions, EPI teams should list donors currently involved in EPI (such as technical partners, members of the national immunization technical agency group (NITAG), UN agencies) and ask what they would be willing or able to fund. During these discussions, be clear about the type of financial and in-kind support you need (printing, meeting space, facilitation support, etc.) and when you need it, so that they can be responsive. For example, eligible countries that need to purchase cold chain equipment could identify Gavi as a potential source of funding and apply for support from the cold chain equipment optimization platform (CCE OP). To fundraise more efficiently, it may be useful to liaise with other programmes and ministries that already receive funds from these donors and make joint requests. Involve the Ministry of Finance early. Countries that involve colleagues from their Ministry of Finance during the planning and budgeting exercise generally have greater success raising funds and implementing their cIP. The presence of Ministry of Finance staff not only increases the accuracy of the cost estimates and sources of funds, but also accelerates the timeline for signing the budget and dispersing funds. tip 39How to Develop a Continuous Improvement Plan (cIP) 4 4.1 Implementing and monitoring the continuous Improvement Plan (cIP) One of the key reasons WHO/UNICEF decided to relaunch the EVM initiative is because EVM improvement plans were rarely implemented. The comprehensive EVM approach addresses some of the critical shortcomings of the original EVM process (see supplement 11 below). It establishes management mechanisms to support the lifecycle of continuous iSC improvement, improves the quality of cIP planning, and incorporates iSC planning and budgeting within broader national and partner financing processes. Most importantly, however, the comprehensive EVM approach understands the value of involving a wider range of relevant stakeholders from within and outside the immunization programme and seeking their commitment to support supply chain improvement. Socialize and institutionalize the cIP What: Socializing and institutionalizing a plan is the process of engaging staff working on iSC at all levels of the health system, talking to them about the cIP, and explaining how it should be used to guide iSC-related activities in their work plans, and how they can contribute to the success of the programme. Copies of the plan should be shared and presented to relevant Ministry of Health and Ministry of Finance leaders and staff at all levels, as well as partners and donors so they can support implementation by contributing expertise, resources, and technical assistance as needed. Why: A frequent complaint of field level staff is never seeing a copy of the improvement plans they are responsible for implementing. Sharing the cIP or a summary of the cIP with all stakeholders who have participated in its development, and to all staff working to implement it, is recommended. Technical partners also need to understand the cIP so they can help with implementation and complement the cIP within their own plans. supplement 11 WHO/UNICEF Joint Statement. Achieving immunization targets with the comprehensive effective vaccine management (EVM) framework www.who.int/immunization/programmes_systems/supply_chain/ EVM-JS_final.pdf 40 When: After the cIP has been formally endorsed by the ICC. Who: The EPI team (or a credible designee from the NLWG, or any coordinating mechanism you have put in charge) is responsible for disseminating the plan to all EPI staff and highlighting areas of the plan that will impact EPI staff, other health staff, partners, and agencies. Output: All immunization and supply chain staff receive a copy of the cIP (in full or summary). Once all staff receive the cIP document and monitoring indicators, they should be referenced and consulted routinely, during supportive supervision and at EPI managers’ meetings. Implement the cIP What: Once the cIP is endorsed and disseminated, cIP activities and objectives will need to be integrated and reflected in annual national, regional, and district level work plans and budgets, as well as review processes. Committed resources must also be made available in time for staff at all levels to implement activities and keep to the cIP’s implementation timeframe. Why: Implementation of cIP activities allows stakeholders to transform the supply chain into a more efficient and effective function of the immunization programme. 4.2 Hold a national dissemination event. Some countries have successfully held a national cIP dissemination event, coinciding with the official endorsement of the cIP from the government and other stakeholders, paired with subnational meetings with district/regional health officers and EPI staff. tip Engage the workforce at all levels in managing and monitoring iSC performance. The cIP strategic plan and indicators should be widely disseminated and discussed at all levels of the immunization system, and staff should be encouraged to track and monitor iSC performance indicators as they make changes to the programme. EPIs can recognize and develop “champions” of iSC continuous improvement by documenting best practices and success stories and sharing them with relevant national, regional, and global initiatives. tip 41How to Develop a Continuous Improvement Plan (cIP) When: Implementation can begin as soon as the plan is finalized, with some activities being taken up earlier if they are already approved. The key to rapid implementation is clear and frequent communication with staff and managers who are responsible for different activities and sufficient resources, tools, and support to ensure that staff members are equipped to carry out their work. Who: While the EPI team is responsible for day-to-day oversight of cIP implementation, the NLWG is responsible for monitoring implementation progress and KPIs and addressing challenges as they occur. Output: The EPI management team should have regular meetings with regional/district supply chain personnel to discuss implementation progress and problem-solve issues that may arise. Monitor implementation and outcomes What: The annual operational plan should include a set of monitoring indicators that can be used to track implementation progress for day-to-day activities. The strategic plan should include a set of key performance indicators that should be tracked at least yearly or on a schedule agreed with the NLWG or other coordination mechanism in charge. Why: Monitoring indicators and key performance indicators are helpful ways of holding accountable staff members, partners, and consultants for the quality and timeliness of their work. These indicators can also be used to report progress to donors in the Joint Assessment for Gavi and other donor reporting mechanisms. When: Ideally, cIP implementation is reported in regular NLWG (or similar) meetings on a monthly or quarterly basis. If this is not possible, the NLWG should organize at least one in-depth review meetings annually to review end-of-year progress and develop year-two activities. Who: The NLWG is responsible for monitoring iSC performance through KPIs, and the EPI is responsible for managing and monitoring cIP implementation. Output: Routine monitoring reports or presentations should be shared with the NLWG, showing progress along the indicators agreed within the M&E section of the improvement plan. 4.3 42 5Continuous learning and improvement Implementing iSC improvement activities and using performance metrics to improve management requires all EPI staff to understand iSC standards, procedures, and best practices. EPI and iSC managers must have the capability to design new iSC systems, choose new cold chain technologies, and adopt an HSS perspective to improve and sustain systems performance. This cadre of leaders requires advanced and comprehensive skills to manage change and adopt innovation. Mid-level managers must be able to handle complex processes such as planning, forecasting, budgeting and supervision across the iSC. Front-line health workers require skills, capabilities, and support to help them diagnose poor iSC performance and resolve such problems as they arise. The need is urgent in remote and low-access areas (particularly in emergency settings) where front-line workers are largely autonomous; however the need is applicable everywhere that programmes rely on motivated, self-driven professionals to pursue continuous improvement. The comprehensive EVM offers an opportunity to position capacity development and iSC professionalization at the centre of iSC improvement. EPI programmes are encouraged to engage national and regional training institutions – including those proficient in the use of information and communication technologies for health –to participate in the EVM process and adapt EVM standards into dynamic learning curricula and to develop robust M&E systems for the cIP and its implementation. Improvement planning is a continuous process that requires ongoing investments of time, personnel, and planning. Not all supply chain problems will be solved in one cycle, and new problems and challenges will arise as immunization programmes continue to grow and change. For this reason, a continuous improvement mindset is needed to ensure supply chain performance over time. Build a coalition of supply chain supporters. By asking national and regional capacity development institutions – and their academic networks – to support the EPI and its supply chain, countries can translate the needs of the programme into a robust, continuous learning agenda. tip 43How to Develop a Continuous Improvement Plan (cIP) 44© World Health Organization 2018. Some rights reserved. This work is available under the CC BY-NC-SA 3.0 IGO licence. WHO/IVB/18.10

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Printed in Switzerland 3How to Develop a Continuous Improvement Plan (cIP) Contents 1 Introduction 1.1 What is the Effective Vaccine Management (EVM) initiative? 9 1.2 The immunization supply chain continuous Improvement Plan (cIP) 12 1.2.1 Why develop a cIP? 12 1.2.2 Aligning EVM assessment results with the six supply chain essentials 14 2 The continuous Improvement Plan (cIP) development process 2.1 When should the cIP be developed? 17 2.2 Who is responsible for developing the cIP? 18 2.3 What is the best way to develop a cIP? 19 2.3.1 Compile and disseminate a situation analysis 19 2.3.2 Convene a cIP workshop 20 2.3.3 Align cIP goals and objectives with broader national health plans 24 2.3.4 Draft the five-year strategic cIP, including annual operational plan 27 2.3.5 Conduct a planning and budgeting exercise 28 3 The continuous Improvement Plan (cIP) content 3.1 Situation and root-cause analyses 31 3.2 The cIP strategic plan 33 3.2.1 Long-term vision for the immunization supply chain 33 3.2.2 Goals, objectives, strategies, key performance indicators, and costs 34 3.3 The cIP annual operational plan 36 3.3.1 Operational plan 36 3.4 Associated costs and sources of funding 37 4 Implementing and monitoring the cIP 4.1 Socialize and institutionalize the cIP 39 4.2 Implement the cIP 40 4.3 Monitor implementation and outcomes 41 5 Continuous learning and improvement 42 4Supplemental resources supplement 1: Establishing or strengthening a National Logistics Working Group www.technet-21.org/en/library/explore/supply-chain-and-logistics/3735 supplement 2: Situation analysis www.technet-21.org/en/?option=com_sobipro&sid=4800&pid=57&Itemid=2586 supplement 3: cIP workshop agenda repository www.technet-21.org/en/?option=com_sobipro&sid=4819&pid=57&Itemid=2586 supplement 4: Collaborative workshop techniques www.technet-21.org/en/?option=com_sobipro&sid=4801&pid=57&Itemid=2586 supplement 5: WHO Framework for National Health Policies, Strategies and Plans www.who.int/nationalpolicies/FrameworkNHPSP_final_en.pdf supplement 6: Root-cause analysis www.technet-21.org/en/?option=com_sobipro&sid=4802&pid=57&Itemid=2586 supplement 7: Human-centred design methodologies and toolkit www.hcd4i.org supplement 8: Guidance on Dashboards for Immunization Supply Chain www.technet-21.org/iscstrengthening/index.php/en/data-for-manage- ment-documents-and-downloads/guidance-on-dashboards supplement 9: Activity and monitoring plan template (cMYP Guidelines, page 69) apps.who.int/iris/bitstream/10665/100618/1/WHO_IVB_14.01_eng.pdf supplement 10: cMYP costing tool www.who.int/immunization/programmes_systems/financing/tools/cmyp/en/ supplement 11: WHO/UNICEF Joint Statement: Achieving immunization targets with the comprehensive Effective Vaccine Management (EVM) framework www.who.int/immunization/programmes_systems/supply_chain/ EVM-JS_final.pdf 5How to Develop a Continuous Improvement Plan (cIP) Acronyms and abbreviations CCE Cold Chain Equipment CCE OP Cold Chain Equipment Optimization Platform cIP Continuous Improvement Plan cMYP Comprehensive Multi-Year Plan DISC Dashboard for Immunization Supply Chain EPI Expanded Programme on Immunization EVM Effective Vaccine Management EVMA Effective Vaccine Management Assessment Gavi Gavi, The Vaccine Alliance GF Global Fund GFF Global Financing Facility GVAP Global Vaccine Action Plan HR Human Resources HSIS Health Sector Improvement Strategy HSS Health System Strengthening HSSP Health Sector Strategic Programme ICC Inter-agency Coordinating Committee for immunization IP Improvement Plan iSC Immunization Supply Chain KPI Key Performance Indicator LMIS Logistics Management and Information System M&E Monitoring and Evaluation MoH Ministry of Health NGO Nongovernmental Organization NHSP National Health Sector Plan NITAG National Immunization Technical Advisory Group NLWG National Logistics Working Group SOP Standard Operating Procedure TA Technical Assistance UNICEF United Nation Children’s Fund WHO World Health Organization 6About this Guidance Note This document provides guidance to countries on how to develop a continuous immunization supply chain (iSC) improvement plan. Its purpose is to help countries build a case for supply chain investments and develop an improvement plan that engages relevant stakeholders, thus setting the immunization programme on a path for successful implementation. This Guidance Note includes: • An overview of the continuous improvement plan (cIP) development process, including who should be involved, when the plan should be drafted, and how best to gather the required inputs and feedback. • Strategies for aligning Effective Vaccine Management (EVM) assessment outputs with national immunization and health sector planning and financing mechanisms, such as the comprehensive multi-year plan for immunization (cMYP); application for support from Gavi for health system strengthening (HSS); the national health sector improvement strategy (HSIS), and other health sector strategies and plans. • Guidance on preparing a cIP, to include a five-year strategy and a yearly operational plan that can be used to allocate responsibilities and map progress towards a common vision. • Suggestions on how to develop a budget and finance the cIP to ensure sustainability and identify resource gaps. Countries may be familiar with the previous EVM improvement plan process that immediately followed an EVM assessment (EVMA). Whereas the previous EVM improvement plan was designed to address certain short-term supply chain deficiencies, the new, continuous EVM improvement plan described here is designed to be more strategic and inclusive of a wider set of stakeholders who can help reveal the root causes of supply chain problems and mobilize human and financial resources to address them. Supplemental resources for each step of the EVM improvement planning process are also provided. 7How to Develop a Continuous Improvement Plan (cIP) Foreword In the context of renewed global efforts to increase immunization coverage and leave no child unvaccinated, the role of strong national immunization supply chains is hard to overstate. Supply chains are complex and include many elements – people, technologies, systems – that need to be brought together through a plan of continuous action. Such a plan can catalyse not only the immunization supply chain professionals working in the national Expanded Programme of Immunization (EPI), but also their colleagues from the ministries of finance, planning, human resource management departments, senior leadership, development assistance partners, funders and academia. Without this commitment and support, the immunization supply chain professionals are unlikely to succeed in addressing existing gaps in performance and setting up the programme on a path to a sustained, country-driven excellence in ensuring continued vaccine availability, quality and systems efficiency. The purpose of this guidance is to help make the plan of action robust and credible. A robust plan is based on evidence and a strong programming logic, i.e. it focuses investments on activities that together add up to a defined set of objectives and thus help realize the vision of the future and address the deficiencies of the past. The plan is credible when it responds to country needs, and represents a shared vision of the stakeholders who have bought into the plan of action and have a way to track implementation progress against predefined performance targets. These attributes elevate the plan to a powerful investment case for iSC improvement – an advocacy tool for ministries of finance to include and retain iSC activities in their national budget, and for partners to continuously support the cause. These are also the prerequisites of the “holy grail” of institutionalization: the programme putting iSC improvement activities on the radar of national leadership by linking them to the annual operational plans and budget performance metrics. 8However, even a fully funded plan is at risk of remaining a piece of paper unless it touches the hearts and minds of those whose mission is its implementation. Aligning continuous growth – continuous learning – of the EPI workforce at all levels with the process of continuous improvement of the iSC system, is the essential element that makes the coalition for sustained excellence in iSC whole. The EPI workforce is the first to learn what does not work, and often has the clearest insights on how to make it work in the programme context. Participatory models that empower and give implementers a stake in the design and implementation of iSC improvement plans are being embraced increasingly by countries, centralized and devolved contexts alike. The EVM initiative has progressed significantly from being associated with an assessment tool. It has been transformed to help national programmes make major health systems strengthening investments work as intended – to address the underlying systemic bottlenecks to iSC performance. WHO and UNICEF hope that this guidance can inspire and equip you with the knowledge and skills on how to make this initiative work for you. 9How to Develop a Continuous Improvement Plan (cIP) What is the Effective Vaccine Management (EVM) initiative? The 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 It is geared towards the six essentials of immunization supply chain: 1 In 2016, WHO and UNICEF issued a joint statement on the EVM initiative and the vital role that immunization supply chains play in achieving immunization targets set by the Global Vaccine Action Plan (GVAP). This was preceded by a Call to Action issued by the Immunization Practices Advisory Committee in 2014 that recommended a process of assessment, planning, implementation and monitoring to improve immunization supply chains. 1 1.1 Introduction Immunization supply chains are not only limited to equipment and distribution: they are dynamic systems that are flexible, adaptable to changing needs and changing contexts and reactive to ensure vaccine availability in all conditions. A well-designed strategy allows countries to holistically model their supply chains to improve supply chain performance and resilience. Reliable, well-maintained and cost-effective cold chain equipment is vital to ensure that there is adequate, sustainable vaccine storage for current and planned vaccines, that maintenance requirements are kept low, and running costs are reduced. A virtuous cold chain equipment strategy allows countries to access existing guidance and technical assistance, and allocate financial support to better plan for, select, install, manage and maintain their cold chain equipment. Vaccine quality needs to be maintained throughout the immunization supply chain to avoid vaccine wastage due to exposure to heat or freezing temperatures, whether at fixed storage location or during transport. A valuable temperature management strategy helps countries ensure good storage and distribution practices; effective, well-managed temperature monitoring and record-keeping procedures. Countries need effective transport of vaccines between each level of their supply chain to ensure vaccine potency is not compromised by a weak distribution system. A productive distribution strategy includes adequate use of passive containers, satisfactory packing practices with coolant packs, temperature indicators, and accessible transport contingency plans. s y s t e m d e s i g n c o l d c h a i n e q u i p m e n t temperature management d i s t r i b u t i o n 10 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 (see figure 1 ). As a preliminary step, Expanded Programmes on Immunization are encouraged to mobilize national commitment to continuous improvement by bringing stakeholders together to adapt the comprehensive approach to EVM and its four steps, and establish the mechanisms for continuous iSC improvement. Organizing a consultation with key stakeholders is recommended to secure commitment to the EVM initiative, assign clear roles and responsibilities, and agree on an implementation and monitoring process. If schedules allow, a short learning visit for participants to another country that has implemented the EVM process would be beneficial. The key elements of the comprehensive EVM approach are summarized in table 1 . Next generation supply chains require dedicated and competent managers as well as adequate numbers of skilled, accountable, motivated and empowered personnel at all levels of the supply chain. An efficient iSC human resources (HR) strategy helps countries strengthen and build capacity for their supply chain managers by providing access to training, encourage collaboration, positive supervision and professional development opportunities. Data are essential to supply chain managers for managing all aspects of the immunization supply chains, be they vaccine availability, or stock management efficiency. A sound iSC data strategy allows countries to align with data standards, and develop useful tools such as dashboards to monitor effectively their supply chain and make data-informed decisions. h u m a n r e s o u r c e s d ata figure 1 comprehensive approach to evm MONITOR Monitor implementation measure progress toward outcomes ASSESS Collect and review evidence to identify iSC strengths, weaknesses, opportunities, and bottlenecks PLAN Create vision, strategy and operational plan for iSC improvement IMPLEMENT Disseminate plan, ensure funding, and put plan into operation CIP C O M M I T t o c o n t i n u o u s i m p r ov e ment 11How to Develop a Continuous Improvement Plan (cIP) table 1 Suggested Timetable For The EVM Approach Step Estimated duration (in days) Process Format Cost types PREPARATION 0.5–2 Orientation of in-country stakeholders on EVM initiative Workshop Operational costs, facilitation ASSESS 5–10 Preliminary learning visit of select representatives of the Ministry of Health (MoH) and national institutions to participate in EVMAs in another country Visit Travel costs 15–20 EVM assessment planning; training and implementation; sharing and validating findings/results with EPI and MoH Workshop, Assess- ment Individual or institutional contract for EVMA management; operational costs; facilitation 5–10 Situation analysis from the EVMA, plus other assessments and studies that are available (see Table 3) Review Individual or institutional contract PLAN 1– 2 Preparation of the materials for a second workshop and explore how the six iSC essentials can be used to improve the nine EVM criteria2 Staff time 3–5 cIP development workshop: • Establish appropriate oversight and project management mechanisms (through the National Logistics Working Group (NLWG) or other continuous improvement group). • Review situation analysis and identify root-causes. • Define five-year iSC vision, strategic goals, key performance indicators (KPIs) and tactics based on evidence from the performance assessments. • Determine additional technical assistance (TA) needed to complete the cIP (e.g. for planning and budgeting or developing a monitoring and evaluation (M&E) framework). • Discuss how to achieve the three iSC objectives of availability, quality and efficiency by using the six supply chain essentials to improve the nine EVM criteria (see Figure 2) Workshop Operational costs; facilitation 5–15 Alignment with cMYP, national health sector plan (NHSP), funding proposals (e.g. health strengthening systems (HSS) and cold chain equipment optimization procedures (CCE OP). Working group Staff time 15–25 cIP drafting and budgeting: Secure endorsement of the cIP from the Inter-Agency Coordinating Committee (ICC), its development timelines, roles and responsibilities, and dissemination plan. Working group Staff time; operational costs; possibly individual or institutional contract IMPLEMENT 15–25 • Share cIP with all stakeholders, including EPI workforce at subnational level. • Ensure that national HR plans reflect the HR needs of supply chains / if no national HR plan, translate the cIP objectives/tactics into an iSC specific HR plan • Engage a national institution to support M&E • Mobilize funding sources as per your budgeting plan. Working group Staff time MONITOR On a yearly basis • Monitor implementation progress according to plan. • Evaluate key performance indicators for dynamic, data-driven management. • Ensure timely availability and use of resources. Working group Staff time 2 2 The nine EVM criteria: E1 – Vaccine arrival; E2 – Temperature control; E3 – Storage capacity; E4 – Infrastructure; E5 – Maintenance; E6 – Stock Management; E7 – Distribution; E8 – Vaccine Management; E9 – Information Systems. Further information is available at: http://www.who.int/immunization/programmes_systems/ supply_chain/evm/en/ 12 1.2 The immunization supply chain continuous Improvement Plan (cIP) 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. Why develop a cIP? Considerable progress has been made to improve EPI programmes in recent years, partly due to increased investments in supply chains. Immunization supply chain investment cases are now more likely to contain robust situation analyses, be more focused on strategic and evidence- based interventions, and more likely to be costed in a rigorous manner. The cIP builds on these developments and addresses shortcomings of previous planning requirements. 1.2.1 strategic and actionable Many countries develop multiple plans to address the iSC system at different levels, often in response to short-term funding or technical assistance (TA) opportunities and split between national budgets, donor grants, and partner commitments. The planning process may thus be reduced to annual incremental exercises at the expense of a longer-term, strategic planning effort that accounts for contextual changes and changing priorities. As a result, some highly effective (and cost-effective) interventions are neglected in favour of other interventions or may be redundant or programmed inefficiently. The cIP is part of a comprehensive EVM process that enables countries and development assistance partners (where these are present) to learn together which strategies and interventions work and do not work in the country. By using the cIP as an investment case for iSC, immunization staff can pool government and donor resources and TA from partners to address country priorities that already have strong links to multi-year national EPI programme and national health sector plans. In this way, the cIP benefits the country directly, beyond any donor-related consideration. 13How to Develop a Continuous Improvement Plan (cIP) 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. 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. 14 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. Aligning EVM assessment results with the six supply chain essentials Historically, EVM assessments have focused on performance scores organized along the nine EVM criteria. While this helps the programme to focus on discrete tasks (for example, plan to develop a standard operating procedure (SOP) where that procedure was found missing), the same EVMA data can also be analysed to determine which of the six iSC essentials require more urgent focus, as well as giving a high-level benchmark on how the programme managers can achieve the three iSC objectives (availability, potency, efficiency). These new uses of EVM assessment data make for a powerful advocacy and communication tool which helps the EPI programme “manage upwards” by making a more nuanced case for support and resources. The analysis of the data generated by EVM assessments is illustrated in figure 2 . 1.2.2 15How to Develop a Continuous Improvement Plan (cIP) 6 s u p p ly c h a i n e s s e n t i a l s 9 e v m c r i t e r i a 3 o b j e c t i v e s va c c i n e a r r i va l s1 m a i n t e n a n c e5 s to r ag e c a pa c i t y3 d i s t r i b u t i o n7 t e m p e r at u r e m a n ag e m e n t2 s to c k m a n a g e m e n t6 i n f r a s t r u c t u r e4 va c c i n e m a n ag e m e n t8 wa s t e m a n a g e m e n t9 figure 2 Aligning the six supply chain essentials with the nine EVM criteria s y s t e m d e s i g n c o l d c h a i n e q u i p m e n t temperature management d i s t r i b u t i o n h u m a n r e s o u r c e s d ata ava i l a b i l i t y q u a l i t y e f f i c i e n c y By focusing on the six supply chain essentials, countries can systematically increase scores along the nine EVM criteria, and more readily achieve the three objectives. 16 Analysis of EVM assessment data in terms of the three objectives and six iSC essentials enables the programme to frame its cIP as a roadmap to attaining not only compliance with the WHO technical standards, but also the iSC objectives. This helps the programme to build the cIP around a monitoring and evaluation (M&E) framework that measures the relative value and progress of the implementation of cIP activities in terms of their contribution to such established programme indicators as “no vaccine stock-outs at subnational level” (availability: for example, “0% health facilities reporting vaccine stock-outs”), uptime of cold chain equipment (quality: for example, “100% of facilities with functional cold chain equipment”; “100% instances of malfunctioning cold chain equipment reported within 48 hours and addressed within 72 hours”), EVM scores above 80% (efficiency), etc. Once the high-level indicators have been decided, iSC systems performance, in terms of the six essentials, represents an intuitive and comprehensive way of organizing the cIP along the six corresponding strategies that contribute to the attainment of the above-mentioned performance indicators. figure 3 illustrates this logic. figure 3 Proposed cIP framework 2016 2020 ro ad ma p f or im pr ov em en ts s u p p ly c h a i n e s s e n t i a l 1 s u p p ly c h a i n e s s e n t i a l 2 s u p p ly c h a i n e s s e n t i a l 3 s u p p ly c h a i n e s s e n t i a l 4 s u p p ly c h a i n e s s e n t i a l 5 s u p p ly c h a i n e s s e n t i a l 6 % % % % % % E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E >80% 17How to Develop a Continuous Improvement Plan (cIP) 2 2.1 When should the cIP be developed? The cIP is one component of a many-layered planning process for the immunization programme. It cannot be developed without preparation and a baseline understanding of how the supply chain operates, the status of equipment and infrastructure, and a clear understanding of the situation in which the supply chain operates. To this end, the implementation of the EVM approach should be tailored to each country context as described in table 2 . Key assessments should be used to inform the development of a cIP, including the Effective Vaccine Management assessment, system optimization studies, EPI review, and HR assessments (see table 3 ). Using available baseline assessments as a starting point, the cIP can be developed at any time. It is designed to feed into the national immunization planning process, becoming a section, for example, in the cMYP for immunization or health sector strategy. Ideally, a cIP should be developed immediately following the completion of an EVM assessment, and serve as an input to a new (or updated) cMYP or health sector strategy. The timing and format of cIPs will differ between countries according to context and familiarity with the EVM process. ( table 2 proposes several scenarios; table 4 can also be referred to for more detailed information on preparing the plan.) The continuous Improvement Plan (cIP) development process Scenario How to implement the comprehensive EVM approach When 1 Your country has been actively and successfully using a previous EVM improvement plan to determine strategy and implement improvements throughout the EVM cycle (3–5 years) Develop the following cIP based on the present Guidance Note. Socialize the next cIP with all EPI staff and embed it into the next cMYP or health sector strategy. Schedule your next EVM assessment to occur prior to the next cMYP or health sector strategy plan process, as this will allow the cIP to be integrated into the larger immunization planning process. 2 Your country has a strong iSC component already embedded in the cMYP or health sector strategy, which constitutes your country’s iSC plan Develop your next cIP based on the present Guidance Note. Design the cIP to become an annex to the health sector strategy or Section Five of the cMYP3: “Vaccine, cold-chain and logistics.” Option 1: If the cIP is being developed close to and prior to the revision of the cMYP or health sector strategy, then the cIP should be integrated and endorsed as part of that document. Option 2: If the timing of the cIP does not allow an integration into either your cMYP of health sector strategy, develop a stand- alone cIP until the next revision cycle and use it as the main iSC component for your next plan. 3 Your country has no iSC strategy or a weak iSC improvement plan. Develop the next cIP based on this Guidance Note. Mobilize technical assistance, as needed, to establish a mechanism that can manage the cIP development process. Contact your WHO or UNICEF country office to start the EVM initiative, and begin planning your next EVM assessment. table 2 implementing the evm approach in different country contexts 3 See p.28 WHO-UNICEF Guidelines for cMYP for Immunization – Update September 2013. Available at: http://apps.who.int/iris/bitstream/10665/100618/1/WHO_ IVB_14.01_eng.pdf?ua=1 18 Who is responsible for developing the cIP? The national EPI team is responsible for developing the cIP. The process, however, should be supported by a permanent subgroup of the Inter-Agency Coordination Committee (ICC) for immunization, for example a NLWG or supply chain coordinating committee. In countries lacking such mechanisms, engaging with national learning institutions (such as universities) to complement the work of or be a substitute for the NLWG is strongly recommended. Beyond the development of the document itself, the coordinating committee in your country (for example, the NLWG) will play an essential role in monitoring implementation progress and outcomes. Strong leadership from these groups has proven a key success factor for substantial improvement of national iSCs. The cIP itself should be assigned to a specific individual or a small “secretariat” responsible for drafting the plan, soliciting input, making changes, and seeing the plan through to finalization. Half-day commitment workshop. It is critical that all EPI team members, NLWG members, and ICC members understand the EVM initiative and their roles and responsibilities. We recommend that every five years the EPI team organize a half-day orientation to the EVM initiative prior to the EVM assessment. tip supplement 1 Establishing or strengthening a National Logistics Working Group www.technet-21.org/en/library/explore/ supply-chain-and-logistics/3735 2.2 box 1 Launching the comprehensive EVM approach in Sierra Leone and Nigeria In Sierra Leone, the EPI organized a half-day workshop in Freetown for national and subnational MoH and administrative chiefs from all districts. During the workshop, participants examined past EVM performance and discussed how improvements along the six iSC essentials could improve availability, quality, and efficiency of the immunization programme. In the end, participants had a clear vision and a shared understanding of the EVM approach. The decision to include administrative district chiefs was critical to onboarding them in the discussions of priorities, strategies, and performance indicators, particularly in this context where subnational EPI staff are subordinate to the administrative district chain of command. A month later, after a new EVM assessment report was presented, there was already a broad consensus – and a momentum – for developing a cIP that was subsequently linked to the Gavi HSS financing process. 19How to Develop a Continuous Improvement Plan (cIP) What is the best way to develop a cIP? 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 box 2 ). Once the cIP has been approved by the ICC and NLWG, the EPI can disseminate and socialize the plan, integrate it into the cMYP or health sector strategic plan, and begin implementation and monitoring activities. Compile and disseminate a situation analysis What: A situation analysis is a summary of the recent EVM assessment report as well as other available assessments, including the EPI review, cold chain inventory, new vaccine readiness, and HR capacity assessment. It should provide a succinct analysis of the strengths and weaknesses of the supply chain and opportunities for improvement. It should also show changes from past EVMA scores, the implementation status of previous improvement plans, and the overarching context of the immunization programme and the health system. Developing a cIP “at-a-glance” process Compile and disseminate a situation analysis • Detailed situation analysis • Broad stakeholder understanding of EVM and other assessment results • Bottleneck/root cause analysis • Vision, goals, objectives, strategies and KPIs for iSC improvement during the next five years • A list of possible interventions and solutions • Alignment between iSC goals and the Global Vaccine Action Plan/ HSS goals • Align with cMYP, NHSP and other national health strategies • Strategic plan describing vision, goals, objectives and strategies • Detailed operational plan listing activities, responsibilities, timelines, costs, sources of financing, and indicators to achieve strategic goals • ICC/NLWG meeting to endorse the cIP for implementation Convene cIP workshop Align cIP goals and objectives with the cMYP and HSIS Draft and finalize the five-year cIP outputs 2.3 2.3.1 box 2 20 Why: A situation analysis provides a starting point for discussion and ensures that all participants at the cIP workshop (described in subsection 2.3.2 ) are working with up-to-date evidence on the status of the supply chain and can devise improvement target, strategies and activities for the cIP, based on a common understanding of the current context. When: The situation analysis should be conducted after the EVMA has been completed. It should be disseminated to cIP workshop participants at least one week prior to the cIP workshop. Who: Some countries have asked the EVM assessor to summarize the situation analysis on behalf of the EPI team and the members of the NLWG. Other countries have asked a local technical assistance partner or academic institution to summarize the situation analysis, as these institutions are sometimes tapped to do the same for HSS proposals. Convene a cIP workshop What: The cIP workshop is a multi-day, interactive meeting where relevant supply chain stakeholders can collaborate to review the situation analysis in depth, conduct a rapid assessment of root causes, and define the five-year vision, goals, objectives, strategies and KPIs for improving supply chain performance to achieve broader immunization goals. Why: The workshop serves as an opportunity to align supply chain stakeholders around a common understanding of the challenges in the immunization supply chain and a long- term vision and goals for its improvement. When: The cIP workshop should occur after the situation analysis is available, and prior to the development of a new cMYP or a new national health plan. Effective collaborative workshops can be resource-intensive and time- consuming. It is therefore crucial to allocate adequate time for each session to avoid compromising the quality of collaboration, which is a predictor of the quality of the cIP. Length of cIP workshop. Many countries have reported that four days is adequate for a cIP workshop. However, some countries may require more than one workshop to agree on a vision and a set of viable goals and objectives. EPI managers should plan accordingly. tip 2.3.2 supplement 2 Situation analysis www.technet-21.org/en/?option=com_sobipro&sid=4800&pid=57&Itemid=2586 21How to Develop a Continuous Improvement Plan (cIP) Who: The EPI, with support from national institutions (such as NLWG, academia) and WHO and/or UNICEF, is responsible for organizing the cIP workshop, developing the cIP document, and monitoring its implementation. Following the cIP workshop, a single individual or “secretariat” should be assigned responsibility for drafting the plan, soliciting inputs, making changes, and facilitating the necessary buy-in and approvals. Core participants should include EPI and iSC staff representing different levels of the health system as well as regional and district administrators. If the iSC is integrated with, or overseen by, another government department, relevant staff from that department must also be involved. Stakeholders who are involved in the development of other national plans (for example cMYP, HSIS, NHSP) should be included as a priority. Representatives from other ministries, including human resources and infrastructure, as well as the National Regulatory Authority (NRA) or other regulatory bodies when applicable should be invited, as they can recommend solutions to problems that the MoH cannot solve directly, as well as champion investments in these solutions at key junctures of the political process during national budget negotiations. Other participants may be considered, and should be included based on their ability to contribute to the technical discussion on the supply chain. This includes nongovernmental stakeholders such as outside consultants, donors (World Bank, Japanese International Cooperation Agency, the Bill & Melinda Gates Foundation, the US Agency for International Development, and others as applicable), technical partners (UNICEF and/or WHO Country Offices, the US Centres for Disease Control and Prevention, International Development Research Centre, PATH, John Snow, Inc., and others as applicable). Where: Conducting workshops off-site has been shown to notably reduce distractions and elevate the engagement level of participants; however, this may not always be feasible. The location must have adequate space for both plenary and breakout discussions. Include non-supply chain experts in the workshop. By including non- supply chain experts in the workshop, the EPI team can explore a greater array of choices on how to solve supply chain problems. For example, with input from officials from ministries of finance, education, infrastructure, and the MoH department of human resources, EPI staff may suggest solutions that the EPI team had not previously considered. tip 22 How: Advanced planning is critical to ensure a productive workshop. An agenda and supporting documents must be produced and shared in advance (for example a succinct note summarizing the situation analysis and five to six strategic options to discuss). Several countries have developed cIP workshop agendas that can be followed or adapted. Most workshops start with a discussion on the status of the supply chain (situation analysis) and the ways in which the supply chain supports, or fails to support, immunization objectives. This discussion naturally brings up the question of benchmarks: what the performance should be (vision), and how it can be measured (KPIs defined for each iSC level). From there, participants can explore root causes of existing challenges and propose strategies, goals and objectives that would progress the programme to where it would like to be in five years. Output: The output of the cIP workshop should be a five-year vision, a set of six goals (one for each supply chain essential) with high-level performance indicators, and the corresponding objectives and strategies that should come out of the root-causes analysis carried out during the cIP workshop (see section 3 ). Because members of other planning groups (for example NHSP; cMYP; Gavi, the Global Fund (GF) or Global Financing Facility (GFF) grant applications; health commodity supply chain) are included in the cIP workshop, the cIP should already reflect the highest priorities of other programme and planning instruments. supplement 3 cIP workshop agenda repository www.technet-21.org/en/?option=com_sobipro&sid=4819&pid=57&Itemid=2586 Collaborative workshop techniques. Many countries have adopted collaborative workshop techniques to generate productive stakeholder conversation during the workshop (see supplement 4 ). Experience has shown that breaking cIP workshop participants into groups – with each group focused on one of the six supply chain essentials – can be highly effective. Each group then presents goals, objectives, strategies and activities, along with an estimated budget and any additional tasks required to operationalize activity. It is important, however, during this focused process to also allow for an exploration of strategies that take on a broader system view. One suggestion is to assign one group to focus on a problem that does not necessarily fit into a single strategic area (such as polio transition or staff shortages). It is also advisable to examine best practices, or examples of “positive deviance”, within the country to identify possible solutions that are already working. tip 23How to Develop a Continuous Improvement Plan (cIP) box 3 Positive Deviance EVM assessments identify the flaws of the iSC system which then become the focus of the cIP. The associated tools and processes, including the bottleneck analysis, are designed to identify and correct problems, not to identify or understand when and why things work well. The consequence is a lack of motivation and engagement from countries, who may feel threatened by the process as it highlights the deficiencies without recognizing the specific drivers of achievements. The purpose of positive deviance is to enable communities4 of practitioners to discover their successful behaviours and strategies, and transform them into plans of action to promote sustainable change. The approach is based on the following principles: • Communities of practitioners have solutions and “know-how” • Communities of practitioners can organize themselves to solve an agreed problem • Collective intelligence to solve a specific problem is more effective than solutions imposed by external experts • Sustainability is at the core of the response The methodology of positive deviance consists of five basic steps: 1. Define the problem, current perceived causes, challenges and constraints, common practices, and desired outcomes. 2. Determine the presence of positive deviant individuals or groups. 3. Discover uncommon but successful behaviours and strategies through inquiry and observation. 4. Design activities to allow community members to practice the discovered behaviours. 5. Monitor and evaluate the resulting project or initiative, which further fuels change by documenting and sharing improvements as they occur, and helps the community discern the effectiveness of the initiative. In the context of EVM, the health workforce involved in iSC would constitute communities at each iSC level. Ideally, a positive deviance approach should be an intricate part of the EVM process, reflecting itself in the additional qualitative information collected during the EVM assessment and, most importantly, in ensuring that reiterating feedback loops capture the perspectives, solutions and know-how of the iSC workforce throughout the assessment, planning and implementation processes. This approach can help ensure that the cIP is derived from local needs, contextualized through generating deviance from community. In addition, the approach can offer a reality check on the EVM assessment process, including evidence that could help improve the EVM approach in future. The recent cIP development process in Sierra Leone used elements of this approach in two ways: (i) national EVM assessors were encouraged to collect structured notes on the background to any good practices they observed during their assessment visits; and (ii) the cIP development workshop encouraged the participants – some of whom were elected district representatives who could bring in community perspectives – to discuss whether any districts may have “got it right” contrary to the nation-wide EVM assessment findings. One such conversation identified a district that paid performance-based incentives that had a positive impact on core iSC performance indicators; this was a revelation to representatives from some other districts and provoked genuine reflections on the strategies available. 4 For definitions and components of successful communities please refer to https://community-canvas.org/ 24 Align cIP goals and objectives with broader national health plans What: With cIP goals and objectives in hand, EPI staff should participate in relevant, parallel planning efforts (such as the NHSP, cMYP and HSS investment cases) and discuss how the cIP and its implementation can contribute to immunization and health system goals, EPI equity analysis, and EPI reviews. figure 4 illustrates how the cIP can be fully incorporated into broader national and other health plans, cutting across the six essentials of the immunization supply chain. 2.3.3 box 4 Nigeria Nigeria designed a four-day cIP workshop to enable EPI managers from 36 states and the Federal Capital Territory to reflect on the results from the recent EVMA and jointly examine the causes of insufficient improvement and inadequate implementation of previous plans. This event differed notably from typical training workshops and planning meetings. It was designed to be highly dynamic, iterative, and engaging to maximize substantive contributions from all participants and secure maximum buy-in for the cIP, particularly from the state-level government EPI managers. The approach enabled the new cIP to bring measurable and sustainable improvement to the country’s iSC, and ensured that the cIP was appropriate in the context of Nigeria’s devolved health sector. supplement 4 Collaborative workshop techniques www.technet-21.org/en/?option=com_sobipro&sid=4801&pid=57&Itemid=2586 25How to Develop a Continuous Improvement Plan (cIP) Why: Incorporating the cIP into the NHSP, cMYP and other relevant plans will make those plans stronger and more specific. The more integrated the planning efforts become, the easier it will be to eliminate duplicate efforts and identify opportunities for efficiencies (such as a shared set of indicators or outcomes) with other plans. Who: Key EPI staff should attend relevant planning committee meetings to present the cIP and discuss how the plan supports the NHSP, cMYP (and other relevant plans). By attending these meetings, planning participants can look for redundancies as well as opportunities for efficiencies. figure 4 integrating the cIP to broader health plan processes Immunization multi-year plan (cMYP) National health sector plan EVM cIP system design Cold chain equipment temperature management distribution human resources data 26 When: During the cIP workshop, relevant stakeholders involved in other planning processes (for example NHSP; Gavi, GF or GFF grant application, health commodity supply chain plan) should already be participating in the development of overarching goals, strategies and activities for the supply chain. After the cIP workshop, EPI staff and external planning participants should share the draft vision, goals, objectives and strategies with committees working on relevant immunization and health strategies and brief them on the cIP workshop discussions and outcomes. Output: The primary output of this step should be the welcome inclusion of the cIP into the cMYP, NHSP, and other planning documents. A secondary output could be a list of suggested revisions that will further align the cIP with other planning instruments based on discussions with relevant planning groups. As needed, these recommendations should be used to adjust the goals, objectives, and strategies developed during the cIP workshop. Making the most of HSS programming. When considering iSC improvements through the HSS lens, EPI staff should ask: which specific health systems need to be strengthened to help us resolve the most urgent iSC bottlenecks facing our programme? The answers will likely relate to the HSS “building blocks”: health sector governance, human resources, information systems, financing. Building alliances with stakeholders outside the EPI chain of command may be key to resolving problems and is a worthy investment of effort. Donors often encourage (for example through Gavi HSS grants) national EPI programmes to enlist support from other government departments to address urgent EPI problems. tip 27How to Develop a Continuous Improvement Plan (cIP) Draft the five-year strategic cIP, including annual operational plan What: The cIP should be written in two parts (see section 4 ). First, a strategic section stating the vision, goals, objectives, KPIs, and estimated costs5 for activities identified and developed during the cIP workshop. Second, the plan should include an annual operational plan with associated costs, sources of financing, and implementation indicators. Once completed, the full cIP becomes the cMYP section on cold chain and logistics (see section 5 ) or an annex to the health sector strategy. Why: The five-year cIP aligns all stakeholders, including TA providers, to a common set of goals that improves immunization efficiency, quality and availability. The cIP is a continuous learning tool that links EVMA results with the overall strategic vision for immunization. When: The time required to develop the cIP will vary by country. The EPI team should agree on a reasonable deadline, given available staff resources. If a new cMYP or NHSP are being developed, the cIP should be finalized within the development timeframe of these plans. Sufficient time should be allocated to the budgeting and financing component of the cIP, as this will improve the viability of the plan (see subsection 3.4 ). Who: The cIP should be developed by (or in close partnership with) senior EPI staff, as EPI will be primarily responsible for executing the plan. Working groups formed during the cIP workshop may be willing to draft sections of the plans relating to strategic focus areas, but the EPI team is responsible for integrating those sections into a complete plan. There may be exceptions in some contexts where cIP drafting may need to be carried out externally, particularly when there is insufficient relevant capacity in-country. Output: The cIP includes a five-year strategic plan, and an annual operational plan that can be presented to the NLWG and the ICC for endorsement. 5 WHO and UNICEF recommend conducting a full planning and budgeting exercise for the cIP, and linking it to the cMYP budget. 2.3.4 28 2.3.5 Conduct a planning and budgeting exercise What: A planning and budgeting exercise is an effort to identify all costs and sources of funding associated with activities listed in the cIP during the five-year period. Associated costs can include: • Personnel (e.g. staff assigned to reporting) • Capital expenditures on equipment and infrastructure (e.g. acquisition of vehicles, cold chain equipment) • Operational expenditures (e.g. cold chain repair or maintenance) • Transport • Outsourced services • Workshops and international exchanges • Technical assistance needs (e.g. system design technical support, NLWG set-up support) Why: As with all plans, the cIP is only useful to the extent that it is supported and funded. A planning and budgeting exercise defines the costs associated with cIP implementation and monitoring, and enables EPI managers and logistics coordinating committees to identify sources of funds to meet the needs of the programme. When: The planning and budgeting exercise should be conducted as soon as the draft cIP plan is completed and before it is approved by the ICC. Who: The EPI is responsible for completing a planning and budgeting exercise, whether by identifying a TA partner to conduct the planning and budgeting exercise or a private agency. Involve the Ministry of Finance early. Countries that involve colleagues from their Ministry of Finance during the planning and budgeting exercise generally have greater success raising funds and implementing their cIP. The presence of Ministry of Finance staff not only increases the accuracy of the cost estimates and sources of funds, but also accelerates the timeline for signing the budget and dispersing funds. tip 29How to Develop a Continuous Improvement Plan (cIP) 3The continuous Improvement Plan (cIP) content • a clear description of what the country wants to achieve: the vision, goals, and anticipated outcomes for the iSC, which can serve as a rallying point for all relevant stakeholders; • logical and strategic – answering what, why, and when specific activities should occur, who is responsible, and how progress will be measured using KPIs; • based on a systematic, evidence-based analysis of the root causes of poor iSC performance, as well as an analysis of the enablers of strong iSC performance; • created as part of a participatory planning process with relevant stakeholders from other ministries and levels of the health system so it responds to, and is supported by, broader national planning processes for immunization (such as cMYP) and health; used to raise awareness and advocate for investment and oversight from higher management levels of the MoH. • either a stand-alone document or directly integrated into existing annual work plans; • a tool to track implementation progress of the annual work plan with direct links to outcomes described in the strategic plan that can be reported during yearly reviews; • developed annually with a description of objectives and activities, timelines, responsibilities, costs, and indicators to monitor progress; • reviewed and endorsed by the ICC and a supply chain working group or committee; • reviewed at least quarterly by EPI managers and reported at least annually to the ICC and NLWG where it exists. The strategic plan should be: The operational plan should be: As previously mentioned in this Guidance Note, the cIP will consist of two main parts: (i) the strategic plan which describes the vision, goals and key strategies for the supply chain during the next five years; and (ii) the operational plan – an annual work plan detailing activities, timelines, responsibilities, costs, and indicators. 30 Suggested cIP content “at-a-glance” 1. Situation and root-cause analyses • See above subsection 2.3.1 a. Long-term vision • Describes the desired future state of the immunization supply chain • Describes how the cIP vision and goals support the objectives of the immunization programme and the health sector b. Goals, objectives, strategies, KPIs, and estimated costs • Describes high-level goals to improve availability, quality and efficiency of the iSC • Describes key objective for each goal with indicators that show progress toward them • Describes strategies based on the root-cause analysis that will move the country closer to achieving the goals within the next five years • Describes selected KPIs that will allow progress measurement throughout the continuous improvement cycle • Provides estimated costs for all activities within the five-year plan and describes possible and confirmed sources of funding (including partner- supported activities) a. Activity and monitoring plan for year 1 • Describes the key activities and progress indicators that will be used to track implementation • Describes governance of the cIP (e.g. roles of NLWG, partner, TA providers, etc.), as well as timelines, and responsibilities b. Associated costs and sources of funding • Calculates the specific costs associated with the operational plan • Identifies sources (and timing) of funding from partners, donors, and government budgets 2 . The cIP strategic plan 3. The cIP operational plan box 5 31How to Develop a Continuous Improvement Plan (cIP) supplement 5 WHO Framework for National Health Policies, Strategies and Plans www.who.int/nationalpolicies/FrameworkNHPSP_final_en.pdf Use the WHO Framework for National Health Policies, Strategies and Plans to strengthen your plan. Experience shows that the policy dialogue for building comprehensive national health policies, strategies and plans is as much a political as a technical process. It requires attention for the inspirational side of defining vision and policy; it also requires attention for operational detail. The balance between vision, policy, strategic planning and consistency in implementation varies considerably from country to country. You are encouraged to consult the WHO Framework for National Health Policies, Strategies and Plans (see Supplement 1 below) on prerequisites for sound planning documents that match your country’s overall national health strategies. tip 3.1 Situation and root-cause analyses The situation analysis (see supplement 2 ) is the first section of the cIP. It describes the status and current performance of the supply chain and its components by summarizing the key results and recommendations from the EVMA and other relevant assessments. table 3 below lists the assessments, plans and situations that may be analysed as part of the situation analysis. The right-hand column shows suggestions of where inputs, information and data can be found. 32 table 3 Assessments, inventories, and reports to include in a situation analysis Assessments, inventories and reports Where to find them National EPI review • National EPI programme EVMA reports and EVM improvement plans (IPs), including details of EVM implementation • National EPI programme, or WHO and UNICEF country offices Up-to-date cold chain equipment inventory (CCEI), including expansion and equipment rehabilitation requirements • National CCEI, if available • CCE OP application • EVMA reports • Logistics management and information system (LMIS) • Procurement plans and records New vaccine supply chain readiness assessment • EVMA reports • Applications for introduction of new vaccine to Gavi, WHO, UNICEF, etc. • cMYP • Gavi HSS applications HR capacity assessment • EVMA reports • Gavi HSS applications • cMYP • Health sector HR assessments Temperature monitoring assessment of the cold chain • Recent temperature monitoring study • Temperature monitoring system data Transportation network design assessment • EVMA reports • Supply chain assessments (USAID, etc.) and strategic plans National immunization and health sector strategies, policies and priorities • EPI annual plan • EPI multi-year plan • National health sector multi-year strategy • cMYP • Gavi HSS strategy • Other health commodity supply chains strategies/assessments Equity assessments • National EPI programme 33How to Develop a Continuous Improvement Plan (cIP) A root-cause analysis examines why supply chain performance is low in certain areas. The root-cause analysis is an opportunity to resolve challenges that result from failures. There are many ways to conduct a root-cause analysis (see supplement 6 below); the approach can be determined by the EPI team. Three components are essential to a root-cause analysis: problem statement, root-causes, and possible strategies to address the root causes. Some countries have successfully used the human-centred design methodologies toolkit (see supplement 7 below) to guide the root-cause discussion in cIP workshops. Taken together, the situation and root-cause analyses provide national policy-makers with an overview of the strengths, opportunities, weaknesses, and threats of the immunization supply chain and help prioritize activities so that investments can be focused accordingly. The cIP strategic plan The strategic plan should be concise and easy to read. It should display the long-term vision for the supply chain, and the high-level goals, objectives and strategies that have been identified for the next five years (including indicators to measure outcomes and progress toward those outcomes). A one- to two-page summary of the strategic plan should be widely disseminated and used as a tool to track progress. Long-term vision for the immunization supply chain The long-term vision should describe how the iSC supports the immunization programme: how it performs, how it is organized, and what it contributes to the immunization programme and to the national health sector. The vision should describe a resilient iSC that can accommodate changes to health system priorities (for example health security, polio transition, electronic records), as well as anticipated changes to the general infrastructure and the political climate (such as investments in rural electrification, infrastructure and roads, and increased internet access). Most importantly, it reflects the goal of supply chains to improve availability, efficiency, and the quality of vaccines and immunization supplies across the country. Example: “We envision a supply chain that reliably delivers sufficient quantities of vaccines and immunization supplies directly to all fixed immunization posts (including new posts that are opening during the next five years) and does so without compromising quality due to exposure to heat or freezing temperatures. By doing so, the supply chain will support the EPI goal of 90% vaccination coverage by xxxx, and decrease child mortality by xxx.” supplement 6 Root cause analysis www.technet-21.org/en/?option=com_sobipro&sid=4802&pid=57&Itemid=2586 supplement 7 Human-centred design methodologies and toolkit www.hcd4i.org 3.2 3.2.1 34 Goals, objectives, strategies, key performance indicators, and costs Goals describe the medium- and long-term outcomes that are necessary to achieve the vision. In the case of supply chains, goals are easy to write when they are aligned with core supply chain objectives of increasing availability, quality, and efficiency. A manageable strategic plan usually lists between three and five goals that are achievable within five years. Each goal should have at least one KPI that can be measured and reported over the course of the year. Example: Goal #1: Increase immunization coverage by ensuring all EPI vaccines and immunization supplies are available at the point of vaccination in at least 20 high-priority districts by 2023. KPI: Number of priority districts achieving 12 months of full stock availability (see below). Objectives are quantitative measures of the goals that are time-bound. They often start with the words “increase” or “decrease” or “establish”. It is a country’s discretion to select any number of objectives per goal that are realistically achievable within the timeframe and budget available. Typically, a country would select relevant iSC performance indicators from the Guidance on Dashboards for Immunization Supply Chain (DISC) (see supplement 8 below). Example: Objective #1: Increase the number of facilities in high-priority districts achieving full stock availability6 within a 12-month period. 6 Full stock availability (from DISC indicators) is the percentage of storage points with full availability of all or selected set of tracer vaccines and immunization supplies over a resupply period. Full availability is defined as no stock-out in the store or health facility at any point during the period. 3.2.2 supplement 8 Guidance on Dashboards for Immunization Supply Chain (DISC) www.technet-21.org/iscstrengthening/index.php/en/data-for-management- documents-and-downloads/guidance-on-dashboards 35How to Develop a Continuous Improvement Plan (cIP) Strategies describe the approach that will be used to achieve the goal or objective. Strategies usually answer questions that emerge when faced with choices or constraints, and for this reason, strategies can differ significantly depending on who is involved in the discussion. For example, when new refrigerators are needed, does it make more sense to buy solar-direct drive refrigerators or invest in micro-grids for rural electrification? When health workers need to be trained on basic refrigerator maintenance, would it be more effective to offer refresher training, supportive supervision, or develop and include the relevant curricula into MoH-accredited pre- service training linked to career progression of the relevant workforce? Consultations should be held with a broad range of stakeholders, not just immunization supply chain professionals, to identify the best strategic options. Depending on the situation, some countries may find it easiest to form cIP strategies around the six supply chain essentials (see subsection 1.1 ). The sample strategy below leverages two supply chain essentials: Distribution and System Design to improve overall iSC performance. Example: Strategy #1: Implement a pull-based (demand driven) distribution system for vaccine and cold chain with reliable transportation system based on efficient network design and route planning. Outcome indicator: Number of districts with a functioning pull-based distribution system based on efficient network design and route planning in [specific] districts. let availability, quality and efficiency drive your plan. Introducing the iSC objectives of availability, quality and efficiency at the start of the cIP design workshop is an excellent way to focus the conversation – and the resulting cIP – on what matters most. EVMA data can be presented graphically to show how iSC performance meets (or fails to meet) three objectives across the distribution levels. Workshop discussions can then be steered to discuss and quantify desired performance levels for each of the three objectives, which in turn would clarify investments required to meet the objectives. For example, a discussion of what it takes to assure vaccine quality at the service delivery level will lead to a discussion on two DISC indicators: (i) functional status of cold-chain equipment; and (ii) temperature alarm rate. Participants can then agree on minimum performance levels (for example, all failed cold chain equipment units are reported/logged within two days, and repaired or replaced within five days), which will clarify investments required to capture and monitor these data and to ensure compliance with the agreed performance levels. tip 36 supplementn 9 Activity and monitoring plan template (cMYP Guidelines, page 69) apps.who.int/iris/bitstream/10665/100618/1/WHO_IVB_14.01_eng.pdf The cIP annual operational plan Operational plan The operational plan is the part of the cIP that translates goals, objectives, and strategies into a set of activities that can be assigned and accomplished within a 12-month period (for example, Activity #1: “List the functional requirements for a stock management system for each major user group”). Because activity-level planning can be dynamic and dependent on external factors, it is not necessary to articulate specific activities beyond 12– 14 months. The recommendation is to develop a plan that can be used by those managing the iSC, in a format that feeds into existing EPI annual work plans. Each activity should have an associated measurable process or completion indicator and estimated cost. The activity plan also should specify the governance structure for implementation oversight (i.e. roles/responsibilities of NLWG, partner agencies, and TA providers) and a timeline for monitoring indicators. Include a monitoring process and schedule. Countries have emphasized the importance of including a schedule for monitoring (e.g. dates when the KPIs are reviewed and discussed) and indicating which person or team will be responsible for collecting and reviewing KPIs according to the schedule. tip Include partner activities in operational plan. To ensure accountability of all stakeholders, the operational part of the cIP should include both activities (and implementation indicators) supported from within the EPI programme plan, and activities (and implementation indicators) supported by TA partners. tip 3.3 3.3.1 To ensure the cIP operational plan is useful, countries are encouraged to tailor the format of the plan to match their needs, integrating it into any annual planning tool(s) the EPI is already using. table 4 below describes different scenarios and suggestions for formatting the cIP to best fit a country’s needs. 37How to Develop a Continuous Improvement Plan (cIP) table 4 Finding the appropriate format for the cIP operational plan Scenario Suggested Action Risk Mitigation 1 The EPI team has been successfully using the current EVM IP to assign activities and measure progress on a yearly basis. Use the cIP as the supply chain chapter of the cMYP and add cIP activities to the annual cMYP activity work plan template. [add link] Although the cIP work plan will be part of the cMYP, it must be socialized with all EPI as a stand-alone document. The NLWG or other EPI coordination mechanism is responsible for tracking progress on the cIP, which should be reported by the EPI every 12 months, even if it is a section in the cMYP. 2 The EPI team uses the EPI annual work plan or cMYP to assign and track supply chain improvement activities. Option 1: If the cIP is being developed close to and prior to the revision of the EPI annual work plan or cMYP, then the cIP operational plan should be integrated into the annual work plan or cMYP template. Option 2: If the timing of the cIP does not allow an integration into EPI annual work plan or cMYP, then use the annual work plan or cMYP template to develop a stand-alone cIP work plan until the next revision cycle. Keep iSC activities in one section within the EPI annual work plan or cMYP, as this will make it easier for the NLWG or the designated coordination mechanism to conduct the yearly review of the cIP. 3 The EPI team needs a stand-alone cIP work plan because no other planning tool exists or because it makes it easier to track partner support to EPI activities. Add the cIP as the supply chain section of the cMYP or health sector strategy and add cIP activities to the annual cMYP activity work plan template. Include a supply chain professional in the cMYP monitoring team to ensure that iSC activities are indeed integrated to the overall cMYP. Keep cIP activities together in the cMYP, as this will make it easier to extract iSC activities for the yearly cIP review. Associated costs and sources of funding The planning and budgeting section of the cIP plan has two parts: a cost estimate and a funding plan. cost estimate The planning and budgeting section should list a full estimate of costs associated with activities listed in the operational and strategic portions of the plan. A tool was developed for the cMYP costing exercise. Since the cIP plan was designed to become part of the cMYP, using the cMYP costing tool as a key resource is recommended. supplement 10 cMYP costing tool www.who.int/immunization/programmes_systems/financing/tools/cmyp/en/ 3.4 38 As part of the planning and budgeting exercise, researching how budgeting is carried out in your country’s immunization programme is recommended so that the cIP cost estimate is aligned with the usual budgetary cycle. If completed in isolation from other budgeting exercises, cIP costs are unlikely to be prioritized and met. Budgeting research should answer: • What is the budgeting process for the EPI, and who is responsible for it? • When are budgets allocated? Annually? Biannually? • Is it preferable to create a stand-alone cIP budget plan or to integrate cIP costs into an existing budget document? • Who should be aware of or involved in the cIP planning and budgeting exercise, and who should review drafts for feedback and validation? funding plan The funding portion of the plan should indicate possible and reliable sources of funding for those costs and the estimated timing of funds availability. Few countries will rely on a single source of funding to maintain activities. Funding diversification is essential for the long-term sustainability of any programme or organization, including the supply chain. Generating in-kind and financial support from donors and other organizations (for example the private sector) should be included among fundraising strategies. To identify possible grants and contributions, EPI teams should list donors currently involved in EPI (such as technical partners, members of the national immunization technical agency group (NITAG), UN agencies) and ask what they would be willing or able to fund. During these discussions, be clear about the type of financial and in-kind support you need (printing, meeting space, facilitation support, etc.) and when you need it, so that they can be responsive. For example, eligible countries that need to purchase cold chain equipment could identify Gavi as a potential source of funding and apply for support from the cold chain equipment optimization platform (CCE OP). To fundraise more efficiently, it may be useful to liaise with other programmes and ministries that already receive funds from these donors and make joint requests. Involve the Ministry of Finance early. Countries that involve colleagues from their Ministry of Finance during the planning and budgeting exercise generally have greater success raising funds and implementing their cIP. The presence of Ministry of Finance staff not only increases the accuracy of the cost estimates and sources of funds, but also accelerates the timeline for signing the budget and dispersing funds. tip 39How to Develop a Continuous Improvement Plan (cIP) 4 4.1 Implementing and monitoring the continuous Improvement Plan (cIP) One of the key reasons WHO/UNICEF decided to relaunch the EVM initiative is because EVM improvement plans were rarely implemented. The comprehensive EVM approach addresses some of the critical shortcomings of the original EVM process (see supplement 11 below). It establishes management mechanisms to support the lifecycle of continuous iSC improvement, improves the quality of cIP planning, and incorporates iSC planning and budgeting within broader national and partner financing processes. Most importantly, however, the comprehensive EVM approach understands the value of involving a wider range of relevant stakeholders from within and outside the immunization programme and seeking their commitment to support supply chain improvement. Socialize and institutionalize the cIP What: Socializing and institutionalizing a plan is the process of engaging staff working on iSC at all levels of the health system, talking to them about the cIP, and explaining how it should be used to guide iSC-related activities in their work plans, and how they can contribute to the success of the programme. Copies of the plan should be shared and presented to relevant Ministry of Health and Ministry of Finance leaders and staff at all levels, as well as partners and donors so they can support implementation by contributing expertise, resources, and technical assistance as needed. Why: A frequent complaint of field level staff is never seeing a copy of the improvement plans they are responsible for implementing. Sharing the cIP or a summary of the cIP with all stakeholders who have participated in its development, and to all staff working to implement it, is recommended. Technical partners also need to understand the cIP so they can help with implementation and complement the cIP within their own plans. supplement 11 WHO/UNICEF Joint Statement. Achieving immunization targets with the comprehensive effective vaccine management (EVM) framework www.who.int/immunization/programmes_systems/supply_chain/ EVM-JS_final.pdf 40 When: After the cIP has been formally endorsed by the ICC. Who: The EPI team (or a credible designee from the NLWG, or any coordinating mechanism you have put in charge) is responsible for disseminating the plan to all EPI staff and highlighting areas of the plan that will impact EPI staff, other health staff, partners, and agencies. Output: All immunization and supply chain staff receive a copy of the cIP (in full or summary). Once all staff receive the cIP document and monitoring indicators, they should be referenced and consulted routinely, during supportive supervision and at EPI managers’ meetings. Implement the cIP What: Once the cIP is endorsed and disseminated, cIP activities and objectives will need to be integrated and reflected in annual national, regional, and district level work plans and budgets, as well as review processes. Committed resources must also be made available in time for staff at all levels to implement activities and keep to the cIP’s implementation timeframe. Why: Implementation of cIP activities allows stakeholders to transform the supply chain into a more efficient and effective function of the immunization programme. 4.2 Hold a national dissemination event. Some countries have successfully held a national cIP dissemination event, coinciding with the official endorsement of the cIP from the government and other stakeholders, paired with subnational meetings with district/regional health officers and EPI staff. tip Engage the workforce at all levels in managing and monitoring iSC performance. The cIP strategic plan and indicators should be widely disseminated and discussed at all levels of the immunization system, and staff should be encouraged to track and monitor iSC performance indicators as they make changes to the programme. EPIs can recognize and develop “champions” of iSC continuous improvement by documenting best practices and success stories and sharing them with relevant national, regional, and global initiatives. tip 41How to Develop a Continuous Improvement Plan (cIP) When: Implementation can begin as soon as the plan is finalized, with some activities being taken up earlier if they are already approved. The key to rapid implementation is clear and frequent communication with staff and managers who are responsible for different activities and sufficient resources, tools, and support to ensure that staff members are equipped to carry out their work. Who: While the EPI team is responsible for day-to-day oversight of cIP implementation, the NLWG is responsible for monitoring implementation progress and KPIs and addressing challenges as they occur. Output: The EPI management team should have regular meetings with regional/district supply chain personnel to discuss implementation progress and problem-solve issues that may arise. Monitor implementation and outcomes What: The annual operational plan should include a set of monitoring indicators that can be used to track implementation progress for day-to-day activities. The strategic plan should include a set of key performance indicators that should be tracked at least yearly or on a schedule agreed with the NLWG or other coordination mechanism in charge. Why: Monitoring indicators and key performance indicators are helpful ways of holding accountable staff members, partners, and consultants for the quality and timeliness of their work. These indicators can also be used to report progress to donors in the Joint Assessment for Gavi and other donor reporting mechanisms. When: Ideally, cIP implementation is reported in regular NLWG (or similar) meetings on a monthly or quarterly basis. If this is not possible, the NLWG should organize at least one in-depth review meetings annually to review end-of-year progress and develop year-two activities. Who: The NLWG is responsible for monitoring iSC performance through KPIs, and the EPI is responsible for managing and monitoring cIP implementation. Output: Routine monitoring reports or presentations should be shared with the NLWG, showing progress along the indicators agreed within the M&E section of the improvement plan. 4.3 42 5Continuous learning and improvement Implementing iSC improvement activities and using performance metrics to improve management requires all EPI staff to understand iSC standards, procedures, and best practices. EPI and iSC managers must have the capability to design new iSC systems, choose new cold chain technologies, and adopt an HSS perspective to improve and sustain systems performance. This cadre of leaders requires advanced and comprehensive skills to manage change and adopt innovation. Mid-level managers must be able to handle complex processes such as planning, forecasting, budgeting and supervision across the iSC. Front-line health workers require skills, capabilities, and support to help them diagnose poor iSC performance and resolve such problems as they arise. The need is urgent in remote and low-access areas (particularly in emergency settings) where front-line workers are largely autonomous; however the need is applicable everywhere that programmes rely on motivated, self-driven professionals to pursue continuous improvement. The comprehensive EVM offers an opportunity to position capacity development and iSC professionalization at the centre of iSC improvement. EPI programmes are encouraged to engage national and regional training institutions – including those proficient in the use of information and communication technologies for health –to participate in the EVM process and adapt EVM standards into dynamic learning curricula and to develop robust M&E systems for the cIP and its implementation. Improvement planning is a continuous process that requires ongoing investments of time, personnel, and planning. Not all supply chain problems will be solved in one cycle, and new problems and challenges will arise as immunization programmes continue to grow and change. For this reason, a continuous improvement mindset is needed to ensure supply chain performance over time. Build a coalition of supply chain supporters. By asking national and regional capacity development institutions – and their academic networks – to support the EPI and its supply chain, countries can translate the needs of the programme into a robust, continuous learning agenda. tip 43How to Develop a Continuous Improvement Plan (cIP) 44

1How to Develop a Continuous Improvement Plan (cIP) How to Develop a Continuous Improvement Plan (cIP) Guidance Note Effective Vaccine Management (EVM) Version 1.0 February 2018 2Guidance note: how to develop a continuous improvement plan (cIP) ISBN 978-92-4-151429-3 © World Health Organization and the United Nations Children’s Fund (UNICEF) 2018 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY-NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO or UNICEF endorses any specific organization, products or services. The unauthorized use of the WHO or UNICEF names or logos is not permitted. 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Printed in Switzerland 3How to Develop a Continuous Improvement Plan (cIP) Contents 1 Introduction 1.1 What is the Effective Vaccine Management (EVM) initiative? 9 1.2 The immunization supply chain continuous Improvement Plan (cIP) 12 1.2.1 Why develop a cIP? 12 1.2.2 Aligning EVM assessment results with the six supply chain essentials 14 2 The continuous Improvement Plan (cIP) development process 2.1 When should the cIP be developed? 17 2.2 Who is responsible for developing the cIP? 18 2.3 What is the best way to develop a cIP? 19 2.3.1 Compile and disseminate a situation analysis 19 2.3.2 Convene a cIP workshop 20 2.3.3 Align cIP goals and objectives with broader national health plans 24 2.3.4 Draft the five-year strategic cIP, including annual operational plan 27 2.3.5 Conduct a planning and budgeting exercise 28 3 The continuous Improvement Plan (cIP) content 3.1 Situation and root-cause analyses 31 3.2 The cIP strategic plan 33 3.2.1 Long-term vision for the immunization supply chain 33 3.2.2 Goals, objectives, strategies, key performance indicators, and costs 34 3.3 The cIP annual operational plan 36 3.3.1 Operational plan 36 3.4 Associated costs and sources of funding 37 4 Implementing and monitoring the cIP 4.1 Socialize and institutionalize the cIP 39 4.2 Implement the cIP 40 4.3 Monitor implementation and outcomes 41 5 Continuous learning and improvement 42 4Supplemental resources supplement 1: Establishing or strengthening a National Logistics Working Group www.technet-21.org/en/library/explore/supply-chain-and-logistics/3735 supplement 2: Situation analysis www.technet-21.org/en/?option=com_sobipro&sid=4800&pid=57&Itemid=2586 supplement 3: cIP workshop agenda repository www.technet-21.org/en/?option=com_sobipro&sid=4819&pid=57&Itemid=2586 supplement 4: Collaborative workshop techniques www.technet-21.org/en/?option=com_sobipro&sid=4801&pid=57&Itemid=2586 supplement 5: WHO Framework for National Health Policies, Strategies and Plans www.who.int/nationalpolicies/FrameworkNHPSP_final_en.pdf supplement 6: Root-cause analysis www.technet-21.org/en/?option=com_sobipro&sid=4802&pid=57&Itemid=2586 supplement 7: Human-centred design methodologies and toolkit www.hcd4i.org supplement 8: Guidance on Dashboards for Immunization Supply Chain www.technet-21.org/iscstrengthening/index.php/en/data-for-manage- ment-documents-and-downloads/guidance-on-dashboards supplement 9: Activity and monitoring plan template (cMYP Guidelines, page 69) apps.who.int/iris/bitstream/10665/100618/1/WHO_IVB_14.01_eng.pdf supplement 10: cMYP costing tool www.who.int/immunization/programmes_systems/financing/tools/cmyp/en/ supplement 11: WHO/UNICEF Joint Statement: Achieving immunization targets with the comprehensive Effective Vaccine Management (EVM) framework www.who.int/immunization/programmes_systems/supply_chain/ EVM-JS_final.pdf 5How to Develop a Continuous Improvement Plan (cIP) Acronyms and abbreviations CCE Cold Chain Equipment CCE OP Cold Chain Equipment Optimization Platform cIP Continuous Improvement Plan cMYP Comprehensive Multi-Year Plan DISC Dashboard for Immunization Supply Chain EPI Expanded Programme on Immunization EVM Effective Vaccine Management EVMA Effective Vaccine Management Assessment Gavi Gavi, The Vaccine Alliance GF Global Fund GFF Global Financing Facility GVAP Global Vaccine Action Plan HR Human Resources HSIS Health Sector Improvement Strategy HSS Health System Strengthening HSSP Health Sector Strategic Programme ICC Inter-agency Coordinating Committee for immunization IP Improvement Plan iSC Immunization Supply Chain KPI Key Performance Indicator LMIS Logistics Management and Information System M&E Monitoring and Evaluation MoH Ministry of Health NGO Nongovernmental Organization NHSP National Health Sector Plan NITAG National Immunization Technical Advisory Group NLWG National Logistics Working Group SOP Standard Operating Procedure TA Technical Assistance UNICEF United Nation Children’s Fund WHO World Health Organization 6About this Guidance Note This document provides guidance to countries on how to develop a continuous immunization supply chain (iSC) improvement plan. Its purpose is to help countries build a case for supply chain investments and develop an improvement plan that engages relevant stakeholders, thus setting the immunization programme on a path for successful implementation. This Guidance Note includes: • An overview of the continuous improvement plan (cIP) development process, including who should be involved, when the plan should be drafted, and how best to gather the required inputs and feedback. • Strategies for aligning Effective Vaccine Management (EVM) assessment outputs with national immunization and health sector planning and financing mechanisms, such as the comprehensive multi-year plan for immunization (cMYP); application for support from Gavi for health system strengthening (HSS); the national health sector improvement strategy (HSIS), and other health sector strategies and plans. • Guidance on preparing a cIP, to include a five-year strategy and a yearly operational plan that can be used to allocate responsibilities and map progress towards a common vision. • Suggestions on how to develop a budget and finance the cIP to ensure sustainability and identify resource gaps. Countries may be familiar with the previous EVM improvement plan process that immediately followed an EVM assessment (EVMA). Whereas the previous EVM improvement plan was designed to address certain short-term supply chain deficiencies, the new, continuous EVM improvement plan described here is designed to be more strategic and inclusive of a wider set of stakeholders who can help reveal the root causes of supply chain problems and mobilize human and financial resources to address them. Supplemental resources for each step of the EVM improvement planning process are also provided. 7How to Develop a Continuous Improvement Plan (cIP) Foreword In the context of renewed global efforts to increase immunization coverage and leave no child unvaccinated, the role of strong national immunization supply chains is hard to overstate. Supply chains are complex and include many elements – people, technologies, systems – that need to be brought together through a plan of continuous action. Such a plan can catalyse not only the immunization supply chain professionals working in the national Expanded Programme of Immunization (EPI), but also their colleagues from the ministries of finance, planning, human resource management departments, senior leadership, development assistance partners, funders and academia. Without this commitment and support, the immunization supply chain professionals are unlikely to succeed in addressing existing gaps in performance and setting up the programme on a path to a sustained, country-driven excellence in ensuring continued vaccine availability, quality and systems efficiency. The purpose of this guidance is to help make the plan of action robust and credible. A robust plan is based on evidence and a strong programming logic, i.e. it focuses investments on activities that together add up to a defined set of objectives and thus help realize the vision of the future and address the deficiencies of the past. The plan is credible when it responds to country needs, and represents a shared vision of the stakeholders who have bought into the plan of action and have a way to track implementation progress against predefined performance targets. These attributes elevate the plan to a powerful investment case for iSC improvement – an advocacy tool for ministries of finance to include and retain iSC activities in their national budget, and for partners to continuously support the cause. These are also the prerequisites of the “holy grail” of institutionalization: the programme putting iSC improvement activities on the radar of national leadership by linking them to the annual operational plans and budget performance metrics. 8However, even a fully funded plan is at risk of remaining a piece of paper unless it touches the hearts and minds of those whose mission is its implementation. Aligning continuous growth – continuous learning – of the EPI workforce at all levels with the process of continuous improvement of the iSC system, is the essential element that makes the coalition for sustained excellence in iSC whole. The EPI workforce is the first to learn what does not work, and often has the clearest insights on how to make it work in the programme context. Participatory models that empower and give implementers a stake in the design and implementation of iSC improvement plans are being embraced increasingly by countries, centralized and devolved contexts alike. The EVM initiative has progressed significantly from being associated with an assessment tool. It has been transformed to help national programmes make major health systems strengthening investments work as intended – to address the underlying systemic bottlenecks to iSC performance. WHO and UNICEF hope that this guidance can inspire and equip you with the knowledge and skills on how to make this initiative work for you. 9How to Develop a Continuous Improvement Plan (cIP) What is the Effective Vaccine Management (EVM) initiative? The 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 It is geared towards the six essentials of immunization supply chain: 1 In 2016, WHO and UNICEF issued a joint statement on the EVM initiative and the vital role that immunization supply chains play in achieving immunization targets set by the Global Vaccine Action Plan (GVAP). This was preceded by a Call to Action issued by the Immunization Practices Advisory Committee in 2014 that recommended a process of assessment, planning, implementation and monitoring to improve immunization supply chains. 1 1.1 Introduction Immunization supply chains are not only limited to equipment and distribution: they are dynamic systems that are flexible, adaptable to changing needs and changing contexts and reactive to ensure vaccine availability in all conditions. A well-designed strategy allows countries to holistically model their supply chains to improve supply chain performance and resilience. Reliable, well-maintained and cost-effective cold chain equipment is vital to ensure that there is adequate, sustainable vaccine storage for current and planned vaccines, that maintenance requirements are kept low, and running costs are reduced. A virtuous cold chain equipment strategy allows countries to access existing guidance and technical assistance, and allocate financial support to better plan for, select, install, manage and maintain their cold chain equipment. Vaccine quality needs to be maintained throughout the immunization supply chain to avoid vaccine wastage due to exposure to heat or freezing temperatures, whether at fixed storage location or during transport. A valuable temperature management strategy helps countries ensure good storage and distribution practices; effective, well-managed temperature monitoring and record-keeping procedures. Countries need effective transport of vaccines between each level of their supply chain to ensure vaccine potency is not compromised by a weak distribution system. A productive distribution strategy includes adequate use of passive containers, satisfactory packing practices with coolant packs, temperature indicators, and accessible transport contingency plans. s y s t e m d e s i g n c o l d c h a i n e q u i p m e n t temperature management d i s t r i b u t i o n 10 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 (see figure 1 ). As a preliminary step, Expanded Programmes on Immunization are encouraged to mobilize national commitment to continuous improvement by bringing stakeholders together to adapt the comprehensive approach to EVM and its four steps, and establish the mechanisms for continuous iSC improvement. Organizing a consultation with key stakeholders is recommended to secure commitment to the EVM initiative, assign clear roles and responsibilities, and agree on an implementation and monitoring process. If schedules allow, a short learning visit for participants to another country that has implemented the EVM process would be beneficial. The key elements of the comprehensive EVM approach are summarized in table 1 . Next generation supply chains require dedicated and competent managers as well as adequate numbers of skilled, accountable, motivated and empowered personnel at all levels of the supply chain. An efficient iSC human resources (HR) strategy helps countries strengthen and build capacity for their supply chain managers by providing access to training, encourage collaboration, positive supervision and professional development opportunities. Data are essential to supply chain managers for managing all aspects of the immunization supply chains, be they vaccine availability, or stock management efficiency. A sound iSC data strategy allows countries to align with data standards, and develop useful tools such as dashboards to monitor effectively their supply chain and make data-informed decisions. h u m a n r e s o u r c e s d ata figure 1 comprehensive approach to evm MONITOR Monitor implementation measure progress toward outcomes ASSESS Collect and review evidence to identify iSC strengths, weaknesses, opportunities, and bottlenecks PLAN Create vision, strategy and operational plan for iSC improvement IMPLEMENT Disseminate plan, ensure funding, and put plan into operation CIP C O M M I T t o c o n t i n u o u s i m p r ov e ment 11How to Develop a Continuous Improvement Plan (cIP) table 1 Suggested Timetable For The EVM Approach Step Estimated duration (in days) Process Format Cost types PREPARATION 0.5–2 Orientation of in-country stakeholders on EVM initiative Workshop Operational costs, facilitation ASSESS 5–10 Preliminary learning visit of select representatives of the Ministry of Health (MoH) and national institutions to participate in EVMAs in another country Visit Travel costs 15–20 EVM assessment planning; training and implementation; sharing and validating findings/results with EPI and MoH Workshop, Assess- ment Individual or institutional contract for EVMA management; operational costs; facilitation 5–10 Situation analysis from the EVMA, plus other assessments and studies that are available (see Table 3) Review Individual or institutional contract PLAN 1– 2 Preparation of the materials for a second workshop and explore how the six iSC essentials can be used to improve the nine EVM criteria2 Staff time 3–5 cIP development workshop: • Establish appropriate oversight and project management mechanisms (through the National Logistics Working Group (NLWG) or other continuous improvement group). • Review situation analysis and identify root-causes. • Define five-year iSC vision, strategic goals, key performance indicators (KPIs) and tactics based on evidence from the performance assessments. • Determine additional technical assistance (TA) needed to complete the cIP (e.g. for planning and budgeting or developing a monitoring and evaluation (M&E) framework). • Discuss how to achieve the three iSC objectives of availability, quality and efficiency by using the six supply chain essentials to improve the nine EVM criteria (see Figure 2) Workshop Operational costs; facilitation 5–15 Alignment with cMYP, national health sector plan (NHSP), funding proposals (e.g. health strengthening systems (HSS) and cold chain equipment optimization procedures (CCE OP). Working group Staff time 15–25 cIP drafting and budgeting: Secure endorsement of the cIP from the Inter-Agency Coordinating Committee (ICC), its development timelines, roles and responsibilities, and dissemination plan. Working group Staff time; operational costs; possibly individual or institutional contract IMPLEMENT 15–25 • Share cIP with all stakeholders, including EPI workforce at subnational level. • Ensure that national HR plans reflect the HR needs of supply chains / if no national HR plan, translate the cIP objectives/tactics into an iSC specific HR plan • Engage a national institution to support M&E • Mobilize funding sources as per your budgeting plan. Working group Staff time MONITOR On a yearly basis • Monitor implementation progress according to plan. • Evaluate key performance indicators for dynamic, data-driven management. • Ensure timely availability and use of resources. Working group Staff time 2 2 The nine EVM criteria: E1 – Vaccine arrival; E2 – Temperature control; E3 – Storage capacity; E4 – Infrastructure; E5 – Maintenance; E6 – Stock Management; E7 – Distribution; E8 – Vaccine Management; E9 – Information Systems. Further information is available at: http://www.who.int/immunization/programmes_systems/ supply_chain/evm/en/ 12 1.2 The immunization supply chain continuous Improvement Plan (cIP) 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. Why develop a cIP? Considerable progress has been made to improve EPI programmes in recent years, partly due to increased investments in supply chains. Immunization supply chain investment cases are now more likely to contain robust situation analyses, be more focused on strategic and evidence- based interventions, and more likely to be costed in a rigorous manner. The cIP builds on these developments and addresses shortcomings of previous planning requirements. 1.2.1 strategic and actionable Many countries develop multiple plans to address the iSC system at different levels, often in response to short-term funding or technical assistance (TA) opportunities and split between national budgets, donor grants, and partner commitments. The planning process may thus be reduced to annual incremental exercises at the expense of a longer-term, strategic planning effort that accounts for contextual changes and changing priorities. As a result, some highly effective (and cost-effective) interventions are neglected in favour of other interventions or may be redundant or programmed inefficiently. The cIP is part of a comprehensive EVM process that enables countries and development assistance partners (where these are present) to learn together which strategies and interventions work and do not work in the country. By using the cIP as an investment case for iSC, immunization staff can pool government and donor resources and TA from partners to address country priorities that already have strong links to multi-year national EPI programme and national health sector plans. In this way, the cIP benefits the country directly, beyond any donor-related consideration. 13How to Develop a Continuous Improvement Plan (cIP) 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. 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. 14 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. Aligning EVM assessment results with the six supply chain essentials Historically, EVM assessments have focused on performance scores organized along the nine EVM criteria. While this helps the programme to focus on discrete tasks (for example, plan to develop a standard operating procedure (SOP) where that procedure was found missing), the same EVMA data can also be analysed to determine which of the six iSC essentials require more urgent focus, as well as giving a high-level benchmark on how the programme managers can achieve the three iSC objectives (availability, potency, efficiency). These new uses of EVM assessment data make for a powerful advocacy and communication tool which helps the EPI programme “manage upwards” by making a more nuanced case for support and resources. The analysis of the data generated by EVM assessments is illustrated in figure 2 . 1.2.2 15How to Develop a Continuous Improvement Plan (cIP) 6 s u p p ly c h a i n e s s e n t i a l s 9 e v m c r i t e r i a 3 o b j e c t i v e s va c c i n e a r r i va l s1 m a i n t e n a n c e5 s to r ag e c a pa c i t y3 d i s t r i b u t i o n7 t e m p e r at u r e m a n ag e m e n t2 s to c k m a n a g e m e n t6 i n f r a s t r u c t u r e4 va c c i n e m a n ag e m e n t8 wa s t e m a n a g e m e n t9 figure 2 Aligning the six supply chain essentials with the nine EVM criteria s y s t e m d e s i g n c o l d c h a i n e q u i p m e n t temperature management d i s t r i b u t i o n h u m a n r e s o u r c e s d ata ava i l a b i l i t y q u a l i t y e f f i c i e n c y By focusing on the six supply chain essentials, countries can systematically increase scores along the nine EVM criteria, and more readily achieve the three objectives. 16 Analysis of EVM assessment data in terms of the three objectives and six iSC essentials enables the programme to frame its cIP as a roadmap to attaining not only compliance with the WHO technical standards, but also the iSC objectives. This helps the programme to build the cIP around a monitoring and evaluation (M&E) framework that measures the relative value and progress of the implementation of cIP activities in terms of their contribution to such established programme indicators as “no vaccine stock-outs at subnational level” (availability: for example, “0% health facilities reporting vaccine stock-outs”), uptime of cold chain equipment (quality: for example, “100% of facilities with functional cold chain equipment”; “100% instances of malfunctioning cold chain equipment reported within 48 hours and addressed within 72 hours”), EVM scores above 80% (efficiency), etc. Once the high-level indicators have been decided, iSC systems performance, in terms of the six essentials, represents an intuitive and comprehensive way of organizing the cIP along the six corresponding strategies that contribute to the attainment of the above-mentioned performance indicators. figure 3 illustrates this logic. figure 3 Proposed cIP framework 2016 2020 ro ad ma p f or im pr ov em en ts s u p p ly c h a i n e s s e n t i a l 1 s u p p ly c h a i n e s s e n t i a l 2 s u p p ly c h a i n e s s e n t i a l 3 s u p p ly c h a i n e s s e n t i a l 4 s u p p ly c h a i n e s s e n t i a l 5 s u p p ly c h a i n e s s e n t i a l 6 % % % % % % E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E E V M S C O R E >80% 17How to Develop a Continuous Improvement Plan (cIP) 2 2.1 When should the cIP be developed? The cIP is one component of a many-layered planning process for the immunization programme. It cannot be developed without preparation and a baseline understanding of how the supply chain operates, the status of equipment and infrastructure, and a clear understanding of the situation in which the supply chain operates. To this end, the implementation of the EVM approach should be tailored to each country context as described in table 2 . Key assessments should be used to inform the development of a cIP, including the Effective Vaccine Management assessment, system optimization studies, EPI review, and HR assessments (see table 3 ). Using available baseline assessments as a starting point, the cIP can be developed at any time. It is designed to feed into the national immunization planning process, becoming a section, for example, in the cMYP for immunization or health sector strategy. Ideally, a cIP should be developed immediately following the completion of an EVM assessment, and serve as an input to a new (or updated) cMYP or health sector strategy. The timing and format of cIPs will differ between countries according to context and familiarity with the EVM process. ( table 2 proposes several scenarios; table 4 can also be referred to for more detailed information on preparing the plan.) The continuous Improvement Plan (cIP) development process Scenario How to implement the comprehensive EVM approach When 1 Your country has been actively and successfully using a previous EVM improvement plan to determine strategy and implement improvements throughout the EVM cycle (3–5 years) Develop the following cIP based on the present Guidance Note. Socialize the next cIP with all EPI staff and embed it into the next cMYP or health sector strategy. Schedule your next EVM assessment to occur prior to the next cMYP or health sector strategy plan process, as this will allow the cIP to be integrated into the larger immunization planning process. 2 Your country has a strong iSC component already embedded in the cMYP or health sector strategy, which constitutes your country’s iSC plan Develop your next cIP based on the present Guidance Note. Design the cIP to become an annex to the health sector strategy or Section Five of the cMYP3: “Vaccine, cold-chain and logistics.” Option 1: If the cIP is being developed close to and prior to the revision of the cMYP or health sector strategy, then the cIP should be integrated and endorsed as part of that document. Option 2: If the timing of the cIP does not allow an integration into either your cMYP of health sector strategy, develop a stand- alone cIP until the next revision cycle and use it as the main iSC component for your next plan. 3 Your country has no iSC strategy or a weak iSC improvement plan. Develop the next cIP based on this Guidance Note. Mobilize technical assistance, as needed, to establish a mechanism that can manage the cIP development process. Contact your WHO or UNICEF country office to start the EVM initiative, and begin planning your next EVM assessment. table 2 implementing the evm approach in different country contexts 3 See p.28 WHO-UNICEF Guidelines for cMYP for Immunization – Update September 2013. Available at: http://apps.who.int/iris/bitstream/10665/100618/1/WHO_ IVB_14.01_eng.pdf?ua=1 18 Who is responsible for developing the cIP? The national EPI team is responsible for developing the cIP. The process, however, should be supported by a permanent subgroup of the Inter-Agency Coordination Committee (ICC) for immunization, for example a NLWG or supply chain coordinating committee. In countries lacking such mechanisms, engaging with national learning institutions (such as universities) to complement the work of or be a substitute for the NLWG is strongly recommended. Beyond the development of the document itself, the coordinating committee in your country (for example, the NLWG) will play an essential role in monitoring implementation progress and outcomes. Strong leadership from these groups has proven a key success factor for substantial improvement of national iSCs. The cIP itself should be assigned to a specific individual or a small “secretariat” responsible for drafting the plan, soliciting input, making changes, and seeing the plan through to finalization. Half-day commitment workshop. It is critical that all EPI team members, NLWG members, and ICC members understand the EVM initiative and their roles and responsibilities. We recommend that every five years the EPI team organize a half-day orientation to the EVM initiative prior to the EVM assessment. tip supplement 1 Establishing or strengthening a National Logistics Working Group www.technet-21.org/en/library/explore/ supply-chain-and-logistics/3735 2.2 box 1 Launching the comprehensive EVM approach in Sierra Leone and Nigeria In Sierra Leone, the EPI organized a half-day workshop in Freetown for national and subnational MoH and administrative chiefs from all districts. During the workshop, participants examined past EVM performance and discussed how improvements along the six iSC essentials could improve availability, quality, and efficiency of the immunization programme. In the end, participants had a clear vision and a shared understanding of the EVM approach. The decision to include administrative district chiefs was critical to onboarding them in the discussions of priorities, strategies, and performance indicators, particularly in this context where subnational EPI staff are subordinate to the administrative district chain of command. A month later, after a new EVM assessment report was presented, there was already a broad consensus – and a momentum – for developing a cIP that was subsequently linked to the Gavi HSS financing process. 19How to Develop a Continuous Improvement Plan (cIP) What is the best way to develop a cIP? 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 box 2 ). Once the cIP has been approved by the ICC and NLWG, the EPI can disseminate and socialize the plan, integrate it into the cMYP or health sector strategic plan, and begin implementation and monitoring activities. Compile and disseminate a situation analysis What: A situation analysis is a summary of the recent EVM assessment report as well as other available assessments, including the EPI review, cold chain inventory, new vaccine readiness, and HR capacity assessment. It should provide a succinct analysis of the strengths and weaknesses of the supply chain and opportunities for improvement. It should also show changes from past EVMA scores, the implementation status of previous improvement plans, and the overarching context of the immunization programme and the health system. Developing a cIP “at-a-glance” process Compile and disseminate a situation analysis • Detailed situation analysis • Broad stakeholder understanding of EVM and other assessment results • Bottleneck/root cause analysis • Vision, goals, objectives, strategies and KPIs for iSC improvement during the next five years • A list of possible interventions and solutions • Alignment between iSC goals and the Global Vaccine Action Plan/ HSS goals • Align with cMYP, NHSP and other national health strategies • Strategic plan describing vision, goals, objectives and strategies • Detailed operational plan listing activities, responsibilities, timelines, costs, sources of financing, and indicators to achieve strategic goals • ICC/NLWG meeting to endorse the cIP for implementation Convene cIP workshop Align cIP goals and objectives with the cMYP and HSIS Draft and finalize the five-year cIP outputs 2.3 2.3.1 box 2 20 Why: A situation analysis provides a starting point for discussion and ensures that all participants at the cIP workshop (described in subsection 2.3.2 ) are working with up-to-date evidence on the status of the supply chain and can devise improvement target, strategies and activities for the cIP, based on a common understanding of the current context. When: The situation analysis should be conducted after the EVMA has been completed. It should be disseminated to cIP workshop participants at least one week prior to the cIP workshop. Who: Some countries have asked the EVM assessor to summarize the situation analysis on behalf of the EPI team and the members of the NLWG. Other countries have asked a local technical assistance partner or academic institution to summarize the situation analysis, as these institutions are sometimes tapped to do the same for HSS proposals. Convene a cIP workshop What: The cIP workshop is a multi-day, interactive meeting where relevant supply chain stakeholders can collaborate to review the situation analysis in depth, conduct a rapid assessment of root causes, and define the five-year vision, goals, objectives, strategies and KPIs for improving supply chain performance to achieve broader immunization goals. Why: The workshop serves as an opportunity to align supply chain stakeholders around a common understanding of the challenges in the immunization supply chain and a long- term vision and goals for its improvement. When: The cIP workshop should occur after the situation analysis is available, and prior to the development of a new cMYP or a new national health plan. Effective collaborative workshops can be resource-intensive and time- consuming. It is therefore crucial to allocate adequate time for each session to avoid compromising the quality of collaboration, which is a predictor of the quality of the cIP. Length of cIP workshop. Many countries have reported that four days is adequate for a cIP workshop. However, some countries may require more than one workshop to agree on a vision and a set of viable goals and objectives. EPI managers should plan accordingly. tip 2.3.2 supplement 2 Situation analysis www.technet-21.org/en/?option=com_sobipro&sid=4800&pid=57&Itemid=2586 21How to Develop a Continuous Improvement Plan (cIP) Who: The EPI, with support from national institutions (such as NLWG, academia) and WHO and/or UNICEF, is responsible for organizing the cIP workshop, developing the cIP document, and monitoring its implementation. Following the cIP workshop, a single individual or “secretariat” should be assigned responsibility for drafting the plan, soliciting inputs, making changes, and facilitating the necessary buy-in and approvals. Core participants should include EPI and iSC staff representing different levels of the health system as well as regional and district administrators. If the iSC is integrated with, or overseen by, another government department, relevant staff from that department must also be involved. Stakeholders who are involved in the development of other national plans (for example cMYP, HSIS, NHSP) should be included as a priority. Representatives from other ministries, including human resources and infrastructure, as well as the National Regulatory Authority (NRA) or other regulatory bodies when applicable should be invited, as they can recommend solutions to problems that the MoH cannot solve directly, as well as champion investments in these solutions at key junctures of the political process during national budget negotiations. Other participants may be considered, and should be included based on their ability to contribute to the technical discussion on the supply chain. This includes nongovernmental stakeholders such as outside consultants, donors (World Bank, Japanese International Cooperation Agency, the Bill & Melinda Gates Foundation, the US Agency for International Development, and others as applicable), technical partners (UNICEF and/or WHO Country Offices, the US Centres for Disease Control and Prevention, International Development Research Centre, PATH, John Snow, Inc., and others as applicable). Where: Conducting workshops off-site has been shown to notably reduce distractions and elevate the engagement level of participants; however, this may not always be feasible. The location must have adequate space for both plenary and breakout discussions. Include non-supply chain experts in the workshop. By including non- supply chain experts in the workshop, the EPI team can explore a greater array of choices on how to solve supply chain problems. For example, with input from officials from ministries of finance, education, infrastructure, and the MoH department of human resources, EPI staff may suggest solutions that the EPI team had not previously considered. tip 22 How: Advanced planning is critical to ensure a productive workshop. An agenda and supporting documents must be produced and shared in advance (for example a succinct note summarizing the situation analysis and five to six strategic options to discuss). Several countries have developed cIP workshop agendas that can be followed or adapted. Most workshops start with a discussion on the status of the supply chain (situation analysis) and the ways in which the supply chain supports, or fails to support, immunization objectives. This discussion naturally brings up the question of benchmarks: what the performance should be (vision), and how it can be measured (KPIs defined for each iSC level). From there, participants can explore root causes of existing challenges and propose strategies, goals and objectives that would progress the programme to where it would like to be in five years. Output: The output of the cIP workshop should be a five-year vision, a set of six goals (one for each supply chain essential) with high-level performance indicators, and the corresponding objectives and strategies that should come out of the root-causes analysis carried out during the cIP workshop (see section 3 ). Because members of other planning groups (for example NHSP; cMYP; Gavi, the Global Fund (GF) or Global Financing Facility (GFF) grant applications; health commodity supply chain) are included in the cIP workshop, the cIP should already reflect the highest priorities of other programme and planning instruments. supplement 3 cIP workshop agenda repository www.technet-21.org/en/?option=com_sobipro&sid=4819&pid=57&Itemid=2586 Collaborative workshop techniques. Many countries have adopted collaborative workshop techniques to generate productive stakeholder conversation during the workshop (see supplement 4 ). Experience has shown that breaking cIP workshop participants into groups – with each group focused on one of the six supply chain essentials – can be highly effective. Each group then presents goals, objectives, strategies and activities, along with an estimated budget and any additional tasks required to operationalize activity. It is important, however, during this focused process to also allow for an exploration of strategies that take on a broader system view. One suggestion is to assign one group to focus on a problem that does not necessarily fit into a single strategic area (such as polio transition or staff shortages). It is also advisable to examine best practices, or examples of “positive deviance”, within the country to identify possible solutions that are already working. tip 23How to Develop a Continuous Improvement Plan (cIP) box 3 Positive Deviance EVM assessments identify the flaws of the iSC system which then become the focus of the cIP. The associated tools and processes, including the bottleneck analysis, are designed to identify and correct problems, not to identify or understand when and why things work well. The consequence is a lack of motivation and engagement from countries, who may feel threatened by the process as it highlights the deficiencies without recognizing the specific drivers of achievements. The purpose of positive deviance is to enable communities4 of practitioners to discover their successful behaviours and strategies, and transform them into plans of action to promote sustainable change. The approach is based on the following principles: • Communities of practitioners have solutions and “know-how” • Communities of practitioners can organize themselves to solve an agreed problem • Collective intelligence to solve a specific problem is more effective than solutions imposed by external experts • Sustainability is at the core of the response The methodology of positive deviance consists of five basic steps: 1. Define the problem, current perceived causes, challenges and constraints, common practices, and desired outcomes. 2. Determine the presence of positive deviant individuals or groups. 3. Discover uncommon but successful behaviours and strategies through inquiry and observation. 4. Design activities to allow community members to practice the discovered behaviours. 5. Monitor and evaluate the resulting project or initiative, which further fuels change by documenting and sharing improvements as they occur, and helps the community discern the effectiveness of the initiative. In the context of EVM, the health workforce involved in iSC would constitute communities at each iSC level. Ideally, a positive deviance approach should be an intricate part of the EVM process, reflecting itself in the additional qualitative information collected during the EVM assessment and, most importantly, in ensuring that reiterating feedback loops capture the perspectives, solutions and know-how of the iSC workforce throughout the assessment, planning and implementation processes. This approach can help ensure that the cIP is derived from local needs, contextualized through generating deviance from community. In addition, the approach can offer a reality check on the EVM assessment process, including evidence that could help improve the EVM approach in future. The recent cIP development process in Sierra Leone used elements of this approach in two ways: (i) national EVM assessors were encouraged to collect structured notes on the background to any good practices they observed during their assessment visits; and (ii) the cIP development workshop encouraged the participants – some of whom were elected district representatives who could bring in community perspectives – to discuss whether any districts may have “got it right” contrary to the nation-wide EVM assessment findings. One such conversation identified a district that paid performance-based incentives that had a positive impact on core iSC performance indicators; this was a revelation to representatives from some other districts and provoked genuine reflections on the strategies available. 4 For definitions and components of successful communities please refer to https://community-canvas.org/ 24 Align cIP goals and objectives with broader national health plans What: With cIP goals and objectives in hand, EPI staff should participate in relevant, parallel planning efforts (such as the NHSP, cMYP and HSS investment cases) and discuss how the cIP and its implementation can contribute to immunization and health system goals, EPI equity analysis, and EPI reviews. figure 4 illustrates how the cIP can be fully incorporated into broader national and other health plans, cutting across the six essentials of the immunization supply chain. 2.3.3 box 4 Nigeria Nigeria designed a four-day cIP workshop to enable EPI managers from 36 states and the Federal Capital Territory to reflect on the results from the recent EVMA and jointly examine the causes of insufficient improvement and inadequate implementation of previous plans. This event differed notably from typical training workshops and planning meetings. It was designed to be highly dynamic, iterative, and engaging to maximize substantive contributions from all participants and secure maximum buy-in for the cIP, particularly from the state-level government EPI managers. The approach enabled the new cIP to bring measurable and sustainable improvement to the country’s iSC, and ensured that the cIP was appropriate in the context of Nigeria’s devolved health sector. supplement 4 Collaborative workshop techniques www.technet-21.org/en/?option=com_sobipro&sid=4801&pid=57&Itemid=2586 25How to Develop a Continuous Improvement Plan (cIP) Why: Incorporating the cIP into the NHSP, cMYP and other relevant plans will make those plans stronger and more specific. The more integrated the planning efforts become, the easier it will be to eliminate duplicate efforts and identify opportunities for efficiencies (such as a shared set of indicators or outcomes) with other plans. Who: Key EPI staff should attend relevant planning committee meetings to present the cIP and discuss how the plan supports the NHSP, cMYP (and other relevant plans). By attending these meetings, planning participants can look for redundancies as well as opportunities for efficiencies. figure 4 integrating the cIP to broader health plan processes Immunization multi-year plan (cMYP) National health sector plan EVM cIP system design Cold chain equipment temperature management distribution human resources data 26 When: During the cIP workshop, relevant stakeholders involved in other planning processes (for example NHSP; Gavi, GF or GFF grant application, health commodity supply chain plan) should already be participating in the development of overarching goals, strategies and activities for the supply chain. After the cIP workshop, EPI staff and external planning participants should share the draft vision, goals, objectives and strategies with committees working on relevant immunization and health strategies and brief them on the cIP workshop discussions and outcomes. Output: The primary output of this step should be the welcome inclusion of the cIP into the cMYP, NHSP, and other planning documents. A secondary output could be a list of suggested revisions that will further align the cIP with other planning instruments based on discussions with relevant planning groups. As needed, these recommendations should be used to adjust the goals, objectives, and strategies developed during the cIP workshop. Making the most of HSS programming. When considering iSC improvements through the HSS lens, EPI staff should ask: which specific health systems need to be strengthened to help us resolve the most urgent iSC bottlenecks facing our programme? The answers will likely relate to the HSS “building blocks”: health sector governance, human resources, information systems, financing. Building alliances with stakeholders outside the EPI chain of command may be key to resolving problems and is a worthy investment of effort. Donors often encourage (for example through Gavi HSS grants) national EPI programmes to enlist support from other government departments to address urgent EPI problems. tip 27How to Develop a Continuous Improvement Plan (cIP) Draft the five-year strategic cIP, including annual operational plan What: The cIP should be written in two parts (see section 4 ). First, a strategic section stating the vision, goals, objectives, KPIs, and estimated costs5 for activities identified and developed during the cIP workshop. Second, the plan should include an annual operational plan with associated costs, sources of financing, and implementation indicators. Once completed, the full cIP becomes the cMYP section on cold chain and logistics (see section 5 ) or an annex to the health sector strategy. Why: The five-year cIP aligns all stakeholders, including TA providers, to a common set of goals that improves immunization efficiency, quality and availability. The cIP is a continuous learning tool that links EVMA results with the overall strategic vision for immunization. When: The time required to develop the cIP will vary by country. The EPI team should agree on a reasonable deadline, given available staff resources. If a new cMYP or NHSP are being developed, the cIP should be finalized within the development timeframe of these plans. Sufficient time should be allocated to the budgeting and financing component of the cIP, as this will improve the viability of the plan (see subsection 3.4 ). Who: The cIP should be developed by (or in close partnership with) senior EPI staff, as EPI will be primarily responsible for executing the plan. Working groups formed during the cIP workshop may be willing to draft sections of the plans relating to strategic focus areas, but the EPI team is responsible for integrating those sections into a complete plan. There may be exceptions in some contexts where cIP drafting may need to be carried out externally, particularly when there is insufficient relevant capacity in-country. Output: The cIP includes a five-year strategic plan, and an annual operational plan that can be presented to the NLWG and the ICC for endorsement. 5 WHO and UNICEF recommend conducting a full planning and budgeting exercise for the cIP, and linking it to the cMYP budget. 2.3.4 28 2.3.5 Conduct a planning and budgeting exercise What: A planning and budgeting exercise is an effort to identify all costs and sources of funding associated with activities listed in the cIP during the five-year period. Associated costs can include: • Personnel (e.g. staff assigned to reporting) • Capital expenditures on equipment and infrastructure (e.g. acquisition of vehicles, cold chain equipment) • Operational expenditures (e.g. cold chain repair or maintenance) • Transport • Outsourced services • Workshops and international exchanges • Technical assistance needs (e.g. system design technical support, NLWG set-up support) Why: As with all plans, the cIP is only useful to the extent that it is supported and funded. A planning and budgeting exercise defines the costs associated with cIP implementation and monitoring, and enables EPI managers and logistics coordinating committees to identify sources of funds to meet the needs of the programme. When: The planning and budgeting exercise should be conducted as soon as the draft cIP plan is completed and before it is approved by the ICC. Who: The EPI is responsible for completing a planning and budgeting exercise, whether by identifying a TA partner to conduct the planning and budgeting exercise or a private agency. Involve the Ministry of Finance early. Countries that involve colleagues from their Ministry of Finance during the planning and budgeting exercise generally have greater success raising funds and implementing their cIP. The presence of Ministry of Finance staff not only increases the accuracy of the cost estimates and sources of funds, but also accelerates the timeline for signing the budget and dispersing funds. tip 29How to Develop a Continuous Improvement Plan (cIP) 3The continuous Improvement Plan (cIP) content • a clear description of what the country wants to achieve: the vision, goals, and anticipated outcomes for the iSC, which can serve as a rallying point for all relevant stakeholders; • logical and strategic – answering what, why, and when specific activities should occur, who is responsible, and how progress will be measured using KPIs; • based on a systematic, evidence-based analysis of the root causes of poor iSC performance, as well as an analysis of the enablers of strong iSC performance; • created as part of a participatory planning process with relevant stakeholders from other ministries and levels of the health system so it responds to, and is supported by, broader national planning processes for immunization (such as cMYP) and health; used to raise awareness and advocate for investment and oversight from higher management levels of the MoH. • either a stand-alone document or directly integrated into existing annual work plans; • a tool to track implementation progress of the annual work plan with direct links to outcomes described in the strategic plan that can be reported during yearly reviews; • developed annually with a description of objectives and activities, timelines, responsibilities, costs, and indicators to monitor progress; • reviewed and endorsed by the ICC and a supply chain working group or committee; • reviewed at least quarterly by EPI managers and reported at least annually to the ICC and NLWG where it exists. The strategic plan should be: The operational plan should be: As previously mentioned in this Guidance Note, the cIP will consist of two main parts: (i) the strategic plan which describes the vision, goals and key strategies for the supply chain during the next five years; and (ii) the operational plan – an annual work plan detailing activities, timelines, responsibilities, costs, and indicators. 30 Suggested cIP content “at-a-glance” 1. Situation and root-cause analyses • See above subsection 2.3.1 a. Long-term vision • Describes the desired future state of the immunization supply chain • Describes how the cIP vision and goals support the objectives of the immunization programme and the health sector b. Goals, objectives, strategies, KPIs, and estimated costs • Describes high-level goals to improve availability, quality and efficiency of the iSC • Describes key objective for each goal with indicators that show progress toward them • Describes strategies based on the root-cause analysis that will move the country closer to achieving the goals within the next five years • Describes selected KPIs that will allow progress measurement throughout the continuous improvement cycle • Provides estimated costs for all activities within the five-year plan and describes possible and confirmed sources of funding (including partner- supported activities) a. Activity and monitoring plan for year 1 • Describes the key activities and progress indicators that will be used to track implementation • Describes governance of the cIP (e.g. roles of NLWG, partner, TA providers, etc.), as well as timelines, and responsibilities b. Associated costs and sources of funding • Calculates the specific costs associated with the operational plan • Identifies sources (and timing) of funding from partners, donors, and government budgets 2 . The cIP strategic plan 3. The cIP operational plan box 5 31How to Develop a Continuous Improvement Plan (cIP) supplement 5 WHO Framework for National Health Policies, Strategies and Plans www.who.int/nationalpolicies/FrameworkNHPSP_final_en.pdf Use the WHO Framework for National Health Policies, Strategies and Plans to strengthen your plan. Experience shows that the policy dialogue for building comprehensive national health policies, strategies and plans is as much a political as a technical process. It requires attention for the inspirational side of defining vision and policy; it also requires attention for operational detail. The balance between vision, policy, strategic planning and consistency in implementation varies considerably from country to country. You are encouraged to consult the WHO Framework for National Health Policies, Strategies and Plans (see Supplement 1 below) on prerequisites for sound planning documents that match your country’s overall national health strategies. tip 3.1 Situation and root-cause analyses The situation analysis (see supplement 2 ) is the first section of the cIP. It describes the status and current performance of the supply chain and its components by summarizing the key results and recommendations from the EVMA and other relevant assessments. table 3 below lists the assessments, plans and situations that may be analysed as part of the situation analysis. The right-hand column shows suggestions of where inputs, information and data can be found. 32 table 3 Assessments, inventories, and reports to include in a situation analysis Assessments, inventories and reports Where to find them National EPI review • National EPI programme EVMA reports and EVM improvement plans (IPs), including details of EVM implementation • National EPI programme, or WHO and UNICEF country offices Up-to-date cold chain equipment inventory (CCEI), including expansion and equipment rehabilitation requirements • National CCEI, if available • CCE OP application • EVMA reports • Logistics management and information system (LMIS) • Procurement plans and records New vaccine supply chain readiness assessment • EVMA reports • Applications for introduction of new vaccine to Gavi, WHO, UNICEF, etc. • cMYP • Gavi HSS applications HR capacity assessment • EVMA reports • Gavi HSS applications • cMYP • Health sector HR assessments Temperature monitoring assessment of the cold chain • Recent temperature monitoring study • Temperature monitoring system data Transportation network design assessment • EVMA reports • Supply chain assessments (USAID, etc.) and strategic plans National immunization and health sector strategies, policies and priorities • EPI annual plan • EPI multi-year plan • National health sector multi-year strategy • cMYP • Gavi HSS strategy • Other health commodity supply chains strategies/assessments Equity assessments • National EPI programme 33How to Develop a Continuous Improvement Plan (cIP) A root-cause analysis examines why supply chain performance is low in certain areas. The root-cause analysis is an opportunity to resolve challenges that result from failures. There are many ways to conduct a root-cause analysis (see supplement 6 below); the approach can be determined by the EPI team. Three components are essential to a root-cause analysis: problem statement, root-causes, and possible strategies to address the root causes. Some countries have successfully used the human-centred design methodologies toolkit (see supplement 7 below) to guide the root-cause discussion in cIP workshops. Taken together, the situation and root-cause analyses provide national policy-makers with an overview of the strengths, opportunities, weaknesses, and threats of the immunization supply chain and help prioritize activities so that investments can be focused accordingly. The cIP strategic plan The strategic plan should be concise and easy to read. It should display the long-term vision for the supply chain, and the high-level goals, objectives and strategies that have been identified for the next five years (including indicators to measure outcomes and progress toward those outcomes). A one- to two-page summary of the strategic plan should be widely disseminated and used as a tool to track progress. Long-term vision for the immunization supply chain The long-term vision should describe how the iSC supports the immunization programme: how it performs, how it is organized, and what it contributes to the immunization programme and to the national health sector. The vision should describe a resilient iSC that can accommodate changes to health system priorities (for example health security, polio transition, electronic records), as well as anticipated changes to the general infrastructure and the political climate (such as investments in rural electrification, infrastructure and roads, and increased internet access). Most importantly, it reflects the goal of supply chains to improve availability, efficiency, and the quality of vaccines and immunization supplies across the country. Example: “We envision a supply chain that reliably delivers sufficient quantities of vaccines and immunization supplies directly to all fixed immunization posts (including new posts that are opening during the next five years) and does so without compromising quality due to exposure to heat or freezing temperatures. By doing so, the supply chain will support the EPI goal of 90% vaccination coverage by xxxx, and decrease child mortality by xxx.” supplement 6 Root cause analysis www.technet-21.org/en/?option=com_sobipro&sid=4802&pid=57&Itemid=2586 supplement 7 Human-centred design methodologies and toolkit www.hcd4i.org 3.2 3.2.1 34 Goals, objectives, strategies, key performance indicators, and costs Goals describe the medium- and long-term outcomes that are necessary to achieve the vision. In the case of supply chains, goals are easy to write when they are aligned with core supply chain objectives of increasing availability, quality, and efficiency. A manageable strategic plan usually lists between three and five goals that are achievable within five years. Each goal should have at least one KPI that can be measured and reported over the course of the year. Example: Goal #1: Increase immunization coverage by ensuring all EPI vaccines and immunization supplies are available at the point of vaccination in at least 20 high-priority districts by 2023. KPI: Number of priority districts achieving 12 months of full stock availability (see below). Objectives are quantitative measures of the goals that are time-bound. They often start with the words “increase” or “decrease” or “establish”. It is a country’s discretion to select any number of objectives per goal that are realistically achievable within the timeframe and budget available. Typically, a country would select relevant iSC performance indicators from the Guidance on Dashboards for Immunization Supply Chain (DISC) (see supplement 8 below). Example: Objective #1: Increase the number of facilities in high-priority districts achieving full stock availability6 within a 12-month period. 6 Full stock availability (from DISC indicators) is the percentage of storage points with full availability of all or selected set of tracer vaccines and immunization supplies over a resupply period. Full availability is defined as no stock-out in the store or health facility at any point during the period. 3.2.2 supplement 8 Guidance on Dashboards for Immunization Supply Chain (DISC) www.technet-21.org/iscstrengthening/index.php/en/data-for-management- documents-and-downloads/guidance-on-dashboards 35How to Develop a Continuous Improvement Plan (cIP) Strategies describe the approach that will be used to achieve the goal or objective. Strategies usually answer questions that emerge when faced with choices or constraints, and for this reason, strategies can differ significantly depending on who is involved in the discussion. For example, when new refrigerators are needed, does it make more sense to buy solar-direct drive refrigerators or invest in micro-grids for rural electrification? When health workers need to be trained on basic refrigerator maintenance, would it be more effective to offer refresher training, supportive supervision, or develop and include the relevant curricula into MoH-accredited pre- service training linked to career progression of the relevant workforce? Consultations should be held with a broad range of stakeholders, not just immunization supply chain professionals, to identify the best strategic options. Depending on the situation, some countries may find it easiest to form cIP strategies around the six supply chain essentials (see subsection 1.1 ). The sample strategy below leverages two supply chain essentials: Distribution and System Design to improve overall iSC performance. Example: Strategy #1: Implement a pull-based (demand driven) distribution system for vaccine and cold chain with reliable transportation system based on efficient network design and route planning. Outcome indicator: Number of districts with a functioning pull-based distribution system based on efficient network design and route planning in [specific] districts. let availability, quality and efficiency drive your plan. Introducing the iSC objectives of availability, quality and efficiency at the start of the cIP design workshop is an excellent way to focus the conversation – and the resulting cIP – on what matters most. EVMA data can be presented graphically to show how iSC performance meets (or fails to meet) three objectives across the distribution levels. Workshop discussions can then be steered to discuss and quantify desired performance levels for each of the three objectives, which in turn would clarify investments required to meet the objectives. For example, a discussion of what it takes to assure vaccine quality at the service delivery level will lead to a discussion on two DISC indicators: (i) functional status of cold-chain equipment; and (ii) temperature alarm rate. Participants can then agree on minimum performance levels (for example, all failed cold chain equipment units are reported/logged within two days, and repaired or replaced within five days), which will clarify investments required to capture and monitor these data and to ensure compliance with the agreed performance levels. tip 36 supplementn 9 Activity and monitoring plan template (cMYP Guidelines, page 69) apps.who.int/iris/bitstream/10665/100618/1/WHO_IVB_14.01_eng.pdf The cIP annual operational plan Operational plan The operational plan is the part of the cIP that translates goals, objectives, and strategies into a set of activities that can be assigned and accomplished within a 12-month period (for example, Activity #1: “List the functional requirements for a stock management system for each major user group”). Because activity-level planning can be dynamic and dependent on external factors, it is not necessary to articulate specific activities beyond 12– 14 months. The recommendation is to develop a plan that can be used by those managing the iSC, in a format that feeds into existing EPI annual work plans. Each activity should have an associated measurable process or completion indicator and estimated cost. The activity plan also should specify the governance structure for implementation oversight (i.e. roles/responsibilities of NLWG, partner agencies, and TA providers) and a timeline for monitoring indicators. Include a monitoring process and schedule. Countries have emphasized the importance of including a schedule for monitoring (e.g. dates when the KPIs are reviewed and discussed) and indicating which person or team will be responsible for collecting and reviewing KPIs according to the schedule. tip Include partner activities in operational plan. To ensure accountability of all stakeholders, the operational part of the cIP should include both activities (and implementation indicators) supported from within the EPI programme plan, and activities (and implementation indicators) supported by TA partners. tip 3.3 3.3.1 To ensure the cIP operational plan is useful, countries are encouraged to tailor the format of the plan to match their needs, integrating it into any annual planning tool(s) the EPI is already using. table 4 below describes different scenarios and suggestions for formatting the cIP to best fit a country’s needs. 37How to Develop a Continuous Improvement Plan (cIP) table 4 Finding the appropriate format for the cIP operational plan Scenario Suggested Action Risk Mitigation 1 The EPI team has been successfully using the current EVM IP to assign activities and measure progress on a yearly basis. Use the cIP as the supply chain chapter of the cMYP and add cIP activities to the annual cMYP activity work plan template. [add link] Although the cIP work plan will be part of the cMYP, it must be socialized with all EPI as a stand-alone document. The NLWG or other EPI coordination mechanism is responsible for tracking progress on the cIP, which should be reported by the EPI every 12 months, even if it is a section in the cMYP. 2 The EPI team uses the EPI annual work plan or cMYP to assign and track supply chain improvement activities. Option 1: If the cIP is being developed close to and prior to the revision of the EPI annual work plan or cMYP, then the cIP operational plan should be integrated into the annual work plan or cMYP template. Option 2: If the timing of the cIP does not allow an integration into EPI annual work plan or cMYP, then use the annual work plan or cMYP template to develop a stand-alone cIP work plan until the next revision cycle. Keep iSC activities in one section within the EPI annual work plan or cMYP, as this will make it easier for the NLWG or the designated coordination mechanism to conduct the yearly review of the cIP. 3 The EPI team needs a stand-alone cIP work plan because no other planning tool exists or because it makes it easier to track partner support to EPI activities. Add the cIP as the supply chain section of the cMYP or health sector strategy and add cIP activities to the annual cMYP activity work plan template. Include a supply chain professional in the cMYP monitoring team to ensure that iSC activities are indeed integrated to the overall cMYP. Keep cIP activities together in the cMYP, as this will make it easier to extract iSC activities for the yearly cIP review. Associated costs and sources of funding The planning and budgeting section of the cIP plan has two parts: a cost estimate and a funding plan. cost estimate The planning and budgeting section should list a full estimate of costs associated with activities listed in the operational and strategic portions of the plan. A tool was developed for the cMYP costing exercise. Since the cIP plan was designed to become part of the cMYP, using the cMYP costing tool as a key resource is recommended. supplement 10 cMYP costing tool www.who.int/immunization/programmes_systems/financing/tools/cmyp/en/ 3.4 38 As part of the planning and budgeting exercise, researching how budgeting is carried out in your country’s immunization programme is recommended so that the cIP cost estimate is aligned with the usual budgetary cycle. If completed in isolation from other budgeting exercises, cIP costs are unlikely to be prioritized and met. Budgeting research should answer: • What is the budgeting process for the EPI, and who is responsible for it? • When are budgets allocated? Annually? Biannually? • Is it preferable to create a stand-alone cIP budget plan or to integrate cIP costs into an existing budget document? • Who should be aware of or involved in the cIP planning and budgeting exercise, and who should review drafts for feedback and validation? funding plan The funding portion of the plan should indicate possible and reliable sources of funding for those costs and the estimated timing of funds availability. Few countries will rely on a single source of funding to maintain activities. Funding diversification is essential for the long-term sustainability of any programme or organization, including the supply chain. Generating in-kind and financial support from donors and other organizations (for example the private sector) should be included among fundraising strategies. To identify possible grants and contributions, EPI teams should list donors currently involved in EPI (such as technical partners, members of the national immunization technical agency group (NITAG), UN agencies) and ask what they would be willing or able to fund. During these discussions, be clear about the type of financial and in-kind support you need (printing, meeting space, facilitation support, etc.) and when you need it, so that they can be responsive. For example, eligible countries that need to purchase cold chain equipment could identify Gavi as a potential source of funding and apply for support from the cold chain equipment optimization platform (CCE OP). To fundraise more efficiently, it may be useful to liaise with other programmes and ministries that already receive funds from these donors and make joint requests. Involve the Ministry of Finance early. Countries that involve colleagues from their Ministry of Finance during the planning and budgeting exercise generally have greater success raising funds and implementing their cIP. The presence of Ministry of Finance staff not only increases the accuracy of the cost estimates and sources of funds, but also accelerates the timeline for signing the budget and dispersing funds. tip 39How to Develop a Continuous Improvement Plan (cIP) 4 4.1 Implementing and monitoring the continuous Improvement Plan (cIP) One of the key reasons WHO/UNICEF decided to relaunch the EVM initiative is because EVM improvement plans were rarely implemented. The comprehensive EVM approach addresses some of the critical shortcomings of the original EVM process (see supplement 11 below). It establishes management mechanisms to support the lifecycle of continuous iSC improvement, improves the quality of cIP planning, and incorporates iSC planning and budgeting within broader national and partner financing processes. Most importantly, however, the comprehensive EVM approach understands the value of involving a wider range of relevant stakeholders from within and outside the immunization programme and seeking their commitment to support supply chain improvement. Socialize and institutionalize the cIP What: Socializing and institutionalizing a plan is the process of engaging staff working on iSC at all levels of the health system, talking to them about the cIP, and explaining how it should be used to guide iSC-related activities in their work plans, and how they can contribute to the success of the programme. Copies of the plan should be shared and presented to relevant Ministry of Health and Ministry of Finance leaders and staff at all levels, as well as partners and donors so they can support implementation by contributing expertise, resources, and technical assistance as needed. Why: A frequent complaint of field level staff is never seeing a copy of the improvement plans they are responsible for implementing. Sharing the cIP or a summary of the cIP with all stakeholders who have participated in its development, and to all staff working to implement it, is recommended. Technical partners also need to understand the cIP so they can help with implementation and complement the cIP within their own plans. supplement 11 WHO/UNICEF Joint Statement. Achieving immunization targets with the comprehensive effective vaccine management (EVM) framework www.who.int/immunization/programmes_systems/supply_chain/ EVM-JS_final.pdf 40 When: After the cIP has been formally endorsed by the ICC. Who: The EPI team (or a credible designee from the NLWG, or any coordinating mechanism you have put in charge) is responsible for disseminating the plan to all EPI staff and highlighting areas of the plan that will impact EPI staff, other health staff, partners, and agencies. Output: All immunization and supply chain staff receive a copy of the cIP (in full or summary). Once all staff receive the cIP document and monitoring indicators, they should be referenced and consulted routinely, during supportive supervision and at EPI managers’ meetings. Implement the cIP What: Once the cIP is endorsed and disseminated, cIP activities and objectives will need to be integrated and reflected in annual national, regional, and district level work plans and budgets, as well as review processes. Committed resources must also be made available in time for staff at all levels to implement activities and keep to the cIP’s implementation timeframe. Why: Implementation of cIP activities allows stakeholders to transform the supply chain into a more efficient and effective function of the immunization programme. 4.2 Hold a national dissemination event. Some countries have successfully held a national cIP dissemination event, coinciding with the official endorsement of the cIP from the government and other stakeholders, paired with subnational meetings with district/regional health officers and EPI staff. tip Engage the workforce at all levels in managing and monitoring iSC performance. The cIP strategic plan and indicators should be widely disseminated and discussed at all levels of the immunization system, and staff should be encouraged to track and monitor iSC performance indicators as they make changes to the programme. EPIs can recognize and develop “champions” of iSC continuous improvement by documenting best practices and success stories and sharing them with relevant national, regional, and global initiatives. tip 41How to Develop a Continuous Improvement Plan (cIP) When: Implementation can begin as soon as the plan is finalized, with some activities being taken up earlier if they are already approved. The key to rapid implementation is clear and frequent communication with staff and managers who are responsible for different activities and sufficient resources, tools, and support to ensure that staff members are equipped to carry out their work. Who: While the EPI team is responsible for day-to-day oversight of cIP implementation, the NLWG is responsible for monitoring implementation progress and KPIs and addressing challenges as they occur. Output: The EPI management team should have regular meetings with regional/district supply chain personnel to discuss implementation progress and problem-solve issues that may arise. Monitor implementation and outcomes What: The annual operational plan should include a set of monitoring indicators that can be used to track implementation progress for day-to-day activities. The strategic plan should include a set of key performance indicators that should be tracked at least yearly or on a schedule agreed with the NLWG or other coordination mechanism in charge. Why: Monitoring indicators and key performance indicators are helpful ways of holding accountable staff members, partners, and consultants for the quality and timeliness of their work. These indicators can also be used to report progress to donors in the Joint Assessment for Gavi and other donor reporting mechanisms. When: Ideally, cIP implementation is reported in regular NLWG (or similar) meetings on a monthly or quarterly basis. If this is not possible, the NLWG should organize at least one in-depth review meetings annually to review end-of-year progress and develop year-two activities. Who: The NLWG is responsible for monitoring iSC performance through KPIs, and the EPI is responsible for managing and monitoring cIP implementation. Output: Routine monitoring reports or presentations should be shared with the NLWG, showing progress along the indicators agreed within the M&E section of the improvement plan. 4.3 42 5Continuous learning and improvement Implementing iSC improvement activities and using performance metrics to improve management requires all EPI staff to understand iSC standards, procedures, and best practices. EPI and iSC managers must have the capability to design new iSC systems, choose new cold chain technologies, and adopt an HSS perspective to improve and sustain systems performance. This cadre of leaders requires advanced and comprehensive skills to manage change and adopt innovation. Mid-level managers must be able to handle complex processes such as planning, forecasting, budgeting and supervision across the iSC. Front-line health workers require skills, capabilities, and support to help them diagnose poor iSC performance and resolve such problems as they arise. The need is urgent in remote and low-access areas (particularly in emergency settings) where front-line workers are largely autonomous; however the need is applicable everywhere that programmes rely on motivated, self-driven professionals to pursue continuous improvement. The comprehensive EVM offers an opportunity to position capacity development and iSC professionalization at the centre of iSC improvement. EPI programmes are encouraged to engage national and regional training institutions – including those proficient in the use of information and communication technologies for health –to participate in the EVM process and adapt EVM standards into dynamic learning curricula and to develop robust M&E systems for the cIP and its implementation. Improvement planning is a continuous process that requires ongoing investments of time, personnel, and planning. Not all supply chain problems will be solved in one cycle, and new problems and challenges will arise as immunization programmes continue to grow and change. For this reason, a continuous improvement mindset is needed to ensure supply chain performance over time. Build a coalition of supply chain supporters. By asking national and regional capacity development institutions – and their academic networks – to support the EPI and its supply chain, countries can translate the needs of the programme into a robust, continuous learning agenda. tip 43How to Develop a Continuous Improvement Plan (cIP) 44

كيفية وضع خطة للتحسين المستمر 1 كيفية وضع خطة للتحسين المستمر مذكرة إرشادية الإدارة الفعالة للقاحات النسخة 1-0 فبراير/ شباط 8102 2مذكرة إرشادية: كيفية وضع خطة للتحسني املستمر [ )PIc( nalp tnemevorpmi suounitnoc a poleved ot woh :eton ecnadiuG] 8-924156-4-29-879-NBSI © منظمة الصحة العالمية و منظمة الأمم المتحدة للطفولة (اليونيسيف) 9102 بعض الحقوق محفوظة. هذا المصنف متاح بمقتضى ترخيص المشاع الإبداعي “نسب المصنف – غير تجاري – المشاركة بالمثل 0.3 لفائدة المنظمات الحكومية الدولية” ) /ogi/0.3/as-cn-yb/sesnecil/gro.snommocevitaerc//:sptth ;OGI 0.3 AS-CN-YB CC(. وبمقتضى هذا الترخيص يجوز أن تنسخوا المصنف وتعيدوا توزيعه وتحوروه للأغراض غير التجارية، وذلك شريطة أن يتم اقتباس المصنف على النحو الملائم كما هو مبين أدناه. ولا ينبغي في أي استخدام لهذا المصنف الإيحاء بأن المنظمة )OHW( و اليونيسيف تعتمدان أي منظمة أو منتجات أو خدمات محددة. ولا يُسمح باستخدام شعار المنظمة )OHW( او شعار اليونيسيف وإذا قمتم بتعديل المصنف فيجب عندئٍذ أن تحصلوا على ترخيص لمصنفكم بمقتضى نفس ترخيص المشاع الإبداعي )) ecnecil snommoC evitaerC أو ترخيص يعادله. وإذا قمتم بترجمة المصنف فينبغي أن تدرجوا بيان إخلاء المسؤولية التالي مع الاقتباس المقترح: “هذه الترجمة ليست من إعداد منظمة الصحة العالمية )المنظمة )OHW(( أو منظمة الأمم المتحدة للطفولة )اليونيسيف(. المنظمة )OHW( و اليونيسيف غير مسؤولة عن محتوى هذه الترجمة أو دقتها. ويجب أن يكون إصدار الأصل الإنكليزي هو الإصدار الملزم وذو الحجية.” ويجب أن تتم أية وساطة فيما يتعلق بالمنازعات التي تنشأ في إطار هذا الترخيص وفقاً لقواعد الوساطة للمنظمة العالمية للملكية الفكرية ) /selur/noitaidem/ne/cma/tni.opiw.www//:ptth(. الاقتباس المقترح مذكرة إرشادية: كيفية وضع خطة للتحسني املستمر [ )PIc( nalp tnemevorpmi suounitnoc a poleved ot woh :eton ecnadiuG] جنيف: منظمة الصحة العالمية و منظمة الأمم المتحدة للطفولة )اليونيسيف(: 9102. الترخيص OGI 0.3 AS-CN-YB CC. بيانات الفهرسة أثناء النشر. بيانات الفهرسة أثناء النشر متاحة في الرابط /siri/tni.ohw.sppa//:ptth. المبيعات والحقوق والترخيص. لشراء مطبوعات المنظمة )OHW( انظر الرابط sredrokoob/tni.ohw.sppa//:ptth. ولتقديم طلبات الاستخدام التجاري والاستفسارات الخاصة بالحقوق والترخيص انظر الرابط gnisnecil/tuoba/tni.ohw.www//:ptth. مواد الطرف الثالث. إذا كنتم ترغبون في إعادة استخدام مواد واردة في هذا المصنف ومنسوبة إلى طرف ثالث، مثل الجداول أو الأشكال أو الصور فإنكم تتحملون مسؤولية تحديد ما إذا كان يلزم الحصول على إذن لإعادة الاستخدام هذه أم لا، وعن الحصول على الإذن من صاحب حقوق المؤلف. ويتحمل المستخدم وحده أية مخاطر لحدوث مطالبات نتيجة انتهاك أي عنصر يملكه طرف ثالث في المصنف. بيانات عامة لإخلاء المسؤولية. التسميات المستعملة في هذا المطبوع، وطريقة عرض المواد الواردة فيه، لا تعبر ضمناً عن أي رأي كان من جانب المنظمة )OHW( و اليونيسيف بشأن الوضع القانوني لأي بلد أو أرض أو مدينة أو منطقة أو لسلطات أي منها أو بشأن تحديد حدودها أو تخومها. وتشكل الخطوط المنقوطة على الخرائط خطوطاً حدودية تقريبية قد لا يوجد بعد اتفاق كامل بشأنها. كما أن ذكر شركات محددة أو منتجات جهات صانعة معينة لا يعني أن هذه الشركات والمنتجات معتمدة أو موصى بها من جانب المنظمة )OHW( و اليونيسيف تفضيلاً لها على سواها مما يماثلها في الطابع ولم يرد ذكره. وفيما عدا الخطأ والسهو، تميز أسماء المنتجات المسجلة الملكية بالأحرف الاستهلالية )في النص الإنكليزي(. وقد اتخذت كل من المنظمة )OHW( و اليونيسيف كل الاحتياطات المعقولة للتحقق من المعلومات الواردة في هذا المطبوع. ومع ذلك فإن المواد المنشورة تُوزع دون أي ضمان من أي نوع، سواء أكان بشكل صريح أم بشكل ضمني. والقارئ هو المسؤول عن تفسير واستعمال المواد. والمنظمة )OHW( و اليونيسيف ليست مسؤولة بأي حال عن الأضرار التي قد تترتب على استعمالها. طُبع بواسطة خدمات إنتاج الوثائق التابعة لمنظمة الصحة العالمية في جنيف بسويسرا dnalreztiwS ni detnirP كيفية وضع خطة للتحسين المستمر 3 المحتويات 1 المقدمة 7ما هي مبادرة الإدارة الفعالة للقاحات؟1-1 01خطة التحسين المستمر لسلسلة إمدادات التمنيع1-2 01لَِم نضع خطة التحسين المستمر؟ 1-2-1 1-2-2 مواءمة نتائج تقييم الإدارة الفّعالة للقاحات مع العناصر الأساسية الستة لسلسلة 21الإمدادات 2 التحسين المستمرعملية وضع خطة 51متى ينبغي وضع خطة التحسين المستمر؟2-1 61من المسؤول عن وضع خطة التحسين المستمر؟2-2 71ما هي أفضل طريقة لوضع خطة التحسين المستمر؟2-3 71تجميع تحليل الحالة وبثه2-3-1 81عقد حلقة عمل بشأن خطة التحسين المستمر2-3-2 22مواءمة أهداف خطة التحسين المستمر وغاياتها مع الخطط الصحية الوطنية الأوسع نطاقا ً2-3-3 52صياغة الخطة الاستراتيجية الخمسية للتحسين المستمر، بما في ذلك الخطة التشغيلية2-3-4 62إجراء عملية التخطيط والميزنة2-3-5 3 التحسين المستمرمحتوى خطة 92تحليل الحالة وتحليل الأسباب الجذرية3-1 13الخطة الاستراتيجية للتحسين المستمر3-2 13الرؤية الطويلة الأجل لسلسلة إمدادات التمنيع3-2-1 23الأهداف والأغراض والاستراتيجيات ومؤشرات الأداء الرئيسية والتكاليف3-2-2 43الخطة التشغيلية السنوية للتحسين المستمر3-3 43الخطة التشغيلية3-3-1 53التكاليف ذات الصلة ومصادر التمويل3-4 4 ورصدهاالتحسين المستمر تنفيذ خطة 73تعميم خطة التحسين المستمر وصبغها بالصبغة المؤسسية1-4 83تنفيذ خطة التحسين المستمر2-4 93رصد التنفيذ والحصائل3-4 04التعلم والتحّسن المستمران5 4موارد إضافية المورد الإضافي 1: إنشاء أو تعزيز فريق عامل وطني يُعنى باللوجيستيات 5373/scitsigol-dna-niahc-ylppus/erolpxe/yrarbil/ne/gro.12-tenhcet.www المورد الإضافي 2: تحليل الحالة 6852=dimetI&75=dip&0084=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www المورد الإضافي 3: مستودع برنامج عمل حلقة العمل الخاصة بخطة التحسين المستمر 6852=dimetI&75=dip&9184=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www المورد الإضافي 4: تقنيات حلقة العمل التعاونية 6852=dimetI&75=dip&1084=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www المورد الإضافي 5: إطار السياسات والاستراتيجيات والخطط الصحية الوطنية الخاص بالمنظمة fdp.ne_lanfi_PSPHNkrowemarF/seiciloplanoitan/tni.ohw.www المورد الإضافي 6: تحليل الأسباب الجذرية 6852=dimetI&75=dip&2084=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www المورد الإضافي 7: منهجيات ومجموعة أدوات التصميم الذي يركز على الناس gro.i4dch.www المورد الإضافي 8: الإرشادات الخاصة بلوحات متابعة سلسلة إمدادات التمنيع -ucod-tnemeganam-rof-atad/ne/php.xedni/gninehtgnertscsi/gro.12-tenhcet.www sdraobhsad-no-ecnadiug/sdaolnwod-dna-stnem المورد الإضافي 9: نموذج الأنشطة وخطة الرصد )الإرشادات الخاصة بخطة التمنيع الشاملة المتعددة السنوات، صفحة 96( fdp.gne_10.41_BVI_OHW/1/816001/56601/maertstib/siri/tni.ohw.sppa المورد الإضافي 01: أداة حساب تكلفة خطة التمنيع الشاملة المتعددة السنوات ne/pymc/sloot/gnicnanfi/smetsys_semmargorp/noitazinummi/tni.ohw.www المورد الإضافي 11: البيان المشترك لمنظمة الصحة العالمية واليونيسيف تحقيق الغايات الخاصة بالتمنيع من خلال الإطار الشامل للإدارة الفّعالة للقاحات /niahc_ylppus/smetsys_semmargorp/noitazinummi/tni.ohw.www fdp.lanfi_SJ-MVE كيفية وضع خطة للتحسين المستمر 5 نبذة عن هذه المذكرة الإرشادية تقدم هذه الوثيقة إرشادات إلى البلدان بشأن كيفية وضع خطة للتحسين المستمر لسلسلة إمدادات التمنيع، ويتمثل الغرض منها في مساعدة البلدان على وضع دراسة جدوى للاستثمار في سلسلة الإمدادات وإعداد خطة للتحسين يشارك فيها أصحاب المصلحة المعنيون، ووضع بذا برنامج التمنيع على المسار الصحيح صوب التنفيذ الناجح. وتشمل هذه المذكرة الإرشادية ما يلي: • نبذة عن عملية إعداد خطة التحسين المستمر، بما في ذلك الجهات التي ينبغي أن تشارك فيها، والتوقيت الذي ينبغي أن تصاغ الخطة فيه، وأفضل طريقة لجمع المدخلات والتعليقات اللازمة لها. • الاستراتيجيات الخاصة بمواءمة مخرجات تقييم الإدارة الفعالة للقاحات مع الآليات الوطنية المعنية بتخطيط قطاع التمنيع والصحة وتمويله، مثل خطة التمنيع الشاملة المتعددة السنوات؛ وتقديم طلبات الدعم إلى التحالف العالمي من أجل اللقاحات والتمنيع من أجل تعزيز الُنظم الصحية؛ والاستراتيجية الوطنية لتحسين قطاع الصحة، وسائر الاستراتيجيات والخطط الخاصة بقطاع الصحة. • الإرشادات الخاصة بإعداد خطة للتحسين المستمر تشمل استراتيجية خمسية وخطة تشغيلية سنوية يمكن استخدامهما في توزيع المسؤوليات ورسم خرائط التقدم المُحرز صوب تحقيق رؤية مشتركة. • اقتراحات بشأن كيفية وضع ميزانية خطة التحسين المستمر وتمويلها لضمان الاستدامة وتحديد الثغرات في الموارد. وقد تكون البلدان على دراية بالعملية السابقة لوضع خطة تحسين الإدارة الفعالة للقاحات والتي جاءت مباشرة في أعقاب تقييم الإدارة الفعالة للقاحات. وفي حين أن الخطة السابقة لتحسين الإدارة الفعالة للقاحات استهدفت معالجة بعض جوانب القصور القصيرة المدى في سلسلة الإمدادات، فإن خطة التحسين المستمر للإدارة الفعالة للقاحات الموضحة هنا ُصّممت لتتسم بمزيد من الاستراتيجية ولتكون شاملة لمجموعة أكبر من أصحاب المصلحة الذين يمكنهم المساعدة على الكشف عن الأسباب الجذرية للمشكلات الخاصة بسلسلة الإمدادات وعلى تعبئة الموارد البشرية والمالية اللازمة لمعالجتها. وتقدم الوثيقة أيضا ًموارد إضافية لكل خطوة من خطوات عملية التخطيط لتحسين الإدارة الفعالة للقاحات.   6تصدير في سياق الجهود العالمية المتجددة الرامية إلى زيادة التغطية بالتمنيع وعدم إهمال أي طفل، تصعب المبالغة في تأكيد ما لدور سلاسل إمدادات التمنيع الوطنية القوية من أهمية. وتتسم سلاسل الإمدادات بالتعقيد وتشمل العديد من العناصر - الأشخاص والتكنولوجيات والُنظم - التي يلزم جمعها معا ًمن خلال خطة للعمل المتواصل. وهذه الخطة ليس من شأنها أن تحّفز المهنيين في مجال سلسلة إمدادات التمنيع الذين يعملون في برنامج التمنيع الوطني الموّسع فحسب، بل وزملاءهم في وزارات التمويل، وأقسام التخطيط وإدارة الموارد البشرية، والقيادات العليا، والشركاء في المساعدة الإنمائية، والجهات الممولة، والأوساط الأكاديمية. وفي غياب هذا الالتزام والدعم، تضعف احتمالات نجاح المهنيين في مجال سلسلة إمدادات التمنيع في معالجة الثغرات التي تتخلل الأداء، وفي وضع البرنامج على المسار الصحيح صوب تحقيق الامتياز المستدام والخاضع للتوجيه الُقطري في ضمان التوافر المستمر للقاح وجودته وفّعالية الُنظم. ويتمثل الغرض من هذه الإرشادات في المساعدة على جعل خطة العمل ذات قوة ومصداقية. وتستند الخطة القوية إلى البيّنات وإلى المنطق البرمجي السليم، أي أنها تركّز الاستثمارات على الأنشطة التي تؤدي مجتمعة إلى مجموعة محددة من الأغراض وتساعد بذا على تحقيق الرؤية المستقبلية وعلى معالجة أوجه القصور التي كانت موجودة في الماضي. وتتسم الخطة بالمصداقية عندما تلبي احتياجات البلد، وتمثل رؤية مشتركة لجميع أصحاب المصلحة الذين انضموا إلى خطة العمل، وتتضمن طريقة لتتبع التقدم المُحرز في التنفيذ قياسا ًعلى غايات الأداء المحددة مسبقا.ً وترتقي هذه الخصائص بالخطة وتحيلها إلى دراسة جدوى قوية للاستثمار في تحسين سلسلة إمدادات التمنيع - أي أداة لدعوة وزارات الصحة إلى إدراج الأنشطة الخاصة بسلسلة إمدادات التمنيع واستبقائها في ميزانياتها الوطنية، ودعوة الشركاء إلى دعم القضية على نحو متواصل. وتُعد هذه أيضا ًشروطا ًأساسية لتحقيق الغرض المنشود من إضفاء الطابع المؤسسي، ألا وهو وضع البرنامج للأنشطة الرامية إلى تحسين سلسلة إمدادات التمنيع نصب أعين القيادة الوطنية بربطها بخطط التشغيل السنوية وبمقاييس الأداء الميزني. ومع ذلك، فحتى الخطة الممولة تمويلاً كاملاً تبقى عرضة لأن تظل مجرد ورقة إلى أن تمس قلوب وعقول الأشخاص المكلفين بمهمة تنفيذها. وتُعد مواءمة التنمية المستمرة - التعلم المستمر - للقوى العاملة في البرنامج الموّسع للتمنيع على جميع المستويات، مع عملية التحسين المستمر لنظام سلسلة إمدادات التمنيع، العنصر الأساسي الذي يجعل التحالف من أجل تحقيق الامتياز المستدام في سلسلة إمدادات التمنيع كاملاً. والقوى العاملة في البرنامج الموّسع للتمنيع هي أول من يتعرف على الأمور التي لا تُفلح، وعادة ما تحظى بأوضح رؤية عن الطريقة التي يمكن بها إفلاحها. وتعمد البلدان الآن على نحو متزايد إلى اعتماد النماذج التشاركية التي تؤدي إلى تمكين المنفذين وإشراكهم في صياغة خطط تحسين سلسلة إمدادات التمنيع وتنفيذها، في السياقات المركزية وتلك التي تُفوض فيها السلطات سواًء بسواء. وقد تقدمت مبادرة الإدارة الفعالة للقاحات تقدما ًكبيرا ًمن حيث عدم ارتباطها بأداة التقييم. فقد تم تحويلها من أجل مساعدة البرامج الوطنية على جعل الاستثمارات الكبرى في تعزيز الُنظم الصحية تعمل على النحو المرجو - لمعالجة الصعوبات النظامية الأساسية في أداء سلاسل إمدادات التمنيع. وتأمل منظمة الصحة العالمية واليونيسيف في أن تنجح هذه الإرشادات في أن تمدكم بالإلهام وفي أن تزودكم بالمعارف والمهارات اللازمة لكي تستفيدوا من هذه المبادرة. كيفية وضع خطة للتحسين المستمر 7 ما هي مبادرة الإدارة الفعالة للقاحات؟ استُهلت مبادرة الإدارة الفعالة للقاحات في عام 0102 من أجل استرعاء الانتباه على الصعيدين العالمي والوطني إلى القياسات الخاصة بأداء سلسلة إمدادات التمنيع، وتحديد المجالات التي يمكن أن يؤثر فيها تحسين سلسلة الإمدادات تأثيرا ًإيجابيا ًعلى التمنيع وعلى الحصائل الصحية.1 وتتوّجه المبادرة إلى العناصر الأساسية الستة لسلسلة إمدادات التمنيع، ألا وهي: 1 في عام 6102، أصدرت منظمة الصحة العالمية واليونيسيف البيان المشترك بشأن مبادرة الإدارة الفعالة للقاحات والدور الحيوي الذي تلعبه سلاسل إمدادات التمنيع في تحقيق الغايات الخاصة بالتمنيع التي تنص عليها خطة العمل العالمية الخاصة باللقاحات. وكان قد سبق ذلك دعوة إلى العمل صدرت في عام 4102 عن اللجنة الاستشارية المعنية بممارسات التمنيع التي أوصت بإجراء عملية للتقييم والتخطيط والتنفيذ والرصد من أجل تحسين سلاسل إمدادات التمنيع. 1 1-1 المقدمة لا تقتصر سلاسل إمدادات التمنيع على المعدات والتوزيع، بل هي نُظم ديناميكية تتسم بالمرونة وإمكانية التكيّف وفقا ًللاحتياجات المتغّيرة والسياقات المتغّيرة والتفاعل لضمان توافر اللقاحات في كل الظروف. والاستراتيجية الجيدة التصميم تسمح للبلدان بتشكيل سلاسل الإمدادات لديها تشكيلاً متكاملاً من أجل تحسين أدائها ومرونتها. إن معدات سلسلة التبريد التي يمكن الاعتماد عليها والتي تخضع للصيانة الجيدة وتتسم بالفّعالية من حيث التكلفة، تكتسي أهمية حيوية لضمان توافر أماكن التخزين الكافية والمستدامة للقاحات الحالية والمخطط لها، ولضمان تقليص الاحتياجات من الصيانة وخفض تكاليف التشغيل. وتسمح الاستراتيجية الجيدة بشأن معدات سلسلة التبريد للبلدان بالحصول على الإرشادات والمساعدات التقنية المتاحة، وتخصيص الدعم المالي للتخطيط على نحو أفضل لمعدات سلسلة التبريد واختيارها وتركيبها وإدارتها وصيانتها. يلزم الحفاظ على جودة اللقاح في جميع مراحل سلسلة إمدادات التمنيع لتلافي إهدار اللقاح نتيجة لتعرضه للحرارة أو للتجمد، سواء في مواقع التخزين الثابتة أو أثناء النقل. ومن شأن الاستراتيجية الجيدة لإدارة درجات الحرارة أن تساعد البلدان على ضمان اتّباع ممارسات التخزين والتوزيع الجيدة، والإجراءات الفّعالة والخاضعة للإدارة الجيدة في رصد درجات الحرارة وحفظ السجلات. تحتاج البلدان إلى وسائل فّعالة لنقل اللقاحات بين مختلف مستويات سلسلة الإمدادات لضمان عدم تقويض نجاعة اللقاحات نتيجة لضعف نظام التوزيع. وتشمل استراتيجية التوزيع المثمرة الاستخدام الكافي للحاويات الخاملة، وممارسات التعبئة المُرضية باستخدام العبوات المبرِّدة، ومؤشرات الحرارة، وخطط الطوارئ المتاحة بشأن النقل. معدات سلسلة التبريد إدارة درجات الحرارة التوزيع تصميم الُنظم 8ومنذ عام 5102، تطورت مبادرة الإدارة الفعالة للقاحات لتصبح عملية قوية تساعد البلدان على بناء سلاسل الإمدادات القادرة على الاستجابة لبرامج التمنيع والبرامج الصحية. ويشمل النهج الشامل للإدارة الفعالة للقاحات أربع خطوات، وهي: التقييم والتخطيط والتنفيذ والرصد على نحو متكرر في دورة مستمرة من التعلم والابتكار )انظر الشكل 1(. تُشجع البرامج الموّسعة للتمنيع، كخطوة أولية، على حشد الالتزام الوطني بالتحسين المستمر عن طريق جمع أصحاب المصلحة معا ًلتكييف النهج الشامل للإدارة الفّعالة للقاحات وخطواته الأربع، وإنشاء آلية للتحسين المستمر لسلسلة إمدادات التمنيع. ويوصى بتنظيم مشاورة مع أصحاب المصلحة الرئيسيين لضمان الالتزام بمبادرة الإدارة الفعالة للقاحات، وتوزيع الأدوار والمسؤوليات بوضوح، والاتفاق حول عملية التنفيذ والرصد. وإذا سمحت الجداول الزمنية بذلك، سيكون من المفيد إجراء المشاركين لزيارة تعلمية قصيرة إلى أحد البلدان الأخرى التي نفذت عملية الإدارة الفّعالة للقاحات. ويرد ملّخص للعناصر الرئيسية للنهج الشامل للإدارة الفّعالة للقاحات في الجدول 1. يتطلب الجيل القادم من سلاسل الإمدادات مديرين مخلصين وأكفاء وأعداد كافية من الأفراد المهرة والخاضعين للمساءلة والمتحمسين والمتمكنين على جميع مستويات سلسلة الإمدادات. ومن شأن حيازة استراتيجية فّعالة بشأن الموارد البشرية الخاصة بسلسلة إمدادات التمنيع أن تساعد البلدان على تعزيز وبناء قدرات مديري سلاسل الإمدادات بتوفير إمكانية الحصول على التدريب، والتشجيع على التعاون، والإشراف الإيجابي، وإتاحة فرص التطور المهني. تُعد البيانات ضرورية لمديري سلاسل الإمدادات من أجل إدارة جميع جوانب سلاسل إمدادات التمنيع، سواء فيما يتعلق بتوافر اللقاحات أو بفّعالية إدارة المخزون. ومن شأن اتّباع استراتيجية سليمة بشأن بيانات سلسلة إمدادات التمنيع للمواءمة مع المعايير الخاصة بالبيانات، ووضع أدوات مفيدة مثل لوحات المتابعة لرصد سلسلة الإمدادات بفّعالية وصنع القرارات التي تسترشد بالبيانات. الموارد البشرية البيانات النهج الشامل للإدارة الفعالة للقاحات الشكل 1 ا لتقييم جمع البيّنات واستعراضها لتحديد جوانب القوة وجوانب الضعف والفرص والصعوبات التي تنطوي عليها سلسلة إمدادات ا لتمنيع ا لرصد رصد التنفيذ وقياس التقدم المُحرز صوب ا لحصا ئل ا لتنفيذ بث الخطة وتأمين التمويل ووضع الخطة موضع التشغيل ا لتخطيط وضع الرؤية والاستراتيجية والخطة التشغيلية لتحسين سلسلة إمدادات التمنيع الالتزام بالتحسين المستمر خطة للتحسين ا لمستمر كيفية وضع خطة للتحسين المستمر 9 2 2 المعايير التسعة للإدارة الفعالة للقاحات: ف1 - وصول اللقاحات؛ ف-2 ضبط درجات الحرارة؛ ف-3 السعة التخزينية؛ ف4 - البنية التحتية؛ ف5 - الصيانة؛ ف6 - إدارة المخزونات؛ ف7 - التوزيع؛ ف8 - إدارة اللقاحات؛ ف9 - نُظم المعلومات. يمكن الاطلاع على المزيد من المعلومات على الرابط التالي: ne/mve/niahc_ylppus/smetsys_semmargorp/noitazinummi/tni.ohw.www//:ptth الجدول الزمني المقترح لنهج الإدارة الفّعالة للقاحات الجدول 1 الخطوة المدة المقدرة أنواع التكاليفا لشكلا لعملية)باليوم( التكاليف التشغيلية والتيسيرحلقة عملتوجيه أصحاب المصلحة في البلدان بشأن مبادرة الإدارة الفعالة للقاحات5.0-2الإعداد ا لتقييم زيارة أولية للتعلّم يقوم بها بعض ممثلي وزارة الصحة والمؤسسات الوطنية المختارين 5-01 للمشاركة في عمليات تقييم الإدارة الفّعالة للقاحات في بلد آخر تكاليف السفرزيارة تخطيط عملية تقييم الإدارة الفعالة للقاحات؛ والتدريب والتنفيذ؛ وتبادل الاستنتاجات/ 51-02 النتائج والتحقق منها مع البرنامج الموّسع للتمنيع ووزارة الصحة حلقة عمل، تقييم العقد الفردي أو المؤسسي لإدارة عملية تقييم الإدارة الفّعالة للقاحات؛ والتكاليف التشغيلية؛ والتيسير تحليل الحالة المستمد من تقييم الإدارة الفّعالة للقاحات وسائر التقييمات والدراسات المتاحة 5-01 )انظر الجدول 3( العقد الفردي أو المؤسسياستعراض ا لتخطيط إعداد المواد اللازمة لحلقة العمل الثانية وبحث الطريقة التي يمكن أن تُستخدم بها العناصر 1-2 الأساسية الستة في تحسين المعايير التسعة للإدارة الفّعالة للقاحات2 وقت الموظفين حلقة عمل بشأن وضع خطة التحسين المستمر3-5 • إنشاء آليات الإشراف وإدارة المشاريع الملائمة )عن طريق الفريق العامل الوطني المعني باللوجيستيات أو غيره من الأفرقة المعنية بالتحسين المستمر(. • استعراض تحليل الحالة وتحديد الأسباب الجذرية. • تحديد رؤية خمسية لسلسلة إمدادات التمنيع، وأهدافها الاستراتيجية، والمؤشرات الرئيسية لأدائها، وأساليبها التكتيكية بالاستناد إلى البيّنات المستمدة من عمليات تقييم الأداء. • تحديد المساعدة التقنية الإضافية اللازمة لاستكمال خطة التحسين المستمر )من أجل التخطيط والميزنة أو وضع إطار للرصد والتقييم مثلاً(. • مناقشة كيفية تحقيق أغراض سلسلة إمدادات التمنيع الثلاثة المتمثلة في التوافر والجودة والفّعالية، باستخدام العناصر الستة الأساسية لسلسلة الإمدادات في تحسين المعايير التسعة الخاصة بالإدارة الفعالة للقاحات )انظر الشكل 2( التكاليف التشغيلية؛ والتيسيرحلقة عمل المواءمة مع خطة التمنيع الشاملة المتعددة السنوات، والخطة الوطنية لقطاع الصحة، 5-51 ومقترحات التمويل )نُظم تعزيز الصحة والإجراءات التي تعظم كفاءة معدات سلسلة التبريد مثلاً (. فريق عامل وقت الموظفين صياغة خطة التحسين المستمر والميزنة: ضمان اعتماد خطة التحسين المستمر من لجنة 51-52 التنسيق المشتركة بين الوكالات، والأُطر الزمنية لوضعها، والأدوار والمسؤوليات، وخطة البث. فريق عامل وقت الموظفين؛ والتكاليف التشغيلية؛ والعقد الفردي أو المؤسسي المحتمل ا لتنفيذ • تبادل خطة التحسين المستمر مع جميع أصحاب المصلحة، بما في ذلك القوى العاملة في 51-52 البرنامج الموّسع للتمنيع على الصعيد دون الوطني. • ضمان أن جميع خطط الموارد البشرية الوطنية تُجّسد احتياجات سلسلة الإمدادات من الموارد البشرية، وفي حال عدم وجود خطة وطنية للموارد البشرية، ترجمة أغراض/ الأساليب التكتيكية لخطة التحسين المستمر إلى خطة موارد بشرية تتعلق تحديدا ً بخطة التحسين المستمر • المشاركة مع إحدى المؤسسات الوطنية دعماً للرصد والتقييم • تعبئة موارد التمويل وفقا ً لخطة الميزنة. فريق عامل وقت الموظفين الرصد على أساس سنوي • رصد التقدم المُحرز في التنفيذ وفقا ً للخطة. • تقييم مؤشرات الأداء الرئيسية الخاصة بالإدارة الديناميكية القائمة على البيّنات. • ضمان توافر الموارد واستخدامها على نحو ملائم التوقيت فريق عامل وقت الموظفين 01 خطة التحسين المستمر لسلسلة إمدادات التمنيع1-2 تُعد خطة التحسين المستمر المسّندة بالبّينات عنصرا ًجديدا ًمن عناصر المبادرة المنّقحة للإدارة الفعالة للقاحات. وتؤدي الخطة وظيفة حاسمة الأهمية تتمثل في إتاحة فرصة استخدام البرنامج الموّسع للتمنيع لمبادرة الإدارة الفعالة للقاحات على النحو المتوخى منها - كعملية مستمرة لتحسين سلسلة إمدادات التمنيع، لا كعملية تقييم تحدَّ ث كل ثلاث أو خمس سنوات دون التأثير على السياسات أو الممارسات. وتنظر خطة التحسين المستمر نظرة شاملة إلى العناصر الستة الأساسية لسلاسل إمدادات التمنيع وتراعي التغييرات الاستراتيجية التي يمكن إدخالها لتحقيق المزيد من توافر الخدمات التي يقدمها برنامج التمنيع وجودتها وفّعاليتها. وبإذكاء الوعي بشأن التحديات الخاصة بسلسلة إمدادات التمنيع والحلول الممكنة، يمكن استخدام خطة التحسين المستمر كدراسة لجدوى الاستثمار عند الدعوة إلى التمويل. ِلَم نضع خطة التحسين المستمر؟ أُحرز تقدم كبير في تحسين البرامج الموّسعة للتمنيع في السنوات الأخيرة، ويُعزى ذلك جزئيا ًإلى زيادة الاستثمار في سلاسل الإمدادات. وتزداد الآن احتمالات احتواء دراسات جدوى الاستثمار في سلسلة إمدادات التمنيع على تحليلات الحالة الوثيقة، كما تزداد احتمالات أن تكون أشد تركيزا ًعلى التدخلات الاستراتيجية والمسّندة بالبيّنات وأن تكون محسوبة التكلفة على نحو من الدقة. وتستند خطة التحسين المستمر إلى هذه التطورات وتعالج أوجه القصور التي كانت تتخلل متطلبات التخطيط السابقة. 1-2-1 استراتيجية وقابلة للتنفيذ يضع العديد من البلدان خططا ًمتعددة لمعالجة نظام سلسلة إمدادات التمنيع على مختلف المستويات، وعادة ما يكون ذلك استجابة لفرص التمويل أو المساعدة التقنية المتوسطة الأجل وانفصال الميزانيات الوطنية عن المنح المقدمة من الجهات المانحة والالتزامات المقطوعة من ِقبل الشركاء. ولذا فإن عملية التخطيط قد تتراجع لتصبح عمليات تدريجية سنوية على حساب جهود التخطيط الاستراتيجي الأطول أجلاً التي تراعي التغّيرات في السياق والأولويات المتغيرة. ونتيجة لذلك، فإن بعض التدخلات الشديدة الفّعالية )والعالية المردود( قد تُهمل لصالح تدخلات أخرى أو تصبح زائدة عن الحاجة أو تُبرمج على نحو غير فّعال. وتمثل خطة التحسين المستمر جزءا ًمن العملية الشاملة للإدارة الفعالة للقاحات التي تمّكن البلدان والشركاء في المساعدة الإنمائية )حيثما ُوجدوا( من التعرف معا ًعلى الاستراتيجيات والتدخلات التي تصلح وتلك التي لا تصلح في البلد المعني. وباستخدام خطة التحسين المستمر كدراسة لجدوى الاستثمار في سلسلة إمدادات التمنيع، يمكن للموظفين المعنيين بالتمنيع تجميع الموارد الحكومية والموارد المقدمة من الجهات المانحة والمساعدة التقنية المقدمة من الشركاء، في معالجة الأولويات الُقطرية التي تربطها صلات وثيقة بالفعل بالخطط المتعددة السنوات للبرنامج الوطني الموّسع للتمنيع ولقطاع الصحة. وبهذه الطريقة تفيد خطة التحسين المستمر البلد مباشرة، على نحو يتجاوز أي اعتبارات تتعلق بالجهات المانحة. كيفية وضع خطة للتحسين المستمر 11 مدمجة في النظام الصحي الأوسع نطاقاً تتمثل إحدى عواقب التخطيط المجزأ لسلسة إمدادات التمنيع في أنه نادرا ًما يبحث في المشكلات التي ينبغي التصدي لها على صعيد الُنظم الصحية، حيث يتطلب ذلك عادة التعاون السياسي مع سائر الإدارات )مثل إدارات الموارد البشرية ونُظم المعلومات الإدارية والتمويل(. وفي كثير من الأحيان، يُخطط للمنح التي تقدمها الجهات المانحة لتعزيز الُنظم الصحية والتي تستهدف حصائل التمنيع، على نحو منفصل عن سلسلة إمدادات التمنيع حتى يحين موعد حساب تكلفة الاحتياجات من المشتريات الخاصة بمعدات سلسلة التبريد والبنية التحتية. ويؤدي ذلك إلى ضياع الفرص وإلى البرمجة الزائدة عن الحاجة )مثل التدريب غير الفّعال المخّصص لسلسلة إمدادات التمنيع بدلاً من دمج الاحتياجات المتكررة من التدريب الخاص بسلسلة إمدادات التمنيع في خطة تنمية قدرات الموارد البشرية الصحية(. وتعتمد عملية وضع خطة التحسين المستمر منظور تعزيز الُنظم الصحية وتضمن أن التخطيط لسلسلة إمدادات التمنيع لا يُنّفذ بمعزل عن البرنامج الموّسع للتمنيع وسائر الجهات الحكومية صاحبة المصلحة على جميع المستويات، بما في ذلك الهيئات المعنية بتصريف الشؤون على الصعيد دون الوطني، ووزارات المالية، والإدارات المسؤولة عن الموارد البشرية وتكنولوجيا المعلومات والاتصالات وإنما بالتعاون معها. وأصحاب المصلحة المعنيون مدعوون إلى المساهمة في تحليل العقبات القائمة في الُنظم الصحية التي تسهم في أوجه القصور التي تكشف عنها عمليات تقييم الإدارة الفّعالة للقاحات أو تؤدي إلى تفاقمها. وتستند هذه العملية إلى مبررات قوية للدعوة إلى تقديم الدعم على مستوى الُنظم إلى سلسلة إمدادات التمنيع. محددة الأولويات بالاستناد إلى البّينات والتمويل المتاح يواجه العديد من البلدان قدرا ًكبيرا ًمن التفاوت بين تكلفة التدخلات المقترحة والموارد المتاحة. وحيثما تكون أولويات الخطط غير محددة صراحة، فإنها تُحدد ضمنا ًعندما تكون الموارد غير كافية. وأحيانا ًما تكون جميع التدخلات غير ممولة إلا جزئيا ً)06 ٪ من مبلغ التكاليف اللازمة مثلاً(، وأحيانا ًما “يربح” التمويَل عدٌد قليل من التدخلات في حين “تخسر” التدخلات الأخرى وتحصل على قدر أقل بكثير من الدعم. وعادة ما تتوقف سيناريوهات الربح/ الخسارة على المصالح الراسخة، والأوضاع الراهنة، وأفضليات الجهات المانحة، بدلاً من أن تستند إلى تقييم البيّنات والفّعالية من حيث التكلفة على نحو من الشفافية، وقد يؤدي ذلك إلى تقويض الجهود المبذولة لإجراء التخطيط المسّند بالبيّنات. وتساعد خطة التحسين المستمر على تحديد أولويات الاستثمار في سلسلة إمدادات التمنيع صراحة على مستويين اثنين. أولاً، تقدم خطة عمل سنوية محسوبة التكلفة مربوطة بالتمويل المجّمع المتاح أو المتوقع )مثل المظروف المحدد لمنحة التحالف العالمي من أجل اللقاحات والتمنيع المقدمة لتعزيز الُنظم الصحية في إطار التنمية(. وثانيا،ً تحدد أولويات الاستراتيجيات التي تعالج الأسباب الجذرية للمشكلات المحددة من خلال الإدارة الفعالة للقاحات وعمليات تقييم الوظائف المعينة )مثل تقييم قدرات الموارد البشرية في سلسلة إمدادات التمنيع، وتقييم تصميم نظام سلسلة إمدادات التمنيع، ودراسات رصد درجات الحرارة، وجرد معدات سلسلة التبريد، وتقييم الاحتياجات التوّسعية(. وفضلاً عن ذلك، فإن عملية الإدارة الفعالة للقاحات تنطوي على دورات مستمرة لاستعراض الأداء تسمح بالمرونة اللازمة لتعديل الخطط بالاستناد إلى القاعدة الدقيقة نفسها التي استُخدمت بداية في وضع خطة التحسين المستمر. 21 تركز على التنفيذ من خلال الملكية المشتركة يُعد عدم تحديد طريقة رصد التنفيذ أو قياسه، خطأ شائعا ًفي التخطيط. وفي السابق، أُشير إلى عدم الانتباه إلى آليات التنفيذ والمشاركة المحدودة على المستوى الإداري )الوطني ودون الوطني( وعلى مستوى القوى العاملة، كأسباب رئيسية لضعف تنفيذ العديد من الخطط الوطنية الخاصة بسلسلة إمدادات التمنيع. وتتعمد عملية التخطيط للتحسين المستمر شمول الجميع، بدءا ًمن الاستعراض المشترك للبيانات الحديثة المستخلصة محليا،ً والفهم الجماعي للعوامل السياقية الخاصة بنظام التمنيع والصحة. وقد ثبت أن هذا النهج التعاوني يزيد من احتمالات ملكية المشاركين للقرارات الاستراتيجية والتكتيكية التي تُتّخذ، ما يؤدي إلى المزيد من دعم التنفيذ. وتتطلب عملية الإدارة الفعالة للقاحات أيضا ًأن تحدد البلدان آليات التنسيق )مثل الأفرقة الوطنية المعنية باللوجيستيات( لرصد التنفيذ قياسا ًعلى مؤشرات الأداء والغايات السنوية التي حددها البرنامج الموّسع للتمنيع والشركاء. 1-2-2 مواءمة نتائج تقييم الإدارة الفّعالة للقاحات مع العناصر الأساسية الستة لسلسلة الإمدادات ركّزت عمليات تقييم الإدارة الفعالة للقاحات فيما مضى على درجات للأداء تتمحور حول المعايير التسعة للإدارة الفّعالة للقاحات. وفي حين أن ذلك يساعد على تركيز البرنامج على فرادى المهام )مثل التخطيط لوضع أحد الإجراءات التشغيلية الموحدة حيثما يُكتشف غياب مثل هذا الإجراء(، فإن بيانات تقييم الإدارة الفّعالة للقاحات نفسها يمكن تحليلها في سبيل تحديد أي من عناصر سلسلة إمدادات التمنيع الستة يحتاج إلى تركيز عاجل، وفي سبيل إعطاء معيار مرجعي رفيع المستوى للطريقة التي يمكن بها لمديري البرامج أن يحققوا الأغراض الثلاثة لسلسلة إمدادات التمنيع )التوافر والفّعالية والكفاءة(. وتُعد هذه الاستخدامات الجديدة للبيانات الخاصة بتقييم الإدارة الفعالة للقاحات بمثابة أداة قوية للدعوة والتواصل، تساعد البرنامج الموّسع للتمنيع على إدارة المديرين بوضع مبررات أكثر تفصيلاً للدعم والموارد. ويوضح الشكل 2 تحليل البيانات المستمدة من عمليات تقييم الإدارة الفعالة للقاحات. كيفية وضع خطة للتحسين المستمر 31 المعايير التسعة للإدارة الفّعالة للقاحات وصول اللقاحات الصيانة القدرة الاستيعابية للتخزين التوزيع إدارة درجات الحرارة إدارة المخزونات البنية التحتية إدارة اللقاحات نُظم المعلومات 1 5 3 7 2 6 4 8 9 مواءمة المعايير التسعة للإدارة الفّعالة لقاحات مع العناصر الستة الرئيسية لسلسلة الإمدادات العناصر الأساسية الستة لسلسلة الإمدادات الأهداف الثلاثة التوافر الجودة الكفاءة وبالتركيز على العناصر الستة لسلسلة الإمدادات، يمكن للبلدان أن تحرز درجات أعلى في معايير الإدارة الفعالة للقاحات، وأن تحقق الأغراض الثلاثة بمزيد من اليسر. معدات سلسلة التبريد إدارة درجات الحرارة التوزيع تصميم الُنظم الموارد البشرية البيانات الشكل 2 41 ومن شأن تحليل البيانات المستمدة من تقييم الإدارة الفّعالة للقاحات فيما يتعلق بالأغراض الثلاثة والعناصر الستة الأساسية لسلسلة إمدادات التمنيع، أن يمّكن البرنامج من عرض خطته للتحسين المستمر كخريطة طريق ليس فقط صوب تحقيق الامتثال للمعايير التقنية للمنظمة، بل وتحقيق أغراض خطة التحسين المستمر كذلك. ويساعد ذلك البرنامج على تنظيم خطة التحسين المستمر على أساس إطار للرصد والتقييم يقيس القيمة النسبية والتقدم المُحرز في تنفيذ أنشطة الخطة فيما يتعلق بمساهمتها في مؤشرات البرنامج المحددة مثل “عدم نفاد مخزونات اللقاح على الصعيد دون الوطني” )أي التوافر: “تبليغ صفر ٪ من المرافق الصحية عن نفاد مخزونات اللقاح”، مثلاً(، ووقت اشتغال معدات سلسلة التبريد )أي الجودة: “001 ٪ من المرافق لديها معدات سلسلة التبريد الصالحة”؛ و”التبليغ عن 001 ٪ من حالات الخلل في معدات سلسلة التبريد في غضون 84 ساعة ومعالجتها في غضون 27 ساعة” مثلاً(، وتسجيل الإدارة الفعالة للقاحات لدرجات أعلى من 08 ٪ )أي الفّعالية(، وما إلى ذلك. وبعد تحديد المؤشرات الرفيعة المستوى، يمثل أداء نُظم سلسلة إمدادات التمنيع، فيما يتعلق بالعناصر الستة الرئيسية، طريقة تلقائية وشاملة لتنظيم خطة التحسين المستمر على أساس الاستراتيجيات الست المقابلة التي تسهم في تحقيق مؤشرات الأداء المذكورة أعلاه. ويوضح الشكل 3 هذا المنطق. 6102 0202 حسين ب الت ق صو الطري ريطة خ العنصر الأساسي 1 لسلسلة الإمدادات العنصر الأساسي 2 لسلسلة الإمدادات العنصر الأساسي 3 لسلسلة الإمدادات العنصر الأساسي لسلسلة الإمدادات 4 العنصر الأساسي لسلسلة الإمدادات 5 العنصر الأساسي لسلسلة الإمدادات 6 % % % % % % الدرجة الممنوحة للإدارة الفّعالة للقاحات الدرجة الممنوحة للإدارة الفّعالة للقاحات الدرجة الممنوحة للإدارة الفّعالة للقاحات الدرجة الممنوحة للإدارة الفّعالة للقاحات الدرجة الممنوحة للإدارة الفّعالة للقاحات الدرجة الممنوحة للإدارة الفّعالة للقاحات >08% الشكل 3 الإطار المقترح لخطة التحسين المستمر كيفية وضع خطة للتحسين المستمر 51 2 متى ينبغي وضع خطة التحسين المستمر؟2-1 تمثل خطة التحسين المستمر عنصراً من عناصر عملية التخطيط المتعددة المستويات لبرنامج التمنيع. ولا يمكن وضعها دون تحضير وفهم أساسي لكيفية عمل سلسلة الإمدادات، والوضع الراهن للمعدات والبنية التحتية، وفهم جلي للوضع الذي تعمل فيه سلسلة الإمدادات. ولهذا الغرض ينبغي أن يصمَّ م نهج الإدارة الفعالة للقاحات بما يتناسب مع السياق الخاص بكل بلد على النحو الموضح في الجدول 2. وينبغي الاسترشاد بالتقييمات الأساسية في وضع خطة التحسين المستمر، بما في ذلك تقييم الإدارة الفعالة للقاحات، والدراسات الخاصة بتعظيم كفاءة الُنظم، واستعراض خطة التحسين المستمر، وعمليات تقييم الموارد البشرية )انظر الجدول 3(. وباستخدام التقييمات الأساسية المتاحة كنقطة انطلاق، يمكن وضع خطة التحسين المستمر في أي وقت. وهي مصمَّ مة لكي تصب في عملية التخطيط الوطني للتمنيع، بحيث تصبح قسماً من أقسام خطة التمنيع الشاملة المتعددة السنوات أو استراتيجية لقطاع الصحة، على سبيل المثال. وفي الحالات المثلى، ينبغي وضع خطة التحسين المستمر بعد استكمال تقييم الإدارة الفّعالة للقاحات مباشرة، واستخدامها كمدخلات جديدة )أو محدثة( في خطة التمنيع الشاملة المتعددة السنوات أو استراتيجية قطاع الصحة. وسيختلف توقيت خطط التحسين المستمر وشكلها من بلد إلى آخر وفقاً للسياق والدراية بعملية الإدارة الفّعالة للقاحات. )يعرض الجدول 2 عدداً من السيناريوهات؛ ويمكن الإشارة إلى احتواء الجدول 4 أيضاً على معلومات أكثر تفصيلاً بشأن إعداد الخطة.( عملية وضع خطة التحسين المستمر 3 انظر الصفحة 82 للاطلاع على إرشادات منظمة الصحة العالمية واليونيسيف بشأن خطة التمنيع الشاملة المتعددة السنوات - ُحّدثت في أيلول/ سبتمبر 3102. متاحة على الرابط التالي: 1=au?fdp.gne_10.41_BVI_OHW/1/816001/56601/maertstib/siri/tni.ohw.sppa//:ptth. الجدول الزمني المقترح لنهج الإدارة الفّعالة للقاحات الجدول 2 السيناريو كيف يُنّفذ النهج الشامل للإدارة متى يُنّفذالفّعالة للقاحات ستخدم بلدك خطة سابقة لتحسين 1 الإدارة الفّعالة للقاحات بنشاط ونجاح في تحديد استراتيجية وإدخال التحسينات في جميع مراحل دورة الإدارة الفعالة للقاحات )3-5 سنوات( ضع خطة التحسين المستمر التالية بالاستناد إلى هذه المذكرة الإرشادية. عمِّ م خطة التحسين المستمر التالية على جميع موظفي البرنامج الموّسع للتمنيع وإدمجها في خطة التمنيع الشاملة المتعددة السنوات التالية أو استراتيجية قطاع الصحة. حدد موعد التقييم التالي للإدارة الفّعالة للقاحات بحيث يسبق عملية التخطيط لخطة التمنيع الشاملة المتعددة السنوات أو لاستراتيجية قطاع الصحة التالية، حيث سيسمح ذلك بدمج خطة التحسين المستمر في عملية التخطيط الأوسع نطاقا ً للتمنيع . بلدك لديه عنصر قوي من عناصر سلسلة 2 إمدادات التمنيع مدمج بالفعل في خطة التمنيع الشاملة المتعددة السنوات أو استراتيجية قطاع الصحة التي تشّكل خطة البلد بشأن سلسلة إمدادات ا لتمنيع ضع خطة التحسين المستمر التالية بالاستناد إلى هذه المذكرة الإرشادية. صمِّ م خطة التحسين المستمر لتكون ملحقة باستراتيجية قطاع الصحة أو القسم الخامس من خطة التمنيع الشاملة المتعددة السنوات:3 «اللقاحات وسلسلة التبريد واللوجيستيات.» الخيار 1: إذا كانت خطة التحسين المستمر توضع قبل استعراض خطة التمنيع الشاملة المتعددة السنوات أو استراتيجية قطاع الصحة بوقت قصير، ينبغي دمج خطة التحسين المستمر واعتمادها كجزء من تلك الوثيقة. الخيار 2: إذا كان توقيت خطة التحسين المستمر لا يسمح بدمجها في خطة التمنيع الشاملة المتعددة السنوات أو استراتيجية قطاع الصحة، ضع خطة مستقلة لخطة التحسين المستمر إلى حين بدء دورة الاستعراض التالية، واستخدمها بوصفها العنصر الأساسي لخطة التحسين المستمر في خطتك التالية. بلدك ليس لديه استراتيجية لسلسلة 3 إمدادات التمنيع أو لديه خطة ضعيفة لتحسين سلسلة إمدادات التمنيع. ضع خطة التحسين المستمر التالية بالاستناد إلى هذه المذكرة الإرشادية. احشد المساعدة التقنية حسب الاقتضاء، لإنشاء آلية قادرة على إدارة عملية وضع خطة التحسين المستمر. اتصل بالمكتب الُقطري لمنظمة الصحة العالمية أو اليونيسيف لبدء مبادرة الإدارة الفعالة للقاحات، وابدأ في التخطيط للتقييم التالي للإدارة الفّعالة للقاحات. 61 من المسؤول عن وضع خطة التحسين المستمر؟ يُعد الفريق الوطني للبرنامج الموّسع للتمنيع مسؤولاً عن وضع خطة التحسين المستمر. ولكن هذه العملية ينبغي أن يدعمها فريق فرعي دائم للجنة التنسيق المشتركة بين الوكالات المعنية بالتمنيع، مثل الفريق العامل الوطني المعني باللوجيستيات أو لجنة التنسيق المعنية بسلسلة الإمدادات. وفي البلدان التي تفتقر إلى مثل هذه الآليات، يوصى بشدة بالمشاركة مع مؤسسات التعليم الوطنية )مثل الجامعات( لاستكمال عمل الفريق العامل الوطني المعني باللوجيستيات أو العمل كبديل له. وفيما يتجاوز وضع الوثيقة نفسها، ستضطلع لجنة التنسيق في بلدك )مثل الفريق العامل الوطني المعني باللوجيستيات( بدور رئيسي في رصد التقدم المُحرز في التنفيذ والحصائل. وقد ثبت أن اضطلاع هذه الأفرقة بالقيادة القوية يشّكل عاملاً رئيسيا ً من عوامل النجاح في إدخال قدر كبير من التحسين على سلاسل إمدادات التمنيع. وينبغي إسناد خطة التحسين المستمر إلى فرد معين أو “أمانة” صغيرة مسؤولة عن صياغة الخطة والتماس المدخلات وإدخال التغييرات، ومتابعة الخطة إلى أن توضع في صيغتها النهائية. نظم حلقة عمل بشأن الالتزام تستمر نصف يوم. من الأهمية البالغة بمكان أن يفهم جميع أعضاء فريق البرنامج الموّسع للتمنيع وأعضاء الفريق العامل الوطني المعني باللوجيستيات وأعضاء لجنة التنسيق المشتركة بين الوكالات، مبادرة الإدارة الفّعالة للقاحات والأدوار والمسؤوليات المنوطة بهم. ونوصي بأن ينظم فريق البرنامج الموّسع للتمنيع حلقة عمل تستمر نصف يوم، للتوجيه بشأن مبادرة الإدارة الفّعالة للقاحات، قبل تقييم الإدارة الفّعالة للقاحات. نصيحة المورد الإضافي 1 إنشاء أو تعزيز فريق عامل وطني يُعنى باللوجيستيات /erolpxe/yrarbil/ne/gro.12-tenhcet.www 5373/scitsigol-dna-niahc-ylppus 2-2 استهلال النهج الشامل للإدارة الفّعالة للقاحات في سيراليون ونيجيرياالإطار 1 نَظَّم البرنامج الموّسع للتمنيع في سيراليون حلقة عمل في فريتاون استمرت نصف يوم، لصالح الرؤساء في وزارات الصحة على الصعيدين الوطني ودون الوطني والرؤساء الإداريين من جميع المناطق. وأثناء حلقة العمل، نظر المشاركون في الأداء السابق للإدارة الفّعالة للقاحات وناقشوا كيف يمكن أن يؤدي تحسين العناصر الستة لسلسلة إمدادات التمنيع إلى تعزيز التوافر والجودة والفّعالية في برنامج التمنيع. وفي النهاية، توصل المشاركون إلى رؤية واضحة وإلى فهم مشترك لنهج الإدارة الفّعالة للقاحات. وكان قرار ضم رؤساء المناطق الإدارية حاسم الأهمية لإشراكهم في مناقشة الأولويات والاستراتيجيات ومؤشرات الأداء ولاسيما في هذا السياق الذي يخضع فيه موظفو البرنامج الموّسع للتمنيع للتسلسل القيادي للمنطقة الإدارية. وبعد مرور شهر على ذلك، وعقب تقديم تقرير جديد عن تقييم الإدارة الفّعالة للقاحات، كان هناك بالفعل توافق آراء عريض - وزخم متولد - بشأن وضع خطة التحسين المستمر التي ُربطت بعد ذلك بعملية تمويل التحالف العالمي من أجل اللقاحات والتمنيع لتعزيز الُنظم الصحية. كيفية وضع خطة للتحسين المستمر 71 ما هي أفضل طريقة لوضع خطة التحسين المستمر؟ بعد توجيه أصحاب المصلحة في مبادرة الإدارة الفّعالة للقاحات وإجراء تقييم الإدارة الفّعالة للقاحات، يمكن للبرنامج الموّسع للتمنيع أن يقوم بدعم من الفريق العامل الوطني المعني باللوجيستيات ومنظمة الصحة العالمية و/ أو اليونيسيف، باستهلال عملية وضع خطة التحسين المستمر من أجل التصدي على نحو استراتيجي للتحديات التي لوحظت في سلسلة إمدادات التمنيع )انظر الإطار 2(. بعد موافقة لجنة التنسيق المشتركة بين الوكالات والفريق العامل الوطني المعني باللوجيستيات على خطة التحسين المستمر، يمكن للبرنامج الموّسع للتمنيع أن يبث الخطة ويعممها، وأن يدمجها في خطة التمنيع الشاملة المتعددة السنوات أو الخطة الاستراتيجية لقطاع الصحة، وأن يبدأ في تنفيذ الأنشطة ورصدها. تجميع تحليل الحالة وبثه ماذا تحليل الحالة هو ملخص للتقرير الخاص بتقييم الإدارة الفّعالة للقاحات وسائر التقييمات المتاحة، بما في ذلك استعراض البرنامج الموّسع للتمنيع، وجرد سلسلة التبريد، وتقييم استعداد اللقاحات الجديدة وقدرات الموارد البشرية. وينبغي أن يقدِّ م تحليلاً موجزا ً لمواطن القوة ومواطن الضعف في سلسلة الإمدادات والفرص المتاحة للتحسين. كما ينبغي أن يبّين التغّيرات التي طرأت على الدرجات الماضية المسّجلة في تقييم الإدارة الفّعالة للقاحات، والوضع الراهن لتنفيذ خطط التحسين السابقة، والسياق الجامع لبرنامج التمنيع والنظام الصحي. الحالة وبثهتجميع تحليل العملية تحليل الحالة • المفّصل فهم أصحاب المصلحة على • نطاق واسع للإدارة الفّعالة للقاحات ونتائج سائر عمليات التقييم تحليل الصعوبات/ الأسباب • الجذرية الرؤية والأهداف والأغراض • والاستراتيجيات والمؤشرات الرئيسية للأداء الخاصة بتحسين سلسلة إمدادات التمنيع خلال السنوات الخمس التالية قائمة التدخلات والحلول • المحتملة المواءمة بين أهداف سلسلة • إمدادات التمنيع وأهداف خطة العمل العالمية الخاصة باللقاحات/ تعزيز الُنظم الصحية المواءمة مع خطة التمنيع • الشاملة المتعددة السنوات والخطة الوطنية لقطاع الصحة وسائر استراتيجيات الصحة الوطنية الخطة الاستراتيجية التي • توضح الرؤية والأهداف والغايات والاستراتيجيات الخطة التشغيلية المفّصلة • التي تنص على الأنشطة والمسؤوليات والأُطر الزمنية والتكاليف ومصادر التمويل والمؤشرات الخاصة بتحقيق الأهداف الاستراتيجية اجتماع لجنة التنسيق • المشتركة بين الوكالات/ الفريق العامل الوطني المعني باللوجيستيات من أجل اعتماد خطة التحسين المستمر للتنفيذ عقد حلقة عمل بشأن خطة التحسين المستمر مواءمة أهداف خطة التحسين المستمر وغاياتها مع خطة التمنيع الشاملة المتعددة السنوات واستراتيجية تحسين قطاع ا لصحة صياغة خطة التحسين المستمر الخمسية ووضع صيغتها النهائية المخرجات 2-3 وضع خطة التحسين المستمر “في لمحة” الإطار 2 2-3-1 81 2-3-2 لماذا يوفر تحليل الحالة نقطة بداية للمناقشة ويضمن أن جميع المشاركين في حلقة العمل الخاصة بخطة التحسين المستمر )الموضحة في القسم الفرعي 2-3-2( يستخدمون أحدث البيّنات الخاصة بالوضع الراهن لسلسلة الإمدادات ويمكنهم تحديد غايات التحسين والاستراتيجيات والأنشطة الخاصة بخطة التحسين المستمر، بالاستناد إلى فهم مشترك للسياق الحالي. متى ينبغي إجراء تحليل الحالة بعد استكمال تقييم الإدارة الفّعالة للقاحات. وينبغي نشره على المشاركين في حلقة العمل الخاصة بخطة التحسين المستمر قبل بدء حلقة العمل بأسبوع واحد على الأقل. من طلب بعض البلدان من المسؤول عن تقييم الإدارة الفّعالة للقاحات تلخيص تحليل الحالة نيابة عن فريق البرنامج الموّسع للتمنيع وأعضاء الفريق العامل الوطني المعني باللوجيستيات. وطلب بعض البلدان الأخرى من إحدى الجهات الشريكة المقدمة للمساعدة التقنية أو المؤسسات الأكاديمية المحلية تلخيص تحليل الحالة، نظرا ً إلى أنه أحيانا ً ما يُستفاد من هذه المؤسسات في هذا الأمر فيما يتعلق بالاقتراحات الخاصة بتعزيز الُنظم الصحية. عقد حلقة عمل بشأن خطة التحسين المستمر ماذا تتمثل حلقة العمل الخاصة بخطة التحسين المستمر في اجتماع تفاعلي يعقد على مدى عدة أيام ويمكن فيه لأصحاب المصلحة المعنيين بسلسلة الإمدادات استعراض تحليل الحالة بتعمق، وإجراء تقييم سريع للأسباب الجذرية، وتحديد الرؤية والأهداف والأغراض والاستراتيجيات والمؤشرات الرئيسية للأداء على مدى السنوات الخمس، من أجل تحسين أداء سلسلة الإمدادات وتحقيق أهداف التمنيع الأوسع نطاقا.ً لماذا تتيح حلقة العمل فرصة أمام أصحاب المصلحة المعنيين بسلسلة الإمدادات للتوصل إلى فهم مشترك للتحديات القائمة في سلسلة إمدادات التمنيع والرؤية والأهداف على المدى الطويل من أجل تحسينها. متى ينبغي لحلقة العمل أن تُعقد بعد أن يصبح تحليل الحالة متاحا،ً وقبل وضع خطة التمنيع الشاملة المتعددة السنوات الجديدة أو الخطة الصحية الوطنية الجديدة. وحلقات العمل التعاونية الفّعالة قد تستهلك الكثير من الموارد وتستغرق وقتا ً طويلاً، ولذا فمن الأهمية الحاسمة بمكان تخصيص وقت كاٍف لكل جلسة لتلافي تقويض جودة التعاون التي تُعد مؤشرا ًعلى جودة خطة التحسين المستمر. المورد الإضافي 2 تحليل الحالة 6852=dimetI&75=dip&0084=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www مدة حلقة العمل الخاصة بخطة التحسين المستمر. أفاد العديد من البلدان بأن أربعة أيام تُعد مدة كافية لإجراء حلقة العمل الخاصة بخطة التحسين المستمر. ومع ذلك، فقد يحتاج بعض البلدان إلى إجراء أكثر من حلقة عمل واحدة من أجل الاتفاق على رؤية ومجموعة من الأهداف والأغراض المجدية. وينبغي لمديري البرنامج الموّسع للتمنيع التخطيط وفقاً لذلك. نصيحة كيفية وضع خطة للتحسين المستمر 91 من يُعد البرنامج الموّسع للتمنيع مسؤولاً بدعم من المؤسسات الوطنية )مثل الفريق العامل الوطني المعني باللوجيستيات والأوساط الأكاديمية( ومنظمة الصحة العالمية و/ أو اليونيسيف، عن تنظيم حلقة العمل الخاصة بخطة التحسين المستمر، وإعداد الوثيقة الخاصة بخطة التحسين المستمر، ورصد تنفيذها. وبعد انعقاد حلقة العمل الخاصة بخطة التحسين المستمر، ينبغي تكليف شخص وحيد أو «أمانة» وحيدة بمسؤولية صياغة الخطة والتماس المدخلات وإدخال التغييرات وتيسير الحصول على ما يلزم من التأييد والموافقات. وينبغي أن يتضمن المشاركون الرئيسيون موظفي البرنامج الموّسع للتمنيع وسلسلة إمدادات التمنيع والمديرين على صعيد الأقاليم والمناطق. وإذا كانت سلسلة إمدادات التمنيع مدرجة في إدارة حكومية أخرى أو خاضعة لإشرافها، يجب أن يشارك موظفو هذه الإدارة المعنيون. كما ينبغي ضم أصحاب المصلحة المشاركين في وضع الخطط الوطنية الأخرى )مثل خطة التمنيع الشاملة المتعددة السنوات واستراتيجية تحسين قطاع الصحة والخطة الوطنية لقطاع الصحة( كأولوية. وينبغي دعوة ممثلين من سائر الوزارات، بما في ذلك وزارتا الموارد البشرية والبُنى التحتية، وممثلين من السلطات التنظيمية الوطنية أو غيرها من الهيئات التنظيمية حسب الاقتضاء، حيث يمكنهم التوصية بحلول للمشكلات التي يتعذر على وزارة الصحة حلها مباشرة، ومناصرة الاستثمار في تلك الحلول في المراحل الحاسمة من العملية السياسية عند إجراء المفاوضات حول الميزانية الوطنية. ويمكن النظر في انضمام مشاركين آخرين، وينبغي أن ينضموا بالاستناد إلى قدرتهم على المساهمة في المناقشة التقنية بشأن سلسلة الإمدادات. ويشمل ذلك أصحاب المصلحة غير الحكوميين مثل الخبراء الاستشاريين الخارجيين، والجهات المانحة )البنك الدولي ووكالة التعاون الدولي اليابانية ومؤسسة بيل وميليندا غيتس ووكالة التنمية الدولية التابعة للولايات المتحدة وغيرها حسب الاقتضاء(، والشركاء التقنيين )اليونيسيف و/ أو المكاتب الُقطرية للمنظمة ومراكز الولايات المتحدة لمكافحة الأمراض والوقاية منها ومركز بحوث التنمية الدولية وبرنامج اعتماد التكنولوجيا الملائمة في مجال الصحة ومؤسسة جون سنو، وغيرها حسب الاقتضاء(. أين ثبت أن إجراء حلقات العمل في غير مقر العمل يحد بقدر كبير من تشتيت الانتباه ويرتقي بمستوى مساهمة المشاركين، ومع ذلك فقد لا يكون ذلك ممكنا ًفي جميع الأحوال. ويجب أن يتسع الموقع للمناقشات العامة والمناقشات الفرعية سواًء بسواء. ضم الخبراء في غير مجال سلسلة الإمدادات إلى حلقة العمل. فبضم الخبراء في غير مجال سلسلة الإمدادات إلى حلقة العمل، يمكن لفريق البرنامج الموّسع للتمنيع أن يستكشف طيفا ً أوسع من الاختيارات بشأن كيفية حل المشكلات التي تعترض سلسلة الإمدادات. ومثال على ذلك، أن المدخلات التي يسهم بها موظفو وزارات المالية والتعليم والبنية التحتية، وإدارة الموارد البشرية في وزارة الصحة، وموظفو البرنامج الموّسع للتمنيع، قد تجعل موظفي البرنامج الموّسع للتمنيع يقترحون حلولاً لم ينظر فيها فريق البرنامج الموّسع للتمنيع من قبل. نصيحة 02 كيف يُعد التخطيط المسبق حاسم الأهمية لضمان عقد حلقة عمل مثمرة. ويجب إعداد جدول الأعمال والوثائق الداعمة وتوزيعها مسبقا ً )مثل مذكرة موجزة تلخص تحليل الحالة وخمسة أو ستة خيارات استراتيجية للمناقشة(. وقد وضعت عدة بلدان جداول عمل حلقات العمل الخاصة بخطة التحسين المستمر التي يمكن اتّباعها أو تكييفها. وتبدأ معظم حلقات العمل بمناقشة حول الحالة الراهنة لسلسلة الإمدادات )تحليل الحالة( والطرق التي تدعم بها سلسلة الإمدادات أغراض التمنيع أو لا تدعمها. وبالطبع فإن هذه المناقشة تتطرق إلى مسألة الأسس المرجعية، أي كيف ينبغي أن يكون الأداء )الرؤية(، وكيف يمكن قياسه )تحديد المؤشرات الرئيسية للأداء لكل مستوى من مستويات سلسلة إمدادات التمنيع(. وانطلاقا ً من هنا يمكن للمشاركين بحث الأسباب الجذرية للتحديات القائمة واقتراح الاستراتيجيات والأهداف والأغراض التي من شأنها أن تدفع البرنامج قُدما ً إلى المكانة التي يرغب في الوصول إليها بعد خمس سنوات. المُخرج ينبغي أن يتمثل مخرج حلقة العمل الخاصة بخطة التحسين المستمر في رؤية خمسية، ومجموعة مكونة من ستة أهداف )واحد لكل عنصر من العناصر الأساسية لسلسلة الإمدادات( مصحوبة بمؤشرات الأداء الرفيعة المستوى، والأغراض والاستراتيجيات المقابلة التي ينبغي أن تُستمد من تحليل الأسباب الجذرية الذي يُجرى خلال حلقة العمل الخاصة بخطة التحسين المستمر )انظر القسم 3(. ونظرا ً إلى أن أعضاء أفرقة التخطيط الأخرى )مثل الأفرقة المعنية بالخطة الوطنية لقطاع الصحة، أو خطة التمنيع الشاملة المتعددة السنوات، أو طلبات الحصول على منح التحالف العالمي من أجل اللقاحات والتمنيع أو الصندوق العالمي أو مرفق التمويل العالمي، أو سلسلة إمدادات المنافع الصحية( قد انضموا إلى حلقة العمل الخاصة بخطة التحسين المستمر، فإن هذه الخطة تجّسد بالفعل الأولويات الأولى لسائر أدوات البرامج والتخطيط. المورد الإضافي 3 مستودع برنامج عمل حلقة العمل الخاصة بخطة التحسين المستمر 6852=dimetI&75=dip&9184=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www تقنيات حلقة العمل التعاونية. اعتمد العديد من البلدان تقنيات تعاونية في حلقات العمل لإجراء حوارات مثمرة بين أصحاب المصلحة عند انعقاد حلقات العمل (انظر المورد الإضافي 4(. وقد أثبتت التجربة أن تقسيم المشاركين في حلقة العمل الخاصة بخطة التحسين المستمر إلى مجموعات - تركز كل مجموعة منها على أحد العناصر الستة الأساسية لسلسلة الإمدادات - يمكن أن يكون شديد الفّعالية. فكل مجموعة تعرض بعد ذلك الأهداف والأغراض والاستراتيجيات والأنشطة، والميزانية المقدرة والمهام الأخرى اللازمة لتنفيذ الأنشطة. ولكن من الأهمية بمكان أثناء هذه العملية المركزة، أن يُسمح أيضاً باستكشاف الاستراتيجيات التي تعتمد منظورا ً أوسع نطاقاً للنظام. ويتمثل أحد الاقتراحات في تعيين مجموعة لتتولى التركيز على مشكلة لا تنتمي بالضرورة إلى مجال استراتيجي واحد (مثل الانتقال في مجال شلل الأطفال أو نقص الموظفين). كما يُنصح ببحث أفضل الممارسات أو الأمثلة من “الانحرافات الإيجابية” القائمة داخل البلاد لتحديد الحلول الممكنة التي ثبتت صلاحيتها بالفعل. نصيحة كيفية وضع خطة للتحسين المستمر 12 تحدد عمليات تقييم الإدارة الفّعالة للقاحات العيوب التي تشوب نظام سلسلة إمدادات التمنيع، لتصبح بعد ذلك محور تركيز خطة التحسين المستمر. وتهدف الأدوات والعمليات ذات الصلة، بما في ذلك تحليل العقبات، إلى تحديد المشكلات وتصحيحها لا إلى تحديد متى ولَِم تسير الأمور على ما يرام. ويؤدي ذلك إلى غياب الحافز وعدم المشاركة من ِقبل البلدان التي قد تشعر بأن العملية تشكل تهديدا ًلها بتسليطها الضوء على أوجه القصور دون الإقرار بالدوافع المحددة للإنجازات. ويتمثل الغرض من نهج الانحراف الإيجابي في تمكين جماعات4 الممارسين من اكتشاف سلوكياتهم واستراتيجياتهم الناجحة، وإحالتها إلى خطط عمل لتعزيز التغيير المستدام. يستند هذا النهج إلى المبادئ التالية: • جماعات الممارسين لديها حلول ودراية • جماعات الممارسين يمكنها تنظيم نفسها من أجل حل المشكلات المتفق عليها • الذكاء الجماعي الموّجه إلى حل مشكلة معينة يُعد أشد فّعالية من الحلول التي يفرضها الخبراء الخارجيون • الاستدامة هي جوهر الاستجابة وتتضمن منهجية الانحراف الإيجابي الخطوات الخمس الأساسية التالية: 1- تحديد المشكلة، والأسباب الحالية المتصورة، والتحديات والعقبات، والممارسات الشائعة، والحصائل المنشودة. 2- تحديد مدى وجود الأفراد أو الجماعات التي تمارس انحرافا ًإيجابيا.ً 3- الكشف عن أي سلوكيات أو استراتيجيات غير الشائعة لكن ناجحة عن طريق التحري والملاحظة. 4- تصميم الأنشطة التي تسمح لأعضاء الجماعات بممارسة السلوكيات المكتشفة. 5- رصد المشروع أو المبادرة الناتجة عن ذلك وتقييمها، فمن شأن ذلك أن يحفز التغيير بتوثيق التحسين عند حدوثه وتبادلها، ويساعد الجماعات على إدراك فّعالية المبادرة. وفي سياق الإدارة الفّعالة للقاحات، ستشكل القوى العاملة الصحية المشاركة في سلسلة إمدادات التمنيع الجماعة الموجودة على كل مستوى من مستويات سلسلة إمدادات التمنيع. وفي الحالات المُثلى، ينبغي أن يكون نهج الانحراف الإيجابي جزءا ًلا يتجزأ من عملية الإدارة الفّعالة للقاحات، وأن يتجّسد في المعلومات النوعية الإضافية التي تُجمع عند تقييم الإدارة الفّعالة للقاحات، وما هو أهم من ذلك، أن يتجّسد في ضمان أن قنوات تبادل التعليقات تسّجل وجهات نظر القوى العاملة والحلول التي تطرحها والدراية التي تتمتع بها، عن طريق عمليات التقييم والتخطيط والتنفيذ. ومن شأن هذا النهج أن يساعد على ضمان أن خطة التحسين المستمر مستمدة من الاحتياجات المحلية وملائمة للسياق عن طريق تحديد الانحرافات القائمة في الجماعة. وفضلاً عن ذلك، فإن هذا النهج يوفر اختبارا ًواقعيا ًلعملية تقييم الإدارة الفّعالة للقاحات، بما في ذلك البيّنات التي قد تساعد على تحسين نهج الإدارة الفّعالة للقاحات في المستقبل. وقد استخدمت عملية وضع خطة التحسين المستمر التي أُجريت مؤخرا ًفي سيراليون عناصر هذا النهج بطريقتين: )1( ُشّجع المقيّمون الوطنيون للإدارة الفّعالة للقاحات على جمع ملاحظات منظمة عن خلفية أي ممارسات جيدة يلاحظونها أثناء زيارات التقييم؛ )2( شجعت حلقة العمل الخاصة بوضع خطة التحسين المستمر المشاركين - الذين كان بعضهم ممثلين للمناطق منتخبين وقادرين على الإعراب عن وجهات النظر المجتمعية - على مناقشة ما إذا كانت هناك مناطق “تُبلى بلاًء حسنا”ً على عكس ما تُشير إليه نتائج تقييم الإدارة الفّعالة للقاحات على الصعيد الوطني. وتبين من أحد هذه الحوارات أن هناك منطقة تقدم حوافز على أساس الأداء تُحدث أثرا ًإيجابيا ًعلى مؤشرات الأداء الأساسية لسلسلة إمدادات التمنيع؛ وكان هذا اكتشاف بالنسبة إلى ممثلي بعض المناطق الأخرى وأدى إلى تفكير جدي في الاستراتيجيات المتاحة. 4 للاطلاع على تعاريف الجماعات الناجحة وعناصرها يُرجى الرجوع إلى الرابط التالي: /gro.savnac-ytinummoc//:sptth الانحراف الإيجابيالإطار 3 22 3 مواءمة أهداف خطة التحسين المستمر وغاياتها مع الخطط الصحية الوطنية الأوسع نطاقا ً ماذا بعد أن تصبح أهداف خطة التحسين المستمر وغاياتها في المتناول، ينبغي لموظفي البرنامج الموّسع للتمنيع المشاركة في جهود التخطيط الموازية ذات الصلة )مثل الخطة الوطنية لقطاع الصحة وخطة التمنيع الشاملة المتعددة السنوات ودراسات جدوى الاستثمار في تعزيز الُنظم الصحية( ومناقشة كيف يمكن لخطة التحسين المستمر وتنفيذها أن يسهما في أهداف التمنيع والُنظم الصحية، وفي تحليل الإنصاف للبرنامج الموّسع للتمنيع، واستعراضات البرنامج الموّسع للتمنيع. وينبغي دمج خطة التحسين المستمر دمجا ً كاملاً في جهود التخطيط الأوسع نطاقا ًهذه، على النحو الموضح في الشكل 4. نيجير يا الإطار 4 نظمت نيجيريا حلقة عمل بشأن خطة التحسين المستمر استمرت أربعة أيام لتمكين مديري البرنامج الموّسع للتمنيع في 63 ولاية وفي إقليم العاصمة الاتحادية من التفكير حول نتائج تقييم الإدارة الفّعالة للقاحات الذي أُجري مؤخرا ًوالمشاركة معا ًفي بحث الأسباب الجذرية للتحّسن غير الكافي والتنفيذ غير الوافي للخطط السابقة. واختلف هذا الحدث اختلافا ًكبيرا ًعن حلقات العمل التدريبية واجتماعات التخطيط المعتادة. فقد ُصّممت لتكون ديناميكية وتكرارية وجذابة من أجل تعظيم المساهمة الفعلية من جانب جميع المشاركين وضمان أقصى قدر من التأييد لخطة التحسين المستمر، ولاسيما من ِقبل المديرين الحكوميين للبرنامج الموّسع للتمنيع على صعيد الولايات. وأدى هذا النهج إلى تمكين خطة التحسين المستمر الجديدة من إحداث تحّسن قابل للقياس ومستدام في سلسلة إمدادات التمنيع وضمان ملاءمة خطة التحسين المستمر لسياق مستويات قطاع الصحة النيجيري المفوضة بالسلطة. المورد الإضافي 3 : تقنيات حلقة العمل التعاونية 6852=dimetI&75=dip&9184=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www 2-3-3 كيفية وضع خطة للتحسين المستمر 32 لماذا سيؤدي دمج خطة التحسين المستمر في الخطة الوطنية لقطاع الصحة وخطة التمنيع الشاملة المتعددة السنوات وسائر الخطط ذات الصلة، إلى إضفاء المزيد من القوة والنوعية على تلك الخطط. وكلما كانت جهود التخطيط المبذولة أكثر تكاملاً، سهل التخلص من ازدواجية الجهود وتيسر تحديد الفرص المتاحة لتحقيق أوجه الفّعالية )مثل مجموعة مشتركة من المؤشرات أو الحصائل( مع سائر الخطط. من ينبغي للموظفين الرئيسيين للبرنامج الموّسع للتمنيع حضور اجتماعات لجان التخطيط ذات الصلة لعرض خطة التحسين المستمر ومناقشة الطريقة التي تدعم بها هذه الخطة الخطة الوطنية لقطاع الصحة وخطة التمنيع الشاملة المتعددة السنوات )وسائر الخطط ذات الصلة(. وبحضور هذه الاجتماعات، يمكن للمشاركين في التخطيط البحث عن الإجراءات الزائدة عن الحاجة وعن الفرص المتاحة لتحقيق أوجه الفّعالية. تصميم الُنظم معدات سلسلة التبريد إدارة درجات الحرارة التوزيع الموارد البشرية خطة التحسين المستمر للإدارة الفّعالة للقاحات البيانات خطة التمنيع المتعددة السنوات الخطة الوطنية لقطاع الصحة الشكل 4 دمج خطة التحسين المستمر في عملية التخطيط للصحة الأوسع نطاقاً 42 متى في حلقة العمل الخاصة بخطة التحسين المستمر، ينبغي لأصحاب المصلحة المعنيين المشاركين في سائر عمليات التخطيط )مثل الخطة الوطنية لقطاع الصحة وطلبات الحصول على منح التحالف العالمي من أجل اللقاحات والتمنيع أو الصندوق العالمي أو مرفق التمويل العالمي، وخطة سلسلة إمدادات المنافع الصحية( أن يكونوا مشاركين بالفعل في تحديد الأهداف والاستراتيجيات والأنشطة الجامعة المتعلقة بسلسلة الإمدادات. وبعد انعقاد حلقة العمل الخاصة بخطة التحسين المستمر، ينبغي لموظفي البرنامج الموّسع للتمنيع والمشاركين الخارجيين المعنيين بالتخطيط أن يتبادلوا مسّودة الرؤية والأهداف والغايات والاستراتيجيات مع اللجان العاملة بشأن استراتيجيات التمنيع والصحة ذات الصلة وإحاطتهم علماً بمناقشات حلقة العمل الخاصة بخطة التحسين المستمر وحصائلها. المُخرج ينبغي أن يتمثل المخرج الأولي لهذه الخطوة في الدمج المحمود لخطة التحسين المستمر في خطة التمنيع الشاملة المتعددة السنوات والخطة الوطنية لقطاع الصحة وسائر الوثائق الخاصة بالتخطيط. ويمكن أن يتمثل مخرج ثانوي في قائمة من التنقيحات المقترحة التي من شأنها أن تزيد من مواءمة خطة التحسين المستمر مع سائر أدوات التخطيط بالاستناد إلى المناقشات مع الجماعات ذات الصلة المعنية بالتخطيط. وينبغي استخدام هذه التوصيات حسب الاقتضاء في تعديل الأهداف والأغراض والاستراتيجيات التي ُوضعت في حلقة العمل الخاصة بخطة التحسين المستمر تحقيق الاستفادة القصوى من البرمجة لتعزيز الُنظم الصحية. عند النظر في تحسين سلسلة إمدادات التمنيع من منظور تعزيز الُنظم الصحية، ينبغي لموظفي البرنامج الموّسع للتمنيع أن يتساءلوا: ما هي الُنظم الصحية المحددة التي ينبغي تعزيزها للمساعدة على إزالة العقبات الأشد إلحاحاً في سلسلة إمدادات التمنيع التي تعترض برنامجنا؟ وغالباً ما ستتعلق الإجابات بلبنات البناء الخاصة بتعزيز الُنظم الصحية، أي تصريف شؤون قطاع الصحة، والموارد البشرية، ونُظم المعلومات، والتمويل. وقد يكتسي بناء التحالفات مع أصحاب المصلحة خارج التسلسل الإداري للبرنامج الموّسع للتمنيع أهمية بالغة في حل المشكلات ويستحق استثمار الجهود فيه. وعادة ما تشّجع الجهات المانحة (عن طريق المنح المقدمة من التحالف العالمي من أجل اللقاحات والتمنيع لتعزيز الُنظم الصحية) البرامج الوطنية الموّسعة للتمنيع على التماس الدعم من سائر الإدارات الحكومية من أجل التصدي للمشكلات الملّحة التي يواجهها البرنامج الموّسع للتمنيع. نصيحة كيفية وضع خطة للتحسين المستمر 52 صياغة الخطة الاستراتيجية الخمسية للتحسين المستمر، بما في ذلك الخطة التشغيلية السنوية ماذا ينبغي صياغة خطة التحسين المستمر في جزأين )انظر القسم 4(. أولاً، فرع استراتيجي ينص على الرؤية والأهداف والأغراض والمؤشرات الرئيسية للأداء والتكاليف المقدرة5 للأنشطة التي ُحددت وُوضعت أثناء حلقة العمل. وثانيا،ً ينبغي أن تشمل الخطة خطة تشغيلية سنوية مصحوبة بالتكاليف المرتبطة بها، وموارد التمويل ومؤشرات التنفيذ. وتصبح خطة التحسين المستمر بعد استكمالها قسماً يتناول سلسلة التبريد واللوجيستيات في خطة التمنيع الشاملة المتعددة السنوات )انظر القسم 5( أو ملحقا ً لاستراتيجية قطاع الصحة. لماذا تؤدي الخطة الخمسية للتحسين المستمر إلى التفاف جميع أصحاب المصلحة بما في ذلك مقدمو المساعدة التقنية، حول مجموعة مشتركة من الأهداف التي تحّسن فّعالية التمنيع وجودته وتوافره. وتُعد خطة التحسين المستمر أداة للتعلم المستمر تربط نتائج تقييم الإدارة الفّعالة للقاحات بالرؤية الاستراتيجية العامة بخصوص التمنيع. متى سيختلف الوقت الذي يستغرقه وضع خطة التحسين المستمر باختلاف البلدان. وينبغي لفريق البرنامج الموّسع للتمنيع الاتفاق على موعد نهائي معقول وفقا ً للموارد المتاحة من الموظفين. وإذا كانت هناك خطة جديدة من خطط التمنيع الشاملة المتعددة السنوات أو الخطط الوطنية لقطاع الصحة قيد الإعداد، ينبغي وضع الصيغة النهائية لخطة التحسين المستمر في غضون الإطار الزمني المحدد لوضع هذه الخطة. وينبغي تخصيص وقت كاٍف لعنصر الميزنة والتمويل لخطة التحسين المستمر، حيث سيحّسن ذلك من جدوى الخطة )انظر القسم الفرعي 3-4(. من ينبغي أن توضع خطة التحسين المستمر بمعرفة )أو بالتعاون الوثيق مع( كبار موظفي البرنامج الموّسع للتمنيع، حيث سيكون هذا البرنامج المسؤول الأول عن تنفيذ الخطة. وقد ترغب الأفرقة العاملة التي ُشّكلت أثناء حلقة العمل الخاصة بخطة التحسين المستمر في صياغة أقسام الخطة المتعلقة بمجالات التركيز الاستراتيجي، ولكن فريق البرنامج الموّسع للتمنيع هو المسؤول عن دمج هذه الأقسام في الخطة الكاملة. وقد تكون هناك استثناءات في بعض السياقات التي قد يلزم فيها إسناد مهمة صياغة الخطة إلى جهات خارجية، ولاسيما عندما لا تتوافر القدرات اللازمة لذلك في البلاد. المُخرج تشمل خطة التحسين المستمر خطة استراتيجية خمسية وخطة تشغيلية سنوية يمكن عرضهما على الفريق العامل الوطني المعني باللوجيستيات ولجنة التنسيق المشتركة بين الوكالات لإقرارهما. 5 توصي منظمة الصحة العالمية واليونيسيف بإجراء عملية كاملة للتخطيط والميزنة لخطة التحسين المستمر، وبربطها بميزانية خطة التمنيع الشاملة المتعددة السنوات. 2-3-4 62 إجراء عملية التخطيط والميزنة2-3-5 ماذا عملية التخطيط والميزنة هي السعي إلى تحديد جميع التكاليف وموارد التمويل المرتبطة بالأنشطة المدرجة في خطة التحسين المستمر طوال فترة السنوات الخمس. وقد تشمل التكاليف المرتبطة بذلك ما يلي: • الأفراد )مثل الموظفين المكلفين بالتبليغ( • النفقات الرأسمالية الخاصة بالمعدات والبُنى التحتية )مثل شراء المركبات ومعدات سلسلة التبريد( • النفقات التشغيلية )مثل إصلاح سلسلة التبريد أو صيانتها( • النقل • الخدمات المسندة إلى جهات خارجية • حلقات العمل والتبادلات الدولية • الاحتياجات من المساعدة التقنية )مثل الدعم التقني لتصميم الأنظمة والدعم المقدم لإنشاء الفريق العامل الوطني المعني باللوجيستيات( لماذا كما هو الحال بالنسبة إلى جميع الخطط، لا تكون خطة التحسين المستمر مفيدة إلا بقدر ما تُدعم وتمّول. وتحدد عملية التخطيط والميزنة التكاليف المرتبطة بتنفيذ الخطة ورصدها، وتمّكن مديري البرنامج الموّسع للتمنيع ولجان التنسيق اللوجيستي من تحديد مصادر التمويل اللازم لتلبية احتياجات البرنامج. متى ينبغي أن تُجرى عملية التخطيط والميزنة فور استكمال صياغة خطة التحسين المستمر وقبل موافقة لجنة التنسيق المشتركة بين الوكالات عليها من يُعد البرنامج الموّسع للتمنيع مسؤولاً عن استكمال عملية التخطيط والميزنة، سواء عن طريق تحديد شريك يقدم المساعدة التقنية لإجراء عملية التخطيط والميزنة أو وكالة خاصة. أشرك وزارة المالية في مرحلة مبكرة. عادة ما تحقق البلدان التي تُشرك الزملاء من وزارة المالية في عملية التخطيط والميزنة نجاحا ًأكبر في جمع الأموال وتنفيذ خطتها للتحسين المستمر. فوجود موظفي وزارة المالية لا يؤدي إلى المزيد من الدقة في تقدير التكاليف ومصادر التمويل فحسب، بل ويؤدي أيضا ًإلى تقليص الإطار الزمني المحدد للتوقيع على الميزانية وصرف الأموال. نصيحة كيفية وضع خطة للتحسين المستمر 72 • وثيقة مستقلة أو مدمجة على نحو مباشر في خطط العمل السنوية القائمة؛ • أداة لتتبع التقدم المُحرز في تنفيذ خطة العمل السنوية، تربطها صلات مباشرة بالحصائل الموضحة في الخطة الاستراتيجية والتي يمكن التبليغ عنها في الاستعراضات السنوية؛ • توضع سنويا ًوتتضمن وصف الأهداف والأنشطة والأُطر الزمنية والمسؤوليات والتكاليف والمؤشرات لرصد التقدم؛ • تخضع للاستعراض والاعتماد من ِقبل لجنة التنسيق المشتركة بين الوكالات وفريق عامل أو لجنة معنية بسلسلة الإمدادات؛ • تخضع لاستعراض مديري البرنامج الموّسع للتمنيع فصليا ًعلى الأقل، ويُرفع تقرير بشأنها، سنويا ًعلى الأقل إلى لجنة التنسيق المشتركة بين الوكالات والفريق العامل الوطني المعني باللوجيستيات حيثما ُوجد مثل هذا الفريق. • وصفا ًواضحا ًلما يرغب البلد في تحقيقه، أي الرؤية والأهداف والحصائل المتوقعة من سلسلة إمدادات التمنيع، التي يمكن أن تكون بمثابة نقطة التقاء لجميع أصحاب المصلحة؛ • منطقية واستراتيجية - تجيب على الأسئلة بشأن ما هي الأنشطة المحددة التي ستُجرى ولَِم ومتى، ومن المسؤول عنها، وكيف سيُقاس التقدم المُحرز باستخدام المؤشرات الرئيسية للأداء؛ • تستند إلى تحليل منهجي مسّند بالبيّنات للأسباب الجذرية التي تقف وراء ضعف أداء سلسلة إمدادات التمنيع، وتحليل لعوامل التمكين من الأداء القوي لسلسلة إمدادات التمنيع؛ • توضع كجزء من عملية تخطيط تشاركية تُجرى مع أصحاب المصلحة المعنيين من سائر الوزارات ومستويات النظام الصحي حتى تلبي احتياجات عمليات التخطيط الوطني الأوسع نطاقا ًبشأن التمنيع والصحة وتحظى بدعمها )مثل خطة التمنيع الشاملة المتعددة السنوات(؛ وتُستخدم في إذكاء الوعي والدعوة إلى الاستثمار والإشراف من ِقبل مستويات الإدارة العليا لوزارة الصحة. وينبغي أن تكون الخطة الاستراتيجية: وينبغي أن تكون الخطة التشغيلية: ستشتمل خطة التحسين المستمر على النحو المذكور في المذكرة الإرشادية على الجزأين الرئيسين التاليين: )1( الخطة الاستراتيجية التي توضح الرؤية والأهداف والأغراض الاستراتيجية الرئيسية لسلسلة الإمدادات طوال السنوات الخمس التالية؛ )2( الخطة التشغيلية - خطة عمل سنوية توضح تفاصيل الأنشطة والأُطر الزمنية والمسؤوليات والتكاليف والمؤشرات. محتوى خطة 3 التحسين المستمر 82 1- تحليل الحالة وتحليل الأسباب ا لجذر ية انظر أعلاه القسم • الفرعي 2-3-1 أ- الرؤية الطويلة الأجل توضح الحالة • المستقبلية المنشودة لسلسلة إمدادات التمنيع توضح كيف تدعم • الرؤية والأهداف الخاصة بخطة التحسين المستمر أغراض برنامج التمنيع وقطاع الصحة ب- الأهداف والأغراض والاستراتيجيات والمؤشرات الرئيسية للأداء والتكاليف المقدرة توضح الأهداف الرفيعة المستوى • لتحسين التوافر والجودة والفّعالية في سلسلة إمدادات التمنيع توضح الأغراض الرئيسية لكل هدف • وتحدد المؤشرات التي تبين التقدم المُحرز صوب تحقيقها توضح الاستراتيجيات المستندة إلى • تحليل الأسباب الجذرية، التي ستدفع البلد قدما ًصوب تحقيق الأهداف في غضون السنوات الخمس التالية توضح مؤشرات الأداء الرئيسية • المختارة التي تتيح قياس التقدم طوال دورة التحسين المستمر تحدد التكاليف المقدرة لجميع • الأنشطة المدرجة في الخطة الخمسية وتوضح مصادر التمويل المحتملة والمؤكدة )بما في ذلك الأنشطة التي يدعمها الشركاء( 3- الخطة التشغيلية للتحسين المستمر2- الخطة الاستراتيجية للتحسين المستمر المحتوى المقترح لخطة التحسين المستمر “في لمحة” الإطار 5 أ- خطة الأنشطة والرصد للسنة الأولى تصف هذه الخطة • الأنشطة الرئيسية ومؤشرات التقدم التي ستُستخدم في تتبع التنفيذ وتوضح تصريف • شؤون خطة التحسين المستمر )مثل الأدوار المسندة إلى الفريق العامل الوطني المعني باللوجيستيات وإلى الشركاء ومقدمي المساعدة التقنية، وما إلى ذلك( ب- التكاليف ذات الصلة ومصادر التمويل تحِسب التكاليف • المحددة المرتبطة بالخطة التشغيلية وتحدد مصادر • )وتوقيت( التمويل المقدم من الشركاء والجهات المانحة والميزانيات الحكومية كيفية وضع خطة للتحسين المستمر 92 تحليل الحالة وتحليل الأسباب الجذرية 3-1 يمثل تحليل الحالة (انظر المورد الإضافي 2) القسم الأول من خطة التحسين المستمر. ويصف الحالة الراهنة لسلسلة الإمدادات ومكوناتها وأداءها الحالي بتلخيص النتائج الرئيسية والتوصيات المستمدة من تقييم الإدارة الفّعالة للقاحات وسائر التقييمات ذات الصلة. في الجدول 3 أدناه ترد التقييمات والخطط والمواقف التي يمكن تحليلها كجزء من تحليل الحالة. ويوضح العمود الأيمن اقتراحات بشأن الأماكن التي يمكن العثور فيها على المدخلات والمعلومات والبيانات. المورد الإضافي 5 إطار المنظمة للسياسات والاستراتيجيات والخطط الصحية الوطنية fdp.ne_lanfi_PSPHNkrowemarF/seiciloplanoitan/tni.ohw.www استخدم إطار السياسات والاستراتيجيات والخطط الصحية الوطنية الذي وضعته المنظمة لتعزيز خطتك. أثبتت التجارب أن الحوار حول السياسات الذي يُجرى لوضع خطط وطنية شاملة بشأن السياسات والاستراتيجيات والخطط الصحية، يُعد عملية سياسية وليست تقنية فحسب. وتتطلب هذه العملية الاهتمام بالجانب الملهم من تحديد الرؤية والسياسة؛ كما تتطلب الاهتمام بالتفاصيل التشغيلية. وتختلف الموازنة بين الرؤية والسياسة والتخطيط الاستراتيجي واتساق التنفيذ اختلافا ًكبيرا ًمن بلد إلى آخر. ويُحث على الاطلاع على إطار المنظمة للسياسات والاستراتيجيات والخطط الصحية الوطنية )انظر المورد الإضافي 1 أدناه( فيما يتعلق بالشروط الأساسية لوثائق التخطيط السليم التي تتلاءم مع الاستراتيجيات الصحية الوطنية العامة لبلادك. نصيحة 03 الجدول الزمني المقترح لنهج الإدارة الفّعالة للقاحات الجدول 3 أين يمكن العثور عليهاالتقييمات وقوائم الموجودات والتقارير • البرنامج الوطني الموّسع للتمنيعاستعراض البرنامج الوطني الموّسع للتمنيع التقارير الخاصة بتقييم الإدارة الفّعالة للقاحات وخطط تحسين الإدارة الفّعالة للقاحات، بما في ذلك التفاصيل الخاصة بتنفيذ هذه الخطة • البرنامج الوطني الموّسع للتمنيع أو المكاتب الُقطرية لمنظمة الصحة العالمية واليونيسيف القائمة المحدثة للموجودات من معدات سلسلة التبريد، بما في ذلك متطلبات التوّسع وإصلاح المعدات • القائمة الوطنية للموجودات من معدات سلسلة التبريد، إن ُوجدت • تطبيق الإجراءات التي تعظم كفاءة معدات سلسلة التبريد • التقارير الخاصة بتقييم الإدارة الفّعالة للقاحات • نظام الإدارة والمعلومات الخاصة باللوجيستيات • خطط وسجلات المشتريات تقييم مدى استعداد سلسلة إمدادات اللقاحات الجديدة • التقارير الخاصة بتقييم الإدارة الفّعالة للقاحات • الطلبات المقدمة إلى التحالف العالمي من أجل اللقاحات والتمنيع ومنظمة الصحة العالمية واليونيسيف وما إلى ذلك، من أجل اعتماد لقاحات جديدة • خطة التمنيع الشاملة المتعددة السنوات • الطلبات المقدمة إلى التحالف العالمي من أجل اللقاحات والتمنيع بشأن تعزيز الُنظم الصحية تقييم قدرات الموارد البشرية • التقارير الخاصة بتقييم الإدارة الفّعالة للقاحات • الطلبات المقدمة إلى التحالف العالمي من أجل اللقاحات والتمنيع بشأن تعزيز الُنظم الصحية • خطة التمنيع الشاملة المتعددة السنوات • التقييمات الخاصة بالموارد البشرية لقطاع الصحة • البيانات الخاصة بنظام رصد درجات الحرارة• الدراسة الحديثة لرصد درجات الحرارة تقييم رصد درجات الحرارة في سلسلة التبريد تقييم تصميم شبكة النقل • التقارير الخاصة بتقييم الإدارة الفّعالة للقاحات • التقييمات )الخاصة بوكالة الولايات المتحدة للتنمية الدولية، وما إلى ذلك( والخطط الاستراتيجية الخاصة بسلسلة الإمدادات الاستراتيجيات والسياسات والأولويات الوطنية الخاصة بقطاع التمنيع والصحة • الخطة السنوية للبرنامج الموّسع للتمنيع • الخطة المتعددة السنوت للبرنامج الموّسع للتمنيع • الاستراتيجية الوطنية المتعددة السنوات لقطاع الصحة • خطة التمنيع الشاملة المتعددة السنوات • استراتيجية التحالف العالمي من أجل اللقاحات والتمنيع الخاصة بتعزيز الُنظم الصحية • الاستراتيجيات/ التقييمات الأخرى الخاصة بسلاسل إمدادات المنافع الصحية • البرنامج الوطني الموّسع للتمنيعالتقييمات الخاصة بالإنصاف كيفية وضع خطة للتحسين المستمر 13 3-2-1 يبحث تحليل الأسباب الجذرية في السبب الذي يقف وراء ضعف أداء سلسلة الإمدادات في بعض المناطق. ويُعد تحليل الأسباب الجذرية فرصة للتصدي للتحديات الناتجة عن جوانب الفشل. وهناك طرق عديدة لإجراء تحليل الأسباب الجذرية )انظر المورد الإضافي 6 أدناه(؛ ويمكن لفريق البرنامج الموّسع للتمنيع أن يحدد النهج الذي سيُتّبع. وهناك ثلاثة عناصر أساسية في تحليل الأسباب الجذرية، وهي بيان المشكلة، وأسبابها الجذرية، والاستراتيجيات الممكنة للتصدي لها. وقد استخدم بعض البلدان مجموعة أدوات منهجيات التصميم الذي يركز على الناس )انظر المورد الإضافي 7 أدناه( استخداما ًناجحا ًفي توجيه مناقشة الأسباب الجذرية في حلقة العمل الخاصة بخطة التحسين المستمر. ومن شأن تحليل الحالة وتحليل الأسباب الجذرية أن يزودا معا ًراسمي السياسات الوطنية بلمحة عامة عن جوانب القوة والفرص المتاحة وجوانب الضعف والمخاطر المطروحة في سلسلة إمدادات التمنيع، ويساعدا على تحديد أولويات الأنشطة حتى يمكن تركيز الاستثمارات وفقا ًلذلك. الخطة الاستراتيجية للتحسين المستمر ينبغي للخطة الاستراتيجية أن تكون مقتضبة وسهلة القراءة، وينبغي أن تعرض الرؤية الطويلة الأجل لسلسلة الإمدادات والأهداف الرفيعة المستوى والأغراض والاستراتيجيات التي ُحددت للسنوات الخمس التالية )بما في ذلك المؤشرات لقياس الحصائل والتقدم المُحرز صوب هذه الحصائل(. وينبغي نشر موجز من صفحة أو صفحتين للخطة الاستراتيجية على نطاق واسع واستخدامه كأداة لتتبع التقدم المُحرز. الرؤية الطويلة الأجل لسلسلة إمدادات التمنيع ينبغي أن توضح الرؤية الطويلة الأجل كيفية دعم سلسلة إمدادات التمنيع لبرنامج التمنيع، أي كيف هو أداؤها وطريقة تنظيمها، وما الذي تسهم به في برنامج التمنيع وفي قطاع الصحة الوطنية. وينبغي أن تصف الرؤية سلسلة لإمدادات التمنيع تتسم بالمرونة والقدرة على استيعاب تغّير أولويات النظام الصحي )مثل الأمن الصحي والانتقال في مجال شلل الأطفال والسجلات الإلكترونية(، والتغّيرات المتوقعة في البُنى التحتية والمناخ السياسي على وجه العموم )مثل الاستثمار في إمداد المناطق الريفية بالكهرباء، والبُنى التحتية والطرق، وزيادة إتاحة شبكة الإنترنت(. وما هو أشد أهمية، هو أن تجّسد هدف سلاسل الإمدادات المتمثل في تحسين توافر اللقاحات وإمدادات التمنيع وفّعاليتها وجودتها على نطاق البلاد. مثال: “نتطلع إلى تحقيق سلسلة إمدادات تقدم كميات كافية من اللقاحات وإمدادات التمنيع على نحو يعتمد عليه مباشرة إلى جميع مراكز التمنيع الثابتة )بما في ذلك المراكز الجديدة التي تُفتتح خلال السنوات الخمس التالية( وتقوم بذلك دون تقويض جودة هذه المنتجات بسبب تعرضها للحرارة أو التجمد. وبقيام سلسلة الإمدادات بذلك، ستدعم هدف البرنامج الموّسع للتمنيع المتمثل في التغطية باللقاحات بنسبة 90٪ بحلول عام ؟؟؟؟ وخفض معدل وفيات الأطفال بحلول عام ؟؟؟. 3-2 المورد الإضافي 6 تحليل الأسباب الجذرية 6852=dimetI&75=dip&2084=dis&orpibos_moc=noitpo?/ne/gro.12-tenhcet.www المورد الإضافي 7 مجموعة أدوات ومنهجيات التصميم الذي يركز على الناس gro.i4dch.www 23 الأهداف والأغراض والاستراتيجيات ومؤشرات الأداء الرئيسية والتكاليف تصف الأهداف الحصائل المتوسطة والطويلة الأجل اللازمة لتحقيق الرؤية. وفي حال سلاسل الإمدادات، تسهل صياغة الأهداف عندما تتواءم مع الأغراض الجوهرية لسلاسل الإمدادات المتمثلة في زيادة التوافر والجودة والفّعالية. وعادة ما تنص الخطط الاستراتيجية التي يمكن التمّكن منها على ثلاثة أو خمسة أهداف قابلة للتحقيق في غضون خمس سنوات. وينبغي أن يصاحب كل هدف مؤشر واحد على الأقل من المؤشرات الرئيسية للأداء القابلة للقياس، وأن يُبلغ بشأنه خلال العام. مثال: الغرض رقم 1: زيادة التغطية بالتمنيع بضمان أن جميع اللقاحات وإمدادات التمنيع اللازمة للبرنامج الموّسع للتمنيع متاحة في مراكز التطعيم في 20 منطقة على الأقل من المناطق ذات الأولوية، بحلول عام 2023. المؤشر الرئيسي للأداء: عدد المناطق ذات الأولوية التي يتحقق فيها التوافر الكامل للمخزونات طوال 12 شهرا ً )انظر أدناه(. الأغراض هي قياسات كمية للأهداف المحددة بإطار زمني. وعادة ما تبدأ بكلمة «زيادة» أو «خفض» أو «تحديد». وللبلدان حرية اختيار أي عدد من الأغراض الخاصة بكل هدف من الأهداف بحيث يمكن تحقيقها واقعيا ًفي غضون الإطار الزمني وباستخدام الميزانية المتاحة. وعادة ما يختار البلد مؤشرات أداء سلسلة إمدادات التمنيع من الإرشادات الخاصة بلوحات متابعة سلسلة إمدادات التمنيع )انظر المورد الإضافي 8 أدناه(. مثال: الغرض رقم 1: زيادة عدد المرافق في المناطق ذات الأولوية الأولى التي تحقق التوافر الكامل للمخزونات6 طوال فترة الاثني عشر شهرا.ً 6 التوافر الكامل للمخزونات )وفقا ًلمؤشرات لوحات متابعة سلسلة إمدادات التمنيع( هو النسبة المئوية لمراكز التخزين التي تتوافر فيها جميع اللقاحات وإمدادات التمنيع التتبعية أو مجموعة مختارة منها توافرا ًتاما ًخلال فترة التزويد الدوري. ويُعرّف التوافر الكامل بأنه عدم نفاد المخزون المتاح في المخزن أو المرفق الصحي في أي وقت خلال تلك الفترة. 3-2-2 المورد الإضافي 8 الإرشادات بشأن لوحات متابعة سلسلة إمدادات التمنيع -dna-stnemucod-tnemeganam-rof-atad/ne/php.xedni/gninehtgnertscsi/gro.12-tenhcet.www draobhsad-no-ecnadiug/sdaolnwod كيفية وضع خطة للتحسين المستمر 33 تصف الاستراتيجيات النهج الذي سيُتّبع لتحقيق الهدف أو الغرض. وعادة ما تجيب الاستراتيجيات عن الأسئلة التي تنشأ عند مواجهة الخيارات أو العقبات، ولهذا السبب، فإن الاستراتيجيات قد تختلف اختلافا ًكبيرا ًوفقا ًللأشخاص المشاركين في المناقشة. فعندما تنشأ الحاجة إلى ثلاجات جديدة مثلاً، هل يكون من الأفضل شراء ثلاجات شمسية أم الاستثمار في إنشاء شبكات صغرى لإمداد المناطق الريفية بالكهرباء؟ وعندما يحتاج العاملون الصحيون إلى التدريب على الصيانة الأساسية للثلاجات، هل يكون من الأفضل من حيث الفّعالية تقديم التدريب لتجديد المعارف؛ أم توفير الإشراف الداعم؛ أم وضع مناهج ملائمة وإدراجها في التدريب السابق للخدمة المعتمد من ِقبل وزارة الصحة والمرتبط بالتقدم في المسار المهني للقوى العاملة المعنية؟ وينبغي أن تُجرى المشاورات مع طيف واسع من أصحاب المصلحة، وليس مع المهنيين في مجال سلسلة إمدادات التمنيع فقط، من أجل تحديد أفضل الخيارات الاستراتيجية. وقد يجد بعض البلدان وفقا ًلحالتها، أنه من الأسهل وضع الاستراتيجيات الخاصة بخطة التحسين المستمر بالاستناد إلى العناصر الستة الأساسية لسلسلة الإمدادات )انظر القسم 1-1(. ويستند نموذج الاستراتيجية الموضح أدناه إلى عنصرين من العناصر الأساسية لسلسلة الإمدادات، ألا وهما التوزيع وتصميم الُنظم لتحسين الأداء العام لسلسلة إمدادات التمنيع. مثال: الاستراتيجية رقم 1: تنفيذ نظام توزيع قائم على الجذب )يخضع لتوجيه الطلب( في سلاسل الإمداد باللقاحات وسلاسل التبريد المزودة بُنظم النقل التي يمكن الاعتماد عليها، بالاستناد إلى فّعالية تصميم الشبكات وتخطيط الطرق. مؤشر الحصائل: عدد المناطق التي لديها نظام توزيع عامل قائم على الجذب بالاستناد إلى فّعالية تصميم الشبكات وتخطيط الطرق في مناطق [ محددة ]. استخدم التوافر والجودة والفّعالية في توجيه خطتك. يُعد اعتماد أغراض سلسلة إمدادات التمنيع المتمثلة في التوافر والجودة والفّعالية في بداية حلقة العمل الخاصة بخطة التحسين المستمر طريقة ممتازة لتركيز الحوار - والخطة الناتجة عنه - على الأمور الأشد أهمية. ويمكن عرض البيانات الخاصة بتقييم الإدارة الفّعالة للقاحات في شكل رسوم بيانية لتوضيح الطريقة التي يلبي )أو لا يلبي( بها أداء سلسلة إمدادات التمنيع الأغراض الثلاثة على نطاق مستويات التوزيع. ويمكن بعد ذلك توجيه مناقشات حلقة العمل إلى تناول مستويات الأداء المنشودة لكل غرض من الأغراض الثلاثة وقياسها كما،ً حيث سيؤدي ذلك بدوره إلى توضيح الاستثمارات اللازمة لتحقيق الأغراض. فمناقشة ما يلزم لضمان جودة اللقاح على مستوى تقديم الخدمات مثلاً سيؤدي إلى مناقشة مؤشرين من مؤشرات لوحات متابعة سلسلة إمدادات التمنيع، وهما: )1( حالة أداء معدات سلسلة التبريد؛ )2( معدل الإنذارات الخاصة بدرجات الحرارة. ويمكن للمشاركين بعد ذلك الاتفاق على الحد الأدنى لمستويات الأداء )مثل التبليغ عن/ تسجيل جميع الوحدات المعطلة في معدات سلسلة التبريد في غضون يومين، وإصلاحها أو تبديلها في غضون خمسة أيام(، ما سيوضح الاستثمارات اللازمة لتسجيل هذه البيانات ورصدها وضمان الامتثال لمستويات الأداء المتفق عليها. نصيحة 43 الخطة التشغيلية السنوية للتحسين المستمر الخطة التشغيلية الخطة التشغيلية هي الجزء من خطة التحسين المستمر الذي يترجم الأهداف والأغراض والاستراتيجيات إلى مجموعة من الأنشطة التي يمكن التكليف بها وإنجازها في إطار فترة 21 شهرا ً)مثل النشاط رقم 1: “قائمة الاحتياجات الوظيفية لنظام إدارة المخزونات لكل مجموعة من المجموعات الرئيسية للمستخدمين”(. ونظرا ًإلى أن التخطيط على مستوى الأنشطة قد يكون ديناميكيا ًوقد يتوقف على عوامل خارجية، فليس من الضروري صياغة أنشطة محددة لما بعد 21-41 شهرا.ً ويوصى بوضع خطة يمكن أن يستخدمها القائمون على إدارة سلسلة إمدادات التمنيع، في شكل يصب في خطط العمل السنوية الحالية للبرنامج الموّسع للتمنيع. وينبغي أن يرتبط كل نشاط بمؤشر قابل للقياس للعملية أو الاستكمال وبالتكلفة المقدرة. كما ينبغي لخطة النشاط أن تحدد أيضا ًهيكل تصريف الشؤون الخاص بالإشراف على التنفيذ )أي أدوار/ مسؤوليات الفريق العامل الوطني المعني باللوجيستيات، والوكالات الشريكة، ومقدمي المساعدة التقنية( والإطار الزمني لمؤشرات الرصد. لضمان فائدة الخطة التشغيلية الخاصة بخطة التحسين المستمر، تُشّجع البلدان على تصميم شكل الخطة خصيصا ً ليتماشى مع احتياجاتها ودمجها في أداة )أدوات( التخطيط السنوي التي يستخدمها البرنامج الموّسع للتمنيع بالفعل. والجدول 4 أدناه يوضح مختلف السيناريوهات والاقتراحات لتصميم خطة التحسين المستمر بحيث يتلاءم شكلها مع احتياجات البلد المعني على أفضل وجه. 3-3-1 3-3 أدرج عملية للرصد وجدولاً زمنيا.ً شددت البلدان على أهمية إدراج جدول زمني للرصد )مثل مواعيد استعراض المؤشرات الرئيسية للأداء ومناقشتها(، وتحديد الأشخاص أو الفريق الذي سيكون مسؤولاً عن جمع المؤشرات الرئيسية للأداء واستعراضها وفقا ًللجدول الزمني. تتضمن فعاليات الشركاء في الخطة التشغيلية. لضمان مسؤولية واعتمادية جميع المساهمين, الجزء التشغيلي من خطة التحسين المستمرة يجب ان تتضمن كلا الفعاليات )ومؤشرات التنفيذ( المدعومة من خطة البرنامج الموسع للتحصين ) والمؤشرات التنفيذية( المدعومة بالمساندة التقنية من الشركاء. نصيحة نصيحة المورد الإضافي 9 نموذج الأنشطة وخطة الرصد (الإرشادات الخاصة بخطة التمنيع الشاملة المتعددة السنوات، صفحة 96) fdp.gne_10.41_BVI_OHW/1/816001/56601/maertstib/siri/tni.ohw.sppa كيفية وضع خطة للتحسين المستمر 53 التكاليف ذات الصلة ومصادر التمويل يتكون القسم المعني بالتخطيط والميزنة في خطة التحسين المستمر من جزأين ، وهما تقدير التكاليف وخطة التمويل. التكلفة المقدرة. ينبغي أن ينص القسم الخاص بالتخطيط والميزنة على تقدير كامل للتكاليف المرتبطة بالأنشطة المدرجة في الجزء التشغيلي والجزء الاستراتيجي من الخطة. وقد ُوضعت أداة لعملية حساب تكلفة خطة التمنيع الشاملة المتعددة السنوات. ونظرا ًإلى أن خطة التحسين المستمر قد ُصّممت لتكون جزءا ًمن خطة التمنيع الشاملة المتعددة السنوات، فإنه يوصى باستخدام أداة حساب التكلفة الخاصة بخطة التمنيع الشاملة المتعددة السنوات بوصفها أحد الموارد الرئيسية. 3-4 المورد الإضافي 01 أداة حساب تكلفة خطة التمنيع الشاملة المتعددة السنوات /ne/pymc/sloot/gnicnanfi/smetsys_semmargorp/noitazinummi/tni.ohw.www تخفيف المخاطرالإجراء المقترحالسيناريو كان فريق البرنامج الموّسع للتمنيع 1 ناجحا ً في استخدام الخطة الحالية لتحسين الإدارة الفّعالة للقاحات في إسناد الأنشطة وقياس التقدم على أساس سنوي. استخدم خطة التحسين المستمر بوصفها الفصل المعني بسلسلة الإمدادات في خطة التمنيع الشاملة المتعددة السنوات وأضف أنشطة خطة التحسين المستمر إلى نموذج خطة العمل الخاصة بأنشطة خطة التمنيع الشاملة المتعددة السنوات. [إضافة الرابط] على الرغم من أن خطة العمل الخاصة بخطة التحسين المستمر ستكون جزءا ً من خطة التمنيع الشاملة المتعددة السنوات، فينبغي بثها على البرنامج الموّسع للتمنيع بأكمله كوثيقة مستقلة. سيتولى الفريق العامل الوطني المعني باللوجيستيات أو آلية أخرى معنية بتنسيق البرنامج الموّسع للتمنيع، مسؤولية تتبع التقدم المُحرز في خطة التحسين المستمر، الذي ينبغي أن يبلّغ البرنامج الموّسع للتمنيع بشأنه كل 21 شهرا،ً حتى وإن كان قسماً من أقسام خطة التمنيع الشاملة المتعددة السنوات. يستخدم البرنامج الموّسع للتمنيع 2 خطة العمل السنوية للبرنامج أو خطة التمنيع الشاملة المتعددة السنوات في إسناد الأنشطة الرامية إلى تحسين سلسلة الإمدادات وتتبعها . الخيار 1: إذا كان وضع خطة التحسين المستمر يُجرى قبل تنقيح خطة العمل السنوية للبرنامج الموّسع للتمنيع أو خطة التمنيع الشاملة المتعددة السنوات بقليل، ينبغي دمج الخطة التشغيلية لخطة التحسين المتسمر في النموذج الخاص بخطة العمل السنوية أو بخطة التمنيع الشاملة المتعددة النوات. الخيار 2: إذا كان توقيت خطة التحسين المستمر لا يسمح بدمجها في خطة العمل السنوية للبرنامج الموّسع للتمنيع أو خطة التمنيع الشاملة المتعددة السنوات، استخدم النموذج الخاص بخطة العمل السنوية أو بخطة التمنيع الشاملة المتعددة السنوات في وضع خطة عمل مستقلة لخطة التحسين المستمر إلى حين بدء دورة التنقيح التالية. احتفظ بأنشطة سلسلة إمدادات التمنيع في قسم واحد من خطة العمل السنوية للبرنامج الموّسع للتمنيع أو خطة التمنيع الشاملة المتعددة السنوات، حيث سيسهل ذلك إجراء الفريق العامل الوطني المعني باللوجيستيات أو آلية التنسيق المعنية للاستعراض السنوي لخطة التحسين المستمر. يحتاج فريق البرنامج الموّسع 3 للتمنيع إلى خطة عمل مستقلة لخطة التحسين المستمر لعدم وجود أدوات أخرى للتخطيط أو لأنها تسهل تتبع دعم الشركاء للأنشطة الخاصة بخطة التحسين المستمر. أضف خطة التحسين المستمر بوصفها القسم المعني بسلسلة الإمدادات في خطة التمنيع الشاملة المتعددة السنوات أو استراتيجية قطاع الصحة، وأضف أنشطة خطة التحسين المستمر إلى نموذج خطة العمل الخاصة بأنشطة خطة التمنيع الشاملة المتعددة السنوات. ضم أحد المهنيين المتخصصين في سلسلة الإمدادات إلى الفريق المعني برصد خطة التمنيع الشاملة المتعددة السنوات لضمان أن الأنشطة الخاصة بسلسلة إمدادات التمنيع مدمجة بالفعل في عموم خطة التمنيع الشاملة المتعددة السنوات. اجمع الأنشطة الخاصة بخطة التحسين المستمر معا ً في خطة التمنيع الشاملة المتعددة السنوات، حيث سيسهل ذلك استخراج الأنشطة الخاصة بسلسلة إمدادات التمنيع عند الاستعراض السنوي لخطة التحسين المستمر. تحديد الشكل الملائم للخطة التشغيلية الخاصة بخطة التحسين المستمرالجدول 4 63 يوصى كجزء من عملية التخطيط والميزنة، ببحث كيفية إجراء ميزنة برنامج التمنيع الخاص ببلدكم، من أجل مواءمة عملية تقدير تكلفة خطة التحسين المستمر مع دورة الميزنة المعتادة. وإذا ما استكملت هذه العملية بمعزل عن عمليات الميزنة الأخرى، فغالبا ًما لن تُعطى الأولوية لتكاليف خطة التحسين المستمر ولا تُغطى. وينبغي لبحث الميزنة أن يجيب عن الأسئلة التالية: • ما هي عملية ميزنة البرنامج الموّسع للتمنيع ومن المسؤول عنها؟ • متى يجري تخصيص الميزانيات؟ سنوياً؟ كل سنتين؟ • هل من الأفضل وضع خطة ميزنة مستقلة لخطة التحسين المستمر أم دمج تكاليف خطة التحسين المستمر في إحدى وثائق الميزنة الموجودة بالفعل؟ • من ينبغي أن يكون على علم بعملية التخطيط والميزنة لخطة التحسين المستمر أو مشاركا ًفيها، ومن ينبغي له استعراض المسّودات للإدلاء بالتعليقات ولاعتمادها؟ خطة التمويل ينبغي أن يشير الجزء من الخطة المتعلق بالتمويل إلى مصادر التمويل المحتملة والتي يمكن الاعتماد عليها لتلك التكاليف والتوقيت المقدر لتوافر الأموال. وسيعتمد عدد قليل من البلدان على مصدر واحد للتمويل لاستمرار الأنشطة. ويُعد تنويع التمويل ضروريا ًلاستدامة أي برنامج أو مؤسسة على المدى الطويل، بما في ذلك سلسلة الإمدادات. وينبغي إدراج الحصول على الدعم العيني والمالي من الجهات المانحة وسائر المؤسسات )مثل مؤسسات القطاع العام( ضمن استراتيجيات جمع الأموال. ومن أجل تحديد المنح والمساهمات المحتملة، ينبغي لأفرقة البرنامج الموّسع للتمنيع أن يضموا الجهات المانحة المشاركة حاليا ًفي البرنامج الموّسع للتمنيع )مثل الشركاء التقنيين، وأعضاء الفريق الاستشاري التقني الوطني المعني بالتمنيع، والوكالات التابعة للأمم المتحدة( إلى القائمة والاستفسار عن ما يرغبون أو يستطيعون تمويله. وخلال هذه المناقشات، كن واضحا ًبشأن نوع الدعم المالي والعيني الذي تحتاج إليه )طباعة أم مكان للاجتماع أم دعم التيسير، أم غير ذلك(، والوقت الذي ستحتاج فيه إلى هذا الدعم، حتى تتمكن هذه الجهات من الاستجابة. فالبلدان المستحقة التي تحتاج إلى شراء معدات سلسلة التبريد مثلاً، يمكنها تحديد التحالف العالمي من أجل اللقاحات والتمنيع كمصدر محتمل للتمويل وتقديم طلب الدعم من المنصة الخاصة بتعظيم كفاءة معدات سلسلة التبريد. ومن أجل جمع الأموال بمزيد من الفّعالية، قد يُفيد التواصل مع سائر البرامج والوزارات التي تتلقى الدعم بالفعل من هذه الجهات المانحة وتقديم طلبات مشتركة. أشرك وزارة المالية مبكرا.ً عادة ما تحقق البلدان التي تُشرك الزملاء من وزارة المالية في عملية التخطيط والميزنة نجاحا ً أكبر في جمع الأموال وتنفيذ خطتها للتحسين المستمر. فوجود موظفي وزارة المالية لا يؤدي إلى المزيد من الدقة في تقدير التكاليف ومصادر التمويل فحسب، بل ويؤدي أيضا ًإلى تقليص الإطار الزمني المحدد للتوقيع على الميزانية وصرف الأموال. نصيحة كيفية وضع خطة للتحسين المستمر 73 4-1 يتمثل أحد أسباب اتخاذ منظمة الصحة العالمية/ اليونيسيف قرار بإعادة استهلال مبادرة الإدارة الفّعالة للقاحات في أن خطط تحسين الإدارة الفّعالة للقاحات نادرا ًما تنفذ. فالنهج الشامل للإدارة الفّعالة للقاحات يعالج بعض أوجه القصور الحرجة التي شابت العملية الأصلية الخاصة بالإدارة الفّعالة للقاحات )انظر المورد الإضافي 11 أدناه(. فهذا النهج يتضمن إنشاء آليات الإدارة التي تدعم دورة التحسين المستمر لسلسلة إمدادات التمنيع، ويُحّسن جودة التخطيط لخطة التحسين المستمر، ويدمج تخطيط سلسلة إمدادات التمنيع وميزنتها في العمليات الوطنية وعمليات الشركاء الأوسع نطاقا ًالخاصة بالتمويل. ولكن ما يكتسي قدرا ًأكبر من الأهمية، هو أن النهج الشامل للإدارة الفّعالة للقاحات يجّسد أهمية إشراك طيف أوسع من أصحاب المصلحة المعنيين من داخل برنامج التمنيع وخارجه والتماس التزامهم بدعم تحسين سلسلة الإمدادات. تعميم خطة التحسين المستمر وصبغها بالصبغة المؤسسية ماذا تتمثل عملية تعميم الخطة وصبغها بالصبغة المؤسسية في إشراك الموظفين العاملين في سلسلة إمدادات التمنيع على جميع مستويات النظام الصحي، والتحدث إليهم بشأن خطة التحسين المستمر، وتوضيح كيف ينبغي استخدامها في توجيه الأنشطة المتعلقة بسلسلة إمدادات التمنيع المدرجة في خطط عملهم، وكيف يمكنهم المساهمة في نجاح البرنامج. وينبغي تبادل نسخ من الخطة وتقديمها إلى المعنيين في وزارة الصحة ووزارة المالية من القادة والموظفين على جميع المستويات، وعلى الجهات الشريكة والجهات المانحة حتى يمكنها دعم التنفيذ عن طريق المساهمة بالخبرات والموارد والمساعدة التقنية حسب الاقتضاء. لماذا تتمثل شكوى متكررة للموظفين الميدانيين في عدم إطلاعهم على نسخة من خطط التحسين التي يعدون مسؤولين عن تنفيذها. ولذا يوصى بإطلاع جميع أصحاب المصلحة الذين ساهموا في وضع خطة التحسين المستمر وجميع الموظفين العاملين على التنفيذ على الخطة أو على ملخصها. كما يلزم أن يفهم الشركاء التقنيون خطة التحسين المستمر حتى يمكنهم المساعدة في تنفيذها والعمل على تكميلها بخططهم. تنفيذ خطة التحسين 4 المستمر ورصدها المورد الإضافي 11 البيان المشترك لمنظمة الصحة العالمية واليونيسيف: تحقيق الغايات الخاصة بالتمنيع من خلال الإطار الشامل للإدارة الفّعالة للقاحات. fdp.lanfi_SJ-MVE/niahc_ylppus/smetsys_semmargorp/noitazinummi/tni.ohw.www 83 4-2 متى بعد أن تعتمد لجنة التنسيق المشتركة بين الوكالات خطة التحسين المستمر رسميا.ً من يعد فريق البرنامج الموّسع للتمنيع )أو مسؤول معين يتمتع بالمصداقية من الفريق العامل الوطني المعني باللوجيستيات أو أي آلية كلفتها بهذه المهمة( مسؤولاً عن بث الخطة على جميع موظفي البرنامج الموّسع للتمنيع وتسليط الضوء على مجالات الخطة التي ستؤثر على موظفي البرنامج الموّسع للتمنيع وسائر العاملين الصحيين والجهات الشريكة والوكالات المعنية بالصحة. المُخرج يحصل جميع الموظفين المعنيين بالتمنيع وبسلسلة الإمدادات على نسخة من خطة التحسين المستمر )كاملة أو ملخصة(. وبعد أن يحصل جميع الموظفين على وثيقة خطة التحسين المستمر ومؤشرات الرصد، ينبغي الإشارة إليها والرجوع إليها على نحو روتيني عند إجراء الإشراف الداعم واجتماعات مديري البرنامج الموّسع للتمنيع. تنفيذ خطة التحسين المستمر ماذا بعد اعتماد خطة التحسين المستمر وبثها، سيلزم دمج الأنشطة والأغراض الخاصة بالخطة وتجسيدها في خطط العمل والميزانيات السنوية التي توضع على الصعيدين الوطني والإقليمي وعلى صعيد المناطق وفي عمليات الاستعراض. كما يجب أن توفّر الموارد المتعهد بها في الوقت المناسب حتى يتمكن الموظفون على جميع المستويات من تنفيذ الأنشطة ومن الحفاظ على الإطار الزمني المحدد للخطة. لماذا يسمح تنفيذ الأنشطة الخاصة بخطة التحسين المستمر لأصحاب المصلحة بتحويل سلسلة الإمدادات إلى وظيفة أكثر فّعالية وكفاءة لبرنامج التمنيع. نظّم حدثا ًللبث الوطني. نظم بعض البلدان أحداثا ًوطنية بنجاح لبث خطة التحسين المستمر، بالتزامن مع الاعتماد الرسمي للخطة من ِقبل الحكومة وسائر أصحاب المصلحة، إلى جانب عقد اجتماعات على الصعيد دون الوطني مع الموظفين الصحيين للمناطق/ الأقاليم وموظفي البرنامج الموّسع للتمنيع. أشرك القوى العاملة على جميع المستويات في إدارة أداء سلسلة إمدادات التمنيع ورصده. ينبغي أن تُبث الخطة الاستراتيجية الخاصة بخطة التحسين المستمر ومؤشراتها على نطاق واسع وأن تُناقش على جميع مستويات نظام التمنيع، وينبغي تشجيع الموظفين على تتبع مؤشرات أداء سلسلة إمدادات التمنيع ورصدها مع إدخالهم للتغييرات على البرنامج. ويمكن للبرامج الموّسعة للتمنيع تقدير “مناصري” التحسين المستمر لسلسلة إمدادات التمنيع وإيجادهم، بتوثيق أفضل الممارسات وقصص النجاح وتبادلها مع المبادرات الوطنية والإقليمية والعالمية ذات الصلة. نصيحة نصيحة كيفية وضع خطة للتحسين المستمر 93 4-3 متى يمكن أن يبدأ التنفيذ بعد وضع الصيغة النهائية للخطة مباشرة، وبدء إجراء بعض الأنشطة قبل ذلك إذا كانت قد اعتُمدت بالفعل. ويتمثل العامل الرئيسي في سرعة التنفيذ في التواصل الواضح والمتكرر مع الموظفين والمديرين المسؤولين عن مختلف الأنشطة، وتوافر القدر الكافي من الموارد والأدوات والدعم لضمان أن الموظفين مجهزين لإجراء عملهم. من في حين أن فريق البرنامج الموّسع للتمنيع مسؤول عن الإشراف اليومي على تنفيذ خطة التحسين المستمر، فإن الفريق العامل الوطني المعني باللوجيستيات مسؤول عن رصد التقدم المُحرز في التنفيذ والمؤشرات الرئيسية للأداء ومواجهة التحديات عند وقوعها. المُخرج ينبغي لفريق إدارة البرنامج الموّسع للتمنيع أن يعقد اجتماعات منتظمة مع الموظفين المعنيين بسلاسل الإمدادات على مستوى الأقاليم/ المناطق لمناقشة التقدم المُحرز في التنفيذ والمسائل المتعلقة بحل المشكلات التي قد تنشأ. رصد التنفيذ والحصائل ماذا ينبغي أن تشمل الخطة التشغيلية السنوية مجموعة من مؤشرات الرصد التي يمكن استخدامها في تتبع التقدم المُحرز في تنفيذ الأنشطة اليومية. وينبغي أن تشمل الخطة الاستراتيجية مجموعة من مؤشرات الأداء الرئيسية التي ينبغي تتبعها على أساس سنوي على الأقل أو وفقا ً لجدول زمني يوضع بالاتفاق مع الفريق العامل الوطني المعني باللوجيستيات أو آلية التنسيق الأخرى المسؤولة. لماذا تُعد مؤشرات الرصد ومؤشرات الأداء الرئيسية طريقة مفيدة لإخضاع الموظفين والشركاء والخبراء الاستشاريين للمساءلة بشأن جودة عملهم وملاءمة توقيته. ويمكن استخدام هذه المؤشرات أيضا ًفي رفع التقارير بشأن التقدم المُحرز إلى الجهات المانحة، في التقييم المشترك للتحالف العالمي من أجل اللقاحات والتمنيع وآليات التبليغ الخاصة بسائر الجهات المانحة. متى في الحالات المثلى، يُبلغ عن تنفيذ خطة التحسين المستمر في اجتماعات منتظمة للفريق العامل الوطني المعني باللوجيستيات )أو ما شابه( على أساس شهري أو فصلي. وإذا تعذر ذلك، ينبغي لهذا الفريق أن ينظم اجتماعا ً واحدا ًعلى الأقل سنويا ً للاستعراض الموّسع للتقدم في نهاية العام وتحديد الأنشطة الخاصة بالعام الثاني. من يُعد الفريق العامل الوطني المعني باللوجيستيات مسؤولاً عن رصد أداء سلسلة إمدادات التمنيع عن طريق المؤشرات الرئيسية للأداء، ويُعد البرنامج الموّسع للتمنيع مسؤولاً عن إدارة تنفيذ خطة التحسين المستمر ورصده. المُخرج ينبغي إطلاع الفريق العامل الوطني المعني باللوجيستيات على التقارير أو العروض الخاصة بالرصد الروتيني التي تبين التقدم المُحرز وفقا ً للمؤشرات المتفق عليها في القسم المعني بالرصد والتقييم في خطة التحسين. 04 5 يتطلب تنفيذ الأنشطة الرامية إلى تحسين سلسلة إمدادات التمنيع واستخدام قياسات الأداء في تحسين الإدارة، أن يفهم جميع موظفي البرنامج الموّسع للتمنيع المعايير والإجراءات وأفضل الممارسات المتعلقة بسلسلة إمدادات التمنيع. ويجب أن يتمتع مديرو البرنامج الموّسع للتمنيع وسلسلة إمدادات التمنيع بالقدرة على تصميم نُظم سلاسل إمدادات التمنيع الجديدة، واختيار تكنولوجيات سلسلة التبريد الجديدة، واعتماد منظور تعزيز الُنظم الصحية من أجل تحسين أداء الُنظم واستدامته. ويتطلب هذا الكادر القيادي مهارات متقدمة وشاملة لإدارة التغيير واعتماد الابتكار. ويجب أن يكون المديرون على المستوى المتوسط قادرين على التعامل مع العمليات المعقدة مثل التخطيط والتنبؤ والميزنة والإشراف على نطاق سلسلة إمدادات التمنيع. ويحتاج العاملون الصحيون في الخطوط الأمامية إلى مهارات وقدرات ودعم لمساعدتهم على تشخيص ضعف أداء سلسلة إمدادات التمنيع وحل المشكلات عند نشأتها. والحاجة ملّحة في المناطق النائية وتلك التي يصعب الوصول إليها )ولاسيما في ظروف الطوارئ( التي يكون فيها العاملون في الخطوط الأمامية مستقلين إلى حد كبير؛ ومع ذلك فالحاجة قائمة في جميع الأماكن التي تعتمد فيها البرامج على المهنيين المتحمسين الذين لديهم دوافع ذاتية للسعي إلى التحّسن المستمر. والنهج الشامل للإدارة الفّعالة للقاحات يتيح الفرصة لوضع تنمية القدرات وإضفاء الطابع المهني على سلسلة إمدادات التمنيع في صميم عملية تحسين سلسلة إمدادات التمنيع. وتُشّجع البرامج الموّسعة للتمنيع على إشراك مؤسسات التدريب الوطنية والإقليمية - بما في ذلك تلك التي تجيد استخدام تكنولوجيا المعلومات والاتصالات من أجل الصحة - في عملية الإدارة الفّعالة للقاحات وتكييف المعايير الخاصة بالإدارة الفّعالة للقاحات في مناهج ديناميكية للتعلم ووضع نُظم قوية لرصد وتقييم خطة التحسين المستمر وتنفيذها. ويمثل التخطيط للتحسين عملية مستمرة تتطلب استثمارا ًمستمرا ًفي الوقت والموظفين والتخطيط. ولن تُحل جميع مشكلات سلسلة الإمدادات في دورة واحدة، وستنشأ مشكلات وتحديات جديدة مع استمرار برامج التمنيع في النمو والتغّير. ولذا فإن مفهوم التحّسن المستمر لازم لضمان أداء سلسلة الإمدادات عبر الزمن. التعلّم والتحّسن المستمران أنشئ تحالفا ًلداعمي سلسلة الإمدادات. يمكن للبلدان أن تترجم احتياجات البرنامج إلى برنامج قوي ومستمر للتعلم بمطالبة المؤسسات الوطنية والإقليمية المعنية بتنمية القدرات - وشبكاتها الأكاديمية - بأن تدعم البرنامج الموّسع للتمنيع وسلسلة الإمدادات الخاصة به. نصيحة كيفية وضع خطة للتحسين المستمر 14 42