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Photo: GAVI/2015/Phil Moore

Vaccine cold chain is the beginning, not the end, for rural healthcare

Countries around the world are now gearing up for mass immunization against Covid-19. WHO released guidelines in late 2020 for national authorities to manage the process of deployment, implementation, and monitoring  vaccines, which  included a prioritization roadmap that would help countries inform their immunization strategy, and a framework for the allocation and prioritization of vaccination for certain target populations. It also provides six core principles to guide vaccine distribution, among them global equity.  

But equity cannot exist without energy for all. Mass immunization only succeeds with reliable power supply, both at the transportation stage as well as for last-mile delivery. In countries and regions that face poor power supply, the storage and transport of these vaccines at optimal temperatures will be a massive challenge. COVID-19 has already brought about a paradigm shift in the way critical public services are delivered, especially health care. However, while vaccine development was treated with much urgency, and rightly so, the scale and robustness of cold chain infrastructure for deployment at the country level has not been fully thought through. 

Effective cold chain: the first domino to universal healthcare

A cold chain consists of a sequence of refrigerated production, storage, and transportation infrastructure that can maintain a desired temperature range from start to finish, and is used to preserve and extend the shelf life of products. In regions where access to electricity is unreliable, decentralized solutions, like solar powered refrigerators, mounted on trucks or at health facilities, can provide a quick and affordable solution that will have far-reaching implications, not only for COVID-19 vaccine deployment, but for rural health care services as a whole in the long term.

For instance, a 2018 report by SEforALL stated that an estimated 1.5 million people die annually from vaccine-preventable diseases. The WHO estimates that nearly 50 percent of freeze-dried and 25 percent of liquid vaccines are wasted largely because of cold chain disruptions. In India, close to 20 percent of all temperature-sensitive health care products arrive in a damaged or degraded condition because of broken or insufficient cold chains. The distribution of the COVID-19 vaccine, which requires temperatures ranging from 2 degrees C to - 90 degrees C, could provide the impetus for low-access countries to deploy decentralized solar at scale to upgrade and improve public health care infrastructure and thereby, services.

Many countries have already started vaccine distribution, or are in planning stages for the same, but many infrastructural components need to be addressed urgently. According to Efficiency for Access’ 2020 Off-Grid Appliance Market Survey, in order to deliver the COVID-19 vaccine to 60-70 percent of the world’s population (4.7-5.5 billion people), new cold chain equipment will need to be rolled out on a massive scale.

“A critical component of vaccine rollout is storage, which requires high-quality cold chain equipment. We must ensure a robust supply and cold chain system to store and move both the COVID-19 vaccine and life-saving immunisations from the national level to delivery points at primary health centres and outreach sites,” said Dr. Karan Sagar, Gavi’s Head of Health System and Immunisation Strengthening, in an interview with CLASP.

The 2020 survey found vaccine refrigerators as the most essential devices for health care delivery underscoring the perception that vaccine cold chains are the foundation for healthcare provision in underserved areas. 

Are countries ready?

WHO analysis based on a Vaccine Readiness Assessment Tool of the 47 countries in the WHO African Region found that the region is largely unprepared for what would be the continent’s largest ever immunization drive, with an average score of 33 percent readiness for a COVID-19 vaccine roll-out, which is well below the desired benchmark of 80 percent. The tool provides a roadmap for countries to plan for COVID-19 vaccine deployment, covering 10 key areas such as planning and coordination; resources and funding; vaccine regulations; service delivery; training and supervision; monitoring and evaluation; vaccine logistics; vaccine safety and surveillance; and communications and community engagement.

In a press statement, Dr Matshidiso Moeti, WHO Regional Director for Africa, said, “The largest immunisation drive in Africa’s history is right around the corner and African governments must urgently ramp up readiness. Planning and preparation will make or break this unprecedented endeavour and we need active leadership and engagement from the highest levels of government with solid, comprehensive national coordination plans and systems put in place”.

The analysis found that less than half of the African countries assessed had identified priority populations for vaccination and have plans in place to reach them; only 44 percent have coordination structures in place; less than a fourth have plans for resources and funding; less than a fifth have data collection and monitoring tools ready; and only 12 percent have outreach and communications plans for engagement at the community level.

India has kicked off the world’s largest vaccination drive. Administering the vaccine to 1.3 billion people will be no small feat. The health ministry has already announced the country’s plans for this drive, including 29,000 cold chain points, 240 walk-in coolers, 70 walk-in freezers, 45,000 ice-lined refrigerators, 41,000 deep freezers, and 300 solar refrigerators. However, a lot more will need to be done to ensure that the equipment works reliably, power supply is accessible, and staff are adequately trained.

Focus on medical devices and long-term solutions

Moving beyond cooling, other critical services like testing and diagnostics, surgeries and other procedures, and life-saving equipment like ventilators and baby warmers also require access to reliable power. Now is the time for governments to enhance health care infrastructure in a holistic manner. Medical devices powered by decentralized renewable energy technologies, improvements in the efficiency of medical equipment, and business model innovation in the health sector will also gain greater importance.

Takehiro Kawahara from Bloomberg New Energy Finance in a recent Power for All podcast speaks of an example from the Rural Electrification Agency in Nigeria where several health care facilities have been electrified via solar hybrid mini-grids as a response to COVID-19, and predicts that we will see more of these in the coming year. In India, portable, solar-powered COVID testing facilities were set up almost overnight to allow for rapid sample collection.

On the efficiency side, a focus on energy efficiency for medical devices and equipment will lower the overall cost of health care services by reducing the size of the energy system required to deliver basic health services. 

Partnerships for success

The global development community is also stepping up engagement to support country level plans towards ensuring efficient and effective COVID-19 vaccine roll-out.  In South Sudan, the least electrified country in the world, where temperatures frequently exceed 40°C, more than 700 health facilities have been equipped by  the United Nations Children's Fund (UNICEF) with solar-powered fridges - about 50 percent of all facilities in that nation. In 2021, through Gavi’s cold chain equipment optimization platform (CCEOP), UNICEF expects the deployment of 85,000 solar fridges around the world. In Rwanda, the government has launched the new African Centre of Excellence for Sustainable Cooling and Cold Chain (ACES) to improve cold-chains for vaccine logistics.

Elsewhere in Zambia, Differ Group, an off-grid solar company is providing electricity for LED lighting, charging of equipment and powering vaccine fridges to health posts under the United Nations Development Programme’s (UNDP) Solar4Health progamme. In Uganda, through its Beyond the Grid Initiative, USAID-Power Africa has deployed PV systems in 135 rural health facilities ensuring safe storage of vaccines. In Nigeria, Dulas has been contracted to supply 780 solar-powered vaccine refrigerators to hospitals to enable healthcare institutions to better store vaccines and guarantee a better quality of care for their patients.

In India, health care and energy sector organizations came together last year, united in the objective of solarizing close to 40,000 public health facilities that lack electricity, working with the central and state governments to implement an Action Plan to make this happen.

A paper by UNECA concludes that with strong collaboration between governments, the private sector, the international development community, and financiers, solar energy can play a critical role in accelerating the post-COVID-19 recovery in Africa.  As nations consider economic packages to jumpstart their economies post-COVID-19, energy access ought to be a central consideration and a robust off-grid cold chain infrastructure can play a key role in building back stronger and more resilient health systems.

Hon. Dr. Bachir Ismael Ouedraogo, Burkina Faso’s Minister of Energy, speaking at the Eleventh Session of the IRENA Assembly, said that “COVID-19 provides us with an opportunity to scale up renewable energy solutions, especially with the continuously reduced costs of these technologies. This is good news for countries like Burkina Faso. That way, more renewable energy can be deployed, connect it to healthcare facilities, and save lives.”

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