Citation
Supply chain analysis for a thermostable PPR vaccine in Karamoja, Uganda

Material Information

Title:
Supply chain analysis for a thermostable PPR vaccine in Karamoja, Uganda
Creator:
Acosta, Daniel ( author )
Language:
English
Physical Description:
1 online resource (46 pages) : illustrations, maps ;

Subjects

Subjects / Keywords:
Sustainable Development Practice field practicum report, M.D.P
Genre:
government publication (state, provincial, terriorial, dependent) ( marcgt )
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )
Project in Lieu of Thesis ( local )

Notes

Abstract:
This project report summarizes the supply chain analysis for the thermostable Peste des Petits Ruminants (PPR) vaccine in the Karamoja subregion in Uganda. This analysis is part of a USAID funded research project currently being conducted by the University of Florida through its Feed the Future Innovation Lab for Livestock Systems and Tufts University in Kenya and Uganda. In Uganda, the project is implemented in collaboration with Mercy Corps, Ministry of Agriculture, Animal Industries and Fisheries (MAAIF), and Makerere University. Project activities, including vaccination, are implemented in three districts of the Karamoja subregion: Amudat, Kotido, and Kaabong. The information collected during the supply chain analysis will help the project understand in detail all the costs associated with vaccination. In addition, data gathered is used to design inventory policies and the selection of key locations for storage (called vaccine hubs) that reduce risk of overstocking and understocking while being cost effective. This also allowed the project to further understand the role of Community Animal Health Workers (CAHW's) in vaccination activities. The scope of this research takes into consideration the portion of the supply chain that starts in the thermostable PPR vaccine production center going downstream to the livestock keeper who buys the vaccine in the three selected districts of Karamoja.
Bibliography:
Includes bibliographical references.
General Note:
Major departments: Latin American Studies, African Studies.
General Note:
Major: Sustainable Development Practice.
General Note:
Committee member: Hendrickx, Saskia.
General Note:
Committee member: McKune, Sarah.
General Note:
The MDP Program is administered jointly by the Center for Latin American Studies and the Center for African Studies.
Statement of Responsibility:
by Daniel Acosta.

Record Information

Source Institution:
University of Florida
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
037467956 ( ALEPH )
Classification:
LD1780.1 2019 ( lcc )

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Feed the Future Innovation Lab for Livestock Systems Peste des Petits Ruminants Vaccine Associate Award Supply Chain Analysis for a T hermostable PPR V accine in Karamoja, Uganda Field Practicum Report Presented by: Daniel Acosta Committe e: Saskia Hendrickx , Dr. Sarah McKune

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2 Recommended Citation Acosta, D. 2019. Supply Chain Analysis for a Thermostable PPR Vaccine in Karamoja, Uganda Field Practicum Report. Gainesville, FL, USA: Feed the Future Innovation Lab for Livestock Systems. Essential Bibliographic Information Leader with Associates Cooperative Agreement Award No. AID OAAL 15 00003 Sponsored by the USAID Bureau for Food Security Sustainably intensifying smallholder livestock systems to improve human nu trition, health, and incomes Disclaimer This report is made possible by the generous support of the American people through the United States Agency for International Development (USAID) and its Feed the Future Innovation Lab for Livestock Systems managed by the University of Florida and the International Livestock Research Institute. The contents are the responsibility of the University of Florida and do not necessarily reflect the views of USAID or the United States Government.

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3 Table of Contents Acronyms ............................................................................................................................................................ 6 Glossary ............................................................................................................................................................... 6 Introduction, Scope and Clarificati ons ........................................................................................................... 7 Objectives ........................................................................................................................................................... 8 Methodology ....................................................................................................................................................... 8 KAABONG DISTRICT .......................................................................................................................................................................... 9 AMUDAT DISTRICT ........................................................................................................................................................................... 10 KOTIDO DISTRICT ............................................................................................................................................................................ 11 MOROTO............................................................................................................................................................................................. 12 KAMPALA/ENTEBBE ....................................................................................................................................................................... 13 Results................................................................................................................................................................ 13 THE SUPPLY CHAIN .......................................................................................................................................................................... 13 STORAGE CAPACITY: COLD CHAIN ............................................................................................................................................... 15 LEVEL 1: PRODUCTION, TRANSPORTATION AND STORAGE IN KAMPALA ............................................................................ 15 LEVEL 2: TRANSPORTATION AND STORAGE IN MOROTO ........................................................................................................ 16 LEVEL 3: REFRIGERATION AT OTHER DISTRICTS ...................................................................................................................... 17 Advantages: .................................................................................................................................................................................. 17 Disadvantages .............................................................................................................................................................................. 18 Sustainability for other thermostable vaccines ....................................................................................................................... 18 LEVEL 4: COMMUNITY ANIMAL HEALTH WORKERS PROCURE VACCI NES AND VACCINATE LIVESTOCK ....................... 18 ASSOCIATED COSTS AT EVERY LEVEL ......................................................................................................................................... 19 Level 1 ........................................................................................................................................................................................... 19 L evel 2 ........................................................................................................................................................................................... 20 Level 3 ........................................................................................................................................................................................... 22 Depreciation of vehicles ............................................................................................................................................................ 23 Fuel Consumption ...................................................................................................................................................................... 23 Depreciation of refrigerators ..................................................................................................................................................... 25 Level 4 ........................................................................................................................................................................................... 26 COST OF NON-THERMOSTABLE VA CCINES ................................................................................................................................. 26 COST SUMMARY ................................................................................................................................................................................. 27 Comparing costs with non-thermostable vaccines ................................................................................................................ 27 HUB SELECTION AND INVENTORY POLICY ................................................................................................................................ 29 Amudat .......................................................................................................................................................................................... 31 Kotido ........................................................................................................................................................................................... 32 Kaabon g ........................................................................................................................................................................................ 33 CHALLENGES AND OPPORTUNITIES WITH COMMUNITY ANIMAL HEALTH WORKERS ...................................................... 34 OTHER THERMOSTABLE VACCINES: CONSIDERATIONS FOR A MARKET BASED APPROACH (AN OVERVIEW) ............. 35 Conclusion ........................................................................................................................................................ 36 Final Reflection ................................................................................................................................................ 36 Acknowledgments ........................................................................................................................................... 37

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4 Bibliography ...................................................................................................................................................... 38 Annex: Instruments ......................................................................................................................................... 39 DATA COLLECTION BE FORE VACCINATION: COMMUNITY ANIMAL HEALTH WORKER ................................................... 39 Information needed .................................................................................................................................................................... 39 FOCUS GROUP DISCUSSIONS WITH CAHW ................................................................................................................................. 39 DATA COLLECTION BEFORE VAC CINATION: LIVESTOCK KEEPERS ....................................................................................... 40 Information needed .................................................................................................................................................................... 40 FOCUS GROUP DISCUSSIONS WITH LIVESTOCK OWNERS ........................................................................................................ 41 DATA COLLECTION BEFORE VACCINATION: VETERINARY STORES ...................................................................................... 41 Information needed .................................................................................................................................................................... 41 STRUCTURED INTERVIEW FOR HUB OWNERS. ............................................................................................................................ 42 DATA COLLECTION BEFORE VACCINATION: KAMPALA STORAGE ........................................................................................ 43 Information needed .................................................................................................................................................................... 43 STRUCTURED INTERVIEW FOR MAAIF OFFICIAL IN KAMPALA .............................................................................................. 43 DATA COLLECTION BEFORE VACCINATION: MOROTO STOR AGE.......................................................................................... 44 Information needed .................................................................................................................................................................... 44 STRUCTURED INTERVIEW FOR MAAIF OFFICIAL IN MOROTO ............................................................................................... 45 Lists of Figures Figure 1 Map of Kaabong District with Refrigerated Points ...................................................................... 9 Figure 2 Map of Amudat with Refrigeration Points ................................................................................... 10 Figure 3 Map of Kotido with Refrigeration Points ..................................................................................... 11 Figure 4 Thermostat showing the temperature 9 10C .............................................................................. 15 Figure 5 Outdated Bitzer Cooling System .................................................................................................... 15 Figure 6 St orage of Vaccines .......................................................................................................................... 15 Figure 7 Refrigerator at KV ........................................................................................................................... 17 Figure 8 Refrigerators at C&D Lab ............................................................................................................... 17 Figure 9 Map of Karamoja with Refrigeration Points ................................................................................ 30 Lists of Tables Table 1 I nterviews Conducted in Loyoro, Kaabong Town Council, and Kalapata Sub Counties ...... 10 Table 2 Interviews C onducted in Loroo and Amudat Town Council Sub Counties ............................ 11 Table 3 Interviews Conducted in Nakapelimoru, Kotido Town Council, and Panyangara Sub counties .............................................................................................................................................................. 12 Table 4 Cost per level with cold chain ending at district level (Option 1) .............................................. 27 Table 5 Cost per level with cold chain ending in Moroto (Option 2) ..................................................... 27 Table 6 Cost per dose ...................................................................................................................................... 27 Table 7 Costs using nonthermostable vaccines ......................................................................................... 28 Table 8 Cost per dose of nonthermostable vaccines ................................................................................ 28 Table 9 Comparison of percentages of logistical cost with different approaches .................................. 28 Table 10 Cost comparison by approach ....................................................................................................... 28 Table 11 Inventory Policy for Amudat for the first two weeks ................................................................ 31 Table 12 Inventory Policy for Amudat after week two .............................................................................. 32

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5 Table 13 Inventory Policy for Kotido for the first two weeks .................................................................. 33 Table 14 Inventory Policy for Kotido after week two ............................................................................... 33 Table 15 Inventory Policy for Kaabong for the first two weeks .............................................................. 34 Table 16 Inventory Policy for Kaabong after week two ............................................................................ 34

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6 Acronyms CAHW Community Anim al Health Worker C&D Cooperation and Development NonGovernmental Organization DVO District Veterinary Officer FGD Focus Group Discussion FIFO First In First Out JICAHWA Jie Community Animal Health Workers’ Association. KVL Karamoja Veterinary Lab kW h Kilo Watt Hours MAAIF Ministry of Agriculture, Animal Industries, and Fisheries MC Mercy Corps NGO Non Governmental Organization PPR Peste des Petits Ruminants TC Town Council UGX Ugandan Shillings USD United States Dollars VO Veterinary Officer Gl ossary Cold chain: A continuous series of refrigerated storage and distribution system. Also referred as a temperature controlled supply chain. Community Animal Health Workers: Members of the community that have received basic trainings in animal healthca re, like vaccination. First In First Out (FIFO): An inventory method in which goods that are obtained first, are the first to be sold. Hub: A central place where an activity takes place, and i n this context, storage hubs are storage points at the S ubcounty level. Inventory Policy: The guidelines to control inventory in terms of cost, losses, and shortages. Supply chain: The processes that take part in the production and distribution of goods. Thermostable vaccine: A vaccine that can be outside of the cold chain without risking spoilage for a determined amount of time.

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7 Introduction, Scope and Clarifications This project report summarizes the supply chain analysis for the thermostable Peste des Petits Ruminants (PPR) vaccine in the Karamoja subregion i n Uganda. This analysis is part of a USAID funded research project currently being conducted by the University of Florida through its Feed the Future Innovation Lab for Livestock Systems and Tufts University in Kenya and Uganda. In Uganda, the project is i mplemented in collaboration with Mercy Corps, Ministry of Agriculture, Animal Industries and Fisheries (MAAIF), and Makerere University. Project activities, including vaccination, are implemented in three districts of the Karamoja subregion: Amudat, Kotido, and Kaabong. The information collected during the supply chain analysis will help the project understand in detail all the costs associated with vaccination. In addition, data gathered is used to design inventory policies and the selection of key locati ons for storage (called vaccine hubs) that reduce risk of overstocking and understocking while being cost effective. This also allowed the project to further understand the role of Community Animal Health Workers (CAHW’s) in vaccination activities. The sco pe of this research takes into consideration the portion of the supply chain that starts in the thermostable PPR vaccine production center going downstream to the livestock keeper who buys the vaccine in the three selected districts of Karamoja. It is imp ortant to highlight that the information gathered can be used to further analyze the sustainability of other thermostable livestock vaccines if they were to be introduced into the market. The following considerations were made in this project report: Numbe r of PPR vaccines allocated to each district as follows: Amudat (250,000), Kotido (162,500), and Kaabong (87,500). Of the districts mention above, activities will focus on the following sub counties: Loroo in Amudat district, Nakapelimoru in Kotido distri ct and Loyoro in Kaabong district. Cooling equipment performing within factory guidelines thresholds. The thermostable vaccine remains viable for use up to four weeks outside the cold chain Salaries paid to other employees who are not civil servants estim ated based on market average in August 2018. Vials of thermostable vaccine will have the same dimensions as the vials for the conventional vaccine. USD $1 = 3,800 Ugandan Shillings. Flights with small airplanes are possible within some districts of Karamoja, however , due to their high cost and limited availability they are not considered for this project. PPR vaccination strategy is based on targeted vaccination based on epidemiological assessments, geared towards containment and achieving a 90% seroconve rsion rate.

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8 Objectives 1) Assessment of the logistical perspective of the vaccination strategy for PPR. Provide a diagnostic of the logistical challenges and ways to improve them for further livestock vaccination programs in the Karamoja . 2) Enhance understand ing of the role of community animal health workers (CAHWs) in the vaccination program. Determine the sustainability of CAHWs in low income settings where there are financial constrictions . 3) Identify constraints in the supply chain. Identify possible bottlenecks, measure lead time in different levels of the supply chain, determine optimal inventory levels and economic order quantities. Methodology Throughout June, July and August of 2018, a series of interviews, focus group discussions, and assessments wer e done in various regions of Uganda with different stakeholders active in the process of vaccination and as providers of veterinary services. There were two different groups of people interviewed during the process, CAHW’s and Livestock Keepers. The reason behind this selection is that as objective 2 states that we want to explore the role of CAHW’s within the community, so having semi structured interviews with CAHW’s separate from Livestock Keepers allowed me to address questions about the working relationship between both groups. These data collection methods were selected as they are the most appropriate given the context, time constraints, and the nature of the data being collected. The objective of the semi structured interviews varied depending on the group interviewed . In the case of CAHW’s, more focus was placed on the process of vaccination and treatment in general of livestock, more concisely: working conditions, lead times, incentives, and constraints. For livestock keepers: knowledge of vaccines , willingness to pay (WTP), access to vaccines, and perception of the work being done by CAHW’s. The following tables and lists show in detail the places, dates, and people involved in the data collection process. The places are: Kaabong District Amudat District Kotido District Moroto Kampala/Entebbe

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9 Kaabong District Figure 1 Map of Kaabong District with Refrigerated P oints Kaabong District is in the most northern part of the Karamoja region, and it shares border s with both S outh Sudan and Kenya. This district is the largest in area of all the districts in this project, however, it is likely to receive the least amount of vaccines. The reason fo r this is that the disease is more of a concern in the other selected districts. Be sides sharing these two borders, this district also has one of the most famous national parks of Africa, Kidepo National Park. Loyoro Subcounty is located in the southern part of the district, and often pastoralist move to the south into Kotido district. Kaabong Town Council (TC) is where the main town of this district is located. This small town is similar to other district capitals, as it has some governmental offices as well as NGO field offices. Kalapata S ubcounty is in the northeastern part of the d istrict, in the border with Kenya.

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10 Field Work Dates : 0309 July 2018 Table 1 Interviews Conducted in Loyoro, Kaabong Town Council, and Kalapata Sub Counties Amudat District Figure 2 Map of Amudat with R efrigeration Points Amudat is located in the southern part of Karamoja, and is culturally different from the other selected districts, which are all populated by Karamojong people. The people of Amudat is Pokot, which has a different language and a history of confrontation with the Karamojong. This is probably the district with most need for intervention, as livestock concentration is high and as they also share Type of Interview Number of Interviewees Number of Interviews F ocus Group Discussions with CAHW 14 3 Focus Group Discussions with Livestock Keepers 8 2 Interview with Veterinary Shop Owner 0 0 Interview with District Veterinary Officers 1 1

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11 a border with Kenya, movement in and out of the district towards Kenya is very common, even done daily by pastoralist living in the most eastern sub counties. Field Work Dates : 1218 July 2018 Table 2 Interviews Conducted in Loroo and Amudat Town Council Sub Counties Kotido District Figure 3 Map of Kotido with R efrigeration Points Type of Interview Number of Interviewees Number of Inte rviews Focus Group Discussions with CAHW 11 2 Focus Group Discussions with Livestock Keepers 15 3 Interview with Veterinary Shop Owner 1 1 Interview with Veterinary Officers 1 2

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12 Kotido district, which is located north of Moroto, and South of Kaabong could potentially play an important role in the project as pastoralist from Kaabong often move south into Kotido following the rain pattern. Distribution of vaccine s might be at a larger scale in Kotido depending on the timeframe on which they are carried out. It is important to note that rains can also affect the state of the roa ds from Moroto to Kotido, so proper inventory management would be crucial in Kotido, as they might be cut off due to heavy rains. All this must be considered when the final schedule for vaccination is released. Field Work Dates : 2327 July 2018 Table 3 Interviews Conducted in Nakapelimoru, Kotido Town Council, and Panyangara Sub coun ties Moroto Field Work Dates : June 07 July 31, 2018 Interviews and Meetings with: • Manager of C&D NGO Lab : Manages the storage and offices, this interview allowed us to estimate the cost of storage at Mo roto. • Lab technician for C&D and Karamoja Veterinary Lab : Works as the acting lab technician and is the record keeper, which allowed us to understand the process better. • District Veterinary Officer , who know the challenges and resources the region has. • Lo gistics Specialists from Mercy Corps, who has worked for years the logistical area of MC, enabling us to calculate costs of transportation within the Karamoja region more accurately. • Two veterinary shop owners in Moroto, which help us quantify and analyze if privatizing storage was feasible (it was not). Type of Interview Number of Interviewees Number of Interviews Focus Group Discussions with CAHW 18 3 Focus Group Discussions with Livestock Keepers 18 3 Interview with Veterinary Shop Owner 2 2 Interview with Veterinary Office rs 1 1 Interview with District Veterinary Officers 1 1

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13 Kampala/Entebbe Field Work Dates : July 31 – Aug 02 2018 Interviews with: • Karamoja Veterinary Lab Manage r , manages the KVL, has vas t experience with vaccination programs. • Storage Manager in Kampala, who manages the central store in Kampala for vaccines that are distributed around the whole country. Results This section will showcase the results of the study by providing the possible viable options for distribution identified for thermostable PPR vaccine s . Detailed cost calculations and recommended hub selection, with their respective inventory policies , are also covered within the result s . Lastly, the result s section will include an assessment of the challenges and opportunities of CAHWs in the districts of Amudat, Kaabong, and Kotido. The Supply Chain Within the scope of the project, we considered two main distribution options suitable for Karamoja: 1) Maintaining a cold chain as far as district level: 2) Maintaining the cold chain up to a central location ( Moroto) in the Karamoja subregion and distribute to other districts from here out of the cold chain. Both approaches are suitable, however, there are certain variables that need to be taken into consideration, as they can affect the overall performance of the supply chain. The variables for each option are illustrated and discussed in this order: Option 1: Level 1: Production, Transport to Entebbe, Transport to Kampala, Storage in Kampala Level 2: Transport to Moroto, Storage in Moroto Level 3: Transport from Moroto to district Vet Officer, Storage at District Office, Transport from district officer to drug shop with or without refrigerator Level 4: CAHW’s procure vaccines, vaccination fee (paid to Community Animal Health Workers) Option 2: Level 1: Pro duction, Transport to Entebbe, Transport to Kampala, Storage in Kampala Level 2: Transport to Moroto, Storage in Moroto Level 3: Transport from Moroto to drug shop, no refrigerator needed. Level 4: CAHW’s procure vaccines, vaccination fee (paid to Communi ty Animal Health Workers)

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14 Option 1: Maintaining cold chain up to district level Option 2: Maintaining cold chain up to central location (Moroto).

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15 Storage Capacity: Cold Chain Level 1: Production, Transportation and Storage in Kampala Transportation from production center up to the central storage in Kampala is done using refrigerated vehicles and cool boxes, ensuring the cold chain is maintained. In Kampala, the official livestock vaccine storage facility consists in a cold room, which is 4 meters in length, 4 meters in width, and 3.5 meters in height. The storage facility is in an area where power outages are very rare, and when they do occur, the area is prioritized to be reconnected as soon as possible. This is important as the facility d oes not have a working generator. Cold room equipment is outdated, and the average temperature the cold room has is 9 10C, which is not recommended for the storage of vaccines (2 8C). According to the storage manager, the equipment is to be upgraded in t he by the end of 2018. Photographic record of the Assessment: Figure 4 Thermostat showing the temperature 9 -10C Figure 5 Outdated Bitzer Cooling System Figure 6 Stora ge of Vaccines

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16 Level 2: Transportation and Storage in Moroto There are several transportations methods that are used to move vaccines from the storage facility in Kampala to Karamoja, which are: 1) A District Veterinary Officer picks up vaccine and t akes them back using cool boxes in his vehicle. 2) MAAIF sends vaccines to the District Veterinary Offices using a refrigerated vehicle. 3) A n NGO (Mercy Corps for the current research project) picks up the vaccine in Kampala in cool boxes and transports them t o Moroto. 4) Courier using public transportation between Kampala and Moroto. Ideally, using a refrigerated vehicle utilized to maximum capacity should be the standard practice, as this would foster sustainability and decrease the dependency of government i ntervention in vaccinations. However, this method is the less commonly used as the refrigerated vehicle is rarely used to its maximum capacity increasing the overall costs. This makes the option of a courier using public transportation a more suitable opti on, however, some contingencies should be put in place in case their unexpected events cause a significant delay. The use of NGO vehicles as couriers could also be implemented, however this is not sustainable and fosters dependency on foreign intervention. Once in Moroto, the vaccines are stored either in the Karamoja Veterinary Lab (District Lab) and/or the Cooperation and Development Lab (NGO Lab). Both labs are equipped with various freezers and refrigerators as well as proper backup generators, both so lar and diesel powered. An alternative storage option in Moroto that was explored are the various Veterinary Drug Shops, however, they do not have enough storage capacity to hold more than 25,000 doses each and they do not possess generators (electrical gr id is highly unreliable). Therefore, this is not a suitable option as compared to the other 2 storage facilities. For option 2, the cold chain ends in Moroto, either at the Karamoja Veterinary Lab and/or in the Cooperation and Development Lab. This is probably the most convenient course of action for the PPR eradication strategy using a thermostable vaccine, as transportation between districts is manageable in a short period of time.

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17 Figure 7 Refrigerator at KV Figure 8 Refrigerators at C&D Lab Level 3: Refrigeration at Other Districts Option 1 Option 2 Refrigeration outside of Moroto is not ne cessary for Option 2, however, there are certain advantages/disadvantages that refrigeration at the district level can bring: Advantages: Less stress on transportation within Karamoja: Transportation within Karamoja is very challenging due to the poor sta te of the roads, if vaccine is not centralized in Moroto, there would be less transportation expenses and risks. Faster reaction to surges in demand: If drug shops run out of vaccines, they could restock within 1 hour if vaccines are stored in the VO or DV O office. Less inventory needed at nonrefrigerated drug shops: As restocking would be easier, nonrefrigerated drug shops can have less inventory, reducing the risk of overstocking.

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18 Disadvantages It would increase storage costs significantly: Maintaining a cold chain outside of Moroto would increase the cost of storing the vaccines, as fuel for generators and/or propane gas for fridges would be needed. Additional manhours would be needed as well. Spread out inventory increase risk of theft and spoilage: Higher levels of inventory outside the safety of Moroto increases the risk of theft as well as spoilage as they do not have possess backup generators as they do in Moroto. Sustainability for other thermostable vaccines If other thermostable vaccines w ere to be introduced to the market to be sold in the veterinary drug shops, the use of refrigeration equipment outside of Moroto would be recommended for the following reasons: Sustainability: Moroto storage for the PPR project is provided by government and NGO’s, so ideally this should not be used if economic sustainability for vaccines is sought. Vaccines could go to Moroto (or other cities like Mbale) and stored in veterinary drug shops for a fee before being sent to the other districts or they could be sent directly to other districts from Kampala. To Avoid Bad Practices: Often livestock keepers complain that drug shops sell expired drugs. Veterinary shops with refrigerators can buy a higher bulk of thermostable vaccines (reducing costs) without risking spoilage. This shops then can serve as a “hub” for other veterinary shops with no refrigerator so they can buy smaller quantities, therefore reducing risk of overstocking. Increase Area of Coverage: Refrigerated locations outside of Moroto would increase the area of coverage as they can serve as providers to multiple drug shops with no access to a refrigerator, similar to the purpose Moroto storage facilities serves the PPR project, but in smaller scale. Level 4: Community Animal Health Workers procure vaccines and vaccinate livestock With thermostable vaccines there is no need for refrigeration at this level for both options explored. With conventional nonthermostable vaccines, the use of cool boxes would be necessary, accompanied by support from Go vernment and possibly NGOs regarding transportation, as some CAHW’s would have to travel for days with the cool boxes if done by bicycle or foot.

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19 Associated Costs at Every Level Detailed calculation of the cost at every stage are covered throughout t his section as well as an overall summary. Calculations of expenses in Uganda are done using local currency (Ugandan Shillings, UGX) and later summarized in US Dollars. The exchange rate used in these calculations was $1 USD=3,800 UGX. Level 1 Production Costs Currently the production cost for the thermostable PPR vaccine is $0.20 USD per dose, however, this cost is due to the procurement required for the project set up. For the analysis we will use this cost but also compare it with the predominant market cost of $0.10 USD per dose (as shown on the tables above). Transportation from Manufacturer to Kampala Storage The estimated cost to transport 500,000 thermostable PPR vaccines from the manufacturer to Entebbe airport by plane, including all fees, insura nce, and taxes is approximately UGX 35,000,000 ($9,210 USD). Transportation from Entebbe to Kampala storage is done immediately and the costs associated with this transportation are approximately UGX 300,000. Storage in Kampala Storage in Kampala in the c old room costs are not directly associated with the project as this storage is provided by the government, however, it is important to consider this cost, as it will allow the project to be better informed of the full spectrum of costs involved. Also, for research related to the sustainability and economic viability of other thermostable vaccines , these costs become more important as it will allow to get a more accurate assessment of the costs incurred at every level. There are two main components associate d with the storage costs incurred in Kampala, cost of refrigeration, and personnel. Other costs associated with the operations where the cold storage facility operates are minimal as they are shared with other on going operations. Assumptions/Clarificati ons: Vaccines will be stored in Kampala for up to a week, however, this might change. Equipment is working with the same efficiency as if it were new, it was not possible to determine the level of efficiency in which this equipment was working, however, according to the storage manager the equipment is going to be fully replaced. If so, the estimate would be accurate, if not, the margin of error associated at this level would increase slightly . Personnel associated with the cost of storage are: Storage Manager and security guards of the complex. As the complex has other operations, 30% if the cost of maintaining security guards is going to be associated with the storage of vaccines. The percentage of utilization of the cold room is directly related to the number of vaccines to be stored there.

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20 Electricity The total cost of refrigeration of the cold room is calculated as shown below: = = 240 7 648 = 1 , 088, 640 /7 To estimate the cost of refrig eration t he kWh consumption per day was consulted with the manufacturers of the cold room ’s equipment. As for the price of kWh, the price used is the one listed in the “Electricity Retail Base Tariffs for 2018” ( https://www.umeme.co.ug/file/Tariffs.pdf ). Personnel Salaries paid to the storage manager and the security guards are considered to be direct costs associated to the storage of vaccines, however, security guards are costs shared for the enti re complex, not just the storage facility . The total estimated cost of security guards is UGX 1,400,000 /month ($368 USD/month) and the approximate salary of a storage manager would be around UGX 598,882 /month ($158 USD/month) a ccording to the salary stru cture for civil servants in Uganda for 2017/2018. These values represent an entire month of storage; thus, they are multiplied by 0.25 (1/4 of a month) as vaccines will stay in this storage facility up to one week. Depreciation Assuming cold rooms have a n economic life of 15 years (as often done in the literature (Mvundura et al., 2015) ), we can estimate the yearly cost of depreciation in the equipment. We will assume, as is often the reality, that this equipment has no salvage value. According to the storage manager the new equipment that is going to be installed has a cost of UGX 20,000,000 ($5,263 USD) . = = 20 , 000 , 000 15 = 1 , 333, 333 / = 1 , 333, 333 = 27 , 777 / Level 2 Trans portation to Moroto There are several options viable for transportation from Kampala to Moroto, however , we will focus on the three that are considered the most sustainable and/or cost effective. The first option would be a courier transporting the vaccines in public transportation (bus). This option is cost effective;

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21 still, contingencies have to be put in place in case there are unexpected events that might delay significantly the bus. Another option is a refrigerated vehicle, however, for this option to be cost effective, the vehicle should be used to maximum capacity. A third option would be using Mercy Corps cars that travel on a weekly basis from Kampala to Moroto. For the short term eradication PPR vaccination strategy, using a courier in public tran sportation or Mercy Corps transportation are the most cost effective methods. For the scenario of other thermostable vaccines being commercialized, product aggregation with other similar commodities to share costs of refrigerated vehicle could be a better fit for a market based strategy where long term reliability is important. = 100 , 000 / = 75 , 000 / *The cost associated with MC car was estimated with logistics specialists and it i s calculated by sharing a percentage of the cost MC incurs in their weekly transportation from Kampala to Moroto. Storage in Moroto There are two main options for storage in Moroto: using the Karamoja Veterinary Lab and the Cooperation and Development Lab and using veterinary drug shops that have refrigerators. For the PPR eradication project, the first option is the most appealing as these institutions fall under the umbrella of part ners in the project, and they are by far safer and more reliable than veterinary drug shops, however, using veterinary drug shops must be considered to understand the costs associated if other thermostable vaccines were to be introduced as a commodity. C ost of Storing in Karamoja Veterinary Lab Electrical Costs This lab is equipped with 3 types of refrigerators/freezers, solar powered freezer, propane gas powered refrigerator, and refrigerators powered by the electric grid (with back up generators). The r efrigerators that are going to be used for the storage of the vaccines are the ones connected to the electric grid. The KVL uses a Vitrifrigo DP2600 IX refrigerator, which have a kWh consumption of 1.657kWh/day, 0.069kWh/hour (calculations done with the te chnical manual of the refrigerator). We must also consider that Moroto does not possess the same electrical grid reliability that the storage facility in Kampala has, so in the calculations there should be a portion of the cost attributed to the use of a diesel generator. According to the interviewees, power is lost for approximately 60 hours a week on average, excluding extraordinary circumstances when power can be lost for weeks. With this assumption, we proceed to calculate the cost as follows: = # [ ( ) + ]

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22 The PPR vaccination activity ideally s hould take between 2 3 months, so calculations would be made under the assumption that vaccines would be stored in Moroto up to 2 months. = 2 [ 972 0 . 069 648 + 540 3 , 333 ] 2 = 86 , 972 + 3 , 600 , 000 = 3 , 686, 972 Depreciation Assuming a lifespan of 15 years for refrigerators, as done by Mvundura et al. (2015), and assuming no salvageable value of the assets, we can calculate depreci ation costs as follows: = # = 2 7 , 041, 400 15 2 12 = 156 , 475 /2 Personnel The KVL is staffed wi th several employees, however, regarding the PPR project, there is only one lab technician responsible for the vaccines. According to the salary structure for civil servants in Uganda for 2017/2018, the cost of staffing one lab technician is 600,000 UGX/mo nth ($158 USD/month) . The cost of security for the complex is approximately 400,000 UGX/month ($106 USD/month) . Time allocated to the project is estimated to be 50% of their working time. Cost of storing in C&D Costs in C&D are essentially the same as KVL , even though they have a different type of refrigerator (Angelantoni FR 360 V), it has roughly the same energy consumption and price. Level 3 There are several options regarding the transportation from Moroto to other districts. For the PPR eradication s trategy, transport within districts will be done by Mercy Corps. Costs associated at this level vary depending on both the district and the strategy for distribution. For the PPR project, there are two main options to be considered, extending the cold chai n to Amudat, Kotido, and/or Kaabong, or ending the cold chain at Moroto. The benefits and drawbacks of each approach vary greatly, and one of the factors is the cost difference, which will be explored in this section. Cold Chain Ending in Moroto Transport ation Regarding transportation costs for the PPR vaccination project, the cost Mercy Corps incurs has two separate components, with the first one being the vaccines being transported between two cities as a

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23 part of their normal transportation operations. T he other component would then be the transportation from MC field office to the selected vet shop. For the first component, an estimated value was determined with logistics and operation specialists from MC , in which they determined the associated costs of transporting a package within their normal operations between field offices in Karamoja to be approximately 40,000 UGX ($10.5 USD) . The second component however is harder to estimate as there are three assumptions that must be made: The car is not being shared with other MC staff and it i s exclusively used for the PPR vaccination project, the veterinary shops proposed in this report are the ones selected, and the type of car that is going to be used has the same fuel efficiency than the others. The veter inary drug shops (hubs) that are going to be assumed as selected are the ones in the following sub counties/parishes: Loroo, Watakau and Loyoro (there is no vet shop in Loyoro, however, the sub county premises are going to be used for storage and distribut ion to CAHW’s). The section covering inventory policy details why this drug shops were selected. Depreciation of vehicles Depreciation for vehicles was calculated assuming a 10 year life cycle for the Toyota Land Cruiser vehicles which Mercy Corps uses i n the field. The depreciable value of this cars was estimated from interviews and researched online ($75,000). It was also estimated that the use of this cars for the PPR project in the month of operation would not exceed 20% of the time for which deprecia tion can be attributable. = 3 $75, 000 10 3 , 800 1 1 12 20% = 2 , 850 , 000 Costs associated are estimated based on fuel consumption, driver, and depreciation. The c osts vary depending on the distance and time, as shown in the table below: Fuel Consumption Fuel consumption was estimated assuming a 7liter/km consumption as stated by drivers from Mercy Corps. This might seem like a high consumption rate, but the state of the roads and the need to often use the 4 wheel drive are the main drivers of this elevated fuel consumption. Assuming the hubs proposed are the ones the vehicles transport the vaccines from Moroto, the total consumption is shown in the tables below: F uel Kotido UGX 288,000.00 USD $76.00 Fuel Amudat UGX 720,000.00 USD $190.00 Fuel Kaabong UGX 432,000.00 USD $114.00

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24 Storage/Management of vaccines A 50 UGX per dose fee was agreed among partners to be the fee paid to the veterinary drug shop owner for storing and overall management of the vaccines. This cost is directly associated with the number of vaccines received by each district. Tentative demand is shown on table below: Location Demand Total Cost (UGX) Total Co st (USD) Kotido 162,500 UGX 8,125,000 USD $2,138.20 Amudat 250,000 UGX 12,500,000 USD $3,289.47 Kaabong 87,500 UGX 4,375,000 USD $1,151.31 Cold Chain Ending at District Level Transportation Transportation costs are calculated the same way as if the cold chain ended in Moroto, however, the frequency of transportation would be less as uncertainty on the demand is less of a threat in the risk of spoilage. Capacity, cold chain costs, and security become a concern with this option, with the tradeoff being a slightly cheaper transportation and reduced level of risk of spoilage due to uncertainty in the demand. The table below shows the cost of transportation with this scenario: Location Total (UGX) Total (USD) Transport between cities UGX 160,000.00 USD $42.11 Depreciation of vehicles UGX 2,850,000.00 USD $750.00 Fuel used within Kotido district UGX 256,000.00 USD $67.37 Fuel used within Amudat district UGX 640,000.00 USD $168.42 Fuel used within Kaabong dis trict UGX 288,000.00 USD $75.79 Driver UGX 1,000,000.00 USD $263.16 Storage/Management of vaccines Savings on transportation and reduced risk of overstocking might seem an appealing option, however, this also adds another level of c omplexity and cold chain which brings added risk of theft and mishandling of vaccines, as well as adding more costs associated with the storage. This costs also vary greatly depending on the district, as some are equipped with solar refrigerators and other s rely in propane gas powered fridges. Amudat and Kotido Storage Amudat and Kotido would be the districts where the cold chain would extend (not in Kaabong) if this option is to be considered because:

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25 1) Target place for vaccination in Kaabong is geographically closer to Kotido 2) The amount of vaccines allocated to Kaabong is smaller The place in Amudat with an extended cold chain would be the VO’s office in Loroo (propane gas powered refrigerator). Kotido has both propane gas and solar powered, however, sola r freezers are not going to be considered for the PPR vaccination program for the following reasons: 1) They are freezers and not fridges, although they can be set to temperatures above the freezing point, it is not ideal to use freezers. 2) The amount of vaccines they can hold is very limited compared to the propane powered refrigerators, so the use of this fridges will not eliminate the need for propane gas powered fridges. 3) Personnel responsible for operating these fridges are not adequately trained on the appropriate use of theses freezers. However, use of these freezers is going to be considered for the economic analysis of introducing other thermostable vaccines to Karamoja from a business perspective. Depreciation of refrigerators The propane gas refri gerators used are Sibir V170GE, which cost approximately USD $2193.07 (approximately UGX 8,478,728). Price estimated using the pricelist provided by PharmaMundi. = 8 , 478 , 728 15 1 12 2 = 94 , 208 Operational Costs The cost of having one refrigerator in each district is calculated as follows: = + = = % One 25 liter propane gas tank can power a fridge for 10 days in average. These tanks have an approximate cost of 115,000 UGX ($30.26 USD) . The salary of the person involved is assumed to be the one of a public servant with pay scale U3, which is the pay scale a Senior Veterinary Officer receives on average. = 115 , 000 6 = 690 , 000

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26 = 1 , 600 , 000 = 3 , 200 , 000 2 Summa ry of Storage and Management of vaccines cost: Location Storage Cost (UGX) Storage Cost (USD) Kotido UGX 3,984,208.09 USD $1,048 .46 Amudat UGX 3,984,208.09 USD $ 1,048.46 For this option, there are also the costs mentioned above associated with v eterinary shops outside of the cold chain managing and distributing the vaccine: Location Demand Total Cost (UGX) Total Cost (USD) Kotido 162,500 UGX 8,125,000 USD $2,138.16 Amudat 250,000 UGX 12,500,000 USD $3,289.47 Kaabong 87,500 UGX 4,375,000 US D $1,151.32 Level 4 Vaccination fee paid by the livestock keeper is 100UGX/dose ($0.026USD/dose) . The project will pay an additional 150UGX/dose ($0.039USD/dose) to the CAHW. Paid by Total (UGX) Total (USD) Livestock Keeper UGX 50,000,000 USD $13,157. 89 Project UGX 75,000,000 USD $19,736.84 Total Cost UGX 125,000,000 USD $32,894.74 Cost of Non thermostable V accines The approach of nonthermostable vaccines for this comparison is the usual government approach with CAHWs, in which veterinary super visors oversee a team of CAHW’s usually using cars to mobilize each team. It will be assumed that the number of vaccines and the time of implementation is the same, in order to more accurately compare the difference in cost between these approaches. All c osts are calculated as above, however the following considerations are taken into account : 13 vehicles needed (One per veterinary supervisor) Cost associated to vehicles (depreciation, drivers, fuel, opportunity cost) increases as the number of vehicles i ncreases Veterinary supervisors’ salaries are now included in the calculation 1 Cool box / CAHW

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27 Opportunity Cost of the vehicles Cost Summary The following tables summarize the cost of each approach transformed to USD assuming the exchange rate is 1USD=3 ,800UGX. Table 4 Cost per level with cold chain ending at district level (Option 1) Cost with vaccine price 0.2USD/dose Cost with vaccine price 0.1USD/dose Level 1 $109,714.85 $59,714.85 Level 2 $1,406.17 $1,406.17 L evel 3 $10,042.74 $10,042.74 Level 4 $32,894.74 $32,894.74 Total $154,058.50 $104,058.50 Table 5 Cost per level with cold chain ending in Moroto (Option 2) Cost with vaccine price 0.2USD/dose Cost with vaccine pri ce 0.1USD/dose Level 1 $ 109,714.85 $59,714.85 Level 2 $1,406.17 $1,406.17 Level 3 $8,276.32 $8,276.32 Level 4 $32,894.74 $32,894.74 Total $152,292.07 $102,292.07 Table 6 Cost per dose Comparing costs with nonthermostable vaccines The supply chain showing option 1 describes what would be the procedure to follow for a nonther mostable vaccine, however level 4 would be very different. Additional vehicles would be needed to transport daily the vaccines to vaccination sites. The following table shows the estimated costs: Cost with vaccine price 0.2U SD/dose Cost with vaccine price 0.1USD/dose Option 1 $ 0.30812 $0.20812 Option 2 $ 0.30458 $0.20458

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28 Table 7 Costs using non -thermostab le vaccines Cost with vaccine price 0.2USD/dose Cost with vaccine price 0.1USD/dose Level 1 $ 109,714.85 $ 59,714.85 Level 2 $1,406.17 $ 2,072.16 Level 3 $67,368.00 $ 67,368.00 Level 4 $32,894.74 $32,894.74 Total $211,383.76 $162, 049.75 Table 8 Cost per dose of non -thermostable vaccines Table 9 Comparison of percentages of logistical cost with different approaches Table 10 Cost comparison by approach The costs difference betwee n the two options and the use of nonthermostable vaccine is significant (0.12 USD per dose, as seen in table seven ), however, other reasons to advocate for thermostability are: Community involvement: Using thermostable vaccines allows more engagement from the community as CAHWs are key within the distribution process, as well as veterinary drug shop owners who do not own refrigerators. Logistical costs are reduced and relocated more towards the community in lieu of refrigeration and transportation using ve hicles. Reduces Dependency: Using a thermostable vaccine allows CAHWs to work more independently, as they are not subjected to cold chain and refrigerated transportation. Cost with vaccine price 0.2USD/dose Cost with vaccine price 0.1USD/dose $0.4228 $ 0.3241 % of logistical cost (price 0.2USD/dose) % of logistical cost (price 0.1USD/dose) Option 1 Thermostable 35.09% 51.95% Option 2 Thermostable 34.34% 51.12% Option 3 Non Thermostable 52.7% 69.1% Cost (price 0.2USD/dose) Cost (price 0.1USD/dose) Option 1 Thermostable $ 0.30812 $0.20812 Option 2 Thermostable $ 0.30458 $0.20458 Option 3 Non Thermostable $0.4228 $ 0.3241

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29 Wastage: Using thermostable vaccines can reduce wastage of vaccines as vaccines that are not thermostable can get spoiled if taken out of the cold chain (e.g. bringing more vaccines to the field than needed). (Kristensen, Lorenson, Bartholomew, & Villadiego, 2016; Lee et al., 2017) Hub Selection and Inventory Policy The cost difference betwee n the two approaches is not that significant under the current scenario, however, the second approach (ending cold chain at Moroto) poses less risk in terms of mismanagement and theft of vaccines. As the vaccinations are targeted at specific sub counties; Loroo in Amudat, Nakapelimoru in Kotido, and Loyoro in Kaabong, the selection of the hubs is done considering two main factors: geographical proximity to livestock keepers, and ownership and management capacity of the veterinary shop. FGD showed that there is more trust in veterinary shops owned by CAHW’s compared to other veterinary shops. There are certain challenges in establishing an effective inventory policy, however it is crucial to have an effective policy in place to reduce the risk overstocking o r understocking, which can result in economic losses. The main challenges are: 1) High level of uncertainty in the demand and its distribution (sudden spikes or drops in demand) 2) Once vaccines are out of the cold chain they must be treated as perishable within 30 days 3) External factors (such as weather) could interfere with operations, lead times can be highly variable 4) No information platform to monitor levels of inventory in real time 5) Lack of capacity of the vaccine ‘hubs’ to organize and maintain a consistent inventory and records adequately. Addressing these challenges would not only reduce the risk of over and under stocking, but they would also simplify the logistical operations of the project.

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30 Figure 9 Map of Karamoja with Refrig eration Points

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31 Amudat Context and Hub Selection Amudat is currently targeted to get 50% of the vaccines, and it is also one of the most challenging places for the project. The inventory policy for Amudat is perhaps the most important one. The vaccination program is targeted to be completed 2 months after it has started, which means, if successful, on average each week 31,250 small ruminants would be vaccinated. According to the information gathered, there are 23 active CAHWs in Loroo. This means that to ac hieve target vaccination they would have to either vaccinate 200 animals every day for 2 months or increase the number of animals they vaccinate per day. However, it is extremely unlikely demand would behave which such uniformity, it is likely that there a re going to be weeks with higher demand than others. However, the limited number of CAHW’s poses an additional challenge, as this leaves small room to gauge the demand the first weeks with small quantities of vaccines and then increase the supply (as sugge sted by several stakeholders). Regarding the veterinary drug shop initially selected as a hub for the project in Loroo town, information from the community and assessment from members of the team have found that this veterinary drug shop is not always open during the weekdays, with no clear schedule or pattern of working hours. This issue must be addressed before the vaccine is distributed or otherwise use the office of the Veterinary Officer as a storage hub. Inventory Policy Ideally, by the end of the fi rst month there should be around 125,000 animals vaccinated, however, as uncertainty is high, it is also very important that overstocking is avoided as this could lead to spoilage. For the first week, a recommended amount of 31,250 vaccines (625 vials) sho uld be taken out of the cold chain in Moroto and moved to the selected hub in Loroo. This quantity is recommended because it is the average number of animals that should be vaccinated per week at the end of the 2 month vaccination program. Using the averag e to gauge the demand in this case could be appropriate because uncertainty is high, and this quantity would provide enough flexibility to react in case of an initial high demand of the vaccine while it is also a manageable value in case demand is low. The following table proposes an inventory and re stocking policy for the first 2 weeks. Table 11 Inventory Policy for Amudat for the first two weeks Inventory Policy Week 1 2 Week 1 Starting Inventory Inventory at the end of week 1 Quantity to be shipped at the start of week 2 31,250 0 10,000 40,000 31,250 10,001 20,000 20,000 31,250 20,000 30,000 10,000 31,250 30,001+ 0

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32 Table 12 Inventory Policy for Amudat after week two Inventory Policy after week 2 I nventory at the end of week x Quantity Shipped at the beginning of Week x +1 0 10,000 40,000 10,001 15,000 30,000 15,001 20,000 20,000 20,001 30,000 10,000 30,001+ 0 This proposed policy takes advantage of the thermostability of the vaccine to reduc e the risk of understocking without significantly increasing risk of overstocking. If inventory levels at the end of the week are low, the quantity of vaccines shipped plus the remaining inventory would be above the average. This would allow the drug shop to continue supplying vaccines if the demand remains high. If demand suddenly drops, and inventory levels are high at the end of the next week, the next shipment of vaccines would be considerably less, to avoid overstocking but always aiming to maintain le vels of inventory above average to properly react to spikes in demand. For this policy to work, it is imperative that the method of distribution used is First In First Out (FIFO). This method consists in distributing to the CAHW’s the vaccines that were re ceived first (the ones that have been out of the cold chain longer). Every vaccine shipment should be clearly labeled with the dates they were shipped; this inventory policy only works on the assumption that a FIFO inventory method is in place. Kotido C ontext and Hub Selection The sub county of Nakapelimoru is to receive approximately 162 ,500 vaccines, which means that if carried successfully over a period of two months the average number of animals vaccinated per week would be 20,313. The veterinary dru g shop selected as a hub would be the one located in Watakau Parish. This drug shop is operated by CAHW’s and it is affiliated to JICAHWA, it is also highly trusted within the community and by the veterinary officers. Inventory Policy The approach used in the first week for Amudat (using the average to stock during the first week) could be used in Kotido as well, however, as the number is considerably lower, the project could take advantage of the thermostability of the vaccine and aim to stock a higher nu mber of vaccines during the first week.

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33 Table 13 Inventory Policy for Kotido for the first two weeks Inventory Policy Week 1 2 Week 1 Inventory Inventory at the end of Week 1 Quantity Shipped Week 2 25,000 0 5,000 25,000 25,00 0 5,001 10,000 20,000 25,000 10,001 15,000 15,000 25,000 15,001 20,000 10,000 25,000 20,001+ 0 After the second week, a similar inventory policy as the one proposed in Amudat could be put in place, as shown on the table below: Table 14 Inventory Policy for Kotido after week two Inventory Policy after week 2 Inventory at the end of week x Quantity Shipped Week x +1 0 5,000 25,000 5,001 10,000 20,000 10,001 15,000 15,000 15,001 20,000 5,000 20,001+ 0 This approach would always aim to maintain the number of vaccines in stock higher than the weekly demand. This would allow to take full advantage of the thermostability of the vaccine to reduce the risk of understocking , while at the same time reducing the risk of spoilage by shipping less if the quantity of vaccines in inventory is between 15,000 and 20,000 after week two. A FIFO inventory method as suggested for Amudat is also needed for this approach to work. Kaabong Context and Hub Selection The sub county of Loyoro is t o receive approximately 87,500 vaccines, which means, that if carried successfully over a period of two months the average number of animals vaccinated per week would be 10,938. A challenge that this sub county faces is, there is no veterinary shop in all the sub county and the closest one is in Kaabong TC, which takes approximately 6 8 hours by foot for CAHW’s to reach. For this case the project has secured premises within the sub county headquarters to serve as

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34 a hub for the vaccines. This is very benefic ial as it makes access to the vaccines easier for CAHW’s as well as reducing the logistical burden for the project. Inventory Policy Several approaches can be taken in Kaabong as the number of vaccines is considerably less than in Kotido and Amudat. Ther mostability of the vaccine could be used to the projects advantage to reduce transportation costs, so in the first week a larger amount of vaccines could be supplied, and the next shipment could be delivered on week 3, and so on, so the strategy for Kaabong would be a biweekly restocking strategy. A FIFO inventory method as suggested for Amudat and Kotido is also needed for this approach to work. Table 15 Inventory Policy for Kaabong for the first two weeks Inventory Policy Week 1 3 Week 1 Inventory Inventory at the end of Week 2 Quantity Shipped Week 3 30,000 0 5,000 30,000 30,000 5,001 10,000 20,000 30,000 10,001 15,000 15,000 30,000 15,001 20,000 10,000 30,000 20,001+ 0 Table 16 Inventory Policy for Kaabong after week two Inventory Policy after week 3 Inventory at the end of week x Quantity Shipped Week x+1 0 5,000 30,000 5,001 10,000 20,000 10,001 15,000 15,000 15,001 20,000 10,000 20,001+ 0 Challenges and Opportunities with Community Animal Health Workers Semi structured interviews with CAHW’s in the 3 selected districts were conducted in order to assess what challenges and opportunities there might be regarding the logistics and distribution of vaccines in the region. Several conclusions th at can be drawn of these assessments are: 1) Positive perception towards having vaccines available for sale in veterinary shops. Although not always a unanimous thought, there was an overall positive perception of an ongoing vaccine business model rather than the current model where vaccines are supplied by

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35 the government or NGOs as part of a campaign. The main reason being that often vaccination programs don not have enough vaccines and that they are not that frequent. 2) Strong link with CAHW owned veterinary shops in Kotido and Kaabong, not in Amudat. The great majority of CAHW’s prefers to buy drugs at shops that are owned and operated by other CAHW’s, the main reason is because they trust that the drugs are high quality and they work. Another reason listed i s that as they are trained CAHW’s, they have knowledge of the diseases and the proper way to address them. They say other drug shops are run by people who do not know about veterinary medicine. In Amudat however, Livestock keepers and CAHW’s say that the s ervice provided in the CAHW drug shop is good, but that prices are higher than drugs sold at the market or in Kenya (which is XX miles Amudat). Some also mentioned that sometimes the drug shop is closed during normal business hours. Additional information from other team assessments revealed further issues with the Loroo veterinary shop. 3) Distance from veterinary shops directly affects their performance and motivation. CAHW’s who are within 1 2 hours walking distance of the closest veterinary shop reported having better business performance compared to those who must walk for 6 8 hours. 4) All CAHW’s interviewed have participated in previous vaccination programs. There are many CAHW’s who are very experienced and have become leaders within the community. 5) Prot ective gear use varies greatly, some reported not having gumboots and overalls. If possible, this should be addressed in order to improve working conditions. 6) CAHW’s stated that they would like to have more CAHW’s as there are too few. They also expressed that refresher trainings would help them a lot. 7) Education is needed for livestock keepers on the purpose of vaccines – prevention vs. treatment. This challenge, if it i s not addressed, can affect the demand for the vaccine and give false expectations of w hat a vaccine can do. Other Thermostable Vaccines: Considerations for a Market Based Approach (An Overview) Using the information gathered, a cost analysis of the logistics involved on the distribution of thermostable vaccines in Karamoja could help gove rnments, private enterprises or donors, to analyze and quantify the viability of a project and to estimate the approximate cost. There are some considerations to be taken into account and will be explored in another paper with the same amount of detail as this report has to the PPR vaccination project. A brief overview of these considerations includes: Government and NGO role in vaccination should be minimized: Market based solution aiming for sustainability should consider the least use possible of governm ent or NGO resources. The supply chain could therefore have different actors to the ones considered here, for example, storage in Kampala and Moroto could be with private businesses which will have different costs. The same applies to transportation.

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36 Cold chain would probably end at district level: It would be too complicated to end the cold chain in a central location like Moroto, this might lead to overstocking or understocking, which could quickly lead to bad practices (selling vaccines that have been o ut of the cold chain more than recommended). Free vaccinations could impact the demand: If NGO’s or the government continue to provide free vaccines, this would discourage private drug shops to buy vaccines. Communication with the public sector and NGO’s is important. Improve the level of coordination: Better coordination within actors in the supply chain is needed to sustain a long term sustainable market based approach . Investment in infrastructure and capacity building downstream of the supply chain aim ed to improve storage and inventory practices would enhance communication of between stakeholders as needs would become clearer. Conclusion The supply chain analysis for the current PPR Vaccine Associate Award can help quantify the economic viability of other thermostable livestock vaccines in Karamoja as well as actively contributing to improve the distribution and logistics of the vaccines for the project. The cost analysis has shown that for the project, the logistical cost is around 35% of the total c ost when the price for the vaccine is $0.2 USD and 50% when the price for the vaccine is $0.1 USD, however, approximately 78% of these costs paid to veterinary drug shops and CAHW’s, which means they go back to the community. This is possible because therm ostability of the vaccines allows a much cheaper storage and transportation in the most challenging areas. Although vaccine thermostability provides flexibility in terms of logistics, inventory policy still plays a crucial role in reducing costs and incre asing availability. For the PPR vaccination project, priority was given to avoid understocking , without increasing the risk of overstocking significantly. The inventory policy suggested aims to maintain inventory levels above the weekly average demand in order to be able to anticipate spikes in the demand, while using a FIFO method of distribution to avoid spoilage if demand suddenly drops at high levels of inventory. Capacity building on inventory management and record keeping is crucial to avoid spoilage of vaccines and to gather data on demand distribution for the next vaccination round. CAHW’s are probably the most important element in the supply chain as they are trusted members of the community who can deliver vaccines to remote locations. The assessment showed that they have a positive perception to the commercialization of vaccines which could probably mean that similar projects as this one could be replicated if proven successful. Final Reflection Studying the supply chain of a commodity that has no market information, but at the same time can potentially help reduce food insecurity in one of the most impoverished areas of subSaharan Africa was a challenge both for the analysis and the field research conducted. On a project with an already

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37 tight schedule, spending s everal hours, and even days dealing with issues on the road, can be frustrating at the time, however looking back, these were all learning experiences. Coming from working in the private sector in a company that i s listed in NASDAQ I ca n see now how development programs are infinitely more complicated than any professional challenge I had faced before. It i s hard to put into words the complexity of working in such crucial topics as livestock vaccinations in food insecure pastoralist comm unities. I believe that the research done regarding my FP has the potential to improve vaccination activities and veterinary services in Karamoja and other areas, however, this is only possible if the findings are disseminated correctly and more work is done studying the supply chain and logistical challenges adherent to these remote places with limited infrastructure. The methods used in this research project could be replicated in other projects to understand the supply chain and make decisions that would benefit the overall outcome of the project. Acknowledgments This project could not have been done without the support of the USAID funded Feed the Future Innovation Lab for Livestock Systems and the Masters of Sustainable Development Practice program at the University of Florida . Special thanks to my advisory committee, Dr. Sarah McKune, and Saskia Hendrickx, both incredible mentors and there to support me at every step of the way. It was through their guidance and confidence in me that any of this was possible.

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38 Bibliography Kristensen, D. D., Lorenson, T., Bartholomew, K., & Villadiego, S. (2016). Can thermostable vaccines help address cold chain challenges ? Results from stakeholder interviews in six low and middle income countries. Vaccine , 34(7), 899–904. https://doi.org/10.1016/j.vaccine.2016.01.001 Lee, B. Y., Wedlock, P. T., Haidari, L. A., Elder, K., Potet, J., Manring, R., Brown, S. T. (2017). Economic impact of thermostable vaccines. Vaccine , 3 5 (23), 3135–3142. https://doi.org/10.1016/j.vaccine.2017.03.081 Mvundura, M., Lorenson, K., Chweya, A., Kigadye, R., Bartholomew, K., Makame, M., Kristensen, D. (2015). Estimating the costs of the vaccine supply chain and service delivery for selected di stricts in Kenya and Tanzania. Vaccine , 33 (23), 2697–2703. https://doi.org/10.1016/j.vaccine.2015.03.084

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39 Annex : Instruments Data Collection before Vaccination: Community Animal Health Worker Function: Community Animal Health Worker (CAHW) Organization : Self employed Location : Target Districts: Amudat, Kotido, Kaabong. Information needed Historical distance travelled from Hubs Decision making process of routes to provide services Capacity (Volume x weight they can transport) Historical distribution times Experience as CAHW Costs of operating Equipment Perception of proposed model Handling of similar products Focus Group Discussions with CAHW Obtaining Consent Prayer Introductions Questions 1. This is a very beautiful place that kinds of reminds me of home (Colombia), but I’m new here, can you show me in a map (Tool: participatory mapping [1]) Points to ensure are captured in the map: Grazing areas, watering points, settlements, vet stores, markets (As vet drugs are also sold there) 2. Show of hands, who have been working for more than a year. 3. What animal species did you treat most during the last month, (Proportional piling [1]) 4. So, talking more about animals treated, how is business going? Has this changed in the past 5 years? 5. What is the product you buy/sell the most?

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40 6. What vet store do you get your supplies from? Do they sell any vaccines at all? If so, which ones? 7. How long do you have to travel to go to the vet store? 8. How long does it take to get from the vet store to your customers? Can everyone describe the route? (Tool: refer back to the map produced under 1). 9. Have you ever had any problems with your bike? Which is the most common problem? 10. Where do you prefer to set up vaccinations with livestock owners? Why? 11. What is the hardest place to re ach? Why? 12. What is the easiest place to reach? Why? 13. During a working day or week, how much time do you spend with livestock, and how much time do you spend riding your bike? 14. What has been their involvement in previous vaccination programs (how did they go) ? 15. How are you going to carry the vaccines? 16. Would you take other things besides the vaccines? 17. Imagine vaccines are not going to be given freely any more, but they would be available all year round at the vet store, would you buy vaccines? What price would you consider would be fair? 18. (If answer to 17 is no), Would you do it with access to credit? 19. Do you think access to credit can help you growing your business? 20. Do you think people would continue to vaccinate if the vaccine were always available? Data Colle ction before vaccination: Livestock Keepers Function: Livestock keepers Organization: self employed Location : Target Districts: Amudat, Kotido, Kaabong Information needed Cost perception of vaccine Vaccine uptake (demand) Historical Lead Times of supplie s Willingness to pay under different prices and conditions CAHW perception

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41 Focus Group Discussions with Livestock Owners Obtaining Consent Prayer Introductions Questions 1. This is a very beautiful place that kinds of reminds me of home (Colombia), but I ’m new here, can you show me in a map (Tool: participatory mapping [1]) Points to ensure are captured in the map: Grazing areas, watering points, settlements, vet stores, markets (As vet drugs are also sold there), location of nearest CAHW 2. What services you normally get from CAHWs? 3. Are there other services that you get from CAHWs? 4. How frequently do you go to the vet store? 5. How do you normally get access to vaccines? Which vaccines? Why? 6. Have there been any vaccination campaign for cattle or goats in the p ast years? 7. Did you vaccinate you animals? Which animals? What vaccines? 8. Where do you prefer to set up vaccinations with CAHWs? Why? 9. Have you heard about a vaccine against PPR? 10. PPR vaccine would cost 100 UGX Shillings, what do you think about this price? 11. W hat is the maximum price you would pay per vaccine if it were available always and not only during vaccination campaigns? 12. Would you go to the town to get vaccinations if they would be available for purchase all year round? Data Collection before Vaccinat ion: Veterinary Stores Function: vet store owner (so called hub as part of the project) Organization: self employed Location : Target Districts: Amudat, Kotido, Kaabong. Information needed Operational Costs Constraints (Electrical Grid and Capacity?) Historical Lead Times of supplies

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42 Perceived demand Inventory policy perception (no more than 10 day supply) Handling Structured Interview for Hub owners. 1. How long have you been in business? Has business change over time? 2. Who are your more common custome rs? 3. What do you normally keep in stock? Where do you get these products? 4. What are your best seller products? 5. How often do you order them? 6. Where do you get them from? 7. How many times in the last year people came in and asked for one of them and you didn’t have it? 8. How many times people ask for something you don’t have because you ran out? 9. How many times people ask for products you don’t sell? 10. How about vaccines? Why? If you would have access to them would you sell them? 11. People that come to your shop, how fa r do they travel to come? 12. What is the product that gives you more profit? 13. What type (reference) of refrigerators will be used for storing the vaccine? (Visual inspection and measurements to determine capacity if allowed by hub owner) 14. How long have you had electricity? 15. In the last 2 weeks, how many times did power go out? What do you when power goes out? How much do having electricity costs and cost of backup if any. 16. Are other vaccines or elements stored in this refrigerator when it is being used for PPR? If so, what and how much? 17. Who else haves access to the refrigerator? 18. How many CAHW come to you in one week? What do they usually buy? 19. Do you keep any records of your sales to CAHW? 20. If PPR vaccine were always available for sale from Moroto or other place an d the government and NGO’s stopped giving it for free, would you buy it? How much profit would you expect to make from it?

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43 21. Where do you get your products from? How long does it take to get you products here? Do they come together or in separate deliveries? 22. What is the biggest expense (business related) you have? 23. What is the greatest difficulty (business related) you have? 24. Do you think the PPR vaccine can generate profit for you if there was always a steady supply? 25. What do you think of the quantity of vaccin es you will receive from Moroto? Should you receive more, less, or is the number good? Why? Data Collection before Vaccination: Kampala Storage Function: Head Vaccine Storage facility Organization: Ministry of Agriculture, Animal Industry and Fisheries ( MAAIF) Location: Kampala, Uganda Information needed Holding costs Capacity Historical Lead Times Equipment used Handling of similar products Fixed operational costs Variable operational costs Structured Interview for MAAIF official in Kampala 1. What typ e (reference) of refrigerators will be used for storing the PPR vaccine? 2. Are other vaccines or elements stored in this refrigerator when it is being used for PPR? If so, how much space is allocated to each element on average. 3. In case of power outage, is there a generator in place? If so, what is the average time of outage? 4. What type of generator (if any) is used as a backup? What is the cost of fuel used by this generator? 5. How many personnel will be involved with the storage a nd handling of the vaccine? Including security and maintenance if any.

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44 6. What is the role of each of the people involved with the storage and handling of the vaccine? 7. Do vaccines (in general) arrive when they are scheduled to arrive? If not, how much does t his time vary. 8. Describe the process of storing, registering and distributing vaccines in general. 9. Have vaccines damaged/spilled during storage? If so, what was the reason for this? 10. What other products are sent to Karamoja besides the PPR vaccine? Is there possibility for aggregation? 11. To what cities/districts does MAAIF ship vaccines or supplies? What vaccines/supplies are this? 12. How long are vaccines stored before leaving to Moroto or other districts? Why? 13. Who handles transportation to each place MAAIF ships supplies? Is there information about times and costs? 14. How long does it take to deliver products to Moroto and other places? 15. How are vaccines delivered? What is the cost of delivery (Mileage, driver, vehicle used) Data Collection before Vaccination: Mor oto Storage Function: Head of the Regional Veterinary Laboratory (where vaccine is stored) Organization: Ministry of Agriculture, Animal Industry and Fisheries (MAAIF) Location: Moroto, Uganda Information needed Holding costs Capacity Historical Lead T imes Equipment to be used Handling of similar products Distribution decisions of similar products Strategy for PPR Fixed operational costs Variable operational costs

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45 Structured Interview for MAAIF official in Moroto 1. What type (reference) of refrigerators are used for storing the vaccine? 2. Are other vaccines or elements stored in this refrigerator when it is being used for PPR? If so, how much space is allocated to each element on average. 3. In case of power outage, is there a generator in place? If so, what is the average time of outage? (In case of power outages being common, a variation of a seasonal calendar that maps weekly the frequency of outages) 4. What type of generator (if any) is used as a backup? What is the cost of fuel used by this generator? 5. How m any personnel is involved with the storage and handling of the vaccine? Including security and maintenance if any. 6. What is the role of each of the people involved with the storage and handling of the vaccine? 7. Do vaccines arrive when they are scheduled to arrive? If not, how much does this time vary. 8. How long does it take for supplies/vaccines to arrive from Kampala and other places? 9. Describe the process of storing, registering and distributing vaccines. 10. Have vaccines damaged/spilled during storage? If so, what was the reason for this? 11. What other products are received other the PPR vaccine? Is there possibility for aggregation? 12. Describe the process of shipping out vaccines in general. 13. How are quantities of vaccines in general that will be shipped to each lo cation determined? 14. How do you know the quantity to ship to each location? 15. Who handles this transportation? Time/costs?

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www.feedthefuture.gov Feed the Future Innovation Lab for Livestock Systems University of Florida Department of Animal Sciences P.O. Box 110910 Gainesville, Florida 326110910 Livestocklab@ufl.edu http://livestocklab.ifas.ufl.edu