A DISCIPLINED APPROACH TO DEVELOP AND DELIVER THE COVID 19 VACCINATION PROGRAM
CONTEXT
As of September 22 nd , 2020, the COVID 19 pandemic has infected 32 million people with 1 million fatalities globally. It is just over six months since WHO declared a global pandemic. No countries have been able to prevent subsequent waves of COVID 19 cases , and with each subsequent wave, governments have no new responses apart from different variations of lockdowns. What is becoming more apparent is that with each successive iterations of lockdowns, the health, social, and economic impact becomes exponentially worse.
The long-term societal impact of such a scale of disruption and upheaval from COVID 19 and government responses are still unfolding and will not be known for some time yet. Despite government support in various forms, recessions, business failures, and unemployment has already started and will get worse before it gets better. Growing anxiety and stress from an uncertain future is another area of genuine concern globally.
Governments know they are racing against time to get this pandemic is under control.
Much of the hope of getting this pandemic under control and restarting a post-COVID 19 society is dependant on a combination of improved diagnostic tests, better therapeutics, and the development of safe, effective, and affordable vaccines.
This article looks at what it takes to have a disciplined approach to deliver a mass vaccination program for COVID 19.
There is global cooperation as well as a race to develop safe, effective, and affordable vaccines. Debates, speculations, and controversy are ongoing when an effective, affordable, and safe vaccine becomes available. Allegations of political interference in the vaccine development process potentially undermine public confidence and trust. This has prompted nine prominent pharmaceutical companies 1 signing up to a public declaration that they would stand with science and not put forward a vaccine until it had been thoroughly vetted for safety and efficacy. This will go some way to reassure public confidence, but more will be needed in the months and years ahead to keep and strengthen public confidence and support.
Any vaccine developed and released for a mass vaccination program must be safe and second, effective.
The landscape for COVID 19 vaccine development is constantly changing. The National Geographic 2 article published on September 14 th ,2020, provides a good overview and update on vaccine developments.
VACCINATION PROGRAM - GETTING STARTED
Most COVID 19 vaccination programs will be under pressure to stand the program up as soon as possible. The eventual timeframe for a successful vaccination program will depend on multiple variables. Safety for various population groups, effectiveness, length of immunity, number of doses required, manufacturing, distribution, and delivery capacity are just some of the variables that can impact timeframes. Any vaccination program must be flexible to pivot as some of the above variables change.
Any vaccination program underway will be bombarded with a growing list of "workstreams” that includes:
a. Vaccine(s) – the type of vaccines to be procured, imported, or produced locally.
b. Vaccines(s) - transport, warehousing, storage and cold chain requirements, distribution channels and mode of delivery to vaccinators organisation.
c. Prioritization of target population.
d. Vaccination - referral/walk-in, recording, monitoring, and follow up
e. Vaccinators organisation - quantity and storage and cold chain requirements.
f. Workforce (vaccinators & support staff) - recruitment, training, and certification
g. Method and frequency of delivery – injections (single or double)
h. Equipment & Devices (needles, syringes, vials, fridges, backup generators)
i. PPEs for vaccinators
j. Facilities & locations – clinics, pharmacies, learning institutions, religious & worship places, workplace, community centers, health facilities (hospitals, aged care, disability, home care), correction facilities, shopping centers & community markets, sporting clubs and venues, public venues (library)
k. Updating or creating a national immunization register/platform – stand- alone or integrated (with other immunization programs, primary and hospital EHRs), only for COVID 19 or future pandemics.
l. Communication and engagement with general and target population
m. Governance, oversight, and reporting
The main challenges for the program team include knowing:
a. how to deal with the complexity of prioritizing the various work streams,
b. how various workstreams complement and support each other, and
c. how to pivot, change pace and momentum if fundamental, and assumptions about the vaccine to be procured change on short notice.
Any country's vaccine program will be built on the following four pillars:
(1) Vaccine selection and procurement are in full flight, with some developed countries pre-ordering hundreds of millions of doses from multiple vaccine developers and manufacturers. This has given rise to growing and ongoing concern on "vaccine nationalism." To mitigate against such nationalism, initiatives such as COVAX 3 brings together governments, global health organizations, manufacturers, scientists, the private sector, civil society, and philanthropy, aim to provide innovative and equitable access to COVID 19 vaccines.
(2) Vaccine delivery program for COVID 19 is also ramping up. Even if the science of herd immunity requires 70%of the population to be vaccinated, undertaking a mass population vaccination is no mean feat.
Designing and delivering a vaccination delivery program will not be a straight forward and simple exercise, even for developed countries with resources and expertise.
(3) The prioritization of target population groups is vital as it is clear there will not be enough doses immediately for everyone. Issues such as criteria, process, exemptions will require careful and thoughtful policy work, engagement, and communication.
(4) Cold chain, supplies, and infrastructure will need to deal with freezers, fridges, needles, syringes, plungers, transportation, and IT platform for registration and recording are details that need careful organization.
Interdependencies between each of the four pillars are significant and often underestimated. The risk is very high for confusion, distractions, delays, disappointment, fragmentation, and frustrations from an uncoordinated and siloed approach in designing and implementing such a program.
A disciplined approach will provide a structure and clarity for program teams facing competing demands from many "workstreams".
Purpose, vision, mission, strategy, plan, and target operating model.
Always start with an overview of “purpose, vision, mission, strategy, plan, and target operating model. Purpose is about the "why we are doing this." Vision is about what does progress and success look like for who and when. Mission, strategy, plan, and target operating model are about what, how, who, and when to get things done.
a. This vaccination program's purpose, vision, and mission statements are high level but are entirely interlinked.
b. The strategy provides the key elements of the program.
c. The plan provides the details for each of the strategic elements, and
d. The target operating model describes the 12 essential components needed to execute the plan.
Simple, Complicated & Complex
The SCC concept identifies the "simple, complicated and complex" nature of the target operating model's various elements. The approach to making progress for simple, complicated, and complex workstreams or tasks are very different:
a. Simple – we use “best practice.”
b. Complicated – we use “good practice.” There is more than one good practice.
c. Complex – we use a "discovery approach" with a portfolio of many small, innovative initiatives. Some will "fail," while others will show a new way of getting things done.
Target Operating Model
The 12 essential components of a target operating model are:
d. Customers, partners, stakeholders
e. Outcomes desired
f. Services & products
g. Processes, Policy & Regulation
h. Channels & communication
i. Funding j. People, culture, capacity, capability, and leaderships
k. Facilities & locations
l. Information & technology
m. Organization, governance, and management (including financial) models
n. Performance measures, incentives, and levers
o. Accountability and responsibility models
SUPPORTING FRAMEWORKS
The integration between the 12 components of the target operating model is critical. To that end, several frameworks are suggested below.
Three triangles framework
Use the three triangles framework to work out – (a) target customer, partners, stakeholders, (b) outcomes desired, and (c) service delivery approach for the prioritized target population groups to be vaccinated. Be clear on outcomes for each group and the tailored delivery approach. Develop "persona(s)" for each group. Develop a process map of multiple channels to communicate, engage, and vaccinate them.
Four components of service delivery design framework
Use the four components of service delivery framework to work out the “service, products, processes, channels, communication, policy, regulation, funding, workforce (culture, capacity, capability, and leadership), facilities, locations, devices, information and technology” components. There has to be synergy between all these components. The lack of synergy will create unnecessary work, duplication, conflicts and confusion.
Performance framework
Use the Performance framework to work out the linkages between actions, measures, targets, levers, and incentives to deliver the outcomes desired. Clarity here will avoid being innudated with unnecessary reporting measures and targets.
ARSCI framework
Use the ARSCI framework to work out who is accountable, responsible, supporting, consulted, and informed for various program elements. Clarity here will avoid unnecessary meetings, discussions, and reporting,
FINAL WORD
All of the above overviews, concepts, and frameworks are useful "tools." These tools used correctly can help provide a disciplined approach for an agile, flexible, scalable, and sustainable vaccination program. There are many more details behind each of these "tools," but getting an initial understanding of these tools is a good starting point.
Chai Chuah Wellington, New Zealand September 23rd, 2020
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