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NATIONAL ASSESSMENT OF SOLAR COLD CHAIN EQUIPMENT UNDER INDIA'S UNIVERSAL IMMUNIZATION PROGRAMME 2014
NATIONAL ASSESSMENT
OF SOLAR COLD CHAIN
EQUIPMENT UNDER
INDIA'S UNIVERSAL
IMMUNIZATION
PROGRAMME
2014
PRINCIPAL INVESTIGATOR
Dr. Bhrigu KapuriaTeam Lead-Vaccine Logistics and Cold Chain ManagementImmunization Technical Support Unit, MoHFW
CO-INVESTIGATORS
1. Priyanka Parmar, ITSU2. Juthika Talukdar, ITSU3. Nithiyananthan Muthusamy, ITSU 4. Dheeraj Kumar Bhatt, ITSU
FIELD INVESTIGATING TEAMS
S.No Name of Team members State
1 Dr. Bhrigu Kapuria & Mr. Amit Sharma Odisha
2 Mr. Arvind Kumar & Ms. Nidhi Bisht Uttar Pradesh
3 Dr. Deepak Polpakara & Dr. Priyanka Parmar Meghalaya
4 Dr. Manish Pant & Ms. Juthika Talukdar Maharashtra
5 Dr. Bhrigu Kapuria & Ms. Apoorva Sharan Nagaland
6 Mr. Amit Sharma & Mr. Muzammil Lone Himachal Pradesh
7 Mr. Laxman Sharma & Ms. Amrutha Bahulekar Assam
8 Mr. Prashant Chitkara & Mr. Nithiyananthan Muthusamy Arunachal Pradesh
TABLE OF CONTENTS
1.1 Solar Cold Chain Refrigerator 14
2.1 Objective
2.2 Methodology
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3.1 National Overview
3.2 Discrepancies between NCCMIS and State-provided data
3.3 Field Assessment
3.4 Log tag data analysis
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40
4.1 Infrastructure and equipment
4.2 Practices to be introduced and maintained
4.3 Capacity building
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LIST OF FIGURES
LIST OF TABLES
LIST OF ABBREVIATIONS
ACKNOWLEDGEMENT
EXECUTIVE SUMMARY
Chapter 1 - INTRODUCTION
Chapter 2 - METHODOLOGY
Chapter 3 - RESULTS
Chapter 4 - RECOMMENDATIONS
Case Study 1 - ARUNACHAL PRADESH
Case Study 2 - ASSAM
Case Study 3 - HIMACHAL PRADESH
Case Study 4 - MAHARASHTRA
Case Study 5 - MEGHALAYA
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63
Case Study 6 - NAGALAND
Case Study 7 - ODISHA
Case Study 8 - UTTAR PRADESH
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71
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Figure 1: Model of Solar Cold Chain Equipment
Figure 2: Map showing all the states in the country having solar CCE installed
Figure 3: Percentage distribution of functional, non-functional and not installed solar CCE as per State data
Figure 4: Percentage distribution of functional solar CCE in each State
Figure 5: Percentage distribution of non-functional solar CCE in each State
Figure 6: Percentage distribution of not installed solar CCE in the identified 15 States as per State data
Figure 7: Percentage distribution of various reasons of non-functionality of solar CCE
Figure 8: Comparison of the NCCMIS and State data in percentage
Figure 9: Comparison of NCCMIS and State data in total numbers
Figure 10: Percentage distribution of average electricity supply per day of the 15 visited CCPs
Figure 11: Percentage distribution of CCH designations in the field
Figure 12: Percentage distribution of utilization of compartments of solar CCE at the functional solar CCE sites
Figure 13: Percentage distribution of reasons of non-functionality at the 8 Districts visited
Figure 14: Percentage distribution of total years of non-functionality of the non-functional equipment
Figure 15: Percentage distribution of common parts repaired
Figure 16: Percentage distribution of maintenance procedures followed by the CCH at the functional solar CCE sites
Figure 17: Difficulties faced by the State, District and CCP level officials in use of solar CCE
Figure 18: Percentage distribution of CCH trained in cold chain management and solar equipment
Figure 19: Percentage distribution of the number of immunization days in a week at the CCPs
Figure 20: Percentage distribution of the different cadres of staff members involved in vaccine distribution at the sites
Figure 21: Percentage distribution of readings of ILR within 2-8°C in the selected States
Figure 22: Percentage distribution of the readings of ILR >8°C in the selected States
Figure 23: Percentage distribution of the readings of ILR below 0°C in the selected States
Figure 24: Percentage distribution of the temperature readings of DF between 0°C to -7°C in the selected States
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LIST OF FIGURES
1
Table 1: Sampling of eight states of the identified original 15 states
Table 2: Total number and category of respondents interviewed at each level
Table 3: Framework for the assessment questionnaire
Table 4: Total number of solar CCE allocated, functional, non-functional and not installed in each of 15 states
Table 5: Detailed enumeration of the reasons (in Fig. 7) for non-functionality in solar CCE
Table 6: Matching and not matching data of total solar CCE of respective States comparing NCCMIS and State data
Table 7: Working Equipment- NCCMIS vs. State Reported
Table 8: Non Working Equipment- NCCMIS vs. State reported
Table 9: Percentage distribution of working and non-working solar equipment CCPs visited on the parameters listed below
Table 10: Percentage distribution of sites with the listed solar panel parameters
Table 11: Percentage distribution of the difficulties faced by the State, District and CCP level officials in use of solar CCE
LIST OF TABLES
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25
27
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32
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LIST OF ABBREVIATIONS
ANM Auxiliary Nurse Midwife
AVD Alternate Vaccine Delivery system
BCG Bacillus of Chalmette Guerin
CCE Cold Chain Equipment
CCO Cold Chain Officer
CCP Cold Chain Point
CCH Cold Chain Handler
CCT Cold Chain Technician
CHC Community Health Centre
DF Deep Freezer
DIO District Immunization Officer
DPM District Program Manager
DPT Diphtheria Pertussis Tetanus
HepB Hepatitis B
ILR Ice-lined Refrigerators
ITSU Immunization Technical Support Unit
LHV Lady Health Visitor
MoHFW Ministry of Health and Family Welfare
MOiC Medical Officer In-Charge
NCCMIS National Cold Chain Management Information System
OPV Oral Polio Vaccine
OVP Open Vial Policy
PHC Primary Health Centre
PHFI Public Health Foundation of India
RI Routine Immunization
SEPIO State EPI Officer
SIO State Immunization Officer
SMO Surveillance Medical Officer
SOP Standard Operating Procedure
UIP Universal Immunization Programme
UNICEF United Nations International Children's Emergency Fund
VPD Vaccine Preventable Disease
VVM Vaccine Vial Monitor
WHO World Health Organization
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We wish to acknowledge the support and guidance of officials at the Ministry of Health & Family Welfare, Govt. of India with special thanks to Dr. Rakesh Kumar (Joint Secretary -RCH), Dr. Ajay Khera (Deputy Commissioner), Dr. Pradeep Haldar (Deputy Commissioner) and Dr. M K Agarwal (Deputy Commissioner). Their continuous leadership has been pivotal in conducting this assessment.
We are grateful to all the State and District Immunization officials, State Cold Chain Officers, Cold Chain Handlers and Technicians of the visited States/Districts/Health Facilities for their valuable inputs, honest opinions and generous hospitality to the survey team.
ITSU is thankful to all partner agencies and institutions for providing the necessary guidance and support.
ACKNOWLEDGEMENT
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EXECUTIVE SUMMARY
India implements one of the largest immunization programs in the world targeting 27 million new-borns and 30 million pregnant mothers every year. Availability of potent vaccines in every part of the country, stored and transported under recommended temperatures, is a prerequisite for an effective immunization programme. Key challenges such as improperly maintained or antiquated refrigeration equipment, poor compliance with cold chain procedures and inadequate monitoring contribute to weaknesses in the vaccine cold chain network. Storing vaccines under the recommended temperature in geographically challenging areas (i.e. hills, forests, remote tribal habitations, regions with erratic or no electricity supply, or regions prone to natural catastrophes) remains a challenge for the Universal Immunization Programme (UIP). A sustainable and eco-friendly solution to ensure immunization services in such areas is the use of solar cold chain equipment which can maintain requisite temperatures to store vaccines. The Government of India, under the Immunization Programme, supplied solar cold chain equipment (CCE) to many states to increase vaccine availability and immunization coverage in hard to reach areas. As these equipment have been in place for some years now, the need was felt to review their current situation, and the advantages, disadvantages and operational challenges associated with them. In this regard, the Immunization Technical Support Unit (ITSU) of the Ministry of Health & Family Welfare (MoHFW) commissioned an assessment of solar cold chain equipment with the following objectives:
To assess the operational functionality of installed solar cold chain equipment in the vaccine cold chain
To identify implementation challenges and gaps in the operation, maintenance, and fixing of solar cold chain equipment
To understand facilitating factors and obstacles in the use and maintenance of solar cold chain equipment
To evaluate the effectiveness of solar equipment in maintaining ideal vaccine storage temperatures in various geo-climatic areas
To document best practices in relation to solar equipment use and maintenance
Methodology
A mixed methods approach was utilized, by using both qualitative and quantitative information from the field. The exercise began with a desk review of current solar cold chain equipment data extracted from two sources; the National Cold Chain Management Information System (NCCMIS), and received directly from all States. The NCCMIS portal (central electronic database) data provided an initial picture of the national status of solar CCE and their functionality. The NCCMIS data information was compared with what the States reported, and reporting gaps were identified jointly with State officials. This exercise produced a master list of solar cold chain equipment, and their status, in the country.
The master list data indicated that 15 states have received pure solar CCE. These states were divided topographically into five zones and arranged in descending order based on the number of solar CCE allocated to each. From each zone 50 percent of the states with the highest number of solar CCE were selected. One District from each state with one functional and one non-functional solar CCE was shortlisted for a field visit. Thus two Cold Chain Points (CCPs) were selected from each District representing one functional and one non-functional solar CCE. In all, 16 sites in eight states were included in the study. All officials at the State and District level who were directly or indirectly involved with the allocation, installation, repair and maintenance of solar CCE were selected; this included supervisory staff from the State and District and the end users at the cold chain point, comprising in total 31 participants. The study tool consisted of six sets of semi-structured questionnaires for interviewing participants, designed separately for the officials at different levels.
A World Health Organization (WHO) PQS temperature monitoring device ('log tag') was installed in all the eight visited functional solar CCE sites for approximately 48 hours (approximately 24 hours in the ice-lined refrigerators and 24 hours in the deep freezers) to capture the effectiveness of solar CCE in temperature maintenance. Field data collection was carried out in September-October 2014 by two member teams from ITSU, MoHFW for each state.
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Results and Discussion
a. National Overview – The national data identified 288 pieces of solar CCE in 15 states. The functionality of this equipment proved to be quite low (64%). The states of Madhya Pradesh (75%) and Assam (50%) were reported to have the highest percentage of non-functional equipment. The highest reported causes for non-functionality were battery problems (32%) followed by thermostat issues (16%).
b. Discrepancies between NCCMIS and State-provided data – There was high variability in the data shared by the respective States and their data on the NCCMIS portal. This pointed to errors in the data uploaded on the NCCMIS by Districts and was an indication that this data were not routinely monitored or checked by the State. Additionally, the functionality of solar CCE was reported to be high (84%) at the NCCMIS portal, though in actuality in the field it was found to be low (64%).
c. Field Assessment – The study findings highlighted areas with weaknesses which are critical for the success of solar CCE on a national scale. Most of the sites visited were rurally located. 94 percent had electricity supply, of which 61 percent reported less than eight hours of power supply with sporadic and frequent power cuts. In such areas, solar CCE is the only reliable means of vaccine storage.
The solar CCE was allocated to the majority of States in 2010-11 and 63 percent of SEPIOs claimed that it had been helpful to their immunization programme. Seventy five percent of SEPIOs requested more installations in their respective states. Insufficient training and staffing (data operator) were highlighted by the Cold Chain Officers (CCOs) as the main reasons behind inconsistency in information at the State level and NCCMIS.
The assessment results indicate the lack of dedicated Cold Chain Handlers (CCHs), high variability in the designations of staff given cold chain responsibilities and high staff turnover. There HR challenges result in lack of knowledge for maintaining solar CCE and neglect of the equipment. Interestingly, non-solar ice-lined refrigerators (ILR) and deep freezers (DF) were available more at functional solar CCE sites than non-functional sites, whereas the necessity was greater at non-functional sites because of their lack of functional equipment to store vaccines.
In cases with functional solar CCE equipment, their usage to store vaccines was extremely poor with only 50 percent utilization, and the remaining equipment utilized rarely or not at all. One of the major reasons for this poor utilization of functional equipment was the lack of clear communication among block/District and State officials.
STATES
Not Installed 3%
Working 64%
Not Working
33%
NCCMIS
Not Installed 0%
Working 84%
Not Working
16%
Percentage variation in data reported by state and NCCMIS
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Equipment reported as functional by the State was actually found to be empty with no vaccines stored, defeating the entire purpose of supplying solar CCE. State and District officials travelling with the assessment team were surprised to find this on reaching the health facility, and said that they were unaware of the fact that vaccines were not being stored in the equipment for months and even years together. There were security concerns raised about guarding the vital components of the solar CCE and at some places the theft of solar panel and wiring was reported. Results indicate inconsistent temperature recording practices and the presence of stem thermometers at only 25 percent of the functional solar CCE sites. The respondents did not report confronting any issues in the performance of the solar equipment on cloudy days, although they did report that the battery performance diminished as the number of cloudy days increased.
Notwithstanding the fact that seventy one percent of the Cold Chain Technicians (CCTs) had their cold chain tool kit present, the key challenges in maintaining the equipment consisted of the lack of training and spare parts. The State CCOs said that they had a shortage of spare parts and therefore could not meet demands by CCTs in the Districts. There were also no required maintenance practices to be carried out by the CCH. The study found a very low rate of staff training on the use and maintenance of Solar CCE. Only 37.5 percent of CCH were trained on the standard two day Cold Chain Handler module and in addition, only six percent had some form of training on the use and maintenance of solar CCE. The non-functional solar CCE had been non-functional either from the time of installation, or for between one to five years, and this highlights the absence of measures to
restore this critical equipment - a vital part of immunization which allows the programme to reach the unreached. The hinges and battery were the most commonly reported non-functional and defective components of the solar CCE. The study found that the hinges were fragile (75% of the functional and 62% of non-functional solar CCE visited during the study had broken hinges), were not able to support the door of the refrigerator, and broke within a few months of installation of the equipment. Besides problems with the physical equipment, the supervisory visits (41%) were also discovered to be low.
General cold chain practice findings – The practice of using handmade registers was observed at 81 percent (both functional and non-functional) of sites, while standardized printed stock registers were found at only 19 percent of sites. Similarly, the execution of the Open Vial Policy (OVP) was observed at only 38 percent of the visited CCPs (both functional and non-functional). The rest followed OVP for vaccines used for institutional deliveries.
d. Log tag findings – The temperature performance of ILR and DF spaces of the solar CCE at the functional sites was remarkably good. The overall score for the temperature readings of the ILR space from six sites was 71 percent. Two of the sites had a very low performance score whereas, the other four averaged at 95 percent. Similarly, the Deep Freezer score was also high. The overall performance score from five sites was 81 percent. Except one site, all of the sites had 100 percent performance scores, demonstrating a high level of efficacy. This emphasizes the dependability and viability of the solar CCE if well maintained and utilized.
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ILR
Percentage readings between 2°C to 8°C
0 00
20
40
60
80
100100 99 99
81
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Meg
halay
a
Mah
arash
tra
Aruna
chal
Prade
shUttar
Prade
sh
Himac
hal
Prade
sh Odis
ha
Nagala
ndAssa
m
Percentage readings between 0°C to -7°C
100 100 100 100
0 0
Meg
halay
a
Mah
arash
tra
Aruna
chal
Prade
sh Uttar
Prade
sh
Himac
hal
Prade
sh Odis
ha
Nagala
ndAssa
m
07
DF
0
20
40
60
80
100
120
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Recommendations
Given these findings, the feasibility and potential of solar technology in rural India to improve cold chain infrastructure is promising. There is a lack of a well-developed, reliable service industry to install, maintain, and repair systems in the field. Field technicians and end users must receive regular training and information to acquire and retain knowledge and skills. The recommendations below are focused around the key issues identified above:
1. Ensure availability of additional and commonly required spare parts to States
2. Ensure adequate training for CCTs on installation, repair and maintenance of solar CCE. Technicians of Districts with solar equipment currently in place should be trained with high priority
3. Ensure the inclusion of preventive maintenance for solar CCE in the CCH training regimen, and the availability of quick reference handbooks on solar CCE maintenance at Cold Chain Points
4. Utilize expensive solar CCE to the fullest by robustly mapping health facilities that need solar CCE for storing vaccines
5. Support States to update NCCMIS on a regular basis by routine monitoring
6. Redesign solar CCE installation plan to ensure safety of solar panel from theft. Building secure storage for solar CCE
7. Apply appropriate quality assurance standards during procurement, with special emphasis on quality hinges
8. Standard operating procedures should be followed during transportation and innovative mechanisms used to protect and prevent damage in extreme weather conditions
9. Issue directives issued for States to utilize cold chain maintenance funds for repair and maintenance of solar CCE
10. Streamline designation and experience of people handling cold chain and only trained personnel should be allocated solar CCE responsibility
11. Deploy transfer posting strategies to ensure that trained CCHs are deployed at required locations
12. Replace aged non-solar ILR/ DF with the newer technologies
Key field findings
Discrepancies in the data at the State and as uploaded on NCCMIS
Unavailability of spare parts at the State/ District level
Insufficient training of CCT on installations, repair and maintenance for solar Cold Chain Equipment
Poor training levels for CCHs on the use and maintenance of solar CCE
Lack of dedicated CCH and high variability in the designations of the staff given cold chain responsibilities
Under-utilization of efficiently working solar CCE
Solar CCE being non-functional since installation or for more than one year with no measures taken to make them functional at some of the sites
Defective broken hinges at a majority of sites
Safety issues; solar panel and wiring theft
Good temperature maintenance by functional solar CCE
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Immunization is one of the most cost-effective public health tools available for reducing morbidity and mortality associated with Vaccine Preventable Diseases (VPDs). India implements one of the largest immunization programmes in the world targeting 27 million new-borns and 30 million pregnant mothers
1every year . India's Universal Immunization Programme 2
(UIP) spends more than US$ 700 million a year to immunize children against vaccine preventable diseases (VPDs). The country is propounding new strategies to expand the scope of immunization and cover more children with quality vaccines. This is especially important in the light of the costly new vaccines which are being introduced, and also because of the thrust on the reduction and elimination of certain diseases including, Measles and Tetanus.
Vaccines under the UIP are sensitive to both heat and cold, and rely on temperature-controlled supply chains from the point of manufacture to the point of delivery. In a developing country like India, consistently maintaining cold chain temperature within the required range (+2 to
0+8 C ) until the last cold chain point (CCP) in geographically challenging areas (i.e. hilly, forest, remote tribal habitations, regions with erratic or no electricity supply, or prone to natural catastrophes) remains a challenge for the UIP. Critical gaps in maintaining the ideal temperature for vaccine potency limits immunization coverage in such areas. Thus for the effective implementation of the UIP, which necessitates delivering potent vaccines to the child, Cold Chain and
3Vaccine Management needs greater focus .
Improperly maintained or outdated refrigeration equipment, poor compliance with cold chain procedures and inadequate monitoring contribute to weaknesses in the vaccine cold chain. There are also huge gaps in knowledge and practice among Cold Chain Handlers (CCHs). Innovative cold chain technologies can help to improve the reliability of vaccine distribution, reduce unnecessary wastage of valuable commodities, and strengthen vaccine delivery. The current challenges are: erratic power supply, remote inaccessible areas, extreme weather conditions and transportation issues. A sustainable and eco-friendly solution to ensure immunization services in difficult areas is the use of solar refrigerators which can maintain ideal temperatures to store vaccines. Solar refrigerators can be highly reliable and effective, but have certain
limitations such as requiring an energy storage battery that needs to be replaced every three to five years, regular maintenance, trained staff, fragile parts etc. The use of solar cold chain equipment can compensate for power supply unreliability but it has its own challenges. The Government of India, under the Immunization Programme, supplied solar cold chain equipment to many States to increase vaccine availability in hard-to-reach areas.
In India, solar energy availability averages (Insolation) 5.0 kwh/sq. m/day. India has abundant solar resources, receiving about 3000 hours of sunshine every year. The field trial of the first solar powered refrigerator was carried out in 1981 in Bhoorbaral Primary Health
4Centre (PHC), Meerut . The trial in 5 regions had following results -
Refrigerator can work as a freezer to store vaccine at 0 0-10 C or as a cooler to store at 4 C but not both
The ice pack freezing capacity is low
AEG solar panel found to be fragile
High battery cost and sophisticated instrumentation for field workers
In Jharkhand state only 15 percent of the villages are electrified and a village is considered electrified even if there is only one house with electricity. Often, in many places, there is no electricity supply for weeks together. On a pilot basis, the Jharkhand government commissioned multi-power operating (hybrid solar CCE) cold chain equipment in 2005. Equipment worth INR 6 crore (approximately 1 million US dollars) was purchased initially for the pilot phase in 131 PHCs across 17 Districts. Ice-lined Refrigerators (ILRs) and Deep Freezers (DF) were connected with the batteries, which could be recharged with solar power or with electricity,
5depending on whichever was available .
Moving forward, 18 Indian States in total received solar CCE, some in 1999 and others during 2010-2011. This equipment has now been in place for a few years and the need was felt to review its current situation, the advantages, disadvantages and operational challenges associated with it.
CHAPTER 1 - INTRODUCTION
1 National Cold Chain Assessment, India, July 2008 2 MultiY ear Strategic Plan, MoHFW 2012 3 Govt. of India, Ministry of Health & FW, September 2004, UIP review, National and State Report, New Delhi 4 A. Scnur, Dr R Aslanian and Dr R kim Farley, 1985, Cold chain and Refrigerator field trials, WHO; Pg 321-3635 Health Sector Policy Reform Options database (HS-PROD). 2006. Central Bureau of Health Intelligence, MoHFW. [ONLINE] Available at: http://hsprodindia.nic.in/listdetails.asp?roid=14 [Accessed 10 December 14]
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Source: Handbook for Vaccine and Cold Chain Handlers, 2010, MoHFW, UNICEF
Refrigeratorcompartment
Freezer
Directcurrentelectricity
Changecontroller
Direct currentelectricity
Supportstructure
4-Modulephotovoltaicarray
Rechargeablebatteries
Vapor-compressionvaccine refriderator
1.1 SOLAR COLD CHAIN REFRIGERATOR
A solar refrigerator operates on the same principle as normal compression refrigerators but incorporates low voltage (12 or 24V) DC compressors and motors, rather than mains voltage AC current. A photovoltaic
refrigerator has higher levels of insulation around the storage compartments to maximize energy efficiency, a battery or a number of batteries depending upon the size of the panel for electricity storage, a battery charge regulator and a controller that converts the power from the battery to the DC form required by the compressor motor.
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Figure 1: Model of Solar Cold Chain Equipment
VC150 REFRIGERATOR / FREEZER
Solar Module Array
Module Interconnect CableArray Output Cable
30A photovoltaic Controller
Fridge Power Cable
Battery Cable
Batteries
VC150 Refrigerator
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Field Photographs of the solar cold chain equipment and its parts
Charge Controller Digital Display showing temperature reading
Solar PanelBatteries
Solar Refrigerator with ILR & DF compartmentSolar Refrigerator
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CHAPTER 2 - METHODOLOGY
2.1 OBJECTIVES
The study was carried out to assess the status and utilization of solar CCE, for India's UIP. The objectives of this study are: To assess the operational functionality of installed
solar CCE in the vaccine cold chain
To identify implementation challenges and gaps in the operation, maintenance, and fixing of solar CCE
To understand the facilitating factors and obstacles in the use and maintenance of solar CCE
To evaluate the effectiveness of solar equipment in maintaining ideal vaccine storage temperatures in various geo-climatic areas
To document best practices in relation to solar equipment use and maintenance
2.2 METHODOLOGY
To address the above objectives, the study team, utilized both qualitative and quantitative data from the field.
Both quantitative and qualitative data were collected using a survey tool with the following components: a semi-structured questionnaire with open and closed ended questions for interviewing solar equipment users and their supervisors in the selected States (interviews captured through survey investigator notes with no audio recordings); checklists on field implementation practices, knowledge and attitude of end users; and temperature data from solar CCE using a temperature monitoring device (log tag). The following steps were undertaken:
a. Desk Review The first component of the study was to assess the nationwide status of solar CCE supplied under the UIP. The data available on the central electronic database for CCE known as NCCMIS (National Cold Chain Management Information System) was reviewed for current inventory status and functionality. It was found
that two types of solar CCE are used in the country: pure and hybrid. The pure solar CCE is powered entirely by solar energy whereas the hybrid version has the provision to utilize electricity and solar power alternatively to charge the battery bank. Since the assessment addresses only pure solar CCE, hybrid equipment was not included in the study. Data were extracted from the NCCMIS on the total number of pure solar CCE in different States in the country as updated on 12 July 2014. These were listed State wise and segregated by total functioning and total non-functioning. The information available in the NCCMIS was sent to State officials for verification.
The State EPI Officer (SEPIO) or State Cold Chain Officer (CCO) was contacted via telephone or email and the data from the NCCMIS was shared. The updated data from the States was then compared with the data available from the NCCMIS portal. The States' data was used for the sampling of Districts and CCPs.
b. Sampling of sites
The sampling methods for State, District and site selection are detailed below:
State selection: Fifteen states were identified to have been allocated pure solar CCE and were divided
6geographically into five zones . States were ordered according to the number of pieces of equipment they had and the top 50 percent were selected (Table 1). Since the north-eastern zone had the maximum number of States, four out of seven states (57%) were selected from this zone. Hence, out of the original 15 states, eight states were selected for the assessment.
6 In total, there were 17 states with solar CCE in India but two states Karnataka and Andaman & Nicobar were excluded from the study data collection. Karnataka because it had only one solar CCE in the entire State, the lowest representation compared to other States, indicating lower significance; Andaman & Nicobar was purposefully excluded because of time and resource constraints.
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Table 1: Sampling of eight states of the identified original 15 states
*Jammu & Kashmir was replaced by Himachal Pradesh due to heavy floods situation in state during the field assessment in Sept 14.
Selected States
Maharashtra
Uttar Pradesh
Odisha
Himachal Pradesh*
Arunachal PradeshMeghalayaNagaland
Assam
Total Equipment
20
17
20
18
26
6
38
15
10
10
10
15 States
Maharashtra
Rajasthan
Uttar Pradesh
Madhya Pradesh
Odisha
Chhattisgarh
Jammu & Kashmir
Himachal Pradesh
Arunachal Pradesh
25Assam
15Meghalaya
Nagaland
Sikkim
Mizoram
Tripura
Zone
Western
Central
Eastern
Northern
North-Eastern
14
10
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District Selection: One District was selected from each selected state. The selection was based on Districts having at least two health facilities with one functional and one non-functional solar CCE respectively.
Site Selection: Two cold chain points were selected from each District; one with functional solar CCE and one
with non-functional solar CCE. These were selected based on recommendations by State officials on the phone or by email guided by considerations on the feasibility of access from the District headquarters. States were intimated about the selected District and health facilities well in advance of the field visits.
Arunachal Pradesh
Assam
Chhattisgarh
Himachal Pradesh
Jammu & Kashmir
Madhya Pradesh
Maharashtra
Meghalaya
Mizoram
Nagaland
Odisha
RajasthanSikkim
Tripura
Uttar Pradesh
States selected for field visit
Figure 2: Map showing all the states in the country having solar CCE installed
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c. Study Participants
All the participants at the State and District level who were directly or indirectly involved with the allocation, installation, repair and maintenance of solar CCE were selected. At the State level this comprised the State EPI Officer (SEPIO) and State Cold Chain Officer (CCO),
and at District level it comprised of the District Immunization Officer (DIO), Cold Chain Technician (CCT) and Cold Chain Handler (CCH).
The desk review, State data collection and sampling were carried out in the month of July-August 2014.
S. No. Category of RespondentsNumber as
plannedTotal number interviewed
1
2
State EPI officer 1 per state 8
State Cold Chain Officer 1 per state 8
2 per state 16Total Respondent
STATE LEVEL
S. No. Category of RespondentsNumber as
plannedTotal number interviewed
1
2
District Immunisation Officer 1 per district
1 per district
1 per district
8
8
District cold chain technician 7*
3 Functional point cold chain handler
Table 2: Total number and category of respondents interviewed at each level
* At one District there was no officially assigned CCT
DISTRICT LEVEL
1 per district 84 Non-functional point cold chain handler
Total Respondent 4 per state 31
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d. Study Tool
A semi structured questionnaire was designed to collect data from the field and interview the participants. Six sets of questionnaires were designed for interviewing participants at different levels to capture observations from the field and feedback from users on handling, maintenance and implementation issues. The framework below presents the broad headings and the areas of inquiry under which the questions were formulated.Interviewer observations were included via field notes. In order to visually document the condition of equipment, photographs were taken.
Log tag - A WHO PQS temperature monitoring device ('Log Tag') was installed in all eight functional solar CCE sites for approximately 48 hours (approximately 24 hours in the ILR and 24 hours in the DF) to capture the effectiveness of solar CCEs in temperature maintenance. The log tag took temperature readings at intervals of five minutes. A total of 3924 readings were recorded by the log tag for both ILRs and DFs, and the analysis was carried out for ILRs and DFs independently.
Our outcome of interest was the percentage of readings, within a 24 hour period, that fell within the ideal temperature range for ILRs and DFs respectively.
e. Field Data Collection
The field visits were planned in consultation with the Ministry of Health and Family Welfare (MoHFW) and State governments. Field collection was carried out between September-October 2014 by two member teams from ITSU, MoHFW for each visited each state. The State and District Immunization Officers (DIOs) were informed about the final site selections, and the officials assisted in contacting the participants and arranging appointments to visit the facilities. Every site visited by the team was pre-informed well in advance. All the interviews were guided by the study tool (detailed above). The qualitative data were collected by interviewing staff at all levels and survey investigators' notes captured staff responses and feedback. The quantitative data were collected from sources ranging from the log tag, to the equipment data extracted from the NCCMIS and State officials.
21
Table 3: Framework for the assessment questionnaire
Site Profile
Human Resource
Avg. Electricity Supply & Voltage
Training
Vaccine Logistics & Cold Chain Management
Training and regular practice
Processes
Maintenance-Tool Kit
availability-Spares
Availability
Accessibility of the site
Knowledge and practices
Safety and handling
Maintenance of stock registers
Feedback and suggestions Wear & Tear
Knowledge and practice of Open
Vial Policy
Solar Equipment
Refrigerator Condition – Panel,
Battery, Charge Controller, digital display and wiring
Catchment Population
Need of capacity building
Repair periodicity
Alternate Vaccine Delivery system
Freezing Capacity
Functionality/ Usability
Temperature Maintenance
3.1 NATIONAL OVERVIEW
A total of 288 pieces of pure solar CCE have been allocated to 15 states in India. Jharkhand reported all equipment to be of the hybrid variety procured under the National Rural Health Mission (NRHM), while Maharashtra reported a mix of hybrid and pure solar devices. Since the objective of the assessment was to assess only pure solar CEE, the hybrid equipment was not included in the study. The functionality ratio of the solar CCE was reported by the States to be very low. Of the total 288 pieces allocated, 97 percent were reported to be installed, with the remaining three percent not installed. 64 percent of the equipment was functional and 33 percent non-functional.
CHAPTER 3 – RESULTS
Not Installed 3%
Functional 64%
Non - Functional 33%
Figure 3: Percentage distribution of functional, non-functional and not installed solar CCE as per State data
The graph below depicts the status of each State with Madhya Pradesh and Assam reported to have the lowest number of functional equipment and highest number non-functional equipment. The two best solar CCE performing states were Rajasthan and Mizoram having 100 percent functionality.
0
20
40
60
80
100
120%Functional
Raj
asth
an
Miz
oram
Trip
ura
Chh
attis
garh
Meg
halay
a
Mah
aras
htra
Sikk
im
Aru
nach
al P
rade
sh
Utt
ar P
rade
sh
Jam
mu
& K
ashm
irH
imac
hal P
rade
sh
Odi
sha
Nag
alan
d
Ass
am
Mad
hya
Prad
esh
100 100
90
7974 70 70
60 60 60 60 5853
42
25
Figure 4: Percentage distribution of functional solar CCE in each State
22
Raj
asth
an
Miz
oram
Trip
ura
Chh
attis
garh
Meg
halay
a
Mah
aras
htra
Sikk
im
Aru
nach
al P
rade
sh
Utt
ar P
rade
sh
Jam
mu
& K
ashm
irH
imac
hal P
rade
sh
Odi
sha
Nag
alan
d
Ass
am
0
10
20
30
40
50
60
70
80 % Non-functional
Mad
hya
Prad
esh
75
5047
4240
35
30 3026
21 20 20
10
0 0
Figure 5: Percentage distribution of non-functional solar CCE in each State
0
2
4
6
8
10
12
% Not-Installed
Raj
asth
an
Miz
oram
Trip
ura
Chh
attis
garh
Meg
halay
a
Mah
aras
htra
Sikk
im
Aru
nach
al P
rade
sh
Utt
ar P
rade
sh
Jam
mu
& K
ashm
ir
Him
acha
l Pra
desh
Odi
sha
Nag
alan
d
Ass
am
Mad
hya
Prad
esh
10
5 5 5
0 0 0 0 0 0 0 0 0 0 0
Figure 6: Percentage distribution of not installed solar CCE in the identified 15 States as per State data
23
Table 4 : Total number of solar CCE allocated, functional, non-functional and not installed in each of 15 states
StatesTotal
AllocatedWorking
Not working
Not Installed
Arunachal Pradesh 40 24 14 2
Odisha 26 15 11 0
Assam 26 11 13 2
Maharashtra 20 14 6 0
Uttar Pradesh 20 12 8 0
Jammu & Kashmir 20 12 15 0
Madhya Pradesh 20 5 4 4
Rajasthan 19 19 9 0
Meghalaya 19 14 5 0
Nagaland 19 10 0 0
Chhattisgarh 19 15 4 0
Mizoram 10 10 2 2
Tripura 10 9 1 0
Sikkim 10 7 0 0
Himachal Pradesh 10 6 3 0
Total 288 183 95 10
The States were asked to provide reasons for non-functionality of the solar CCE. Reasons were grouped under appropriate umbrella categories.
Battery Issues32%
Solar Panel Issues20%
Refrigerator Components
issues 38%
Other Issues10%
Percentage of non-functionality reasons of the solar CCE reported by the State data
Figure 7: Percentage distribution of various reasons of non-functionality of solar CCE
24
Table 5 : Detailed enumeration of the reasons (in Fig. 7) for non-functionality in solar CCE
9%Compressor
ProblemPV Array
burnt1%
Equipment broken during
transportation
2%
10%Charge Controller
ProblemPanel Broken
10% 5%
9%
Equipment not
working3%
3%Internal Leakage
3%Wiring Problem
Main Issues
Other IssuesSolar Panel IssuesBattery Issues
Refrigerator Components issues
Specific Issues
32%Thermostat
Problem13% Panel Theft
Site not ready
Table 5 shows that the single highest reported cause for non-functionality were battery problems (32%), followed by issues with the components of the refrigerator such as the thermostat (13%), charge controller (10%), internal leakage (9%) and wiring
(3%). Problems related with the solar panel also constituted a significant portion of reasons for non-functionality (20%). Apart from these major issues, the other issues were related to readiness of the site, breakage of equipment during transportation etc.
25
3.2 DISCREPANCIES BETWEEN NCCMIS AND STATE-PROVIDED D ATA
Discrepancies were observed between the data uploaded by States on NCCMIS and the data received by the study team from State officials. This indicates that States are not updating cold chain information on the NCCMIS regularly. The NCCMIS data and State-
received data matched in only one of the 15 states. According to the NCCMIS, there were 254 items of pure solar CCE allocated to 15 states in India, of which 84 percent were stated to be working and 16 percent not working. However the data received from the States showed a much lower percentage of working equipment; 64 percent of the equipment working and 33 percent not working.
Figure 8: Comparison of the NCCMIS and State data in percentage
NCCMISSTATE
Not Installed 3%
Working 64%
Not Working
33%
Not Installed 0%
Working 84%
Not Working
16%
NCCMIS
State
Comparison of NCCMIS vs State data
0
50
100
150
250
300
Total Functional Non-functional Not Installed
254288
213
183
41
95
0 10
200
350
Figure 9: Comparison of NCCMIS and State data in total numbers
There is no data available in the NCCMIS on solar equipment which has not been installed because the NCCMIS database does not have the ability to absorb this data, thus the variation in not installed equipment is high.
26
Table 6: Matching and not matching data of total solar CCE of respective States comparing NCCMIS and State data
Sl. No. StateTotal Equipment as
per NCCMISTotal Equipment as
State reported
1 Himachal Pradesh 10 10
States having matching data
2 Maharashtra 20 20
3 Mizoram 10
4 Odisha 26 26
10
5 Sikkim 10 10
6 Tripura 10
7 UP 20 20
10
States having non-matching data
1 Chhattisgarh 6 19
2 J&K 14 20
3 Meghalaya 15
4 Nagaland 15 19
19
5 Rajasthan 17 19
6 Madhya Pradesh 18
7 Arunachal Pradesh 38 40
20
8 Assam 25 26
The data received from States and the data retrieved from NCCMIS reflect discrepancies in terms of allocation of total equipment, and working and non-working status as shown in Tables 6, 7, 8.
However, the serial numbers of equipment collected during the study team's field assessment matched the relevant serial numbers on the NCCMIS portal, except for a minute difference of one digit at 2 of the 16 sites, which is indicative of typing error.
27
Table 7: Working Equipment- NCCMIS vs. State Reported
Matching Data
Non- Matching Data
S. No.
1
1
2
3
4
5
6
7
8
9
10
11
12
13
14
State
Mizoram
Arunachal Pradesh
OdishaChhattisgarh
Madhya Pradesh
Nagaland
Himachal Pradesh
Assam
Rajasthan
MaharashtraJ&K
Meghalaya
SikkimTripura
UP
NCCMIS
10
38
23
4
11
15
10
14
17
16
10
15
8
10
13
State
10
24
14
5
15
10
11
6
19
14
12
14
7
9
12
Matching Data
Non- Matching Data
S. No. State NCCMIS State
Table 8: Non Working Equipment- NCCMIS vs. State reported
1 Mizoram 0 0
00Rajasthan2
1
2
3
4
5
6
7
8
9
10
11
12
13
Arunachal Pradesh 0 16
Odisha 3 11Nagaland 1 9
Madhya Pradesh 7 15
Assam 11 14
UP 3 8Meghalaya 0 5
J&K 4 8
Himachal Pradesh 0 4Chhattisgarh 2 4
Maharashtra 4 6
Sikkim 2 3Tripura 0 1
28
3.3 FIELD ASSESSMENT
a) Responses and feedback from state level officials
63 percent of the SEPIOs believed that solar CCE proved beneficial to the immunization programme in their respective States. Around 75 percent of SEPIOs requested an augmented supply of solar CCE ranging from 20 to 50 pieces per state. These States were supplied with solar CCE in 2010-11, except for one State which had them supplied in 1999. Most supplied equipment's were installed, but one or two items had not been installed in each State either because of broken parts (especially battery or solar panel) or the CCP not being ready. The State CCOs outlined some important reasons behind the discrepancies between NCCMIS and State reported data, which were:
Lack of human resources (data operators) to update the NCCMIS
No training provided for NCCMIS data entry
State CCOs do not have NCCMIS user id or password
Communication gap between State and Central governments on challenges in updating NCCMIS data
b) Cold Chain Point profile
Site - The primary objective for installing solar CCE was to enable vaccine storage for immunization sessions in areas with poor or no electricity supply. All the visited sites were rurally located except for one urban location. The types of health facilities where the equipment were installed were PHCs (50%), Community Health Centres (CHCs) (38%) and sub-centres and mini-PHCs (12%). Half the visited sites were located in the plains, while 38 percent were in hilly areas and 12 percent were located in forest areas.
Rough road conditions in remote areas
Remote Locations (Terrain � hilly and forest)
29
Ninety four percent of CCPs with solar CCE (functional or non-functional) had electricity supply. In Maharashtra, solar CCE was wastefully placed in a facility which received 24 hours electricity from solar hybrid. The graph below depicts the average hours of electricity supply per day at the CCPs:
From the chart above, 61 percent of sites reported less than eight hours of electricity. In Meghalaya there are at times power outages for one to two months due to damage to electric wires, especially during the rainy season. During snowfall in Himachal Pradesh there are power outages for three to four days and it becomes difficult to prevent vaccines from freezing because of low ambient temperatures. A general feedback from most visited sites is unreliable power supply with sporadic and frequent power cuts.
Lack of dedicated CCH and high variability in the designations of the staff given cold chain responsibilities - The staffing pattern to support the vaccine cold chain was also reviewed at all levels. There was no clear cut designation of the CCH in the field, and in combination with high staff turnover, this resulted in a lack of relevant knowledge and neglect in the care of equipment. Health personnel from various cadres were
acting as CCHs (19% being Auxiliary Nurse Midwives). According to government guidelines, all CCE are to be handled by CCHs but there was a lack of dedicated personnel for cold chain responsibilities. In addition, there was high variability in the designations of staff given cold chain responsibilities. The Chart below shows the varied designations of health personnel handling the vaccine cold chain.
ANM 19%
LHV 13%
Health Assistant 19%
Male Health Worker 13%
BCG Technician 6%
HS (Male) 6%
Non Medical Assistant
6%
Staff Nurse 6%
CCH 6%
Vacant Position 6%
Figure 11: Percentage distribution of CCH designations in the field
Average electricity supply reported by the CCP's
8 - 20 hrs31%
< 8 hrs61%
21 - 24 hrs8%
Figure 10: Percentage distribution of average electricity supply per day of the 15 visited CCPs
30
c) Solar cold chain equipment
Status - There was inconsistency in the distribution of the non-solar and solar CCE at the visited sites. Seventy five percent of the functional solar CCE sites and 44 percent of the non-functional solar CCE sites had non-solar ILRs and DFs. This highlights a lack of detailed mapping of sites that need solar CCE for storing vaccines.
All solar sites visited during the field assessment (both functional and non-functional) had Dulas VC 150F solar equipment with ILR and DF capacity. As an exception, at one of the non-functional sites, it was found that the non-functional solar CCE was used to store vaccines because of the absence of any other CCE for vaccine storage (not even a domestic refrigerator); upon further discussion with the health officials it was observed that the equipment was maintaining the requisite temperature intermittently and three vials were found inside with unusable Vaccine Vial Monitor (VVM) status.Usually, the solar CCE supplied under the UIP had both the ILR and DF compartments built into a single piece of equipment, and this was observed at all sites. The chart below illustrates the utilization rates of the ILR and DF compartments.
Under-utilization of solar CCE - A major finding of the field assessment is that functional solar CCE are underutilized in storing vaccines. Sites visited by teams in 50 percent of the States found no vaccines being stored at functional points. Utilization of the solar CCE was very poor in spite of well-functioning equipment. Some District officials were found to be poorly informed on the status and the utilization of solar CCE in CCPs under their jurisdiction. At one health facility the solar CCE was used only during power outages. In others, the solar CCE was utilized to store vaccines only during adverse weather conditions like (snowfall, heavy rainfall) when there was no electricity supply which could vary from two days to two months. Otherwise, these solar refrigerators were left empty. The main reasons for non-usage of functional solar CCE were either wrong site selection, untrained staff, miscommunication or negligence.
One quarter of the functional sites used the deep freezer compartment of the solar CCE to freeze ice packs. The ice packs were found in hard frozen condition at one site and fully melted at another. At the remaining 75 percent of the sites alternative sources (ex. non-solar DF) were used for freezing ice packs. Overall, there was poor utilization of functional solar equipment.
Components of solar CCE - The hinges and battery were the most common non-functional and defective components of the solar CCE. Hinges had the highest percentage of non-functionality and were found broken in 75 percent of functional solar CCE and in 62 percent of non-functional solar CCE (Table 9). 43 percent of batteries were found non-functional at the non-functional sites. Solar CCE and its components, such as electrical wires, charge controllers and solar panels were all reported as “visibly ok”. One of the survey investigator observed that for the defrosting process there was no provision for water drainage outlet in the solar CCE.
None 38%
Both 37%
ILR 25%
DF0%
Figure 12: Percentage distribution of utilization of compartments of solar CCE at the functional solar CCE sites
Empty refrigerator compartments
31
Broken Hinges
Table 9: Percentage distribution of working and non-working solar equipment CCPs visited on the parameters listed below
Functional CCPs (8 sites)
ProcessesReplaced / Repaired
Non-functionalPresent Functional
Battery 100% 100% 0% 12%
Digital Display 88% 71% 29% 0%
Hinge 100% 25% 75% 12%
Door Lock 63% - - -
- - -Insulation Pad 100%
Battery 88% 43% 43% 0%
Hinge 100% 38% 62% 0%
Door Lock 50% - - -
- - -Insulation Pad 100%
Non- Functional CCPs (8 sites)
32
There were serious security issues reported for the solar CCE. Three sites reported theft of one or more components of the solar CCE, of which two consisted of solar panel theft. At one place the stolen items were recovered but then locked away and not used further. At the third site the light wiring (earth wire) was stolen
after one month of installation. Most of the solar panels were placed on the roof top (88%) with 79 percent reported to be fixed with nuts and bolts. The study found variations in the numbers of solar panels installed among the visited sites. There was no uniformity in the number of solar panels supplied to the States.
Table 10: Percentage distribution of sites with the listed solar panel parameters
Location
Condition
Fixing
Clean & dirt free
Replaced or Repaired
Relocated
Solar Panel Parameters Percentage %
Roof top
Outside the building
Kept inside
Intact
Concrete
Nuts & bolts
88%
6%
1%
100%
21%
79%
92%
12.50%
0%
Stolen Solar Panel area on the roof top which had been fixed by nuts and bolts
33
Reasons of non-functionality in the Districts - The visited Districts were questioned to identify reasons for non-functionality of solar equipment. In contrast to the National data, at the Districts the highest stated reasons of non-functionality were solar equipment not working, followed by controller problem.
The above chart indicates that of the non-functional
equipment, 37 percent had been non-functional for less
than one year and 50 percent had been non-functional
for between one to five years or since installation. Thus
the majority of the non-functional equipment has been
non-functional for a prolonged time and this highlights
negligence and an absence of measures taken to restore
defective equipment.
36%
22%
14% 14%
7% 7%
Percentage
Equipment not working
Controller problem
Battery not working
Panel stolen
Choking of compressor
Awaiting SCCE transfer to
upgraded CCP
Figure 13: Percentage distribution of reasons of non-functionality at the 8 Districts visited
Since installation25%
< 1 yr37%
1-5 yr25%
> 5 yr13%
Figure 14: Percentage distribution of total years of non-functionality of the non-functional equipment
34
Temperature recording - Study results indicate inconsistent temperature recording practices and inadequate availability of stem thermometers at the functional solar CCE sites. As per government guidelines, temperature recordings of solar CCE are to be carried out with the help of stem thermometers, and only a quarter of the functional sites were found to have stem thermometers inside the solar CCE. 71 percent of sites had functional digital temperature displays on the solar CCE. However there were 25 percent functional sites having neither a functional thermometer nor a digital display. Temperature logbooks were available in five of the eight functional sites. Upon verification of temperature logbook data for the past year, four had their temperature recorded within range and at the remaining site the temperature had dropped because of snowfall in winter. None of the functional solar CCE had unusable VVM vials stored.
Effect of different weather conditions -The only source of energy for solar CCE is sunlight. The respondents had not faced any issues (0%) in the performance of solar CCE during cloudy days although; they reported that the battery performance decreased as the number of cloudy days increased. Responses on the average effective working days during cloudy weather for a solar CCE were between 2 to 7 days. One CCO also stated that solar equipment work well in daylight and direct sunlight is not required. Rain and the winter season (especially snowfall) have some impact on the amount of battery charge but the equipment practically never shuts down even in the worst of weather conditions.
Repairing solar CCE – The key challenges highlighted by the CCT in repairing solar CCE was lack of training and spare parts. The State CCOs mentioned that they had scarcity of spare parts and therefore were not able to meet demands by the CCT for spare parts in the Districts. Despite multiple requests to the Central government for spare parts, they had not received them. One of the respondents said that if the request was made to the State, it took one week to get spare parts delivered. But requests to the Central government made one to two years ago have not been responded to. Seventy one percent of the CCTs had their cold chain tool kit present. The solar CCE or its components were reported to have been repaired at 33 percent of the visited sites (both functional and non-functional). Of this number 80 percent had been repaired once and 20 percent repaired twice.
The study found that the hinges were fragile and not able to support the door of the refrigerator and broke within a few months of installation of the equipment. Modifications to the solar CCE were only carried out with respect to the hinges. Two of the 16 sites had their hinges repaired and modified by making local arrangements. The wiring was reported to be damaged at one of the sites because of being bitten by rats. Battery replacement was reported as required on an average every 10 years. The CCTs reported that the spare parts ordered were most commonly charge controllers, battery chargers, solar panels and sensors.
Figure 15: Percentage distribution of common parts repaired
Hinges 40%
Wiring20%
Sensor20%
Battery 20%
Locally replaced hinge
35
Figure 16 : Percentage distribution of maintenance procedures followed by the CCH at the functional solar CCE sites
50%
Defrosting
38%
Panel Cleaning
25%
Externally cleaningSCCE
Personal Views of the respondents – The personal views stated by State officials at all levels about the life of solar CCE ranged from two to 15 years, with an average
of 8.5 years. The difficulties faced by officials in use of the solar CCE are detailed below:
Table 11: Percentage distribution of the difficulties faced by the State, District and CCP level officials in use of solar CCE
0% 0% 29% 14% 36%Unreliable temperature maintenance
36%Low hold over time 0% 13% 14% 29%
Frequent breakdown 25% 13% 14% 29% 18%
Spare parts unavailable 63% 100% 86% 100% 45%
Inadequate training 63% 100% 86% 100% 82%
Other 38% 50% 57% 43% 55%
SEPIO CCO DIO CCT CCH
No knowledge on maintenance of solar CCE -There had been no training or guidelines on repair and
maintenance at any of the health facilities. As a result, CCHs
had no appropriate knowledge on the maintenance of solar
CCE. The only guidelines followed were from the solar CCE
manual, and only 25 percent of the 16 visited sites had these
manuals available. Twenty five percent of the functional solar
CCE sites did not practice any maintenance procedures.
Guided by the Medical Officers in Charge (MOiC) and their
knowledge from cold chain handling training, a few of the
steps undertaken at certain sites are illustrated in Figure 16.
36
Difficulties faced by the State, District and CCP level officials in use of solar CCE
0%
20%
40%
60%
80%
100%
120%
Unreliable temperature maintenance
Low hold over time
Frequent breakdown
Spare parts unavailable
Inadequate training
Other
% o
f the
res
pond
ents
sai
d ye
s
Figure 17: Difficulties faced by the State, District and CCP level officials in use of solar CCE
SEPIO CCO CCT CCHDIO
As shown by the graph above, the most common difficulties faced by officials from State to CCP level were inadequate training and unavailability of spare parts. These were followed by unreliable maintenance of temperature, frequent breakdowns and other challenges. The other challenges faced are as follows:
Broken hinges, as hinges are very fragile and plastic hinges should be replaced by metal ones
When the condition of batteries deteriorate, there are problems in solar CCE performance
Security concerns for solar equipment (e.g. theft)
Regular maintenance
High staff turnover
Difficulties in transporting solar CCE to the hard-to-reach CCPs
Deep freezer has low ice pack capacity (e.g. During polio campaign)
Imported spare parts are very costly, indigenous products should be provided
Sensor defects and some equipment received with no/less gas in compressor. Also, some equipment designed for the plains not good enough for hilly areas.
To overcome these challenges, various suggestions were also made during the discussions:
Suggestions for better performance of solar CCE
If solar CCE is maintained efficiently then there is an increase in its lifespan and performance. Capacity building and timely procurement of spare parts plays fundamental role in that
It is very important to build trained manpower to handle solar CCE responsibilities
There should be half yearly or yearly maintenance of solar CCE by the manufacturer, which will prolong the effectiveness of solar CCE
Protection of solar panels from snowfall is vital in extreme weather conditions. Likewise there are concerns about theft of parts of the solar CCE such as solar panels, battery, wiring etc.
There is a need for DFs with increased storage capacity and extra batteries in highly populated areas
As much as possible procurement of solar CCE with widely and easily available spare par ts. Complementing this, as much as possible, decentralized procurement of spare parts and maintenance procedures
Increased funds for cold chain maintenance and clear guidelines on how to use those funds
37
d) Human Resource
Inadequate/ poor training on solar CCE - As per the government guidelines, CCTs should be trained on the installation, repair and maintenance of CCE, and CCHs on its use and maintenance, as part of a two day cold chain handling training. When solar equipment were first a pool of CCTs were trained from those States/Districts where solar devices were to be supplied. These CCTs were provided with hands-on training to install, repair and maintain solar equipment locally. The study found, however, a very low rate of staff training on the repair, use and maintenance of solar CCE. Only 37.5 percent of CCHs were trained on the standard two day CCH curriculum. Moreover, only six
percent had some form of training on the use and maintenance of solar CCE. The charts below show the percentage of CCTs and CCHs who underwent the aforementioned training.
On-the-job capacity building in cold chain management is of utmost important. At present, there is only one specialized training centre in Pune with limited capacity which provides 'on-the-job' cold chain training at the national level.
Supervision - Supervisory visits to the CCPs in the last month were reported to be low; 41 percent of the respondents reported that there had been supervisory visits once a month.
7Figure 18: Percentage distribution of CCH trained in cold chain management and solar equipment
37.50%
6% 6%
2 days CCH training Use & Maintenance of SCCE Any other training
0%
10%
20%
30%
40%
SCCE installation training
SCCE repair &maintenance training
FIELD
29%
14%
0%
5%
10%
15%
20%
SCCE installation training
SCCE repair &maintenance training
STATE
17%
9%
Figure: Comparison of percentage of CCTs who had solar CCE training from the field interviews and in the whole of the selected 8 states
7 At one site the MOiC was handling Solar CCE and had received UIP training
38
e) Vaccine log ist ics and cold chain maintenance system
General cold chain practices - Sixty nine percent of the CCPs had once or twice weekly immunization days, while one State said that immunization days were held only during special immunization weeks over a couple of months. The most common days on which Immunization days were conducted in the States were Wednesday and Saturday (50%), the remaining 50 percent being on the other days of the week. The standardized printed stock registers were found at 19 percent of the sites; elsewhere, in the remaining 81 percent of the sites (both functional and non-functional) handmade registers were used. Fifty percent of these standardized registers were found updated and entered till the latest stock transactions. One of the survey investigator observed that the solar CCE and non-solar CCE were scattered within the same building on different floors.
There was no clarity in the distribution patterns of
vaccines to session sites. Instead of an Alternate Vaccine
Delivery (AVD) mechanism, 72 percent of the CCPs
supplied vaccines to session sites through health workers
of varying designations ranging from Female Health
Worker (FHW), Lady Health Visitor (LHV), Health
Assistant (HA), Pharmacist, staff nurse, Health
Supervisor-male to Grade 4 staff.
Open Vial Policy (OVP) practice - Implementation of OVP was observed in only 38 percent of the CCPs visited (both functional and non-functional). Maharashtra state was not following OVP at session sites and thus District officials had no knowledge about it. However one of the visited health facilities was following OVP for tOPV, Hep-B and TT for institutional deliveries only. Similarly, other states follow open vial policy for Hep – B vaccines during institutional deliveries, or vaccines that are used only at the health facility. At many places OVP is not being followed because of remote session sites and the inability to return vials on the same day.
At the 63 percent of the functional sites where open vials
were found during field visits, 86 percent of open vials
were segregated from the unused vaccines by placing
them in a separate container, basket, polythene bag or
ILR. The Open Vial distribution was not recorded in
stock registers at any of the sites. Contrary to the
guidelines for implementing OVP, the recording of date
and time for open vials was sporadic, and at some places
the CCH stated that due to moisture the writing on the
vials disappeared. Out of the 16 CCPs, one site had vials
with unusable VVM statuses; while two vials had
moderate to large VVM colour degradation.
Percentage of staff members involved in vaccine distribution
Figure 20: Percentage distribution of the different cadres of staff members involved in vaccine distribution at the sites.
72%
14%
14%
AVDASHAHealth Worker
Immunisation days in a week at the CCPs
Figure 19: Percentage distribution of the number of immunization days in a week at the CCPs
Once 31%
Twice 38%
Thrice 8%
Other 23%
*other includes once a month and SIWs
39
3.4 LOGTAG DATA ANALYSIS
a) ILR
The temperature reading of the ILR compartment of solar CCE for 24 hours was divided into three segments
0 0 0 0<0 C, ideal range from 2 C to 8 C, and >8 C. The temperature performance of the ILR compartment of solar CCE at the functional sites was remarkably good. Out of the eight visited sites, solar equipment readings from two sites (Maharashtra and Odisha) were excluded for the total performance score. The field assessment team found that these equipment were not used for
storing vaccines and no attention was paid to them by the staff members.
Among the remaining 6 sites the overall average performance score was 71%. This shows the trustworthiness and efficacy of the solar CCE if maintained, used and paid attention to well. Four of the solar CCE demonstrated very high performance, with the average of their total scores standing at 95%. One site had a 46 percent performance score. Alarmingly, one site that was storing vaccines in solar CCE had only 3% of the temperature readings within the ideal range.
100 99 99
81
46
3 0 0
0
20
40
60
80
100
120
Meghalaya MaharashtraArunachal Pradesh
Uttar Pradesh
Himachal Pradesh
OdishaNagalandAssam
o o% Functionality of solar refrigerator in 2 C - 8 C
0Figure 21: Percentage distribution of readings of ILR within 2 C-8°C in the selected States
Figure 22 : Percentage distribution of the readings of ILR >8°C in the selected States
100 99
1 0 0
0
20
40
60
80
100
120% Functionality of solar refrigerator >8°C
MeghalayaMaharashtra Arunachal Pradesh
Uttar Pradesh
Himachal Pradesh
Odisha NagalandAssam
0 0 0
40
b) Deep Freezer
The temperature reading of the DF compartment of the 0
solar CCE for 24 hours were measured between 0 C to -07 C. The performance of the Deep Freezer
compartment corresponded to the ILR score. Out of the eight sites, solar equipment readings from three sites (Nagaland, Odisha and Himachal Pradesh) were excluded for the total performance score. The field
assessment team found that in these equipment DF space was not-utilized because of availability of alternative non-solar DF, and no attention was paid to them by the staff. Among the five remaining sites the overall average performance score was 82 percent. This showed promising efficacy of the Deep Freezer Space. Four of the devices demonstrated very high 100 percent performance score, except one site with a very low performance of 7 percent.
19
13
0 0 0 0 0 0
0
2
4
6
8
10
12
14
16
18
20 % Functionality of solar refrigerator below 0°C
MeghalayaMaharashtraArunachal Pradesh
Uttar Pradesh
Himachal Pradesh
OdishaNagaland Assam
Figure23 : Percentage distribution of the readings of ILR below 0°C in the selected States
100 100 100 100
0 0
0
20
40
60
80
100
120
MeghalayaMaharashtraArunachal Pradesh
Uttar Pradesh
Himachal Pradesh
OdishaNagalandAssam
7 0
% Functionality of solar freezer in 0°C to -7°C
Figure 24: Percentage distribution of the temperature readings of DF between 0°C to -7°C in the selected States
0The tendency towards freezing temperature i.e. <0 C was found to be low (average 16% readings) at two of the sites.
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ILR DF
Assam
Himachal Pradesh
ILR DF
Individual readings of ILR and DF compartments of solar CCE obtained from their respective States.
ILR DF
Arunachal Pradesh
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MeghalayaILR DF
Maharashtra
ILR DF
Nagaland
DFILR
43
ILR DF
Odisha
ILR DF
Uttar Pradesh
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CHAPTER 4 – RECOMMENDATIONS
In order to address the weaknesses identified by the assessment and to improve solar CCE performance, the following recommendations are proposed. These recommendations will help in effectively utilizing much needed solar CCE to ensure that the immunization programme reaches the most difficult and remote areas. The recommendations are based on field data and the study team's observations, and have been categorized into the following three areas:
1: Infrastructure and equipment
2: Practices to be introduced and maintained
3: Capacity building
Table on next page
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Incidence of solar panel and other equipment damage reported by t h e C C H e i t h e r d u e t o transpor tation or extreme weather conditions (e.g. snowfall/ hailstorm).
Standard operating procedures should be followed during transportation and innovative mechanisms devised to protect and prevent damage in extreme weather conditions.
Central/ State
Major Gaps Action RequiredLevel at which
action is required
Unavailability of spare parts at the State and District level causing easily repairable equipment to be non-functional for a prolonged time.
It should be ensured that additional essential spare parts are provided to the States.
Ensuring that Districts have readily available components of solar CCE in store.
Central
Poor utilization of solar CCE –Functional solar CCE are not utilized for vaccine storage.
Detailed mapping of sites that need solar CCE for storing vaccines.
Utilize expensive equipment such as solar CCE to the fullest.
State/ District
High reported theft and security issues especially solar panel theft.
Rigorous mechanisms to safeguard solar panels either through an iron grill or identifying fixing procedures that are more secure than nuts and bolts.
Building secure infrastructure to store solar CCE and its components.
State
Poor quality easily breakable hinges because of which the top lid of the refrigerator doesn't close properly and compromises temperature maintenance.
Great emphasis should be placed on quality hinges during procurement of equipment.
Alternatively, CCT should be trained during installation on repairing hinges.
Central
Episodes of freezing of vaccines have been reported by the CCH during extreme weather con-ditions (esp. snowfall) due to low ambient temperature.
Provision for room heating should be provided in areas experiencing snowfall and low temperature to maintain ideal ambient temp-erature. Alternatively, special equipment procurement can be considered that can prevent vaccines from freezing in low temperature.
Central
4.1 INFRASTRUCTURE AND EQUIPMENT
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Major Gaps Action RequiredLevel at which
action is required
Varying number of solar panels at the cold chain points in different Districts/ States.
Uniformity should be maintained in number of solar panels with each piece of solar equipment supplied across States.
Central
A high percentage of solar CCE were reported non-functional due to battery problems.
Batteries should be readily available for replacement at the State and District level.
Directives should be given to the States to utilize cold chain maintenance funds for replacing batteries. Alternatively, battery free solar equipment can be procured to avoid non-functionality due to battery problems.
Central
Low DF capacity for SIWs and highly populated areas – insufficient to freeze ice packs to cater to the catchment population.
Robust planning and mapping of areas with increased demand during immunization sessions.
Supplying either 2 Solar CCE or a bigger unit.
Pre-planning and arrangement of ice-packs for SIWs.
Central/ State
Low availability of stem thermometers in the solar CCE.
Regular temperature monitoring and provision of one thermometer in each solar CCE.
State/ CCP
Aged (more than 10 years) non-solar ILR/ DF in use.
Replacement of aged non-solar ILR/ DF with newer techno-logies. Central
All the cold chain equipment should be placed together so that suitable supervision and monitoring of all the devices can be done by the CCH.
District/ CCP
Scattered placement of Cold Chain Equipment (including both solar and non-solar) on different floors in the same building. Abandoning less utilized and non-utilized equipment.
Solar CCE specifications should include drainage system during defrosting. Central
No outlet for water drainage on defrosting.
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Major Gaps Action RequiredLevel at which
action is required
Significant lack of training of CCT on repair and maintenance of solar CCE at the District and State levels.
Significant lack of training of CCH on use and maintenance of solar CCE.
There are 125 Districts in the country with solar CCE and priority action should be taken to train these CCT on repair and maintenance of solar CCE and also on installation and re-installation.
There are approximately 288 CCH handling solar CCE in the country. Priority training should be given to the CCH handling solar CCE. Also, there should be special and mandatory inc lus ion of prevent ive maintenance training of solar CCE in the cold chain handler training.
A quick reference handbook on Solar CCE maintenance should be made available at the Cold Chain Points.
Central/ State
Central
4.2 PRACTICES TO BE INTRODUCED AND MAINTAINED
Lack of supervision and monitoring of solar CCE at the Cold Chain Points.
Uncertainties in fund utilization guidelines and lack of funds for the repair of Solar CCE in the State.
A robust supervision plan to be made at each District to ensure at least quarterly supervisory visits.
Clear guidelines on the judicious use of cold chain maintenance funds in repairing all cold chain equipment (including solar CCE).
District/ State
Central
Negligible attention paid to non-functional solar CCE and the absence of proactive steps to repair them.
Functionality of solar CCE to be monitored by Central and State governments and provisions to be undertaken to make them functional.
Central/ State
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4.3 CAPACITY BUILDING
Major Gaps Action RequiredLevel at which
action is required
Non-uniformity in designations of staff handling cold chain and solar CCE, in combination with insufficient training.
Streamlining designation and experience of people handling cold chain. This should include special training for people handling solar CCE. Only trained personnel should be allocated solar CCE responsibility.
State
High staff turnover (Cold Chain Equipment).
Deploying transfer posting strategies to ensure that trained CCH are deployed in required positions.
State
Discrepancies in data uploaded on NCCMIS and State.
Supporting States in capacity building and other activities to ensure timely data uploads.
Routinely monitoring NCCMIS for updated data.
Central
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CASE STUDY 1 – ARUNACHAL PRADESH
Arunachal Pradesh is a north eastern state of India with riverine and hilly terrain, thus having hard to reach areas. It has sparsely populated areas. Arunachal Pradesh was allocated 60 pieces solar CCE out of which 58 were installed. The team was informed that UIP Routine Immunization (RI) activities had been suspended in all of Arunachal Pradesh since September 2013, especially in hard to reach and inaccessible areas. Special Immunization Weeks were carried out in such areas and vaccines were sent through cold boxes. Earlier when RI was undertaken the difficulty was that the ANM had to walk for hours to reach session sites because of the very poor condition of roads and hilly terrain, and therefore it was discontinued. Five Districts had vaccine vans and used these to pick up vaccines from the State store. The remaining Districts were awaiting the receipt of vaccine vans – currently using 4WD vehicles with cold boxes for transporting vaccines.
Functional solar equipment site
The PHC was located in a plain area and easily accessible from the District headquarters with good road conditions. There was only one item of cold chain equipment that was a solar refrigerator. The electricity supply of the area was very poor with average power supply of 10-12 hours a day and very low voltage, which could not support electrical equipment and damaged the equipment. It was reported that electricity was supposed to be supplied at 100 volts, but in reality only 50 volts was received.
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Photo 2 : Solar Cold Chain Equipment
Photo 1 : Remote hilly location of the Cold Chain Point
The solar panels provided were for installation on flat surfaces, whereas the PHC had a slanting roof, so the staff had to apply some degree of ingenuity in ensuring that the panels were firmly fixed on the roof. The panels looked well installed. The temperature in the solar CCE was within the requisite range but there was a two degree difference between the display and the dial thermometer. The hinge had broken and new locally arranged hinges were installed. These new metal hinges were taken from another electrical appliance (not for vaccine cold chain), and modified to ensure appropriate fit for the CCE.
Photo 4: Locally replaced metal hinges
Photo 3: Solar panel placed on slanting roof top
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Issues Identified:
VVMs were all within the usable range. Certain vials displayed some heat exposure, but the CCH explained that sometimes vials were received from higher levels with VVMs in Stage 2.
While no frozen vials were found, heavy sedimentation was observed in some (not all) DPT vials, which is a sign of severe freeze damage.
Photo 6: Vials showing heavy sedimentation
Photo 5: Heat exposed vials with VVM in stage 2
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Non-Functional solar equipment site
The PHC was very remotely located and road condition was very poor. The team took five hours from the District headquarters to reach the PHC which was approximately 90 km away. Because of the isolated location only Special Immunization Weeks were carried out in the area. The sub-centres could only be reached by foot – it took up to four hours one way to walk to some of them. The population of the health facility numbered 65. The MOiC claimed that the voltage was alright – but this statement needs to be qualified by the fact that his knowledge of the vaccine cold chain was generally poor. Cold chain responsibility was given to the staff nurse/ General Nurse Midwife who was not trained for cold chain work.
Key issues and recommendations
The DIO reported that local procurement of spare parts, such as batteries, could not happen due to non-availability of funds.
The State government provides very little financial support to health programmes – there is almost complete dependence on the National Rural Health Mission for funding.
An outlet drain is required for the defrosting of the Deep Freezer.
The Solar refrigerator was non-functional and ice packs were stored inside. The wiring of the charge controller was broken and it was not functional.
Photo 8: Ice packs stored in non-functional deep freezer Photo 9: Broken charge controller wire
Photo 7: Sparsely populated hilly areas
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CASE STUDY 2 – ASSAM
Assam is located in the north eastern part of India and has hilly terrain. The state was provided with 26 pieces of solar CCE of which 24 had been installed. When the study team visited Assam it had been raining heavily there for three to four days and the entire Guwahati District area was water- logged and flooded. Therefore, after meeting the State CCO at the State capital, it was decided to change the pre-selected District because of water-logging.
Functional solar equipment site
The functional site had well installed solar CCE which was in good condition. In spite of heavy rainfall in the area during the past few days the solar CCE was found operating efficiently. Due to the rainy season they were using only the ILR component for keeping the vaccine and not the DF component. According to them, the available batteries were not sufficient in the rainy season to operate both of the spaces of solar CCE, and thus they had switched off the DF component. The CHC building was clean.
Photo 11: Solar panel installed at the slanting roof top
Photo 10: Bad road conditions to the health facility
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The good practices observed were timely defrosting and temperature monitoring and regular cleaning of the equipment. The issue reported by the staff was insufficient capacity of the DF and they suggested additional batteries to meet the need.
Non- functional solar equipment site
The visited health facility was initially a State Dispensary, now converted into a mini PHC. Earlier, when the solar equipment was working the facility was serving as an operational CCP. Since the theft of the solar panel from the rooftop eight years ago, however, the health facility had been non-operational. Vaccines were not stored there. Electricity was available for only two to three hours every day and the low voltage meant that it was unable to support electric cold chain equipment. The vaccines were supplied from the nearby health facility. Batteries were dead because of non-use since the last few years and were locked in a box. The CCH stated that even when the solar CCE was functional, the solar DF was not sufficient to freeze icepacks as per the requirement.
Key Issues and recommendations:
The efficacy of the solar CCE decreased during the rainy and winter seasons. The batteries which were supplied were insufficient in the areas of increased demand and additional batteries were required to support increased demand.
There was lack of maintenance knowledge.
There were security issues and the health facility lacked the provision to securely store solar CCE.
There were no supervisory visits to the area in the last month. A supervisory plan should be created at District level to ensure all CCPs were visited at least once a quarter.
Photo 13: Roof top area from where the solar panel was stolen
Photo 12: Detached insulation pad
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CASE STUDY 3 – HIMACHAL PRADESH
Himachal Pradesh is located in the northern part of India having hilly terrain. It has remotely located areas with extreme weather conditions especially during winter when there is snowfall. Additionally there are poor road conditions and lack of infrastructure. A total of 10 items of solar CCE were allocated to Himachal Pradesh state in 2010. Eight of them had been installed. The remaining two were allocated to Kinnaur District but were not installed because the health facility was not ready. Out of the eight installed in the State, two were reported to be non- functional.
Officer on Special Duty (OSD) – Reproductive and Child Health had additional charge of SEPIO in the State. There were three CCTs for the whole State to maintain the cold chain equipment, but none of them were trained on installation, repair and maintenance of the solar CCE. The CCT from Madhya Pradesh was called for installation of solar CCE in the State. Three CCPs were visited by the study team. The electricity supply to these facilities was throughout the year except during winter. During heavy snowfall power disruption for two to twenty days was reported. The ambient temperature
0went below 0 C during snowfall and because of power disruption cottons were used inside the ILR to prevent vaccines from freezing. The District was sparsely populated and as a result immunization sessions were conducted once in a month or once in two months. Thus at the PHC level DF /ILR was more than sufficient or hardly utilized for storing the vaccine Some health facilities preferred to get the vaccine directly from the CHC instead of storing it at the PHC. The State was implementing OVP, A health worker from one of the health facilities was trained in OVP and had an official letter certifying this, but the CHC official was not confident about this. It was observed that in many places OVP could not be implemented as sessions were conducted once in two months or three months.
Functional solar equipment site
ndThe PHC was located in a hilly terrain with sparse population. The immunization sessions were held once on the 2 of every month. The PHC was headed by a Medical Officer and catered to one sub-centre. Though the PHC had fully functional solar CCE with proper temperature display and 99 percent battery, it had not been utilized since it was installed. This solar refrigerator was initially planned to be installed at the CHC but it was installed at the PHC without any planning. The reason for not installing at the CHC was because of inaccessibility to the roof. The PHC had proper power supply and an additional power generator, and as per the Medical Officer, the solar refrigerator was not required at this facility and could be shifted to some other place where it was required.
Photo 14: Solar cold chain refrigerator
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The area faces extreme weather conditions especially snowfall, and there was no provision to protect the solar panel placed on the roof top. As a result one of the three solar panels was broken due to snowfall.
Issues:
Lack of proper planning and need for installation of solar CCE.
Lack of personnel to handle solar CCE.
Wastage of solar CCE by non-utilization of its potential.
Photo 16: Broken solar panel photograph 2
Photo 15: Broken solar panel due to snowfall
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Non- functional solar equipment site
The health facility was a sub-centre. On visiting the non-functional solar equipment site, the sub-centre was found locked and CCH was not present. The CCH was interviewed on the phone but could not continue for long because of weak network. The health supervisor of a nearby PHC opened the health facility door and helped in accessing the facility. As per the PHC staff and DIO, the solar CCE worked for two months only, but nobody knew the reason for non-functionality. The solar CCE temperature log book had readings recorded from the month of September 2012 to March 2013, and the last recorded days showed the high temperature readings. During investigation it was found that battery indicator showed 98 percent battery backup but no indicator light on the solar ILR. The solar refrigerator was visually OK and but as soon the lid was opened, the left plastic hinge broke.
Key Issues and recommendations
There was lack of monitoring and personnel to handle solar CCE in the State.
There was the safety issue of protecting the solar panels from heavy snowfall as a solar panel of one of the health facilities got damaged in this way.
Need for training of CCHs on solar CCE.
Mapping of CCPs which needed solar CCE. Relocation of solar CCE based on electricity supply, population to be catered to and available infrastructure/human resource.
Replacement of plastic hinges to steel ones as plastic cannot sustain the load.
Photo 17: Broken hinge
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CASE STUDY 4 – MAHARASHTRA
Maharashtra state is located in the western part of the country with plain terrain and areas with high solar insolation A total of 20 items of solar CCE were allocated to the state in 2010 and all of them have been installed. Of the total, 14 were reported functional at the time of assessment. In Maharashtra, the State government has initiated projects where numerous health facilities located in the remote areas are run entirely on solar power. Multiple solar posts have been installed in the premises of the health facilities and the whole facility utilizes electricity generated from these solar posts. As a result, the health facilities visited did not utilize solar CCE having alternative dependent solar sources with 24 hour back up. The State CCO stated that even during the rainy season there was a good amount of back up supply that sustained the equipment for one week without sunlight.
Functional solar equipment site
The PHC was situated at a distance of about 150 kms from the District headquarters and it took around four and a half hours for the study team to reach there. It was hilly terrain and the conditions of the roads had deteriorated due to heavy rainfall in the past week. The PHC was located in a forest area and catered to the tribal inhabitants residing in that area. This whole facility had eight solar posts and the entire facility was dependent on the power generated by them and not on the regular electric supply. There were two CCTs for the District – one permanent and one in a contractual position.
We were informed that if fully charged, the whole facility could run for a week continuously on this power even if there was no proper sunlight, and even during rainy days it performed well. There was one solar refrigerator and one non-solar ILR and DF running on external solar power supply. The outward physical appearance of the solar CCE was good but both the hinges were broken and the digital display was not functioning properly. The refrigerator was empty and the non-solar refrigerator was used for vaccine storage. The solar refrigerator was used for the initial one year after installation and then discontinued. It was reported there were some issues with the battery and charge controller but exactly what was not known.
Photo 18: Multiple solar posts installed at the health facility by the State government
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Photo 20: Compartments of solar cold chain equipment showing ILR and DF spaces
Photo 19: Solar Cold Chain refrigerator
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Issues:
Newly appointed CCT with no training and knowledge of solar CCE.
According to the MOiC, no proper instructions were given during installation; hence they were unaware of any problems which could arise. Also there was the need for regular training for routine care and maintenance.
Non-utilization of the solar CCE.
Non- functional solar equipment site
The PHC was around 100 kms from the District headquarters situated in a dense forest region. The road to the facility was very bad and due to rainy season the road was further degraded, thus the team was not able to reach the health facility. Similar to the previous health facility the entire facility was off-grid (solar) and there was 24x7 power supply available in the PHC.
Photo 22: Bad road conditions to the health facility
Photo 21: Multiple solar posts photograph 2
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The solar CCE had not been working since the day it was installed i.e. in 2010. The batteries of the equipment started leaking after installation and therefore it was not usable. Also the capacity of the solar ILR was not enough to cover the entire PHC and the session sites.
Key Issues and recommendations:
The unutilized well-functioning solar CCE should be shifted to another health facility where it is needed.
There should be better communication between the State and District officials.
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CASE STUDY 5 – MEGHALAYA
It is a north eastern state of India with hilly terrain, which has in total 20 pieces of solar CCE allocated in 2009. In the 1990s Meghalaya was given six items of solar equipment which are now redundant and not in use. The team was informed that there was electricity supply in 90 percent (17 out of 19 sites) of the solar equipment sites. The visiting team met the State Immunization Officer (SIO), State Cold Chain Officer (CCO), District Immunization Officer (DIO), CCT and CCH. The State CCO had been in this position for 25 years and provided all the requisite information about the solar cold chain equipment's condition and requirements in the State and Districts. The CCT had joined recently, two years ago, and lacked detailed information about the solar equipment in the State.
The main issues highlighted by the State officials were lack of Central support in maintenance, training and supply of spare parts. No challenges were mentioned with regard to equipment functionality and usability. They also mentioned that the equipment worked efficiently even during cloudy days as daylight was sufficient for the solar panels to work. The CCT suggested that the ILR and DF should not be designed as one piece of equipment but instead should consist of separate items so that if one broke down the other would remain functional.
Functional solar equipment site
The CHC had an ILR and DF as well as a solar refrigerator (ILR and DF). Vaccines were stored in the non-solar ILR. The electricity supply of the health facility was very erratic with high fluctuations in voltage, and at times power supply was disrupted continuously or completely for one to two months at a time (eg. during the monsoons) and that was when the solar refrigerator was used to store vaccines, or during other emergencies. The non-solar ILR & DF were very old and the non-solar ILR was actually a DF (MK142) converted to ILR. An old stem alcohol thermometer was being used in the ILR. The solar refrigerator was located on the first floor while ILR and DF on the ground floor. The CCH had to maintain both types of equipment in separate rooms on separate floors and lock the rooms daily. There was no stem thermometer found in the solar equipment. The records (Log book) and physical verification showed ideal temperature maintenance by the solar equipment even during cloudy days. Solar equipment and solar panel were very clean and well maintained. As it rained frequently in the area there was no dirt accumulation on the panels and the need to clean panels had never arisen.
Issue The hinges were of very poor quality and broken and therefore the refrigerator lid could not be closed properly.
Photo 23 : Broken hinge and non-closing solar refrigerator lid because of broken hinge
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Good practices - It was found that there was good quality installation, wiring and maintenance. The solar panels were securely placed on the rooftop with a locked door and there had been no shifting of any equipment.
The non-solar ILR and DF were very old so there was unreliability of temperature maintenance. Also there was lot of voltage fluctuation as we found when we switched on the bulb, and it hardly lit.
Photo 26: Solar Panel
Photo 25: Aged non-solar ILR and DF
Photo 24: Low voltage of the electricity
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Non-functional solar equipment CCP
It was reported that the solar refrigerator at the PHC was non-functional but on visiting the site it was found to be functional and vaccines and ice packs (hard frozen) were stored in it. The PHC had only one item of cold chain equipment i.e. the solar refrigerator. The PHC was very remotely located and had bad road conditions in patches. The CCO informed that it was a very hard task transporting solar equipment to the CCP. The electricity supply was very erratic on average <2 hours a day. Along with vaccines HB testing tool kit and rabies vaccine were found stored in the solar refrigerator as this was the only cold chain equipment at the facility.
0Initially in the solar refrigerator the digital display had a reading of 5 C and eventually on doing the inspection and checking 0 0the refrigerator from inside the temperature rose to 8 C and then 10 C in the span of one hour and remained the same even
30-40 minutes after closing the lid.
The CCT said that twice the CCH had informed of malfunctioning of the equipment that it was showing an error on the digital display at times, but whenever the CCT visited the site the equipment was found to be working satisfactorily. Then the CCO inspected the refrigerator properly and heard a crackling sound coming from the refrigerator and informed us that refrigerator was malfunctioning due to "choking". This happens when the oil enters the cooling unit and gets frozen and the compressor stops working and stops cooling. As the oil melts the compressor restarts and the cooling begins again. This could have happened during transportation. Three unusable OPV vials were found in the ILR compartment of the solar refrigerator.
Photo 27: Haemoglobin testing kit and Rabies vaccine stored in the solar cold chain equipment
Photo 28: High variation in the temperature on the digital display of the non-functional solar CCE
Photo 29: Un-usable vials
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Issues
Absence of supervision by the Medical Officer in-charge of the PHC because he was on study leave; unavailability of spare parts for cold chain equipment; bad quality hinge was found broken.
Summary
The state has remotely located health facilities with hilly terrain and unreliable power supply. The state CCO was the only one well-versed in knowledge of solar equipment. The CCT and CCHs had knowledge gaps about usability of solar refrigerator and had received no training on repair and maintenance. The solar equipment was found to be well installed, maintained and locked but there was lack of supervision regarding usability of the solar refrigerators. There was a critical information gap between the health facility, District and State and basic information like functionality of the equipment was not known to the State in-charges. At the visited sites functional devices were found not to be in use and non-functional device being used somehow. The State officials complained about inadequate support from the Centre in supplying spare parts, training and transportation. Overall the functioning and usability of solar equipment was reported as satisfactory by the officials.
Key issues and recommendations
There is a requirement of 48 solar cold chain devices in the state specially in hard to reach areas with erratic electricity supply.
There is a vital need for supervision, spare parts supply and trainings.
It is advisable to shift vaccines to the solar equipment from old outdated non-solar ILR/DF as it maintains good temperature and is in much better usable condition.
The solar equipment if transported and installed properly will need minimum maintenance.
Solar refrigerator reporting problems should be investigated by a senior CCT or State CCO.
Careful consideration and support should be given by government while transporting equipment in hard to reach areas having bad roads as solar panels are fragile and do not have strong packing.
Photo 30: Broken Hinge
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CASE STUDY 6 – NAGALAND
Nagaland is a hilly state located in the far north eastern region of India. The state was equipped with a total of 19 items of solar CCE, which were allocated to the state in 2010 and of these all but one had been installed. Of the 19 solar cold chain points, 15 are functional currently. All the solar cold chain points had electricity supply for at-least six to eight hours a day.
The visiting team met the State Immunization Officer (SIO), District Immunization Officer (DIO), CCT and CCH. The team was unable to meet the state CCO but was provided with most of the information by the Refrigerator Mechanic accompanying the team during the visit. Key issues highlighted by the State officials were equipment functionality, particularly malfunctioning thermostats and fragile hinges, lack of proper training for maintenance of the equipment and lack of availability of spare parts. On the other hand, the State officials were happy with the performance of the functional solar CCE its durability in diverse weathers and terrain. CCT suggested that given the State requirement, only solar ILRs would be sufficient and also requested for additional smaller sized ILRs.
Functional solar equipment site
The CHC had an ILR and DF as well as a solar refrigerator (both ILR and DF). Vaccines were stored in the non-solar ILR. The solar refrigerator was located on the same floor as the ILR and DF. Hinges of the solar equipment were broken and had been fixed by local arrangement by the health officials working at the CHC. There was no door lock in the solar equipment. Although the equipment was visually alright, the solar panels appeared to be dirty to the naked eye and the CCHs said that the direction of the panels had not been changed since they were fixed. The stem thermometer inside the solar equipment was found to be defective. Both the BCG technician and the LHV were the designated CCHs responsible for maintaining the equipment, dispensing the vaccines to the ANM and maintaining the log book, which was well maintained.
Issue
The hinges were of very poor quality and due to lack of proper training, routine maintenance practices, such as cleaning panels, altering panel direction etc. were not carried out. Also, it was found that OVP was being implemented only for the birth dose of Hep B and DPT, but the vials were not properly labelled. The stock registers were only partially standardized and did not accommodate for OPV.
Photo 31: ILR space of the solar CCE storing vaccines
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Non-functional solar equipment CCP
The CHC with the non-functional solar equipment also had a non-functional ILR and a functional DF. The solar equipment had been installed in 2011 and had been functional for three years before breaking down in May, 2014. Here too, the hinges had broken and had been fixed by the MOiCs. Prior to its breakdown the temperature log for the solar equipment was well maintained. The main reason for breakdown of the solar equipment was the breakdown of the thermostat. In addition to his duties as the MoiC at the CHC, the MOiC was managing all cold-chain related activities, including dispensing of vaccines, maintenance of log books etc.
The MOiC had received no prior training for maintenance of the equipment and no training manuals could be found. In the absence of a functional ILR all vaccines were being stored in the emergency cold box, using ice packs that were replaced by the MOiC twice a week. The thermometer in the cold-box indicated that the temperatures were being correctly maintained and the OVP was also being implemented at this CHC. The electricity supply was very erratic on average - less than 10 hours a day. The DIO had already informed the State department about the breakdown of the equipment, but the State officials were unable to process the demands as the State store had not been replenished since 2010.
Photo 34: Bad road condition to the health facility
Photo 33: Solar panel placed on roof topPhoto 32: Locally replaced wooden hinges
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Issues
In the absence of a functional ILR and solar equipment, the MOiC had the tedious job of maintaining vaccines at the right temperature using ice packs and an emergency cold box. The MOiC was not properly trained in the maintenance of the equipment and no trained CCHs were available. There is an urgent requirement for a functional ILR at the CHC. In addition, the MOiC highlighted that since there were no vehicles attached to the CHC and the ambulance had also broken down, there was no mechanism to transport the vaccines to the sub-centres. As a result, the sub-centres had to hire personal vehicles to obtain the vaccines.
Photo 36: Solar panel fixed with nuts and bolts
Photo 35: Broken hinges locally fixed together with the help of a wire
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Summary
The CCT and CCHs had knowledge gaps about the usability of the solar refrigerator and had received no training on repair and maintenance. The key issue regarding functionality was the severe lack of spare parts in the State. It was interesting to note that at both the CHCs visited, health officials had improvised to fix some of the smaller parts of the equipment (hinges) to maintain functionality of the equipment. There is a critical communication gap between the health facility, District and State, and basic information like functionality is actually not known to the State person's in-charge. The State officials complained about receiving inadequate support from the centre with regards to spare parts supply, training and transportation. Overall the functioning and usability of solar equipment was reported satisfactory by the officials.
Key issues and recommendations
Adequate training and refresher courses should be provided to CCTs for maintenance of solar equipment.
State has requested for an additional 20-30 solar ILRs, preferably smaller in size, as currently they are in short supply.
Spare parts maintenance.
Optimal arrangement for transportation of solar ILRs. Currently they are transported in vaccine vans and often get damaged in transit due to hilly terrain and poor road quality.
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It is the central eastern state of India having abundant under-developed forest areas. A total of 30 pieces of solar CCE were allocated in 2010, of which 29 had been installed. One piece of the solar equipment was broken and therefore could not be installed. As per the CCO, of the total installed, 50 percent of the solar equipment was functional. At present there were 30 CCTs in the state of whom six were trained on installation and repairing of solar CCE. However two retired in March 2014, thus effectively only four technicians were responsible for maintenance of all 29 pieces of equipment. The CCO said that all the functional solar CCE had worked efficiently in all weathers except during the rains, if there was more than 10 days of rain.
Functional solar equipment site
This PHC was 50 kms from District headquarters and located in deep forest, having a plain terrain and inhabited by tribal population. In 2012, the health facility came under the Public Private Partnership-model. The facility was equipped with one solar CCE with broken hinges and one non-solar deep freezer having intermittent electricity supply.
CASE STUDY 7 – ODISHA
There was no CCH assigned to the health facility because the solar CCE was not utilized for vaccine storage. The unit was functional but nothing was stored in it and it was empty.
Photo 37: both hinges broken
Photo 38: Empty Solar refrigerator
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The deep freezer was functional but not used to prepare ice packs as vaccines were supplied from the CHC directly. The room where the solar CCE was placed had leakage from the roof and no provision had been made to protect the equipment from this.
There had been supervisory visits by the District Immunization Officer (DIO) along with DPM and SMO but no attention was paid to the non-functionality of the solar CCE. There was lack of maintenance of the solar CCE and no provision was seen to have been made by the District and block level for monitoring. The District officials commented that they were unaware of the non-utilization of the solar CCE.
It was recommended to relocate the equipment with remedial repair to another location where there was requirement for solar CCE.
Photo 39: Empty Deep Freezer
Photo 40: Leakage in the solar CCE room
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Non-functional solar equipment CCP
This PHC was 80 kms away from District headquarters and located in a less habited forest area in arural vicinity. The road was not motorable at places and site was challenging to approach by any means of transportation.
There was one Medical Officer assigned to the area, who had been in position since June 2009. The facility was supplied with one solar CCE in 2011 but it was installed only in April 2012. Due to an unsuccessful theft attempt in September 2013, the solar panel broke down and thereafter it was kept in a locked storeroom. The solar CCE had not been in use since then.
Photo 42: Solar Panel stored in a room with its broken stand
Photo : Deteriorated road conditions to the health facility
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The vaccines were supplied directly from the CHC. As at the previous site, the hinges were found broken, which had been the case since April 2013. Prior to this, the solar CCE had been utilized for vaccine storage and catered to six session sites. The log book was maintained efficiently but discontinued after the theft attempt, as they stopped using the solar cold chain equipment.
Photo 43: Broken solar panel nuts and bolts
Photo 44: Easily accessible way to the roof top for Solar Panel indicating poor security.
Photo 45: Broken hinge
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An ANM had been working as the CCH but was promoted and transferred to another health facility. The AVD system used local men on motorcycles to distribute vaccines but the vaccine carriers were not collected back on the same day because of the long distance (30-35 km) and bad road conditions inside the villages. The unused vaccines were stored in their domestic fridges by the ANMs.
Key Issues and recommendations
Immediate and adequate delivery of spare parts to the Districts.
Training of more CCT and CCH on preventive maintenance.
Relocation of the functional solar CCE to a different location for its proper utilization.
Main reasons mentioned for non-functionality of equipment were unavailability of spare parts and inadequate training on handling of solar CCE, particularly preventive maintenance. Hinges, display and sensors were the most common spare parts that were ordered from the District but not delivered so far.
The non-functional solar CCE should be restored.
All the solar CCE should be securely placed by building a secure infrastructure.
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CASE STUDY 8 – UTTAR PRADESH
Uttar Pradesh (UP) is one of the largest States in India and densely populated. The area is largely plain terrain and located in the northern part of India. There are 1162 CCPs in UP. A total of 20 pieces of solar equipment were allocated to the State and all were installed. Each CCP catered to a large population. The District visited had a total catchment population of 3,498,507. Areas in UP had electricity supply but it was very sporadic and reliability on continuous supply was low. SEPIO mentioned the need for 1200 more pieces of solar CCE for the State. There were 90 CCTs in the State of whom only two had been trained on installation and repair and maintenance of the solar CCE.
Functional solar equipment site
The CHC was located in an urban area having plain terrain. The health facility had a total of five items of CCE including one item of solar CCE installed in 2011. The facility had an erratic power supply with average supply of four to five hours in a day. Although the CHC had a generator for power backup, due to budgetary issues in the last two years this had not been working.
The main issue stated by the staff was insufficient capacity of the solar DF as the facility catered to a large catchment population. Therefore, along with the solar CCE, non-solar ILR and DF were used to store vaccines. The site reported issues of theft as there was an incident of earth wire theft during installation. Hinges were found to be broken. The OVP Policy had been implemented in the CHC.
Photo 48: Vaccines and ice packs stored in the functional solar CCE.
Photo 46: Broken hinge Photo 47: Solar Panel
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Good Practices
There were regular visits by the District CCT to the health facilities. He visited at least one unit every five to six days. Parts from the condemned equipment were utilized to repair the other equipment.
Non- functional solar equipment site
The PHC was located around 30 km from the District headquarters having an infant catchment population of 6885 annually. The health facility had total of five items of cold chain equipment including one piece of solar equipment that was installed in 2011. The solar CCE had not been working since the last two years due to a problem with the charge controller. A team had come from Lucknow two years ago to replace the charge controller, but they did so with a local one which worked only for two to three days. Due to lack of infrastructure, the staff quarters of the MOiC was being used for keeping the cold chain equipment. The facility had an erratic power supply of only three to four hours which did not maintain the requisite
0temperature of 2-8 C essential for the storage of vaccine vials. Owing to the irregular power supply, two deep freezers of the PHC were kept
*in the nearby School. The school had 24 7 power supply. The CCT distributed vaccines vials for the session sites to the ANMs from this point.
The OVP policy had been implemented in the PHC. However, a few of the vials didn't have the dates mentioned. The CCH explained that the due to moisture the cover got moist and the details got rubbed off.
Key Issues and Recommendations:
Regular service/maintenance should be done and CCTs should be trained on solar equipment.
Spare parts like hinge, charge controller, relay, and thermostat should be available at District level.
Because of TA+DA problem, no frequent visits to sites.
Hybrid solar cold chain equipment may be considered in areas with intermittent power supply as these works on both solar energy and electricity.
The District complained of an insufficient budget for carrying out repairs.
Because of the electricity problem POL budget should be increased.
Photo 49: Broken hinge
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ABOUT IMMUNIZATION TECHNICAL SUPPORT UNIT (ITSU)
The Immunization Technical Support Unit (ITSU) was established by the Public Health Foundation of India (PHFI) in March 2012, under the auspices of the Ministry of Health and Family Welfare (MoHFW) to support the Universal Immunization Programme (UIP).
The overall vision of the ITSU is to catalyze national improvements in routine immunization by providing technical and management expertise required to design, create, implement and institutionalize a stronger immunization program fully led by the Government of India and supported from the Bill and Melinda Gates Foundation.
The ITSU works with the MoHFW to strengthen Government of India's efforts to improve routine immunization coverage through six different pillars:
SIX PILLARS OF ITSU
Monitoring &
Evaluation
Vaccine Logistics
and Cold Chain
Management
AEFI Management
and Vaccine Quality
and Safety
Strategic Planning
and System Design
Evidence to
Policy
Strategic Communication
The ITSU serves to harmonize various initiatives being piloted or implemented in different states by all immunization partners and provide a single platform for discussion, development of strategies and coordination with partners for scaling up the successful models.
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