The lack of reliable electricity at public health facilities in Kenya has been a significant challenge to expanding its vaccine cold chain. While residential energy access increased from 52 percent to 70 percent between 2016 and 2019, energy access at government-operated health facilities only grew by 1 percent from 69 percent to 70 percent in the five-year period 2016 to 2021.
Historically, and in the absence of reliable electricity, absorption technology refrigerators have played a key role in expanding the cold chain. This cooling technology is intended to be mains powered with liquified petroleum gas (LPG) serving as a backup. However, in 2016, 13 percent of facilities relied entirely on LPG as a main source of power as they lacked access to any other form of electricity. Despite effectively expanding the cold chain where it otherwise did not exist, LPG refrigerators proved to be environmentally damaging, expensive and unreliable.
With an estimated monthly LPG consumption rate of 11.4 kg, these refrigerators consume approximately 123 tonnes of LPG in a single year and cost USD 422 per health facility. They also have shorter life spans than optimal cold chain equipment (CCE) and are often responsible for vaccines freezing as they lack freeze-protection mechanisms. This contributes to a facility-based freeze excursion rate of 3.5 percent.
Optimizing the cold chain with innovative cooling solutions
To overcome the challenge of a costly and environmentally damaging cold chain, the Ministry of Health (MoH) has set the ambitious goal of strengthening the vaccine supply chain by equipping all facilities with optimal CCE by 2026. Optimal CCE consists of cooling solutions that meet a standard of performance criteria set out in the World Health Organization’s (WHO) Performance, Quality, and Safety Catalogue requirements that is referred to as platform-eligible CCE (in line with Gavi’s Cold Chain Equipment Optimization Platform (CCEOP)).
Key performance features include Grade A user-independent freeze protection, meaning that without any human action these appliances ensure vaccines are not exposed to damaging freezing temperatures. They also possess greater holdover time, i.e., the number of hours that an appliance remains below 10°C during power outages. Finally, these innovative cooling solutions can operate at higher ambient temperatures and are equipped with voltage protection that will maintain functionality in volatile power conditions. Importantly, they do not use any fossil fuels for power, resulting in a climate-friendly cold chain that is often more cost-effective over its lifespan.
The effort to update Kenya’s cold chain inventory began in 2016 with the country’s successful application to Gavi’s CCEOP and a World Bank loan that resulted in the deployment of 3,082 new refrigerators. 20 percent of these appliances were solar-direct drive (SDD) refrigerators, which use solar energy via photovoltaic panels to maintain the required 2–8°C for vaccine storage. SDD refrigerators allow for expansion to health facilities with no electricity, are low maintenance and have low OPEX costs as they do not require a battery, electricity, or backup power source. The remaining 80 percent of appliances procured were ice-lined refrigerators. While they are mains-powered, the water or PCM-based coolant packs lining the walls enable long holdover times – a minimum of 20 hours and often more than two days.
2,463 units of optimal CCE were introduced to Kenya through these investments over a five-year period, increasing the rate of optimized equipment to 33 percent by 2021. This was accomplished through a blend of deployment across sub-optimal sites, new sites, those with unqualified storage refrigerators, and facilities that previously had no CCE. The number of sub-optimal sites decreased by 18 percent (4,036 sites to 3,300), however, this figure also accounts for the introduction of new sub-optimal equipment at other site types.
In 2021, these Grade A refrigerators directly contributed to vaccine administration for 833,238 infants out of a total population of 1.7 million (50 percent) despite only comprising a third of the total CCE.
The road to success
Despite its success in deploying 8,342 refrigerators to date, Kenya now faces the challenge of maintaining the CCE. The current staff of 490 cold chain technicians are insufficient in number and face the additional challenges of limited transportation and technical resources that hinder their ability to respond to CCE malfunctions effectively and efficiently.
While considerable progress has been achieved to date through nearly 50 percent equipment optimization and 92 percent functionality rates, continued expansion of the cold chain will inevitably result in increased maintenance needs. Kenya’s cold chain expansion proves that this ecosystem is only as strong as its weakest link. There is a need to strengthen the cold chain holistically, rather than in silos. Integrated planning, increased budgetary allocation aligning equipment scale-up with maintenance resources, and a systems approach must be firmly in place to ensure the sustained national scale-up of this lifesaving equipment.