Table 2.

Country-identified bottlenecks in the current iSC and priorities for the system design approach

Bottlenecks	Priority
Sierra Leone
●Inadequate workload balance ●Additional skills building needed ●Forecasts do not match consumption ●Insufficient funds for distribution	●Ensure availability of vaccines to all children ●Reduce operating costs/improve cost effectiveness ●Ensure CCE at all (or at least 80% of) HFs ●Optimize storage space ●Integrate with other cold chain products ●Consider different vaccine vial presentations ●Reach underserved/hard-to-reach areas (equity) ●Reduce time spent in logistics ●Guarantee distribution from district to HF ●Optimize district/regional stores and their linked network/transport routes ●Optimize transport system for district distribution and supervision
Niger
●Insufficient transport, particularly at sub-national levels ●Security challenges in conflict-prone areas ●Human resource (HR) constraints in availability and skills	●Achieve a more reliable system ●Guarantee regular delivery of vaccines to the last mile ●Ensure quality of vaccines in sufficient quantity ●Optimize use of CCE ●Base supply chain decisions on actual data ●Integrate management system with qualified staff
Madagascar
●Failure to use the regional administrative level for the iSC ●Unused regional cold rooms ●Antiquated facility-level CCE depend on propane tanks ●Inadequate funds and insufficient vehicles to support distribution ●Insufficient HR for iSC management ●Ad hoc district distribution to HFs	●Ensure an effective, equitable, and adaptable system ●Provide reliable data ●Reduce operating costs ●Increase immunization coverage ●Reduce expired vaccines ●Promote sustainability ●Upgrade CCE
Guinea
●Lack of cold chain at regional level ●Insufficient cold chain capacity at districts and HFs ●Insufficient means of transport ●Insufficient HR capacity for CCE maintenance ●Inadequate budgeting and planning based on inaccurate population estimates	●Ensure an effective, equitable, and adaptable system ●Provide reliable data through computerized system ●Introduce cost savings ●Promote sustainability ●Decentralize to ensure all products are available at HF ●Integrate and provide high-quality services ●Ensure availability of CCE at all levels ●Allocate qualified and sufficient HR ●Establish regional cold chain depots