COVID 19 Vaccine Distribution Analysis from Philip Palin

This article written by Philip Palin summarizes a tremendous amount of valuable information about the supply chain and logistics challenges for global distribution of COVID 19 vaccines. Many thanks to Phil for compiling and sharing this information, and for giving me permission to post it! Please help us spread the word by sharing with your networks, and feel free to add additional information and links in the comments below.

?There has been significant attention to supplying vaccines. We now need vaccines to become vaccinations. For this purpose, equal or greater attention should be given to demand management. This requires a significant shift in strategy.

Just before Christmas several members of the cohort were assigned to planning and preparing for Phase 2 and 3 vaccinations. Since Christmas many of you have been reassigned to support Phase 1. This reflects increasing concern that in many places the number of vaccinations-per-day is too slow (update). As of New Years Eve only about twenty-five percent of distributed vaccines had been converted into actual in-the-arm vaccinations (more and a January 3 update).

Some of you are reporting to me (and the news media seems to confirm) that many local efforts have been slow to scale. Several causes are implicated: lack of funding, Christmas distractions, fatigue among public health professionals (more), health care providers being seriously overextended, stockpiling for rollout this week to Long-Term Care facilities, lagging throughput data, and much more. In a few places a lack of supply equal to demand is being reported.

Some of you are reporting to me (and this is also confirmed by other reports) that actual coronavirus vaccinations are taking twice to three-times longer than the typical seasonal flu vaccination. This reflects several pandemic-specific and product-specific differences in the two processes. System-wide constraints on scale and speed will accumulate unless this reality is effectively and quickly engaged. Recognizing, measuring, and actively managing throughput at each vaccination venue is crucial. Developing capacity and organizing vaccination processes to achieve explicit numerical throughputs -- and adapting as necessary -- will be fundamental to achieving system-wide success. Part of this is effective Queue Management (similar to what we have studied with post-disaster operations at fuel racks). Queuing tens-of-thousands of humans in the midst of a pandemic is more complicated than hundreds of post-hurricane tanker trucks (scheduling software can help (more)).

Given your reports, I perceive that many decision makers may not (yet) recognize the strategic difference between a high volume, low velocity roll-out of the seasonal flu vaccine and the higher volume, very high velocity expectations for covid-19 vaccines. Several of you report working with health care and public health professionals who have never stood-up a mass vaccination clinic (and neither have you). I hear something analogous to a high volume, high velocity grocery supply chain successfully delivering a new high demand product to a set of stores that have traditionally sold boutique cheeses, high end bakery, and carefully curated wines. Effective retail practices for these legacy products are very different than for this new whiz-bang product. (background)

Or another analogy that might work better for your elected officials: Our vaccination rollout is like a political campaign where the candidate has great credentials and a policy-shop par-excellence, but there is no ground game, no precinct level ability to get voters to the polls or early ballots returned. We need to develop and deliver this ground game ASAP.

This is done by knowing our sources of demand, knowing where they live, what they do, how they feel about our product. This is done by packaging our product -- physically, functionally, and even emotionally -- in a form that resonates with sources of demand. This is done by building relationships with preexisting and trusted networks of demand fulfillment. Don't reinvent the wheel, whenever possible wrap yourself around already well-established wheels. This is done by closely examining and optimizing our processes and procedures for fulfilling demand. How much time does each step in the process require? Are there mission-advancing opportunities to improve time performance or reduce process steps? How can you reduce friction and increase flow to actual vaccinations in actual arms? How can you expand delivery (vaccinations-in-arms) capacity?

Phase 1a vaccinations -- mostly to health care workers and residents/staff of Long-Term-Care Facilities -- should be the most friction-free of any vaccination phase. Vaccines are being delivered to places where high-risk recipients are resident or regularly work. As much as possible this should be the preference for each subsequent phase, but this level of "customer service" will be difficult as the numbers increase. And... December results suggest a sluggish start even with these advantages. What can we learn and how do we adapt future performance accordingly?

Here is helpful CDC guidance on conducting mass vaccinations. The guidance is great on step-by-steps procedures and product safety. The guidance is mostly silent on demand management, demand motivation, or demand fulfillment.

Here is a helpful primer on Queue Management. Those of you with pre existing relationships at grocery distribution centers and fuel racks know folks with expertise in high volume, high velocity queuing... such as needed now for vaccinations. A colleague suggests -- brilliantly, I think -- seeking out your nearest ski lift operator. Theme park managers also know Queue Management secrets. Asking for advice from those with relevant experience can be a success-multiplier.

As some of you have been reassigned to support Phase 1 vaccinations, you are mostly being given very specific tactical duties to support a vaccination strategy that adapts seasonal flu campaigns and the H1N1 response. You are not (yet) being expected to offer strategic advice. But you can look for opportunities to ask strategic questions.

Based on what you are telling me and what I am otherwise hearing/seeing, there is not yet a whole-community strategy for covid-19 vaccinations.  Recognizing and articulating this absence is an important step toward accelerating actual in-the-arm vaccinations.. As emergency management professionals you are (or should be) competent to guide your public health peers, health care colleagues, and elected officials toward a more demand-oriented whole-community approach. Enclosed is an ancient scripture (2011) on emergency management's Whole Community strategy. Six strategic themes are outlined: 

• Understand community complexity. 
• Recognize community capabilities and needs. 
• Foster relationships with community leaders.
• Build and maintain partnerships.
• Empower local action.
• Leverage and strengthen social infrastructure, networks, and assets  

I hope you recognize the coherence of Whole Community principles with Supply Chain Resilience principles. None of these are easy. Undertaking these efforts in the midst of the crisis is less than ideal, but it is possible. Unless these principles are meaningfully engaged, the mass vaccination campaigns are likely to encounter more false starts and increasing friction. For high volume, high velocity vaccinations, a Whole Community strategy is not just nice-to-have, it will be essential both now and especially as we approach the higher population phases.

In advancing a Whole Community strategy for vaccinations you will be a pioneer. There is not an abundant supply of experience-based competence in pandemic management. We are now two generations distant from the sort of "whole community" vaccination campaigns of the 1950s and sixties. The need for demand and supply velocity -- so important to Supply Chain Resilience -- has not been a priority for seasonal flu or other US vaccination efforts. This is new.  

Sun Tzu is often quoted (translated) as saying, "strategy without tactics is the slowest route to victory. Tactics without strategy is the noise before defeat." The wrong strategy can be even noisier than no strategy. A strategy that is effective for X number in 30 days may not scale to 4X in ten days. Throwing more money or personpower at the wrong strategy is unlikely to improve outcomes -- and often makes bad outcomes worse. A fully conceived Whole Community vaccination strategy without effective demand management tactics, especially for scheduling and queuing is "the slowest route to victory." And in this case, speed is built-into our definition of victory.

A personal observation -- and confession -- I want to defer to the expertise of others. Over my career I have found such deference to be substantively helpful. There are usually plenty of real experts available. But this has been a bad habit for pandemic response. I should have taken more risks contributing my bit to push policy, strategy, and operational priorities. Maybe you too? Every thoughtful -- and especially self-critical -- bit is needed to engage this novel problem. Your community needs you to be creative and courageous, blending your competence with others to cook-up the new real-world expertise needed now to quickly vaccinate as many as possible as safely as possible.

Below is a December 21 note focused on Phase 3 vaccinations but there are also helpful notions for demand management in Phase 1.

Again, please share with each other what you see working (and best efforts that turned out to be bad ideas). I am also happy to receive and share, anonymously or with attribution. What you share with each other may be helpful to others as well. Cross-Community Collaboration -- especially among and between this cohort -- could be an important contribution to the entire nation.

[Philip J. Palin supports the FEMA-NIC Supply Chain Resilience Technical Assistance Program as a Subject-Matter-Expert. The background, points-of-view, and opinions expressed by Subject-Matter-Experts do not necessarily represent the positions or policies of the Department of Homeland Security or the Federal Emergency Management Agency.]    

---------- Forwarded message ---------

From: Philip Palin <[email protected]>

Date: Mon, Dec 21, 2020 at 5:23 AM

Subject: Engaging vaccine hesitancy with demand management

To: 

Some members of the Supply Chain Resilience Technical Assistance cohort have recently been assigned to plan and prepare for Phase III vaccine distribution, delivery, and demand management. Similar assignments are on the horizon for several others.

As we saw last week, anytime a new flow is channeled where there was essentially no previous flow, there is likely to be -- almost certainly will be -- surprises (more and more and more and more). Some happy, some unhappy. But there is cause for confidence that vaccine flows will grow considerably over the next several weeks (more).

At this point, with something between sixty and 120 days until population-wide Phase III inoculations can be seriously started, and with sources, scale, and scheduling of vaccine flows necessarily ambiguous, one of the most constructive steps available is to reduce vaccine hesitancy. Most epidemiologists continue to call for at least 60 to 70 percent of the population to be vaccinated. Toward this purpose, following are some information sources for your consideration:

1. A December 14 opinion piece in the Journal of the American Medical Association (JAMA) is entitled, "Behaviorally Informed Strategies for a National COVID-19 Vaccine Promotion Program." The authors outline five specific recommendations: 1) Make the Vaccine Free and Easily Accessible, 2) Make Access to Valued Settings Conditional on Getting Vaccinated, 3) Use Public Endorsements From Trusted Leaders to Increase Uptake, 4) Provide Priority Access to People Who Sign Up to Get Vaccinated Before Vaccines Are Widely Available, and 5) Transform Individual Vaccination Decisions Into a Public Act. More details on each recommendation are available at the JAMA link.

2. A December 10 feature story in the New York Times Magazine is entitled, "We Know How to Curb the Pandemic. How Do We Make People Listen?" The article concludes with, "Right now, everyone is flooded with Covid information from all kinds of sources; it’s unlikely that a single public health initiative will change the trajectory of the virus. But employing research-based communication strategies could help scientists and government officials make their messages more influential, thereby saving lives. Yet... the focus instead has been “on health science, epidemiology and medical science. Not on behavioral science.” Several behavioral science principles and practices are outlined.

3. A December 18 thought-piece from McKinsey & Company is entitled "COVID-19 Vaccines Meet 100 Million Uncertain Americans". With convenient alliteration, the consultants encourage a three-fold strategy of commitment, convenience, and costlessness. (Beginning to see some recurring themes?) Related to commitment, one angle involves, "Our peers may be the most potent influencers of all, and peer encouragement will be vital if COVID-19 vaccines are to become the norm. Normalization can occur based on social-media posts, sharing with friends, and even wearing “I was vaccinated” stickers. The reciprocal approach—the social stigma of going against the group—is also powerful, sometimes even more so. If the consequences of harming other people by not being vaccinated can be demonstrated, a stigma could attach to those who eschew the vaccine and are perceived as harming others." It is another aspect of the behavioral science approach noted in the NYT and JAMA pieces.

I also suggest reading Thinking Fast and Slow by Daniel Kahneman, the psychologist who won a Nobel prize for economics. There are deep issues of bias, heuristics, and narrative that will need creative attention to achieve effective demand management... just as much as any of the pandemic-specific and vaccine-specific issues outlined in the other three sources. Kahneman is great on all these factors. The classic text on motivating demand for innovative products -- such as entirely new vaccines, made with a brand-new technology, very rapidly implemented -- is Diffusion of Innovations by Everett Rogers.

In any supply constrained environment there is an understandable temptation to focus on maximizing supply. This can, however, be myopic and strategically self-subverting. The more high volume, high velocity supplies are needed, the more valuable is validated, differentiated targeting of demand. This may seem a subtle distinction. But as a matter of strategic discipline it is as different as night and day. By knowing what is needed when and where by who... you are much more likely to optimize your limited supplies.

One final suggestion (possible nag): Many of the good ideas set out in the first three sources above are a bit tarnished by treating the population as something to be manipulated, rather than fellow human beings with whom you want to collaborate and co-create (not just enforce compliance). As the TA cohort has often discussed in regard to the private sector, asking questions, listening carefully to answers, and authentic conversation is a very good place to start.

Given that demand management is an assignment that many of you will apparently share, please begin to share your questions and plans with each other. I am happy to broker risk-free exchanges, but also don't want to get in the way.

{Philip J. Palin supports the FEMA-NIC Supply Chain Resilience Technical Assistance Program as a Subject-Matter-Expert. The background, points-of-view, and opinions expressed by Subject-Matter-Experts do not necessarily represent the positions or policies of the Department of Homeland Security or the Federal Emergency Management Agency.]