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SOLAR: A high-quality cold chain to improve the health of Mali's mothers and children

"Vaccination prevents disease, especially meningitis and polio,” says MakataAguissa, shown here with her husband, Souleymane Ag Alf, and their daughters, in their home in the Abaradjou neighbourhood of Timbuktu | Photo credit: UNICEF Mali/S. Keita /2017

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This is a major advance in a country like Mali, with a climate with sun all year.

Project background

Mali faces significant human development challenges, notably with regard to the survival of mothers and children. Mali’s maternal and infant mortality rates are among the highest in the world, and there are great urban-rural disparities. The leading causes of death in women are obstetrical complications (hemorrhaging, eclampsia, infection, etc.). In children, the leading causes of death are malaria, diarrhea, pneumonia, malnutrition and vaccine-preventable diseases.

This situation was made worse by the 2012 political-military crisis. As a result of this crisis, basic social-service structures were destroyed, and state services were partly or completely absent for a relatively long time. In the country’s northern regions, over 80% of health structures were looted or vandalized, and almost all the medical staff left.

Given these conditions, the government, with the help of UNICEF and other partners, has undertaken actions to accelerate the reduction of maternal and infant mortality, notably through immunization and the introduction of new vaccines. This strategy has taken shape as the Expanded Program on Immunization (EPI), as well as multiyear budgeted plans. The current plan covers 2017 to 2021.

One of the greatest challenges to vaccination in Mali is maintaining the cold chain. This includes all the operations (transportation, handling, storage) that maintain vaccines at a specific temperature for quality-assurance purposes. What this involves becomes clearer when we consider the size of Mali and the constraints to storing fragile health products in high-heat areas. An evaluation of vaccine management conducted in July 2011 highlighted serious shortcomings at all levels of the healthcare pyramid, in the areas of vaccine storage capacity and quality and vaccine management. The proposed rehabilitation plan could not be implemented because of the 2012 crisis. A new evaluation of vaccine management done in August 2014 showed that the situation had deteriorated, due to factors like the following: the obsolescence of the cold chain equipment (over half the refrigerators were 10 years old or more); the low capacity of storage facilities at the central, regional and district levels; the unavailability of emergency plans in some districts and community health centres; the lack of studies done on systematic temperature monitoring and thermal mapping of cold rooms across Mali; the frequent cold chain failures due to fuel or parts shortages; long-lasting equipment failures; and the lack of maintenance and cold chain rehabilitation plans.

This 2014 evaluation was accompanied by a plan to fully rehabilitate the cold chain, to allow vaccine storage and to guarantee the quality of immunizations administered to the target populations.

Canadian involvement

Canada was especially concerned by the health conditions of women, girls and children and was very receptive to the findings of this study, which were worrisome at best. The issue of access to appropriate services and to immunizations that can prevent devastating illnesses is a fundamental need for mothers and children and priority that development partners must focus on.

Given this situation, and in keeping with Mali’s national priorities, Canada and UNICEF partnered to contribute to the survival of mothers and children by strengthening the health system. The first steps in this initiative were improving the cold chain and relaunching basic health services, especially in the northern Mali and Mopti regions. This initiative is part of the overall plans to revive the health sector nation-wide, and it includes rehabilitating the basic social services in northern areas, which were suspended after the 2012 crisis.

The SOLAR project’s overall objective is to help reduce maternal and infant mortality by the following means: implementing an effective immunization program that relies on an effective cold chain; providing health training on essential medications and technical equipment to staff in northern regions; and building the capacity of healthcare staff and of community health association members and users. Administering quality vaccines to a very large number of children will stop preventable diseases and, as a result, reduce infant morbidity and mortality. The project covers the period of June 2015 to March 2019 and is valued at CAN$20 million.

Mariam Alboukhary is in charge of the CSCOM cold chain in the Sankoré neighbourhood of Timbuktu: “This solar refrigerator allowed the Sankoré CSCOM to improve its performance. One of the services we can provide more easily now is the advanced vaccination strategy.” | Photo credit: UNICEF Mali/S. Keita /2017

The targeted outcome is an improvement in the health of women and children living in priority regions, by rehabilitating looted or vandalized health centres, and thereby increasing access to quality healthcare services. For the previously mentioned amount of CAN$20 million, UNICEF was able to buy 800 refrigerators; 5 cold rooms measuring 30 cubic metres; 15 long-range vaccine carriers; 7 ambulances for major healthcare centres in the Gao, Mopti, Kayes, Koulikoro and Timbuktu regions; 7 health district supervision vehicles; 2 refrigerated trucks for vaccine transport; 6 vehicles for regional maintenance services; 500 kits containing drugs and various medical-technical equipment for northern healthcare centres; 500 gynecological tables for health training; 150 lighting kits for healthcare training in northern regions; and 70 motorcycles for use in the advanced vaccination strategy.

SOLAR also provided for skills development for healthcare staff, including members of health centre management associations, to ensure the following: (1) management and maintenance of cold rooms across the country, (2) better data management and better monitoring of intervention quality, and (3) appropriate biomedical waste management.

Involvement of other partners

Canada chose to partner with UNICEF, by giving it the funds to work on strengthening the cold chain, for a number of reasons. UNICEF has been one of Canada’s long-term partners and is considered a priority, credible and effective partner. UNICEF provides not only funding but also technical support for the various steps involved in implementing the SOLAR project. It has expertise in cold chains, in emergency obstetric and neonatal care adapted for Mali’s healthcare training context, in transportation to the field from Bamako, in installation, and in quality-control techniques, etc.

Primary responsibility for project monitoring and evaluation falls on the Malian government, in partnership with UNICEF and the World Health Organization (WHO).

Results

At the root of the SOLAR project is the installation of a top-tier technological innovation: a network of refrigeration devices that no longer require fossil fuels but instead operate on solar energy. This is a major advance in a country like Mali, with a climate with sun all year. According to UNICEF representative Lucia Elmi, Mali, with Canadian support, is spearheading a real innovation that will improve child survival and development: “It’s an enormous investment to purchase and install clean energy systems. Today, there are some 1,000 refrigerators powered by solar energy across the country, and especially in areas that are hard to reach or that were affected by the conflict. This technology is a real revolution, one that has a positive impact on immunization rates.” The proof? Replacing oil and gas refrigerators by solar-powered ones makes it possible to store vaccines at constant temperatures. This means children can be given quality vaccines, so they can all start life protected from preventable deadly diseases. The temperature of each refrigeration system can be monitored remotely online in real time.

On the occasion of the arrival of the medical and technical equipment, Mali’s Minister of Health and Public Hygiene, Marie-Madeleine Togo, recognized the project’s innovative nature and anticipated major advances in the field thanks to Canada and UNICEF’s contributions: “This means the equipment can work everywhere in the country. Some of it has already been installed. Another advantage of this equipment is the holding capacity: close to 100 litres, in addition to a reservoir of 125 litres of conditioned water on the side. This means that, if there is a problem with the solar panel, we have a guarantee that the vaccine will not be altered for 9 or 10 days.”

This equipment is not only innovative, it plays a critical role in strengthening Mali’s healthcare system, notably through the rehabilitation of healthcare services in northern regions and by improving vaccination coverage for women and children across the country. According to the UNICEF representative, the benefits of installing solar refrigerators do not end with the storage of vaccines at a constant temperature: solar energy is also highly economical. And, as the representative points out, the sun is free and environmentally friendly, which helps reduce greenhouse gas emissions.

Installation of solar-powered refrigerators

Thus, the SOLAR project, with its national scope (involving 80% of Mali’s community health centres) is adding a new dimension to the cold chain in vaccination centres. The country will not go back to gas-powered refrigeration, which had several constraints: (1) fuel availability and quality; fuel price, which was covered by community health associations; (2) the expense of replacing wicks, glass and burners, which considerably increased operating costs; and (3) any malfunction of these parts would prevent the refrigerator from working, affecting vaccine quality. Solar refrigerators solve all these concerns and allow community health associations to save a substantial amount of money.

Increased vaccine storage capacity and quality

As of March 2018, the SOLAR project had installed 800 refrigerators and 5 cold rooms. Thanks to these investments, the country now has a significant storage capacity: there is now enough central vaccine storage, and 704 healthcare centres have new refrigerators. All refrigerators are equipped with a continuous temperature-control system. The cold rooms have remote temperature-monitoring systems. The temperature required to safely store vaccines is 2° to 8°C.

Improved vaccination coverage

Thanks to the contribution of Canada and several other donors, the initial targets for child vaccination against tuberculosis have been exceeded, as shown by the administrative data from Mali’s Expanded Program on Immunization (EPI). The number of children who were to be vaccinated in 2017 had been set at 836,962, but the number reached was 896,770. The reason for this increase was that some newborns had not been registered at birth. To address this under-registration problem, the approaches being favoured are community notebooks and a birth registration project.

The following are the 2017 vaccination rates for other vaccine-preventable diseases among 756,614 children:

Advanced vaccination strategies have been carried out to reach children, thanks to the donation of 70 motorcycles to community centres in northern regions, where households are often located far from health facilities.

Rehabilitation of northern health centres

"Vaccination prevents disease, especially meningitis and polio,” says MakataAguissa, shown here with her husband, Souleymane Ag Alf, and their daughters, in their home in the Abaradjou neighbourhood of Timbuktu. The family had the children vaccinated at the Sankoré CSCOM, which got a new solar refrigerator through the SOLAR project. | Photo credit: UNICEF Mali/S. Keita /2017

In Mali’s northern regions, over 80% of health structures were looted or vandalized during the 2012 occupation, and almost all healthcare staff left. The SOLAR project has contributed to rehabilitating the healthcare system, by providing 500 obstetrical tables, essential medications, 7 ambulances and 7 supervision vehicles. This has made it possible to resume curative care activities and, more importantly, to evacuate women with obstetrical emergencies. In addition to these equipment donations, healthcare workers in targeted structures were trained in emergency obstetrical and neonatal care. Also, in order to improve how childbirths and obstetrical emergencies are handled, 150 northern healthcare centres, which were without power, were equipped with photovoltaic lighting.

Capacity building for stakeholders of the Expanded Program on Immunization (EPI)

Skills development for workers in the area of immunization was ongoing. Training was given to 1,286 vaccine givers (1,085 men, 201 women) on the topic of effective vaccine management; to 28 technicians (all men) on solar equipment maintenance; and to 892 EPI managers (835 men, 57 women) and to 5,600 members of community health committees (5,271 men and 329 women) on preventive maintenance for refrigerators. This capacity building is critical to the immunization program’s quality and ensures that knowledge will be passed down.

Gender equality

Taking gender equality into account is one of the pillars of the SOLAR program. Indeed, women’s perinatal health is a major issue in Mali. Too many women experience complications during labour due to lack of specialized care, and too many mothers die as a result. By building capacity in community health centres and providing equipment for basic obstetrics and for emergency obstetrics and neonatal care, SOLAR helps reduce the occurrence of birth-related accidents that result from a lack of equipment.

Children’s health is directly connected to the health of mothers. A major goal of the SOLAR project is to improve access to vaccines, so children’s risk of contracting destructive viruses will be considerably reduced. By installing a cold chain network for vaccine storage, SOLAR will allow boys and girls to receive primary preventive care that will protect them from health accidents, so they can develop to their full potential.

Under the immunization program, girls and boys benefit equally from vaccination services. However, in certain communities, there is some reticence to get girls vaccinated, due to a false belief that vaccines contain products that will make them sterile. Such preconceptions are being successfully addressed through communication via traditional channels: programs on community radio, and mediation by local leaders and by members of the traditional communicator network.

To get to hard-to-access communities, advanced and mobile strategies are organized regularly. Motorcycles are used to ensure that vaccination services are offered equitably. The rehabilitation of healthcare services in the north also supports efforts toward social inclusion and cohesion. The repercussions of Canadian support on so-called cross-cutting values also include the SOLAR project’s contribution to environmental viability. The new solar refrigerators strengthen the Malian government’s support for renewable energy. The use of solar panels, as a source of renewable energy to power refrigerators, better protects the environment, as compared to the use of fossil fuels.

Another form of renewable energy has been introduced into the healthcare system. Some 150 health centres in the north, which do not have electricity, have been equipped with solar lamps to facilitate nighttime births. The project also emphasizes the management of biomedical waste, which remains a priority for the government and UNICEF. At least 1,200 health agents and members of community health associations were targeted by the project to receive training on biomedical waste management.

Challenges faced and lessons learned

Certainly, there are sizable challenges involved in transporting and delivering medical equipment and material across Mali’s vast territory, especially in the northern part of the country. These challenges include the poor condition of roads and the persistent and growing lack of safety in some areas.

Lessons were learned during the first solar refrigerator installations. The SOLAR project handles land transportation from Bamako to community health centres, with the help of a private transporter. However, equipment installation at some sites had to be delayed during the rainy season because of the poor condition of roads leading to remote sites. In other regions, land transportation was hindered by the lack of security on the main roads. In response to these challenges, dugouts were deployed to transport equipment in some flooded areas of Mopti, Ségou and Timbuktu. In Gao, planes were used for speed and safety reasons. In other highly insecure areas, especially Kidal, installing equipment has remained a challenge ever since the first attempts to install solar refrigerators.

KadaTouré, aged 67, oversees a vaccination session at the Bellafarandi CSCOM in Timbuktu. “The solar refrigerator has solved all our vaccination problems. We no longer spend money on gas, wicks and other inputs. We no longer experience inventory shortages and we are able to provide better-quality care.” | Photo credit: UNICEF Mali/S. Keita /2017

Another challenge is maintaining these new types of technology, when there is no previously existing technical expertise at the central level. To address this, an international expert was recruited by UNICEF to train technicians from the Ministry of Health and Public Hygiene on installation methods and on quality control. However, maintenance remains a challenge, both in terms of ongoing upkeep of fragile equipment at community health centres and of repairs (provided by the regional health directorates). To guarantee the sustainability of this major investment, a maintenance plan was developed, and training was provided to healthcare agents and to the members of the community health associations who manage the maintenance and use of the solar refrigerators. It is also planned to set up regional maintenance teams who will be given appropriate tools and logistics.

Innovation serving efficiency

Many aspects of the SOLAR project help solve a sizable issue in Mali: the insufficiency of the cold chain. Using an innovative approach, it ensures that vaccines arrive at the right place at the right time and in good condition. This contributes to reducing maternal and infant mortality.

This new technology draws on the sun, a renewable resource, which therefore contributes to reducing greenhouse gas effects and climate change. Since refrigerators are no longer gas-powered, we have noted a decrease in operating costs for the community health associations that manage the health centres. These savings can therefore be used for other purposes, including buying medication and building or renovating infrastructure.

Information sources

We would like to sincerely thank the following for their assistance in creating this impact story:

At the regional/health-district levels:

At the local level:

The Impact Stories series of Canadian aid in Mali was produced by the Field Support Services Project (FSSP) and in collaborationwith the above-mentioned stakeholders.

Rue Sotuba/ACI, rond-point de l’ancienne chaussée
Bamako, Mali
Tel.: +223 44 90 44 45
Email: info@psat-mali.org
Note: The FSSP received funding from the Government of Canada.

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