While a number of new vaccines have been rolled out across the developing world (with more vaccines in the pipeline), cold chain systems are struggling to efficiently support national immunization programs in ensuring the availability of safe and potent vaccines. This article reflects on the Clinton Health Access Initiative, Inc. (CHAI) experience working since 2010 with national immunization programs and partners to improve vaccines cold chains in 10 countries—Ethiopia, Nigeria, Kenya, Malawi, Tanzania, Uganda, Cameroon, Mozambique, Lesotho and India – to identify the root causes and solutions for three common issues limiting cold chain performance. Key recommendations include:

(1)
To address cold chain capacity:
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developing an accurate picture of cold chain capacity gaps based on current and future needs;
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resource mobilization, and;
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effective monitoring during implementation.
(2)
To encourage upgrade of cold chain with latest technology suitable in country:
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in-country piloting of new equipment;
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utilization of tools to better understand equipment trade-offs, and;
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guide equipment selection and regular engagement with suppliers.
(3)
To control temperature excursions and equipment breakdowns
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introduction of temperature monitoring and control (TMC) devices and practices;
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improve competence and availability of existing and future technicians, and;
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ensure availability of spare parts.

Collectively, the solutions detailed in this article chart a path to substantially improving the performance of the cold chain. Combined with an enabling global and in-country environment, it is possible to eliminate cold chain issues as a substantial barrier to effective and full immunization coverage over the next few years.