In Mozambique, we have been working for two years to implement a national expansion of a logistics system for vaccines and other medicines. Our efforts have focused on four provinces, which cover nearly half of the country. So how is it going? I’d say it’s time for adjusting our hiking path. Our biggest challenge is securing that the distribution system is reliable; logistics without reliable distributions in terms of quantity, quality, and timing undermines health services and access to those health services.  When distributions are delayed or incomplete, we find health facilities without stock of critical medicines. This is a problem for us because funding to the government for the distributions is often delayed or funds are simply not available from the government despite all the required components being there (budgets, plans, funds requests, political will, etc). We set up this national expansion with a vision that the government would support its own costs because sustainability has been a top priority for us. However, that sustainability can come at the expense of results.

As a learning organization, trial and error is a part of our work. We tried an approach with sustainability as a main driver, but we have been forced to re-examine the approach because we value results. Our work is to achieve results. Now it’s time to try a adapt our approach. We aren’t willing to throw out sustainability, so we need to find the magic balance between results and sustainability. Now we are embarking on a cost-sharing model. We will continue our close collaboration and capacity building of the government systems, but also address the very real challenges of funding critical pieces. This requires additional effort in consideration of sustainability, but we are up to the challenge.

The challenge of funding a reliable logistics system has been our biggest lesson learned from the first year of the national expansion. We’ve also learned that providing technical assistance to a logistics system requires more intense monitoring than implementing a logistics system. This has implications on our staffing structure and level of expertise, so we have hired additional staff in our Maputo office. We’ve found that progress with this approach is slower than anticipated because our work is more dependent on schedules, funding, priorities, and staff of the government, which must constantly balance priorities in an under-resourced environment. For example, the logistics system involves government staff collecting data to analyze the performance of the logistics system. In our pilot project in Cabo Delgado province from 2002 – 2007, those staff were ours. When we trained them on data collection and made it a part of their job, they did it. In using government staff to do this, the staff need to balance other activities and we need to work more with management to help them understand the value of the activity and include it as a priority. As we learned this, we’ve adjusted our plans and expectations. Finally, we’ve been working to incorporate Rapid Diagnostic Tests for HIV, malaria, and syphilis into the logistics system. This integration has encountered operational and political challenges as additional people and departments are involved in the logistics and use of tests so we’ve had to focus more on establishing routine and comprehensive coordination and communication. Months from now we will certainly be mulling over lessons learned from this modified approach, and we’ll adjust our paths to the top of the mountain again.

[2] Ibid.

Leah Hasselback, Mozambique Country Director

Maternal and infant health outcomes are worse in Balaka district (where Kwitanda resides) than Malawi overall in most important indicators. For example, almost a third of women in Balaka give birth at home while, nationally, less than a quarter do. Given the high rate of home birth it’s not surprising that only 63% of Balaka women have a skilled attendant present at their birth (versus 79% nationally). Additionally, the postnatal period is crucial for both the health of the mother and infant, but only about a third of Balaka women receive a check-up within the first two days of giving birth compared to 43% of women nationally. Luckily, over 90% of women in both Balaka and receive some prenatal visits before giving birth; nonetheless, the proportion of Balaka women who receive prenatal care is slightly less than the national average.

In Malawi, many newborns like the one pictured here (left) are delivered by traditional birth attendants in rooms that often look similar to the one above (right). While some mothers prefer the comprehensive care provided by TBAs, others are wary of their ability to handle obstetric complications.

In order to design a program aimed at improving maternal and neonatal health outcomes for the Kwitanda community, it is essential to have an understanding of the unique needs of the community. While the Balaka-level information is illuminating, it doesn’t tell us what’s happening in Kwitanda specifically and, more importantly, it doesn’t tell us why. So we conducted three focus groups in Kwitanda with the following groups: women who recently gave birth at a health center, women who recently gave birth outside a health facility, and community health workers as well as several key informant interviews. Here are some of our most important results:

Some women prefer to give birth with a traditional birth attendant rather than in a hospital. We expected cost and transportation to be barriers preventing women from giving birth in a health facility – and they were (several women gave birth on the way to the hospital since they could not arrive fast enough). But some women also prefer to giver birth with a traditional birth attendant (TBA) rather than in the hospital. There are familial and cultural traditions that encourage women to utilize TBAs as well as the fact that TBAs are often located closer to the women’s homes. But in addition, women cite fears about harsh treatment from hospital nurses as a major reason they’d prefer to give birth with a TBA. First time moms in particular are drawn to the support and one-on-one attention they can receive if giving birth with a TBA. Even some mothers who have delivered a previous child at a hospital say they’d rather deliver their next child with a TBA.

Women recognize that traditional birth attendants are not prepared for every complication. Despite some preference to give birth with TBAs, many women recognize that TBAs are often ill-prepared for complications during labor and delivery and that there are advantages to delivering at a hospital. One woman, who experienced complications while giving birth at a hospital, said she believes she might have died had she given birth with a TBA instead. Women also pointed to the fact that if you give birth in a hospital, you have access to crucial post-natal care not available with a TBA.

Women wish that prenatal care were more accessible. The good news is that most women are attending at least some prenatal care visits at a health center. However, women wish that they could receive care in their villages without having to travel to the health centers. Some women said they would prefer to receive prenatal care from community health workers close to home. Currently, community health workers treat childhood illnesses at “village clinics” – women sited this as something that this could be a useful model for prenatal care.

Not all women know when to get postnatal care. Women had heard mix messages about when to visit a health center for postnatal care: some said it was 6 weeks after giving birth; others said they were told to bring their child after one week for immunizations; and some knew that if they gave birth at home or on the way to the hospital they should go for a check-up the next day. In addition, women pointed out that the getting to a health center or hospital for a check-up right after giving birth wasn’t always easy because of the difficulty of walking or finding transport while simultaneously recovering from labor and delivery.

Women face difficult decisions when deciding where to give birth. In addition to major cost and transportation barriers, women have to weigh family, cultural and emotional factors into their decision-making. While women tend to have more positive experiences accessing prenatal care in a health facility (compared to labor and delivery) women would still prefer a model that allows them to receive care from a community health care worker closer to home. The Health Systems Group at VillageReach is processing all the information we’ve gathered and actively discussing possible interventions and solutions. We’re excited to update you soon!

Perhaps not surprisingly, more than 60% of the 34 million people living with HIV live in Sub-Saharan Africa. In Malawi, one in every 12 people is infected with HIV – that’s 90,000 children living with the disease and another 30,000 newborns contracting the infection from their mothers at birth. Additionally, 650,000 Malawian children have been orphaned by the epidemic, and are counted among the infection’s burden in this country. Similarly, 1.5 million adults and children are living with HIV/AIDS in Mozambique, where the infection claims the lives of nearly 100,000 people every year.

Despite these challenges, incredible progress has been made. Mother to child transmission is almost entirely preventable with the right care and rates of prevention are increasing (10% in 2004 to 45% in 2008). Antiretroviral therapy (ART) is more readily available now than it ever has been, with more than 5 million people receiving the treatment they need to live longer, healthier lives. While this is a twelve-fold increase in the number receiving care since 2003, it still represents only one-third to one-quarter of the total population in need of treatment. With more than 1,200 children infected around the world each day, it is vital to sustain this momentum toward testing and treatment in resource-constrained countries.

Working in Sub-Saharan Africa, it is unimaginable for our efforts not to be impacted by this infectious disease. With treatments available in most government facilities, international emphasis has shifted to helping people live with this infection. Many of the community members we work with are living with the illness, but the health systems we support are often overextended trying to reduce the burden of disease.

So on this World AIDS Day, we’re excited to be expanding our programs over the upcoming year to have a more direct impact on the reduction of HIV/AIDS burden in Sub-Saharan Africa. In Malawi, we are incorporating community-based HIV counseling and testing into our adult health service initiatives so that more people can access treatment that is already available from at government facilities. In Mozambique, we already help support the distribution of rapid diagnostic tests for HIV to ensure that diagnosis is available at service delivery points. In 2012, we are starting a study of RDT usage to better understand the barriers to utilizing new technology for improved diagnosis and to further improve the distribution of these tests. In both situations we hope to be able to improve accessibility to HIV testing in rural communities so that individuals can get the care they need.

Pneumonia can be caused by viruses, bacteria, or fungi and is a type of acute respiratory infection that affects the lungs and limits oxygen intake in infected children. Streptococcus pneumoniae – or pneumococcal disease – is the most common cause of bacterial pneumonia in young children. Beyond pneumonia, the bacterium can also cause meningitis and sepsis, either of which can be fatal or permanently debilitating.

Pneumonia can be spread through infected air-borne droplets produced by a child’s cough or a sneeze. A child might also contract the infection through exposure to infected blood during birth. While a healthy immune system would enable a child to fight off this infection, a child with a weakened immune system resulting from malnutrition (as is prevalent in low- and middle-income countries) may require antibiotics to heal. Immunization remains the most effective way to prevent infection.

Since 2000, the pneumococcal vaccine has been readily available in the US and Europe. It has remained prohibitively expensive for low- and middle-income countries where most of the mortality burden is borne. Additionally, the pneumococcal vaccine administered in developed countries was determined to be ineffective in developing countries where it failed to target the bacterium strains present in developing countries.

Without vaccination or effective treatment – currently only 30% of kids in developing countries who need antibiotics receive them – pneumococcal disease threatens to compromise the economic vitality of many countries. Families are overburdened caring for children disabled by the disease and health systems are overextended trying to care for patients with sepsis, meningitis, and pneumonia.

Aiming to eliminate the 10- to 15-year delay between vaccine availability in high- and low-income countries, GAVI (Global Alliance for Vaccines and Immunization) was created; the organization is a public-private partnership striving to increase access to immunization in poor countries. Born out of a unique collaboration between the Bill and Melinda Gates Foundation, UN agencies, and leaders of the vaccine industry, as well as bilateral aid organizations, GAVI funds immunization programs in 70 countries. The organization estimates it will help avert at least 650,000 future deaths by 2015 and as many as seven million by 2030.

Pneumococcal vaccines are among those delivered by GAVI funds. Fifteen developing countries are already rolling out these vaccines with GAVI support. Mozambique was among 18 additional countries approved for the program in September 2011. Preparing for a new vaccine introduction is intense work. Infrastructure needs to be developed and/or refined: refrigerated storage space may need to be constructed to support the cold chain space, and transport routes and information systems must be developed, waste management systems need to be established, staff need to be trained, and a supervision system must be in place.

So, lot’s of work ahead! However we’re excited that the VillageReach Dedicated Logistics System might help support the distribution of pneumococcal vaccines next year in Mozambique. We are confident that our work with distribution, supervision, and information management will help to ensure that vaccines get to the health centers, that health workers are trained to administer the new product, and that the right quantities reach the right facilities to balance supply and demand. GAVI recipients have produced impressive rates of immunization and VillageReach is thrilled that our work may help reduce the burden of pneumonia among the under-five population.

The availability of rapid diagnostic tests (RDTs) – in conjunction with decreasing rates of transmission and fewer fevers due to malaria – has instigated a policy revision. Trending toward parasitic diagnosis based on positive laboratory tests, researchers and policy makers are reviewing the criteria for treatment based on the availability of this new technology, which makes testing feasible in previously unfeasible settings.

Long considered the ‘gold standard’ of malaria diagnosis, microscopy is a highly sensitive and low cost technique if performed under quality controlled conditions. Unfortunately it is labor intensive, has a lag time between test completion and diagnosis, and requires both laboratory technicians and expensive equipment in order to complete.

Many clinics that cannot support this technology prescribe malaria treatment based on presumptive diagnosis. While presumptive treatment based on febrile presentation is still considered appropriate for children under-five and other high-risk individuals, it is no longer considered cost-effec¬tive or best practice. Antiquated antimalarial medications such as chloroquine may cost less per unit, but the recent reliance on expensive artemisinin-based combination therapies (ACT) demands more careful distribution. Decreasing the rate of prescription for non-malarial cases is vital to keeping costs down and keeping subsidies high – a combination that ultimately increases the drugs’ availability for the most impoverished populations. Over-prescription this regimen based on the presumptive treatment protocol commonly employed in remote clinics not only wastes medi¬cation and costs more money than antibiotic alter¬natives that would otherwise be appropriate for non-malarial febrile illnesses, but also increases the risk of ACT resistance developing in the community.

In an effort to minimize these consequences of presumptive treatment, RDTs  have been designed as new laboratory-confirmed diagnostic technique. Alternatives to microscopy, RDTs are now em-ployed around the world by countries adhering to the World Health Organization’s recommendation of parasite-based malaria diagnosis. Requiring no formal laboratory equipment and able to be admin¬istered by any trained community health worker, RDTs are presenting changing the face of malaria diagnosis in rural clinics where microscopy is not feasible.

Immediate advantages of RDTs include lack of de¬pendency on laboratory equipment, electricity, and personnel, as well as lower levels of training required for implementation. With rural health centers in endemic areas seeing hundreds of cases of fever every day, a more conservative prescription of antimalarials will not only decrease the rate of parasitic resilience, but will also conserve limited medical resources. What’s more, RDTs now exist for many diseases including HIV and syphilis! To this end, they have become a game-changer for accurate diagnosis and resource conservation in underserved communities.

Excited to be engaged in this international shift and acutely aware of the benefits it has for health service provision, VillageReach has been actively involved in the distribution of RDTs in Mozambique since 2010. Taking this one step further, we have proposed a collaborative RDT consumption study with our partners in Mozambique to refine our understanding of the challenges to stocking and utilizing these incredible products. By estimating stock shortages and overages, and identifying factors of supply and demand that are associated with these we hope to be more effective in eliminating barriers and improving access to this awesome technology. While the research is still in its infancy, the insight it will afford into RDT consumption and distribution will provide a wealth of data with which to refine programs and improve service delivery in last mile communities.

Kassia Binkowski

I was speaking on a panel about the nexus of technology, global development and social enterprise in the VillageReach experience.  Judging from the audience of early stage entrepreneurs and academics, there’s growing interest from this region’s community of professional engineers in developing technology innovations for broader social benefit.

An interesting question was asked concerning example strategies to develop demand for new innovations, given the economic challenges and low purchasing power of Base of the Pyramid countries and their communities.  The question assumed we can apply to BoP what Steve Jobs famously said about wealthy consumers he was seeking: “give them what they don’t know they want …” (I paraphrase).

While it’s a great leap to make a connection between Job’s realm of innovation, investors and customers with the realities of BoP, social enterprises do need to be profitable and scale in order to sustain the social benefit of their work.   That requires, among other things, an active understanding of the marketplace and the beneficiaries’ needs.

Developing that knowledge is difficult enough in markets in developed countries where there’s ready access to broad economic and market data, consumer trends, etc.  It’s quite another challenge to evaluate the market opportunity for a product and service with a presumed social benefit in a country where there is little current or historical consumption data.

We have seen this in our own work with VidaGas, the for-profit propane distribution business we own with other partners in Mozambique.   We created the business to provide fuel for rural health centers that otherwise would be unable to refrigerate vaccines, sterilize instruments and have light for evening medical procedures.   In our case, the social benefit of supporting the health system was obvious, but in itself insufficient to support the business.  We asked “can we expand the service to a broader customer base to achieve scale and profitability that in turn sustains the social benefit?”

Well, it’s a work in progress, but we’re excited with what we’ve achieved in the past year.   In 2011, we expect a 40% growth in shipments: to the ministry of health, to small- and medium-sized businesses, and to consumers.  The addition of a new filling plant facility gives us the capacity to deliver more fuel, but it’s the recent efforts in developing the customer base – sales and marketing, and an expansion of support for the ministry to a fourth province – that is driving both stronger financial performance and ultimately greater social benefit.  More on the company’s work and results by the end of the year.

John Beale

VillageReach recently completed an annual evaluation of its Kwitanda Community Health Project. The results of the evaluation indicate that VillageReach is making great progress toward meeting its goals to reduce incidence of malaria and diarrhea and to increase treatment of malaria and diarrhea in the Kwitanda community.

Highlights of the evaluation include:

• Household net ownership has increased from 74% of households reporting ownership of a net in 2010, to 82% of households in 2011. This is much higher than the national average of only 67.3% of households reporting ownership of a net.[1]
• Mosquito net use increased overall from 40% of individuals reporting sleeping under a mosquito net in 2010 to 58% in 2011.  Among children under-5, mosquito net use increased as well from 65% in 2009 to 71% in 2011.
• More than 83% of pregnant women sleep under a mosquito net. This is a new indicator in this year’s evaluation so no comparison is available from 2010, but this is much higher than the national average of 43.3%.
• The highest proportion of mosquito nets in use in the Kwitanda catchment area were distributed by VillageReach. Of the individuals sleeping under a mosquito net, nearly half of them reported the net was received from VillageReach.
• The proportion of households reporting a clean drinking water source increased from 2009. However the proportion of households fell slightly from last year. In 2009, 82% of households reporting clean drinking water, 91% in 2010 and 86% in 2011.
• Malaria incidence is declining. The proportion of households reporting at least one case of malaria in the three months prior to the survey has declined from 91% in 2010 to 72% in 2011. The percentage of individuals reporting suffering from malaria in the three months prior to the survey declined from 30% in 2010 to 26% in 2011, with an average monthly incidence of 6.7%.
• Diarrhea incidence is declining. The proportion of households reporting at least one case of diarrhea in the three months prior to the survey has declined from 61% in 2010 to 18% in 2011.  The percentage of individuals surveyed reporting at least one case of diarrhea in the three months prior to the survey declined from 12% to less than 6%.
• Access to care has increased for children under-5 as well as for the general population. 70% of households surveyed reported a village clinic in their area and nearly half had used a village clinic. Overall treatment rates for malaria and diarrhea have increased and most people access care at the Kwitanda Health Center or village clinics.

Read more about the Kwitanda Community Health Project on our Malawi page.  The full evaluation report is available here.

In my work, I’ve realized that information can be a hard commodity to sell or even to give away. Even when we try to make information available, when living under constrained circumstances, we often have bigger fish to fry (like trying to get the actual fish!). The focus is on tangible resources. And in developed countries we may treat our technology and especially its outer manifestations—phones, computers, televisions—as the end in itself.  We value the package as much as what it brings us.

This year, VillageReach launched a new project in the Balaka District of Malawi to provide women and caregivers of young children new ways to access information and advice about pregnancy and child health through mobile phones.  This project reminds me that information is another valuable missing resource in the most rural communities. We have heard from health providers that women often attempt to “wait out” their own or their child’s medical problems, rather than seeking care quickly when local resources may be of use because the often arduous journey to seek health care may represent a risk or a cost in and of itself.  It can be a difficult decision to make. The simple practice of informing people of when something is serious and when it can be managed at home can both save lives and ensure the strategic use of existing resources.

Of course information isn’t enough, and a pregnant woman may still have to walk for three hours to reach the health center. We can’t afford to forget that, even while we are helping women and caretakers make informed decisions about seeking care. For me, this means remembering the context for the advice and information we are providing.  I keep this picture on my desktop. I took it as we were traveling to a rural clinic. It’s a reminder of what rural really means, but it’s also a reminder that there are life-changing resources that go beyond the tangible.

Stacey Cunningham

Stacey Cunningham is the Maternal, Newborn, and Child Health Project Manager for VillageReach, based in rural Malawi.

I’m an MPH graduate student and a recent addition to the VillageReach team as a summer Health Systems Group intern. When I was asked to come up with some ideas for how to evaluate active case finding for VillageReach’s new tuberculosis (TB) program in Kwitanda, Malawi, I was ecstatic.

Step one: figure out what active case finding is (preferably before anyone realizes I have no idea). Once I did the research, I realized it’s a pretty simple concept: the more people who have TB, the more people they can spread it to. If we can actively find people with TB and treat them (rather than waiting for them to come to the health center which may only happen after they become very sick or may not happen at all), then we can reduce TB. Easy!

Step two, how do we decide if our active case finding program worked? The health centers keep track of new TB cases so we can use those numbers to evaluate our program. If the numbers of TB cases seen at the health center goes up, then we were successful in finding more cases of TB. If the number of TB cases goes down, then we were successful in reducing the number of people who have TB. So no matter what the numbers say, we can say we were successful? While I was tempted to bring back a no-fail assessment plan to my supervisors, I had a sneaking suspicion that it wasn’t going to fly in an organization that highly values evaluation.

Step three, more research. Turns out lots of people are interested in evaluating TB programs and the Millennium Development Goals have set the goal of increasing the “case detection rate” to 70%. That means for every 10 people who actually have TB we want to find 7 of them. Ok, that could work. We already know how many people we’ve found with TB because of the health center data but how do we find out how many people actually have TB, assuming that many of them are undiagnosed? We would need to go door-to-door in Kwitanda and test everyone for TB (or at least test a large sample of people). That would be expensive. And frankly, if we had that kind of resources we WOULD just go door-to-door and test everyone. Not for evaluation purposes but because it would be the right thing to do!

So back to square one. After driving myself crazy with statistics and indicators for at least several days, I came up with an idea. We already do an annual house-to-house survey of questions – what if we asked every person if they have a cough and if they’ve been tested for TB? That way, we can know the percent of people with TB symptoms who’ve been tested and that number should always go up. If TB incidence in Kwitanda goes down (which we hope it will) the number of people with symptoms should go down too. But, with any luck, the percent of people with symptoms who have been tested will continue to increase until 100% of people who need to be tested can get tested.

All of this got me wondering the same thing non-profits have been wondering for years: how much money do we spend running our programs versus how much money do we spend finding out if we’ve actually run them well? While our indicators for the TB program may not be perfect, they’ll give us enough information about whether or not our approach is working while still leaving lots of time and resources to actually do the work.

Erin-Larsen Cooper