Yet, the information is crucial not only because it can strengthen the overall performance of the health system by enabling data-driven decision making by our partners on the ground, it is necessary in order to measure progress and impact. And as I’ve written previously, VillageReach is committed to monitoring and evaluating the progress and impact of the Dedicated Logistics System in Mozambique.

The key questions to ask when attempting to evaluate impact are whether or not the Dedicated Logistics System has met its objectives to improve health system performance and increase immunization coverage. In the baseline evaluation, we attempt to answer questions such as: how many children are immunized and how often do health centers run out of vaccines. Unfortunately, this type of information is just not available. There are no immunization registries to search. Health centers don’t keep patient records. Even if they did, we still wouldn’t be able to know how many children are not immunized because there are no vital record systems either. These things just aren’t tracked.

In order to get the information we believe is valuable to answer these questions, we went out and collected it. In order to estimate the immunization coverage, we conducted more than 800 household surveys in randomly selected villages across the two provinces of Cabo Delgado and Niassa. The sample size gives us enough statistical power to make an estimate of the true immunization coverage rate with 95% confidence and because the villages were randomly selected, the sample is representative of the population. In each household, we essentially asked whether or not the children living there had received certain vaccines. In addition, we conducted surveys in more than 60 health centers in those villages to get an idea of how the health centers were performing. We worked with a group in Mozambique who hired and trained local staff to conduct the surveys and complete the data entry. The process took about nine months from the time we first sought Ministry of Health approval for the study until we started seeing the data.

Despite a few challenges along the way including delays in schedules with field teams, traveling time to remote villages, and correcting for concerns with the data such as missing entries and incorrectly completed surveys completed, we have real numbers. We have real data from the very last mile. Finally, we can use this data to answer our questions regarding how many kids aren’t being reached by vaccination services and what we can do to improve this. Using this information, we can tailor our program activities in ways that can make the biggest impact and that is what we intend to do.

Before we can share the results publically, we need approval from the Ministry of Health. We’ve started the process and have already shared the results with provincial leaders in Cabo Delgado and Niassa. We will be presenting the results to the Ministry later this month or early next year. We are looking forward to sharing our results with you as soon as possible. Stay tuned.

Jessica Crawford
Program Associate
VillageReach

Even while researchers continue to develop and test new interventions such as vaccines, diagnostic tools, and drugs through thorough clinical research, we don’t know how best to deliver them in countries with weak health systems. The result is an innovation pile-up where proven interventions to prevent and treat disease are available yet millions of people are dying because these interventions don’t reach them.

As a graduate student in public health, it seems to me that the field of global health is turning in this direction and placing a lot more value on measuring impact. As President Obama said in his speech at the MDG Summit; “let’s move beyond the old, narrow debate over how much money we’re spending and let’s instead focus on results-whether we’re actually making improvements in people’s lives.” We need to know what is working and what isn’t so we can better our efforts and get the interventions out to the people who need them.

Unfortunately, evaluation is difficult to do well. As I quickly learned in the IHME course, there are some serious limitations to deal with ranging from poor data quality and availability to the fact that the methodology of conducting a rigorous evaluation just sometimes isn’t possible or is really expensive. As expressed in a Lancet editorial: “Evaluation matters. Evaluation is science. And evaluation costs money. It’s time that the global health community embraced rather than evaded this message.”

VillageReach makes a sincere commitment to evaluation of its programs and has ever since its inception. For example, as we begin to scale-up the Dedicated Logistics System in Mozambique, we are engaged in operations research to inform our program decisions. In addition to routine monitoring, we are conducting baseline evaluations in every province followed by process and outcome evaluations. We want to know what is working and more importantly, what isn’t working and why, so we can ensure that the resources we put into our programs really make improvements in people’s lives and that those interventions make it to the people who need them. We’ll keep you posted on our progress.

Jessica Crawford, MAPS, MPHc
Program Associate
VillageReach

In order to increase the demand and awareness of LPG among households, we will be launching a social marketing campaign tailored to the realities on the field. From personal demonstrations of around 10 people to big events where we expect over 200 people to attend, we will be testing different methods to stimulate demand and awareness. In the end, our goal is to be able to learn from this experience and create a social marketing model and toolkit which we will be able to implement in other developing countries and with a variety of product (whether that be bed nets or batteries).

Check in regularly for updates on our progress.

Peter Nakamura, Project Administrator

As we move forward into fall, we look forward to even more good news…

VidaGas was started in 2002 to support the health system improvement program developed by VillageReach and FDC.  More than 80% of Mozambique’s population is rural and depends on charcoal and wood for basic cooking and heating.  Safe and reliable propane from VidaGas enables health centers to provide critical health services including vaccinations, equipment sterilization and nighttime birthing.  Additionally, propane from VidaGas is a clean and affordable alternative to charcoal and wood for households, small businesses, and light industry clients.  VidaGas has grown over 500% since 2002 and is now the largest propane distributor in northern Mozambique.

Oasis Fund is a Luxembourg investment fund which finances innovative, growth stage, commercially viable enterprises that deliver basic goods and services that improve the lives of low-income communities.  This investment is the first investment in Africa for the Oasis Fund.  Oasis Fund is advised by Bamboo Finance, a Geneva based investment advisory firm.

VillageReach’s Social Business Director, Craig Nakagawa, will be speaking with Keely Stevenson, of Bamboo Finance, about the investment at SoCap tomorrow.

There are 4 main categories of players: Governments, NGOs, multi-lateral organizations (WHO, UNICEF) and public-private alliances.  While there are many, many important and interesting stakeholders in the field, the most interesting evolution over the last decade has been the ways these groups cross boundaries to find creative ways to work together.

When Global Alliance for Vaccines and Immunization (GAVI) was established in 2000, it had an enormous impact on the field of vaccines.  GAVI refocused attention on vaccine-preventable diseases which waned in the 90’s after the highly successful immunization campaigns of the 70’s and 80’s. And as a public-private partnership funded by donor governments and private organizations such as the Bill & Melinda Gates Foundation, it brought serious financial resources to the table (over $2 billion of net assets in 2007).  Currently, GAVI supports 72 low and middle-income countries in vaccine financing and procuring.  While considerable resources at GAVI have been directed towards augmenting the supply of existing vaccines and developing new vaccines, GAVI and its stakeholders are increasingly beginning to consider the inadequacies of the health systems into which these vaccines must enter.

One particularly interesting initiative is The Optimize Project, a joint collaboration between the WHO and PATH.  The Optimize Project seeks to identify and advocate for the “immunization systems and technologies for tomorrow.”  Funded by the Gates Foundation, the Optimize Project is a recognition that discovery and development of vaccines is only half the battle.

Here at VillageReach, it has been exciting to see the development of enthusiastic recognition and articulation of the problems of logistics at theLast Mile.

We ’re launching with our thoughts on the “Innovation Pile-up.” Chris Elias, the Executive Director of PATH, coined this phrase to describe the coming challenge facing public health systems around the world as years of medical research and development, particularly for vaccines, come to fruition.

When VillageReach started working in Mozambique in 2001, we found there was no system for distributing medical supplies beyond the provincial level … a situation that’s unfortunately the norm in most developing countries.

The Mozambique system was chaotic and under-resourced in 2001. Since then, the world has begun to invest heavily in new medical products, such as vaccines, to address the huge disease burden affecting developing countries. Governments, international organizations, and private charities have spent trillions of dollars in research and development of new products. But new opportunities bring new challenges. The new vaccines just starting to become available are much more expensive and are physically, much larger.

For example, polio is a basic vaccine administered around the world today. Twenty doses of polio fit in a vial about the size of your little finger. At 13 cents per dose, the vial is worth only a few dollars. A twenty-dose, polio vial doesn’t take up much room in the refrigerator, and if the distribution system ruins a few vials, or has a few leaks in it, then the loss is not huge.

In contrast, one new vaccine to prevent rotavirus, a stomach bacteria that kills thousands of children every year, costs $5 and is the size of your fist. The HPV cervical cancer vaccine is expected to be priced between $50 and $100 per dose in developing countries. The malaria and HIV vaccines, which we hope are coming soon, are also likely to be very expensive. Current distribution systems are overwhelmed now; the new products will swamp them.

Unless we invest in improving the ability of developing countries to handle these new products, trillions of dollars of investment will be wasted and, more importantly, children in those countries will once again, be passed by. While we can get excited about new product developments, and rightly so, we can’t forget that our job is not done, until drops are in mouths, and needles are in arms.