Thoughts From the Last Mile

How a Phone Call Saved a Life

A frontline perspective of the CCPF “Health Center by Phone” Program
By Novice Gauti
Hotline Supervisor
VillageReach, Malawi

When I trained as a midwife, I had no idea that I would be helping deliver babies over the phone. Technology has come a long way, especially in the district of Balaka in Malawi.

In September of this year, Mercy, a 24 year old pregnant woman from Dailesi village in Balaka, told her family that she wasn’t feeling well, and set out for Kalembo Health Center seated on the back of a bicycle driven by her neighbor. Dailesi village is 12 km away from Kalembo, the nearest health center, and is located in a hilly area far from paved roads. The only transport available is by foot, by bicycle taxi, or – in case of emergency – by ox cart or bicycle ambulance.

Dailesi village is 12 km away from the nearest health center, and is located in a hilly area far from paved roads. The only transport available is by foot, by bicycle taxi, or–in case of emergency–by ox cart or bicycle ambulance.

After an hour of traveling, Mercy started feeling intense muscle contractions signaling the birth of her baby and could no longer sit on the back of the bicycle. Mercy asked the bicycle driver to stop in a nearby village so that the women living there could help her deliver her baby.

With no other transport available, still far from the health center, and without any skilled personnel nearby to help with Mercy’s delivery, her neighbor decided to call Chipatala cha pa Foni for assistance.

Chipatala cha pa Foni (CCPF), which translates to “health center by phone,” is a toll-free hotline that women in rural Malawi can call to speak directly with a hotline worker for information on pregnancy, newborn and child health, and reproductive health issues such as family planning. A VillageReach project, CCPF provides clients with advice they can follow at home, or refers them to a health center or hospital if they’re displaying “danger signs” which require further care. Women in the community can also sign up for CCPF’s “Tips and Reminders” mobile messaging service to receive regular text or voice messages tailored to their week of pregnancy or their child’s age.

Besides information and referrals, CCPF has also linked key services to the community, as in the case of transport. After visiting the CCPF Hotline Room, the Balaka District Transport Officer was so impressed with the potential of CCPF to save lives that he offered to assist in arranging transport logistics for callers in critical condition or in need of immediate care. He gave us his telephone number and requested that we let him know of any emergency transport needs.

Less than one week later, we took him up on his offer when Mercy called the hotline.

Rose Nkupsya, a nurse and CCPF hotline worker, answered the call from Mercy. Rose understood the urgency of the situation and informed the transport officer. He immediately responded by sending the district ambulance to pick up Mercy and bring her to the nearest health facility.

Before the ambulance could reach her, Mercy delivered a baby boy. Mercy was bleeding heavily when the ambulance arrived and needed to be helped by health workers. But she was afraid of being reprimanded by them for delivering her baby outside of a facility and was concerned that the nurses would not admit her. Over the phone, Rose reassured her, and Mercy agreed to go to the health center where the nurse on duty was able to stabilize her condition and successfully stop the bleeding. Had it not been for CCPF and the transport officer, Mercy would have suffered severe bleeding and infection. Fortunately, she and her baby boy received timely and appropriate care, and both are happy and healthy today.

Chipatala cha pa Foni provides an important service to women in four districts of Malawi, but our work is far from finished. I look forward to continuing to help women have safe pregnancies and deliveries and for children to grow up happy and healthy.

Program Update: Mozambique DLS Performance Report January – June 2013

We recently posted the latest performance report update for the Dedicated Logistics System (DLS) in Mozambique, covering January – June 2013. You can find the report here.

The implementation of the DLS is conducted in close partnership with the Mozambique Ministry of Health and provincial governments to improve access to vaccines for millions lacking sufficient healthcare in four of the country’s ten provinces. The focus of the program and the metrics we track concern vaccine distribution, one of the most cost effective interventions to save a life.

These reports, which reqire government approval for us to publish, cover a variety of metrics including:
• Health centers visited and data reported
• Delivery of vaccines
• Stock outs of vaccines
• Functioning refrigerators
• Number of vaccines administered

For the health centers receiving deliveries of vaccines from the DLS, vaccine stock outs continue to be below ten percent. More than 95 percent of refrigerators at health centers are functioning within the range necessary to ensure vaccines remain at desired temperatures. At the same time, the timing of vaccine deliveries is not as high as our target … this is a work in progress as we assist the provincial ministries of health to absorb the logistics system into their budgets and workplans.

Please feel free to send in your comments or questions to info@villagereach.org.

VillageReach Featured in Seattle International Foundation’s 2013 Global Giving Guide

We are proud to be featured again this year in SIF’s annual Global Giving Guide. See our profile in the guide, below, and visit the Seattle International Foundation.

Rose is a Group Village Head in central Malawi and is responsible for overseeing the well-being of a community of a 32-village community. She has long been concerned with the challenges women and children face in her community when trying to access health information and services. Women and children in Rose’s villages, and in Malawi as a whole, experience high rates of maternal and child mortality as a result of limited health care and lack of reliable information on safe motherhood and child health practices.
SIF.2013_2b

Today, women and children in Rose’s community are getting help from Chipatala cha pa Foni (health center hotline, in English), a toll-free maternal and health hotline that provides health information, advice and referrals. Service users also have the option of signing up for weekly voice or text messages to receive health tips & reminders to access preventive health care services. Village volunteers help women understand and use the service and ensure access for those without cellphones through project phones.

Chipatala cha pa Foni effectively extends the reach of the health system, allowing women and children to access health services from their home without having to travel long distances to the nearest health center. As a mother, grandmother and community leader, Rose has been a strong advocate for use of the Chipatala cha pa Foni in her community. Rose encourages those who have cell phones to lend them to those who cannot afford one, and has even contributed her own phone to those who don’t own phones. As a result, the Chipatala cha pa Foni program has had a vast reach into the community, receiving over 11,000 calls and registering nearly 6,000 women and caregivers of young children for the tips and reminders service.

Since 2000, VillageReach has worked to improve the performance of health systems, serving more than 10 million people in remote communities across sub-Saharan Africa.

Pushing Vaccines: Improving the Supply Chain in Mozambique

The first time I went on a vaccine distribution trip in rural Mozambique, we returned to the  warehouse at the end of the day with more vaccines than we took with us that morning. Yes, we  brought back more!

How is that possible?

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 At that time, the health distribution system in that area was based on a “pull” system— essentially health centers requested a quantity of vaccines each month based on population numbers and the group of children they expected to vaccinate. This number was not necessarily matched with the actual consumption of vaccines and the actual number of children vaccinated each month. And the warehouse sent out vaccines based on this request, without confirming actual stock or use.

You can imagine what the result of that can be. In some places where population data is underestimated, a health center runs the risk of running out. In some places where population data is underestimated, a health center runs the risk of running out of vaccines because more children than expected are showing up. Their mothers are being turned away and told to return another day when, hopefully, they will have more vaccine. In other places where population is overestimated, more vaccines are being delivered than they can use. If the distribution team isn’t confirming existing stock levels and actual consumption, you find stockpiles of vaccines, overcrowding precious space in refrigerators, just waiting to be discarded because they spoil before they can be used.matched with the actual consumption of vaccines and the actual number of children vaccinated  each month. And the warehouse sent out vaccines based on this request, without confirming actual stock or use.  essentially health centers requested a quantity of vaccines each month based on population    numbers and the group of children they expected to vaccinate. This number was not necessarily matched with the actual consumption of vaccines and the actual number of children vaccinated each month. And the warehouse sent out vaccines based on this request, without confirming actual stock or use.

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Since 2011, I’ve been working with VillageReach to prevent scenarios like this one. In four provinces in Mozambique, we support the health sector with an “informed push” distribution system. Working with the government, the distribution team goes to each health center, confirms the existing stock and verifies consumption data for the past month. Based on this information, the appropriate quantity of vaccines are stocked – enough to cover all of the children who will arrive in the next month, but not so much as to lead to underutilization and overstock. of vaccines because more children than expected are showing up. Their mothers are being turned away and told to return another day when, hopefully, they will have more vaccine. In other places where population is overestimated, more vaccines are being delivered than they can use. If the distribution team isn’t confirming existing stock levels and actual consumption, you find stockpiles of vaccines, overcrowding precious space in refrigerators, just waiting to be discarded because they spoil before they can be used.

The distribution team goes beyond just delivering vaccines. They ensure the quality of data in the child registers and stock cards. They make sure the nurses understand changes in the system, such as when the pneumonia vaccine (PCV) was introduced a few months ago and the vaccine schedule as well as the child registry changed. And all of this leads to their ability to ensure that vaccines are available when and where they are needed.

I can see the impact that this different distribution system has had. The “before” and “after” is clear in the registry books, with completed and correct data now available. More children are getting vaccinated, and stock outs are less than 10%. Even nurses have told me they better understand their jobs because they can now communicate with members of the distribution team.

We have come a long way since that first day when I found stockpiles of vaccines in health centers. There is, of course, much more to do. I’m looking forward to the day that 100% of children are completely vaccinated.

Aida Coelho, National Program Officer, Health Systems Group

Originally posted on Impatient Optimists, the blog of the Bill & Melinda Gates Foundation

You Can’t Manage What You Can’t See

One of the biggest challenges in a vaccine supply chain is the information system—a way to know the stock levels of each vaccine at each health center, knowing how much has been delivered and used each month in order to plan for what will be needed in the next month. Without this information, a manager can’t manage.

VillageReach has been working in Mozambique for a decade, supporting the Ministry of Health and its Expanded Program on Immunization (EPI) to strengthen the vaccine supply chain. One aspect of our work is the information system, making data available for evidence-based decision making.

A new video shows how this information system is helping EPI better manage the vaccine supply chain. vrMISvrMIS is a web-based logistics management information system designed to provide health workers with up-to-date information on the vaccine distribution system. It provides nearly real-time data, showing not only how many children were vaccinated but also how the distribution system is operating and where the bottlenecks are.

With vrMIS, information collected at the health center level can be used by province-level decision-makers to monitor performance, assess overall vaccine distribution needs, and take measures to reduce stock outs and improve coverage rates.
vrMIS helps the Ministry of Health see what’s happening with vaccine distribution. Health centers that were once isolated are now part of a larger network of information sharing. Having this information available has improved logistical planning, provided better accountability mechanisms, and strengthened the capacity of the existing health system.

We are in the process migrating vrMIS to OpenLMIS, a collaborative, community-focused initiative to create an open-source electronic LMIS for supply chains. This will provide an opportunity for Mozambique to be part of a larger system allowing for more timely decisions to improve health system performance.

This video is part of a series developed by PATH, highlighting different health information systems around the world. Check it out on YouTube.

Wendy Prosser, Program Manager, Health Systems Group

VillageReach Announces Final 20 Project – Bill & Melinda Gates Foundation Awards Grant to Improve Vaccine Delivery in Mozambique

Today we’re excited to announce the Bill and Melinda Gates Foundation is awarding VillageReach a grant to improve vaccine delivery in Mozambique. The two-year Final 20 Project targets more than 400 of the Mozambique Ministry of Health’s rural health centers that serve a population of approximately 13 million. See our press release announcement and this blog that is also featured at Impatient Optimists.

Who are the Final 20 and Why do we Need to Reach Them?

Today, more than 80 percent of children around the world receive a complete routine of life-saving vaccines during their first year of life. That is a significant increase from the 17 percent coverage 30 years ago, giving millions of children each year a better chance of seeing their first birthday. This increase in coverage is the result of decades of hard work to establish immunization systems in countries where previously, they simply did not exist.

Despite this huge success, these immunization systems have reached their maximum capacity. A considerable gap remains in reaching the final 20 percent–the children who are the hardest to reach, and the ones currently not served by existing immunization programs.

These children usually live in remote, rural communities, several miles from a health facility with little transport available, in villages that can’t be reached by large delivery vehicles, beyond the reach of cell phones, and where electricity is available only sporadically, if at all. In these communities, vaccine coverage rates are very low and child mortality unacceptably high because weak underlying infrastructure limits the potential of what the health system can deliver.

To reach this final 20 percent–24 million children–with the current group of life-saving vaccines, not to mention the exciting new vaccines that are just being introduced, it’s time to apply new innovative approaches and delivery models.

Increased attention is now being directed to this challenge. As part of a broad strategy by the Bill & Melinda Gates Foundation to improve vaccine supply chains, VillageReach is working to scale new system innovations to improve vaccine distribution across Mozambique.

The Final 20 Project is building a sustainable model of innovative supply chain design, enhanced data collection and reporting, and public-private partnerships to improve the underlying infrastructure the health system requires. Our goal is to provide tools, research and evidence that will benefit Mozambique and other countries as they work to improve their immunization systems to accommodate the new vaccines and improve the health of their children.

The Final 20 Project is an extension of a model we have applied in Mozambique for over ten years, while working with provincial government health departments (DPS) to streamline their logistics system. The ad hoc collection-based approach, where frontline health workers must leave their health posts every month to collect vaccines and related supplies from their district office, was replaced by a dedicated distribution system (Dedicated Logistics System or DLS) with a small number of specialized government workers visiting the health centers monthly to deliver vaccines and supplies, repair equipment, collect data, and provide supportive supervision.

The project incorporates an electronic logistics management information system that enables more practical and reliable data collection. This system allows the DPS to improve the monitoring of commodity availability at the health facility level and delivery components in order to improve the flow of vaccines through the supply chain and reduce shortages of stock even in the hardest to reach areas. With more regular data being reported, administrators are now able to see what is happening and make informed management decisions to improve system performance.

VillageReach also leverages the private sector to supply critical infrastructure services, such as communications, energy and transport, that are critical for both the health system and the private sector.

For example, one of the barriers to a functioning cold chain for vaccine distribution in the remote northern provinces is a lack of fuel to power vaccine refrigerators in regions far from the electrical grid. In response we established an energy services company, VidaGas, in partnership with a local organization, to provide propane gas to the health centers.

Since its establishment in 2002, the company has grown significantly to become the largest independent energy services supplier in northern Mozambique. The revenues VidaGas gains from selling to non-health sectors help sustain the company and support its obligations to the health system. With propane-based refrigeration now being replaced by new, more efficient solar and passive refrigeration technologies, in the Final 20 Project, we will work with the private sector, DPS, and other partners to support this transition, as well as, continue to develop creative private sector-based solutions to fill gaps in infrastructure needed to support vaccine distribution.

These are just a few examples of system innovations to improve vaccine distribution in Mozambique. We are excited to be a part of these and other efforts to extend the availability of life-saving vaccines to all children around the world.

Now is the time to reach that final 20 percent.

Allen Wilcox
President

Mozambique Dedicated Logistics System Performance Reports

The Mozambique Dedicated Logistics System (DLS) Performance Reports are regularly issued, government-approved updates on the status of key performance indicators monitored by the DLS which serve as a gauge of quality system implementation. The first of these reports for publication is featured here.

The performance reports present and explain trends across the following indicators:

  • Health centers visited and data reported – Health centers visited refers to the percent of health centers visited out of all health centers in the provinces operating the DLS. The percent of health centers that are consistently visited is measured by the percent of health centers visited within a 33-delivery interval. Data reported refers to the percent of all health centers reporting data through the DLS logistics management information system, vrMIS.
  • Full delivery of vaccines – This refers to the percent of health centers visited who have received a full supply of vaccines. This indicator is broken down by specific vaccine type. The information system currently tracks all vaccines used in the public health system including BCG, measles, tetanus, pentavalent, polio, and pneumococcal.
  • Stock-outs by vaccine – A stock-out means that there is no remaining dose of any one vaccine at the health facility. The Reports monitor the percent of health centers visited that have experienced a stock-out of a specific vaccine type.
  • Functioning refrigerators – The percent of refrigerators at all health centers visited that are operating at the optimal 2-8˚C temperature range required by all vaccines in Mozambique’s supply chain.
  • Vaccines used – The number of supplies used in the previous month by all health centers visited.

VillageReach, in partnership with Mozambique’s Ministry of Health also aim to produce information on the overall impact of the DLS. However the measurement of impact indicators such as improved immunization coverage and improved community trust in and use of health services are not covered by these Performance Reports since such information requires point-in-time surveys and evaluations conducted over a longer time frame (i.e. every three years). VillageReach’s intention is to issue these Reports every six months, however the schedule of release of the reports will always be subject to partner review and approval prior to sharing.

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