Thoughts From the Last Mile

A Relief for Rural Health Workers

IMG_20141010_142302By Andrew Hauli
Medical Assistant In Charge (Health Center Manager)
Nyungwe Health Center, Malawi

I am a clinician by profession, serving a population of over 30, 000 in the 25 villages that my health center serves. I am the only clinician at the health facility with a single nurse to assist covering when possible.  We recently lost the only health surveillance assistant that was trained as a drug clerk as she has left to pursue a one and a half year course in midwifery. This leaves me as the only clinician and also the only person to manage stocks in the medicine store (pharmacy).  I undertake the majority of dispensing responsibilities as the hospital attendants that sometimes need to fill this role are not knowledgeable about medicines. When it’s month end, I am also responsible for doing the physical inventory and producing a monthly report.  Each of these tasks requires time away from my primary responsibility of treating patients. This results in less time with patients, and inadequate reporting of essential information required to manage inventory. For example, I am not sure the reports that I send are even a true representation of the situation on the ground due to the limited time I have to devote to this task.IMG_20141010_133242

I am completely relieved to have this additional workload of dispensing and inventory management taken over by those specially trained to do the job through the introduction of the Pharmacy Assistant Training Program.  Through this program, our health center receives one student who has already received training in the areas of dispensing and inventory management – more training than anyone currently working at the health center, including myself.

The Pharmacy Assistant Training program is a very exceptional program because it is practicum- oriented. The student assigned to our health center the past five months is already doing an amazing job. I am no longer dispensing, or dealing with supply chain issues other than approving issues and orders.  Now,  I am able to see more patients in a day, and provide more thorough examinations.

This program is a big relief to us clinicians working in the rural and remote health centers. I am already getting calls from fellow in charges (Health Center Managers) who are enquiring on how they can get a placement at their facility.

This is such an amazing program which should not end at a few facilities, but expand to all the facilities in the country (Malawi).  I would like to thank VillageReach, their partners and donors who make the Pharmacy Assistant Training Program possible.  I hope that this program continues to grow as it is filling a critical need, and making a big difference that could change the way all rural health centers function- to the benefit of our patients, those in most need of care and attention.

For more information on VillageReach and the Pharmacy Assistant Training Program

The Building Blocks of Vaccine Supply Chains – A Lego Experiment

By Wendy Prosser
Program Manager Health Systems Group





It seems like a stretch—using Legos to find efficiencies in a vaccine supply chain. But that was the concept we worked with last week in Mozambique with representatives from both national and provincial level Ministry of Health, UNICEF, WHO, and VillageReach, led by the HERMES logistics team taking us through the use of the HERMES modeling tool. The HERMES model, which stands for Highly Extensible Resource for Modeling Supply Chains, allows a ministry of health to simulate different scenarios in a vaccine supply chain by changing the different components to find efficiencies.

To simplify the concept, take a bunch of Legos where each one represents different components of the supply chain—transport, fuel, health centers, cold chain, vaccines, per diem, transport loops, and, of course, the logistician. Putting those components together in one way may cost $0.42 per dose per child vaccinated and would result in an 80% availability of vaccines at the health center, which is what the HERMES model can show. Changing those components by possibly adding a transport loop or moving the cold chain equipment may result in a cost of $0.28 per dose per child vaccinated with availability increasing to 95%. The HERMES model can easily change those scenarios to find those efficiencies—almost as easily as changing around pieces of Legos but with much better insight into the actual performance of the system design.


This workshop was the first step of putting the concept of modeling into practice in Mozambique. The local team got to work with the user-friendly interface of the HERMES tool to build their own supply chains. I could see the light bulbs going off in people’s heads as they figured out how to add in a vehicle in one place, a refrigerator somewhere else, and introduce new vaccines to their supply chains. This local team is now building up their capacity to run different computer simulated models and use those models for actionable results in the on-the-ground supply chain to find efficiencies and cost savings.

A few key themes resounded during the week-long workshop:

  • The power of “crazy ideas.” The team was able to think about those out-of-the-box, “crazy ideas” of supply chain design because there are no actual costs to experimenting with transport loops or different delivery intervals when using a computer simulation. Improvement comes from change–thinking and doing things differently, as the MOH Immunization Program manager pointed out; modeling provides a way to do that.
  • Improving the performance of the vaccine supply chain is a priority. All participants were concerned about improving the supply chain, sharing new approaches they have been involved with directly or have heard about, and bringing up areas that need more attention like outreach efforts and wastage rates. This initial pilot focused on two provinces, but there was a general consensus that a modeling exercise would be even more beneficial at the national level.
  • Tools are available to help improve the supply chain. The HERMES tool is one of many ways of looking at the supply chain. The participants agreed that results of any HERMES model must be analyzed within the realistic context and with information from other sources, such as health services data.
  • Technology and knowledge transfer is part of the process. This was a first introduction to the concept of modeling and actually running the model. No one became an expert by the end of the workshop, but each person is developing their modeling skills and ability to ask important questions to improve the functioning of the supply chain.

It was great to see the local team running models and debating the different options for the Mozambique vaccine supply chain. Of course, this is only the first step of changing and improving the system. More modeling needs to be done to test out those “crazy ideas”, and the different decision makers need to decide which ideas are truly “crazy” and which ones can actually improve the supply chain and ensure more children are vaccinated and stay healthy.

About the Author: As Program Manager, Wendy Prosser is responsible for the design, implementation, and monitoring and evaluation of health system program for VillageReach in Mozambique. Efforts in Mozambique seek to streamline vaccine logistics with an improved logistics management information system and transport services. Wendy has over a decade of global health experience in program development and management, research and analysis, capacity building, and behavior change communications. This experience has taken her to Mozambique, Malawi, Angola, Kenya, and South Africa in various public health settings, starting with Peace Corps in Cape Verde. Wendy holds a MPA in International Development and Global Health from the University of Washington.

Technically Speaking–the Deployment of OpenLMIS in Mozambique


By Rachel Powers
Technology Associate


Since beginning my technology associate internship at VillageReach, I’ve learned that strengthening health systems in developing countries requires reliable health information and improved decision-making capacity at all levels. Without real information on who needs what and where things are going it’s impossible to keep health centers supplied with the commodities they need to treat their patients.

Over the past six months, I have been working within the information systems group at VillageReach on a project that seeks to address these very issues. Together with various partners and collaborators, we have developed an electronic logistics management information system (LMIS) that helps countries keep track of and manage everything from tongue depressors to polio vaccines. This platform, called OpenLMIS, is free, open source, and designed especially with the needs of low-resource environments in mind. Essentially, it’s a web-supported system with a complex back end but simple user interface that can be customized to the tracking needs for medical commodities needs of any country. Most interestingly, (in my opinion) it has an offline mode where users can still record stock data even when they have no Internet connection.

In the summer of 2014, VillageReach deployed OpenLMIS to manage the vaccine supply chain in four provinces of Mozambique. After a year of hard organizational work, two implementation trips from my Seattle colleagues to Maputo, on-the-ground support work from my Mozambique colleagues, and a lot of system testing and documentation from my own desk, the system is now in place and serving more than 400 health facilities and a population of 10 million. But from a connectivity and network perspective, what does it take to implement OpenLMIS in a country like Mozambique? Visit the OpenLMIS blog to see the post I wrote that answers this very question, and learn more about the work VillageReach is doing with the OpenLMIS initiative.

The Technical Aspects of OpenLMIS Deployments: SELV in Mozambique

Promising Practices in Supply Chain Management


By Erin Larsen-Cooper
Program Associate


When VillageReach began work with the Supply and Awareness Technical Reference Team for the UN Commission on Life-Saving Commodities for Women’s and Children’s Health to document promising practices in supply chain management, I was both excited and daunted.  Excited because there is a growing recognition that strengthening supply chains is a fundamental aspect of increasing access to medicines and quality healthcare at the last mile; daunted because while there is so much work being done to improve supply chains in low and middle income countries, documentation and evidence of these interventions can be hard, if not impossible, to find.

One of the team’s first tasks was to conduct a literature review to see how many peer-reviewed articles on supply chain interventions in low and middle-income countries we could find. After a thorough search of several research databases, we came up with almost 500 articles.  Of these, only three met our criteria of using experimental or quasi-experimental methods to determine whether the interventions were successful. Even though I expected there to be limited evidence, I couldn’t help but be surprised by how limited it was. Experiments published in academic journals are not the only types of evidence, so we branched out our search to white papers, engage our professional networks, and use word of mouth to learn more about what governments, businesses and other non-governmental organizations are doing to strengthen supply chains. Many supply chain management interventions, for example, evaluate their effectiveness through key performance indicators. For instance, measuring how long it takes from the time a medication is ordered by a health center for it to be delivered, or how often hospitals are stocked out of essential medicines. The problem is, sometimes the only way to find out this information is to figure out who is working on the project and contact them personally, as many people do not have the time or resources to publish their work and results.

A year after we started, and after hours of research, interviews with experts, and conversations with those working in the field, the Promising Practices in Supply Chain Management series is complete. The team was able to identify more than 30 promising practices in public health supply chain management and find almost 50 examples of where these practices are being implemented in low and middle-income countries. This, in and of itself, is promising!

I’m excited about this work because at VillageReach we believe that more rigorous evaluation of supply chain interventions and more transparent dissemination of results is vital to increasing access to medications to those who need them the most. Creating a body of evidence on what works, advocating that evidence-based practices be implemented, and learning from each other’s progress and each other’s challenges, is the best way to make sustainable change.

A Visit From Dr. Kabambe

By Fannie Kachale
The Director of Reproductive Health Malawi Ministry of Health

I recently joined Dr. Dalitso Kabambe, the Director of Planning and Policy Implementation of the Malawian Ministry of Health, for a meeting with Jessica Crawford and Zachariah Jezman, Country Director and Project Manager of VillageReach.

We discussed Chipatala Cha Pa Foni and the possibilities of scaling the project nationally. Chipatala Cha Pa Foni, or CCPF, is an innovative mHealth solution for maternal and child health case management and health education in Malawi’s most remote areas. It provides two services: a toll free hotline offering health information, advice and referrals and a tips & reminders service that sends voice or SMS messages to registered pregnant women, women of childbearing age and guardians of children under one year of age.

mHealth in Malawi

(Photo:  Dr. Kabambe observes the CCPF call center and staff. Learn more about Doreen, and her role and impact as a CCPF health worker  here)

Mr. Jezman and Mrs. Crawford provided a thorough review of the history of CCPF, the services it provides and the impact it has made in its expanding catchment areas. At the end of our meeting, Dr. Kabambe and I were escorted by the VillageReach staff for a tour of CCPF’s hotline located on the Balaka District Hospital campus. Doreen Namasala, one of the five hotline workers for CCPF, explained the procedures for handling phone calls and how information is logged into the system. Even during our brief tour, calls came through to the hotline and Dr. Kabambe and I were able to observe CCPF in action.

Throughout the visit, Dr. Kabambe expressed deep concerns about the state of maternal health in Malawi and the great need for effective solutions that can change health behaviors on a large scale. He stressed that maternal health is among the top three health priorities in Malawi today. Most notably, Dr. Kabambe commented that the great work CCPF has accomplished sounds like “sweet, sweet music” to his ears. His excitement about CCPF is no doubt a positive step for the future of VillageReach’s project and, most importantly, the state of maternal health. I look forward to our continued partnership in reducing the burden of disease in Malawi.

For more information on mHealth innovation and additional VillageReach work in Malawi

Fannie Kachale Director of Reproductive Health Ministry of Health, Malawi

Shopping Around for Vaccine Supply Chains? Try it On.

How HERMES modeling tools allow decision-makers to see the impact of vaccine supply chain system changes- before they “buy.”
wendy-300x200By Wendy Prosser
VillageReach Program Manager
USA and Mozambique

You may not think that the world of fashion relates to vaccine supply chains, but let me make the connection. When shopping for that perfect outfit, sweater or shoe- I can go to a store and try on all kinds of options—different sizes, styles, colors, and all combinations therein. And then, with a lot of help from my friends, I can pick the best option for that particular occasion.  When that purchase becomes outdated, worn out or just doesn’t fit anymore, this process can be repeated.

Along the same lines, vaccine supply chains need to be upgraded as new vaccines are introduced or new technologies become available that could bring efficiencies to distribution systems. Unfortunately, there is no supply chain store where a government can go to “try on” different systems to see if they fit properly. Trying different warehouse locations or transport loops, for example, is not as easy as trying on a dress. Yet making a change to a supply chain requires major system changes that no one would want to implement — without trying them out first.

That is why it is so exciting to see the work that the HERMES Logistics Modeling Team is doing with the Ministry of Health in Benin. Keeping with the metaphor, Benin is looking to upgrade its vaccine supply chain “wardrobe” – new vaccines are being introduced and the Ministry of Health is interested in finding efficiencies in distribution.

That is where the HERMES modeling activity has a role – as reported in the journal Vaccines. The HERMES computer modeling and simulation helped the Benin Ministry of Health evaluate different options of redesigning the vaccine supply chain. The modeling exercise looked at the current system, considered consolidating community warehouses, and examined the option of adjusting the national warehouses into a different configuration. The investigators also evaluated the effects of changing transportation routes.

This “virtual laboratory” for the vaccine supply chain identified the most cost-saving results coming from structural redesign and introducing transport loops to the vaccine supply chain. The modeling exercise estimated that the improved plan would save Benin over $500,000 in total costs over the next five years while improving vaccination rates.

As a global health advocate and program manager at VillageReach, I am most excited about the Benin experience because we can draw from it in our work with the Ministry of Health in Mozambique where leadership are using HERMES modeling to consider changes to the vaccine supply chain in order to bring efficiencies and improvements in coverage.  Together, we will be looking for the best “fit” in terms of evaluating system redesign options as new vaccines are introduced into the supply chain. The modeling exercise will consider many of the same issues as Benin: transport loops, different distributions strategies for different areas of the provinces, and inclusion of outreach activities.

Until a supply system “store” is available, a modeling exercise is the next best option. By sharing our learning in Mozambique and Benin, we help build a knowledge set that others can benefit and learn from, considering new approaches to system optimization of the vaccine supply chain. For more information on our work in Mozambique

About the Author: As Program Manager, Wendy Prosser is responsible for the design, implementation, and monitoring and evaluation of health system program for VillageReach in Mozambique. Efforts in Mozambique seek to streamline vaccine logistics with an improved logistics management information system and transport services. Wendy has over a decade of global health experience in program development and management, research and analysis, capacity building, and behavior change communications. This experience has taken her to Mozambique, Malawi, Angola, Kenya, and South Africa in various public health settings, starting with Peace Corps in Cape Verde. Wendy holds a MPA in International Development and Global Health from the University of Washington.


 loveness By LOVENESS KASIYAMPHANJE                                                       Pharmacy Assistants Training Program- Class of 2015                             

My name is Loveness Kasiyamphanje. I am originally from Ntcheu, in the Central Region of Malawi, but I currently live in Namiyango in Blantyre District. I am pursuing a Certificate in Pharmacy Programme at Malawi College of Health Sciences (MCHS), Lilongwe Campus. The programme was created by VillageReach, the Malawi College of Health Sciences (MCHS) and their partners. The Programme is for two years and I am in the first year.

I had always desired to work in the health sector because I was sure that after training I would get a job. Secondly, the deplorable state of our health services mainly due to lack of trained human resource meant that once I get training, I will be of great help to rural communities who are the least served when it comes to health services. I was not sure about what I was getting into because the pharmacy program in Malawi is one of the least known programs, as compared to nursing and the clinical field, hence this is one of my motivating factors to take up this challenge.

While waiting to find out if I was accepted to the programme, I decided to observe some of the duties and pharmacy practices at the nearest Health Centre from my home. Although I was not trained, I could observe some of the poor services being offered at the clinic in regards to the pharmacy. The dispensers were not clearly giving instructions as to how the medicine should be taken, not mentioning the name of the drugs. I recall one time when my sister, who was asthmatic, was given aspirin which had an adverse effect on her. Some of the pharmacy personnel who were responsible for dispensing would leave patients on the queue and go to mop rooms whilst patients were waiting for them. Medicines were being dispensed without packs, with bare hands, and ailing patients were not receiving proper attention and care. For reasons like these, I was interested in the program so that I can make a difference after graduation.

I was invited for oral interviews at Lilongwe campus. It was a big challenge for me because I had never attended an oral interview in my life. This was also an opportunity for me to see the city of Lilongwe. I attended the interviews and one week later, I received a phone call from MCHS, Lilongwe Campus informing me about the good news of my admission into the programme.

When we arrived on campus, the Head of Programmes said that we would stay for ten weeks for basic orientation and half of the class would go for District practical attachments. We started learning basic courses like Anatomy and Physiology, First Aid, Microbiology, Parasitology, Chemistry, Counseling, Communication and Computer Skills. After that, we were partly introduced to programme courses like Pharmacology, Pharmaceuticals and Medicine Management. Then our group, which has 50 students, was divided into two cohorts. I was part of cohort one. Cohort two stayed at the campus while cohort one went to District Hospitals for practical attachments.

I was allocated to Mulanje District Hospital. I was under the supervision of the Pharmacy Technician. I performed a number of activities like pre packing and dispensing medicines, labeling the pill packs, issuing medicines and medical supplies, recording on the stock card any transaction carried, going to Regional Stores for emergency orders and also making sure that the pharmacy was tidy all the times. I was also compiling monthly reports and entered them in the supply chain manager computer program.

I then went to a local health centre in the same district for two weeks. I observed several problems, but the most critical problems were

1)     Dispensing personnel had not gone through an intensive training on medicines and their pharmacological properties.

2)     Poor record keeping led to the facility either having too much stock or not enough.

I managed to make changes at the Health Centre, advising them based on what I had learned at the District Hospital– to help them improve hygiene and safety standards. In addition, I informed them of the importance of keeping records properly to provide accurate consumption data, the losses and adjustments made, the stock outs experienced and the quantity to be reordered.

I was very happy to see the resolutions that I made being implemented at the facility.

This programme, therefore is very important because it will help in combating some of the problems that many health centres are experiencing in Malawi. It will help fill the gap that currently exists in terms of qualified pharmacy assistants in the health centres. With better trained pharmacy personnel, there will be proper record keeping, good dispensing skills and proper management of medicines. Patients will receive recommended combinations and full information on how to take the medication.

The need for more pharmacy assistants in Malawi cannot be over emphasized. Ward attendants, guards and drug clerks who are currently being entrusted with the responsibility of dispensing drugs leaves patients at the risk of getting adverse effects of taking medication without proper information.

Although the program is being taught by well experienced lecturers and also at an institution with a long history of producing quality products, there is still a need for more resources to support the program such as books, classroom space, full-time lecturers, and other resources.

I am looking forward to the five months health centre practical allocation. I hope I will make a much greater change than that of two weeks stay at my local health centre. I hope this programme will continue so that there are pharmacy assistants in the health centres all over the country.

Lastly, I would like to express my special thanks to the programme sponsors who make this program possible, and the Lecturers for the wonderful job that they are doing of ensuring that we get the best skills at school.

Learn more about VillageReach Pharmacy Assistants Training Program

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