The program is being rolled out in the various provinces in a series of rolling starts, covering four phases: preparation, implementation, supervision, and evaluation. The time required to complete each of these phases depends on the capacity of each province and their resources available to support the work. we expect the order of the provincial rollouts to look like this, but check back in regularly for updates.

Orange – Preparation Phase
Green – Implementation Phase
Yellow – Supervision Phase
Brown - Evaluation Phase

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For a historical timeline of VillageReach’s activities in Mozambique, see here.

Program Goals:

Fully vaccinate 44,000* additional children aged less than one year, plus:

• Improve child health in Mozambique by sustaining high vaccination coverage rates and low vaccination dropout rates;
• Improve the community’s knowledge of, trust in, and use of health services;
• Increase the capacity of DPS to manage and operate the dedicated logistics system in order to ensure sustainability of the new system;
• Increase the cost‐effectiveness and cost‐efficiency of the logistics systems for vaccines and other related commodities in Mozambique;
• Reduce stock outs of vaccines in all health centers where the system is implemented;
• Reduce interruptions in service delivery due to stock shortages, health worker absence and lack of health worker time;
  Integrate additional key commodities – such as rapid diagnostic tests – into the dedicated logistics system.

*The estimated # of additional immunized children are for an initial four province deployments only through 2015. If the program continues to expand to other provinces, this estimate will be revised upward.

To strengthen the health system, VillageReach applies personnel and other resources more intensively at the beginning of each provincial program implementation that decline over a three-year period, as the provincial health authorities build capacity to sustain the model. At the conclusion of three years, the government health system is expected to be fully independent of VillageReach resources and have documentable evidence of the benefit of maintaining the model and resources to support it well into the future.

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The design and deployment of effective supporting logistics systems are dependent on the use of information management practices that ensure adequate capture and flow of information. VillageReach’s Management Information System, vrMIS, produces ongoing, routine metrics to enable continuous adjustments to improve health system and/or program performance. The versatility of the system enables the collection and real‐time tracking of any data points defined by the program, which drives critical decision‐making by health administrators and maximizes the capacity of health program workers. The system significantly enhances overall transparency of the distribution process adding a higher level of security into the supply chain. vrMIS also provides critical data for the management, monitoring, and evaluation of the overall program or intervention.

VillageReach provides critical last-mile support for health intervention programs through a complementary set of skills and approaches covering logistics and supply chain optimization, information management, and technical assistance.

VillageReach also serves as a social enterprise. We identify gaps in community infrastructure that can limit the capacity and performance of health systems, and then evaluate these gaps to assess opportunities for new social businesses that can develop a broad customer base beyond the health system and lower the overall cost of service.

The goal is to leave behind a legacy of successfully developed, profitable businesses that are market competitive and socially beneficial. For more information on our expertise, see details here.

The Mozambique Program will be conducted over a five‐year period, depending on the availability of funding and demonstrated readiness of each province. The estimated cost for the program is $4,063,674. VillageReach has revised this estimate several times, as new information is made available and it assesses the capacity and expertise of the ministry of health and enters new provinces. We will continue to provide updates if and when there are significant changes to the program.

The current funding is expected to support VillageReach activities in Mozambique through mid FY2012.  This translates to a remaining funding gap of approximately $1.2M that will be required to support the program in the four provinces through the estimated period.  This gap would be larger if the program extends beyond these four provinces. VillageReach is actively seeking new sources of funding, including foundations and individuals.

VillageReach maintains a team of program administrators who provide program management, technical training and evaluation support. The team works with national, provincial, district, and health facility Ministry of Health employees to improve their technical skills in support of the program and to ensure appropriate levels of oversight to monitor the effectiveness of the dedicated logistics system. In addition to staffing personnel for the national program, VillageReach also incurs costs for assets it deems critical to ensure the program is implemented on schedule in each province.

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Cabo Delgado is the northernmost province of Mozambique, with a population of 1.8 million, bordering the province of Nampula and Niassa, and the country of Tanzania. The province produces marble, clay, graphite, and hardwood timber. Many communities in northern Mozambique and poorly connected to the rest of the country, including those in Cabo Delgado, where roads in rural communities may only be accessible by 4-wheel dive vehicles for much of the year.

Gaza, in the south, has a population of approximately 1.4M, and borders South Africa and Zimbabwe.

Maputo is the most southern of Mozambique’s provinces and borders South Africa and Swaziland, with a population of 1.1M.

Niassa is one of Mozambique’s most remote provinces, and the country’s most sparsely populated, with 1.2 million residents.

Method for evaluation

Information on key indicators for the baseline was collected through a household and health facility survey by a third party research group in Mozambique. The household survey was designed to estimate the immunization coverage rate and used the WHO methodology for conducting a cluster study in Cabo Delgado and Niassa provinces. Instruments were adapted from the WHO Immunization Cluster Study Manual.  The health facility survey was designed to assess current health system performance as it relates to the Dedicated Logistics System for vaccines and RDTs and instruments were adapted from the previous study completed by VillageReach in 2008.

Selected key indicator results

• Vaccination coverage has remained high in Cabo Delgado province although it has decreased since the end of the VillageReach program; 2010 estimates of DTP3 are approximately 91.9% compared to 95.6% in 2008. Coverage rates of DTP3 are significantly lower in Niassa province at 78.1% of children.
• Despite high vaccination coverage rates, adherence to the vaccine schedule is low in both provinces. Less than 50% of children surveyed in Cabo Delgado and less than 25% in Niassa had received the vaccines at the recommended time. Poor adherence may result in lowered vaccine efficacy and continued susceptible populations.
• More than 40% of respondents reported having visited a health facility to vaccinate their child and failing to do so. The primary reason reported was due to a lack of vaccines.
• Stock outs of vaccines and RDTs were common. 65% of health facilities in Niassa and 22% in Cabo Delgado were out of stock of at least one type of vaccine at the time of the survey.[1] Stock outs of RDTs were found in 40% of health facilities in Niassa and more than 90% in Cabo Delgado.

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[1] The survey occurred during a global recall of the Pentavalent vaccine. Thus the reported figures did not include stock outs of Pentavalent in the estimate.

Click on the image to the left to view the Baseline Report Summary.

To view the Cabo Delgado Vaccine Coverage and Vaccine and Rapid Diagnosis Tests Logistics Study, click here.

To view the Niassa Vaccine Coverage and Vaccine and Rapid Diagnosis Tests Logistics Study, click here.

VillageReach and Mozambique provincial health authorities (DPS) together conduct process evaluations every six months to assess the implementation of the Dedicated Logistics System. The process evaluation includes a review of the challenges and successes encountered in implementing the system and an evaluation of the DPS’s ability to implement and maintain the system without technical assistance from VillageReach or other partners.

Information for these evaluations are prepared from:

• A review of the monthly key indicators in VillageReach’s Management information System (vrMIS),
• Review of technical assistance reports prepared by VillageReach staff in Mozambique,
• Site visits by an evaluation team to the province and health centers, and
• A series of interviews with stakeholders (provincial health authorities)

Results of the first six-month evaluation in Cabo Delgado (June – December 2010) and Niassa (September 2010 – March 2011) revealed that both provinces made substantial progress toward a successful implementation of the Dedicated Logistics System. The following activities were completed in the first six months of implementation:

• Budget planning for activities in 2010 and 2011.
• Baseline data collection, analysis, and report writing.
• Field coordinator training and training for the district directors and those responsible for Community Health and Maternal and Child Health (SMI).
• Installed the VillageReach Management Information System (vrMIS) to enable effective data capture and reporting of various performance metrics of the system.
• Distributions to health centers in all districts in Cabo Delgado and six of 16 districts of Niassa using the Dedicated Logistics System.
• Collected data and started distribution of Rapid Diagnostic Tests (RDTs) in Cabo Delgado

Results Summary

• Distributions of medical commodities reached health centers every month in Cabo Delgado and reached health centers in five of six months in Niassa.
• The program saw delays in distributions, primarily due to unavailability of sufficient transportation or the lack of funding for fuel and/or per diems for government staff.
  • In Cabo Delgado, the average delay in scheduled distributions was three days
  • In Niassa, the average delay in scheduled distributions was 10 days

• The availability of data from the health units was significantly lower than desired for the project.  On average, 68% of health units in Cabo Delgado and 20% in Niassa had data collected and entered in the logistics management information system in a given month. Due to irregularities in the data available, the analysis of key indicators was limited in the six-month evaluation.  Subsequent efforts and evaluations will highlight the need to improve data collection and entry practices.

• Of the health units with data reported;
  • On average, 95% of health units were reported as visited in Cabo Delgado, and 72% in Niassa per month.
  • Approximately 16% of health units on average in Cabo Delgado and 7% in Niassa reported a refrigerator problem in a given month.
  • Stock outs of Pentavalent were common, with up to 75% of health units reporting a stock out in a given month, largely due to a national shortage of the vaccine.
  • The stock out rate of the other vaccines ranged from zero to 25% of health centers reporting a stock out of a vaccine in a given month in both provinces with Polio vaccine being the most common vaccine out of stock.
  • Full delivery rate is highest for BCG, Measles, and Tetanus vaccines and lowest for Pentavalent and Polio vaccines.

  

Conclusions

The evaluation revealed that DPS in Cabo Delgado and Niassa provinces have demonstrated the capacity to implement the vaccine logistics system, although funding to support distributions is a significant challenge for the provincial governments: in Cabo Delgado there were delays in securing funds for distributions from the third party contributor; in Niassa, there were routine challenges accessing government funds for the distribution.  The evaluation noted challenges and room for improvement in the operations, highlighting the need for a continued partnership with technical assistance from VillageReach. The results of the evaluation will be used to improve the quality of the system, ensure regular distributions and improve data quality.