Thoughts from the Last Mile Welcome to the VillageReach Blog
12.03 2010

Five months ago as I sat here in Seattle, I found it a difficult exercise to imagine the performance of our health system strengthening programs operating worlds away from my desk chair. Even though geographically much closer, local health staff and management also face the same challenge caused by the extreme difficulty to pull routine data out of these rural, remote communities. Yet an understanding of the performance at this level is critical for health system improvement.

Now, five months after the implementation of our information system, local health staff and I are now starting to see this health system data.

In partnership with the Ministry of Health, my colleagues and I at VillageReach implemented a internet-enabled logistics management information system (LMIS) called vrMIS to provide information management to our health system strengthening program in the three northern provinces of Mozambique, Cabo Delgado, Niassa, and Nampula, serving a population of over 7 million people.

vrMIS, an application of the open source LMIS platform called openLMIS, collects routine data and then provides reporting analysis to health workers and their management in order to increase the effectiveness and efficiency of the supply chain from the provincial medical supply warehouse down to the health center or what we call the “last mile” of the health system.mapping_visualization3

Five months since vrMIS was implemented, I can see the data uploaded by the health staff. It’s incredible to see data from these health centers as well as powerfully insightful. I see medical supply inventory levels for these health centers. I see the number of tetanus vaccinations given last month. I see the refrigerator at a particular health center is currently not functioning correctly because of a leak in the gas line. I can see so many things. Upon further review, I start identifying performance trends and from this areas for improvement.

vrMIS shines a light on the last mile of the health system – all the way down to the health center level. This illumination provides new insights to the reasons why a health system is performing the way it is and enables management to take informed, appropriate action.

Still in Seattle, I can stop trying to imagine the performance of the health system. Now, I just open an Internet browser.

Nick Amland
Program Assistant
VillageReach

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10.14 2010

In Melinda Gates’ recent TEDX talk, she posed the question; how is it that coke can get its product to “far flung” places all over the developing world while governments and NGO’s seem to have so much difficulty delivering health commodities like vaccines?

Well this got us thinking a little about how this applies to us, especially because our work in Mozambique is specifically focused on this effort. Actually, it isn’t the first time we’ve thought about the coke model in our work. We used Mrs. Gates’ observations on Coca Cola as a framework to understand some of our own efforts. Pretty quickly, we see parallels in the way that Coca Cola and VillageReach do their work, at least in the way that it was presented in the TED talk!

Let’s start with the piece about real-time data. We’ve known that this is essential for our program in Mozambique to function even from the start. In fact, it is an integral part of our program design. We need to know when and at what health post there is a stock out of a particular vaccine, if there are problems at particular health centers with their refrigerators, or if immunization numbers drop suddenly from a region so that we can identify the problem and fix it. This is not as easy as it sounds. In our first attempt at collecting routine data, we used paper forms to collect the data and then sent these forms back to our Seattle office for input into our management information system. After the data was entered and reports were generated, we would send electronic versions of data analysis reports back to the field. This process took up to 3 months. We quickly found that the latency this process created significantly decreased the value of the data analysis reports. The reports were out of date and no longer as useful. However, this demonstrated to us how essential and potentially impactful real-time data could be.

Since this experience, we’ve released two versions of this management information system. Our latest version, vrMIS3 (built on the openLMIS platform), was developed on the principle of real-time data. We utilize several different data collection methods (paper forms, SMS, smartphones, computers) allowing us to extract real-time data in any environment. We now have vrMIS3 deployed that does just that – provides health workers with real-time data to enable more appropriate, more rapid decision making. In this way, we can help ensure that the vaccines are safely arriving to these “far flung” health centers and interruptions in vaccine services are avoided.

Mrs. Gates mentions the success of using local entrepreneurs as central to coke’s success. Again, we identified this opportunity and established it as part of our model from the beginning with the establishment of VidaGas. Local entrepreneurs made this happen. We’ve also been successful with “marketing” and by this we mean making people want to come to the health center for immunization services and through mass campaigns. While this hasn’t been a direct objective for us, it has been something we realize has been essential to our success. More to come on these two points in another blog!

We’ve seen success with this model in our demonstration project and are working on getting our “product” out there to the “far flung” places Mrs. Gates speaks about – just like coke. Now if we could just find a way to bring in those billions of dollars like coke does, we’d really be able reach a lot of children! Maybe we just need to add more sugar?

Jessica Crawford & Nick Amland
VillageReach

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09.24 2010

After spending nearly two weeks in an intensive course offered by the Institute for Health Metrics and Evaluation for its incoming fellows (and a couple of fortunate UW graduate students like me), I have an even greater appreciation for the role of evaluation in our work in global health and for the complexity and difficulty in doing it well. In her lecture on Evaluating Health Programs, Dr. Emmanula Gakidou, pointed to what is called “The Evaluation Gap” where billions of dollars from international donors and national governments are being channeled into health programs in low and middle income countries but we know relatively little about what programs are working and how well they are working. The reason being is that most of them are not rigorously evaluated.

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

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07.14 2010

IMG_0669On June 27, 2010, VillageReach staff members competed in the annual Mountains to Sound relay race. Our team, the Last Milers, traveled a total of 100 miles from the Cascade Mountains to Seattle’s Puget Sound. The relay race consisted of a mountain bike, road bike, kayak, and two running legs. We finished the entire race in just over 8 hours and 47 minutes for a 70th place finish (out of 129 teams). In an effort to raise awareness about the VillageReach and some of our work, the “Last Milers” carried a polio vaccine vial from start to finish.

IMG_0669Ethan started the day by completing the 17 mile mountain bike leg in just over 1 hour. At Rattlesnake Lake, Ethan passed the vaccine vial to Allen, who then carried it nearly 50 miles by road bike. Allen finished his ride in just over 2.5 hours and met up with Nick and John at Luke McRedmond Park in Redmond. Nick and John carried the vaccine vial 12 miles along the Sammamish Slough in a tandem kayak. IMG_0669 They finished at the northern tip of Lake Washington in 2 hours and 11 minutes. John passed the vial to Jess and she ran with it just over 13 miles along the Burke Gillman trail. She finished at Gasworks Park after 2 hours and 10 minutes and then passed the vial to Ryan. Ryan carried the vial the remaining distance to Golden Gardens Park where his teammates were waiting to cheer him on over the finish line.

IMG_0669Team VillageReach Last Milers raised nearly $2,000 to support their efforts. All donations received go directly to support the health system strengthening work of VillageReach in rural Africa. VillageReach would like to thank the generous contributions from family and friends as well as from our sponsors: Getty Images, Fairhaven Health, Sound Mind and Body, and Red Door.

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05.18 2010

IMG_0669Over the past two weekends, we ran four “Big Events” in the bairros of Namicopo and Namutequiliua. The Big Events are, as the name suggests, big promotional events to further promote LPG and VidaGas products. We had music, theatre, dancing, and giveaways among other things to entertain and educate people about LPG. We selected high-traffic locations within the bairros and days on the weekends as many households go out to the market to do some shopping.

We completed three Big Events in Namicopo and one in Namutequiliua. In terms of the turnout and reaction from the audience, the results were fantastic. People were glued to the Theatre Group’s performance that effectively demonstrated the difference between using charcoal and LPG, and the music definitely got people up on their feet! Attendance was well over 200 people and included a lot of children. Although they don’t have the direct purchasing power, children are an important part of our marketing campaign as they can spread the message about our product very effectively. Not to mention they’re more open to using new technology as well and will form our future customer base.

IMG_0669Although we can say that our first few Big Events were successes based on attendance and entertainment, there is significant room for improvement. One of the biggest issues that we have to the address for our next Big Event is how do we convert the audience’s interest and knowledge of LPG into actual sales? Of course it’s nice to base our success based on the number of smiles and applause, but our bottom line (no pun intended) is to sell LPG. We did have a number of kits available to be sold at the events but we didn’t sell as many as we’d hoped. Perhaps we were all too focused with running the event according to the plan, but our next event must be able to capitalize on potential sales.

Fortunately, we are planning on running another 21 Big Events over the next 3 months so there are plenty of opportunities for improvement. As I mentioned in an earlier post, this is a learning experience for all of us and hopefully we will have a refined and effective format for Big Events by the end of this project. Please post your comments and suggestions on how we can improve our future events!

Peter Nakamura
Project Administrator

-Peter Nakamura is currently based in Nampula, Mozambique to coordinate a project funded by USAID to help individual households gain access to propane.

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04.29 2010

I’m sure many of you browsing this blog are familiar with C.K. Prahalad’s groundbreaking book,The Fortune at the Bottom of the Pyramid. In his book Prahalad offers us insight into the vast, potential wealth that exists among consumers at the Bottom of the Pyramid (BoP). In fact, he’s talking about over 4 billion people and a multitrillion-dollar market. Although the “poor” are often categorized in a single group, he argues that they are just as – if not more – conscious about price, quality brand image, and accessibility as the “rich”. He believes that if a company/organization intends to succeed in tapping into the fortune at the BoP, it must study and understand the varied needs of the “poor”.

One of our goals with the USAID-VidaGas project is to develop a business model and toolkit that can be replicated for other BoP products around the world (not just LPG!). We’re using this opportunity with VidaGas to find out how one can successfully learn about and reach clients at the BoP level. LPG, as a new technology with significant benefits, provides us with a great product to find out how we can design an effective BoP model.

We begin with surveys among households to get a better idea of their current fuel usage situation, the perception of LPG, and to identify certain areas of the bairro (or neighborhood) that would be more open and financially capable of purchasing LPG. This is an important step in our marketing campaign as it gives us a better idea of the types of market segments that exist within the bairro. Not everyone is a potential LPG customer and our job is to sift through this diverse market to identify those that fit our client profile.

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We follow the surveys with promotional events such as local demonstration of around 10-20 attendees and Big Events of over 200 attendees to further spread the word about LPG and VidaGas. Not only do these events allow us to demonstrate the benefits of using LPG but they also provide an opportunity to answer any question or concerns about LPG. (Often time’s people think that using LPG is very dangerous, too expensive, or difficult to use.) These events also initiate word of mouth among households which is a crucial aspect in the BoP market as traditional mediums of advertisements often do not reach these households. Our final step is follow-ups among households that attended the demonstrations and Big Events. We want to find out whether or not they decided to purchase an LPG kit, and why they made that specific decision. It also gives us an opportunity to make another pitch to use LPG as people often attend the event but forget about it soon afterward.

Throughout the steps shown above, one of our main goals is to learn. As mentioned earlier, the “poor” are not simply the “poor” but conscientious consumers who want to get the best deal whether it be in price, quality, brand image, or accessibility. Eventually all this learning will help us develop a robust yet flexible model and toolkit that we can apply to other BoP products!

Peter Nakamura, Project Administrator

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04.19 2010

March was the month that we began to make significant strides with the project. We gained permission from the community leader of the Namicopo bairro (neighborhood) to conduct our awareness campaign. Fernando, our Lead Promoter, has been busy developing a “toolkit” of resources for the market analysis, and putting together a team for the campaign. He was able to identify and hire four Promoters and a team of “Animators” that will assist him in the execution of various aspects of the project. The team is comprised of people from the bairro who provide insight and a key link into the community.

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After our Promoters and Animators became knowledgeable and comfortable with using LPG, we conducted a household survey within the bairro. The objective of the survey was to get a better sense of the income situation among the households and their interest/willingness to purchase an LPG stove. A week of surveying provided us with 200 completed surveys!

After completing the surveys (which are currently being tabulated and analyzed), our next task was to send our Animators into the bairros to conduct a demonstration on how to use a basic VidaGas LPG kit. We asked each Animator to find at least 10 people to attend the demonstration and to show the basics on how to use a LPG stove. IMG_0669It was also an opportunity to answer any questions or concerns about LPG as people here often have limited (if any) knowledge of liquid propane gas. I followed one of our Animators (Cecelia) and Promoters (Marino) to one of their demonstration locations which was located at one of the secondary schools in the bairro.

The turnout was quite impressive, and the teachers at the school showed quite a bit of interest in LPG. A wild card in all of this was the vast number of students that also attended this particular demonstration, as they can bring the word about gas to their parents. Now this is viral marketing!

Suffice to say, March has definitely been an exciting month. April should also bring much of the same excitement as we will be hosting our first few “Big Events” in the bairro with music, skits, food, and – of course – LPG! The objective, through the event, is to create even more awareness and interest in LPG/VidaGas, and hopefully some new customers. We also plan on moving into new bairros during April and so adventure continues!

Peter Nakamura, Project Administrator

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04.08 2010

IMG_0669My name is Peter Nakamura and I am one of the newest members of the VillageReach team. I am currently based in Nampula, Mozambique to help coordinate a project funded by USAID to help individual households gain access to propane. The project is coordinated through VillageReach and its social business, VidaGas – the largest distributor of LPG (Liquid Propane Gas) in Northern Mozambique. As the next step in its growth, VidaGas is working to expand its customer base to households in order to diversify its clientele and expand the availability of a cleaner and more efficient source of cooking fuel than charcoal or wood (which are the most common types of cooking fuel in Mozambique).

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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

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02.18 2010

Last night my husband and I watched as Olympic speed skater Shani Davis won the gold. Unfortunately for us, we didn’t experience the thrill of surprise in his victory because NBC airs the program hours after it happens and we had read the news earlier in the day. My husband informed me that many frustrated viewers wrote to NBC requesting live coverage of the Olympic games. “Did it work?” I asked and was told no. I suppose we’ll watch Shaun White compete for gold too (even though we already know he wins).

Did it work? This question is integral to our lives. Did my Toyota come to a stop when I pressed the brakes? Did my headache go away after I took Tylenol? We don’t always realize it but we are constantly conducting evaluations. These questions and answers contribute to our understanding of what works and what doesn’t work so that we avoid repeating the failures.  The concept is pretty simple, so shouldn’t it also apply to the health programs we support?

It appears that the importance of evaluation in health programs is gaining attention. Perhaps this is in response to Moyo’s argument that $1 trillion in international aid has actually increased poverty and the shocking lack of evidence to the contrary. Last fall, I attended a lecture by Richard Horton, Editor of the Lancet, at which he urged the global health community of Seattle to use their expertise to support critical evaluation of global health data. President Obama’s recently announced Global Health Initiative highlights the need for robust monitoring and evaluation efforts in order to accelerate best practices and impact. Furthermore, donor communities are increasingly demanding evidence of impact from the organizations they support. With increasing attention on the importance of evaluation, the global health community is turning their efforts to the improvement of metrics, data, and evidence.

Barriers to the evaluation of global health programs are not insignificant. Evaluations are expensive, time consuming and highly political. For one thing, donors typically want their contributions to go to strengthening a health program rather than to a study of it. Furthermore, many government and non-government organizations fear finding evidence that their programs are not successful and potentially lose funding. Despite the difficulty, expense, and potential for undesirable results, conducting rigorous evaluations of our programs is one of the most valuable things we can do. Only with evidence can we attempt to answer the question of “does it work?”

-Jessica Crawford

Program Associate

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02.02 2010

Reliable delivery of medicines, vaccines, and health commodities at the last mile of the supply chain has been the focus of VillageReach since our inception. Earlier, we discussed the challenge of conveying our message and our work when the issues are complex, relatively unknown in the United States, and difficult to describe. We are happy to report, however, that awareness has been growing with help from articles like this one, found in the most recent winter issue of Global Health Magazine. Prashant Yadav, professor of Supply Chain Management at MIT-Zaragoza, outlines the many successes in Global Health but identifies critical gaps in health delivery.

“In my opinion, the weakest link in the chain now is the in-country distribution system. The costs of ignoring this key part of the health system can be extremely high.  A key reason for the poor performance of the in-country supply distribution system is the lack of an institutional and governance framework on how to organize in-country distribution.”

With keen insight, Professor Yadav articulates the challenges VillageReach faces daily in creating sustainable systems for the delivery of basic, life saving supplies. In addition to this article, Global Health Magazine posted a blog just a few days ago challenging various health system misconceptions.  The article challenges some widely held assumptions, many of which VillageReach has heard repeatedly over the years from potential donors and partners:

• Health systems can’t be measured.
• We don’t know what works to strengthen health systems.
• Strengthening health systems will be a money pit, an expensive, open-ended investment that won’t show measurable results.

Challenging these statements, the article cites the availability of measurable and proven methods within health systems, which can allow practitioners to make vital decisions. We were excited to see these acknowledgments, as a cornerstone of the methodology at VillageReach is the measurement and evaluation of our programs, and through our rigorous evaluation we have proven that health system strengthening programs can not only result in measurable impact but impact that tangibly saves lives.  We hope that these publications represent a shift of perspective within the world of Global Health towards a new view that will see “last mile” health delivery systems as a critical piece of the larger picture.

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