Solving supply chain challenges, especially for community health workers (CHWs), requires a people-centered approach. This means solutions must be co-developed with key stakeholders, and a continuous feedback loop on performance and impact is critical to success. At VillageReach we use data and feedback from health workers and communities at the last mile to co-design and scale solutions that increase the availability of products and services in remote areas.
This feedback from health workers is a focus of our current goals and strategies, and for us, increasing the availability of health products (such as medications, vaccines and diagnostic tools) for CHWs means increasing the number of people with access to quality health care. CHWs are critical to the primary health care system delivering preventive, diagnostic and curative services, but to effectively get health products to CHWs we first need to listen.
Listening to CHWs
In Liberia an estimated 29% of the population (1.2 million people) live at least 5 kilometers from the nearest health facility. These communities rely on CHWs, known as community health assistants (CHAs) in Liberia, for access to primary health services. Supply chain challenges are major barriers to accessing primary health services in Liberia. While the Liberian Government established the Community Health Assistant Program, which recommends 20% of health products be allocated to CHAs, this rarely occurs.
Since 2019 VillageReach has partnered with the Liberian Ministry of Health (MoH) and Last Mile Health to connect CHAs to the country’s public health supply chain as part of our Supply Chain for Community Health Workers (SC4CHWs) solution. In November 2021 we received new funding from the Global Fund and Co-Impact to implement a new a new approach in Liberia. This new project, being implemented in two counties (Margibi and Bomi) in Liberia has given us several opportunities to get feedback directly from CHAs. The project began with a workshop that included CHAs and critical stakeholders to design and iterate on the four project objectives (Figure 1).
Figure 1: SC4CHWs New Project Objectives
“As a CHA I feel honored to be involved in this discussion because most of the time the government and NGO’s just impose things on us that don’t even work in our communities and we can’t advise them…. [so] good initiatives end up failing,” said James Duwoe, a CHA in Bomi County, during the November 2021 workshop.
During the workshop CHAs from both counties offered suggestions to make the Strengthening Government Capacity objective more impactful and sustainable.
- Include both the CHA and the CHSS in the capacity building plans not just central MoH staff, because national government turn-over creates large knowledge gaps; and
- Make sure build capacity around all service delivery topic areas, not just related to supply chain to incorporate supply chain logistics into regular ways of working.
Listening in Liberia
VillageReach conducted a baseline evaluation in January 2022 in Margibi and Bomi counties. Interviews were conducted with county pharmacists, CHA supervisors and supply chain coordinators over a period of 3 months. In both counties we found low levels of stock available for CHAs, especially in Margibi where only 15% of CHAs received timely resupply during any given month in 2021.
CHAs, much like CHWs throughout Africa, are often excluded from national health supply chains. This means the people who rely on CHAs in Liberia (about 60 percent of the rural population) are not getting access to life-saving medicines and vaccines when they need them. Most respondents to the baseline evaluation indicated CHAs do not receive supplies due to:
- Slow delivery due to lack of available vehicles and fuel;
- Insufficient supply of health products, causing health facilities to keep more supplies and not provide the 20% allocation to CHAs; and
- Counties not including CHA needs in health product resupply requests.
“The most painful thing for me as a CHA is to send very sick children back without any medicines, we hope this project will make sure this no longer happens as I have gone for about six months without providing services because the drugs are not available to us,” said Phillip Davis CHA in Margibi county.
Another critical finding from the baseline evaluation was the lack of available and reliable data. One important barrier to collecting CHA data was related to the paper-based system used to collect supply data from these workers. The improving data quality and visibility objective will address this by supplying CHAs with tablets and phones and developing a digital logistics management information system app for CHAs to record supply chain data in real-time.
Listening continuously
Another important touch point with CHAs and supply chain stakeholder was through a kit design training also held in March 2022. To achieve the Transforming how medicines and supplies get to CHAs objective of this project we are designing kits for CHAs that will contain 12 items for diagnosing and treating Malaria, Diarrhea, Pneumonia and Family Planning services. Respondents from the baseline evaluation noted as well that these kits would improve timeliness and reliability of CHA health product resupplies.
During the kit design training the goal was for stakeholders to support the design of the kit and to help draft standard operating procedures to guide the implementation and deployment of the CHA kits. Engaging stakeholders during the design phase is key to ensuring a project is feasible, viable and solving a critical need and overall to ensure acceptability by users. One suggestion from the training that will be adapted for this project is not to create a parallel supply chain system for CHAs, but rather strengthen the government structures to better serve the CHAs.
Throughout this two-year project we will be holding monthly engagements with stakeholders, as well as additional qualitative interviews during mid-term and final evaluations. Our aim is to ensure this approach is impactful to eventually scale it to all counties in Liberia through the Sustainable Impact at Scale objective. We believe we can achieve this by regularly listening to stakeholders, particularly CHAs, to adapt the project in real time to increase product availability – allowing CHAs to reach the 1.2 million Liberians with limited access to health care.