Thoughts from the Last Mile Welcome to the VillageReach Blog
07.10 2012

In Malawi, more than eight in every one thousand women die from maternity-related causes, while almost 90 percent of childhood deaths occur during the first year of life. Malawi women have a 1 in 36 chance of dying during childbirth. Reducing the maternal mortality rate in Malawi not only saves the lives of women, but most maternal interventions will also reduce mortality and morbidity among infants. Moreover, saving the life of a mother can protect older children; orphaned children have a three to ten times greater risk of death than those with living parents.
In October and November 2011, VillageReach conducted a needs assessment to identify the barriers to optimal maternal and neonatal healthcare in Kwitanda, Malawi through interviews and focus group discussions with health workers, health surveillance assistants (HSAs) and women in the community. The results pointed to the major barriers to optimal maternal and child healthcare as long distance to the health facility and lack of transportation for antenatal care (ANC), delivery and post-natal care, perceptions of poor treatment and safety at hospitals compared to delivering with Traditional Birth Attendants, traditional beliefs maternal and infant health practices and when and where to access care, and a general lack of knowledge regarding the importance of early post-natal care.
To overcome these barriers, VillageReach is implementing the following programs:

Extend the Reach of ANC services to the community Currently, ANC services are offered at Kwitanda Health Center but women have expressed a great interest in these services being provided closer to home. We will leverage existing structures to conduct ANC outreach clinics by Kwitanda Health Center staff closer the community. ANC outreach is scheduled to begin this month.

Train Additional HSAs in Maternal and Neonatal Health With funding from The Seattle International Foundation, VillageReach will train and support additional HSAs in maternal and neonatal health to extend the cadre available to visit women in their homes. Currently, five HSAs in the Kwitanda catchment are trained in MNH. The specialized cadre of HSAs can provide home-based postnatal care to all newborns, track the health status of pregnant women, encourage ANC visits and facility-based delivery, and support women in the development of a birth plan. Nine HSAs are currently in training.

Leverage Existing Maternal and Neonatal Health Services Provided by VillageReach VillageReach’s work with MNH through the Chipatala Cha Pa Foni (health center by phone) case-management hotline service was rolled out in the Kwitanda area in March. The hotline provides health advice and information to pregnant women and caregivers of children under-5, refers individuals to a health center or village clinic if warranted, and registers women and caregivers for an automated tips and reminders service sent to their phones or accessible through phones of community volunteers. The hotline provides direct access to a health worker for community members who may have previously had a poor perception. Thus, in addition to providing direct advice, the hotline serves to improve community trust in the health system.

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06.15 2012

This summer I am a VillageReach intern based in Maputo where I will be implementing a comprehensive study documenting the range of obstacles challenging the reliable delivery of vaccines, rapid diagnostic tests, and medicines to rural communities of Mozambique. While VillageReach is already actively working to address many of the known challenges in this area (such as lack of transport for vaccine and medicine delivery), the purpose of this study is to quantify the range of logistics challenges and flush out the sources of the problems. For example, is transport a problem because of lack of vehicles, lack of fuel, broken vehicles, or the bureaucracy of gaining access to a shared vehicle when it is needed? Where in the supply chain are problems most frequent: eg.,picking up the healthcare supplies from the central storehouses, or delivering them to the rural health centers? Are health center employees adequately trained in the logistic concepts necessary for effectively keeping track of supplies and forecasting the health center’s needs?

These questions and many more will be answered using a lengthy survey that will be given in every district within the four provinces (Maputo, Gaza, Niassa, Cabo Delgado) where VillageReach currently operates. There are three separate surveys for each district: one for the medical director, one for the director of the pharmacy, and one for the director of vaccination programs. Starting this week I will be training the VillageReach field officers in implementing the survey. We will have an all day training session in our offices in Maputo and then will take two day trips into nearby district health centers to see what surprises we find in translating ideas on paper to workable information gathering in the field. In the weeks following, the Field Officers will gather the data (I will join when possible) and send it all my way for synthesis and analysis. The hope is that this study will provide more detailed information about the current challenges and thus help VillageReach and the Mozambique government prioritize their efforts to increase access to healthcare supplies to rural communities.

First Field Visit: Namaacha

As part of my orientation to VillageReach and the Mozambique health system, last week I joined Margarida, the VillageReach Field Officer for the Maputo Province, for a field visit to the district of Namaacha. Originally, we had planned to head to a different district for supervision, however the night before we left we got a call saying that Namaacha had an urgent need for a vaccine delivery and we needed to head south to respond to this request. Inside a Health Center
We started our trip with a stop at the Namaacha district hospital where we met up with government staff responsible for vaccine delivery in the area. While I was shown the hospital pharmacy, stock room, laboratory, maternity ward, and the general patient area, Margarida headed to the back of the hospital to go over their records of vaccine use and disbursements in the district. She quickly identified some incomplete and inconsistent data records and immediately sat down with the staff until she was convinced they understood what was wrong and how to make it better. Margarida previously held positions as the national vaccine manager for Mozambique and as the director of the Maputo province department of health, and she not only knows her stuff inside and out, but she cares too deeply about the issues to leave a room before she thinks all present understand their role in facilitating vaccine disbursement in Mozambique.

Once things were squared away at the district hospital we set out to visit the seven health units in the district. At each health unit, the government made their vaccine deliveries and Margarida met with the health workers to make sure they were giving vaccines on the right timetable and properly recording vaccine use. Before we left she would check that their refrigerators were functioning properly, check expiration dates on vaccines and rapid diagnostic tests, count their existing stock levels of vaccine and rapid diagnostic test supplies, and verify that the stock matched the records. A visit of this sort typically took well over an hour.

At two of the health centers we encountered refrigerators that were having problems. The refrigerator at the Dibinduane health center was operated entirely by solar power and its performance had been somewhat erratic as of late. According to the records, the temperature inside the refrigerator had been fluctuating, but had so far not warmed beyond the threshold that was safe to store the vaccines. Just to be sure, we checked the vaccine packaging which indicates (via a color changing label) when the vaccines have been exposed to higher than permissible temperatures and thus are no longer safe to use. Happily, the vaccines were still in Margarita and Timoteo checking recordsgood shape, but Margarida left the health center workers with instructions to monitor the temperature in their refrigerator very closely. As a die-hard supporter of renewable energy, I argued that there was no actual proof that the solar power was to blame other than the mere correlation of the fridge being both erratic and solar powered. However, most of the Mozambicans (who admittedly have a lot more experience using solar power than I do) just shook their heads and took this as yet another example of the fussiness of solar energy.

At the Kulula health center, we found a refrigerator (powered by traditional sources) that was not functioning at all. This meant we could not deliver any new vaccines and we had to take away for disposal any existing (and requiring cool storage) vaccines we found at the health center. Everyone seemed pretty glum about this situation and said a replacement refrigerator was unlikely any time in the near future. In the meantime, the district would have to send out a mobile brigade (health workers that operate from a truck and carry their supplies with them) to periodically provide vaccines to the surrounding communities.

Before heading to Namaacha, I had found it hard to grasp the hierarchical structure of the Mozambique health system (the difference between a rural and district health center and how supplies and information moved between them) and what it meant for VillageReach to help with the logistics of getting healthcare supplies to these rural communities. After two days driving around the district with Margarida, however, I was able to get a glimpse of how far removed many of the health centers were from the district hospitals as well as some of the challenges facing the rural health care workers, the Mozambique government, and VillageReach.

Lilly Connett

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06.07 2012

I spent a couple of weeks in Mozambique recently to review our energy services social enterprise, VidaGas, that provides much-needed propane to hundreds of rural health centers throughout the north of the country. VillageReach owns the for-profit business in partnership with Oasis Fund and FDC.

I was joined by two MBAs, Alexandra Fallon and Deborah Hsieh, from MIT’s Sloan School of Management who are enrolled in an intriguing course. ghdLABs, developed by Anjali Sastry, is focused on assessing opportunities to improve healthcare delivery through changes in management, engineering and systems. See here and here for background on the course, which includes links to blogs from Deborah and Alexandra about their experiences. The students have been assisting with our plans to help build a longer business outlook for VidaGas and also to measure the social benefit the company provides. Both efforts will be important in helping attract additional capital for the company in the coming years as it continues to grow and further support the public health system.

Energy Improves Health

When VillageReach first started its work to improve the last mile of delivery capacity in Mozambique’s Ministry of Health, we realized a critical gap in energy supply was affecting the performance and economics of the cold chain, and in turn limiting the ministry of health’s ability to store and distribute vaccines. VidaGas was established to address this lack of reliable energy supply.

Since its founding in 2002, the company has progressively expanded its operations to serve more and more health centers and communities. In the past two years, the growth rate has accelerated, due in part to a critical investment made by Oasis Fund.

The additional capital enabled VidaGas to step beyond its presence in Cabo Delgado Province in the northeast and establish additional filling and storage facilities, greatly increasing the addressable market for propane sales. By the 4th quarter of this year, VidaGas will be operating in all four northern provinces from an operational base of three filling plants in the cities of Pemba, Nampula, and its newest facility in Mocuba. More on Mocuba below.

Operating VidaGas as a business instead of a charity addresses the critical requirement for a sustainable supply of energy for the health system. The majority of Mozambique’s population in the north resides in remote villages with no electricity and little access to transport and communications services. Health centers in these communities need a reliable supply of energy for refrigeration, lighting and sterilization in order to provide even basic medical care.

To ensure its service to the health system is sustainable, VidaGas supports this social mission by selling gas to a variety of enterprise customers: restaurants, hotels, small factories, plus a growing retail network and several urban hospitals. VidaGas Sector Share of RevenueHere’s the share of sales across these categories for 2011 – rural health centers represent only 17%. The message is that without the private sector revenues, the company would not have the resources to support its obligations to the health system.

VidaGas’ social benefit isn’t limited to the benefit it provides to the ministry of health. Other government ministries use propane for their facilities and a growing number of households are buying the gas for cooking, reducing the use of charcoal and wood that produce harmful indoor pollutants. Reductions in biomass consumption also contribute to limiting the rate of deforestation.

What’s Next

pic We’ve been at this effort since 2002. As VidaGas sales have grown, so has its reputation as a reliable supplier to the ministry of health and other customers. In 2011, VidaGas shipped more than 350 tons of propane, an increase of 35% over 2010. Now the business has identified the opportunity to supply health centers in the province of Zambezia. In April, VidaGas broke ground on a new facility in Mocuba City in central Zambezia, see this image on the right. Once the facility is completed in August, Mocuba will have the same 21-ton storage capacity as the Nampula facility you see below. With a population of nearly 4 million and more than 300 rural health centers across Zambezia Province, pic1we anticipate both strong demand and see an important opportunity to assist the health system. In 2012 we expect sales to increase at a significantly higher growth rate than the year before.

Beyond the rural health center network VidaGas supports today are many more health centers that suffer from unreliable energy supply. To expand its social impact, VidaGas must scale further: in the future the company will require additional capital in order to invest in new facilities, equipment and personnel.

Attracting investors is inevitably a challenge, even as the social enterprise industry matures and encourages more socially conscious investors. Our work with MIT will help support VidaGas’ future growth, helping us prepare a more robust strategic outlook for the company and producing an evaluation of anticipated financial and social returns for investors. As this review progresses, we’ll write more on our views of VidaGas, so look for additional reports on the company’s milestones and prospects for the future.

John Beale
Director, Strategic Development &
Group Lead, Social Business Group

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05.25 2012

Rapid Diagnostic Test (RDT) Data and Distribution Systems.

As a partner in Mozambique’s health system, VillageReach is undertaking a study about the shortage of RDTs in the rural health centres. This is the second in a series of updates we expect to provide on the work – see the first post here. The study will conclude this fall.
The study involves gathering and analyzing data that health workers collect as they provide testing services, and using that data to analyze consumption as it informs the test distribution. Data about the use of RDTs is critical to operating a well-functioning supply chain and ensuring that health centers have the right tests at the right time. This data allows planners in the health system to purchase the right quantity of tests and distribute them throughout the health system while minimizing wastage and expiry.
Until now, the national health system in Mozambique has not distributed standardized forms for collecting this data. However, the lower levels in the government recognized the need and value of the data and implemented their own systems. In the first visit made by the study team in January this year, it was found that the data collected was of very poor quality, due to lack of standardized instruments or forms to use for recording data and a lack of training for the health workers. The forms used to collect the data were undergoing numerous changes, which complicates the process of data collection at the service delivery point.
The system for distributing tests and collecting data about tests was designed with the following flow: the RDTs are amassed at a provincial medical store, redistributed to district storage facilities, and then transported to rural health centers. The image on the left represents the ideal.
Last week we visited again and found that key improvements had taken place in the last four months.
1. Systems and processes are in place to collect data about the use of tests. These are being used properly and routinely. This is no small feat in a country so vast and full of infrastructure challenges that can limit access to the health centers.
2. The Logistics Management Information System is installed and in use at the district level. That is a major accomplishment, and one that will improve the distribution and supply of medicines throughout the country.
But this visit revealed another fundamental observation. Despite improvements over the recording and availability of data about test consumption, there continues to be shortages and stock outs of tests in the health centers. Specifically, I observed situations where there were too few RDTs and a number of them had expired before being used. If the data is there to make the system work, then what is happening?
For many cases, we discovered the question can be answered by the following factors:
• A lack of vehicles for transport limits regular distribution of RDTs and medicines to health centers;
• Where there are vehicles available for transport, there is often a lack of fuel;
• Where there are vehicles and fuel, there is a chronic lack of allowances for personnel to carry out the distribution of medicines.
These factors greatly influence the availability of RDTs at the health center level. With delays in distribution, RDTs may expire before they are used, ultimately reducing the quality of service at the health centers. Tim1
All this ultimately results in poor distribution system of RDTs used in the province and a higher cost of distribution. In addition, the lack of regular distributions results in incomplete and inaccurate data about the health centers being reported back to administration levels within the health system. This image on the right represents what we see in reality.
These factors, all too common occurrences for health systems with limited resources, highlight the importance of improving the quality and capacity of the underlying infrastructure the health centers depend on in order to support so many remote communities.

Timóteo Eduardo Chaluco, Monitoring & Evaluation Officer

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04.03 2012

Last week was an important week for Mozambique’s vaccine program. Dr. Seth Berkley, President of the Global Alliance for Vaccines and Immunization (GAVI) and former VillageReach Board Member visited Mozambique. Seth’s participation on our board was critical in supporting and advising VillageReach in the early days so it was an honor to meet him in Mozambique and share what we’ve learned and how far we’ve come. His visit was an opportunity to reflect on progress that VillageReach has made.

I had the pleasure of accompanying the team from GAVI on a visit to a district hospital, rural health center, and a mobile clinic in a rural village. Together we observed the successes and challenges in the vaccine system. We experienced the long distances, difficult roads, lack of transportation available, overwhelming amount of patients, and insufficient health center infrastructure. Being in those rural settings with this global team, I was reminded of the value of the VillageReach approach of looking at all these challenges from a last mile point of view.

There are two ways of looking at the problem of how to get vaccines and supplies to a large number of difficult to reach health centers. The first way is to think about what it takes to make the planned distribution work – what resources are required to make sure that the provinces and districts have the transportation, budgets, staff, and training required? The other way to look at the problem is to look from the health center up – given the existing constraints, how can the system be made to work? The VillageReach perspective is the latter. With minimal investments in the supply chain, we are improving the distribution of vaccines, decreasing stock outs of vaccines, and improving performance of vaccine services. Bringing the global level to rural Mozambique was a reminder of the validity of that approach, and how it’s applicability is relevant the world over.

Having spent almost 7 years working at VillageReach, it was a true pleasure to think back to the early days and see how far we’ve come in Mozambique. We started in 2002 with a pilot project, then evaluated that project to show increased impact and cost-effectiveness of a logistics system redesign. That was followed by 1 ½ years of advocating with the government to change policy, when we reached a major milestone in November 2009 as the Minister authorized each of Mozambique’s 10 provinces to implement our Dedicated Logistics System. We’ve now been supporting four provinces to implement the Dedicated Logistics System for 1 ½ years, and we’ve learned a lot.

We’ve learned that advocating for logistics system design change is a big challenge with global and national policy support for decentralization. Even when the status quo isn’t the best option, change is always hard. There are incentives in any system to maintain that system. We’ve faced those challenges head on and leveraged the incentives to change systems to achieve greater impact. We’ve also faced challenges with the erratic nature of public sector funding, and worked to find solutions to the problems to enable support to a routine vaccine distribution system. We’ve learned a lot about introducing and implementing change, and we continue to learn.

Leah Hasselback

Mozambique Country Director

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03.12 2012

A lot happening this week for our ISG team. We’re attending the annual International Conference on Information and Communication Technologies (ICTs) and Development. The conference brings together software developers, entrepreneurs and development organizations to present new innovations in information technology to support global development.

The conference is co-located with AMC DEV, a conference aimed at providing an international forum for research in the design and implementation of ICTs for social and economic development. Our collaboration with the University of Washington’ Computer Science & Engineering Department resulted in a paper that is being presented at AMC DEV, titled “Digitizing Paper Forms with Mobile Imaging Technologies.” In addition, ODK Scan (formerly called mScan) will be demonstrated during the technology demo session at the ICTD conference. Congratulations to lead author/presenter of the paper and mScan demonstrator Nicola Dell, who is completing her PhD at the university.

Jessica Crawford and Timoteo Chaluco of VillageReach are also authors on the paper, which is available here.

For more information on our work on the ODK Scan project, visit our Information Systems Group on our website.

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03.06 2012

I just finished reading Harvard Business Review’s (HBR) “Megatrends in Global Health.” (You can read it too by clicking here) First off, as I suspected, megatrends is not a real word according Merriam-Webster’s dictionary; but let’s just assume they meant really big, really important trends. Megatrend number seven is “evidence-based medicine.” Duh, it’s better to know if your interventions work, right? But HBR had an interesting take on it:

“Data on outcomes will increasingly be used to develop standard protocols for treating many diseases, resulting in a movement away from the long-dominant “what you and your doctor decide is best” judgment-based medicine. Could this lead to health care Czars who will establish protocols and penalize physicians who deviate from them?”

In a lot of ways, this is a first-world perspective (or really the perspective of insured first-world folks). It assumes that one has a primary care physician, which isn’t true for many Americans and most of the people in the countries where VillageReach works. But I do think this applies in a broader sense to the one-size-fits-all evidence-based intervention philosophy that plagues global health. Let me be clear, I love that VillageReach puts such a big emphasis on evaluating our interventions; it’s a major part of what made me want to work here. We know that you cannot just assume that what should work, will work. That’s why in our annual evaluation of our community health program in Kwitanda, Malawi we don’t just ask if people have a mosquito net but also if they sleep under one. And when it turned out that more people have nets than use them, we changed our strategy to make sure that we our addressing the need for nets and addressing the barriers in actually using them.

But what about when a good program that everyone likes doesn’t have the outcomes they expect? Our maternal and child health hotline in Balaka District, Malawi is getting amazing feedback from the community. People love having someone who will listen to them, answer their questions, and give sound advice. We’re still waiting for our final evaluation results and I anticipate that our results will be as good as we hope. But even if if they’re not, I’m still pretty sold on the program. There has to be room in “evidence-based” to say “Ok, it may not have changed the outcome of the pregnancy, but it was comforting and made pregnancy easier and less scary for our clients” just like I want to be able to say to my doctor “I understand that the drug that you take for five days is more effective, but I want the one that I only have to take for two days because it’s easier for me.” I think evidence-based interventions are a good thing, a very good thing. We just need to make sure we do it in a way that honors what VillageReach is all about: extending the reach and improving the quality of the health system. And sometimes we do that in ways that are hard to measure.

Erin Larsen-Cooper
HSG Intern

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02.15 2012

I recently joined a few of my VillageReach colleagues in the northern province of Cabo Delgado, Mozambique to start the data collection process for our Rapid Diagnostic Test (RDTs) Consumption study.  As Kassia mentioned in a previous post, VillageReach is conducting a consumption study in order to quantify stock shortages at health centers throughout the province and to better understand the factors contributing to the shortage. The study was prompted by concerns that the supply of RDTs in the province is insufficient to meet demand and the gap between supply and demand is largely unknown.  We believe the shortage may, in part, be due to the fact that the requisitions for tests are based on consumption. In shortage situations, this causes a vicious cycle of under-stocking: insufficient stock leads to stock outs, which leads to lower consumption amounts, which leads to fewer tests ordered the next month, and so on.  Our study is attempting to quantify the difference between supply and demand throughout the province by estimating the true demand for tests.
Over the course of three days, we traveled to five health centers in three different districts and two of the district storerooms to find out what information was available regarding the use and stock of RDTs, validate our assumptions about the type and quality of the data, identify additional data sources, and finalize a data collection plan. We prepared a data collection tool in advance that covered a variety of potential forms that might be in use so that we could test it at the health centers. Once there, I was struck by the amount of information available at health centers but in ways that were difficult to capture as researchers. For example, standardized forms weren’t used across all health centers and the data weren’t captured in consistent ways month to month, or health center to health center. All of this caused us to rethink our data collection methods a bit. Also, some of our assumptions regarding the type of information that would be available didn’t hold up. While our preparations provided us with a good starting place, we still have a bit of work to do to refine the methodology and we look forward to the data collection and analysis!
On our second night in Cabo Delgado, a cyclone off the coast of Mozambique touched ground further south of where we were. While we didn’t experience cyclone intensity, we did have extremely heavy rains and winds and the next morning, on our way to the third and final district, we came to an impassable road due to floods. In fact, the area was so flooded that the resident crabs had climbed up into the trees! During the first two days, we traveled to remote health centers through roads I would never have imagined were passable and yet after the storm, the main road to the district headquarters was completely cut off due to floods.  I took a step back to appreciate that knowing the number of tests that are needed at a health center and ensuring that those tests are available to deliver are just part of the work we do and the challenges that must be overcome in our mission of increasing access to quality healthcare.

Jessica Crawford, HSG Program Associate

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02.01 2012

VillageReach strives to be a learning organization. We are trying to increase access to healthcare in countries where the roads are impassable, electricity and cell phone networks are intermittent – if they exist at all, half the population is illiterate[1], and almost 10% of children don’t live to see their first birthday[2]. It’s not easy, to say the least. Some days I see stories of success and I am proud of the work we do. Some days I am reminded that this is an uphill battle bigger than the likes of any mountain I have ever seen, and I search for better paths to the top.

In Mozambique, we have been working for two years to implement a national expansion of a logistics system for vaccines and other medicines. Our efforts have focused on four provinces, which cover nearly half of the country. So how is it going? I’d say it’s time for adjusting our hiking path. Our biggest challenge is securing that the distribution system is reliable; logistics without reliable distributions in terms of quantity, quality, and timing undermines health services and access to those health services.  When distributions are delayed or incomplete, we find health facilities without stock of critical medicines. This is a problem for us because funding to the government for the distributions is often delayed or funds are simply not available from the government despite all the required components being there (budgets, plans, funds requests, political will, etc). We set up this national expansion with a vision that the government would support its own costs because sustainability has been a top priority for us. However, that sustainability can come at the expense of results.

As a learning organization, trial and error is a part of our work. We tried an approach with sustainability as a main driver, but we have been forced to re-examine the approach because we value results. Our work is to achieve results. Now it’s time to try a adapt our approach. We aren’t willing to throw out sustainability, so we need to find the magic balance between results and sustainability. Now we are embarking on a cost-sharing model. We will continue our close collaboration and capacity building of the government systems, but also address the very real challenges of funding critical pieces. This requires additional effort in consideration of sustainability, but we are up to the challenge.

The challenge of funding a reliable logistics system has been our biggest lesson learned from the first year of the national expansion. We’ve also learned that providing technical assistance to a logistics system requires more intense monitoring than implementing a logistics system. This has implications on our staffing structure and level of expertise, so we have hired additional staff in our Maputo office. We’ve found that progress with this approach is slower than anticipated because our work is more dependent on schedules, funding, priorities, and staff of the government, which must constantly balance priorities in an under-resourced environment. For example, the logistics system involves government staff collecting data to analyze the performance of the logistics system. In our pilot project in Cabo Delgado province from 2002 – 2007, those staff were ours. When we trained them on data collection and made it a part of their job, they did it. In using government staff to do this, the staff need to balance other activities and we need to work more with management to help them understand the value of the activity and include it as a priority. As we learned this, we’ve adjusted our plans and expectations. Finally, we’ve been working to incorporate Rapid Diagnostic Tests for HIV, malaria, and syphilis into the logistics system. This integration has encountered operational and political challenges as additional people and departments are involved in the logistics and use of tests so we’ve had to focus more on establishing routine and comprehensive coordination and communication. Months from now we will certainly be mulling over lessons learned from this modified approach, and we’ll adjust our paths to the top of the mountain again.


[2] Ibid.

Leah Hasselback, Mozambique Country Director

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