Thoughts from the Last Mile Welcome to the VillageReach Blog
11.08 2011

To date, malaria treatment in most endemic countries has been based on presumptive treatment. This means that any febrile child under five years of age is immediately prescribed antimalarial medication, based on the assumption that they are likely to have malaria. When lab tests were costly and rarely available, this policy undoubtedly saved countless lives. But times have changed.

The availability of rapid diagnostic tests (RDTs) – in conjunction with decreasing rates of transmission and fewer fevers due to malaria – has instigated a policy revision. Trending toward parasitic diagnosis based on positive laboratory tests, researchers and policy makers are reviewing the criteria for treatment based on the availability of this new technology, which makes testing feasible in previously unfeasible settings.

Long considered the ‘gold standard’ of malaria diagnosis, microscopy is a highly sensitive and low cost technique if performed under quality controlled conditions. Unfortunately it is labor intensive, has a lag time between test completion and diagnosis, and requires both laboratory technicians and expensive equipment in order to complete.

Many clinics that cannot support this technology prescribe malaria treatment based on presumptive diagnosis. While presumptive treatment based on febrile presentation is still considered appropriate for children under-five and other high-risk individuals, it is no longer considered cost-effec¬tive or best practice. Antiquated antimalarial medications such as chloroquine may cost less per unit, but the recent reliance on expensive artemisinin-based combination therapies (ACT) demands more careful distribution. Decreasing the rate of prescription for non-malarial cases is vital to keeping costs down and keeping subsidies high – a combination that ultimately increases the drugs’ availability for the most impoverished populations. Over-prescription this regimen based on the presumptive treatment protocol commonly employed in remote clinics not only wastes medi¬cation and costs more money than antibiotic alter¬natives that would otherwise be appropriate for non-malarial febrile illnesses, but also increases the risk of ACT resistance developing in the community.

In an effort to minimize these consequences of presumptive treatment, RDTs  have been designed as new laboratory-confirmed diagnostic technique. Alternatives to microscopy, RDTs are now em-ployed around the world by countries adhering to the World Health Organization’s recommendation of parasite-based malaria diagnosis. Requiring no formal laboratory equipment and able to be admin¬istered by any trained community health worker, RDTs are presenting changing the face of malaria diagnosis in rural clinics where microscopy is not feasible.

Immediate advantages of RDTs include lack of de¬pendency on laboratory equipment, electricity, and personnel, as well as lower levels of training required for implementation. With rural health centers in endemic areas seeing hundreds of cases of fever every day, a more conservative prescription of antimalarials will not only decrease the rate of parasitic resilience, but will also conserve limited medical resources. What’s more, RDTs now exist for many diseases including HIV and syphilis! To this end, they have become a game-changer for accurate diagnosis and resource conservation in underserved communities.

Excited to be engaged in this international shift and acutely aware of the benefits it has for health service provision, VillageReach has been actively involved in the distribution of RDTs in Mozambique since 2010. Taking this one step further, we have proposed a collaborative RDT consumption study with our partners in Mozambique to refine our understanding of the challenges to stocking and utilizing these incredible products. By estimating stock shortages and overages, and identifying factors of supply and demand that are associated with these we hope to be more effective in eliminating barriers and improving access to this awesome technology. While the research is still in its infancy, the insight it will afford into RDT consumption and distribution will provide a wealth of data with which to refine programs and improve service delivery in last mile communities.

Kassia Binkowski

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11.04 2011

Interesting series of proposals and exchanges coming out of the first gathering of IEEE’s Global Humanitarian Conference this week in Seattle … IEEE has committed to making this an annual event, so look for their planning updates for next fall.

I was speaking on a panel about the nexus of technology, global development and social enterprise in the VillageReach experience.  Judging from the audience of early stage entrepreneurs and academics, there’s growing interest from this region’s community of professional engineers in developing technology innovations for broader social benefit.

An interesting question was asked concerning example strategies to develop demand for new innovations, given the economic challenges and low purchasing power of Base of the Pyramid countries and their communities.  The question assumed we can apply to BoP what Steve Jobs famously said about wealthy consumers he was seeking: “give them what they don’t know they want …” (I paraphrase).

While it’s a great leap to make a connection between Job’s realm of innovation, investors and customers with the realities of BoP, social enterprises do need to be profitable and scale in order to sustain the social benefit of their work.   That requires, among other things, an active understanding of the marketplace and the beneficiaries’ needs.

Developing that knowledge is difficult enough in markets in developed countries where there’s ready access to broad economic and market data, consumer trends, etc.  It’s quite another challenge to evaluate the market opportunity for a product and service with a presumed social benefit in a country where there is little current or historical consumption data.

We have seen this in our own work with VidaGas, the for-profit propane distribution business we own with other partners in Mozambique.   We created the business to provide fuel for rural health centers that otherwise would be unable to refrigerate vaccines, sterilize instruments and have light for evening medical procedures.   In our case, the social benefit of supporting the health system was obvious, but in itself insufficient to support the business.  We asked “can we expand the service to a broader customer base to achieve scale and profitability that in turn sustains the social benefit?”

Well, it’s a work in progress, but we’re excited with what we’ve achieved in the past year.   In 2011, we expect a 40% growth in shipments: to the ministry of health, to small- and medium-sized businesses, and to consumers.  The addition of a new filling plant facility gives us the capacity to deliver more fuel, but it’s the recent efforts in developing the customer base – sales and marketing, and an expansion of support for the ministry to a fourth province – that is driving both stronger financial performance and ultimately greater social benefit.  More on the company’s work and results by the end of the year.

John Beale

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11.03 2011

In Zambia, the Ministry of Health is developing a new information system for collecting and managing the data needed from the service delivery point to inform the procurement, management and distribution of medical commodities. VillageReach, in partnership with PATH, is working with the MOH and its partners to develop a vision and roadmap for logistics management information systems (LMIS) in the country. Over the last six months, PATH and VillageReach facilitated a series of workshops with the MOH, Medical Stores Limited (MSL), and the partners who support the MOH in supply chain strengthening, to develop a shared vision and a comprehensive set of user requirements using the Collaborative Requirements Development Methodology (CRDM) as the starting point. An article on this work is available in the USAID | DELIVER Project quarterly newsletter here.

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10.28 2011

More on the issues of transparency and disclosure … an interesting piece from today’s Puget Sound Business Journal …

Nonprofits debate merits of admitting failure
Puget Sound Business Journal
Friday, October 28, 2011

Tacoma-based nonprofit A Child’s Right is doing something a bit controversial these days: admitting failure. The group, which provides clean water systems in the developing world, is staking its financial future on transparency. The group wants to attract donors who have realistic expectations and won’t pull funds when things go wrong. “We actually think it’s more fruitful in the long term,” said Peter Drury, development director.

A Child’s Right posted pictures on its website of orange water from a failed system it had installed in Nepal that couldn’t handle the region’s high volume of iron. Resolving the problem took more money and time than anticipated, but A Child’s Right shares its project financials — even when the numbers are over budget, said Eric Stowe, the nonprofit’s founder and director. When to admit failure is an intense debate going on in the nonprofit sector, where some leaders worry that good intentions for transparency will backfire.

A notable example of that is The Global Fund, an international partnership based in Geneva that works to treat diseases in the developing world. In January, news exploded of mismanaged funds. Media treated the news like an investigative report, but the story had come out because the Global Fund had freely released information about the unaccounted funds — some $34 million out of a total $13 billion disbursement — in a detailed report. The group had been working to correct the situation when the news broke. “To be perfectly honest, we were taken aback by what seemed to be a negative media onslaught,” said Andrew Hurst, spokesman for the Global Fund. “Our feeling was that some of the reporting to an extent misrepresented (the Global Fund), or at least was misinterpreted by some of the people who received that information, and it gave rise to a lot of negative commentary.”

The largely negative reaction raised concerns for many nonprofits that were considering admitting their own failures. “You can’t help but be a little gun shy,” said Lisa Cohen, founding director of Seattle-based Washington Global Health Alliance. “Hopefully, we can learn from this. It’s a very complicated, and kind of a frightening climate when you have people so willing to jump in and vilify and take things out of context.”

Still, many — including Cohen — argue transparency is a valuable tool for communicating with donors about the realities of how their money is spent and the challenges of creating real change in the developing world. “We need to learn from what didn’t work,” she said. “You learn more from that sometimes than from what did work.” That’s the approach that leaders of A Child’s Right took when they recently launched a program called ProvingIt, which closely tracks the exact number of children they provide clean drinking water to every day. The group continues to monitor and upgrade the water systems for 10 years, with the idea of helping local governments prepare to take over in the 11th year.

But it’s not all good news; the nonprofit freely shares stories about its failures, including the orange water problem in Nepal. “Hearing them talk about failure makes us more excited to support them because their ability to admit when things aren’t working — and the attention they are paying to that — inspires a lot of confidence,” said Katie Briggs, managing director of the Seattle-based Laird Norton Family Foundation, one of the group’s major funders. “Honestly, I wish more would do that.”

Many nonprofits, according to A Child’s Right’s Drury, feel pressure to present a perfect image at all times, or risk losing donor funding. “You’ll hear people in business say all the time that the only way you learn is to fail … but in the nonprofit sector people get so scared to talk about failure,” he said. “The overwhelming number of organizations have a disincentive to tell the full truth, the unvarnished truth, at all times because of what it will mean for donations.”

Marc Bellemare, a development economist who teaches public policy and economics at Duke University, views admitting failure as a public relations move to enhance credibility and reputation, similar to touting corporate social responsibility efforts in the for-profit world. “When I started hearing about admitting failure, it is very nice, but there’s nothing that prevents you from learning from your own failures without having to admit them,” Bellemare said. “For me, it really is a marketing tool more than anything.” However, he said the move toward disclosure could eventually have a positive effect overall, when it reaches a tipping point and every nonprofit has to be more forthcoming about failure. “We may soon be moving toward a new equilibrium where everyone has to admit failure, and say ‘where did we go wrong?’” Bellemare said. “Everyone has to look contrite in a way — or else they start looking suspicious.”

Still, disclosing the failure of a project or cost overruns is less scary for nonprofits than disclosing financial mismanagement or fraud, Bellemare said. “That’s a whole different ball game,” he said. “I think it’s much more likely to scare away donors than failure of projects.” Many groups argue that admitting failure is more than just image insurance; it’s part of helping donors better understand the complexities of doing work in global development.

“I think in our case, we’ve actually found it’s competitively advantageous in fundraising, and also in terms of supporting the causes that we love most, to have disclosure,” said John Beale, strategic development director for Seattle-based VillageReach, a group that works to improve access to healthcare in remote parts of the developing world. The group makes available its tax documents and annual independent audit information on its website. VillageReach also has updated its scheduled reports to notify donors when projects are running behind and hitting technical problems.

“It’s not merely an exercise in admitting failure or explaining success,” Beale said. “It’s giving context for what we do. I think more organizations would be more comfortable with being transparent and admitting failure if they had already made an effort to explain to donors what they are trying to do in the first place.”

Valerie Bauman covers nonprofits, biotech and research for the Puget Sound Business Journal.

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09.16 2011

VillageReach recently completed an annual evaluation of its Kwitanda Community Health Project. The results of the evaluation indicate that VillageReach is making great progress toward meeting its goals to reduce incidence of malaria and diarrhea and to increase treatment of malaria and diarrhea in the Kwitanda community.

Highlights of the evaluation include:

  • Household net ownership has increased from 74% of households reporting ownership of a net in 2010, to 82% of households in 2011. This is much higher than the national average of only 67.3% of households reporting ownership of a net.[1]
  • Mosquito net use increased overall from 40% of individuals reporting sleeping under a mosquito net in 2010 to 58% in 2011.  Among children under-5, mosquito net use increased as well from 65% in 2009 to 71% in 2011.
  • More than 83% of pregnant women sleep under a mosquito net. This is a new indicator in this year’s evaluation so no comparison is available from 2010, but this is much higher than the national average of 43.3%.
  • The highest proportion of mosquito nets in use in the Kwitanda catchment area were distributed by VillageReach. Of the individuals sleeping under a mosquito net, nearly half of them reported the net was received from VillageReach.
  • The proportion of households reporting a clean drinking water source increased from 2009. However the proportion of households fell slightly from last year. In 2009, 82% of households reporting clean drinking water, 91% in 2010 and 86% in 2011.
  • Malaria incidence is declining. The proportion of households reporting at least one case of malaria in the three months prior to the survey has declined from 91% in 2010 to 72% in 2011. The percentage of individuals reporting suffering from malaria in the three months prior to the survey declined from 30% in 2010 to 26% in 2011, with an average monthly incidence of 6.7%.
  • Diarrhea incidence is declining. The proportion of households reporting at least one case of diarrhea in the three months prior to the survey has declined from 61% in 2010 to 18% in 2011.  The percentage of individuals surveyed reporting at least one case of diarrhea in the three months prior to the survey declined from 12% to less than 6%.
  • Access to care has increased for children under-5 as well as for the general population. 70% of households surveyed reported a village clinic in their area and nearly half had used a village clinic. Overall treatment rates for malaria and diarrhea have increased and most people access care at the Kwitanda Health Center or village clinics.

Read more about the Kwitanda Community Health Project on our Malawi page.  The full evaluation report is available here.


[1] DHS Preliminary Report 2010

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09.07 2011

Remember the days when you had to go to a library to look something up? What if you had to walk there?  And it took three hours.  And the book you wanted was checked out.  Technology has brought so much to our lives that we sometimes forget the value of information.

In my work, I’ve realized that information can be a hard commodity to sell or even to give away. Even when we try to make information available, when living under constrained circumstances, we often have bigger fish to fry (like trying to get the actual fish!). The focus is on tangible resources. And in developed countries we may treat our technology and especially its outer manifestations—phones, computers, televisions—as the end in itself.  We value the package as much as what it brings us.

This year, VillageReach launched a new project in the Balaka District of Malawi to provide women and caregivers of young children new ways to access information and advice about pregnancy and child health through mobile phones.  This project reminds me that information is another valuable missing resource in the most rural communities. We have heard from health providers that women often attempt to “wait out” their own or their child’s medical problems, rather than seeking care quickly when local resources may be of use because the often arduous journey to seek health care may represent a risk or a cost in and of itself.  It can be a difficult decision to make. The simple practice of informing people of when something is serious and when it can be managed at home can both save lives and ensure the strategic use of existing resources.

Of course information isn’t enough, and a pregnant woman may still have to walk for three hours to reach the health center. We can’t afford to forget that, even while we are helping women and caretakers make informed decisions about seeking care. For me, this means remembering the context for the advice and information we are providing.  I keep this picture on my desktop. I took it as we were traveling to a rural clinic. It’s a reminder of what rural really means, but it’s also a reminder that there are life-changing resources that go beyond the tangible.Blog_Stacey

Stacey Cunningham

Stacey Cunningham is the Maternal, Newborn, and Child Health Project Manager for VillageReach, based in rural Malawi.

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08.29 2011

“The pure and simple truth is rarely pure and never simple”
Oscar Wilde

I’m an MPH graduate student and a recent addition to the VillageReach team as a summer Health Systems Group intern. When I was asked to come up with some ideas for how to evaluate active case finding for VillageReach’s new tuberculosis (TB) program in Kwitanda, Malawi, I was ecstatic.

Step one: figure out what active case finding is (preferably before anyone realizes I have no idea). Once I did the research, I realized it’s a pretty simple concept: the more people who have TB, the more people they can spread it to. If we can actively find people with TB and treat them (rather than waiting for them to come to the health center which may only happen after they become very sick or may not happen at all), then we can reduce TB. Easy!DSC00130

Step two, how do we decide if our active case finding program worked? The health centers keep track of new TB cases so we can use those numbers to evaluate our program. If the numbers of TB cases seen at the health center goes up, then we were successful in finding more cases of TB. If the number of TB cases goes down, then we were successful in reducing the number of people who have TB. So no matter what the numbers say, we can say we were successful? While I was tempted to bring back a no-fail assessment plan to my supervisors, I had a sneaking suspicion that it wasn’t going to fly in an organization that highly values evaluation.

Step three, more research. Turns out lots of people are interested in evaluating TB programs and the Millennium Development Goals have set the goal of increasing the “case detection rate” to 70%. That means for every 10 people who actually have TB we want to find 7 of them. Ok, that could work. We already know how many people we’ve found with TB because of the health center data but how do we find out how many people actually have TB, assuming that many of them are undiagnosed? We would need to go door-to-door in Kwitanda and test everyone for TB (or at least test a large sample of people). That would be expensive. And frankly, if we had that kind of resources we WOULD just go door-to-door and test everyone. Not for evaluation purposes but because it would be the right thing to do!

So back to square one. After driving myself crazy with statistics and indicators for at least several days, I came up with an idea. We already do an annual house-to-house survey of questions – what if we asked every person if they have a cough and if they’ve been tested for TB? That way, we can know the percent of people with TB symptoms who’ve been tested and that number should always go up. If TB incidence in Kwitanda goes down (which we hope it will) the number of people with symptoms should go down too. But, with any luck, the percent of people with symptoms who have been tested will continue to increase until 100% of people who need to be tested can get tested.

All of this got me wondering the same thing non-profits have been wondering for years: how much money do we spend running our programs versus how much money do we spend finding out if we’ve actually run them well? While our indicators for the TB program may not be perfect, they’ll give us enough information about whether or not our approach is working while still leaving lots of time and resources to actually do the work.

Erin-Larsen Cooper

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08.23 2011

I joined VillageReach Mozambique in June of this year as the Monitoring and Evaluation Officer. With previous experience working with other nongovernmental organizations and government in the area of health information, I was excited to work with VillageReach to strengthen the health system with evidence-based decision making. Since I joined, I have had the opportunity to make several visits to the provincial offices and health centers, and I’ve seen first-hand the role of information in the health system.  Read more on VillageReachFocus.

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08.05 2011

I’ll admit that before I started working for the HSG Team as a summer intern, I would not have considered myself a “systems” person.  Systems are boring, right? But now, only 6 weeks later, I find myself a full convert. It turns out everything is about the system.

When I began delving in to what it might take to improve access to emergency transportation in Kwitanda, Malawi, I thought I was going to learn about bicycle ambulances.  Or lack of bicycle ambulances. Or broken ones.  Or maybe even full-on motor vehicle ambulances with sirens and flashing red lights.  But alas, I learned about systems.

It’s true that one of the major barriers to successfully accessing emergency medical services in resource-limited environments is the lack of reliable and affordable transportation between the location of the emergency and the nearest hospital.  And in Kwitanda, bicycle ambulances are filling that gap. But when people need to get to a hospital in a hurry, the vehicle that takes them there is only one piece of the puzzle.  First, someone needs to recognize the need to get to a hospital.  Sure that may be obvious in the case of a serious accident, but it might not be in the case of a woman, giving birth at home, whose labor is taking a turn for the worse.  Next, there has to be a way to notify the ambulance that there is an emergency and in a place with limited access to electricity and cell phones, this can be tricky.  Once the bicycle ambulance is located, someone needs to drive it to the hospital, and equally importantly, bring it back so it’s available for the next emergency.  In the best-case scenario, there would be a way to notify the hospital that a seriously injured or ill person is on the way, so that the hospital can be ready when s/he arrives.  In short, there needs to be a system.

Luckily, the communities we work with in Kwitanda understand the importance of systems (and understood it much more quickly than I did, I might add).  Currently, there are village committees in place to oversee the use and maintenance of the ambulances.  In fact, the number of households that have “ever used” a bicycle ambulance saw a three-fold increase between 2010 and 2011.  To keep seeing these kinds of results, we need to ensure that the systems, not just the ambulances, are working.

Erin Larsen-Cooper

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06.01 2011

A few months ago at the start of my medical treatment, I contrasted the Fortunate Last Mile with the Not-So-Fortunate Last Mile. Now that I am nearing the end of what I jokingly refer to as my “Swedish spa treatments,” I would like to add a few additional thoughts. The second part of my treatment has involved chemotherapy and radiation treatment. The mapping_visualization3 picture shows me receiving radiation through a device called an Electra Linear Accelerator at the Swedish Cancer Institute Swedish Cancer Institute in Seattle. The device costs approximately $6 million to install and I am fortunate it is available at my health center. With this level of medical resources available to me, my doctors expect a full recovery.

In contrast, Stacey Cunningham, VillageReach’s Project Manager for our Malawi Maternal, Newborn, and Child Health Project Malawi Maternal, Newborn, and Child Health Project recently sent pictures of a village clinic operated by VillageReach and the Malawi Ministry of Health. These mothers are seeking medical treatment for their young children to prevent them mapping_visualization3 from dying from afflictions common to their area: malaria, pneumonia and diarrhea. The village clinics are rudimentary but effective in treating medical challenges that are barely given a second thought in the United States. Unfortunately, medical resources are still very limited and far too many children die of easily preventable diseases.

When faced with a serious medical challenge, it’s mapping_visualization3 common to be overwhelmed with a rush of thoughts and emotions. In the midst of that swirl, the picture of this young boy caught my eye. With a simple twist of fate our birth places could have been reversed. I can’t say I have sorted out the bigger picture, but I do know there is a serious problem with lack of access to quality healthcare and it’s time to act. And for me, it’s personal.

Allen Wilcox

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