Thoughts from the Last Mile Welcome to the VillageReach Blog
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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12.06 2011

VillageReach recently conducted a maternal and neonatal health needs assessment in Kwitanda, Malawi in order to understand the barriers (actual and perceived) to accessing quality maternal and neonatal health services in the community. After three years of building infrastructure, making connections in the community, and demonstrating success in improving child health outcomes, particularly for malarial and diarrheal disease in Kwitanda, VillageReach is preparing to expand our program to include maternal and neonatal health services. Expansion into this area is an exciting opportunity for VillageReach to improve health outcomes among this vulnerable population.

Maternal and infant health outcomes are worse in Balaka district (where Kwitanda resides) than Malawi overall in most important indicators. For example, almost a third of women in Balaka give birth at home while, nationally, less than a quarter do. Given the high rate of home birth it’s not surprising that only 63% of Balaka women have a skilled attendant present at their birth (versus 79% nationally). Additionally, the postnatal period is crucial for both the health of the mother and infant, but only about a third of Balaka women receive a check-up within the first two days of giving birth compared to 43% of women nationally. Luckily, over 90% of women in both Balaka and receive some prenatal visits before giving birth; nonetheless, the proportion of Balaka women who receive prenatal care is slightly less than the national average.


In Malawi, many newborns like the one pictured here (left) are delivered by traditional birth attendants in rooms that often look similar to the one above (right). While some mothers prefer the comprehensive care provided by TBAs, others are wary of their ability to handle obstetric complications.

In order to design a program aimed at improving maternal and neonatal health outcomes for the Kwitanda community, it is essential to have an understanding of the unique needs of the community. While the Balaka-level information is illuminating, it doesn’t tell us what’s happening in Kwitanda specifically and, more importantly, it doesn’t tell us why. So we conducted three focus groups in Kwitanda with the following groups: women who recently gave birth at a health center, women who recently gave birth outside a health facility, and community health workers as well as several key informant interviews. Here are some of our most important results:

Some women prefer to give birth with a traditional birth attendant rather than in a hospital. We expected cost and transportation to be barriers preventing women from giving birth in a health facility – and they were (several women gave birth on the way to the hospital since they could not arrive fast enough). But some women also prefer to giver birth with a traditional birth attendant (TBA) rather than in the hospital. There are familial and cultural traditions that encourage women to utilize TBAs as well as the fact that TBAs are often located closer to the women’s homes. But in addition, women cite fears about harsh treatment from hospital nurses as a major reason they’d prefer to give birth with a TBA. First time moms in particular are drawn to the support and one-on-one attention they can receive if giving birth with a TBA. Even some mothers who have delivered a previous child at a hospital say they’d rather deliver their next child with a TBA.

Women recognize that traditional birth attendants are not prepared for every complication. Despite some preference to give birth with TBAs, many women recognize that TBAs are often ill-prepared for complications during labor and delivery and that there are advantages to delivering at a hospital. One woman, who experienced complications while giving birth at a hospital, said she believes she might have died had she given birth with a TBA instead. Women also pointed to the fact that if you give birth in a hospital, you have access to crucial post-natal care not available with a TBA.

Women wish that prenatal care were more accessible. The good news is that most women are attending at least some prenatal care visits at a health center. However, women wish that they could receive care in their villages without having to travel to the health centers. Some women said they would prefer to receive prenatal care from community health workers close to home. Currently, community health workers treat childhood illnesses at “village clinics” – women sited this as something that this could be a useful model for prenatal care.

Not all women know when to get postnatal care. Women had heard mix messages about when to visit a health center for postnatal care: some said it was 6 weeks after giving birth; others said they were told to bring their child after one week for immunizations; and some knew that if they gave birth at home or on the way to the hospital they should go for a check-up the next day. In addition, women pointed out that the getting to a health center or hospital for a check-up right after giving birth wasn’t always easy because of the difficulty of walking or finding transport while simultaneously recovering from labor and delivery.

Women face difficult decisions when deciding where to give birth. In addition to major cost and transportation barriers, women have to weigh family, cultural and emotional factors into their decision-making. While women tend to have more positive experiences accessing prenatal care in a health facility (compared to labor and delivery) women would still prefer a model that allows them to receive care from a community health care worker closer to home. The Health Systems Group at VillageReach is processing all the information we’ve gathered and actively discussing possible interventions and solutions. We’re excited to update you soon!

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12.01 2011

Around the world, HIV remains one of the world’s foremost infectious killers. Despite the fact that it may take 10-15 years for HIV to digress to Acquired Immunodeficiency Syndrome (AIDS), collectively HIV and AIDS are responsible for the deaths of more than 25 million people in the past thirty years. Infecting almost 3 million people every year, HIV remains a huge threat to well-being around the world despite enormous advancements in the capacity of health systems to support people living with the disease.

Perhaps not surprisingly, more than 60% of the 34 million people living with HIV live in Sub-Saharan Africa. In Malawi, one in every 12 people is infected with HIV – that’s 90,000 children living with the disease and another 30,000 newborns contracting the infection from their mothers at birth. Additionally, 650,000 Malawian children have been orphaned by the epidemic, and are counted among the infection’s burden in this country. Similarly, 1.5 million adults and children are living with HIV/AIDS in Mozambique, where the infection claims the lives of nearly 100,000 people every year.

Despite these challenges, incredible progress has been made. Mother to child transmission is almost entirely preventable with the right care and rates of prevention are increasing (10% in 2004 to 45% in 2008). Antiretroviral therapy (ART) is more readily available now than it ever has been, with more than 5 million people receiving the treatment they need to live longer, healthier lives. While this is a twelve-fold increase in the number receiving care since 2003, it still represents only one-third to one-quarter of the total population in need of treatment. With more than 1,200 children infected around the world each day, it is vital to sustain this momentum toward testing and treatment in resource-constrained countries.

Working in Sub-Saharan Africa, it is unimaginable for our efforts not to be impacted by this infectious disease. With treatments available in most government facilities, international emphasis has shifted to helping people live with this infection. Many of the community members we work with are living with the illness, but the health systems we support are often overextended trying to reduce the burden of disease.

So on this World AIDS Day, we’re excited to be expanding our programs over the upcoming year to have a more direct impact on the reduction of HIV/AIDS burden in Sub-Saharan Africa. In Malawi, we are incorporating community-based HIV counseling and testing into our adult health service initiatives so that more people can access treatment that is already available from at government facilities. In Mozambique, we already help support the distribution of rapid diagnostic tests for HIV to ensure that diagnosis is available at service delivery points. In 2012, we are starting a study of RDT usage to better understand the barriers to utilizing new technology for improved diagnosis and to further improve the distribution of these tests. In both situations we hope to be able to improve accessibility to HIV testing in rural communities so that individuals can get the care they need.

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11.30 2011

Every year, more than 1.4 million children die from pneumonia, accounting for more than 18% of deaths in children under-five.

Pneumonia can be caused by viruses, bacteria, or fungi and is a type of acute respiratory infection that affects the lungs and limits oxygen intake in infected children. Streptococcus pneumoniae – or pneumococcal disease – is the most common cause of bacterial pneumonia in young children. Beyond pneumonia, the bacterium can also cause meningitis and sepsis, either of which can be fatal or permanently debilitating.

Pneumonia can be spread through infected air-borne droplets produced by a child’s cough or a sneeze. A child might also contract the infection through exposure to infected blood during birth. While a healthy immune system would enable a child to fight off this infection, a child with a weakened immune system resulting from malnutrition (as is prevalent in low- and middle-income countries) may require antibiotics to heal. Immunization remains the most effective way to prevent infection.

Since 2000, the pneumococcal vaccine has been readily available in the US and Europe. It has remained prohibitively expensive for low- and middle-income countries where most of the mortality burden is borne. Additionally, the pneumococcal vaccine administered in developed countries was determined to be ineffective in developing countries where it failed to target the bacterium strains present in developing countries.

Without vaccination or effective treatment – currently only 30% of kids in developing countries who need antibiotics receive them – pneumococcal disease threatens to compromise the economic vitality of many countries. Families are overburdened caring for children disabled by the disease and health systems are overextended trying to care for patients with sepsis, meningitis, and pneumonia.

Aiming to eliminate the 10- to 15-year delay between vaccine availability in high- and low-income countries, GAVI (Global Alliance for Vaccines and Immunization) was created; the organization is a public-private partnership striving to increase access to immunization in poor countries. Born out of a unique collaboration between the Bill and Melinda Gates Foundation, UN agencies, and leaders of the vaccine industry, as well as bilateral aid organizations, GAVI funds immunization programs in 70 countries. The organization estimates it will help avert at least 650,000 future deaths by 2015 and as many as seven million by 2030.

Pneumococcal vaccines are among those delivered by GAVI funds. Fifteen developing countries are already rolling out these vaccines with GAVI support. Mozambique was among 18 additional countries approved for the program in September 2011. Preparing for a new vaccine introduction is intense work. Infrastructure needs to be developed and/or refined: refrigerated storage space may need to be constructed to support the cold chain space, and transport routes and information systems must be developed, waste management systems need to be established, staff need to be trained, and a supervision system must be in place.

So, lot’s of work ahead! However we’re excited that the VillageReach Dedicated Logistics System might help support the distribution of pneumococcal vaccines next year in Mozambique. We are confident that our work with distribution, supervision, and information management will help to ensure that vaccines get to the health centers, that health workers are trained to administer the new product, and that the right quantities reach the right facilities to balance supply and demand. GAVI recipients have produced impressive rates of immunization and VillageReach is thrilled that our work may help reduce the burden of pneumonia among the under-five population.

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11.23 2011

In 2012, we expect to increase the number of our initiatives, adding to existing programs that are continuing from 2011. Financial support goes to helping us further develop our expertise in improving access to quality healthcare for remote, underserved communities by investing in research and development, collaborating with new partners, and conducting programs.

VillageReach’s initiatives are funded by a combination of individual donations, foundations, and similarly focused technical organizations in the global health community. All of our supporters share a common goal: to improve the capacity of health systems in developing countries in order to serve the millions of underserved.

In 2012, VillageReach’s goal is to raise $950,000 to support a total organizational budget of $3.16M. Contributions we receive will enable us to continue achieving impact in our current programs, and help us develop additional expertise and expand our work into new programmatic initiatives. Contributions received will be applied across our various initiatives, covering both direct and indirect costs.

Following is a summary of the scope and support of these initiatives. If you prefer to download this update, visit here.


Malawi: Community-Level Health System Strengthening Program
2012 Budget: $408,000

VillageReach has been working at the district level in Malawi since 2008 to improve the health of children less than five years of age by decreasing childhood illness and mortality in the southern region of Malawi. The focus of the program is to strengthen the health system at the community and health center levels by supporting community health workers, implementing cost-effective interventions to reduce malaria and diarrheal diseases, supporting immunization and other preventative health programs, implementing community-based treatment programs, and improving communication between community health workers and health centers. The majority of this program is supported by a single anonymous funder, who provided initial support in 2008 and has continued supporting the program in subsequent years. For more information on this program, visit here.

Malawi: ICT to Improve Health Services for Mothers and Children Program
2012 Budget: $450,000

We are entering the second year of a multi-year program to increase access to maternal, newborn and child health (MNCH) services by developing an integrated set of information and communications services. The program includes a toll‐free case management hotline for maternal and child health advice and referral, and uses mobile phones to send personalized voice and SMS health messages to women regarding their pregnancy and the health needs of their children. VillageReach is also working with the ministry of health to test a facility‐based scheduling system for antenatal and postnatal care in order to reduce wait times and improve health center readiness for maternal and neonatal health. This project is supported primarily through an agreement with an international nongovernmental organization. For more information on this program, visit here.

Mozambique: Dedicated Logistics System Program
2012 Budget*: $1,400,000

VillageReach is engaged in a multi-year program to improve the performance of the health system in Mozambique, focusing on rural communities that represent over 60% of the country’s population. The program, started in January 2010 and run in partnership with the Mozambique Ministry of Health (MISAU), aims to reduce vaccine preventable diseases and improve health system performance by implementing dedicated distribution channels for vaccines and other medical commodities to community health centers. The program is expected to cover eight of ten provinces, with more than 12 million people served. The focus of the program in 2012 is in achieving results for four provinces. Opportunities for expanding into additional provinces will be evaluated in mid-2012. The program is supported by both individual donations and private foundations. For more on this program, visit here.

(Note: this program is expected to extend to 2014 at a minimum. The current estimated program budget is $5.6M, with a current funding gap of $3.05M.)


VillageReach seeks opportunities to improve its technical capabilities and capacity to strengthen health systems in order to improve the health for rural, underserved communities.

mScan Project: Digitizing Paper‐Based Data Via Mobile Image Technologies
2012 Budget: $105,000

We are working with the University of Washington Computer Science and Engineering Department to develop and test mScan, an android-based mobile phone application. The research is evaluating the potential to automate and make more efficient the collection of data in low‐resource field environments by digitizing paper‐based data into usable information via low‐cost, image‐based, mobile technologies. The project leverages the growing supply of lower‐cost smartphones to bridge the gap between the mHealth movement, focused on digitizing all content, and the current paper‐based systems that prevail in low‐income countries. Members of the research team recently spent two weeks in Mozambique testing the new application in the field with our Mozambique DLS program. See here for further details on this initiative.

OpenLMIS: Logistics Management Information System Initiative
2012 Budget: $305,000

This is the first year of a two-year initiative to improve the quality and level of collaboration in developing of information technology for health systems, specifically the logistics management information systems (LMIS) that collect and report data on the performance of distribution networks for health systems. OpenLMIS is a community-lead initiative dedicated to furthering collaboration and development of logistics management information systems to support improvements in health system supply chains in low-income countries around the world. The majority of the project is supported by a grant from the Rockefeller Foundation. For more information on this initiative, visit the OpenLMIS website.

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