Thoughts from the Last Mile Welcome to the VillageReach Blog
05.17 2011

In his last blog, John noted VillageReach places a high value on transparency, and that has attracted a crowd of supporters who are challenging non-profit sector paradigms about transparency. This is a force for change to improve on donor-NGO relationships, and ultimately to create better impact. But what does it mean to be transparent? In international development, being transparent has impact on two distinct relationships: those between NGOs and donors, and those between NGOs and partners on the ground. Today I’m writing about the latter.

VillageReach’s work is often conducted in close partnership with governments. We’re not in the practice of creating or running health systems. Instead, our role is to strengthen what exists – typically the public health system. For example, in Mozambique we work with the provinces to implement a vaccine logistics system, and the work only starts when both partners are ready. For our own purposes, we must plan our work and forecast what needs we will have. Naturally, we base our plans on what we know about the provinces: eg. financial, personnel and transportation resources, and broader scheduling plans for various other health program initiatives.

But situations often change for government agencies and communities in low-income countries with limited resources. As a result we may publish plans that don’t coincide with the unique scheduling and resource planning priorities of the government.

When government representatives see our plans, they may naturally jump to the question, “whose health system is it anyway?” and wonder why VillageReach is making plans for them.

Planning is best done by talking with government partners about when they will be ready to work on a program. Their assumption will be that we have identified the resources before we begin discussions with them. Of course that is not always the case – we will want to present a case to donors that indicates prior government commitment. If our response to the provinces is that we haven’t [yet] identified the resources, then they may question our ability to make a long-term commitment.

In a similar vein, being transparent raises questions of data ownership. We strongly believe that it is critical to have data for monitoring and evaluating the impact of our work, and our donors and partners agree. The extent to which we share that data publicly is not always agreed upon with our partners. For example, when we carry out a baseline study with household surveys about vaccination coverage rates, that data and decisions about sharing it don’t belong to us – they rest with the government who factors in the various reporting obligations it has to other constituents, including other government and private donors. An important fact to consider in understanding government decision-making in low resource countries can be seen in what dependencies these governments have on external parties – as an example, as much as 70% of the public health budget may be supplied by donors.

We want to report on our program data, yet at the same time, the government needs to report on national indicators to other donors. The story the national data supports and the story for a province might be very different. The more NGOs, the more complicated this becomes for the government.

So balancing transparency for our donor partner needs and our government partner needs is a challenge. We’re committed to the principle of transparency – without it we might alienate donors, or at least limit their ability to make informed decisions about investing in our expertise and contributing to our programs. We’re similarly committed to being a trusted partner to governments we work with in order to ensure we’re valued and our expertise is applied at the greatest scale for maximum benefit.

Leah Hasselback

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04.25 2011

Kevin Starr at the Mulago Foundation has an interesting piece in the Stanford Social Innovation Review this month about the future of philanthropy and social entrepreneurship (note the Mulago Foundation supports VillageReach). Kevin’s blog has a number of perspectives in it that are each worthy of comment, but I’ll focus on one issue today.

Kevin is concerned about evaluations of impact, or the lack thereof, in the social sector. He expresses frustration about the sector “…operating in a dysfunctional market for impact.” Kevin had just returned from the annual Skoll World Forum, as I had. He was struck with what he heard: that highly evaluated organizations with demonstrated impact can’t always attract the capital they require. Whereas “… zombie NGOs can operate for years …” This in comparison with the private sector, where capital tends to follow the most appealing investment cases. The lack of an established social sector marketplace, where entrepreneurs – the Doers – and investors/donors find each other efficiently through common standards of evaluation, is a source of frustration for Doer and funding organizations alike.

Kevin suggests the fault lies with investors/donors for the most part – they don’t always insist on stringent evaluations of the work they fund. That’s cause for concern right there because it suggests more could be achieved with the same resources, but isn’t.

But we can’t place all the blame on the sources of funding. Doers are also charged with evaluating their performance in order to improve results, and of course many already do this. But some Doers may be reluctant to make their results public, out of fear that the challenges they face will not be appreciated. Achieving sustainable results at large scale in international development is just hard, and can be unpredictable.

But I think you have to give the donor more credit. Our supporters want to see tangible evidence of our performance, but also explanations of the challenges. Many are not foundations or organizations – they’re individuals who want to make a difference. I’d make the case for individual donors being a real force for change in wanting to evaluate the impact that financial support provides for social causes.

The smart giving movement encourages measurable, sustainable impact for their donor dollars. There’s a growing number of people eager to track the Social Return on Investment (SROI) of their personal contribution. The movement doesn’t only encourage reporting of results. In fact, it seems investors/donors also respond well to organizations that document their plans. For our donors, results matter. But they gain confidence in us when they see project plans, program metrics and financial plans online. GiveWell, and their positive rating of VillageReach, is further evidence that being more public with plans for effecting change is a natural attraction for investors and donors.

Transparency itself becomes a differentiator. And we can always improve upon that.

On that note we recently published updates to our work in Mozambique, with new details of the project plan and the financials, with an explanation of what has changed. We’ve seen some delays in deploying the model to additional provinces, but we’ve also received support that enables us to plan more effectively for the longer term. See VillageReachFocus for details, including the updated program report.

John Beale

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03.16 2011

After weeks of elaborate tests using very sophisticated health technologies, my diagnosis has been confirmed and I can begin my treatment. The first step in the treatment was surgery last Monday, only a few miles from my house. As part of the procedure, the surgeon made a six-inch long incision from my left ear to the center of my throat. To close it, he gave me zipper of temporary metal staples.
I can now claim to be the first in my family with body piercings, teenagers notwithstanding. The rest of the treatment will keep me from my day-to-day duties at VillageReach for about three months. At the end of which, however, my prognosis is for a full recovery and I will be back at my desk by early summer. That’s because I live in a high-income country where quality healthcare is readily accessible – at the Fortunate Last Mile. But for billions of people living in low-income countries where access to quality healthcare is scarce, my same diagnosis would be a death sentence. As we all know, life isn’t fair. But that’s just one more reason those of us living at the Fortunate Last Mile need to work to address the inequities in access to quality healthcare for those living at the Not-So-Fortunate Last Mile.

Allen Wilcox

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02.01 2011

Join Us for an Evening of Fun & Jeopardy!

Hey gang in Seattle! We hope you can join us for a fun evening of celebration and excitement here in Seattle.

The first-ever man vs. machine Jeopardy! competition will air on February 14, 15 and 16. As noted in the Seattle Times, Ken Jennings, the celebrated Jeopardy! contestant who broke the record for the most consecutive games played by winning 74 games in a row, is a local hero and is competing in mid February with the IBM Watson computing system. Ken has generously named VillageReach as beneficiary for half of his winnings at the competition.

The VillageReach team and friends will be getting together on the evening of February 16 to watch the final show and find out the results. Please join us to watch the fun and cheer on Ken!

Dad Watsons Pub
3601 Fremont Ave. N.
(corner of Fremont Ave. N. & N. 36th St.)
Seattle, WA 98103
(206) 632-6505

Wednesday, February 16, 2011
6:30 p.m. – whenever you like.
Jeopardy airs at 7:30 p.m.

Please RSVP to make sure we reserve enough space.
Tel. (206) 925-5203.

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01.13 2011

Answer:   Who is VillageReach?

Exciting news for us today as the popular game show Jeopardy! is announcing further details of the competition that will pit man against machine.    Ken, who broke the Jeopardy! record for the most consecutive games played by winning 74 games in a row, has selected us as beneficiary for half of his winnings from the competition.   See more details in our announcement and this one from IBM.   We’re thrilled Ken selected us after reviewing many non-profit organizations.

As Ken noted:  “VillageReach’s innovative approach to improving access to healthcare and their commitment to documenting the results of their work for donors motivated me to select them for the Jeopardy! competition.”

Where will you be February 14, 15, and 16?

Go Ken!

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12.09 2010

In the previous post, Nick shared the exciting news that data from health centers in Mozambique is now available for us to see. Living in an environment where information is easily available at our fingertips, we often take the availability of data like this for granted. In reality, obtaining data from a place where information systems and health records aren’t commonly used is quite challenging!

Yet, the information is crucial not only because it can strengthen the overall performance of the health system by enabling data-driven decision making by our partners on the ground, it is necessary in order to measure progress and impact. And as I’ve written previously, VillageReach is committed to monitoring and evaluating the progress and impact of the Dedicated Logistics System in Mozambique.

The key questions to ask when attempting to evaluate impact are whether or not the Dedicated Logistics System has met its objectives to improve health system performance and increase immunization coverage. In the baseline evaluation, we attempt to answer questions such as: how many children are immunized and how often do health centers run out of vaccines. Unfortunately, this type of information is just not available. There are no immunization registries to search. Health centers don’t keep patient records. Even if they did, we still wouldn’t be able to know how many children are not immunized because there are no vital record systems either. These things just aren’t tracked.

In order to get the information we believe is valuable to answer these questions, we went out and collected it. In order to estimate the immunization coverage, we conducted more than 800 household surveys in randomly selected villages across the two provinces of Cabo Delgado and Niassa. The sample size gives us enough statistical power to make an estimate of the true immunization coverage rate with 95% confidence and because the villages were randomly selected, the sample is representative of the population. In each household, we essentially asked whether or not the children living there had received certain vaccines. In addition, we conducted surveys in more than 60 health centers in those villages to get an idea of how the health centers were performing. We worked with a group in Mozambique who hired and trained local staff to conduct the surveys and complete the data entry. The process took about nine months from the time we first sought Ministry of Health approval for the study until we started seeing the data.

Despite a few challenges along the way including delays in schedules with field teams, traveling time to remote villages, and correcting for concerns with the data such as missing entries and incorrectly completed surveys completed, we have real numbers. We have real data from the very last mile. Finally, we can use this data to answer our questions regarding how many kids aren’t being reached by vaccination services and what we can do to improve this. Using this information, we can tailor our program activities in ways that can make the biggest impact and that is what we intend to do.

Before we can share the results publically, we need approval from the Ministry of Health. We’ve started the process and have already shared the results with provincial leaders in Cabo Delgado and Niassa. We will be presenting the results to the Ministry later this month or early next year. We are looking forward to sharing our results with you as soon as possible. Stay tuned.

Jessica Crawford
Program Associate

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12.03 2010

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

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

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

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

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

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

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

Nick Amland
Program Assistant

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10.14 2010

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

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

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

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

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

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

Jessica Crawford & Nick Amland

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09.24 2010

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

Even while researchers continue to develop and test new interventions such as vaccines, diagnostic tools, and drugs through thorough clinical research, we don’t know how best to deliver them in countries with weak health systems. The result is an innovation pile-up where proven interventions to prevent and treat disease are available yet millions of people are dying because these interventions don’t reach them.

As a graduate student in public health, it seems to me that the field of global health is turning in this direction and placing a lot more value on measuring impact. As President Obama said in his speech at the MDG Summit; “let’s move beyond the old, narrow debate over how much money we’re spending and let’s instead focus on results-whether we’re actually making improvements in people’s lives.” We need to know what is working and what isn’t so we can better our efforts and get the interventions out to the people who need them.

Unfortunately, evaluation is difficult to do well. As I quickly learned in the IHME course, there are some serious limitations to deal with ranging from poor data quality and availability to the fact that the methodology of conducting a rigorous evaluation just sometimes isn’t possible or is really expensive. As expressed in a Lancet editorial: “Evaluation matters. Evaluation is science. And evaluation costs money. It’s time that the global health community embraced rather than evaded this message.”

VillageReach makes a sincere commitment to evaluation of its programs and has ever since its inception. For example, as we begin to scale-up the Dedicated Logistics System in Mozambique, we are engaged in operations research to inform our program decisions. In addition to routine monitoring, we are conducting baseline evaluations in every province followed by process and outcome evaluations. We want to know what is working and more importantly, what isn’t working and why, so we can ensure that the resources we put into our programs really make improvements in people’s lives and that those interventions make it to the people who need them. We’ll keep you posted on our progress.

Jessica Crawford, MAPS, MPHc
Program Associate

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