Thoughts from the Last Mile Welcome to the VillageReach Blog

Category Archives: Mozambique

04.03 2013

(This blog was originally posted at Next Billion).

One of the harsh realities of the current state of global health is that the quality and supply of life-saving innovations exceeds the capacity of many health systems to deliver them. Exciting new innovations are being developed. But for many low-income countries, gaps in the underlying infrastructure to support their delivery – especially for rural areas – limit the potential of these innovations to improve health care.

In our experience at VillageReach, looking at the problem from the point where health care is delivered to patients ensures that capacity development focuses on the weakest link – the last mile – but also where underlying infrastructure is most limited. We’ve determined that private enterprise has a significant role to play in developing the infrastructure necessary to achieve sustainable improvements in health care.

Vaccine development – arguably global health’s greatest innovation – is a case in point. With billions invested, the aggressive introduction of vaccines has saved millions of lives. But subsequent gains have been more elusive: Many low-income countries have seen immunization rates essentially stuck at 80 percent. GAVI Alliance CEO Seth Berkley estimates that today as many as 22 million children are unable to access vaccines. More than two million die from vaccine-preventable diseases every year.

Efforts to reach the remaining 20 percent – the Final 20 – have been insufficient, largely because much of this neglected population is rural and remote. For many of these communities, long travel distances, minimal transportation services and high poverty rates prevent mothers from making their kids available for immunization and other basic health care measures, raising the cost of health services. Families with sick children find it more difficult to exit poverty, and their communities have fewer opportunities to advance.

Investing in Community Infrastructure
With so much investment and innovation in vaccine development, we should be looking to where leverage can be applied to fulfill that promised value. Much of VillageReach’s work has focused on improving vaccine delivery by increasing frontline health worker productivity and capacity, and making information technology more useful and practical in the field in order to improve data reporting and performance measurement. Our model also leverages private enterprise to develop common infrastructure that both health systems and the communities require.

In creating opportunities for investment in infrastructure, we look at gaps in key community services – transport, communications and energy supply, for example – that limit health care delivery. The intent is to address the health access and capacity problem by creating enterprises that also serve commercial customers in order to achieve financial sustainability.

This focus on infrastructure isn’t only to provide single solutions for common problems. The economic multiplier is higher for investments in infrastructure than in other sectors, since the construction of roads, bridges, communications, and energy supply networks employ workers and enable commerce. World Bank President Jim Yong Kim acknowledged the importance of this link recently, noting that investment in Africa’s infrastructure increased from 16 percent to 22 percent of GDP over the past decade. Africa’s 5 percent annual GDP growth during the period is greater than for any other region worldwide.

Supplying Energy for Mozambique’s Health System – VidaGas
Mozambique and its health system have faced many of the same challenges of other countries in sub-Saharan Africa. Much of the population lives in remote communities that are difficult to reach. Less than 35 percent of the country has access to the electrical grid – access is much lower for rural communities. Health services are also impacted: The supply of vaccines to rural health centers is irregular due to the great travel distances involved, and limited refrigeration results in wasted vaccine stock. This lack of reliable energy also impacts health center performance well beyond vaccine delivery, making it difficult to sterilize medical equipment and provide the necessary lighting for procedures conducted after dark.

We set a goal of improving the capacity and reducing the cost of health care delivery in Mozambique. It was clear that a solution was required that would address the critical gap in energy supply affecting the performance and economics of the cold chain for the health system. It was also clear that the solution must be sustainable by attracting broader demand for the service.

In 2002, we established an energy services company, VidaGas, in partnership with Fundação para o Desenvolvimento da Comunidade (Foundation for Community Development). When VidaGas was created, the initial network of rural health centers comprised 100 percent of gas shipments. Today, that percentage is 17 percent. The majority of VidaGas’ service is now directed at enterprise customers – restaurants, hotels, small factories, and a growing retail network that enables households to replace traditional wood and charcoal that produce harmful indoor pollutants. The message is that without revenues from the private sector, the company wouldn’t have the resources to support its obligations to the health system.

The company’s growth – in excess of 35 percent annually since 2010 – has accelerated with additional capital investment from Bamboo Finance/Oasis Fund. Today, VidaGas is expanding its operations into new geographies and market segments. The company is now the largest independent energy services provider in northern Mozambique, with three large-tonnage storage and filling facilities across the region serving five provinces and more than 50 percent of the country’s rural health centers.

We anticipate similar growth in the future, as the business expands its base of enterprise customers, builds a larger retail network to reach more households, and expands operations into new provinces in order to supply more rural health centers.

John Beale
Group Lead, Social Business

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07.19 2012

We recently sent out this latest update … here’s our news in case you missed it …

Malawi

  • update on our work to improve maternal and newborn health in Kwitanda
  • the latest on our Chipatala Cha Pa Foni (health center by phone) program, part of the Innovations for Maternal, Newborn and Child Health initiative
  • Mozambique

  • new update to our Mozambique Dedicated Logistics System (DLS) program
  • collaboration with the William Davidson Institute (University of Michigan) Supply chain & logistics study: new research to quantify the logistics challenges for a variety of medical commodities
  • Dr. Seth Berkley, President of the Global Alliance for Vaccines and Immunization (GAVI) visited the DLS program
  • Technology Initiatives

  • ODK Scan: update on our collaboration with the University of Washington’s Computer Science & Engineering to improve the quality of data collection
  • OpenLMIS: new website with updated details on activities and partners
  • Social Enterprise

  • VidaGas: our collaboration with the ghdLABs program at MIT, to evaluate the marketplace for our social enterprise in Mozambique
  • New Additions to Our Team

    Malawi:

  • George Chinkwita – Project Officer, Kwitanada Economic Development Initiative
  • Erin Larsen-Cooper – Program Associate
  • Mozambique:

  • Antonio Gaspar Tomboloco – Field Officer, Niassa Province
  • See here for details …

    Updated Financial Report

  • our recently posted 2011 independent financial audit
  • We welcome your questions and comments,

    Allen Wilcox
    President

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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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    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
    VillageReach

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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
    VillageReach

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    04.08 2010

    IMG_0669My name is Peter Nakamura and I am one of the newest members of the VillageReach team. I am currently based in Nampula, Mozambique to help coordinate a project funded by USAID to help individual households gain access to propane. The project is coordinated through VillageReach and its social business, VidaGas – the largest distributor of LPG (Liquid Propane Gas) in Northern Mozambique. As the next step in its growth, VidaGas is working to expand its customer base to households in order to diversify its clientele and expand the availability of a cleaner and more efficient source of cooking fuel than charcoal or wood (which are the most common types of cooking fuel in Mozambique).

    IMG_0669

    In order to increase the demand and awareness of LPG among households, we will be launching a social marketing campaign tailored to the realities on the field. From personal demonstrations of around 10 people to big events where we expect over 200 people to attend, we will be testing different methods to stimulate demand and awareness. In the end, our goal is to be able to learn from this experience and create a social marketing model and toolkit which we will be able to implement in other developing countries and with a variety of product (whether that be bed nets or batteries).

    Check in regularly for updates on our progress.

    Peter Nakamura, Project Administrator

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    09.21 2009

    We’re happy to say it’s been a busy month of September here at VR.  While we haven’t had much time to write- others are writing about us!  Over at the Discovery Channel, they cheekily suggest we should get involved in the US healthcare debate (thanks, but no thanks), while the author at the Scientific American blog sees the link between our work and the new Swine Flu vaccine.  Meanwhile, the NextBillion blog covers our panel at the SoCap Conference.

    As we move forward into fall, we look forward to even more good news…

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    09.01 2009

    Canister_StacksAs the Social Capital Market Conference (SoCap) begins today in San Francisco, VillageReach is very excited to announce that Oasis Fund, a European investment fund, has committed a $1.375 million investment in VidaGas, the propane energy company owned by VillageReach and the Mozambique Foundation for Community Development (FDC).  SoCap is full of social entrepreneurs, investors and innovators excited about using private money for social good- but thus, far there are few true real-world examples of large scale, social investing.  This investment is a landmark transaction that demonstrates the potential for channeling private investment capital into commercially viable social businesses in developing countries.  Furthermore, the investment affirms the effectiveness of VillageReach’s model for enacting sustainable, systemic change to global health by establishing for-profit businesses to fill gaps in infrastructure.  The investment will enable VillageReach to expand its customer base and energy service offering to impact a greater number of households and businesses in remote areas of northern Mozambique.

    VidaGas was started in 2002 to support the health system improvement program developed by VillageReach and FDC.  More than 80% of Mozambique’s population is rural and depends on charcoal and wood for basic cooking and heating.  Safe and reliable propane from VidaGas enables health centers to provide critical health services including vaccinations, equipment sterilization and nighttime birthing.  Additionally, propane from VidaGas is a clean and affordable alternative to charcoal and wood for households, small businesses, and light industry clients.  VidaGas has grown over 500% since 2002 and is now the largest propane distributor in northern Mozambique.

    Oasis Fund is a Luxembourg investment fund which finances innovative, growth stage, commercially viable enterprises that deliver basic goods and services that improve the lives of low-income communities.  This investment is the first investment in Africa for the Oasis Fund.  Oasis Fund is advised by Bamboo Finance, a Geneva based investment advisory firm.

    VillageReach’s Social Business Director, Craig Nakagawa, will be speaking with Keely Stevenson, of Bamboo Finance, about the investment at SoCap tomorrow.

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    06.08 2009

    So who is paying attention to medical distribution systems and more specifically to the innovation pile-up we highlighted in the last post?

    There are 4 main categories of players: Governments, NGOs, multi-lateral organizations (WHO, UNICEF) and public-private alliances.  While there are many, many important and interesting stakeholders in the field, the most interesting evolution over the last decade has been the ways these groups cross boundaries to find creative ways to work together.

    When Global Alliance for Vaccines and Immunization (GAVI) was established in 2000, it had an enormous impact on the field of vaccines.  GAVI refocused attention on vaccine-preventable diseases which waned in the 90’s after the highly successful immunization campaigns of the 70’s and 80’s. gavi-logoAnd as a public-private partnership funded by donor governments and private organizations such as the Bill & Melinda Gates Foundation, it brought serious financial resources to the table (over $2 billion of net assets in 2007).  Currently, GAVI supports 72 low and middle-income countries in vaccine financing and procuring.  While considerable resources at GAVI have been directed towards augmenting the supply of existing vaccines and developing new vaccines, GAVI and its stakeholders are increasingly beginning to consider the inadequacies of the health systems into which these vaccines must enter.

    One particularly interesting initiative is The Optimize Project, a joint collaboration between the WHO and PATH.  The Optimize Project seeks to identify and advocate for the “immunization systems and technologies for tomorrow.”  Funded by the Gates Foundation, the Optimize Project is a recognition that discovery and development of vaccines is only half the battle.

    Here at VillageReach, it has been exciting to see the development of enthusiastic recognition and articulation of the problems of logistics at theLast Mile.

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    06.05 2009

    Welcome to the VillageReach blog! This blog follows VillageReach’s progress as well as interesting ideas, projects and events at the intersection of health with social enterprise, technology & logistics.

    We ’re launching with our thoughts on the “Innovation Pile-up.” Chris Elias, the Executive Director of PATH, coined this phrase to describe the coming challenge facing public health systems around the world as years of medical research and development, particularly for vaccines, come to fruition.

    When VillageReach started working in Mozambique in 2001, we found there was no system for distributing medical supplies beyond the provincial level … a situation that’s unfortunately the norm in most developing countries.

    The Mozambique system was chaotic and under-resourced in 2001. Since then, the world has begun to invest heavily in new medical products, such as vaccines, to address the huge disease burden affecting developing countries. Governments, international organizations, and private charities have spent trillions of dollars in research and development of new products. But new opportunities bring new challenges. The new vaccines just starting to become available are much more expensive and are physically, much larger.

    For example, polio is a basic vaccine administered around the world today. Twenty doses of polio fit in a vial about the size of your little finger. At 13 cents per dose, the vial is worth only a few dollars. A twenty-dose, polio vial doesn’t take up much room in the refrigerator, and if the distribution system ruins a few vials, or has a few leaks in it, then the loss is not huge.

    In contrast, one new vaccine to prevent rotavirus, a stomach bacteria that kills thousands of children every year, costs $5 and is the size of your fist. The HPV cervical cancer vaccine is expected to be priced between $50 and $100 per dose in developing countries. The malaria and HIV vaccines, which we hope are coming soon, are also likely to be very expensive. Current distribution systems are overwhelmed now; the new products will swamp them.

    Unless we invest in improving the ability of developing countries to handle these new products, trillions of dollars of investment will be wasted and, more importantly, children in those countries will once again, be passed by. While we can get excited about new product developments, and rightly so, we can’t forget that our job is not done, until drops are in mouths, and needles are in arms.

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