Field visit:Namaacha

As part of my orientation to VillageReach and the Mozambique health system, a few weeks ago week I joined Margarida, the VillageReach Field Officer for the Maputo Province, for a field visit to the district of Namaacha.  Originally, we had planned to head to a different district for supervision, however the night before we left we got a call saying that Namaacha had an urgent need for a vaccine delivery and we needed to respond to this request. 

Margarida leaving a health center

We started our trip with a stop at the Namaacha district hospital where we met up with government staff responsible for vaccine delivery in the area.  While I was shown the hospital pharmacy, stock room, laboratory, maternity ward, and the general patient area, Margarida headed to the back of the hospital to go over their records of vaccine use and disbursements in the district.  She quickly identified some incomplete and inconsistent data records and immediately sat down with the staff until she was convinced they understood what was wrong and how to make it better.  Margarida previously held positions as the national vaccine manager for Mozambique and as the director of the Maputo province department of health, and she not only knows her stuff inside and out, but she cares too deeply about the issues to leave a room before she thinks all present understand their role in facilitating vaccine disbursement in Mozambique. 

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

Damaged solar panel at Dibinduane

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

Broken frig being used as a table

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

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

Getting settled in Mozambique

Rural health center flanked by VillageReach vaccine delivery vehicles

Greetings from Mozambique.  After several weeks in Maputo, I have settled into my apt, figured out the best place to buy the famous Mozambique prawns, participated in several eye-opening field visits with my co-workers at VillageReach, and begun to wrap my head around the Mozambique health care system. 

Prawns at the fish market

This is my first time in Africa and everyday offers a new adventure, however, one of my first great surprises was rooted not in the unknown, but in the European financial crisis!  Finding an affordable apartment in Mozambique was no easy task, apparently thanks to a recent influx of foreigners snapping up lodgings and driving up prices.  Mozambique is a former Portuguese colony and the contracting economy of Portugal seems to have spurred a torrent of Portuguese entrepreneurs looking for new opportunities in Mozambique.  Of all the challenges I had prepared myself for, unemployment in Portugal was certainly not one of them!  Luckily, eventually VillageReach found me a room to rent in the apartment of a young Mozambique professional.  Despite the occasional lack of water and 15 minutes it takes to get through all the padlocks, it is a beautiful apt perfectly located for me to get to work and around the city…not to mention that  I have a private balcony with a view of the city.  

Vaccine transport

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

Data collection at a district health center 

These questions and many more will be answered using a lengthy survey that will be given in every district within the four Mozambique provinces (Maputo, Gaza, Niassa, Cabo Delgado) where VillageReach currently operates.  Last week we began training the VillageReach Field Officers in implementing the survey.  We will had an all day training session in our offices in Maputo followed by 3 days of visits to nearby district health centers to see what surprises we found in translating ideas on paper to workable information gathering in the field.  In the coming weeks, the Field Officers will continue to gather the data (I will join when possible) and send it all my way for synthesis and analysis.  The hope is that this study will provide more detailed information about the current challenges and thus help VillageReach and the Mozambique government prioritize their efforts to increase access to healthcare supplies to rural communities.  

View from a rural health center 

By far my favorite problem we encountered in the training came from trying to explain the concept of a “typical month”.  There are several questions in the survey that ask questions along the lines of  “In a typical month what sort of vehicles did you use to distribute vaccines?”  The concept of a “typical month” spurred a very spirited half hour discussion.  I was told that there was no such thing as a typical month and the question would confuse people.  The Portuguese translation was fine, the difficulty lay in the fact that everything changes so frequently and without notice in rural Mozambique, that the concept of things happening on a regular schedule in a manner that could be expected was just very difficult to digest.  I think there are few moments that sum up the challenges of working on logistics in rural Mozambique much better than this!