Change does not come easily,
particularly to systems that have been operating in a specific way for a long
time and where many people have a stake in the decision making. But sometimes
it becomes clear that change is necessary to improve how things operate.
As Medical Chief in Gaza
Province in Mozambique, I have seen this first hand with a distribution system in
great need of transformation to increase accessibility of vaccines for
Up until a few years ago, our
vaccine distribution system followed the government administrative tiers, a
system widely adopted by countries across our region. Here at the provincial
level, we received the vaccines from the national medical stores and delivered
the appropriate amount to the 12 district levels. From there, each district was
responsible for delivering the vaccines to the health centers, about 10 in each
district with some that are extremely isolated and difficult to get to.
On paper this system looks
great—very systematic and methodical. Reality is a different matter at the last
mile of delivery. Following administrative tiers requires several vehicles at
the provincial level and a vehicle at each district, which were often not
available or were broken down. Or the funds were not available at the district
level to purchase fuel or to pay the costs of delivery to the health centers.
Many times, the responsibility fell on the health workers from the health
centers to arrange transport to the district to pick up the vaccines. This
required a day away from the health center (and away from patients who actually
need care), arranging available public transport that is infrequent and
unreliable, and the health worker paying for the transport out of her own
pocket if she had money available.
The results of this
multi-tiered, ad hoc system were lost opportunity for care, frequent stock-outs
of vaccines at the health centers, unreliable and infrequent data, and a system
that depended on the willingness of a health worker to spend her own money to
make sure she has supplies available to do her job.
Simply put, the system needed
In 2009, with technical
support from VillageReach,
we introduced the Dedicated Logistics System (DLS) for our vaccine distribution. The DLS is an informed push system
which involves level jumping, task shifting, dedicated personnel, and improved
data management. Essentially, instead of following the administrative tiers, we
have divided the province into two delivery zones with a dedicated field
coordinator and a vehicle for each zone. Each month, the field coordinator
follows a transport loop to each health center to deliver the appropriate
quantity of vaccines based on actual consumption during the month before,
collects data on vaccine utilization and confirms its quality, checks the refrigerator to ensure it is functioning correctly, and
provides supportive supervision to health workers. The data is entered into a
new information management system that enables improved data visibility with
key information on system performance for decision-makers.
The benefits have been
phenomenal. I have seen more improvements in distribution and vaccine
availability in the past few years than in the three years before that. Stock-outs
of vaccines have dropped from above 15% to around 5%. This system gives us more
visibility into the data coming from the health centers with improved
frequency, regularity, and quality. And this has made the data credible,
creating more confidence in the distribution system and in the government and
providing more evidence for decision making.
Now we have a cost-share
approach, where we cover part of the costs and VillageReach, with support from
the Bill & Melinda Gates Foundation, covers the other part. We are so
committed to this system that we made sure to include the total costs of
program implementation in our proposed plan for the state budget next year, which
will eventually lead to us sustaining the program ourselves.
It was not easy to convince
policy makers in Gaza to change from a system that had been followed for more
than 30 years to a new and innovative approach. I admit that initially there
was some resistance, but, with time, good sense prevailed and with it came a
readiness for higher quality of care to the community, particularly in rural
areas at the last mile of service delivery.
The evidence is there to
justify the change. We have increased vaccine coverage and healthier children.
I heard someone say once that
those who cannot change their minds cannot change anything.
changed our minds in Gaza and changed our distribution system. And our children
are healthier for it.