The last mile: improving healthcare delivery by understanding current challenges to supply chains in Mozambique

Kirsty Scott

14 October 2020

This is an article from the CSC Development Themes: Strengthening Health Systems and Capacity
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14 districts in Zambezia went from never knowing when they were getting their medication to always getting it on time.

Yara Manuela Cumbi

Commonwealth Alumnus Yara Manuela Cumbi shares her work on the Last Mile Health Supply Chain project in Zambezia, Mozambique, and the importance of health supply chains in strengthening healthcare systems.

Public health supply chains play a critical role in improving healthcare by delivering medicine and medical commodities to healthcare facilities. As advancements are made in increasing public health awareness and improving health seeking behaviour, assessing and developing these supply chains to run efficiently and sustainably is of great importance in meeting public health needs and ensuring access to medicine, vaccines, and other medical supplies.

Understanding the current challenges to supply chains across stakeholders and highlighting the importance of data to monitor medical supplies and inform public health needs is key to this, Yara Manuela says:

“Understanding where the disconnect is and where the bottlenecks are and why things aren’t working is really important… You need to empower local health facilities to be able to have resources so that they can do certain things.”

Following her Commonwealth Scholarship, in 2018 Yara Manuela joined the USAID-funded Last Mile Health Supply Chain project in Zambezia, Mozambique, as a public health analyst. The project aimed to develop a more streamlined and effective distribution system to address chronic logistics and transport challenges in the public health supply chain and focused on improving access to medicine and other medical commodities at the health facility level.

One of the core challenges Yara Manuela identified to the supply chain was the disconnect between where the data is collected or generated and where it is used. At the central level, data on medical commodities is used by the Ministry of Health to liaise with NGOs and other donors to implement projects and secure necessary funding, however this relies on accurate data being gathered and reported at the health facility level. With health facilities under pressure to treat patients, often with limited human and facility resources, the addition of data collection to their workload is often not a priority, resulting in data gaps and incorrect information being used to inform health supply chains.

Working on the ground with health facility workers enabled Yara Manuela to understand the pressures on workers and how and where data gaps were appearing, as well as how best to fill these.

As such, improving data culture at the health facility level became an integral part of her work with the project. Key to this was working closely with those collecting the data to ensure they understood why it was important to report accurate data to avoid stock-outs and efficiently request medicine and other medical commodities. It was also an opportunity for Yara Manuela to understand where health facility workers were experiencing difficulties with current processes in gathering and reporting data and incorporate these into the project. This included running workshops to gather feedback on their learning and obstacles to improving data culture within health facilities.

“…we’d sit with them and talk about the problems that they’re having with the tools that they’re using… Once they’re involved and they give their suggestions, we can take on certain suggestions. They’re also just a lot more invested. And again, it helps improve the data culture all around.”

Some of the difficulties shared by health facility workers included issues using the data collection system and unreliable internet connectivity to access it. In response to this, Yara Manuela and her team developed an evaluation dashboard, in collaboration with the health facility workers, that made it easy for them and those at the district and provincial levels to report and monitor medicine stock and identify stock-outs to inform future decision making and planning.

Medical transportation

Another significant part of the project was to assess and improve the transportation of medicine and medical commodities to health facilities. Prior to the project, transportation of medical supplies in Zambezia had been managed by the government as part of the health system, however inaccessible roads and the remote locations of some health facilities pose a significant challenge to this part of the supply chain.

To overcome this, the project put in place a public-private partnership with logistics company, Bolloré, to take on the transport aspect of the supply chain, following research conducted by Yara Manuela and the project team on outcomes of public-private partnerships in healthcare.

She shares, “There are districts that are so remote, there are roads that you can’t even get through… And I think that’s the expertise of the logistics company, they’d have to take a boat and then take a motorbike. There are places that cars can’t go.”

Following completion of the project, the health supply chain across districts in Zambezia significantly improved, with patients able to access medication at health facilities.

“14 districts in Zambezia went from never knowing when they were getting their medication to always getting it on time.”

With such a high success rate, the project has been scaled up to the rest of the province and implemented in other provinces in Mozambique. Further recommendations were also shared with the Ministry of Health on additional ways public-private partnerships could be implemented to support healthcare delivery.

Looking collectively for a greater understanding

Yara Manuela attributes her Commonwealth Scholarship to understanding the way health systems work and the importance of looking at them collectively, rather than as individual projects and programmes. This was particularly important on the Last Mile Health Supply Chain project, where assessing the logistical management of transportation and medical stock was a critical part of understanding and meeting public health needs.

“I’d never worked in supply chain before, but I was like, this is absolutely important. It’s very important and it’s not really something that we think about when we think about public health…

 

“It’s where I really understood the importance of statistical skills and data analysis and where I really just started having those skills. And I didn’t realise how important they were until I was out working.”

Accessing information on COVID-19

Yara Manuela is currently a Data for Impact programme coordinator for Vital Strategies in Mozambique, where she works with the Ministry of Health analysing health data and advising on how to collect relevant data to advise on health planning programmes.

Prior to this role, Yara Manuela was the Health Information Manager for Mozambique mobile-based health education platform, PENSA. The platform, which is accessible on any mobile phone, allows the user to access information on health issues, including symptoms and where to seek medical attention. During the COVID-19 pandemic, the platform has become an important and relevant tool in raising public health awareness and has been accessed by approximately 300,000 users a month and has 60,000 registered users. As an information manager, Yara Manuela was responsible for analysing the data to understand people’s usage of the platform and ensure the platform effectively meets user needs.

She attributes the current monthly figures to people accessing information about COVID-19 and a positive change in attitudes and awareness of public health.

“I think the way people consume health information [and] their ideas around public health has completely changed with Coronavirus now. I think that when the next pandemic comes, they’ll be a lot more prepared because they’ll understand a lot of the principles a lot better than they do currently…

 

“I’ve worked in public health my whole career basically, and I’ve never been able to have conversations with people about the work that I do. It’s just a bit too insular. And now it’s every day that people are talking to me about public health and prevention.”

Yara Manuela Cumbi is a 2014 Commonwealth Scholar from Mozambique. She studied for an MSc Public Health in Developing Countries at the London School of Hygiene and Tropical Medicine.