VillageReach: innovating for improved health care at the last mile Cynthia Schweer Rayner, Camilla Thorogood and Francois Bonnici Teaching case Introduction In October 2012, Allen Wilcox called a VillageReach Leadership . Specifically, they would need to decide whether or not to continue with the organizations flagship programme called the Dedicated Logistics System (DLS). For the previous 12 years, VillageReach had worked at the last mile of public health care, bringing innovative solutions to the challenging task of reaching the most underserved communities in the world. Globally, more than one billion people lacked access to health care, and approximately 6.3 million children died every year, primarily from preventable diseases. The DLS provided a new approach to delivering vaccines for the World Health Organization (WHO)s Expanded Program on Immunization (EPI), and was a collaborative initiative launched in Mozambique in 2003 with a local non-governmental organization partner, Fundacao para o Desenvolvimento da Comunidade (Foundation for Community Development, FDC) and the Mozambican Ministerio da Saude (Ministry of Health, MISAU). VillageReach had painstakingly built up a dedicated supply chain that brought together improvements in human resourcing, transportation, cold chain and logistics management information to reliably improve the uptake and effectiveness of childhood immunizations for one of the poorest and most under-resourced provinces in Mozambique, Cabo Delgado [1]. This innovative approach to the immunization supply chain had undergone a rigorous external evaluation, which had revealed a significant increase in routine vaccine coverage in the province during the period of VillageReachs intervention (Kane, 2008). With urging from MISAU, and the infusion of unrestricted funding, VillageReach had embarked on an effort to push the DLS toward national scale, and, for the previous three years, the organization had begun to roll out the DLS to three additional provinces in Mozambique. At the same time, with the support of other donors, VillageReach had embarked on a series of additional innovations, including a mobile health platform (Health Centre by Phone) in Malawi and an open-source logistics management information system ( These innovations were still in the pilot stage, and their effectiveness had not yet been proven. The DLS expansion to four of 10 Mozambican provinces upon which the organizations reputation had been largely staked had now drained the nonprofits precious unrestricted funding. It was clear that to continue on the path toward national scale-up would require different organizational capacities as well as additional funding. But there was no clear funder in sight. The Leadership Team needed to decide whether to continue the national scale-up of the DLS, or leave the project behind in pursuit of the other innovations that were in pilot phase. The two new projects Health Centre by Phone and OpenLMIS would bring in much-needed funding and allow them to continue on their path as an innovator in last mile health systems. However, walking away from the national rollout of the DLS would leave the programme in jeopardy as there was no clear partner to take on the national scaling of the programme. Ultimately, Wilcox wanted a decision that would allow VillageReach to have the greatest impact for the underserved communities seeking quality health care. After Wilcox posed the question to the team, he gave them a few minutes to consider their positions before asking for a response. He knew that there were very strong opinions around the table. Regardless of the outcome, Wilcox knew that they needed to make their decision quickly, as their current reserve of unrestricted funding would only cover them through the end of the year. The expanded programme on immunization The historical record shows that the development of vaccines has consistently involved sizable doses of ingenuity, political skill, and irreproachable scientific methods (Stern and Markel, 2005). VillageReachs DLS was an initiative within the WHOs EPI, one of the largest global efforts in public health that the world had ever undertaken. S The implementation of EPI required numerous components including a cold chain logistics system, vaccine transport and distribution routes, health worker training, community advocacy, and systems for data collection. With the acknowledgement that rural access was one of the primary challenges, public health experts were seeking solutions to strengthening rural health systems. Furthermore, newer and more expensive vaccines were being introduced into national regimens; yet, poorer regions had markedly lower coverage rates of these newer immunizations. This disparity was largely due to delivery systems rather than availability and affordability of vaccines. While the technology supporting the creation, testing and procurement of vaccines was world-class, the corresponding infrastructure for delivering life-saving vaccines in low-income countries was often woefully inadequate (Chokshi & Kesselheim, 2008). This was no easy task. The transport and storage of vaccines required a cold chain logistics system that keeps the vaccine supply at a consistent temperature of 2 to 8 degrees Celsius through transport, storage and usage. In poor countries like Mozambique, sporadic electricity, unreliable communication, bad roads and lack of vehicles created numerous hurdles to keeping vaccines cold. At the same time, high staff turnover and insufficient technical personnel made it nearly impossible to create effective systems that sustained any meaningful impact for the majority of their populations. It was clear that EPI needed new solutions to reach the Final 20, or the final 20% of the population in need of vaccines. Therefore, organizations such as VillageReach, which served the most rural and underresourced health systems in the world, were instrumental to the success . He therefore conceptualized the idea of creating a social business that could fund the delivery of vaccines. This concept was piloted with a social business called VidaGas, which distributed propane gas in rural communities where the electrical grid was not available to power the immunization cold chain. While VidaGas was fairly successful commercially, providing part of the infrastructure needed to support vaccine delivery in northern Mozambique, by 2007 it was clear the business needed any available profits to grow and achieve commercial scale. VidaGas could not reliably subsidize the funds needed to support vaccine distribution and VillageReachs investment capacity was understandably limited. In the absence of revenue from VidaGas, VillageReach had to rely exclusively on other funding sources [3]. VillageReachs dedicated logistics system With the creation of GAVI in 2000, and funding increases for immunization programmes worldwide, countries struggling to achieve immunization coverage rates of 80% or more were given greater attention and support. When VillageReach began operating in 2000, it was an opportune time to propose a project to reach the rural and underserved villages in Mozambique, with low immunization rates and poor delivery systems. Mozambiques health system consisted of 10 provincial health directorates, 144 district health facilities and 1277 clinics (Ministry of Health of the Government of Mozambique (MISAU) 2011) [4]. The aim was to use existing infrastructure and transport conditions in Mozambiques Cabo Delgado region, but improve the sophistication, reliability and efficiency of the supply chain. At the outset, VillageReach realized that while most programmes seeking to improve immunization coverage focused on incremental changes to existing supply chains, they believed it was essential to reconsider the entire supply chain system as a whole. Drawing on modern, private sector techniques, the VillageReach team redesigned the immunization supply chain to optimize the components based on available resources for performance and cost. VillageReachs DLS approach was simple but innovative. Prior to the DLS, vaccines were delivered from the national to provincial to district storehouses, but the final trip from district to clinic required clinic staff to take time off from their duties to retrieve vaccines. During these trips, clinic staff would close their clinic and use their own funds to take public transport to pick up the vaccines. If clinic staff were unable to front the transport fees collect vaccines, clinics would experience a stockout and be unable to provide vaccinations to patients. Furthermore, clinic staff were often not trained in vaccine storage and transport, and vaccine supplies were often compromised by lack of reliable transport or faulty clinical equipment for cold storage. Problems with logistics created stockouts and the resulting lack of care frustrated patients, particularly in rural areas. Many health clinics within rural areas were situated far apart and most patients had to walk long distances to access health care, only to be turned away when vaccines and other medicines were not available. This created a lack of trust and a further breakdown of the system. VillageReachs Country Director for Mozambique, Leah Hasselback, described the issue with trust: The biggest issue with inconsistency in vaccine distribution is the loss of relationships with mothers and the distrust in the system. The primary change was to introduce a new, full-time field-level role, the field coordinator, who would be responsible for vaccine delivery, data collection and routine maintenance of cold storage equipment. This coordinator was trained in basic procedures to resolve problems, while also given authority to make decisions based on on-the-ground circumstances. By adding a new cadre of worker into the system, the DLS addressed one of the primary bottlenecks of the system: lack of accountability. Additionally, the DLS introduced routine data collection through an open-source, webbased logistics platform that allowed for data visibility and access. It was also important to monitor temperature control, so that the cold chain was not compromised throughout transport and storage. Data was crucial to the supply chain process, allowing appropriate and timely procurement of vaccines, as well as real-time decision-making and continuous improvement through key performance indicators. Finally, the DLS allowed for better transport options, including third party transport from the private sector to augment the use of government vehicles. Although there were some within the organization who objected to outsourcing a key function such as distribution, where an opportunity to connect with the health workers was potentially lost, this decision ultimately provided more time and capacity for EPI staff to spend on training and implementing other elements of the immunization programme. Among communities served by health facilities benefiting from the project, knowledge of, trust in, and use of health services increased. As field coordinators became a more consistent presence within the communities, so the knowledge of and trust in the government health services increased. This trust was evidenced by greater participation and lower drop-out rates in vaccination programmes. Judja-Sato knew VillageReach, as an organization, needed to mature beyond its initial pilot project phase. With so much at stake, he needed to find a new leader to take VillageReach to the next level. The independent evaluation of its pilot project in Cabo Delgado province was underway, and the results coming in were dramatic. Cabo Delgado was a province located 1,450 kilometres north of the capital city of Maputo, with a population of 1.5 million people. When VillageReach began its work in the province, less than 70% of children under five years of age had been fully vaccinated against childhood disease, all of the 90 clinics experienced frequent stockouts of critical vaccines and medicines, and poorly trained EPI workers spent up to 50% of their time struggling with logistics and equipment maintenance. The evaluation revealed that by the end of the project, stockouts had decreased from 80% to less than 1%. As a consequence, the percentage of children Cabo Delgado receiving the full treatment of vaccines had increased from 68% to over 95%, all at a 20% reduction in the cost of operating the vaccine supply chain. These impressive results seemed to prove that under-resourced health systems could, in fact, be improved to reach far greater numbers in their vaccination efforts. Informal engagement between coworkers across provinces had commenced during its pilot phase and the newly identified provinces EPI officials were familiar with the VillageReach logistics system and focus could be given to training. As it had done in Cabo Delgado, the DLS produced impressive improvements in the vaccine delivery systems in the three new provinces. In Gaza and Maputo provinces for example, the government ran the DLS with limited support from VillageReach and were now consistently operating with stockouts below 5% and cold chain uptime over 90%. However, global and national EPI policies still needed to be changed to allow MISAU to implement the DLS nationally without risking bilateral and multilateral donor support for its EPI programme. Provincial health systems required extensive technical support and capacity building from VillageReach and FDC to incorporate the new approach into their existing supply chains. In addition, the upfront cost to transition to a new supply chain model nationwide was prohibitive for MISAUs budget. In 2012, the health expenditure per capita for the country was just $30.61, with only half of this spending coming from government sources (World Bank, 2020). Unfortunately, VillageReach was quickly realizing that they did not have enough unrestricted funding to continue the national scale-up without commitments from a larger donor. The GiveWell funds which were a one-time event were quickly dwindling, and there was no new funding partner in sight for the DLS. It was clear that supplementary funding from donors would be necessary to complete the national implementation plan. openLMIS VillageReach also started OpenLMIS, a global initiative to provide an open-source logistics management information system software for health supply chains in low-income countries. VillageReachs partners in this project were high profile and committed health systems funders and implementers, including the US Agency for International Development (USAID), PATH and John Snow Inc. OpenLMIS was potentially transformative for health systems, capturing and providing critical health data at all levels of health systems, ensuring optimal supply of essential medicines and equipment.

Questions:

1. Discuss resourcefulness and innovation in relation to the VillageReach case study, concluding on one type of resourcefulness like Bricolage or innovation such as Jugaard at VillageReach.
2. Explain what type of social capital founder had in the VillageReach case study. How did this type of social capital affect VillageReach. Recommend actions or practices that YES could adopt to overcome any limitations identified.
3. Drawing on the theory discussed during lectures, explain the factors that enabled and constrained Village Reach to grow their venture. Draw only on information mentioned in the case study