SPECIAL FEATURE - April 2003
Not just better healthcare, but a better life as well
An ingenious development project in northern Mozambique aims to improve health service delivery, generate income from clean fuel sales, and even free up children to do their school work. Phyllida Brown reports
BACK in 2000, after Mozambique suffered some of the worst floods in its history, a Cameroonborn businessman called Blaise Judja-Sato went to help the relief effort. What he saw profoundly affected him. "I was struck by the weakness of the infrastructure and the impressive resilience of the local people, despite the daunting challenges they faced," he recalls. He met Graça Machel, the former minister of education and Nelson Mandela's wife, and asked how he could contribute. (Graça Machel is also vice chair of The Vaccine Fund -- read her bio here.)
Judja-Sato left his job as director of international business development for Teledesic LLC, a broadband satellite company co-founded by Bill Gates, and set up VillageReach, a nongovernmental organization based in the US. In 2001, VillageReach began working in partnership with Mozambique's Foundation for Community Development and its national government in the northernmost province of Cabo Delgado to increase people's access to healthcare, while also benefiting households, the local economy and the environment.
Cabo Delgado is a remote province, some 900 miles from the capital Maputo. Incomes are minimal, roads are poor, and healthcare is basic. Almost half the population lives more than two hours' walk from a health facility, and mothers taking their children to clinic have grown accustomed to finding no vaccines in stock, no appropriate medicines either, or that the fridge storing the vaccines has broken down. A survey (1) last year in the province found that only 29% of babies had been fully immunized, well under half the average rate for Mozambique.
To address the logistical problems of the health service, VillageReach has a contract with the health ministry to deliver vaccines and medicines to clinics in Cabo Delgado. The contract, which began last year, also covers the supply and maintenance of cold-chain equipment -- mainly fridges -- and other clinic essentials such as lamps and sterilisers. And, because the central aim is to reach underserved households, VillageReach is also working with the health ministry to increase staff outreach, for example by providing them with bicycles.
But the Northern Mozambique Project, as the partnership is called, is not just about health service delivery. "We're developing an innovative model to improve lives in a number of ways for the hardestto reach populations," says Judja-Sato. Rather than define the need in terms of the health system alone, VillageReach and the Foundation for Community Development have identified a broader development need and set about meeting it.
Fresh thinking: Blaise Judja-Sato
They explored several options for generating income alongside the healthcare logistics work, such as using the trucks that deliver vaccines to return with a load of local farmers' vegetables for sale. Most were rejected as unworkable. Judja-Sato discussed the issue with colleagues in Mozambique and abroad, including Dr Michael Free, vice president for technology at the Program for Appropriate Technology in Health (PATH) in Seattle.
Then they hit on an idea: to supply a clean and reliable fuel, not only to the cold chain, but also to the community as a whole. "We were spinning ideas and this one came out of the spin," says Free. A reliable power supply is critical for the effective function of a cold-chain. Rural clinics in low-income countries such as Mozambique have traditionally run their fridges and lamps on kerosene. But kerosene deliveries can be erratic, and kerosene-powered fridges are inefficient, unreliable and difficult to repair.
Outside the clinics, fuel shortages are equally pervasive and disruptive. Most families rely on gathering firewood or buying charcoal to cook their meals, but the trees are dwindling and the bare soil is eroding. The task is becoming more and more timeconsuming, occupying hours of each day for women and children. Along the coast, people are starting to burn mangrove, but this is beginning to deplete the habitat of several species of fish and prawn that have been important to the local fishing industry. The only alternative is kerosene, but it causes many domestic fires and poisons too many young children in accidents.
Hard labor: time freed up from gathering firewood can be put to better use
"We realised that the cold chain was the central problem, but knew that we could not focus solely on that," says JudjaSato. "You have to have a comprehensive and rigorous approach, and try to bring business experience to the problem."
VillageReach and the Foundation for Community Development decided to replace the old kerosene powered fridges with new and more efficient models that run on liquefied petroleum gas (LPG), sometimes called propane. To ensure a steady supply of the gas, they have set up a company called VidaGas, a Mozambican forprofit entity, with its own distribution plant in Pemba, the main town in Cabo Delgado. The gas comes up from the port by tanker and is stored at the distribution plant, opened last November, from which it is sold to the Ministry of Health in 11-kilogram cylinders. VidaGas is also working with the government's energy and environment ministries and is now starting to sell gas commercially to households and small local businesses, such as restaurants and hotels. The profits of these commercial sales are intended to help fund the activities of VillageReach in Mozambique. And the gas will make a big difference to daily life and the environment.
Instead of spending hours gathering firewood, children can go to school and women can devote more time to education, childcare and small businesses. After dinner is cooked, the stove burner can be removed from the gas cylinder and replaced by a lamp attachment. For the first time, children can do their homework after the daylight has faded. Adults who cook dinner over a gas stove suffer fewer respiratory problems than when they cook over firewood or charcoal, and their babies suffer fewer infections. VidaGas is selling a starter pack consisting of the burner, lamp and 5 kg of gas to households for around $45. VillageReach and its local partners are setting up microloan schemes to enable families to pay for the equipment over a period.
To set up the project Judja-Sato worked with a team, including Lionel Pierre, a Haitian who has worked for years in healthcare and transport logistics in developing countries with WHO and others and Didier Lavril, a French energy expert with particular experience of working with LPG in African settings.
Critical to the success of the project was the support of Graça Machel, who is the Foundation's president. "Graça gave us the credibility and enabled us to take the idea from concept to programme," says Judja-Sato. He attributes much of the success of the project to the Mozambique government, whose role has been key. "This project would not have been possible without the government's dedication and commitment. Their willingness to try new solutions to longstanding problems is commendable and has allowed us to work quickly and effectively."
Pierre describes the "before" and "after" scenarios in the clinics. Before, fridges were ancient, maintenance was appalling, and training of users nil. Health district staff were powerless to act; technicians had no means of transport and no money to intervene where necessary. Wastage for some vaccines had been as high as 80%. Now, gas fridges are up and running in 36 initial clinics, serving some 800 000 people or half the population; this will rise to 90 when all 17 districts in the province are equipped.
The gas cylinders are initially supplied to the clinics by VillageReach, which also provides the first filling of gas. Thereafter the district health budget pays for refills, based on estimates of known consumption rates, says Pierre.
VillageReach's local staff, and government health staff, are all trained in maintaining the fridges, and spare parts are available. Training continues, and vaccine storage conditions have improved markedly and are now monitored monthly. VillageReach is also introducing equipment and procedures to improve injection safety. And the initiative includes a system to regulate the vaccine supply to avoid stockouts and wastage, through proper management.
There are wider benefits for the local economy too; VillageReach has not only trained and employed its team of delivery and cold chain maintenance workers, but additional local work has been created, for example to maintain the trucks and look after the VidaGas distribution plant. "There are jobs, more self respect, and a virtuous spiral," says Free. And, as Lavril points out, the project should combat deforestation and reduce greenhouse emissions, by reducing the inappropriate use of biomass fuels. If fewer trees are felled, he adds, there should be less soil erosion and the impact of flooding should also be reduced.
Carlos Fumo, executive director of the Foundation in Maputo, is pleased by progress so far. "The ultimate aim is to ensure that children have greater access to vaccines, and to ensure that the quality of life of Mozambican communities improves." Even the most perfectly stored and transported vaccines would be useless, says Fumo, if children did not actually get them. So he is delighted to report that the number of fully immunized children has risen by 40% in the project area in the short time since it began.
The key role of the Foundation now, says Fumo, is to educate and inform communities. "We need to make sure that there is local ownership of the programme." He is proud of the collaboration between private and public sectors.
No one pretends that the project is without risk. Can the commercial sale of the gas make enough money to sustain the project in the longer term? Can enough people afford the burner, the lamp and even the cost of the gas to make the commercial side selfsustaining? Even though it costs less to cook with gas than with charcoal, several weeks' worth of gas has to be paid for upfront, whereas charcoal supplies can be bought daily. Some families simply don't have that kind of cash in hand. "But I think this is an extraordinarily interesting, and very viable, model," says Free, a member of VillageReach's board. Free pays tribute to Judja-Sato's huge personal commitment to the project, to his networking skills in involving others and his ability to make the idea work.
Fumo does not believe that the cost of the equipment will be a significant barrier to most households. Many still use traditional fuels simply from habit, he says, and it is up to the Foundation to inform them about the alternative. "The very few people who have been exposed to this idea so far see a clear advantage in using gas instead of firewood."
Alfred Durão, former head of the Mozambican government's immunization programme and now working with VillageReach, is in no doubt about the difference the project has made so far. "There is no shortage of vaccines in the districts, and the fridges work. We have seen a good result and more vaccination of children."
The project is also attracting outside interest. "There is nothing like this in the world," says John Lloyd at PATH. "It is an extremely important piece of work." VillageReach itself is keeping a modest and cautious tone for the time being. Several governments have approached Judja-Sato and asked about pursuing a similar approach in their own country. VillageReach is definitely planning a series of other demonstration projects to ensure that the idea can work in a range of different settings. But it is not going to be rushed. The first step is to prove that the idea can work in just one province of just one country. So far, the signs are distinctly good.
References and further reading
(1) Survey conducted in 2002 by Foundation for Community Development, The Ministry of Health and VillageReach.
The Foundation for Community Development of Mozambique
PATH: www.path.org. VillageReach works with PATH to field test new vaccination technologies. The Children's Vaccine Program at PATH provided seed funding for this project.
Immunization Focus April 2003 - Contents