MEDA Blog - Stories from the Field

Numbers Are Deceiving

Days out of office with the field staff are a good break from sitting in front of a computer all day. I enjoy seeing new parts of the city of Dar Es Salaam and viewing people going about their daily lives in this ‘Haven of Peace’. On field days with Kapaya and Gabriel the experiences are always unique and differ from the previous drives. I have visited more than a few dukas (shops), kliniki (clinics), and hospitali (hospitals) around Dar in districts of Illala, Kinondoni, and Temeke. I have quickly discovered some of the struggles, and issues with the current voucher system/health care system in place. As well as encountered the deceptive progress reports which are examined and shown to clinic staff. A few trends I have noticed are:
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1. Overworked staff. After regular kliniki (clinic) hours, only doctors may be working, and they don’t have enough time to hand out the TNVS voucher’s to women so they often write down their names and number and the nurses then have to give them the voucher on their second, or third visit. This translates to a time problem with the nurses, who along with their other duties have to catch up on the paperwork from past patients: fill in the MEDA logbook with the Hati Punguzo net sticker and information, write down the Hati Punguzo number on the Antenatal Card, and check off that it was given to the patient.

2. Problems with competing bed net companies.  The two main suppliers of bed nets are A-Z and BestNets. On one occasion, we encountered a situation where the retailer wanted a certain type of net, and ordered it but there was no stock with the original supplier (who had the contract). The other supplier wanted to deliver nets, but a contract was already in place. The duka had already confirmed to receive even though they were not yet delivered. The result of this situation is that TNVS insisted the supplier not to confirm delivery before the duka (retailer) actual received the bed nets. The delivery is still pending.
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3. Potential for new duka contracts. One observation I noticed on a few occasions was the doctors and nurses at the kliniki (clinic) being helpful in offering new, more reliable, and closer dukas to sell the bed nets to patients. On one occasion we walked with the doctor to a very close duka to see the progress of their start up into the TNVS program. The retailer had been contacted by a supplier to sign a contract for bed nets, but hadn’t received a shipment yet.

4. The above situations lead us to the problem of stock. Often times there are more than enough vouchers and e-vouchers being given out to patients but when the customers go to the dukas to purchase the bed nets they are out of stock. With only two suppliers with operations in Tanzania, and a very large country to cover and service, often times there is an issue either getting the bed nets to locations with drivers, or keeping up with the amount needed to service the clients. This creates a problem of a want for more dukas involved in the program, but not enough stock to maintain them. Thus, the need for more suppliers and competition between suppliers, which will bring down the price of the net, and allow stock to be maintained and readily available. As well, a solution might be if stock had to be ordered far in advance, then maybe availability issues could be avoided.

5. As well the quality of the bed nets from the suppliers may differ. While all companies b2ap3_thumbnail_Showing-a-nurse-how-to-send-the-SMS-messages.png
bed nets in the program are insecticide treated already, a user may have a preference for a type of net which may be out of stock. Also, most nets aren’t designed to last forever, and instead only last up to five years. At the start of the program the mother may obtain a second bed net for their child as well as herself. If the mother becomes pregnant again she may gain another net for herself as well as her 2nd newborn child and so on.

6. Another issue is education of SMS, texting, shortcodes and phones. While most clinics and hospitals have staff that are well-versed in using a cell phone and its functions to report info to suppliers, there are a few holdouts. One kliniki we visited we had to educate the nurse to show her how to use her phone to SMS the supplier on bed net numbers. This is why the pamphlets and paper leaflets given to the duka owners and kliniki staff are a good tool to educate about the program. In some isolated cases repetition of SMS demonstrations is the only way to proceed. You have to have patience, especially with a generational gap with respect to technology, cell phones, and their use. Sometimes, a helping hand is needed to learn.

7. Dukas playing their part. Dukas writing the numbers of the nets handed out in the log book (which sometimes doesn’t exist if they haven’t made one) and putting the net sticker in as well for confirmation in the MTUHA (Mfumo wa Taarifa za Uendeshaji Huduma za Afya) (record book). It is important for dukas to keep records, and be educated on the importance of being organized for the program. After all, they are benefiting from the process with profits and need to keep up their end of the bargain.

8. Cell phone network issues, and signal problems. Often times different cell phone b2ap3_thumbnail_Showing-a-duka-worker-how-to-organize-a-log-book.pngcompanies (Airtel, Tigo, Vodacom, Zantel etc.) have different reception problems in rural communities and one might work better than another in an area.  Investment in updating and providing larger cell coverage is key to the success of the e-voucher system. Also it is cheaper to SMS in multiple Hati Punguzo net numbers together in one message. This info could be compiled for a while, and thus reporting numbers may be off if the duka waited too long to report. It is not hard to figure out that if these problems exist in the large urban city of Dar, then they will be highly heightened issues outside in the rural areas.

All of this translates to much lower reporting percentages and number for kliniki (clinics) and hospitals for how many vouchers are being sent out to women and children and the redemption rates for them. A large factor is motivation. The workers and field staff at MEDA Tanzania needs to make sure all of the suppliers, duka owners, clinic staff, nurses, doctors etc. know how they are making a difference and helping save lives every day by completing and maintaining their part in Hati Punguzo.

An idea of providing a specific phone for each clinic to use has been thought of and mentioned a few times, as whose phone do you use for SMS messages? This is a difficult question, as there may be four plus nurses working on the program. An idea of a specific phone to be used for SMSing voucher codes might make sense, and be affordable for a larger clinic or hospital, but wouldn’t work in smaller cases. Whose talk time minutes do you use? Or, do you use those minutes to SMS a supplier about bed nets or call your family and children? A moral dilemma in some cases.

Data shows significant achievements in the fight against malaria in Tanzania after Hati Punguzo was introduced, with the infection of under-five year olds declining to 10% from 18% in 2008. (http://medatanzania.org/) Also, the number of patients attending health facilities to seek treatment has increased since then. In July 2013, in the Dar Es Salaam region most clinics averaged about a 70% redemption rate for vouchers from the kliniki to the dukas and to the user.

Even though some of the kliniki, and hospitali redemption rate numbers are low due to several issues explained above, the fact that the MEDA TNVS program is making a difference in pregnant women and children’s lives and helping them from falling ill to malaria is incredible. This is a far more important fact than any number or reporting figure!

Ninapenda Kula Chakula!!
Karibu Tanzania

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