Case Study: Tuungane Project in Tanzania - Reaching Clients at the Last Mile
Publication date: 2017
Case Study Tuungane Project in Tanzania: Reaching Clients at the Last Mile The “Last Mile” is a term used to describe how products make their way to the point of distribution. In terms of reproductive health, the Last Mile is about getting life saving contraception to a community-based health outlet, and then into the hands of clients. The Last Mile is the most fragile part of the supply chain because it depends on transportation, adequate supplies, trained health providers, and a host of other factors. For a number of reasons—from transportation breakdowns to stockouts—the Last Mile represents an important challenge in ensuring access to reproductive health supplies for all. Addressing these barriers is a crucial step towards reaching health equity and universal health coverage as outlined in the Sustainable Development Goals.1,2 For the remote and rural villages around Lake Tanganyika in Western Tanzania, there are a number of Last Mile challenges, including lack of transportation and little access to health services or modern contraception. In addition, these communities face a number of environmental barriers, such as lack of clean/safe drinking water and a declining fish supply due to forestry sediment. The Tuungane Project was designed to overcome these varied challenges through an integrated approach, addressing environmental and reproductive health issues simultaneously. Working at the Last Mile, this project and has successfully provided contraceptive supplies to thousands of women and men over the last 5 years. This case study outlines the barriers, successes, and lessons learned from the Tuungane Project that can be helpful for others looking to reach clients at the Last Mile with crucial reproductive health supplies. Photo: PATHFINDER INTERNATIONAL | Sala Lewis 1 http://deliver.jsi.com/dhome/whatwedo/supplychainsys/scsyslastmile 2 http://www.villagereach.org/wp-content/uploads/2011/12/UsinLastMileDist.pdf Tuungane Project - Strategy for Reaching Clients at The Last Mile The Tuungane (pronounced TOO-un-gah-nee, Kiswahili for “Let’s Unite”) Project serves the villages around Lake Tanganyika. Focusing on Population, Health, and the Environment (PHE), the project supports maternal and reproductive health as well as conservation efforts, to create healthier families, fisheries, and forests. Implemented by Pathfinder International and The Nature Conservancy, Tuungane also engages with other stakeholders (including Frankfurt Zoological Society, Jane Goodall Institute, Tanzania National Parks [TANAPA], Tongwe Trust, and the Government of Tanzania). “The project started with no clients, and has since reached about 17,000 clients with family planning counseling and access to modern contraception, through male and female locally trained community health workers. In this region, the birth rate is one of the highest in the world, with over 7 births per woman. While some women want larger families, many women are looking to space or limit their births. Since 2012, Tuungane has served 24 hard-to-reach communities around Lake Tanganyika: The project started with no clients, and has since reached about 17,000 clients with family planning counseling and access to modern contraception, through male and female locally trained community health workers. They are also leading upgrades to health clinics, which are dramatically reducing maternal and neonatal deaths in the region. Tuungane’s strategies for reaching clients at the Last Mile has consisted of a community-based system of distributing family planning supplies, primarily condoms and pills. (Clients are refereed to health facilities for other methods, including long-acting methods.) The project also supports transportation of commodities throughout the villages. The integrated approach has allowed Tuungane to address communities in a holistic way, with intensive campaigns focused on positive change. Tuungane’s Challenges and Breakthroughs Although the project has seen a number of successes, there are still barriers to overcome. For example, the districts are meant to maintain the supply chain, but requests are often delayed, leading to stockouts. This lack of commodities can be a major setback in the program, and can lead to unintended pregnancies among clients waiting on contraceptive supplies. To address this issue, program staff communicates with the district health office frequently. This frequent contact is important, as the program staff would have the opportunity to ask the district health office to bring in supplies, notify them when there were stockouts, and discuss transportation of supplies. To make sure there is a buffer of supplies, Tuungane staff often transports supplies to the remote villages themselves, but that is clearly not sustainable. One main issue is that the Medical Stores Department does not have all the methods available at any given time, despite being the sole supplier of all drugs and medical supplies (including contraceptives) to all health facilities in the country. The Tuungane Project has thus been advocating with the district to use other sources or raise revenue specifically for the procurement of FP commodities to maintain consistency in supplies. To allow the district to follow up and control supplies adequately, Tuungane staff submits a supply requisition through at the dispensary/health center level. This passes through the District Pharmacist to the Medical Stores Department (MSD). The request will be processed Photo: PATHFINDER INTERNATIONAL | Sala Lewis by MSD and the requested commodities will be delivered directly by the MSD to the facilities. Tuungane staff first contacts the district, and if the district does not respond, the staff approach the regional health office. The project also attends annual meetings between the MSD and districts, in order to advocate for reproductive health supplies. Last Mile advocacy efforts are dependent on supportive leadership and government officials. Tuungane deploys community-based advocacy tactics to garner support. It can take time to cultivate relationships with decision makers, but these activities ensure community support and understanding of the integrated program. Another strategy the Tuungane Project employs to advocate for contraception has been community engagement. The project encourages community members to raise their voices and seek accountability. They conduct community scorecard activities, during which communities provide feedback about the services received, and they can raise their voices to advocate for more supplies and discuss priority issues when meeting with health providers about the scorecard responses. They have also been inclusive of all community members, including men and youth in their reproductive health programs. Involving the community-at-large and emphasizing the long-term health of communities (with regard to both conservation and reproductive health) has helped the program staff develop creative strategies for reaching those at the Last Mile. For example, young men, many of whom are fishermen, have been present during information sessions about both conservation and reproductive health which are presented at the same time. This has made them more likely to be informed and engaged in reproductive health decisions as well as conservation efforts. Conclusions & Recommendations The Tuungane Project represents an example of a successful and strategic partnership that has worked to overcome numerous barriers to ensure that contraceptive supplies reach people at the Last Mile. Tuungane staff recommend the following steps for others working to reach clients at the Last Mile: › Involve the district government from the start. Target decision makers to ensure support, as these leaders are key in maintaining the supply chain. › Involve a wide variety of stakeholders within the communities. Those who understand the community can ensure broad reach and distribution of supplies. › Cultivate a committed, dedicated staff. Make sure that staff are empowered to address stockouts and ensure smooth distribution of supplies. Have a backup plan (for example, if the district does not respond, contact the regional office). › Involve men and boys in community activities. Recognize all community activities as an opportunity for messaging around the benefits of contraception. For more information on the project, contact: Sono Aibe, Pathfinder International, firstname.lastname@example.org | Website: www.pathfinder.org This brief was prepared by Sarah V. Harlan, Senior Program Officer at The Johns Hopkins Center for Communication Programs on behalf of the USAID-funded Knowledge for Health (K4Health) Project. The brief was written in collaboration with Sono Aibe and Dr. Ernest Athumani of Pathfinder International.