On a hot April morning (in 2023), a team of 21 gathered at Cameroon's Regional Delegation of Public Health of the North and Far North Regions. For the next week, they will leave behind their homes, families, and jobs as epidemiologists, pharmacists, statisticians, logisticians, and other public health professions to visit health facilities in Cameroon’s North and Far North regions, where malaria mortality rates are at their highest. Once there, they will collect data to determine if critical commodities to prevent and treat malaria–Cameroon's most widespread endemic disease–are available to the people who need them most.
The team’s mission: to facilitate the End-Use Verification (EUV) survey by collecting quantitative and qualitative data on malaria commodities from health facilities scattered throughout these populous and predominantly rural regions. The activity was funded by the U.S. President’s Malaria Initiative (PMI) through the USAID Global Health Supply Chain Program-Procurement and Supply Management (GHSC-PSM) project, as part of initiatives to strengthen the supply chain management for malaria commodities in Cameroon.
“It [the EUV] makes it possible (enables informed decision-making) to make the product available until the last mile. It is the patient who is the main beneficiary at the end of the chain.”– Edia Marcelline Nnana (Data Collection Team Member)
In Cameroon, the entire population is at risk of malaria–with over 2.7 million cases reported annually. Cameroon is among the 11 countries that carry 70 percent of the global malaria burden - access to malaria commodities is essential. The EUV survey asks two crucial questions: Are malaria commodities available where they are most needed? If not, what are the root causes for stockouts?
The Cameroon Ministry of Health can use this EUV data to monitor the availability of commodities and improve supply chain management processes. For PMI, the data informs in-country operational plans and helps identify high-impact interventions for the sustainable reduction of stock-out rates. This, in turn, can help ensure essential malaria products are available in the communities with a high burden of malaria, wherever they are located.
“It [the EUV survey] (leads to actions that) allows the patient to have medication at the right time, in the right place, and under the right conditions.”– Douryang Ressong (Data collection team member)
The team traversed over 13,468 kilometers collectively to reach remote health facilities.
“[I learned] endurance, patience in the face of geographical accessibility difficulties."– Dr. Fatima Aicha Dandy (Data collection team member)
Overcoming Obstacles
To complete their assignment, the EUV data collectors overcame security challenges and difficulty accessing hard-to-reach locations, knowing that the information from the survey is a crucial step to ensure essential malaria commodities are available in these hard-to-reach communities.
Areas with security concerns were excluded from previous EUV surveys, resulting in a lack of real-time data on the availability and use of malaria commodities. GHSC-PSM worked with the NMCP to identify new selection criteria for recruiting data collectors, including a good understanding of the local areas, being district/region and/or site-level MOH personnel, and willingness to work in hard-to-reach areas.
The project took steps to keep the team safe, and if there were areas that were too dangerous due to security concerns, the team did not go there. They alerted village chiefs and the military to ensure they were on the lookout when the team was traveling in the region. The military advised additional security precautions, including driving in a caravan and observing a strict curfew. All of the data collectors remained safe throughout their journey.
“The EUV 2023 has made it possible for me to come to an area where there has never been any supervision.” Dikla Mai Michael (Data collection team member)
The Long and Rocky Road
The mostly dirt roads and the rural landscape meant vehicle repairs were likely along the journey. Many kilometers away from the nearest repair shop and often the only vehicle in sight for hours, vehicle breakdowns were another challenge that the group overcame.
Water Everywhere
Adding to the challenges, the team conducted the EUV survey during the rainy season, during which the number of people diagnosed with malaria is five times higher than in the dry season. The rains brought a cascade of logistical challenges. With an average of 60 inches of rainfall each season, roads flooded, washing away hopes of easy access to rural regions.
“We drove to the health district to establish a connection with the responsible authorities, but just a few kilometers from there, we got stuck in a muddy area, and it took us approximately three long hours to navigate our way out.”– Dr. Abamou Minkoh (Data collection team member)
“Our car got stuck in the bed of a stream...Without the invaluable assistance of the local community, we would have remained trapped in the muddy quagmire indefinitely.”– Salvador Tala (Data collection team member)
GHSC-PSM was constantly in contact with the data collectors throughout their journey, documenting all incidents of vehicle and road problems and the solutions. The team on site often turned to the nearby communities familiar with the local terrain to help them get cars out of ditches and mud, locate usable tires, and identify alternate routes where the roads may be in better condition. When vehicles couldn't be repaired, the team reverted to alternate transportation modes, including motorbikes, walking, and hopping on animal-pulled carts.
“To get to the health area of Zagara, we insisted on taking the car to Fadare. Getting there, we found that cars could not get there. So, we rented a motorbike that was in charge of accompanying us to the site, to try to work quickly.”– Dikla Mai Michael (Data collection team member)
Despite the challenges of the journey, the team was determined to complete their assignment, knowing that the information they provide is an important step to ensure these hard-to-reach communities have essential commodities to protect them from malaria, and also support the long-term efforts of Cameroon's Ministry of Health to reduce malaria.
Why the EUV Matters
Health supply chains are complicated systems involving hundreds of people, and for the supply chain to function well, they all need to be connected. Data is the connective tissue binding the entire supply chain together. When data is good, timely, and accessible, supply chain actors can make informed decisions about when and where stock is needed to plan for sufficient supplies and prevent a stockout. While health facilities regularly collect and share commodity data, they are often of low quality (the data quality assurance survey conducted in these regions in 2022 indicated that data accuracy was only 43 percent). This hampers decision-making and leads to stockouts and expired products remaining on shelves.
The EUV allows the Ministry of Health and other supply chain stakeholders to examine what is happening locally and why the data is inaccurate. It establishes missing stock statuses, provides data to triangulate malaria commodities, and identifies missing data, stock management challenges, and the reasons for stockouts from the local perspective. This information informs health supply chain strategic planning and staff training.
“The EUV survey conducted in 2019 recommended that data quality assurance (DQA) surveys be implemented with a focus on root cause analysis for poor data quality. The EUV survey helped identify high-impact activities including DQA surveys, the implementation of which improved the percentage of health facilities having all four formulations of artemether-lumefantrine (Alu) (anti-malaria medicines) from 14% in 2018 to 96% in 2023 (based on the EUV surveys).”– Catherine Mentou Tadzong, Senior M&E Advisor, GHSC-PSM
“This survey ensures good management of antimalarial inputs in each facility of the districts, but also creates a climate of effective communication between the actors of the district, the actors of the facility, and the beneficiaries.” – Bouba Samuel (Data collection team member)
EUV Survey Accomplished
Through their unwavering dedication, the data collectors visited 117 health facilities in 30 districts.
Since the implementation of the EUV survey, the average stockout rate of Alu, one of the most preferred artemisinin-based combination therapies (ACT) for the treatment of malaria in the North and Far North Regions, dropped to an average of one percent in 2023–down from an average of 57.8 percent in 2018, while the percentage of facilities having all four forms of Alu improved from 14% in 2018 to 96% in 2023 (based on EUV survey data). Based on EUV findings, GHSC-PSM trained staff in all PMI focus regions (North and Far North) on stock management, monitoring, and supervision of supply chain activities. Stock cards were provided to health facilities that could not afford them to improve reporting. The project also collaborated with the Regional Delegation of Public Health for quarterly district-level supportive supervision visits to increase their supply chain and data management skills.
“Personally, it was an honor to participate in the EUV [survey], which allowed me to find ways and means to overcome the difficulties encountered by the nursing staff and on the professional level to contribute through this survey to the improvement of the health of the populations.”– Dr. Avom Joel (Data collection team member)
By participating in the EUV survey, the data collectors gained new skills; sharpening their knowledge and developing solutions to challenges experienced by local staff during routine data collection.
"It has allowed us to see and solve the realities and problems on the ground in other districts and has allowed me to take the same approach to solving the problems of my district."– Dr. Abamou Minkoh (Data collection team member)
GHSC-PSM and the EUV survey data collectors understand the power of collaboration, teamwork, and reliable data in the fight against malaria. Through their resolve, Cameroon can move closer to being malaria-free.
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