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MDA experiences from Mozambique

Watch Sharone Backers talk about her experiences planning and coordinating mass drug administration for the elimination of trachoma in Mozambique.
Daksha Patel: Hello. Today we are joined by Sharone Backers who works for ENVISION in Mozambique. Hi, Sharone. Thank you for joining us on Skype today. So from your experiences, where does one start when you have to reach out to a community to make them understand and accept mass drug administration.
Sharone Backers: Well, when we’re looking at the district level in an MDA, we really need to be looking at who the key partners are at that level. So normally, we need to be looking at the key leaders who are community leaders, elders, other partners that are in the area. But specifically to engage with the leaders, the community leaders. And they can be anybody who just has the positioning in the community that people will listen to and listen to their advice as well. So really, social mobilisation as part of talking to the leaders is really, really crucial and important.
Also so we need to make sure that the district level ministry is on board and that they understand that the partners are there to fully support them in the MDA. There are many layers to an MDA. It’s really a lot about planning and communication as well. As part of the MDA, I think a bonus is also if the communities can be better educated about trachoma and ways to prevent it from forming in the future.
Daksha: So it’s fairly evident that you can’t just simply turn up at a community and start distributing the drugs. Can you give us an example of the types of challenges that you have had to face in delivering MDA?
Sharone: In the case of Mozambique, last year actually we had an example in one of the northern provinces whereby the MDA was actually confused for a political campaign. And it was at a time where most of the country was undergoing some political tension. So it was actually quite complicated in the sense that we arrived fully equipped. And we arrived ready. And there was one particular district that was, there were– well, especially the people were scared to come out of their houses because they thought it was going to be something political.
And so it took a lot of going and taking a step back and really talking to the leaders again and talking to the community, talking to their health technicians and the health workers to help them to help the communities to understand that the MDA had nothing to do with anything political and that we were here on the basis of health. So you’re always– you know, I think it’s normal to encounter– depending on the country, depending on the region, political beliefs, cultural beliefs, social beliefs. And you always have to be prepared– and I think with a very open mind– the best way to deal with a situation as it comes up. In the end, it was fine. And we went back.
And we had people there to take the job. So it worked out. But you always have to just be prepared that people– especially in districts– may not be as well-informed. And it takes that little bit more work than it would maybe in a province. So it’s all about communication again and making sure that the right messages get across beforehand and, if needed, reinforce them while the MDA is taking place.
Daksha: MDA is clearly a complex activity often across difficult terrains. Can you talk us through the process that needs to take place from receiving the drugs to ensuring that they are delivered to these communities that require them?
Sharone: So getting drugs the drugs to the communities is definitely a long process and one that needs really careful planning. So the planning goes from them being imported from outside the country to the country, from the capital city to the provinces, and then from the provinces to the districts. So there is a line. And there’s a lot of steps to follow. Depending on the country– each country is different– but Mozambique, for example, has quite rigid importation for drugs. So it takes time. So planning is key. You need to give yourself enough time from the time that the drugs arrive in the country.
Here, we need to give us about a month before we can get back out again and back to the districts. So it’s really a complicated process. But with careful planning, these are the times that you sit down with the ministry. And you really work together to plan how long each trip will take and how many drugs can fit on one airplane, how many drugs can fit on a truck or on a boat, whatever you need to do to get them, whatever means. You have to find them. You have to be very flexible in your way of thinking as well. And there’s always challenges. That day there may be no planes. Or they’re too small to take them on.
Or the roads aren’t good. Or the weather’s not good. So bridges are not OK to travel across. It doesn’t matter. You just have to be so open in your thinking and flexible because, at the end of the day, what is needed is for the drugs to get to the district level. So I would really emphasize at this point the planning from the very beginning to the very end with the ministry is essential.
Daksha: MDA programmes depend on partnerships and planning. What would be your key tips for success?
Sharone: So I think after every MDA, I think it’s really important to take stock of how that MDA went. Not only in terms of coverage, but also where each phase is of the MDA to the maximum. I’m talking and making reference specifically to social mobilisation, where that is such a crucial, crucial phase of an MDA. Because that happens just before the MDA. So lessons learned are super important to engage with and really reflect. You can’t assume that just because one year, there’s high coverage– participation is fantastic, the drugs arrived safely, that everything went well– that it’s going to be the same next year.
You have to really take in stock that every campaign, every MDA can be different, has its own set of challenges. And you have to really learn from those lessons. So if something didn’t work really well, ask yourself why and then try build on that and not to make the same mistake twice. So really engagement and information, engagement with the community leaders, engagement with the ministry at all different levels, putting time also– if you use IEC materials– putting time into those. It’s really important that people take away something from a campaign.
They may look at the poster, for example, and you want to know that they’re actually understanding– if it’s not by words, then by images– that they’re understanding the process of why they are there particularly. The population is important. And that’s who we’re trying to reach. So we want to make that they are engaged and are able to be a little bit more informed by the end of the campaign. But also we make sure that we have a meeting at the end of each campaign. And that’s just a restock of how the campaign went from the start to the finish. And then that determines changes you need to make for the next year.
Daksha: Sharon, can you describe your role in the MDA programmes in Mozambique?
Sharone: Sure. ENVISION is here to support the ministry. Our main focus is trachoma. So we provide clinical support, financial support. And we really want to make sure that the MDAs are a success. So that means the highest coverage population that is possible. A campaign free of incidents. The drugs are there. The drugs are in the right quantities. The people are well informed before the MDA so they do turn up. And again, planning with the ministry is one of our big roles. And then we also have relationships with ITI, the International Trachoma Initiative who donate the drug Zithromax. So it’s a chain of partners working together. And I think that’s where you get success.
If you have a good relationship not only with the donor of the drug but also with the ministry and then with other maybe local NGOs where you’re working, with national NGOs, if you have that relationship and you can build on that relationship, then the MDA is more likely to be successful. Because it is a complex activity. And we want to make sure that we are reaching everyone that we can reach, even the hardest to reach populations. So planning and dialogue with the ministry, communication, troubleshooting problems, learning from problems, having solutions for various incidents also. So it’s definitely a partnership. In MDA, nobody can do an MDA on their own. It’s a partnership. And the ministry owns the MDAs.
So we need to support them. I think you’ll find a lot of partners that we’re simply here to support and provide the best possible support for the ministry. They are at the heart of the campaigns.
Daksha: Thank you, Sharone, for sharing your experiences with us today.
In this step, Sharone Backers, Country Representative for RTI International, talks about her experiences planning and coordinating MDA in Mozambique.

Sharone works as part of ENVISION, a global project funded by the US Agency for International Development (USAID), which works in partnership with ministries of health to control and eliminate seven neglected tropical diseases.

MDA programmes requires a wide range of partners

They work together to:

  • Manage, deliver, store and distribute donated drugs

  • Mobilise the community and ensure people and leaders understand the benefits of MDA

  • Liaise closely with the health ministry

The MDA supply chain is adapted for the local context and co-ordinated by the national programme.

Stages of the MDA supply chain

  • Confirmed allocation of donated azithromycin shipped from international warehouses

  • Shipment arrives in country

  • Receipt and customs clearance at the port of entry to country

  • Distribution and transport to regional and district storage facilities

  • Distribution and transport to health centres and health posts

At each point in the supply chain, information on the action being carried out is updated and communicated. Full visibility on shipments from the International Trachoma Initiative is now provided with the Zithromax® Shipment Tracker.

MDA supply chain: Times for the drugs to flow from central warehouse through several stages to the beneficiaries (~11-26 days) and times for the information to flow back (~14-42 days (Click to expand)

Tools used to manage the supply chain

  • Contact tree: Contact information on each person receiving the drugs during distribution and transport

  • Excel sheets: Logistics information with the date, location and quantity of drugs and which transport carrier is responsible

  • Inventory lists and stock cards: Information on the storage and transfer of drugs from warehouses, and on damaged cartons and expired drugs

As you watch the interview, consider why a reflection meeting at the end of each MDA cycle each year is so important.

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