Continuation: The Farthest Reaches of Our Impact Evaluation

June 10th, 2013

This post is a continuation of the last update on our blog, a trip report by George Muwowo, program manager of the Riders for Health evaluation. For more information about Stanford’s work in Zambia, please visit our website.

CONTINUED: On the second day of our trip to Itezhi-Tezhi district, our team ventured to two health facilities, Kaanzwa and Ngoma, both were accessible only by poorly maintained roads.

A typical road in the Itezhi-Tezhi flood plain, cut-off by running water. Davis Albohm

A typical road in the Itezhi-Tezhi flood plain, cut-off by flowing water. Davis Albohm

Ngoma, although well stocked with medical supplies, is located inside the Kafue National Park and patronage is limited to a small population comprising Wildlife Police camp staff and their families. Mambwe Ng’oma, the Stanford Data Collection Officer working in this area, collected data at this center at the beginning of the study but had a difficult time traveling there because park regulations restrict access due to large and dangerous game such as lions and elephants.

Next we visited other distant health facilities. Unbelievably, because of the vast distances, we spent more time on the road than at the actual health facilities. This gave us an opportunity to understand the distances and obstacles our DCOs face. Even with a vehicle we could not reach the two furthest health centers: Nansenga and Mbila. The roads are poor and the vehicle basically can only run at 30 km per hour for most of the journey. We however managed to reach seven health centers in four days.

More about the dusty roads in Itezhi-Tezhi, these have a fine deposit of alluvial soils from flood waters in the low lying areas. But higher ground is not spared by the dusty conditions. A slight movement of  our vehicle’s wheels raises a lot of dust particles. A large number of health centers are located in the flood plains which are seasonally inundated and for most part of the year are impassable by vehicle. The grasslands are devoid of woody vegetation, dominated by grass and bush fires in the dry season are common. Due to flooding the district tends to have seasonal routes as well, created by vehicles during the dry season. There are no standard roads and they are difficult to map, because they shift to a large extent after every rainy season. Only housing infrastructure is permanent and is built on higher ground within the flood plains.

An EHT providing health education at an Itezhi-Tezhi health center. Davis Albohm

An EHT providing health education at an Itezhi-Tezhi health center. Davis Albohm

We kept wondering how these settlements received their supplies of food, medicines, clothing, etc. We got the same response from everyone; that supplies are stocked prior to the rains starting, which could be in November, earlier or later. The rains stop in March or April, but the plains remain impassable until somewhere May or June. On average, for six months in a year residents are cut off from the rest of the district.

You can never run out of amazing surprises in Itezhi-Tezhi district. While there is no gas station operating as a business entity we had to plan ahead of each day to ensure we had enough diesel to take us into the field. The only gas station in town belongs to the electricity supply company (ZESCO) for its private use, but has extended this facility to the community. It operates at unreliable hours, which again ensures that our work remains unpredictable in Itezhi-Tezhi!

Earthquake Strikes Research District

April 22nd, 2013
The expansive flood plain of Itezhi-Tezhi district.  George Muwowo

The flood plain of Itezhi-Tezhi district. George Muwowo

George Muwowo, author of this post, is a Stanford University program manager based in Livingstone, Zambia. He oversees on-the-ground administration of the Riders for Health evaluation. For more information about Stanford’s work in Zambia’s Southern Province, please visit our website.

In this article I provide a recount of exciting field experiences from our work on the Riders for Health evaluation.  My approach is from a social and logistical perspective, providing lessons for future work. The first visit to Itezhi-Tezhi in July 2011 still remain fresh in our memories due to the earthquake which sent the town into panic. I will also share stories  from other research districts.

Itezhi-Tezhi is a small town in the south west section of the Central Province of Zambia. It is the seat of the Itezhi-Tezhi District. It lies west of the town of Namwala on the border of the Kafue National Park.

Itezhi-Tezhi came into existence when the Itezhi-Tezhi Dam was constructed on the Kafue River in the early 1970s. The dam was created to hold and regulate water flow in the river for Kafue Gorge Power Station, 260 kilometres downstream. The town’s estimated population is 4,000 and the largest employer is the electricity company ZESCO.We made several trips on the dam wall because this is the only route south east of the town to get to some remote rural health centers. Itezhi-Tezhi district boasts of vast quantities of aquatic and terrestrial natural resources which sustain local livelihoods and beyond. Besides other species, breams are the dominant fish in the lake and the Kafue River.

Almost half of the land surface cutting through Itezhi-Tezhi central business district is a Game Management Area because of its status as a buffer zone for in-situ wildlife management in the Kafue National Park (KNP). KNP is the largest wildlife sanctuary in Africa. Small and large game are present in this park and includes Lions, lechwe, hippo, impala, elephant, monkeys and so on and so forth.

Our first project trip to Itezhi-Tezhi was meant to familiarize ourselves with the district health officials at the district head quarters (District Health Office) as well as to visit some of the remote rural health centrers including those located within and near the KNP.

The first stop was at the District Health Office to meet the District Medical Officer (DMO). The DMO was very welcoming and took time to listen to our stories on health care delivery and challenges thereof. The chat delved into project background, Ministry of Health project approvals, planned activities, data collection process and associated data collection tools. It was generally a good meeting and we quickly retired in the parking lot to plan how the rest of the day will be spent.

At that moment, in a seemingly serene environment, far from the hustle and bustle of the cities, Itezhi-Tezhi woke up to a rude shock of the Earth.

Home with collapsed roof after earthquake. George Muwowo

Home with collapsed roof after earthquake. George Muwowo

A significant earthquake rocked the town. Unconfirmed sources claimed a measure of 5.8 on the Richter Scale, but regardless of the strength, there was enough movement to scare the town and cause great panic. It was the talk of the day.  Out of panic, health officials and all able bodied patients sprang out of the hospital building to watch from a distance. Cats were seen jumping off the roof tops of hospital buildings. It was a mind boggling event and was on news broadcasts all over the country within a short time. Luckily there were no lives lost.

When the incident occurred we were leaning on the tail body of our Ford Ranger truck. We noticed unusual movement of the truck and nearby buildings, followed by a heavy sound from down the earth’s crust. Earthquakes are unheard of in Zambia, but there have been isolated incidents of earth tremors. While the town was readjusting to the earth quake we decided to start with our field visit to the clinics.

Health Centres in Itezhi-Tezhi are sparsely located with distances in the range of 25 kms to the nearest and more than 250 kms to the furthest clinics. However within town there is an urban clinic referred to as Hospital Affiliated Health Center (HAHC) which attends to all urban dwellers. The team comprising of myself, Davis Albohm, Lawson Mwamba and Mambwe Ng’oma decided a visit to the HAHC and found the Environmental Health Technologist (EHT) conducting Health Education to a group of mothers and their small babies. We also checked the motorcycle transport available at this clinic which also had a store room for the entire district. We spent a full day in the district as we were combining activities between the team to ensure maximum utilization of time.

To read about the second day of our trip, stay tuned for the next blog post.

Twa’ Luumba

March 19th, 2013

Dr. Kala Mehta, author of this post, is the lead research consultant working on the Riders for Health evaluation. Using data collected by the team based in Zambia, Kala conducts numerous analyses to measure the impact and effectiveness of the Riders for Health model. To learn more about the research, visit our website.

Twa’ Luumba.

Touching down in Livingstone, Zambia was at once a thrilling and exciting experience for me. As a lifelong researcher devoted to public health, I have always dreamed of working on health systems strengthening.  The team at the Stanford Global Supply Chain Forum has given me that unique opportunity.

Livingstone General Hospital.

Livingstone General Hospital. Davis Albohm

Our group is conducting a 2.5 year field trial of a health transport intervention in Southern Zambia. The premise is that if motorcycles and vehicles are newer and maintained, health workers will be able to do their work more efficiently and they will be able to serve more people. Perhaps this seems only logical, but pinning down the link between strengthening the health system and actual outcomes in health can be considered ‘the holy grail’ of public health. It is very hard to prove that building health infrastructure actually makes a difference in the health of the population served. Without that proof, there is no reason for big funders like the Bill & Melinda Gates Foundation to put their time, money and effort into this work. On the other hand, it will be a game changer for public health if this trial proves that a better infrastructure leads to better health.

In September, 2012, I spent eight days with Davis Albohm and George Muwowo, our team on the ground in Zambia. We went to several district health and medical offices, visited health workers and saw Riders for Health motorcycles and vehicles in action. I had the occasion to round at the hospital, where the inpatient population is virtually all HIV+ and babies die regularly of HIV-related complications. The visit in general helped me to see the critical role of health transport in the context of the supply chain.  For example, I witnessed how it affects emergency services, mobile health clinics, the cold chain for vaccine delivery, and daily health outreach to villages with no local health services. But one experience stood out for me above all others.

Village, Kazungula, Zambia.

Kazungula district village, Zambia. Davis Albohm

We stopped at a village alongside one of the few tarmac roads. There were several thatched roof houses, each with its own cooking fire, one per family. A woman with a child strapped to her back approached. I smiled and said “Twa’ Luumba”. The only words I knew in her language. She countered with a wide full toothed smile, universal for acceptance. She showed me to her home, the inside about 10 feet in diameter. Her whole family, and her baby slept together in this home. I was curious about her health, and that of her baby—who at the time had a mild persistent cough.  I asked her about her family, how she lives, and lastly, where she received health care. She said that she took her baby for shots at the nearby clinic. It was in our sample, and it was about 7 kilometers (approx. 4 ½ miles) away. She said she would go there walking. I asked her if health workers ever came to her village, she said ‘no’.  Though there were probably a hundred more questions to ask, time was short and we had to leave. The woman, whose name I still don’t know, was still smiling and waving. I said ‘Twa Lumbaa’ again through the open car window. I realized then, that if health systems strengthening and the Riders’ model works, it would reach… her.

Ambitious Measles Campaign Targets Zambia’s Youth

February 27th, 2013

Davis Albohm is a project manager for Stanford University’s Global Supply Chain Management Forum. He spends significant time in Zambia managing the logistics of the Riders for Health impact evaluation alongside his partner, George Muwowo. For more information on our research in Zambia, visit our website.

On a recent trip to Zambia, I witnessed the launch of the nation’s long-anticipated measles vaccination campaign. The goal for the week-long exercise was ambitious – 95 to 100 percent coverage of all children between 6 months and 15 years old – an estimated 6.5 million to be immunized. Here’s what I witnessed on the ground:

A health worker prepares a measles immunization inside a rural school, Itezhi-Tezhi.

As part of a fortuitously timed routine work trip, my partner George Muwowo and I set out from our Livingstone, Zambia office for the most remote district in our study area, Itezhi-Tezhi. Located more than 400 km away from Livingstone, Itezhi-Tezhi lies in the northwest corner of the province, its population living in small villages among the boundless floodplains.

When we arrived, I expected to witness significant challenges for the organizers, especially in a rural setting like Itezhi-Tezhi where the terrain is unforgiving and distances – even between neighboring villages – are vast.

However, we saw first-hand that local health officials were up to the challenge. Uniformed health workers and community volunteers were stationed at schools and health centers methodically moving children from one station to the next, beginning with paperwork and ending with vaccinations. Because of the district’s sparse population, lines appeared to be short.

Children receiving measles immunizations, Itezhi-Tezhi.

But all reports noted that turnout was extremely high. Throughout Itezhi-Tezhi and other districts we visited later in the week, there was no evidence of stock outs or delayed immunization deliveries. Children who had the means to travel to an immunization site were treated. Beyond measles, many children also received Vitamin A supplements and polio immunizations.

We spoke with several health workers who cited that a well-executed vaccine distribution plan, advance staff training and strong external support from organizations like UNICEF were critical to the efficiency of the campaign.

Children waiting for measles immunizations outside a school, Itezhi-Tezhi.

But, successful planning and logistics are just part of the success story. Comprehensive social mobilization efforts also appeared to play a key role. I witnessed a widely coordinated media outreach effort which seemed to penetrate much of Zambia. Daily advertisements in the two major national newspapers were published for weeks in advance. The national television broadcaster ZNBC ran PSAs every hour. Billboards were placed all over towns and posters were attached to the walls of every health center and school we visited. People we met reported strong awareness of the campaign, and had enough notice to plan a trip to the nearest immunization site.

While official numbers have not been tallied, the government reports success.  As part of our research in Zambia, our team collected immunization data from Environmental Health Technologists (EHTs), the cadre of health workers partly responsible for managing campaign logistics.


Wildlife & Flooding Rains: Challenges of Riding to Health Centers

January 20th, 2013

James Mwanza, author of this post, is Stanford’s longest serving Data Collection Officer. He provides another perspective to the challenges of working in and traveling to rural health centers. To learn more about Stanford’s groundbreaking research in Zambia, visit our website.

I am based in Livingstone district, the town well-known tourism due to the Victoria Falls, one of the Seven Wonders of the World.

A new river cuts a road in Kazungula. J. Mwanza.

I also cover Kazungula District, the second largest town in the Southern province of Zambia. Every month, I travel approximately 1,300 kilometers to access my health centers to collect data. The distance to the health centers differs from season to season due to meandering road networks. During the rainy season, which is now, most roads are closed due to poor conditions and new ones open up. Six out of 11 of my health centers in Kazungula are not accessible by vehicle due to lack of bridges.

EHT with patients at Nyawa health center. J. Mwanza

Kazungula has experienced rains starting the end of October until the present. The roads and vegetation have already changed. Some roads are impossible to use. I often pass through water to continue the journey to Kauwe, Nyawa, Katapazi, Simango and Mandiya health centers to collect the data. Kauwe is one of the most remote health posts in Kazungula district, 250 km from my base.

During the rainy season I am forced to use the National Park or Game Management Area, meeting elephants and lions. It is interesting to rub shoulders with wildlife. Human animal co-existence is really happening during our research. But I love wildlife and I enjoy riding in dusty roads. Collecting data from the health centers is the key business, no matter how hard it is, data collection is always close to my heart.

Ministry of Health mobile health unit. J. Mwanza

During my most recent multi-day trip to 6 centers,  I had the opportunity to find a Zambian mobile hospital at Nyawa health post 195 kilometers from Livingstone town. The EHT who is the main focus person in the study was busy facilitating the visit of the mobile health trucks. The visit of a mobile hospital is a benefits the community by providing people with chest, eye and ear exams. They also bring medical equipment not otherwise available in rural areas.

Like my colleague Samson who posted earlier, I met my goals of the trip by scanning the HIA1, HIA2 tally sheets including Child Health tally sheets. These forms help Stanford fully understand the activities of EHTs and the impact of Riders for Health’s intervention. I also managed interviewed the EHT Mr. Mukhombwe in-person to learn about his health outreach activities although it was quite difficult since he was busy with the mobile hospital.

Every trip is different from the other and challenges differ. During this trip the journey was much longer than usual – by 150 KM – due to the roads that have been affected by rains, but I managed to collect data from the health centers as planned.

Early Morning on the Motorcycle

December 9th, 2012

Samson Muchumba is a Stanford data collection officer based in Choma District. He interviews 23 Envionmental Health Technologists (EHTs) every week at urban and rural health centers, asking them about their health outreach work and access to transport. Every month, he visits each health center in-person to collect data critical to the evaluation. To learn more about Stanford’s health supply chains evaluation in Zambia, visit our website.


In Choma District where I work, there are four routes to reach the remote rural health centres. These routes are; Mapanza, Pemba, Sikalongo and Masuku.

It was 6 am when I peeped outside; it was cloudy and appeared as if it was going to rain. I became reluctant to wake up to prepare for the trip along Masuku route. When I was still debating within myself whether to go or not, my phone rang. It was one of the Environmental Health Technologists (EHTs) I was supposed to visit that day. He was trying to find out if I was still going to visit the health centre. I told him the visit remained as scheduled. I got out of bed and started my routine preparations.

Along Masuku route there is Simakutu, Simukanka, Masuku mission and Masuku terminal health centres, the furthest being Masuku terminal which is 82 km from the District Health Office.

Before starting off I did the routine motorcycle check up, i.e. I checked if there was enough fuel, the engine well lubricated, the lights and brakes were operating well, if tyres were well inflated, and nuts and bolts were tight enough.

I started off from my home around 7 am so that I could reach the first health centre at 8 am. It was too early for me to eat my breakfast, so I carried packed snacks for breakfast and some also for lunch.

Just a few kilometers from town, the road became sandy for some kilometres. I had tough time riding the motorcycle along this road, for the wheels were sinking. And at some places, the road became rough with pot-holes and ridges. The speed was literally reduced and I kept swerving to avoid pot-holes and ridges.

The first stop was at Simakutu health centre which is 35 km from the District Health Office, and it took almost an hour to reach there due to the bad nature of the road.

I was met by the EHT, Mr. Cliff Chiluka and I found him facilitating a meeting for the community health workers.  It was an emergent meeting. He explained to the meeting attendants so that he could attend to me. So the meeting had to be temporarily suspended.

I interviewed the EHT, thereafter, he got the folder where he keeps the official tally forms, which contain monthly health records for the  health center. I scanned these for the month of September 2012 and the motorcycle log book sheets. I also took a photo of the motorcycle odometer.

I sat somewhere to have my breakfast which I carried along with so that I could have energy to ride on. I still had a rough road ahead.

I bade farewell and started off to the next health centre which is Masuku mission, another 30km from Simakutu. The road from here had ridges and stones in most places. The stretch from Masuku mission to Masuku terminal is the worst part of the road with ridges, rocks and is sloppy.

It took the whole trip from town to Masuku terminal (82km) about four hours. It’s a nightmare to ride along this Masuku road. The road network is the biggest challenge as far as in-person visits for data collection is concerned. However, the reception in the health centres is always positive and I was able to collect the important health data necessary for our evaluation.

- Samson Muchumba, Stanford Data Collection Officer, Choma District

Welcome to Zambia

December 8th, 2012

Dear Reader,

Welcome to Zambia. This new blog takes you straight to the ground for first-hand storytelling of the adventures, challenges and unexpected surprises that are part of the GSB’s evaluation of Riders for Health’s work in Zambia.

Health workers participating in motorcycle training during Riders for Health’s launch in Southern Province.

The GSB has 9 Zambian staff working, living and collecting data in the country’s Southern Province, a region the size of Indiana that 1.5 million men, women, and children call home. Conditions are extreme. Rain turn valleys into lakes, roads into rivers, and paralyze movement and transport for half of the year. Summer heat tops 110 degrees some days.

Through photos, videos and first-hand accounts, you will journey alongside our team as they travel by motorcycle to remote health centers, as they meet community health workers, collect data and survey the availability and condition of health-related vehicles and motorcycles.

Join Samson Muchumba for your first ride through Choma district by reading the post below.

But first, here’s a little background about our partner and the study:

A health worker administers measles immunizations in rural Zambia.

Riders for Health is a nonprofit organization focused on providing reliable and cost-efficient transportation solutions for health workers who are reaching out to rural communities in sub-Saharan Africa. Riders has developed a model where they manage vehicles and motorcycles with planned preventative maintenance, fuel, repair and driver training. In 2008, The Bill & Melinda Gates Foundation tasked Stanford University with evaluating the effectiveness and efficiency of contracting out vehicle fleet management as an approach to strengthening the performance of health delivery organizations. The Stanford data collection team is working in 8 districts in Zambia’s Southern Province. Every week, Stanford data collection officers interview health workers, collect health data and assess motorcycles and vehicles at more than 120 health centers. To learn more about the evaluation, visit our website.

-Davis Albohm, Stanford Project Manager