In Tanzania, despite recent declines, malaria continues to contribute significantly to morbidity and mortality. The U.S. President’s Malaria Initiative’s (PMI) VectorWorks project supports continuous and equitable access to insecticide-treated nets (ITNs), and provides support to the Tanzania National Malaria Control Program (NMCP) in developing vector control interventions appropriate to the specific challenges in Tanzania.
VectorWorks supports Tanzania in distributing ITNs through health facilities in 14 higher-burden regions in the Chandarua Kliniki program, delivering free ITNs to pregnant women and infants, who are particularly biologically vulnerable to malaria. As part of this health facility-based distribution, VectorWorks partnered with the Regional and Local Government division of the Office of the President (PORALG) to develop an accountability information system (AIS) dashboard to monitor ITN distribution to vulnerable populations. The Chandarua Kliniki dashboard facilitates transparency by monitoring and accounting for every ITN distributed through the health facilities. Built on existing Tanzanian government infrastructure, the Chandarua Kliniki dashboard is part of the District Health Information System 2 (DHIS 2) platform already in use at health facilities, and visualizes comparisons between the numbers of clients seen—children getting their first measles vaccination and pregnant women at their first ANC visits—and the number of ITNs distributed in the health facility.
VectorWorks Director of Field Implementation Noela Kisoka described that before the PMI VectorWorks project, ITNs were not distributed directly to end users; clients received vouchers for ITNs directly from health facilities and then redeemed the vouchers at retail points for ITNs. “There were challenges under the previous system in reconciling the number of vouchers given out versus the total number of nets distributed and issued to clients. With the Chandarua Kliniki program, ITNs are issued directly to targeted clients at the health facilities. This accountability system tracks the total number of targeted clients seen in a facility and how many received a net, and allows the health facility to determine if they are hitting their targets.”
The Chandarua Kliniki dashboard generates monthly and quarterly accountability reports. The government’s district teams use these reports to account for ITNs in their respective districts by comparing the expected and actual numbers of target beneficiaries with the actual numbers of ITNs being issued. Instances of variance from the expected numbers are flagged for further investigation. A monthly accountability report is automatically generated from the system for each district. District malaria officials document any corrective action required and submit the report to District Medical officer for approval. The district authorities then forward the accountability report to regional authorities, who coordinate with the Regional Health Management Team to take appropriate actions, like making sure data is aggregated from monthly registers into the monthly summary forms, and reports and requisitions are submitted on time.
Ms. Kisoka noted that Chandarua Kliniki has greatly increased accountability and productivity. “Before we had the dashboard, you might go out on a site visit to a clinic and realize you’d spent two hours at a facility where ITN distribution was going quite well. Now with the Chandarua Kliniki dashboard, once information is in the system, it can be used to determine which health facilities have issues, and where district monitoring teams should visit to conduct mentoring. You look at the color-coded level of discrepancies between issuing and clients seen at a facility and you can see immediately which facility has bigger issues, which allows the team to focus on those facilities.”
During the first three months of the dashboard’s rollout in 2017, VectorWorks collaborated with University of Dar es Salaam Health Information System Programme and the government’s regional and district health teams to conduct an evaluation of the Chandarua Kliniki dashboard in Mtwara Region. The main objective of the evaluation was to get input from users and to assess the practicality, ease, and frequency of using the Chandarua Kliniki dashboard by the region and district health council personnel. VectorWorks used a semi-structured survey to conduct interviews in the nine districts of Mtwara Region. Interviewees included district medical officers, district Health Management Information System (HMIS) focal people, and district malaria focal people. During VectorWorks’ evaluation of the Chandarua Kliniki dashboard, VectorWorks discovered that several aspects of the dashboard and its associated activities increased data visibility, accountability of the program, and improved the process of managing ITN distribution in the region visited.
In 2018, VectorWorks rolled out the Chandarua Kliniki dashboard nationwide so as to ensure proper accountability of ITNs across the country, even in areas supported by the Global Fund rather than PMI. Ms. Kisoka noted that “VectorWorks trained the other non-PMI regions to use the system. It is one country, so you can’t have two different systems.”
Response to rollout and use of the accountability system has been positive. Dodoma Regional Medical Officer Dr. James Kiologwe participated in the Chandarua Kliniki expansion training and was quite positive about the dashboard. Dr. Kiologwe noted that “the Chandarua Kliniki dashboard’s ability to alert me to facilities having trouble stocking and managing nets allows me to ask the DMOs (district medical officers) in each district specific questions, and to focus on where the problems were.” He felt this represented a real advantage for his supervisory responsibilities.
Ruvuma Regional Medical Officer Dr. Gozbert Mutahyabarwa stressed the importance of PORALG in the accountability process, and the necessity of including them in planning and implementation. He noted that he found the report forms “extremely helpful, as they help me identify facilities and districts which need attention, which is critical for management.”
Ms. Kisoka noted that the system has been even further strengthened through use of WhatsApp groups. “Users can take a screenshot of their performance on the computer, and then upload that onto WhatsApp, and have group conversations pertaining to performance. Through these groups, they can discuss differences in performance between districts, and determine what the issue is — stock, data quality, etc.” These WhatsApp groups are used by Regional Health Management teams and the District Health Management Teams. Ms. Kisoka asserted: “WhatsApp has eased communication. Before, they were required to call every person at council level or facility level. Now, they can communicate via group chat on a more regular basis.”
Another advantage of the system noted by Ms. Kisoka: “Right now, we are able to account for every net that has been distributed. We are on top of every issue. It is not easy to have your eye on all 5,000 health facilities. But the Chandarua Kliniki system gives us a quick snapshot of what is going on, to allow us to focus our attention.”
The Tanzanian government has demonstrated strong ownership of the accountability system. Part of that success is due to the fact that the Chandarua Kliniki dashboard was built on an already existing DHIS2 platform. In addition, the indicators were not new and health facilities already had access to the system and were using it to capture malaria related information. Using a dashboard for tracking distribution of ITNs has made their jobs easier. The success of the Chandarua Kliniki dashboard on the mainland has led to its expansion to Zanzibar, and strong government ownership of the dashboard means that it can continue to be a useful tool even after the VectorWorks project ends in 2019.