Tanzania National Voucher Scheme: Hati Punguzo

Quarterly Report for January – March 2007

Prepared for The Ministry of Health and Social Welfare, Tanzania and United States Agency for International Development

by Mennonite Economic Development Associates

Mennonite Economic Development (MEDA) Plot 261 Msonge Street at Old Bagamoyo Rd Mikocheni A PO Box 10817 Dar es Salaam Tanzania Phone +255 (22) 270-1333, -1313, -1334 Fax +255 (22) 270-1297

TABLE OF CONTENTS

EXECUTIVE SUMMARY ...... 1 PERFORMANCE INDICATORS...... 2 1.0 Strategy: Design and implement systems to ensure effective and efficient transfer of vouchers to pregnant women via the RCH clinics...... 2 1.1 Vouchers Procured ...... 2 1.2 Regional Logistics Teams Identified and Trained...... 2 1.3 Vouchers Issued to the District Medical Officers ...... 3 2.0 Strategy: Set up systems of free distribution of IRKs to mothers of infants at vaccination milestones at three and nine months ...... 5 2.1 Insecticide Re-treatment Kits Secured and Stored:...... 5 2.2 Number of RCH Clinics Distributing IRKS to Mothers: ...... 5 2.3 Number of IRKS Distributed ...... 5 3.0 Strategy: Identify, train, & monitor selected retail outlets eligible to receive vouchers.... 5 3.1 Retail Outlets Identified and Trained In All Regions by Regional Teams...... 5 4.0 Strategy: Design and Manage Voucher Redemption Scheme ...... 6 4.1 System Design and Upkeep...... 6 4.2 Redemption Rates ...... 6 4.3 Vouchers Redeemed and Coverage Rates...... 7 5.0 Strategy: Design & implement risk management systems to minimize misuse & fraud... 8 6.0 Additional comments...... 9 6.1 Zanzibar ITN Voucher Programme...... 9 6.2 PLAN Project Voucher (PPV) ...... 9 6.3 GPS Mapping ...... 9 6.4 Special Events and Visitors...... 9 7.0 Challenges for the January-March 2007, Q11 ...... 10 7.1 Misuse ...... 10 7.2 Early Stages of Equity Voucher Operation ...... 10 7.3 Scanning machine ...... 10 7.3 MEDA’s Contract Addendum...... 10 7.4 New MEDA Country Manager ...... 10

LIST OF ACRONYMS

CHMT Council Health Management Team DPS Director of Preventive Services DED District Executive Director DMO District Medical Officer DVP District Voucher Provider EV Equity Voucher GPS Global Positioning System HPFP Hati Punguzo Focal Person IHRDC Ifakara Health Research and Development Center IV Infant Voucher IRKs Insecticide Re-treatment Kits MIS Management Information System MEDA Mennonite Economic Development Associates MoHSW Ministry of Health and Social Welfare MEC Monitoring and Evaluation Contractor MU Monitoring Unit MVC Most Vulnerable Children NMCP National Malaria Control Programme PS Permanent Secretary PPV PLAN Project Voucher PWV Pregnant Woman Voucher PMI President’s Malaria Initiative PCB Prevention Corruption Bureau RCH Reproductive and Child Health (RCH) Clinic RM Regional Manager RMO Regional Medical Officer(s) TNVS Tanzania National Voucher Scheme TPRI Tanzania Pesticide Research Institute TPC Training and Promotion Contractor USAID United States Agency for International Development VEO Village Executive Officer VTS Voucher Tracking System WEO Ward Executive Officer WV World Vision ZM Zonal Manager

EXECUTIVE SUMMARY

Infant Voucher Launched. Hati Punguzo entered a new phase with the launch of the Infant Voucher (IV). Funded by the President’s Malaria Initiative (PMI) through USAID, the IV was introduced in 15 regions (89 districts) during this quarter. With World Vision, MEDA trained District Medical Officers (DMOs), Council Health Management Teams (CHMTs), clinic staff, wholesalers and retailers in the remaining 31 districts by the first week of March. Infant Vouchers are now operational and flowing in all 89 IV districts.

Vouchers distributed hits 4 million. During the quarter 630,025 vouchers were distributed to DMOs: 358,025 Pregnant Woman Voucher (PWV) and 272,000 IV. Since the Tanzania National Voucher Scheme (TNVS) started in August 2004, a total of 3,357,475 PWVs and 654,900 IVs have been distributed to RCH clinics and DMOs.

Equity Voucher Prepares to Launch. The Equity Voucher (EV) made progress toward launch. Agreements were signed with the selected NGOs and Ministry of Health and Social Welfare (MoHSW) and community-based Most Vulnerable Children (MVC) committees. MEDA regional teams and district level partners were trained on EV procedures. 26,040 vouchers were distributed to DMOs. Of the six districts, Dodoma Rural successfully launched and vouchers were being issued by March 31 st . The other five districts are expected to launch during April.

Distribution Network Grows, New Target Set. The number of retailers and wholesalers involved in the program grew by 237, or 5.5 percent, over the three month period, from 4,280 to 4,517 and the number of wholesalers increased from 206 to 226. At the MEDA retreat held in December, MEDA’s regional teams committed to the ambitious goal of doubling the number of retailers in their region over the coming 12 months.

Voucher Redemption Nears 2 million. By the end of the program’s 11th quarter the number of vouchers redeemed was 1,985,988, comprised of 1,901,947 pregnant woman vouchers and 84,014 infant vouchers. PWV redemption averaged 117,470 monthly, up 41% from the previous quarter.

To date, 66,736 PWV stub books have been returned to MEDA from the DMOs, representing a total number of 1,668,400 vouchers. Of this voucher sub-set, 1,368,073 have been redeemed by MEDA, making the effective redemption rate 82%. This represents a drop by 1% in the redemption rate and was caused by a surge in stub books being returned this quarter. It is too early to calculate redemption rates for IVs as very few IV stub books have been returned.

Database improves with addition of GPS mapping coordinates. Global Positioning System mapping has also begun in 14 regions this quarter with the provision of GPS units from USAID.

Insecticide issues from the field. Without registration of KO tab 123, most of the regions have exhausted supplies of traditional Insecticide Retreatment Kits (IRKs).

Risk Management a Primary Concern. The Monitoring Unit (MU) has engaged in a revision of weekly and monthly report templates for Regional Managers to include data on follow-ups regarding statistical irregularities and voucher analysis reports. MU also created a clinic tracking database to record findings of visits.

TNVS Program Visibility. The Canadian Minister of Health, the Honorable Tony Clement, visited MEDA’s office. The MEDA board visited Tanzania for their annual board meeting and made several TNVS site visits to clinics and retailers in Morogoro region.

PERFORMANCE INDICATORS

Performance indicators for TNVS and MEDA appear in Table 2 appended to this document. They correspond to the Key Performance Indicators table developed by the MoHSW and USAID. MEDA is working with MoHSW and USAID to update the program indicators. Until then, the existing targets will be used in these quarterly reports.

1.0 Strategy: Design and implement systems to ensure effective and efficient transfer of vouchers to pregnant women via the RCH clinics

1.1 Vouchers Procured The TNVS vouchers are currently printed by a security printer in Johannesburg following a tender process undertaken in June 2006.

Pregnant Women Vouchers (PWV): Last quarter we received 400,000 PWVs. In February, this quarter, 650,000 PWVs were received from the printer in South Africa. Next quarter we expect 450,000 PWVs to complete the order of 1,500,000 that was placed in August 2006. These new PWVs have a subsidy value of 3,250 TSh, as opposed to the previous 2,750 TSh. They are also distinct in that they have an image of a pregnant woman.

Infant Vouchers (IV): All 875,000 Infant Vouchers ordered in August 2006 were received last quarter. Therefore, no Infant vouchers were received this quarter.

Equity Voucher (EV): 40,050 EVs were received from the printer in February. The Equity Voucher book is distinct from the Infant and Pregnant Woman Voucher book as it has the USAID logo on it and 15 vouchers per book instead of the 25 in PWV and IV.

1.2 Regional Logistics Teams Identified and Trained Pregnant Woman Voucher: As reported in the previous quarter, PWVs are flowing in all districts of the country, and the program is operating at full staffing levels.

Infant Voucher: By the first week of March, all 15 IV regions were fully launched. IVs are currently being issued to infants in all 15 regions.

USAID Milestone 1.2 : This quarter, 3,280 RCH clinics were trained and received infant vouchers. Additionally, 3,717 private sector outlets were trained on Infant Voucher procedures by the end of this quarter. About ten RCH and private sector outlets were inaccessible due to the rains and will be trained next quarter.

Equity Voucher: This quarter, significant progress has been made to launch the Equity Voucher in the 6 selected districts. Of the six Equity Voucher districts, Dodoma Rural was fully launched and vouchers were being issued to target recipients by March 31 st .

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 2 Delays to roll out on time were caused by impassable roads during the rainy season. While DMO cooperation for the IV and PWV was very high, there has been some hesitation in taking on the EV. This resulted in delays of the training and voucher distribution exercise.

USAID Milestone 2.1 : In January all net manufacturers were trained on EV procedures.

USAID Milestone 2.2 : After a tendering process involving USAID and NMCP, six NGO and local government partners were identified. Contracts were signed with NGOs and work agreements were established with the government partners this quarter.

USAID Milestone 2.3 : In March Regional Managers trained government and NGO partners on the procedures for the Equity Voucher. Training on EV procedures at clinic and retailer level began in March. Dodoma Rural was able to finalize all activities and vouchers were being issued by March 31 st . The remaining five districts are expected to be operational early next quarter.

1.3 Vouchers Issued to the District Medical Officers According to established policy, MEDA’s Regional Managers (RM) and the DMO re-order PWVs and IVs from MEDA HQ when the stock of voucher books reaches approximately 50% of the optimal amount for that district. In most cases, requests for vouchers are based on an estimated six month requirement. Vouchers are then sent to the DMOs where they are warehoused, and distributed to the respective RCH clinics after clinic staff have returned the empty voucher book stubs to the DMOs.

Equity Vouchers, however, differ from PWVs and IVs in that training and voucher distribution goes to the District Voucher Provider (DVP), only some of whom are DMOs, and the training is not always done by MEDA. In EV districts an NGO or local government partner is responsible for training DVPs and delivering vouchers to them. Similar to the PWV and IV vouchers, the Equity Voucher has also been sent out in six month stocks and replenishment will occur when stock levels at the DMO reach 50%.

Pregnant Woman Voucher: During the quarter 358,025 PWV were distributed to DMOs making a cumulative total of 3,357,475 distributed nationwide since the start of the TNVS Programme in October 2004.

Figure 1 shows the number of vouchers distributed compared with target numbers since the beginning of the project, while Figure 2 demonstrates the cumulative and monthly issuing of PWV since launch.

Figure 1: PWV issued to District Medical Officers (Cumulatively)

Pregnant Woman Vouchers Issued vs. GF Target

4,000,000 3,500,000 3,357,475 2,999,450 3,000,000 2,646,900 2,430,050 2,500,000 1,836,850 PWV 2,000,000 1,500,000 1,269,325 Target 922,850 1,000,000 500,275 362,575 500,000 189,200 2,250 - Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 3 Figure 2: PWV issued to District Medical Officers (By Quarter and Cumulatively)

Pregnant Woman Vouchers Issued

3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 - Issued Cumulative Q1 Q2 Issued Quarterly Q3

Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11

Infant Voucher: 272,000 vouchers were distributed to the DMOs making the cumulative total of 654,900 vouchers distributed to the districts nationwide.

USAID Milestone 1.3 : By the end of March only three districts required a replenishment of IV voucher books: Musoma Urban in Mara region, Mtwara Urban in Mtwara Region, and Mkuranga in Coast region. The remaining vouchers (220,100) currently in stock at MEDA will be used to replenish DMO stocks next quarter.

Figure 3 illustrates the number of IVs delivered to DMOs over three quarters.

Figure 3: IVs issued to District Medical Officers

Infant Vouchers Issued

700,000 600,000 500,000 400,000

300,000

200,000 100,000 Issued Cumulative - Q9 Issued Quarterly Q10 Q11

Equity Voucher: 40,050 EVs were received from South Africa and entered into the MEDA database. In mid-March of this quarter 26,040 vouchers were issued to DMOs.

USAID Milestone 2.4 : Distribution of EVs to DMOs in all six districts occurred in March. Distribution of EVs to RCHs, VEOs and WEOs was finalized in Dodoma Rural. The remaining five districts are expected to complete voucher distribution to RCH and VEO/WEO level early next quarter.

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 4

2.0 Strategy: Set up systems of free distribution of IRKs to mothers of infants at vaccination milestones at three and nine months

This strategy remains inactive for the same reasons reported during the previous reporting period. Distribution of the long life KO Tab 1-2-3 will resume if and when the MoHSW has accepted the insecticide’s TCRI registration and an addendum has been added to MEDA’s contract.

2.1 Insecticide Re-treatment Kits Secured and Stored: Although a tender was issued for the planned purchase of up to 750,000 long life insecticide kits (KO Tab 123) the order was not placed because of the restriction described earlier. Of ten bidders invited, only one was able to meet all of the requirements of the tender.

2.2 Number of RCH Clinics Distributing IRKS to Mothers: To date 4,270 clinics throughout mainland Tanzania have been distributing vouchers as verified by the MEDA database. It is expected that a similar number of clinics have also been involved in distributing IRKs, although this information is not captured by the MEDA MIS system. It is believed that most RCH Clinics have now run out of stocks of IRKs and are no longer issuing them to infants.

2.3 Number of IRKS Distributed No IRKs or K-O Tab 123 have been distributed by MEDA during the reporting period.

3.0 Strategy: Identify, train, & monitor selected retail outlets eligible to receive vouchers

3.1 Retail Outlets Identified and Trained In All Regions by Regional Teams The number of retailers and wholesalers involved in the program grew by 5.5 percent over the three month period. The number of retailers grew to 4,517 from 4,280 (an increase of 237 retailers) and the number of wholesalers increased to 226 from 206. Although MEDA has recruited one private sector outlet (retailer) per RCH clinic in accordance with the established project target, regional teams are now working towards a new and more aggressive target of doubling the number of retailers involved in the TNVS within the calendar year.

Figure 4 depicts the growth of the commercial sector participating in the TNVS.

Figure 4: Number of Retailers and Wholesalers

Number of Retailers and Wholesalers

5,000

4,000

3,000 Wholesalers 2,000 Retailers

1,000

Q1 Q2 Q3 Q4 Q5 Q6 Q7 Q8 Q9 Q10 Q11

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 5

MEDA also records the number of retailers and wholesalers per region and district. Table 1 indicates the number of retailers and wholesalers registered in the programme in each region at the end of the quarter.

Table 1: Total Numbers of Retailers and Wholesalers as of March 31, 2007

Region Q11 Total Q11 Total Retailers Wholesalers Infant Voucher and Equity Voucher: Arusha 136 9 All of the retailers and wholesalers that Dar es Salaam 38 7 currently accept and process the PWV are Dodoma 236 6 also accepting and processing the IV and Iringa 278 6 EV in areas where these vouchers have Kagera 202 14 been introduced into the program. Kigoma 192 14 Kilimanjaro 221 15 USAID Milestone 3.1 : This quarter 3,546 Lindi 144 11 retailers and 171 wholesalers were trained Manyara 113 7 and contracted to receive Infant Vouchers Mara 204 14 by the end of February. This well exceeds Mbeya 263 12 the 2,860 target figure for retailers. There Morogoro 283 16 are approximately 10 retailers that will be Mtwara 165 8 trained next quarter due to inaccessible Mwanza 328 14 Pwani 192 10 roads during the rainy season. Rukwa 229 10 Ruvuma 255 9 USAID Milestone 3.2 : By end of March, Shinyanga 337 15 346 retailers and 13 wholesalers were Singida 150 6 trained and contracted to receive Equity Tabora 203 11 Vouchers by end of March. This well Tanga 248 12 exceeds the 230 target figure for retailers. TOTAL 4517 226 NATIONWIDE

4.0 Strategy: Design and manage voucher redemption scheme

4.1 System Design and Upkeep We increased the scanning capacity of our Voucher Tracking system with the purchase of a new scanner. The system was modified to allow the scanning of all vouchers (new PWV, IV, EV and Plan vouchers) by both machines. Upon testing, the read accuracy for the new scanning machine was low. The new scanner configuration and mis-calibration delayed the scanning of redeemed vouchers into the database and created a backlog of vouchers. Our Voucher Tracking System (VTS) team eliminated that backlog through exceptional effort, and we are working with the database programmer in South Africa to fix the software and scanner.

4.2 Redemption Rates To date, 66,736 PWV stub books have been returned to MEDA from the DMOs, representing a total number of 1,668,400 vouchers. Of this voucher sub-set, 1,368,073 have been redeemed by MEDA, making the effective redemption rate 82% for the program to date. This represents a drop by 1% in the redemption rate. We expect this drop was caused by a surge in the return of coupon books this quarter, and does not represent a slowing of voucher redemption by consumers.

It is too early to calculate redemption rates for IVs as very few IV stub books have been returned. No EV stub books have been returned to date.

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 6 4.3 Vouchers Redeemed and Coverage Rates Pregnant Women Voucher: By the end of the 11 th quarter the redemption of pregnant woman vouchers totaled 1,901,974 cumulatively. During the quarter 352,412 PWVs were redeemed and entered into the database. This represents an average monthly redemption figure of 117,470 which is 34,370 more vouchers per month compared to the previous quarter.

The following chart (Figure 5) indicates the number of vouchers redeemed each quarter and the cumulative totals. Figure 6 represents the number of PWV redeemed each month since launch.

Figure 5: Total Pregnant Woman Vouchers Redeemed (By Quarter and Cumulatively)

Pregnant Woman Vouchers Redeemed

2,000,000

1,500,000

1,000,000

500,000

- Redeemed Cumulative Q1 Q2

Q3 Redeemed Quarterly Q4 Q5 Q6

Q7 Q8 Q9

Q10 Q11

Figure 6: Total Pregnant Woman Vouchers Redeemed Monthly

PWV Redeemed Monthly 204,574 157,568 250,000 146,559 118,779 200,000 95,702 93,233 87,074 84,199 82,507 82,720 81,771 79,882 71,906 70,298 60,557 150,000 56,669 39,211 37,340 37,829 35,092 31,749 24,949 21,185 22,469 18,994 20,585 17,930 100,000 13,670 6 , 30 8

50,000 665 - Apr-05 Aug- 05 Apr-06 Aug- 06 Sep- 04 Oct-04 Nov-04 Dec-04 Jan-05 Feb-05 Mar-05 May-05 Jun-05 Jul-05 Sep- 05 Oct-05 Nov-05 Dec-05 Jan-06 Feb-06 Mar-06 May-06 Jun-06 Jul-06 Sep- 06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07

Infant Voucher: Cumulative infant vouchers redeemed total 84,014, with 70,199 redeemed during the quarter. Infant vouchers were steadily redeemed throughout the quarter. In launched districts IVs are being distributed to the caregivers of all nine month old infants when attending the health clinic for their measles vaccination. By the end of March, staff in all 15 regions had received training and had started voucher distribution.

Figure 7 shows the monthly redemption of IV vouchers monthly.

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 7 Figure 7: Total Infant Vouchers Redeemed Monthly

Infant Vouchers Redeemed Monthly

35,000 30,976

30,000

25,000 21,836 17,387 20,000 15,000 11,708 10,000 5,000 2,107 -

Nov-06 Dec-06 Jan-07 Feb-07 Mar-07

Equity Voucher: Redemption of equity vouchers will begin next quarter with the launch of the program.

5.0 Strategy: Design & implement risk management systems to minimize misuse & fraud

MoHSW have been supportive in the process of addressing voucher misuse. This quarter, the Ministry sent a letter to all Regional Medical Officers asking for action and follow-up with regards to misuse initially identified by MEDA. In response to this request, the District Medical Officers in Geita and Sengerema districts have required clinic staff involved in misuse to repay the value of the misused vouchers to MEDA. This experience has proven that there is a need to formalize the process of repayment. In March MEDA sent a memo to all District and Regional Medical Officers stressing the need for submission of reimbursed funds to MEDA to be used for the procurement of more vouchers. The Monitoring Unit has engaged in the following risk management activities from January to March:

• Revision of weekly and monthly reports by Regional Managers to include data on follow- ups regarding statistical irregularities and voucher analysis reports. • Production and analysis of monthly statistics and reports, relaying irregularities to the field staff to assist in the identification of voucher misuse. • Working with the coordinators and Regional Managers to develop an action plan whenever misuse was suspected. • Creating a clinic tracking database to record the findings of clinic visits.

In January, a new quarterly report was developed by MEDA’s MU and was circulated to all MEDA regional staff, the National Malaria Control Program, the Permanent Secretary, the Deputy Permanent Secretary, Regional Medical officers and District Medical Officers. The report reflected the current quarterly performance of each of the regions and provided a district and clinic breakdown. The next quarterly report to MEDA regional staff, NMCP, PS, DPS, RMOs and DMOs will be sent during April, next quarter.

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 8 6.0 Additional comments

6.1 Zanzibar ITN Voucher Programme During this quarter MEDA won the grant to perform voucher distribution on Zanzibar as a subcontractor to RTI and working in cooperation with the Zanzibar Malaria Control Programme (ZMCP). We will establish a mechanism for a routine distribution of ITNs through private sector in Zanzibar that is sustainable beyond donor support.

On March 26, 2007 MEDA and ZMCP signed a Memorandum of Understanding (MoU). In the MoU, it was agreed that MEDA will handle the logistics component of the programme from printing to distribution of vouchers to primary health facilities. It was agreed that MEDA will participate in community sensitization that will be done by ZMCP. The project will run through November 30, 2007.

6.2 PLAN Project Voucher (PPV) 95,800 vouchers were issued to the field bringing the cumulative total to 107,700. A total number of 30,776 (29%) were received at MEDA. No more children under five were registered during the period.

One concern of the PPV was that some of the rural retailers found it difficult to sell the OLYSET nets as they are more expensive than the standard ITN. This led to an insufficient supply of OLYSET nets in some areas. To solve this, PLAN and A-Z are working together to sensitize communities to the benefits of OLYSET, to mobilize voucher holders and to drive redemption.

The expiry date for the PLAN voucher has been extended from 30 th April to 31 st May 2007. MEDA distributed an official letter of extension to stakeholders early in the next quarter.

6.3 GPS Mapping Last quarter, USAID supplied MEDA with 14 GPS units to conduct the mapping of TNVS RCH clinics, retailers and wholesalers. The 14 regions that participated in this activity this quarter were Arusha, Mwanza, Iringa, Rukwa, Morogoro, Manyara, Tabora, Singida, Mtwara, Tanga, Kilimanjaro, Ruvuma, Dar es Salaam and Coast.

By the end of March, 413 RCH clinics and 224 retailers were mapped with the 14 GPS units. The remaining seven regions (Mbeya, Mara, Lindi, Kagera, Dodoma, Kigoma and Shinyanga) will be provided with the GPS units next quarter, once mapping is complete in the first 14 regions.

In February 2007 two MEDA employees participated in a Geographic Information System Training course on ArcView Geographic Information System software provided by Interchurch Medical Assistance (IMA). MEDA has received ArcGIS software and Global Data for mapping TNVS RCH clinics, retailers and wholesalers. Next quarter, in-office training will take place at MEDA headquarters and MEDA will soon provide reports in GIS map graphics.

6.4 Special Events and Visitors At the end of January the MEDA Board, comprised of Mennonite businessmen and women from Canada and the United States, came to Tanzania where they conducted their annual board meeting and participated in clinic and retailer site visits in Morogoro region.

Other visitors who conducted TNVS site visits and tours this quarter included the Canadian Minister of Health, the Honorable Tony Clement, Kai Ebata, a communications officer for Canadian International Development Agency (CIDA), Adrian Schlapfer the Assistant Director for

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 9 Swiss Development Cooperation (SDC), Jackson Muyambi from Regional Health for Quality Health Care in Uganda and various staff members from USAID/Tanzania.

A delegation from USAID/Mali also consulted MEDA about the feasibility of duplicating the voucher programme in that country. Lastly, the Permanent Secretary for the Ministry of Health in Zanzibar visited MEDA to discuss the launch of the Zanzibar voucher.

7.0 Challenges for January-March 2007, Q11

The following issues are highlighted for special attention during the next quarter.

7.1 Misuse Reports of isolated clinic level misuse from MEDA Regional Managers in Dar es Salaam, Tabora, Shinyanga, Arusha and Kilimanjaro have been submitted in the first quarter of 2007. All identified misuse is reported to MEDA headquarters and to DMOs who are expected to follow-up as per the MoHSW request. MEDA has passed this information to the Prevention of Corruption Bureau (PCB) and USAID to further investigate such findings, and is looking for ways to improve its working relationship with PCB.

Extra effort is being made at MEDA/Tanzania headquarters to provide frequent communication to stakeholders and regional teams on any misuse findings.

7.2 Early Stages of Equity Voucher Operation The finalization of Equity Voucher roll out will take place in the first three weeks of the next quarter. As a variety of voucher issuing mechanisms are in place in each of the six EV districts, close monitoring and follow up of EV activities will be necessary to troubleshoot challenges and ensure smooth voucher flow.

7.3 Scanning machine The database and scanning machines have undergone several adjustments this quarter. The database was adjusted to begin the redemption of the new PWV, IV, PPV and EV. Although the new scanner was expected to improve the scanning speed this quarter, the read accuracy rate was very low due to poor configuration. This caused several delays in scanning and a backlog of un- scanned vouchers which will be entered into the database in April next quarter. Currently MEDA is working with Sybrin in South Africa to reconfigure the new scanner and improve the scanning pace.

7.3 MEDA’s Contract Addendum MEDA is awaiting the signature by MoSHW on the first contract’s addendum which we requested in August of 2006.

7.4 New MEDA Country Manager MEDA welcomed a new Country Manager this quarter. Joining MEDA as the incoming Country Manager is Tim Piper, formerly of TechnoServe here in Tanzania. Greg Foster, the outgoing country manager has taken a position with Habitat for Humanity based in Pretoria, South Africa.

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 10

Table 2: Performance Indicators

3rd Quarter 4th Quarter 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 1st Quarter 2nd Quarter Milestones and Results 2004-Q1 2004-Q2 2005-Q3 2005-Q4 2005-Q5 2005-Q6 2006-Q7 2006-Q8 2006-Q9 2006-Q10 2007-Q11 2007-Q12 Strategy 1: Design and implement systems to ensure effective and efficient transfer of vouchers 1.1 Vouchers Procured PWV PWV PWV PWV PWV PWV PWV PWV PWV and IV PWV, PPV PWV, PPV securely securely securely securely securely securely securely securely securely and IV and IV stored and stored and stored and stored and stored and stored and stored and stored and stored and securely securely available for available for available for available for available for available for available for available for available for stored and stored and distribution distribution distribution distribution distribution distribution distribution distribution distribution available for available for distribution distribution Results Completed Completed Completed Completed Completed Completed Completed Completed Completed Completed Completed

1.2a Regional logistics 2 Regional 2 regions 5 regions 7 regions 11 regions 17 regions 21 regions 21 regions 21 regions 21 PWV 21 PWV teams identified and Teams operational operational operational operational operational operational operational operational regions regions trained to manage trained operational operational distribution of vouchers/IRKs

Results Completed 5 regions 8 regions 11 regions 15 regions 20 regions 21 regions 21 regions 21 regions 21 PWV 21 PWV operational operational operational operational operational operational operational operational regions regions operational operational 1.2b IV training and prep All net IV retailers IV retailers manufacturers and and informed and wholesalers wholesalers trained in IV trained and trained and procedures registered in registered in 15 regions 15 regions

Results Completed Partial Complet ed

1.2c EV training and prep N/A Part ners Partners identified identified and and contracted in contracted in 6 EV districts 6 EV districts

Results N/A Partial Completed 1.3a Vouchers Distributed 0 22,000 77,000 160,000 300,000 607,000 880,000 1,200,000 1,475,000 N/A N/A (Targets) PWV Results PWV 2000 232,125 428,227 528,000 947,323 1,271,618 1,788,902 2,424,987 2,646,775 2,999,325 3,357,475

1.3b Vouchers Distributed 0 N/A 875,000 (Targets) IV Results IV 90,000 382,900 654 ,900

1.3c Vouchers Distributed N/A N/A N/A (Targets) EV

Results EV N/A N/A 26,040

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 11

3rd Quarter 4th Quarter 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter 1st Quarter 2nd Quarter Milestones and Results 2004-Q1 2004-Q2 2005-Q3 2005-Q4 2005-Q5 2005-Q6 2006-Q7 2006-Q8 2006-Q9 2006-Q10 2007-Q11 2007-Q12 Strategy 2: Set up systems for the free distribution of IRK to mothers/caretakers of infants 2.1 Insecticide Re- IRKs stored IRKs stored IRKs stored IRKs stored IRKs stored IRKs stored IRKs stored IRKs stored IRKs stored IRKs stored IRKs stored treatment Kits and available and available and available and available and available and available and available and available and available and available and available procured for for for for for for for for for for for distribution distribution distribution distribution distribution distribution distribution distribution distribution distribution distribution Results Tendered Supplier 200,000 IRKs 120,000 IRKs 90,000 IRKs 350,000 ready 18,000 IRKs 800,000 IRKs No activity No activity No activity selected and in storage in in storage in in storage in for distribution in stock at received and order placed DSM DSM DSM, in January MSD, 800,000 distributed. 1,000,000 on order ordered

2.2 Number of RCH 0 0 250 500 1,200 3,826 4,160 4,394 4,160 4,270 N/A facilities distributing IRKs to mothers/caretakers of infants

Results 0 0 0 5 regions 11 regions 20 regions 21 regions 21 regions 21 regions 21 regions 21 regions

2.3 Number of IRKs 0 0 0 40,000 105,000 410,000 815,000 1,005,000 1,2 05,000 N/A distributed (Target) N/A Results 0 0 0 80,000 330,400 450,000 764,000 1,600, 000 1,600,000 1,600,000

Strategy 3: Identify, train and monitor selected retail outlets eligible to receive vouchers 3.1a Retailers Accepting Outlets Outlets Outlets Outlets 2,650 3,000 3,100 3210 retailers N/A N/A Vouchers (Target) identified in identified in identified in 7 identified in retailers retailers retailers identified in PWV 2 regions 5 regions regions 11 regions identified identified in identified in 21 regions accepting accepting accepting accepting in17 regions 21 regions 21 regions accepting vouchers vouchers vouchers vouchers accepting accepting accepting vouchers voucher voucher vouchers

Results PWV 5 regions 8 regions 12 regions 15 regions 20 regions 21 regions 21 regions 21 regions 21 regions 21 regions operating operating operating operating operating operating operating operating operating operating involving 681 involving involving 1372 involving involving 2618 involving involving involving 4058 involving involving 4517 retailers 1022 retailers retailers and 2091 retailers retailers and 3,773 retailers 3932 retailers retailers and 4,263 retailers retailers and and 63 83 and 1119 134 and 174 and 197 206 and 208 226 wholesalers wholesalers wholesalers wholesalers wholesalers wholesalers wholesalers wholesalers wholesalers

3.1b Retailers Accepting N/A N/A 2,860 Vouchers (Target) IV

Results IV N/A Retailers Retailers 3556 2170 and and wholesalers wholesalers 208 171 3.1c Retailers Accepting N/A N/A 230 Vouchers (Target) EV

Results EV N/A N/A Retailers 346 and wholesalers 13

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 12

4.2a Redemption Rate 85% 85% 85% 85% (Target) PWV Results PWV 83% 83% 83% 82%

4.2b Redemption Rate N/A N/A N/A (Target) IV Results IV N/A N/A N/A

4.2c Redemption Rate N/A N/A N/A (Target) EV Results EV N/A N/A N/A

4.3a Vouchers Redeemed 408,000 591,600 807,500 935,000 N/A N/A PWV (Targets) Results PWV 0 33,881 92,264 182,879 279,204 414,878 662,140 1,157,566 1,300,185 1,549,494 1,901,974

4.3b Vouchers Redeemed N/A N/A N/A IV (Targets) Results IV N/A 13,892 84,014

4.3c Vouchers Redeemed N/A N/A N/A EV (Targets) Results EV N/A N/A N/A

Strategy 5: Design and implement risk management systems to minimize misuse and fraud 5.1 Risk Management Record Record Record Record Record Record Record Record Record Record Record System Development keeping keeping keeping keeping keeping keeping keeping keeping keeping keeping keeping system to system to system to system to system to system to system to system to system to system to system to document document document document document document document document document document document movement of movement of movement movement of movement of movement of movement of movement of movement of movement of movement of PWVs PWVs of PWVs PWVs PWVs PWVs PWVs PWVs PWVs PWVs and PWVs and IVs developed/int developed/in developed/i developed/int developed/in developed/in developed/in developed/in developed/inte IVs developed/int egrated tegrated ntegrated egrated tegrated tegrated tegrated tegrated grated developed/in egrated tegrated

Results Completed Completed Completed Completed Completed Completed Completed Completed Completed Completed Completed

Tanzania Voucher Scheme–Hati Punguzo – 11 th Quarter Report, January - March 2007 page 13