We used the domains from WHO MAPS toolkit to structure the main findings of our qualitative study (summarised in Table 3)(13).
Table 3
Summary of main themes identified in the thematic analysis across the MAPS domains
MAPS Domain
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Main themes identified
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Positive
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Negative
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Groundwork
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¬ Very successful pilot
¬ The goal of the programme aligned with the country’s priorities
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¬ SMS for Life was short in objective-setting (focus on stock-out visibility and not on an appropriate response to stock-outs)
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Partnerships
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¬ SMS for Life aimed to engage with all key stakeholders
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¬ Not all key stakeholders were involved in the design and deployment (e.g district pharmacists)
¬ Narrow partnership scope focussed on limited commodities for a single disease control programme
¬ No inclusion of Zonal or National MSD in the system
¬ Lack of ownership at MSD and district level led to a lack of action when stock-outs were reported
¬ Changes in government, ministerial leadership and political agendas led to the loss of SMS for Life’s momentum
¬ This loss of momentum was strongly influenced by the arrival of competitor mHealth solutions
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Financial health
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¬ SMS for Life project managers described the system as a very low cost solution as it didn’t need any maintenance or technical support
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¬ The costs of the programme were stated as one of the main reasons for discontinuation although no real costing was done
¬ It was difficult for the government to allocate a substantial share of its budget to malaria commodities and not to others
¬ Main drivers of the programme’s costs were: SMS and health worker incentives (pay-for-performance)
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Technology & architecture
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¬ Real-time data in rural health facilities in a time when this was uncommon
¬ Described as a user-friendly system
¬ Technology included quality checks
¬ Interoperability within mobile network operators was an innovation and at the same time challenge for the programme
¬ Technology was an innovation for Tanzania and mHealth globally
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¬ Lack of adaptability of the technology to new circumstances in the country
¬ Data server and hosting in the United Kingdom seen as a political challenge
¬ Lack of interoperability with the national health management information system (HMIS)
¬ No change or improvement in the user interface between 2009 and 2015
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Operations
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¬ SMS for Life trained health facility personnel to store commodities more efficiently, these changes are still visible today
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¬ The scale-up planning only included the organization of training
¬ Lack of response from the health system in case of stock-outs (see Table 4)
¬ High turnover of personnel at the health facilities caused a knowledge loss of the programme, as only one person was trained per facility. This led to high attrition rates from the system
¬ No continuing training plans
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Monitoring & evaluation
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¬ Antimalarial stock situation improved during the years, mainly due to other changes in Tanzanian supply chain system (e.g. MSD Direct Delivery system).
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¬ No monitoring and evaluation framework
¬ One external evaluation conducted in 2013 reported several challenges that were never addressed
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The high costs of the programme (50’000 USD/month), combined with its focus on a single disease, its failure to adapt to the arrival of competitor systems to Tanzania, and the lack of continuity between ministerial leaders, were shown to be the main reasons for its discontinuation. Most interviewees expressed that SMS for Life was well aligned with the country’s priorities when it was implemented because the malaria burden was high and delivering first-line drugs was essential and a challenge for the country. However, the interviewees stated that focussing on stock-outs and not on appropriate stock management fell short of solving the problem and caused some political challenges as no-one wanted to report bad news.
In terms of partnerships, SMS for Life aimed to engage the right partners before rolling out the programme. Its internally-approved, not publicly available implementation guidelines stated that: “before the SMS for Life project is rolled out in any country, it is vital that the key stakeholders involved in Malaria Prevention and Control, and the relevant people responsible for drug distribution and management are informed about, and involved in, the project.” However, the opinions of the interviewees differ. A substantial number of interviewees mentioned that not all key stakeholders were involved in the design and deployment of the programme. Some examples given that were not engaged were district pharmacists, MSD or officials at the regional level.
SMS for Life had strong champions during the pilot, but there were many changes in the government during the scale-up, which led to changes in priorities.
“Changes in leadership, changes in the background in the people in charge, changes in the priorities, this all influences sustainability of programmes.” District Medical Officer
With changes in leadership, questions were also raised regarding the costs of the programme. Most interviewees agree that the main reason for discontinuation was that the programme was too expensive to cover just one disease and that it was not possible to justify why a substantial share of the MoH’s budget should be dedicated to the supply chain of one programme and not others.
“The system was very expensive. The government asked itself should I pay for a system that costs over 500`000 USD/year or buy drugs for that amount of money?” External researcher
Despite some challenges being identified in the political arena, the programme was well-received among health facility personnel and it demonstrated that health facilities could use SMS technologies easily and provide continuous stock reporting(17).
The simplicity of sending a weekly SMS was a contrast to the complexity and delays of responding to stock-outs using the quarterly paper system. The response by the health system to the stock-outs SMS for Life was reporting, was not properly designed. Interviewees at the highest level of the national institutions explained that the response to stock-outs was a big challenge of SMS for Life. The reasons for the lack of response when a stock-out was reported through SMS for Life are shown in Table 4.
Table 4
Reasons stated for the lack of action to solve stock-outs at district level
1) Commodities claimed not to be available at MSD, often due to delays in procurement
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2) Lack of resources for transport between health facilities or to pick up drugs at MSD
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3) Unwillingness by the health facilities to reallocate their surplus stock due to lack of confidence in a replenishment delivery
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4) Lack of ownership of district leadership of the programme, which led to a lack of use of the collected data
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Nevertheless, the evidence found, including the WHO MoH Service and Availability Readiness Assessment (SARA), showed that antimalarial stock-outs were occurring less frequently in most parts of the country during the time of SMS for Life, especially from 2014(18–20). The main reason stated by most interviewees for this improvement were modifications in the procurement system that were occurring in parallel to SMS for Life. Vertical programmes (e.g. national malaria control programme) and health facilities were allowed to receive funds directly to purchase drugs, instead of having to go through the MSD. The purchase of drugs was decentralised and direct delivery was introduced. As part of this substantial initiative to improve the stock situation, the electronic Logistics Management Information System (eLMIS) was launched and the Logistics Management Unit (LMU), within the MoH, was created to manage the system(20).
In addition, shortly after the scale-up of SMS for Life, other supply chain information systems entered the Tanzanian landscape, including ILS Gateway. This programme had a similar objective and was also an SMS-based solution, but included 20 different products and had lower running costs. However, users reported this second system was more difficult to use.
The coexistence of both programmes with similar objectives but funded by different donors led to competition between them, even if thought to be complementary. ILSGateway and SMS for Life were making each other redundant. In a Global Fund Audit the following was reported: “Although developed for different purposes and meant to be complementary, some of the developed systems have duplicative functions, e.g. the SMS4life and ILS gateway (costing USD 600,000 and 60,000 annually, respectively) collect similar information. There are plans to discontinue SMS4life under the new grants." (20)
SMS for Life was a stand-alone system, so the information was not flowing to any other information system in the country. This was reported in almost all interviews as a big challenge for the sustainability of the programme.
Several information systems have been implemented since SMS for Life was scaled-up. MSD works with Epicore 9 to track the logistics of their procedures, while the health system has had different independent systems to track stock since the pull system was implemented: Request&Requisition (R&R) paper forms, end-use verification forms, tracer forms, ILS Gateway, DHIS2, and, most recently, eLMIS(21).
These systems increased the complexity of taking action against stock-outs, as they were often reporting contradictory results. To harmonize Tanzania’s digital systems, including the supply chain information systems, the country launched its national e-health strategy in 2013(21).