In Togo, Mobile Clinics Reach the Unserved

LOME, Togo - A gritty Harmattan wind from north Africa swirls leaves around a small clearing beneath shea trees in the middle of the village. It is oddly silent for midmorning. Wooden chairs in front of the school are the only inhabitants of this parched and dusty place. A small sound starts in the distance; the thump, thump of a drum grows louder. Suddenly, a group of young women, dancing two by two and holding white handkerchiefs in the air, turns the bend followed by hundreds of children running behind with the band, a motley ensemble of men playing African drums and banged-up brass and wind instruments. It sounds like a New Orleans second-line gone native. The ceremony commences as three Togolese doctors step out of a white Suburban and begin to set up tables in an empty room of the local grade school.

These villagers from Tokpevia, Togo are celebrating the first visit of PSI's Project Mivado - "We have arrived" in the local Mina language. The project, which started in 1998 funded by UNFPA, UNICEF, and USAID, is a mobile clinic that brings medicine, medical equipment and trained personnel to remote rural villages that have no other access to modern health care. Tokpevia - with a population of about 2,000 and 18 kilometers by winding dirt road to the closest health clinic - is the first village to be chosen for Mivado's expansionary second phase. Normally, village women, who rise each morning as early as 3 o'clock to go in search of water for their families, could not make the journey to the national clinic if they or their children were ill. Now, once a month, PSI's mobile clinic comes to them.

As Togo is predominately a rural country with an agricultural economy, Mivado was initially envisioned as a tool to sell PSI health products to populations in extremely remote areas. However, due to the overwhelming demand for medical care, Mivado has evolved into a full-time mobile hospital that visits 16 villages in the Plateau and Maritime Regions of Togo once a month. The second vehicle allows two teams to be on the road at all times.

Mivado is servicing more and more communities, and more want to be put on the list. One of the advantages of the system is that villagers feel comfortable with Mivado staff, as they have developed a personal connection with the physicians who come into their community every month. The staff gets to know the parents and their children by name after only a few visits. This ongoing and in-depth relationship allows Mivado doctors to understand the needs of these communities more accurately. This new information can then be used to modify PSI's strategies for product development and distribution as well.

Working to include local health workers in this outreach effort, Mivado invites Togolese government caregivers from the closest urban area to accompany them to villages for each visit. The team (PSI physician, government health worker and PSI product promoter/vendor) then works together to provide a variety of services. In the area of maternal and child health, Mivado physicians give each child a health card which charts their growth and vaccinations. Oral rehydration therapy is also offered to combat frequent episodes of diarrhea. Pre- and post-natal care is offered for moms, and family planning products are sold at a subsidized price. In the fight against HIV/AIDS, Mivado is in the forefront by giving training in risk reduction to large groups of assembled villagers, followed by the sale of condoms.

Sexually-transmitted infection (STI) treatment is effective because villagers can ask for help from Mivado doctors in their own village without the embarrassing wait at the large, over-crowded national clinic a day's walk away. As many as 25% of Mivado's clinical consultations are related to STIs. UNICEF and other donors have acknowledged that Mivado is one of the most effective methods of reaching isolated rural populations with information, health products, and clinical services to reduce the risk of HIV infection.

PSI Togo Country Rep Auguste Kpongon is enthusiastic about the health impact of Mivado. "The MIVADO project is the only integrated services delivery outreach project in the PSI world," he says. "It is a very successful tool in our program to reach undeserved rural areas and could be easily replicated in other programs."

Chief among the lessons learned from the Mivado experience is that it was not sufficient to go into rural areas and sell health products. To draw crowds and promote product sales, PSI had to offer an incentive - a broad package of clinical services. The Mivado teams learned that when people have their children weighed and immunized and their illnesses treated, they are much more receptive to buying products like oral rehydration salts and birth control pills. They are also much more likely to listen and respond to educational sessions on STIs, AIDS, family planning, and child health. A bundle of health services is the draw - and it draws thousands - and the sale of health products is the result.

Mivado has had a significant impact on sales in rural areas. Togo is predominantly rural, and it is always a challenge to reach isolated populations. With two Mivado teams, PSI/Togo now covers a large swath of two rural regions and sells large quantities of products - male and female condoms, oral and injectable contraceptives, oral rehydration salts, and soon, mosquito nets and multivitamins. Though sales figures in these rural areas will never compare to urban areas, they are nonetheless significant in that they target the hardest-to-reach and the neediest populations.

—Rene Van Slate

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The Mivado program offers infant services during its once-a-month visits.