In the first quarter of 2025, the uncertainty as the U.S. Government’s aid freeze cast a shadow over the R4H program. For two long weeks, the organization, including the Sample Transport couriers, faced a stop-work order, affecting the transportation of medical samples and results.

 Medical samples and results were not being transported.” I was receiving calls from healthcare workers to report to health facilities for sample collection, but I could not do so at that time due to the stop work order”, reported Matilda Banda, R4H Sample Transport Courier, Lilongwe district. The silence was worrisome, and the weight of responsibility felt heavier than ever with the uncertainty.

But then, in the week of 17th February, we were back on the road and it felt like a breath of fresh air. I remember the moment I received the communication from the head office through the Programs Manager, Angellina Mwase. “I called the healthcare workers from the health facilities I reach to inquire about the samples which were to be prioritized and sent to the molecular and hub laboratories for urgent testing” added Maltida.

Commenting on the impact of the executive stop work order in healthcare delivery, Francis Mdzingah- Health Surveillance Assistant (HSA) at Chiwamba Health Center in Lilongwe said “R4H couriers are known for their reliability; however, the stop work order disrupted operations in their implementing health facilities. Clients rely on timely results to manage their health based on viral load outcomes. Unfortunately, during this period, the delay in sample transportation posed a significant challenge, impacting the ability to provide timely health advice”.

“My heart was filled with joy as I loaded the first batch of HIV viral load and TB sputum samples into my courier bag. I was reminded that each sample represents a life, a story, and the hope for better health,” Matilda concluded.

Together with the Ministry of Health (MoH), and other implementing partners, R4H continues to transport medical samples and results in all 29 districts of Malawi,currently reaching 810 health facilities.

In the quarter October to December 2024, the R4H programs and Monitoring, Evaluation, and Learning (MEAL) teams conducted visits to 80 health centers across three regions of Malawi: the Southern, Central, and Northern regions. Specifically, they visited health centres in Chikwawa, Zomba, and Blantyre in the Southern Region; Mchinji and Ntchisi in the Central Region; and Rumphi and Karonga in the Northern Region. The primary objective of these visits was to review the sample transport program and engage with key stakeholders. These engagements were aimed at gathering feedback on the program’s successes, identifying areas that are functioning well, and highlighting aspects that require improvement. One of the motivating factors during these visits was hearing positive feedback from partners, including HIV Diagnostic Assistants (HDAs) and Health Surveillance Assistants (HSAs), who are deployed under various partners such as the Ministry of Health (MoH) and Right to Care. These partners work closely with the R4H sample transport couriers at health centers, ensuring that samples are collected and transported on time for diagnosis.

A key testimonial shared during the period from October to December 2024 came from Peter Mpinga, HDA under Right to Care at Malomo health centre. He described a situation that occurred within October to November 2024 in which a client who had difficulty in walking needed to have a viral load sample drawn but could not make it to the health center. In response, the HDAs traveled to Chakulanjala, a village 10 kilometers from Malomo Health Centre, to draw the sample. Fortunately, R4H courier Brino Katchengera arrived at Malomo Health Center to collect the samples but the HDAs were not available. Upon contacting them, he was informed that they were at Chakulanjala, drawing the sample from the client. Brino followed the HDAs to Chakulanjala, successfully collected the dry blood sample, and transported it to the laboratory for diagnosis. Malomo Health Center is located 36 kilometers from Ntchisi District Health Office, and this scenario exemplified the critical role that couriers and HDAs play in ensuring the smooth transportation of samples even under challenging circumstances.

Further, Ernest Manda, Laboratory Technician from Khuwi Health Centre, highlighted how R4H couriers are making a significant contribution to improving patient outcomes. His feedback reflects the importance of the collaborative efforts between HDAs, couriers, and health facility staff in ensuring that diagnostic samples are transported efficiently, leading to better patient care and timely diagnosis.

These testimonies and interactions showcase the impact of the R4H sample transport program and emphasize the ongoing need for improvement in coordination, resources, and logistics to ensure continued success in transporting clinical samples across Malawi’s health centres.

R4H continues to make significant strides in improving healthcare delivery through the implementation of the optimized medical sample transport system in the 11 districts of Phalombe, Mzimba North, Rumphi, Lilongwe, Salima, Zomba, Chiradzulu, Mulanje, Chikwawa, Blantyre, and Mangochi. The Optimized Sample Transport (OST) system utilizes a USSD-based reporting mechanism, where healthcare workers (HCWs) report the number of clinical samples available for R4H courier pickup at the site each working day. Between October and December 2024, R4H route optimization team visited 6 OST implementing districts of Blantyre, Chikwawa, Lilongwe, Zomba, Rumphi and Mzimba North for a support visit.

This initiative started by addressing gaps through distribution of Standard Operating Procedures (SOPs) and Job Aid, for USSD sample volume reporting, to healthcare facilities (HCFs) that fell short of them, had worn out or got lost, and administering of checklist.  In addition, hands-on training sessions, were carried out, to ensure that HCWs were proficient in using the USSD system.  Followed by on-site supervision, to monitor the effectiveness of reporting procedures, and ensure HCWs adhere to the best practices outlined in the SOPs. 

The interaction, enhanced coordination that creates a sustainable model for ongoing support, which included activating contacts numbers for new HCWs, and new phone numbers, to ensuring that all HCWs receive timely SMS reminders for USSD sample reporting, and daily notification of ST courier visit to the facility among others.

The outcomes include the distribution of USSD SOPs at targeted HCFs, training and retraining of HCWs on USSD sample reporting, and the establishment of a strong relationship with HCWs, for continuous implementation of OST program activities. Additionally, HCWs demonstrated a stronger appreciation of the USSD reporting system, with many taking on mentorship roles to train their colleagues.

In the quarter of July to September 2024, R4H made significant strides in improving healthcare delivery through the implementation of the optimized medical sample transport system in the 11 districts of Phalombe, Mzimba North, Rumphi, Lilongwe, Salima, Zomba, Chiradzulu, Mulanje, Chikwawa, Blantyre, and Mangochi. Healthcare workers in various health centers are commending the system, for enhancing the efficiency and quality of medical sample logistics, ensuring quicker diagnostic results and better patient care.

Augustine Mamala, healthcare worker from Mbalama Health Centre in Mangochi, shared his experience: “Before the introduction of the Optimized Medical Sample Transport Program, we relied on scheduled days for couriers to collect samples from the health centers. Now, we use the USSD system to notify the couriers when samples are available, and they report for collection either on the same day or the next, depending on the time the availability of samples is reported.”

The OST system utilizes a USSD-based reporting mechanism, where healthcare workers (HCWs) report the number of clinical samples available for R4H courier pickup at the site each working day. The new system has empowered health workers to manage the sample collection process better, reducing delays and ensuring that samples are collected in optimal conditions for accurate laboratory analysis. R4H’s initiative supports the Ministry of Health’s efforts to improve healthcare logistics, particularly in ensuring that medical samples are transported promptly and remain in good quality until they reach the laboratory.

Alfred Kamwendo, health worker from Kadango Health Centre, commented on the remarkable improvement in turnaround times. “Before the optimized sample transport system, the turnaround time could reach up to seven days. Now, this has been reduced to 2-3 days, which is a big improvement. It has minimized the risk of sample compromission, especially for sensitive samples like sputum for Tuberculosis, which could easily get damaged before reaching the laboratory for GenXpert testing. The same applies to VL (Viral Load) samples – once results are ready, couriers are notified, and they promptly collect and transport them to the health centers.”

By ensuring timely transportation of samples, R4H has improved the challenge of needing to redraw blood and sputum samples due to deterioration, significantly enhancing the efficiency of health care delivery. This program has not only improved diagnostics but also reduced patient stress, as health workers no longer have to request repeated sample collection.

In partnership with the Ministry of Health, R4H is committed to continuously improving its services, striving to deliver quality healthcare logistics to all Malawians.

Between July and August 2024, R4H’s Programs and MEAL team conducted a Spot Check and Data Quality Assessment (DQA) exercises across six districts of Chikwawa, Nsanje, Salima, Nkhotakota, Kasungu, and Chitipa. This exercise aimed to gather feedback from healthcare workers at 108 health facilities; 35 in the Southern region, 36 in the Northern region, and 37 in the central region.

Healthcare workers praised R4H couriers for their professionalism and effective communication. The couriers have been instrumental in the timely transportation of medical samples, reducing the Turn- Around Time (TAT) which was usually 3- 5 days to 2 days. According to Silida Mkokamasa, the Environmental Health Officer for MAFCO, the optimized sample transport system has significantly streamlined healthcare delivery. She highlighted the effectiveness of the USSD system used to report sample availability. The OST system uses a USSD-based reporting method, allowing healthcare workers (HCWs) to report daily on the volumes of clinical samples ready for pickup by the R4H courier at each site.

Lucy Chiyenda, R4H Country Director (L), Silida Mkokamasa- Environmental Health Officer (HEO) and Alice Mbozi- R4H Central Region Sample Transport Coordinator during spot check activity at Malawi Armed ForcesCollege (MAFCO) in Salima district

 

Mkokamasa shared an incident from the April-June 2024 quarter where a courier, collected Viral Load samples in the morning, and promptly returned later the same day to collect a newly reported TB GeneXpert sample through the Unstructured Supplementary Service Data (USSD) system, ensuring swift transport to Salima District Hospital for diagnosis. She stressed the importance of timely sputum transportation for TB diagnosis in preventing spoilage and the need for sample redraws. Efficient transportation of TB samples is crucial as delays can compromise sample integrity, leading to inaccurate diagnoses and affecting patient outcomes.

Fatsani Salamba, an HIV Diagnostic Assistant at Thavite Health Center, added that in June, R4H couriers played a crucial role in urgently transporting Quality Controls (QCs) for Dry Tube Specimen (DTS) needed at the health facility. He further mentioned that when the USSD system is down, they use a WhatsApp forum to notify couriers, who respond promptly. Salamba pointed out that there is need for better coordination among healthcare workers to ensure no samples are left behind when couriers arrive.

These testimonials highlight R4H’s crucial role in overcoming challenges to ensure accessible healthcare in Malawi.

 

In one of the R4Hs Sample Transport Program implementation areas; Dowa District, Titus Juga stands as a beacon of dedication and service. As a medical sample transport courier, Titus is entrusted with a crucial task: transporting medical samples from 24 health facilities across Dowa to the district health office for diagnosis. Once the results are ready at the laboratory, he promptly delivers them back to the respective health facilities. This cycle of transport and communication ensures timely diagnoses and treatments, saving countless lives.

Juga’s role under the R4H is critical. “The work that I do under R4H is assisting in ensuring that clients are diagnosed in good time and prescribed treatment,” he explains. For him, this responsibility is more than just a job; it’s a calling. “This experience is fulfilling,” added Juga.

The shortest route he undertakes is 9 kilometers from Dzaleka Health Center to Dowa District Hospital, while the longest stretches up to 96 kilometers one way. Despite the challenges posed by varying terrains and distances, Titus remains committed to his task. For instance, the route from Thonje Health Center to Dowa District Hospital is particularly demanding, it is a 36km journey with challenging terrain that demands endurance and determination. Yet, these obstacles strengthen his determination to serve the community.

Juga takes  pride in his ability to serve the community, recognizing the vital impact of his work on the health and well-being of the people in Dowa. “I appreciate all the healthcare workers I interact with in health centres in Dowa,” he says. Their support and organization play a significant role in the efficiency and success of his duties. “They welcome us well and make our work easy with their timely support and organization.” Concluded Juga.

Through his tireless efforts, Jugas  dedication to his role as a medical sample transport courier under R4H ensures that health facilities in Dowa can provide timely and accurate diagnoses, saving lives and fostering a healthier community.

 

 

R4H Couriers are making strides towards a healthier future, aligned with Sustainable Development Goal 3, which focuses on health and well-being. The couriers play a crucial role in the healthcare system by ensuring the swift and safe transportation of medical samples and results between health facilities and laboratories. This ensures timely diagnoses and treatments.

In June 2024, Angellina Mwase, the Programs Manager for Quality Assurance at R4H, embarked on a quality check mission. She scheduled meetings with District Medical Officers at Mchinji and Salima District Hospitals to evaluate the program’s impact. Dr Steria Mlepo, the District Medical Officer at Mchinji, praised R4H for their punctual and adaptable service, noting how they assist in transporting other parcels as needed.

At Salima District Hospital, Francis Chimberenga, the laboratory technician and deputy safety officer, echoed the same view. He highlighted how R4H couriers have significantly reduced turnaround times for medical results while maintaining the integrity of the samples, ensuring they remain intact throughout the medical sample transportation process. This efficiency has markedly improved patient treatment outcomes.

In conclusion, Dr Steria Mlepo commended the exceptional work of R4H and expressed a desire for R4H to expand their operations to additional facilities like Faniwelo and Mphelero, spreading their positive impact even further. Through their dedicated service, R4H Couriers continue bringing hope and efficiency to Malawi’s healthcare system.

R4H’s Optimized Sample Transport (OST) system is transforming healthcare logistics, through improving clinical sample transport times to testing laboratories, in Malawi across 11 districts of Phalombe, Mzimba North, Rumphi, Lilongwe, Salima, Zomba, Chiradzulu, Mulanje, Chikwawa, Blantyre, and Mangochi. These districts were strategically selected due to their high HIV burden, the potential for scaling up plasma HIV viral load testing, the high volume of antiretroviral therapy (ART) clinics, and the significant distances between healthcare facilities and central hubs.

The OST system revolutionizes the transport of clinical samples, ensuring they reach testing facilities on time and with maintained optimal quality standards. The OST system comprises an Unstructured Supplementary Service Data (USSD)-based reporting mechanism, whereby health care workers (HCWs) report on each working day the volumes of clinical samples available for pick up by R4H courier at site. The USSD reports are received centrally and used to generate courier routes for the subsequent day through an OST semi-automated algorithm. Courier routes are based on healthcare facilities (HCFs) with clinical samples to be picked. Similarly, couriers actively inform the R4H OST central team on the availability of laboratory test results to be delivered at requesting HCFs and routes are also generated for site laboratory test result delivery.

Between 29th and 31^st May 2024, as a way of onboarding HCFs on OST, Steven Maluza the OST Program Office Assistant at R4H, embarked on an exercise to orient HCWs at three new HCFs, thus Chilinde Health Centre, Biwi Health Centre, and Bunda College of Agriculture Clinic.

During the initial stages of OST scale up to HCFs under Lilongwe district health office (DHO), HCWs, including HCF in charge, HIV Diagnostics Assistants (HDAs) and TB focal person from each health centres were trained on USSD sample volume reporting system. On any working day, each of the HCFs is supposed to report on the availability or non-availability of clinical samples by 2 pm. The facilities were selected based on their USSD noncompliance status in the month of April 2024. The visit was aimed at providing capacity building to HCWs at site on OST technical areas including USSD sample volume reporting training and retraining, thus, improving the quality of specimen referral mechanisms under Lilongwe DHO. The following HCFs, implementing OST, were visited: Area 36 Drop-in Centre (DIC), Lilongwe Private Clinic, City Centre Clinic, Kawale Health Centre, Ndaula, Nthondo, Area 36 Pvt, Area 18, Likuni DIC, Fidelity, Area 47 DIC, Chilobwe, Mbabvi, Airwing, Ukwe, and Kabudula.

The long-term technical benefits of this exercise include improved USSD clinical sample volume reporting compliance by HCFs, HCWs skill retention on USSD clinical sample volume reporting, improved clinical sample/ laboratory test result transport time i.e., turnaround time and reduced courier empty trips to HCFs.

In conclusion, an efficient OST program implementation improves clinical care standards for ART clients as reduced clinical sample/result transport translate to timely laboratory diagnosis and linkages to clinical care for ART clients.

In the past 6 months, there has been a successful implementation of the Optimized Sample Transport (OST) program by R4H across 11 districts in Malawi. The districts include Phalombe, Mzimba North, Rumphi, Lilongwe, Salima, Zomba, Chiradzulu, Mulanje, Chikwawa, Blantyre and Mangochi. Operating on a pull system, health facilities notify R4H couriers to collect samples upon confirmed availability. This is done by recording the number of available samples in R4H’s USSD reporting system which operates on phones by HIV Diagnostic Assistants (HDAs) and Health Surveillance Assistants (HSAs) who handle Viral load (VL), Early Infant Diagnosis (EID), and TB samples.

The unstructured supplementary service data (USSD) messages generated by healthcare workers create demand for sample collection. The couriers now only visit health facilities when they are notified of the availability of samples at the facility, significantly reducing turnaround time, empty trips, wastage of resources and wear and tear.

A total of 44 health facilities were visited during the sample transport spot checks and data quality assessment exercise that took place from February to March 2024. The exercise was conducted in Mangochi and Zomba districts aiming to assess the effectiveness of the sample transport program and inquiring on the challenges faced by healthcare workers in accessing the USSD reporting system.

The OST system has refined healthcare logistics in Malawi, improving the efficiency and effectiveness of sample transport and diagnosis. Omar Chingomanje, the site supervisor at Jalasi Health Centre in Mangochi, highlighted the reliability and effectiveness of the OST system. He praised R4H for the improved Stage 1- TAT: from the day that samples are drawn from clients to the day that couriers collect the samples from the facility to the laboratory. Using the USSD reporting system, the TAT has been reduced from 3- 5 days to 2 days. “This improvement is ultimately enhancing healthcare service delivery at the grassroots level” concluded Chingomanje.

Similarly, Mark B Mmwala, HSA for Mtimabi Health Center which is located 42kms from Mangochi District Health Office (DHO) praised the system’s reliability and effectiveness.

Through spot checks and data quality assessments, R4H ensures the effectiveness of the OST system in improving sample transportation and addressing the challenges faced by healthcare workers.

With positive feedback from healthcare workers like Chingomanje and Mmwala, R4H is eager to continue enhancing the OST through improved USSD sample reporting to ensure quality healthcare delivery nationwide.

In March 2024, healthcare workers in 123 health centres of Zomba, Thyolo, Mangochi, Dedza, Mzimba North, and Nkhatabay districts lauded the R4H Medical Sample Transportation Program. Davie Jere, HSA at Dzindevu Health Center in Dedza, emphasized how the program fills the gap in providing timely clinical sample transportation to the laboratories and results back to the health facility. For instance, TB samples and EID-positive results are swiftly transported, aiding prompt clinic decisions. Feedback from other health facilities like Chintheche Health Centre in Nkhatabay and Hoho Health Centre in Mzimba district echoed appreciation for the program’s efficiency in sending samples to the laboratory and delivering results back to the health facilities in time.

Some of the notable successes where R4H couriers assist health facilities are cases where they transport other samples like Plasma which were missed out by the facility transport. This happened at Namwera Health Centre in March 2024, where Felix Masakasa, R4H Courier was asked to transport a Plasma sample to Mangochi District Hospital when it was realized that the facility transport had already left for the DHO and the sample was left out. Similarly, it was reported that R4H couriers also play a vital role when there are emergencies requiring immediate administration of treatment, for example, on certain occasions couriers are sent from Mtakataka Police Training School in Dedza which is situated 43 kilometers away from the DHO, to collect medicine from the District Hospital when needed immediately.

It is encouraging to hear healthcare workers express their satisfaction with the Sample Transport program and highlight any challenges for improvement, ultimately this is leading to improved clinical sample transportation services by R4H.