Ensconced between folds of gently rolling hills in rural Rwanda lies the Ruhunda Health Center. This clinic is fairly typical by African standards. Cows graze in the adjoining pasture; mothers and tired children wait in negligibly clean, open air sitting areas; and staff members support operations in the maternity and general consultation wards by running buckets of water from a pump outside. It’s no Beth Israel or even Patient First in America, but it is suffices, meeting the needs of the 22,167 people whom it serves in the villages of Gishari, Munyiginya, and Ruhunda. To them, the clinic is merely an extension of their daily reality - poverty - and there is little which they can do to change that.
At Ruhunda, patients can access a range of services, including maternity, general consultation for children and adults, minor surgery, family planning, vaccination, and voluntary counseling and testing for HIV, among others. The center also runs a successful community health worker (CHW) program which trains Joe Schmo Rwandans to go into communities and conduct information sessions on a range of health topics.
A cursory review of the facilities and programs in place at Ruhunda would yield a positive review in the eyes of many a Rwandan health official. They would interpret the above description as evidence that Ruhunda is a self-sustaining health center. But they would be wrong. Oversight and planning of any kind is minimal. Reform is needed to improve the quality of care offered at Ruhunda and the countless health centers like it, but change won’t originate in top down Rwandan reform or by peasant uprising. Nor can we entirely rely on staff members who are too consumed by processing patients quickly and day-to-day survival to be the whistle blowers. There can be no doubt that the Ruhunda Health Center is in great need of additional reform and aid. The real question is what type of aid do they need most.
Different people would answer this question differently. Jeffrey Sachs might visit Ruhunda and proclaim the need for increased bed net distribution to allay the high prevalence of malaria, one of Ruhunda’s most frequently-treated afflictions. If Bono trekked out to Ruhunda, he might lobby for increased ARV monitoring and distribution as the keys to success. Scarlett Johansson would probably talk about malnutrition, kitchen garden demonstrations, and maybe a de-worming campaign. And me? What is my recipe for improvement at Ruhunda? An annual budget plan, drug requisition formulas, and a modem to update antivirus definitions on the center’s three out of four functioning computers. This, my friends, is the less sexy, but equally important aspect of development work.
Allow me to clarify. I say “sexy” because concepts like financial management and data processing do not pull at the heartstrings like AIDS orphans or school fees. Terms like these will never grab headlines and will forever struggle to grab the attention of most development workers. And yet these issues are equally as important and influence the quality of service for patients with illnesses like malaria, AIDS, and malnutrition. How can a health center with no annual budget in place afford to plan vaccination campaigns, buy or replace equipment, or even pay its staff? If the pharmacy is stocked out on mebendazole, how will they treat 5-year old Esperance who has contracted ascaris worm and subsequently suffers from malnutrition? Indeed, how can a center expect to achieve progress on any front if they fail to accurately record and analyze monthly data? This is what The Access Project and I, as a member of this organization, strive to improve each day.
Peace Corps assigned me to The Access Project – a project run out of Columbia University and The Earth Institute - in early December. In the beginning, I had only a vague idea of the organization and its goals. “They focus on macro-level management and infrastructure issues,” I told people, not really knowing what I meant by those words. But my friends seemed to buy it, nodding their heads knowingly in response. I bought into this hazy idea too, intrigued by the prospect of working on big picture issues after concentrating so heavily in health education on the ground in Mauritania.
After a few weeks in “the field” - traveling to remote health centers, interviewing staff members, and surveying record books and general conditions - the heretofore fuzzy objectives of The Access Project became increasingly defined. Suddenly, I was cross-checking health metrics data, brainstorming methods to streamline insurance information, and admonishing health center directors to purchase internet modems. In between, practicing English with every other Rwandan, of course. Suddenly, I understood how useful a business mentality could be if applied to the health system. Each of the centers I visited was functioning below its optimal capacity because of poor management and/or lack of obvious incentive to change its current practices. Believe it or not, the resources and money were there; all they needed was a little training, a push or, more likely, a shove in the right direction, and, most importantly, a change in mindset about their responsibility to provide the best care possible…which is where my work begins.
Each day, my fellow team members and I drive 30 minutes, 1 hour, 2 hours out to health centers tucked away in remote corners of the district. Our team of four consist of Anatole The Hun, our driver; Charles “The Strongarm” Ngirabatware, former politician and head of Access in the Rwamagana District; our resident number cruncher and erstwhile bookie, Pascal; and yours truly, the supposed tech guru (laughable, I know). You’ll have to pardon the nicknames; I like to pretend that our cadre is a highly-specialized team akin to the one amassed by Ethan Hunt in Mission Impossible, just without the marshal arts and bloodshed. It spices up long drives.
When we arrive at the health centers, the act ends, and we all set to work on our respective tasks. Pascal meets with the accountant and/or the insurance manager to discuss budget plans, review financial records, and check insurance enrollment. Charles discusses necessary improvements in infrastructure, planning and coordination, and human resources with the center director. He also steps in whenever Pascal or I need help applying pressure or, in my case, translation in one of our sectors. Officially, I split my time between data management and IT, but, more often than not, I end up teaching Excel 101, virus prevention, and how to use System Restore to rooms crammed with administrators.
Crowding around a beat up laptop, we wile away hours on end, experimenting with different formulas, plugging data into graphs, and reveling in the mystery that is file creation. On slow days, I start scanning all computers at one time and reward the staff member with the lowest number of infected files. They love to mock the person with the most computer viruses; it’s an interesting spin on peer pressure. In those sectors which record information electronically like Finance, Data, and Insurance, I stress weekly and quarterly data back-up. I never thought I’d derive as much pleasure from IT as I did from health education, but I do. The joy on Victoire’s face when she master’s graph creation in Excel is the same as Aminetou’s when she learns how to convince others not to use skin lightening cream.
Some might perceive my IT and data management lessons as a drop in the bucket in terms of effectiveness, but I know they’re not. I’ve seen the results – the spike in efficiency and tech comfort, the greater care afforded equipment at the center, the increased awareness and response to predominant health issues among health center staffs. This is the less sexy side of aid at work. If you’d like learn more about the efforts of The Access Project, you can read up on them at www.theaccessproject.com. I am also in the process of applying for a grant to install running water in the maternity and general consultation rooms at the Ruhunda Health Center. If you’d like to donate to my specific project, wait a week and then look for it at http://appropriateprojects.com.
Applying MBA practices to health care management is not a revolutionary thought in the world of international development. In the wake of massive, billion dollar aid programs which produce mediocre results, academics and practicians have long hailed the need for increased oversight and application of a business-like mentality to development work. “Reward results, not grandiose plans!” they cry. I get it. Now, I understand their arguments in a very real sense. Only, my battle cry is a bit different and, again, not as catchphrase-worthy. If I yelled, “Improved efficiency, monitoring, and management!” into the LiveAid crowd, I would probably get a few polite claps, some confused shrugs, and the overwhelming sound of crickets. But it’s true. We need to focus on the managerial and systemic roots of certain problems in order to improve the overall quality of care and response to those big name diseases. (In America too!)
