First day in the Land of a Thousand Hills

After a 10-hr flight from Houston to London Heathrow, 8-hr layover in London, 9-hr flight from London to Nairobi, 1.5-hr layover in Nairobi, and 1.5-hr flight from Nairobi to Kigali (capital of Rwanda), we finally made it to our final destination: the Land of a Thousand Hills.

The weather here is cool-to-warm, ranging from temperatures of 66 to as high as 82 degrees Fahrenheit.

My very first impression of Kigali is the neatness and organization of the city, especially in comparison to the other African countries that I have visited.  Ghana is bustling and hectic, and Malawi just lacks the appropriate infrastructure.  With well-maintained roads  and new buildings sprouting up in places, Kigali seems like a surprisingly ordered and clean city.

We used our first day in Rwanda to recover from the travels and jet-lag.  We had a couple good meals and enjoyed the local beer. Tomorrow, we will visit several cultural locations in Rwanda to get a better idea of the Rwandan culture and perspective.

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Across the Pond to London!

I’ve officially embarked on my journey to Rwanda, and we’ve made an eventful layover in London.

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Second Microenterprise Training Sessions

The glaring problem that we identified when visiting our target student population of HIV support groups and Village AIDS committee was the lack of long-term planning. It seemed like these people focused on meeting their own daily needs for basic necessities in the present, and that planning for the future was an impossibly difficult task. To address this problem, the hospital decided to encourage planning for the future by requiring an action plan from each of the HIV Support Groups and VACs. However, when we requested action plans from some of the groups that we had visited, we received plans that ranged from being comprehensive to being rather cursory. Therefore, we decided to integrate lessons on 1) developing an action plan, 2) developing a budget, and 3) keeping an accounting ledger, all to encourage planning for the future. Moreover, these lessons would instruct our students how to implement what they had previously learned in our previous session with the six lessons from Barefoot MBA.

This time, the conference room of the new Family Care Center Unit (FCCU) of St. Gabriel's Hospital was available for us to use. It was certainly an upgrade from the make-shift conference room in the cafeteria from our first training session!

Action Plan Lesson
During the Action Plan lesson, I noticed an absence of class participation, which was quite odd since I had structured questions concerning the importance of vision in developing an action plan. Vision is important because it represents a long-term goal or dream that provides motivation and direction. A vision can guide actions and unify a group of people to work in a united effort, which is especially important for these HIV Support Groups that have a hard time motivating their members to contribute to the group. At first, I thought that Angela (HIV Support Group Liaison who was the one lecturing) was skipping over the Vision section of the lecture. However, I found out that Angela did in fact go over the Vision section of the lecture. The responses to “What is your vision?” were just inadequate: most of the students simply said that their vision was to “start a business.”

The problem with the vision of “starting a business” is that it’s short-term and hardly provides the guidance for future actions. Yes, starting a business is a goal, but what’s the true purpose of starting the business? Is it to ensure financial and food stability during the infamous “hungry season” that lasts from September to January? Is it for personal gain? Is it to send children to secondary school? Is it to start an HIV orphanage? My point is that the vision “starting a business” isn’t a great vision because it’s a means to an end that hasn’t been specified. The vision should be the end. It should be the dream that not only guides and provides a clear path for actions, but continually motivates everyone. “Starting a business” is an action that one can take, but it is by no means the dream or long-term goal that people are shooting for. What happens when one “starts a business?” If one says their vision is to “start a business,” then I guess one has already accomplished their dream, and must come up with another vision to replace their previous, short-term vision. Perhaps the reason why our students gave the answer as “starting a business” is simply because our entire trainings were focused on business skills, and they thought that this was a satisfactory answer.

It took me a while to explain this to Angela, and she either understood it quite well or was in polite agreement, which is customary for Malawians. It was just impossible to understand what exactly was going on during class and judge whether or not our students really understood our lessons. During the first class two weeks ago, Angela started to translate students responses for us, but we told her to stop since that would make the class too inefficient and bore the students (who didn’t know English). Perhaps the best solution is to ensure that 1) the teacher fully understands the entire lesson (maybe make the teacher rehearse the lesson in English to ensure the teacher’s comprehension) or 2) learn the native language.

Microfinance Loan Survey
After the budgeting lesson, we passed out a paper survey to assess students’ knowledge of microfinance loans. During our first training, we had given a lesson on debt, and the students had asked why we were not offering them money. We were shocked, and we became very interested in finding out whether our students knew of how to obtain a loan from the biggest microfinance organization in Malawi, Opportunity International Bank of Malawi (OIBM). Tiffany designed a 8-question survey that assessed the students’ knowledge and experience with microfinance. Administering the survey was frustrating: questions were left blank or answered in the incorrect form, even after Angela had provided additional instruction. We had to look at each survey one-by-one before collection to ensure that all the questions were answered completely and correctly, to ensure the validity of the survey. Nevertheless, the initial results were interesting: most of them knew of OIBM, some of them had tried to get a loan, but very few of them knew how to get the loan, and almost none of them had actually gotten the loan.

Filling out a survey. These were hard to administer, but we appreciated our students' cooperation!

Accounting Lesson
Despite being the shortest in duration, the accounting lesson was definitely the most interactive and fun. When we visited the HIV support groups, we noticed that those that did keep records kept stray pieces of written paper in plastic bags. It looked like records could have easily been lost or damaged among the jumble of papers. Therefore, we wanted to get accounting books for our students to encourage organization and maintenance of financial transactions related to their support groups. We ended up going to Lilongwe to purchase accounting books from ShopRite, which is a major South African supermarket chain all over southern Africa. We stapled printed review material in Chicewa to the covers of each accounting book as reference. We also purchased blue pens and plastic sleeves to protect the books from the prevalent red dust here. We bundled the three and gave an accounting package to each of the HIV support groups and Village AIDS committees.

Accounting package with an accounting book, blue pen, and protective plastic cover

We also stapled a study guide review in Chichewa covering materials from both training sessions.

Their excitement and gratitude were apparent, especially as the treasurer of each group came up to the front of the room to receive his/her accounting kit. It was also apparent that other members who were not in possession of a kit were jealous.

Angela (HIV support group liaison) explaining how to fill out the accounting books.

Here, students are labeling the columns for their accounting ledgers.

Tiffany and Angela explaining how to fill out the accounting books using an example.

At the end of the training sessions, some of the students rose for a couple minutes to speak. Since it was in Chichewa, we only found out later that our students were expressing the gratitude for the trainings we had put on for them, especially since it had been about a year since they had received trainings at the hospital. Of course, Tiffany and I were grateful that they had expressed their appreciation, and it was only at the end of the fourth and last training did we have the opportunity to say our “parting words” with the students.

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High Tech Medical Records System at St. Gabriel’s ART Clinic

The Baobab Tree. It's supposed to look like it was planted upside down.

The Baobab tree is famous here in southern Africa. It’s a majestic tree with an enormously thick trunk that also lives and grows for hundreds of years. One organization here in Malawi has adopted the iconic Baobab name to demonstrate their commitment to improve the health of the people of Malawi. Baobab Health, based in Lilongwe, offers innovative and high-tech medical records solutions for hospitals here in Malawi, and we got a glimpse of the recent Baobab medical records system installation in the new ART (AntiRetroviral Therapy) clinic, which provides free medication for HIV suppression to hundreds, if not thousands, of HIV patients within St. Gabriel’s catchment area.

Funding for this new medical records system specifically for St. Gabriel’s ART clinic was generously provided by the fellowship of Issac Holeman, co-founder of FrontlineSMS:Medic, who was stationed at St. Gabriel’s for the majority of this year. It’s an amazing, innovative, high-tech, and robust system that is quite unlike any of the traditional book and paper systems observed in the rest of the hospital.

Here are some highlights:

  • Four touch-screen terminals with barcode scanners and label printers are individually stationed in the nurse’s room, two ART clinician rooms, and the ART dispensary.

Networked, touchscreen kiosk with label printer

  • Terminals are networked to a main server, and the entire system is powered by either the hospital’s electric grid or a backup battery system that can last for several days.
  • ART patients are first received in the nurse’s room. For patients already in the Baobab system, the nurse scans the patient barcode, which pulls up the patient file.
  • The system asks if the patient is present, and if the guardian is present.
  • If the patient is present, the system asks for weight, and presents a numerical BMI number (to detect malnutrition) and a historical graph of BMI. BMIs that are unacceptably low are highlighted in red, and the nurse will then counsel the patient.

The Baobab system tracks BMI and notifies users if BMI is too low so that the patient can be counseled.

  • The system then asks for patient’s health complaints, and the nurse can select from a list of symptoms that are related to HIV.
  • The system then asks for numbers of ART pills remaining, and automatically calculates adherence on the spot. The nurse counts the few pills remaining in the bottle (rather quickly by eye). If the patient has missed any pills, then the nurse questions the patient.

    The Baobab system requests for number of pills left over to calculate adherence, which is crucial for effective ART treatment since HIV mutates so fast.

    If the Baobab system has calculated poor adherence, then the ART staff will counsel the patient.

  • Based on an existing algorithm taking into account BMI, symptoms, and past history, the Baobab system will decide whether or not to refer the patient to the ART clinician in the next room, who has his own Baobab terminal.
  • Patients are then automatically scheduled to come back based on the number of pills they will receive.
  • Scheduling is optimized to equally distribute patients that come in on each of the 3 HIV clinic days to even out the workload for the ART staff.

The ART clinician brings up the patient record via barcode, and makes the appropriate updates to the patient file.

  • The system is capable of performing HIV staging based on the symptoms that he enters into the system and World Health Organization (WHO) HIV staging standards.
  • If the clinician observes any respiratory distress (TB) or infection, then the patient is admitted to the hospital.

The patient then proceeds to the dispensary.

  • The amount of pills (often extra pills) is automatically calculated by the computer to allow for future calculation of adherence.
  • Pill packaging is labeled by barcode and automatically scanned and associated with a patient record.

The Baobab system currently being implemented in the St. Gabriel’s ART clinic is truly a remarkable and revolutionary system. The ART staff that used to almost be overwhelmed by the amount of patients and tasks associated with HIV treatment is now delivering great treatment with remarkable efficiency. It is truly an example of the efficiency that is greatly needed in developing healthcare settings all over the world. However, I am not sure what were the costs of such a system, and whether it is practically affordable for the health organizations here that truly need it.

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Innovation key to getting medical supplies to those who need them most (via The Unreasonable Man)

This is a very well-written article that elucidates current problems in the medical supply chain in developing countries and provides ideas on potential solutions to these problems.

This story was originally published in the Georgia Straight on January 26, 2010. By Goldis Chami, Rebecca Goulding, and Calyn Shaw Imagine that you have a steady stream of vaccines, medicines, and diagnostic tests that you want to use to help improve the health of hundreds of thousands of children, women, and men in low and middle income countries. How would you go about reliably and cost-effectively delivering steady supplies of these goods to v … Read More

via The Unreasonable Man

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Potential Talent for the Tour de France…in Malawi!

Remember when we saw pictures of Chris Horner giving a ride to a poor guy who had wrecked his bike at the Cascade Classic?

Ski Star Demong hitching on Chris Horner's bike in Cascade Classic 2008 (credit: Velonews)

This was the first image that came to mind when I made my first trip to the main road from the hospital, which is separated by about 3 miles of red, dirt, and bumpy road.  To access the main transportation on the main road, we needed to first get TO the main, paved road.  Luckily, bikes are so commonplace here in Malawi that you can hire a bike taxi to take you places!

For only $1.33 (200 MK), you get a 15-minute ride from the hospital to the main road on the padded seat on the back of a bike!  Never mind that you sometimes feel like you’re going to get launched off the back when going over giant bumps or that many Malawians, including the bike taxis, don’t ever use deodorant.  It’s exhilarating going so fast down hills (I guess heavier weight helps), especially on these bumpy dirt roads.

Bike Taxi with Heavy Bike (probably 35 lbs), heavy cargo (175 lbs). I'm impressed!!

However, going uphill is a different story.  Heavier weights make it more difficult to go up a hill.  It’s especially evident when I see my (lighter-weighted) friends zooming pass me on their own bike taxis, and when I pass other people who are heavier than I am.

One time, I had the misfortune of choosing a bike taxi that was probably not as fit to carry someone my weight.  On the uphill, he was grunting and sweating, and we eventually came to a stop on the hill, and I had to get off and walk up.  I really felt quite bad for that bike taxi.  Another time, the chain fell off, which was quite scary; the only thing I was thinking about was, “Am I going to crash?!”

Regardless, I’m always impressed every single time I take a bike taxi. We go surprisingly fast for how heavy the bike and the passenger are.  When we take bike taxis in groups, they even draft off of each other, and take turns drafting.  It’s quite amazing! I swear that these people probably have an amazing base from riding so much everyday and carrying such huge loads all the time.  I really think that it wouldn’t be completely out of the realm for some of these bike taxis to do REALLY well in bike races. Who knows? Maybe someone is already recruiting these bike taxis for the Tour de France…

Team of bike taxis drafting (blocking the wind for people behind)

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First Microenterprise Training Sessions

We had our first microenterprise lessons to the leaders of HIV Support Groups and Village AIDS Committees (Community Healthcare Volunteers that facilitate the formation of these groups) under the auspices of St. Gabriel’s Hospitals here in Namitete, Malawi.

Of the 144 students we were anticipating, about 100 arrived from all over the Namitete region, mostly by bike.  Our students were a diverse group of men and women of all ages.  We had informed them of the trainings using Frontline SMS, an innovative and affordable technology that uses existing SMS and cell-phone networks as a means of communication among large groups of people such as our students.

Our students arrived on bike.

We had divvied them up into four groups of 36 to facilitate group discussion. We covered 6 topics that Angela (the HIV Support Group Liaison here at St. Gabriel’s Hospital) had handpicked from our Malawian-adapted Barefoot MBA lessons, and she worked hard to translate all 6 topics into Chichewa

These topics included:

  1. Planning and Records
  2. Savings
  3. Production
  4. Debt
  5. Investing
  6. Incentives

The general structure of the Barefoot MBA lessons included (in the following order):

  • Overall concept
  • Background story
  • Specific, story A demonstrating a bad example of the concept
  • Specific, story B demonstrating a good example of the concept
  • Questions asking about the stories, ranging from simple recall questions to full-on application to their own experiences.
  • Summary of the stories and concept

We decided that it would be best to reinforce the concepts and stories using PowerPoint. It was useful to have the stories displayed on the wall, as the students often repeated and read over the stories after Angela presented the stories, which is typical of the Malawian learning style.   Also, we thought that it would be best to have stories remain on the PowerPoint for reference while Angela asked them questions.

We had a PowerPoint set up to reinforce main concepts and stories. Screen reads "Planning and Records" in Chichewa. Trainings took place in the hospital's cafeteria.

Halfway through the training, we had a 15-minute break with refreshments. This worked wonders in terms of livening up discussion. It’s amazing what sugar can do to a class!

It is customary to provide a meal or refreshments at any trainings at the hospital, especially because transportation to and from the hospital is such a burden. Coconut cookies ($0.67) and Soda ($0.40)

Because the entire lesson was taught in Chichewa, it was hard for us to understand what was really going on.  We did get quite excited, though, when we observed energetic discussion going on about the stories and topics.

Angela (St. Gabriel's HIV Support Group Liaison) teaching our lessons in Chichewa (local language here)

We were reminded of the HIV Support Group and VAC’s dependence on St. Gabriel’s Hospital during our lesson on Debt; the students had asked why St. Gabriel’s was not giving them money at this training.  This dependence on the hospital is a source of frustration for not only us, but the leaders of the hospital.  Financial and agricultural resources recently given to these groups as a means of setting up income-generating projects have not been used wisely, since the groups tend to simply distribute these resources among themselves.  For example, instead of ensuring that donated pigs reproduce enough piglets for a steady and consistent supply of pigs, the groups tend to simply distribute these pigs amongst themselves instead of breeding them, and after the pigs are slaughtered, they ask the hospital once more for another donation of pigs.

During our next lessons on the 26th and 27th of July, we plan on teaching our students how to implement the business skills that they learned during this week’s training.  We will also emphasize achieving financial independence from the hospital by taking a loan from Opportunity International Bank of Malawi (OIBM), which would make them much more accountable spending loaned resources wisely.  A major difficulty with obtaining a loan from OIBM is that one must go to the Malawian capital Lilongwe (about 45 minutes transportation by minibus) to obtain this loan.  Also we have heard that there are stringent requirements such as business plans and training classes.  This is perfectly understandable from OIBM’s perspective; business operations must be sustainable, and these stringent requirements ensure that the majority of loans are repaid.  Hopefully, our training will be adequate preparation for these students to take this next step in obtaining capital for their small business.

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