Isaac Mutabizi

16th January 2010 was an important day for Global Health Corps (GHC)! This was the day GHC organized its first retreat since the organization was founded. GHC has fellows working in Africa and the USA, and it was the African retreat that was organized first since the majority of the fellows are working in Africa, i.e Rwanda (8 fellows), Tanzania (6 fellows) and Malawi (2 fellows).

It was thoughtfulness and foresightedness of the leaders of GHC to have this retreat take place! First of all, we had spent six months in our placements. A lot had taken place in terms of our adjustment and integration to the work environment and the partner organizations. How we faced the work challenges in our first months and the approaches we took to overcome those challenges was essential and had to be shared not only with other fellows but also the GHC leaders so that it would help them refocus their mission.

Cross-sites sharing came out as an important approach for the fellows to share the challenges from different societal settings and different work environments and ethics. The approaches to health problems in Rwanda are different from those in Malawi or in Tanzania and it was vital to understand the cultural, political and social setting of these problems and how home-made or borrowed solutions are used to address these health challenges.

It was quite refreshing how huge mounds of problems became very manageable after sharing ideas, approaches and solutions from other fellows who had experienced same problems or gone through same situations. Equally humbling was the fact some challenges became insignificant in respect of what the other fellows were facing!

I couldn’t come to imagine setting in motion the Expert Client project of CHAI in malawi and managing the challenges involved, understanding the health management information systems  of a remote island off the coast of Dar es Salaam, getting involved in organizing and running a new and important multi-country infectious diseases surveillance organization that would be the epitome of an africa-led rapid response to infectious disease outbreak, understanding the intricacies involved in Government-Donor supply chain of  central medical stores nor was I in position to solve issues related to cooperatives that support the important work carried out by Community Health Workers!

By sharing all the above challenges, every fellow came out of the retreat with a new focus and a new way of approaching problems. The retreat set a platform for teams (pairs) to find constructive moments to reflect on their work and how their contribution has impacted on health care delivery in their respective GHC partner organization. The same platform made it possible for the fellows to set new individual and team goals and the integration of the borrowed good practices in their refocussed vision.

And the retreat was closed with a GHC Hiking For Health of Bisoke Volcano Mountain (12175ft) of Rwanda. For, in order to  promote global health issues, one needs a health body?!

Two months have passed since we started our placements. Two months are enough for one to have quit given the insurmountable challenges with no immediate solution over the horizon! You have experienced various forms of despair:

You dropped into the middle of a developing world, more to that, to an area where the basics of life are considered dreams; where load-shedding (electricity rationing) is the norm; access to constant running hot water or even cold clean water is a nightmare; where food is bought hundreds of miles away and on top of that it is strange food; where mosquitoes and bugs haunt you at night and insects haunt you during the day; where drinking bottled water makes you a millionaire or if you’re the soft-hearted you convert the equivalent of the bottled water with two-days of food for a whole family living near by your dwelling place; where connecting to the internet or lack of it thereof astounds you – imagining how you can spend a day, a week without chatting, skyping, tweeting, e-mailing your buddies and family; where kids run after you calling you ‘ Mzungu’ and begging and in your frustrated Americanness, you can do nothing to change their plight; where language and cultural barriers derail your progress; where you witness sheer poverty, extreme and disgusting health conditions, etc, etc

But the beauty of it all is that you have stayed on! And that to me is the whole essence of social justice – Not to give up when faced with challenges!

To understand where we have reached, let me take you through how my journey started…

The Orientation Week

It is on the morning of August 4^th, 2009 that the Rwanda GHC team (Ian, Benoît, Mia, Melissa, Soline, and I – mark was still on holiday) meet at the PIH/CHAI office in Kigali. The American fellows are still experiencing jetlag because they arrived the previous day but the enthusiasm for the task ahead fuels them to make it to the next day’s meeting. Eric, the CHAI representative at the orientation and their Procurement Analyst take the team through what CHAI stands for and how it goes about its activities. Eric takes through the history of the Clinton Foundation/CHAI existence in Rwanda, how it collaborated with the Government of Rwanda and the communities. The procurement analyst took us through the UNITAID system of procurement whereby some countries that have sought membership in this organization help each other to access ARVs cheaply due to bulky negotiation and purchasing. Airlines in these member countries accept to donate a percentage of their air-ticket fees to UNITAID. Clinton Foundation being a member of this organization has been able to benefit from this system in as far as procurement of ARVs is concerned.  However, we would the following day come to understand that PIH procures medicines through a different system.

On the evening of the same day, Ingrid Kamikaze – the Training Manager of PIH – took us briefly through the reflection of what we intend to do for the whole year – what she termed the ‘NOW’ and THEN. NOW – to mean what were our first tasks (short-term goals) and THEN – to mean our long-term objectives for achieving our yearlong placement at our two organizations: PIH & CHAI.

The following day, Victor – the Director of Procurement and Logistics at PIH gave us a break-down of procurement at  which PIH was involved in procurement of medicines and consumables, hospital sanitaries, office stationery, Car maintenance, buying cars, medical equipment and procurement of infant formulas for malnutrition. He stressed that procurement is done locally and internationally. Locally through public tendering procedures. Procurement of medicines and consumables, and hospital equipment need approval from the Ministry of Health and then Boston (PIH Head Office) helps in identifying qualified drug companies and equipment donors. PIH enjoys a blue channel system with the Government of Rwanda where all PIH importations are not off-loaded at the customs for inspection to avoid delays.  This was good news since the stringent inspections protocols at the customs would affect the timely delivery of medicines and consumables to the hospitals and health centers. However, there are arrangements to have the goods checked on site by the customs and Rwanda Bureau of Standards so that quality is maintained.

After Victor’s presentation, we were treated to a glorious lunch at Africa Bite in one of Kigali’s posh suburb where Ian, Melissa and Mia were introduced to Rwandan food.

On Thursday of the same week, the whole team journeyed to Rwinkwavu where PIH operates. The Kigali office is small and is there to coordinate activities in Kigali and outside. At Rwink, Emily – the head nurse – welcomed us and took us through what their operations were, other sites they operated from nearby in Kayonza and Kirehe Districts. She had us visit the different areas within the hospital such as the Pharmacy and its warehouse, the Electronic Medical Records fondly known there as the EMR and talked to Cheryl, the director of this department. We found out that the EMR was organized in two ways. The EMR for monitoring HIV/AIDS patients who are either on follow-up (have not yet started ARVs) or those that are already on medication. The system helps to monitor CD4 levels to determine how patients are improving or when to start taking medication.

Friday morning saw us on our way to the North of the country (Burera District) where PIH is running a hospital (Butaro Hospital) and health centers and CHAI operates some community social programs which would be home to Melissa and Soline for the next twelve months. Butaro with its lush green mountains and valleys is eye-catching with a pleasant climate.

The warm welcome accorded the group upon their arrival with ready refreshments of Kinyomoro juice (another kind of passion fruit juice) and Eagle Beer set the jovial mood rolling. With the constant attention from Jean d’Amour – the head of Administration and Finance – and Mickey, a visiting Dr from UK – everyone felt at home within an instant. After the heavy meal washed down with Mutzig, Primus, Amstel and Eagle beer it was campfire time, which was enjoyed under a specially built traditional, grass-thatched hut with a fireplace.

The singing birds that were accustomed to the cold highlands woke us to another beautiful day (Saturday) in Butaro. After a satisfying breakfast of oats, Spanish omelet, French bread – pain français – spread with Rwandan honey, margarine, homemade peanut butter and washed down with the famous Rwandan coffee and tea, Dr. Mickey was ready to take us through what PIH is doing in Butaro Hospital and elsewhere in the District.

He took us through the mission of PIH, which he summarized, in the following words: We (PIH) endeavor to do a lot more in regard to health – whatever it takes! (Medical care + Social services + social justice)

In this holistic approach that PIH takes, Dr. Mickey summed it up in this way: It takes more than just building hospitals, training doctors, training Community Health Workers…

The Work Starts

Back in Rwink (short for Rwinkwavu) work starts! East – West, North – South, we are not sure where to start, what is expected of us (Ian and I) and how to go about it! But we have to start somewhere anyway! We are rescued by Emily, the Head Nurse who introduces us to the Warehouse that houses some medical equipment and consumables; who introduces us to Amber who is in-charge of procurement at PIH Boston; who takes us around the different services introducing us to the different people we might later need such as doctors, nurses, pharmacists, drivers, maintenance technicians… In short, she gave a direction and from there we have never looked back. We have managed to chart a clear direction for ourselves, set goals (short-term and long-term) and what remains is how we get there.

A Bit of Geography

By the way I didn’t give you a run down of the different locales we are oscillating to and from every other week!

The new hospital is being constructed in the Northern Province of the country in a District known as Burera. It is approximately a two-hours’ drive from Kigali, the capital if you are traveling in a 4×4 wheel drive, strong car because part of the journey is by a dirt road. Burera area is mountainous with beautiful display of lush green-topped mountains mostly by eucalyptus trees and terraces (to prevent soil erosion and also use the terraces for farming since there is no flat land in the area for farming). The Northern province is densely populated and is considered the food-basket of the whole country since most of the food that feeds the capital comes from there.

Furthermore, the North is home to the extinct volcanoes popular among them are: Muhabura, Sabyinyo and Bisoke! Muhabura is famous in Rwanda because I have come to find out that most places are named after it: buildings, hotels, transport companies, etc. Two plausible reasons come to mind as to why this particular volcano is famous: one, it is the home of the biggest remaining Gorillas and second, during the war of liberation, the freedom fighters (Rwanda Patriotic Army – RPA) now the Rwanda Defense Forces used the volcanoes as their base.

Another site where Partners In Health (PIH) is working is Rwinkwavu in Kayonza District, Eastern Province. Rwinkwavu is considered as the Headquarters of PIH where it runs one hospital (Rwinkwavu Hopsital) and a number of Health Centers. The Eastern Province is an arid area populated by cattle keepers (so, they supply the capital with milk and meat). Water is scarce and during the dry season, the area becomes barren and people and animals suffer a lot. The area is proud of the Akagera National Park with all sorts of animals, birds, and flora. It is called Akagera because it is near Akagera River that separates Rwanda from Tanzania and Uganda in the East. In the East also, PIH operates another hospital (Kirehe Hospital) and some health centers in Kirehe District towards Tanzanian border. This link below will give you an insight into what PIH is doing in Rwinkwavu if you have not seen it already.

http://www .pbs.org/n ow/shows/5 37/index.h tml

Back To Work

Back to my work! Once we started at PIH, we found out that there were lots of ways we could improve the management of the medical equipment – their procurement, distribution, and maintenance. Furthermore, the procurement protocol that exists is not detailed enough to give procedures and guidelines so as to strengthen aspects of accountability and transparency. The procedures would help in undertaking procurement of anything – office supplies, food supplies, vehicle and spare parts acquisition, construction and facilities’ maintenance, and drugs (PIH has some protocols on drug procurement) etc.

Our immediate challenge was to carry out an inventory of the medical equipment that had been donated by different donors such as Medshare, International Aid and AFYA Foundation. The purpose of this inventory was to come up with a feedback report for the donors on the condition of the equipment, how useful they have been and the issues of maintenance.

Another task was to come up with an inventory of all equipment that needed immediate repair so that we could procure the services of the Ministry of Health Maintenance Workshop for their repair (of course it is not free, PIH has to pay these guys).

Coupled with the above is the compilation of a needs list for the new hospital in Burera District. It is an important project to PIH and to the Government. The Government needs the hospital to be complete by March next year which is not an easy task since PIH had planned to complete the project to take two years but the Government wanted the services of the hospital in one  year as Buerera District is densely populated with few health services available. You can imagine the strain on the project management in terms of time, resources and personnel! With this short timeframe, a lot could go wrong in terms of procuring expensively the construction materials, supervision of quality is impacted upon, and keeping track of project expenses becomes challenging.

The challenge we have in coming up with this list of equipment is that we have to move fast before major constructions are done. We need to understand the kind of equipment we will need, their dimensions so that they could fit in the designated rooms. For example, we don’t want to construct an x-ray room with floor area that will not accommodate the machine and if it does, to have extra floor area for functionality of staff and patients. Even then, we need to know in advance the equipment dimensions so that it could easily pass through the assigned doorway. Another major challenge is that we have to scavenge all over the Internet searching for the equipment (some of which I don’t know about, I have never seen, I don’t know their names, what treatment they are meant for, etc). There is no local manufacturer or supplier of biomedical equipment we could visit and easily get this information from!

But so far so good! The hospital construction is moving on at a terrific speed and the quality is fine! The list of equipment is coming up fine. We started by doing an inventory of the existing equipment in the old hospital, and then made a spreadsheet for the heads of hospital departments to fill out the necessary equipment they think the new hospital needs and also make their wish list (dream list). With these lists we are going to first compare with the Ministry of Health norms for a District Hospital (in terms of quantity and floor area) and then also compare with the floor area and the number of services envisaged in the New Hospital. This list is essential so that PIH and the Ministry of Health (MoH) can start planning where to get the equipment – either by looking for donors or the MoH footing part or all of the costs.

After we are done with the list, we are planning to embark on designing a procurement manual and a Medical Equipment Management System for PIH in as far as the three hospitals are concerned (Rwinkwavu – Kirehe – Butaro).

In a nutshell, this is how the situation has been and is at the moment. I know it is a long Newspaper story! I took time to blog! Better Late Than Never!

On the social life, that will be next…