Melissa Levenger

I can’t believe six months has already gone by, half way through the fellowship already. Cliché as it sounds time really is flying by.  We just finished our mid-year retreat for Global Health Corps here in Rwanda and it was great to see the GHC staff and fellows from Tanzania and Malawi. One of the really cool things we were able to do was cross site learning; discussing our work’s challenges and successes.

This year many of us are working on supply chain issues and one re-occurring theme that will impact my work for the next six month is supply chain data capture. This data capture is essential forecasting pharmaceutical and consumable needs, as well as tracking stock management improvements.  In many in country supply chains in the developing world, the management of supply chain information is insufficient impacting everything from the central medical stores to the patient.  Without adequate information the health centers, district pharmacies, and central medical stores are unable to manage the supply chain efficiently.

In light of these problems, my main project for the next six months is data collection and forecasting for the district of Burera. I’ll be supporting the district pharmacy in supervising the health facilities in the district (health centers and health posts). This supervision tracks consumption, as well as stock management data, thus improving supply data capture and assessing stock management. The hope is with regular data capture, the district pharmacy will have a better idea of the supply chain reality within the district, be able to track stock management improvements, and enhance supply chain data to improve forecasting of pharmaceutical and consumable needs.

As the Burera pharmacy manager and I often say ‘petit a petit’ or little by little. It sometimes feels daunting when you see all the of the challenges that in county supply chains are facing but hopefully in the next six months we can really make an impact little by little on the supply chain here in Burera.

Imagine a hospital or a doctor’s office without electricity. No computers, mothers delivering babies by light equivalent to that of a camping lantern. This is the reality that exists for several thousand residents in Burera. We have begun assessing the data reporting quality of health centers within the district and while sitting in a meeting at one of these health center’s I couldn’t help but turn my mind towards the broader implications of the lack of power.

Specifically for data collection, this means that each patients visit records are kept in a register (notebook) maintained by a nurse. The breadth of data collection by hand is exhausting. There are registers for consultation, hospitalization, vaccination, maternal health, and that is not an exhausted list. Each time a patient comes all their basic information must be re-entered without computers to recognize name, date of birth, allergies, previous conditions etc. As one can imagine this leaves room for human error, with each nurse attempting to maintain these registers.

Burera undertakes an innovative data reporting mechanism, where essential statistics (collected in the registers) are reported to the district hospital via text messages sent from the health center each week. An example of a text message for reporting malaria cases would be “P.S.C 20” indicating that there were 20 cases of confirmed malaria during the week.

Despite this innovative technology, the human error mentioned above appears to be hindering accurate reporting. Imagine attempting to compile data from 11 or more hand written registers for reporting to the district hospital each week. It becomes easy to see why there is human error when one thinks of the breadth of data being compiled, not only different departments but different nurses each have registers as well. In addition to this, imagine compiling the data with a lantern for lighting, while interpreting several of your colleagues’ handwriting. It makes me think of difficulties deciphering my former bosses’ handwriting (no offense if you’re reading this) and how it would compound if I had to read 5 or more people’s writing as well.

But at the end of the meeting, I couldn’t help returning to thoughts of the human impact that a lack of electricity must have. I picture the man or women who injure themselves after dark while performing basic household chores or the pregnant mother being rushed to the health center to deliver by candlelight. While this is reality in many places, not just my district in Rwanda, one can’t help but think about how uncomfortable we Americans would be with this type of health care. And, in addition to that, why we in the West are by birth entitled to a quality of care that significantly exceeds this (no matter how poor we are).  Someone living Burera had no more choice of their birthplace and the resources available there than we do our own. Observing these differences makes the issue of health equity ever more poignant and important.

As I continue my fellowship working on issues of data, management, and the supply chain I’ve found it important to remind myself that these task are contributing to health equity as well. Continually witnessing more immediate needs it is often challenging to see the value in my work. But I’ve realized that improvements at the District Pharmacy will ensure better availability of medicines throughout the district and improving data reporting will allow for adequate and accurate financing and planning of the health sector by the government and partners. While not filling immediate medical needs such as increased staffing at health centers, these interventions can also contribute to health equity.

This is how they track monthly cases of malaria, diahrrea, and other diseases at the health centers here.

the team analyzing the registers for accurate data collection

Work here in Rwanda is beginning to get busy. Rainy season has arrived a month early, so the North Face gear is getting good use. I’m getting better at navigating the market and even the bus system in Kigali. And I’m even used to cold bucket showers (well sort of).

So it’s looking like I’ll be dedicating a lot of my time here to supporting the district pharmacy in Burera. The pharmacy has identified a lot of issues with its infrastructure and the pharmaceutical supply chain in the district that I’m helping them prioritize and hopefully implement. The district pharmacy, like many of the other facilities in Burera, lacks the necessary infrastructure and funding. Some of the pharmacies needs can have serious impacts on health care within the district. For example, the pharmacy does not have a back up generator. For those of you supply chain people out there I’m sure you’re already cringing. Basically this means that all ‘cold chain’ medicines, or those that need to be refrigerated/frozen, are likely to spoil if the electricity is not working (which happens more than you‘d think). For now, they take the medicines to the nearest health center, but it lacks the adequate space to hold all the cold chain medicines for the district along with other product loss issues associated with moving the product.

Availability of power has been a pretty constant theme over the last week as we implement our other projects as well. In Burera, only 9 of the 14 health centers even have access to electricity. And of those 9 centers, only 6 have consistent electricity access because of a lack of funding for generator fuel and the inability to use solar power in the rainy season. Can you imagine going to a doctor’s office or ER without electricity? Doesn’t leave much space to debate electronic medical records in the halls of Russell or Longworth in Washington.

The Clinton Foundation secured a grant for IT training for health care workers, including building an IT training center. But one question we’ve had to ask is whether training staff without electricity, let alone consistent access to a computer, on Word, Excel, and PowerPoint will actually have any long term impact. It’s a chicken before the egg type of issue. For now, we are training those who have access to electricity and computers. And as the district rolls out electricity to the remaining health centers, they will be trained at the new IT training center. Puts your frustration with losing your 3G network on the blackberry and iphone into perspective though right?

I’ll leave you with a few astute observations from the last three weeks in Rwanda

1. Michael Bolton, Celine Dion, & Kenny Rogers are still cool and possession of any of the three on your ipod immediately elevates your popularity. (good thing I’m super cool)

2. Goat liver and kidney are actually kind of tasty

3. Nitwa Mzungu. Just call me mzungu (white person).

4. Playing with your neighbors baby livestock indicates you would like to buy it and they will show up at your front door every morning with the sheep.

5. If you pick up a utensil or plate that you dropped, you are ready to get married. So ladies be careful if you ever find yourself in Rwanda and clumsy (like myself)

Health Center in Burera

Its the beginning of week three in Rwanda and its been a whirlwind of meetings and visits across the district. We’ve seen health centers, Butaro hospital, the district pharmacy, and visited the sites of some of the community health worker cooperatives that we will be working with.

For now, I am taking it all in. Soaking in the sites and the knowledge of the people that I am meeting. Burera is a beautiful part of Rwanda. Villages and the health facilities are nestled into mountains that surround two lakes, Lac Burera and Lac Ruhondo.

Soline and I are eager to get started with the day to day work here in Burera. We’ll be working with the district health director, community health worker cooperatives, and the district pharmacy.

Of course, we’ve been having a little fun as well. Eating brochettes, drinking Primus, and enjoying the DJ’s selections that transition from soul decision to akon to kenny rogers as if it is the smoothest transition a dj ever spun.

More to follow…