Tanzania Needs More Mamas

The Economist recently released an article about the challenges international organizations have faced when attempting to do business in Tanzania entitled “What’s the Hurry?” It resonates with my experience and offers some validation to what has felt like the most challenging aspect of my work thus far. The last paragraph captures the gist:

Mr Kikwete (the President of Tanzania) has at least tried to give the appearance of curbing corruption. A Bank of Tanzania official was acquitted of puffing up the cost of building a bank from $73m to $357m but found guilty of “abusing power”. Visiting businessmen, however, say they are still deterred by red tape, a weak legal system and a lack of skilled labour. Above all, they say, Tanzanians seem to lack a sense of urgency.

Call it a lack of urgency, a lack of motivation, or failed incentives, the real problem is that things do not get done. I can’t remember how many times deadlines have been missed, commitments have not been met, or meetings have been delayed by weeks, all while constituents assume a complete lack of responsibility or remorse. Inaction and failed follow through is business-as-usual and even a small amount of pressure against this culture can be viewed as being pushy and culturally insensitive.

When I’ve outwardly exhibited impatience during my year here, I’m invariably reminded by a Tanzanian around me “This is Africa” read "what do you expect?" But my travels to neighboring East African countries and this article suggest the lethargic pace of life is actually a culture more distinctly Tanzanian than African or East African. Some Tanzanians, however, are paving the way for a cultural paradigm shift.

One woman I’ve had the pleasure of working closely with this year from the district health management team in Kilwa defies the prevailing work culture in Tanzania. Innocentia Mangosongo, or Mama as everyone calls her, is the district head of maternal and child health though she clearly stands out as the leader of the male-dominated health management team. Tirelessly working 10 hour days and most weekends, I’ve observed Mama’s passion and vision driving the impressive progress being made to Kilwa’s health system. She leads by example and sets high expectations for staff members throughout the district. And, against all odds, things get done!

While long delays for business deals are undoubtedly frustrating, inaction and delays in the health field, unfortunately, have truly dire consequences in Tanzania. Kilwa is lucky to have Mama Mangosongo but many parts of Tanzania aren’t as fortunate. With time, my hope is that more Tanzanians continue to step up to work in a proactive, determined way because there’s no telling what a country full of Mamas can achieve.

Barbara Bush on Good Morning America about GHC

Here's the transcript of the interview but I couldn't find a good link to the video (search around a bit and you'll find it, just don't have the bandwidth here...).

An Eye Towards Sustainability

With only two months left to go in our fellowship, Goodluck and I have been focusing on how to ensure the work that we have done to increase data accuracy and system support is sustainable and maintainable by the health system’s own infrastructure when we leave.

We have recently been able to establish that the project we designed and implemented over the last 10 months to increase data accuracy has had a long term, lasting impact on the staff we enrolled in the program. I explained in an earlier post that during our data workshops we tested participants at the start and end of the workshop and established a resulting increase in data accuracy of over 200%. Although we designed our program to include additional visits to staff members to help cement the learning, I’ve continued to be concerned about long-term skills retention.

Last week, every facility from Kilwa was invited to a training on a new set of PMTCT (maternal health) data tools that we helped get translated from English to Swahili so that staff members could actually understand the forms they’ve been asked to compile. We took this opportunity to give them similar data tests that we gave them during the data workshops they attended up to six months ago to see both the long term efficacy of our previous training program and also the effect of the translated tools. Health workers achieved the same scores at the start of this training as they achieved at the end of the data workshops. In other words, the 200% increase in accuracy was maintained over time. Additionally, after sharing the newly translated tools, we tested them again and saw another significant increase in accuracy. All totaled, combining our training program and the translated tools facility staff has achieved close to a 300% increase in accuracy that we now expect to see sustained well beyond our fellowship year.

Another sustainability-focused program we’ve worked on has been to partner with the district health management team to design a decentralized management structure of mentors. The goal of the decentralized structure of mentors is to ensure consistent supervision and support throughout the district with data accuracy and supply stocking. District managers are supposed to provide this support but lack the time and funds to visit every facility each month, oftentimes failing to visit for months at a time. To solve this problem, we identified Kilwa’s most organized and passionate staff members and invited them to a weekend workshop to introduce the mentorship program, run them through in-depth data, lab, and health services training, and ask them to commit to taking on the extra responsibility to help improve the overall system of support for Kilwa health facilities.

I was skeptical about how our proposal would be received, considering all the difficulties we’ve run up against with overworked, poorly motivated staff members. I’m happy to report, however, that while there was an acknowledgement of the increase in work this would mean for each of the mentors, they fully grasped the significance of how much this type of system was needed and were excited at the opportunity to be involved. We’re looking to roll out the first two rounds of mentorship activities with our 12 mentors in June and July and adjust the program as necessary so that it will be fully functional in August when our fellowship year has been completed.

Goodluck and I are working with Clinton Foundation staff and Ministry of Health officials to roll out our programs to surrounding districts with the hopes of replicating the results we’ve achieved in Kilwa. There’s also a good chance that Goodluck will be staying on with the Clinton Foundation in Tanzania to help continue leading efforts to improve data quality and health systems. While I’m excited about the possible broader impact of the expansion of our programs, I’m mostly encouraged to know that the work we’ve done this year has had some significant impact, even if just to the Kilwa district.

Global Health Corps [GHC] has taken a chance in sending people like Goodluck and me into the global health field to try to create new, innovative solutions to persistent problems without having any experience with health care. As we’ve come up against seemingly never-ending roadblocks and unpredicted challenges throughout the year, I’ve doubted my efficacy and value to the cause of global health. However, going through the challenges and coming out with meaningful results has made me appreciate GHC’s model that much more. We need people who have enough energy and passion to persevere through bureaucracies, inefficiencies, and stale solutions to find a better way to do things because there’s always a better way.

Another GHC Article

This time it's on CNN. I even get a shout out in this one.

GHC at the National Press Club in DC

GHC President Barbara Bush gave a great speech about GHC yesterday. View the video here.

The Value of a Good Experience

Goodluck and I have been trying to understand what defines a good health facility in Kilwa to be able to replicate the model to other facilities. In my last video I described how it’s hard to analyze data by health facility because, for example, we don’t know if increased diagnosis at a given facility implies poorer health for their surrounding communities or better service provided to attract more patients to get treatment. Based mostly on qualitative evidence gathered from on site visits and patient interviews over the past month, however, we’ve concluded that higher aggregate numbers aare almost always an indication of exemplary medical services being performed. But what does “exemplary medical services” mean?

IDEO CEO, Tim Brown, summarizes a popular concept coined in Daniel Pink’s book A Whole New Mind saying, “once our basic needs are met − as they already have been for most people in the affluent societies of the West − we tend to look for meaningful and emotionally satisfying experiences. The value of services lies in the emotional resonance they create.” The implication is that when basic needs are NOT being met, i.e. in most third world countries and certainly all of the communities Goodluck and I serve in Kilwa, the human mind doesn’t care about emotionally satisfying experiences. Fulfilling basic needs is the primary driver behind what the mind desires.

In reference to our health facilities, I’d expect “exemplary medical services” then to mean that the necessary drugs are always on hand and ailments are successfully getting treated. And that’s it. This would also imply that each health facility we work with who has low statistics doesn’t have proper drugs in stock and that the medical staff are misdiagnosing patients who therefore aren’t getting treatment.

Goodluck and I know this is not the case. We’ve been delivering medical supplies to all facilities through the year and patient numbers remain the same. The medical knowledge of health staff, though indeed varied, doesn’t vary with the number of patient attendance (we’ve moved well-skilled health staff from a strong facility to a weaker one and after a year still haven’t seen much increase in attendance).

What we have seen is that health facilities with staff who enjoy working together, are organized with paperwork and office supplies (including drug stocks), who clean their facilities (even the cobwebs by the roof), who maintain equipments such as patient beds, and who even groom their grounds with rakes and flowers, are the facilities getting the most patients. These are the marks of exemplary medical services and they contradict Daniel Pink’s notion that only certain groups of people can afford valuing emotionally satisfying experiences. He would contend that the experiential enhancement of an inviting landscaping would provide little value in terms of increasing attendance at health facilities in Kilwa, Tanzania because it’s not fulfilling a basic need. Our experience here has suggested, however, that everyone values emotionally satisfying experiences.

What I think Pink misses in his analysis is that the definition of basic needs changes for people in the third world. Not everyone in Africa is living a stress-filled existence worried about fulfilling basic daily needs. Tanzanians in my village seem to have come to a knowing realization of what their life is like. They can depend on food sources based on the season and the amount of rain in a given season. They know the best places to get water to drink so as to avoid fatal illnesses. They know that any electricity service is always temporary. And they don’t celebrate the birth of a child because they know there’s a real possibility that the child will die in its first 6 months.

Basic needs being met in the US and basic needs being met in rural Tanzania look completely different. But from the point of view of the respective communities, basic needs are being met in the majority of cases. The implication being that it is incredibly important to think about how to create safe, enjoyable, satisfying emotional experiences when trying to achieve successful services of any kind. And in the context of critical experiences such as public health services in the third world, where there aren’t private alternatives to create natural competition, the responsibility lies on the system managers to seek out facilities who are creating this type of experience and hold them up as the standard experience all facilities should be striving to provide their patients.

Freshly planted flowers at Somanga Health Facility