My Umbrella

Another gem from Jean D’Arc, who has terrific stories about rural Rwandan culture and superstitions. She is somewhat unusual for Rwandan woman – she talks about sex. As a nurse, I suppose it comes with the territory.

As part of her job, Jean D’arc advises couples on family planning, including condom use. Sometimes she demonstrates how to unroll a condom (think the banana in health class).

One day, a man she had counseled came to her, confused and upset:

“Jean D’Arc,” he said, “I followed your instructions exactly for using the condom, but my wife still got pregnant!”

“Tell me what happened,” she asked.

“I did it just like you showed me. Before I made love to my wife, I put the condom on my umbrella.”

Mutuelle

Shortly after I arrived, Elie and Consolate brought me up-to-speed on their efforts on Mutuelle (community insurance). It’s one of my big projects here and it consists of three goals:

1. Boost Mutuelle enrollment in the Shingiro catchment area for 2010
2. Develop a report for the District Mayor on common barriers to enrollment and recommendations to overcome those barriers.
3. Liaise with the Shingiro Mutuelle office as part of the broader effort to make Shingiro a better health center

Mutuelle enrollment costs RWF 1,000 per household member for each year. The Mutuelle-subscription year corresponds to the calendar year. To prevent people from only purchasing Mutuelle when they become sick, aka to prevent adverse selection, Mutuelle must be purchased before the year begins. If families wait until the subscription year to purchase Mutuelle, they face a 30-day waiting period before their Mutuelle enrollment becomes active and can only purchase for the current year until June. Mutuelle enrollment for the next year begins in August. Thus, from now until the end of December is the important period for enrolling community members. An additional measure against adverse selection, heads of household must purchase Mutuelle for every member of their households, not just those that are mostly likely to become sick.

Mutuelle enrollment is the key to creating access to the formal health system in Rwanda. Indeed, looking at the data from 2008 in the Musanze district, there is a strong correlation between Mutuelle enrollment and health center use at the 11 health centers:

*I should note, in loyalty, fairness, and kudos to CCHIPS, that “Mutuelle Enrollment vs. Target” and “New Cases Seen vs. Target” in Shingiro are both up considerably in 2009 - no doubt helped by CCHIPS involvement.

While correlation does not prove causality there are a few points of reality that make the distinction moot:

• Mutuelle is a great deal for its members. The true cost of health care is far higher than the RWF 1,000 enrollment fee, which is ‘only’ about $2. Mutuelle is subsidized by various NGOs and the government. Thus, beyond the normal insurance functions of consumption smoothing, risk pooling and so on, Mutuelle gives preferential access to the health center vs out of pocket payers.
• We do see enrollment creep up between January and June, as people recognize that they need Mutuelle after they get sick. However, this just reinforces the argument for educating people about the cost-savings of using Mutuelle before they get sick. Mutuelle creates access to health centers at an affordable price.
• The subsidization means that adverse selection is less of a problem, in the short run at least. Very few families have a risk profile for illness that makes not purchasing Mutuelle a good bet.

Therefore, I suspect that the Mutuelle enrollment rate indicates the proportion of the population that a. believes in the formal healthcare system vs traditional healers or doing nothing at all and b. is able to pay for coverage.

Focusing on Mutuelle enrollment allows the health center to ‘bag’ wins and concentrate its ‘sales’ effort within a relatively small window of time. We don’t have to expend significant resources all year round trying to one-off convince people on the benefits of using the health center. We know how many people will use the health center based on our enrollment figure, and we know the time period that we need to focus on to sell health center use for the whole next year.

A question raised by the subsidization of Mutuelle is: ‘if you are already heavily subsidizing the system, why not just give free healthcare to everyone? Why make people pay anything at all, if that will get them to use health services more often?’

There are a few reasons:

• The poorest (“indigents” in local parlance) receive financial aid to cover the Mutuelle enrollment fee (though we are looking at the current system of identifying these people – it does not work very well).
• Forcing people to pay for at least part of the cost of care helps prevent adverse incentives from forming (such as creating a sense of entitlement, etc). It might also create good habits and general acceptance of health insurance as ‘just something you do’.
• NGO pockets are deep, but not limitless. In fact, we are currently doing analyses of what would happen to the Shingiro budget if various sources of income were delayed or ceased (my working hypothesis: if Mutuelle cut back on its reimbursements, the health centers would quickly become insolvent).
• Most important is the recognition that the current system is developing alongside the Rwandan economy. The goal is for most parts of the healthcare system to not fundamentally change when the system becomes self-sustaining. It is important to sensitize (a favorite word of Rwandan technocrats) the population to the benefits of using the health centers, even if they cannot afford them currently. Indeed, using the health centers now might help people be able to afford them in the future. The hope is for the development of a virtuous cycle with better health standards driving income growth driving a greater ability and willingness to pay for health services.

Despite these qualifications, it is clear that Mutuelle is not an ideal system for paying for care. However, it’s hard to imagine an ideal system, given the willingness to pay for most people is lower than the cost of providing healthcare. But we’re not here to create an ideal system. We are working at a local level; we are not trying to redesign the Rwandan healthcare system or how the government should ask its citizens to pay for that system. We are trying to help the health center staff maximize the quality and usage of the health center in a way that is implementable, replicable, and can be easily monitored. Mutuelle is clearly important to this effort.

Nyarabuye and Development Economics

This post is a first of a handful oriented towards development economics that I hope to publish over the next few months. There is a world of difference between the theories in the Ivory and Ivy Towers and the world around me. Whereas academics are clean, the world is messy. But both are interesting…

We had a much stronger turnout for the Mutuelle meeting at Narabuye than at Mudende. We did our schpiel, and then Elie translated for me as a local official explained several government policies.

Two policies in particular piqued my interest...

Umudugudu

Under the Umudugdu (Village) policy, rural citizens will be given a 20m by 25m plot of land within a village to construct a house. These villagers will relocate from their homes which are scattered across the countryside.

A lonely house far from neighbors.

Homes in the fields.

Currently, these villagers live near their fields, but clumping will (hopefully) allow human and health services to be more easily delivered. These services include:

· Rural electrification

· Sanitation and indoor plumbing

· Communications infrastructure

· Local trade and commerce

· Closer access to health facilities

By moving closer together, individuals lower the marginal cost of all of these services/transactions. Additionally, to mitigate the switching costs, the government is giving advanced warning, including recommending that people do not invest in permanent homes until the villages are laid out. This policy has not yet been enacted and surveyors continue to plot the ideal locations for villages and homesteads within villages.

Though on the whole I think it is a sound idea , there are a handful of potential drawbacks to the policy:

• This policy will increase the monitoring costs for residents. Currently, it is easy to make sure no one steals your crops – you look outside. Now people will have to monitor their crops in some other way. Perhaps it will give rise to security services – this could be an important value add for a crop insurance program.
• It is unclear who will bear the switching/moving costs
• People here are really poor. If they have a good thing going where they live now, it sucks to force them to move.

Crop Specialization

The speaker next spoke about a crop policy the government is enacting. Going forward, people will only be allowed to grow particular types of crops in different regions. For example, some regions may grow maize while others potatoes and others wheat. The speaker told the people that at some point the government would be inspecting fields and tearing out plants that are not allowed to be grown in the region.

This drew a loud outburst from the assembled villagers. They did not seem to love this policy. My initial reaction was first-world, freedom-loving indignation. People should be able to grow whatever they want! But then I thought about it a bit:

Positives:

1. Encourages specialization

a. Hopefully, farmers will more efficiently grow one or two crops instead of 5 or 6.

b. This specialization should generate a net surplus of food, which will encourage trade and employment opportunities outside of farming

2. Encourages trade

a. People will sell the one type of surplus crops that they grow for cash and purchase a basket of other types of crops and goods and services.

3. Encourages the use of currency

a. Currently, one of the issues we face with Mutuelle (community health insurance) is that people use bartering instead of cash, and therefore have no way to pay for enrollment.

b. Trade will necessitate the use of money

Negatives

1. Ignores individual preferences / abilities

a. Hopefully government agronomists designated districts best suited for growing maize as maize districts and so on

b. Even so, there will be certain farmers that are currently better at growing some crops over others and areas of land within regions that are better suited for different types of crops than is designated based on region-wide characteristics. This will lead to sub-optimal use of land. (Though that is not to say that the land is currently being used more optimally.)

2. Will interfere with market function

a. Related to the first point, in a perfect system, market demand, field characteristics, and farmer abilities would determine the most profitable crops to grow in a particular field.

3. Several residents noted that they do not currently grow the crops designated for their region. Thus, they faced switching costs such as 1) learning how to grow the new crops and 2) buying the initial inputs such as seeds or crop-specific tools

4. Our nutrition program emphasizes, among other things, a balanced diet. While in theory it is great for farmers to specialize and trade, the policy might encourage “diet specialization”.

5. Crop diversification may help hedge risk. Farmers might plant different crops that are resistant to different disasters, like drought-resistance crops, pest resistant crops, etc. With specialization, a whole region can be wiped out by a particular crop disaster (think Ireland in 1848).

The policy will not be enforced for some time period, so people will have time to adjust. At its core, the crop policy assumes that the government will make better choices than local farmers. Given the low penetration of education among the rural poor, I’m not convinced that this is untrue.

Generally, it seems hard to know whether it makes sense to wait for an endogenous impetus to push such a large change or use the force of law to induce an exogenous shock. There will likely be a number of unforeseen consequences of both these policies, but the long term benefit may outweigh the short to medium term pain.

Over a long time horizon, the hope is that these policies together will encourage better access to human services, economic specialization, the development of a rural service sector, and, generally, economic development. These policies take a step in the right direction. However, in the short run the policies are likely to 1. provoke widespread non-compliance from the population and 2. create unintended and unforeseen complications for everyone involved. The successful implementation of these policies will depend on the government’s flexibility in reacting to these issues and strong monitoring and enforcement mechanisms.

I’ll keep watching, talking, and listening to people.

Adjusting to a New Reality

Sometimes you have to take the slow boat to China, or Mudende. Patience is not really part of a 23 year old’s repertoire of emotional or mental paces. Slothfulness, sometimes, but patience not so much. A recent Mutuelle outreach trip to Mudende tempered my ambitions and fantasies somewhat, but also gave me hope for the long term potential of CCHIPS and Rwanda.

On a beautiful Tuesday morning, we hoped to lead a Mutuelle (community health insurance) information session at Mudende. We drove the 20 minutes to Shingiro, picked up representatives of Mutuelle and several Shingiro nurses.

As we were about to leave Shingiro, I realized that the two pots of coffee and two liters of water I had consumed earlier would be catching up to me at some point during the course of the morning. Thinking nothing of making assumptions like: “oh, they’ll have a toilet at Mudende” I decided to wait.

We then drove the half hour up the winding, rocky, bumpy road to Mudende. The road is narrow and at times seems to shoot straight up the side of the hills. Elie remarked that the road was newly resurfaced, which is good because it’s hard to imagine driving on a less passable road.

I sat up front with Elie, and asked him about the people and plants as we drove. We passed fields of beans, potatoes, gooseberry, maize, eucalyptus, and bamboo. Elie explained that the altitude prevents the cultivation of coffee and that avocados grown here are much smaller than those grown in the south. The sun was bright and I waved to the constant stream of children who would run to the side of the road as the Land Cruiser rumbled by. It was a nice drive except for all the bumps in the road (and we’re talking softball to volleyball sized rocks here).

Mudende sits on what seems to be a peninsular hill jutting out into the openness of the falling hillside. As we made the final turn down the hill peninsula, we came upon a young shepherd and his flock of about a half dozen sheep. The shepherd stood on one side of the hill and his sheep on the other and as we drove past the sheep got out in front of the truck. They began running away from the Land Cruiser and down the path and we nearly herded them to Mudende. It was only a quarter mile and the shepherd ran behind us, yelling at us, the sheep, or whoever would listen. The sheep finally turned up into a field just before we entered Mudende.

As we arrived, I was in for my first “Muzungu Celebrity Experience”. Literally dozens of children began shouting “Muzungu! Muraho Muzungu!” and variations on that theme as they began chasing the Land Cruiser. We pulled up next to the community offices and we all got out. I didn’t know quite what to do, so I smiled and waved to the children. Soon, a police officer chased them away in a hilarious flock of giggles and yelling.

As is common in Rwanda, and I would guess most places with poor roads, communication, and little automobile ownership, everyone was late. We settled in to wait for the community to arrive so that we could begin our presentation. Unfortunately, as the only Muzungu in the group, this meant a lot of standing around and laughing along at jokes that I didn’t understand.

After a few minutes, I asked Rene if he could ask someone where a toilet was. He came back a minute later reporting that the nearest toilet was at the school we passed on our way in. The school was only a quarter mile away, but it also lay in the treacherous territory of the Lollipop Guild. I didn’t need 100 Rwandan school children watching me pee – talk about stage fright.

We waited some more as Elie went to find out why there were no locals present for the meeting.

I took this opportunity to take in the view. The town overlooks a large valley, stretching out into the haze. Rwanda is a beautiful country, all green and brown. And yet the beauty of the landscape clashes forcefully with the poverty of its rural population. From a distance, the tin roofed huts and the smoke rising from cooking fires and slash-and-burn agriculture present a beautiful image. Rustic. For an American, it stirs within the myths of our American frontier. But when you approach one of the tin-roofed hut s and you are greeted by a small child with the big belly that signifies not over-indulgence but such malnurouishment that his body is too weak to keep his organs tight below his chest cavity, well, the myths disappear. Reality sinks in. The need is immediate, but the obstacles are many and, at times, desperately frustrating.

Elie returned and reported that no one had canvassed to spread the word about the meeting. We would need to reschedule. However, before we could reschedule we needed to wait for another member of the Mutuelle team to arrive.

I squirmed as we waited some more. Elie is a gregarious guy, so he kept everyone entertained. All the Kinyarwanda speakers anyway.

I began to circle the cell office. I noticed, excitedly, that on the back of the building seemed to be several latrines. I tried each door down the line. Locked. Locked. Locked.

I returned to the group talking and asked Rene about a toilet. He pointed to a man coming out of a small group of trees. “You can probably do that.” I considered it, but Rwanda is very densly populated, especially around the cell office. No, best not be the foreigner that comes in and pees on the country.

I returned to the group again, and noted that there was not a large group of residents waiting, but there were 15-20 elderly people waiting. I asked Elie about them. He said that they were not here for our Mutuelle presentation, and wanted to meet with cell officials to discuss other matters. Fair enough, I thought, but they look bored, we were certainly bored, why not talk to each other about Mutuelle anyway? I asked Elie. Politics. We didn’t want to step on any toes by appearing to take these people’s attention. I understood, and was grateful for the informed local perspective. But, still, frustrating.

Waiting...

Rene tries the tardy Mutuelle official’s phone, with no response...

Waiting…

She arrives! We can go! But first, the team decides we should look at the Twa resettlement project located next to the cell office. The Twa, sometimes referred to as a pygmy group (though they seemed normal height to me) are the smallest of Rwanda’s 3 “ethnic” groups.

We went and surveyed the Twa settlement. A broken door and they need a latrine. So did I. I died a little inside as my bladder nearly ruptured.

After 2 hours of sitting around, we finally left.

On the way back, we passed through the small town of Gwanda Riushya. Hikers park their vehicles here before they climb the nearby Virunga range volcanoes. With the Mutuelle meeting date for the next week set, we decided to inform the locals. We parked the Land Cruiser, and a group began to grow, curious at what we were doing/would say. Rene smiled, “this is grass roots organizing.” Note to self: Grassroots organizing is easier when your presence draws a crowd.

Rene and Elie said a few words and we were off again.

Now began the serious descent to Shingiro. I was smushed in the back of the Land Cruiser with 8 other people. The back of the Land Cruiser has narrow benches on either wall, facing each other. Maximum capacity, Zack has told me, is however many can squeeze in. So I guess I should have been happy that there were only 8 people in the back. As my legs fell asleep, this probably wouldn’t have been consolation. I am still learning things about the best place to sit in the Land Cruiser. On the way up to Mudende, I sat shotgun, which is the best spot. On the way down I discovered a basic rule of thumb for sitting on the benches in the back of the Land Cruiser: when you are mostly going uphill, sit near the front. When you are going mostly downhill, sit near the back. The key is to ride on top of everyone else, and not be ridden.

The dreaded back of the Land Cruiser.

Unfortunately, as we descended toward Shingiro, I was in the front of the back, with 3 people uphill of me. Ugh. At this point, the combination of altitude and my desperate need to relieve myself was inducing some serious claustrophobia. Rene sat in front, happily snapping pictures with my camera. We slowed down several times for him to get better shots of Shingiro from above. My bladder screamed: Ahhhhhhh!

Finally, in a ride that seemed like an hour instead of twenty minutes, we rolled back into Shingiro. I ran into the new Global Fund building, and found the restroom. How do you spell relief?

I met up with Monique who was taking notes on a community health worker (CHW) training session. After our utter lack of turnout at Mudende, I was reminded that with trained CHWs and a system for deploying them, such a problem should never occur again. After a seemingly wasted morning at Mudende, I have the personal experience to know the value of such a system.

While I came away from the morning with my grand ambitions somewhat tempered, I took from the experience a perspective which will allow me to actually have an impact. The wild dreams and fantasies are gone, mostly. I know more of the reality of Rwanda – its poverty, its frustrations, but also the enormity of good that can be accomplished.

Holy Guacamole

Jean D’Arc relayed an interesting anecdote to us one morning as we drove up to Shingiro. We were discussing food and, of course, I touched on my love of avocados. Apparently it is very hard to find avocados in the Musanze District. The locals believe that avocados cause HIV.

The reason why hilariously illustrates the leap of logic from correlation to causality.

Avocados are a staple food in southern Rwanda. When migrant laborers, soldiers, and truck drivers from Musanze returned from working in southern Rwanda, people noticed that these groups were more likely to have HIV/AIDS. Because the biggest difference in their lives was what they ate, these people assumed it was the avocado that was causing HIV.

Just remember kids: if it’s casual, it might also be causal.

Tell Me More

My name is Michael Rossiter. Well, my legal name is Michael Brian Sloan-Rossiter. But let’s keep things simple.

I grew up outside Boston and recently moved into an apartment in the South End of that city. I spent four happy years at Dartmouth College in Hanover, New Hampshire. I studied trade, development economics and government. I graduated in June of 2008 and moved back to Boston.

After college, I started a job at a firm that provides consulting services to private equity funds. Mostly, the firm generates due diligence reports on an acquisition target’s market, market position, and customer base. Also, I snuck onto a couple of strategy projects, which I really dig. It is an engaging and interesting job and the fast project timelines has allowed me to look at a large number of companies in a short period of time. I think I was actually proving to be useful towards the end of my first year. Not bad.

So, to take stock, after a year in the real world I had a good job, a nice apartment, and great friends. Life was easy…I hate – no, I f***ing despise – easy.

So about a month and a half ago, I sat in my cube when a gchat message popped into my reality. It was from Zack Scott, my freshman and sophomore roommate. Zack had been diverted to Rwanda for some do-goodery by the financial consulting firm he was planning to start with. “I think we’re hiring someone to come for the rest of the year. you interested?”

I was working on something while I chatted and I didn’t think at all about my response. It was, in the terminology of Malcolm Gladwell, a “blink” moment.

“Yeah. Tell me more.”

So I type these words from Musanze, Rwanda. For the next four months I will be taking a hard look at the workings of a health center that serves the 30,000 people of a rural, low income community in northwest Rwanda.

Please expect this blog to be a lot different in tone and content than this post. Mostly, I will be posting about Rwanda and the project, CCHIPS. Check out the project website, http://www.wwhps.org . Also, I will be cross posting a lot of what I put here on the Field Blog on that site: http://www.wwhps.org/field-blog.