Thursday, December 17, 2009

Do You Realize?

I’m leaving Rwanda today. It will certainly be hard to leave such a talented, passionate, fun team and such an important project. I've learned a lot being here.



Management Lessons

As CCHIPs assessed health centers for expansion, we visited nine of eleven health centers. Our visit to Murandi was eye opening. Murandi has no NGO support and yet it is THE model health center.

As the Titulaire of Murandi tells it, two years ago he sat the staff down and they set a goal: to be the best health center in Musanze District. They organized a PBF committee to implement improvements to get a higher score on the Performance Based Funding (PBF) evaluation. Other committees regularly meet to coordinate other improvements. The staff even decided to forego some of their personal PBF bonuses to use the money to improve the health center.

Essentially, Murandi has a functional management structure. The structure allows it to identify problems and implement improvements.

Zack and Jeanne d’Arc decided it would be a good idea to get the Shingiro staff together with the Murandi staff. We wanted to see if some of the spark at Murandi might rub off on Shingiro.

So on a Thursday afternoon we picked up ten members of the Shingiro staff. We brought key personnel – the Titulaire, the Adjunct Titulaire the Accountant, the Data Manager, the Cashier, the Mutuelle Accountant – all of the key management people that we needed to take more initiative.

The drive to Murandi is gorgeous, driving up and up through the hills.









On the ride, Zack talked a lot about how great it would be for the Shingiro staff to see the Murandi staff at work, “We need to implement improvements at Shingiro based on the Murandi model as quick as possible.”

After introductions, the staffs paired with their counterparts. I followed Marie Josee, the Shingiro Accountant, and Desiree, the Murandi Accountant. Desiree showed Marie Josee how he calculates the daily balance in his computer, how he checks it with the Mutuelle office, and how he manages the work of the Cashier. It was a really impressive system: efficient and accurate. The staff had clearly spent a lot of time and effort thinking about and implementing the best way to do the accounting.

I thought about the importance of the visit: If we could show the Shingiro staff the benefits of how Murandi functions, we might convince them to adopt the same management systems.

Instead of spending months making iterative improvements, we found a model that works now. If Shingiro could implement it quickly, it might save a lot of time: probably the most effective way to turn a weakness into a strength is to identify the strongest performer and copy what they do.

There is a strong counterargument to this position, which advocates fixing a recognized gap in performance by improving slowly in steps that lead to the ultimate goal.

I wrote the rough version of the above right after the trip to Murandi, in early October. I didn’t post it or expand on it at the time. I tried. But I felt like there wasn’t enough to say. We didn’t know what the true result of the trip would be. I didn’t know which side of the debate to take: the radical or the iterative approach to developing management systems.

At the time, the choice seemed binary – either the management team could identify areas for improvement and take slow and steady steps toward improvement or it could implement radical improvements based on a successful outside model.

After working with the Shingiro management team for several months, I’ve come to realize that the choice is not binary. The choice is not even particularly important. What is important is the capacity to recognize and implement the appropriate approach depending on the needs of the moment.

Three months after the visit to Murandi, Shingiro does not have the Murandi-type management systems in place: the accounting is still a bit of a mess, there is no PBF review committee, the Pharmacy management isn’t as good as it should be. Zack’s goal to quickly put the Murandi systems in place before the Shingiro staff forgot them could not have been done under the circumstances. At the time of the Murandi visit, Shingiro did not have a management structure that was capable of implementing much of anything.

The CCHIPs approach is to work closely with health center staff to help them develop their own solutions to problems. In this way, solutions will be thoroughly understood by those applying them and the staff will feel a sense of ownership and control over how the health center operates.

At the beginning of the project, both Zack and I made the mistake of trying to create ‘tools’ for the health center staff that are extremely user-friendly. For example, Zack developed an Excel accounting workbook. I developed a database for health data – just put the data in here and presto!, all set.

Both of these tools failed. Zack and I assumed that by locking formulas and making it very clear where to input the figures, the Shingiro staff couldn’t mess up our perfect workbooks.

But, of course, they could and they did.

Even more importantly, the Accountant didn’t understand how the income and expenses link together to create and follow a budget and the Data Manager couldn’t interpret the output of the health database. Without the understanding of why the tool was useful, neither tool had much value.

We decided we needed to give the staff a more comprehensive understanding of the logic underlying the tools, so that, if they chose to do so, they could create the tools themselves.

What we realized is that to impart real and lasting change, you need to help a manager develop the capacity to ask ‘why?’ Our managers must have a comprehensive understanding of the systems that they are managing. Without a comprehensive understanding of how processes fit into the wider scope of health center operations, the health center cannot respond to change and its managers cannot recognize areas for improvement.

There are mechanisms out there, like surveys of health centers that help managers to identify areas for improvement at the health center level. These tools can be useful. For example, we were excited to visit Murandi because they do extremely well on the surveys. But the surveys rely on outsiders to identify areas for improvement. Outside standards cannot be as effective as expert managers that are deeply engaged with their own health center operations.

As we continued to work at Shingiro, we came upon a vital insight:

Empowered managers ask questions. These questions lead to an understanding of why things are the way that they are. On the basis of that understanding, managers can proactively develop plans to optimize operations.

At the time of the Murandi visit, there was no structure to facilitate the process of questioning to understanding to action. Shingiro needed a management structure to facilitate the implementation of such a decision.

A strong management team can identify areas for improvement and address them through iterative solutions OR by importing a system from outside. The team can mix and match strategies because they have the capacity to understand problems and develop the right solution.

Murandi showed us that our efforts are possible. Murandi proves, beyond a doubt, that Rwandans can manage themselves, that our efforts are not in vain. Not that we doubted that. But it was powerful for the Shingiro staff to see it.

In response to this problem, Zack has worked very hard to develop and implement a new management structure at Shingiro.

Under the old system, every employee directly reported to the Titulaire. When CCHIPs arrived at Shingiro health center, there were only about 10 nurses. However, as the staff has grown to about 20 nurses, this arrangement has become completely ridiculous.

Additionally, no one was responsible for the management of any particular Specialty. Technically the Titulaire was responsible for ensuring the Pharmacy was fully stocked, that the vaccine cold-chain was maintained, that Wound Dressing had gauze, that HIV/AIDS had retroviral drugs, and so on. In reality, this meant that in some Specialties individual nurses took responsibility and in other Specialties there was chaos. There was no way to ensure that equipment was not missing, that the files were not out of order, and so on.

Inevitably, such as system only had enough capacity to ensure the health center was running OK. The Titulaire would have needed heroic personal strength and no need for sleep to implement and monitor any changes.

So it’s no surprise that the Titulaire is a huge fan of the new management structure.The new structure is not particularly innovative or complex. It doesn’t need to be – it just needs to work. There are two major components of the new system:

  1. There is now a level of management between the Titulaire and each Specialty. Four nurses serve as Service Managers who report to the Titulaire. Each Service Manager is responsible for their Service – Curative, Preventative, Promotional, and Administrative.
  2. Each Specialty has a Specialty Responsible - one nurse accountable for the operation and improvement of each Specialty. The Service Responsibles report to the Service Managers.

During the orientation of the new managers, Damascene, the new Curative Service Manager, said, “Woah, I’m responsible for so many people now – in Reception, Consultation, Wound Dressing, Pharmacy, and the Laboratory.”

To which Felicien, the Titulaire, replied, “Yeah, imagine how I felt directly managing all of those Specialties and all of the others.”

At the Specialty level, the Specialty Responsibles are now motivated to improve their Specialties. The Responsibles know that they have the support of the Service Managers to implement lasting improvements. And when the Service Manager needs feedback from the Specialty level, the Responsibles can provide upward perspective.

This structure gives the Titulaire and Service Managers the time and space needed to set direction. It increases the capacity of the management structure because the Titulaire is no longer solely responsible for identification, implementation, and monitoring.

Over the last two months since the new structure was put in place, it has been amazing to see how quickly the health center has begun to do things for itself. The new management system created the institutional capacity to be proactive.

The Titulaire and the Service Managers meet regularly, without CCHIPs’ presence. They have been able to create

  • Based on their experience as nurses, the Service Managers identified the problem of nurses sleeping on night guard duty. The Titulaire, Felicien, and the Curative Service Manager, Damascene, coordinated the staff to relocate the Child Consultation room and use the old Child Consultation room as a Night Guard room. This lets the night guard nurses sleep when there are no patients but they are close to where patients arrive for help.
  • The Service Managers noticed that the hand-washing facilities were insufficient. Based on the system developed at Murandi, Felicien and the Service Managers designed and oversaw the construction of new hand-washing points at Shingiro.
  • I have worked with the new Preventative Services Manager, Aggripine, to improve the filing and patient follow up systems in Preventative Services. We collaborated with her and the Family Planning Specialty Responsible to reorganize the filing system in Family Planning. Now Aggripine will be able to oversee the implementation of similar systems in Antenatal Counseling, Vaccination, and HIV/AIDS.

The new management structure allows the health center to identify problems, to understand why the problems exist, and to develop and implement solutions. Whether those solutions are big changes or small ones, developed at Shingiro or elsewhere, the important thing is that those solutions will be implemented successfully.

Saturday, December 12, 2009

Thanksgiving



Around 6 PM on the Sunday before Thanksgiving, I sat on the front porch of the project house, reading. Zack, Amber, Consolate, and Gabby pulled up in the Land Cruiser. They had just been to Kigali to drop Dr. Cairo off at the airport.

Emi, the house dog, was VERY excited as they pulled up, because she could smell the turkeys. The team had picked up the turkeys from a farm just outside the capital. To transport the birds home, the farmer had stuffed the turkeys into white plastic trash bags. Now the turkeys sat in the back of the Land Cruiser, falling over themselves as they tried to get out of the bags.

We found that the birds could live comfortably in the gatehouse, which Muzehe (literally “old man”, our gatekeeper) never uses – he prefers to hang out in his room in the house. For a couple days we fed the turkeys corn and millet and Emi tried to find a way to break into the gatehouse.

On Tuesday night we decided it was time. Zack, Rene, and I myself took turns through three positions: holding down the bird, sarcastically commenting on the struggles of the butcher, and removing the head from the turkey. I was first up at severing the head.

Everything I’ve seen about killing poultry has indicated that one strong, quick blow across the neck will remove the head. Rene held the turkey down, and I raised the knife.

We did not have many options for which knife to use. Most of our cutlery is oriented towards chopping vegetables. We don’t boast a full-scale kosher kitchen. So, after reviewing out limited choices, we settled on the chopping knife. The chopping knife has the big flat blade and a good amount of weight. It is particularly useful for scooping chopped vegetables into stir frys.

I brought the blade down, finding that same blank state of mind that I’ve used in the past on the rugby field. It’s comfortable in its certainty. The mental state is sustainable only just before impact. It relies on the conviction that ‘I will break through and cannot be stopped’ to power complete effort of force.

Almost as soon as the knife hit the turkey’s neck, I was shocked to discover it bouncing back up. There had been no effect. I tried again.

“No! No! No!” yelled Rene, “you must saw it off!”

The chopping knife was not serrated and therefore miserably suited for such a job. I pressed the knife down, sawing back and forth.

After a few seconds, with no obvious progress I looked up, “We need a different knife!” I yelled desperately at Zack, who began to laugh. The whole point of the quick chop is that it is humane – the suffering is minimized. But here I was, standing over an animal that I intended to kill, it knew I intended to kill it, and I was doing a very bad job of it.

I crouched down again and continued to saw. Now I cut into the neck, drawing blood. It bubbled up from the wound, warm and sticky, coating my hands.

My goal was still to minimize suffering. The actual spine was proving difficult to cut through, so I focused on severing the windpipe and main arteries – removing whatever connections I could from head and body. I saw the outlines of the windpipe under the skin of the neck. I slipped the blade between the spine and the windpipe and pulled the blade up and out, severing it. But the bird continued to try to breathe, and now I could hear rasping coming from the exposed windpipe.

Finally, the knife found a notch in the spine. I pressed with my force, and pulled on the head. The spine cracked and I cut through the last bit of skin connecting the head to the body. I stood up. The turkey’s head was in my hand and its lifeless body lay on the ground beneath me.

“Ugh,” I threw the head down on the ground. I was shaking a little bit, jacked up on adrenaline. “Wow,” I chuckled, “that was ridiculous.”

Rene went next, with Zack holding down the bird.

Rene was much more experienced and efficient than I was, and the turkey’s head came off after only 10 or so seconds of sawing. However, Rene had cut very close to the base of the head, and this particular turkey was not totally ready to die.

Zack held down the turkey as it began to flap its wings.

“Don’t let go,” said Rene, “it might fly away.”

At that moment, the neck, which Zack was not holding down, turned up and looked Zack in the face. It then began spraying blood…everywhere.

The turkey flapped and flapped and sprayed and sprayed. For two minutes Rene and I howled with laughter and Zack continued his grim task, holding the turkey down as it sprayed him with blood.

Zack was to kill the last turkey and it was my turn to hold the bird down. Having studied my and Rene’s approach, Zack pulled the head firmly away from the body and quickly sawed through the neck. Learning from Zack’s experience, I held down the body with one hand and pinched the neck down to the ground. The body struggled for about a minute, then went still.

The next task was plucking.

Muzehe, Gabby, and I each grabbed a bird and a pot of boiling water. We poured the water over the turkeys, which blanched the feathers. They were surprisingly easy to pull out. Everyone I had asked told me that plucking is a pain, but it seemed very easy.

At first.

I looked over and noticed Gabby and Muzehe’s turkeys looked much less plucked than mine. I realized that they were being very deliberate, removing 100% of the feathers from a particular area before moving on. On the other hand, my bird now only had 5% of its feathers left, but they were scattered more or less evenly across the bird. I went back and plucked each remaining feather individually.

20 minutes later, the birds were plucked. Now Gabby and Muzehe took over completely. They first removed the stomach through the base of the neck. Then they cut into the bottom of the turkey to remove the intestines and other organs. It was fascinating to watch. Also grim.

After the birds were plucked and cleaned, we bagged them in the few plastic bags we had, and put them in the refrigerator to chill overnight.

On Wednesday morning, I fired up my computer and searched for “turkey recipe” on Google. I found a Thanksgiving turkey recipe by Alton Brown, of Food Network.

Back in my sophomore year of college, I watched a decent amount of Food Network. Alton Brown hosts a show called “Good Eats”. Alton distinguishes himself by applying ‘food science’ to his cooking methods. He thinks about how heat and chemicals interact in a dish. He clearly loves the process of cooking. He’s a quirky dude, a bit of a nerd, but his food always looks incredible.

The recipe called for the turkeys to soak overnight in 5 gallons of brined. So I got out the big pot and added salt, sugar, and spices to boiling water. I prepared several gallons of the stuff and put it in the fridge to cool.

The brine needs to stay cold to prevent any bacteria from getting the wrong idea, so I also prepped a bunch of ice. Since we only have two ice trays, this meant checking the ice every few hours, emptying ice into the bucket, and adding water to the trays to make more.

That night, I thoroughly washed out our big garbage can. I put the three turkeys in it, and then added the gallons of brine. I put a big rock in a plastic bag to keep the turkeys submerged. Then I added the ice.

Finally, I refilled the trays and went to bed.

The next morning, I boiled apples, cinnamon, and onions. I washed the birds and put them on our only cooking sheet. I added the ‘aromatic’ mixture to the bird’s cavities, coated them in olive oil, rosemary, and sage, turned the oven on, and put the birds in.

Several hour later, I dined with our team and about 20 guests (Muzungus and Rwandan friends). Even though I was exhausted from cooking all day, I greatly enjoyed the event.

Later, I reflected that I was very glad to have had the experience of killing the turkeys, but at first I wasn’t sure why.

Originally, I simply thought of the experience as a rejection of the hypocrisy of eating meat but never preparing it. And that’s true, but it’s not the whole story.

There are many things that we do in modern society which are removed from our natures. Sitting in an office for 12 hours a day is an obvious example. We submit to the modern life because it enables the way we prefer to live. The efficiency generated through the division of labor frees up time and resources for the things we like – a nice apartment, tasty food, a laptop, leather couches, a decent sized TV (with cable, DVR, and HBO of course), and an iPhone. But there is something lost in the efficiencies that allow us to own these things. Through the daily trudge, there can be a disconnection of life and living.

The life and living disconnection limits the joy of life. In a Platonic sense, we feed only our appetites and not our souls. There’s that empty feeling of a Sunday afternoon spent on the couch – dulling your senses before the work week begins. That’s not living – it’s surviving life.

I was glad to have the experience of a carnivore – to find an animal, to kill it, and to eat it. I watched the turkeys bleed and suffer and die before me. I felt the regret of killing, the power of taking a life, and the joy of a small task of living.

The experience increased the value and joy of the meal. I was connected – through a shared experience – to my meal. I was more thankful of the ability to be with friends and to feel alive. Zack says that the turkeys were the best he’s ever had at Thanksgiving. I suspect that’s as much related to the value of the experience as to our skills in the kitchen.

It was not pretty, it was a little bit sad, but it was a thanksfull experience – it made me happy to be living.

The whole process was very deliberate. There was joy in experiencing each of the iterative tasks – killing and cleaning the birds, preparing the brine, cooking the meal, and sharing the meal with friends. The division of labor of modern society allows us to feed our appetites without thinking too much about the joy of experiencing the whole process.

That said, I do not believe that modernity is unredeemable – we got the turkeys from a farm, we drove them home in our SUV, the recipe came from the Food Network website. Ask any of the people that use Shingiro health center if they enjoy growing their own food, preparing it and cooking it. It’s not possible in their context of extreme poverty.

The efficiencies of modern life are preferable to a life in the poverty of complete self-reliance.

But life and living are much more enjoyable when connected.

Saturday, December 5, 2009

Bus to Uganda

Right after Thanksgiving, we took a four-day weekend to go rafting in Uganda at the source of the Nile.


I plan to write up the experience, which was really cool. The only downsides were a deep, deep, equatorial sunburn (sorry mom) and the 12 hour bus ride each way:





Friday, December 4, 2009

Dedicated People Following Their Instincts

Sometimes, in the midst of all the work I’ve been doing with CCHIPs in Rwanda, I lose track of what I’ve learned. It’s easy to lose sight of the big lessons in the day-to-day, but recently I read something that helped crystallize a thought.


I saw a blog post by William Easterly at Aid Watch. Easterly writes about his visit to a maternity and family planning clinic in Ethiopia. After only an afternoon visiting the project, he developed a positive assessment of the program. The post touched on two things that I have found to be true:


1. The key to an effective organization is the dedication of its people


2. For evaluating human resources and management, the value of randomized trials/statistical analyses is often not worth the cost (in time, resources, etc) compared to a quick site visit and the instincts of experts


Since CCHIPs is a small team, I have had the opportunity to work with the Jeanne d’Arc and Zack on management and strategic planning issues. For example, in preparation for CCHIPs’ expansion to 4 additional health centers in 2010, I analyzed the available surveys of health center performance and the health data of patients seen.


We evaluated health centers based on two dimensions: Need and Capacity. The CCHIPs team wants to work with health centers where we can have the biggest Impact – we do not want to be dropped into the worst possible situation and have little means of fixing anything, nor do we want to be dropped into the best health center and have little to fix. We want to identify health centers that have a lot of needs for help, but specifically needs that align with the expertise that we developed at Shingiro. Therefore, for the expansion presentation I wanted to quantify both the NEEDs of the health centers and our CAPACITY to address those needs.


Our capacity to help a given health center varied in three very specific ways:

Distance: A few of the health centers are very far from our project house in Ruhengeri, up to an hour and a half drive each way. If we worked with those health centers, we would use 3 hours each day just travelling to the health centers.


Public Health Centers: Some health centers are run by the Catholic Church. We expect to work with the diocese health centers in the future. But for now the Church’s veto power over potential reforms/changes/initiatives would sap a LOT of our capacity to have an impact.


Rural/Urban: We are developing a model for the delivery of primary healthcare in a rural context. The health center in Ruhengeri was not a good option.


Our capacity also varied in less specific ways. There are intangible management and human resource considerations: ‘Does the Titulaire seem professional and focused on results? How does the management communicate with the staff? How receptive is the management to our help?’ The many potential answers to these questions do not easily fall into a standard ‘check-the-box’ survey.


We visited 9 out of 11 health centers in the District to get a read on these intangibles. We considered developing a standard assessment form across each of the 5 Elements to score needs and our capacity. However, we didn’t have time to develop the standard survey before we had to choose new health centers.


So we conducted site visits and had meetings afterward to talk about what we saw.
The process wasn’t scientific. We didn’t have a standard assessment form. We didn’t even have a standard ‘de-briefing’ form. We had no definitive statistical ‘proof’ that our choices for expansion were correct.


Even so, I am 100% confident that we chose the right health centers.


I know we chose the right health centers because I know our team. We are focused. We are dedicated to our mission. We know what kind of challenges we are capable of handling.


The capacity assessments came from our guts. Our gut instincts were right because we have dedicated ourselves to understanding what we do well.


We share a mission and we are all guided by the same set of values. Because we are experts on ourselves, we can assess our capacity to create an impact accurately without the need for a standardized form. We can go to a health center, look around a bit, and get a feeling: We know whether the Titulaire wants to work hard. We can tell whether the staff is attentive to the patients. We recognize problems that we have seen before – and we know how to fix those problems.


Only a dedicated, motivated team thinks in this way. A dedicated, motivated team sees problems in the right way. A dedicated, motivated team knows how the pieces fit together. A dedicated, motivated team pulls the right levers to achieve results.
And a dedicated, motivated team can see its own values in the actions of others – we are looking for the same dedication and motivation in the health center staffs that we work with.




Maybe that focus is not there at the beginning. At no health center we saw was it fully formed or functioning. Shingiro’s getting there, bit by bit. But with a couple health centers, you saw where the shift might start. Saw small good habits already in place, a Titulaire’s unconscious consciousness.




A statistical study or analysis cannot see how everything fits together in the same way experts can. A standardized survey can’t see that spark.




This has be a big shift in perspective for me – looking for that spark. Looking for that dedication. It’s been a vital thing to learn. I remember starting work last year and trying to develop the ‘perfect analysis’ to every problem. Now it seems like such a silly goal. It’s like in econometrics: as you add more variables to a regression your model will ‘explain more’. But that model may not tell you much about what’s actually going on.




The reason you do statistical analyses is to look at things in isolation and to present challenges to your assumptions. There’s no proof in data. It can only push you towards or away from the ‘common sense’ beliefs you hold.




The more expert a team becomes, the more the ‘common sense’ thoughts will be correct.


And the only way for a team to become experts is through motivation and dedication.


I love doing statistical analyses. It is really fun to clearly show a relationship or a trend through data. But I have learned, and now I really understand, how data only carries the explanatory power of the frame you put around it.




The current perception in the District is that Shingiro is doing amazingly well. Most District officials would probably guess that Shingiro is performing much stronger on all the surveys and health data than it actually is.* Yes, Shingiro is improving across the standard surveys and in the health data but the gains are not enough to justify the highly positive assumptions in the District leadership.

However, the District’s perceptions are not wrong.


There have been fundamental improvements at Shingiro. The new management structure is far more coherent and capable. The infrastructure investments will continue to attract greater use by the community. The nutrition program is identifying and treating many children. Medical trainings and protocols are improving the quality of care. The staff feels empowered to make decisions and take the initiative to get things done. The health center is more engaged with the community and community members are beginning to use the health center more often. In short, Shingiro is a different health center than it was a year ago.


So Shingiro’s scores on the surveys and health data do not tell the story of improvement that is taking place at Shingiro. Not yet, though the improvements will no doubt be manifested in the data over time. But even then the data will never be able to tell the story of Shingiro or measure the intangible spark that’s been animated here. To see that spark, you have to drive up the bumpy clay road and take a look around.






*Shingiro ranked #1 on one key survey for the third quarter. But Shingiro still is only ranked third to fifth on the other major survey. Meanwhile, the actual usage rates as reflected by the health data are as much a function of the community’s attitudes and incomes as the quality of care provided at the health center. The health data is improving, and faster than the District as a whole, but off of a much lower base.