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.