After deciding to extend my service for another year in Rwanda, I: 1) climbed Muhabura Volcano, 2) returned to America, 3) trained in Senegal, and 4) arrived in Rwanda eager to begin work (see previous posts). Throughout my “updates”, I have often alluded to my new position, always with the caveat that I will expound in a future blog. Today, I am going to share the details of what I will be doing for another year. Perhaps you already know the gist from the clues present in my posts- I will be extending my service to work in malaria in Rwanda.
On World Malaria Day in 2011, Peace Corps joined the fight to end malaria on a level unprecedented in the organization’s history through the creation of the Stomping Out Malaria in Africa initiative. SOMA is an Africa-wide Peace Corps initiative aimed at significantly supporting the international effort to eliminate malaria from Africa. Now, 3,000 volunteers (6,000 stomps strong!) in 20 Peace Corps programs across Africa are exchanging ideas and working together in the name of malaria elimination. The goals of this unique Peace Corps initiative are to:
· Reduce malaria where we work: We will accomplish universal bed net coverage and malaria education programs on prevention and treatment in all Peace Corps Volunteer communities in Africa by 2013.
· Contribute to the reduction of malaria in target countries: Through host country initiatives and work with partner organizations, we will achieve the Millennium Challenge goals of reducing deaths caused by malaria globally (by 50% or more), and substantially reducing deaths caused by malaria in all 22 African countries where we work by 2020.
· Help build an online community of malaria prevention volunteers: We will promote documentation and sharing of malaria prevention practices between posts across the continent and internationally between the initiative’s partners.
To achieve these goals, Peace Corps is recruiting Peace Corps Response and third year volunteers in every African country to be Malaria Volunteers (that’s me!) focused tightly on malaria prevention and working with designated staff Malaria Focal Points liaising with partner organizations and supporting work in the field. The key partner is the President’s Malaria Initiative (PMI) (that’s who I work for!). Started in 2006, PMI is a joint initiative of the CDC and USAID and is responsible for all malaria prevention work by US Government Agencies.
The convolution doesn’t end with PCVs placed with PMI. PMI also has its own operation and partnerships. PMI manages the US Government’s malaria funding and works through local implementing partners who conduct malaria projects and activities. I am placed with PMI, but on a day-to-day basis, I work out of the offices of the Rwanda Family Health Project, PMI’s implementing partner in Rwanda. I have a real computer, on a real desk, in a real office, and I feel like a real professional with a real position and real responsibilities. My experience in the village was very surreal; this is reality, or as close as exists in Africa.
Rwanda Family Health Project (RFHP) is a new USAID project. As a result of the economic difficulties in America, the US Government cut budgets and demanded more accountability for funds granted. Recently, USAID has been consolidating its projects. USAID determined that fewer offices meant smaller overall operational costs. In response, five USAID health projects in Rwanda are phasing out and consolidating as one, RFHP. The merger has been ongoing, chaotic, and messy, but a calm order is eventually settling.
The proposal for RFHP was written by a team from Chemonics International in response to a call from USAID two years ago. I learned that USAID has two types of projects- traditional agreements when funding is granted to a partner for approved activities, and contracts when the partner receives money to produce agreed deliverables. The most important difference is, if the project fails for an understandable reason, there is a bit of leeway in the former type; in the latter, the project must produce the deliverables or it is in trouble- breach of contract. Usually contracts are used when the project is an important one, requiring a lot of money, or an activity that USAID wants to ensure is completed well. On the ground, there is a lot more pressure to produce the deliverables on a team in the office of a contracted project. In the planning phase of the project, the team has to be extra careful and sure that it will be able to produce the deliverables before agreeing to sign their life away on the dotted line.
Development is occurring rapidly in Rwanda. A lot has changed in two years. Many components of the original proposal were no longer accurate or necessary. As a team, we had to revisit and edit the proposal in order to develop a solid work plan. We had to make sure that the information was up-to-date, the context accurate, the activities necessary, and the deliverables achievable. We also had to ensure that it reflected the five USAID projects that are phasing out, remained within the original scope of work approved by USAID, and followed the policies and priorities of the Ministry of Health in Rwanda. There were a lot of factors to take into consideration. The feat required a lot of coordination, as well as a meeting that lasted three days when we sat in a conference room with representatives from the Ministry of Health, agencies, and organizations operating in Rwanda to learn, sort through information, and establish what needs to be done and their priorities.
The first task of a team on a new project is work planning. The goal is to answer the question, what the heck are we going to be doing for the next year, five years? We accomplished the first step during our three-day meeting, when we determined what we could and should be doing. Now, we had to decide what we would do. We broke down into technical groups. At first, we brainstormed until every conceivable idea was on the table, written somewhere on one of the innumerable flipchart papers or sticky notes that littered the surface. Then, we examined, filtered, sorted, combined, and discarded our ideas until we narrowed them down to a few of the best options. Finally, from this short list, we chose the activities we would do. It was a relief to see order coming at the end of a long period of chaos.
The process was not only long and tedious, but a beneficial and learning experience. It introduced and improved our understanding of RFHP. We had a solid base to build from. We contributed to the planning process so we were empowered to carry out our responsibilities. We witnessed the whole process required for a project to develop its plan. We were able to apply the same concepts to strengthen our individual work planning. It also reinforced the lesson I have grappled with throughout my service; you can’t do it all, so better to focus on a few things and do them well. It’s been a hard reality for me to accept during my Peace Corps service.
Three years ago, I developed a plan for the youth center in Kiramuruzi. That was another learning experience. It was my first time participating in a planning process, and I was directing it. It involved me, a couple of coworkers, and a few stakeholders in an empty building in a small village conducting surveys with unknowing youth and villagers who were trying to express what they envisioned for a community center while not really comprehending what it was. My first experience was ad hoc, disorganized, and informal. We didn’t know what we were doing, but we tried and did the best we could to make something with what we had. I recall a slight glitch in the survey translation when we asked a group of male youth whether they preferred to play with dolls instead of theatre puppets. I bet you can guess what they said! But, the overall result wasn’t bad- a functioning youth center. In retrospect, I compared and realized the first was what we call participatory planning in community development; the second was professional work planning.
RFHP is not only working in malaria as I am; malaria is just one component of health in Rwanda and what it does. There is also HIV/AIDS, tuberculosis, maternal and child health, and family planning, to name a few. We are the Malaria Team; one component, and a small one at that. In fact, we are not even a standalone component. Rwanda is implementing a framework of integrated community case management (ICCM). What is ICCM? It is health care taking place at the community level through Community Health Workers (CHWs) who practice integrated case management. The common health issues they treat are not approached individually, but as a whole. That’s the integrated part.
An element of ICCM is integrated management of childhood illnesses (IMCI). When a childhood case presents, the CHW follows an algorithm to diagnose and treat it. Here’s how it works when a sick child visits the CHW in his or her village.
1. The CHW records the child’s identification and basic information.
2. The CHW measures the child’s middle-upper arm circumference to determine his or her nutritional status.
3. Before continuing, the CHW checks a list of danger signs that would result in a referral to the health center if present, such as severe malnutrition, vomiting, or respiratory difficulty, because CHWs do not have adequate training and experience to handle these cases.
4. If none of the danger signs are present, the CHW continues by identifying whether the child has fever, diarrhea, cough, pneumonia, or minor malnutrition. These signs are characteristic symptoms used to diagnose different illnesses. If any of these conditions exist, the CHW follows the algorithm for treatment. For example, if the child has fever, the CHW does a rapid diagnostic test for malaria and treats with Coartem. If the child has diarrhea, the CHW treats with zinc and oral rehydration salts. If the child has both, both are treated. And so on.
The guiding principle of ICCM is that a sick child is not considered for malaria and then diarrhea alone. Rather, all his or her symptoms are taken into account and treatment occurs as an integrated package in order to be comprehensive and complete. Integrated case management has been very successful in Rwanda, applied in the context of limited resources to save many lives. The other day, I was listening to a professional forum discussing health care in America, and I couldn’t help but notice that the word, “integration”, was used frequently. It appears America has a lot to learn from countries, like Rwanda, that have already implemented integrated case management. And it doesn’t stop there- community health and performance-based financing were also mentioned. It’s ironic because it’s contrary to the traditional flow of knowledge and experience from America to developing countries.
Integration determines how we work. For the Malaria Team at RFHP, integration means we are not working on our own, but as a part of community health. We work as members of a diverse team of officers from many technical areas. Despite our different backgrounds, we all have the same goal- to improve ICCM/IMCI by CHWs- because it will benefit every technical area.
The Malaria Team is composed of two people. My colleague is working to improve ICCM/IMCI trainings by ensuring the incorporation of a quality component for diagnosing and treating malaria. She will also promote the proper use and care of long-lasting insecticide-treated bed nets and assist with National Mother and Child Health Week malaria outreach activities.
On the other hand, I will be supporting improvement in the quality and timeliness of malaria data reported by CHWs to SISCom, Rwanda’s community health information system. The health system in Rwanda is based on two innovative health financing programs, namely performance-based financing and community-based health insurance (mutuelle), which have greatly increased access to affordable and quality health care, but depend on robust data to function. Currently, community data is transmitted by paper to the catchment health center where it is entered into SISCom and transmitted to the central level for analysis, aggregation, and incorporation in the Health Management Information System (HMIS). As Rwanda works towards pre-elimination of malaria, quality data that is reported on a timely basis and used to inform programmatic decisions will be necessary. Utilizing the network of PCVs in Rwanda, I will conduct a malaria data quality audit by carrying out a retrospective review of SISCom data compared to CHW-collected data. I will work with the National Malaria Control Program to incorporate a data component into CHW trainings, as well as organize a ToT for PCVs who will train CHWs in data reporting. Further, I will analyze data reported to SISCom and relay feedback to health centers where PCVs are placed to encourage data use in decision-making. Under my scope of work for the PMI, I will also be surveying long-lasting insecticide-treated bed net use and tracking malaria commodities in communities through the PCV network.
I have spoken a lot in this blog about ICCM and IMCI. I hope that you have gained a better understanding of what those are. I realize that I brought up a lot of unfamiliar or additional terms in my position description above- Rwanda’s health care system, performance-based financing, community-based health insurance, community health information system, and pre-elimination of malaria- that require elaboration. An explanation of each would be helpful to understand exactly what it is I will be doing, but that would require additional pages of writing and I fear this blog is turning out to be a long one. For today, we’ll stop at ICCM and IMCI. In another blog, I’ll introduce you to the rest of the terms that are critical for my work. Look for that coming soon.