The Paper Trail

In an early blog post from Niger, I mentioned my interest in health data and record keeping. Well, I am in the right country. Rwanda has some of the best health related record keeping in Africa. At my fingertips are stacks of logbooks on everything from the number of HIV/AIDS counseling and testing sessions conducted in my district this year, to the number of ibuprofen tablets in the pharmacy and their value. This impeccable data recording does, however, come at a price.

My health center has only two computers and very few people who know how to use them. One computer is used mainly for accounting purposes, the other for sending monthly reports to the Ministry of Health in Kigali. Day to day statistics are all kept in large graphing paper notebooks.

It takes three or four of the ten trained nurses at the center to work prenatal consultations. Every Thursday, as pregnant women line the hallway and outside waiting area of the center, the nurses sit in the consultation room and write.

The forms to fill out during each prenatal visit include: the center’s prenatal logbook, the laboratory logbook, the mosquito net logbook, the HIV/AIDS voluntary testing and counseling logbook, the individual prenatal health sheets for the health center, and the individual prenatal health sheets for the pregnant women. Each form/book requires a lot of the same information in a slightly different order, plus one or two additional facts (usually irrelevant to your health) that make it unique.

Recordkeeping is essential for successful monitoring and evaluation, and overall better healthcare. I spent many hours writing my thesis in Olin Library convinced that if only developing countries could record data effectively, most health issues could be resolved in no time. Now I spend my mornings in the consultation room wanting to tear the record logs apart.    

Rwanda’s healthcare providers are currently under a performance based financing system, which has been largely praised by the international community. This system stresses data accountability and puts pressure on health workers to record their every move.

All of this is great, until a twenty year old woman, eight months pregnant, who can neither read nor write, stands in front of a row of nurses with enormous notebooks who ask very personal questions and write answers without bothering to look up.

Keyword in all Peace Corps projects: behavior change.