Performance Based Financing

In an earlier blog post on data recording, I mentioned Rwanda’s use of the performance based financing system, which has been largely praised by the international community. Because I obviously think my opinion is more important than that of the United Nations, the World Health Organization, Rwanda’s Ministry of Health, and hundreds of International NGO’s and think tanks, I would like to inform you all that I too, am ready to praise Performance Based Financing; and that the Peace Corps is turning me into a staunch supporter of capitalism, free market enterprise, and fiscally conservative social policy (sort of).  

wedding guests arrive (Gitarama District)

Traditionally, governments and international organizations have funded inputs in developing countries. That is to say, money is given to build facilities, pay doctors, purchase medicine—results are assumed to follow suit. But decades and billions of dollars later, malaria has not been eradicated and many of my neighbors still opt to give birth at home.

Performance Based Financing (PBF) rewards health care providers (like my health center staff or the community health workers’ cooperative) for work they have already done. Money, proportional to the quantity and quality of the job, is given after results are reported. Then, the people who delivered the results decide what to do with the money.

The staff meetings where PBF is discussed can get pretty heated. My health center happens to be the worst performing of the district, and the bonuses reflect it. For months I’ve been trying to talk to staff about giving pregnant women iron and folic acid tablets (which are required by national policy). No one seemed to care until the PBF report came back criticizing the low attendance at prenatal consultations. Suddenly everyone was brainstorming how to get pregnant women to the health center. Three months later, I now help distribute the vitamin supplements during prenatal consultations and am happy to report that the number of women coming for consults during their first trimester has increased!

Choosing the Right Battles

During my Peace Corps job interview I was asked to describe a time in which I had been part of a group that was doing something I did not agree with, but I could do nothing to change the situation. The question surprised me. When I disagree with something, I’m generally not shy about voicing my opinion or trying to change the situation—that’s why I wanted to join the Peace Corps, to make change happen! Was this a trick question?

My (boy) neighbor, Queen of the Universe

After some thought, I told the recruiter about my Catholic upbringing which directly conflicts with my strong beliefs about women’s reproductive rights. “In high school I often attended mass with my mother, and there was a particular Sunday the priest was delivering his sermon, talking about the evils of contraception. I got so upset I had to walk out of the Church to collect myself in the bathroom before going back in”. The recruiter smiled, “You’re going to have a lot of situations like that in Peace Corps; it’s all about picking your battles”.

There are plenty of battles to choose from at my health center. The number of battles I choose not to fight is actually rather depressing. But, if I told everyone at work when I disagreed with their actions, I would have no friends and probably no job. Gaining trust and acceptance is a long, daily process that I’m working hard on. If I attain the trust and respect of my coworkers, I can hopefully fight, and win, one or two battles. What often keeps me up at night is that seven months into my work, I have friends, and I’m starting to notice that coworkers do trust and respect me, but I still haven’t picked a battle.

Rwandan national policy requires every malnourished child who comes to a health center for treatment to receive an initial health check up. In theory, a nurse will complete a malnutrition patient chart and file that includes prior medical history, vital signs, and tests for tuberculosis, HIV/AIDS, and parasites. At my health center, this does not happen. When a mother comes with her malnourished child, my counterpart, the health center nutritionist, takes down the family names and address, the child’s age, weight, and MUAC, gives the mother Plumpynut, some advice, and then sends them on their way.

A few months ago I organized the patient files for all the malnourished children. When I say organized, I mean I started charts for all children who were enrolled in the program. I included all the information available (which was not much) and talked with the nutritionist about completing the rest. She seemed genuinely interested, but then reminded me that she is not a nurse and has no training or knowledge on how to complete the files. So I sighed, and we agreed to keep better records and complete as much as the two of us were capable. 

Several weeks later, the district hospital nutritionist along with the nutritionist from the International NGO working on childhood nutrition in the district, came to “supervise”. They asked for the files of all children being treated for malnutrition. We took out the incomplete files I had worked on. When they remarked about the incompleteness, my counterpart stared blankly and then asked me “Alma, why aren’t these done?”. 

I was furious. Was this not her job? Had I not tried to get her to complete the files? Was she seriously putting the blame on me? What I was most furious about, however, was my sudden realization that this was a battle I had decided not to fight, and in retrospect, I probably should have. There are a million excuses to let things go here. Was I becoming lazy and apathetic? Am I ever going to choose a battle?

Since the “supervision” I have made more contact with the nutritionists at the hospital and NGO. With my counterpart and the health center director, I have discussed the challenges we need to overcome to ensure all children receive checkups and proper service, not just Plumpynut. Everyone verbally agreed to collaborate, but action remains slow. Still, I think I have found a battle to fight.

A Day in the Life

6:00 AM- I wake up, realizing I’ve pressed my cell phone’s snooze-button too many times to make it for a run. This happens often, which I always regret later in the day when someone inevitably reminds me how much weight I’ve gained since arriving. They say in Peace Corps you learn a lot about yourself; I have learned I am an emotional eater. 

6:30 AM- The tea kettle on my kerosene stove is ringing. I have hot water for my bucket bath, oatmeal, and coffee. I have always been a morning person and I take after my father in truly relishing this peaceful morning ritual. Sipping the delicious Rwandan coffee, I try to relax and prepare for the day.

7:00 AM- Daily Health Center staff meeting, which begins anywhere from five to twenty minutes late. These meetings help me gage language progress. In seven months I’ve made a lot of progress but still not enough to give me confidence to contribute my opinions during the meetings. Accustomed to running meetings in college, this is often a source of frustration for me. 

8:00 AM- I spot the new nutritionist for the international NGO that works in my district. The organization have just started a “new” nutrition program across the district—which is exactly the same as the HEARTH program the previous volunteer worked on, except it has a different name, and therefore everyone I work with insists on completely dismissing all previous work and starting from scratch. I want to show the nutritionist all the data I’ve imported onto excel from the nutrition work I’ve built on, and discuss with him how we can collaborate. I take my computer to his office, and realize it’s broken. The nutritionist is busy and my lack of visual aids and language skills makes him quickly lose interest.

9:30 AM- I sulk back to “my office”, only to realize that my counterpart has left for the primary school in the village furthest away from the health center. She’s gone to work on the national Maternal and Child Health Campaign that is being implemented across the country this week. I’m frustrated that she didn’t let me know she was going, since I try to take every opportunity I can to leave the Health Center to make field visits and get to know the community better.

10:00 AM- M&CH Campaign is fully underway. I help the staff distribute Vitamin A supplements to children under 5; mebendazole (which kills intestinal parasites) to children under 14; iron and folic acid to pregnant women; and bleach (to clean water) to all mothers. This is very cool, but at this point in my service I’m itching for a project of my own. What I’m doing can and should be done by health center staff. My attempts to conduct “education sessions” as I give out medicine are received with blank stares by mothers, terrorized faces by children, and hysterical laughs by my coworkers.

12:30 PM- A friend from the hospital invites me for lunch, which I accept immediately despite being exhausted from the morning activities. Peace Corps is all about integration! On our way, I see a few nurses staring and whispering to each other, to which all I can do is sigh. Rwanda is fairly progressive when it comes to gender relations, but two young people of opposite sexes enjoying time together seems to translate to gossip in small towns everywhere around the globe. But, lunch is delicious and our conversation is a rather comical mix of Kinyarwanda, English, and French on topics that range from Colonel Kadafi to why my father insists on 600 cows.

2:00 PM- Back to work, which in the afternoon is slow to nonexistent. I sit with the nurses, help distribute medicine, try to understand the conversations around me, and try to laugh off the jokes. Teasing is a huge part of Rwandan culture, which on a good day is funny, and on a bad day unbearable. Today is turning out to be rather difficult, so the various imitations of my poor Kinyarwanda pronunciation, the poking of my acne, pinching of my muffin tops, and demands for money and American visas are not appreciated.

5:00 PM- Work day is over! As I leave the health center with a coworker, another nurse invites us for drinks. Despite my exhaustion, I accept. I might not be saving the world, but at least I’m making friends!

6:00 PM- As we sip our sodas, I’m feeling inspired to study more Kinyarwanda. The two nurses are talking and giggling, and I’m getting parts of it, but still feel pretty left out. When I realize my friend is telling the other nurse about her brother’s newborn son, I jump in the conversation. “Congratulations! Your family must be so happy,” I exclaim. Both women become silent and the nurse tells me in French, “she’s an orphan, her parents died during the genocide”. There’s a few seconds of awkward silence and then the two women continue the conversation as usual, but I remain dumbfounded. This part of Rwandan history and culture, no matter how good my language gets, I will never truly understand.

7:00 PM- I’m ready to go home after a long day, but just as I get ready to say goodbye, one of the men who works at the local government office comes to greet us. In a loud voice, so that everyone at the bar can hear us, he begins to berate me. “ARRRRIIIIIMAR! Where have you been?! What work are you doing?! Why have you not come to see me?!” I’m caught off guard and embarrassed that everyone is now staring at us, but he continues, telling me how much the previous Peace Corps Volunteer did for the community, how well she spoke Kinyarwanda, and how good of friends they were. “She gave me reports every week! What work are you doing? You are not seenable! You do not speak Kinyarwanda!”. This hurts, a lot. I try to remain calm and collected, when one of my supervisors from the health center comes over and tells me “Alma, people at the health center are not happy because you refuse to speak in English with them. They want to learn English but you only want to speak in Kinyarwanda”. Confused and exhausted, I tell the government worker that I am not the previous volunteer, that I do not like comparisons, and that if he has specific work he wants me to do he can talk to me at work. Rwandans seldom show their emotions and talk about them much less, but I make sure he understands that what he has said has made me unhappy. I say goodbye to everyone else and head home.

8:00 PM- Frustrated and exhausted, I get into bed. I want to tell someone about what just happened: talk about my emotions and get advice, but who? Tomorrow I can talk to my counterpart about it, but the language and cultural barriers will make the discussion limited; I can call another volunteer, but the truth is not having gone through training in Rwanda, I have not formed very close friendships with many other volunteers; I can call home—but explaining the situation, the context, and the repercussions make relatability and any advice offered rather strange.

Through this blog I try to document the more positive aspects of my days, but I would be lying if I said it was all easy and fun. I get a lot of emails asking me to describe what my average day is like, and what my most difficult challenges are. There is no such thing as an average day, and what I might consider difficult one day I might find easy and enjoyable the next. What I just described is a particularly bad day, but the difference between a bad day and a good day generally depends on my attitude, and maybe my computer not breaking.

Preschool Graduation

Owning a digital camera provides me with the unique privilege of a guaranteed invitation and good seat to pretty much every event in the community, like the preschool graduation at the local primary school.

The graduating class included about twenty students, most of them children of my coworkers, who were precious beyond words. 

While the setting for this graduation (bare classroom with wooden benches and no electricity) was worlds away from any preschool graduation in the United States, everything else was remarkably similar.

The President of the Parent-Teacher Association talked for a bit and then handed over the stage to the students, who could barely sit still, unaccustomed to so much attention. The very patient and graceful teacher then lead the students in the recital of English, French, and Kinyarwanda lessons. Parents ogled, awed, drooled and clapped at their children’s work, praising each other and their children for how well they performed, completely ignoring any and all mistakes that were made. 

In case you’re wondering what aspects of my daily life I really enjoy, I suggest checking out the video--