Health Insurance

I haven’t been able to keep up with U.S. national news, so I don’t know where the debate on healthcare stands right now. (Feel free to send me news articles to keep me updated though! hint, hint). What I have been keeping up with, however, is the rapid pace at which the Health System in Rwanda improves.

My sector health center and government are currently campaigning to get everyone health insurance. In Rwanda, you pay 1000 RWF (around $1.50, about the same price as a liter of vegetable oil) and receive health insurance for a full year. Each time you visit the health center you present your card and pay 200 RWF (30¢, about the price of a kilo of onions) for whatever you need: consultation, lab tests, medications, etc. If you don’t have health insurance, just like in the U.S, things get pretty expensive.

Health Center Staff

I cannot imagine this system being feasible without the enormous donations Rwanda receives in foreign aid. Still, the government’s management of the health system is impressive and should serve as a model for other developing and developed countries.   

This month I’ve seen the health center and local government staff mobilize in an incredibly effective manner. People were posted on the road Friday (market day) ready to sell insurance. After Saturday’s umuganda every village leader rounded up her community to discuss the benefits of health insurance. Monday, most of the health center administrative staff went out to visit the villages furthest away from the center, talking to more people about the benefits of health insurance. 

I am fortunate enough to never have been in a position where I have had to make a choice between buying health insurance and buying food or shelter—but I am currently surrounded by those who do, and they mostly chose health insurance. It’s certainly an interesting comparison to attitudes and debates in the United States!

Sleep Out

For once I am not talking about the Cover Africa Sleep Out on the Arts Quad… although shout out to those who did just a few weeks ago!

A week after the National Genocide Memorial Week, my community organized its own memorial event: a sleep out at the exact place (and on the exact date, I think) where seventeen years ago hundreds of Tutsi were locked inside the local government building where they had been seeking asylum, and burned to death.

Around 6pm on Friday April 22^nd the community gathered in the center of town and slowly, singing, walked together to the site at the top of a hill. There, the local Genocide Memorial Association had set up large tents, chairs, and spread hay over the rocky ground.

People greeted each other with silent nods and smiles instead of the usual handshakes and loud “Muraho!”s. Waiting for the final preparations to conclude, everyone spoke in whispers. Once the microphones were hooked up to a generator and enough people were seated, several older community members gave speeches. These were followed by more lighthearted youth performances: dance, song, poetry, and even theatre. These acts served to lighten the mood, and by the 9pm when a storm hit the tents, most people were smiling.

Once the weather calmed down around 11pm, a TV was turned on and music videos of songs remembering the genocide played on repeat. At this point most of the older adults went home to bed. The young people stayed and invited friends, who came and crowded around the bonfire and the television. By midnight there were at least 600 people watching music videos on a screen no bigger than the one in my family’s basement in Pennsylvania.  

Throughout the evening and into the night the atmosphere became noticeably less solemn. What seemed to prevail throughout the entire event, however, was a powerful feeling a unity and collectivity. It’s very possible that my lack of understanding of the language, culture, and each individual’s background allowed me to have rose tinted glasses for the event… but I know the toddler sitting in front of me throughout the night was laughing genuinely, and I’m pretty sure the adults who surrounded him were smiling frankly as well.

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.

Hilariousness

--Overheard at the health center: "Alma, why don't you take one of the mosquito nets for pregnant women? The mosquitoes are really getting at your face!" Unfortunately I have yet to find the word for pimple in Kinyarwanda. 

--Overheard at the market: “Alma, are you a nun? We must find you a husband immediately! We will find you a Rwandan husband in no time!”

--Overheard at the bread store/tea shop: “You are American! Take me to America! I know the visa is complicated, but you can marry me, it will be no problem!
 

--Responses to “If you want to marry me, you must give my father 600 cows” have included:

• Your father is crazy. 
• Only President Kagame has that many cows.
• I have 800 cows. Call your father. 
• They have cows in America?
• How many children does your father have? Only three?! No sons?! He cannot ask for so much!
• My favorite: And how many cows did your father give when he married your mother?

--The Kinyarwanda expression for someone who is courting/dating: umuhinzi. Also means farmer or farming. In Rwanda you are not a player, rather, you are a farmer.
 

--I milked a cow. It was amazing. Also really hard, but amazing. I can die happy now.


Other miscellaneous:
Check out my amazing and talented sister Daniela dance Swan Lake!

Conference Culture

In the world of aid, conferences and trainings are huge. In many ways, it makes sense. Bringing together professionals, healthcare workers, and other various community leaders to share information about health, education, and development is a good idea in any setting. But I’m starting to think too much of a good thing can be bad.

During the first fifteen weeks of 2011 the ten nurses and high level administrators at my health center have attended a cumulative total of fourteen weeks worth of trainings and conferences. This does not include the various lower level administrative staff and nurses who also attend conferences.

These trainings are almost always sponsored by international NGOs or foreign aid agencies like USAID, UNICEF, or Save the Children. The events generally take place at nice hotels in the larger cities. Hosting organizations provide all attendees with lodging, food, transport, and per diem. Topics include family planning, vaccination procedures and policies, HIV/AIDS, tuberculosis, etc. and are repeated often. Three different nurses at my health center have attended three separate conferences on TB this year.

I sat in on a very modest two-day conference held at my health center where the daily per diem was 30,000 RWF. The standard salary for a nurse at my health center is around 90,000 RWF a month (approximately 150USD). Needless to say, people are ager to attend trainings and conferences. This creates quite a bit of tension and animosity among staff.

I do think trainings are important and beneficial for development. I am, however, becoming much less enthusiastic about them.

A few weeks ago, there was quite a bit of drama at the health center. Two nurses were mad at each other. Turns out a nurse (we’ll call her Nancy), was attending a conference in Butare, the big city two hours away, with one of the administrators (we’ll call him Bob). Another Nurse (we’ll call her Betty) was furious. The conference’s topic was Betty’s area of expertise, but Bob decides who goes to the conferences, and he chose Nancy. Betty is an older nurse, married with children. Nancy is a younger nurse, single and flirtatious. Bob is also a well-known womanizer. Everyone at work thinks Bob invited Nancy to the conference so he could sleep with her. … And I thought I was going to miss Grey’s Anatomy!

Ascaris Lumbricoides

In Peace Corps they tell you to celebrate the small victories, so allow me to gloat. Last Monday I correctly identified a case of worms.

Every Monday morning between ten and twenty malnourished children and their mothers come into the clinic for Out Patient Therapeutic Treatment. My counterpart, the health center nutritionist, and I weigh the children (who are generally between six months and five years of age) to check for progress and give out Plumpynut. Plumpynut is a Ready to Use Therapeutic Food (RUTF). A highly nutritious food bar, sort of like a Slim Fast bar except instead of overweight American adults eating it to lose weight; malnourished African children eat it to gain weight.

Mondays are both heartbreaking and incredibly inspiring. To say these kids are adorable doesn’t even begin to describe it. Now that I’m relatively established none of the kids cry when they see me. In fact, some even run to greet and hug me when they arrive at the health center!

Generally speaking, there are two general types of malnutrition: chronic and acute. Acute malnutrition is generally more temporary and if quickly addressed, ramifications are not severe. Children with acute malnutrition often have swollen cheeks and bellies. Chronic malnutrition is a result of long-term malnutrition. It causes stunting, hair loss, and generally slows the development of children. Eventually your body loses the ability to absorb nutrients so treatment is more complicated and can require years of medical attention. (To my friends who studied nutrition or are in med school-- please forgive this dumb-ed down explanation).

Both types of malnutrition affect your body’s ability to fight off foreign bacteria and viruses, which is particularly problematic for small children living in environments with very poor hygiene.

Surrounded by malnourished children on a daily basis, I am slowly learning to identify the warning signs and characteristics of the various levels. So, last Monday when I saw a very upset four-year-old girl with a particularly swollen stomach, but normally sized ankles, wrists, and cheeks I knew something was wrong. After consulting with my counterpart I took my small friend to the lab and where the technicians identified the intestinal parasite causing her pain and weight loss.

I feel a little embarrassed to admit I did take advantage of my umuzungu status to break protocol, insurance procedures, and lines in order to get the diagnosis and the drugs to cure her. I do not plan to act in this manner for the next two years, but I’m not losing any sleep about it this time. At a health center that serves over 12,000 people staffed with only ten nurses (no doctors) there are times people rush and patients get overlooked.

I am hoping that as my language skills improve and health center staff trusts me more, I will be able to help address more of these types of issues. Plumpynut will not cure malnutrition in a child with worms just like ibuprofen will not kill the tuberculosis virus misdiagnosed as a common cold.

While I personally cannot positively diagnose any of it or provide care to cure it, I can work on making it easier and more effective for those who do.

Genocide Memorial Week

April 7^th marked the beginning of a three-month national mourning period to commemorate the victims of the 1994 Genocide. During the week of April 7-13^th the National Commission to Fight Against Genocide organizes events nationwide to honor the memory of those who perished.

Leading up, I had hoped the week and the events scheduled in my community would be a chance for me to be a positive presence and really integrate in my community. In retrospect it was incredibly naïve and insensitive of me to expect genocide victims and survivors to discuss such traumatic events with the new foreign white girl in town who barely understands the language. To put it simply, the week was depressing and I think confusing for everyone, including myself.

I woke up on the 7^th and prepared myself for the community event at the local memorial site, which I knew was planned. I was unclear at what time everything was happening (a common predicament in my life), but I figured I would just go with my roommates.

As the minutes and then hours passed with no sign of life from my roommates’ rooms other than the really loud radio playing sad songs about the genocide, I began to get anxious. Finally, one of my roommates emerged and told me the community event was at 2 PM. But two o’clock came and went and no one in my house seemed to be going anywhere. When I finally asked if we were going, my roommate told me she did not like going to any memorial sites because it was too difficult. I later found out both her parents and two siblings were killed in the genocide. She was barely ten years old.

Although I missed the opening event, I attended most of the afternoon discussion sessions the rest of the week. I understood next to nothing, no one offered to translate and I didn’t think it appropriate to ask. Throughout the week I observed friends who I thought were incredibly outgoing and cheerful really shut down. I am hoping my presence was seen as a sign of respect and solidarity as well as a step in the right direction.