Hearth Program Challenges

I will preface this post by saying that it is extremely critical (and long), mostly because I believe the project I am working on has enormous potential. I can be an awfully opinionated and critical person at times, and this is one of those times. However, I feel incredibly lucky to be working with the Hearth model and I have tremendous respect for PCV who lived here before me, and the work she did. Having said that… 

One of the incredible things about the Positive Deviant/Hearth model is that it requires very little funding. Peace Corps Volunteers should be able to conduct a Hearth course without having to fill out any grant proposals or ask for outside resources. Generally, Peace Corps projects rely on partnership with the community. The best projects come from initiatives made by local stakeholders, who have the most invested in the project’s success, with PCVs acting simply as facilitators. 

At my health center, Peace Corps provided an enormous one-time grant for this project. In the words of my former roommate, the health center accountant (who is considered by people in my community to be rich), funding for the Hearth Project was “more money than she had seen in her entire life”.

The money was used to buy some durable goods (notebooks, pens, cooking pots), lots of ingredients for cooking (corn flour, soy flour, dried fish, oil), take-away’s for Hearth participants (soap, chlorine, live chickens) and lots, lots of per diems. Money for the project is now gone—all spent. Left are ingredients for the cooking classes and staff members who are expecting to get paid.

Now you might be thinking to yourself, Alma, you are a heartless ice queen. Are you turning into a republican? Since when did you become so fiscally conservative? You live in a country where annual per capita income is $290 and the poverty rate is 64%, what could possibly be wrong with providing extra cash flow? The answer is quite a few things.

Let me just briefly comment (ok, let me complain about) the ridiculous number of Western NGOs dropping all sorts of materials, projects and cash in Rwanda and then leaving. I’m not saying these organizations are bad or that I know better, I’m just saying it makes my job (and explaining my job) a lot harder. Dependency on foreign assistance in Rwanda, particularly in the health sector, is enormous. This is not what Peace Corps Volunteers are supposed to do. Unfortunately, the Hearth Project, bringing in such an incredible amount of money, has rather distorted the perception of Peace Corps and the PCV in my community. 

I discussed the issue of per diems in a previous blog post. With the former volunteer, every time someone in the community helped with the Heart Project they received daily per diem. Providing per diem when there is all weekend training makes sense. Paying the nutritionist per diem to weigh children in the community (i.e., her job) does not. The expectation that I would continue providing per diem has been challenging and very frustrating to break. Not only do my coworkers see no incentive to work on the project; but also I am once again seen as inferior to the previous volunteer because she gave them money and I do not.

Luckily, my counterpart is an incredible woman who cares about the children in her community. After lots of grunting and eye rolling, we settled on me buying her a drink and brochettes (delicious barbequed goat meat) at the beginning and end of each Hearth course.  

The fundamental problem with providing so much to the Hearth Project, however, is that by giving almost all the cooking supplies to mothers (not to mention the chickens), the core objective of the course is defeated. Oil, soy flour, and dried fish are available locally, but more expensive than the beans and nutrition-less sweet potatoes that poor families feed their children everyday. By requiring mothers to bring ingredients to the class, parents realize that they are able to provide for themselves and that the slightly higher cost is worth it when their children are healthy. When I provide the ingredients, mothers understand what foods help their children grow but still think it’s impossible to do without assistance.

These are issues I am working on. For starters, my counterpart and I are going back to the villages where Hearth classes have already been conducted (some already a whole year back) and seeing whether or not mothers have retained the information learned and children are healthy. Through monitoring and evaluation I hope to help my counterpart and other health staff members understand the downfalls of simple handouts and the importance of sustainability. Stay tuned!

Jeannette, who began the Hearth Program crying every time
she saw me and ended up my best friend

Rwanderings

In my experience, in Africa, everyday is a new adventure.

Most afternoons I take walks around the various villages within my sector, in an attempt to become more familiar with the area and allow people to become more familiar with me. Slowly, I am beginning to feel more comfortable with my site and with Kinyarwanda, which allows me to go a little bit further each day. Last week I walked two hours to a neighboring sector where market was being held, and where a British VSO (a slightly more sophisticated version of Peace Corps) volunteer is posted.

Walking anywhere in Rwanda is a pleasure (and a work out) because of the spectacular views and endless green hills. On my way to the market, I passed the base site of the water project going on in the district right now. I’m told by December (actually I’ve been told this month, August, and December… so I’m going with December) the district will have running water and electricity! Talk about being a part of development!  

Passing a primary school, I put recess to a halt as all kids either froze or ran closer to the road to see me. This is a school I’ve visited before so there were less “umuzungu!” and more “Arrrrma!” which I assure you is no small feat.

As I edged toward the dividing line between my district and the next, I saw Mama Theofile, a very friendly woman I visited a few weeks ago. She was also going to the market, and so we continued together. Inevitably, we ran into several of her friends and stopped to greet them.

This particular market is a big one, set on a very steep hill. The “ground level” is a mostly animal—lots of rabbits, chickens, and very cute piglets! The second level, about half way up the hill, is what I call the general stuff section (baskets, pots and pans, and lots of plastic junk). The third and final level is where all the fruits and vegetables vendors sit, and all the used clothes. On my favorite screen print shirt of the day read: DO THE MACARENA!

Looking around, I felt a little bit like I was in the opening scene of a spy movie. You see George Clooney in sunglasses, walking through an African market unnoticed, until he realizes large scary men in khaki vests with earpieces and walky-talkies are following him. Next thing you know he’s back at the CIA operative office talking to his boss about an arms trade gone wrong.

Except here, instead of George Clooney it’s me, and I am very much noticed by everyone, and instead of being followed by large scary men, I have a long trail of small laughing children. I am not heading to any important office to discuss arms deals or potential coups; I’m just trying to find the only other native English speaker for miles so we can grab a Fanta and maybe complain about our latest outdoor latrine troubles.

While I walk through town, I realize I have no cell phone reception and no idea where exactly my friend lives. Luckily, I am in a remote African village so this presents absolutely no problem. I ask the nearest three-year-old where the umuzungu lives, and suddenly I have fifteen people (kids, adults, old people) offering to take me there. Te minutes and four different guides later, I reach her! After lunch, I take a bumpy motorcycle cab ride back home. This, all in a day’s “work”. 

Amandazi

 

I learned how to make amandazi, Rwanda’s version of fried dough! Although amandazi are at the bottom of my list of delicious international versions of fried dough, learning to make them is at the top of my international culinary experiences list.

It should come as no surprise that I have made great friends with the woman who sells amandazi and fresh bread. Athanasia is hilarious. She is an older, childless, unmarried woman—a rather marginal group in Rwandan society, yet she thrives. I admire her savvy and her wit, and I really enjoy spending time with her. When I visit, she always greets me with a huge hug and two kisses, “Muraho cheri!,” she says with open arms.

I recently confessed my love of all bread related things to Athanasia (as if it weren’t already painfully obvious), and she told me how much she loves chocolate. So we made a deal: she would teach me to make amandazi arachushe (the hot kind) and I would bring her cocoa to put in her milk.

The actual making of the amandazi was left mostly to Isa, a very nice young man who did not need or want much help from Athanasia or myself. He mixed the flour, sugar, yeast, hot water, oil, and eggs into a paste that he then kneaded, and kneaded, and kneaded some more. Then Isa cut the dough into small balls and fried them in oil, lots of oil. Amandazi arachushe: biraryoshe cyane! Delicious!

Pop Music in Rwanda

Despite my mother’s best efforts, I am not a musician. So I will spare you a useless and inaccurate analysis of Rwandan music and let you come to your own conclusions. Below, one of my favorite Rwandan pop songs at the moment. Hopefully I will post my own videos of traditional song and dance in the future.

Shout outs to the lovely Jesse Hyman and my wonderful sister Cristina, who I know will feel moved to dance to Rwandan music at the next Hyman Christmas party while everyone else laughs hysterically. 

Also heard on the radio (very often): Bob Marley, Enrique Iglesias, Backstreet Boys and, of course, Africa’s favorite-- Celine Dion.  

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.