Human Rights and Sustainability

The other night, a man came to the health center. The only nurse, Stephen Sangara, works eight hours per day and then sleeps on the premises. But he’s on call 24 hours a day, every day. The man awoke him, shouting in the night. Mr. Sangara came to the gate and opened it. The man is standing there with his son who has a bean stuck in his nose.

Immediately to the patient’s right is a wall-sized painting of his rights. Though he can’t read them (because they’re in English; MOH loves looking Westernized), he fully understands them.

Mr. Sangara opened his office and asked the man for payment (40/=, ~$0.50). The man said he had nothing, but he’d get it later (which he never did). In the exchange, he was rude to Mr. Sangara partly because he had to wait for him to wake up. And according to the Rights Mural, he has the ”Right to timely services” and the “Right to Optimum Care by qualified health Care providers .” His rights are clear, are extensively listed, customer obligations notably omit payment. He was annoyed in being asked to pay; paying for medical service is not mentioned as a customer obligation.

For reasons that are beyond the scope of this blog, the Ministry of Health (MOH) cannot reliably keep its health facility operating optimally. There is never enough staff, so wait times are very long in most MOH clinics. The supply of medical personnel comes from Nairobi and is doled out according to need. And the need is always too great.

Medication resupply shipments come in with random supplies at random intervals. They’re supposed to come every three months, but sometimes it’s five months between shipments. They’re supposed to be filled with medicines based on patient loads, but it seems quite random (we have about 40,000 condoms and almost no antibiotics).
So health facilities have two options. The first option is to violate customer rights #1 and #2, the right to “Optimum service” by not providing the drugs patients need and the right to “Timely service” by not having sufficient staff. This is what most clinics are forced to do. The other option is to add a customer obligation: the obligation to “Share in the cost of treatment.”

Those who chose the second option begin acting like private clinics. They buy medications from local pharmacists (which are always in stock) and sell them at a premium. The premium then goes to hire casuals, nurse assistants and clerks to help with patient management.

But when they sell drugs, people are angry. Even one of our good-hearted entrepreneurial boda drivers felt cheated when he was charged for medicines beyond the flat (subsidized) government rate. He went on and on about how they were very “funny” [devious] people at the hospital. The very people who used a bit of business sense to provide better treatment to their patients are perceived by the community as cheaters. Because, after all, people have a right to optimum service. And you shouldn’t have to pay for rights.

Maybe free healthcare for all should be the goal. We (theoretically…maybe…I hope) can afford it in the West. But Kenya’s not there yet, even counting foreign aid. So in the meantime, most government clinics have chosen to do their best to provide decent service to as many as they can, bearing the scorn of those who feel their rights have been violated.

Nuru aspires to sustainability. That means that we want our programs to be running full-steam without extra Western money within 5 years. And the “Healthcare is a right” worldview makes sustainability extremely difficult in the absence of a reliable well-funded government system. Every price increase, every user fee, every shilling asked for at a clinic is a perceived violation of rights.
People here have been told all their lives that healthcare is and should be a handout. Nuru’s No-Handouts ambition is confronting that view head-on. Our next major step is figuring out a mechanism for doing that. Do we increase fees at the clinics? Do we try to offer private options? Can a health plan or insurance plan be a financing mechanism? The real question is: do people value healthcare as something valuable enough to be paid for? Or are they satisfied in accepting whatever the government can hand out? And, an even harder question, if they see it as valuable for themselves, would they be willing to contribute so that the less fortunate can have it?

Is there a fundamental human right to healthcare? Let’s leave that to the philosophers (or me on my personal non-Nuru affiliated blog). But from the perspective from one on the ground, the idea that healthcare is a right has proved to be a significant obstacle to actually providing it.

Health Center Update

When I arrived in Kenya, Nyametaburo Health Center (NHC) was in a sorry state. Janine, my predecessor, did an excellent job of identifying needs at the center. And believe me, even listing the problems was quite a task. Counting down, I’ll describe the top three problems at NHC and what we’ve done.

Problem 3:
Lab services are far away and take a long time. For full lab services (to test for TB, for example), patients had to go to Isibania Sub District Hospital. For some in our area, that would be a two-hour walk (average would probably be about an hour). And once they got there, it would probably take an hour at least (probably several) to see the laboratory technician. Once seeing him, you’d then have to wait for the test to be performed. All in all, the experience would take you all day if you decided to do it. Most people don’t. And so their conditions remain undiagnosed. With Malaria, this isn’t a huge problem (except, of course for the development of drug-resistant Malaria), but it is a real big problem for diseases like TB and HIV which are quite contagious.

Solution 3:
We have constructed and outfit a laboratory. We’ve hired a laboratory technologist who is very proficient and very ready to work. Now NHC is able to test for HIV, TB, Malaria, intestinal worms and Typhoid, to name a few. “Great!” you may say, “Having HIV testing abilities does no good if stigma prevents people from being tested.” Which is true. But, whether it is the warm and friendly staff of NHC or the HIV training we recently did, there have been nearly 100 people from the community who have been tested since the lab opened in September. [With an adult population of ~2000, we’d get them all tested in about two years at that rate; however, we hope to accelerate it]

Problem 2:
KEMSA (the Kenya Medical Supply Agency… I don’t know what happened to the ‘E’) is supposed to keep the Health Center supplied with drugs. There are quarterly shipments of medications which are adjusted based on the level of the facility and the patient loads. And by ‘quarterly’ I mean that I got here in July and the only shipment yet received was at the end of October. And when I say ‘adjusted’, I mean that they give facilities whatever they happen to have in stock, whatever is trendy amongst international donors and whatever is about to expire. Also the District has not managed to fill the form to upgrade us to a Health Center in KEMSA’s registers since August 2008 (sic). So in our latest shipment, we got roughly 3.4 million condoms (we distribute precisely zero per month…), lots of otherwise expensive Malaria meds (thank you, Global Fund) and almost no antibiotics. Even though respiratory tract infections account for more lost life than Malaria, it’s not as sexy, so no money goes to it. Even though $0.50 of amoxicillin could potentially save more life by curing pneumonia than $5.00 of Artemether-Lumefantrine could by curing Malaria, we have plenty of the expensive stuff and none of the other. Also, KEMSA never supplies certain injections which could considerably improve patients’ conditions.

Solution 2:
Nuru has established a Pharmacy Reserve for the NHC pharmacy, guaranteeing that, no matter what KEMSA provides or fails to provide, patients who come for treatment don’t have to be told to go to the private pharmacist 6 kilometers away. As the financial situation of NHC continues to improve, this subsidy can be reduced until NHC does not have to depend on KEMSA or Nuru.

Problem 1:
There were no patients. NHC only had a handful of patients per day. There was no delivery couch; a broken exam bench was all that they had and no amenities (think uncomfortable doctor’s table, but with the padding falling apart).
The present In-Charge was pushed into his “temporary” position at NHC, undesirably out and away from the town. After a month, he discovered that there would be no backup and he could not re-transfer. He was bored because there were no patients, and was frequently absent. Also he lived in town so was not available for emergencies.
What was very troublingly for us who aspire to sustainability, the revenues of the center were quite low. NHC (as most government facilities) charges a flat rate per patient, so keeping that the same, this part of it was directly dependent on patient load. Additionally, very few were coming to deliver at NHC. A preference for home birth is a significant challenge with a lack of trained midwives.

Solution 1:
We improved the facility by buying a delivery couch for the maternity ward and renovating the staff house to make it livable. Through a combination of efforts, we have marketed the heck out of NHC. We’ve pushed it with our health reps (we even had a “sale” with coupons; the rep who referred the most patients got a prize). We pushed it with Traditional Birth Attendants (following after other innovative local dispensaries, we paid them $2 for delivery referrals and charged women $2.50 for deliveries). And most of all, we encouraged and supported the staff to get quality of treatment high and keep it there (see solutions 2 and 3). Word of mouth is the best advertisement.

What happened? It worked. A total of 1000 outpatient services delivered in the month of July, and 1700 by October and rising. The number of monthly births at the facility has doubled since July (7 per month). And along with the patients, revenues have dramatically increased. Mr. Sangara moved into the staff house and has been seeing patients at night. Other staff keep it running on weekends. And with all this new activity, with the ability to practice proper medicine (with a lab and reliable drug supply), Mr. Sangara has been around a lot more frequently than before.

So all in all, things are improving. I cannot, either as a scientist or Nuru employee, toot my own horn too much. As a scientist, I can say that correlation is not causation; as a Nuru employee, I believe that it is the work of the people here which is the biggest effect. Mr. Sangara (the In Charge) and Ms. Alice (the Lab Tech) have been the foundation of the service improvements at NHC; Nuru has empowered them with the tools they need to work. And work they have! And perhaps most of all, Nelly Andega, my Nuru counterpart, has been fundamental in carrying out all of these many things with a competence and coolness of demeanor that I love.

[Bonus anecdote: Nelly was In the process of delivering cement for construction and sent me the following text: “Hello. The vehicle is on fire.” Upon calling, Nelly was completely calm. I asked, “Do you need help?” She said, “No. I am just helping the driver of the vehicle put it out. I was just calling to inform you.” She successfully extinguished the vehicle fire and then successfully deliver the bags of cement]

The End - Jake's Story

Nuru Media just put out a video about how Jake got into this work and discusses the connection between terrorism and poverty. It's a really powerful story and makes me proud to be able to work with him. I would encourage all you, my dear readers, to watch it and respond.

http://www.nuruinternational.org/takeaction/theend.html

P.S. The music was done by Tyler Bates, the guy who did the music for "300".

Help me address malnutrition

I'm reading and thinking about severe malnutrition interventions. WHO says RUTF (home-made power-bar paste) is the way to go; about $45 and 8 weeks to treat a kid (which much cheaper than the hospital route but not quite affordable to the poorest of the extreme poor). A tape measure can be used to identify kids (mid upper arm circumference < 110mm =" malnourished).">

Comment/message/email me with ideas on how to find and treat kids with malnutrition, especially ideas that fit with Nuru's aim to do things sustainably. Sure I can screen kids and feed them this stuff while I'm here, but who will do it/pay for it when I leave?