There are 57 countries with fewer than 23 health workers for every 10,000 people, as a result infant and maternal mortality rates far exceed that of developed countries, such as the UK and US
The old town of Oxford is really beautiful. It is so easy to lose ones-self in the old buildings that make up the colleges and the…
My friend Sandro Demaio has started a new Translational Global Health blog over at the PLoS network.
As a contributor to the blog I will be focussing on technology and global health.
I’m Fred Hersch, a medical doctor and techy with a passion for global health. I’m interested in the role of technology for improving access to essential healthcare. With years of experience developing web solutions (prior to studying medicine though I still do it), I bring a bit of pragmatic reality to the discussion about technology and healthcare. Don’t get me wrong, I’m a believer that technology has a huge role to play but it’s no silver bullet either. It’s what you do with it that counts. This article is the first that looks at what is going on in the health technology space and thoughts about how technology can be harnessed to improve the health of people everywhere.
mHealth is everywhere you turn these days. The mobile phone has become the new “must have” for any serious “innovative” global health project. Everyone’s doing it, hell, we’re even making jokes about it! Have you heard the one about how there are more pilots in mHealth than there are in the US Air Force? So, what is it about the mobile phone that has the global health community so excited, and what are the opportunities offered by technology and innovation?
My short 3 week trip to Europe for a conference and meetings whilst awaiting the results of this god-forsaken-grant has turned into a bit more of…
Heading north from Kigali, the land of a thousand hills truly comes into being. Whilst Kigali itself is built around a series of mountains, the landscape changes dramatically as one heads towards the volcano regions of Ruhengeri and the lake side town of Gisenyi (on the border with Goma in the DRC). Like anthills, paths wind there ways through the mountains, each dotted with plots of land and streams of people coming and going; constantly engaged in the daily toil of the land.
In the foothills of the Virunga range of Volcanoes, the home to the mountain gorillas, the north is truly breathtaking. The plan was to hike one of the volcanoes – an 8 hour trek to the crater top and the lakes within. Unfortunately this was not to be. The sting was not the US$75 entrance fee to do the walk, but rather the US$80 cost of hiring a car and a driver to escort us to the start point and await our return. Whilst it would have been beautiful, $US100+ to walk a mountain just seemed a bit too rich.
So, instead I together with my intrepid travellers from Holland (Yaap and Alenka) decided to hike the 12km back to town and in the process take in all the local scenery of the villages. It was a great decision. The trip back was beautiful. We were accompanied by some local kids who spoke great english and helped us with our local greetings. As is the way we drew plenty of attention – 3 muzungus walking, greeting people in the local Kinyrwanda language drew cries of laughter and smiles all around. The ‘hike’ didn’t last long. We ended up making most of the (down hill) journey on the back of bicycles, taking in all the colour at speed – exhilarating.
With the morning activities wrapped up by 9am, we decided to head west to Gisenyi, home to the beautiful Lake Kivu and also the border town with Goma in the DRC.
Playa del Gisenyi
Seemingly out of place is the beautiful lake side town of Gisenyi. The lake, Lake Kivu has all the potential of a sea side resort. Dilapidated and run down, there are a few hints at past beauty and perhaps over the next decade this place will see a renaisance of sorts. Sitting on deck chairs on the beach at the Serena Resort, sipping expensive orange juice or cappucinos, looking over the beautiful lake towards the mountainous DRC on the other side, one could forget you were in Rwanda at all. This is where the rich and famous of Rwanda play, not to mention the UN types and expats looking for a bit of R&R on the weekend. A great place to relax, take a swim and even do some wind surfing and all sorts of other activities. Nice.
A brush with Goma
Gisenyi sits abreast with Goma, the border town with the Democratic Republic of the Congo (DRC). With an adventurous spirit, we had to check it out. With all the reports of the fighting going on just across the border, who knew what would await? The writing was on the wall, but perhaps a glimpse of the unfolding crisis or a heavily militarized zone would await us. I offer two versions of the events that followed:
The bravado story goes something like this.
After hiking part of the way along the coastline, we managed to coerce some moto drivers to get us to the border. Not understanding their apparent reluctance we insisted and negotiated a reasonable price. On the backs of the motorcycles, we diverted to an off road path bumped our way towards the heavily gaurded border arriving within meters of the crossing into Goma and the DRC.
Unfortunately, the truth is never as exciting …
After a lovely breakfast we walked out of our hotel and along the costal road towards the border. Believing it to be about 5km away we opted for the easy option and flagged down a few motos. Thinking it was still a distance to the border we negotiated what seemed to be a resonable prices and off we went. The drivers headed off in the opposite direction only to detour via some pretty crappy bumpy roads. Within about 5 minutes, we arrived to find nothing more than a border crossing (yes, there was a guard) and a regular procession of cars, people and trucks making the 20m crossing into Goma.
By all accounts the brush with Goma was a huge let down. Nothing really to see. When we got there it becamce apparent that the moto drivers had taken us on the detour to give the sense that we were going some distance. In fact had we kept walking we would have got there sooner. Obligatory pictures were taken and then it was back on the bikes and onto the beach side resort for a swim in the lake and some R&R. All in a days work I suppose.
I read this morning about a massacre in a village further north in the DRC. For the people of the eastern DRC this is yet another tragedy. The current UN peace keeping effort is by all acounts failing the people it is entrusted to protect whilst government troops and rebels outfits continue to terrorize the region. I hope that peace and some stability comes to this region soon.
William of the Black Eyed Peas reminding us of the promises made in our names.
In 2009, let’s do more to remind our politicians to keep the promises we have made. Let’s do more to end global poverty and do our bit to make the Millennium Development Goals a reality.
In Australia, the Rudd Government has thrown its support behind the Millennium Development Goals and has taken steps in the right direction. Its time to keep our promises and set Australia on a path to achieving the 0.7% GNI target. C’mon Kevin, Let’s go to 0.7!
For the most part, and certainly in poor countries (with a few notable exceptions … read Cuba), poor people have shitty health care. If they have access to any sort of primary health care facility it is likely to be under-staffed, under-resourced, probably lacks a secure water supply and electricity, may have a few drugs in the pharmacy, and will most certainly cost to use. Doesn’t sound like value for money. Sometimes I think the response to the dire health needs of many in poor countries is simply, “build it and they will come”, as if by just having a structure in place, the health of the community will be serviced. Bullocks. It’s all about the system people.
Independent of whether it is a public or private facility, like a business, a health clinic servicing 20,000+ people does not function effectively without some element of management. Providing acute care to a population is one thing, add into the mix, HIV/AIDS, TB and the emergence of other chronic diseases (like Hypertension, Cardio-vascular disease and diabetes to name a few) and the importance of a well functioning system is imperative. Oh, and did I mention there are no doctors. What I am talking about is health centers in rural places …. the same places where the majority of the worlds population live and not surprisingly, most doctors don’t work.
The picture I have painted is the challenge facing Rwanda, but really it could be any developing country, particularly any in sub-saharan Africa. Like many places, Rwandas health care system is rooted in the provision of primary health care services to the rural majority. These are then supported at a district level by a hospital staffed by only generalists and finally tertiary hospitals in Kigali where specialist services are available. If you are wondering where are the GP’s (family doctors), there are none. The above mentioned health centers, staffed by nurses and supported by community health workers (who do follow up visits in the community) are the first port of call for any health problem.
When you think about it, providing health care in this kind of environment (or any for that matter) is not just about a room, a table, a practictioner and a few medications. What about good management? The use of information systems for monitoring and reporting? The Human resources? Retaining staff? Improving service delivery? What about maintenance and upgrading the facilities? Who manages the budget? Who ensures that the health insurance scheme is running properly? That the pharmacy is stocked is with the appropriate medications, available at the right time? And so on … trivial stuff perhaps but often overlooked in our haste to ‘build it …’.
The Access Project
It is these less glamorous (but vitally important) aspects of health care provision that the Access Project is working on. To introduce some new skills and a way of thinking and acting that is so often missing from the health system and thereby strengthening it.
The Access model: to apply business and management skills to public health systems in poor countries to increase access to life-saving drugs and critical health services.
The activities of the Access project include:
- Ensuring the health facilities are adequately resourced (including access to running water and electricity), and that plans are made for upgrades where necessary
- Introduction of new management systems for HR, Accounting, Mutuelle (health insurance), budgeting etc
- Introduction of IT systems and training
.. and more
Working with a dedicated team and an ambitious mandate the Access project is slowly transforming health care facilitites throughout the Bugesera district and 5 others in Rwanda.
Health care is complex and continues to get ever more so. Getting the systems right is as important to the long term health of the community as is having adequately trained nurses or doctors. I would argue it is more important.
Rwanda is a poor country. Cursed by colonial intervention which led to decades of violence, land locked with pretty crappy neighbours, no natural resources and situated at a latitude that is a hot bed for infectious disease (least among them Malaria) its not hard to imagine why.
A few statistics:
- Life expectancy at birth: 46 (Compared to ~80 in Australia)
- Infant mortality rate: 118/1,000 live births (compared to ~4/1,000 in Australia)
- GNI: $1300; ~50% population lives on < $1 USD (Compared to GNI ~$30+k)
Pretty bad hand! But this post is not about the tragedy of the Rwandan lot, but rather an optimistic piece about a project that is working towards demonstrating that even in places dealt such a hand as Rwanda things can change … and pretty significantly.
The Millennium Villages Project
The Millennium Villages offer a bold innovative model for community led, sustainable development. At the core of the MV Project is that through a integrated set of interventions in agricultural development, health, education, and infrastructure, the Millennium Development Goals can be achieved by 2015 – even in those countries apparently stuck in a poverty trap.
The Millennium Villages project was first started in 2002 and has since expanded to include at least 10 countries in Sub-saharan Africa covering 80+ villages (read more: official site).
Here in Rwanda the MVP has been running for almost 3 years in Mayange in the Bugesera district. Chosen due to its propensity for drought, its poverty and its poor health services, Mayange over the past few years has been transformed. Granted it has had a lot of money pumped into it, but the aim of the MVP is to demonstrate that at funding levels in line with what the rich world has pledged to give, these types of achievements are a reality – the Millennium Development Goals can be achieved even in the poorest parts of the world.
Sustainability is the buzz word of the 21st century and obviously the test of time will be whether in the next couple of years the Millennium Villages model can prove itself to be just that. Given the level of business development activities through the formation of co-ops, linkages with micro-finance programs and diversification into high value crops to name just a few, this is the goal.
In the meantime, it should be noted that over the past 2 years people who prior to the interventions were hungry now have food security, have access to a functionaing health service (that is very well attended), can send their kids to (at least) primary school and live in an area where water is slowly coming to within 500m of each and every house in the sector, I’d say it’s pretty impressive … wouldn’t you?
I will be spending part of my time whilst I am here working on a health project at the Mayange health center. I plan to visit the other areas of the project. I’ll be sure to share what I find out!
Looking for more
If you are interested in reading more about the Millennium Villages Project, here are some good links:
- UN Millennium Villages Site
Good FAQ’s section
- Overseas Development Institute, Review of Millennium Village Project
Independent review of the Millennium Villages project by UK based ODI
- Millennium Promise
Fundraising body for the Millennium Villages Project – donate today!
- Millennium Development Goals
The goals, the targets
- C’mon Kevin, Let’s Go To 0.7
Encouraging Australia to do its bit to fulfill the Millennium Development Goals
- UN Millennium Villages Site
Since arriving here a week ago I think I have experienced every emotion. The flight over was long! Over 30 hours of anxiety fuelled flying. The anxiety was due to that fact that I semeed to overlook the need for a visa! Whilst I wasn’t too concerned the airline put the fear of god into me by almost refusing to put my luggaue (and me for that matter) on the plane. Once I had signed away all responsibility they had in the event that I was forced to turn around, they were happy. I on the other hand was left in a bit of a state. Not the best way to begin a 30 hour flight. I crafted so many explanations, stories, excuses on the plane that I was almost disappointed when the anti-climax arrived that of course I was able to purchase a visa on arrival. Not the best of beginnings.
It has taken me a good week to settle in. The first few days really evaporated in a jet lag induced blur, but being the type A I hate to admit I am, I wanted things to happen .. NOW. Of course they didn’t. I mean, OF COURSE THEY DIDN’T. What was I thinking. I spent the first couple of days in Kigali, got somewhat orientated, saw the genocide museum and ate at expensive restaurants. I then moved out to (rural) Nyamata (1/2 hour south) where I have been able to settle in and get some insight into the work of the Access Project. It took me a few days to venture out alone …. I am the only MUZUNGU (white guy) in the village (or at least 1 of three), but since I have it has been fantastic. More on that another time.
So for the first week these are my thoughts:
Not many countries experience a living hell the likes of what took place in Rwanda in 1994. Fewer still are able to turn around and against all odds set themselves on a path of growth and success. This is the modern Rwanda, a land with a horrific past, rebuilding itself with eyes firmly on the future and the possibilities that await.
Not to overstate things, Rwanda is still an incredibly poor country. Over 90% of the population live rurally, the majority of those living a subsistence existence, and a very small % are educated. What strikes you about Rwanda (and this is in the week that I have been here), is that there is a sense of purpose, a belief that whilst things are bad, they are moving in the right direction. There is an order here that seems out of place for its place in the world, an honesty, an integrity. I don’t quite have the words for it yet … time will surely reveal more.