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) 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 further away, 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 Healthcare counterpart, has been fundamental in carrying out all of these many things with a competence and coolness of demeanor that I envy.
[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 delivered the bags of cement]