The other week I walked the footpaths of Nyaminia, a sub-location of the Millennium Village Project in Sauri, Kenya, to visit households with Richard*, a Community Health Worker (CHW). Going around with a CHW was eye-opening. It’s one thing to read about nutrition screenings and the use of mobile phones for health monitoring, but quite another to see it in action. Richard and I visited seven households where he took the nutrition measurements of children under-five with a simple tool called a “MUAC” – mid-upper arm circumference tool. This flexible ruler that goes around the arm of a child is an uncomplicated, effective field tool for identifying malnourished children under five.

CHW performs a nutrition screening using a MUAC

After measuring the children, Richard then let me use his mobile phone to text in the results of the screening to a central database which records all the personalized health data the 108 CHWs send in.

A major benefit of this system, known as ChildCount+, is that it provides immediate feedback to the CHW, guiding their action. For instance, if any of the children we monitored had had a MUAC below 115 mm, Richard would have received a message to refer them to the clinic for treatment of Severe Acute Malnutrition. Similar feedback is provided for malaria cases. In one home, after texting in the results of the rapid malaria diagnostic test (positive) and the estimated weight of the child displaying malaria symptoms, the system sent back a text message of the appropriate dosage of Coartem the child should take. Although an experienced CHW may know these prescriptions by heart, each of these texts acts as a check of diagnosis and prescription.

The ChildCount+ system confirms receipt of nutrition screening information through a reply message

I see great value in mobile systems such as the one used by the CHWs in Sauri. Beyond providing immediate feedback, this type of system can reinforce the learning of newer CHWs, increase accountability by quantitatively measuring the actions of CHWs, improve tracking of health and disease patterns in a community, inform resource allocations, and with proper monitoring and evaluation tools, assist in measuring the effectiveness of interventions.

Although I’ve been impressed with the use of ChildCount+ in the field, my time with Richard reminded me once again that an information system is only as good as its people and its tools. Although none of the children monitored were severely malnourished, there were some children clearly not receiving all the necessary micronutrients which the MUAC measurement did not capture. This could only be recognized and acted upon by a trained health worker like Richard who is familiar with the people he works with and has resources at his disposal. For the families of malnourished children, the CHW may refer the family to a clinic for supplementary or emergency feeding. For longer-term solutions he may refer the mother to the agriculture team to attend an upcoming gardening training, or talk to a facilitator about the family’s eligibility for subsidized fertilizer and improved seeds.

Richard himself had some critiques of the ChildCount+ and CHW systems. The texting of medical information takes time and errors do occur. As the CHW system has become more professionalized, responsibilities have expanded and many feel that the pay, a stipend provided by MVP, is far from adequate. Even though there are challenges, all the CHWs I’ve spoken with have seen an improvement in the nutrition status of the children in the region, and attribute these changes to MVP interventions such as door-to-door health screenings, nutrition training, and immediate clinic referrals for emergency and supplementary feeding.

CHW entering a new person into the ChildCount+ system

For a short video of Community Health Workers using the mobile system in Sauri, Kenya, please click here.

*names changed

We spent the weekend in Busia, where Stephanie used to live, and met up with some folks from Innovations for Poverty Action/Poverty Action Lab (IPA/JPAL), where she used to work. Busia is the essence of a border town: aggressive, trade-driven, dirty, and bustling. Busia also has the distinction of being the location where Jung almost got arrested. Apparently guards frown upon taking pictures at the Kenyan/Ugandan border. But our trip wasn’t all harassment and almost-arrests. On Saturday night we had one of the best dinners we’ve had while in Kenya at Chauma, where we actually ate something beside ugali, chapati and chicken! We also watched the World Cup games (go USA! go Republic of Korea!), went to a nightclub (a real nightclub!), and bought a good amount of dry-goods for the upcoming weeks (read: ramen, cookies, and chocolate), which made the crammed, hot, 2+ hour matatu (minibus) ride back completely worthwhile.

My first week’s rotation at the Sauri Millennium Village was with the education sector. In three short days I observed MVP sponsored computer labs, school feeding program kitchens, gender separated latrines, a monitoring and evaluation planning meeting, rainwater harvesting, school livestock; the list goes on. The education team is constantly on the move; traveling to schools and attending meetings to move projects along, share knowledge and solve problems.

At the first meeting I attended, MVP and school management committee members quickly identified community contributions for classroom construction, made plans to solicit bids, and set a plan into action to identify a contractor and begin construction. At another meeting series I observed, participants chose to create a zone-wide evaluation of MVP interventions. Three business days later items had been identified and costed and test dates set. Three business days after that, the committee will design the test, a month later it will launch. These are turn-around times that would make corporate bigwigs green with envy!

Unlike corporations, MVP constantly considers what will happen after they leave. Requiring that parents contribute maize and beans for their kids to participate in the school feeding program is a solid step toward sustainability. However, these actions risk hurting the poorest families who cannot always provide. Until local coordinators determine how to engage parents and adjust programs to support needy families, like those in Nyamovinia Primary have done, coordinators will constantly struggle to maintain the balance between sustainability and immediate impact from education interventions initiated by MVP.

Sauri Primary

A primary component of the MVP education strategy is to improve the quality of education. But are MVP interventions such as school feeding programs, classroom construction, and teacher training truly having an impact on student performance? On Wednesday I attended a planning meeting for an evaluation designed to measure just that. The standardized test will measure knowledge in a variety of subjects and will be launched by the end of the year to all 6th and 8th graders in the zone, including students from four schools which did not receive MVP interventions, who will act as a control group.

The four hour meeting attended by teachers, MVP staff and interns went over, detail by detail, the costs necessary to execute this evaluation which will reach around 2,000 students. What struck me was the amount of teacher participation in executing this evaluation, the results of which will be distributed to not only the MVP team, but the schools and the teachers, allowing them to measure individual student, school, and class performance across the zone and reward high performers. If the level of teacher involvement struck me, the more mundane challenges of executing such an evaluation floored me. Proof-reading, cross-checking, transportation for proctors and correctors, stationary costs, communication, compilation, if classrooms even had enough desks for the test; all costs had to be considered, tallied up, compared against the available budget. If the costs were greater than the budget, strategies to bridge the gap had to be developed.

Critics have charged that MVP’s monitoring and evaluation system isn’t comprehensive enough, and during my first three days in the Sauri MVP I have been surprised to hear constant discussions on surveys, evaluations, and sustainability planning. From what I have seen in a short amount of time, the M&E process extends beyond official community evaluations performed by MVP into participatory evaluation systems that integrate community members.

* An extremely important one

Originally posted at http://teamsuriname.wordpress.com

Expanding further on communication, cell phone coverage is coming to Kwamala. Telesur, one of the major telecom companies in Suriname, has built the base of a cell phone tower in the village. The buzz was that the local community is excited, and my focus groups with men and women reflected this. However, almost every person I spoke to mentioned the cost of text messaging and using a cell phone and how expensive it is. Kwamala isn’t a huge money economy; at markets goods are bought with currency, but you will not see small shops and public exchanges of money as you will in many other communities, most likely because of the isolation (compare with my colleagues who visited sights on rivers). Focus group participants advocated for the use of computers and internet, which have start up and maintenance costs, but not necessarily the per usage cost of mobile phones which is more difficult for families to budget for.

The building of the cell tower has been steeped in rumor. National elections are coming up in the next few months and it was rumored that the base was built to build political capital. Or that the telecom company was building to mark its territory and didn’t plan to complete the tower unless another telecom company started to move in. I heard that the tower was supposed to be completed in the last few months, but will now be finished by the end of 2010.

Eventually, mobile coverage will come to Kwamala and probably sooner than later. What will the effects be on communication? On acquiring resources? On social fabric?

Originally posted at http://teamsuriname.wordpress.com

Maggie Schmeitz, Communications Program Officer, and I stayed behind in Kwamala with our generous host, Joe Adams, a Peace Corps volunteer who is wrapping up his 2+ year service in Suriname this summer. Quick aside: Joe and I quickly discovered that we had grown up 20 minutes away from each other in Minnesota, USA, and knew some of the same people. Talk about a small world!

Maggie and I stayed at a lodge run by Conservation International (CI), an NGO working in Kwamala. Although no cell coverage and few computers exist in Kwamala, existing means of communication quickly (and loudly!) jumped out. The radio at CI was used 6+ hours every day we were there by a core group of village members. Although it was possible to receive radio news broadcasts from Brazil, people used this to communicate to other villages, with friends. There are 7 radios in Kwamala including one at the airport office and one at the health clinic. It’s used to report emergencies, order supplies, and share general news, just like a cell phone is.

During my interview with Suzanne, the head of the school in Kwamala, she shared that she used to use the radio to communicate with a teacher at another AmerIndian village in the interior to swap tips and ask for teaching suggestions, but now it is too busy. Although radio and mobile phones fulfill similar communication needs, community members advocated for cell phones so that they wouldn’t have to wait so long for the radio. In fact, some just stopped using the radio because it would take so long to gain access. Also, a number of people said that the channels were getting busier and harder to use.

The radio in the picture above is powered by a car battery which is recharged by a generator.

Originally published at http://teamsuriname.wordpress.com

My teammates introduced you to the village of Kwamala in the previous post, and I would like to repeat, that that was one very small plane! The view from Paramaribo to Kwamalasamutu was breathtaking. For two hours we flew over the northern portion of the Amazon that few are lucky to see. Our Peace Corps friend, Joe, said that the trees were so tightly spaced and numerous that they resemble broccoli, and I have to agree.  

Once safely on the ground on the grassy airstrip, our mixed group of 8, from Peace Corps, the Ministry of Education, UNICEF, Columbia University, and Tufts University went to have our formal meeting and introduction to the Granman, the head of Kwamalasamutu. Conversations flew back and forth in English, Triol, Sranan Tongo, and Dutch, aided by local residents who served as translators. We were introduced to the Granman and stated our reasons for being there. After being given his support, and being introduced to a Captain, a figurehead of the political structure, we walked around the alternately sandy and grassy village, looking at the houses, school, clinics and market structures. We walked by the shaman clinic and learned that people typically go to the “modern” clinic first, and the shaman clinic second if the first’s treatment does not stick. Local medicine, using age-old extracts, herbs, and treatments from the forest, is a distinctive part of the indigenous culture in Kwamala.