Wednesday, June 18, 2008

Differing View on Community Health Workers

17 June 2008

Good interview today with Martha Kwataine, executive director of the Malawi Health Equity Network (MHEN). Despite recovering from a bout of malaria last week (for which she has received treatment), Kwataine was very passionate about the need for civic organizations, like hers, to hold government accountable. An umbrella group for health service organizations, advocacy groups and others, MHEN (pronounced May-hen) nearly folded in 2004, she says, because of "governance issues."

Trained as an economist, Kwataine has been rebuilding the group ever since she came on board two years ago and has garnered 68 million Malawian kwachas in funding from six international organizations, including Oxfam, Cortaid (an Irish group) and the Canadian government.

Among the things I want to remember: Kwataine became rather agitated when I asked her about community health workers, basically lay people who have gone through six to eight weeks of training primarily in preventive care. Community health workers are perhaps best known in the US as a centerpiece of the Partners in Health model for delivering health care in rural areas of Haiti, Rwanda and Peru.

But Kwataine clearly saw community health workers as a fig leaf used by governments to dodge their obligations to provide good accessible health care. Take that, Paul Farmer!
I suggested to her that no one expected community health workers to do it all, but that they could be useful in extending the reach of more highly qualified nurses, clinical officers and physicians but Kwataine was having none of it. "You cannot replace a nurse with a community health worker," Kwataine says.

And, of course, that's a point on which the proponents of community health workers would wholeheartedly agree. But what happens if the community workers are promoted in the absence of more qualified professionals? That's the realistic fear that Kwataine is describing. Will be interesting to see once I begin traveling around the country if this point of view is widely shared.

16 June 2008
Who Says Journalists Should Be Lone Wolves?

Power cut tonight, just about 6:40 PM. This is why I carry a flashlight (or torch) with me at all times. Am typing by candlelight tonight. (Yes, it is that dark at 6:40 PM.)
You can hear the generator at the restaurant next door. The hotel staff has placed candles on the floor in the hallway.

Hardly had a chance to finish the last sentence when the lights came back on. The generators have fallen silent. Went outside to peek and sure enough the candles are already out. I return to my room and snuff mine as well.

Very productive day today, setting up appointments. I showed Kondwani the list of names I had gleaned from the Internet and sources in the U.S. He told me about others I wouldn't have known about, then introduced me to staff at the Ministry of Health, the Churches Hospital Association of Malawi, the Council of Nurses and Midwives, the National Organization of Nurses and Midwives (the first is a government agency and the second is a kind of trade union), the University of Malawi College of Nursing and finally the Malawi Health Equity Network (a civil society group). K also introduced me to a driver I can hire as I follow up on all these appointments over the next two weeks.
Was even able to talk with Diana Jere, principal of the University of Malawi College of Nursing, and Evelyn Chilemba, dean of faculty, for a good 45 minutes. Great overview from both of them.

What a great introduction to a country and how grateful I am to Kondwani for smoothing the way. Makes me question once again why journalists strive so often to be lone wolves, always working on our own. Oh, I know the reasons well enough—fear of being scooped, worry that someone else will get the credit for all the legwork you have done. Sharing all your sources is the fastest route to no longer being indispensible. (Just ask any consultants or corporate headhunters you know whether they would be willing to share their Rolodex—that's their bread and butter.) It takes time to build trust and find compatible working styles.

And yet, and yet. As journalists tackle more and more complex topics, like global health, that cross more and more borders, cooperation and collaboration makes an increasing amount of sense. And not just with other journalists but with the folks we previously called sources as well. All ideas to develop at a later date. Right now I need to type up my notes from today's interviews.

15 June 2008
A Study in Contrasts

Celebrations of Malawi's win yesterday were still continuing this morning outside the hotel. One young man kept saying the same Chichewa phrase, which even this mazungu could understand: "Malawi 1, Egypt 0."

Perhaps even more important than the Egyptian team having been the defending champion of the African Cup of Nations, is the fact that the Malawian coach, Kinnah Phiri, is Malawian. Previously, I've been assured, Malawi always looked to expatriates to coach their football (soccer) teams—often with less than stellar results. Now a Malawian had proven that Malawians are indeed up to the job.

The rest of the morning was spent in church (my choice) although the only service available in English by the time we got going was at the Lilongwe Pentecostal church—a first for this Presbyterian. Lots of great praise hymns. The minister took a verse from Zechariah chapter 4 as his main text: " 'Not by might nor by power, but My Spirit,' says the Lord of hosts." (I just looked up the reference in the Gideon Bible in my hotel room.) But there were contributions from Ephesians, a word about men loving their wives as Christ loved the church and women being submissive to their husbands and a long, funny story about how hard it is to be a Christian when British Airways loses your luggage for more than a week.

Then we took a quick tour of former President Banda's mausoleum, the war memorial commemorating Malawians who died in World Wars I and II and other conflicts and the Capital City where the government and most of the international agencies and banks are headquartered. At one point we drove through a poorer neighborhood.

Flying by in the car, I tried to take it all in. Mud huts and squat brick homes. Shiny glass and concrete buildings. Chickens and goats. Mercedes Benzes, Land Rovers and reconditioned cars from Dubai. And everywhere people. Standing, walking, sitting, talking. A child with a stick watching after four goats by the edge of the tarmac. People walking home from church. Two men in suits walking side by side, one carrying a Bible, the other had a wooden lectern over his shoulder.

Lunch was out of town at a Malawian cultural center on the border of a river or was it a small lake? A well-dressed man and woman left rather quickly after we arrived. Did our presence offend? Was she not his wife? Were they just tired of waiting for their food? None of the above? Who knows? I was reminded of small communities I have visited in Texas, New Mexico and Missouri where everyone notices and remarks on other people's comings and goings. I come from an island with 2 million people in a city of 8 million or so. We often rely on our anonymity and the freedom we think it gives us and yet just last week I ran into three different people I knew running some last-minute errands on Broadway. Last week. Was it really only last week?


Catherine said...

Christine, my nursing professors would agree with Martha Kwataine. I look forward to hearing more on the topic of what truly constitutes quality health care.
I'm already addicted to the blog. Glad everything is going so well. - Catherine

Dr. Sue Makin said...


Welcome to Malawi! Glad you are in Lilongwe and seeing so many interesting things and getting to talk to many people.

There is another category of health worker here called "HSA". The "HSA's" are health surveillance assistants. Their training is six months if I am not mistaken. I work with a nurse at Mulanje District who trains them.

I personally think HSA's can be very helpful in mobilizing communities and informing people about health issues. When you get to Mulanje Mission Hospital I hope that you can speak with some of our workers in the Primary Health Care Department. The HSA's work mainly in the villages.

The welcome mat is out at my house. My friends Sam and Khumbo are looking forward to meeting you and helping you do everything you want to do in Mulanje.

Sue Makin

Christine Gorman said...

Catherine, it's a great topic.
Sue, thanks for the welcome mat. It much appreciated.