I (and most people I know working in international development) have always struggled to figure out what my role should be as a foreigner. It is a very sensitive issue – how to avoid imposing your own norms, how to avoid creating a system of dependency, how to ensure you are not taking away opportunities from local people. I do believe I can play a role (otherwise I wouldn’t be here), but that is why I have always been most interested in capacity building – supporting others to help them grow their skills, create their own opportunities, take on greater leadership roles, increase their resources. Even still, there are limits on what I can accomplish as an outsider.
One of my main roles here is to support communities that have chosen to implement a health clinic as their Spark project. I am working to support their management, finance, and sustainability. This objective has been exceedingly difficult. In communities with such limited financial resources, developing a realistic sustainability plan can seem impossible. Communities need to figure out a way to pay for a qualified nurse, a clinical officer (to register the clinic and supervise), a Village Health Team member to do record-keeping and education, medicine and other medical supplies, stationery, cleaning supplies, and more. Their monthly budget is usually around US$120.
Finding qualified medical professionals within their budget has proven to be particularly challenging. We have struggled with nurses quitting after short terms due to low pay and long distances and sometimes not even being able to identify a qualified nurse to begin with who would accept the salary. For instance, the nurse in one of our communities that first opened its clinic two months ago quit within a couple short weeks on the job. Even when he was there, he was not the most reliable person – often showing up late and sometimes not coming at all, citing transportation as a major issue. After he quit, the clinic had to close until they could find someone new, which was no easy task.
Moreover, the community wanted to find someone who would work 5 days a week (they were previously only open for 3 days a week) because they felt that the low patient numbers during the first month were due to the limited working days. If finding someone to work for 3 days a week on their budgeted salary was difficult, finding someone to work 5 days would be impossible. Nevertheless, we do not make decisions for the community, so while we warned them of the difficulties of finding someone willing to work 5 days a week, we agreed that we would wait until someone was identified and discuss salary and work days at that point.
The former nurse identified a potential candidate to take over for him while the community also identified two people for the nursing role. My co-fellow Tracy interviewed all of them (she’s the one who actually has a health background and is a trained nurse). She was impressed by the person identified by the previous nurse, but the other two identified by the community turned out to be nursing assistants rather than accredited nurses. Nursing assistants cannot legally run clinics in Uganda. After some debate, the community agreed to hire the qualified nurse to work 3 days a week, but they still wanted to hire one of the nursing assistants as well to keep the clinic open 5 days a week, meaning two days of operating illegally each week and an additional person to factor into the already overly tight budget.
This put us in a difficult position. The community always gets to make all of its own decisions. We do not put any conditions on them so we could not force their hand. I attempted to discuss the implications of their choice with them, but nothing I said caused their view to budge. Next Tracy tried. I though that her being a Ugandan might make it easier for her to get through to them, but we still had no luck. We knew going in that this conversation was going to be difficult, so we had also invited Wilson, the chairman of a nearby community that is implementing a health clinic project, to share his experiences. Now I don’t know all of what he said since he was speaking in Lugisu and different people kept getting up to leave the room to discuss things in private outside, but by the time he was done, the community agreed that they should have a qualified nurse working 3 days per week. I asked them what changed – they said that they now understood the legal and budget concerns of their original plan.
Something that the community could not hear or fully grasp when coming from a foreigner or even when it came from a Ugandan who was still an outsider in this community, could be conveyed tactfully from a local person with whom they could relate. If Wilson had not been there, I am confident that the community would currently be moving forward with a nursing assistant running the clinic 5 days a week and that their budget would not be sustainable. Wilson was able to help them see what would best serve their ultimate goals. And me? My biggest role was simply facilitating their meeting and I am completely comfortable with that. Ultimately that’s a huge part of what Spark does – it brings people together in a forum where they can harness their collective power, knowledge, and skills to solve problems and reach their self-identified objectives.
Err sorry for the lack of pictures in this post – apparently I haven’t been very good about getting photos at the clinics. Here’s the one photo I have. It is one of the community’s clinics with the management committee and the former GHC fellows posing in front. I will try to get more clinic photos soon!