Building Health through Better Management
Since June, I’ve been participating in a fellowship through Global Health Corps (GHC), an organization aimed at developing leaders for health equity. GHC matches fellows with placement organizations in five different countries — Rwanda, Uganda, Malawi, Zambia, and the US. Applications are position-specific, and I was accepted as a Monitoring and Evaluation Associate for the organization Health Builders (HB).
Though one post can’t do it justice, I’ll do my best to explain HB’s work and my role within the organization.
What does Health Builders do?
Health Builders’ vision is “that all people have access to high quality healthcare, allowing them to live dignified, healthy, and prosperous lives.” This vision is not yet a reality for many Rwandans. But why not?
Rwanda, unlike the US, has a tiered healthcare system. In the US, patients go straight to hospitals for many services, whereas in Rwanda, patients first go to health centers. If their medical issues cannot be resolved at the health center, they are referred to a district hospital, and subsequently if needed, a referral hospital. In theory, this tiered setup enables basic medical needs to be resolved with fewer resources, while more resources can be allocated for more complex conditions.
Unfortunately, these health centers, responsible for 92 percent of all health services in the country, are under-resourced. As a consequence, 95 percent of morbidity cases in Rwanda occur at the health center level.
With such high stakes, improving healthcare at the health center level is imperative. Health Builders seeks to achieve this through its work in three areas: management, infrastructure, and technology. Since management is HB’s main pillar and the primary concern of my work, that’s what I’ll focus on.
Management
Because health centers are responsible for providing many services but are under-resourced, it is of utmost importance that they use resources with maximum efficiency. Health center staff have adequate medical skills to treat patients but lack the administrative skills needed to run their centers efficiently. Poor management often leads to inefficient use of already-scarce resources, which can mean lower quality services and revenue streams. This is a vicious cycle that can lead to even worse resource management.
Health Builders seeks to reverse this cycle. Our model centers around mentoring health center staff to manage the health center better so that resources are maximized to achieve optimal patient outcomes and increased revenue. Four days a week, HB sends Health Management Advisers (HMAs) to various health centers, where they mentor staff to adopt best practices in domains ranging from finance to pharmacy management to data management.
HB’s focus on management can have a strong impact on a community’s health. For example, managing a pharmacy well and using drugs before they expire allows a health center to save money that can be invested in providing better quality services. When a community gains access to better quality services, its health outcomes improve.
What is my role?
My job is monitoring and evaluation (M&E), which is a fancy term that means I measure the impact of our work. One way to think about it is like this: if a public health program is a car going from A to B, then M&E is the GPS that tells you how far you’ve traveled and if you’re going the right way.
HB’s theory of change is that improved management in health centers leads to improved access to better quality health care, and ultimately better health outcomes. The purpose of M&E at HB is to define and measure these improvements to demonstrate a link between management, healthcare access and health outcomes.
The way we measure improved management is through the Management Performance Survey (MPS). The MPS is a detailed questionnaire that gauges the health center’s capabilities in six different management domains, including infrastructure, finance, and pharmacy logistics. For example, in finance, the MPS evaluates things like if the cash and bank books are up-to-date; in pharmacy, it’s whether drugs are out of stock or expired.
Every six months or so, the HMAs will conduct the MPS at health centers. Subsequently, the M&E team analyzes the results and gives them as feedback to the HMAs so they understand the specific challenges of each health center and can better focus their mentorship to address these issues before the next MPS evaluation.
My day-to-day responsibilities are generally focused on enabling optimal use of these results. My biggest project thus far has been to develop dashboards in Excel that enable HMAs and other audiences to visualize this data quickly and effectively. It’s been a lot of learning about fancy formulas like VLOOKUP and INDEX/MATCH, but more importantly, as I’ve iterated prototypes of these dashboards by seeking feedback from the HMAs, I’ve learned about the value of user-centered design thinking. More on this later.
It’s satisfying to work in an organization where M&E is seen as critical to our success. It means I get to have a hand in many activities, since data and measuring impact are part of all our programs. For example, I’ve had the chance to provide data and input into reports for important stakeholders, including the Ministry of Health and Kate Spade (who knew Kate Spade does humanitarian work?).
What have I learned?
While not everything has been easy, these four months I’ve been constantly learning.
I’ve (re)learned the power of listening. Whether it’s in designing the Excel dashboards or improving the MPS, feedback from the HMAs has proved priceless. They have given me countless wise suggestions that I would not have imagined; design thinking works because the end user does know best.
I’ve learned the importance of data. Specifically, I’ve been forced to think critically about which metrics are important, how to measure them, whether the data is trustworthy, etc. As our world becomes more data-driven, having this framework to approach data will be invaluable.
I’ve learned the importance of management in public health. At the start of the fellowship, I made a list of goals, of which the most important was “to gain an on-the-ground perspective of all the factors that influence healthcare delivery and outcomes: health systems, culture, politics, economics, and technology.” Ironically, I never considered management among those factors, but now that it’s staring me in the face, I’m seeing that it’s an essential part of the story.
And that may be my biggest lesson so far in Rwanda: that there’s always more to the story than I thought.
Benjamin Tien is a 2017–2018 Global Health Corps fellow in Rwanda. All GHC fellows, partners, and supporters are united in a common belief: health is a human right. There is a role for everyone in the movement for health equity. Join the movement — applications for our 2018–2019 class open December 6.
