Pré Avis in the Congo

If you are given 1 chicken, it is a sign of appreciation. If you are given a pair – a rooster and hen so they can mate – that has real value and you must be extra special. If you are given 5 CHICKENS, it is really just too much!!!

…that is what was explained to me as I accepted a box full of chickens on behalf of MSF following a community meeting in the village of Katonta a few weeks ago. Seriously…5 chickens in a box! Check out these pictures.

Photo: Grant A. | Receiving chickens

Photo: Grant A. | Receiving chickens

Photo: Grant A. | Receiving chickens

Photo: Grant A. | Receiving chickens

Community Support

Over the past months, I have invested a lot of time trying to ensure that the reasons for which MSF is leaving are clear to our partners, local authorities and the community in general. This takes many forms…informal discussions with staff at the hospital, official meetings with the village authorities and, of course, community meetings.

These are never easy. Essentially the equivalent of a town hall meeting, it involves at least 2 hours in a hot and sweaty school room answering questions and trying to explain to the community why they are losing their free health care. Imagine the uproar if you were to do this in Canada! Everyone is invited: the local health committees, Ministry of Health (MoH) nurses from the health center, MSF community outreach workers, the village chief, traditional birth attendants, the local Red Cross, school principles, priests, traditional healers.

Photo: Grant A | Community meeting in Katonta – 70 people present!

Since I called the meeting, I sit up front and face the crowd. As many can’t speak French, my translator starts to convert my message into the local dialect and off we go. I’ve given this speech a few times, so now it comes a bit easier.

We talk about how things have changed over the past 5 years. How there is no longer war, the displaced population has all gone home and we have entered a developmental stage. How MSF is an emergency relief organization and this doesn’t fit our mandate. How the MoH is now present, trained and will take over as of May 31st.

How the free care that MSF provides is not sustainable. How the MoH will install a user fee system. How we will make a 3 month drug donation to help in this transition period. How it is THEIR village, THEIR health centre, THEIR family…and that it is time for them to step up and take ownership.

Not my favorite part

This is a pretty tough message when I know that the level of care will drop. That the MoH is present but is not nearly as effective as MSF. That even a nominal user fee (20 cents for a consultation!) will exclude a large portion of the population and that a C-section will cost an astronomical and unobtainable $30. That emergency referrals from the health centre to the hospital will be by bicycle and take half a day. That there will be more drug ruptures and the MoH staff will not be paid as well or as often, or at all.

From my perspective, these are the poorest people I have ever seen and most really have nothing. Yet it is all relative and while it might seem like a pretty desperate situation to me, this population has known much worst and not so long ago. The fact that there is a Ministry of Health, that they are present and that they are willing to take over, is a huge sign of progress.

So far, my message seems to be getting through as people know that we are leaving, understand why and have an idea about how things will look after we are gone. Everyone is sad and wishes we could stay…but people are not angry. I ask them to think of this as not only an end, but a new beginning. The beginning of a more sustainable system, a truely Congolese system. They understand that health care is not normally free and they are thankful to have had MSF come to their community in their time of need.

…and giving me 5 chickens is their way of showing this.

Hello Readers!

Over the weekend, MSF hosted our official Project End party. Around 270 people – from staff to village chiefs to local suppliers – came out and it was a huge success. This is also a significant milestone as it officially started a 2 week countdown to the official handover date of May 31st. As such, I was asked to write a brief update for the folks back in our Amsterdam headquarters and thought that you might also be interested to hear how things are going.

MSF is just like any other organization and is full of acronyms. To help you out:

• MoH = Ministry of Health
• Inpats = people who are working in the project but were hired somewhere else.

Here in Dubie, we could not find many qualified medics locally so many have been hired in Lubumbashi and then sent to Dubie to work. Now, at the end of their contract, we have to transport them all back home.

Cheers,
Grant

———————————-

While I can’t say that it hasn’t been without the odd hiccup, the handover of our project in Dubie is progressing well and things are largely on track. Outreach activities are officially over as we spent the first two weeks of May on final visits to each MSF supported health center. We have also started to re-align services in the hospital to match the current Ministry of Health staffing and the anticipated drop in patient numbers. Here in Dubie, we could not find many qualified medics locally so many have been hired in Lubumbashi who were then sent to Dubie to work. Now, at the end of their contract, we have to transport them all back home. Our first set departs on May 18th and a steady stream will follow until our official handover date of May 31st.

In all outreach sites, the MoH will assume responsibility after our departure. However, here in Dubie, the hospital and health center will be run in partnership between the Ministry of Health and the Catholic Sisters. In theory, at least, as it is not yet clear if they have come to an agreement. To avoid taking sides, MSF will be donating everything to the “health structure”, as represented by the MoH and the Sisters. While all sides have officially agreed to this and I do not anticipate any huge problems, things continue to brew below the surface so only time will tell.

Over this past weekend, we held our project closure party…Shamwana vs. Dubie soccer match on Friday, National Staff tombola on Saturday morning, followed by a very successful party with 270 people in attendance and dancing until 3:00 am!

On a final note, our HIV program will not be handed over and will continue to be managed through support from the Shamwana project. As was done in Kilwa, no new patients will be added and an MSF national staff nurse will stay in Dubie to manage the cohort. Quality control will be maintained through bi-monthly expat visits.

Photo: Grant A. | Anne Marie Loof, Head of Mission, giving the handover speech

As the project coordinator, I am the official representative of MSF in the field.  I like this part of the job as it gets me out in the community, gives me a better perspective and allows me to develop a deeper understanding of the context.  It also means that I spend a lot of time going to meetings, receiving visitors and reading letters addressed to “Monsieur le Coordinateur du Project Dubie”

Over the past few weeks, I have met with a pretty large variety of people for a number of reasons.  I was invited to an official meeting with the territorial administrator – the federal government representative for the region – about why we’re closing and who will replace us.

A courtesy visit to the customary village chief to discuss the image of MSF in the community.  The first birthday party of the son of the Director of the Dubie hospital.  A meeting with the local police commandant to explain again why MSF is leaving and to ask how he thinks the community will react in the coming weeks.

Discussions on road conditions and 2010 programming with the coordinator of Concern Worldwide, the other international NGO present in Dubie.  Meetings with the UNHAS (United Nations Humanitarian Air Service) flight coordinator on the possibility to have their plane land again in Dubie.

“Journée de L’Ensignement”

My latest event was an official invitation to come celebrate “Teachers Day” with the Catholic Sisters who run the secondary school in Dubie.  It was scheduled for April 30^th and a quick check on the internet shows International Teachers Day on October 5^th…but who am I to question!?  Gathering at 7:30 am, procession at 9:00 and then some music and theater, with refreshments served afterwards!

OK.   It was scheduled for a Friday and my To-Do list is getting longer every day, but this is the sort of thing that you just need to make time for.  After my morning team meeting and getting everyone started for the day, I arrived just before things were getting going.

There was a bunch of desk arranged in a U-shape with 15 wooden chairs up front for the distinguished guests.  I found the chair with “MSFH PC Dubie” on it and settled in for the show.

Theatrical

It started with a procession of the various classes.  Some marched by, saluting and arms swinging as if they were soldiers.  Others stopped to sing or dance in unison.  One class sang the national anthem.

There were a few poems and some dancing, but it was the theater skits that were my favorites.  They were quite well done and had themes that absolutely reminded of where, in fact, I was!

The first skit was about teen pregnancy and had “stay in school” as its main message.  A girl dropped out of school, starting hanging around with the guys in the market, got pregnant and died during childbirth.  A pretty direct message to the young girls watching –  MOST women in this region have their first child when they are only 15 or 16 years old…but it was nice to see the school AND the church supporting this message.

The second skit was about corruption and how it doesn’t do anyone any good.  A $10 bride was paid to a teacher to get good grades on a test.  For the next dozen scenes, this same $10 bribe passed hands to get a son out of trouble with the police, to get a new job, to bribe a soccer referee…and eventually returned to the original person.

The final skit was about a teacher who asked a girl to marry him.  As is customary here, the man needs the approval of the father before the marriage can take place.  However, since the teacher had not been paid for the past 3 months, the father refused!  The message?  Teachers are undervalued and suffer because of their non-functioning government.  A message to finish off the “Teachers day” celebrations I thought!

Afterwards, I was invited by the Sister’s for refreshments and shared some pretty toxic homemade mango wine with the village chief and the commandant of the police.  After a few quick sips, a piece of cake and discussions on the upcoming end of the rainy season and the progress of our closure plans, I headed back across the street to my office and another hectic Friday.  It was a nice way to start my day and a pretty good insight into some of the cultural issues faced by the Dubie population today.

At one point in a project, you wake up and realize that time is running out! That happened to me last week and although I’m not sure where the past 3 months have gone, we have started to count by weeks until the closure and not months!

It is Sunday afternoon and I’m sitting in my office working on a few emails and catching up on blog entries. I’m also staring at a calendar that I presented to the expat team yesterday to help coordinate the coming weeks. Written on a flip chart, the calendar includes expat evaluation and end-of-mission dates, a final donation schedule and our project closure party. For me, it also drives home the point that our closure date – May 31st 2010 – is not so far away anymore.

Making Progress

Our team has been busy with the thousands of tiny details that need to be taken care of before we leave.  Additional trainings for the Ministry of Health staff.  Another round of visits to village authorities.  Sorting out administrative details for final payments.  Stock counts, inventory list updates and discharge of liability forms.

This list is in a spreadsheet that is 6 pages long!

On the medical side, we have also been scaling back our operations.  The outreach team finished their final round of supervision visits to the health centers.  Our mental health councilors have stopped taking on new patients and are busy trying to close their existing files.  Since the Ministry of Health is not able to take over our feeding center, we have started to incorporate any new malnourished children into the pediatrics ward of the hospital.

Donations

As pat of the handover, we will also make a donation that will, in theory, allow operations to continue for 3 months after our departure.  While this certainly includes a 3-month supply of drugs, it also includes everything from pens to fuel for lanterns to medical forms.  Everything must be calculated, compared to current stocks, ordered, transported, sorted and prepared before it can be delivered to its final destination.

While all of this work is part of the regular activities that we do on a monthly basis, you have to multiply the amount (and volume!) by three and, at the same time, eliminate the buffer stock that normally covers for emergency needs or sudden changes in consumption.

We will also donate most of the items currently found in the health structures.  If MSF needs these articles to run a hospital, certainly the Ministry of Health will need these items after our departure!  These inventory lists need to be reviewed, converted into an official donation form and then presented to the Ministry of Health in an official ceremony.

…what about the rest?

We also have a fully functioning office, a garage and a fleet of 6 land cruisers, various storerooms, expat living quarters, etc., etc.!  These are items needed by MSF to run a project, but not to run the hospital itself.  As you can imagine, this is a pretty long and varied list.

To help you get an idea of the magnitude of these ‘details’, I will go through the contents of my small office and explain the plan for each item:

• My wooden desk and chair will be returned to the Sisters.   It was one of the items listed on the original contract we signed when we rented the school from them and promptly converted it into an office.
• The small printer will be donated to the ministry of health, as per our Memorandum of Understanding signed in 2009.
• My laptop will be returned to LBB, kept as a backup or sent to one of the other operational projects in Katanga.
• A small, poorly constructed cabinet will be added to what our national staff call a “Tambula”.  In essence, this is a lottery in which our staff ‘draw’ items for which we cannot find another suitable home.  Everything from old car batteries to used mattresses to broken TVs.  It may seem like junk, but in this resource poor setting the batteries will be hooked up to solar panels, you can’t even buy a mattress and the TV will certainly be fixed and used as the local version of a cinema.   The empty powdered milk tin I use to hold my pens, my paper trays and the curtains will also be added!
• The two wooden chairs where my visitors sit will be sent to Shamwana just before we close, along with the power bar and the garbage can.
• The 2 dozen binders will have to be emptied, with some documents being sent to LBB and others to the waste zone to be burnt.

…and that is just my office!  Extrapolate for an entire base, a fully functional hospital and 7 supported and fully stocked rural health centers and you start to get some pretty big lists.  The logistics team has been busy making these lists and then trying to find homes for each and every item.  Not small task, for sure!