Sunday, August 8, 2010

Watch Yourself!

I am sitting in a lovely house in Lilongwe writing this, contemplating how much different Malawi is from that other M-country in Africa. Yes, Malawi. I arrived here a month ago and will not be returning to Bamako until early September. I haven't written in nearly three months, and clearly, so much has changed!

It has been an exciting, stressful, frustrating, and awesomely rewarding spring, and I am relieved to finally have a minute to stop, breathe, and write about it. Funny to say now that I have left Mali for awhile, but I can't escape the feeling that I've just started to do the work that I came here to do. As my mother constantly reminds me, that is not entirely the case. There has been a lot of work to do to get MHOP's clinic and Action for Health projects off the ground, and I am very grateful to have had the opportunity to help. Selfishly though, I feel that the launch of the PatientView pilot is different. It is what I came here to do, and I have been itching to do it! Though I know I have had a hand in the successful opening of the Sourakabougou community clinic, the launch of Action for Health, and the ongoing development of our other community programs, there have been many times in the past nine months when I felt a little like I was stuck on a race track, speeding around without getting anywhere.

Starting out in January with the basics of the CHW program laid out, let me briefly describe the race highlights.

February:  Computers arrived at the airport customs office.
March:  Computers languished at the airport customs office.
CHW program launched.
April:  Computers rescued from the airport customs office. Wrote the PatientView user manual with the Ministry of Health's e-Health Office and began negotiating our partnership contract.
May: CHW and clinic training!
ORANGE Foundation $$$$$$$$$$$$ for the pilot year's SMS credit promised!
Then system testing...more testing...sleepless nights of testing...
... and finally, on June 20th, the pilot LAUNCHED!

The community health worker team for Action for Health has been seeing children for four months now, and more than 300 children have been referred to one of our partner community clinics, where they have received free consultations and treatment. For every patient encounter, our CHWs fill out a paper record to track the child through their in-home, in-clinic and follow-up care. The physicians can consult the paper referral form when the child comes in for a visit, but until now, they had no access to longitudinal medical information (a medical record beyond the CHW's report of immediate symptoms and reasons for referral). With 403 patients (and growing!) in the program, the coordinator has to process more than 800 records each month in order to ensure that each child receives appropriate services and that CHWs can be given proper field support.

With PatientView, all that has changed. Text message forms are filled out at every home visit and sent to the clinics, where they can be reviewed by a physician and monitored for developing illnesses or treatment problems. When a patient is referred, the clinician can pull up their record and immediately have access to their in-home and in-clinic visit history. They can enter their consultation into the clinic visit form and, with one click, send follow-up instructions to the patient's community health worker.

So, I feel as though the circling around has finally paid off. We have reached...well, not the finish line, but certainly a checkpoint. The Final Turn. Those of you who spent holidays playing RidgeRacer in your grandmother's basement will know exactly what I mean. In the words of the wisest race announcer to ever grace a PlayStation demo game: "Next corner's tough, watch yourself!"

For my less evolved readers, I would liken it to reaching the Willamette in Oregon Trail, a joyous event dampened only by the fact that you must now caulk your covered wagon and float it down a treacherous river full of boulders that are ready to splinter your floor boards and drown the last of your family who have not already died of typhoid or dysentery during the arduous journey.

(Apologies to my more ancient friends...I tried to think of a witty metaphor involving Pong but I just can't do it.)

Of course, I do not meant to say that the next few months will involve the kinds of crashes that end RidgeRacer careers or a crush a pioneer family's hope of reaching the land of milk and honey. My point is only that starting a program is one battle, and helping it survive, another.

Co-opting the term from the information and communications techno-lexicon, development folk often talk about the "last mile." Both a useful metaphor and a geographical reality, the last mile is the "farthest endpoint of connectivity," that final leg separating a population from needed services. Mobile phone-wielding community health workers are a last mile solution in multiple senses: using the only type of telecommunications infrastructure accessible, these outreach workers bring primary care to populations who are not otherwise connected to health services.

Yet, in development work, the last mile is not only a physical barrier, but a temporal one as well. How do you make a project sustainable in the world's most impoverished, inaccessible, and under-educated areas? Keep it simple. Both FrontlineSMS:Medic and the Mali Health Organizing Project are founded on the idea that solutions to health problems must be accessible to frontline health workers. Whatever we provide, it is precisely those under-resourced communities who must bear the cost of sustaining a program, which means the system must be low-tech and easily manageable by people who have more than enough work to do already!

The RidgeRacer devotee that I am, however, I must say I prefer the "final turn" metaphor to this "last mile" business. It implies a greater degree of unknown, an inability to see the obstacles that lie ahead. Despite how much effort you put into research and planning, the world is always going to surprise you. So we will not be resting on our laurels just yet. I am quite sure that our pilot testing will bring to light many of the problems we couldn't foresee -- my only hope is that we are flexible and responsive enough to deal with them. I know we are.

Leaving for two months during PatientView's teething period has caused me much anxiety and distress, but I am convinced it is necessary, even good. It is time to put our last mile philosophy to the test. After training our community health workers, physicians and nurses, and setting up the (relatively little) infrastructure needed to support the program, my job here is nearly done! I'm handing over the reins to Dramane Diarra, my colleague and a Sikoro native who has been an irreplaceable asset to MHOP's work in the community. He will now be putting his technical skills to use as the FrontlineSMS:Medic PatientView Coordinator, and I am confident that he'll do a great job. Even so, these next few months are going to be difficult for everyone as we uncover technical and programmatic problems we couldn't plan for or predict.

So, as tough as it may be, here's to hoping we round the Final Turn intact and on track.

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