MSF in Uganda


Bringing the Hospital to You: KIHEFO Health Camps in Rural Uganda

KIHEFO (Kigezi Healthcare Foundation) is providing health care to not only the urban residents of Kabale but also to people in the outlying villages. In many of these remote, rural areas someone might go months or more than a year without seeing a healthcare provider, due to the cost of seeing a doctor and the distance of travel.

In Uganda, health care covers a range of services. There are the Village Health Teams at the very bottom of the health pyramid; they do some public health services and coordinate with others if needed. Higher up, there are the Health Center II’s, III’s (might have beds), and IV’s which offer a wider range of services. And at the very top, there are the private and government hospitals, where doctors midwives, and all sorts of services are found.

KIHEFO bridges these gaps by bringing hospital-quality staff to the village level. At a major outreach, like the one I attended in Kakarisa, there was the General Clinic, where doctors check patients’ wide assortment of needs. If a patient requires blood work or other testing, they send it to the Laboratory. If they finish their examination but need medication before they leave, they will take their doctor’s note to the Dispensary. For anyone with Eye or Dental needs, there are separate areas with specialists on hand. Lastly, there is also Family Planning where women (and hopefully men) can come to receive guidance in their sexual and reproductive health.

In Kakarisa, our venue was the local primary school. This venue offered two major benefits to the KIHEFO team. Firstly, it was vacant, as students were on break. It had several rooms, which could be transformed into the health areas I noted above. It had a large grassed area in the middle, for a waiting area. And, lastly, it was centrally located in town and easy for everyone to find.

As someone without any medical background, I was unsure where to help. Some of the other students started in the Dispensary, helping to un-box medications and sort them for distribution later in the day. Some shadowed the doctors, while other assisted in the lab with testing. I was less eager, so I stood outside the makeshift hospital areas and eventually landed on a bench in the center of all the newcomers, in Intake.

Coordination was relatively simple. The administrators to my left created an information slip for every patient that arrived. It had their name, age, gender, village on the top. They were then asked to stand on a scale to acquire their weight, which was also added to the form. My role was to then hand them one of three sheets, each with a number on it to represent their place in line. There was one stack for general clinic, another for dental, and a final pile for eyes. In the end, we had seen over 200 patients for general clinic and over 30 for the dental and eye clinics each.

It was extremely fast-paced with commotion as people waited hours (not including their travel time walking) to see a doctor. But there was some humor during the day. One woman who wanted a second slip of paper pretended that she was a twin and had not received anything yet. As the level of English here was low to nonexistent, I heard many of these things after the fact, usually by asking why the women were laughing.

In the afternoon, after things began to slow down in Intake, I walked around and tried to peek inside the rooms to see what everyone else was up to. I eventually landed outside of the General Clinic, asking how I could help. One of the coordinators handed me about five of the information forms I had seen at the start of the day and told me to manage the queue. On the outset I was quite disoriented, mostly because there was no queue, everyone was sitting in front of me, like an audience.

I announced the name on the top of the stack as one of the three nurses inside released their current patient. After a while, one of the nurses pointed out where the queue starts – where the foot path cut the grass into two – and I began to enforce it vigorously. The men on the left were trying to jump the queue. I was having none of it. I would grab another five slips and politely ignore their attempts to thrust their papers into my hand. After a few cycles of this, they got the message and stood in line like all the other men, women, and children were doing. Order restored!

On my second outreach, to the village of Rubira, I would be working inside a clinic, not on the outside. I would spend the day with Joanne, a dentist, acting as her assistant. This was a much smaller outreach, as KIHEFO comes here monthly and the village is much closer to town than Kakarisa.

Our first patient was a girl of only 14 years whose mother requested two ‘extractions’. Due to a number of overlapping reasons – poor oral hygiene or just being poor – this girl was to have two teeth removed, permanently. Her fear was palpable. Simply looking inside her mouth with the traditional tool of a mirror caused her to wince and cry. It was not going to get easier. Joanne administered a local anesthesia to allow for the extraction to take place with a minimum level of pain. But this action – inserting a syringe into the gums and releasing the fluid – caused its own pain. A metal object with a pick at one end and a handle is then wedged on both side of the tooth removed. The last implement, a pair of dental pliers, pulls the tooth out. This required the mother to hold down the girl and Joanne to move quickly. I have never seen so much fear in a person’s eyes. Well, I was going to see a lot more of it.

Joanne and I saw 4 patients under the age of 18 who together lost 6 teeth that day. An older man also visited the clinic but didn’t actually need any dental treatments. Many of the teeth we removed that day could be saved, but the opportunity to receive a ‘free’ tooth extraction was too good of an offer to pass up – the cost of filling a tooth would be too much for anyone in Rubira. Sadly.

Money Loans and Satellite Dishes: A Short Introduction to SACCO

Other Stories from Kabasheshe: Hills of GreenGhost Water Taps | Fish and Chips

SACCO is the acronym for Savings And Credit Co-operative.

I had never heard of this acronym before coming to Uganda. While in Kabasheshe, on at least two occasions, I had seen signs with such a reference on them.

I had asked my family if there were any nearby and if they could take me. They told me of one in Rusoka, which a friend worked at. We planned to arrive there on Wednesday.

IMG_3663The walk through Rusoka was interesting. We passed a vocational training center and a primary school for orphans. There were some exposed water pipes next to a hand pump, indicating previous scavenging. Beside some business and across from a hair salon, we arrived at the Turibamwe SACCO in the center of town.

The building wouldn’t be that noticeable – one-story, concrete walls, with a small amount of white paint – if it wasn’t for the high level of security that comes with a high level of money changing hands. I walked under their slogan of “Save & Invest in the Future” to see the familiar sight of cashiers to the right and management to the left. There were four or five patrons sitting next to the SACCO’s armed security guard. They were busy but seemed to welcome the excuse to take a break and talk.

Judith, my host sister, spoke with Susan, one of the two cashiers behind the wooden and glass divider, and asked her if I could speak with someone to learn more about how this institution operates. We moved towards the back room.

Sitting there was Carol, an accountant and the person who was willing to answer my questions. After talking with her and feverishly writing down points into my iPhone, I learned nearly everything about this SACCO.

The SACCO began nearly a decade ago, back in 2006, and has already grown to have a second branch, opened 3 years ago. Unlike a typical bank, a SACCO consists of members who are, in effect, the owners. Rather than maximizing profits, it operates to serve the community. They are accommodating to a range of needs and often offer lower interest rates that normal moneylenders.

Although we have a similar financial structure in North America with credit unions, the thing that surprised me about this SACCO was that it was the only place where people could get credit. There were no banks in Rusoka or in Kabasheshe. Without a SACCO, people would be limited simply to what they could produce and sell, unable to ever lend money (at a reasonable rate) to improve their lives.

What services are provided by the SACCO?

At the most basic level, a person can deposit money into the SACCO without having to become a member; but this excludes them from accessing other services. The more common approach is to become an Individual Member. This requires depositing 26,000# (26,000 Uganda shillings, or about 10 US dollars). The money goes towards membership (10,000#), stationary to keep records (6,000#), and shares in the co-operative (10,000#). A group or pair can also open an account; this type is similar to the individual member with the membership fee costing an extra 10,000#.

For members with money to spare, the SACCO also offers a Fixed Account option. This allows a member to earn money by leaving money in the coffers. If a person can let some amount sit untouched they will get back 1% interest per month. Fixed accounts are as little as 2,000# or over a million shillings; it’s up to the member.

What can a loan be used for?

By having a membership with the SACCO, an individual, pairing, or group is now one step closer to acquiring a loan. I was quite astonished at the breadth of items that qualify for a loan. Taking a loan to buy farmland or to build a business make sense enough, but the co-operative also allows people to pay for their children’s school fee, make home improvements like solar power or piped water, and even for luxuries like satellite television. All of these come with a 3% monthly interest rate. The lower rate of 2% is for motorcycle loans, typically used for someone who will start a boda-boda moto taxi service. The loans are additionally unique in that a loan officer will be the one collecting the item, not the loan signer; cash is never exchanged. Whether your loan is for business or pleasure, the maturity will be between three and twelve months, depending on what the client wishes.

How much are the loans?

“It all depends on the number of shares”, Albert explained to me just after he entered the room. Albert is a loan officer and entered the room midway through my flurry of questions.

Shares are bought and sold by the members. To qualify for a loan, a member must have a minimum of 3,000# in shares. They must also have an active account, making deposits and withdrawals, and wait at least six months after opening their account. Once these requirements are met, a member can apply for a loan. The 10,000# in shares that each member receives initially are multiplied by a factor of eight, meaning that a loan of 80,000# is available. If a larger loan is needed, a member simply needs to buy more shares and will then be able to apply for a loan eight times in size.

Are there any risks?

This was the last question and one I thought was crucial to the co-operative’s success.

The SACCO has two methods to making sure re-payment of the loans is successful. The first, as Albert explained succinctly, is to have the member receiving the loan to put up collateral. This is normally some asset – land, livestock, or possession – of real value, usually near twice the value of the loan. But cows can move. This is problematic if a loan is based on a movable commodity as collateral. So, the SACCO has a second device. This is family.

In addition to the member signing the loan, a co-signer, usually a family member, with also attach their name. That way, if the original signer does anything shady, like sell some assets after receiving their new motorcycle or other item, the family will have to become involved. It means that the SACCO has more oversight and the most powerful kind in one’s own family.

I left by thanking everyone for their time and patience. They thanked me for coming by and let me know that I was always welcome to open an account, even in the future.

Susan walked me out to the front courtyard, reminding me that they are “open Monday through Friday, from 8:30 to 4:30” before saying goodbye.

Fish and Chips: How a Small Business Can Have Big Impact in Rural Uganda

Other Stories from Kabasheshe: Hills of Green | Ghost Water Taps | Money Loans and Satellite Dishes

IMG_3640At the end of a fun weekend, I was driving from Queen Elizabeth National Park back to Kabale. Along with a group of American and Canadian medical and public health students, I was returning from three days filled with safari and boat adventures in Southwestern Uganda. Before our weekend came to a close, we stopped at the Satellite Hotel for lunch. The hotel offers an impressive lookout for travelers along the Mbarara-Kabale Road and its restaurant was advertising a special of Fish and Chips. I jumped on the bandwagon and ordered a plate.

Fast forward two weeks and now I’m standing next to the pond where the fish I ate was raised. This fish breeding pond – one of four – is part of a business called Satellite Farmers Limited, located at the junction to Kabasheshe in the Ntungamo district. I originally decided to come here to see and learn about their first farms, but I ended up leaving with a much better understanding of how this small enterprise was playing a big role in the community.

My tour guide and teacher would be Godrey, a 20-year-old secondary school student, who was in charge of this facility. As we talked (or, more accurately, as I continually asked questions) he began to open up and seemed excited to share his work with me.

We started outdoors, walking along the trail that connects the fish ponds. Some filled with catfish and others of an unknown kind, these ponds were dug and filled only six months ago, but already had thousands of fish. To help me see their scope, as the water was murky and hid what lay underneath, Godrey went into the green, aluminum building nearer to the road to grab some feed. He threw it into the water and little mouths started to appear. Above the water were lines, closing each other in a grid formation and about 12 inches apart. These lines are used to prevent birds, which are abundant, from flying down and stealing a meal.

On top of the fish sold to the hotel down the road, Satellite Farmers Limited sells local eggs, handheld sprayers, building materials, and the animal feed (mostly for chickens and pigs) that Godfrey used earlier. But catfish are special. Instead of regular feed, they are given meat, chicken to be exact. I was fortunate to see a farmer come in and leave a bucket of future fish food. The blue plastic bucket contained slurry of meat byproduct. The innards of a chicken – heart, lungs, intestines – that people don’t consume and farmers can’t use can be brought here and sold, adding to their income and maximizing the usefulness of a single chicken.

Speaking of chickens, they have those too, both layers and broilers. Layers are the hens that produce eggs, while a broiler is a chicken raised for just the meat. An egg here sells for 250# (250 shillings, or 10 US cents), while the same egg at the rural market would sell for 400#. Say you’re the head of a household and you were looking for an affordable source of protein, this would be your best place to start. Or, if you are a market seller and looking for something to sell, this place could be your supplier, where you can buy and then sell eggs, making 150# profit on each one; you wouldn’t even need to own a chicken.

Godrey led me inside the Feed Mill, which has been in the community for over two years and was started by a man simply known as Chief.

“Who else works here?” I asked Godfrey, as we passed through the doors. “No one”, he responded, “just me.” I was perplexed. The feed mill is massive. It is similar to something I would find back home in Rural Canada. Inside, there were bags everywhere. Scales for weighing, office desks to handle paperwork, and an unorganized stack of water troughs in the corner took up more space inside this building.

It turns out that Godrey is the only full-time employee of the operation, selling eggs, equipment and bags of feed, and feeding the fish as needed. When animal feed needs to be mixed, he goes to the local trading center and hires up to five temporary workers. Together, they can produce one to two tons of feed each hour. This high level of productivity is probably the reason why Godrey can manage everything alone.

The animal feed they manufacture consists of various elements, including silverfish, maize bran, broken maize, cotton cake, shells, sunflower, and calcium. Some are sourced locally, while other bags come from the capital of Kampala. In either case, the concrete floor where these bags are tossed provides another destination for farmers to bring their grains.

It might not seem like much, but in a country where youth unemployment can reach 80%, it is nice to see a successful and growing business that is providing full- and part-time jobs to local residents. Not only that, they are providing tools to farmers to maximize their productivity and earn more, all within walking distance from their fields. Additionally, Satellite Farmers Limited is acting as a link from rural farmers, buying their excess grains, to outside markets, meaning a greatly level of economic stability in this community of a few thousand low-income farmers.

I left by thanking Godrey for his time and sharing so much knowledge with me. I also bought some eggs; it was too good of a bargain not to. This small business, invisible from the paved main roads, in Southwestern Uganda is quietly achieving what so many educated experts have failed to do – foster employment, assist farmers, and grow the local economy.

If you’re interesting in learning more about businesses in emerging markets or innovations in rural agriculture, feel free to contact myself. Questions are welcome and encouraged.

Ghost Water Taps

Other Stories from Kabasheshe: Hills of Green | Fish and Chips | Money Loans and Satellite Dishes

“One tap…two taps…three taps.”

This is what I was hoping to count to myself on Monday when I walked through town. Unfortunately, my optimism would be squashed.

IMG_3651The day before, Mzee, my host grandfather, described the water project he hoped to start in Kabasheshe. Currently, the closest water source is located at the very bottom of the valley; at least 30 minutes there and back, up and down hills. My host sisters (and me on a few occasions) make the journey at least once a day, but more commonly multiple times. Older sisters would carry 20-litre jerry-cans on their head. When full with water, these would weigh 20 kilograms or 44 pounds! I barely managed when I tried. Younger children carry 10- and 5-liter jugs; one or two, depending on their strength. These feats of strength are more impressive when considering that a 2-year-old toddler may also be on a woman’s back.

I should also point out for clarity that my household is somewhat lucky in that it is located directly uphill from the community spring. Other families have the dual challenges of living uphill and down the road from the water source, increasing their walking time.

IMG_3677If you walk 30 minutes up the road, towards the main junction, you find a completely different reality. The village of Rusoka seems to be an oasis of water projects – piped water, community boreholes, and others. On our way to see their current gem, my hosts and I passed a centrally placed hand pump. I was told that it was spoiled, not in use. I trust that this is true as I saw nearby pipes ripped out from the ground. After months of no more flowing water, the plastic pumps are commonly extracted; these can then be used by families to illegally smuggle power into their homes or any other use that they can come up with.

The Rusoka Primary School has another interesting feature – a
play pump; age unknown. Play pumps are water projects that replace the typical manual hand pump with a circular merry-go-round, one intended for children to play on. These work when kids are nearby and willing to use it, but are problematic for a woman by herself. It is also a sad part of development that many communities are conditioned to attract international donors, so children may come out to play for photos, but will stop once the abazungus (foreigners) leave. It was interesting to see one, though. If I had more time, I might have tried to uncover its history and current level of use.

IMG_3708After walking through town, passing orphanages, training centers, and hair parlors, we arrived at the pump house. This relatively large building provides piped water to the entire Rusoka community. It pumps water uphill to a storage tank and then downhill to several taps. This is the model that my village hopes for. Built many years ago, it has run flawlessly.

A cynic might propose that Kabasheshe’s mostly Muslim population missed out on the charity that Rusoka received from Catholic organizations that visited it, being a majority Catholic population itself.

A realist might say that Kabasheshe’s location further down the dirt road has left it with worse luck. Rusoka is closer to the main road, which also acts as a pathway between Uganda and Rwanda.

Either way, my host village finds itself without easy access to water.

IMG_3386Eight or maybe nine years ago, they did get a borehole, supplied by the local sub-county government. But, after 3 years of use, it broke down and was never fixed. It sits there today, a skeleton of its former self, with all removable components scavenged and probably sold.

This is the start of Mzee’s plan. Three years ago, Rusoka received electricity and thanks to a politician who lived here, the line was extended to Kabasheshe. Him, his brother, my host family, and a few others now have power.

Power is quite a life changer. It means that you can own a cellphone, as it needs to be charged regularly, and connect with others far away. It means a steady, cheap source of light. And it mean that you can own a TV and relax while watching it, as my host family regularly does.

But it also means one more thing, more options for community projects. Rather than the manual water pump that failed in Kabasheshe before, Mzee wants to install a motorized pump to provide piped water to his community. Just like Rusoka.

Going uphill, the water would be pumped to storage tanks, either polyurethane or concrete, and then downhill to various sources. Using storage tanks mean that water can still flow, even when there’s a power outage. Also, meters can be placed on the multiple tanks to track usage.

After seeing the borehole and location for future tanks, I was taken to see the community taps. There were three of them. Or, at least, that was what I was told.

One at the primary school. One at the trading center (local store and outdoor pool hall). And one near a home on the main road.

IMG_3571First, the school. Like what I saw in Rusoka, a plastic pipe was sticking out of the ground. After the borehole stopping providing water, someone dug up the line, cut it, and took it home. But, there was hope that a new line could be installed. It would be nice to see this school receive running water, as the alternative is children missing school to fetch water.

Next, the family home. We arrived at our destination, but I saw no tap. There was a hedge dividing two properties. A gated house on the left and a small business on the right. It turns out that this tap was demolished after the borehole broke and was in the way of the homeowner’s plan. All that is left is a memory of what was.

The third and final tap, at the trading center, had the same fate. It was demolished some time ago. Nothing left to signify that it was ever here.

This left me puzzled. Mzee told me about the three taps and my mind raced with possibility. But to have so much infrastructure missing, it would be a daunting project.

So, what can be done?

It is definitely possible to provide piped water to the community. The borehole is there. At least one tap (probably the most important one, in my view) is still in the ground and ready to be connected. And the community wants it.

How to do it?

As with most things, money is primary. Funding can come from one of three sources. It can be through the community, everyone pitching in and taking full ownership. The government could come in, but people have little to no trust in them. Or an outside source, like an international charity or aid organization, could be the one to manage the project.

In any case, some things would need to be bought and installed. A motorized pump at the borehole, connected to the power line. A house would need to be built to contain everything. A 200-meter trench would need to be dug, at least 5-feet deep to prevent the thievery of the past, and plastic piping laid. The hilltop would be leveled and a few tanks installed on concrete or other structure. More trenches and piping would go downhill. The school would be re-connected and new taps would need to be constructed elsewhere

All in all, this would be a massive project. Probably the biggest one Kabasheshe has every received. I want to make it happen but have my reservations.

Will the village be able to repair future breakdowns? Will they be able to prevent thievery? Is it better to wait and lobby the government to change its ways?

What do you think? Is there anything not considered or missing?