robbed!

Our office was robbed! (This actually happened over a week ago, but I've been so busy, I didn't have time to write about it...) Apparently a group of 10 thieves hopped the walls of our office compound, tied up our guards, and robbed us in the middle of the night.. They cut through the bars on 3 windows and stole a laptops, printers, some money, and then one of our cars to escape!

Fortunately, can't get far w/ a truck w/ NGO stickers on it, so that dropped that off nearby (even left the keys in the visor - thoughtful). Also fortunately, the health office, which we leave unlocked, was barely touched..

This is what they used to tie up our guards

So much for feeling safe w/ bars on the window...

Suspiciously, they broke in through the windows of 3 offices: 1 happened to have a bunch of new equipment, still in boxes, about to be sent to field the next day... the admin office with the keys to all the other offices... and the logistics office with the keys to all the cars. The guys definitely knew where to look, suggesting they were either tipped off by a staff member or someone who has done work in our office (like a plumber or something). Boo corruption...

rebels with minnie mouse hats

This past week I visited our office in Man, in the western part of the country. It is a beautiful area: hilly and lush. I had all intentions of hiking and seeing the mountains a little closer (there are supposedly tons of wild orchids), but I was derailed by too many late nights of drinking whiskey with the staff ... I did see a family of monkeys on my runs though. Here's the view from the office steps:
This area is known for its production of cocoa and coffee. Côte d'Ivoire is one of the world's largest producers of cocoa but since all of it is exported and processed elsewhere, most of the chocolate here is imported. This is where chocolate comes from:

Coffee...

Anyway... western Côte d'Ivoire has seen a lot of strife. It is close to the border with Liberia, which experienced years of civil war. Liberians fleeing that conflict often came to CI (where they were generally not welcomed by suspicious locals) and the Ivorian government even sponsored and trained rebel fighters here to fight against Charles Taylor. So when CI had its crisis in 2002 rebel fighters, doing what they do best, poured into the area. One of the managers explained it best to me, rebels here are generally not tied to a cause or an idealogy. They are often young, uneducated, they just fight. Apparently, there are still a lot of rebels in Man. One night we visited a local rebel hang out, a really popular maquis where the DJ gave us shout outs every 5 minutes. This is where I saw a guy with the minnie mouse skull cap.

So the influx of rebel fighters brought the government forces and there was a lot of fighting. In the city of Man, the destruction is evident: bullet holes in the walls, skeletons of looted buildings waiting to be rehabbed. Staff here tell me there were villages completely emptied. One thing my organization has done is to create comités de paix, peace committees representing different factions of the villages. At a community meeting I attended, villagers took turns speaking their minds, give their préoccupations et doléances. Almost everyone mentioned how much they lost during the fighting here.
It baffles my mind a little too, because I know in terms of African civil conflicts, Côte d'Ivoire is one of the lucky countries. The fighting here was relatively short lived here, compared to places like DRC or Sierra Leone or Liberia. And yet the devastation is so blatant and the rebuilding so prolonged...

So while I was in Man, I was out in the field everyday (yeah!) and I learned a little about some of our other programs. A lot are youth focused, for example we train and support youth in micro-enterprises like opening their own coiffure:

or chicken house:

or café named the Far West Gang:

These are actually really cool, inspiring projects. Although they don't affect huge numbers of people, it is a big deal for the youth that are involved. For example, the young men who started the salon have, in less that year, already opened a women's salon next door and are doing petit commerce in their store front. Projects like this, that invest in the youth and help villages rebuild themselves, are always good. Multiple people, both staff and beneficiaries, commented to me how even just the presence of NGOs has helped this area: people feel more confident to return, there is help rebuilding institutions like schools and health centers. Petit à petit, l'oiseau fait son nid.

more field experiences...

This week I've been out the field, visiting our nearly finished health center rehabs. We've been going to the villages, doing the formalities with the chiefs and village leaders, and then touring the rehabs with ministry of health workers who check to see if the buildings meet country standards (one of which is that the building is painted blue and white to a specific height).
These are my first sur terrain missions that actually feel sur terrain, as I'm getting to meet the nurses and midwives and the beneficiaries, like these kids:
As part of the formalities, we sit in front of the village elders, give introductions and les nouvelles, thank you's all around. In the villages, most of the people don't speak French, so there's always some translation going on. For one of the traditional greetings in this area, the elders stand in front of us and repeat something in Baoulé while showing their palms to us, every time they repeat the greeting we respond by saying "yo". I have to figure out what it is they're saying, but the yo's kind of crack me up.

After our first visit we were offered palm wine. You can't really say no to any offer and it was my first opportunity to drink some so I was excited. I got a lot of laughs for taking this picture:
After our second day of visits, we were given a goat:
I'm excited to see what we'll get tomorrow!

ateliers

This week we've been preparing for a conference and 3 week-long trainings for all the health workers in the districts we work in.

We work closely w/ government officials, specifically the Ministère de la Santé et d l'Hygiène Publique and the Programme National de Santé Infantile. I've mentioned before, it took the Ministry 4 months (and numerous meetings and presentations) to agree to support our community case management (CCM) project. And even now, we only have their oral consent. So to guarantee the government's continued cooperation (especially in light of the upcoming elections which might result in a new administration), my organization along w/ UNICEF will be holding a conference to validate our CCM tools. Health officials and prominent doctors are invited to a multi-day conference to learn about our project and look at the tools we'll be using to implement the project (i.e. the training manual, teaching aides, supervision check-lists). It's ceremonial really, a way to get buy in from medical community and ensure continued government support for our program.

Its also a good way for administrators to make extra money.. Participants, in addition to their salaries, receive a per diem and, if the conference is not in their city, transportation money in addition to meals and lodging. Government officials love ateliers. The prime spot for conferences here is Bassam, a former capital and beach town about 45 minutes outside of Abidjan (just far enough so that participants will qualify for transportation money).

The trainings are for nurses and midwives that work in the rural health centers and will cover the ministry's new directives on IMCI (Integrated Management of Childhood Illnesses or in french PCIME: prise en charge intégrée des maladies de l'enfant - it has not been easy relearning all these acronyms in french!). Because the ministry doesn't have enough funds to train everyone, part of our collaboration is to pay for the trainings in our districts. So basically we will be paying the ministry to do trainings that they should be holding on their own.

Seems messed up, no? Why is donor money, that should be helping the beneficiaries, families and children, going to ministry people to take trips to the beach and do what they should already be doing? It is frustrating to me. On the other hand I know how little ministry workers make, especially considering what they could make if they leave the country. They are all doctors, they could easily get visas out of here. If what we do supplements their income and is incentive enough to keep the good, smart people here, perhaps its worth it?

another field visit

... so my prospects for doing more field visits were squashed a few weeks ago when a sub-contractor for one of our projects was car-jacked on the way to buy supplies. it was likely not a random mugging: she was leaving the project site w/ lots of cash and taking a route that not many cars go on. probably someone in the project site tipped off some thugs. corruption is lame. like i said, she wasn't staff of our organization and she wasn't even in one of our cars, but the word on the street was that it was associated with our organization. which makes it more dangerous if people assume we travel with lots of cash. so my plans to visit the other 2 districts we work in have been put on hold indefinitely! sad but understandable.

this past week I was able to go back up to Tiébissou district for a day visit. we visited 2 villages where rehabilitations having been taking place. here is the water committee of Lomokankro (all men, interestingly):
in this village, this committee already existed. they collect fees from the villagers who use the pumps, which go towards pump maintenance and repair. we trained them to do pump maintenance and also to spread basic hygiene messages to the rest of the village. the connection between clean water and health isn't lost on any of these guys. they know that those who get water from creeks usually get sick and they acknowledge that this does happen to those who can't pay. they mentioned they usually are willing to give a few free basins of water for these poorest households and the pumps aren't always monitored.. but it made me a little weary.

Lomokankro has 4 pumps, including one which is newly repaired and back in use:

we also put in a new well in this village, which will be hooked up to a water tower (château d'eau) to deliver running water to the health center:

so seems like we're doing a pretty good thing here. the biggest issue w/ pumps is that usually no one in the village can fix them when they break. if the village does have money to bring a professional in to fix it, there are often delays getting equipment and personnel out there. moreover, it takes a lot of time and energy to carry a household's worth of water from a well every day. just watching the young women who are usually charged with this task is tiring. so understandably, the people of Lomokangro are now asking for another water tower and an improved running water system to bring water to more areas of the village (which will also be easier to regulate, they noted).

on a side note, at the household water is often stored in these huge pots:

more about my internship...

My first month+ I spent most of my time cleaning and analyzing data from a baseline survey that was done in April. It was a smaller survey (2 page questionnaire carried out in just over 700 households) that set out to describe the target population and provide information on a few specific indicators: key behaviors, levels of knowledge, and coverage and utilization of water and sanitation services. Surveys like this are often part of international health projects. They are done at the beginning and end (and sometimes mid-way) and help NGOs and their donors know whether their projects were effective. An important thing I learned from doing this is that a good baseline survey does not have to be very complicated or long. Every question in this survey related directly to one of our indicators or answered a specific question we had about the target population. Although it is often tempting to ask more questions and collect more information (because it is interesting to learn more!), time and money and interviewee fatigue are good reasons to keep it simple.

So after analysis comes report writing, report reviewing, more report reviewing, and then finally a finished English draft. There is no money in our budget for translation, so I've offered to do a rough draft in French in my down time and hopefully our health manager will help me edit!

Since finishing the report I've been working on creating a monitoring and evaluation tool to hold all the information we'll be collecting for the health systems strengthening project. Basically its a massive spreadsheet where we input all data we collect from 50 health centers in 3 districts. I often dream in Excel! Luckily, a good monitoring tool for the CCM project exists already since its been implemented in other countries.

In addition to that, I am also helping the team get ready to train hundreds of community health workers: working on medication projections, revising communications materials (am I really qualified to know what will make sense to rural Ivorians?), and filling out purchase requests to buy all the materials we'll need (there must be a more efficient way than carbon copy).

Needless to say, there is a lot to do here and I'm learning a ton!

oh yeah..

I guess I should blog about what I do all day, why I am here.

Like I've said before, I am an intern for the health program of an international NGO. Our department is pretty small, we are just 6 people currently. There is the program coordinator (an expatriate also), the health manager (an Ivorian doctor who studied public health in Japan), 3 assistant health managers (also Ivorians), and then me, the stagiaire.

We currently have 2 major grants. The first grant is for a health systems strengthening project: re-equipping rural health centers, supporting them with essential medicines, training health staff and health management teams (i.e. community members who are responsible for managing the health center's finances), building pumps and water towers.

The second grant is part of a large multi-country grant for implementing community case management (CCM) for malaria, pneumonia, and diarrhea. These are the top three killers of children under 5 in developing countries (not counting neonatal deaths in the first four weeks from infection or prematurity complications). There is good research that suggests that a lot of these deaths can be avoided if care for these illnesses is made accessible at the community level. In West Africa, for example, about half the population lives in a rural area, the majority of who live further than 5km from a health post. So when a child is sick, its often not very reasonable for the mother (who is also responsible for most if not all of the household duties) to take her child to a health center. So the idea behind CCM is to train local women and men (who are often illiterate and have little education) to identify these illnesses and provide treatment (antibiotics, zinc, rehydration salts, and malaria combination therapy). If it sounds radical to you, then you aren't alone because many governments and local doctors are initially very skeptical too. It took our management staff 4+ months of meetings with the Ministry of Health and the medical community to get their support for a pilot project of CCM in Côte d’Ivoire.

Both of these projects are being implemented in central Côte d’Ivoire, in the former "confidence zone". In 2002, rebel forces from the northern part of Côte d’Ivoire launched a coup d'etat, using Bouaké (2nd largest city, located in central part of the country) as their base. Many people in the surrounding districts fled, including essentially all the government and health workers. The confidence zone was established by the UN mission to separate the government controlled south from the rebel held north. As you can imagine, basic social services in this area greatly deteriorated. So that's where we're working!

To keep this manageable (for you to read and me to write) I'm going to break this into a few posts. Here are a few links if you'd like to read more about pneumonia (short article from NYTimes) and the conflict in Côte d’Ivoire.

what am i doing here anyway?

So as I mentioned before, I am here to fulfill a practicum requirement for my masters degree. I am working for a non-profit, non-governmental organization which works in over 40 countries. Typically they work in conflict areas, offering services to refugees and internally displaced peoples (IDPs) and helping to rebuild in post-conflict areas. They opened an office in Cote d'Ivoire following the crisis in 2002. Initially, their program focused on offering IDPs education and health care services. But as things have become more stable here, they've started programs in water and sanitation (building and rehabbing water pumps and latrines), gender-based violence, economic recovery, and community-building.

I am working with the health program here. There are 2 main health programs just getting started. One is a health system rebuilding program. It includes training community health workers and traditional birth attendants, reestablishing the health committees and management teams that were functioning before the crisis, as well as some clinic rehabilitation and ensuring clinics are stocked with essential medicines. The other project is a pilot project for community case management of diarrhea, malaria, and pneumonia. Basically this program entails training community health workers to treat these 3 diseases, which are the top killers of children in lower income countries. Treating these diseases at the community level, and not just in health posts and clinics which the poorest cannot access, is critical to lowering the mortality rates of children. However, because it requires community members to handle medications, many doctors are resistant to it.

One way organizations evaluate how well their projects are carried out and what impact they have is to conduct pre and post surveys. This was done before I arrived, so my first task here has been to analyze the data from the survey. I'm hoping to finish my first draft of the report this week. This is my first real data analysis project, so its been a lot of work! Here is my proudest accomplishments from the report - a population pyramid of the survey population. Check it out:


As you can see, there are lots of young kids here. Over half the population here is under 20 years old. Also notice how the female side is bigger than male side. A lot of males here leave their villages to work on farms and factories. Anyway, this graph may not be interesting for everyone, but I think its super cool!