GBF in Bangalore, India: Summation

Neelam, founder of Industree, is an incredible person. A designer by training and trade, she joined her husband Jacob in founding a furniture production unit after design school because there were no production units in India that could handle producing their designs. Today, that same production unit is the base and inspiration for a large chain of high end furniture throughout south India. Inspired by working with artisan craftsman, she decided that the best way for the least well off of them was to expand their market. Combining this altruism with her passion and talent for design, her retail industry experience and network that she founded Industree, first as a retail channel for contemporarily designed natural fiber based products and later as a retail outlet for everything from apparel, furniture and home décor to dried foods, all with the mission of providing rural artisans access to a lucrative market of young professional Indians.

With an enormous presence, Neelam captivates a room with a fast paced summary of what she envisions for her company from what details should be included on men’s shirts in next year’s collection to size and layout of the massive production space Industree would provide for many of the artisan production units they incubate.

Grassroots Business Fund invested in Industree because they are an emerging market medium size social enterprise with significant growth potential. I consider myself considerably lucky to have been placed in a position not just work alongside such an impressive person, but to also have an opportunity to directly impact almost every aspect of a company on the verge of growth and one that I could get excited about. Furthermore, I was located in Bangalore, a city rich in history, culture and food. Geographically, Bangalore is also is fairly central in southern India, providing ready access to a some wonderful destinations. On the weekends, with other WDI fellows as well as with friends from Bangalore, my girlfriend and I travelled to Kerala, Hampi. Below are a few videos from those trips as well as one video of my entire experience (Click on titles of each photo)

KERALA

HAMPI

WDI/GBF EXPERIENCE

A profile: Somanth

Somanth smiled humbly as our team examined his water trough with great interest. The trough, which spanned the length of his cow shed, was connected to a rain water tank in which Somanth had affixed a buoy and valve to regulate the flow of water to his fifteen jersey cows. This simple yet crafty mechanism allows Somanth to conserve water and it’s one of several measures he’s taken to ensure his cross-bred cows remain healthy and productive. Cross-bred cows require significantly more care than India’s hardy local, non-descript variety but they produce a more abundant -- and consistent -- supply of milk.

Farmers like Somanth, are an example of the target beneficiary under the Godhan project, a Gates Foundation funded collaboration between TechnoServe and BAIF, a large national NGO. The goal of Godhan is to create wealth for India’s rural poor through cattle development. BAIF pioneered livestock development in the 1970s. Their flagship cattle development program includes doorstep-delivery artificial insemination and comprehensive livestock management services such as vaccinations and deworming. To establish the most efficient delivery model with long-term sustainability, BAIF engaged TechnoServe to create a sustainable business model for its services. TechnoServe’s expertise social enterprise development made it an ideal partner to accomplish BAIF’s goal of a self-sufficient livestock development program.

Over the past few years, Somanth has made significant investments in his cattle with the assistance of BAIF’s cattle development centers (CDCs). By upgrading his non-descript cows to cross-bred varieties, Somanth’s income has increased almost six fold per milking. Using the additional income Somanth earned from selling higher quality milk, he recently invested in a bulk milk cooling center which he operates in partnership with a local dairy and earns about $50 every day in addition to the milk he sells. He collects up to 8,000 liters of milk every day during the flush season from farmers within his village. While Somanth’s story is pretty exceptional, similar success stories are increasingly common in the district of Beed, where farmers are capitalizing on BAIFs services to improve their cattle breeds and produce quality milk.

Traditionally, dairy farming has been a secondary activity to crop farming, with the average small landholder owning one to two indigenous cattle, just enough for household consumption. However, the opportunity for dairy farming in India is significant. India’s growth has set the set the stage for dairy to take a prominent hold with small and marginal landholders. With rapid urbanization and the increase in per capita income, there has been a steep rise in the domestic demand for milk and milk products. The demand for milk is expected to rise to 180 million tons per year in 2022 from the current level of 95 million tons.

Somanth’s success means that his future and his family’s hold vastly greater opportunities. With TechnoServe’s expertise in building sustainable enterprises, BAIF can continue to innovate and develop more effective programming to meet the challenges of India’s next generation of farmers.

Wrapping up with something different

In the flurry of activity accompanying the end of my internship, and the subsequent weeks of nomadic lifestyle, I’ve left a major facet of my time in Bangladesh unaddressed. As I mentioned in earlier posts, the key focus of my project in Dhaka was to perform a landscape analysis on the Bangladeshi rice industry, nutrition outreach programs and food fortification efforts. This was a broad charge to complete in 12 weeks, and as I neared the end of my internship, I found myself rushing to squeeze in a few more meetings and was near-constantly enveloped in writing. Writing, writing always, writing without end—except that finally, it did end and I was able to hand over a comprehensive report to PATH on the prospects and recommended next steps for expanding rice fortification into Bangladesh.

Yet, as I handed over that final report, I had only completed 11 weeks of work. My final week in Bangladesh was devoted to a much more focused problem—how to mix the fortified Ultra Rice grain with normal rice at the village level. As in many rice-producing countries, a significant portion of the rice that is consumed in Bangladesh never enters the commercial, marketed value chain. Instead, rice farmers take their paddy to local millers and have it processed into the rice that they will consume for a majority (or entirety) of the year. Providing rice fortification to this sizable portion of the population thus requires an intervention strategy that is oriented around the local miller. Aside from the logistical challenges of linking the tens of thousands of such millers into the fortified grain supply chain, there is also a technological challenge of ensuring that the blend of fortified and normal rice is accomplished accurately. Without reliable blending methods, the comparatively low ratio of fortified grains to normal grains (1:100) could result in pockets of dense fortification and huge portions of the end rice that was essentially unfortified.

PATH had already recognized the importance of establishing a reliable, affordable blending method through previous work in Latin America and had consequently initiated development of a dedicated piece of blending equipment before I joined the project. Given the ubiquity of local millers in Bangladesh, the country offered an ideal opportunity to test the resulting prototype. Thus, in my final week in Bangladesh, I was joined by two of my PATH colleagues and, along with a local partner, we ventured into the field for several days of trials with the blender prototype.After assembling the blender prototype from its heavily broken-down travel state, the four of us headed back out to the Dhamrai area that I had visited during some of my earlier field work. We started by returning to one of the millers that Jonathon and I had interviewed back in July, and although he was handling a pre-Ramadan rush of customers, he agreed to work us in for some testing. With the expected amount of complications and adaptations, we managed to run successful trials at that first miller, as well as at a more remote miller further down the road and finally, at a prominent miller at the edge of Dhamrai itself.

Pleasantly, the trials were a success on numerous fronts. The prototype operated largely as designed, but working in the hot, humid climate of Bangladesh unearthed some important differences in functionality that did not show up in the more controlled environs of the Bay Area. As hoped for, the millers quickly grasped how the device could fit into their existing operations and the blender’s design proved fairly intuitive for the millers to use. More surprising was the extremely positive reaction that the device had with the local population. A certain amount of enthusiasm is expected—a group of outsiders with a strange contraption are always going to garner attention. Still, the impressive aspect was just how much the people at each milling location seemed to grasp the purpose of the device and appreciate its potential benefit. The word “vitamin” floated in the air above each crowd that gathered to see what we were doing and at the last site the assembled locals eagerly requested that their mill be among the first to receive access to the fortification. Given the proximity of the location to Dhaka, such high awareness of micronutrient importance shouldn’t be extrapolated much beyond the immediate surroundings, but the interest and excitement that rice fortification generated among the local population was nonetheless encouraging for the long-term prospects of my project. I started the summer thinking that rice fortification would be challenging but had high promise; I end it thoroughly convinced of its enormous potential.

Children's Home

Before leaving Sigua, I was very fortunate to be able to visit the children's home, an NGO that the Hospital supports.  The home houses nearly 45 children ages ranging from 6 months to 15 years.  The home provides a loving atmosphere where the kids learn to respect and honor each other.  It's common to see the 7yr olds feeding and cuddling the infants and the teenagers helping the primary students with their homework. All of the children are supported by the home to go to quality schools, an opportunity that would be beyond reach otherwise. 

Here you'll see me helping Wilmur with his homework.  He was teaching me some Spanish phrases, but clearly my procunciation was atrocious.  His body language explains it all. 

All of the kids have responsibilities that they are held accountable for: washing the dishes, mopping the floor, hanging the laundry to dry.  Their favorite chore, which they've only had for 2 weeks now, is caring for the hens!  Through a generous donor, the home was able to set up a chicken shack in the backyard!!  Aside from being a neat experience for the kids, the home is hoping to generate some income to help support the kids.  Here are a few pictures in chicken shack.  It's the first time I've ever held chicken with my bare hands.  The kids are beautiful aren't they?

On a final note, I noticed that all of the kids were wearing Toms.  So if you were wondering whether or not a child really got a pair for the pair you bought, its true!!!  All of the kids received a pair of Toms last month when the company came out to Honduras.  Check their blog for details.  TOMS in Honduras  The kids LOVE their TOMS.  :D

mBillions (and growing)

This month I attended the 2011 South Asia mBillionth conference, a mobile technology conference that aims to recognize innovations in mobile and telecom solutions, and provide a platform for idea exchange within the industry. Not only was the PharmaSecure squad out in full force to present and demonstrate its solution, they also won this year's award for the mHealth division! This is phenomenal news at such a pivotal time in the company’s growth and direction -I hope this visibility will bring more opportunities for the company to spread its message, through anything from relationships with telecom providers to collaboration on public health education.

I learned some fun stats about South Asia’s telecom industry between attending breakout panels and perusing the stalls of companies in attendance. As of 2010, mobile penetration by population in India was 46%, 51% in Sri Lanka, 59% in Pakistan, and 31% in Bangladesh. India’s wireless market in February 2011 had 752 million mobile phone subscribers alone, and in 2014, when the population is expected to reach 1.26B, teledensity is expected to surpass 80% (and the population living in urban centers will grow at a similar tack). By the end of 2015, data use (via services such as mobile broadband) is projected to account for 40% of mobile revenues earned by telecom operators, which maps to just over US $12.4B.

PharmaSecure’s founder and CEO Nathan, who recently returned to India after several months of travel for fundraising, was given a five minute slot to present on PharmaSecure at the conference’s mobile health workshop. His approach to this opportunity was an apt demonstration of what he learned on the road meeting with investors; the pitch was high-level, concise, energetic, interactive, and focused on the company’s big picture vision, without getting too technical or detailing the company’s evolution. Given that everyone in attendance would hear the names of nearly a hundred new ventures that day, this strategy allowed PharmaSecure to leave a lasting impression, and the product demo gave the attendees something to talk about. As such, I left the conference having learned as much from the company I was representing as any other.

Monkeys, Motorbikes, and Matatus

Sean Morris - Ruli, Rwanda

My penultimate weekend in Rwanda was spent in Nyungwe National Park. I traveled 7 hours south with two German medical students, and a Spanish architecture student, all of whom are also working with Ruli District Hospital this summer. Along the way we sampled a variety of different modes of transportation: matatus, motorbike taxis, truck beds, and a great deal of hiking in the Nyungwe rainforest. I’m sure many of my fellow WDI interns are familiar with the likes of a matatu – a 14-person van that won’t leave the station without a capacity of 19 people or more… and maybe a few chickens. Needless to say, personal space and lap space take a back seat (if there’s room) during matatu rides.

Our guesthouse was located on the campus of a small conservation and environmental management college in Kitabi. Our $8/night rooms on the edge of the park overlooked a beautiful, rolling tea plantation, with dark, dense hills of jungle just beyond. Early Saturday morning we each took motorbike taxis 40 km through to the starting point of our day-hikes in the forest. Leaning around corners at 50kph, passing buses on said corners, all the while taking in the increasingly beautiful vistas of Nyungwe – truly exhilarating. Once you set aside any regard for personal safety or survival, motorbike taxis are loads of fun!

We had daylight enough for two loops in the south of the park. The first hike was less than exciting, after we got past the novelty of being in the midst of an African rainforest, cicadas singing, tropical bird calls reaching us from deep in the forest. Not much to speak of in the way of wildlife sightings, though. Our second hike, was amazing. After about 2km, our guide informed us that we were way ahead of schedule (remember, we have two sturdy Germans, both of great hiking prowess, setting the pace). He offered to take us on a side trail further up the ridge, which led to a great view of the surrounding hills. We obliged, and began an ascent that seemed nearly vertical.

After 15 minutes the trail leveled out, and up ahead we saw three colobus monkeys blocking our path! We walked toward them slowly, but when we were about 10 meters away they spotted us and bolted into the trees. Suddenly, the trees directly above our heads came alive with activity – colobus hoots, monkeys leaping gracefully from one tree, crash-landing in the boughs of the next. Sticks and leaves were falling on us as we frantically tried to catch the acrobatic display on our cameras and iPhones .... 40 or 50 friendly Colobus monkeys were swooping between the trees, just as curious about us as we were about them!
The remainder of the hike included waterfalls, wild orchids, giant mahogany and buttressed Newtonia buchana trees, baboons, blue monkeys, and another group of Colobus monkeys. Upon arriving in the capital city of Kigali the following day, we indulged several western cravings – pizzas, beer, and we also stocked up on Nutella for our remaining time in Ruli.

I’ve presented my project findings and recommendations to the nutrition center personnel, several Ruli doctors, and the community health worker heads in Ruli. With their feedback in hand, I’m working to complete my final report for the Ihangane Project. Only a week remains in my Rwandan adventure, and I find myself experiencing very mixed emotions. I am very much looking forward to reuniting with friends and family, but the “au revoirs” to my Ruli friends and family will be truly difficult. I’m making the most of every minute, and praying for the opportunity to come back to Ruli someday!

the home stretch

Wow, can there really be only 2 weeks to go?  My time in Delhi is starting to get short and already we have already said goodbye to some good friends who have headed back to the states.  Things have really kicked up a gear in the last couple of weeks here.  I've been running here and there having meetings with a wide variety of organizations operating in the healthcare and BoP spaces in India trying to understand what they do, what challenges they face and how the organization I'm working for can help them overcome these challenges.  This has involved experiencing a wide range of Indian 'office' spaces, which are mostly apartments with the trappings of corporate life transplanted into them...a video conferencing system is a common fixture in most offices of international NGOs for example.  But this is something you come to expect from India and from Indians...there is a way of making do here, of getting things done despite a lack of resources, infrastructure or political support.  A way of reusing what is around you, of repurposing it to fit your needs.  Indians refer to it as 'Jugar', the practitioners of which are the ‘Jugari’.  If we have a word in English to describe the unique combination of resourcefulness, creativity and willingness to operate outside the rules that constitutes the Indian way, it would probably be MacGyver (used as a verb).  Of course, it isn’t just a lack of resources that encourages this approach.  Indian bureaucracy and regulations are legendary, with a dizzying array of rules, laws, policies, institutions, ministries and layers of administration.  So much so that daily life in India seems to revolve around figuring out how to get things done…not so much working the system, as working around the system.

Now, time to MacGyver myself up some coffee in this chai-obsessed country.

Focus Groups

Today we conducted focus groups with women entrepreneurs, framers and youth in attempt to learn more about how they use technology. Observing the groups I not only realized the gaps between users and technology, but that proper surveying is an art-form.

The most pertinent conversation revolved around technology and how respondents use it in their everyday lives. To many respondents technology was a nebulous concept that they could neither define nor describe the benefits of. Is this because the question was too broad or because respondents were genuinely unaware of technology’s benefits?

“Technology is for the educated,” one proclaimed, “not us.” Many explained that a cellular phone would be nice to keep in touch with people, but computers and Internet had no place in their everyday lives. While these responses may not be representative of all of our target market, it did stress the importance of education. Users not only need to be informed on how to use the product, but how it can improve their lives. The respondents seemed frightened by technology and felt they would erase important information if they used a high-tech phone or computer. In order to create a desire to learn, we first need to show consumers how technology can impact their life on a day-to-day basis.

Frontline SIC - Part 2

Arusha, Tanzania

"It's like fire rescue!" Anton, one of our three Field Officers, said excitedly after I described to him the basic idea of Frontline.

"What?" I replied, slightly confused but curious.

"You know, it's like a fire rescue system. When a patient is sick or something, you just text and then," he pauses to snap his fingers, "we know! Just like the fire station."

I nodded and agreed with a big smile. Anton was the longest continuous employee of SIC and had an enthusiasm that was as infectious as it was indefatigable. He had a mountain of dreads that he always kept tucked into a collection of ridiculously oversized knit hats. Whenever he was in the office, he was singing or making jokes, but in the field he was an amazingly dedicated and passionate worker.

And although I initially just stored the "fire rescue" analogy as one of a long list of quirky things Anton has said, I quickly realized that he was onto something that was very important for the success of the program. From the beginning, one of the biggest obstacles that we foresaw for the system was the potential inertia among the CHWs, the people that would be doing the actual texting. Would they be excited about a new way to transmit information, or will they be reluctant to make changes to a system that they had learned and mastered?

"Fire rescue" embodied the idea of the immediacy of information transfer -- and that was after all one of the most significant benefits to adopting the Frontline system. What I hadn't realized was that this sense of immediacy was something that could be felt by CHWs as well. I could be fairly certain that even though CHWs always filled out their numerous forms for each patient every month, they had very little visibility into what actually happened with that data. To them, they spent the time to write up all the information. Then, once they handed them off to the Field Officer, they disappeared into the ether.

And in some ways, the data was truly in the ether, stuck somewhere between the delivery of forms to the office and the hours that it would take to enter the data manually. The Frontline system was designed to allow for immediate data delivery and entry, and this was something to explain in full detail to the CHWs to get buy-in. Pretty soon, the phrase "fire rescue" stuck among the staff, serving as a constant reminder of the selling point of the Frontline system. It had a nice ring to it as well, considering that the office was on Fire Road (named aptly after the fire station that was down the road from us).

My job was now to turn this "fire rescue" into a real and functioning system. There were many fronts that needed to be attacked at the same time -- on the front end, I needed to figure out the easiest and most widely compatible method of data delivery from the CHW perspective, while on the back end, I needed to build a database that would accept and integrate this data. And these functionalities did not come easily or quickly.

In the end, after two weeks of intense work, punctuated by the occasional frustrated banging of the head against the computer screen, we had a system that had enough components in place to initiate a roll-out. The Frontline system was online and receiving texts through a wireless GSM modem with a SIM card. The CHWs were to text the Frontline SIM number, just as they would text any other number. We made laminated handouts with three different survey formats -- each was designated by a keyword and had a series of questions that the CHWs had to answer in the correct order. They would only need to write the answers to the questions, each separated by a space. Most of the answers were numbers (either variable numbers like CD4 count, or answer choices like 1 for male, 2 for female). Then, they would receive an automatic confirmation text from Frontline, saying that they had submitted a particular survey.

This data was automatically exported to a text file by the Frontline software, which was then linked to an Access-based database. This included a patient table, organized from a spreadsheet that the staff had put together after months of collecting forms to get a basic sense of how many patients we had in addition to some basic information, such as age, registration year, and anti-retroviral status. Each patient was assigned a unique four-digit ID number, allowing each CHW to text about a specific patient without having to write out their name every time. This way, new information coming in could be connected to an existing database of patient data and then automatically updated.

In some ways, the most challenging part of the roll-out process was not designing the methodology or database, but rather the subsequent training of staff members. Field Officers had to individually be trained on how exactly the CHWs needed to send their texts in order for the system to work. Despite all the automated steps, the texts had to be very accurate in terms of formatting (like separating each answer with a space or putting the number "0" as a placeholder for answers that were not available).

After extensive discussions with Kati (my direct supervisor and Managing Director of all operations in Tanzania), we decided that I should not go with the Field Officers to the CHW training sessions. We needed to know if the system could be scaled up to all the wards, and we knew that the training could not depend solely on me to be there.

And so, we trained the field officers and sent them off to the field to train the CHWs in their respective wards. It was an incredibly exciting and anxious moment, but we had to trust that the training was sufficient and believe in the capabilities of our field officers. And despite my extreme confidence in Anton and the others, I still dreadfully counted the hours until the first text came in.

Next time: results, data, and sustainability...

Lost Without A Phone

Over the weekend I went to a concert and was assaulted and mugged. Left with no money, keys or a cellphone, I felt lost. In my moments of panic and the days following, I experienced the true value of having a cell phone.

Immediately after the attack, I had no way to contact people 1) to warn friends of the potential danger that awaited them outside the gates and 2) to call for assistance. Luckily, I was traveling with my two roommates, who between the two of them had a key and enough money in their pockets to get us home in a cab. Suppose they were not with me, how would I contact anyone to pay for the cab or let me into the apartment? Unfortunately, after one month in East Africa my proficiency in the local language still consists of greetings and haphazard directions. My cellphone served as my emergency translator, a tool in which I used to call a local friend who would explain the situation to others.

The next day was devoted to canceling my credit cards, cellular service, and informing the U.S. Embassy of the attack. Thankfully the Internet gods created Google Voice, so calling the United States was no problem. Credit card canceled. Cellular service suspended. Mother notified and consoled.

However, calling the Embassy proved to be much trickier. It was much more expensive to call a local number on Google Voice than the United States and I had no credit card to recharge my account. After 5 minutes talking to an Embassy officer my Internet USB ran out of credit. Without a cellphone I could not subscribe to another plan!

With no Internet and cellphone, I had to ask others for a cellphone to borrow. However, with my roommates without phones, I had to visit my neighbor upstairs for a phone to use. Limited access to cellular phones. I was also reluctant to continually ask to borrow her phone. I offered to pay her more than I was charged for the calls, but was still reluctant to continually ask her. Embarrassment. At work, I needed to follow-up with the Embassy, but was still without a phone. I used my co-workers phones, but as a result my personal calls were directed to them. Privacy. And I still did not have a number for people to reach me directly. Accessibility.

Each of the inconveniences I faced, were the same obstacles rural users face everyday when trying to make mobile calls. The difference was I was going to buy a cellphone with the next few days and they would remain without one. My personal experience, served as my first understanding on how CloudPhone services could positively effect rural communities.

The Longest Sand Beach in the World is in Bangladesh

Arturo Huesca Santos - Chittagong, Bangladesh

With a length of more than 136 Km, Cox's Bazar Beach is the longest sand beach in the World. It used to be undisturbed, but nowadays Cox's Bazar is the first destination for domestic tourism in Bangladesh and there is a huge proliferation of hotels and appartment buildings.

This massive real estate bubble is threatenig beautiful natural assets like ancient paddy fields parallel to the coast, estuarine ecosystems and fauna and flora living in sand stone cliffs just by the sea. Moreover, real estate projects are not being executed along with an infrastructure master plan, so roads, bridges, sewage and drinking water systems are rather underdimensioned for the population that is going to live in Cox's Bazar. Real estate is so profitable that first comes the building and second comes the master plan and the infrastructure, this remids me how in the 60s and 70s the Spanish Mediterranean coast (in some places) was abused and mismanaged by politicians and speculators. This lack of policy will damage a tresure for the Bangladeshi economy if nobody takes action, I believe there is still time to do something good about it. Ecotourism and high-end hotels and low density residential buildings will be able of preserving Bangladesh's last treasure and will prevent the ugliness of uncontrolled growth to take over of Cox's Bazar beach.

Field work in Bhutan

It’s definitely crunch time! I have only three weeks left in my internship here in Bhutan. I’m working non-stop to finish all my deliverables so this will be a quick blog update. I am 90% done with my cost analysis and about to start with creating my presentation material and report document. I presented my initial output to Mr. Kharka, my director, and I am happy that he liked the direction and content of my work. This week, I plan to finish my two other deliverables for the Natural Resources Development Corporation (NRDCL). I need to compute a standard cost for sand and a standard price for timber, sand, and stone. I hope I finish all my analysis this week so I will have two weeks to prepare for my presentation. I am not letting stress defeat me thus I am eating a lot (haha!), am exercising everyday by hiking to and from the office, and am listening to classical music (Beethoven's Symphony No. 7 in A major Op. 92 and Mozart's Sonata in D major for two pianos on repeat).

I went last week to the Wangdue business sites of NRDCL. Their CEO arranged the trip for me and he also met me for lunch in the field. I observed the company’s sand, stone, and timber operations. I understood a lot clearly the cost drivers and pricing constraints of NRDCL after that field work.

Timber is transported through aerial ropeways. I heard people also use this form of transportation!

Sand is extracted from October to April when the water level is very low. For the rest of the year, NRDCL sells sand from their inventory. You can see many trucks waiting to load on sand.

Sand, stone, and timber depot

As I wrap up my internship in Bangalore, I’ve been mulling over a quote I heard recently: “Every human idea that has ever been thought has already been considered in India.” To me, the quote captures the idea that India is full of surprises that actually should not be very surprising; everything is happening in India, and therefore nothing should be unexpected.

This message surely applies to healthcare. Thousands of private facilities offer advanced level care from world-class physicians. And, thousands of “trust” hospitals, created through public-private partnerships, provide quality care to both paying and non-paying patients. Unfortunately, there are many things that should not be possible too. Thousands of rural health clinics are unstaffed by anyone with formal medical training. And, millions of births are happening at home, oftentimes without a skilled birth attendant.

But not only is everything happening, everything is changing too. My favorite question to ask friends and colleagues is “what did this area look like 10 years ago?” Wherever I am—a corporate campus, a village primary health center, an urban private hospital, the back of an autorickshaw—the answer invariably boils down to “completely different.”

Of course, change can be superficial and is not always positive. But the necessary resources and dynamism are present in India to make some of today’s statistics—like an infant mortality rate of 50/ 1,000 live births—impossible and unthinkable in the future.

Farmers Market!

Buenas!  I had the pleasure of checking out the local farmers market this weekend.  The best produce you can find anywhere in town, and the prices are unbeatable.

I can hardly believe that my time is coming to a close.  I've spent the last couple of weeks piecing together the results of an employee survey that I launched about a month ago.  The organizational/behavioral aspects of the hospital have been extremely interesting to observe.  There are a number of behavioral/cultural issues that need to be addressed at the hospital, my hope is that the employee survey will help leadership parse through the issues and get the hospital moving forward in the cultural realm.  My final report out will be next week, and my deck is 64 slides and growing.  I hope it doesn't turn into a dissertation....maybe it already has.

Frontline SIC - Part 1

Dave Seo - Arusha, Tanzania

With a familiar click, the lights flicker and dim, making the office look somewhat like a dark room. A couple seconds of belabored buzzing, and then the electricity finally gives out, shutting off all the electronics in the house. I frantically pull up my battery meter on my laptop to see how much juice I have left before I too have to sit idly. Three hours, it says, but I know it’s exaggerating.

An urban Tanzanian town such as Arusha is full of odd juxtapositions between anachronisms of the past and ultra-modern influences. Fully wired businesses and offices often sit powerless for hours during a business day due to the recent and massive national power cuts. I’ve seen people dressed in full traditional Masai garb – a tribal outfit consisting mainly of overlaying colorful pieces of cloth, usually accompanied by shoes made out of old tires and a cow-herding stick – checking his Facebook messages at the local internet café. Often, I see brand new Range Rovers owned by local government officials, inching along gingerly on uneven and rocky unpaved roads to their offices.

And this kind of seemingly contradictory images is not limited to the urban centers. While Arusha is a bustling and extremely crowded town, you don’t have to go more than 30 minutes outside of city limits to be in a very rural setting. These villages are still for the most part heavily dependent on farming, and though there aren’t as many luxurious accessories as in Arusha, you can still routinely see interjections of modern technology.

I came and lived in one of these farming villages in the summer of 2008, when I was working as a volunteer for an organization called Support for International Change (SIC). At the time, I was living with a homestay family and teaching local students and farmers about HIV/AIDS prevention. I still remember my sense of surprise when I realized that, though most of the houses in my village had no electricity and no running water, almost everyone had a mobile phone. Our homestay father would use it regularly to talk to townspeople about the going price of rice and other crops. We took advantage of this widespread penetration of mobile phones too, by organizing teachings and meetings simply through calling teachers and leaders.

That summer cemented my general interest in global health issues, particularly with people affected by HIV and AIDS, and I always told myself that I would come back to this place to offer something more than just my time. When I heard about the student led WDI fellowships, my mind went straight back to my experiences in the villages. I quickly realized that the penetration of mobile technology wasn’t simply something to marvel at simply because it had initially seemed somehow out of place in the extremely rural setting. This was a technology that was helping people connect and transfer information to and from each other. It was something to be leveraged.

SIC, in addition to training volunteers from the US and the UK to run rural awareness campaigns, also supports HIV+ clients in 19 wards (which are sort of like counties for rural villages). The patient network has well over 550 currently registered, and each of them receives support from a Community Health Worker (CHW), an SIC-trained employee who lives in the local villages. Using this network of over 100 CHWs, SIC can reach out to patients in even the most rural areas and provide them with basic needs – vitamins and soap, teaching and advice about HIV/AIDS, as well as reimbursements for monthly visits to clinics in town.

But while this top down approach works great for distributing services to rural areas, it’s designed poorly for sending information about clients back up the chain. Currently, CHWs fill out many different paper forms about clients, which then get brought to Field Officers (full time SIC employees who are in charge of training and managing the CHWs). The Field Officers then collate this information and bring it to meetings at the office in Arusha, where another staff person has to enter the information manually into a spreadsheet. This whole process takes a lot of hours, and the information is delayed by weeks, if not months at a time.

So the idea was simple: replace the paper forms with electronic ones using mobile phones. I had already seen first-hand how widespread and available mobile technology was even in the most rural villages. A quick Google search found FrontlineSMS, an NGO dedicated to providing the technical support and software required to do this exact thing in resource-poor settings. And from there, the writing was easy.

But as with most things, there is a big gap between formulating a plan and executing it. And usually, it takes much longer than one expects to fully bridge this gap.

The power whooshes back and sets the office alive with sounds of printers and monitors turning back on. Time to get back to work.

Next time: More details on our plan and current progress…

New York vs. Istanbul – A different assessment of internship experience

Hi everyone,

It looks like everybody is having great experience at different parts of the world. Previously, I wrote about my internship and my initial takeaways. This time I would like to make a little detour from the analysis of my internship from business perspective. As a Turkish MBA student who lived in Istanbul for 10 years, I would like to share my observations about some interesting similarities between Istanbul and New York City. I would like to group these similarities under four main categories, namely: landscape, culture, city life and business/economy.

Landscape
The first similarity between the two cities is the landscape. Istanbul and New York City are surrounded by water. This gives a similar landscape to these cities. Particularly, the bridges connecting different parts of the city enhance this landscape similarity even further.

The similarity between the cities becomes more obvious especially at night. Bridges decorated with lights, boats that sail on the water and people watching the landscape at the shore are just a few of the factors that create this similarity.

Istanbul vs. New York

Culture

Istanbul is a city with a very long history, accordingly you can see many historical remains while you walk around the city. New York is also quite an old city with a long history. As a consequence of this, it’s not uncommon to see historical remains in NYC. For instance the Washington Square Arc which is close to New York University, reminds me of the entrance of Istanbul University in Istanbul.

Entrance of Istanbul University vs. Washington Square Arc

Both Istanbul and New York are among the cities that attract many local and international tourists, so it’s very common to see many tourists, especially during the summer time. This keeps both cities quite lively especially during the summer. Even though, the residents of the cities leave the city for summer vacation, tourists keep these cities busy during the summer.

City Life

The city life in New York and Istanbul are also quite similar. Both of them are very crowded and lively cities. They offer unlimited opportunities to their residents and to the tourists. Theaters, concerts, live performances, beaches and unlimited dining options are just a few of these opportunities. For instance, whenever I go to Times Square, the crowd in that part of NYC reminds me of Taksim Square in Istanbul, which is one of the key tourist attractions and which is always full of people.

Taksim Square – Istanbul vs. Times Square - NYC

Additionally, it’s worth mentioning the resemblance of the culture between these cities. Even though Turkish culture is not very individualistic, Istanbul has a more individualistic culture. I believe that this is mainly driven by the high number of people in the city (Istanbul population: ~11mn). Similarly, NYC is also a very crowded city (NYC population: ~19mn,) and I have been observing a similar culture in here too. Certainly, everybody is not the same in these cities, however this is the overall feeling that I get from both of the cities.

Economic/Business Importance

New York is clearly the business and finance center of the world and this is a key reason that makes NYC as one of the most popular cities globally. The headquarters of many big companies, New York Stock Exchange and NASDAQ are located in New York. Similarly, Istanbul is the “New York” of Turkey. It’s the heart of business world and economy, and it hosts all the big corporations and the biggest stock market in Turkey. Finally, like NYC Istanbul is not the capital of the country, however it is more popular and globally known city of the county.

Other Similarities

Another similarity is about the traditional “snack” of the countries. It’s very common to see people selling “simit” in Istanbul and in many other cities in Turkey. Simit is a very traditional snack made of dough. It’s soft inside and crusty outside, and covered with sesame. Whenever I see people selling pretzel on the street, I remember people selling simit in Istanbul.

Simit (Istanbul/Turkey) vs. Pretzel (NYC/USA)

Unlike most of the other cities in US, NYC has a significant Turkish population. Since I started my internship, I frequently hear Turkish speaking people on the streets and see many Turkish restaurants all around the city. I believe that these similarities are among key reasons that attract Turkish people to NYC.

Training and Implementing the Registers

It’s 7:30 am and slightly muggy as I climb the little hill towards the hospital, pass through the gate, and wait for Justice and Moses in our designated pickup spot. We’re in the middle of the third stage of our project: the implementation of new maternity registers, and I’m carrying five green, oversized recording books under a bright yellow poncho for protection. Three of the registers will go to Tepa, a large rural hospital with 4 doctors, and two to Mankranso, a smaller hospital staffed by one young, but very energetic doctor. Each register implementation visit is similar: we greet the hospital administrator, medical superintendent and nurse matron before trekking down to the maternity ward. Having confirmed in advance with the nurse midwife in-charge, we sit down with her and explain the entire book. Typically, she is well informed of the parameters and the project, and she calls in her staff. I hand them a printed out version of the register guidelines, which define and give examples for each of the columns and we go through it together, some of the parameters being: Treatments/Medications Prior to Admission, If woman received treatment before arriving to hospital, please record, e.g. Anti-hypertensives, Blood Transfusion, Herbal, IV Infusion of Antibiotics, MgSO4 Loading Dose, Misoprostal, Oxytocins, If woman received NO treatment before arriving please record NONE EBL (mL), Record estimated blood loss (ml), Complications If a woman has one or more complications that developed Antepartum, during labor or postpartum, please record them here. e.g. placenta previa, preeclampsia, eclampsia, PIH, PPH, Obstructed labor, placental abruption, incomplete abortion, severe malaria, severe anemia, etc.

Together, we go through the parameters and practice examples. I’ve been extremely impressed with how engaged the midwives are with the process. They ask and answer each others questions, provide their own hypotheticals, and work together as a team to ensure everyone understands how to fill out the register. If there aren’t enough questions, Justice and I start running through examples and have the midwives fill out the register with our scenarios. We stay at each hospital long enough so that they feel comfortable, and then bid our adieus, promising to come back in two weeks for a follow-up.

Harsh Realities of Malnutrition and Hope for the Farm

Sean Morris - Ruli, Rwanda

Last week was a very productive combination of survey data collection, a follow-up visit with the Nyange PLWHA (People Living With HIV Association) to discuss their farming association proposal, and observation of village screenings for children <5 years old in the countryside. At the screening of Gitaba village, Theo and I had a tremendous discussion with the mothers in attendance. They had many wonderful ideas for improving the community nutrition program. One of these suggestions was a mandatory meeting for their husbands, in order to sensitize them to the importance of their child’s health, fiscal responsibility, family planning, etc. – this will absolutely find its way into my final report.

We shared our ideas for SOSOMA production in Ruli, and how this would make SOSOMA affordable for their families. When we ask the mothers in these rural villages whether or not they can buy the industrially produced SOSOMA, maybe 5-10% raise their hands. The price of SOSOMA is simply too large a percentage of their monthly income to justify purchasing. Instead, they are forced to make some bastardization of SOSOMA on their own: they buy the cheapest of the three SOSOMA grains (usually sorghum), grind it into flour, mix with water, and call it SOSOMA. This homemade concoction lacks the most important of SOSOMA’s three constituent grains, soya, which contains a complete package of essential amino acids necessary for growth and development. Suffice it to say, these mothers need a more affordable, fortified SOSOMA option. My hope is that through the development of Ihangane Project farming cooperatives, the hospital will have a source of SOSOMA grains, which it can then process, fortify, package, and distribute to the far reaches of the Ruli Hospital catchment area.

At this same Gitaba village screening I witnessed the weighing of children <5 years old, as I always do. Most of the children were healthy, progressing at an appropriate weight for their age. One infant, though, went to the scale, and it was obvious that she would be in the “red” on the growth chart: I could see clearly the outlines of the bones in her tiny arms and legs, and her eyes were barely able to open from lack of strength. Sure enough, this one-month-old child was deep into the “severely malnourished” portion of the growth chart. Strangely, the health workers asked me for my opinion on what to do for the child - I told them they should probably refer the child and her mother to the hospital immediately. When this directive was translated to the mother, she became visibly shaken and nervous. She told the health workers that she might be able to bring the child next week, but wasn’t sure how she could find the money. You see, this mother is 18 years old, an orphan, living with a distant relative, a secondary school dropout (after she discovered she was pregnant), and her home food security is essentially non-existent. Where could she possibly find the money to pay for services at the nutrition rehabilitation center, which, by the way, are not covered by government health insurance? I knew her response meant that she couldn’t afford to keep her child alive, so “might go next week,” meant “can’t go next week, or ever.” I told her not to worry about the costs, just to get to the hospital as soon as possible. I said that I would pay for any expenses at the hospital, and that her child’s life depended on her getting to the hospital as quickly as possible. She agreed, and I asked the Gitaba CHWs to supervise her to make sure that she made it to the hospital on Monday.

Sure enough, on Monday morning, after a 3-hour walk with a 2.5-kilogram infant in her arms, Sarafina arrived at Ruli Hospital. Her little one, Oliva (photo on right), looked no stronger than when we had seen her on Friday at the village screening. Theo and I walked with them to the health center, where they were given a preliminary check-up, and a referral to urgent care in the hospital. Theo’s skills in negotiation led the way to the front of very large lines at both the health center and hospital (yes, this presented an ethical dilemma, cutting in line at a developing country hospital and all, but this child required immediate attention). Soon, Oliva’s pulse was taken, and an IV was ordered: in addition to being severely malnourished, Oliva was severely dehydrated. What came next was a very difficult task for the nurses: locating a vein in the tiny, skeleton-like arms of Oliva. They tried 10 times, unsuccessfully, in each arm, and several times in each foot. At each attempt, Oliva let out a soft cry, barely audible, but with the look of a infant screaming at the top of its lungs - she was simply too weak to cry. Finally, the nurses had to shave a small patch of Oliva’s head, and were able to successfully insert the IV in her superficial temporal vein (thank you Google). Oliva is now stable, and taking therapeutic formula, in addition to breast milk.

This whole experience with Oliva and her mother has been both gut wrenching, and eye opening. Being able to follow Oliva’s referral from the screening at the village level, to the health center, to the hospital, to her ultimate destination (the nutrition rehabilitation center with her mother) sheds light on the costs and treatment measures associated with this extreme level of malnutrition. The idea that mothers of children in the “red” have to weigh the survival of their child against their capacity to pay for treatment is alarming. The Ihangane Project would like to implement some system of work-exchange, where extremely poor mothers staying with their child at the nutrition rehabilitation center could, perhaps, cultivate a plot of hospital land to reduce the costs of treatment. This could provide participant mothers and their children with nutritionally dense vegetables, and, more importantly, it could increase the likelihood that they will follow through with the referral and get their child into the nutrition rehabilitation program.

In addition to village screening observations, I was able to reconvene with the Nyange PLWHA last week to discuss their proposed farming association. Their initial proposal was basically a list of material needs. I tried to open a dialogue with the group to discuss the organizational considerations they needed to make before receiving the funds and beginning this venture. Would they use the same leadership board as their existing association? Did they have a plan for entry into a market for income generation in the future? What were their ideas for a Nyange Farming Association code of ethics? What will be their protocol for accepting new members into the group? This meeting was very helpful in getting the group’s ideas for the sustainability of their proposed project, and laying out the expectations of the Ihangane Project. In exchange for the start-up costs of the farming association, the Ihangane Project would expect donation of a certain quantity of SOSOMA grains for hospital production from the land. I asked the group if I could see the property that they were interested in buying, and they said this would be no problem – it was five minutes away from the health center.

The land is incredible – not only is it near the site of the group’s monthly meetings, it includes a small house for storage of surplus crops and equipment, many small coffee plants started in the shade, access to water (even in the dry season) less than 200 yards away, and it’s on a very gradual slope (a rare trait in arable Rwandan land). The property is quite large, as well – roughly 2 hectares (photo on left). This would provide ample room for diverse crop production (both for the group’s nutrition, and for income generation), and SOSOMA constituent production for the hospital. I am meeting with the group, once again, on July 28th. I intend to bring various stakeholders from the hospital to get their impressions of the potential of this farming association, and the quality of the proposed space.

Theo and I have finished entering the 100 CNW surveys that we were able to gather this summer. Our observation of village screenings, and home-visits by CNWs is ongoing. I’m preparing my soul for a fun-filled week of data analysis next week! Based on this information, I will present my preliminary recommendations to the hospital in two weeks. This will give me some time to gather hospital stakeholder input and feedback for the recommendations in my final report.

Risky Business

Shilpa Gulati - Delhi, India

I feel lucky to have had the chance to meet up weekly with the other Delhi Fellows (Colm, Dave, and Rachana) for a some wonderful conversations about work and life in India. A topic we've reflected on a few times is the idea of risk. The question I find myself thinking about daily, which I ask you to consider, is: what risks do you accept in your everyday life that you ordinarily don’t think twice about?

I believe this question lies at the heart of my project. The valuable public health outcome that PharmaSecure seeks to achieve requires population-wide behavioral change, such that consumers demand accountability for genuine drugs. Counterfeit pharmaceuticals have been produced and distributed here for years, and my interviews have shown that this is common knowledge. But no solution for this problem has existed in the past; I hypothesize that because of this lack of power to change a system fraught with problems, people have come to accept the questionable authenticity of drugs as a risk they have to live with. This has become a fact of life, similar to the way that driving or walking around Delhi during rush hour on any given day is dangerous, simply because most traffic rules are seen as effectively unenforceable.

Fast forward: now that a solution exists (in the form of a free SMS authentication service), a major hurdle to its adoption seems to be getting people to recognize that counterfeit medications are a hazard that they can, and should, actually do something about.

This behavioral change is especially tough because the related danger isn’t always tangible – most often a spurious medication just won’t work, and the patient needs to exchange it for another batch. So despite the fact that fake drugs are widely distributed, I’d bet only a tiny fraction of the population here has heard of anyone having an adverse event attributed to this cause. The problem is just not personal or relevant - yet.

In sum: I’ve been thinking a lot about how to deliver a public health message to better convey the dangers associated with a phenomenon that goes largely ignored. Lately there has been a bit of press on counterfeit raids and changing government pharmaceutical regulations, and I’m always thrilled to hear chemists reference these in our conversations. I hope that there is a way to increase awareness of the topic before a major adverse event brings it to the forefront of the country’s news pages.

A vibrant Bhutanese festival

I am currently busy finishing up my cost benchmarking activities. As I predicted, this second phase of my project is a tad challenging. Most of the comparable peers of the Bhutan companies are unlisted and therefore, do not disclose annual reports. This makes my job difficult in getting enough and relevant data to compare the cost of local companies with that of international companies. Nonetheless, I am still hopeful in generating meaningful information to support my final recommendations. I am in contact with Kresge Director Corey Seeman and he is helping me with the research of comparable companies.

Something very memorable happened to me last week. I had a long conversation with the CEO of Bhutan’s Natural Resources Development Corporation. It was my first time to work closely with a chief executive. It was interesting to hear his thoughts on the local market, business constraints, and potential growth opportunities. He gave me two new project deliverables related to standard pricing and costing. I am looking forward to tackling these new challenges. I am happy to hear that the CEO values my opinion and is looking forward to seeing my project output.

As I mentioned in my last blog post, I am done with the first phase of my project. What better way to celebrate than to immerse oneself in a festival, right? So yes, that is exactly what I did! J

Last week, my co-interns at DHI took three days off from work to visit a city eight hours away from Thimphu to see a festival. I did not join them because I had work. Nevertheless, I went on a day trip to a nearer city to experience a different festival. I went to the Haa district with the lawyer at DHI and interns from UNICEF and the Gross National Happiness Commission. Below are some pictures of the colorful festival.

Beautiful Bhutan: people dressed in traditional clothes + majestic mountains

Opening ceremonies

Traditional dances

Stalls

Delicious buckwheat momos (dumplings filled with vegetables and cheese)

Dairy Farming in Rural India Pt.One

Sorry I’ve been a little infrequent with my posts! I’ve been interviewing farmers in rural Maharashtra and Uttar Pradesh (UP) these past few weeks so I’ve had limited access to the internet.

The first several villages I visited were in a district called Beed, in northern Maharashtra. I accompanied the TechnoServe team to conduct interviews with farmers and processors on dairy marketing. I’ve been happy to have In Spite of the Gods with me on my travels because the book has given me a context with which to digest my experiences in and around India. I had the uncanny experience several times of discussing national initiatives or passing landmarks that I’d suddenly find myself reading about a paragraph or two later when I returned to my book.

The dairy landscape in Maharashtra is very different from the UP. During phase I of the Godhan project, cattle development centers were segregated into four segments based on two criteria – farmer affluence (high, low) and agroclimatic conditions (good, poor). In phase II, because the focus is on creating sustainable business operations, only CDCs with good agroclimatic conditions were selected. The idea was to focus on areas that exhibited strong potential for dairy farming enhancement. The villages in Maharashtra that we visited were characterized by high farmer affluence in contrast to the villages in the UP, which were characterized by low farmer affluence.

On my visits, I adapted the SWOT framework to gain an understanding of each regional dairy ecosystem and used it to begin thinking of strategies to improve milk marketing linkages. Right now, I’m back in the office sketching out a draft for my recommendations and identifying where I have gaps in my information.