Saturday, December 17, 2011

Managing Help

"Condom Ball"= inflated condom sewn inside cloth patches: surprisingly robust football
When I heard last week that a delegation of the senior managers from the Amhara Health District were going to be at the hospital I asked our local medical director if I could meet  them to discuss the “human resources” problems we were having in Maternity.  I was told there was a meeting at 10 the next morning I could come to, but when I went it had been deferred to later in the day. I waited for a call but nothing happened for the rest of the day or for the first part of the next morning so I went looking for them, because I knew they would be heading back to Bahar Dar later, and I didn’t want to let them get away without hearing what I wanted to say to them.  I gate crashed a meeting they were having with the supplies and store managers, introduced myself and they agreed to meet me at 11. And they arrived in Maternity at 12.30 just as I was starting to think maybe they had got away after all!

I told them that in the year before volunteers like myself and Myrte started coming to Motta – about 18 months ago – there had been less than 700 births at Motta, which was staffed by 8 midwives. Since then two midwives had left and not been replaced, but birth numbers had increased to over a 1000. Were the two midwives not replaced because now there were two “Farenji” working there for free? Of the remaining six, three were “Degree” midwives and three were “Diploma” midwives and of the senior “Degree” midwives, two were away getting training most of the time and the third had been formally warned about his attitude to work and was today, as usual, not at work though he was supposed to be – I told the bureaucrats I wanted him replaced as he had already had his three formal warnings and nothing had changed. Of the three junior “Diploma” midwives one, an excellent guy, had gone to work in a private clinic in Bahar Dar for triple the pay he got at Motta. Why would he return to work really hard in Motta for half the pay of the lazy one? He was a real loss but I had every sympathy for him. Of the remaining two diploma midwives, one was away again training somewhere and the last remaining midwife I had just sent home as she had worked alone – except for students and myrte and myself – all the previous day and the night just gone – she was exhausted. There were no employees  left, so Myrte and I were once again the only trained staff in the unit. What I wanted from the bureaucrats was a commitment to replace the lazy one and to bring staffing levels back to eight. Then, I said , midwives would still be able to attend training and education courses, but this would  have to be done in a co-ordinated way, and staffing levels could always  be maintained at a safe level without individuals becoming exhausted and disenchanted with the local system.

Lots of agitated talking in Amharic followed, and the leader of the delegation thanked me and expressed his concern about what had been happening and apologized. He promised “action” and seemed genuinely concened, but then he said something that worried me, not about replacing the lazy one or finding more midwives but about punishing the ones who had taken unauthorized time off, and about the local managers having the authority to deal with these problems – it sounded as if they were washing their hands of the problem. 
Selling corn
Now I am afraid all Ive done is make things worse for the midwives who are already here, who possibly regarded the ability to go and get more training as a benefit that made staying here bearable. The reality is that Motta is a backwater, and most of the  doctors midwives and other staff are here because  by working in such  a place they work off their free education sooner than they would if they stayed working in the bigger centers. And once they’ve worked it off they can go wherever they like and work for whoever they like – all the doctors here cant wait to get back to Addis and do further training and “get rich” as one said gleefully to me a while back.. Its disappointing to realize they are preoccupied with their own advancement and aren’t  all that interested in the terrible problems of rural Ethiopia, but then again they are just ordinary people, and have the same desires, strengths and weaknesses as all  of us.

So  they know they can get rich  by working in “Private “ clinics and for overseas Aid organizations -  NGO’s – which, thoughtlessly and needlessly often pay  rates which are as much as 5 and 10 times higher than what local medical personnel would otherwise get. This clearly, in the context of  such extreme poverty and dire need, is obscene and it completely distorts demand and supply, and undermines the ability of the public system to function except with the “left overs” that the NGO’s and Aid organizations didn’t want. The NGO’s of course then have the problem of staff who see themselves as being on the “Gravy Train” of western aid - I have heard that not far from here, in a hospital funded by overseas donations to a famous charity, massively overpaid local specialists with 4WD vehicles, Laptops and Mobile Phones supplied are working hours and at a pace that suits, and doing very well for themselves thank you very much. Its easy to imagine how donors in the west would respond if they knew how their funds were being squandered on a gravy train for already well off doctors. Meanwhile in the understaffed public hospital a few minutes away, a hospital from which those on the Gravy Train were lured, women are literally dying in the corridors. And this is happening right now.

This aspect of the way in which “Aid” can undermine and corrupt an indigenous system struggling to take root, and create a cargo cult mentality and dependence rather than self reliance and independence is really the very opposite of what aid should be about.  In that context “Aid” is more like a salve to a guilty conscience for the west and a nice little earner for a privileged few in the third world, with the added benefit of some direct assistance to a few of the underprivileged. In fact “aid” should be about enabling those needing it to take charge and deal with their problems themselves. This is what we are trying to do in Motta, and I think progress is being made but it’s a long slow process and there may well be setbacks on occasion. If the “action” that the managers here take is the easy option of punishing individuals and not remedying the underlying staffing problems, my recent efforts will have to be counted as a blunder and we will have to think of a better approach and try again.

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