What Rural Africa Can Teach America About Healthcare

By Wendy Leonard, MD, AAHIVS

This post was first featured on Seeds of Hope on February 28, 2014. Seeds of Hope is the story blog by our dear friends at Skees Family Foundation. You can find it, along with more photos, on their website: Seeds of Hope


Strengthening Health Care Delivery from the Bottom Up

DSCN0076Imagine that you are Sarafina, an HIV+ mother of a daughter who has been treated for moderate malnutrition three times. The health care providers in your rural African village went through the steps required by government protocols at each visit, and say little when you return for the fourth time, as your child continues to be malnourished. This time your daughter is diagnosed with severe malnutrition and hospitalized. Despite being in the hospital for two weeks, she loses her battle to survive. You believe that the health care providers did not act quickly enough, and did not truly care about you or your child. In contrast, the health care workers felt helpless to change the situation and quietly believed that a fast death for this child may not be worse than prolonged suffering from malnutrition and poverty that would ultimately have the same deadly outcome.

Imagine now that you are 9,000 miles away and working as a health care provider in the United States. A scruffy-looking man comes into your office complaining of abdominal pain. He tells you that he drinks a six-pack of beer a day, although you suspect that he drinks more. The next step should be to refer him for treatment, but you have little faith in the resources within your community to address these issues. You decide not to further pursue these topics, and choose instead to focus on his original compliant—his stomach pain. You do an exam, prescribe some pills, and send him on his way. Sadly, this man passed away three months later from complications of alcoholism. Me and DadThe second scenario describes my father’s last few months of life. He was an aeronautic engineer who could sit for hours and draw me diagrams of the latest cool wind tunnel he was designing to test supersonic aircraft. I worshiped him—not only because he was brilliant, but also because he believed that I was bright enough to follow along. Yet, even as a child, I had a sense that he did not understand his own capacity. Although he joked freely, he had a sadness to him and a sense that he was not worthy of self-care. I was so sure that if he could see the amazing being that I saw, he would realize that he had the strength to stop drinking. Unfortunately, my father died before he was able to realize this. I suspect that his physician had felt a similar sense of hopelessness as the health care provider in Africa about his ability to influence the outcome of his patient’s health. This sense of hopelessness in health care occurs around the world every day. Even in the United States, health care providers often feel incapable of treating conditions exacerbated by vulnerability such as substance abuse, mental illness, or lack of access to healthy foods. Governments and global agencies have developed protocols to guide health care providers in these settings, but on-the-ground health workers must believe that they are capable of carrying out efforts that will lead to improved outcomes. Even the most evidence-based health care protocols will fail to reach the desired outcome if those who carry them out do not understand or believe in the interventions.

DSCN0058Now, let’s imagine a different situation. Oliva, an HIV+ mother living in rural Rwanda, gives birth. She is referred to the health center’s Nutrition for HIV-Exposed Infants (NHI) program, where she is personally provided with fortified porridge while she breastfeeds; the same porridge will be available to her six month old infant when complementary foods are introduced into her diet. Oliva is advised of what she can expect from her health care provider over the next 24 months, as well as what will be expected of her. She is encouraged to join the local farming cooperative so she will continue to have access to food after the program ends, and is referred to the artisan skills training program to learn marketable skills. Each month, she brings her baby to a health assessment where her child is evaluated for malnutrition and HIV, and she is offered health education sessions with other HIV+ moms. The nurses are confident, thorough, and engaging. When barriers to quality care are identified at the health center, Oliva and all of the HIV+ mothers in the program are encouraged to contribute their ideas to improving the system of care.

The difference in the quality of care received by Sarafina and Oliva is clear. In Oliva’s case, her health care providers have found a way to bring Ministry of Health protocols to life. They understand the rationale behind the protocols and believe that their actions will lead to improved outcomes despite their limited resources. At The Ihangane Project (TIP), we believe that self-efficacy is an essential component of successful health care delivery. Self-efficacy describes the extent to which a person believes in her/his ability to carry out tasks and achieve goals. Success depends upon front line health care providers’ capacity to provide care and to inspire community members to implement healthy changes in their daily lives. What motivates local health care providers to decipher the intent behind cumbersome health protocols and foster innovation in a setting of extreme resource limitations? This is where The Ihangane Project comes in. We believe that individuals who are living and working in their community are most likely to have thoughtful solutions. We work closely with health care providers and recipients of care to understand the existing health care infrastructure, current resources, and barriers to their ability to fulfill the spirit of Ministry of Health protocols. We consider patience and empathy to be essential qualities needed to foster engagement and long-term sustainability and weave these concepts into our four key strategic concepts as we work with communities: Partnership, Capacity Building, Data Quality, Sustainability. Partnership to Encourage Engagement & Ownership 20131223_121758The foundation of our work is based upon the development of long-term relationships with our partners in the field. One example involves HIV testing for HIV-exposed infants. Health centers are expected to do regular HIV testing at particular intervals, but we found that this was not happening consistently. In order to get context for this issue, we reached out to nurses and HIV+ mothers. Through this process we discovered that some women are fearful of learning the HIV status of their infants. This contributes to delays in testing. To counter this fear, our participants have created a Testing Log that they manage together. Within each group, a participant leader has volunteered to reach out to women when their child is due for testing, and helps to support her through the process. Their motto is “Together, We Can”.     photo7

Capacity Building to Improve Skill Sets and Increase Confidence

Every four months, TIP holds a collaborative NHI program meeting for nurses from our seven partnering health centers. Our staff introduces key concepts that explain the reasoning behind Ministry of Health protocols, and incorporates fun, interactive activities to reinforce the information. For the subsequent three months, we work with the nurses during NHI health assessments to strengthen their skills. Nurses have hopeful reactions: •“By the end of our training session, everyone was trusting that if we correctly intervene on time, we can successfully achieve the elimination of HIV transmission!” •“I was afraid to diagnose malnutrition before- I didn’t know if I was correct, and I was not sure that it would matter. Now I feel very comfortable making the diagnosis!”

Improving Data Quality to Foster Sense of Impact At Ihangane, we love data! We believe that it is an inspiring way to show that efforts have an impact. We utilize a Continuous Quality Improvement model to demonstrate the benefits of accurate, consistent data for training, staff engagement, quality patient care, and program improvements. Our staff attends health assessments, and use an objective checklist to assess skill sets in clinical care, compassionate care, data management, health education, and logistics. After receiving their scores for our initial Observational Check List, the nurses chose three areas to focus efforts to improve. We worked with the nurses to strengthen skill sets and modify their systems of care to reach their goals. For example, Ministry of Health protocols recommend that all HIV-exposed infants with severe malnutrition be tested for HIV regardless of their age. This was not happening in part because of nurses lacked confidence in their ability to diagnose malnutrition. Four months later, here are their exciting results! •150% improvement in nurses’ ability to calculate nutrition scores •100% increase in nurses’ communication of health data to mothers •300% increase in HIV testing for HIV-exposed infants diagnosed with severe malnutrition 2013-01-16_04-22-32_139 Sustainability of Programs & Health Care Recipients: We want Oliva and her daughter to continue to thrive beyond graduation from the NHI program. For this reason, TIP provided the start-up costs to establish a farming cooperative associated with each health center. All HIV+ community members are invited to participate. These cooperatives provide an essential opportunity for ongoing food security and income generation. These farmers work together to grow a combination of crops that can be taken home to their families or taken to the market for sale. Although some crops have been taken to market, the majority of cooperatives have chosen to begin by providing food to their most vulnerable members. TIP’s agronomist provides ongoing training and support to foster success. We are now working with 500 HIV+ farmers via 7 health centers!coop farming In our NHI Program, HIV-exposed infants are provided with fortified porridge for the first 24 months of their lives. This provides short-term relief for families while we are working together to strengthen their long-term food security. To foster sustainability, we are learning how to make our own fortified porridge! The farming cooperatives are donating the soya and maize needed in exchange for their start-up costs, and we are working with experts like Catapult Design to produce a quality and low-cost product. Within three years, we hope to produce enough of the porridge, or sosoma, that the health centers will be able to absorb the cost of the NHI Clinical Program. What can we learn from this experience in the United States? From scarcity comes great opportunity. Rwandese understand this and are open to new ideas that will help them reach their goals. In the United States, we suffer from a health care system that exists in silos, and is often torn between expectations of payer sources and patient needs. Interventions are often linked to funding requirements, and local health systems are strictly regulated to such a degree that ownership and innovation can be discouraged. Even more frustrating, socioeconomic barriers like substance abuse, mental illness, and lack of access to healthy foods can disrupt our ability to have any real impact. The concepts we’ve used in Rwanda are equally relevant to the United States. To truly succeed, we will need to give local communities the flexibility to rethink our response to health. I would challenge local communities in the United States to follow Rwanda’s lead by thinking innovatively about how we can work together to address the health care needs of our community.

Announcing a $5000 Matching Grant!

Thanks to a generous anonymous donor, we are excited to announce a $5000 matching grant.  This means that every dollar you donate will be matched, up to $5000. This generous offer only lasts through December 31st……we appreciate your help!

What your donation brings~

  • $10 – seeds to begin a kitchen garden for an HIV + family 
  • $15- 4 weeks of weaving training for an HIV + mother
  • $25- 1 month supply of nutritional supplements for HIV+ mother and her infant
  • $100- Complete supply of hoes, pitch forks, and shovels to supply newly established farming cooperatives by People Living with HIV/AIDS
  • $500- Cost to expand HIV Clinical Nutrition Program to an additional health center 
  • $750- Cost of land to establish establish a farming cooperative that brings sustainable nutrition and economic development to 60 HIV + families  



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Artisans Speak! Interview with Igihe, National Rwandan Newspaper

IGIHE.com In Rwanda


Gakenke: The women from Ruli have decided to participate in business even though, they met some problems.

Written on 7-08-2012 – Time 09:55′ by Abdou Nyampeta

 (Original Post in Kinyarwanda)

’’Now, we decided to stand up to specify our inventions whether in Rwanda or abroad, in selling for gaining funds and continuing to own respect.’’

Said by Mukankuranga Beata, a member of handcraft cooperative called (COVARU) localized in Ruli sector. She lives in Busoro cell, Ruli sector, Gakenke district, Northern Province, and she spoke in an interview with IGIHE  on Monday, 06th August 2012 at Gikondo where the 15th  international exhibition take a place.

This cooperative is composed by ladies who are determined to fight against the poverty by making handcraft products fabricated in banana leaves and sisals sponsored by the National women council.   

Mukankuranga Betty said it is the first time our cooperative gets here in the international exhibition. She said ’’ We came here to publish our inventions for being known and selling to gain money. Secondly we came to learn how others work in order to get something from them or they get something from us”. Some problems emerged for them are: Delay to go back to their hotels caused by the lack of transportation and a bit matter of stopping for a short while of electricity power in the exposition area.

Press Release~ Join TIP at the International AIDS Conference!



The Ihangane Project Selected as Global Village Participant on Sustainable Health Innovations


Our Marketplace Booth is an Official Global Village Activity for the XIX International AIDS Conference (AIDS 2012)


July 15, 2012, Santa Cruz, California—The Ihangane Project has been selected to participate in the Global Village at the XIX International AIDS Conference (AIDS 2012), which will take place at the Walter E. Washington Convention Center in Washington, D.C. from July 22 – 27, 2012.


The Global Village, open to conference delegates and the general public, aims to intensify the involvement of key stakeholders in the conference and in the global response to AIDS. The Ihangane Project’s selected activity will be a marketplace booth to support business development for a large women’s artisan cooperative in rural Rwanda. In Sub Saharan Africa, lack of access to food due to extreme poverty is a risk factor for HIV. The Ihangane Project supports economic development for those at highest risk of HIV.  Additionally, it was one of only 280 Global Village activities accepted for inclusion in the AIDS 2012 programme out of over 1,000 submissions. Examples of other activities at the Global Village include sessions, forums, oral presentations, awards, networking zones, NGO exhibition booths, marketplace booths, art exhibits, film screenings and performing arts.

The Ihangane Project empowers Rwandan communities to develop integrated approaches to the complex challenges of HIV by supporting community-driven projects that increase access to health care, improve health care quality, and foster long term success through economic development. We envision a world in which preventative health care is the norm, access to health care is considered a basic human right, and short term health gains are not cut short by socioeconomic marginalization.

“We are extremely proud that this activity was chosen to be a part of the AIDS 2012 programme,” said Executive Director, Wendy Leonard. “This conference comes at what has the potential to be an historic moment in the AIDS epidemic. The world’s attention will be on Washington in July to see how all of us – clinicians, scientists, policymakers, and advocates – are able to come together to chart a path forward in the HIV/AIDS epidemic in a way that is integrated with overall improvements in health care delivery systems around the world.”


All are encouraged to attend the Global Village Programme at AIDS 2012. Returning to the U.S. after a 22-year absence, the Conference is expected to be a landmark event. The return to the U.S. is due in large part to years of advocacy to end the nation’s entry restrictions on people living with HIV (PLHIV). This return represents a huge success for human rights and will have a positive impact on the response to HIV and AIDS both at a national and international level.

The theme of AIDS 2012, Turning the Tide Together, has been selected to emphasize how a global and decisive commitment is crucial to change the course of the epidemic now that science is presenting promising results in HIV treatment and biomedical prevention.


More information on the selection process for the International AIDS Conference Global Village Programme is available here.


About AIDS 2012


AIDS 2012 is expected to convene more than 20,000 delegates from more than 200 countries, including more than 2,000 journalists. As the largest gathering of professionals working in the field of HIV, including people living with HIV and other leaders in the HIV response, the biennial International AIDS Conference plays a fundamental role in shaping the global response to HIV and in keeping HIV and AIDS on the international political agenda. www.aids2012.org.


Conference Organization


AIDS 2012 is convened by the International AIDS Society and the conference’s international partners: the Global Network of People Living with HIV (GNP+); the International Council of AIDS Service Organizations (ICASO); the International Community of Women with HIV/AIDS (ICW) and the United Nations Joint Programme on HIV/AIDS (UNAIDS): the Caribbean Vulnerable Communities Coalition (CVC); Sidaction. 


The U.S.-based Black AIDS Institute; the District of Columbia Department of Health (DOH); the HIV Medicine Association (HIVMA) of the Infectious Diseases Society of America (IDSA); the National Institutes of Health (NIH); the Office of National AIDS Policy (ONAP) at the White House; and the U.S. Positive Women’s Network (USPWN) are serving as local partners.  


AIDS 2012: Join the conversation

Get the latest conference updates and share your thoughts and ideas through the Conference Facebook and Twitter.   We are tweeting – @aids2012 – and hope many of you will tweet along with us, using #AIDS2012 to keep the conversation going. Become a fan of AIDS 2012 on Facebook and stay in touch with the latest conference updates and developments. Please visit www.facebook.com/aids2012 to become a fan.


About the IAS 

The International AIDS Society (IAS) is the world’s leading independent association of HIV professionals, with over 16,000 members from more than 196 countries working at all levels of the global response to AIDS. Our members include researchers from all disciplines, clinicians, public health and community practitioners on the frontlines of the epidemic, as well as policy and programme planners. The IAS is the custodian of the biennial International AIDS Conference and lead organizer of the IAS Conference on HIV Pathogenesis, Treatment and Prevention, which will be held in Kuala Lumpur, Malaysia from 30 June– 3 July 2013.   www.iasociety.org | www.ias2013.org 


Wendy Leonard, MD, AAHIVS



AIDS 2012 Media Team

Sian Bowen (Geneva, Switzerland), AIDS 2012 Senior Communications Manager                           

Email: Sian.Bowen@iasociety.org / Tel:  +41 22 710 0864                                                     


Adina Ellis (Washington, D.C.), AIDS 2012 U.S. Communications and Public Affairs Manager

Email:adina.ellis@aids2012.org / Tel: +1 (202) 714-6793


Shawn Jain (Washington, D.C.), AIDS 2012 U.S. Communications & Media Relations Coordinator

Email: shawn.jain@aids2012.org / Tel: +1 (202) 470-3127

TIP Featured on Huffington Post!

Rwanda Now: Healing the Grandchildren of Genocide

Huffington Post story by Suzanne Skees shows what happens when social-change activists from two continents ask what’s needed and then design sustainable solutions together.


Suzanne Skees

To view the original piece, click here




Julienne was just four during the 1994 genocide. She is HIV-positive and works as an artisan for this member-owned women’s collective through The Ihangane Project. Ihangane brought solar lighting to the health clinic where she gave birth safely without transmitting the virus to her 4-month-old son, Kingi; they also provide nutrition supplements for Kingi and gardening and nutrition training for Julienne.

Ruli: Rwanda: Far up in the hills of central Africa in a village called Ruli, families live as do 90% of Rwandans, working the land. To get to Ruli, you have to go off the map, over 2.5 hours of bumpy roads, winding your way northwest of Kigali; and you have to be willing to leap backward in time. Here, people live mired in the past, swinging hoes and hoisting water, centuries behind in infrastructure, yet also suffering the aftereffects of a more recent past — the 1994 Rwandan genocide.

Already challenged by poverty, this land-locked country with a legacy of colonizer-instilled tribal conflict experienced decades of violence that culminated in a gruesome genocide of nearly 1 million Tutsis and Hutus. Another 2 million fled to hellish refugee camps in neighboring countries. Houses burned, livestock died, fields languished, and the economy nosedived. It took years to discern whom to prosecute and forgive, who owned what, and how to live together again. Women were widowed, children orphaned, and an already-high prevalence of HIV skyrocketed among women survivors of rape.




Dr. Wendy Leonard practices family medicine and HIV/AIDS/TB care in California and Rwanda.



U.S. physician Dr. Wendy Leonard decided to take action. She boarded a flight in 2006 as the first physician volunteer for the Clinton Foundation’s HIV clinical mentoring program in Rwanda. They sent her to a remote village called Ruli, and told her to oversee government health initiatives. She found, instead, that she had a lot of listening — and learning — to do.

"It’s really about understanding who it is you’re trying to help," Wendy says. "Every time I’m in Rwanda, I learn more about the people and the culture."

The first week on the job, Wendy’s mentor, Dr. Jean de Dieu Ngirabega, told her, "If you want to help our community, you must first get to know us." He took her to a local wedding, a Catholic/traditional ceremony that carried on all day. Hundreds of guests sat patiently in searing heat on wobbly wooden benches, trading stories and gossip, watching a never-ending procession of neighbors bearing gifts in agaseke, hand-woven lidded baskets borne atop women’s heads filled with rice, beans, seeds — anything the new couple may need to start their life together. The father of the bride presented them with a cow. Wendy knew the hosts were among the poorest of Africa’s poor, and all her theories about charity evaporated in the stifling air as she watched them feed every single person who showed up.

"Everyone gets a Fanta, and everyone gets fed — even if only corn on the cob," she marvels. "No matter how poor you might be, everyone provides for each other." She saw this practice again at the clinical level. For example, surveys revealed that 200 community health volunteers wished for increased nutrition training — not salaries. "It makes sense to try and raise funds to pay even a small stipend," Wendy reflects now, "but just by asking, we discovered that was not their motivation at all."

Then, the doctor from America flipped the model — from top-down development to community-based grassroots–and launched The Ihangane Project in 2008. The name means being patient; its mission is to improve healthcare and economic development. Ihangane is "just facilitating what Rwandans are already doing," Wendy explains. "All our projects are initiated by Rwandans. We always ask, What can we do to strengthen their capacity?"




45-year-old Dr. Avite runs the 168-bed Ruli District Hospital, where he sees patients for accidents on motorbikes and in "unofficial local mines"; cardiovascular and cirrhosis problems. Throughout Rwanda, the population suffers a high rate of alcoholism and PTSD, anxiety, and depressive disorders: Part of the legacy of the genocide. Dr. Avite and his wife have three adopted teenage children.



Ihangane provides technical and financial support for community-created models:

  • artisan sales by microenterprise collective
  • cross-sector collaborations
  • solar power initiative
  • maternal and infant care
  • rural hospital improvements
  • local healthcare linkages
  • nutrition, gardening, and pig-farming projects


Ihangane aims for self-sustaining solutions that soon will graduate from donor inputs. "For example," explains Wendy, "for HIV-exposed infants in Ruli at high risk for malnutrition, we provide sosoma, a porridge of soya, sorghum, and maize fortified with vitamins and minerals. This supports one of the many truly beautiful protocols from the government [Ministry of Health]; but the funding is not there. So, we are building farming collectives to grow component grains. We’ll grow locally and sell to Ruli hospital at a much more affordable cost. The farmers also can sell their surplus crops for an additional profit."

The day we visit, rain falls softly at the top of one of Rwanda’s "thousand hills," and the red soil looks rich. However, this land has been stripped by one-crop farming and poisoned by toxic pesticides. Many farming families have been reduced to a diet of rice and maize. Banana trees carpet the hills, yet only a few still produce fruit — often used to make beer. Now, Ruli residents have asked for diversified garden inputs and training on how to grow high-yield crops and cook nutritious meals.



American MBA students learning on the job: four University of Michigan interns are spending four weeks in Ruli, testing an SMS-texting system of communications between district healthcare centers and the main hospital to improve patient care. They sleep in the local church. They’ve been amazed by the beauty of the land and the kindness of people here, and report a fondness for Rwandan cuisine and the local beer.



The main hospital has electricity; however, several of the eight outlying health centers previously had no power. Women who went into labor at night had to give birth in the dark. "Now we have solar lighting in eight health centers," Isaac, an Ihangane volunteer and lab technician, tells us. "We can light the maternity ward 24 hours a day, power a microscope and a radio phone used to call for an ambulance if needed." Partnering with Catapult Design, "the Ihangane solar project is just on time," Isaac smiles.

Gratien, another intern, bicycles from his father’s nearby farm to help the Ruli Women’s Cooperative launch a pig farming enterprise in nearby Nyange. Livestock farming will diversify their income and allow them to increase their membership. "Pigs are simple," Gratien laughs. "They are not complicated. They need only a small pen. They eat slop." Ihangane will raise funds for initial building and livestock materials, and then Ruli will take it from there.



A few of the thirty artisans of the Ihangane Women’s Association. Each member pays $25 to join. They put 10 percent of profits into savings, create group loans for one another, and divide the remaining 90 percent among members. Founding president Madeleine (far right) taught the members to dry sisal fibers, dye them, and weave into traditional wedding baskets. They also produce cards, pictures, and jewelry.



"Sometimes when we want so badly to help, we just come in and try to help," Wendy muses. "If we come in to learn who they are first, sometimes we find amazingly rich resources already in the community." For the artisans, Ihangane provided startup materials, and will provide follow-up training through local fair-trade expert from Rwanda Economic Development Initiative (REDI).

For the grandchildren of the genocide like baby Kingi, across Rwanda’s 15,000 rural villages, the future looks brighter — maybe. Currently, 12 million residents crowd into a country the size of Maryland; 43 percent are under age 15, and 46 percent of children under five suffer chronic malnourishment.

However, Rwanda promotes equality for women (more than half their members of Parliament); public education for all (now through 9th grade, soon to extend through 12th grade); economic development (GDP rose steadily 6 percent per year during the global economic recession) through enterprise (Rwanda aims to become the business/IT hub of Africa; currently it takes just six hours to set up a new business here). President Paul Kagame says, "Poverty contributed to the genocide. If that past is never to happen again, we must grow our economy." The way forward yokes education and enterprise–"enlightened self-interest"–as Head of Strategy and Policy Serge Kamuhindu puts it. "What we want is a second chance for everyone born in this country," he told us at the Hôtel des Mille Collines (Hotel Rwanda) last week.




The future belongs to growing leaders across Rwanda.



A second chance — and a healthy start — is what Ihangane wants for Kingi, and all the youth who will build a prosperous, healthy future rooted in the best of Rwandan culture.