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.

~Welcoming Leadership~

What is Most Effective?

Management or Leadership


In my ‘day job’, I work for a governmental health department. I find myself continually frustrated by the top-down, dictatorial management style that is all too common in the United States. As I sat in traffic today, I pondered where this approach has come from.  Is it a sense of need to ‘control’ the work so as to control the outcome? Is it the sense that funds are scarce, and must be tightly managed?   I began to wonder if it is because managers often do not understand the work of those who they are managing. Most managers are trained to be “managers”, not doctors or medical assistants, or even receptionists. Is this the problem? Maybe…..but then I thought of Stephanie Blount, our first Country Director for The Ihangane Project, and realized that it does not have to be this way!

Stephanie has a Master’s Degree in Global Public Policy. She is not a physician, an agronomist, or business specialist. Yet, in the two short months since she has been in Rwanda, she has shown immeasurable leadership on programs that range from clinical care for HIV-exposed infants to farming cooperatives and business development for women artisans. How has she accomplished this? She has sat with all stakeholders, asked questions, listened to the answers, developed clear expectations and encouraged empowerment of team leaders. Her ability to lead, rather than manage, has created an effective team of thoughtful and motivated partners who feel respected for the expertise they bring.  Steph does not pretend to know more than those who she is leading. Instead, she allows them to educate her.  

Managers who ‘manage’ may believe that they need to keep employees in line to assure productivity. Unfortunately, this stifles innovation, causes poor morale and creates a mediocre product at best. This is true whether the ‘product’ is a service or a physical commodity. This is the old, dusty way of managing. The wonderful news is that we have “breathes of fresh air” young leaders like Steph Blount who can show us the way out of management and into leadership! ~ Wendy


Introducing our Friends @ the Rwandan Economic Development Initiative

We are excited to introduce you to Rwandan Economic Development Initiative (REDI)!  We have been inspired by the impressive work of REDI’s founder, Christine Condo. She is a powerful Rwandan woman who is organizing other women to lift themselves out of poverty.  Christine has taken her extensive experience working with coffee cooperatives through Fair Trade USA (formally Trans Fair USA) to support rural farmers as they strengthen their cooperatives and business strategies.


REDI is a non-profit organization founded in February of 2010 with the main objective of proving strategic trade-related assistance to the small holder coffee farmers. It is engaged in the entire value chain of improving production and building up sustainable market access through improvement of business performance, increasing market linkages and quality production supply.


REDI Mission:

To provide support and technical expertise, institutional and financial capacity building for coffee cooperative members to meet the requirements of the international Fair Trade certification.

REDI Vision:

To improve the living standards of cooperative members and their families through members’ empowerment, education for better community health, and a healthy environment.


REDI Values: Empowerment, Fair Trade, Partnerships,Transparency, Accountability, Sustainability, Efficiency, Participation, and Profitability.


Main Activities of REDI


Negotiating financial support for processing and marketing operations

Sensitizing new cooperatives to obtain Fair Trade certification

Supporting cooperatives to meet all standards requirements

Encouraging and promoting women in the coffee sector

Capacity Building within the cooperative to ensure that all systems are in place

Participating in national and international producer conferences and exhibitions

Producer trainings, exhibitions, and workshops




Core Objectives:


Increase and strengthen the capacity of farmers’ cooperatives with particular attention to those involved in the coffee sector

Optimize the benefits given such organizations to their members and vice versa

Strengthen the capacities and abilities of the executive secretaries, the cooperative management and staff, and the representative bodies of the organizations, improve the overall business performance of farmers, rural business people and their organizations.

Promote the women’s agenda and perspective operating in the sector

Collaborate with other national and international organizations

Improve the socioeconomic welfare of the farmers through:

  •  Fighting against HIV/AIDS & stigmatization of people living with HIV/AIDS
  •  Sanitary education and Family Planning
  •  Adult Literacy
  •  Education for environmental education and literacy



Reflections on World AIDS Day 2011


World AIDS Day is recognized around the globe on December 1st of every year. This year marks 30 years since the beginning of the epidemic. Around the world, there were candlelight vigils, speeches, and red ribbons to honor those who were lost, those who have survived and those who now thrive despite living with this terrible infection.

This year, I had the extreme pleasure of being at University of California, San Francisco’s HIV Update conference. Not only is this a premier conference for yearly updates on the latest research and treatment guidelines, but the conference organizers generously provide The Ihangane Project a place to offer conference attendees access to our Rwandan crafts. It is a wonderful mix of dedicated medical professionals, many of whom have been leading the fight against the HIV epidemic since the beginning. We had the great fortune of listening to Dr. Paul Volberding, interviewed on stage by journalist Hank Plate, share his experiences during the early days in San Francisco. Several things struck me during his talk and documentary presentation. The first was a better understanding of the fear and trauma experienced by the communities hit hardest by the disease. There was uncertainty regarding the source of transmission for health care providers, as well as the terrible trauma of burying loved ones on a weekly basis.  This type of extreme trauma leaves scars that are often not seen initially, but that can shift one’s consciousness for a lifetime. The other important take home point for me was the incredible collaborative response that occurred in San Francisco during this time. Some of the most effective aspects of the response occurred when the medical community (at all levels) responded together with the Gay community that was being affected.  What an important lesson to recognize as we enter this era of rethinking how we organize our health care delivery systems around the world.

Dr. Volberding’s conversation with Hank Plante was followed by an eloquent presentation by Dr. Diane Havlir that was designed to instill optimism regarding the potential future (or end) of this epidemic. Indeed, our armamentarium of research-based approaches to prevention, diagnosis, and treatment of HIV inspires hope that we can dramatically turn the tide in the next decade. Dr. Havlir also emphasized that we MUST take the opportunity now. To wait may mean that we miss our chance at having a substantial impact on the direction of HIV/AIDS.

During this second presentation, my iPhone announced that I had received an email. It was our Rwandan partner, Dr. Ngirabega, who was responding to my recent email question to him: “will the Global Fund announcement to halt the next grant cycle affect Rwanda?”  Sadly, his response at that moment was “Yes. The Global Fund has cancelled the round of grant funding that Rwanda was going to request for 2013. This will affect many activities, and we will have to find other ways to provide services.” What a devastating contrast between the possibilities projected on the screen in front of me via Power Point and Dr. Ngirabega’s email message.

I firmly believe that AIDS Exceptionalism, and the resulting AIDS Fatigue, has played a role in leading us to this day. We founded The Ihangane Project for exactly this reason. We believe that long term success in curbing this epidemic will come from strengthening comprehensive health care infrastructure, addressing health care provider overwhelm, improving overall quality of health care, and erasing the socioeconomic barriers to good health. AIDS is a symptom related to marginalized communities and economic poverty, and cannot be addressed in a silo. That said, the strong push for HIV-specific programs such as PEPFAR and the Global Fund happened in response to the huge disparity between HIV care for the Global North and the Global South. Hundreds of thousands of people would have died due to lack of access to life-saving medications, and thousands of infants would have become perinatally infected with HIV if was not for the disease-specific outreach of these entities. It is true- it is time to pull away from the AIDS Exceptionalism approach that has frustrated so many Global Health experts. But, we cannot eliminate the very fabric that has brought us to this place in the epidemic. We are actually at a point that we can talk about ELIMINATION of HIV transmission to infants born to HIV+ mothers. How can we allow the Global Fund, with its commitments to our global partners, to disintegrate?!

We should learn from the mistakes made here in the United States. Domestic AIDS Fatigue hit as soon as the economy began to decline. In California, for example, 100% of funding for HIV prevention was cut from the State Budget in 2009. Since this time, our small community of Santa Cruz has seen the number of new HIV infections and syphilis cases more than double. Of course, by now, most people know how to prevent HIV. Unfortunately, these extremely marginalized communities no longer hear the message that they are worthy of protection and HIV prevention. Is this the message we will offer for the Global Epidemic as well? 

Learn more about the Global Fund cuts as bluntly described by Stephen Lewis at aidsfreeworld.org  

~ Wendy 

Sharing Our Shoes

~Sharing Our Shoes~

Lessons Learned from Opportunity Collaboration

Last month, I had the opportunity to attend Opportunity Collaboration. This is the third year that I was able to attend, and each year brings new thought-provoking insights. For those of you who do not know about OppColl, it is billed as the un-conference that brings “poverty alleviators” from around the globe to convene in Ixtapa, Mexico for 4 days of intense discussion. Attendees include representatives of social enterprise, family foundations, non-profit organizations, and community-based organizations from around the world. The design of the conference encourages conversation at all turns- during meals, during group sessions, and while swimming in the ocean. As one could imagine, the diversity of perspectives is immense. Although conflict would be understandable, this is the first year that I heard open discussion about these conflicts……hallelujah! We are finally getting somewhere!

Opportunity Collaboration is an eclectic mix of capitalists, environmentalists, socialists, do-gooders, financial bottom-liners, (and everything in between) from resource-limited and resource-rich communities. With this vast array of experiences, it is inevitable that we will see the world with different lenses. This year, I heard a wide array of complaints……here is a sampling of grumblings I heard….

• Funders feeling upset for being asked (or stalked!) for money – Funders are looking for relationships, as well as ways that they can positively impact our global community. They do not want to be reduced to deep pockets. On the other hand, many organizations (especially those coming from resource-limited settings) have broken the bank to get to Opportunity Collaboration and feel a pressure to return home with some sort of financial gain.

• Bullying &/or Intolerance amongst those looking for money- it took two years of being interrupted and criticized by the same person before I finally realized that I was being seen as ‘competition’ for funding. Who knew little ol’ Ihangane could be considered competition?!

• Social enterprises feel that NGOs “get all the money”, and NGOs feel that social enterprises “get all the money”

• Several people from developing countries were surprised and concerned to hear the language being used to describe them by "Global Northerners". For example, phrases such as “poor people” minimize the richness of economically impoverished communities.

• Fears surrounding the potential impact of Impact Investing (I have some fears of this myself!)

• Sense of ‘segregation’ – for example, people from Africa tended to sit with each other. Funders tended to sit with each other, etc. In addition, there was a sense of assumption that people from resource-limited settings must all be Cordes Fellows.

We all bring our unique strengths and issues to the proverbial table, and I know this list seems somewhat petty. But, it seems like it was these kinds of issues and conversations that were undermining the positive aspects of the conference. Not only do they need to be addressed, but we should embrace the opportunity to address them. Our world of Opportunity Collaboration serves as a microcosm for our global community. If we can find ways to bridge our unique perspectives, then imagine the impact we can have! On the other, if this intelligent and pro-active group cannot build these bridges, then I fear for our world. As human beings, we all have our stories. These stories cannot be seen on the surface, and cannot be determined by skin color or socioeconomic background. Striving to better understand what inspires and drives each of us, from all backgrounds and perspectives, will lead to a better world. I have faith that our mini-world of Opportunity Collaboration can lead the way to this enlightened understanding of one another. Then, we can scale our learnings to the rest of the world!  ~ Wendy

Walk A Mile In My Shoes

I’ve been to hell and back on a rocky path of shards
falling along the way
I’ve played in fenced grassy yards
on a sunny day
I know what it’s like to win
I know what it’s like to lose
if you want to go to places I’ve been
walk a mile in my shoes
I’ve been accepted applauded respected by people along the way
I’ve been stepped on kicked beat rained on till I was wet on a cloudy day
sometimes it’s not what you choose
if you don’t believe me
walk a mile in my shoes
I’ve been beat down thrown around
had my days of blues
I’ve been helped praised let down raised
by people with different views
if you want to see what it’s like
to be me
walk a mile in my shoes
just when I had enough times were too rough
sick of bad news
leaving town looking down
lost all I could lose
I noticed
I was walking in your shoes



Gratitude, Generosity, Faith and Red Clay

In rural Rwanda, red clay covers everything. Not just the roads, but the cars, the plants, and all clothing. When driving to the city, men in their suits and women in their finest cover themselves from head to toe in hopes that they can avoid the red film of dust when they arrive at their destination.  They are occasionally successful, but usually have quite a bit of shaking out to do!  I always suggest that visitors bring red colored shoes to hide the stains. One intern asked me how long it would take for the red coloration of his toenails to go away! Ahhhh…..the red clay!  

When Michella, our project lead extraordinaire, gave me a Gillian Welch CD, the song “Red Clay Halo” was an immediate favorite. The song describes the experience of the people in the rural community of Ruli so well!  Although written as a folk song that describes life in rural America, it could have just as easily been written to describe rural life in Rwanda. To me, the song is a reflection of the commonality of rural life everywhere.

Many people ask me what draws me to Rwanda. My response is that I “feel like I am going home”. I’ve often wondered about this sense of familiarity. Then I think of my Gramma Minnie Lee- a tiny 91 year old spitfire who grew up dirt poor in southern New Mexico during the Great Depression.  Stoic, faithful, loving, and stubborn as a mule, she has always been grateful for everything she has and generous to anyone in need. She has very few expectations for herself, and holds a faith that I have always admired.  When prompted, she tells stories of moving from place to place while her father looked for work. She remembers picking cotton until her fingers bled, and being separated from her family after the only home they ever knew burnt to the ground in a fire.  She tells her stories in a matter of fact way without ever instilling a sense of self pity.

When I arrived in Ruli, Rwanda, I was met with a familiar sense of gratitude, generosity, and faith. I am not speaking just of faith as in a particular religion, but of a faith that sustains one through the toughest of times. I am not sure why these traits are such common threads amongst rural folk around the globe. Maybe they are essential to survival, or maybe they come from living close to the earth. Regardless, they fuel the resilience needed to walk through the challenges in life, and unites all of us as human beings.  

“When I pass through the pearly gates, my gown be gold instead, or just a red clay robe, with red clay wings, and a red clay halo for my head!” –Gillian Welch

The best of mankind is a farmer; the best food is fruit.    – Ethiopian Proverb


Rwandan Greetings

Down the road we hear a voice yelling, “Wendy, Wendy”. I turned to see a smiling wide-eyed face running towards us.  Within moments I’m embraced by this stranger, hands grasping my upper arms, pulling me toward them, then gently tapping their left temple to my left temple once, then repeating this gesture to my right temple.  I’m then gently pushed back to an upright position and a hand is extended in front of me. I shake it and say, “Hello”.   My new friend, smiling, giggling and nearly out of breath, embraces Wendy and immediately jumps into a half dozen questions. “How are you?“ How is your family?” “How long will you stay?” Everything was happening so quickly and I stood there thinking, “Wow, I don’t know this person and that was perhaps one of the best greetings I’ve ever gotten.”  


While I initially assumed this response was unique to this individual, I quickly found that nearly everyone welcomed me to Ruli with this exceptional level of warmth and friendship.  And while I have no doubt that Rwandan culture harbors a certain degree of warmth and personal extension, I got the sense that I was privy to a bit more hospitality and a bit more interest than most would experience on their first trip to a rural village in Rwanda. I was reaping the benefit of relationships long established by The Ihangane Project (TIP) founder Wendy Leonard.    




Had I been truly paying attention, my first hint would have been the weight of Wendy’s suitcases – particularly the one that was 70lbs and filled with photos.  Initially I thought, why not medical supplies or clothes or gifts – not to say that we didn’t bring those too. But the photos had a tremendous significance.  Over the month I spent there, Wendy carried photos from her previous trips to Ruli with her everywhere.  And each time she saw a friend, or someone she worked with, or someone she simply met just once, if they were in a photo, she gave them a copy.  The response was overwhelming.  It was clearly a treasured gift and for some it was the only photo that they had of themselves.  Further, it demonstrated the commitment and reliability of TIP in Ruli. It is such a simple and genuine gesture, and it so completely embodies the spirit of TIP.




Trips to Ruli, Rwanda by any participant of TIP, is a shared experience. And not just with those back home with whom we share Picasa or Snapfish links. These are not merely memories in which one reflects on how fortunate they are in their own circumstance. The relationships established during one’s time spent there are real and significant.  The people you meet become your friends, extended family, and part of our own global community.  The health disparities and extreme poverty are challenging but expected. I knew I would be stepping into a community with a lack of resources. I read and researched and prepared myself for this.  What I didn’t know was the strength of the community and their dedication to the projects they have initiated for themselves through TIP.  The Ihangane Project has become part of the community and each participant represents the commitment to not only the projects, but to the individual members of the Ruli community.     ~ by Michella