If you’ve been long enough in the aid/ development industry you know you can always count on two facts:
- No-one ever agrees on anything; and
- Except everyone agrees that the world needs more “capacity building”.
Imagine a rural clinic somewhere in Africa, the country. There are two nurses in this clinic. That’s it. No doctor. No store-keeper.
Every day they these nurses get there early, but by the time they arrive there is already a long queue outside. They open the place up and start seeing patients. They do what they can for each of them. They often run out of stuff. That is frustrating. Once they are done seeing the patients they need to do the paperwork. More frustration. They clean up. Catch a bus home.
Meanwhile, somewhere far away, in a capital, a group of “experts” are having a meeting. They are frustrated because they hear about constant stock-outs and they are not satisfied with the data that comes out from these clinics.
Invariably they decide the two nurses need more capacity building – to do stock management and to do “better M&E”.
Soon enough, “capacity needs are assessed”, training curricula are prepared and “data collection forms” are designed, along with the training required for their correct use. And since it is 2014, technology must be employed, ideally mobile. Maybe tablets get procured, with some awesome stock management app pre-installed. There is another app for data collection. A generator is budgeted for to charge the tablets that run the apps. Maybe solar panels. More training on how to maintain the generator and the panels.
This is all very convenient. Donors love accurate spending against budgets – there is nothing easier to forecast than trainings. They also love indicators – nothing easier than measuring inputs and processes (# of people trained is a lot better than quality of care, right?).
Also, underpaid people love per-diems which ensures the trainings are well attended. Not always by the right people, but hey, capacity is capacity.
Then there is also the expert factor. Nothing more reassuring than projecting the idea that professionals in the development community are “experts” and of course, nothing like teaching someone how to fish. Sustainability and all that.
I say, bulls**t.
Nurses are health-care providers. That’s what they should do, exclusively. What we should do is take stuff off their plates, rather than expecting them to do more. M&E? Stock management? Outsource or automate.
Here’s one way to do that: Start by defining some outputs related to the provision of health care: Quality of service? Happy patients? Find a way to measure that and provide an incentive based on performance in that area over and above the little that they earn now. Worried there are no resources for that? Well, repurpose those per-diems.
That will align the nurse’s incentives with what it is all about: health care.
Then, minimize their involvement in stock management. Anything that is not required for procedures happening at the clinic? Use a voucher. But make the voucher both virtual and trigger-able. That means that a nurse should be able to simply trigger a voucher whenever one is needed, rather than worrying about managing a stock of vouchers which is as frustrating as managing stocks of commodities.
It also means that she doesn’t have to remember keeping vouchers nearby: whenever she is in front of a patient that needs one, she simply generates the voucher on her phone.
Importantly, it also means the patients don’t lose trust in the system. Because we have a whole communication machine that tells poor women that they will get a free product (Mosquito nets, for example) when they go to a clinic for a consultation. These women make huge efforts to get there: Arrangements for the children. Fare for two-three buses each way. Long queues. At least one day lost. Then they get to see the nurse and the nurse goes: “Ohh, about that free product. We are out of stock. Um… can you come back tomorrow?”.
(Or maybe she doesn’t even see the nurse because the nurse is attending a training about stock management).
Fact is, that woman won’t come back. But what she will do is what every disappointed consumer does: tell her friends that the campaign about the free product is a lie. Tell them that ALL such campaigns are lies.
Giving the nurse the option to generate a virtual voucher will ensure that NEVER will there be anyone leaving the clinic empty-handed. No stock-outs, ever. And no “capacity building” either.
So how about M&E then? Well, the code is generated through a phone, so there you have it – a data-point in a large data-set with a lot of useful meta-data associated. All we need to do is analyze that. In an office. Somewhere where we won’t bother those hard-working nurses.
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