[July 27, 2010]

Two weeks ago, we had finished with the first round of our microenterprise training – teaching six different concepts selected by Angela from the Barefoot MBA repertoire. With this foundation of business principles, we felt that the program could move forward to teach the implementation of those concepts.

As such, today marked the completion of our second round of training. Again, we followed a similar format, with the HIV Support Groups and Village AIDS Committees separated into four different morning or afternoon sessions. This time, the program consisted of:

• Oral review of Session 1
• Lesson: Developing an Action Plan
• Lesson: Using 6 Steps to Create a Budget
• Lesson: Learning How to Keep a Cash Flow Ledger

For the new lessons, we taught the group leaders the steps to making an action plan and budget. We concluded those lessons by asking each group to use the process (as well as provided examples on a take-home review sheet) to draft both an action plan and budget for themselves. We also distributed accounting books that they could use to keep track of their finances. For this lesson on using a cash flow ledger, we showed them an example ledger, and had them set up their books according to our organization, with separate columns for Date, Description, Money In, Money Out, and Balance.

Although I felt a similar sense of detachment from the group training (due to my continued deficiency in Chichewa), I was actually able to offer some help this time! When the time came to distribute the Accounting Books and walk through the organization of the cash flow ledger, I walked around the room checking to see if the participants were writing down the correct headings. When I noticed confused faces and blank stares from individuals, I did my best to verbalize the process. Sometimes, (I think) I was successful in communicating my message. Other times, I was able to call on the help of participants with greater English proficiency and explain the process to them. It must have been an entertaining site to see… *Ask me for a video to see my teaching in action! (Thanks to videographer Casey Nesbit!)

On her next visits to each of the groups, Angela will follow-up on the drafting of the action plans, budgets, and ensure that they are updating their accounting books. Since application of these business skills will take time to monitor, we plan to keep in touch with Angela for reports on the HIV Support Groups’ and VACs’ progress.

Even so, the question certainly arises: What next?

We have planned to leave all of the materials in a handy binder for Angela to keep. These materials include: all of the individualized lesson plans from Barefoot MBA (such that Angela can pick and choose which concepts she would like to review and teach in subsequent meetings/trainings), the lesson plans for creating an Action Plan, Budget, and Cash Flow Ledger along with a print-out of the PowerPoint slides that highlighted main points and was displayed on a projector during the training sessions, a copy of the review sheet that covered all concepts taught in the first and second parts of training and was sent home with each group, and extra accounting books.

We have discussed with Angela the immediate future of the program, and we agreed for her to conduct follow-up with each group, reporting back to us via e-mail about business progress. We’re certainly eager to see how the Support Groups and VACs will apply their acquisition of new business knowledge, and hope that we have broken ground for this new program for microenterprise training at St. Gabriel’s Hospital.

 [July 20, 2010]

We’ve taken a break with our microenterprise training to bring Sally centrifuge (the hand-powered centrifuge testing for hematocrit as a measure of anemia) and the NoHands portable handwashing device to St. Gabriel’s mobile clinic.

As a handy reference:

• Mobile clinic – this service provided by St. Gabriel’s nurses and hospital personnel specifically brings Antenatal and Pediatric care to patients in surrounding villages. A car loaded up with staff and supplies heads out to a village one or two times a month, where eager patients wait for check-ups, testing, immunizations, and nurse consultations. Although there are no visits from clinical officers and patients must make a trip to the hospital for serious problems or further lab testing, this outreach program brings healthcare to the frontline convenience of the patients.
• Sally centrifuge – a BTB technology for a hand-powered centrifuge used to test hematocrit levels and serve as a diagnostic test for anemia. This technology was developed by Lila and Lauren, and is the same one that I mentioned in a previous post.
• NoHands portable handwashing device – another BTB technology for providing running water in the field. A plastic water carrier is capped with a spigot attached to a string that connects to a levered foot pedal. As the foot pedal is pressed, the string pulls on the spigot and water descends from the opening. The water carrier sits atop a sturdy construction tripod and can be adjusted to a desired height. This technology was developed by a Rice senior design team during the 2009-2010 school year.

Given the limited car space and eagerness of other volunteers to witness the mobile clinic in action, we were lucky enough to accompany St. Gabriel’s on two different outings – both of which were quite the experience!

Despite having gone out into the field to visit the HIV Support Groups, this mobile clinic outing was a chance to see healthcare being concretely delivered to patients. The first location was more bare: there was only one covered room that housed the nurse’s consultation. For taking vitals as well as testing, the hospital staff was situated outside, working from the bed of the pickup truck as well as off a few feet away, from the ground. This set-up was a serious concern, as our hematocrit testing was one of the diagnostics being conducted for pregnant mothers. With the supplies simply spread out (albeit within carrying containers and in sterile packages) on the dirt, Gift sat on a crate as patients lined up and kneeled down to greet him at ground-level. He recorded their information and then proceeded to take a finger-prick for blood samples. When we had enough samples for a complete run of the centrifuge, we spun down 30 capillary tubes within ten minutes of hand pumping and were able to read the results from an accompanying reader card.

We were relieved to have brought the handwashing device, as we were able to send patients to the water stand to wash up with soap prior to the finger prick. Watching the mothers use the handwashing device, we noticed how intuitive the device was. Of course, immediately after setting up, we all had a go with the handwashing device – under the curious stares of the Malawian mothers. While our demonstration probably helped them understand more of what the mysterious technology was, there still seemed to be no difficulties with usage of the device by locals.

The second site had many more antenatal mothers arrive at the clinic. There was even a long line ready and waiting as we pulled up in the hospital car. Fortunately, this clinic was housed at a community center, and we were able to set up both testing and nurse consultation stations indoors. The process followed suit – with workers first gathering the patients’ body weight and vitals, sending them for testing with me, Jasper, and Gift, and then directing them to a visit with a nurse.

Both outings were incredibly busy, time-consuming, and left me completely worn out on the drive back to the hospital. Stationed with Sally centrifuge, we saw and tested patient after patient, with the only break between mothers being the ten minutes for hand pumping of the centrifuge. Nevertheless, I was extremely pleased to see both technologies that we brought being used to their potential. St. Gabriel’s mobile clinic is such an inspiring program, and I’m glad we were able to contribute our BTB technologies.

[July 13, 2010]

Translating all of the lesson plans has proven to be a long and cumbersome process. As my fingers trip over “ndi-” prefixes and Word Auto Spell-Check continues to change “zonse” to “zones,” I’m finding out how challenging a seemingly simple task can be. Nevertheless, Angela and I have gone a long way with the lessons, managing to translate every written word, including phrases like “Lesson” and “Learning Objective,” into Chichewa so that the entire teaching material can be in the Malawian language – with minimal error!

If only the translation process could have taught me more Chichewa…

My struggle with the complex and mysterious language has unfortunately expanded to our training sessions. Speaking of which, I am proud to announce that Angela, Jasper, and I have finished all four meetings of the first part of our microenterprise training program! In the past two days, we held four separate sessions for the 43 different Support Groups and VACs that we had aimed to teach from the Kalolo and Mavwere districts (the districts in the catchment area of St. Gabriel’s). We invited three leaders from each group – the Chairperson, Secretary, and Treasurer – to come to the trainings, and had approximately 75% successful attendance. *Note: We were able to contact the groups through the SMS Frontline system that Josh Nesbit (another Nesbit family member!) implemented at St. Gabriel’s for communication with its widespread base of community healthcare workers. You should Google SMS Frontline for more info about this incredible technology!

Witnessing the trainings was an amazing feeling, despite my struggles with comprehending Chichewa. It was difficult to tell, as an outsider, how the Support Group and VAC members were receiving the information. All throughout the trainings, I kept trying to read their nonverbal behaviors and assess the intake of information by seeing who was responding to questions, how long their response was, what their response was (if it was repeating the example story, etc.), and even (as much as I could) trying to read their attitudes. Only by discussing with Angela after each session did I find out that some students were very interested in the concepts and were indeed introduced to new ways of thinking about business principles. Others, though, seemed to be familiar with the material but have had trouble implementing the knowledge.

As I mentioned, the Malawian learning style seemed to work best through repetition. When talking to Angela, she explained to me how she tried to describe the concept in different ways and stress repetition of the example stories. Yes, repetition.

Of course, the flow of the discussions varied according to group dynamics. In the first session, we had hoped for more participation – but whether it was because of shy members or just the uncertainty of the first run-through, few students seemed to come forth with answers. A later session showed marked improvement, and we considered it a result of different leaders in the group that offered their opinions when they saw there was a shortage.

Regardless, the first part of our program was really insightful into Malawian education. We will certainly be using our experiences in these past two days to adapt the second portion of our program to be held in two weeks.

[July 9, 2010]

With Barefoot MBA under our belts, we can still incorporate some of our original lesson plans. Specifically, we’ll be teaching the process of drafting an Action Plan, creating a Budget, and the skills of Accounting. We have decided that this is still critical knowledge that the students can benefit from.

Combining Malawi-inspired Barefoot lessons on business principles and our lessons on microenterprise implementation, we’re set to teach.

Well, almost. Now comes the challenge of translating all of the course materials into Chichewa (the Malawian language). As Jasper and I discovered from a special American Independence Day gathering at the US Ambassador’s Residence in Malawi, there are many other people trying to tackle the same project of teaching microenterprise skills to Support Group members. We want these materials to have widespread accessibility, especially since we know that they can be useful to so many other people here in Malawi.

But even more than accessibility is sustainability. We will be leaving microenterprise training in the hands of the HIV Support Groups’ and VACs’ facilitator Angela, so we want her to take ownership of the program from the get-go. Luckily, the concept of individualized and varied Barefoot lessons allows her to do just that – pick and choose the business principles that she would like to teach and when. However, the issue of sustainability will also involve finding a way to measure the students’ progress with their businesses. As a result, I think a monthly “progress report” required from every Support Group and Village AIDS Committee would be incredibly useful. We cannot just evaluate based on understanding of the importance of Saving or imitation of a Cash Flow Ledger. We need to make sure the students are using these skills and achieving measurable results! With Angela’s role as a facilitator who spends her weeks visiting the groups out in the field, adopting such a reporting system would be easy to implement.

So that is our plan for this ever-adapting microenterprise program. Time to do some transcribing!

[July 6, 2010]

There really is no better way to learn than to experience. I cannot stress how much visiting the field, interacting with the HIV Support Groups and Community Healthcare Workers, and conversing with Malawians and those familiar with Malawian customs has opened my eyes to the application of our microenterprise training project. While I have needed the time to gain perspective, see the big picture and also investigate the finer details, I’ve actually discovered so much more to the process of learning.

Take Malawian learning style. By fate and good fortune, we had the opportunity to discuss our project (just in the nick of time, too!) with Casey Nesbit, mother of our friend and previous BTB student intern Elizabeth Nesbit. Casey shared with us her own experiences training nurses at St. Gabriel’s on the basics of physical therapy. Last summer, she held 25 1-hour sessions, in which each session covered one basic concept of physical therapy. She showed us her teaching materials and even a video clip of her training session, in which Casey would introduce new material with great repetition and then require her students to repeat and imitate the task. Casey found it effective to show both the correct and incorrect methods, using contrast to reinforce the concepts of what was proper physical therapy. Moreover, what Casey shared was that Malawians are very didactic learners. They are accustomed to lecture-style learning where the teacher presents new material and they repeat the concept verbatim.

This discovery initially posed a conundrum. We had left Houston with a comprehensive educational course based on a discussion framework. There was little straight-lecture, but rather the objective to create ideas through the formation of trust groups and discussion-based learning. Now, here we are, with real students who are used to a formal learning style. Will we be able to reach them through that same discussion framework? Can we still impart new concepts simply through discussion of shared experiences?

Out of fear that our original program would not achieve the desired effectiveness – and perhaps that our students would not be as forthcoming with their opinions, we have decided to incorporate more formal instruction into our lesson plans. Thinking back on the entire design process from the spring, we traced our steps back to a suggestion made by BTB staff and mentor Grace Wichmann, who recommended we look at a resource called Barefoot MBA. Barefoot MBA has established lesson plans for a variety of business topics, divided into modules of People, Businesses, and Markets. Each lesson plan follows the same structure: concept, background story, a comparison of two stories (in which one is “right” business behavior and one is “wrong” business behavior), guided questions, and finally the overarching lesson. According to Casey, the questions are even ordered according to a sequence appropriate to teaching – going from understanding information to application of knowledge. We have found that the beauty of Barefoot is that the concepts are so fundamental to business; they can be applied anywhere with just a few tweaks of the example stories such that the lessons can be culturally and economically relevant to different countries.

It’s definitely hard to backtrack on all of the hard work that went into our original course. However, being here in Malawi where our students are no longer just an idealized demography, Jasper and I are thinking that there is tremendous wisdom in the Barefoot lessons. Even so, we know that we can stay true to our initial discussion framework, since the simple concept of bringing together these Support Group members and Community Healthcare Workers can inspire trust-building and group motivation.

[June 29, 2010]

Today was our second (and final) trip to the field to see the HIV Support Groups. We were able to visit three groups from the middle tier – groups that are relatively stable but not well-organized with their business management practices.

The first was named Mapuyu, and they were, like Geni, the most inspiring for the day. Every Tuesday, the members meet and spend time making HIV pins (beaded patterns attached to safety pins that they sell to other HIV/AIDS patients as a way to unite and raise awareness), practicing songs and drama, and distributing local medicine. When I first heard the term “local medicine,” I wasn’t sure what that meant. The first thought that came to mind was, “Antiretrovirals? Are they being produced locally?” Luckily, I didn’t have to stay confused for long because soon enough, one representative of the support group announced that she wanted to show us their medical supplies in the room behind us. When we entered, what I found was amazing. Spread out neatly on a blanket on the ground was a whole display of 14 types of plant leaves, stems, and flowers. As one woman proceeded to describe each herbal remedy and how it was used, I just kept thinking about the effectiveness. We’ve all heard of alternative medicine and its legends – maybe even its miracles, but what concerned me was the potential reliance of HIV+ patients on these remedies. Is it enough? Will adopting local medicines prevent them from one day seeking ARVs? Regardless of the actual usage, it turned out that Mapuyu Support Group was selling these medicines as a business. Producing these 14 types of herbs was their income-generating activity. And if it was a successful venture, then it would be of benefit. The problem now was sustaining this business. They have limited supplies to produce the medicine and are limited by transportation costs to reach new patients/consumers. They need some business management help.

The second visit was to a village called Mferamanyzi. They were also a “middle-tiered” group, who had recently suffered a setback that probably drove them to unstable, “bottom-tier” waters. 5 pigs and 13 piglets died recently, with unknown reasons, leaving the few active members of the group disheartened. As opposed to other support groups that seemed to have a lively spirit among their members, only three members were present to meet us and the mood was dreary. From asking questions, we found that there was, in general, low participation among members due to laziness. It seemed that the leaders were not motivating their members well enough, and without this foundation of teamwork, the recent piggery devastation only worsened the situation. Hearing this, I felt inspired to incorporate training in leadership in our program, though I’m not sure how much time we will have. It seems like such an important message to relay to these support groups though, that maybe it will need to be an entire underlying theme to our program.

The final visit was to Lonjezo, a village that had recently received government assistance to build an irrigation system for their crops. Unfortunately, they had also experienced a recent setback in the form of ill-growing maize, and had not saved properly to deal with such emergency times. It sounded like this support group could certainly benefit from our Savings lesson, which we had already developed over the spring semester. If anything, this visit provided verification that we were on the right track with our program components.

[June 23, 2010]

Earlier this week marked the first visit to the field – to actually meet members of 3 different support groups and understand their environments. It’s one thing to talk about owning a pig, and another to step foot in a piggery with this gigantic hog digging into the dirt in the corner!

In each of the villages, all of the community members were so kind in their welcoming. They provided us with chairs and benches, sitting around us to catch our every word. (Well, hearing us through Angela, the facilitator of the Support Groups who deserves a tremendous “Thank You” for acting as our translator and interpreter.)

In the first village (named Geni), after an initial conversation where group leaders provided us with some background on their community and answered some questions regarding their current business practices, the group members then led us on a tour through the village. We saw gardens of vegetables, fields of tree saplings, and collections of animals like fowls and pigs that could be sold. We spent the most time that day at this first village, trying to take in everything and ask as many questions as we could. I could sense so much happiness and excitement from our visit. As we walked, a group of women followed us and sang beautiful songs. Children gathered around us, smiling and waving frantically (and also yelling “Mazungu,” which we have gotten a lot). And as we departed with words of our intentions to help with training in business management, they even gave us a round of applause. The community members were so respectful and appreciative, and all I could think about was how honored I was to get to work with them.

The subsequent village visits to groups named Tidziwane and Namitete were a little more condensed, but followed with similar events. We had accidentally spent too long at the first village and were only able to talk a little with the other group members and take a short tour through their gardens and fields. Nevertheless, I felt more confident the second and third times around, as I knew what questions to ask and concerns to address with each meeting.

These three support groups are, according to Angela, the best of them all. They’re the most stable and organized in terms of group management and using their St. Gabriel’s starter packs. However, I noticed that even among the three, there were still very different levels of progress. Two wanted to draft an action plan. One had a budget to show us – though it was hard to follow and did not seem to track expenses consistently.

Next week, we’ll have the opportunity to make another trip to the field and visit support groups from the middle and bottom tiers (groups that are not as stable and possibly have had starter packs revoked from misuse). With the variation across the groups from just today’s visit, I have no idea what to expect. All I can hope for now is that they are operating within the realm of our help – and our potential training lessons wouldn’t be so out of context or inconsistent with their current activities. Until next week!

[June 17, 2010]

With permission from the Matron, we took BTB’s hand-held centrifuge device, developed by Lila Kerr and Lauren Theis, to the Antenatal ward this morning. We met with Gift, the worker who takes blood samples from pregnant women and tests for HIV, anemia, and syphilis (although they are currently out of the syphilis reagent and cannot conduct that test at the moment). After explaining how our device worked, Gift appeared very excited to try out the technology. We took this as a great sign, and immediately got to work.

He called in patients one at a time, and we decided to start easy – with 5 samples for the first run, then 10, and then 15. Knowing that Sally is accurate to 10%, we cautioned Gift that the device was not to be used for diagnostic purposes, and simply to get feedback. Nevertheless, as we started to fill the combs, pump the spinner, and make the readings, I could see the anticipation grow and the desire to give patient recommendation for the device.

A few notes on the centrifuge: I think a better numbering system could be put in place. Aside from the fact that the Sharpie-marked numbers 1-5 were easily rubbed off when cleaning the spinner after use with alcohol, as we began to fill the combs with more and more samples, we had to mentally keep track of which capillary tube belonged to which patient. We decided to give subclassifications A,B,C, etc. to the multiple samples in the 1^st comb, then 2^nd comb, and so on, but it would be nice if such a system were already (permanently) marked. Another suggestion was to change the color of the bottom plate. Red looks nice, but makes it difficult to see any potential blood spills and splatters during the cleanup process.

Tomorrow will be another visit to the Pediatric ward to test out Sally. As for now, I’m happy with the feedback from this first trial and am excited that we’ve already gained some ground on our projects.

[June 15, 2010]

I have never been the best at picking up new languages. Even after one week and multiple introductions, I still become flustered when Sister Annie, Sister Justa (the hospital chaplain), or one of the nurses asks me in Chichewa, “Muli bwanji? (How are you?).” I respond with a timid “Dili brino, calle inu? (I’m fine, and you?)” and wait for their similar answer of “Ndiri bwino.” The language barrier presents a challenge and I’m sure that my Chichewan-struggles are providing the native Malawians here with a source of entertainment. But I gladly play along, happy to see that I have brought some laughter to their busy day.

It has already been one week since we arrived in Namitete! Time seems to fly by. This afternoon, Jasper, Liz, Yiwen, and I met with Matron Kamera (our mentor and head nurse of St. Gabriel’s) to once again introduce ourselves and our technologies. Loaded with our goodies in hand, we briefly took her through each technology as she directed us to the appropriate wards to implement them and acquire feedback.

In the middle of it all, I suddenly felt worried that we were bombarding her with all of our exciting projects. Sure, it seemed like a reasonable list throughout our packing and planning process, but perhaps the combination of me and Jasper’s projects and technologies with those of Liz and Yiwen’s may have been overwhelming. I’m sure we were all thinking the same thing: the Matron is extremely busy, so this might be our only chance to sit down with her to discuss everything! However, looking back on it now, the four of us probably should have set some technologies aside, like the demos and donations, or grouped our technologies into a more manageable batch.

Nevertheless, this meeting gave us the green light to bring our technologies into the wards. More importantly, it gave Jasper and me some new developments in our Microenterprise Program.

Since the first assignment in BIOE260, our project has gone through a few transformations. What began as a microenterprise education course designed for community health workers selling PUR packets and ended as a seminar program establishing trust groups amongst the workers, our general focus has always been microenterprise, but with varying contexts. Well, our context is shifting again, and the newest revelation assigned by Matron Kamera is now to help teach microenterprise skills to promising HIV/AIDS support groups. As part of their partnership with St. Gabriel’s, these groups are given community starter packs to help families establish businesses. These starter packs may include seeds, fertilizer, tools, or even goats. The problem is that most groups do not understand how to think in the long-term – save, budget, create a business plan. This is where we would come in.

Apparently, there has been one successful community that has really grasped the idea of the starter pack. If we can model their success into an appropriate business plan for other communities, I think we can achieve the goal of implementing microenterprise in the villages around St. Gabriel’s and really help establish a steady source of income for the people in the support groups.

Ah, the importance of being adaptable! Just like we were advised throughout the semester and reminded again at orientation, you never know what will happen in the field. Luckily, we’ve had some experience with being flexible in our project, and I’m sure we’ll be able to modify our microenterprise lesson plans according to their needs. I’m actually really excited by this turn of events, knowing that this is what happens in real life!