1

The Dian Fossey Gorilla Fund International (DFGFI)

Comprehensive Community Health Initiatives and Programs (CCHIPS)

In Collaboration with the Ministry of Health, Government of Rwanda

6 Month Progress Report

Report Prepared By:

Laura Clauson

Director, DFGFI-CCHIPS

2

Contents

Summary 1

I. Data Bisate Health Data 3

Bisate Financial Data 4

II. Infrastructure Water 5

Sanitation (Toilets) 6

Sanitation (Medical Waste) 7

Sanitation (Bio Gas) 8

Power 9

Building Upgrades 10

Construction 11

III. Human Capacity Building Staff Salaries & Caisse Sociale 12

Medical Volunteers Information 13

Non-Medical Volunteers Information 14

Health Center Staff 15

Health Animators 16

Improved Medical Service 17

IV. Community Participation 18

V. Financials 19

VI. Attachments

January — April 2007 Health Records (accurate) 1

January — December 2006 Health Data (suspect) 2

October 2006 — April 2007 Financials 3

January 2006 — September 2006 Financials 4

MIT Water Study Proposal 5

Water: Technical, economical and social feasibility study 6

Training Guide: Management of the Rainwater Supply System 7

4 Zone Waste System Design 8

4 Zone Waste System Costing (does not include training cost) 9

SELF Preliminary Electrical Load Evaluation & Costing 10

A General Assessment of Mental Health Information 11

By Dr. Joseph Marzano

A Clinical Review 11

By Dr. Doctor Peter Mogielnicki

A Personal Account 11

By Dr. Mary Horder

Example of Heath Animator Hand Outs 12

DFGFI-CCHIPS October 2006– April 2007 Detailed Receipts 13

3

DFGFI-CCHIPS 6 Month Progress Report

Summary of Activities at Bisate Health Center

Mission: Working in partnership with the Ministry of Health, DFGFI-CCHIPS was created to

pilot a cost efficient and sustainable solution to improving primary health care at

Bisate Health Center. The goal is to develop a model that has a proven positive

impact on the health of rural communities and can be realistically replicated in other

rural areas.

Progress: Significant progress has been made in all 3 core areas of DFGFI-CCHIPS activities:

1) Infrastructure 2) Capacity Building 3) Community Participation.

41,350 liters of rainwater storage have been installed and are now operational. 2

toilets have been refurbished. 9 new plastic Aqua-San toilets and a shower are ready

to be installed; their pit has been dug and once the cement has been poured it will dry

for twenty-one days. A Meeting Area building for health education, trainings and

projects is nearing completion. Installation of an Incinerator is planned for this

summer with installation of Solar Electricity to follow in the fall.

All patient wards and clinic offices have been whitewashed and painted. Patient

wards have been outfitted with new curtains, privacy screens, mattresses, sheets,

blankets, bed covers, and pillows. Locals now say their ward looks like a ―city

hospital‖ and take their shoes off before entering. Bisate has been named #1 in Hy-

giene for the District.

In addition, two pilot projects are forthcoming 1) A health center biogas system will

be built this June to process human waste and provide free, clean cooking fuel for

patients and their families; and 2) In July, the engineer who built Kigali‘s low cost

demo house is planning a new kitchen/shop building for the health center.

Sixteen DFGFI-CCHIPS Volunteers have donated approximately 2,848 hours to the

health center in assessment, training and assistance. This includes hundreds of

one-on-one training hours for the nursing staff by volunteer doctors who jointly

conduct in-patient rounds and patient consultations. Also included are numerous

group-training sessions for the entire Staff and sessions for the local Health

Animators. Health Animators (42) have now been trained on hygiene, burn care,

infections, charting growth, prevention and treatment of diarrhea and nutrition. A

Bisate School Outreach program has been initiated and health education sessions now

reach over 80 school children per week.

In order to be successful, the DFGFI-CCHIPS project must promote community

involvement and a sense of local ownership. To date, over 800 community members

have helped rebuild their health center by donating over 1,000 hours towards

cleaning, painting, hauling rocks, and clearing land. Local labor has contributed

22,000 RWF in discounts on their work.

4

Financial

Expenditures: To date, under the DFGFI Ecosystem Health Program, 9,049,328.79 RWF has been

spent at Bisate Health Center from the DFGFI-CCHIPS Project and 3,138,500 RWF

from the DFGFI- Water & Sanitation Project for a total DFGFI direct contribution

to Bisate Health Center of 12,187,828.79 RWF.

DFGFI-CCHIPS has stocked the pharmacy with 1,817,920 RWF worth of drugs and

consumables in order to remedy the ruptures and shortages that have plagued the

health center. The health center is now 2-3 months ahead of its demand and with

timely insurance reimbursements this stock may now be maintained indefinitely.

DFGFI-CCHIPS raised the salaries of all health center employees in January 2007

and now contributes 256,500 RWF every month. A further raise is under review in

collaboration with MoH and their GOR Health Sector Strategy Plan.

Leadership: Accurate health data and financial record keeping have replaced the minimally

functioning management system that had been in place for seven years. Health

center revenues are now steadily rising along with health indicators such as new

family planning inscribers and total consultations.

The first six months have been both challenging and rewarding. Many problems

remain to be addressed, but with good leadership and continued community

participation we believe that these problems can be surmounted and that the steady

improvement to local health services that have characterized the first six months of

DFGFI-CCHIPS will continue.

Long Term

Goals: DFGFI-CCHIPS will continue to provide MoH with 6 month progress reports and

an end of the year report. Our primary goal, through our reporting process, is to

provide MoH with useful information from our rehabilitation of their rural health

clinic in Bisate which will help them reach their HSSP.

5

Bisate Health Data

Assessment:

The health data records under the previous Titular, Ali, are not correct. We believe the Consultation data is

valid because of the nurse recording the data. However, we believe the rest of the data to be highly inaccurate.

Per Dr. Felix‘s recommendation, we are starting at zero and will monitor and evaluate data beginning in Octo-

ber 2006.

The tools/ forms provided by the MoH to record heath data are excellent. However, the staff does not know

how to use these tools correctly.

1. No hospitalization data was being kept because the health center understood that the record was to only be

filled out if a patient ―caught something‖ while admitted as an in patient.

2. Addition and simple formulas were consistently incorrect.

Action:

DFGFI– CCHIPS computerized the health data so there are no more mathematical mistakes. The staff has

been trained on the Hospitalization record and it is now being filled out correctly.

Now that accurate data is being collected, we can evaluate how effective the health center is and where re-

sources should be allocated in order to improve indicators.

Below are some of the indicators we follow in order to evaluate our work and discuss improvements. For

example, we want to see pre-natal visits increase. This line graph is an effective tool for discussion with the

health staff. One of Bisate‘s cells, Kabazungu, is such a long walk that the women who need CPN do not come

to the health center. In May, we started going to Kabazungu once a month in order to make sure these women

there are covered.

Pre-Natal Indicators

0%

20%

40%

60%

80%

100%

120%

140%

Oct -

06

Nov-

06

Dec-

06

Jan-

07

Feb-

07

Mar-

07

Apr-

07

CPN Ut ilizat ion by

Pop.

Adequat e CPN

Coverage (4 visit s)

[Attachment 1: January — April 2007 Health Records (accurate)]

[Attachment 2: January — December 2006 Health Data (suspect)]

Nu

mb

er

of

Wo

men

N

um

ber

of

Wo

men

Nu

mb

er

of

Ou

t P

ati

en

ts

6

Money available at the end of the month (Q)=

m+n+o+p

0500,000

1,000,0001,500,0002,000,0002,500,000

Oct-

06

Nov-

06

Dec-

06

Jan-

07

Feb-

07

Mar-

07

Apr-

07

RW

F

Bisate Financial Data

Assessment:

The 2006 financial data was compiled and is considered to be completely inaccurate. The cash box was not

monitored. Some staff were allowed to take/ borrow large sums of money from the health center. No bank

statements were kept. Insurance reimbursements had not been requested for many months. When we met with

RAMA to untangle the mess they explained that they did not think Bisate needed the money because it had

been so long since a reimbursement had been requested.

Total amount received from population = C = (A)-(20+21+22+23)

RWF 0.00

RWF 200,000.00

RWF 400,000.00

RWF 600,000.00

RWF 800,000.00

RWF 1,000,000.00

RWF 1,200,000.00

RWF 1,400,000.00

RWF 1,600,000.00

Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07 Apr-07

Gestion des Creances

State of Credits - April 2007

RAMA Mutuelle MMI TOTAL

Date Drugs Other Date Drugs Other Date Drugs Other

Credits at the begin-ning of the month

(Jan) RWF 22,706.00 (Feb) RWF 186,812.00 (Feb) RWF 34,862.33

(Feb) RWF 21,964.00 (Mar) RWF 838,884.00 (Mar) RWF 44,647.95

(Mar) RWF 20,309.00 RWF 16,030.35

Total RWF 81,009.35 Total RWF 1,025,696.00 Total RWF 79,510.28 RWF 1,186,215.63

Credits dur-ing the month RWF 20,291.00 RWF 700,115.00 RWF 51,876.00 RWF 772,282.00

Reimburse-ments dur-ing the month

Jan RWF 22,698.00 Mar RWF 689,996.00 RWF 148,904.00

Feb RWF 21,886.00

Total RWF 44,584.00 Total RWF 838,900.00 Total RWF 0.00 RWF 883,484.00

Total Credits Owed at End of Month

RWF 56,716.35 RWF 886,911.00 RWF 131,386.28 RWF 1,075,013.63

An example of how monthly insurance is tracked:

Action:

Significant time was spent working with and teach-

ing the staff how to correctly manage finances.

February 2007 was the first month that the books

balanced. All insurance reimbursement requests are

now submitted monthly. The cash box is now moni-

tored and tracked in a ledger. Bank statements are

reviewed monthly.

[Attachment 3: October 2006—April 2007 Financials]

[Attachment 4: January 2006—September 2006 Financials]

RW

F

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WATER

Assessment:

Bisate Health Center did not have enough water to maintain even a minimum hygiene program. The delivery

table was not washed between births, there was no hand washing, rooms were dirty and filled with cobwebs.

The water that was used came from a rain water tank at the Titular‘s house and from the town source, both

contaminated.

A team of water engineers from the Massachusetts Institute of Technology visited Ruhengeri in January 2007

to conduct a water supply and quality study. Their final report will be available in June 2007.

[MIT Proposal — Attachment 5]

Action:

Water, quantity and quality, is the priority when trying to improve health. DFGFI‘s Water and Sanitation Ini-

tiative provided funding for a solution to the lack of water at Bisate Health Center. The health center now has

41,350 liters of rain water storage.

There were two main questions:

1. What kind of rainwater tanks should be used a) plastic b) metal c) stone/cement?

2. How much water storage would be required for a growing health center?

When initially researching an appropriate solution, concrete information was difficult to find.

1. Choice of tank seemed to be based on aesthetics and repetition of what had been used at other sites, rather

than a close review of what was most appropriate for the health center site.

2. The size of the tanks seemed to be recommended on the basis of where they would fit rather than a mathe-

matical equation of supply (roof surface area and rain fall) and demand (water needs of health center).

DFGFI conducted a technical, economical and social feasibility study in order to make the best decision for the

health center. [Attachment 6] Subsequently, DFGFI created a Training Guide for the Management of the

Rainwater Supply System. [Attachment 7]

Coliform E. Coli Turbidity (NTU

WHO Standard 0 colonies/100ml 0 colonies/100ml < 5 NTU for chlorina-

tion

Titular’s Tank 700 0 1.01

Titular’s Roof 400 0 33.8

Heath Center Roof 0 0 23.1

Collecting sample from Titular‘s tank Testing Results Presenting to community

Preparing ground Reinforced steel Building super structure Base finished 41,350 liters of water

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Sanitation (Toilets)

Assessment:

Bisate Health Center had one patient toilet which was full and a health hazard, and two dilapidated staff toilets.

To fulfill WHO standards, the health center needed 9 toilets in total. This amount would service the current

number of people using the health center and also allow for substantial growth.

Estimation of the number of toilets to be installed at Bisate Health Center:

NB. The number of toilets required has been estimated based on the standards established by WHO in 1978. They said that 100 boys have

to share one squat hole and 100 girls 3 squat holes.

V = R x P x N V: Volume; R: Accumulation rate of solids per year; P: Number of users and N: Interval of emptying

Action:

9 new plastic Aqua-San toilets and 1 shower have been purchased (there will be a total of 11 toilets in all).

There were two main questions:

1. What type of toilet should be used a) plastic b) brick?

Plastic was chosen for two reasons:

1. Mobility: If, as sometimes happens, the pit below the toilet were to collapse, the investment in the

toilets would not be lost. They could be moved to another location.

2. Cleanliness: The plastic toilets are easier to clean and therefore more hygienic.

2. What type of waste reservoir should be used a) dug pit latrine b) plastic septic tanks?

The pit latrine was chosen after lengthy discussions. The septic tanks were the preferred option until we

addressed the issue of social behavior. The rural population throws a variety of materials into toilets and does

not use toilet paper on a regular basis. We opted for what the community would be most comfortable with and

did not risk continually clogged septic pipes.

Patient Toilet: Health Hazard Burned and limed Digging new pit 9 toilets, 1 shower waiting to be installed

Number

Of users

Number of stances

(toilets) required

Number of stances

(toilets) to be installed

Sick

(hospitalized)

Males 50 1 1

Females 50 2 2

Daily attendance

Females 100 3 3

Males 100 1 1

Males 9 1 1

Females 4 1 1

Total 313 9 (stances)

Volume 12,520 L (4 Septic tanks)

Roof renovated Septic rebuilt Painted, hand washing station installed

Rebuilding toilets New roof Rebuilding septic Painted

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Sanitation (Medical Waste)

Assessment:

Bisate Health Center burns its medical waste in an open pit behind the center. There is no system in place for

liquid waste. Placentas are put down a pipe in the delivery room which leads to a special pit. Rodents are

climbing up the pipe into the delivery room.

MSF (Medicine Sans Frontier) has developed a 4 part system for properly disposing of medical waste which is

appropriate for a developing country setting. The medical waste ‗Zone‖ consists of: 1) Incinerator 2) Ash pit

for the incinerator 3) Pit for placentas and body parts 4) Pit for metal and glass which also has a small oven for

disposing of syringes. Training for the health staff in how to properly separate waste is included along with

special training for the waste manager in how to safely use the waste system. [System Design - Attachment 8]

In evaluations of this system, it is found to work well and problems only arise due to inadequate training and

therefore misuse. This health care waste system can be seen in operation at Ruhengeri Hospital and Kinomi

Health Center.

Action:

E.CO.TE, a construction company in Kigali, has worked with MSF to build this system in Rwanda. E.CO.TE

has conducted a site visit at Bisate Health Center, has advised on the best location for the waste site and has

submitted a cost proposal. The placenta pit will be constructed in June. Further issues with the incinerator are

being discussed. [System Costing (does not include training cost) -Attachment 9]

In the interim: Waste receptacles have been purchased along with protective clothing for the waste manager.

Lime is now being used to manage the current placenta pit. A metal drum was purchased for burning waste,

but then stolen.

Issues to be addressed:

Heat resistant material — The bricks and mortar on the inside of both the incinerator and the smaller oven

above the sharps pit must be constructed with refractory bricks and refractory mortar in order to resist high

temperature and temperature variations. The necessary material cannot be found in Rwanda. The Rwandan

Portland cement can only resist temperatures up to 300°C.

It is possible to get refractory bricks from Malawi. However, their composition is not ideal for incinerators.

The European refractory bricks are more expensive, but will last longer.

European refractory materials for 1 incinerator is estimated at 2,000 EUR

Shipping of materials to Rwanda is estimated at 3,700 EUR

Musanze District‘s Strategic Plan calls for incinerators at every health center.

● Is there a plan for implementation?

● Is the MoH‘s approach to use local materials with a short life span or to import European materials

that will last a long time?

● If the approach is to import, it would be more cost efficient to ship materials for many incinerators

at the same time.

Placenta Hole Bisate Waste Pit

MSF 4 Zone Waste System

10

Sanitation (Bio Gas)

Assessment:

Bio gas is effectively being used in Rwanda to process human waste and to produce a cheap,

clean energy source. Rwanda has looked at Nepal as an example of a mountainous, land-

locked country that has successfully used bio gas. The functioning bio gas systems in

Rwanda have been built with wood fired bricks that are no longer legal. The challenge now

is to innovate and design something new that will result in a low cost, high impact solution.

A site visit and Biogas system assessment were completed by a visiting engineer from

Thayer School of Engineering at Dartmouth College, Hanover, NH USA.

Action:

DFGFI-CCHIPS will pilot a bio gas system at Bisate Health Center. The intent is to process

the human waste from 1000+ people a month and to provide daily cooking gas in-patients as

well as for cooking demonstrations and a soap making project. Humanitarian Engineering

Leadership Projects (HELP) at Dartmouth College‘s Thayer School of Engineering has de-

signed the system. Final Proposal Due May 31, 2007.

One member of the team visited Bisate in December 2006 to do an initial site assessment.

The project team will arrive on June 15th, 2007 for two months to build the system. HELP

is in contact with Guy Dekelver, Biogas/Natural Resources Management Advisor at SNV

who is working with MININFRA‘s National Domestic Biogas Programme, to share lessons

learned.

Preliminary design:

Front View

Side View

Overhead View

Visiting Rwaza School Biogas with KIST technicians Visiting Kigali City Demo House Bio gas with EWB Engineer

11

Power

Assessment:

Bisate Health Center is not connected to the electrical grid. The vaccination refrigerator is run on petrol and

candles are used after dark.

According to information received from the Mayor of Musanze District‘s conversation with ElectroGas, it

would cost an estimated 1 million US Dollars to connect Bisate to the grid. It does not seem likely that a con-

nection will occur in the near future. However, there are local rumors that some high end hotels may be built

near Bisate and that grid power might follow.

We believe that a generator is unsustainable the long run because of fuel costs and fuel transportation difficul-

ties.

Action:

DFGFI-CCHIPS will install solar power.

The Solar Electrification Light Fund (SELF) has completed a site visit and assessment. Preliminary Electrical

Load Evaluation and costings have been done. A detailed load evaluation will be finished in June 07 with ex-

pected installation in September/ October 07. SELF is a non-profit charitable organization founded in 1990 to

promote, develop, and facilitate solar rural electrification and energy SELF-sufficiency in developing coun-

tries. SELF has made a commitment to working in Rwanda and developing human capacity. They are pres-

ently working on several projects in the Eastern Province with Partners in Health.

Question:

How big should the system be? How much should be spent on it?

The preliminary estimate ranges from $15,000 (for just lights) - to - $30,000 (for lights w/ appliances).

The size of a photovoltaic (PV) power system is determined by two principle variables: the amount of electri-

cal energy required and the average amount of solar radiation present at the site.

Because recorded solar radiation data is scarce in Rwanda, we are having to make an educated guess as to how

much is available in Bisate. In other parts of Rwanda that do have data, it ranges from 5 to 5.5 kilowatts per

day per square meter of solar panel area. For Bisate, we are estimating half of that for design purposes due to

the often cloudy conditions. We‘re sizing the batteries for these systems to provide as much as 5-7 days of

autonomy – in other words, the batteries will power the load for that many days without any solar contribution.

The predicted low level of solar radiation results in much larger PV arrays than are usually installed and larger

battery banks as well- both of which account for increased costs.

In the meantime:

A chargeable bright light has been provided in maternity for night deliveries. Battery powered head lamps

have been provided for wound care. A bright flashlight has been provided for the lab technician to better see

the slides.

Appliances are being purchased that will work most efficiently with solar. For example, DFGFI-CCHIPS has

purchased a laptop w/ 7 hour battery for the health center. Desktops will not be purchased due to their incom-

patibility with solar.

[Preliminary Electrical Load Evaluation & Costing —Attachment 10]

Find out more about

Solar Electric Light Fund powering a brighter 21st century

www.self.org

12

Building Upgrade

Assessment:

The buildings were dirty and uncared for due in part to poor leadership rather than lack of resources. A general

building upgrade needed to be carried out in order to:

1. Improve hygiene and create a healthy environment.

2. To create a warm and welcoming health center that the sick and pregnant will want to come to.

Action:

All rooms were washed and painted. Windows were repaired and scrapped of dark privacy paint. Curtains

were made and installed. New medical mattress were purchased along with sheets, blankets, pillows and pillow

cases. Privacy screens were constructed. A leaking roof was mended and a water damaged ceiling was re-

paired.

Hospitalization: BEFORE Hospitalization: AFTER

Maternity: BEFORE Maternity: AFTER

Driveway: BEFORE Loosening ground 5cm of small rock 10cm of soil

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Construction

Assessment:

More space is needed to accommodate all of the activities we wish to implement and to meet the MoH‘s stan-

dards for a health center.

The staff cannot yet provide an adequate quality of service for the space they already have. Construction of

new buildings will be focused on immediate needs and will be continually assessed with regard to what the

staff can manage.

The health center has 16 beds. Below is the rate of occupied beds for the last 5 months:

Dec 06 Jan 07 Feb Mar Apr 07

Rate of occupied beds (d*100)/c 32% 42% 40% 61% 45%

Action:

Our immediate need is for a meeting area and kitchen. Construction is almost finished on the meeting area

which will serve as a place to hold staff and animator trainings, weekly CPN and vaccination days, community

health education and staff meetings. It will also serve as a temporary kitchen and as the site for our first micro

soap making project.

Meeting Area Construction: Made from local materials, using local labor. The wood was acquired with the help of the

Kinigi Agronomist in order to insure that it met DFGFI‘s conservation standards and was legal. The rock was dug from the

health center‘s land.

The DED engineer who built the very well received Kigali Low Cost

Demo House has conducted a site visit at Bisate Health Center.

Initial soil tests have been conducted by KIST and the engineer is

working on a low cost housing proposal for the Bisate area.

He will return to the site in July to finalize plans for building a kitchen

and shop.

Kigali Demo House

DFGFI-CCHIPS has an initial donation to purchase and rehabilitate the dilapidated Soperya house that abuts

the health center property. We are currently waiting for the Titular and the Ex. Sec of Kinigi to inquire about

this possibility. If this is a possibility, it would provide a stop-gap to some of our space issues and potentially

provide housing for new staff.

14

Human Capacity Building — Staff Salaries & Caisse Social

Assessment:

“The lack of well-trained, highly motivated health professionals in the health system has been identified as one

of the core problems for the sector. The HHSP cites poor management of human resources as the key cause for

the low availability of health professionals. A critical underlying cause is the salary and incentive structure,

which has been recognized as a key area to address over the next five years.” (MoH HHSP)

DFGFI-CCHIPS strongly agrees with the HHSP. At the projects beginning some of the Bisate Staff were

highly unmotivated. Also, to make significant improvements in the quality of service at the health center, it is

necessary for the entire staff to work together as a team. DFGFI-CCHIPS is looking forward to the implemen-

tation of Performance Based Indicators (PBI) in the Musanze District (reportedly starting in April 07) as we

believe it will greatly improve staff motivation. No staff contracts had been signed for at least two years.

There was no Caisse Social system in place and it was revealed that the previous Titular was taking money out

of staff paychecks for Caisse Social, but not putting it in the bank accounts. Apparently this had been going on

for 5 years. Emmanuel, Supervisor of Musanze Health Centers, is investigating this alleged crime.

Action:

DFGFI-CCHIPS raised salaries in January 2007, effectively doubling most staff‘s pay. The sustainability of

this salary structure was discussed at length with the Health Committee. Although it is a risk, we believe that

we can reach our goal of having the health center support this structure on its own through raised revenue and

by the MoH‘s stated goal of paying for more A2 nurses. DFGFI-CCHIPS also took on the responsibility of

paying the vaccinator as he was no longer eligible for MoH payroll and is the reason Bisate Health Center is #1

in Vaccination. We had hoped to match the MoH salaries, but the MoH salary structure was changed the same

month that Bisate‘s salary increase was implemented. Further increases are under discussion.

Contracts have been written and signed with all staff employed by the health center.

All staff have applied for and received Caisse Social numbers. Bisate Health Center has been meeting its legal

requirements for Caisse Social since January 2007.

Salaries are now being paid through the bank and not in cash.

Contract Salary CS Pays CCHIPS Pays Employee 3% CS 5%

CCHIPS Pays

Caisse Social Total

Jacqueline (A2) RWF 102,061.86 RWF 55,000 RWF 44,000.00 RWF 3,061.86 RWF 5,103.09 RWF 8,164.95

Chantal (A2) RWF 51,546.39 RWF 25,000 RWF 25,000.00 RWF 1,546.39 RWF 2,577.32 RWF 4,123.71

Jean Baptiste (A2) RWF 51,546.39 RWF 25,000 RWF 25,000.00 RWF 1,546.39 RWF 2,577.32 RWF 4,123.71

Jacqueline (A2) RWF 51,546.39 RWF 25,000 RWF 25,000.00 RWF 1,546.39 RWF 2,577.32 RWF 4,123.71

Teogene (Vacc) RWF 46,391.75 RWF 0 RWF 45,000.00 RWF 1,391.75 RWF 2,319.59 RWF 3,711.34

Alexis (Traveiller) **RWF 25,000.00 RWF 15,500 RWF 9,500.00 0 0 RWF 0.00

Emmanual (Traveiller) RWF 25,773.20 RWF 12,000 RWF 13,000.00 RWF 773.20 RWF 1,288.66 RWF 2,061.86

Joseph (Cleaner) RWF 22,680.41 RWF 9,500 RWF 12,500.00 RWF 680.41 RWF 1,134.02 RWF 1,814.43

Leonedas (Cleaner) RWF 22,680.41 RWF 9,500 RWF 12,500.00 RWF 680.41 RWF 1,134.02 RWF 1,814.43

Leonard (Night Guard) RWF 25,773.20 RWF 12,000 RWF 13,000.00 RWF 773.20 RWF 1,288.66 RWF 2,061.86

TOTAL RWF 400,000.00 RWF 188,500 RWF 224,500 RWF 32,000.00

Monthly DFGFI-CCHIPS Salary Subsidy:

15

Medical Volunteers Information

Volunteers – Medical:

1. Title/Name: Doctor Brian Lombardo (CCHIPS Medical Director)

Arrived: 09/18/07

Departed: 10/01/07

Working Days: 9

Working Hours: 72

Description: Meetings w/nursing staff to assesses skills/needs.

2. Title/Name: Doctor Mary Horder

Arrived: 09/20/07

Departed: 10/18/06

Training Days: 19

Training Hours: 152

Description: Daily in-patient rounds and patient consultations w/staff nurses.

3. Title/Name: 3rd-Year Psychiatry Resident Joseph Marzano

Arrived: 09/03/06

Departed: 11/19/06

Days: 30

Hours: 240

Description: Conducted initial Mental Health Assessment for Dr. Kathleen All-

den (Mental Health Doctor coming June 2007).

[A General Assessment of Mental Health Information — Attachment 11]

4. Title/Name: Doctor Peter Mogielnicki

Arrived: 11/14/06

Departed: 12/01/06

Training Days: 15

Training Hours: 120

Description: Daily in-patient rounds and patient consultations w/staff nurses.

Two training sessions w/entire nursing staff.

[ A Clinical Review — Attachment 11]

5. Title/Name: Doctor Mary Horder (2nd Visit)

Arrived: 01/31/07

Departed: 02/24/07

Training Days: 17

Training Hours: 136

Description: Daily in-patient rounds and patient consultations w/staff nurses.

Two training sessions w/entire nursing staff. Two training sessions w/ Health

Animators.

[A Personal Account - Attachment 11]

6. Title/Name: Physician‘s Assistant Nancy Mogielnicki

Arrived: 04/21/07

Departed: 05/20/07

Training Days: 23

Training Hours: 184

Description: Daily pediatric in-patient rounds and pediatric patient consultations

w/staff nurses. Four Vaccination Day & Growth Chart supervisions. Three

Health Animator training sessions. Three Bisate School Outreach sessions. One

training session w/entire nursing staff.

Approximate Work Hours (Assessing & Training) of CCHIPS Medical Volunteers since October 2006: 904 hours

16

Non-Medical Volunteers Information

Volunteers – Non-Medical:

1. Title/Name: Solar Electric Light Fund (SELF) Project Director Jeff Lahl

Job: Solar Electric Assessment for Bisate Health Clinic.

Arrived: 07/31/06

Working Days: 1

Working Hours: 8

Description: Solar Assessment for Bisate Clinic & creation of various solar array/pricing options.

2. Title/Name: Engineer Mike Bolger (Thayer School of Engineering)

Job: Biogas Assessment for Bisate Health Clinic.

Arrived: 12/16/06

Departed: 12/29/06

Working Days: 9

Working Hours: 72

Description: Assessment of Biogas feasibility at Bisate Clinic. Assessment of local resources &

equipment. Lead member of Thayer Bio Gas Engineering Team coming July 2007.

3. Title/Name: Engineers Chris & Antje Rollins

Job: Testing & Assessment of local Bisate soils for manufacture of pressed-bricks for constructing

new clinic kitchen.

Arrived: 02/27/07 (w/one week of testing in Kigali)

Working Days: 5

Working Hours: 11

Description: Collected various soil/pumice samples for testing at Kigali lab.

4. Title/Name: Videographer Sean Clauson

Job: Documenting CCHIPS project. Creation of fundraising videos for CCHIPS donor solicitations

and for instructional planning use for project replication.

Arrived: 11/20/06

Departed: TBD

Working Days: 158

Working Hours: 1264

5. Title/Name: MIT Water-Quality Assessment Team (4 Members)

Job: Testing & Assessment of Bisate Town/School/Clinic water quality.

Arrived: 01/05/07

Departed: 01/28/07

Working Days: 15

Working Hours: 45

6. Title/Name: Volunteer Flora Lansburgh

Job: General Volunteer.

Arrived: 01/09/07

Departed: 04/14/07

Working Days: 68

Working Hours: 544

Description: Created nutritional garden project. Cultivated & donated seedlings to Bisate residents.

Conducted quality assurance on data-entry for Clinic‘s insurance book-keeping). Created plan for

soap making project.

Approximate Work Hours of CCHIPS Non-Medical Volunteers since July 2006: 1944 Hours

17

Human Capacity Building—Health Center Staff

Assessment:

Based on our initial assessment of the health center‘s medical services, we had to take several steps backwards

from our anticipated starting point. There was no system in place for methodically evaluating patients and

then communicating the evaluation to them. Nothing was being written in the patient‘s pink book, except the

name of the drug they were given.

There was no schedule with assigned responsibilities and consequently in-patients were routinely ignored for

long periods of time. There was no passing of information during a shift change and all staff often went to

lunch at the same time leaving the health center with no medical supervision.

Action:

All medical volunteers follow the same system and schedule to provide continuity between trainers. They

come to Bisate to train the nurses how to better care for patients, not to directly care for patients themselves.

There are two main themes that every volunteer teaches:

1. S.O.A.P. – Communication

This is the methodical system taught for evaluating patients and translates well in both English and French:

Subjectif, Objective, Assessment, Programme (and Patient Education). The evaluation is written in the pa-

tient‘s pink book so their medical information will be communicated to the next nurse that sees them.

The staff understands this concept and were taught it in school, but do not yet practice it consistently.

2. Don‘t Drop the Egg (ie. Patient)

The staff is being taught to work together as a team. A cloth with an egg on it is held by 4 people —

consultation, pharmacy, lab, hospitalization. If one person does not hold up their corner, the egg will fall and

break. A responsibility schedule and lunch schedule have been implemented to ensure patient care.

Staff Training: Don‘t drop the patient Staff Training: Communicable disease: Viruses, bacteria,

parasites, worms, fecal/oral, soil born, droplets, fomites

Consultation Training Teaching wound care

18

Human Capacity Building — Health Animators

Assessment:

Educating Health Animators is critical to improving community health. The Bisate animators strong desire to

learn and help their neighbors is impressive.

Action:

DFGFI-CCHIPS pays animators 1000RWF to come to a training in order to promote attendance. They have

been engaged in the trainings and eager to learn. Trainings have been held on: hygiene, burns, infections,

charting growth, prevention and treatment of diarrhea and nutrition.

All of the trainings so far have been given by visiting medical professionals. We would like to begin having

some of the nurses give trainings.

A soap making project will be started in June for the benefit of the health animators.

[Example of Heath Animator Hand Outs - Attachment 12]

PA Nancy teaching animators how to Chart Growth

Dr. Mary teaching animators what to do if a person is burned

19

Improved Medical Service

Pharmacy

Assessment: The pharmacy had many ruptures in stock. There was no stock management system. The drugs were not la-

beled or organized in a coherent manner.

Action: A stock card management system has been implemented. DFGFI-CCHIPS has spent 1,817,920 RWF on drugs

and consumables in order to get the health center 2-3 months ahead so it can now purchase drugs in a timely

manner and there are no ruptures of stock. The drug shelves have been labeled and organized and a A2 nurse

has been hired to manage the pharmacy.

Pharmacy: BEFORE Purchasing and stocking drugs Pharmacy: AFTER

Laboratory

Assessment: The Bisate Lab Technician is highly motivated and capable. He needs the resources necessary to do his job.

Action: Upgrades to lab equipment and furniture have begun. The Lab Tech was sent to a 10 day Ecosystem Health

Parasite training at Rwinkwavu Hospital. A budget is ready to bring the lab to MoH standards. We are waiting

for the Titular to cost the ―needs list.‖ We have asked the Supervisor of Musanze Health Centers to inform us

of the necessary requirements for becoming a registered TB site and a registered nutrition site.

Lab: BEFORE Lab Tech receiving centrifuge and new supplies Painting Lab Lab: AFTER

Maternity Ward: BEFORE Ready for cleaning New Mattresses and blankets Maternity: AFTER

Maternity Ward

Assessment: Newborns and sick patients were in the same room.

Action: The separation of sick and newborns was our first big behavioral change success.

20

Community Participation

Assessment:

Action:

After an initial period of discussion with the health animators about how participation creates ownership, the

community has assisted with every project carried out by DFGFI-CCHIPS from manual labor, to painting to

making lab coats. A good working relationship has been established with the Health Committee (monthly

meeting) and Health Animators who facilitate the community participation.

NK’UKO MINISITERI Y’UBUZIMA IBISABA, ABATURAGE NIBO BAFITE URU-HARE RUNINI MU GUTEZA IMBERE IMIBEREHO MYIZA Y’UBUZIMA BWABO.

Community participation, considered as essential by the Ministry of Health, is a key

element in the implementation of the primary health care strategy. (MoH Policy)

TURASHIMIRA ABA BATURAGE MUBONE BABAYE ABAMBERE MU GUHARANIRA IMIZAMUKIRE Y’IVULIRO RYABO.

Merakoze Cyane!

To the people of Bisate who have contributed to improving their health center, Thank you!

Bisate school children bring rocks for the driveway The community carries rocks for the meeting area

Nov. 23, 2006: The first community members come to clean the hospitalization ward

The community clears land for the meeting area and digs a trench to divert water.

21

Financials October 2006 — April 2007

Assessment:

It is critical that expenses are carefully tracked for budgeting replication, donor transparency and as a tool for

discussing priorities.

Action:

DFGFI-CCHIPS tracks every expenditure with QuickBooks. A monthly breakdown of all receipts is submitted

to the Bisate Titular and Health Committee and also attached to the monthly health and financial record sub-

mitted to the District.

[October 2006– April 2007 Detailed Receipts—Attachment 13]

Sanitation

24%

Small Equipment

4%

Drugs &

Consumables

17%

Salary Subsidy

8%

Furniture

3%Building Upgrade

10%

Painting

5%

Water

27%

Meetings &

Trainings

2%

Furniture

Meetings & Trainings

Salary Subsidy

Drugs & Consumables

Small Equipment

Sanitation

Water

Painting

Building Upgrade

DFGFI-CCHIPS Furniture 369,746.00

Meetings & Trainings 256,950.00

Salary Subsidy 927,659.79

Drugs & Consumables 2,048,278.00

Small Equipment 432,360.00

Sanitation 2,938,800.00

Water 198,500.00

Painting 618,085.00

Building Upgrade 1,258,950.00

Total 9,049,328.79

DFGFI- Water & Sanitation Water tanks 4 10,000L RWF 2,600,000.00

Water tanks 1 1350L RWF 130,000.00

Labor RWF 408,500.00

Total RWF 3,138,500.00

Total Expense Oct 2006- Apr 2007 12,187,828.79

NB. These are unaudited expenses at Bisate Health Center only ie. does not included DFGFI-CCHIPS Project House in Musanze or USA expenses and

does not include in-kind donations in support of Bisate Heath Center activi-

ties ie. donated sheets, blankets, laptop etc.

Distribution of money spent at Bisate Health Center