Sharing knowhow and joining forces towards Health for All
Contribution to the Annual Report 2017 of the MMI Network

Aiming for Autonomy: A Journey through Cultures

Aiming for Autonomy: A Journey through Cultures

It is more than 50 years now since Renato Monolo Hospital has been established in Kiremba, Northern Burundi. Back then, the Diocese of Brescia, Italy, wanted to offer a gift to its fellow citizen, the newly elected Pope Paul VI, and decided to build a new hospital in one of the world’s most underserved regions. Young physicians from Brescia were among the initial staff – and founded Medicus Mundi Italy in support. From then on other organizations gradually flanked the founder, until in 2014 “ATS Kiremba” (a Purpose Temporary Association) was created, including, beside the Diocese of Brescia, the “Ancelle della Carità”, the Poliambulanza Hospital, Museke Foundation, AsCoM Association and Medicus Mundi Italia. An alliance with the main purpose of guiding Kiremba Hospital towards financial autonomy and full self-governance thus empowering it to stand on its own legs, and (eventually!) walk further.

Far back in 1965 Kiremba really was a small village, lost in a swampy marsh, that was inhabited by crocodiles and hippos. Actually, that was the very reason for the choice to build a hospital right there: to bring medical care to the poorest and most derelict people, settling, living and dying in an authority-abandoned, malaria prone region.

In these 50 years, countless missionaries, doctors, nurses, technicians and volunteers of any kind contributed, every single one of them bringing his personal share: sometimes little grains of work to be done in short and others bringing huge experiences and long-term commitments. Altogether made Kiremba what it is now: a 190 beds District Hospital deploying 9 doctors, 80 nurses and some other seven dozens employees including technical support, administrative and auxiliary staff.

They run a gynecology and obstetrics ward that helps mothers give birth to 160 newborns every month; a 42-beds pediatric unit taking care to a mean of 90 children each day plus a surgical/orthopedic unit performing 80 interventions per month (among others, they also treat children affected by hydrocephalus or osteomyelitis). An internal medicine ward and an emergency department complete the picture, along with a clinical analysis laboratory, a radiological service, a physical-therapy facility and last but not least, a nutritional unit.

On the support side, technicians installed an oxygen extraction device that delivers medical quality oxygen to several wards, an intravenous fluid production unit, a sterilization system, and a housekeeping and maintenance facility including carpentry and mechanics. Electricity is assured 24 hours per day to the whole hospital by a small hydropower plant, located a 30 minutes’ walk east through the gorgeous valley,

Every year the whole facility admits more than twenty thousand patients for hospitalization, and several ten thousand more are followed on an outpatient basis.

Well, at this point it looks like the small Kiremba Hospital in five decades has grown up to be a full working, perfectly tuned never-stopping health machine. But…..

Realities like the one we live and work in here, and there are many, where international cooperation is under way for a very long time and so much has been achieved, now face a new challenge, one we were not really prepared to tackle: to hand over the whole hospital, including its managerial accountability, to locals and allow for the much demanded autonomy and full self-governance.

This is something that needs to be dealt with in a cultural framework, and often leaves both sides of the partnership unprepared on a little-traveled road.

To manage a hospital and thus to organize and provide healthcare necessarily includes a definition of health itself; that definition is depending and influenced by the cultural context. Every definition of illness and suffering is cultural, and the definition of what it means “to take care of” as opposed “to cure” is. One has to be embedded deeply in the local culture, to understand and define the needs and to understand the best approach. This doesn’t mean that proposing a model is unnecessary, it is rather something that must be done to avoid being merely external donors; both local staff and international partners have to walk together through each one’s expectations, longtime established habits that must be challenged and new ones that need to be created, new perspectives to build along with changing priorities; to guide with respect, to allow to be guided without dodging responsibilities. To let go and to go on! Finding this balance is now the hardest part of the job.

Add to this cultural side the economic momentum: Receiving money for years can lead to think that this is enough to face problems, rather than a correct work method is; for funders, to hand resources and money out along with already made expertise is easier – and, in the short run, more effective – than to teach beneficiaries how to exploit them. And getting money is becoming harder, for international NGOs and even more for stand-alone locals.

And now, Burundi. Let’s consider the place. Recent history of this country is terrible and dramatic, still deeply marking people’s capability of trusting each other and to see reliability as an asset in relationships. To be an international cooperator here means that you must keep doing soul-searching, knowing that never mind how much you struggle to do the best, you always should’ve done better, in a context where mistakes always matter more than successes.

Partnership in the late phase of longstanding cooperations, like Kiremba is, demands a full paradigm shift: what you think right, may be wrong in your partners’ mind, and sometimes you need to silence the voice in your head that yells “Hey, you are right!!” Instead trust and foster the (sometimes long hidden) capabilities to find innovative solutions. You don’t need to deny your principles, but they may be different from those who welcomed you long ago (and may change over time). While trying to build autonomy, you are challenged by your own reluctance to leave the driver’s seat, to let things go even if you don’t agree with the new direction – you don’t have to agree.

You feel reluctant to clear the field, not ready to turn roaring days into memories, for as slowly and progressively it might be, and you observe concerned the partners looking for the balance between the pride of true self-governance and the fear to be abandoned by the organization that has been backing it up for so long; a matter of trust.

Just to give an example, in Kiremba some years ago both sides agreed on the need for an isolation ward to be build. Contagious patients, namely those with active pulmonary tuberculosis, were hospitalized side by side with uninfected patients, hence creating conditions for easy spread of TB.

Looking with European eyes, we proposed to finance the construction of a brand-new ward in the upcoming years. Local managers enthusiastically accepted, we raised money, and project proposals were drawn up. Now that the time to place the bricks has come, diversity of standpoints shows up: local manager always thought (or perhaps gradually shifted to think) that the new building was meant to be mainly used as a private room block! This let to quite some confusion, as obviously the project specifics are very different, and thus the planning process had to be restarted, money and time are wasted.

So what went wrong? It’s our fault? Maybe we are accountable for a lack of sharing thoughts? Was there not enough joined analysis of needs in the early phase? Maybe we are responsible for bad communication management? Or are the local partners to blame? Did they know from scratch that such a specialized and resource-consuming ward, that furthermore falls out of the recent National Guidelines, was not among the top priorities of a low-income-country, poor-oriented, charity-inspired and autonomy-aiming District Hospital? If so, did they never argue because they were afraid of losing aid? Maybe they simply changed their priorities and failed to communicate. What else? It’s easy to walk on different and diverging rails, sometimes.

We listened to each other and ended up with a common solution: refurbish the existing structures and enlarge the medicine ward adding four single-bed isolation-rooms with filters and forced ventilation (and save excess resources for further projects in Kiremba). And so we are reworking once more, together, understanding better and trusting more in self-governance and receiving the confidence it takes to support our friends on their way to long run sustainability.

This is the biggest challenge in autonomy: trust, understand that you have shown the direction now others hit the road to reach the common goal: health for all!



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