Sunamganj in Numbers

Surabhi Rajaram

Today I started my last week in Sunamganj.  It is hard to believe that my two months in the field have passed. These are some stats from my time here. Some of these are of equivalent estimation accuracy to the assumptions in my financial model.

7 sub-districts traversed. The health delivery system has a service area of 10 out of 11 sub-districts of Sunamganj. I travelled extensively through the 7 that were yet accessible this season

Lessons: You must live in the field to learn the field. Be relentless.
 

The field

6 modes of transportation utilized. Boat, foot, pickup truck, auto rickshaw, motorcycle, cycle rickshaw. These are ordered from least painful to most.

Lessons: There is no place worth getting to without hard work. Transit time is observation time. Quicksand(mud) is real.

If the boat doesn't come to you, you go to the boat

80 stakeholder interviews conducted. These past two months have been filled with nonstop research to learn everything and anything about this system and inform recommendations towards sustainability. I have spoken to skilled birth attendants, mothers, family members, community health workers, drug shop owners, traditional birth attendants, village doctors, government officials, community leaders, transporters, suppliers, field team staff, franchisors, nonprofits, the list goes on.

Lessons: Primary sources are the best sources. Just listen. You cannot refuse tea no matter how many cups you have had.

Interviewing

30 ORS packets consumed. Oral rehydration system (ORS) is a soluble electrolyte powder to prevent dehydration, which is crucial in this heat. The feelings I had buying my first ORS-Saline for 5 Taka will probably rival that of purchasing my first car.  I get a smile on my face when I see those orange packets sitting in a small shop in a most remote village of the most remote Sunamganj. You see, it took many strategic years for this life-saving commodity to be universally accessible and affordable. The BRAC-SMC ORS scale-up in Bangladesh was my hook into the health delivery niche and will always be one of my favorite stories. I also get really excited seeing the SMC Blue Star and Smiling Sun franchise clinics.

Lessons: Health access is possible here. I am in the right field. The taste of ORS is not exciting.

SMC Blue Star clinic

0 tomatoes spotted. My mind has fixated on wanting to see one glorious red tomato. For all the water, Sunamganj is a food desert. The wetlands are only conducive to growing rice and breeding fish. Vegetables and fruit are few and expensive. As a vegetarian this means being content with the same meal three times per day. For many of the poor and extreme poor quintiles though, this can mean high rates of malnutrition and  long-term health consequences. The government provides free vitamin supplements for mothers and children to attempt to aid this crisis, but there is still a long way to go.

Lessons: Gratefulness for food. Happiness in little things, like a tomato.

Fishing contraption

50 mosquito bites received. The mosquitos here are as welcoming as the people. I received many greetings, my favorite of which were on my eyelid and pinky toe. And although this is mosquito paradise, the rates of malaria in Sunamganj are very low due to a highly effective malaria control program. Insecticide-treated bed nets are widely distributed through public health, nonprofit, and private sectors. Residents are quite resistant to getting bitten – many kids had good laughs at my itching as they pushed the burning incense closer to me.

Lessons: Prevention is the best. Children laughing sound the same everywhere. Incense does not really work.

Insecticide-treated net

Unquantifiable: What I have gained from the devoted people of Sunamganj. The love I have for the CARE family that made me their own. The number of tears shed, laughs laughed, and thought boundaries crossed.

Some of the best

 

A Balancing Act

My starry-eyed, healthcare-from-the-heart, “free for service” self is having a real world wake-up call. I wanted to share a drop from the flood rushing through my head and quite literally around me.

The CARE-GSK Community Health Worker Initiative is a donor-funded NGO project. And although there is a network of Private-Community Skilled Birth Attendants (P-CSBAs) who generate income from selling their services, this means that social impact trumps financial considerations. These agents must provide services to BoP populations, regardless of ability to pay. But as we well know, donor money doesn’t pour from the sky like these monsoon rains.

This poses an interesting setup as the project seeks to transition to a sustainable social business model, where tradeoffs exist between profit maximization and social impact. This setup has led me to many questions, of which I will share one: How can you have financial sustainability while maintaining equity in healthcare delivery at the BoP?

Here are two brief thoughts within this context.

Entrepreneurs are the Sun in the (solar) system.
If the agents cannot and do not perform their tasks, the system will fail. No service and no money. I have been observing for many weeks now the difference between achieving and not achieving service and financial goals. The balance point lies at the interface of the agent and her surrounding structures.

She is a mother with young children and social norms dictate her presence in the household. She needs be mobile to reach dispersed service recipients. Procuring quality supply involves a long and expensive trip. Oh, opportunity costs…the list goes on. Suffice to say, the value proposition of the organization (or potential franchisor) to these P-CSBAs must have in-built contingencies to address these barriers to equitable care, while yet promoting a stable income.

Taking the blinders off of sustainability.
In discussions I am finding the need to clarify what people mean by “sustainability” when they articulate their future vision for the system. Through this process I am also clarifying my own understanding.

When asked to elaborate on sustainability, I often hear a solely financial scope and that too, the traditional definition of a competitive and self-sufficient franchise. But when 60% of service recipients are in national wealth quintiles of poor and extreme poor designations and the services are essential and often lifesaving, is this a realistic conceptualization? I am quickly seeing the need to broaden the scope of financial sustainability in my discussions to even begin to accommodate equitable healthcare delivery.

Perhaps financial sustainability in this model includes a certain dependency on donor funds? Perhaps it means harnessing partnerships in a voucher program for the poor and extreme poor? Or transportation subsidies for P-CSBAs to reach the dispersed population?

And to extend this past the money, I am learning to conceptualize a sustainability ecosystem. Leveraging community and political structures such as local government and village groups as accountability mechanisms for equity. Honing a skill set that ensures a competitive advantage of mobility and quality unlike quack central, the Village Doctors and Traditional Birth Attendants. Designing a lifestyle that addresses barriers to equitable care provision while fulfilling the entrepreneurial spirit.

This is an intricate, crucial balancing act.

A Day in the Life

This is a typical day of operations research in the field, conducting Private-Community Skilled Birth Attendant (P-CSBA) interviews.

I quickly finish my aloo (potato) and roti (bread), carb-loading for the day ahead. My backpack is stocked with three water bottles (one containing coconut water for electrolytes), a protein bar, a voice recorder, a camera, a notebook, and rain gear. I sling my backpack on and hop into the heavy duty CARE pickup truck. We swing by the office to pick up a colleague and our planning for the day begins.

This is why we have a pickup truck

It is essential to optimize our time so that we can reach our target of 5 PCSBAs, dispersed throughout the sub-district. Our strategy is dependent on location and mode of transport – we will reach the farthest first and work our way back to the roadways, with consideration to limit travel by foot.

We stop to pick up our traditional field meal of bhalo (good) quality bread and bananas. I am told the bread counters the acidity of the bananas so you don’t throw up. The next couple hours are spent on the road, passing by paddies and paddies, everywhere green and watery. Finally, we arrive in the main marketplace.

We tread carefully towards the dock. I always find it is best to look down while walking to avoid stepping in the cow dung. The boat ride takes us gently along the still haor (wetland) waters to our destination. A P-CSBA is smiling and waiting to lead us to her home. We go the extra mile (well, kilometer) to her home so that we can deepen our understanding of the service area. We follow in her expert footsteps for a couple kilometers until we reach. The structure is quite modest with tin and bamboo-fortified walls and roof.

Typical home

She encourages us with “aashen, aashen” (come, come) and we take our seats. We introduce ourselves and as soon as I speak English, she looks surprised and asks “She is not Bangladeshi?” My colleague is always excited by this comment and replies, “No, but you cannot tell the difference!”

We then begin to administer the questionnaire. This is a very focused time for me as the message goes from English on paper to Hindi and hand gestures in my speech to Bengali in translation, and back again. Bengali and Hindi are sister languages, which has facilitated my communication here.

We listen and revelations come! We understand her challenges in moving over this tough terrain, in working while pregnant, in engaging with the community, in competing with Traditional Birth Attendants, in gaining her husband’s support.

We are humbled by her motivations behind this work. Her first child was lost in pregnancy complications, as no skilled workers were present at the clinic – she says this cannot happen to another mother. Her husband passed away and she has no sons, but she is working to pay for the education of her five daughters, her “best assets.” Her husband divorced her and she must raise her three children alone. She battles depression but doing this work helps her cope.

On the ride back I am full of thoughts, ruminating on the new lessons of the day. Health delivery here is a high stakes game on a rough playing field. The sun has set.

The heat is exhausting so I collapse on the bed under the fan.

WDI on a boat!

 

Internship beginnings!

Surabhi Rajaram

In the twenty-minute stretch from Dhaka International Airport to Gulshan Thana alone, the driver pointed out Save the Children, BRAC, UNFPA, UNICEF, ICDDR, WTO, DFID, Grameen Bank, CARE, GSK, and various country embassies - an overwhelming presence of international heavyweights in the form of offices, billboards, and marked vehicles. This silo of foreign relations leaks into the bustling markets, cottage industries, and traffic gridlock that is Dhaka. It is an interesting thought on a small country’s affinity for a large global investment and certainly an apt introduction as I engage in the global health field with CARE Bangladesh.

Fragrant jasmine flowers

My name is Surabhi Rajaram and I am pursuing an MPH in Health Behavior and Health Education at the School of Public Health.  I am a professional student with internships abroad as my limited insights into the “real” working world. This, in addition to an obsession with The Office, has probably skewed my understanding of the traditional workplace. I love it!

This summer, I am grateful to be joining the CARE-GSK Community Health Worker Initiative (CGCHWI). The initiative is part of GSK’s 20% reinvestment program to strengthen health systems through development of a skilled workforce. In a remote area of Bangladesh, female health workers called Private-Community Skilled Birth Attendants (P-CSBAs) are being trained and deployed to combat high rates of maternal and infant mortality.  My project this summer is to develop a sustainable and scalable business model for equitable healthcare delivery through this network of P-CSBA entrepreneurs.  I will be primarily field-based in the Sunamganj district with Dhaka bookending my stay.

Safe birthing kit

Thus far, my impressions of CARE BD Headquarters have been provoking. There is not enough to say for an organization that internalizes the core tenants it hopes to foster through its projects – women empowerment, dignity. As much as the workplace is filled with self-aware fathers of daughters, sons of mothers and brothers of sisters, it is filled with daughters, mothers, and sisters empowering themselves through work for their fellow people. The team brings a dignity to their work through compassion and mutual respect. I am thoroughly enjoying being called Surabhi Didi (sister) and welcomed not just as an intern, but as a member of the “family.” Looking forward to learning with this amazing team!

Stay tuned as I continue to share about my experiences this summer! And apologies for the embarrassing amount of acronyms.