Thursday, August 12, 2010

Hustling: Providing Sustainable Aid

NGO signs outside Nabisco Estate in Tamale

The most difficult facet of working in Ghana to grapple with has been negotiating the reality that Ghana is a developing country receiving "help" from an alphabet soup of NGOs, developed countries, and well-intentioned individuals. Whenever I travel to the district hospitals to collect data and interview management team members and front-line staff working in the various departments that keep the hospital running, I'm always greeted with this inexplicable eager attitude. Ghanaians are extremely hospitable and generous people, but I often wonder if the better than anticipated cooperation I have experienced would be different if my skin were darker.

One of the most common questions and comments I have received from my interactions with the district hospitals falls into a category I'd like to call, "What can you give me?" For example, when I tour the lab facilities of the hospitals to determine the types of services offered and gather a general impression of the quality of those services, the lab equipment that is broken or needs replacing are usually the first items I'm shown. At the end of these tours, the lab technicians almost always shyly say that their lab has so much potential if only they had X, Y, and Z and that they would appreciate and benefit greatly from anything I can offer to them. Unfortunately, my work in Ghana is primarily research. I am assessing the types of changes an OB/GYN can make at a district hospital and the potential these district hospitals have as teaching hospital sites. As a poor medical student wallowing in debt, I have nothing tangible to offer. So, my response to these comments is usually a smile, a joke about my medical school debt, and walking away from the situation wondering how many other obroni have toured the facilities before but with the promise of lab equipment to offer. In the end, I comfort myself with the thought that these lab technicians are mistaken. I’m here in Ghana to help at a level much higher than providing medical supplies. I’m here to do research and facilitate change.

The dark truth of my work didn’t occur to me until one of my interviews with a hospital administrator. At the end of the interview, he frankly pointed out that he was aware of and understood the benefits I’d receive from my time in Ghana. I would analyze the data collected and publish my findings. This would then contribute to furthering my career in health care. But, in the starkest of terms, what’s in it for them? What do these hospitals get in return for allowing me to freely wander around, stepping into the shoes of the management team and frontline staff? This conversation immediately triggered the loudest bells and whistles in my head—it was an exact parallel to an account of a conversation that Sudhir Venkatesh had chronicled in his book, Gang Leader for a Day, which describes his sociology research of crack-dealing gang-life in Chicago (highly recommend the book if you have not read it!).

In his book, Venkatesh was discovering the motivations and incentives for the members of this society to engage in drug dealing, prostitution, and other related behaviors. Everyone was hustling for a living. It then dawned on him that he was no different. Venkatesh was hustling the community, nabbing interviews and getting unprecedented access to account books and individual personal lives and to what end…for his own PhD work. My experience in Ghana is really no different. I can’t promise any immediate material benefits to the participating hospitals that have been instrumental to my work. I may be able to make some management and policy recommendations at the end, but I have little power in guaranteeing that my recommendations will change or at the least contribute to the continued regional and national level discussions on how to improve maternal mortality. As someone who enjoys the implementation portion of change, being stuck at the research end can sometimes feel like I’m walking through tar.

Health education workshop at Abono Primary School

My thoughts then moved onto to think about ways that I could sustainably contribute to the operations and improvement of the district hospitals and perhaps even make an impact on maternal mortality in Ghana (all of my travels take at least an hour, so I have plenty of time to think!). Even if I had the means, providing these hospitals with medical equipment or even a monetary donation is unsustainable and only feeds the willing acceptance of hand-outs and donations attitude that I have noticed across the entire country. While I applaud the attention that many NGOs give to developing countries, I think that most of their efforts are largely made in vain. How is it sustainable to ship doctors in for two weeks to perform surgeries within a community and then leave the community waiting for the next visit? Even a short visit I had made to a village elementary school with the IFMSA exchange students to teach healthy nutrition and dental habits could have been executed better to place a greater emphasis on the conceptual lessons learned rather than the toothbrushes and pens we handed out to the children. I can’t say this with certainty, but I do think the time we spent taking pictures with the children and school was comparable to the actual time we spent teaching the children how to brush their teeth and healthy eating habits.

There are three models of aid that I think satisfy the criteria of sustainability and positive impact. At a national level, I think China’s involvement in Ghana, while some say are efforts of colonization, qualifies. The Chinese government enters contracts with the Ghanaian government to bolster Ghana’s infrastructural development. Chinese companies then bring their expertise and equipment to Ghana while employing both Ghanaian and Chinese labor to build much needed transportation networks and other industrial essentials. This represents a knowledge and technology exchange in addition to the concrete infrastructural end products. At the very least, with better roads all of Ghana will attract more domestic and international commercial opportunities, furthering its development and improvement.

Project Fives Alive also qualifies as a sustainable model of aid. Project Officers identify Change Agents, who are local individuals charged with organizing and facilitating the health care improvement efforts in a specific locale. All of the quality improvement (QI) teams are also trained in the basics of quality improvement by attending a series of learning sessions, which empowers them to take on challenges and continuously make improvements. While Project Officers are there to encourage and motivate the teams, there is a clear exit strategy. Project Officers used to check in with the QI teams once a month and now only visit once every other month. Thus giving the QI teams the confidence and freedom to apply the knowledge and skills learned to make improvements on their own.

Although my research project will not yield immediate benefits to the participating hospitals, it is part of an important and sustainable partnership between the University of Michigan and Ghana’s Ministry of Health, Ghana Health Services, and teaching hospitals. Over 30 years ago, a novel postgraduate residency training program was created to address the low specialist retention rate and high maternal mortality rate. Since then, over 80 OB/GYN specialists have been trained and all but one have decided to stay in Ghana to practice. While the majority of the specialists are practicing in the big cities of Kumasi and Accra, a few are beginning to move out to work at the district hospitals—bringing expert knowledge and skills closer to the communities that are struggling with the safe delivery of babies. My research work focuses specifically on identifying the types of changes occurring at these district hospitals both in regards to the clinical treatment of obstetrics, gynecology, and emergency cases and the overall management of the hospitals. While I do have a considerable amount of analysis left to do, I can say that there have been significant positive changes. Since I have also been assessing the potential for district hospitals to become teaching sites for medical students and house officers (equivalent of US intern), this means that policies to move medical training closer to the areas of need are in the works. This academic-government partnership has been a very successful and sustainable effort that is only going to expand to further address maternal mortality concerns.

The gang leader Venkatesh followed, JT, allowed Venkatesh to follow him and document his work for years because he assumed that Venkatesh would one day write a book about him. Gang Leader for a Day isn’t a biography about JT and took years to be published. But now, it’s a popular book sitting on the bookshelves of many all around the world. So, while it may feel like I’m hustling now, I can say with confidence that we’re in it for the long haul. Positive change will happen. It just won’t take the form of a new electrophoresis machine, a skin graft procedure for one individual patient, or a toothbrush. It’ll be even better than that: a solid and sustainable system that allows Ghanaians to deliver quality health care to their people. I hope that is enough of a promise for now.


  1. Eva, I enjoy reading this entry! and am touched by your passion in your research project, and I am sure your efforts will contribute to long-term improvement in Ghanaian health care system!

  2. The hospital administrator is right; no matter what we are doing, development work, voluntourism, research, we have to think of those with whom we are working. We need them to be able to do the work, but if the whole point is to help them, then how are we actually doing so, if we even are? When it comes to research, ethics dictate that we give participants some form of compensation, but when researching in a so-called “developing country”, those rules fly out the window. Why?