• Lwala Progress Report April, 2008
• Lwala Update Spring 2008
• Lwala Holiday Update 2007
• Lwala Clinic Report by Dr. Young, August 2007
• Lwala Community Alliance Blog
• The Vanderbilt University site on Lwala
• The Pulitzer Center on Crisis Reporting on Lwala
• Morbidity Report, May, June 2007 (pdf)

April 2008
By Ian Swan

Since our last update in November, 2007, much activity has surrounded the community of Lwala, Kenya, as well as its new primary health clinic. Beginning in late December, post-election violence rocked Kenya, with a particular focus of the chaos centered in the Western provinces. Long standing inter-tribal conflicts fuelled riots sparked by the questionable polling and vote counting practices. By the time the two feuding political parties had signed a power sharing agreement in late February, more than 1000 deaths and 300,000 displaced citizens had been reported. Throughout these months of turmoil, my thoughts and worries were consistently drawn to the people of Kenya, and particularly to the safety of the community of Lwala. My fears for this beautiful village were thankfully assuaged by the sporadic updates from members of the Lwala Community Alliance (LCA) who were in Kenya when the violence broke out. According to LCA executive director Joel Wickre

"The violence did affect the clinic, though perhaps not in the way you'd imagine. Lwala was peaceful, and for precisely that reason many patients who would otherwise have gone elsewhere walked great distances to get healthcare in Lwala."

Though there was a delay opening after the holiday, the clinic staff took advantage of a relatively peaceful window in mid January to return to the village, and the health center has been running ever since. Because the city hospitals were immobilized by the unrest, the clinic's patient load increased significantly. Well over 2,000 patients per month are now being seen!

The most exciting recent news coming out of the LCA/RMF partnership is the approval by the RMF board of directors for the financing of a vehicle to act as ambulance for the clinic. After many months of searching for a suitable vehicle by people on the ground, RMF received news in mid-March that a well maintained, truck-based 4x4 had been found that, with a few modifications, would serve as a perfectly capable emergency vehicle. Compared to other bids of quotation on other used and new vehicles, this particular proposal clearly stood out due to the quality of the vehicle and the price (including modifications.) The addition of such an emergence vehicle will undoubtedly improve the safety and efficiency with which the Lwala clinic can care for its patients. Past tragic instances speak to the necessity of this ambulance:

[Erastus Ochieng' Memorial Lwala Community Health Center founder], Milton, recalls a pivotal experience as a teenager, when he was called upon in the middle of the night to help push a woman suffering from complicated labor to the hospital in a wheelbarrow. She died on the way, and Milton turned around and wheeled her back home for her funeral.

Another way in which RMF has been actively trying to assist the Lwala clinic is through the procurement of bicycles for use by community health workers (CHWs). The cornerstone of the LCA's proposed HIV/AIDS program is a network of trained CHWs. These CHWs will be recruited from local HIV/AIDS support groups and women's groups. Already, three CHWs have been hired to follow up with patients on ART through partnership with Tabaka Mission Hospital, a quality tertiary care hospital 20km from Lwala. They will be trained at the Lwala clinic in home-based care, ART adherence, and social support for people with HIV/AIDS, using a curriculum designed by Partners in Health. Each CHW will be equipped with a bicycle and basic supplies such as gloves, and will each be paid a small monthly stipend, intended to augment their normal daily activities rather than replace them. Each CHW will be assigned to no more than 4 patients near their home. Every patient on ART from the health center living within a 10km radius will receive daily in-home follow-up and directly observed therapy from a CHW. The CHWs will provide important follow-up to identify drug side effects and reactions, to ensure regular clinic attendance, and to help address threats to patient success as they arise. They will also act as a referral network for new patients.

On a less positive note, the former clinical officer (Peter Ochieng'), whose salary RMF had been funding, recently chose to leave the Lwala clinic in exchange for a government job. Such transient employees are an unfortunate fact of life for this clinic due to its remote location and thus unglamorous lifestyle for its staff. Those in charge of staffing the clinic are well aware of this burden on clinic sustainability and try, at all costs, to employ individuals who have, for whatever reason, a greater commitment to the clinic's continued success. As such, any search for new staff members is tailored to unearth those individuals who express sincere interest in the long-term care and growth of the clinic and its surrounding community.

November 2, 2007 Update
By Ian Swan

In October of 2007, the decision was made for RMF to become an official funding partner of the Lwala Community Alliance (LCA), the U.S. branch of the managing body of the Erastus Ochieng' Memorial Lwala Community Health Center. Committed to helping financially support the Lwala, Kenya based primary health center, RMF has begun subsidizing the salary of the current clinical officer, Mr. Peter Ochieng'. Additional partners in financial support are currently being investigated by the RMF team.

Update on visit to Lwala by LCA Project Director Joel Wickre

Although loaded with a seemingly insurmountable list of work goals (see previous update) Joel Wickre returned from Kenya in October having addressed nearly every task he had set for himself. The following is a description of the current situation for each of the major work goals of his trip:

Milton, left, and Joel at work during a spring 2007 visit to Lwala

Accounting and Budgeting

• Financial policies, including accountability, out-of-budget spending, and operating reserves were discussed and outlined in a document reviewed and agreed upon by the Lwala Village Development Committee (LVDC.) Electronic financial recording is now occurring thanks to newly implemented accounting systems. "Financial Workshops" were held in which those individuals responsible for recordkeeping were trained in the use of the computer based reporting files.
• The banking in Kenya is currently being reworked as a new account is being set up at a different bank. New policies regarding bank account signatories and their roles were outlined and agreed upon by the LVDC.
• Finances are overseen by the Lwala Community Alliance, a 501c3 non-profit organization.

Staff Training

• All the clinical staff employed at the clinic has been taking advantage of training opportunities presented to them by clinic management and Ministry of Health (MOH) partners. New relationships with the MOH and other local health facilities promise to bring more training opportunities in the future, a trend which excites both clinic management and clinic staff as the value of continuing education is well understood by all.
• Some recent training sessions attended include Prevention of Mother-to-Child Transmission (PMTCT) of HIV, vaccination strategies with regards to Maternal/Child Health, and training in tuberculosis (TB) testing. As a result of this training, the clinic now provides specialized maternal and child health care one day a week.
• Continuation of computer skills training was possible while Joel was in Lwala. Coverage included those skills most critical for the implementation of financial, inventory, and patient recordings.

Clinic staff with first baby born at clinic. Left to right: Nurse Olivia, clinic manager Omondi, former lab tech Ezekiel, father, mother, clinical officer Peter, night watchman Richard, and receptionist/committee treasurer Suzzi.

Clinic Management

• Specific job descriptions for each employee were discussed and agreed upon by staff and management. Contracts were written for all employees outlining responsibilities, daily schedules, benefits, salary, and contract period. Time sheets were implemented to promote staff efficiency and accountability.

Reporting/Record Keeping

• Along with a new electronic accounting system, modifications were made to existing electronic inventory and morbidity tracking systems.
• The new inventory system keeps track of weekly pharmacy output and automatically calculates suggested ordering quantities for every medication available at the clinic so as to maintain at least 3 months worth of reserves.

Networking and Referrals

• After months of waiting for a visit from the regional Minister of Health (MOH), his unexpected appearance in September was celebrated. The MOH praised the clinic, complementing the quality of staff and facilities and welcoming the healthcare services being provided to a community which was not being served previously. The benefits of this partnership have already been observed as TB tests/meds have been provided to the clinic and arrangements are in place to bring counselors to Lwala for HIV Voluntary Counseling and Testing (VCT).
• A referral partnership with the St. Camillus Tabaka Mission Hospital, a nearby tertiary care hospital, has been arranged. Along with admittance to Tabaka hospital of referred patients, plans are being made for Lwala to be a satellite facility of Tabaka's newly updated HIV services. This would include the provision of antiretroviral therapy (ART) medications as well as access to sophisticated lab services. This partnership has been strengthened with the creation of a memorandum of understanding (MOU) outlining the continuing relationship between Tabaka hospital and the Lwala clinic.

Ambulance

• The search for a suitable vehicle to act as a clinic ambulance is ongoing. Bids of Quotation (BOQs) are being asked of any potential seller to ensure value of any purchase. The clinic manager, Omondi Ochieng', has been continuing this search through personal contacts in Nairobi.
• In the interim, both Rongo hospital (managed by the MOH) and Tabaka hospital have offered to dispatch their vehicles if an emergency were to arise in Lwala. However, this option for emergency transportation is limited since the vehicles offered would not be able to navigate the road to Lwala in time of rain.

Two final updates from the clinic:

The month of September saw the first two births at the Lwala clinic. In just one night two soon-to-be mothers arrived at the doors after the clinic had closed for the day. Both Olivia, the newest nurse, and Peter, the new clinical officer, were still around and helped the women with their deliveries. Both babies were delivered without complications and two new children were welcomed into the community. Both mothers were grateful for the staff's help and were very happy with the experience of giving birth in the clinic. These births highlight the need for proper maternity services at the clinic (e.g. OB/GYN delivery/surgical table, baby warmer, etc.) a priority that is understood by the clinic staff and management.
On the left: Clinical Officer Peter Ochieng' with the first baby born at the clinic. On the right: the second baby born at the clinic; mother and child.
Ezekiel, the lab technician hired in August, left the clinic due to the draw of other employment. Although his departure has left a gap in the available services at the clinic, the work he did in building a functioning lab will benefit the clinic for years to come. Finding a new lab technician is a high priority since diagnostic capabilities have become an important aspect of daily clinic services.		Former lab tech, Ezekiel, using newly acquired electric microscope

September 9, 2007 Update
By Ian Swan

Staff:

• A new clinical officer, named Peter Otieno Ochieng', was hired in early August. Peter is the third CO to be hired for this postion since the clinic's opening in April, 2007. The quick turnover at this position has been due to the luring away of CO's by more attractive jobs working for Kenyan government institutions. At the present time new staff members are being housed on the Ochieng' family homestead. Comfortable as these conditions may be there remains a need for permanent, independent housing structures on the clinic property for non-local staff.
  
• A laboratory technician, named Ezekiel, was hired in early August. Ezekiel will be the first lab tech at the Lwala clinic as laboratory services are still being developed at the clinic. During this past summer two Vanderbilt Medical students were responsible for implementing both gastrointestinal parasite lab investigations and research on the efficacy of rapid diagnostic tests for malaria. The work done by these students has given the clinic, and Ezekiel, a jumpstart in setting up a useful and active laboratory.

Infrastructure:

• Bringing electricity to the clinic and the community is an ongoing task and will require much community organizing and politicking.
  
• A quotation for the purchase of a new rain water collection tank has been sent to the Lwala Community Alliance (the U.S. governing body) for consideration. With the purchase of a new, larger collection tank a rain water plumbing system can be constructed to supply the clinic with a much needed source of clean water.

The newly appointed project director of the Lwala Community Alliance, Joel Wickre, is currently visiting the clinic in Kenya and will remain there until the end of September, 2007.

A brief categorical look of current work goals at the clinic:

1) Accounting and Budgeting; improving and unifying a computerized accounting structure, developing important accounting and spending policies, streamlining our banking, etc.

2) Training and clarifying misconceptions about organizational structure; teaching staff and LVDC, reconciling LVDC and LCA bylaws

3) Clinic management; creating job descriptions and responsibilities and contracts for each staff member, working on staff benefits, getting Omondi’s management course figured out

4) Other record keeping; improving pharmacy records, morbidity reports, manager’s reports

5) Networking and Referrals; meeting the MOH and discussing our mutual concerns and partnership, setting up a provider agreement with Tabaka hospital for referrals

6) Politics; encouraging along the land transfer process

7) Ambulance; getting 3 bids, appointing a mechanic and driver, developing vehicle use and service policies (we have several promising leads on this in RMF’s price range)

8) Water; developing a plan for pursuing running water at clinic and safe water for the whole area

9) Other infrastructure; details like fences, doors, etc.

10) HIV; updating plan with staff input, looking toward implementation

11) Maternity; developing plan with staff input, looking toward implementation

12) Patient follow-up; following up with some zebra cases Dr. Bill Young saw

August 6, 2007 Update
By Ian Swan, Lwala

Patients waiting to be seen by nurse. Most patients arrive before the clinic opens at 8 am to ensure they will be seen that day.

During the first three months of operations (April-June 2007) the Lwala Community Clinic saw a total of 1854 new patients with nearly 60% of those patients being children under the age of five; approximately 13% more new patients each month.   This trend of increasing patient numbers is expected to continue as word of the clinic spreads throughout the region and as new services are introduced at the clinic (i.e. maternity care, immunizations, and HIV/AIDS testing, counseling, and treatment.)

1. After a period of voluntary scrutiny and hands-on screening by Fred Ochieng' a lab technician has been chosen and will most likely be hired in the near future. This person will help to stock the laboratory with those tests which will increase the accuracy of the clinic's diagnostic capabilities.
2. A more highly trained clinical staff member, most likely in the form of a Clinical Officer, is currently being searched for. In the past three months the Lwala clinic has had two different Clinical Officers on staff but each one quickly left the clinic after being offered more lucrative and more secure government positions elsewhere. It is thought that it will be necessary to increase the attractiveness of the Clinical Officer position in Lwala by not only offering a higher than market wage but also by providing comfortable housing for any employee and his or her family.
   

As of the end of July, 2007, the staff of the Lwala clinic included:

• 2 Rural Community Nurses
• A clinic manager
• An accountant, hired on contract
• A receptionist
• A pharmacist
• A security guard
• A janitor

Finances:

The accountant who is currently under contract with the clinic is producing a trial balance of all the clinic financial records on file since the initial phase of the clinic construction back in 2005. This accountant has much experience creating clear and thorough financial records through his many years of working for the regional primary and secondary schools, however he is not a certified accountant and thus in the future his work will need to be checked and approved by a certified accountant.

1. Inputting all expenditures and income received into a computer database
2. Creating monthly financial projections
3. Scanning and saving of all financial documents

These records will be emailed to all interested parties on a monthly basis and will also be stored more securely by saving them onto a CD which will be stored at the clinic.

A budget proposal for financial requirements for the month of August, 2007 (written near the end of July, 2007) was put together through collaboration between the clinical manager, Omondi Ochieng', the project director, Dr. Bill Young, and Milton Ochieng'. The estimated value of all foreseeable clinic expenditures (i.e. salaries, medical supplies, consumable goods, communications, patient referrals, transportation, construction and repair, utilities, and administration costs) was calculated to be 310,000KSH or approximately 4,500USD for the month of August, 2007. It is unlikely that this value will remain fixed for subsequent months as the clinic is very much in a state of flux and will continue to be for many months and years to come. With new services implemented at the clinic there will no doubt be a rise in monthly expenditures, however the major costs of the clinic will always be staff salaries and cost of medicines, which show greater constancy. The estimated annual financial need of the clinic proposed by Omar Amir in a previous update seems probable at this point, particularly considering the expansion of services that is scheduled for the near future.

At the present, the Lwala clinic is powered by a small array of solar panels which charge a bank of batteries housed in the storage room. This energy source, although not free from occasional technical difficulties, has proved adequate for the energy demands of the clinic over the first three months of operations. Currently, the only energy uses by the clinic are for the computers and printer, the exterior lights during the night, the interior lights, and recharging of staff cell phones. None of these electrical draws are drawing power throughout the entire day, indeed most of them are relatively infrequent. The electrical system is not perfect however in that it has, in the past, gone offline for days on end. At this time, when no crucial medical equipment is being powered by this electrical system, it is not too serious if and when such power failures occur. However, in the future, when potentially life sustaining equipment is being used in the clinic (e.g. a baby warmer) it would be a serious problem to have unreliable power.

Efforts being made to secure reliable power are all focused on connecting the community of Lwala to the regional electrical grid. This would mean putting power lines and poles in place to connect the community to the nearest lines as well as purchasing a transformer for the community. This enhancement is currently being investigated not only by the clinic manager but also by the Lwala Community Clinic Committee.

Clinical Staff:

Maintaining a high level of quality of care is very important to all those involved in the Lwala clinic. The current clinical staff consists only of two Rural Community Nurses. Continuous broadening of the staff's knowledge base and skill sets is already being instituted through out-of-town training programs, the costs of which are covered by the clinic. This is an important and vital way to augment the quality of the clinic's healthcare efficacy and will surely continue in the months and years to come. Aside from continually educating current staff members, it is also deemed necessary to acquire a more senior medical staff member, one who has a higher degree of medical education. To this end, a Clinical Officer is currently being searched for. This individual will not only be able to better perform various medical procedures than the current nurses but will also provide yet another source of knowledge from which other staff members can acquire information and skills.

1. Family Planning/Mother and Child Health services will soon be offered by the newest nurse, Olivia. She has recently completed her training and certification in this area and will begin offering this service, to women primarily, on scheduled afternoons once a week.
2. For safe maternity services to be offered by the clinic it is necessary that both adequate electrical power and safe water supply are up and running at the clinic. On top of this, a trained individual is necessary to perform the various procedures. It is thought that once maternity services are provided by the clinic the patient load will increase dramatically.
3. HIV/AIDS testing, counseling, and treatment services are desperately needed in this community. Before implementing the treatment of HIV/AIDS through pharmacological therapy it will be necessary to have already in place the testing and counseling aspects of such a service. Staff members must be trained and certified by government health authorities before such testing and counseling services will be permitted. On top of the clinical services necessary in providing comprehensive HIV/AIDS care, it is crucial to also supplement these in-clinic services with community outreach initiatives and in home follow-up and care. The new project director of the Lwala Community Health Clinic, Joel Wickre, is very focused on tackling this issue and has many ideas for providing high quality, comprehensive care for those individuals and families suffering the effects of this prevalent disease. Key in Joel's vision is the multi faceted socio-economic support of afflicted individuals. This area of the clinic's operations will undoubtedly see drastic expansion and the creation of unique initiatives in the coming months.
   

Materials and Supplies:

• RMF is currently brokering a partnership between World Bicycle Relief and the Lwala Community Health Clinic. This partnership will see 6 bicycles delivered to the clinic for use by the clinic staff when performing in-home care and patient follow-up.
• A partnership between Direct Relief International and the Lwala clinic is currently being worked on by Martina Fuchs. Such a partnership would provide the clinic with required medicines and medical supplies. As the cost of medicines is such a major expenditure, this type of support would be of great benefit to the clinic.

July 22, 2007 Update
By Ian Swan, Lwala

Arrangements have been made for the donation of six bicycles by World Bicycle Relief for clinic personnel.

At the moment, the biggest project in Lwala is the testing of the well situated close to the clinic. It is being tested not only for biological content but also for output flow to determine whether it would be wise to invest 15,000USD in an electric pump to bring potable water to the clinic.

Bringing electricity to the community is still being investigated through the acquiantance of Dr. McObewa. Since RMF's mandate is medical relief perhaps this project would not suit our funding capabilities, that can be something to discuss. At the moment the clinic draws power from it's bank of solar panels however with the lab being setup and more electrical equipment being used the output of this system may be insufficient.

Regular morbidity, medicine inventory, and financial reports will be compiled and sent by the clinic manager, Omondi Ochieng (MIlton and Fred's older brother.) As well, all receipts and other documentation regarding clinic expenditures will scanned into the computer and sent to RMF headquarters in Los Angeles.

The newest nurse hired, Olivia, is travelling to the nearest hospital this week for three days of MCH/FP training. She already has training in vaccinations and I believe maternity work.

A clinical officer is still being looked for. All the employees salaries will included in the regular financical reports and RMF can decide on it's contribution towards salary support from this information.

July 7, 2007 Update
By Ian Swan, Lwala

-Some blatant clinic necessities are: transportation for patients (4x4 vehicle and bicycles), medicines and finally MORE CLINICAL STAFF.

-The initiatives of the Vanderbilt University students here are noteworthy and include:

• well-water sampling and spring protection,
• improvement of clinic medical records system(ie. filing cabinet and/or e-records),
• small business for the local women's group selling baskets back home in US,
• parasitology study in school kids and subsequent treatment for worms and other GI parasites,
• research about HIV/AIDS beliefs in villagers,
• bed net sales from the clinic,
• malaria testing using rapid diagnostic tests(RDTs) and their efficacy.

Clinic Opening and Celebration

June 2007 Update

By Caitlin Reiner and Milton Ochieng

The clinic opened on April 2, 2007. Milton and Fred were able to return home for the opening ceremony. Over 100 patients showed up on the first day. The clinic has been seeing, on average, about 30 to 40 patients per day, and has seen over 1,000 patients thus far. A clinical officer, nurse, manager, secretary, nurse aid, room attendant, groundskeeper, and night watchman have been hired. With support from UNICEF and Kenya Expanded Programs on Immunization, the clinic is hosting a Mother-Child Week this week, June 9 to 16, for pregnant women and children under five. Immunizations and Vitamin A will be administered. Fred has returned home with several volunteers for the summer. Dr. William Young will follow next week with more volunteers. The focus this summer is on water, mosquito nets, sanitation, and electronic medical records. The clinic well operates by hand pump and the water is carried to the clinic. The water is currently being tested in nearby Kisumu for safety. Our next steps will be to install a solar pump system. This summer, Vanderbilt volunteers are working with Lwala villagers to protect community springs. A group of students from Vanderbilt has raised over $1,500 to buy mosquito nets in Kenya that will then be distributed from the clinic. Other volunteers hope to set up hand-washing stations at Lwala Primary School. Finally, we are working to firmly establish an internet connection at the clinic and use donated laptops to record patient visits and records.

January 2007 Update

By Omar Amir

I. Introduction

This proposal has been prepared for the Real Medicine Foundation by the USA Lwala Development Committee to explain the history, vision, objectives, organizational structure, project components, and funding objectives of the Lwala Public Health Project.

II. Project History

Lwala is a village of approximately 1500 people near Lake Victoria in western Kenya. Within an hour’s walk, approximately 3000 additional people live in nearby villages accessible by dirt roads. The majority of the area residents are subsistence farmers. Poor physical infrastructure, including impassable roads during the rainy season, lack of electricity and lack of reliable drinking water, have helped to create a critical healthcare challenge in Lwala. Malaria, intestinal disorders, tuberculosis, pregnancy complications, HIV/AIDS and other diseases contribute to a significant infant, child and adult mortality rate. For example, of the 408 children in the Lwala primary school, 121 (29%), have lost one or both parents. The official 15% prevalence of HIV in the region is the highest in Kenya (2003 Kenya Demographic and Health Survey). Of the 529 villagers who were tested in 2006, 32% were infected (24% men and 40% women).

The nearest health facilities in Rongo, Riana or Asumbi are approximately 10 kilometers away and provide only basic clinical services. Acute care patients receive treatment at government hospitals in Kisii (40 km away) or Homa Bay (41 km), but travel to these sites is very time consuming and often prohibitive.

The Lwala clinic was conceived by the late Erastus Ochieng, a school teacher and community leader in Lwala. Before his death from AIDS, he organized a community committee to build a clinic so that the village would not suffer from lack of access to health care. Two of his sons, Milton and Fred Ochieng, brought this vision with them as they pursued their education in the USA at Dartmouth College and now at Vanderbilt Medical School. Milton organized his Vanderbilt Emphasis Project around the clinic in 2004. Fred supervised the completion of the clinic in 2006, and conducted a village health survey as part of his Richard Lombard Public Service Fellowship at Dartmouth. The Lwala community committee organized the donation of the land by local farmers and the construction of the clinic by local volunteers. Milton and Fred have been advised by faculty and friends, the Ministry of Health (MOH) in Kenya, and experts in international health care such as Paul Farmer of Partners in Health.

A health clinic has been built and will open in spring 2007. A water well was drilled in September 2006. Our aim is to improve the health of the people by developing the village infrastructure with potable water, electricity, dependable communications, passable roads, and safer cooking systems. Another major goal is to provide education for the village children and implement a micro-finance development plan for the adults to relieve poverty and enable a sustained improvement in the quality of life.

III. Vision

The comprehensive vision of the Lwala Public Health Project is to promote the physical, social, educational, and spiritual health of the people of Lwala village and surrounding rural area. The Public Health Project includes a community medical clinic, village infrastructure development, education improvement, and micro-enterprise development.

IV. Values and Principles

1. Long term commitment: The project will provide lasting benefits for the community.
2. Community-based ownership: The local community will share ongoing responsibility for the project.
3. Accountability: The project will ensure proper stewardship of all funds.
4. Cultural sensitivity: The project will be responsive to local culture and customs.
5. Holism: The project will provide education, prevention and care.

V. Mission

1. The Lwala clinic will provide accessible and sustainable health care, including HIV/AIDS prevention, education and care.
2. The infrastructure projects will improve community health by decreasing the severe disease burden related to water and sanitation, reducing diseases and injuries through safer cooking fires and other measures, and enabling transport of patients to regional medical facilities.
3. The Education project will assist the children of the village to learn, advance, and contribute to the community.
4. The Micro-enterprise project will provide individuals with the means to earn a living for themselves and their families, and thus to be able to contribute financially to the community.

VI. Objectives

1. Clinic (Appendix A)
1. Build, staff, and resource a primary health care clinic in Lwala
2. Provide basic health care services including clinical care for:
1. Acute illnesses, injury management and triage
2. Chronic illness management and appropriate referral
3. Preventive health interventions
4. Health care education for common acute and chronic problems
2. Infrastructure (Appendix B)
1. Provide safe water firstly for the clinic, secondly the school, and then the village.
2. Improve sanitation through construction of ventilated toilets.
3. Provide electricity to the clinic for light, cold chain (for storage of vaccines and medicines), and communication and finally the village.
4. Improve transportation by making the road passable and providing a village truck.
5. Enable communication through cell phones and internet connection for the clinic.
6. Reduce injuries and respiratory diseases by ventilated and safer cooking systems.
3. Education (Appendix C)
1. Provide primary school education assistance though scholarships and loans.
2. Improve elementary school class rooms with desks, black boards, and lights.
3. Improve elementary schools by providing ventilated latrines, a library, and teacher housing.
4. Micro-enterprise (Appendix D)
1. A micro-loan system will be initiated with start up funds and the eventual establishment of a self-sustaining system.
2. Money will be loaned for the following enterprises as identified by Lwala villagers: Agriculture in livestock and crops, transportation schemes including motor bikes or operation of a village truck, technology rentals including cell phone or computer use, and trade in products like hand-woven baskets.

Appendix A

Build, staff, and resource a primary health care clinic in Lwala

I. Timeline

The target startup date is spring 2007. A manager will be employed prior to that date in order to assist with construction completion, hiring of other employees, and provisioning of the clinic with equipment, supplies and medications. Essential provisions will be purchased by the startup date, and additional equipment, supplies and medications will be acquired later in 2007. The specific timeline is given in the budget in Section VI of this Appendix.

II. Services to be Provided

A. A broad primary care public health approach will be applied to all disorders:

i. Clinical care for acute and chronic problems plus triage and referral

ii. Preventive health interventions

iii. Individual and community health education

B. Estimations of disease prevalence used for planning clinical services have been taken from reports for this area, including the World Health Report 2004, Kenya Demographic and Health Survey 2003, the Rapid Catch Health Care Survey of Lwala Village 2006, reports from similar Kenya clinics, and the opinions of villagers. The skills of a rural clinical nurse or a clinical officer have also been taken into account. The goal is to begin operation with basic services, and expand into more complicated diseases such as HIV/AIDS, once clinical skills, finances, and drug supply allow. Specific care planned for the most prevalent diseases is available in a second report.

C. Cost analyses for treatment, prevention, and education regarding specific disorders are based on data from Christian Health Association of Kenya TIME, CHAKs Annual Reports, estimates from similar clinics in Kenya, and advice from the Migori District Ministry of Health.

D. Services will be phased in and targets will be identified for the start-up, 6, and 12 months later.

III. On-Site Clinical Personnel

1. Manager

2. Clinician: Nurse (Registered Nurse or Rural Community Nurse) or Clinical officer (Kenyan equivalent of physician’´s assistant)

3. Night guard

4. Maintenance person - cleaning and laundry

5. Clinical assistant for nurse or clinical officer

6. Laboratory technician

The manager, clinician, maintenance person and night guard will be hired for the start up. We anticipate that the clinical assistant and laboratory technician will be employed later in 2007.

IV. Clinic Organization and Leadership

A. Lwala Clinic Committee

The Lwala Clinic Committee (LCC) is comprised of representatives from the Lwala community who have joint responsibility of the project. It has been functioning since early 2004. It has accomplished land donation for the clinic site, coordinated community meetings to define clinic objectives and helped with clinic design planning, government building permits, construction including the recruitment of village volunteers and employment of skilled workers, purchase of materials, monitoring and bookkeeping regarding expenditures, and similar critical activities. It will hold primary responsibility for management, including supervisory responsibility for clinic staff, operations and finances. Specific responsibilities include:

1. The clinic manager will coordinate the recruitment, hiring and discharge of the clinic staff, and the LCC must approve of employees hired or discharged.

2. The LCC will seek, investigate and establish appropriate partnerships for supplies, medications, services and funding in Kenya.

3. The LCC will provide an annual review on the clinic manager and report to the USA Lwala Committtee.

4. The LCC, with the assistance of the clinic manager, will report to the USA Development Committee through the project manager at least twice a year, and will conduct an annual financial audit.

B. USA Lwala Development Committee

The USA Lwala Development Committee has been functioning since 2004. It includes Milton and Fred Ochieng and their supporters in the USA. Milton and Fred are the planning coordinators. They serve as natural and essential guides to building, staffing and operations. The USALDC holds primary responsibility for fundraising and provides financial oversight. The co-chairs are Craig Parker and Bill Young. Bill Young is the volunteer Project Manager. His responsibilities include:

1. Coordinating fundraising and long-term financial planning.

2. Assisting with the development and delivery of clinical services.

3. Soliciting consultation as needed.

4. Monitoring clinic accounting procedures and reviewing audits as appropriate.

5. Communicating with the USALDC members and donors.

C. Clinic Manager

A clinic manager will be employed to supervise the completion of clinic building, and begin operations. He/she will report to the Lwala Clinic Committee and will be reviewed annually. Maurice Ochieng has volunteered in this role for 2 years and will be hired as the clinic manager. The manager’ responsibilities will include:

1. Supervising completion of construction and maintenance.

2. Assisting with hiring and supervision of the clinic staff. The LCC must approve of employees hired and discharged.

3. Managing daily operations.

4. Maintaining inventories of medications/supplies.

5. Organizing public health, education, and outreach projects.

6. Assisting the LCC to establish partnerships for supplies, services, and funding in Kenya.

7. Maintaining financial records with monthly reports to the Lwala Committee, semiannual reports to the USA Lwala Committee, and annual audits.

D. Liaison to the USA Lwala Development Committee

Joel Wickre and Cathy Wickre will assist the manager in the operation of the clinic during the start up year. This is prudent to demonstrate the investment of the USALDC in the success of the clinic, to add intellectual, organizational, and leadership power to the process, and to help set up effective systems. Systems will include individual patient records, patient care logs, and medication supplies. Joel and Cathy will also explore, identify and establish valuable partnerships in Kenya with non government and government partners to provide services and materials. They will also finalize the structure of the relationships and communication channels among the manager, the LCC and the USALDC.

V. Financial Operations

The project maintains two accounts, one in the US and one in Kenya. The US account is a non-profit account administered by Vanderbilt University. Funds raised in the US are deposited into this account, from which they are wired to the account in Kenya. The latter account, the Lwala Clinic Committee Account in Kisii, Kenya, is used to build and run the clinic. Signatory authority is currently with the Chair, Secretary and Treasurer of the Lwala Clinic Committee. The Lwala committee thus holds financial responsibility for the Kenya account and for clinic financial operations overall. The US account will be overseen by the USA Lwala Development Committee, which will also provide semi-annual oversight of clinic financial operations, coordinated by the USA Lwala Development Committee Project Manager, Bill Young (Appendix E). Thus, ultimate financial oversight resides with the USA LDC.

Records and Accounting

1. Standard accounting procedures will be employed including proper documentation, delivery and review of receipts and invoices.

2. Standard legal contracts (for eg based on the RMF model) will be employed for hiring staff.

3. Semiannual report to the USA Lwala Development Committee from both Vanderbilt and Kenya accounts (Appendix F).

4. Annual audit by Certified Public Accountant in Kenya.

These records, audits, contracts and receipts will be made available to the Sole of Africa Foundation and Real Medicine Foundation as prospective donors, subject to the specific terms of a Partnership Agreement and Memorandum of Understanding (MOU).

VI. Budget

This budget includes all items necessary for full clinic functioning. They will be purchased as funds allow, ideally according to the plan designated herein. As noted above, cost analyses are based on data from Christian Health Association of Kenya TIME, CHAKs Annual Reports, estimates from similar clinics in Kenya, and advice from the Migori District Ministry of Health.

Appendix B

Basic Infrastructure Projects for Lwala

I. Provide safe water for the clinic, the school, and the village.

Safe water is desperately needed to reduce water borne diseases and improve the overall health of Lwala. The first deep water well has been drilled.

A second well will serve the school. Extra water will serve the community.

b. A pump and secure gravity storage system will be installed. Options include a submersible electric powered pump, a hand operated mechanical pump, or possibly a “play pump (for example, see www.playpumps.org).

II. Improve sanitation through construction of ventilated toilets.

Ventilated improved pit (VIP) toilets are economically feasible, relatively easy to construct, and reduce diseases related to insect-borne diseases. There are no VIP toilets in the village and many latrines are in need of replacement. It is possible to dig pits in this region.

a. Replace 10 current latrines with VIP toilets per year.

Employ local workers and possibly families of clinic patients to complete the construction.

Dig pit, poor concrete slab, ventilate and build house

III. Provide electricity to the clinic for light, cold chain, and communication and then the village.

Electricity will be essential for effective operation of the clinic including refrigeration of vaccines, lighting for medical care at night, and recharging cell phones for communication. If electricity is also available to the school and village, safety will be enhanced, the prospects for life and livelihood will be improved, and the economy should grow.

Solar, electric grid and generator produced power will all be investigated. Start up and operational costs, dependability, political feasibility and environmental impact will all be investigated. Fortunately, power lines are only a few kilometers away which may make this optimal source feasible. Some back up will be needed and a mix of solar and grid power is likely.

IV. Improve transportation by making the road passable and providing a village truck.

The last 5 kilometers of road to Lwala are dirt and frequently impassable by standard cars and trucks. Villagers often resort to transporting sick patients in wheelbarrows, on bicycles, on ox carts, or by carrying them in their beds. A dependably passable road will be essential to providing emergency services at the clinic, and to help non-emergent patients see referral clinicians and have specialized tests. A village truck would serve the same goals. Additionally, improved transportation would open the clinic to neighboring villages, assist children traveling to school, and support the anticipated growth of small enterprises.

Road improvement: Grading the dirt road and adding stones/gravel to low, rutted and wet areas will be appropriate on a periodic basis.

Village truck: A dependable truck with a truck bed will serve as an ambulance, as well as transport for patients to larger hospital clinics, students to secondary schools, and villagers to market with their products.

V. Enable communication through cell phones and internet computer connections.

Communication with regional hospitals, medication and equipment suppliers, and the US Clinic Development Committee will be important for efficient and effective operations. Cell phones have become the standard system for Kenya. Computer access to the internet including electronic mail can be established through the cell phone system.

Computer literacy and connections are become more and more important. Providing 4 computers for the elementary school will permit training, access to educational tools, and facilitate the development of computer based or dependent enterprise.

VI. Reduce injuries and respiratory diseases by ventilated and safer cooking systems.

All villagers cook on open fires with wood fuel in unventilated kitchen houses. Smoke exits through windows and the space between the roof and the walls. Women and children spend many hours a day inhaling the smoke. Asthma, pneumonia, bronchitis and other respiratory disorders are common as a result. Improving the ventilation of stoves and the design will reduce these indoor pollution related problems, make cooking faster, and use less fuel. Numerous inexpensive systems that can be built locally could be used (for example, see www.climatecare.org).

Appendix C

I. Support education by providing scholarships and improving school facilities & capacities

Elementary school is now available free to all children, although parents must buy school uniforms and supplies. Secondary school education is competitive and expensive, costing approximately $500 per year per student. Most children do not have this opportunity. The Lwala Development Committee has a working group that provides secondary school fees for 4 of the best students graduating from Lwala Elementary each year. The village Education Committee administers the program. Expanding the scholarships would empower more children with education and skills.

Kofi Annan, UN Secretary General, observed that “Water is intimately linked with education and gender equality. Girls who have to spend time gathering water for the family tend not to be in school. And where schools have sanitation, attendance is higher, especially for girls.” Water and sanitation, also discussed in the Infrastructure Section, are important to education.

a. Post primary school education assistance though scholarships and loans.

b. Improve elementary school class rooms with desks, black boards, and lights.

c. Improve elementary school buildings with new ventilated latrines, a library, and houses for teachers.

Appendix D

Lwala Micro-finance Project

Micro enterprises are critical to the economic well being of the community. The goal of such enterprises is to provide individuals with the means to earn a living for themselves and their families, and thus to be able to contribute financially to the community. The cycle of poverty and discouragement is broken as individuals are able to take control, in a sustainable way, over the provision of their basic needs, including housing, clothing, education and health care.

A primary goal of the Lwala Public Health Project is to establish a program for micro enterprise development. This program would involve several key aspects, including

1. A paid staff person who would administer the project. Important dimensions of this position include
1. Establishing basic operating policies and procedures for the program
2. Interfacing with a bank that will hold any funds
3. Determining, with the aid of a small committee, which individuals are good credit risks
4. Evaluating business plans proposed by individuals in the community
5. Preparing loan documents
6. Ensuring that loans are paid back in a timely manner
2. A computer and printer for the staff person
3. Supplies for the office and staff person
4. Office space for the program and staff person
5. Initial funds to be loaned
6. A list of potential projects that would be viable in Lwala, examples of which include
1. Agriculture
1. Livestock: raising chickens, goats, or cattle
2. Crops: farming tomatoes, kale, corn, and sugar cane
3. Processing sugar cane and other crops
2. Transportation
1. Motorbike for transportation and deliveries of people, produce and products
2. Small truck for the same purposes
3. Handcrafts and other products
1. Basket making
2. Bottled potable water from the well.
4. Technology services
1. Cell phone
2. Computer-based services, such as email
3. Based on the experience of a number of similar projects, the total cost for the first year of this program would be around $20,000, depending on the number and size of the initial loans.