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Tuesday, March 8, 2011

The Mano a Mano Model

One of the main things that differentiates Mano a Mano is the model that we use. Here we'll briefly walk through the entire process for building a rural health clinic, although the model is very similar for all of our projects.

First, the community in Bolivia approaches us to request a project. This is a huge point; the local community is the driver of the process, Mano a Mano does not pick locations or projects itself. The community goes to our office in Cochabamba to request whatever project they have decided is most important, from a clinic to a school to community bathrooms, and are put on the waiting list until funds are available. When there is funding, Mano a Mano meets with the community and local leaders to sign an agreement detailing everyone's responsibilities:

  • Mano a Mano provides a portion of the funding, skilled labor (architect and contract construction workers), construction materials, most of the needed medical equipment and supplies and furnishings, and continuing health education for the staff and local community
  •  the community provides a plot of land, any locally available materials, unskilled volunteer labor (this usually amounts to around 4,000 hours per clinic), and some funding
  •  the local government agrees to pay the staff salaries of the doctor and the nurse and include these expenses as a permanent line item in their budgets, and to purchase specialized equipment (e.g. microscope, centrifuge)
  • as part of its national health program, the Bolivian Health Ministry provides vaccinations, some medications, and free services for expecting mothers and children up to 5 years old (including its newest program that pays mothers to attend pre and post-natal checkups during the pregnancy)

Community meeting at Mano a Mano Bolivia office to discuss a project; signing an agreement

In this way everyone fulfills a specific role, without which the project would not be possible. During the next phase of the process - construction - the community is involved extensively. Typically a schedule is set up and 4-8 local volunteers work at the construction site daily - laying brick, collecting and transporting materials, cooking food for the construction workers, and anything else that is needed.
Community residents working at Apillapama clinic

The partnership doesn't end after the clinic is built. Anyone who has traveled in the developing world has seen the deserted buildings that used to be clinics or schools, but are now empty due to a lack of long-term planning and support. With our model, Mano a Mano provides most of the furnishings needed at the start for the clinic through our medical surplus program - hospital beds, exam tables, dental chairs, and basic medical supplies. Providing supplies is also an ongoing service; without supplies it is almost impossible for clinics to provide the level of service needed. 

In addition, Mano a Mano provides continuing education courses for the doctors and nurses on staff, as well as basic life support training to a group of community residents that become volunteer health promoters.
Community residents learning CPR

All of our clinics are connected by radio to our office in Cochabamba to talk with our staff about difficult cases or in emergencies. As part of the signed agreement, within 3 years administration of the clinic is turned over to the community, but the health education, medical supplies and equipment, and connection with the Cochabamba office are always an ongoing service.

Included in the clinic design is living quarters for the doctor and nurse. Almost all of our clinics are in rural areas, and without adequate housing it's very difficult to recruit and retain staff. We have had no problem in hiring and keeping doctors and nurses, and they often cite our model (consistent availability of supplies, continuing education courses, clean facilities, reliability of being paid their salary) for why they stay.

The critical component to the whole process is the community itself. We work based on the notion that the community is an able and willing partner in the process to improve their own lives. The fact that they request the project and then commit time and resources to complete it demonstrates their commitment to maintaining the project over the long term. As an example, below is a brief story from Jose Velasquez, Executive Director of Mano a Mano Bolivia, describing a situation that came up with one of our first clinic projects over 10 years ago:

“The mayor had signed a commitment to fund the clinic nurses’ salary but she didn’t receive it for a whole month. When she told us on the radio that she hadn’t been paid, I drove to the community and told the mayor that, if he didn’t pay her within a week that we would close the clinic – I knew he had the money from the health care fund.  He didn’t pay her so I drove there again and met with community leaders to explain the situation and then locked the clinic door. About 50 villagers piled into an old truck, drove to the mayor’s office and set up a noisy demonstration in front of his door, demanding that he pay their nurse. The next day he paid the salary. I think everybody in Bolivia heard about it. We have never had a problem again with the government not following its commitments.”

Using our model, we have built 118 clinics, with 737,312 patient visits in 2010. 113 of these clinics are financially independent of Mano a Mano; 98.77% of the salaries for our 366 doctors, nurses, and dentists on staff are paid for by sources within Bolivia. We continue to move ahead and work with new communities, but the need is great. Currently there are 272 communities that have requested a clinic that are on the waiting list.
Bolivian families waiting in Mano a Mano clinic

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