I’m already in the last week of my visit, and as usual things have flown by too fast. This monsoon has been more spirited than last year’s, blanketing us in torrential downpours every night and through each morning. Finally this week the weather seems to have calmed down, but I’m missing the cool and comforting feeling of the rain closing us in with its clattering and clanging.
The main focus of our summer has been a new foray into the world of health care advocacy. We have a model for rural dental medicine, and we want Nepal’s government to fund dental clinics in all of its village Health Posts. Our idea is that if the government would set a standard at which it will finance rural dental services in the national health care system, then the global development industry will start doing what we’ve doing: training, mentoring, supervising and auditing rural dental technicians so they meet the standard (which we can help define). As far as I know, we’re the only organization in Nepal working on this particular topic in this way.
Like many developing world countries, there’s a complicated and often mutually distrustful relationship between the aid sector and the government of Nepal. This largely results in aid agencies privatizing their projects as much as possible; I’ve done this myself, because it’s easier to just do something right yourself than manage a hassle of hectic and sometimes exploitative bureaucracy. Mean time, weak governments spin out more and more self-serving regulations against a flood of foreign funding that is trying to silo itself. Ultimately, it’s development itself that suffers, as decades-old aid industries, still chasing down base level poverty, make apparent. So something that excites me about what we’re doing now is that, setting aside dental medicine itself, I see the process we’re in, if it works, as a strong example of effective collaboration between the private sector, which is great at risk-taking, innovation, and raising money, and a developing-world government, which, at least in Nepal, is by far the best option for scale and stability. I like to think this is a version of life where we all do what we’re good at, with respect for the reality that we need everybody if we’re going to think big and get somewhere.
Now then. Should you choose to work on rights-based health care policy in the developing world, which you might have been considering, here is your primer on how to get started (after refining your particular service of choice for 10 years).
Our advocacy happens at three levels, beginning with the village level, where we’ve been pushing for permanent local government funding. This is not for the faint of heart and best suited for people with a good sense of humor. You’d better be down for a ride that’s 90% culture and 10% policy, and heavily focused on navigating relationships, social dynamics, and weather. The village level is where we’ve focused most in the past, so we’re reasonably adept at this…except that the reality is that institutional services just aren’t very stable at this level.
Next is the district government, where we’ve previously had only very simplistic coordination, such as required letters to required people. But it’s the district government that sanctions and distributes village budgets, so without support here, it’s a lot harder to get anywhere at the local level. The other day we had a District Coordination Meeting where our program director and I presented (in Nepali!) on the role of the government in extending our oral health care model to its predominately rural population, filling a gaping hole in the primary health care system. This meeting exceeded our expectations – we received a lot of positive feedback and useful criticism. I was lavishly complemented, of course, on my village accent.
Lastly, the day before I leave Nepal, we’ll have our first workshop at the central level in Kathmandu, and with this, we’re leaping in to completely new territory. But this is ultimately where it’s at: it’s the central government that fixes funding priorities and distributes earmarked budgets through the national health care system. Recognition of our model at this level would set up a standardized place for rural technicians in Health Posts, providing a framework for agencies with a lot more money to invest in creating rural dental technicians who can then be permanently staffed by Nepal’s own government.
We’re feeling emboldened and encouraged after learning a lot from each and every meeting we’ve had so far. Despite my own resistance in the past to clunky public systems, at this stage of the game, I’m finding some of the cumbersome government procedures to be oddly reassuring. They give us steps to take. We’ve met some very decent and hardworking public officials over the summer, even if they receive us with skepticism and give us some hard knocks. I think this has actually grown our confidence. We can wait for the meetings, answer the questions, submit the documents, do all the things, because we have confidence in our product. There’s also the humbling reality that the government has plenty of reasons to be cynical of the social work sector, so if we have to prove ourselves, that’s fair. It’s forcing us to be both meticulous and more adaptable…eventually, we’re responsible for creating our own good luck.
Besides that, rice planting season concludes with a wonderful festival where everyone puts on green bangles and paints their hands with henna. Kaskikot’s premier henna-drawer has become none other than yours truly. What did you expect with an activity where people let you doodle on them with temporarily-staining plants?! Govinda’s porch had an hour long wait for these skillz on Saun 1.
The best thing about the henna designs is that you start with an idea, and then it becomes a meditation that designs itself, following a pattern in the creases and borders of someone’s palm, incorporating smudges and wayward marks in to unexpected flowers and vines. You just can’t say before you start exactly what you’re gonna make.
Doodle doodle doodle…