Wrapping up this trip - Chilanga Community Clinic
Status of the clinic
On Tuesday 26 November, I was back in Makupo and met with Kenneth, Kenny and Lonje to plan the next steps We had all become very busy with other activities after we had completed the final report in early October. As a result, we had a number organisational matters to look after and we laid out a plan and a to-do list.
The construction is on hold until we can fundraise a larger amount that will allow the contractor to put a more concentrated, one-time effort into the building. The contractor has not done the slab yet. It appears another project came along that has filled his time. It may be another aspect of the contractor's complaint about mobilising for small pieces of the project at a time, rather than getting into it and finishing it in one larger exercise.
In light of our research findings, the budget has to be revised to account for a number of components required to allow the clinic to begin functionning. These include:
3 staff houses (one is already built and will be a counterpart contribution of Chilanga CCAP); incinerator and tissue disposal unit; a well and infrastructure such as tank, pump and piping; electricity including ESCOM hook up and possibly a solar back up system to keep the fridges and pumps going whenever there is a blackout. Kenneth, Kenny and Lonjezo will follow up on getting the costs for this aspect of the work.
A local fundraising initiative should begin and can take 2 prongs. One is to canvas all the local and international NGOs that are easily accessible here in Kasungu and Lilongwe: CARE; PLAN International; Banja la Motsogolo; World Vision; Mai Khande; UNICEF, etc.... This would be to both inform them of the Chilanga Community Clinic project and to seek funding and other support. The second prong is to pursue other local sources such as the Rotarians and the Chilanga alumni. Kenneth, Kenny and Lonjezo will follow up on this.
By shear coincidence, I was introduced at the airport to a fellow passenger on the flight to Addis Ababa, who is a very senior manager of the Local Development Fund, formerly the Malawi Social Action Fund (MASAF) and who is also a graduate of Chilanga Primary School. I put to him the clinic project and he said he would plug it for us at the Kasungu District Council level and would be willing to work as an alumni to rehabilitate the Primary School and perhaps help with the clinic.
For Doug's part, I had arranged to meet Peter Timmerman in Lilongwe to followup with World Renewal the following Thursday before leaving Malawi. More on that below.
Official Approval: Despite verbal reassurances from both the District Health Officer and the District Environmental Health Officer, we are still waiting for a written response to our initiative with the letter to the District Commissioner. Kenneth needs this confirmation letter to pass to the Nkhoma Synod Health Coordinator, Mr Yoas Mvula to allow the project to access all the resources outlined in the Memorandum of Understanding between the government and Nkhoma. Kenneth, Kenny and Lonjezo will follow up on this.
b) Chisomo Community Health Organisation (CCHO)

The project: Village Health Workers

As an outreach and support for the work of the Chilanga Community Clinic representatives of Makupo Village and the minister of Chilanga CCAP mission in collaboration with Makupo Development Group Montreal have come together to found a Malawi based local NGO with the goals and initial methodology as described below.

Goals: - To establish a community based, community run initiative for primary home based health care;

• To improve the capacity of people to take charge of their health care for themselves;
• To improve health outcomes on a self-help basis;
• To deal with health in a holistic manner by including agricultural activities; that supplement dietary needs (vegetable gardens, fruit trees) and provide some income (raising chickens and selling eggs), with infrastructure such as clean water through wells or safe water sites;
• To support the primary health function of Chilanga Community Clinic;
• To provide sustainable long term support to projects related to health;
• To complement and support government initiatives in health delivery and promotion;
• To provide liaison with supporters in other countries.

Structure:

The aim of the proposed structure is to ensure that knowledge and skills are acquired locally and remain local. By establishing the groups in this fashion, dependency on outsiders will be minimised and a sense of ownership and empowerment will see the Village Health Workers move beyond response to advocacy.

In each of the seven villages in Group Village Headwoman (GVH) Kawiza's jurisdiction, the people will choose three Village Health Workers (VHW), 2 women and a man. The teams will meet weekly to discuss and deal with village health issues individual and collective. The seven teams of three, one team from each village, will come together to meet monthly in a VHW Council for Kawiza GPH for reporting and problem solving.

At the same time a storefront support facility will become available, staffed by Kenny and Lonjezo on a daily basis. They will also act as recording secretaries and meeting convenors/motivators. In addition, they will also provide support to the village teams as requested. They will be supported with on-going training in mini courses similar to that provided by the Ministry of Health to the Heath Surveillance Assistants.

Plan of Action – Time line

1. Consultation Phase

District Environmental Health Officer

Senior Chief

Group Village Headwoman Kawiza

2. Gain community support:

• Meet GVH Kawiza to discuss proposal
• Meet village headmen individually to explain proposal and ask for them to chose 3 people from each village (2 women, 1 man)
• Group meeting 1 includes the village headmen and 3 chosen VHW from each of the seven villages in the jurisdiction of Group Village Headwoman Kawiza, plus Makupo representatives.

Purpose: explain organisational set up

Explain needs assessment process

• Group meeting 2 includes all the VHW

Purpose: group to report the local health needs

(include HSA and DEHO)

Plan next step

Decide training priorities -plan first village level courses
c) Peter Minjale (K2/TASO)
The four of us went to St Andrews to meet Peter Mnjale and draw on his experience as a founder of K2/TASO which is an independent NGO he set up because St. Andrews mission did not have the resources to do health promotion, prevention and outreach in the area of Kasungu East. Their focus is very much on HIV/AIDS support from home based care, testing and counselling, to palliative care. There are many village units with local motivators and seven satellite offices and they are slowly building up a secretariat and in-patient palliative care unit not far from St, Andrews. Peter has an extensive background as a clinician and in health outreach and continues his studies in the field. He gave a masterful presentation on how to proceed and what the priorities should be and finished by promising to organise training sessions for our people by starting first with a joint meeting the following week with the Environmental Health Officer at Kasungu District Hospital who is responsible for training the Health Surveillance Assistants. On that note we knew we had found an ally who would guide us wisely into this initiative.


d) Peter Timmerman (World Renew)
Peter and I had been crossing paths since mid-September and never managed to meet. We finally got together Thursday, the day before I was leaving Malawi. It was a brief but very profitable meeting. We explored the possibilities of collaboration. I explained the background to the Chilanga Community Clinic and how we had reached the point we are at today. He explained to me the structure of World Renew and their programming priorities.
For us to become partners, it would have to be through their current Malawian partner, the Nkhoma Synod, which would have to indicate that the Chilanga Clinic fits within the Synod's health development plans. Once that is established, it should then be possible to use the good offices of World Renew in Canada to offer receipts covered by their status with Canadian Revenue Agency for income tax purposes.
For my part, I have assured Peter that I will act as a resource person and fund-raiser. I am quite willing to travel around Ontario which is their main base in Canada to speak about the project and meet people interested in our work. Peter travels north to Mzuzu periodically and he will take the occasion of one of his next trips to stop at Chilanga and familiarise himself with the situation there. It was quite a pleasure to meet Peter and we struck a very cordial note that bodes well for working together in the future.

Now the heavy work begins in Canada.

Report on visit to the District Environmental Health Officer
Ketwin Kondowe


His role
In his words, his work has more to do with disease prevention and health promotion than the science of medicine. The DEHO is a preventive health service that covers everything from enforcing standards, food handling inspections, health programming around, malaria, food safety, hygiene, water, sanitation, disease surveillance and response as well as the Health Surveillance Assistants. Working under his direction, he has 6 degree graduates of environmental health, 5 diplomates, and 548 Health Surveillance Assistants (HSA) throughout Kasungu District.
Clinic
He started by welcoming the initiative to establish a clinic at Chilanga. Kasungu District Hospital is congested and they are looking to build a series of satellite clinics in the area around Kasungu. The DEHO has already established one at Linga in the West on the road to the National Park and another to the East on the road to Mtunthama at Kasalika. The Catholics are opening one to the north at Kafukule West. The Chilanga clinic will provide a much needed service to the community and help relieve the congestion and improve the quality of care available. He pointed out that in terms of road accidents there is no facility on the long stretch of road between Bua and Kasungu, so it will help with that as well.
By his estimate, we will be serving about 7400 people in the area immediately around Chilanga and over 15,000 in the whole catchment area of the clinic. Most of the people are from Chief Kaomba's area, but it will serve part of Chief Lukwa's area to the west as well.
Village Health Workers
He again welcomed the programming initiative Melodie had drafted and especially our re-assurance that it is meant to complement the work of the HSA and not duplicate or drain away from them. He told us that the President has committed to doubling the number of HSA to allow 1 per 1000 population, so our initiative is a welcome adjunct. His department is available for training purposes, or consultation as needed.
Engineers Without Borders (EWB) has had a placement at Santhe rural hospital (ed. note where Bwelezani's wife Mercy works). She developed a method of self-assessment and follow up with the HSA to allow them to improve their performance. He was aware of problems with some HSAs and this was going to be a tool to allow his department to deal with underperformers.
Contact Ketwin Kondowe, District Environmental Health Officer
099 971 7233 kckondowe@yahoo.com

Canadian sustainability
The budget I had allocated for transport finished yesterday and I had to take the car back to Sputnik Car Hire in Lilongwe. The three weeks has flown by with busyness. I used the occasion to check out the Canadian agencies working in the country to establish links and see if any of them can help pick up the Canadian end of this sustainability exercise, now that we have established the sustainability of the project here at the Malawian end.
I went to see what was left of the CIDA office and was informed that the last three professional officers, 2 Malawians and a Brit, will be out of work at the end of November when Canada closes the office permanently. The DFATD, formerly CIDA, desk representative had come up 2 days before to announce the closure. I had planned an hour or more of sharing what we were doing in Makupo and Chilanga, but it was just a series of goodbyes and hand shakes and good lucks, over in 15 minutes. Much as I have little time for the aid industry I left with a sense of great indignity, that the Harper government had removed this last pretense of caring for some of the most disadvantaged people in the world.
My visit to WUSC was much more profitable. Jacob Mapemba is an amiable, extremely competent country director with 9 professional staff running a variety of programmes. They bring as many as 40 volunteers each year and are involved in many programming initiatives. WUSC's new 5 year plan takes effect next April and will feature economic empowerment for women and youth as its focus. Lonjezo and Jacob shared phone numbers and email addresses and he will let us know of funding and placement possibilities for the future. He was forthright and forthcoming, so we need to improve our project writing and reporting skills to take advantage of these opportunities. He will encourage his volunteers to use the guesthouse as a way of learning about village life.
Engineers Without Borders Canada is housed in a small house behind a big house and staffed with about 6 long term people who are sprinkled around the country in water, sanitation and logistical support and evaluation with the Ministry's Health Surveillance Assistants programme. Their big effort is the placement of as many as 15 - 20 engineers in short term positions during the Canadian summer months. I met Holly Lafontaine from Windsor at the DEHO office in Kasungu and we had lunch together. She described some of the programme to me. They operate on very little budgets, use buses to travel and live modestly in local communities. They are not really connected to the established NGO network and work directly with local partners in the Ministry of Health or Water offices in the districts. Check their website. www.ewb.ca I was impressed by the failure report.
Their Lilongwe base is just around the corner from the CPAR office. They are in a big old colonial house with the classic big 4X4 carrying their logo and of course the flag. The programme manager is Joseph Zimba. I explained the work in Makupo/Chilanga and my purpose in visiting. He gave me an overview of their programme, which ironically has very little health component to it. They operate in Ethiopia, Tanzania, Uganda and Malawi and have only ever been involved in clinic building in Uganda. Dokiso Nchama our doctor friend in Cornwall travelled to Malawi on one of their familiarisation trips in the late 90s or early 2000s and had checked with them in Toronto to see if he could solicit any interest in helping with this clinic. They declined and the programme manager here reconfirmed that their programming was already set and did not involve any clinics for the time being. www.cpar.ca
I am not particularly discouraged by the apparent lack of interest. We are coming out of the blue and they have already established programmes, priorities and planning that they are committed to. Nonetheless, I think it would be wise to approach each one of them again through their head office and local representatives to keep the Chilanga clinic and its Canadian connection alive for possible future support. We should add to these the Presbyterian Church in Canada who rebuffed me because they don't support Canadian initiatives. Another movement toward more long term Canadian support would also be the link that we propose to build with the OPSEU health workers sector. Still another initiative would be to approach the doctors who are either from Malawi or who have worked here to check in their networks for help. Dokiso and I have discussed the idea of getting visiting doctors to come to Malawi. With our guesthouse at Makupo and the clinic across the road it would be a good place to contribute their expertise for a month or two at a time.

Ideas are not hard to find, it's something else to make things happen. As Stephen Leacock once said, “Writing is easy. You just write down what occurs to you. It's the occuring that is difficult.”More soon.

Lilongwe Kasungu 3 & 4 October More research




I needed a new quote for Shannon who is fundraising for a well or possibly two for next year. Kenneth joined me in the Ministry of Water Development and Irrigation to learn the process. He is a church pastor with a real commitment to development of the people as a necessary adjunct to his spiritual mission. The new quote came in at K1,810,000 or about $5200 down from about $7500 for Nguwo paid in 2011. The Malawi Kwacha was being held at an artificially high rate by the late Bingu wa Mutharika and is now floating at closer to its true value. The next village for a well on our agenda is Chindui which is on a ridge in line about 1 kilometre north of the Chilanga Secondary School.


We then went to see Mrs Monica Kandodo at her business office also in the Capital City Centre. When I met her with her husband on Sunday, she had offered her services as a Chartered Quantity Surveyor. I had no idea what that was, but was soon to find out how valuable an offer it was. She is going to help us pro-bono, because she often attends church at Chilanga and is a member there. She has her own company and her office is replete with examples of projects she has worked on and is currently working on. She will pass by at least once a month for a site inspection, report on the technical progress, the financial situation and how it conforms to the work done. They have a standard format for reporting which she is going to send to me. With her technical expertise and access to communication and resources, she will be indispensable in monitoring progress once we have fundraised enough to restart the work.


Later in the afternoon, we went to the office of Collins Kaunda, the architect to set up Skype interaction between him, myself and Carl Mulvey in Montreal. Collins high speed hotspot phone was out of battery so we used the dongle and quite successfully communicated for about 15 minutes. The quality of the line and reception improved as we went along. We spent some time clarifying the delegation of authority, how the architect and contractor get paid, interpreting the Bill of Quantity, and how the contractor was selected.


In brief, Collins was approached at my request by Jack Kamanga to review the plan I had brought from Canada in January 2012. He in turn gave it to a quantity surveyor to break down into its components and price. He returned two copies of his estimated price list known as a Bill of Quantities, one with his price figures indicated and another with no figures. Contractors were invited to bid on the project using the blank sheet Bill. A committee representing the Chilanga Church, Senior Chief Kaomba, Makupo Village and the architect reviewed the submissions and selected Jack Kamanga's submission as being both closest to the Quantity Surveyor's figures and with a portfolio indicating a standard of quality in previous projects.


Kenneth and I returned to Kasungu Friday morning to meet the District Medical Officer, Dr Jerome Nkhambule. It was a cordial reception. He was initially reserved about an imported plan, insisting that the Ministry of Health had standards and norms that he would prefer to keep all new installations in line with. However, once we opened the blue print up and walked through some of the features, he very quickly warmed up to the EKM ideas. Once we had established that it was an outpatient facility and that maternity would be referred to the Kasungu District Hospital he was enthusiastically affirmative. He indicated that he would have a written confirmation in the next week to extend his approval to proceed so that the clinic could fall within the CHAM / MoU and receive government staffing, drugs and services accordingly.

He arranged for his colleague, the District Environmental Health Officer, to meet us on Monday morning to pursue the health outreach and promotion work that we are proposing.

We started the report on Monday with an organisational meeting of the research team and I spent all day yesterday writing the draft, which we will review and revise to send tomorrow from Lilongwe. We are already up to 7 pages and growing. It is quite impressive what we have done in a brief 2 weeks since I got here, if I do say so myself

As we do this part of the work, we are still in the process of making the process happen. Monday we submitted a formal request from the Chilanga community to the District Commissioner, the most senior civil servant in the district, with a copy to the District Health Officer who is in charge of all health related activities in the district, governmental and non-governmental. They have both responded favourably by phone and are pursuing the matter along the administrative pipeline to get the final approval of the Ministry of Health and any other relevant authorities.

We return to Lilongwe on Thursday to pursue the technical matters further with the architect, contractor and quantity surveyor and also to meet the World Renewal representative from the US about their support in the absence of the Canadian Presbyterians. World Renewal is apparently what the old Dutch Reform Church has evolved into.

At the same time, I have been setting up procedures with the secondary school that can be used later on by the clinic rapporteur as well, to help them with report writing and giving supporters some feedback. (ed. note - I am the least qualified guy to do this function given that it is one of my greatest weaknesses.) It will be good practice for us all. Over the past 3 years, the school has received computers, a new classroom and laboratory block, books for the library, money for scholarships and sports equipment and if they want to continue benefitting from all this goodwill then we must become better reporters.

Next week, we have a meeting to establish the academic scholarship for women students at the secondary school. In another meeting, we will set up the formal Health Advisory Board of the clinic. We foresee a meeting with the District Health Officer and his outreach colleague the District Environmental Health Officer to discuss both the clinic and the Village Health Assistants project that Melodie and I have concocted.

In summary, I am running fast and trying to squeeze the writing into the spaces between the runs.

On a personal note, the friends gave me a discretionary fund and after talking with Nellie we decided to help out 3 women whose teeth had succumbed to infection before they began their ART AIDS medication. It is so evident that they are self-conscious about not smiling and with a couple of bridges or false teeth they will be back to their happy smiles again. We are going to the dentist at St. Andrews for extractions, and fillings and thereafter find out where we can get replacement teeth of some sort.

Weather report. I dressed and carried clothes for the hot, dry season. The last 2 days has seen heavy cloud cover and cool winds from out of the east. I am sitting bundled up like Ebenezer Scrooge as I sit trying to type away on all this writing I have to do. I have had to borrow an old Vanier hoodie from one of the boys because I only brought short sleeve summer stuff.

Enough said. This note stands in the way of an excuse for the report being too long.

Fact Finding Tour
Clinic Blog 25 September 2013
The Rev. Kenneth Alemekezeke Chikondi-Phiri, Lonjezo Kathawa, Sautso Chikapa and I left Makupo early in the morning, Monday 23 January. We were on the road for 6h30 and as we drove through Kasese and Madisi we stopped to arrange meetings with the medical staff later in the week as we return to Makupo/Chilanga. We were on our way to meet the coordinator of health services for the Nkhoma Synod CCAP Hospital, Mr Yoas Mvula at his office in Lilongwe.
He was our first stop and a good thing too. He really knew his stuff and has put us on the path we need to follow to get this clinic up and running. First he briefed us on the church's health infrastructure.
Nkhoma Synod Health consists of Nkhoma Hospital with 330 beds and10 health centres scattered across the Central region. The hospital is a major installation with full service while the clinics provide maternity care, voluntary counselling and testing for HIV, anti-retroviral treatment and outpatient service. There is a nursing college with an intake of 120 per year in two streams. Sixty are Unicef sponsored midwife technicians in an 18 month basic programme to replace traditional village birth attendants and the other 60 are full registered nurse midwives.
The Synod's Primary Health Care Department is in Lilongwe from where they coordinate preventative health awareness in the villages. He cited as an example the IRS Individual Residual Spray programme which ran from 2009 to 2012. It was so effective where it was implemented that it reduced the admission of under fives by 80% at the local hospitals during the rainy season. It was such a significant drop in admissions that it led to a reduction in workload with a consequent savings on drugs and more importantly a significant reduction in the death rate among children and pregnant women.
He dealt with issues of sustainability and the provision of staff and drugs. The health department of the synod is in partnership with the Malawi government and donors for the provision of drugs and staffing. The government provides medical and certain non-medical personnel. CHAM the Christian Health Association of Malawi mobilises resources for all health institutions of the member churches which also includes the provision of drugs and personnel. CHAM also carries out supervision visits to facilities to enforce Ministry of Health MoH and World Health Organisation WHO standards. The synod has an annual Health Day when all member churches make a special collection which goes towards drug procurement
As a result it is very rare that Nkhoma synod facilities run out of drugs.
Structure
The CCAP Synod has a Board of Trustees which governs all church activities including the Health Unit which is headed by a moderator as the chairman, the church's General-Secretary and others. The Health Department has its own board separate from the church's. The chairman is a church representative while other members are from different professions and include MoH and CHAM. The church has internal and external auditors who regularly verify bookkeeping in every facility.
Each facility has a Health Advisory Committee consisting of the chairman who is the local presiding minister; the head of the health facility who acts as the secretary; as well as local traditional leaders, and community members. The advisory committee's role is to provide a lik to the local community. These local Health Advisory Committees report by sending the minutes of its monthly meetings to the Health Management team in Nkhoma. This keeps them aware of issues and allows early problem solving.
In addition to these advisory committees, there is a Health Management Committee at each facility. These are composed of the facility's head Medical Officer, Nurse, and administrator.
Mvula's role as health department coordinator is to visit each facility to enforce the standards established by the 3 regulatory bodies. He ensures that available funds are channeled to the individual units of the Health Department and each unit is registered under Nkhoma.
Nkhoma also has a maintenance department to look after building infrastructure and oversee new construction.
Under the government guidelines Nkhoma provides some free medical services to pregnant women and children under 5 as well as HIV related services. Nkhoma and CHAM are lobbying the government for support to provide free primary health services to all citizens.
Accreditation: The Chilanga Community Clinic will fall under the Nkhoma accreditation not just because it sits on mission land but because it facilitates the necessary government accreditation. The process is as follows:
To reflect an expressed need of the community a request must be made to the Kasungu District Commissioner via the District Assembly. The District Health Officer (DHO) sits there and he and his staff undertake an assessment. The basic criteria are that there be no other facility within 5 kilometres and that the population in catchment basin warrants such a facility. The DHO documents his research which is forwarded to the MoH who will determine that they do not have the resources to satisfy the request. The request is then forwarded to Nkhoma's health unit synod for its support. The DC endorsement is the essential first step to get this process underway since it ensures that it falls within the local development plan and in order for the accreditation process to begin and which leads eventually to staffing arrangements and the provision of drugs, etc...
We have already jumped through some of these hoops but we have clearly not followed procedures in the required order and in most cases the groundwork has already been lain. There are some problems to deal with and after we get back to Kasungu and finish with this round of meetings we will be in a position to outline these and propose a strategy for dealing with them. On our way home, we are going to visit three facilities and try to learn from them. Thursday we have a meeting with St-Andrews. Next Monday, we will draft a more complete report to cover all the above after we get back to Kasungu.

Clinic Report 21Sep13

It appears that I have hit the ground running. Wednesday's arrival was the usual ritual of greeting and arranging accommodation. Thursday was supposed to be busier. Unfortunately, neither the reverend nor the headmaster were available in the morning, having been called to the Ministry of Education office in Kasungu to deal with urgent issues around the boarding facilities in the day schools. That gave me some time to go up to the site of the school Bishop's is building near Senior Chief Kaomba's court about 2 kilometres southeast of us. It is a very ambitious school set up and Ken Manda is acting as site manager. It is a school and does not appear to have a health facility included as had been rumoured.

We finally met the reverend to make begin making our plans in mid-afternoon. We were the folks at Makupo who represent the village on the clinic joint committee and myself. I explained the purpose of the visit and he was super agreeable with the purpose and the validity of the concerns that the Canadian clinic support folk had raised. We agreed to start our exploratory visits by going to St. Andrews and Kasungu District Hospital the next afternoon and begin to plan our trip to Lilongwe for next week.

I decided to travel with Lonjezo as Makupo's eyes and ears to this process. He was one of the 3 Makupo youth to begin health training at St Andrews earlier in the year and originally wanted to train as a nurse. Kenneth Alimekezeke Chikondi-Phiri is the minister in charge of the Chilanga CCAP mission. I wanted Kenneth to see what was happening at other church sites and how they function as compared to the Nkhoma method. Sautso will join me on Saturday and hopefully she will be our project management representative after I leave. She has worked with Nellie and I since the first well in 2004 and is a very trusted collaborator who is a competent administrator, and has completed a certificate in management including accounting

We arrived unannounced at St. Andrews to find Peter Minjale, the medical officer, on vacation and literally everyone else at lunch. Mrs Phyllis Bwanali, the Nursing matron graciously came to introduce us to the facility. I had not really visited the place since we went as group in 2008 and I was impressed at how much it has grown. In fact, it began as a small clinic, even smaller than what we are proposing. It is now a large sprawling facility with several wards, a surgery, delivery facilities and a dentist, ante-natal services, nutrition rehabilitation and outreach services. Most of what is there has been put in place over the last 10 years. A testament to its essential role in the health care system was the fact that the operating theatre was being used by a surgeon from Kasungu District Hospital while we were visiting, because of a problem with their facility. It was an essential orientation for we lay people.

We wanted to visit the District Health Officer at Kasungu District Hospital. We need to coordinate with him and his team around issues of government sanction, standards and support. Unfortunately, the vice-president had come to Kasungu on some specious mission to lay a cornerstone for a new maternity wing at the hospital, which was in fact an excuse for a political rally. The governing coalition of Joyce Banda is facing a real insurgence of the MCP especially in the heartland of Kamuzu Banda. The net result was that all people except essential medical staff were obliged to attend the rally as part of the protocol duties when the VP is in town. We therefore couldn't meet anyone at the hospital and a tour was not really necessary.

We still had some time together so we moved across the road to te Kasungu Inn and spent a couple of hours planning, discussing and sharing ideas. We have our first meeting set up with the Nkhoma Health Unit in Lilongwe for Monday morning and one with the contractor for that afternoon. On the way down to Lilongwe we will stop at Madisi and Lifeline to set up visits on Wednesday afternoon as we return from Lilongwe. So those 3 days are starting to look profitable and I am pleased with how things are shaping up.

Some brief background before I close off. Mission organisations still deliver well over half of Malawi's health care. So collaboration on issues of health care are with government and or the church. The Anglicans have set up St. Andrews as a satellite of their much larger facility in Nkotakota about 1.5 hours to the lakeshore to serve the much under-serviced region of eastern Kasungu. Despite the name Presbyterian as part of the CCAP moniker, Nkhoma Synod of the CCAP operates in the Central region in alliance with the old Dutch Reform Church now known as World Renewal, not the international Presbyterian church of Scottish heritage. Nkhoma is situated about an hour south of Lilongwe and has a rather elaborate set up including a large teaching hospital, training facilities for nurses and other health personnel. Their health unit is in Lilongwe so I will take the opportunity to pass by Nkhoma in a later phase of the trip when I go to the southern region.

The churches depend on outside help and are more than willing to collaborate with funding organisations even old non-believers like me. To that end Kenneth agrees that if it would help fund-raising efforts then we should create a local NGO to make the clinic structure arms length from the church and open to everyone in the community. Sautso is office manager for one of Malawi's preeminent law firms so we will explore the value of this option over the course of the visit with someone from there.