Download Clinic 521 2010 - Gashonyi Clinic Project

Document 521
PRE-ASSESSMENT REPORT
CHAPTER: UW-MADISON
COUNTRY: RWANDA
COMMUNITY: GASHONYI
PROJECT: GASHONYE CLINIC EXPANSION
TRAVEL DATES: 8/15/2010 to 08/31/2010
PREPARED BY
Matt Carlson, Padraic Casserly, Michael Kerins, Elise
Larson, Allison McArton, Tina Ocepek, Gabriel Ryan,
Stephen Petty Valenzuela, Briana Woods
Advisor: Tom Siebers
April 17, 2010
ENGINEERS WITHOUT BORDERS-USA
www.ewb-usa.org
Pre-Assessment Report Part 1 – Administrative Information
1.0
Contact Information
Team Lead
Name
Matt Carlson &
Julia Wagner
Elise Larson
Email
ewb.uw.rwanda.
[email protected]
[email protected]
Phone
Chapter
715.379.4737 UW-Madison
608.577.4412
608.484.0565 UW-Madison
President
Eyleen Chou
[email protected]
608.695.0909 UW-Madison
Mentor #1
Tom Siebers
[email protected]
Faculty Advisor
Giri
Venkataramanan
Norm Doll
[email protected]
Project Managers
Health and Safety
Officer
Assistant Health
and Safety Officer
NGO/Community
Contact
Education Lead
2.0
Carl Houtman
Matt Carlson
normdoll@gmail.
com
choutman@fs.
fed.us
[email protected]
Jean Paul
BAZANSANGA
Jean Berchmas
BAKUNDABATE
eyademapaul@
gmail.com
bakundajebeuli@
yahoo.fr
-
Madison
Area
Professionals
Chapter
608.262.4479 UW-Madison
608.262.4479 UW-Madison
-
UW-Madison
715.379.4737 UW-Madison
-
UW-Madison
Rwanda
Travel History
Dates of Travel
March 2004
Assessment or
Implementation
Assessment
July 2004
Implementation
July 2005
July 2007
January 2009
May 2009
Assessment & Implementation
Implementation
Assessment
Assessment
Description of Trip
Surveyed Water
improvements
Water system source and
pipeline improvements
Water and Energy projects
Rainwater Catchment System
Agriculture and fuel briquette
stoves
Assessed a future pipeline
project, a clinic expansion and
another rainwater catchment
system
January 2009
3.0
Assessment
Travel Team
Name
E-mail
Phone
Chapter
Project Lead (Elise
Larson)
Mentor (TBD**)
[email protected]
-
UW-Madison
Student or
Professional
Student
-
Michael Kerins
[email protected]
UW-Madison
Student
Gabriel Ryan
[email protected]
UW-Madison
Student
Briana Woods
[email protected]
UW-Madison
Student
Allison McCarton
[email protected]
UW-Madison
Student
Padraic Casserly
[email protected]
UW-Madison
Student
Tina Ocepek
[email protected]
UW-Madison
Student
*This travel team will be part of a larger group from EWB-UW Rwanda. The other teams will each
submit their assessment plans by April 18th 2010 according to the EWB-USA schedule. The team size
staying in the town of Gashonyi, Rwanda will not exceed 3 travelers. The travelers listed here are
the possible travelers from this group. The final travel team will be decided before the form
submission deadline of June 29th 2010.
**Several mentors are possible, and we are awaiting their decision by June 29th 2010.
4.0
Safety
4.1
Travel Safety
4.1.1
State Department and International SOS Travel Warning
“Currently no State Department or International SOS travel warnings
present, but travelers should use caution crossing the border into
Burundi and eastern Democratic Republic of the Congo (DRC)
(04/18/2010).”
“Caution is advised while driving, especially at night, as roads and
vehicles are generally poorly maintained.”
“Basic personal safety precautions should be taken to prevent ordinary
street crime.”
4.1.2
Point to point travel detail
NOTE: Travel plan dates are subject to change based on ticket pricing and availability.
Date
Travel Detail
8/13/2010
Fly from USA to Kigali, Rwanda (route subject to ticket prices)
8/13/2010
Meals provided during flights, supplemented at each airport
8/15/2010
Arrive in Kigali, Rwanda
8/15/2010
Stay at St. Famille Parish hotel in Kigali
8/15/2010
Lunch and Dinner in Kigali at St. Famille Parish hotel
8/16/2010
Travel by 4WD vehicle to Muramba, Rwanda
8/16/2010 Spend 5 days in the town of Gashonyi, meals provided at the church
8/21/2010
Travel to Muramba, Rwanda by jeep for progress report*
8/21/2010
Return by jeep in the evening to Gashonyi, Rwanda
8/26/2010
Travel to Muramba, Rwanda by jeep for progress report
8/26/2010
Return by jeep in the evening to Gashonyi, Rwanda
8/30/2010
Return to Kigali by 4WD vehicle, stay the night at Kigali
8/31/2010
Fly from Kigali to USA (route subject to ticket prices)
*As mentioned in section 3, the clinic assessment travel team is part of the larger travel group. Twice during the
travel period all of the teams will meet in the town of Muramba to discuss their progress, troubleshoot any issues,
and reflect on their experiences.
Throughout the trip water will be obtained from local pipeline and spring sources. Water will be
made potable through the use of chemical tablets or ceramic filters such as the MSR Miniworks
filter.
4.1.3
On-the-ground phone number and email for travel team
Cell-phones will be purchased by the team and online email accounts of all members can be
checked. Consistent contact can be made through Jean Paul BAZANSANGA at: (+250) 78-835-1035
[email protected]
4.2
Site Safety – Health and Safety Plan
See attached EWB-UW Rwanda Health and Safety Plan
5.0
Budget
5.1
Cost
Expense
August Team Travel Total
Amount ($)
6500
Transportation 4500
Food/Lodging 1200
Equipment 100
Contact Labor 500
Administrative 200
Clinic Assessment Sub-Total
1780*
Tripod 50
Total Station 1200
Vertical leveling rod for sighting 30
GPS 500
Projected budget (Total)
8280
5.2
Hours
Names
Project Lead (Elise
Larson)
Mentor (Tom
Siebers)
Michael Kerins
Gabriel Ryan
Briana Woods
Allison McCarton
Padraic Casserly
Tina Ocepek
5.3
# of Weeks
30
Hours/Week
5
Trip Hours
0
Total Hours
150
30
3
0
90
10
10
5
10
10
30
3
3
3
2
3
2
0
0
0
0
0
0
30
30
15
20
30
60
Donors and Funding
Donor Name
Type (company, foundation, private,
in-kind)
Travel Team
Private
Future Donations/Funding TBD
Total Amount Raised:
6.0
Project Location
Matyazo Sector (part of Muramba Parish)
(No GPS data available at this time)
District of Ngororero
Western Province
Rwanda
Account Kept
at EWB-USA?
No
No
Amount
1500
6500
8000
7.0
Project Impact
Number of Persons directly affected: 1500
Number of Persons indirectly affected: 2000
8.0
Mentor Resume
THOMAS E. SIEBERS, P.E.
AREAS OF EXPERTISE
 Project Management
 Construction Management
 Public Involvement
 Public Infrastructure
 Land Use & Facility Planning
 Expert Witness
EXPERIENCE
Mr. Siebers has a wide range of management, project management, technical, and construction
engineering experience. Prior to his retirement January 2008, he was the Office Manager of
MSA Professional Services Madison office, responsible for civil/municipal and airport
engineering services.
With 44 years of experience in civil/environmental engineering, municipal engineering, private
sector developments and construction management, he provides clients with a broad
knowledge of issues relating to infrastructure development/redevelopment, waste
minimization/pollution management programs, and public involvement. He served Madison
area communities since 1977 except for a three-year period from 1990 to 1993, when he was
the Managing Director of a Hong Kong civil and environmental engineering office.
His engineering project background includes: 32 years of project management; studies,
planning, design, real estate acquisition, and construction-related services for buildings,
municipal, industrial works, and environmental protection works; and 12 years in building
construction project management and cost estimating.
Most recently, Tom served as the mentor for a UW Madison Civil Engineering Capstone design
and construction project. Tom worked with the student team during the spring semester of
2008 on the design, after which he accompanied the team to Ecuador to construct
modifications to a water distribution system serving five communities and 3,000 people.
Construction was completed June 12, 2008.
American Society of Civil Engineers
EDUCATION
B.S., Civil and Environmental
VOLUNTEER SERVICES
Engineering
University of Wisconsin Capstone
University of Wisconsin-Madison, 1975
Mentor
Engineers Without Borders, Madison,
PROFESSIONAL REGISTRATION/AFFILIATION
Wisconsin Chapter
Professional Engineer, WI, 15645
Student Mentor/Tutor – Sun Prairie
Area School District
EXPERIENCE HISTORY:
2008-Present Retired, Sun Prairie, Wisconsin
1996-2008
MSA Professional Services, Madison, Wisconsin
1993-1996
Rust Environment & Infrastructure, Inc., f/k/a Donohue & Associates,
Madison, Wisconsin
1990-1993
Donohue/JRP, Hong Kong
1988-1990
Donohue & Associates, Madison, Wisconsin
1977-1988
General Engineering, Inc., Portage, Wisconsin
1975-1977
University of Wisconsin, Madison, Wisconsin – lecturer
1972-1975
University of Wisconsin, Madison, Wisconsin – student
1960-1972
The Oudenhoven Construction Co., Inc., Kaukauna, Wisconsin
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Pre-Assessment Report Part 2 – Technical Information
1.0 INTRODUCTION
EWB-UW was introduced to Gashonyi, Rwanda by Kavange, the former executive secretary
of the Matyazo sector. A medical clinic in Gashonyi was described as being understaffed and
overwhelmed with patients. During a trip in May 2009, EWB-UW conducted a preliminary
assessment of the existing clinic, and spoke with its staff about possible improvement. This
document will give:
1) a summary of the need for an improved health facility in Gashonyi, Rwanda,
2) an overview for 2010 assessment trip planned by EWB UW-Madison,
3) relevant community participation and EWB partners, and
4) a summary of anticipated and acquired data for use in the Gashonyi Clinic Expansion
Project.
2.0 PROGRAM BACKGROUND
The community of Gashonyi lies within the north-western Rwandan province of
Gisenyi, within the Matyazo sector, and is in need of improved health facilities. The
building supporting the current Gashonyi medical clinic was used previously as the
community’s vocational school, but was converted after pressure from the Ngororero district
and because of the need for a clinic closer than Muramba, about a half hour’s ride from
Gashonyi.
Currently, the clinic serves 24-50 patients per day with limited space, equipment,
and resources. The facility has only 4 wards, two of which can support patient care. An
estimated 20 patients require overnight observation, though the clinic has only 8 beds,
two nurses, and one nurse’s assistant to serve them. Accordingly, staff report the major
problem in the current clinical facility to be lack of space. In order to meet this most pressing
need, a building expansion has been proposed.
The Gashonyi Clinic Expansion Project would introduce additional space to the clinic
operation, which could be optimized in concert with emerging Rwandan Health Initiatives
(Appendix A) to provide more effective, government-sponsored health care. The Ngororero
District has promised to provide necessary land, and the community has offered to clear,
level, and perform basic construction tasks as required for implementation of the Expansion.
This basic improvement – increasing operative space – is the primary concentration of efforts
in Gashonyi by EWB-UW.
While space is the most pressing issue, it would not be ethically prudent to ignore
the secondary needs of the clinic. Staff report that the clinic’s electrical, plumbing, and
ventilation systems should be improved; reliable function of these systems would create
an environment where improved technology and increased sanitation would allow the
staff to focus on curing the diseases at hand, instead of troubleshooting secondary
problems. Improvements in these areas could be directly integrated into a design which
increases space in the clinic, and are being considered as a part of the Gashonyi Clinic
Expansion Project as well.
For these reasons, the University of Wisconsin-Madison’s Engineers Without
Borders chapter, in partnership with local contacts Jean-Paul BAZANSANGA and
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Innocent KAMBANDA , is working to address the needs at Gashonyi. Information about
current clinical operation, governmental regulation and incentives, climatic behavior,
building techniques and cost, as well as NGO activity in the area has been collected to
frame the design of a clinic expansion. EWB-UW is also engaged in conversation with
experts in the fields of medicine, global health, architecture, and biomedical
instrumentation in order to assemble a feasible plan for implementation and local
maintenance of a functional clinical operation.
Additional space, as well as incorporation of cost-efficient energy, sanitation,
ventilation, and operating procedures into one coordinated facility will help the
community of Gashonyi provide appropriate, sustainable medical care to their patients,
and give a model for further national healthcare improvement in Rwanda, but further
assessment is needed to fully outline the clinic’s building needs, define construction
capabilities in the area, and to begin a closer relationship with clinic staff and the community.
The site assessment will include a survey of the land proposed for building
construction, direct communication with staff members about clinic needs, and an
investigation of material supply and labor availability. It will also include visits to clinical
facilities currently operating in Rwanda, and communication with the Rwandan Ministry of
Health. Because preliminary floor plans have been drafted by EWB-UW (
Appendix B) some initial feedback can be elicited as well. Conclusions drawn from this
gathered information will help our group design the best layout for the Gashonyi Clinic
Expansion, in terms of current need and material feasibility. It is planned that these
assessments will take place in August of 2010.
3.0 OBJECTIVES OF SITE ASSESSMENT TRIP
The primary goal of the assessment trip will be to collect specific information about
clinic needs, materials of construction, and technical data so that we can begin to create an
informed design concept. This will be done directly and indirectly.
Directly, detailed descriptions of the dimensions, materials, and techniques used to
construct the current health care building will be recorded, including an evaluation of the
strength of the foundation and roof framing of the current building. Technical data collected
will include climate conditions, soil types, accessibility, and topography of the land available
for expansion. It will also be important that we develop a thorough understanding of current
clinical culture and operations. While in-country the survey team will observe and document
the number of patients seen on a daily basis, the length of the average medical stay, and how
many family members accompany each patient. An understanding of wards desired by the
clinic staff, as well as the most efficient, safest organization of those wards within the clinic,
will also be determined. Information about storage space, lab space, and accommodations for
specific medical equipment and/or supplies will be collected as well. Resources necessary for
each clinical stay will be determined on a per patient basis, and resources necessary to
accommodate staff who reside permanently in the clinic will also be determined.
11
This trip will provide us with the opportunity to begin a positive interactive
relationship with the community of Gashonyi. Several global health experts have
recommended that we do this by hosting a town hall meeting, though this step may be
postponed until more concrete designs are in place, and debate would be more meaningful.
Indirectly, visits will be made to other Rwandan clinics, and detailed descriptions of
the dimensions, materials, and techniques used to construct a comparable health care building
will be recorded. Visits to sites that implement solar energy and clean water technology will
be scheduled so that practical advice and observation can be made about their
implementation in Rwanda. We realize that a solid understanding of the political
environment in Gashonyi is important to designing an expansion that is sustainable, so we
will work with local contacts to verify our understanding of the benefits available to certain
clinic types under pending Rwandan healthcare, electricity, and transportation initiatives.
In order to understand the spatial needs and performance requirements of the clinic
space the team prepared an Adjacency Matrix. The adjacency matrix will be used to develop
a program of space and proximity needs. From the matrix we have developed a pod design,
bubble diagram, for a patient-care floor plan that will support functional efficiency, employee
productivity, and patient privacy and safety (Appendix B). While in-country the team will
meet with clinic staff and others with a stake in the operation of the clinic to share our
conceptual floor plan and gain a thorough understanding of their goals, objectives, and
cultural needs. See the following Adjacency Matrix for Gashonyi Clinic Expansion.
12
Bubble diagrams show relationships between rooms.
13
Appendix C
Finally, this assessment must collect both quantitative and qualitative data
to define the nature of our structural design: a second story, a completely separate
building, a simple addition to the current structure, or a combination of these. Based on
an adjacency matrix completed by EWB-UW, and subsequent preliminary floor plans (
Appendix B) this process will involve open discussion with local experts about the
availability of the materials and equipment of construction, local construction
capabilities, experience with each design, and observations by team members of existing
Rwandan buildings that are similar to each of these structural types.
4.0 COMMUNITY INFORMATION
4.1 Description of Community
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Gashonyi is a small community within the Muramba Parish, located about a 30
minute ride from the town of Muramba. The main landmarks in the community are the
church and the health clinic, which form part of a town square that is located at the bottom of
a hill below the area where most of the houses are located. In 1994, a water pipeline was built
to supply the community of 5,000 from a nearby spring, but it has since fallen into disrepair,
and many community members get water from contaminated rivers and streams. Conditions
like these are being addressed by community technicians, but meanwhile, they are a source of
health problems that cannot be adequately addressed by the clinic facility currently in place.
Improvements in both education about disease and resources to treat and prevent it would
greatly improve life in Gashonyi (Appendix D).
4.2 Community/NGO Resources and Constraints
Gashonyi does not have a lot of financial resources, but has a valuable resource in its
people. From the time we spent there, the community seems to understand the problems
facing them and they are willing to work together to fix these problems. The land for the
clinic expansion has already been donated. We have a commitment from the community to
supply unskilled labor to help complete this project, and anticipate valuable input and advice
from the conscientious and invested community in Gashonyi.
Gashonyi’s main constraint is its location and access (or lack thereof) to the main
roads. It might be difficult to transfer materials to Gashonyi because of the poor condition of
the roads, though significant improvement has been made in fixing them, and the trip to
Gashonyi is now reliably passable with 4-wheel drive vehicles. Though this would be
sufficient for our assessment goals, community contacts assure us that improvement will
continue as our anticipated travel approaches. Still, we realize that trucking materials and
timely delivery of material to the project site will involve careful planning. Fortunately,
EWB-UW has recently established a relationship with Partners in Health, an NGO working
in a separate Rwandan community. PIH has offered to share international shipping resources
should they be necessary, and offer advice and business contacts that provide reliable
services and materials.
4.3 Community Relations
We first met the people of the community (and they first experienced us) in May of
2009. They seemed to be a hardworking people, and will be willing to help us complete the
clinic improvement project; they hope to implement improvements that will benefit the whole
community.
4.4 Community Priorities
As mentioned briefly above, increasing capacity and space in the current health
facility is the primary concern. The clinic is currently not big enough to serve all of the
community’s health needs, and it is very difficult for them to go anywhere else for healthcare
because of the aforementioned location constraint. The community recognizes also that
improving sanitation, electrical, and education within both the clinic and the community will
be beneficial for overall health in the area in general. They have been supportive of us as
15
demonstrated by their express willingness to help with labor to get this project completed.
The EWB-UW team plans to build on this commitment by keeping the community involved
and informed throughout the design process (Appendix E).
5.0 DATA COLLECTION AND ANALYSIS
5.1 Site Mapping and Building Description
In order to fully understand the clinic and surrounding area, and evaluate the
feasibility of proposed design alternatives, detailed plans must be prepared. The plans should
be prepared in two parts: the first, a site plan, overhead view of the current clinic,
surrounding topography and environmental features. The plan must include the area of the
existing facility and include the area of the proposed expansion; the second plan is a detailed
floor plan, to scale, of the current clinical structure.
The site plan of the clinic and surrounding area will depict the current structure
demonstrating how it is situated with respect to the natural surrounding features. It will
include spot elevations, topography, drainage paths, existing and planned roadways, and
wind flow around the current clinical structure. The plan should also note soil type of the
immediate area, and any substantial vegetation or rock debris present. All plans should be
drawn to scale and orientated with respect to magnetic north.
A detailed floor plan and cross section of the clinic will be sketched while on-site to
enable the team to prepare scale drawings of the facility. The first floor plan should include
explicit, scaled dimensions, of all rooms, windows, doors, and permanent structures. The
cross section should be a scaled diagram of the integration of materials, structural elements,
materials of construction, description of the materials – sizes, spacing, methods of connection
and construction techniques used in the current clinical structure (Appendix F).
5.2 Technical Data Collection
In order to develop the plans and sections described in section 5.1, we will first need
exact dimensions of the building, and the topography of the land on which we plan to build.
Besides exact dimensions, specific data from the current building should include: strength of
the foundation, locations of windows, doors, support beams, and trusses, sheathing materials
and the strength of the roof. The solar panels, electrical wiring, and location of the generator
will also be needed for the consideration of a second story.
The existing roof trusses have been fabricated locally from local materials. The team
will prepare a detailed sketch of a typical truss identifying each member of the truss, size and
spacing of these materials, truss member jointing/connector types, spacing of the trusses, and
the total span of the trusses. While on site the survey team will contact contractors regarding
fabricating trusses for the proposed new clinic and determine if these trusses will be
fabricated on-site (Appendix G).
It is also important to look into material procurement. We need to record exactly how
much basic materials cost, how long it will take to receive any material on site, and whether
there are any limitations on amount or size of construction materials. Local contractors will
be asked the average cost of construction per square meter of building footprint of a typical
building. Documentation requesting this information has been received from local contractors
16
(Appendix H), to make sure that an answer can be given upon arrival, and time to evaluate
this response can be done in country, directly with contractors.
In order to plan an implementation, we must record for consideration the weather and
soil conditions in the area. Temperature variations and wind patterns will be recorded in
preparation for a potential future ventilation system. The rainy season will also need to be
considered when deciding the best time to pour a foundation and build a building. Data must
be obtained on the type of soil so that the safe bearing capacity can be determined. Much of
this will utilize the experience and advice of locals, as our team will directly experience only
a snapshot of Rwandan climate.
With respect to labor, we need to determine who could work on the expansion
project, how long they could work, and when they would be available and willing to help.
The cost of labor is important in estimating the cost of construction. An estimate of the units
of material that can be put in place per day per construction worker is important to estimating
the cost of construction.
While in country, our team would also like to look into current two story buildings in
Rwanda to help determine if a two-story addition to the current health clinic would be
feasible. To do this, we will investigate two-story buildings, and record the types of
foundations, materials used in construction, and the support structures used. We will also
make site visits to hospitals operated by PIH (most likely their operations in Kayonza,
Kirehe, or Ngoma) to observe construction technique as well as operational procedure.
Our last effort will be to talk to the staff of the clinic, and see what they think is most
important in the expansion. We will observe and report what kind of equipment they have,
how many supplies they store on site, and what the average number of patients are per day,
for an estimate of the size and shape for the proposed expansion would be most beneficial.
This information will be an important practical supplement to the extensive research we have
already completed on local diseases (
Appendix J), Rwandan Health Clinic regulations (Appendix A), local hospital layouts
(Appendix K), the country’s political situation (Appendix L), and efficient energy (Appendix
M).
17
6.0 SCHEDULE OF TASKS
A list of general tasks that need to be completed for the Gashonyi Clinic expansion appears
below.
1) Measurements
Area we can expand on
Quality of Foundation
Height width & length of current building
2) Building Analysis
Determine whether the current building has the structural capacity to support the
construction of a second floor
Determine whether the roof is strong enough to be lifted to construct a two story
building, while saving the roof
3) Analysis of Competencies in Construction
Survey local technicians to determine construction skill
Observe other buildings in the area
Contact contractors in the area
Review, acquire construction standards and any required permits
4) Materials
Current materials used in construction
Analysis of quality of materials
From where and how can we get these materials
Approximate costs of building materials
5) Sustainability
Analysis of the quality of construction needed
Analysis of lifespan/lifecycle of project
MOU’s/Contracts
Create Declaration of Intent, MOU
We hope to send three or four people over a two and a half week period. We feel this
team size is optimal, as it is small enough to connect with the community, but large enough
to find and record information needed during the assessment.
A lot of data and measurements must be collected in order for this trip to be effective;
however our experience in Rwanda has taught us to be reasonable with our project outline.
We find the best way to accommodate for the unpredictability of the developing world is for
the project leader to outline each day, and include several tasks that each member must
perform. This way, smaller setbacks do not drastically alter the project plan of the trip, and
members will have the time and opportunity to show respect for the culture of this Rwandan
community.
7.0 PROJECT FEASIBILITY
An inclusive range of alternatives for the clinic expansion have been identified and
the team is open to evaluating the alternatives based on their feasibility and cost. The
alternatives range from constructing a second story on the existing building, a partial second
18
story atop the existing building, a single or two story addition to the existing structure and a
stand-alone one or two story building.
The team is aware of the disruption to clinic services that construction of a second
floor and remodeling the existing building might cause. While in-country the team will
observe clinical practice and evaluate the feasibility of a second story addition to the existing
building.
The community of Gashonyi asked for assistance/aid to improve the clinic building.
The May 2009 EWB survey group witnessed a hardworking group of people who expressed a
willingness to help EWB construct a project that will benefit the whole community. The
EWB 2010 survey team is committed to building on the initial relationship with the people of
Gashonyi, and we believe that through continued research into clinical operation,
maintenance of solid relationships with experienced NGOs in the area and experts in the
field, and the cultivation of mutual respect between EWB-UW members and the local
community, we can build a successful clinic expansion, and significantly help the community
of Gashonyi, Rwanda.
8.0 MENTOR ASSESSMENT
The EWB-UW team has done a thorough job of preparing for their in-country
needs assessment for the Gashone Clinic Expansion project, Rwanda. This past semester
the team, on a weekly basis, advanced and documented their knowledge of the needs of
the clinic staff and patients and began the programming phase of the project.
The goal of this in-country assessment is to collect and catalogue the information
necessary to design the clinic expansion. To prepare for the survey the team members
routinely apply standard practices and techniques in specific situations, adjust and
correlate the data, recognize discrepancies in results and follow tasks through a related
series of steps on the way to understanding the design needs of this project.
The team has a solid and deliberate approach to understanding and defining this
community’s medical needs. On a routine basis the team participates in a programming
exercise. Weekly individual team members are tasked to understand and document
specific project needs ranging from patient care, medical supplies, and medical
instrumentation to electrical energy generated by solar panels and stand-by power
generators. In this way all of the team members are actively involved in advancing their
knowledge of the clinic’s needs. Each member of the team performs assignments
designed to clarify the human and physical needs of the project.
Adding to the knowledge obtained during their first, May 2009, survey trip the
team has greatly enhanced there professional resources base by making contacts with
global health experts from Global Health UW School of Medicine and Public Health,
Partners in Health, Engineering World Health and a practicing physician whose
birthplace is Ethiopia and now practices medicine in Madison, Wisconsin, and is actively
involved in the building of health care delivery systems in Ethiopia. These health experts
have committed their resources to helping the team understand the medical needs and
services which are technologically feasible, economically possible, socially necessary
19
and sustainable. Combined the team and their resources have the education and
knowledge of the developing world healthcare needs to deliver a clinic that will support
the community’s needs today and in the future.
In order to gain knowledge of local construction contractor capabilities and local
materials of construction the team has developed “shopping” lists to aid the in-country
survey team to become aware of and document local resources, in terms of material
availability, availability of labor for construction, labor and material costs. The data
gathering efforts of the in-country assessment team and subsequent evaluation of the
information will lead to the development of a feasible alternative that will meet the needs
of the Gashone Clinic staff and patients.
A full range of alternatives for the clinic expansion have been identified and the
team is open to evaluating the alternatives based on their feasibility and cost. The
alternatives range from constructing a second story on the existing building, a partial
second story atop the existing building, a single or two story addition to the existing
structure and a stand-alone one or two story building.
In my opinion the team’s report is comprehensive and demonstrates they made a
determined effort to research the issues and prepare the travel team for a productive incountry survey of needs.
20
Appendix A
Sample of Standards and Policy for Health Services in Rwanda
Draft taken in French from
http://www.moh.gov.rw/index.php?option=com_docman&task=cat_view&gid=62&Itemid=14
Translated by Padraic Casserly, 2010
1. Introduction
Since 1997, the minister of health has worked on establishing standards for health
structures in the country.
In 2007, it was necessary to revise these standards to adapt to current health conditions in
our country.
The group working on the project read, corrected, and completed existing documents
concerning these standards and put forward new standards concerning:
 Infrastructure
o Community Health Posts
o Health Centers
o Hospitals
 Equipment
o Community Health Posts
o Health Centers
o Hospitals
These standards establish the surface area allotted for each type of health facility and
outline the necessary equipment which each type of facility must carry.*
*Note: For the purpose of this project, only the standards for the Health Center
type of facility have been translated.
2. Primary Health Facility Activities: Health Center (section 2.2)
The national policy of the health service of Rwanda defines a list (le Paquet minimum
d’activités) of the minimum activities required by a health facility to define it as a Health Center.
This list is “a succinct, common list of important activities for all Health Centers which outlines
the most fundamental of health problems to be addressed by Health Centers. This list takes into
account the health needs and demands of the population…”
This list facilitates the allotment of resources and provides a framework for development
according to the health policy of the country.
The current policy of “decentralization” establishes a Health Center in each sector of the
country.
Here is the list of activities required by a Health Center:
A. Preventative activities
 Premarital examination
 Focused prenatal examination
 Voluntary HIV/AIDS screening
 Postnatal examination
 Post-abortion care
 Family planning
21



Vaccination
Epidemiological surveillance
Hygiene and sanitation
B. Curative activities
 Transmittable disease care
 Integrated management of child illness
 Management of chronic maladies
 Support for HIV/AIDS patients
 Malnutrition rehabilitation
 Hospitalization
 Minor surgeries
 Laboratory
 Pharmacy
C. Promotional activities
 Information, Education, and Communication (IEC)/ health education
 Monitoring of child development
 Psychosocial support
 Mutual health insurance
 Community supervision
D. Maternity activities
 Deliveries
 Post-abortion care
E. Administrative activities
 Financial management
 Adult continuing education
 Supervision by health coordinators
 Cross-industry collaboration
4. Infrastructure Standards: Principal Spatial Organization of a Health Center (section 4.1.2)
The basic principles of a Health Center is to provide at one site the following types of
care: maternal and infantile care, vaccinations, deliveries, preventative examinations, ordinary
care, HIV screening, laboratory tests, and all other care as determined by the list of activities
required of a Health Center.
To provide this care, the Health Center must also have a pharmacy with a stockroom and
dispensary which provides proper storage of the drugs.
Additionally, the Health Center designers must accommodate the separation of wards
where preventative medicine is practiced and those where curative medicine is practiced.
The Minister of Health officially assumes the responsibility to plan the arrangement of
Health Centers throughout the territory of the Republic of Rwanda such that there is at least one
Health Center for each administrative zone. Furthermore, each Health Center should not exceed
providing care to more than 20,000 inhabitants.
Principal Areas (section 4.1.2.1)
Property Type
Surface Area
22
Clinical Bloc
Waiting area/lobby
Reception- insurance
Cashier’s desk
2 curative examination rooms for adults
Pediatric curative examination room
Pharmacy dispensary
2 rooms for injections and bandaging
Sanitation room
Bathroom
Administrative Bloc
Secretary/accountant
Office
Archives
Library
Pharmacy stockroom
Bathroom
Preventative Health Bloc
Lobby
Prenatal examination room 1
Prenatal examination room 2
HIV screening room 1
HIV screening room 2
Family planning and prenuptial consultation area
Refrigerating unit
Supervisor’s office
Bathroom
Maternity Bloc
Preparation room
Delivery room
Premature infant nursery (2 beds)
Nursery (4 beds)
Waiting Room (4 beds)
Supervisor’s office
Clinician’s bathroom
Patient’s bathroom
Observation Bloc
Observation room (2 beds)
Staff room
Bathroom
Changing room/locker room
Store
Stockroom
Nutrition Center
Consultation room
Classroom
Demonstration kitchen/kitchen
Food commodity stockroom
Laboratory
23
64 m2
17 m2
12 m2
11 m2 x 2
11 m2
16 m2
16 m2
12 m2
16 m2
16 m2
16 m2
12 m2
12 m2
24 m2
16 m2
42 m2
12.5 m2
12.5 m2
12 m2
12 m2
12 m2
12 m2
12 m2
16 m2
16 m2
16 m2
16 m2
25 m2
25 m2
16 m2
12 m2
12 m2
16 m2
64 m2
12 m2
12 m2
16 m2
16 m2
12 m2
38 m2
30 m2
16 m2
Waiting room (covered veranda)
16 m2
Corridor
8 m2
Specimen sampling room with one sink
6 m2
Tuberculosis laboratory with one sink
12 m2
Clinical and biological laboratory with 2 ceramic sinks
40 m2
Office and archive
6 m2
Stock area
8 m2
Wash, decontamination, and sanitation area
6 m2
Toilets and showers (patient and clinician): 2
8 m2
Notes:
 The laboratory areas must be sufficiently ventilated and well lit.
 The HIV screening laboratory must adhere to the standards of a Health Center
laboratory. When the Health Center and the HIV screening laboratory are
located on the same premises, the laboratory waiting room, the specimen
sampling room, the laboratory stock area, and the laboratory bathrooms are to be
located together.
 The lab bench must be comprised of medium-density fiberboard.
Additional translation can be found: http://sites.google.com/site/ewbuwrwanda/tasks/gashonyeclinic-expansion
24
Appendix B
Adjacency Matrix for Gashonyi Clinic Expansion.
Adjacency unimportant
Adjacency avoided
Adjacency not ideal
Adjacency preferred
Adjacency critical
Bubble diagrams show relationships between rooms.
25
Appendix C
Summary of local contacts established by EWB-UW:
Name of
Location
Contact Person
Partner
District of
Jean Paul
Ngororero
Ngororero BAZANSANGA
A
B
C
D
Matyazo Sector
Innocent
KAMBANDA
Minister of
Health
E
Partners In
Health
F
Engineering
World Health
[email protected]
Executive
Secretary
Pascal
By phone through Jean Paul
BAZANSANGA
Innocent
KAMBANDA
By phone through Jean Paul
BAZANSANGA
EMMANUEL
[email protected]
Justin Miranda
[email protected]
Amit Nimunkar
[email protected]
Hindiro,
Rwanda
Muramba,
Rwanda
Muramba,
Rwanda
Kayonza,
Kirehe,
Ngoma
Madison,
WI
Contact E-mail
26
A. Jean Paul BAZANSANGA grew up in the village of Muramba and
knows the region well. He has exceptional technical expertise, as well as a valuable
network of professional and community contacts who can provide additional knowledge.
He has been a trusted advisor, translator, and organizer in Muramba for our EWB-UW
teams since 2004.
B. Jean Paul has, in particular, facilitated cooperation with the Matyazo Sector
leaders and EWB-UW. We expect that our contacts there will help organize training and
labor sessions with locals in the community, and will give valuable input and feedback
regarding our plans and projects.We have received assurances from the Executive
Secretary of the Matyazo Sector and the new District Mayor through Jean Paul that the
Sector of Matyazo and the District are still able to provide, clear, and level the land for
the clinic expansion, and are currently improving the road to Gashonyi so the travel team
can access the clinic without using hazardous motorbike transportation.
C. Innocent Kambanda, a well-known teacher and recent recipient of a national
award for public service in Rwanda, has agreed to assist us by providing information on
local materials, means and methods of construction, as well as reviewing our designs
throughout theproject to ensure durability and constructability in Rwanda.
D. The Health Secretary of the Matyazo sector is helping our group understand the
governmental regulations that might apply to the expanded clinic. We will continue to
work with the Matyazo government to satisfy appropriate regulations, so that the
expanded clinic can become sponsored by the Rwandan Health Ministry – which will
then help provide the clinic with supplies and equipment to improve the health care in
Gashonyi and the surrounding area.
E. Partners in Health (PIH) has been working to provide the underprivileged with
healthcare options since 1987. At the invitation of the Rwandan government, they started
to establish themselves in Rwanda in 2005. As an organization, they are familiar with the
process of establishing healthcare facilities, and are continually providing us with advice
which will help ensure that an expansion to the clinic will be sustainable and functional
within Gashonyi. They are drafting and sharing with EWB-UW programming designed
specifically to guide the creation of a successful clinic operation in an underprivileged
country.
F. Engineering World Health (EWH) is a national organization which works to
innovate and distribute affordable medical instrumentation; we are affiliated primarily
with the chapter at UW Madison. This organization is helping to procure and modify
medical equipment, so that we can help Gashonyi improve the services they offer reliably
and at low cost. EWH is also helping to teach EWB-UW through seminars how to
manipulate biomedical equipment, so that we can in turn teach Rwandan health care staff
about the equipment’s operation and repair methods.
27
Appendix D
The current health clinic in Gashonyi, Rwanda
Community members patiently awaiting care
28
Nurse administering treatment
Patient facilities – 6-8 beds to serve an estimated 20 patients
requiring overnight care
29
Appendix E
Committed Community Contribution
Size of the place: 45m x 25 m
The Price of this land: 2 500 000 Frs
The value of UMUGANDA: 3200 man power x 500Frs = 1 600
000Frs
Tatal: 4 100 000 Frs, this is the community contribution to build the
Gashonyi Health center.
Example of Communication, Community Enthusiasm
30
Appendix F
October 15, 2009
To:
Re:
From
Gashonye, Rwanda Clinic Expansion Team
Building Expansion
Tom Siebers
The purpose for this document is to generate discussions which will lead to the identification of
feasible alternatives for the clinic expansion. This is also the time to begin to identify the
materials of construction and equipment which can be obtained locally, those materials and
equipment local builders are likely working with on this type of construction.
There are two general alternatives -- building expansion/addition, and a new stand-alone building,
and variations which mix and match these basic alternatives.
Expansion of the existing building - three options:
 Add a partial to full second story
 Add on one story
 Stand alone one/two story building
Addition of a Partial or Full Second Story Alternative
Until we know more about the physical condition of the existing structure (are the foundation and
first floor walls sound -- do they show no or very limited signs of movement, cracks and/or
deterioration) and existing soil(s), we can’t be sure of the feasibility of this alternative.
If we assume the following, a second story may be feasible:
 the soils are clay
 the existing structure is sound
 and there are sufficient interior walls that can be used for bearing walls, or those walls
could be added to the existing structure,
This alternative will require the removal of all or a portion of the existing roof, and probably the
addition of interior bearing walls or columns and beams to support the second floor.
Implementation of this alternative will open the clinic to the weather and result in a significant
disruption, even cessation of medical services in this building for a significant time. An alternate
location for providing medical services will be necessary until the partial or full second story is
enclosed and weather tight.
The advantages of the Second Story:
 No need for additional land
 No need to construct a new foundation
Single or Double Story Addition to the Existing Building Alternative
A single or double story addition to the existing building will be less disruptive to clinic
operations. This is an easy solution to the space needs. While the clinic users will have to put up
with dust and noise, the clinic can continue to operate at its current capacity. Once the addition is
complete and some uses are relocated to the new addition, the existing building can be
remodeled. The remodeling might include the addition of new walls to create new rooms and to
provide support for a second story, mechanical, utilities for the future, skylights, new windows,
doors…
31
Single or Double Story Stand Alone Building Alternative
This alternative is the least disruptive to the existing clinic and medical services. The
disadvantages are:
 higher cost than utilizing the existing building
 the need for more land,
 the need to construct a foundation
 the need to construct a concrete first floor
Materials of Construction and Equipment:
While in-country, it will be necessary to contact local builders and learn what capability they
have and learn about the availability of materials -- and in some cases their structural capabilities.
In a lot of cases, we might have to rely on what materials were used in the past to build similar
buildings with a history of success, as structural grading of the local materials might not be
available.
Materials for the above alternatives will include some or all of the following:
Foundation
 footings
 walls
Concrete for floors and stairs
Masonry wall
Steel
 angle lintels
 columns
 beams
Dimensioned Lumber
 studs
 floor joist
 roof rafters
Sheathing
 floors
 interior walls
 roof
Roofing
Flashing
Skylights
Windows
 fixed
 operable
Doors
 wood
 metal
Finish hardware
Paint
Finish Flooring
 concrete
 wood
 covering(s)
Also consider the distance from material supplier to job site in the choice of materials and
equipment.
Equipment
Identifying the tools that are available will help us to design within the capabilities of the local
contractors.
 scaffolding
 power equipment powered by gas or a gas powered electrical generator
 circular masonry saw blades for gas or electric tools
 trucks and accessibility to site
 common power tools like circular saws, roto-hammers
32
Appendix G
Example of truss analysis and data to be taken.
33
Appendix H
Contractor Innocent KAMBANDA and Jean Paul BAZANSANGA provided a materials cost
analysis (April, 2010).
Number
Designation
1
Terrassement ( Cleaning the
Place)
- Décapage
- Fouille pour la foundation
2
3
4
5
6
7
8
9
Foundation
- Sous colonne
- Foundation en Moellons
- Chape d’étanchéité
Elévation des Murs
- Colonnes
- Longrine
- Roofing
- Maçonneries en Briques
cuites
- Chainage en Béton arme
- Claustra d’aération
Toiture
- Charpente métallique
- Penne métallique
- Tole ondure BG 28
Huisserie
- Porte métallique double
- Porte métallique simple
- Fenêtre métallique
Revêtement des Murs
- Briques rejointoyées
- Plainte
- Enduit sur chainage
Revêtement
- Pavement/sous pavement
- Trottoir et rigoles
Plafond
-Plafond avec triplex
Finissage
- Peinture Email sur les portes,
34
Unit
Unit Cost (Rw Fr)
M3
M3
1500
500
M3
M3
M3
4725
42500
62350
M3
M3
M2
M3
M3
pces
61780
9750
4500
40000
120000
1200
Pces
Pces
pces
90000
9000
18000
Pces
Pces
Pces
220000
140000
80000
M2
M2
M2
17000
5000
6500
M2
M2
4350
4350
M2
7000
M2
7000
10
11
12
13
14
fenêtre plafond et plainte
Plomberie
Tuyaux galvanise
- ½ de 6 m
- ¾ de 6 m
- 1 de 6 m
- 1 ¼ de 6 m
- 2 de 6 m
PVC
- Ф 18 de 6 m
- Ф 25 de 6 m
- Ф 32 de 6 m
- Ф 40 de 6 m
- Ф 50 de 6 m
- Ф 63 de 6 m
- Ф 110 de 6 m
- Coude ф 110
- Attaches ф 110
- Jonction ф 110
- Décente ф 110
- Attaches décente ф 110
- Cheville
- Vis de 3 cm
- Couvercle décente
- Gouttière 4 m
- WC Anglaise
- WC a le tric
- Urinoir
- Douche
- Lavabos
- Evier vessaille
- Porte Savon
- Porte Essuie main
- Chauffe eau
-
15
-
Pces
Pces
Pces
Pces
Pces
Pces
Robinet
Robinet Mélangeur
Robinet Lavabos
Robinet Simple
Vanne ½
Vanne 3/4
Cheville Accessoires
Coude ½
TE ½
Niple ½
35
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Box
Box
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
2000
3000
3500
4000
5500
7500
12000
2000
2000
2500
3000
1000
1000
11000
50000
35000
25000
20000
40000
35000
2500
3000
180000
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
500
500
500
800
2500
16
17
-
Adaptateur ½
Robinet ½
Vanne ½
Raccord ½
Flexible
Réduction 1/2
Electricité
Prises
Boite d’encastrement
Boite de connexion
Interrupteur
Lampes économique
Sockets
Fils conducteur
Fusible de protection
Cache fil (PVC 5/8)
Toile isolante
Ventilateur
Meubles
Table 2m x 90
Chaise Moderne
Banc
Tabouret
Etagere 2m x 2 m
Bureau
Porte Rideau
Lit
Armoire 2m x1 m x 60
36
Pces
Pces
Pces
Pces
Pces
3500
500
1000
800
800
Pces
Pces
Pces
Pces
Pces
Pces
Roulon
Pces
Pces
Pces
Pces
500
500
500
1000
1500
250
9000
3000
400
15000
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
Pces
30000
15000
10000
5000
25000
36000
5500
40000
35000
Appendix J
Exploration of Rwandan diseases (draft of letter to expert physician) and summary of research
into dominant health concerns. Full document can be found under Clinic Assessment/Data:
Disease Spreadsheet at http://sites.google.com/site/ewbuwrwanda/tasks/gashonye-clinicexpansion.
3.31.2010
EWB seeks to design and implement an expansion of an existing clinic in Rwanda. The
task is of great importance and necessity, and we are all very willing to put forth maximum effort
in order to bring our goal to fruition. However, the marked differences between our worlds make
it difficult to proceed without addressing questions concerning practicality and possibility.
One segment of our project has involved an exploration of the medical practices and
problems in the Rwandan area. This knowledge is important to us in terms of planning patient
capacity requirements, necessary medical equipment, electrical power needs, important
medical/testing procedures, and medications that must be stocked.
1)
HIV/AIDS is a significant problem in Rwanda, as it is across much of Africa. However,
there is no perfect cure; the only treatments that exist are preventative and reductive in nature,
and are also very expensive. In a small-scale clinic, is there reason to allocate many resources to
the treatment of AIDS, or is the HIV/AIDS problem more relevant to social-preventative
treatment?
2)
Many diseases can be treated with a range of simple antibiotics, which usually have a
shelf life of about two years unrefrigerated. How difficult is it to obtain these supplies, and how
often must they be obtained? Is it more useful to stock up for 1-2 years at a time to reduce
shipping costs, or to stock up only for several months to prevent waste and reduction in
effectiveness?
3)
The attached spreadsheet shows a collection of the most significant afflictions in Rwanda
and central Africa. I’m surely missing some significant diseases, while some I have mentioned
may not be of the greatest utility to target. I have also not included any physical afflictions like
broken bones, internal bleeding, or blood loss. How common are these problems relative to the
mentioned diseases and how difficult is it to treat them?
4)
The desires for increased patient capacity and increased patient comfort/safety are
conflicting. We would like to be able to house as many patients as possible; however, patients
with certain ailments may need to be kept in isolation to prevent contagion. In your experience,
how significant is the problem of spreading infections between patients? Are curtains effective in
isolating patients or would walled-rooms be necessary? Which diseases pose the most threat for
this problem?
5)
We are not sure what clinics are able to do with medical waste such as infectious blood,
used needles, grey water, etc. What are some options we could choose from, and how
expensive/difficult would they be?
We hope that by your reading this request for information you will be reminded of issues
we haven’t thought of. Please offer you thoughts on those items as well.
To summarize, we simply need more information about how patients must be housed,
what tasks (specific types of treatment, diagnostic tests, and interventions) are most immediately
necessary for basic clinical function (as well as how much training is necessary for these tasks to
37
be carried out effectively), what materials/equipment must be maintained at all times, and how
these materials can be procured. Any help you can give us will be highly appreciated and will
greatly expedite our planning process.
Thank you very much for your time. We all hope that this project will become a quick
success, and that together, we will be able to save countless lives and alleviate the suffering of
the Gashonyi community.
Disease Research:
Disease
Category
Estimated
Prevalence
Mortalit
y
Infectivit
y
Symptoms
Cardiac
failure
Organ
Failure
Approximate
ly 2%
Very
high
Zero
Congestive heart failure
Infection
Rheumatic
heart
disease: 0.11.5%/year,
30% of all
heart-disease
hospiatlizati
ons
Causes
death
almost
exclusive
ly via
congestiv
e heart
failure
Rheumatic
fever
HIV/AIDS
Infection
3-15%
High, but
slow
Migratory polyarthritis,
carditis, subcutaneous nodules
near bone/joints, rash on arms
and legs, purposeless spasms
of face… fever, arthralgia, creactive protein, leukocytosis,
heart block,
streptococcal/previous RF
evidence. Needs 2 major or 1
major + 2 minor criteria.
Antibiotics
About 1-2 years
in a sealed,
controlled vessel
kept in 37° C.
Screen blood or saliva
(Orasune) for HIV antibodies
Highly Active Antiretroviral Therapy
(HAART): Nonnucleoside Reverse
Transcriptase Inhibitors (NNRTIs,
nevirappine (Viramune) and efavirenz
(Sustiva)), Nucleoside Reverse
Transcriptase Inhibitors (NRTIs
zidovudine (Retrovir), tenofovir DF
(Viread), and stavudine (Zerit)),
Protease Inhibitors (PIs), such as
lopinavir/ritonavir (Kaletra), Fusion
Inhibitors enfuvirtide (Fuzeon )
Unknown
Screen for Mycobacterium
tuberculosis bacteria
Isoniazid, rifampicin, pyrazinamide,
and ethambutol for two months, then
isoniazid and rifampicin alone for a
further four months.
Mosquitoe
s
Fever, chills, headache, sweats,
fatigue, nausea, vomiting. Symptoms
may be severe or absent.
Identification of malaria
parasite or its
antigens/products in the blood
of the patient. Microscopic
tests: Peripheral smear study
and Quantitative Buffy Coat
(QBC) test
Prevention: insecticide use, tx of
pregnant women Artemisinin-based
combination therapy (ACT).
artemether-lumefantrine (AL) is
Rwanda’s first-line treatment for
uncomplicated malaria.
About 2 years.
Unknown
Tsetse
flies
Trypanosoma brucei rhodesiense …
fever, severe headache, irritability,
extreme tiredness, swollen lymph
glands, and aching muscles and
joints. Weight loss and a body rash
are also common. Infection of the
central nervous system causes
confusion, personality changes,
slurred speech, seizures, and
difficulty in walking and talking. If
left untreated, the illness becomes
worse, and death occurs within
several weeks to months.
Microscopic examination of
blood and lymph for the
presence of trypanosomes.
Cerebrospinal fluid has
increased levels of white
blood cells.
Suramin, pentamidine, melarsoprol,
eflornithine, nifurtimox
Suramin: Halflife is 5 years,
25° C, in
aqueous soln.
Note:
melarsoprol and
nifurtimox both
have very bad
side effects
which kill several
pts.
Unknown
Unknown
Zero
Hepatomegaly, bloating, lethargy,
decreased muscle, fatigue, infections,
rash, swelling, shock, coma
Arterial blood gas, BUN,
Complete blood count,
creatinine clearance, protein
levels, urinalysis. Observation
of sxs?
Increased caloric intake, protein
N/A
5-10%
.01%
develop
liver
cancer
Medium
loss of appetite, nausea, vomiting,
body aches, mild fever, dark urine,
and then progresses to development
of jaundice. If chronic, liver
inflammation, cirrhosis and
hepatocellular carcinoma.
Blood test: hepatitis B surface
antigen (HBsAg) and IgM
antibody to hepatitis B core
antigen (anti-HBc IgM)
interferon alfa-2b and lamivudine for
chronic Hep B. No tx for acute Hep B.
Interferon: 2-8°
C for two years
as finished
formulation.
Lamivudine: 2
years,
refrigeration of
tablets not
needed (I think)
Infection
900k cases
in 2007
(decreasing)
9% of all
African
deaths
Trypanosomia
sis
Infection
During
epidemics,
reaches 50%
in some
African
areas… in
Rwanda, <50
cases per
year.
Kwashiorkor
Malnutritio
n
Infection
N/A
loss of weight, loss of energy, poor
appetite, fever, a productive cough,
and night sweats.
0.1% of
populatio
n
annually
Hepatitis B
Immunosuppression, weight loss,
swollen glands, diarrhea, whitish
coating of tongue/throat/vagina,
purple spots on skin, mental
deterioration
Surgical/medical intervention
High,
personperson
contact
0.59%;
12,403
deaths in
2007
Malaria
High,
sexual/blo
od contact
From un-tx Strep throat, cardiac
connective tissue damage
Shelf life of
Treatment
Isoniazid: 3 years
kept below 25°
C. Rifampicilin:
5 years below
25° C if in
powder, 2 years
if in lyophilized
form for
intravenous tx.
Pyrazinamide: 3
years kept at 1530° C, powder
form.
Ethambutol:
Unknown, but
store at 15-30° C.
Infection
Tuberculosis
High,
personperson
contact
How to Treat
How to Diagnose
38
Hepatitis C
Infection
Gastroenteriti
s
Infection
Amoebiasis
Infection
0.1-7%
Water borne
diseases,
about 1-2%
.01%
develop
liver
cancer
Low if
treated
High,
sexual/blo
od contact
decreased appetite, fatigue,
abdominal pain, jaundice, itching,
and flu-like symptoms. Chronic: liver
inflammation, cirrhosis and
hepatocellular carcinoma
Detection of HCV antibodies
in blood, liver biopsy
Interferon, interferon + ribavirin.
Cyclosporine..,?
Ribavirin syrup:
greater than 2
years.
Fecal-oral
transmissi
on
Inflammation of stomach,intestines.
Nausea, vomiting, diarrhea, loss of
appetite, fever, headaches, abnormal
flatulence, abdominal pain/cramps,
bloody stool, dysentery, weakness
diagnosis based on symptoms
rehydration and general antibiotics
About 2 years.
Fecal-oral
transmissi
on
90% of cases are aysmptomatic.
Symptoms include diarrhea, bloody
mucus and development of
dysentery.
location of shed cysts in stool,
or anitbody testing. More than
one stool sample is required
because cysts are not always
shed.
amoebicides--tissue: metronidazole,
lumen: paromomycin
Unknown
Blood, marrow or stool tests.
Widal test,.
Oral rehydration therapy, antibiotics.
Ciproflomaxin if resistant.
About 2 years.
Typhoid fever
Infection
Fecal-oral
transmissi
on
High fever, sweating, gastroenteritis,
diarrhea. First stage: headache,
cough, malaise, bloody nose, low
white blood cell count. Second:
delirium, intense fever,
painful/distended abdomen, rose
spots on chest, diarrhea, glandular
swelling. Third: Intestinal
hemorrhage and perforation,
encephalitis, metastatic abscesses.
Fourth week... gets better?
Dysentery
Infection
Fecal-oral
transmissi
on
Bloody diarrhea, cramps, fever, pain
during defecation
Bloody diarrhea
oral rehydration therapy, intravenous
fluid replacement,
antiamoebicidal/antibiotic
(metronidazole + diloxanide furoate,
paromomycin or iodoquinol)
About 1-2 years
in a sealed,
controlled vessel
kept in 37° C.
Scabies
Dermatosis
Unknown
Low
High,
personperson
contact
Sarcoptes scabiei mites, rash
containing blood crusts or papules.
Skin scrape to search for
mites, eggs, fecal matter
permethrin, crotamiton lotions
Permethrin: 5
years stored
below 50° C…
Crotamiton, store
at 15-30° C
Tinea Capitis
Dermatosis
Unknown
low
High,
personperson
contact
Extreme itching of head
fluorescence or microscope
examination
http://www.aafp.org/afp/980700ap/nob
le.html
Variable
Cholera
Gastroenteri
tis
100,000
cases in
Afrida yearly
5% cases
in
Africa…
untreated
: 50-60%
Fecal-oral
transmissi
on
Vibrio cholerae, exhaustive diarrhea
and dehydration, hypotension, shock
and death w/o therapy
Oral rehydration therapy, intravenour
fluid replacement, various antibiotics
shorten course (tetracycline)
About 1-2 years
in a sealed,
controlled vessel
kept in 37° C.
Measles
Respiratory
infection
Unknown
Low
Very high,
mucosal
fluid
contact
Cough, runny nose, red eyes, fever,
potentially Koplik's spots inside
mouth. Pneumonia or encephalitis
may develop.
There is no cure, though antibiotics
may help with some complications (i.e.
pneumonia). Rest.
About 1-2 years
in a sealed,
controlled vessel
kept in 37° C.
Pneumonia
Lung
inflammatio
n
Unknown
High in
children
and
elderly
High,
personperson
contact
Cough, chest pain, fever, and
difficulty in breathing.
Complications involving empyema
(pleural effusuion) or infected
abscesses.
Oral antibiotics, rest, fluids, home care.
Rimantadine or amantadine for viral
cases. Oseltamivir and zanamizir
About 1-2 years
in a sealed,
controlled vessel
kept in 37° C.
Viral: about 2
years.
Meningitis
Brainmembrane
inflammatio
n
Unknown
Untreated
, bacterial
is almost
always
fatal.
Very high,
personperson
contact
Headache and neck stiffness
associated with fever, confusion or
altered consciousness, vomiting, and
an inability to tolerate light
(photophobia) or loud noises
(phonophobia).
Immediate benzylpenicillin,
intravenous fluid replacement in
presence of hypotension or shock,
Antibiotics with corticosteroid
adjuvants (dexamethasone…
expensive). Viral/fungal meningitis
require only supportive care.
Also about 2
years…
39
Symptom history and brief
examination in epidemic
conditions. Officially, stool
sample culture isolation of
cholerae subtypes is
necessary.
Clinical diagnosis of measles
requires a history of fever of at
least three days together with
at least one of the three C's
(cough, coryza,
conjunctivitis). Observation of
Koplik's spots is also
diagnostic of measles.
Chest X-ray, blood test,
sputum culture. Can be
diagnosed via examination
alone.
http://en.wikipedia.org/wiki/C
URB-65
Blood tests: C-reactive
protein, complete blood count.
Spinal tap works, but other
types of inflammation result in
false positives.
Appendix K
Clinic Dimensional Layout in Muramba, Rwanda
Overview of clinic design in Muramba, Rwanda
40
Appendix L
Summary of political history’s affects on healthcare in Rwanda.
In pre-independence Rwanda, the colonial administration of Belgium relied on churches
to provide public services, including healthcare. This dependence continued throughout the rest
of the colonial period of Rwanda. In 1986, Rwanda’s economic situation became dire, and the
country had to borrow money from the International Monetary Foundation (IMF). At the time,
the IMF had a Structural Adjustment Program that any country that borrowed money had to
follow. The program involved a currency devaluation and privatization of the majority of public
expenditures. The privatization led to a loss of access to free healthcare, schooling, and several
other critical services for the country. The Bamako Initiative increased the economic burden of
Rwanda, by suggesting a decentralization of healthcare to the local levels. The Rwandan
government began this process, and was beginning to be successful. However, the genocide in
Rwanda greatly disrupted the process. It is thought that the multitude of physicians and nurses
killed in the genocide has left only one physician for every 500,000 people and one nurse for
every 3,300 people. Today, the Rwandan Ministry of Health is focusing on seven major
objectives to be accomplished by 2015:
 Human Resources Development
 Availability of drugs, vaccines & consumables
 Geographical accessibility of health services
 Quality of and demand for health services in the control of diseases
 Strengthening national referral hospitals, treatment & research centers, and
 Institutional capacity building.
Appendix M
Introduction
Gashonyi clinic identified electricity as one of its top three needs. Providing power to health
clinics is of vital importance. Unpowered clinics have performed procedures in the dark by candle
light. Instruments have had unknown sterility. Even the simple monitoring of patients becomes
exponentially more difficult with the setting of the sun. The need becomes more pressing in diseaseridden countries where vaccines and antibiotics require cold storage not normally found.
Based on information from the Solar Electric Light Fund (SELF), a group that has
implemented power in fifteen Rwandan health centers, solar power is the best method for providing
sustainable power to a rural community such as Gashonyi. That being established, research has been
conducted on what information is required from the community in order to design the most
appropriate system. A successful implementation will require data regarding two areas of
information: technical and community.
Technical
Several groups, including SELF and other EWB chapters, have implemented solar power in
developing countries. The basic format for a solar installation is a solar panel that generates the
electrical signal, batteries that store the power, inverters that convert the solar panel DC to AC, an
41
automated controller to oversee the entire process, and associated wiring. SELF has provided several
potential contractors from their website as well as a potential group of solar implementation experts
from the website www.idealist.org.
The most important piece of information required before moving on with a design is
establishing what the system will need to provide power for. This may cover a broad range of items,
including lighting, heating, refrigeration, lab equipment (centrifuges, autoclaves, microscopes, x-ray
units), computers, and/or communication equipment. SELF has installed systems with enough power
to support all previously mentioned items, but it came with a significant capital investment. To
optimize the needs of the community, we will need to consult with the clinic nurses and community
in order to fully address all possible critical power needs for the clinic as well as needs of an ideal
clinic that the design may expand into. For example, if the community and hospital staffs foresee the
clinic at a size that may include additional staff or a physician, clinic power needs may increase if
more advanced health care is able to be provided. The recommended assessment plan is to ask
community and nurse members to fill in a sheet listing medical supplies and clinic devices that could
be implemented and ask them to rank them in importance in terms of need as well as possibility for
growth. With this information, EWB can categorize and optimize the clinic’s power consumption
with appropriate system wattage.
In addition to investigating what the clinic needs, a further point of investigation would
include investigation of some quantitative data needed for implementing a solar panel. This
information would include data along the following lines:
 Sunlight intensity per day across seasons
 Average temperature(s) throughout day
 Locations and heights of direct sunlight
 Seasonal weather and climate
 Hours of darkness
 Clinic operating hours in darkness
 Desired length of continuous power operation
These are important design considerations in determining system efficiency and losses. In particular,
rainy seasons have caused other groups to install solar/diesel hybrid systems in order to provide
power during periods of minimal sunlight and emergencies. Whether a hybrid of some kind or
another is important can be addressed by the measurements and qualitative assessment previously
mentioned.
The final set of technical standards recommended to investigate during an assessment trip
would be availability of local materials. Since we are trying to create a sustainable system, we are
striving to use local materials. Through a list of common solar cell materials (similar to that above),
we may be able to talk with a local contractor and/or technician to discuss the possibility of finding
such materials. A previous EWB group, however, found many of the materials to be extremely
expensive in Rwanda and thus ended up transporting many from the United States. If this ends up
being the only possible route, we may be able to partner with other organizations to share
transportation costs. On a similar note, many of the materials are large and bulky, such as the solar
cells themselves. These will undoubtedly require large vehicle transportation to Gashonyi for
installation.
Based on failures of certain parts in the past, including batteries and inverters in particular,
parts will have to be rated to a high quality.
Community
The involvement of the community in this project cannot be overstressed or underestimated.
SELF recommended a valuable piece of information that they found in their work. They highly
42
recommended finding a community organization or group who are particularly interested in the solar
aspect of the project. Because power will be a vital portion of the clinic installation, having
community members who are interested in the system from a technical perspective will be invaluable
in maintenance and repairs. This group or individual can also serve as intermediary between the
clinic power desires and what is technically feasible.
Education is also extremely important as a post-implementation procedure. Clinic patients
and staff must know exactly what the system ends up being designed for. Groups have reported that
the power system will be drained by overuse. Batteries will get drained before expected. The
community must be aware of the intended use of the system; unless designed so, the clinic should not
serve as a community meeting space. This harkens back to identifying what the community and
clinic plan on using the clinic for; particularly, any events or power uses outside of the normally
expected realm must be brought up and addressed in assessment and subsequent design.
Education can be extrapolated to maintenance of the system. Operation placards,
troubleshooting guides, and repair contacts should all be included and introduced early in the system.
On an assessment phase, the community should be made aware of this need, and interested
individuals should be acknowledged as system maintainers. These individuals would also serve as
power safety groups; the system will undoubtedly have hazard risks associated with electrical
equipment, and any breaches of safety measures will need to be recognized and fixed by the
community to prevent injury or death. During implementation, identified individuals should be
highly involved in the installation. By helping with the installation, the individuals will be more able
to fix or identify failed sections.
As an aside, security has been reported as an issue, particularly in the post-war phase. Solar
panels have been reported stolen before, so the community must be informed about the importance of
these items, and keeping a “community watch” on the solar panels. The system can also be designed
with certain security features in mind.
Post assessment
Based on information from the assessment trip, multiple designs should be evaluated from a
technical perspective (panel size/number required, battery type and storage capacity, etc.). Solar and
electrical experts should be contacted and utilized, particularly when designing kilowatt load and
incorporating electrical systems into the overall clinic building. Design installation should be tested
in the United States before implementation to ensure correct functioning and aid in the production of
a troubleshooting manual.
43