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Summer Stories -Daniel E. Rosan, Malawi

Days in rural Malawi begin just before dawn. Children start fetching water from the taps in the foyer of our guest house. The bakery run by HIV-positive women out of our kitchen is up and running a few minutes later. And the cook has begun slaughtering a goat for dinner.

I am at the Partners in Health guest house in Neno, in the heart of Malawi’s poor, mountainous border region, in the heart of Africa. Today, I rush through the ice-cold shower, notice the electricity is out again, and head to the hospital to spend the day with the pharmacy team delivering malaria medicines to health centers even more remote than we are.

That day ended with an emergency, a community health worker ill with cerebral malaria whom we found being carried by her family the 20km from her home to the hospital. We put her in our Land Rover and she was successfully treated. It drove home the stakes – good supply chains here are a matter of life and death.

HBS students travel the world for their summer internships, but I would argue none were farther from paved roads or supermarkets than I was in Neno. Partners in Health, an international health delivery organization which operates in nine countries, has just begun operations here in a partnership with the Clinton Foundation and the Malawian Ministry of Health. The main hospital is not yet open, but already over 1,000 patients are on life-saving antiretroviral AIDS drugs. They asked me to serve as an internal consultant focused on food and drug costs. In the process, I got to live and work with an incredible collection of American and Malawian staff who have moved far from their homes to lift this district out of poverty.

There were some missteps along the way – such as my hubristic attempt to help a friend make mud bricks for his mothers’ new house (bottom line: I am bad at making bricks). But overall living in a close-knit rural community was a privilege, and it came with real insight into how development really happens.

To describe PIH as only a health care provider is to fundamentally misunderstand its development role. In Neno, the soil is poor, the roads are bad, and the vast majority of inhabitants have no running water, indoor plumbing, or electricity. PIH is therefore not just the only health care option, it is an economic driver. PIH employs 300 people, a huge number in an area where the economy is based on subsistence farming. PIH runs the largest vehicle fleet in a district where even the ubiquitous minibus is a rare sight. PIH buys hundreds of thousands of dollars of food, feeds staff and patients alike, and is building housing, warehouses, clinics, hospitals, even septic systems.

Outside the main hospital, women sell cell phone airtime, men offer rides on their bicycles for a few kwacha, families run market stalls with bananas and mangos (in season), and a bus has even begun to make the 3.5 hour run to the nearest major city, Blantyre. These services are there because patients, their families, and PIH staff demand those services. For the patients I spoke to, PIH is about health care. But for others, PIH is about job creation and the development of a cash economy. What began as two American doctors and one HBS MBA (class of 2006) is now an economic engine for the whole district.

PIH asked me to function as an internal consultant, addressing a wide variety of problems related to procurement and supply chain management. I did everything from train commercial sex workers in basic accounting to analyze patient flow at the laboratory. But most of my time was focused on two main projects: food aid procurement and pharmaceutical supply chain management.

Uniquely among global health providers, PIH provides each HIV and TB patient with food aid. The food is a porridge of cornmeal, soy, vitamins, and sugar, along with cooking oil. The impact is tremendous. Sick patients fight a constant battle against malnutrition, whose only real cure is food. Giving food also improves compliance with treatment regimes. Patients are more likely to keep their appointments if they will also be getting food for a month. And of course, taking toxic AIDS drugs on an empty stomach is practically impossible.

Currently, PIH buys food from international companies. As global food prices soar, PIH’s costs do as well. Neno’s local farmers should be getting the benefit of rising prices but are shut out because of the poor infrastructure. I developed a business plan for buying from local farmers, processing the food aid, and distributing it to patients. The strategy lowered PIH’s overall food aid costs but re-directed spending to local farmers. The second project unraveled PIH’s complicated pharmaceutical supply chain. Working with local staff, I developed a new information flow which will eliminate stock-outs while lowering inventory costs and reducing paperwork.

On a personal level, working in Malawi for the summer was probably the single most difficult experience in my life. But to any HBS student looking to spend the summer outside of a cubicle, look to places such as Malawi. The impact is real, and really makes a difference.

September 2, 2008
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