Learning to See Clearly

Jamie Clearfield's Musings on Evaluation and Development


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Thoughts from Ghana: Living on the Edge

It’s been awhile since I’ve written – we’ve shifted two countries since my last post. We spent about 3.5 weeks in Madurai, India with the Aravind Eye Center – an amazing place of efficiency and compassion and the largest eye center in the world. I was observing with their training and outreach divisions in preparation for our jump over to Africa. As of last Monday, we are Kumasi, Ghana at the Komfo Anokye Teaching Hospital (KATH) Eye Center…

We are always on the periphery. Living so transiently, it is hard to do anything but skim the surface. This is especially the case working and often living in a hospital setting as we did in Nepal and India. Kathmandu

Observing at a Children's Vision Screening Camp with Aravind

Observing at a Children’s Vision Screening Camp with Aravind

allowed us to live closer to reality. We lived about a mile or so from the hospital and given our love of walking, the safety of the city, and its amazing sites, we learned the narrow alleyways and side streets. During our 4 weeks there, I loved the feeling of the city map connecting in my head, the chaos forming into logic. However in both far western Nepal and in Madurai, India where we spent time at the Aravind Eye Center, we lived within the hospital campus. A literal and figurative wall separated us from daily life with only all too brief chance to voyeur out and glimpse life.

We are learning to live on the periphery and negotiate this challenging precipice. It is far too easy to convince yourself that you belong in one realm over the other, to forget that you are straddling worlds, cultures, beliefs, values, to forget that only those that you claim as your own are real in that moment. It is far too easy to forget yourself and your role on the edge, to let yourself be convinced of your insignificance and to be lulled into a sense of false purpose holed up in your little world. I found this in Far Western Nepal. There I distanced myself even further from the world convincing myself of the “need” to complete one project, only to find myself too distracted, discontented and full of self-doubt to finish anything. Instead of throwing myself into my present surroundings, drinking in all I could, I hid myself, holed up with my computer and convinced myself this was productive. While the beauty of the place will stay with me, those memories fade overtime as do pictures. Regret will linger on. Engagement, friendship, and knowing that your weariness at the end of the day comes from an earnest attempt to connect –those feelings drive you forward and bring reality closer.

My spouse now struggles here in Ghana, with similar feelings of underutilization and a sense of uselessness. It is compounded by the extreme need we see around us and the lack of efficient systems in place to allow him to practice and work effectively as a clinician. We are learning how to support each other, to balance the ups and downs of our two unique souls within the space of our shared guest house room, and our shared experiences. Ghana feels more familiar to me, having worked so long in East Africa – other former British colonies. Despite the separation of thousands of miles, there are similarities of history and experience despite the vastly different cultures. We are too much on the periphery here, too separated from the local culture and people by circumstances and expectations (both ours and the teaching hospital where we are working). We stay at a guesthouse run by the hospital for its visiting doctors and nurses, and are currently living with 3 other Americans.

And some things don't make sense...A brand new desk in the eye center...

And some things don’t make sense…A brand new desk in the eye center…

The hospital wants us to a car and driver they provide to walk the mile to and from the guesthouse. This we have politely declined, and use the time to walk and observe, though it is too short a walk to truly engage. This we are unsure of how best to do, and so far have been too exhausted by our attempts to process our daily work to do much of anything except head back and forth to the eye clinic.

Being an evaluator internationally is challenging since by definition I am to be the outsider yet offer recommendations and advice… there is so much weariness though in never understanding. Not knowing cultural difference places me as the ultimate outsider, often too ignorant to appreciate the complexities at work, and thus my recommendations I fear are ill-advised or laughable. There are also many things that simply just do not make sense. Here in Ghana I am focused much more on operational systems and helping the hospital use data in its decision making processes. A lot of time is spent crunching numbers, a lot of time observing patient flow, and also time spent waiting for someone. I sit writing this post now lying in wait for the eye clinic director in his clinic room so we can finalize a proposal. He has been in and seen several patients in my presence and left again, “We’ll meet in 5 minutes…” he says rushing out the door some 10 minutes ago…

Every experience builds on another, and to have courage to learn from past mistakes is a major focus now. Someone told us recently, “Manage expectations- that is the key to living here.” It is true for so much of life and work, both domestically and internationally. We learned so much from our time in Nepal and India, perhaps most importantly to be filled with compassion, for those around us and also with ourselves. It is so easy to forget, to look away, to be focused on the project instead of the life around it. Ghana is shaking us up and reminding us how much on the edge we are, and as we struggle forward to find our footing, we can only try to our best to follow a mentor’s advice to me, “Go out there and do some good…”


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Nepal Thoughts from the Field: Trying It on for Size

Life is a mix of things here in Nepal – overwhelming beauty, grace, poverty, hope, things known and unknown. After three weeks in Kathmandu, Z and I are currently in far western Nepal based at a rural eye hospital. Kathmandu was everything a developing capital city coming off a decade long civil war could be expected to be – a mix of chaos and blaring horns with temples and shrines on nearly every street corner, millennium-old Buddhist stuppas and glossy new malls beckoning the emerging middle class. Tradition and culture continually struggling against rapid urbanization and globalization; we wondered a lot what Kathmandu will look like in 10 years time.

A stuppa we stumbled upon when we got lost coming home from work...

A stuppa we stumbled upon when we got lost coming home from work…

In Kathmandu, We were attached to Tilganga Eye Hospital – a renown eye care center that provides efficient and effective eye care services in Nepal. Their model is similar to the Aravind Eye Care System has perfected over the past thirty years – a high volume cost recovery model where everyone receives the same quality of eye care, though those who cannot pay are not turned away. Instead those who are able to pay or who wish to have certain amenities (such as a private hospital room, an appointment time rather than walk-in service, after-hours service, etc.) can do so. I could on and on regarding the Aravind model, but I suggest for those interested, to read the case studies and other reports others, much more eloquent than I, have already written.

While my spouse was attached to various specialty clinics and the operating room to learn new a different cataract removal technique widely used in the developing world, I was attached to the hospital’s academic and training department to review their training programs for international ophthalmologists and allied personnel. A major focus for the hospital is developing and broadening the skills and knowledge of medical personnel, both in Nepal and internationally. Doctors, nurses, technicians, biomedical equipment engineers, and more from Ethiopia, Ghana, Bhutan, Indonesia, North Korea, East Timor, Vietnam, Cambodia as well as Australia and the United States have come to Tilganga for a wide variety of training and surgical exposure. Managing all the different logistics and visa difficulties of getting these personnel into Nepal is an incredible feat in of itself. Training so many different people, personalities – each with their own expectations and experiences – is another accomplishment all together. Nearly 150 ophthalmologists from over 20 countries have received specialized cataract training since 2007, in addition to over 70 nurses and scores of other paramedical and nonclinical staff.

Despite the efficiencies already in place to keep the hospital running and solvent, little evaluation work has been conducted with the training programs. While the hospital has a monitoring and evaluation office (currently a department of one!), it is mainly focused on the clinical aspect of the hospital, and ensuring that the numbers are there for the monthly reports to donors. This is not something new or even surprising – as we all know, educational evaluations are involved and are not straight forward. Determining what metrics to use, how to collect them, and how to determine the impact of education is an ongoing challenge as we see from the continuing education testing saga in the United States. To date, the training programs at Tilganga have participants complete a feedback form. The form is reviewed briefly as the person leaves. It is then filed in a 2-ring binder labeled with their country of origin; the binder than sits on a shelf.

In speaking with the training officer, there has yet to be a longitudinal review of the feedback forms, or any type of major follow-up of participants once they return to their home countries beyond a few emails with their sponsoring agency. I had found my job… even if it did mean digitizing 6 years worth of old feedback forms…

Back to the world of paper evaluations...

Back to the world of paper evaluations…

Currently, in the jungles of far western Nepal, I am reviewing and making sense of the data. The  hospital also asked me to help put together some of the training departments strategic planning  notes, for which the feedback forms will be helpful as well. The data proves interesting, the days  here are slow – cups of tea and a backup generator allow for the work to go on…

Coming in to Tilganga has been an educational and if truth be told, awkward experience. For years  working abroad, I chose positions where I would be present for a significant period of time, be able  to stay and live in the community to build relationships and trust. This type of work and  evaluation smacks a bit of everything I learned “not to do”. Not fitting into any label that the  hospital is used to giving to a visiting foreigner (Doctor, medical student, journalist…) – my  presence at Tilganga was stilted though over the weeks we developed a good rapport of sorts.  Reading the strategic planning notes and trying to make heads or tails of meeting minutes from a  workshop this past spring is like reading a book with the pages all mixed up; a not uncommon  challenge of evaluation and I suspect external evaluators globally. It was exciting to sit with Ravi,  the M&E officer and pass ideas back and forth. He loved getting links to EvalCentral, AEA, and other  evaluation blogs and resources (though I’m not sure how well Chris Lysy’s incredible evaluation  humor translates!). And yet… seeing so many people in need of immediate tangible care, while I sit  at my computer day after day, it is easy to be swayed that there is perhaps a better use for my  time here. My previous roles internationally were much more varied and engaged on the ground–   teaching, developing and giving workshops, implementing, as well as conducting monitoring and evaluation.  Having chosen one                     label is a new and interesting challenge, one I am currently unsure of but am trying on for size…

Thoughts and comments as always are welcome! Feel free to shoot questions about Nepal and our work overseas my way, I’ll answer the best I can.

Himalayas peaking through the monsoon clouds...

Himalayas peaking through the monsoon clouds…


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Evaluation Transitions: Nepal Bound…

transition
I apologize for the silence on the blogosphere…it has been a hectic few months. And while my thoughts are always churning on evaluation, they sometimes take awhile to formulate into something that is worth writing or comprehensible. I have been thinking a lot about transitions, since that is where I am in my personal life. My husband I are about to embark on a 6 month international stint working with the Himalaya Cataract Project. The Himalaya Cataract Project (HCP) works to cure and combat preventable blindness globally, focusing specifically on sustainability. They invest in infrastructure and more importantly education and training of doctors, nurses, techs, and other medical personnel needed to make their work as cost effective and efficient as possible. Through innovations by Dr. Sanduk Ruit and many others, cataract surgery can be performed for as low as $20 (compared to over a $1000 in the United States). This is due in part to advances in surgical technique and local production of necessary technology, but also organizationally focusing on efficiency and training people up to perform the highest level task that they can with their given education. This has allowed the hospital supported by HCP, Tilganga Eye Institute of Ophthalmology, and others throughout India and Nepal (most notably Aravind) to operate on a cost recovery model. Within this model, everyone receives the same high quality opthalmologic care; extra amenitites cost extra. Using different figures based on local GDP, generally a percentage of people seeking care pay above cost, some at-cost, and the rest are far below or covered for free.

We’re incredibly honored and tremendously excited to embark on this trip which is taking us to Nepal, Ethiopia, Ghana, and potentially India. My husband Z will be working on the medical side of things, I will be working on a number of different evaluations with the organization.

Transitioning from the United States overseas is always an adventure. I am also playing some mind games thinking about the differences in working with a healthcare organization versus an educational program. While I have previously worked in public health, it was with an HIV education program. Direct services were not provided, rather critical support services and education. I am particularly struct by how easy it is to discuss what we will be doing; there is no hard “sell” for curing blindness. Watching videos from the field and from cataract camps of people who may have been blind for years suddenly able to see their children, parents, friends, homeland once more and be able to work and participate again in communal life once more – that moment is awe-inspiring, a rebirth.

What is harder for HCP and so many other organizations is to find the funding and support for everything else that must take place to get a patient to the operating table.The backstage of any non-profit or NGO is frought with highs and lows, crisis and triumphs. I have seen this cycle with Kibera Girls’ Soccer Academy and other education organizations, where the end result cannot be truly defined and any measure you do use takes a long time to see any result. This transition to HCP is revolutionary for me, yet I know there is so much to learn and so much more to try to understand.

So we’re off … I will do my best to post updates on evaluations from the field, as well as pictures. I look forward to embarking on this new adventure through a broader evaluative lense, and to learning, living, experiencing all that these new transitions will bring!