You Are Doing What?

Improving Health Care Outcomes in Africa and the US

September 19, 2021 Mark Cohen
You Are Doing What?
Improving Health Care Outcomes in Africa and the US
Show Notes Transcript

How free and confident would you feel if you did not have access to reasonable health care?  In the US, most us don't ponder this question.  However, more than half of the world's population does not have access to essential health care according to the World Health Organization and the World Bank.  Today, we have Dr. Wendy Leonard, a founder of TIP Global Health.  This organization has developed processes and technologies to improve health care outcomes in Rwanda, Africa.  Their success is so striking that their work is now being adopted in Detroit, Michigan.  And, this is only the start.  Please listen as Dr. Leonard explains the fundamentals of making gains in health care outcomes in challenging environments.  If you want to learn more, you can visit  Dr. Leonard is pleased to be contacted as well at [email protected]

Improving Health Care Outcomes in Africa and the US

Mark: Today we have Wendy Leonard, M D a H I V S, which I understand is an HIV specialist. Wendy, you are the founder of tip global health, but you also have a lot of other roles. I see that you have been the director of the Santa Cruz county HIV quality management program and president of the board of directors for the Santa Cruz aids project and, also Santa Cruz county tuberculosis controller.  And, you are the first physician to volunteer for the Clinton foundation's HIV clinical mentoring program. And Ron. Did I get all that, right? 

Wendy: Yeah. A lot of hats and over a long period of time, but yes, those are true. 

Mark: Wow. Well, we're going to get [00:01:00] into tip global health and you're going to tell us about some of the important work that you're doing there, but I'd like to just take a step back and just go back to the roots of all of this work that you're doing now with tip global health.

And I wanted to ask you how you found yourself in Rhonda in the first place. 

Wendy: Well, thank you. And thank you for this conversation. I'm really excited to talk with you today. And I, as you mentioned, I'm a physician I practice primary healthcare particularly now for people living with HIV.

And back in 2006, I volunteered to work with the Clinton foundation in Rwanda. They were setting up a clinical mentorship program. So, HIV trained clinicians in the United States would go and work with countries that were starting to put their HIV policies and procedures into place. I went [00:02:00] in 2006, I started with the Clinton foundation and the ministry of health who really showed me what their protocols were and when they wanted to have happen in the rural communities.

And then I was based in this rural community for two months and I worked with them to quote unquote, make sure they were following the ministry of health protocols for prevention of mother to child HIV transmission. And what I found was that it was a very eager, very dedicated and committed group of frontline health workers.

There were a lot of competing priorities, so they wanted to be able to implement the protocols appropriately. But in some cases they didn't have access. They hadn't received the facts, but it was, it had come in. they also had other competing priorities. 

, and so on the ground, they were also really struggling with childhood malnutrition and 50% of their kids had childhood malnutrition [00:03:00] and the subset of children that were HIV exposed with so much smaller. The, for them, they just, they were struggling with, we're prioritizing this group of people over this group of people.

So what we really worked on for those two months is how do we address both priorities? So we have the subset of really vulnerable children and excellent toolkit to take care of them. How do we take that toolkit and extend the benefits to all of the children in their community, 

Mark: regardless of HIV status or potential status?

Wendy: Yeah. And and then we brought what we learned to the ministry and they implemented quite a few of the projects that we had put into place in this community were then integrated international policy. That's how we started. 

Mark: Wow. And was the organization founded at that moment or did you come back to the U S and then start a new [00:04:00] foundation?

 how did that evolve? 

Wendy: So what I found when I came back, I had no intention of founding an organization. But what was so exciting is that the medical community got really fired up around this innovation because what we really were striving for was demonstrating here are the protocols and the policies, but where within that, can you innovate, can you improve upon that?

Given the resources that you have? So I came home and I got so many different proposals and ideas, and I was trying to find entities that would carry these forward. And I really struggled with that. And so eventually I founded it was called the project at the time as a way to support these smaller initiatives that were strengthening HIV care services in a way that would also strengthen the entirety of the health system.[00:05:00] 

Mark: So you said a lot there. Let's try and unpack that a little bit. First. You return to the U S you've got all this stuff going on and you're still going to try and make a difference in Rhonda or Rwanda, depending on who you're talking to. And you then have to circle back and create some kind of structure that separate and apart from the ministry of health.

 , did you form some kind of partnership with the ministry? So as to maintain some kind of authority or ongoing care in the communities, how did that work? 

Wendy: That's a fantastic question. I was very. Fortunate because I started at the ministry and I understood the structures and what they were trying to do.

. It was clear and important that nothing we do bypass that. And so that became very, very important part of the organization[00:06:00] what are the protocols and the expectations that they're working from within where is the room for innovation and where is the systems that don't change?

Where can we innovate within that expectation? And we work really closely from the beginning with the ministry of health. And as I mentioned, I was really lucky that I had those connections and opportunities to collaborate right from the beginning. 

Mark: So, as I understand them, You developed a team of people who work with social workers or healthcare people in the ministry to provide frontline care to vulnerable populations.

And so are these now government run clinics or are they private clinics? What settings are you working in? 

Wendy: The majority of setting in Rwanda? The majority of the system is public sector. There is a a slightly growing private sector and there are [00:07:00] some of the facilities are posts sponsored by various church groups.

But for the most part they're government run facilities. And for the first five or six years, we actually didn't have a team at all because the initiatives were so driven by the medical director and his team that we were working with an initiative that they had completely integrated into the existing work.

So we worked on solar power initiatives and their engineer. She was our lead person to help facilitate that work. So it wasn't until 2013 that we actually built a team on the ground because it was becoming a much more complex and a sophisticated organization. 

Mark: Okay. So can you paint a picture of, what actually happens in the clinics and how tip global health [00:08:00] makes an impact.

Wendy: Sure. So to give a little more context to the environment. So in general, especially in rural communities in Rwanda, there is a district hospital that oversees a number of health centers that then oversees a number of villages with community health workers.

So where we started was with one district hospital, brulee little, they have nine health centers and 200 villages. And so in those 200 villages are managed by with, they have four health community health workers per village. And so then they report to their assigned health center and then those health centers report back up to the district hospital.

So what typ has really been doing from the beginning is working in parallel with that network to [00:09:00] really understand what are the goals, what are the expectations, what are the barriers? And then how can we work together alongside the frontline health workers and the patients to create solutions to that to the barriers that they're facing.

 So we started with those nine health centers, but we are now in five different hospital catchment areas in three different districts, but we start still with the same philosophy. This relationship between a health frontline health worker and her patients is really the critical role for primary health care delivery to be successful.

So you need frontline healthcare where a patient needs to access care. She needs to receive high quality care from the frontline health worker. The patient needs to go home, or the community member needs to go home, adopt those care recommendations, and then she needs to come back. And so all of that, accessing care, receiving [00:10:00] quality care, adopting care recommendations, and sustaining care recommendations, and continuity of care.

That is where we really focus and prioritize what's the barrier at each of those steps, 

Mark: right? Because without some type of patient commitment trust in the program understanding of their opportunities for health outcomes that will allow for some type of lasting impact and the community at large, which I believe is one of your missions.

Wendy: That is our mission is achieving lasting improvements in health outcomes. And that really comes from building a really strong community-driven health system at the local level. That's facilitated by the national level, but there's ownership and a sense of capacity to enact change at the local level.

Mark: Is there a challenge that you have to face when [00:11:00] you're talking about. Providing frontline care to people in villages in that they may have be used to some kind of traditional medicines rather than Western medicines or Western methods. 

Wendy: That's a great question. And one of the things that was so striking to me when I got to Rwanda, , I've worked for over two decades now in county health health centers in the United States.

And as a frontline healthcare worker here, when I went to Rome, I was really struck by the context will completely different, but the challenges were really the same that our role is to convince someone to do something. That isn't within their daily life.

We're asking them to change a behavior, whether it's to take a medicine, they're not sure they trust or receive a COVID vaccine that they may or may not trust or adopt a Western medication as opposed to a traditional medication.[00:12:00] 

It's about how do you build trust? How do you build that relationship? So to answer your question in terms of in Rwanda and healthcare, one of the first things we did was establish an education model, which wasn't about what we're teaching, but it's how to deliver the health information in a way that will inspire a change in behavior.

So if it's traditional to use this herbal medication, it's our job to educate the person in why. , there may be a better way to manage your condition. And so it's really on us to explain, to provide that mentorship and demonstrate. So I'll give an example we use data.

We, we call it that to inspire and inform. And so if we are giving somebody advice say on nutrition, so a child comes in and she's slightly malnourished [00:13:00] and we give advice. And if the mom goes home and takes out of it, we're talking about, it would be a benefit to your child to invest in this sort of food.

 If they've done that, if they've implemented those changes, they come back. We have a digital application that actually demonstrates immediately the growth trend of the child.

And so we're really trying to use data trends to inspire. Everything we do is really about how do we build the case for adopting these health recommendations that we're making.

What are the barriers to implementing what we just shared? And because so often we get information, it gets delivered to us and people walk out the door thinking there's no way I can implement that. And so we make sure that there's opportunities to talk about what are the barriers and what are ways forward so that this could be implemented.

And what are the data points you [00:14:00] want to follow to see if you're being you're successful or not, which that can positively reinforce or give you some information early on that we're not making the progress we thought. So another example would be a continuous quality improvement initiative for HIV exposed infants .

We saw that the testing numbers were low, the children were supposed to be getting tested on a regular basis and they weren't getting the tests they needed. We tend to look at things from an individual and a systems level. So from a systems level, there were challenges in getting the results from the government.

So we worked on that, but we also met with the moms. We work with the frontline health workers. We work with the moms the patients, and we work with them as a team. What do you think is a barrier to getting your your child's test? And we signed one.

One group said [00:15:00] the barrier is that we're terrified. We don't want to know. And we don't want to get the tests. We're so afraid. And so the moms came up with their own system where they created a book and they record exactly when each child is due for their test. And then they have a buddy system where the buddy will remind the mom and go with them to the test and support them and testing.

We thought that was a fantastic idea, brought it out center. And they said, oh no our concern is not about, we're not afraid we celebrate, we can't wait to get the test And so then they created a different solution with their frontline health workers. So that, just gives you a sense of how we work with the health centers and think about how we help integrate this mindset shift.

Mark: That's systems issue , and I'm just wondering if there's any specific care strategies [00:16:00] that you've discovered that you could talk about that have made an impact that you've been able to measure over time. 

Wendy: One of the things that we've done that's been very successful is a continuous quality improvement initiative.

We worked with frontline health workers and patients, community members, primarily moms, because. They are probably 60% of the people who access care, whether it be through antenatal care or pediatric care . So we came together to come up with this. What are the pillars of high quality care that would actually bring you back and inspire you to continue to be engaged in care?

And so those five pillars are clinical skills, mother centeredness, the quality of health, education, logistics, the logistical [00:17:00] management, operations management, and data management. And then we created altogether, what is, what are the definitions of those and created an objective checklist. So what now, what we do is we do the checklist every quarter or so.

And then we present the data to each of the health centers or CHWs, depending on who we're working with, we celebrate the successes. So let's say everyone is going extremely high on clinical skills and mother centeredness, but the logistics are scoring really low. Then they will come up with quality improvement and work that they engage moms in to solve that logistics issue.

And then we bring everyone together and they present their CQI work together. 

Mark: So you have these [00:18:00] ongoing problems to solve, and then you address them as they come up on a regular basis. 

Wendy: And we're really working as a facilitators to help them solve those challenges. And that's, what's really exciting is that it's becoming a systemized approach that the health facilities and the community health workers are identified.

They are becoming innovators. And we do a lot of work also with the diffusion of new ideas. And so really we feel like at the core of our work for facilitating innovators and visionaries on a day to day basis. 

Mark: Because ultimately they're the witnesses of what's necessary in their local communities.

When you talk about, for example, logistical issues, I'm sure a lot of people, don't have a form of transportation other than perhaps a bicycle. Is that a huge thing that you need to deal with on an ongoing basis?[00:19:00] 

Wendy: Yes, definitely. So access to care is a big deal. And so what we really think about systems and how systems support relationships, and the ongoing primary care. So when you think about the entire ecosystem from village to health center to district hospital, how do we build capacity at each level? So that for example, community health worker has all the tools they need to provide the care that they're expected to provide in their village. So that when that referral to a health center, which could be a two hour walk, when that referral happens, it's because the next level of care is required, but they otherwise have all the tools they need to manage uncomplicated, malaria or screen at least symptom screen for COVID, for example, or provide child nutrition assessments.

But when they're referred to the health center, [00:20:00] because they're requiring that next level of care. And then how do you optimize one communication between the two. And then two, how do you optimize then the health center quality so that they have the skills they need. They have the tools they need to provide the care that they are expected to provide at the health center level.

And then how do they have effective communication and referral systems up to the district level? And then what is the district level, hospital level need to facilitate that? 

Mark: Yeah, so multi-layered processes. know a lot of people probably are wondering, Ron does a place that had such a tumultuous history.

And as time has gone on, I know there's been a lot of healing there.

When I went, there was tremendous the level of feeling, but is there tribal or political problems that you need to deal with still?[00:21:00] 

Wendy: No, that's one of the things that, so Rwandan and so in 1994 there was an Institute seas and it was a horrific part of their history. And as you mentioned, there has been a lot of healings since then, and a lot of processes in place for that. There is such a movement forward.

 I feel like there was such a drive to move forward and redefine who Rwanda is that there's a collective innovation mindset. And it's actually was one of the reasons that despite the fact that I was a full-time physician coming back from Rwanda to the U S I couldn't let go because I have always felt this sense of growth and let's just try And it's really centered around health. I think that is extremely committed to improving everyone's health outcomes.

 I feel like [00:22:00] they've done a really beautiful job of that. 

Mark: That's wonderful. I remember when I was there, they were trying to move forward so much so that they were transitioning from French to English just to get out of that past, that was so destructive .

it's been a while since I've been there. I don't know if you can Speak to where people are now in terms of that transition, if they've welcomed it, if they feel like they're more part of a global community now, 

Wendy: that just is another Testament to the strength and resilience of the communities.

People really embraced the shift. And at the same time, one thing that you'll probably experience, there's a strong pride in Rwandan culture.

And so can you, Rwanda is still a very important and especially in rural communities it's the primary language. But English is spoken. I would say most business [00:23:00] activities are conducted in English, but French is now also if they went from French is the international language to official language, to English as an international language.

And now it's both English and French. So there is there is some embracing of the language of which you learned at, of being a Rwanda, because what's amazing to me is most people speak multiple languages , like I said, we built out our team beginning in 2000, late, 2012, 2013, and some spoke English better than others, but they had definitely been taught.

Can you Rwandan French in schools? And now they're just, and they were in their late, early to late twenties, all of them. And they're fluent English speakers, they speak three to five languages. So it's very impressive. 

Mark: That is impressive. If I understand there's about 40 people on the team, [00:24:00] is that right?

And what percentage are around DS versus other nationalities? 

Wendy: So we have three non Rwandis on the team. 

Mark: Yeah. So it's all driven by local considerations from local people. That's wonderful. What are some of the solutions that your team in Rwanda is working on now? 

Wendy: As I mentioned early on, we were really thinking about what are the processes that work to drive this idea of quality improvement of effective health education and then what can help to facilitate that further?

And we really saw one of the biggest barriers on the ground was there are two things on the health worker side, it was overwork and being pulled in a lot of different directions that took them away from their direct interaction with their patients. [00:25:00] And then from the patient's side, it was really about how do they integrate this new advice they're being given into their current circumstances, which are so challenging in many cases, from a socioeconomic standpoint.

We found in particular frontline health workers, data and data reporting was taking about 40% of frontline health workers time. And this is a who statistic that in east Africa, as much as 40% of a health workers time is spent on data reporting. 

Mark: That's so surprising, but it's terrible.

Wendy: It's terrible. It is. And. Sometimes it's in electronic version, but it's not being collected in a way that the frontline health worker uses or that's being shared with her patient. So it's all meant for national upstream reporting. [00:26:00] And so we saw this as a huge opportunity to find a way we had built this whole CQI work that was so effective.

And we were finding health workers were actually double reporting. They were doing their national reports and they were sending it to us to aggregate and help them to show that if you improve the quality of your care, you will also improve health outcomes. But we knew we had to do something. We'll find this problem.

So we created a solution called . It's a play on the word. I has a, which means a bright future, 

 It's a point of care digital tool it's built on the workflow of a healthcare worker. So as she sees a patient, whether she sees the person in a group setting or in an individual setting, you can actually shift the workflow approaches to gathering data and you collect the data.

Every single time you enter a data point, it [00:27:00] tells you something that you can share with your patient. So you enter a weight. It shows that it went up from last month, went down from last month and it's a green or red, and you can share that with your patient. So every single time you're actually leaning in.

And that's what we really love to see that when we see images of people using has that it's demonstrating that relationship is built instead of being distracted. And then progress reports. So once we collected all of that data, it helps the health worker make a decision around the diagnosis. If there is one, if it's they've identified moderate malnutrition, for example, and guide them in next steps or uncomplicated malaria.

And then it provides a progress report that highlights and celebrates the things that are going well, and then gives a really clear understanding of the things that need to be followed and [00:28:00] more carefully. So for example, for pregnant women, there's a timeline that celebrates when the first time of the baby's heart rate is documented.

And he has that when they're doing the physical exam, it shows up as a heart, on a timeline for the woman to be able to see and celebrate what this is what's going on for my baby. Are the healthcare workers working with a tablet and they're showing the patient that information in a kind of real-time basis?

Yes. On a real-time basis at the health centers, they're doing it on a tablet and in the villages, they're doing it on a cell phone, the CHWs. 

Mark: Wow. Wow. And did your team develop this application? Amazing is that something that you want to deploy? Everywhere. You can put it in Missouri or California or anywhere.

Wendy: Yeah, actually I think it really has been it's been absolutely inspired by. The [00:29:00] frontline health workers and the moms that we work with, our team on the ground very much driven by what they care about, what they want to see, what makes their connections stronger is also informed by my experience, working for 15 years in the U S on electronic medical records, where I personally, and all my colleagues will talk about this, feel the need to choose between the computer or my patient because of the way those tools are designed.

And so while it's currently built to reflect who guidelines and more of a global health, low middle-income countries approach to healthcare, the process, the design approach absolutely could be replicated in the U S. Is that something that you have any inkling to promote in the us?

Yes. I think starting with our whole philosophy that philosophy has [00:30:00] led to the success and an implementation. He has that as an example, 

it's about the relationship between a frontline health worker and our patient that drives access to care, quality of care, continuity of care, adoption of care recommendations, and that both the health worker and the community member that they're serving need to be valued within the system need to have the skills or be capable, have the skills they need to deliver the care or to receive the care.

And they need to have a sense of hopefulness in the future. And so we've actually dive more deeply into that hopefulness component. And we doing research on that right now. What does it mean to be hopeful? And we act there's actually a tool called the, her cope index that measures hopefulness and it breaks down.

Hopefulness in two components of interconnectedness readiness for [00:31:00] change and a future oriented mindset. And we're really looking at what are the things that are barriers to hopefulness within that framework. And what are facilitators of that? We're also working with Henry Ford health system in Detroit, Michigan to do that very same thing, but in the context of Detroit, Michigan in maternal health care, that's where we really see the shift, the mindset of what is primary care and what are the drivers of success and how do we need to shift the systems?

And then what are the tools that will facilitate that in various contexts? 

Mark: And is that your hope initiative or is that a different program? 

Wendy: The hope initiative is the research that derives that component. But really that is one, it's really the entirety of the tip philosophy and our approach to primary care [00:32:00] that we're really trying to build advocacy around as well.

Mark: Yeah. Yeah. It sounds please tell me if I got this wrong, but unless there's that connectedness that trust between the healthcare provider and the recipient of that healthcare you're not going to get anywhere and the higher, the level of trust, the more buy-in you're going to get, and the more contact people will have, and the more understanding and concerned for their own health or their child's health, they'll have 

Wendy: a hundred percent too.

Yes. And if you have, if the frontline health workers job is to build trust, But for example, we've got in the U S at various times, as high as 60% burnout rates in the us, very similar rates in Sub-Saharan Africa . And the definition of burnout is depersonalization emotional exhaustion and lack of sense of accomplishment.[00:33:00] 

And so by definition a frontline healthcare worker who feels burned out. It's going to be really challenging for that person to build a relationship that can then build trust. And so that's why the tools need to be able to facilitate the needs of that frontline healthcare worker that can build that relationship and that trust.

Mark: It just leads me to think in the U S here, we have this tremendous problem of trust and it only seems to be getting worse. So many people for example, are un-vaccinated and I've got to believe that the foundation for that is a lack of trust. And it's gotta be, a huge issue in Africa.

 Perhaps you can talk about how COVID has influenced the care that your team and their colleagues are providing.

Wendy: I think Rwanda is a really great counterexample to what we've seen in the U [00:34:00] S but somebody asked me like, how do we build trust to get people to get more vaccines? And I think the challenges that we needed to have built trust prior to the crisis and I think that's where we're stuck now.

. In Rwanda, I will say, I do think that because there has been a culture of prioritizing health outcomes in the country, when the government says This is what we need to do to protect ourselves.

There is a built in level of trust. One of the things that we've seen is that they have quickly adopted mass command dates. They've, as you may know, vaccines have been very scarce, but those that have had access to vaccines are there because they recognize that needs to happen.

One of the things that we've seen in our communities, that's been really exciting. I think in many countries and in different parts of Rwanda, even the lockdowns have caused [00:35:00] fragmentation of routine primary care services. So that's been one of the challenges with COVID than other countries.

They may be doing everything right. They locked down early, they start the mess, they socially distant, but they have to hold out a lot longer than we do to get the vaccines in. And it's causing numbness, worsening, malnutrition, decreased engagement and care for pregnant women. And so a whole host of other complications are happening.

We have seen in our communities that are using heza because we can see what the data that actually month to month we're seeing increased engagement in care. we had a lockdown in Rwanda in July, started July 1st. We saw a 10% increase in the numbers of new pregnant women that came in and a 15% increase in the number individual encounters that happened in that month compared to the previous month.

 I am making an assumption here, but [00:36:00] I do think that because there's built in trust they know that they need to continue to access care.

And so they're still doing that despite the COVID lockdowns are still making sure that they're doing what they need to do for the care of pregnancies. 

Mark: Gotcha. So is the level of COVID illness? awful.

Wendy: Up until more recently. They had done a really excellent job of managing, they locked down early. Like I said, implemented mass mandates and social distancing really quickly and really got all the way to the very rural villages.

And everyone's really been engaged in the solution there more recently, they started to open up and again, having to balance the socioeconomic stress against the immediate challenges. So when they started to open up and then the Delta variants, you may know, has hit Africa very hard.

And Rwanda [00:37:00] is no exception to that. They have definitely seen really significant surges their positivity rates, the rate of tests that are done that are positive, in June, were maybe two to 3% and they've gone to 11 to 15% and now they're around 7%. And the thing I find really frustrating is that they did do everything right.

And if they had the same access to vaccines that we had, they would not have a surge because they would have had a really high uptake of vaccinations and they would not be in this situation now. 

Mark: It's a pity. It's a pity. And how's the situation where they HIV.

Wendy: the HIV rates in Rwanda, they have been well controlled for awhile. I should give the credit to the health workers and the moms that do a beautiful job of managing. We've not seen any mother-child HIV transmission in the districts where we're working, which is amazing.

And overall the country has been [00:38:00] able to get the rates down below 2% from mother to child HIV transmission. They have a really excellent system in place there. in Rwanda for HIV, 

Mark: Can you give us some context because I know you're focusing on the mother child relationship in Rhonda what is the general level of HIV infection in the population, 

Wendy: I'm afraid I'm going to quote this wrong because I haven't looked at the numbers recently for the overall country.

But the rates have been probably around 7% in the more urban areas and lower in the rural areas. 

Mark: Okay. Those levels are dramatically lower than they were 10 or 15 years ago, right?


How many people does tip serve. 

Wendy: right now we serve a catchment area for 150,000 people, and we're now entering into other catchment areas that will be another [00:39:00] 80,000. But as we expand across the entirety of the districts, that will be significantly more. 

Mark: are you expecting to cover the whole country? At some point, 

Wendy: our goal is to cover the whole country. Right now, we have a strategy.

We work with the ministry of health and work within their timelines as well. So they're very excited about he has that. Our current goal is to expand our model and approach through with he has as a facilitator. So in a technology enabled facilitator of our approach to find primary health care delivery and.

Will by the end of this year have a hundred thousand women and children being seen Ani has that by the end of this year and get to 250,000 by the end of next year through the scale up across Rwanda and also entry into another east African country by the end of 2023. 

Mark: Wow. So would that be Burundi or you're thinking of other places 

Wendy: we've done quite a landscape [00:40:00] analysis of Burundi, , Kenya, Tanzania, and Uganda.

Mark: And how do you fund all of this? 

Wendy: A lot of grant writing.

Yeah. I will say that I think we are quite efficient because we have these strong relationships with the health workers and we have built a reputation around mentorship and people get excited that's been a wonderful Testament to our team. And it's also a statement of the health workers that really wants these tools to improve their systems of care.

So we are able with a small, but mighty team do a lot. We recently partnered challenges, Canada, and then transitioned to scale grant that helped us to move.

He has added to several new catchment areas. We also work with Robert Wood Johnson foundation. They primarily fund [00:41:00] US-based. Community health work, but they fell in love with the hope initiative. And so through their reverse innovation work there, they funded our hope initiative and also the work in Detroit, Michigan to replicate what we're doing in Rwanda, in Detroit, Michigan.

Mark: if there's a listener who would want to participate or help out is there a way for them absolutely. I am always happy to have conversations and you can reach out to me at my email, Wendy, a typical will And on our website, tip global health dot org.

 In terms of individual fundings, that's not big part of your funding source. 

Wendy: We're always looking to expand our individual donor funding stream. We have, been a humble workhorse organization. That's really focused on writing and thinking in those terms.

But as we grow, we're really hoping to build out our partnerships with individual donors who are excited about [00:42:00] achieving lasting improvements in health outcomes. 

Mark: All right. I applaud you for just really drilling down to the essence of. What's really important in these communities and I'm sure we can learn a lot from you in the U S as well.

Before we close , are there some things you'd like to talk about? 

Wendy: Like I told you, I could talk forever about tip I'm so proud of our team but I really thank you for the opportunity to share what we're doing. Oh 

Mark: it's my pleasure, Wendy.

Wendy: Thanks. Take care. Okay. You too. Have a good day. All right. You too. 

Mark: Bye-bye.