MANO A MANO – 2007 ANNUAL REPORT

PLANTING THE SEEDS:  MANO A MANO’S EARLY YEARS

For years Mano a Mano’s founder of Mano a Mano rescued usable, often new, tools, building materials and household items from their destined journey to a U.S. landfill and carried them with him on trips to his native Bolivia, certain that his impoverished compatriotas could use them to improve their lives.  When his brother, a pediatrician, began asking for instruments and equipment for the non-profit, Methodist hospital he directed in the city of Cochabamba, the founder decided to create a formally recognized organization to focus on retrieving surplus medical items in Minnesota for use in providing health care to Bolivia’s poorest citizens.  With family and friends joining this effort, Mano a Mano Medical Resources (now Mano a Mano International Partners) incorporated in Minnesota as an all-volunteer 501(c)(3) organization in 1994. 

These volunteers set a formidable goal:  to fully re-equip and supply the Methodist hospital within five years.  By the end of 1996, Mano a Mano’s volunteers reached a milestone that far exceeded their dreams: they had collected a total of 70,000 pounds of medical surplus and met their original goal.  In the process they learned that dedicated volunteers reaching across national boundaries could join hands in literally making the difference between life and death for many of Bolivia’s poorest citizens.  Yet, they recognized that their successful efforts to provide life-saving materials to the poor did not reach those in greatest need: families who had no access to health care because there was no infrastructure through which to serve them.

In 1997, the 70^th birthday of one of Mano a Mano’s most committed volunteers presented an opportunity to address this disparity.  Suggesting that Gloria MacRae’s friends donate funds for building a community health clinic in Bolivia in her honor drew in funds with which to initiate this program.  By the end of 2000, Mano a Mano constructed clinics in seven communities that had no previous access to medical care.   

In 2000, a major donor invited Mano a Mano to submit a proposal for a major expansion of its efforts to build a health care infrastructure in Bolivia’s poorest communities.  Mano a Mano helped create a counterpart organization, Mano a Mano – Bolivia, which hired staff from among its Bolivian volunteers, and  initiated the “30 Clinic Project” in January of 2001.  Successful completion of this project by mid-2004 and a major commitment of additional funds from the same donor led Mano a Mano to plan to add another 96 clinics to its network by 2012. 

MANO A MANO EXPANDS ITS HEALTH AND EDUCATION PROJECTS THROUGHOUT RURAL BOLIVIA

The mission of Mano a Mano International Partners is to create partnerships with impoverished Bolivian communities that improve health and increase economic well-being.  Mano a Mano has been guided by the simple yet powerful premise that groups of committed volunteers can reach across national boundaries to make a dramatic difference in the lives of others. Its accomplishments have grown to include building an infrastructure for health care in Bolivia that is constructed, supported, and ultimately run by Bolivians.  Mano a Mano (Spanish for “Hand in Hand”) operates through a uniquely effective, largely volunteer network, with administrative and fundraising costs remain at less than 5% in the U.S. and less than 6% in Bolivia.  The organization accomplishes its mission to improve health through collaboration with its Bolivian counterpart organization: Mano a Mano – Bolivia.

The Medical Surplus Program:  Mano a Mano seeks donations of surplus medical supplies, instruments, and equipment from hospitals, nursing homes, and other health care facilities in Minnesota and transports them to Bolivia where Mano a Mano – Bolivia staff and volunteers distribute them to health care programs that serve the poor.  Mano a Mano partners with Catholic Relief Services to bring these shipments into the country on a duty free basis. 

Community Clinic Program:  While medical surplus donated from the Twin Cities proved to be an invaluable, life-saving resource for marginalized urban Bolivians, the complete lack of health care facilities in rural areas meant that the rural poor could not benefit from these desperately needed gifts. Mano a Mano’s determination to make medical resources available to those in greatest need led to its decision to construct clinics through which rural residents would, for the first time in their lives, have access to health care.   Mano a Mano used donated medical inventory to furnish and supply the eighty-three clinics that it has completed.    

Mano a Mano clinics average 1800 square feet in size and include:  waiting area, exam rooms for the physician and the nurse, between two and seven inpatient beds, a delivery room, education room, kitchen, patient bathroom, dental office in some clinics, and living quarters for the medical staff.  Mano a Mano finds that by providing comfortable living space, a clean, well-equipped clinic, and an excellent continuing education program it is able to attract and retain competent, dedicated staff in spite of the remoteness of clinic sites.

Each clinic provides these services:

• community organization and outreach: inform community residents about clinic services and encourage their use;

• preventive services: child and adult vaccinations, health education, well child visits, family planning, prenatal and post natal care;

• attended deliveries;

• acute care for illness and accident cases;

• management of chronic illnesses such as tuberculosis;

• Human resource development:  train community residents as community health workers; provide medical supervision and continuing education for professional staff.

Environmental Health Program    Through health education offered in their clinics, residents learn that dangerous roads, lack of clean drinking water, absence of sanitation facilities, and insufficient variety in food supply present serious health hazards.  In 2001 Mano a Mano initiated its third program in response to community requests to address these needs, bringing public showers, bathrooms, laundry tub facilities, and water access to sites near the community’s public school and improving roads into clinic communities.

Schools and Housing for Teachers     Parents in clinic communities, convinced that education provides the greatest hope for improving the lives of their children, ask Mano a Mano to expand its collaboration with them, to build new classrooms and housing for their teachers.  Schools consist of dilapidated buildings, one-room adobe structures without doors or windows, or simply benches under trees.  While Bolivian cities have an over-supply of qualified teachers, rural areas find that teachers refuse to work under these difficult conditions or to live in the one-room, dirt-floor adobe houses available in rural communities.  We find that providing attractive housing (a one-story, brick duplex with two-bedroom units) and well-constructed classrooms positions communities to attract and keep qualified teachers. 

Road Improvement and Air Landing Strips     The lack of passable roads throughout most of rural Bolivia not only impedes access to health care; it also prevents farmers from transporting their produce to market.  Mano a Mano uses its heavy duty equipment in partnership with rural municipalities to re-construct and re-grade rural pathways, creating solid gravel roads that can support truck transport.  Where feasible, Mano a Mano uses the same equipment to construct air landing strips, creating opportunities for air transport into remote communities.

Teachers who are willing to accept rural positions frequently travel to the city for supplies and fail to return for weeks at a time, leaving the children with no one to teach them. Mano a Mano attracts and retains qualified medical personnel to its rural clinics by incorporating living quarters into the clinic building and offering a clean, well-equipped clinic in which to work. 

PARTNERSHIPS: THE FRAMEWORK FOR SUCCESS 

Residents of Bolivia’s poorest rural communities struggle to survive in economic and political environments in which they are often isolated and powerless.  Construction projects are extremely difficult to fund, since communities and organizations can rarely accumulate sufficient funds at one point in time to cover costs; loans and mortgages are rarely available.  In partnership with local communities, Bolivian government agencies, and Bolivian businesses, Mano a Mano - Bolivia has implemented a consistently successful, low-cost approach to building and operating clinics, schools and teacher housing, as well as sanitation and road improvement projects. Community residents participate in all aspects of planning, construction, and operation of these facilities.  Mano a Mano staff organizes residents to partner with them, always beginning with the assumption that villagers are capable, motivated individuals who lack the material and educational resources required to improve their circumstances.  Extensive discussions lay the groundwork for developing formal agreements among the elected community leaders, municipal officials (the municipality is similar in composition to a county in the U.S.), and Mano a Mano and define, prior to construction, the contributions and responsibilities of each participating entity. 

While Mano a Mano provides funding for construction, skilled labor, and heavy equipment, community volunteers contribute all of the unskilled labor and any locally available building materials such as sand or gravel.  Local governments fund such items as refrigerators for clinics, laundry tubs for the sanitation facilities, and fuel for the heavy equipment used to re-grade roads and air strips.  In addition, Mano a Mano seeks small contributions, such as floor tiles and cement, from local businesses.  The agreements among participants become the blueprint for ongoing relationships between Mano a Mano and its partners.  By the time a project has been completed, villagers have developed an intense pride in their accomplishments, a sense of ownership of their new facilities, and a view of themselves as competent individuals who can make things happen. 

Mano a Mano uses every available opportunity to stimulate community involvement, reinforcing this sense of ownership of and responsibility for projects.  Throughout its work with the community, it focuses on long-term viability.  Before building a clinic, it requires that the Bolivian government begin to fund the salary of either the physician or the nurse from the time of clinic opening, and the other position within three years.  Mano a Mano’s success in convincing government officials to include clinic staff positions in their permanent budgets is unprecedented.  Seventy-seven of its clinics have reached the point of financial independence from Mano a Mano.  They are sustained through government funding of staff salaries, by billing the municipality for services to pregnant women and children under six, and through charging 15-30 cents per visit to patients who are able to pay.  Mano a Mano continues to provide medical supervision and continuing education to ensure continued high quality care, and supplies the clinics with donated medical inventory. 

Mano a Mano staff engages community leaders in making all decisions regarding project operations, teaching them about administration, financing, and ongoing maintenance.  Their experience in partnering with Mano a Mano and their own government officials to construct and operate community projects reinforces their motivation and capacity to take action that will benefit the entire community.  Mano a Mano’s remarkable capacity to leverage funds and in-kind donations from within Bolivia makes an invaluable contribution to long-term viability of its clinics and community projects.  These projects in turn provide a significant impetus for community development.  Micro-businesses spring up near clinics, selling food and household products.  In several cases, previously isolated communities have been added to bus routes, increasing villagers’ access to the outside world.

RESULTS ACCOMPLISHED IN 2007

Medical Surplus Re-distribution Program 

• Mano a Mano’s Twin Cities volunteers collected, sorted, and packed 225,000 pounds of medical supplies and equipment and shipped 139,825 pounds to Bolivia.

• Mano a Mano - Bolivia filled 1,478 requests for these donated items.

Community Clinic Program

Mano a Mano - Bolivia  - Bolivia constructed 11 community clinics, and equipped and supplied them with medical donations from the Twin Cities;

• Mano a Mano - Bolivia trained an average of 10 volunteers in each clinic community to serve as health promoters who explain clinic services to other residents and encourage their use, assist with health education classes, and serve as first responders.

• 206 medical personnel (including dentists) work in Mano a Mano - Bolivia clinics. All are Bolivian and received their medical education in Bolivia.  Mano a Mano - Bolivia’s supervising physician and other volunteer medical professionals have designed an excellent program of continuing education for these staff members.

During 2007 Mano a Mano - Bolivia clinics

• Had 375,816 patient visits

• Vaccinated 90,492 women and children

• Delivered 1,577 infants

• Provided health education to 73,316 individuals  

Each clinic sets and is expected to reach service and outcome goals each year under the direction of the Health Ministry and Mano a Mano – Bolivia’s supervising physicians.

In addition to providing health care through its community clinics, Mano a Mano - Bolivia arranges for specialists to travel to rural communities during weekends to provide specialty services that would not otherwise be available. 

• Volunteer specialists dedicated 952 hours to care for patients in weekend clinics last year.

The following graphs reveal that the expansion of health care infrastructure into additional communities consistently results in immediate and extensive use of clinic services.  In many clinic communities residents had never seen a physician or nurse until their clinic opened, yet they clearly act on the value they place on having access to care.

Graph 1 (Number of clinics reporting: 80)

Patient Visits by Year:  2000 through 2007

Births by Year:  2000 through 2007

Graph 3

Vaccination of Women and Children by Year:  2000 through 2007

 Table 1

Funding Sources for Clinic Staff – 12/07

N= 80 Clinics

• Bolivian sources currently fund 97.5% of the clinic staff salaries, a substantially greater portion than the projected 50%;

• Seventy-seven of the clinics have attained complete financial independence from Mano a Mano:  Bolivian sources provide staff salaries, clinics bill a national health care fund for services to pregnant women and children through age five, other patients pay 15 to 30 cents per clinic visit.  These funds cover the operating costs of the clinic.

• Long-term viability also depends on well qualified staff that provides high quality care and education.  Clinic staff participates in Mano a Mano - Bolivia’s continuing education program, regardless of the source of their salaries.  Last year, staff participated in two full workshop days during which they expanded their knowledge and set goals for their clinics.

• In spite of the hardships of working in rural areas, Mano a Mano - Bolivia physicians and nurses remain committed to their communities.  As the staff of the tropical Colonia Andina shared with a visitor from St. Paul, “The doctors and nurses who work for Mano a Mano feel like members of a family.  We work in clean facilities and receive the supplies from the Cochabamba office that we need to cure our patients.  The community also accepts us and listens to us.”  The physician continued, “When I first came here, family violence was a big problem.  I started going to meetings of the compesinos and talking to them about this problem.  One night a group of men rushed into the clinic, carrying a young wife and dragging her husband along behind.  The man had beaten his wife so badly that her face was bleeding and swollen.  Our nurse attended to her while I took the man aside, as if I were his father, and counseled him.  The men in the community decided right then to let men know that they would put them in jail if they beat their wives.  I don’t think that has actually happened but we know that we have made a big difference in reducing violence in our families.”  

Environmental Health Program 

• Mano a Mano – Bolivia improved 40 km of rural roads

• Mano a Mano - Bolivia built public bathrooms, showers, and laundry washing facilities in 7 communities in 2007, bringing to 28 the number of communities in which these projects have been completed.

Schools and Housing for Teachers  

• Mano a Mano - Bolivia constructed school classrooms in 8 communities; 30 communities now have new classrooms built in partnership with Mano a Mano - Bolivia;

Old classroom	New classroom

• Mano a Mano - Bolivia built housing for teachers and their families in 6 communities; 27 communities now have clean brick housing for their teachers.

Floor plan for teacher’s duplex	Interior of teacher duplex

Rural residents seek opportunities to express their excitement and gratitude to visitors from the United States.  When a St. Paul volunteer stopped in Campo Vibora, where Mano a Mano - Bolivia operates a clinic and has constructed classrooms and housing for teachers, its residents emerged from surrounding fields to tell stories of children who had never been able to attend school but now come from many miles around because they have teachers.  They insisted that she see the absymal conditions in which their teachers used to live.  “We are responsible to give teachers a place to live,” said one young father.  “But we can barely afford houses for our own families.  Our teachers have been living in little sheds that should be for animals but we just didn’t have any other place for them, so they would come here for a week or two and then go back to Santa Cruz.  Who would teach our children?  We were so ashamed, but what could we do.  After we built the clinic with Mano a Mano, we asked for help with housing for our teachers.  Now we have eight teachers and they like to live in our community.”

The communities in which Mano a Mano works have been literally transformed through planning for, constructing and operating clinics and other facilities.  Every aspect of this process is directed toward long-term viability by involving the Bolivian entities that will assume ultimate responsibility for their funding and operation.  These results have been accomplished through efficient use of funds and the contribution of hundreds of thousands of volunteer hours.

MANO A MANO SEEKS TO INCREASE THE STANDARD OF LIVING IN RURAL COMMUNITIES THROUGH ECONOMIC DEVELOPMENT PROJECTS:

During 2005, Mano a Mano created its second counterpart subsidiary organization, Mano a Mano – Nuevo Mundo (Spanish for “New World”), through which it focuses on the economic development portion of its mission.  

Water Reservoir Projects:  Cochabamba Valley farmers generally own 1 - 2 acre plots on which they raise corn, potatoes, small grains, and vegetables.  The Valley essentially has two climatic seasons:  a warm, rainy season during which rain falls nearly every day for two to three months and a cooler, dry season during the remaining months when moisture rarely falls.  Farmers plant in August, hoping for early rains that, along with melted mountain snows, will trickle into their streams and begin to flow through their earthen canals.  In good years, crops germinate and reach the half-mature stage before heavy rains begin in December.  If the rainy season brings sufficient water, farmers direct the water to channels and irrigate their fields, watering crops through maturity and harvest in March and April.  During years of light snowmelt or limited rainfall, the lack of water results in widespread failure of seeds to germinate and substantially reduces yields.  In contrast, during years of heavy snow or excessive rainfall, fields flood, washing away germinating seeds and sprouting plants.  Heavy flooding creates added danger by undermining the foundation of adobe (mud brick) homes, leading to total collapse of the structures and serious injury or death for their inhabitants.

For centuries, the Incas in Bolivia’s highland mountains and valleys built channels to retain water in the rainy season (December – February) for release to fields during the dry season.  They based these systems on processes inherent in nature, collecting and channeling rainwater through an extensive, complex canal network.  While centuries of war and neglect destroyed the major part of these systems, farmers still maintain shallow canals to channel water when it is available.  Building on this tradition, Mano a Mano has begun to build and expand water reservoirs. A desperately poor farmer approached Nuevo Mundo with this plea for help, “We know that Mano a Mano helps with many different kinds of projects but, for us, the most important is water.  Water is life. Without water we have nothing.  Many of our men go to the city to find work because their fields do not produce and they cannot feed their families.  Every drop of water is important to us – we do not waste a cup full.  Please help us save our water”. Mano a Mano responded to the farmer’s plea with its first major agricultural water reservoir project, expansion of the levee in his rural Andean community of Ucuchi.

Mano a Mano – Nuevo Mundo organizes community residents to participate in every aspect of its reservoir projects.  Local farmers provide hundreds of hours of volunteer labor, and contribute 5 – 8% of the project cost, as well as locally available materials such as sand, gravel and rock.  Municipalities contribute an additional 20% of project cost.  Nuevo Mundo works alongside these farmers with its heavy machinery and professional machine operators, plus contributing any additional funds required to complete the project.  It assists the farmers who will receive reservoir water to form a water cooperative that will establish user fees, manage water release schedules, and maintain the reservoir.

Reservoir project goals: 

• Increase community capacity to raise sufficient quantities and varieties of foods to provide a healthy diet for its population.

• Increase farm family income through production of grain and livestock that can be sold in larger city markets.

Community residents contribute hundreds of hours of volunteer labor to their reservoir projects, removing brush and stone, laying pipe, and building retaining walls.  Nuevo Mundo’s contribution of heavy equipment, working in tandem with local farm families, makes these projects possible.

RESULTS ACCOMPLISHED IN 2007 

• The results of its first reservoir in Ucuchi topped all expectations:  average income of the participating 600 farm families increased by 100%, from $150 to $300 annually, following the first harvest. 

• Nuevo Mundo completed a 150-acre agricultural water reservoir in Laguna Sulti and three mini-reservoirs.

• To support Mano a Mano’s aviation program, Nuevo Mundo constructed four rural airstrips.

Road Projects

Lack of roads isolates rural Bolivian communities and impedes marketing of agricultural produce. Mano a Mano - Nuevo Mundo works in collaboration with these communities and their municipal government officials to build sturdy gravel roads that will connect them to main roads and thus to city markets.

Using its community organization/participation approach, Mano a Mano – Nuevo Mundo partners with local residents and their municipal governments to plan and execute the project.

RESULTS ACCOMPLISHED IN 2007 

• Nuevo Mundo built 98 kilometers of new roads and

• Improved 99 kilometers of existing but nearly impassable roads

MANO A  MANO’S EMERGENCY AIR TRANSPORT/AVIATION SERVICE

During 2006, Mano a Mano helped create its third counterpart organization, Mano a Mano – Apoyo Aereo (Spanish for “aviation support”). It’s primary goals are to:

• Transport Mano a Mano staff and volunteers to remote communities which the organization would not otherwise be able to serve.
• Airlift critically ill and injured patients to city hospitals for emergency care;
• Make flight hours available to other non-profit organizations with similar missions, on an operating cost-only basis.

In 2002, a Wisconsin-based foundation began donating funds to Mano a Mano with which to purchase flight hours.  Mano a Mano began to use air transport in order to reduce the extensive travel time required for staff to reach the increasingly remote communities that requested partnerships with Mano a Mano and to transport critically ill and injured patients whose medical emergencies could not be managed in a community clinic setting.  The aviation program has since become an integral component of Mano a Mano’s work throughout Bolivia.  Use of the aircraft for travel to remote communities often reduces a 15 to 20 hour mountain drive to a 1 to 2 hour flight.  Mano a Mano simply could not extend its reach into many of these remote communities without availability of air travel.  Given the extensive use of flight hours, the Wisconsin foundation awarded funding to Mano a Mano to purchase the six passenger Cessna aircraft that it had been renting. 

 RESULTS 

• Over 250 patients have been airlifted to life-saving care in urban centers since this program began;

• Mano a Mano staff and volunteers used over 100 flight hours in 2006, saving hundreds of hours of travel time which could then be devoted to program services.

• Mano a Mano – Apoyo Aereo flew 287 hours in support of Mano a Mano’s social service mission in 2007

By making the aircraft available to private individuals and businesses at full fare when it is not scheduled for Mano a Mano programs, Mano a Mano projects that the aviation program will be self supporting in 2007. 

VOLUNTEERS: THE CORE OF MANO A MANO’S WORK FORCE

While, Mano a Mano now has paid staff in the U.S., the major portion of its work is still taken on by volunteers.  Nearly 225 Twin Cities’ volunteers contributed 10,362 hours last year, seeking donations, picking up medical supplies and preparing them for shipment, writing proposals and reports, leading trips to Bolivia, essentially every task required to run an effective, accountable organization. 

In Bolivia, medical professionals from Cochabamba donated 952 hours of their time providing specialist services to Mano a Mano clinics on weekends.  Mano a Mano – Bolivia’s urban volunteers spent over 9,000 hours unloading and distributing medical cargo and preparing new clinics for opening in 2007, and Nuevo Mundo’s new volunteer program drew on more that 3,000 hours of volunteer assistance.  Apoyo Aereo’s pilots volunteer hundreds of hours of flight time to the aviation program. 

Members of the rural communities in which projects were completed contributed over 70,000 hours to their projects. Their extensive involvement deepens their commitment to maintain and use their facilities and projects, and ensures that they will be sustained over the long term.

Our programs simply could not function without the efforts of these generous and dedicated individuals.

 ACCOUNTABILITY:  OUR HALLMARK

Good stewardship is Mano a Manos’ most fundamental guiding principle.  We maintain accounting systems in both the United States and Bolivia that provide detailed accounting of expenditures and produce quarterly financial reports.  Daily clinic income and expenditures within the clinics are controlled and supervised by clinic medical personnel.   Every effort is made to contain costs by ensuring cost effective purchase of all materials, involvement of volunteers in all aspects of the work, and to seek donations of medical inventory in the U.S. and of building materials in Bolivia.

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