In Honduras, a rural hospital suffers from success

PALACIOS, Honduras - Almost anywhere in the world, the economics of running a small rural hospital are not good. To operate a hospital of any sophistication requires a certain critical mass of paying patients - and such a critical mass is rarely to be found in rural areas.

The problem is especially acute here, in and around this remote village of some 700 people on Honduras' isolated northeast coast. Populated mostly by people of Black Carib (Garifuna) descent and by indigenous Miskito Indians, the main occupations are subsistence fishing and subsistence farming - although some men here crew for the hundreds of commercial fishing boats that ply the waters surrounding the nearby Bay Islands.

Further, the population in the zone around Palacios is widely dispersed. The 7,000 to 10,000 people who inhabit the "Zone," as it is called here, live along inland waterways that cut through the jungle-like coastal marshland. And the Zone is quite isolated. There is no road from the rest of Honduras to this region; access is possible only by boat or airplane. And there are no telephone lines into the region.

Yet precisely because of the lack of income and the sense of isolation here, the medical needs of the region are great. In 1985, a pair of Bah´'í doctors and their wives established Hospital Bayan. Their goal, inspired by the spiritual principles to which they adhere, was simply to serve the people of the area - and to provide a starting point for other forms of social and economic development.

Today, more than ten years later, Hospital Bayan has succeeded - perhaps too well. With a small operating suite, an examining room, an X-ray facility, a pharmacy, a laboratory, four adult beds, two pediatric beds, and a waiting room, the hospital offers low-cost and around-the-clock medical services - including periodic visits from specialists in cardiology, gynecology, dentistry, opthamology and major surgery.

The problem is that, like so many small hospitals around the world, it loses money on each patient. "We recently sat down and looked at our income and our costs and discovered that we were actually losing $3 on every patient who came through the door," said Dr. Barry Smith, one of Bayan's founders. "I suppose the easiest thing would have been for us to just close down."

But as is the case at many humanitarian projects and institutions, those who operate Hospital Bayan found taking such a step unthinkable. Bayan had been founded to serve the underserved, and its directors were unwilling to walk away.

Unlike at many humanitarian hospitals and clinics supported by charitable institutions and organizations, however, the organizational - and philosophical - framework under-girding Hospital Bayan will not support a continued loss. Bayan operates without a permanent subsidy from the outside. And the hospital's founding principles stand against such an ongoing subsidy, on the principle that it encourages dependence and is not sustainable.

"From the start, our philosophy has been to make Hospital Bayan a springboard for the general social and economic development of the region. So that the hospital moves from being stricitly a service provider to a testing ground for development."

-- Dr. Barry Smith, Hospital Bayan cofounder

"One of the differences between our concept of 'charity' and the concept that is practiced at most other humanitarian hospitals is one of paternalism," said Dr. Smith. "Bayan is not and never has been paternalistic. And one of our difficulties has been that the paternalistic model was one that the people anticipated. "From the start, our philosophy has been to make Hospital Bayan a springboard for the general social and economic development of the region," said Dr. Smith. "So that the hospital moves from being strictly a service provider to a testing ground for development."

Indeed, it is within this framework that the story of Hospital Bayan is taking a new turn, demonstrating its distinctive approach to providing humanitarian assistance.

The Vision of Two Doctors

Bayan's physician cofounders, Dr. Smith and Dr. Houshang Sabripour, came to Honduras out of a desire to become involved in the social and economic development of the country. Dr. Sabripour arrived from Iran with his wife in 1976; Dr. Smith and his wife Marilyn, who are from the United States, arrived in 1980.

In assessing the needs of the country, the pair decided that this remote region, which at the time had no regular medical clinic or hospital, was in dire need of services which they could provide. Working with the Bahá'í community of Honduras, they founded the Association Bayan and began to build a hospital.

"The project began in a very classic, almost missionary style, through the efforts of the two families," said William Gitchell, an anesthesiologist from the United States who has traveled to Bayan offering volunteer medical services six times. "It was incubated with that kind of intense personal involvement."

In the early stages, the two doctors and their families were involved in almost every aspect of the project. Both doctors worked nearly full-time at the hospital as physicians. But they also undertook other tasks. Dr. Sabripour helped to lay bricks for the hospital building and was largely responsible for its design. Mrs. Smith, a teacher, was the project's administrator. And Mrs. Sabripour worked as a nurse.

Working with a network of Bahá'í doctors and medical specialists in North America, the Smiths and the Sabripours solicited donations of building materials and equipment. At one point, in the late 1980s, with the help of a Bahá'í community in Minnesota, thousands of dollars of surplus medical equipment from the United States was flown into Palacios with the assistance of some US National Guard military units who incorporated the airlift into a training exercise.

The project also succeeded in attracting a stream of professional and youth volunteers over the years. Medical teams composed of physicians from various faiths have provided specialist and surgical services during five- to ten-day visits on several occasions. These visits attracted large numbers of patients and helped to spread Bayan's reputation.

As the hospital became established, it was possible for the founders to step back and to think about how to establish the kind of community participation and involvement that they felt was essential to Bayan's long-term sustainability.

"In our minds, the hospital was always part of a larger project, to help how to think about their problems and how they can find the solutions for themselves" 

-- Dr. Houshang Sabripour

"In our minds, the hospital was always part of a larger project, to help the people learn how to think about their problems and how they can find the solutions for themselves," said Dr. Sabripour. "It was just that the medical situation was so bad, the people were in such need of health services, that had to come before other aspects of the project."

In 1992, Bayan's directors prepared a document depicting a long-term vision for the project's evolution which embraced several interrelated areas - the hospital, the outreach programs, and the development of the capacity of the people in the region. Then they broadened the board itself, bringing in individuals from other faiths.

As a next step, they initiated a number of subsidiary development efforts aimed at building capacity in the people. These efforts ranged from a high school-level tutorial education project to the establishment of a community-based water, sanitation and health education plan.

"The hospital is a very needed service, but for the hospital to survive long term, the directors of Bayan have recognized that there has to be an education and capacity-building element," said Roy Steiner, an international development specialist who has visited the project several times.

"The founders have believed this all along. Bayan very much started as the project of two families. And now it really does provide excellent medical services. It has saved countless lives. But underneath that is a commitment to helping people make their own decisions, helping them take responsibility for their own well-being," said Dr. Steiner.

The adoption of the high school tutorial education project, in particular, said Dr. Steiner and others, is a crucial element in empowering local people. The project is based on the SAT (System for Tutorial Learning) model developed by FUNDAEC in Colombia (see ONE COUNTRY 7.4). It presents a secondary school curriculum formulated especially for rural students through a series of highly interactive workbooks, making it possible for specially trained tutors, who themselves come from the Zone, to provide underserved rural students with a top quality education that is also relevant to their situation and lifestyle. The curriculum is organized around the concept of service to the community and it emphasizes basic moral values like honesty, trustworthiness and trusteeship, as well as essential ecological principles. The net result is a powerful curriculum for community empowerment.

"The Association Bayan has already established the SAT program in 23 of the villages in the area, and at least 300 students will receive high school education through the program over the next two years," said Dr. Steiner. "This program really offers one of the keys in the transition from merely providing service to one of empowerment."

Recent Community Meetings

The next step for Bayan is to make the transition from a project started by outsiders to a truly sustainable entity supported by the community itself. And these steps have gained impetus from a remarkable series of community meetings late last summer. They also showed just how strongly the community felt about the hospital.

The twin gatherings on Saturday, 31 August, and Sunday, 1 September, drew a total of more than 60 representatives from the eight communities that Bayan serves. Presented with the dire financial difficulties facing the hospital, community leaders and representatives indicated that they would strive to find new ways for Bayan to achieve its goal of self-sufficiency.

"No one knows what they have until they lose it. We will follow up on these meetings inorder to save Bayan because it ours."

-- Zulma Norales a Garifuna community leader

"No one knows what they have until they lose it," said Zulma Norales of Batalla, a Garifuna community leader and businesswoman. "We will follow up on these meetings in order to save Bayan because it is ours."

Hilaria Martinez, a nurse representing the Ministry of Health, praised the work of the hospital, saying it plays a key role in the community. "Bayan is the only hospital in the Zone," she said. "I consider that it is inexpensive. If we did not have this hospital, we would have to go to a hospital in the city by airplane and the sick person would have to go with someone."

Since those meetings, the municipal authorities have begun to work more closely with Bayan in an effort to widen the base of support. Recently, talks have been started with the Ministry of Health, as well. No one who is involved with the project anticipates any outcome but success.

The president of Batalla's community council, Natividad Figueroa, said his municipality would work with other communities to develop a proposal to ensure Bayan gets the support it needs. "It is not a good idea to close the hospital," he said. "But now we are in time to help it recuperate."