Nick Laing

The Health Centre That Wasn’t To Be

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Phase 1 – Great hope In March, we rode out with our enthusiastic nurse Walter to the frontier town of Elegu on the South Sudanese border. High population, no health centre, traders with a bit of money. What location could be better? The location even came with our Bishop Johnson’ recommendation.

Phase 2 – Bewilderingly slow Things started surprisingly slowly. Only 60 patients came the first month. 97 the second. Walter was bored. The patients who came appreciated the service greatly, but we were bewildered by how few there were. After an amateur advertising campaign where we shouted through a megaphone, smeared A4 notices around town, and gained the trust of the local Maadi tribe, things started to pick up.

Phase 3 – Maybe yes? In July, the clinic broke even for the first time, with a bunch of sick patients coming for IV treatment, in addition to more minor conditions. 175 patients for the month. Walter called excitedly with the statistics, sharing that the word had spread, that people were appreciating him, the health centre, and the care – the only high quality care available in the area.

FLOODED OUT  – We’ll never know On Tuesday August 22, at around 4:00pm the banks of the Onyama River burst. The flooding was swift and violent. The scale is huge – as of now at least 3 people have been found dead, and over 2000 are displaced. Our nurse Walter ran 50 meters to the clinic from his hut in an attempt save the drugs, but only managed to gather half before the water reached waist deep. By the time he filled a bag with drugs, his own home was flooded. He lost all his rice and beans, but he and his wife made it safely up to the safety of the raised main road.

I thought he exaggerated when he said the water level reached over a meter, until I saw the water line on our drug cupboard today. Around 1.2 meters high. Today, a week later the water is still ankle deep, and Fiona from our Health office went to Elegu to retrieve the cupboard, desks and other equipment that were covered in mud. Amazingly the clinic hadn’t been looted. We spent this afternoon washing them up, so we can use them in another health centre soon. It hurts to lose Elegu clinic. something that could have done so much good. Time to mourn and move on.

There’s a great song, “Flood Waters” by Josh Garrells (do listen) which discusses a deep love which can’t be washed away. A love which can’t fail no matter what. Our love for this place, and Walter’s love for the people he treats won’t be washed away by this flood. We’ll all find new ways to put it into action.

Health Clinics by the Numbers

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We’re 5 months into the trial of the 4 new clinics, with a total of 12 operational months between the health centres – the halfway point in the trial. Cetkana has been running for 5 months, and our most recent Obanga pe Wany. only 1 month. We’re aiming for ‘operationally sustainability’, which means the patient fees cover running costs. The new clinics have already treated 2293 patients combined which is impressive. YAY stats – here goes…

The patients

Here’s the graph of the number of patients seen by each clinic every month. Note Obanga Pe wany only has one dot – the clinic has only been running for a month. I’m not currently collating the data for conditions seen (its available at the health centres), but over 60% of these patients had malaria.

Two Thirds of our patients are kids under 12, which is great from a saving lives perspective, but not so good for our sustainability as they pay less money.

The money

Patients pay a flat fee which covers Consultation + Test + drugs. This means someone knows before they walk 2 hours to the health centre exactly how much money they need. Patients 0-4 years old pay USD 0.70c. 5-12 pay US $1. 13+ pay $1.50. Even in Uganda where people have very little, this is a relatively small amount of money, and always less than transport to the nearest other health facility. You won’t find cheaper healthcare in Northern Uganda outside the hopeless government system.

Over 90% of our running cost are drugs + the nurse’s salary + rent, and from our current experience it takes around 235 patients a month to raise the money required to pay for this. Here’s the graph showing how much money our health centres are losing/gaining each month. The line in the middle is the “sustainability line”, which the health centre has to stay above on average to be viable. Keep in mind a couple of really good months can offset 4-6 not so good ones (see Ocim) If you’re wondering why its US rather than NZ dollars, its because the New Zealand Dollar is a backwater currency and we want to be taken seriously. A beautiful backwater though…

As a side note, we also give some stuff out for free, like condoms, family planning and mama kits for pregnant mothers. Nurse Naume at Ocim gave out 300 free condoms one month. Awesome.

Take away points

Around 235 patients a month is what’s needed for sustainability Even after only 4 months, Ocim is doing well enough for us to say they can continue indefinitely. Sustainability win and compounded good! Obanga Pe wany had a fantastic first month, if this continues it should also become sustainable. Cetkana is doing a great job, but is unlikely to become sustainable,. Elegu has started very slowly and is losing a lot of money, but its early days. Stats alone don’t show the good these places are doing. Stay tuned for the non evidence based stories to pull the heartstrings and give the majority of people who didn’t read this blog a warped view of how awesome these health centres are… 2/3 of our patients are kids, which is great for their health and their future.

PS: We’ve decided to extend Cetkana’s trial another 3 months to 9 months. Despite their currently unsustainably low number of patients, they’ve actually lost very little money. Unfortunately I doubt they will reach the magical 235 number to be able to continue, but we wanted to give them every chance. Their deficit is only USD $40 a month. You might say, why don’t we just fund that shortfall? That’s so little money to help provide healthcare for 150-200 really poor people a month. People have already offered. Maybe in future we will run centres with small subsidies. For now though lets shoot for the moon and go for 100% local sustainability. It may hurt to shut places down, but we can always go back and through this approach we’ll find the areas which desperately need quality health care, rather than just a lot.

If you got to the end my respect for you is immense. More exciting and inspiring stories coming soon.

NGO part 2 – Why all the trainings?

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Three of our staff came into our office after a week long Malaria training. After they raved about how wonderful the training was, I asked them a question. “What is one thing you are going to change, or improve at your Health Center after the training?” Even after prompting and trying to give them ideas, we couldn’t come up with anything. Not one thing. Eight of our staff were there for a week. 320 working hours. Our staff already treat malaria really well. They didn’t need a training on malaria.

The problem

Of all the issues I’ve had with NGOs, meetings and ‘trainings’ is the issue which which has driven me the most crazy, and provided the most hilarity. Don’t get me wrong – trainings can be a core part of NGO work, I run them myself! Just last week Marie Stopes needed to teach our staff how to insert family planning methods, and it worked really well. Often though trainings are a colossal waste of money and time, and more importantly devalue learning by putting barriers, or distractions in the way. I think this is so important, I’ve created my own ridiculous jargon phrase ‘learning distraction’ to emphasise the point. Maybe it can be new NGO speak!

I have so many problems with trainings and meetings, but I’ll limit myself to 7, no… 8.

1) Allowances for participants. Allowances for transport, accommodation, day allowances. ‘Big men’ turn up for 30 minutes to get a wad of cash, reinforcing harmful cultural stereotypes. As well as wasted money, it’s a learning distraction. How can you concentrate on learning when you are waiting for more money than you have seen in weeks? Friends have told me that they sit there all day planning how to spend their 50,000. At one meeting there was nearly a riot when allowances were less than expected. 30 minutes was spent discussing the situation. It was telling when a participant said “this training will be useless if we are not facilitated properly.” In the minds of the participants, I think he was right. At another one day meeting, I was handed 150,000 in allowances, plus a 8 gig pen drive “from the American People.” All 40 of us were. You do the math.

2) Lack of important and practical material taught in effective ways. Material should be evidenced based, with experts, or at least people knowledgeable in their field teaching new information or skills. Models and frameworks are tossed into the ether, never to be used again. Material is often not taught in effective ways that will be practically useful. Much time is also wasted on inefficient group work, which is often a mix of sharing good ideas which most people already know, and reinforcement of bad ones. I’m all for participation, but it needs to be well thought through.

3) General Opulence. Meetings are held in the fanciest hotels. Food is fancier than local wedding food. Everyone is given wee books and pens (and sometimes pen drives!). Bottled water is given on demand. This makes trainings and meetings into a status symbol and I think contributes to a space where people are trying to impress each other, rather than learn together. A huge learning distraction.

4) Meaninglessness of resolutions and action points made. Of the 10 or so meetings/trainings I’ve been to, almost none of the resolutions made have been carried out. So far I’ve been elected onto 3 follow up ‘committees’ that have never met, and never will.

5) Paying the people organising the meeting extra money on top of their salary. Why do you pay staff extra to do something that should be part of their regular job? This just encourages NGO staff to hold unnecessary trainings to fill out their wallets as well as their time.

6) Wasted person hours. Half a days material covered in 2 days. Two days material covered in a week. For our malaria meeting 320 hours of quality patient care were taken from us, for next to nothing gained.

7) Unnecessary attendees. People who only speak Acholi at English meetings (happens at most meetings I’ve been to). Random local government officials who have nothing to do with what’s being discussed. ‘Big Men/Women’ who hijack the meeting with speeches and other agendas.  Having unnecessary attendees present causes random off-topic discussions bringing yet another learning distraction.

8) Use of unhelpful NGO jargon, which muddy the waters and provide yet another learning distraction. Much NGO speak has become a quagmire. People all know vaguely what the word means without being able to pin it down. There is also straight confusion, where the speaker means one thing, and the listener hears another. ‘Volunteer’ for example to the western ear means working for no pay out of the goodness of you heart, while to a local listener can mean quite a well paid job! Here’s my NGO-Speak Bingo game I use at meetings to entertain myself. I’ll generally win within the first 30 minutes of the meeting.  I’m not the only one who thinks this is ridiculous.

NGO Bingo Facilitation Mobilisation Implementation Empowerment/Empowering Sensitisation Capacity Building Stakeholders Governance Girl Child Scaling Or Scale up ‘Volunteer’ Accountability ‘The field’ Gender Balance Resilience High-Impact or Impact

 

Solutions

Lacor Hospital (the biggest mission hospital in Uganda) has a great solution. They don’t let any staff go to trainings and meetings unless they absolutely have to. And it works really well. When I asked a hospital boss why they don’t allow their staff to go, he said. “Trainings are usually 100% useless and they waste time. Why should our staff go?”

When we do hold trainings, here’s 8 ways to make them better

Don’t give allowances. The exception perhaps, is an actual refund of public transport costs for people who don’t live in town. If you’re doing a training in the village, people already live there. If you are training educated people, most of them live in town so no transport is needed Hold a lot less trainings. Many don’t need to happen. A classic category which are often unnecessary are “stakeholder” meetings, where the NGO invites government officials, religious leaders, community members etc. to tell them about the project in their neighbourhood. They achieve very little and can even add barriers when officials inevitably suggest more meetings, or use the opportunity to add unnecessary bureaucracy to the project. I was really impressed that a hundred-million dollar maternity project we’re working with had zero stakeholder meetings. They talked with us, trained our nurses and then started. Invite only people that are going to benefit directly. Target carefully. Don’t invite people who only speak Acholi if you are going to hold the training in English. Don’t invite big people just for the sake of it. Invite people who will be keen to learn, and have a lot to gain. Get Experts and top quality presenters to take sessions where you don’t have the expertise. Spend your money here, rather than on other areas of the training. Don’t just get your NGO staff to cover topics that they are not experts in. If you’re going to do it, do it properly. Hold meetings and trainings in more austere locations. The District Council hall in Gulu costs only 10,000 to hire. Many trainings and meetings could be squeezed into NGO offices. Hold shorter trainings. Can you do this in one day rather than two? What material is less important that you can cut? Can you remove the morning or afternoon tea break? Serve Beans and Greens with Posho and Rice for lunch. Why should every meeting have 2 kinds of meat? Make the thing less about the lunch and more about the learning. People will still appreciate a free lunch (eventually, after they get over the meatless disappointment J). Ban the Jargon words (start with the bingo table) which can’t be used by trainers or participants. Be specific, use real life examples. Give people a list of words at the start of the training that they aren’t allowed to use. Make it fun by rewarding people who notice when the banned words are used.

NGOs part 1 – Pay your workers less

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I don’t usually preface, but in this case it may help people dislike me less. I believe that NGOs go about much of their work the wrong way in Northern Uganda, to the point where some of them may do more harm than good. I’m writing a series of blogs on where I think NGOs are going wrong, and how they could fix it. These here are opinions. Informed opinions after 4 years operating amongst NGOs in Northern Uganda, but opinions only.

Abandon Ship

Last year, one of our best nurses left one of our rural health centers. With no warning and without telling anyone. It was the 3rd nurse that year who left for an NGO job. We rushed to replace him, but it put the only remaining nurse there under a lot of stress, and I’m sure patients weren’t cared for as well in the meantime. Our replacement wasn’t as good. I didn’t hear the nurse who left again until 6 months later, last week. He came to apologise for leaving abruptly. He said he felt really bad about it, that he had let his fellow staff and the patients down. He’s a great guy and it was good to catch up and reconcile everything. When I asked him why he left for the NGO job, he looked at me as if it was a stupid question.

“The money was too much, of course” Too Much Money?

So why is it bad to pay Ugandans a lot of money in NGO jobs? Surely you pay them as much as you can afford to help them and their families get by in a poor country. Unfortunately, its not that simple. There are at least 3 enormous negative effects of high NGO salaries.

1) High quality workers get lured out of sustainable, productive service provision jobs (health work, business, teaching etc.) and into the NGO sector. It’s a local brain drain of epic proportions. In one case this became so extreme that the run-down government hospital wrote to anNGO asking them to stop stealing their nurses! Most of the best minds should be innovating and leading the society from institutions and businesses that will continue serving people indefinitely. Instead the NGO sector is overloaded with the best educated and most capable, while the cogs which drive sustainable progress creak and come to a halt.

2) The distraction of huge NGO salaries means that workers don’t concentrate and get stuck into their current jobs. Many workers have a legitimate ‘grass is greener’ syndrome. People are ever on the look out for that ‘Golden Goose’ job which pays 2 or 3 times as much, even if the NGO job only lasts 6 months. You wouldn’t believe how much time and effort local people spend thinking about and applying for NGO jobs rather than getting on with their current work.

3) High NGO salaries wreck the aspirations of young people and skew the entire education system. When you have a deep, honest conversation with people at university about what they want to do, very few have serious aspirations to help their country, or bring people out of poverty. What they really want is a cushy, high paying NGO job. People should have a heart to start productive businesses, teach at schools, be nurses at hospitals. To work within the system to create lasting change. When we advertised for a job managing our Anglican church health centers, I was expecting degrees in public health, or at least administration. But no, over half of the 80 applicants had a degree in “development studies”. What even is that degree? A ticket in the lottery for a bloated NGO job. Another phenomenon is that many people want to be ‘drivers’ so they  earn more than teachers or nurses by driving NGO workers around. Bizarre.

So why do NGOs pay too much? From talking to a bunch of people about it, these are some of the reasons (again add your own!)

1) The donors back home just don’t understand local salaries 2) NGOs have a budget which they need to spend, and salaries is a way of spending it. 3) NGOs rely on local NGO workers to suggest/decide on salaries – perpetuating the cycle 4) Wanting the best worker possible for their job (not OK, see below) 5) Wanting pay equity between local and Ex-pats (White guilt plus healthy instinct)

The Solution

The good news is that we can solve this problem almost overnight! Here’s how.

Pay the market rate for your staff. Find out what the local market rate is for teachers, nurses, lawyers or whoever else you hire. Ask for the salaries for similar positions among business people, government and private not for profit enterprises (Church Run) and add no more than 10% to that. Not pay Ex-pats much more than you pay locals. Wanting equity between local and expat workers is fantastic, but the solution is not to increase the local salary, but lower the Ex-pat’s! This reduces the tension to have to pay locals ludicrous salaries to match. If Expat NGO workers can’t handle being here on close to local salaries, then I don’t believe they should be here. It should be a sacrifice to work a place like Norther Uganda, a big one. Awesome hard working, caring Ex-pats will still come work for your NGO, even if they are paid less. Be prepared to not hire the ‘best of the best’ with a reduced salary. Why should NGOs get to hire better workers than the government, buisnesses, or mission hospitals? Realise that your work is not usually more important than what everyone else is doing. Be comfortable with hiring good workers, even if they aren’t the best. You’ll still get good workers, don’t worry!

Then spend the money you save on salaries on…. whatever you think is best! Hire an extra worker, sponsor more kids to school, drill more boreholes. It’s a win-win for everyone.

Feel free to disagree, comment, agree, ask questions, disagree or whatever you please.

Clinic No. 3 – Borderline

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Elegu is a “post-apocalyptic shanty town”, explained my wise anthropologist friend. If you only had four words and a hyphen, I don’t think anyone could do better. Arabic music floats out of Shisha bars. Rainbows of money flap in the wind held by flimsy rubber bands. A different language every 10 meters. Refugee intake point with a broken swing. And despite all this hustle and bustle there’s no health clinic – only drug shops. Until now. New clinic number 3: Elegu.

Just three years ago the Border Post between South Sudan was moved 10 km to sit on the actual border, and within those ]three years a bustling ‘gold rush’ town sprung up. Gold, oil and high quality rice is smuggled in from South Sudan. Food is sold at exorbitant prices across the border. NGOs buy up large to look after those the evil war has displaced both in South Sudan itself and the refugee camps nearby in Uganda.

Elegu is a racial melting pot, although as a white person you wouldn’t guess it immediately. We’ll be serving refugees from South Sudan who are making their way outside the camps. The local Maadi tribe. Traders from the East, West, North and South who are trying to escape poverty through the trading gold rush. We asked our waiter Prossy:

Me: “Where do you come from” Prossy “Mbale, Eastern Uganda” Me: “Why did you come to Elegu” Prossy: (Shrugs) “Work, money” Me: “Did you know anyone here before you came?” Prossy: “Not even one person”

The abode we’re renting would not quite meet New Zealand building regulations, but it will do the job. You wouldn’t want to be there in an earthquake that’s for sure! Our nurse Walter is humble, cheerful chap who has moved in with his wife and small child. If anyone can make it work in a weird place like this, he can. He’ll be in Church today, welcoming resurrection and new life. That’s what we’re looking for in Elegu.

This post was originally posted on Nick & Tessa’s blog, Ugandapanda.com

Will it work?

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As the rickety pickup rolled in on the narrow village track, I had two thoughts bumping around. One, the nerves and excitement of starting our second clinic. Did we bring all the equipment? Is our young nurse going to be OK? Is the door even going to be unlocked?

And Two. Who is OJ Maxswel?  The picture above is of the hut right next to the clinic.

Don’t worry, this blog is not about OJ Maxswel.

I try to be objective and use head over heart when selecting new clinic sites, but my heart has broken a bit for this place. Ocim needs a clinic, it really does. If you get sick there, even accessing bad quality health care is difficult. And the place is gorgeous. It’s the closest you’ll get to an idyllic village, with pigeon houses, traditional granaries, and decorated huts. Even in dry season I was captivated.

But my heart breaking doesn’t mean that the clinic is going to become sustainable. It’s a 6 month trial, to see whether the demand from the community will be enough to keep the place going. There’s a whole lot of reasons the thing should work. But there are almost as many why it won’t.

 

Why Ocim Outreach Clinic will work 1) When I assessed Ocim, I asked a bunch of locals how many hours it took to walk to the nearest health centre. I couldn’t get a number, but some people said “We leave to go there just after the sun rises, and we get back just before it sets” 2) It costs $5  for transport alone to access any medical care. Our clinic costs $2 at most 3) Reverend Ojok, the local Anglican minister is an publicity machine. On the way back from the clinic he taped 3 posters promoting the health centre on the walls of shops and talked to everyone he saw about it. Legend. 4) The community is proud of their new clinic. They want to make it work. 5) The clinic has got instant cred and trust by being  run by the Church of Uganda. Our nurse Naume is a Christian, and the community knows she’ll pray with them if they want that. 6) My heart says it will 7) Because “OJ Maxswel, king of the king” is there. What more do you need?

 

Why it won’t 1) People are very poor. Nearly everybody there is a subsistence farmer. One dollar for kids and two dollars for adults may not seem like much to be treated for serious diseases, but for Ocim, it still might be too much. 2) The population is relatively sparse compared to around other clinics 3) It’s not on a main road, or in trade hub. We’re using the only available iron roof building in the area. This means the clinic is not very public and visible, and we can only treat locals, not people who are passing through. 4) The day to day existence of a small clinic like this is fragile. One robbery, one fire, and one aberrant guy harassing our nurse and it could be enough to sink the ship. 5) My heart is often wrong

 

From huts within sight of the health centre, two mothers came with their kids while we were still unpacking the truck. Both had high fevers. One had malaria, and had a seizure in the morning. The other had a large skin infection on their right butt cheek. Both mothers had been trying to wait out their child’s illness, unable or unwilling to pay the large transport cost to the nearest health centre. Both if the kids will now be fine. That’s why we’re here.

And the second thing on my mind? Here he is, OJ Maxwell himself. “King of the King”.

It begins – New Health Center 1.0

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Narrow road, burnt grass, full load. We breathed a sigh of relief as our small pickup  arrived at Cet Kana, laden with all things required to start a new health clinic. The place is gorgeous, with one of the better views in Gulu overlooking thousands of palm trees on an open, sparsely populated plain. The clinic is next to the current and future church. Current is a skeleton of palm tree timbers, covered every Sunday with tarpaulins. Future is the brick building, with half-walls only.

We were a bit shocked to find that the rooms hadn’t been opened for months. After thirty minutes of sweeping and rearranging, Felix our nurse, and Fiona our assistant co-ordinator unpacked the drugs and equipment. Desks and chairs were moved into the clinic room. The blood pressure machine was unboxed. Within a couple of hours, two dusty unused rooms had been transformed into a nice wee health clinic.

There are two big advantages to the health clinic location.

The church owns the building so we don’t pay rent The Pastor and other church members have already been involved in weekly family planning clinics run from the building, so the church/health connection is already rolling.

But we are yet to see whether this will fly. Are there enough people in the area to justify a clinic (my biggest concern)? Can adults afford the 2500 Ugandan shillings (1 New Zealand dollar) we are asking to treat a child? Or the 5000 shillings (you do the math) to treat an adult? Can our nurse juggle the responsibilities of organising the facility, seeing patients and managing the money? After 3 months we’ll have some idea. After 6 months we’ll make the decision whether to continue or not. Taking a risk like this isn’t easy on the nerves, as it’s a big money and time investment. I keep reminding myself that even if the clinic “fails” to become sustainable, we still will have treated around 1000 patients more efficiently than most NGOs could manage. I also can’t help thinking that Jesus is into this kind of risk.

And its exciting. Seeing the first child handed over to nurse Felix to test for malaria was a small victory in itself. I’ll keep you updated with how things are tracking.

We are starting up 3 clinics like this with money already raised, and are aiming to start 2 more. If you’re keen to donate money towards starting the last 2, then message me at ugandapanda.com/contact-us/

A huge thanks to those of you in New Zealand, Australia and beyond who made this possible. You know who you are.

Saving a life, or two

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Our wonderful midwife Gloria ‘in the bush’ at Oberabic Health Centre had a hard night recently. She’s the only midwife there, so has to do most the work that involves mothers and babies, and make all the calls under really difficult circumstances. A miscarriage and a tricky delivery led to a long, intense evening which ended up really well for the mothers and newborn baby. Its hard to overstate what a fantastic job she did under the circumstances.

Apart from being a great story, and example of the great work that goes on at our health centres, this story is a microcosm of the struggles our patients and staff face all the time. Amongst other things Gloria and the patient faced these challenges. Feel free to add your own after watching the video.

The Patients: – No access to transport to get to a higher level facility – Poor knowledge of problems around birth, which led to the mother coming in late and not telling Gloria her waters had broke. – Lack of social support

Gloria – Working in the uncomfortable zone above your level of medical expertise – Having to do everything yourself (sterilise the equipment yourself, after you’ve already completed the delivery) – Understaffing

Opening St Philip Mini-Hospital

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It seems there are ‘wins’ all round for Nick and Tessa Laing. You’ve just seen the amazing progress Tessa’s group has made in bringing new alcohol regulations to their region. Nick has also been hard at work as you’ll see in this video.

As part of our Bishop’s seven years on the job celebration, we officially opened the monstrous 25 room St Philip mini-hospital. Some people, schools and churches reading this article gave money to this cause so a huge thank you. In the video above you can get a glimpse of the outcome!

Important people were everywhere. The Minister of Primary Healthcare was supposed to open it, but in her absence the minister of foreign affairs did the honours instead. He even made a comment about the Christchurch earthquake! Tessa videod my mini-speech. I was supposed to get 2 minutes but I was cut to 30 seconds due to time constraints.

 

To see some more photos from the event click here.