It Takes a System

He was a 10-year-old Malawian boy, born in a rural community like so many in sub-Saharan Africa. His family made the journey to Nkhoma Mission Hospital, a hospital in the Lilongwe district, after he began having difficulty breathing. An exam and ultrasound of his heart revealed he was in severe heart failure.

While the team was discussing treatment, his heart suddenly stopped beating. In most African hospitals, that would have been the end of the story. The boy would have died.

But the clinicians at Nkhoma Hospital wouldn’t accept that. Years of investment to raise their standard of care paid off in that moment. Oxygen was ready at the patient’s bedside, along with a defibrillator to shock his heart back into rhythm. Competent ICU nurses and physicians, trained in critical care at a partner hospital in Kenya, were prepared to leap into action. They knew the protocol, acted quickly—and it worked. After the first shock, the boy’s heart started beating again.

An echocardiogram machine provided by donors a year earlier allowed doctors to look inside his failing heart, understand what was happening, and make appropriate treatment decisions. Over the next several days, his heart function began to recover.

I heard this story firsthand from the doctor on the other end of that defibrillator. Dr. Catherine Hodge, a missionary at Nkhoma Mission Hospital, has been serving there for over 13 years and leads the family medicine training program. She was there during my annual visit as a partner of the hospital. I could tell it had been a long day for her, yet she was energized—excited to tell me about what she’d just experienced.

I lived and worked in Malawi for 16 years, so I am keenly aware of the complexities of providing quality health care to rural communities like Nkhoma. I still travel to Malawian hospitals regularly as part of my work with African Mission Healthcare (AMH), and every time, I’m freshly reminded of the critical work done by their doctors and staff.

As she told me about the boy, Dr. Hodge was still processing what had taken place. But I knew its significance. Years of quiet, deliberate investment in technology and personnel meant this child still had a future. A rural hospital founded more than 115 years ago was now capable of doing what once seemed impossible there. God had used missionaries, donors, the local church, and dedicated Malawian health care leaders to bring about this victory.

It’s not the first time I have seen long-term institutional investments pay off. Much of my time working in Malawi as a missionary physician was during the height of the HIV/AIDS epidemic. It took many years and a whole team to develop a facility—Partners in Hope in Lilongwe—that could provide comprehensive HIV treatment. But by the time I left, even the sickest patients had an excellent chance of recovery.

Since returning to the US 10 years ago, my role has shifted greatly. I now spend far more time in meetings, thinking about systems rather than individual patients. Sometimes I long for the direct impact I once had. It’s easy to think the doctor holding the scalpel or defibrillator—not the mission leader in a meeting—is the real difference maker.

But as I reflected on the story of that boy, I realized I still play a vital role. What saved his life was not only the skill of one physician. The miracle was made possible by an institution planted by missionaries decades earlier, sustained by the local Malawian church, and invested in for years by AMH. The efforts of all those people and organizations over years combined to create the conditions for success in that moment of crisis. None of this happened in a vacuum, nor can it be created overnight.

We are living in a time when institutions are viewed with suspicion. Many powerful organizations have become distant, inefficient, or even corrupt. It is tempting to reject institutions, then, and instead invest in individual acts of compassion, short-term interventions, or informal networks. Helping people in these ways can feel personal and intimate, and it’s easy to see an immediate short-term impact and feel good about it.

There is a place for aid like this. But there are also limits to what these smaller and informal acts can accomplish. The answer to broken institutions is not their dissolution; it is the nurturing of healthy, faithful institutions.

Therefore, the work of building and strengthening hospitals, training programs, and systems of care is not secondary to the gospel. It is one way the gospel takes root in the world. New Testament theologian N. T. Wright describes faithful institutions like these as a “small working model of the kingdom of God.”

The Christian hope is not merely going to heaven when we die but also the future coming together of a new heaven and a new earth. The kingdom of God is not only a promise for the future; it is reflected, however imperfectly, wherever God’s will is done on earth as it is in heaven. When we care for the sick, invest in the next generation, and serve the most vulnerable, it becomes a signpost for the inbreaking kingdom of God.

This is where Christian mission hospitals have a critical role to play. Across the African continent, we are seeing a rise in clinicians, administrators, and educators who understand their context, are committed to excellence, and see their work as a calling that is central to the mission of the church. The task now is to support that leadership: equipping, strengthening, trusting, and holding them accountable.

For US churches and others with abundant resources, that may require rethinking what partnership looks like. It will mean moving beyond short-term mission trips and toward commitments that are long-term and structural—investing not only in what is urgent but in what is enduring. It may not excite donors to talk about training programs, hospital management systems, or infrastructure concerns like water, electricity, and septic, but these are essential to lasting change. When building a load-bearing institutional pillar for a community, the priorities must be strength and resilience.

While I still miss giving care at the bedside, I am beginning to see that I am engaged in another kind of care—one that is less visible but no less valuable.

The day that young boy’s heart stopped, everything that had been built at Nkhoma was put to the test. And a life was saved. For those with eyes to see, the kingdom of God is already working in both the big life-or-death moments and the slow, faithful work that makes them possible.

Perry Jansen is a family physician who served as a missionary with SIM in Malawi from 2000 to 2016, with a focus on HIV/AIDS treatment. He now focuses on strengthening health systems through mission hospitals in eight African countries.

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