Community Organizations Key Component of Primary Health Care

in Developing Countries

• Part 1. Overview, Needs, Possibilities

By Paul Freeman

• Part 2. Community Learning Organizations, in Rural Mozambique facilitated by ADRA

By Sonya Funna Evelyn

Part 1 Overview Needs Possibilities

• Currently many projects with a community level content fail to be sustained post project

• Many possible reasons- lack of local ownership, pace, resource maintenance- personnel, equipment & consumables, technical quality

• Reality communities live with a full range of problems at the one time- NOT just those in a particular project

• Evidence based approaches good but evidence may come from ideal - effectiveness versus efficacy studies. Local cultural aspects maybe VIP but how about “common sense”

i.e real consultation, a real active role in one’s own life,

self esteem, unique contribution, motivation, ownership.

Community Health Needs if these were expressed in programs (Universal HC)

• Maternal, Neonatal and Child Health

includes, antenatal, birth, postnatal, resuscitation of newborn, nutrition of mother and child, family planning, iCCM + ITNs, EPI mother & child, adolescent health.

• Early emotional development of children

• Water and Sanitation

• STIs including HIV/AIDS.

• Early detection of epidemics, collection of vital statistics

• NCD prevention and adult nutrition

• Diabetic management, tobacco control

• First aid for trauma

• Mental health

• Supervision of TB treatment

• Disability management

• BCC in association with many of the above.

• Monitoring system to report activities in most of above.

Sustainable Development Requires Action Learning

• “Development can be neither given nor received; it must be generated from within.”

• “What the less developed have been most deprived of is not the fruits of development, but the opportunity to develop themselves.”

•Ref: “Systems Thinking” Jamshid Gharajedaghi

Interestgroups

Policymakers,planners

Managers,providers Communities,

households

MIS

Evaluations

Research,pilot projects

The “Blueprint” StrategyA fundamental flaw

Health

Learning Action

ProjectBlueprints

Disconnects learning

from action

Policymakers,planners

Managers,providers

Communities, households N

eeds

Tasks

Outp

u

ts

Competencies

Dem

and

Dec

isio

ns

Health System Development - “Learning Organization”

Strategy (H.Moseley)

Interestgroups

Learning

Health

31

2

Adapted from Korten, 1980

Some Characteristics of a Learning Organization

• Common Vision- healthy community.

• Team Learning- together we can master • An appreciation that the different members of the group

contribute different skills and capacities. Technical expert help is needed but community members contribute knowledge and skills that health professionals cannot.

• Personal Mastery-personal capacity growth sought and nourished / motivation ( inner purpose- after Pink “Drive”)

• Mental Models – we can do this.

• Move away from passivity

Community Based Organizations

Definition – a community organization established by a community (with initial and limited ongoing facilitation) bringing together community leaders and all types of community “health” workers in the community.

Ideally includes cross- sectoral workers.(Nepal)

Facilitators could be NGO personnel but why not train a small Cadre within MOHs to do the same?

Properly Facilitated What Can Community Based Organizations Do?

• Plan local community health activities

• Deal with local health problems as they arise

• Together divide up community program needs into manageable work for CHW group members

• Continue to learn together-e.g from one another & local H.Center

• Monitor and Give feedback to one another and the local Health Center. Connection with local H.Center/ Good facilitator VIP

• More capable workers train less capable

• Recruit new workers, motivate one another.

• Meet health needs at the household level

• Identify and Reach those that Health Center staff cannot

• Identify suitable compensation (not necessarily $$s) for those more skilled workers (such as providers of iCCM) who must work longer hours

• Integrate other health related activities-e.g agriculture, school ed

Mozambique Talking Time

Part 2 Community Learning Organizations,

in Rural Mozambique

Part of Health Component of

OSANZAYA Multi Year Assistance Program

Zambezia Province 2009 -2013

facilitated by ADRA

Mozambique- Centuries of Portuguese Colonial neglect- Decades of Marxist economy- 30 years guerilla war- 1990 multi-party political system, market based economy, free elections- 1994 first democratic elections- Pop 25.2 million - Life Expectancy 50.15- Annual per capita income $424 - Low investment in education

- High adult illiteracy- Low agricultural productivity- Limited economic opportunities- High underemployment- Poor infrastructure

Osanzaya Zambezia

- 5 year USAID funded TTII project

- 5 districts of Zambezia (Ile, Pebane, Maganja da Costa, Mocuba and Lugela)

- Income $100/year- Agriculture main

economic activity- 50% of adults > 19 years

old illiterate- Many communities over

20 miles from nearest health center

Osanzaya ZambeziaGoal: To Reduce Food Insecurity in Targeted Five Districts in Zambézia Province.

•  SO1: Improved Income Growth of 37,500 Rural Beneficiaries

By integrating marketing, increased productivity, and

strengthened value chains of select agriculture products (peanuts,

maize, cow peas, sweet potato and commercialization of cashew nuts).

•  SO2: Improved Health and Nutrition Status for 40,000 Beneficiaries

By improved health and nutrition status of children under five, improved

hygiene behaviors, access to sanitation solutions, and adequate clean

water. ( some of SO1 agricultural products to be used in improving child

nutrition)

• Literacy & Disaster Preparedness (ADPP & Samaritan’s Purse)

Overall Activities• Established and strengthened Community Leadership

Councils

• Established mothers’ and fathers’ groups

• Cooking/feeding sessions

• Constructed and rehabilitated boreholes and wells

• Constructed household and community latrines

• Monthly GMP

• Participatory Hygiene and Sanitation Transformation (PHAST)

• Behavior Change Communication

• hygiene, diet diversification, food preparation, breastfeeding, disease prevention, health-seeking and caregiving behaviors

Community Leadership Councils

• Community leadership/elders

• Community health volunteers (1 per 15HH)

• Hygiene promoters

• Mothers’ and Fathers’ group leaders

• Water Well Committee members

• C- IMCI workers

• FP/STI counselors

• Home-based care workers

• Midwives

• Traditional birth attendants

About 25 members and they include:

• Meet at least every two weeks

• Mitigate health issues in communities including in emergencies

• Receive feedback and reports from all CHWs of their activities

• Representatives (2) meet with local HC staff once a month

• Identify community members with special needs

• Usually done via group counseling sessions and household visitation

• Supervised by project staff who would meet with CLCs daily or weekly

Community Leadership Councils

• Nutrition

• Basic nutrition package

• breastfeeding , promotion of Vitamin A rich foods, complementary feeding, food groups and balanced diets

• Preparation of enriched porridge- to give variety of food

• Growth Monitoring

• Caring for the malnourished and referral

• Sickness

• Prevention of malaria, diarrhea, cholera and HIV

• Initial care of the sick child

• Prompt referral of the sick child to the nearest health facility

• Home Based Life Saving Skills (HBLSS)

Community Leadership Councils Training

• Reproductive health

• Family planning

• Child spacing

• General health

• Hygiene

• Sanitation

• Environmental health

• Caring for the needy

• Orphans and vulnerable children

• Basic Organization

• Planning

• Problem solving

• Referrals

Community Leadership Councils Training

KEY FINDINGSFigure 1. Decrease in Portion of Severely Malnourished

Baseline (2008)

2010 2011 2012 20130.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

% of participating children aged 0-23.9 months with weight-for-age z-score <-2

% of participating children aged 0-23.9 months with weight-for-age z-score <-2

KEY FINDINGSINDICATOR BASELIN

EFINAL DIFFERENC

E

% of children less than 24 months with diarrhea in the past 2 weeks”

33.8% 28.6% 5.2%

% of caregivers and food preparers using appropriate hand-washing behavior

56.9% 80.6% 23.7%

% target population using latrines

29.4% 53.8% 24.4%

% target population with year round access to improved water source

23.3% 56.70% 33.4%

Key Findings

Indicator Achievement

Number hygiene promoters trained 4,222

Number caregivers trained in HH hygiene 62,164

Number of caregivers trained in health and nutrition topics

53,252

Pit latrine slabs distributed 3,900

Community leadership councils formed 193

Community health volunteers trained 2,850

Mothers’ and fathers’ groups established 190

Thank You! Mozambique Dancing Time