FOOTSTEPSNo.37 DECEMBER 1998 SUSTAINABLE HEALTHCARE

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I vividly remember a discussion abouthealthcare with a group of village eldersin Barr Parish, northern Uganda. Theytold of high charges for healthcareintroduced in recent years, of how localclinics had closed, of the cost of transportto Lira and the huge charges payablethere for treatment and medicines. Onelady turned to me with tears in her eyes,thinking of friends who had suffered anddied, and said ‘We have no healthservices now. When our people becomesick, all we can do is pray for them.Please tell others how we are suffering.’

This issue looks at ideas to helphealthcare become sustainable. Manygovernments continue to cut backfunding for health services, often becauseof the huge debt repayments they have tomake. This means that local healthcareincreasingly has to raise funding fromlocal people, who themselves may havevery low incomes. In such a desperatesituation, the need to share good ideaswhich have worked in one area becomesmore and more important. Both healthexperts and readers from many countrieshave contributed good ideas for thisissue.

However, health is not just freedom fromdisease. It concerns wellbeing in all areasof life. Improvements in sanitation, watersupplies, nutrition and housing will bereflected in better health in thecommunity. Such improvements canonly be achieved by helping people towork out their own priorities and taketheir own action in tackling poverty.

The case studies in this issue all reflectthe need to let people first establish theirown health priorities. Several of thesestudies are from the Democratic Republicof the Congo whererecent years haveseen hugeupheavals –

including civil wars, the overthrow of theprevious head of state, Mobutu, andhuge movements of refugees. Withvirtually no government funding forhealthcare, any health systems able tofunction well are of considerable interest.

Healthcare is something we all need.Let’s work together to improve our ownlocal situation.

IN THIS ISSUE

• Case studies: Health-care in the DemocraticRepublic of the Congo

• Letters• Community links for

sustainable healthcare• The Bamako Initiative• Safe Motherhood

• Health services for rich and poor

• Bible study: Nehemiah, the development worker

• Resources• Building up your library• Participatory research

in action

GOOD, ACCESSIBLE HEALTHCAREis something we all need. Without itmany of us would be unlikely to recover from serious diseases,

infections or wounds. In an ideal world everyone should have access togood, affordable primary healthcare. No government would claimotherwise. However, the reality is often different…

FROM THE EDITOR

HEALTH

2 FOOTSTEPS NO.37

FOOTSTEPSISSN 0962-2861

Footsteps is a quarterly paper, linking health anddevelopment workers worldwide. Tearfund,publisher of Footsteps, hopes that it will providethe stimulus of new ideas and enthusiasm. It isa way of encouraging Christians of all nationsas they work together towards creatingwholeness in our communities.Footsteps is free of charge to individualsworking to promote health and development. Itis available in English, French, Portuguese andSpanish. Donations are welcomed.Readers are invited to contribute views, articles,letters and photos.

Editor: Isabel Carter

The Footsteps Office has moved…PO Box 200, Bridgnorth, Shropshire, WV16 4WQ, UKTel: +44 1746 768750Fax: +44 1746 764594Email: imc@tearfund.dircon.co.uk

Language Editor: Sheila MelotEditorial Committee: Jerry Adams, Dr Ann Ashworth, Simon Batchelor, Mike Carter, Jennie Collins, Bill Crooks, Paul Dean, Richard Franceys, Dr Ted Lankester,Sandra Michie, Nigel Poole, Louise Pott, José Smith, Mike WebbIllustrator: Rod MillDesign: Wingfinger Graphics, LeedsTranslation: L Bustamante, R Cawston, Dr J Cruz, S Dale-Pimentil, S Davies, T Dew, N Edwards, J Hermon, J Martinez da Cruz,R Head, M Leake, M Machado, O Martin,N Mauriange, J PerryMailing List: Write, giving brief details of yourwork and stating preferred language, to:Footsteps Mailing List, PO Box 200, Bridgnorth,Shropshire, WV16 4WQ, UK.Change of address: Please give us the referencenumber from your address label wheninforming us of a change of address.Articles and illustrations from Footsteps may beadapted for use in training materialsencouraging health and rural developmentprovided the materials are distributed free ofcharge and that credit is given to Footsteps,Tearfund. Permission should be obtained beforereprinting Footsteps material.Opinions and views expressed in the lettersand articles do not necessarily reflect the viewsof the Editor or Tearfund. Technical informationsupplied in Footsteps is checked as thoroughlyas possible, but we cannot accept responsibilityshould any problems occur.Published by Tearfund. A company limited byguarantee. Regd in England No 994339. RegdCharity No 265464. Tel: +44 181 977 9144

After the departure of the UNHCR, thishealth centre was handed over as a freegift to the community. Unfortunatelythey had no experience in managing ahealth centre. Materials and equipmentwere stolen by uncaring people, leavingthe centre in chaos. A health committeewas created but it soon ran intodifficulties, because people were used toreceiving free healthcare and did notwant to pay the fees that were nowdemanded. Local people claimed thatbecause the health centre had been a freegift to the community, healthcare shouldcontinue to be free of charge. Findingthey were unable to manage this healthcentre properly, the people handed itover to the Anglican Church.

Two responsible and well educatedpeople from Aru took the responsibilityand the initiative of closing down boththe Adranga Health Centre and the oldhealth committee and its activities.Instead they elected a new, smallcommittee made up of three local peoplewhose role was…

• to educate the population

• to encourage the spirit of self-financing.

Only once this is done will the AdrangaHealth Centre reopen with the freedomto evolve and progress.

In conclusion, I believe that the evolutionof a successful health centre dependsparticularly upon…

• the initiative of the local community

• a leader who believes a health centre isnecessary, important and valuable forthe people

• nurses with training in communityhealth, who know how to work wellwith the community

• good supervision and advice fromexperienced medical personnel.

Nyangoma Kabarole is Director of theMedical Service of the Anglican Church inBoga Diocese.

Healthcare in the Democratic

by Nyangoma Kabarole

Two case studies of health centres – one which inherited adifficult situation and another which is a real success story

The Adranga Health CentreThe Adranga Health Centre is in Aru health district.It was built in 1970 with funding from the UnitedNations High Commission for Refugees (UNHCR)to help Ugandan refugees in Aru. At first this health

centre was equipped both in materials and in medical supplies by theUNHCR without any assistance or support from the local population.

1CaseStudy

To be sustainable, healthcentres must be valued by

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HEALTH

There are now 25–30 consultations eachday, 130–150 deliveries a month and ateam of 28 community health workers,locally trained and based in the 14surrounding villages, as well as aprogramme for over 100 malnourishedchildren. It is hard to pinpoint the causesexactly, but a combination of factorsseem to have come together so that todaythe busy curative side of the work is nowable to support almost fully an expand-ing community health programme to the25,000 people in its ‘catchment area’.

Factors for change…■ A head nurse with a vision forintegrated healthcare, keeping a goodbalance between the immediate andpressing demands for curative care andthe more long-term vision ofpreventative care and community issues.

■ The allocation of a community healthnurse (helped by Tearfund), with soleresponsibility for getting out into thecommunity and establishing andexpanding various community healthprogrammes. This nurse has noresponsibility for curative work.

■ A population which has realconfidence in its nurses because theyprovide a quality curative service, withthe result that people will listen to advicefrom these same nurses when they givehealth education or help people exploresome of the underlying causes of illhealth in their community.

■ An active health committee that meetsregularly with good representation from

all levels of the population. Thiscommittee has a certain degree ofcreativity that has encouragedcommunity involvement (see box).

■ Building maternity waiting homeswhere up to 50 mothers who either livefar from the health centre or have ‘highrisk pregnancies’ can wait for delivery.

■ Accepting that people who don’t havecash, can pay their bills in produce orlivestock which is either sold or given aspart of staff salaries.

■ Some outside assistance fromTearfund was used to establish differentnutritional projects in the community.This focused on families withmalnourished children. For example,there is a soya bean project which givespractical food demonstrations to mothersand provides seeds for each family with amalnourished child, for planting in theirown fields.

■ A policy to keep costs down andencourage patients to come to the centre.As prices were reduced, the number ofpatients increased and so the incomeincreased. As income grew, the centrewas able to add another full-timecommunity nurse and to buy a second-hand motor bike for the health staff,particularly to collect vaccines.

More than a dreamAll of this has resulted in a high degree ofownership by the population, both of thehealth centre and the community healthprogramme. When local people finishedbuilding a new brick maternity ward

(completely on their own and with healthcentre receipts) they insisted on calling itMaternité Wetu (Our Maternity)!

Needless to say, there are still plenty ofproblems to overcome, but we have beengreatly encouraged by this integratedapproach and see that a project like this– with well trained community healthnurses and an initial helping hand to getit off the ground – can make the word‘sustainability’ a bit more of a reality thana dream, even in one of the world’spoorest countries.

Compiled by Maggie Crewes, Co-ordinator ofNorth Kivu Medical Service, CAZ Boga, PB21285, Nairobi, Kenya.

The Mabuku Health CentreUntil five years ago, the Mabuku Health Centrein North Kivu province was just another ruralhealth centre, struggling financially anddepending on outside funding for major needs.

They averaged 5–10 consultations a day, and 20 deliveries amonth. Today it is very successful, both with curative care and inreaching out to the population with an effective communityhealth programme.

2CaseStudy

Creative communityinvolvement

■ Each baby born in the Centre is given aset of ‘free’ clothes which is included in thecost of the delivery. This has been verypopular and now more women are comingfor delivery. This has reduced the overallcost per delivery. In addition, women at riskof complicated births are now more likelyto come to the Centre.

■ People who participate in communitywork (such as carrying stones or sand tohelp a construction project or water sourceprotection project) are all given a smallreduction in their medicine bill. This hasmaintained a high level of communityparticipation in all the projects.

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4 FOOTSTEPS NO.37

LETTERS

Market for soya beansRABEMAR (Research and Action for theWellbeing of the Rural People) hasinitiated a project to promote thecultivation of soya beans instead ofcotton which has damaging effects on theenvironment. However we are facedtoday with a lack of markets for the soya.Our groups produce more than 100 tonsof soya beans per year. We are lookingfor partners either to export the soyabeans, or to establish a soya oil press.Any partner able to help us reach ouraims would be welcome.

Lucien E AkpinfaRabemarBP 46GlazoueBenin Republic

Advice for smokersI WOULD LIKE TO SHARE with otherreaders this method of giving upsmoking, having experienced it myself inSouth Africa. Take some seeds of Ricinus(castor oil plant) and grind them up.Then leave them for two or three days inthe sun. Mix them with tobacco, and thentake two or three puffs of it. It makessuch an awful smell, that you will neverconsider smoking again! This is a typicaltraditional way of dealing with smoking,and I hope it will help those brothers andsisters in Christ who are addicted tosmoking and who cannot give it up!

Quenan CrispoSo Said – So DoneBox No 99Lichinga, NiassaMozambique

Generating income for health clinicsI FIND YOUR NEWSLETTER rich ininformative and useful articles. Here area few ideas for raising income for healthclinics:

• Use only quality drugs so that patientswill have trust in the treatment.

• Develop a specialised service forexample in eyecare or providinglaboratory services.

• Avoid unnecessary administrators.

• Set up ventures such as canteens, bikerepair services or small businesscentres with telephones andphotocopiers.

• Produce small brochures ornewsletters to share information aboutthe activities of the health clinic. Thismay sometimes move a kindly spiritedindividual to assist the clinic.

Musa GoyolMangu Leprosy and Rehabilitation CentreChurch of Christ in NigeriaPMB 2127Jos, Plateau StateNigeria

Tricycle for disabled peopleWE HAVE DEVELOPED A TRICYCLEhere in Beraca Vocational School in Haiti.This is made by cutting up two old bikes(available very cheaply here) andwelding the parts together. The design islightweight with brakes and gears, somore fun to use than a wheelchair. It iscompletely hand-powered and can beridden by anyone who has lost the use oftheir legs.

It has transformed the life of Benita, whohas TB in her legs and was confined to an

old wheelchair and dependent on othersto push her. Now she can travel alone upto 2 miles even on rough tracks and roadswithout help.

Andrew Lewisc/o MFI/UFM HaitiPO Box 15665West Palm BeachFL 33416USA

EDITOR

If you want to build one of these tricycles and wouldlike full details of the design, please write to theFootsteps Editor.

Palm oil soap productionI READ ISSUE 26 and was veryinterested in the subject of self-financingprojects. In my work as a communityhealth nurse I visit many homes. Onesuccessful example of a self-financingproject I have observed is soap-making.Here is the method they use:

■ Soap-making uses dangerouschemicals. First keep children awayand protect your hands with rubbergloves or plastic bags.

■ Weigh 1.5kg of caustic soda.

■ Measure 4 litres of cold water and pourinto a large plastic or wooden bowl.

THE EDITORFOOTSTEPSPO BOX 200BRIDGNORTH

SHROPSHIRE

WV16 4WQUK

Benita and herhand-powered,lightweight tricycle.

5

LETTERS

FOOTSTEPS NO.37

■ Pour the soda into the water verycarefully and allow it to dissolve andcool. (Be very careful. This mixturecan burn the skin – wash offimmediately. Avoid breathing thefumes.)

■ Pour 16 litres of palm oil into a pan (22measures using a standard 720mlbottle) and heat until the oil changescolour from red to yellow or white andthen allow to cool.

■ Pour the oil very carefully into thecaustic soda solution, always stirring inthe same direction to avoid splashes,until a thick blue paste forms.

■ Pour the paste into a wooden frame(100cm x 65cm x 3cm in height) linedwith cloth on a level surface.

■ Level off the soap and allow it toharden before cutting into bars (wire isuseful).

■ Allow to harden for seven days beforehandling and using.

Nzangya HussaInfirmier C S – BonelekoCommunauté Baptiste du Zaire NordBP 63BangassouCentral African Republic

Rice banksA MAJOR PROBLEM for our region isthat of drought each year betweenJanuary and June. The region producesenough rice – the main food – to last theyear but unfortunately, because of theirneed for cash, people sell much of whatthey produce to buy goods and to payschool fees. This means that there is thena period of hunger each year. I plan toestablish a rice bank in order to build upa stock of rice which will be availableduring the time of annual hunger. Ricewill be made available as a loan whichwill then be paid back during harvest

time. I would like to receive ideas andadvice from readers who have experiencewith this sort of project.

M Abale A LucienBP 36NiambézariaS/P de LakotaIvory Coast

AIDS testingI WORK AS A SOCIAL WORKER with aconcern for sexual health education in theAIDS Information Centre. We provideteaching about AIDS and carry out teststo check if people have either AIDS orany other sexually transmitted disease.We used to do this free of charge.However, we found that when we begancharging a small fee for these tests, manymore people began using them. This isbecause when somebody pays forsomething, they value it more. Since 1990we have tested 350,000 people and set upclubs all over Uganda.

Turyatemba B EddyMengo Institute of TechnologyPO Box 14060KampalaUganda

Save the planet!FORMED LONG AGOfrom craters andvolcanoes, overmillions of years ourplanet became covered in greenery andwater. But if we ‘waste’ the fertilecovering through our unreasonableeconomic activities, our planet will onceagain be without life.

Nohoune LeyeSenegal

Harvest for healthTHE MOST POPULAR WAY of runningclinics with villagers here in Afghanistanis ohshur, meaning one out of ten. Villagersgive a tenth of their harvest to the clinicevery year. In return for this donation, allhealth treatment for their whole familywill be free until the next harvest time.

This system was started in Bambai inWardok province two years ago. Nowthere are many successful clinics in thisprovince. This donation of crops isaffordable by the farmers and covers allthe expenses of primary healthcareservices.

Abdul Hafiz AhmadiKabul Medical InstituteH No232, Str 44, D2Phase I, Hayat AbadPeshawarPakistan

AIDS education projectOUR ORGANISATION initiated aproject called ‘Everyone against AIDS’.This consists of a tour to raise awarenessin the towns and villages of Togo. Since itbegan in December 1997, we havealready been to several colleges in Loméand the surrounding towns, raising theawareness of young people to opposeAIDS and HIV. Debates have attracted asmany as 900 people! The project is nowfacing some material and financialdifficulties. We would welcome supportfrom anybody wanting to help theproject reach its aim.

Amouzouvi E BlewoussiAssociation BrimaxBP 13182LoméTogo

GLARP

GLARP – The Latin-American Group forVocational Rehabilitation – has workshops,symposia and conferences on offer through-out 1999. These cover a number of differentdisabilities and are held in various countries.For full details, write to Nohora Elena Diaz U,GLARP, Carrera 53 A No. 122-02, Santa Fede Bogota, Colombia. Fax: 613-51-24. E-mail: glarp@cable.net.co

In 1999 Footsteps will celebrate its tenth anniversary. We’re planning a specialanniversary issue and are looking for short examples of how Footsteps has helped inpeople’s work, or helped to change situations. If you can send a short story, with aphoto if possible, we’d be pleased to hear from you. Please note that we want practicalexamples that might inspire others – not just nice comments about Footsteps!

Anniversary Issue

HEALTH

6 FOOTSTEPS NO.37

Often the people of Marabo weredescribed as ‘difficult.’ (This could meanhealth professionals have failed tounderstand the population’s difficulties!)Even with patients paying full costs,there was no way in which the healthpost could be self-financing.

In July 1997, following the war and along dry season, students from theInstitut Panafricain de SantéCommunautaire (IPASC) did a healthsurvey of Marabo. They found that overhalf the children under five weremalnourished, and that many peoplewere tired and demotivated.

Puzzling attentionIPASC’s principle is to listen to acommunity and then facilitate theirresponse to key problems. So IPASC staffand students visited the village severaltimes a week to meet the people and heartheir problems. The community waspuzzled by this attention since they hadfelt abandoned for many years – butwithin ten days they formed a committeeto consider their problems logically. Theurgent need was that of the mal-nourished children. The villagers askedfor work, so that earnings would providea communal meal for the children. A fewweeks later, with full stomachs, many ofthe pathetic children had turned intocheerful toddlers. Now the villagersasked for spades for digging. The IPASCagriculturalist went out with students togive advice on what could be effectivelyand economically grown. Soon, gardensstarted to sprout soya beans and othernutritious foods.

The next need expressed was for aprotected water source. A student spentseveral weeks working with thecommunity to clear vegetation from a

Marabo, nutrition, agriculture and waterwere thought to be far more important tothe community than medicines. Untilthese needs were met, it was unlikely thatpatients would attend the health post. Nopatients means no income.

■ We found that a nurse who placescurative care before communityinvolvement will seldom have sufficientpatients to be self-financing. Nurses aremuch more likely to win people’sconfidence if they…

• mix with the community

• visit handicapped, chronic and high riskpatients

• associate themselves with dailyconcerns

• are available to all sectors of thecommunity.

■ If people have confidence in theircommunity nurse, that’s who they willturn to when they fall sick. This automatic-ally increases the number of patients, andthus the income of the health post.

■ Marabo health post is run by acommittee which examines activities,income and expenditure. This ensures thecommunity’s involvement and enablesthem to understand and control the levelof self-financing. A partner programme (inthis case, IPASC) should facilitate, ratherthan impose development and encouragedependency.

Self-financing has more to do with anapproach to a community than with thefinancial management of a health post.

Compiled by Pat Nickson, who is the Directorof IPASC, c/o PO Box21285, Nairobi,Kenya.

spring site and to put in a pipe andcement surround to protect the spring.This protected water source later meantMarabo was one of the few local villagesspared from a serious cholera epidemic.

Only when improvements in nutrition,agriculture and water had been achieveddid the community turn its attention tothe health centre. A dilapidated hut whichpreviously served as a health post couldbe rebuilt – but they needed a nurse andan initial stock of essential drugs. Theypurchased a few important drugs, andsent a male student community nurse,Jean, from Burundi. Another nurse lookedafter the curative care, while Jean wasresponsible for working closely with thecommunity. His caring attitude quicklywon a warm response. As a result, theprimary healthcare activities came alive.In six months the immunisation coverageof under-fives had risen from 23% to 90%.Around ten patients attended the healthcentre each day.

The newest initiative is to upgrade thehealth post to a centre with a maternityward. A community member gave 8,000bricks towards this, while others dug uplarge rocks for the foundations. IPASChelped with their transport.

Conclusions■ Establishing a health post without firstdefining the target community may meanthere are too few people to make the postself-financing. In this area a population of4,000–5,000 is needed for a healthpost and 8,500–12,000 for ahealth centre.

■ A health post may notbe a priority need. In

OUR THIRD CASE STUDY from the DemocraticRepublic of Congo comes from Marabo, a village of

5,000 people. Though near Nyankunde Christian Centre – a 250 bedhospital – health activities were limited to a poorly attended privatehealth post. There was little support for primary healthcare and only23% of children were fully immunised.

Healthcare prioritiesin Marabo village3

CaseStudy

A health post may notbe a priority need…

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FOOTSTEPS NO.37

A typical village The first diagram (page 8) shows a villagedivided by economic and social barriers.It is made up of the following groups ofpeople…

A few wealthy people with easy access to allthe necessary services – such as schools,doctor, government officials, bank andcredit facilities, clean water and transport.

Poor, marginalised people (the majority),who are…

• dependent on home remedies,herbalists and local healers

• dependent on the rich for employment

• without power to make decisions

• without access to outside knowledge,government or NGOs

• without good access to healthfacilities

• without access to safe drinking water.

People with leprosy, AIDS and TB, who aredriven out of the village and live nearby.

Women, who are marginalised both withintheir family and within the community,receive less food than others and nomoney for healthcare.

Effects of community-based healthcareWhen Jamkhed staff first begin work in acommunity, they aim to build uprelationships, and to build andstrengthen community organisations.This takes much time. Games such asvolleyball are good ways of bringingpeople together and relaxing with them.Jamkhed has found that effectiveorganisations of women, men andchildren are vital to successfulcommunity healthcare. Motivatedorganisations can help cut across castebarriers, religious and other differences.They often include a few socially minded

rich people. When both caring healthstaff and effective communityorganisations are present, various resultsmay occur…

■ A community health worker (CHW)will be chosen and supported.

■ The CHW and communityorganisations can work in partnership tomake sure good health services areavailable.

■ If community organisations areprovided with good health information,they can assess the local health situation,analyse the causes and take action.

■ People may also become aware ofharmful cultural practices such asdiscrimination against women, and act.

■ They may also understand the realcauses and treatment of TB, AIDS andleprosy so that sufferers can be cared forwithin the community.

■ Community organisations mayimprove the access to micro-credit forpoor families.

The effects of these changes on the life ofthe village community are indicated inthe second diagram (page 9).

THE IMPACT of sustainable, community-based healthcare has beenstudied recently at the Comprehensive Rural Health Project in Jamkhed,North India, through a one-year study in three villages nearby. Thefindings are shown in the diagrams on pages 8 and 9. The first diagramindicates the pattern of access to healthcare and other facilities invillages before community health staff began work. The second showsthe impact of effective community health work three to five years later.

Case Study

In Ghodegaon, Madhu was found to haveHIV/AIDS. When members of the com-munity organisation were given informationabout AIDS they lost their fear of infectionand took care of him, provided work for hiswife and helped look after his children.

Sri, a leprosy patient, had been driven outof the same village. After understanding thecauses and treatment of leprosy, membersbrought him back home, made sure he hadproper treatment and rehabilitation andtoday he is an active member of the men’sgroup in his village.

by Dr Shobha Arole

Community linksfor sustainablehealthcare

Case Stu

Ashok came from a poor received a serious snake not afford the expensivenom to save his life. contributed the cost of th

HEALTH

8 FOOTSTEPS NO.37

BeforeTypical village with nocommunity healthprogramme

Case Study

In one village people identified mmajor cause of illness. After learmalaria is spread by mosquitoesin stagnant water, they cleanedvillage, built underground drainagreduced malaria cases significantly

Communitylinks for

sustainablehealthcare

(continued from previous page)

Sustainable healthcare involves workingwith the community in an integratedway, promoting good health and dealingwith preventative, curative andrehabilitation services. Staff from thehealth centre need to act as facilitatorswith real sensitivity and ability to bringpeople together. People within thecommunity need to have asense of ownership of thehealth centre.

People need to become aware that goodhealth comes through their own actions,both as individuals and as a community.The more information they receive, themore they can make changes for theirown good.

The World of the Rich

The World of the Poor

The poor have little accessto village facilities such as

transport, clinics, creditand schooling

The World ofthe OutcastPeople with AIDS,TB or leprosy areexcluded fromcommunity

Women have littlesay in how thevillage works

Rich have accessto town and village

facilities

TOWNFACILITIES

VILLAGEFACILITIES

Young peoplehave little hope in

the futureChurch

Water School

Credit unionTransport

Clinic

Healthcare tooexpensive for

the poor

Hospital

Bank Information

NGO Technology

udy

background. Hebite, but could

ive anti-snakeHis communitye venom.

9FOOTSTEPS NO.37

AfterVillage with effectivecommunity healthprogramme

Dr Shobha Arole is a graduate of Christian Medical College, Vellore.After gaining medical experience elsewhere, she returned as AssociateDirector of CRHP, joining her parents who established this work inJamkhed. In addition to sustainable community-based healthcare, herinterests are in developing viable secondary healthcare and, inparticular, low-cost surgery and exploring the use of endoscopic surgery.CRHP Jamkhed, Ahmednagar District, Maharashtra 413 201, India.

Villagers’ suggestions

■ Common minor illnesses can be treated by the village peoplewith scientifically sound remedies and advice from healthworkers.

■ Provide more information and training for health workers. Givethem a supply of simple medicines which are available over thecounter, to treat certain common diseases.

■ Use effective measures to treat preventable diseases.

■ Certain basic health services should be the right of every citizenthrough state health services.

■ Community groups should work in partnership with healthservices to make sure that there is equality in health care.

■ Community organisations should set apart a fund for the fewpeople who need curative health services in either clinic orhospital.

alaria as arning that breeding

d up theire pits andy.

The World of the Rich

The World of the Poor

People now have morehealth information and

skills and are empowered

Village facilitiesnow extended and

improved withaccess for all

Marginalisedgroups now part of

the community, withaccess to facilities

TOWNFACILITIES

Women and youthgain access to credit

and skills training

Access to transportmeans access to a fewof the town facilities

Hospital

Bank Information

NGO Technology

NGO

Church

Water School

Credit unionTransport

Clinic

HEALTH

10 FOOTSTEPS NO.37

Making the patient payAs funding for health services continues to be cut (often through the effects of thirdworld debt), there is great pressure tomaintain salaries for staff and, as a result,available funds for drugs are reduced evenmore. All these difficulties mean that bothgovernments and health programmes areincreasingly trying to raise funding fordrugs directly from the patients.

The Bamako Initiative was agreed byAfrican Ministers of Health in 1987 withWHO and UNICEF, calling for communityparticipation in managing and fundingsupplies of essential drugs. It is basedaround the eight principles listed at thetop of this page (see box). Countries havevaried considerably in the ways they havetried to put these principles into action.

KenyaHere the government has encouraged thesetting up of ‘community pharmacies’run by CHWs (community healthworkers). The pharmacies stock betweennine and twelve essential drugs and theseare charged at prices which not onlycover their cost but also include a profitkept by the CHWs. In addition,insecticide-treated mosquito nets are soldat subsidised prices. Local people havebeen positive and feel that prices are fair,though many struggle to find thenecessary funds. CHWs are positivebecause they can earn a small income –but there are dangers in this, particularlywith the over-prescribing of unnecessarydrugs to earn more money.

GuineaIn Guinea, W Africa, the governmentsupports comprehensive primary healthservices. They have a nationally agreed setof charges for the more commondiagnoses. These include drugs fortreatment and after-care.

GhanaDiscussion groups were set up (byWaddington and Enyimayew) in the Voltaregion of Ghana to examine people’sattitudes to paying for health services. Theactual charges for health services were notthe only issue people considered. Equallyimportant were the attitude of health staff,the availability of drugs, whetherpayments could be made by instalments orin kind and whether credit was available.

Dominican Republic Research here (by Bitran) found thatpeople would prefer to pay for goodquality private healthcare, rather than usegovernment health facilities which werefree or low cost but were believed to offerpoor healthcare and often lacked drugs.

This information was summarised from in-depth research and analysis carried out by DrBarbara McPake and others in the HealthPolicy Unit, London School of Hygiene andTropical Medicine, Keppel St, London, WC1E7HT, UK.

THERE ARE MANY REASONS for drug shortages. Many countries,particularly in Africa, have not adopted an essential drugs list toensure good supplies of the most commonly used drugs. There maynot be enough foreign exchange to import the necessary raw materialsto produce the drugs within country. Drugs can be lost due to theft,poor storage and wastage through expiry. When drugs are prescribedto patients there may be further losses due to over-prescription,unnecessary injections or incorrect prescriptions. Finally, patients mayalso waste drugs they have been prescribed if they are not sure of thecorrect dosage, lack confidence in the health staff or fail to complete acourse of treatment because they feel better.

Providing essential drugs:The Bamako Initiative

The eight principles

■ Improving primary healthcare servicesfor all

■ Decentralising the management ofprimary health services to district level

■ Decentralising the management of locallycollected patient fees to community level

■ Ensuring consistent fees are charged atall levels for health services – whether inhospitals, clinics or health centres

■ High commitment from governments tomaintain and, if possible, expand primaryhealthcare services

■ National policy on essential drugs shouldbe complementary to primary healthcare

■ Ensuring the poorest have access toprimary health care

■ Monitoring clear objectives for curativehealth services

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HEALTH

The mothers’ group atKomandaThis group provides an interestingexample of the benefits of our work.Following each training seminar atIPASC, midwives produce an action planfor improvements in their work. Amidwife in Komanda was concernedabout the risks run by mothers givingbirth at home without medical back-up.She discussed this with the mothers inthe Komanda safe motherhoodprogramme and they decided to start afund, with each mother contributing asmall monthly payment. 25 mothersjoined immediately. After two monthsthey chose leaders, and later formed acommittee composed of a member of thehealth centre staff, some advisers andsome representatives of the mothers.

This committee has taken part in severaltraining sessions on safe motherhood.They considered the followingconcerns…

• Most mothers do not attend an ante-natal clinic.

• Many mothers give birth at homewithout any trained help.

• Mothers who have no money mayneed urgent medical help.

• Many children under five suffer fromanaemia and malnutrition.

All present insurance systems in the areaare simply concerned with burying thedead and make no effort to save lives.

The committee undertook the task ofmaking mothers in their area aware ofthese problems. They are working to meetthe needs of mothers who havecomplications in childbirth and to helpchildren under five whose families can nolonger provide for them.

‘Safe Motherhood’ will help a mother inneed even if she is not a member. Later,when she is better, she is encouraged tojoin. The association will pay for thetransport of a member from any healthcentre in the town to the recommendedhospital and then for their medical care.They help mothers with complications inchildbirth or pregnancy and also withcases of anaemia, malnutrition and otherserious illnesses in children. At presentthere are 270 members in 13 differentgroups, each one paying a monthlycontribution. Twice a week, leadingmembers visit local communities.

EducationFollowing a Bible study, communityactivity and health education is givenevery Monday at ante-natal classes and atall members’ meetings. A sketch entitledWhen Home Delivery is a Mistake has beenprepared, taped and broadcast for localradio. It compares a woman with a narrowpelvis, who did not attend an ante-natalclinic and dies at home with her baby, witha second woman who has a bleedingplacenta and who is transferred tohospital, where both she and her babysurvive. Two songs about safe mother-hood are sung during the drama.

BenefitsSo far, eight mothers have needed hospitaltreatment. One mother was in a state ofshock following a ruptured extra-uterinepregnancy, but the group provided andpaid for the mother’s transport, with afurther US $3 for hospital admission.Another woman had been married formore than ten years without conceiving.When she became pregnant, the baby wasparticularly precious to the family so at 38weeks she was transferred to hospital toawait the birth and avoid any risks. After aweek’s wait, she needed a Caesarean butthey were able to save the baby for whichshe had waited so long. The mother cameback to the committee saying, ‘Thanks to“Safe Motherhood”, my precious baby hasbeen saved.’

In addition to the women needing hospitaltransfers, 60 serious cases were lookedafter with a subsidy from the ‘SafeMotherhood’ groups.

Financial situationDuring this year over US $400 has beenentered in the books. So far, US $200 hasalready been used to help members, US $3has been used for administrative costs, US $80 for buying a cow and just over US $100 remains.

The cow was bought to raise incomethrough the sale of calves and milk. A soyafield has been planted and a manioc fieldis being prepared – again to raise funds.Future plans include raising goats,planting community fields in each villageand buying and installing a mill to lessenthe burden for the mothers and to increasethe cash in the fund.

Kaswera Vulere established The SafeMotherhood and Family Health Programme atIPASC, Nyankunde, DR ofCongo.

THE IPASC PROGRAMME FOR

Safe Motherhood

THE SAFE MOTHERHOOD Programme at IPASC (Institut Panafricainde Santé Communautaire), Nyankunde in the Democratic Republic ofthe Congo recently extended its work in the local communities. Mothersjoin small groups where they can discuss problems and find their ownsolutions, according to local culture and the available local resources.We also hope to start discussions and workshops for young people,couples and women who have reached the menopause.

by Kaswera Vulere

12 FOOTSTEPS NO.37

HEALTH

We at the Luke Society have beenstruggling with this goal for a while. Wework both in the urban areas ofMoyobamba, central Peru, and thenearby deprived jungle areas. We foundno organisation able to support usfinancially in subsidising healthcare.However, moved by our convictions, wecommitted ourselves to providing goodquality, personalised health services forthe poor in our communities. To make itaccessible, we not only fixed subsidisedfees but also began a community andschool health education programme, aswell as promotional and preventativehealthcare programmes.

Painful truthsAfter seven years, however, we weredismayed to discover that…

• The majority of poor people did notuse our services.

• The poor did not appreciate a first-rateservice offered at very low cost,believing low cost meant poor quality.

• The rich were able to take advantageof the situation. Though a minority inthe community, they overused ourservices and got good healthcare atlow cost.

• We needed increasing donations tosustain the programme and feltunhappy, even dishonest, when thosedonations ended up serving the rich.

• With little finance being raisedthrough charges, we finally facedbankruptcy and break-up.

Facing the problemsDid we give up? NO! Over a long periodwe discussed and debated. We lookedback at our experiences and implementedthe following practices, in order to helpthe poor without subsidising the rich…

• We worked out the real costs of ourservices and raised our feesconsiderably.

• We set up a sliding fee system for thepoor. This is worked out on a personalbasis – the staff member dealing with

a patient sets the price on the patient’scard. The rich pay the full cost.

• We set apart 10% of our total incomefor a poor relief fund. Through thisfund we are able to help those who areunable to pay even the basic costs.

• We still apply for donations tosupplement the needs of poorerpatients, but we no longer depend onthese.

• We had meetings with key leaders fromthe civil and religious communities, toexplain how our new system wouldoperate. Our motto was ‘Everythinghas a price, even our salvation.’ (Eventhough we ourselves do not pay for it,it is still of priceless value.)

• Community health workers,volunteers, religious leaders and theirimmediate families were given a typeof insurance.

• We keep a register of all the fees paid,to avoid accusations of religious bias ortax evasion.

Positive outcomesNow we are seeing the following results…

• The demand for health services hassteadily increased. We maintained theattendance of the rich and we increasedthe number of poor patients as theybecame aware of the subsidy system.

• The rich grumbled about paying morebut were satisfied because we offeredhigh quality services.

• The poor became our best promotersand their increased numbers made upthe surplus income. We had to startlimiting appointments to allow spacefor patients from remote villages.

• An awareness that ‘what is expensivemust be worth paying for’ spreadwithout us making any effort. And wecommitted ourselves to live up to that!

IN OUR SOCIETIES, healthcare often becomes a commodity. The richfew can afford good healthcare while the vast majority of people donot have the means to pay – they have no access to healthcare as abasic human right. Is it possible to make healthcare more equal?

Health servicesfor rich and poor

by Dr Apolos B Landa The demand for our health serviceshas steadily increased.

Many peoplestruggle to payfor healthcare.

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13FOOTSTEPS NO.37

Some development guidelines

DEVELOPMENT

BIBLE STUDY

Nehemiah is one of the men of the Bible whose working methodsmust inspire every Christian development worker. As we read thebook of Nehemiah, we can learn much to improve our own workstrategy to obtain better results. If possible, try to read the wholebook before making this study.

Chapter 1:1-11 Prayer. We must ask for God's help before under-taking any development work (Proverbs 16:1-3, Psalms 127:1)

Chapter 2:1-8 Nehemiah sought permission from the King beforebeginning work. The development worker must not disregardpeople in authority such as the chief, community leaders or localgovernment of the State.

Chapter 2:11-15 Listen to and observe the situation before takingaction. Nehemiah began by looking and he certainly listened tohis fellow countrymen before doing anything. It takes time for adevelopment worker to be accepted by the community.

Chapter 2:16-18 Make use of meetings. The development workerdoesn't see problems in the same way as local people. Nehemiahbrought his fellow countrymen together so that they could under-stand what he saw. A meeting helps all those concerned toidentify their problems and to recommend solutions.

Chapter 3 The community must participate. Sound developmentmust eventually become truly self-supporting and independent.This is the aim of community development. People who areconfronted by misery organise themselves and set to work.

Chapter 4:7-15 Even when confronted by the attacks of his enemies,Nehemiah didn't stop work. He worked on with courage, per-severance and self-control. Development work must not beabandoned unfinished, no matter what price has to be paid.Development work is difficult and long-term.

Chapter 7:1-2 The work must be followed up. Measures were takenfor the protection of the walls. If we do not think about the follow-up or maintenance, some time later the work will collapse.

Chapter 7:73-8:8 We should plan for a time of prayer and praise atthe end of the project, in order to thank the Lord for his workingwith us in our task.

Dangako Wango is Director of BDC/CBZN, Bangassou, Central AfricanRepublic, and teaches at FATEB on the Church and development.

Nehemiah, the development workerby Dangako Wango

by Dangako Wango

In order to achieve a sound approach todevelopment, we need to bring together thefollowing elements…

■ Needs must be expressed by thoseconcerned. Don't do anything either on behalf ofor instead of local people without being asked.

■ Those concerned must participatethemselves at every stage of the project.

■ Take into account the capabilities of the localpopulation when looking for solutions to theproblems which have been raised. We make aserious mistake in our development work if wedo not believe in the ability of local people tobring about the change they want to see.

■ Take into account whatever local resourcesmay be available. The solutions to the problemswhich have been raised must not come fromelsewhere. But if a little help is given fromoutside we should simply thank God for it.

■ Take into account past experiences. It issaid that there is nothing new under the sun(Ecclesiastes 1:9-10).

■ We must learn how to evaluate our work.

• Our total income multiplied ten-fold,so we were able to pay our staff anappropriate salary and maintain ourclinics to a high standard.

• We no longer have problems withother local medical services throughunder-cutting local clinics.

• Finally, most people are much happierand more fulfilled.

In this way we are able to be financiallysustainable and, at the same time, toserve the poor. Like the covenant of gracewhere both rich and poor benefit fromthe Lord’s gift, by working together wecan provide quality healthcare for all(Isaiah 65:17-24). Explaining the gospel isclosely linked to all our health servicesand there are many opportunities toshare the love of Christ.

Dr Apolos Landa is Latin American andCaribbean Co-ordinator for the Luke SocietyInc, with wide experience of primaryhealthcare. His address is: Associación SanLucas, Apdo 421, Trujillo, Peru.E-mail: panluk@inglenet.lima.net.pe

A good development worker uses local resourcesand builds up the confidence of local people.

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14 FOOTSTEPS NO.37

RESOURCES

District Laboratory Practice inTropical CountriesThis detailed book (464 pages) is aimedat medical staff working in districtlaboratories and those who train them. Itcontains details of managing andequipping laboratories, health and safetyaspects and numerous clinical andparasitological tests (with a large sectionof colour photos). It emphasises the needfor integration with community healthservices. Details are available onplanning a training curriculum forlaboratory staff.

Normal price is £33.30 but the book isavailable at £10.90 (including surfacepostage and packing) for medical staff indeveloping countries (or £19.00 withairmail postage). Send payment withorder to:

Tropical Health Technology14 Bevills CloseDoddington, MarchPE15 0TTUK

Women’s Health LibraryThis is a special offer of a library pack ofsix books which will provide communityhealth workers with the latestinformation on a wide variety ofwomen’s health problems. They include

Where Women have no Doctor – recentlypublished and providing a health guideto identify common medical problemsand treatments

Helping Mothers to Breastfeed

Setting up Community Health Programmes

Nutrition Handbook for Community Workers

Training Manual for Traditional BirthAttendants

Freda Doesn’t get Pregnant – an easy to readbook for young girls, to help themunderstand the risks of becomingpregnant.

The set of six books is available at aspecial low price of £30, includingpostage, from :

TALCPO Box 49St AlbansHertsAL1 5TXUK

How to Make andUse Visual AidsVisual aids areimportant all over theworld to help teachers,trainers and develop-ment workers tocommunicate effectively.This book shows how tomake visual aids quicklyand easily using low costmaterials. The techniquesdescribed have all beenwell tried and tested by volunteers withVSO, the publishers. The ideas are easyto use with plenty of practical hints andtips. The book encourages the use of localmaterials and techniques. Among theideas included are card games, puppets,masks, models and toys. There is a usefullist of contacts for advice, free cataloguesand other materials.

Available from TALC for £7.15(including surface postage) or £8.15(including airmail postage). Addressabove.

New books on livestock and their careThe Christian Veterinary Mission havejust published two new books calledRaising Healthy Sheep and Drugs and theirUsage as additions to their useful serieson raising healthy animals. This bringsthe total to nine (including pigs, cattle,sheep, goats, fish and rabbits). They costUS $10 each and $15 for Drugs and theirUsage (with 300 pages) including postage.CVM will consider making booksavailable to mission agencies, agriculturallibraries and development agencies indeveloping countries. Requests for thebooks should be typed on letterheadedpaper from the organisation.

CVM also publishes an InternationalAnimal Health Newsletter quarterly.Raising Healthy Poultry, Rabbits and Goatsare also available in Spanish. For furtherinformation, please contact:

Dr Leroy DorminyChristian Veterinary Mission19303 Fremont Ave NSeattleWA 98133USA

E-mail: missionvet@aol.com

Farmer to Farmer Extension:Lessons from the fieldby D Selener, J Chenier and R Zelaya

Published in 1997, 150 pages

This book is the result of two workshopsin Honduras and Ecuador, held todocument and analyse the experiences ofseveral rural development projects. Mostof the information comes from the pointof view of farmer promoters, based ontheir many years of experience. Part Onelooks at many aspects of the work offarmer promoters (extension workers).Part Two looks at five case studies fromMexico, Nicaragua and Ecuador. Thebook would be of interest to develop-ment workers using participatoryapproaches to development. It isavailable in Spanish and English, costsUS $15 including postage, and can beordered from:

IIRRAP 17-08-8494QuitoEcuador

E-mail: daniel@iirr.ecuanex.net.ec

Resolviendo Conflictos en Pareja (Resolving Conflicts as a Couple)

This short, straight-talking booklet inSpanish, written by a Brazilianpsychologist, goes directly to the heart ofmarital difficulties. It identifies the mainsource of conflict as the refusal to accepteach other as different. It describes howeasily couples can retreat into hurtsilence and grow apart. It gives practicaladvice on how couples can appreciatetheir differences, learn from conflict andgrow stronger through it. This 11-pagebooklet is one of a series produced byEIRENE and included free for subscribers

15FOOTSTEPS NO.37

RESOURCES

to their quarterly bulletin, which costsUS $20 a year. Single booklets cost US $3,including postage.

EIRENE Internacional – ALAPFCasilla 17-08-85-72QuitoEcuador

Selecting Medical Supplies forBasic Health CareA list of essential drugs has provided auseful guideline for many healthpersonnel in deciding priorities when

Fixtures and fittingsMake shelves, using wooden boards and bricks. You can use blocks ofwood held up with stones as bookends until a carpenter can make woodenones. Instead of stones, you could use painted pebbles. If a number ofpeople will be using the library, make sure it is open at regular times forpeople who want to come and read. Keep some chairs or mats for peopleto sit on. If space is limited, a cupboard can be used for the library booksand locked up when not in use.

ordering drugs. However, no similar listis available for medical supplies tocomplement that for drugs. ECHO arejust reprinting these guidelines to helpmedical personnel make practicaldecisions when ordering supplies with alimited budget. The booklet costs £3(including postage), but a copy isavailable free of charge to healthpersonnel in third world countries whohave no access to foreign exchange. Asecond booklet in the series called BasicTechnical Maintenance of MedicalEquipment will also soon be available.

ECHO are a leading supplier of low-costmedical drugs and supplies to clinics andhospitalsaround theworld. Write to:

ECHOUllswater CresCoulsdonSurreyCR5 2HRUK

Building up your library

Divide the library into sections This will make books easier to find. Use letters and acolour code to indicate each subject. For example, ifyour library is on health issues, you could use thefollowing sections:

MCH Mother and child health Red

IND Infectious diseases Blue

DAT Disability and appropriate technology Purple

HAE HIV/AIDS education Orange

NCG Nutrition and child growth Green

MSO Medicine, surgery and obstetrics White

HCS Healthcare services Yellow

EC Education and communication Brown

Divide the sections with wooden blocks, marked andpainted with the correct colours. Mark the books onthe outside cover and inside. Give each book a sectionnumber and write this after the letters. For example:MSO 2. If you have several copies of the same bookmark them as: MSO 2A, MSO 2B and MSO 2C.

Keep a registerDivide an exercise book into sections andwrite down all the books you have. If peopleborrow copies, write their name down as wellas the date they should return the book.Decide together on a borrowing policy forbooks. Maybe one person can borrow twobooks at a time and keep them for up to threeweeks. Decide if you will use penalties ifpeople do not return books on time.

Use a box for people to place their returnedbooks. Mark them into the record book andthen place back in the right section.

Adaptedfrom useful

information fromTALC, who provide several

collections of books to set uphealth libraries at low cost.

FinallyKeep a lookout for interestingbooks you can add to the library.Charging a small contribution forthe use of the library may enableyou to buy a few really useful bookseach year. Some organisations willalso support groups building upsmall libraries.

FOOTSTEPS NO.37

COMMUNITY DEVELOPMENT

Published by: Tearfund, 100 Church Rd, Teddington,TW11 8QE, UK

Editor: Isabel Carter, PO Box 200, Bridgnorth,Shropshire, WV16 4WQ, UK

Here in GRAAP (Groupe de Recherche etd’Appui a l’Auto-promotion Paysanne),we have developed a process to helpallow all groups within a society toexpress their views, including womenand children.

The structureEach neighbourhood area is representedby a delegation which consists ofmembers of all the social groups –including leaders, adults (both men andwomen) and young people. These arethen formed into sub-groups as follows…

• Leaders’ group

• Men’s group

• Women’s group

• Girls’ group

• Boys’ group

Sometimes more groups may benecessary to include minority groupssuch as tribal groups, refugees, disabledpeople or migrant workers. In order toget a balanced result it is helpful to makesure that numbers in each group reflectthe actual numbers in the population.

Areas of concern Each of these sub-groups chooses aspokesperson and an organiser to leadthe discussions. The same subject isdiscussed by all the sub-groups, whomake a list of all their ideas and rankthem in order of importance. Their threemain concerns are then brought to theGeneral Assembly of all sub-groups. Thereporters present the three prioritiesselected by their sub-group, usingeveryday symbols to represent these (forexample: a twig to represent timber, ashoe to represent transport, beans torepresent seeds).

PrioritiesWhen all the sub-groups have putforward their views, all delegates are ableto decide on their overall priorities as acommunity. Each person takes the same

seen to be the main priorities for most ofthe community, and discussion can moveon to how to improve and tackle thesepriorities.

When to keep quietI have found that the best method ofleading discussions is not to express yourown opinions and knowledge, butinstead to enable people to discover thesituation for themselves and then thinkabout it and act accordingly. This can beachieved by using the art of questioningskillfully, just as Jesus did (Luke 7:36-43).Sometimes, however, there are difficultor embarrassing situations which peoplewill avoid tackling, and there may be noalternative but – with sensitivity – toexpress our opinions and encourageaction (Matthew 12:9-13, Luke 14:1-6).

We should not hesitate to share the truthif necessary, as we are the salt and lightof the world (Matthew 5:13-16).

Boureima Kabre is a facilitator working withGRAAP. His address is BP 143, Koujiela,Burkina Faso, West Africa.

Participatoryresearch in action

IT IS ESSENTIAL when beginning a new community project to havethe full involvement of all the layers of society which make up thiscommunity. Each society has its own particular knowledge and abilitywhich enables it to function, however poor its members may be.

CommunityViewpoint

by Boureima Kabre

number of pebbles (this can be based onthe number of priorities listed, butbetween 5 and 10 is a good number).They place their pebbles alongside thesymbols representing their ownpriorities. At the end of the session,people who are not members of the sub-groups add up the pebbles. By using thismethod, the views of accepted leadersand the issues they see as priorities donot automatically get pushed forward.The views of each sub-group can beexpressed and heard by all sections of thecommunity, ensuring that women andyoung people have the opportunity toshare their points of view. Prioritiesreceiving most votes (pebbles) are thus

Children in Burkina Faso using pebbles to indicate their priorities for community development.

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