Workshop Minutes 2005

• Bridge to Health Teams working at the community level;
• the training of birth attendants in life-saving skills;
• quality improvement of preventive and curative services; and
• community-based case management. 

Professor presented a video focusing on causes of infant and maternal death at the project site in Ethiopia. Key information demonstrated in the video included:

• local beliefs promoting maternal and fetal malnutrition. For example one mother said their reason for not eating when pregnant was because (eating would) make the baby fat within the womb, not able to deliver, and therefore the mother would die;
• the 3 main causes of infant death were difficult breathing --Acute Respiratory Infection (ARI)--, fever (malaria), and diarrhea;
• the community was presented as depressed and lethargic;
• the local doctor emphasized the need for more specialist nurses to deal with their local problems especially ARI. (Many believe that such an approach emphasizing and relying on specialization is not consistent with the best use of the limited numbers of health professionals available in rural areas in developing countries.)

Professor emphasized the importance of capacity building at community level and of encouraging young professionals who understand community capacity building and empowerment.
 
Professor asked Charles to comment on the film. Charles had lived in Ethiopia for 8 to 9 years, doing research and teaching. Charles spoke the local Ethiopian language. He expressed that the video and the interviews in it did not adequately present the strength, resilience and civilized nature of the local culture but rather focused on negatives. Although the local maternal mortality rate was high it was not 1400- as presented in the video. Although the community had suffered much from prolonged war and drought - as a result of which they could not practice their usual nomadic lifestyle with their cattle-, they were a strong resilient group of people. He identified the local priorities-not demonstrated in the video- as cattle diseases, water, and malaria. Mark Gettleman who had worked in Africa commented that traditional African cultures had been heavily impacted by AIDS, drought, lack of health personnel-especially nurses migrating to Western countries-, US agricultural policies with regards to cotton and sugar cane that discouraged local crop production, and tourism. He also said that poor mental health and disability are also major common unaddressed problems in this part of Africa. Malcolm Bryant commented that we should not forget about the community aspects of CBPHC such as little access to health care, no transport for emergencies and no access to water that are common to poor rural communities throughout the developing world.
 
Four smaller groups were then formed. Each group was given data specific to the health problem they were to tackle in relation to maternal or child health in the Ethiopian situation. The task of each group was to come up with practical strategies that they recommend be used to solve their health problem. Discussions within the groups ranged over the video, the large group discussion, and the data given to each group. Each group then prepared a presentation that was subsequently presented in a plenary session.
 
The groups reported a range of problems and strategies to solve them -- consistent with good standard CBPHC practice. Important points made in relation to maternal care were:

• The need to provide culturally appropriate, accessible pregnancy care that identifies complications early and includes readily available transportation for emergencies;
• The need for outreach services to be provided to reach the women in their communities especially in relationship to antenatal care including immunizations;
• The need to train and supervise local traditional birth attendants (TBAs) to practice maternal care correctly;
• The need for adequate maternal nutritional throughout pregnancy-Vitamin A deficiency is apparently common amongst women in the project area;
• The need to see that women who reach hospital do get the appropriate care they need in a timely manner –especially caesarian section- professionals apparently sometimes refuse to do these when indicated;
• The need to understand local cultural beliefs about pregnancy and to deal with them appropriately both through education and efforts to make interventions consistent with strongly held local beliefs;
• The need to provide adequate accessible culturally consistent family planning services - these and other grassroots services above will need to be partly mobile in some areas where people follow a nomadic lifestyle.

Important points made in relationship to child care included:

• Adequate, accessible, quality, water supply and sanitation are essentials along with education about good personal hygiene and safe handling of food and water;
• Those families and children with good practices in the area of personal, food hygiene and breast feeding should be identified (positive deviance) and involved in or act as models for teaching those who do not;
• Health services such as immunization, nutritional assessment, IMCI and education about these, breastfeeding and child nutrition should be provided at the community level at least through outreach services;
• Calorie-dense foods and micronutrients should be promoted and made available at least for those with the greatest risk of intercurrent illness;
• Community committees should be encouraged to see that adequate transport is made available for mothers and children to attend preventive and curative health services;
• A system providing prompt referral for sick mothers and children according to established guidelines is an essential part of CBPHC that should be routinely provided;
• Community empowerment and development for women and men are necessary to empower them to make positive changes for themselves and their children;
• Microcredit schemes and enterprises are part of this empowerment process;
• As cattle are so important to the community in question, the community’s expressed desire for a veterinary health program should be met- meeting this need should also help encourage community participation in human health activities.

More general comments were that coverage and quality of CBPHC programs are a good indicator of the likely impact of the programs. The government has a key role in providing support, district team management and resources. Similarly pastoral and peasant associations can also be important facilitators. In short a three way partnership between the community, helping agencies and experts and the government is important for successful and sustainable CBPHC.
 
Lunchtime Discussions
 
During the lunch break 3 small group sessions were led by Sarah Shannon, Ketan Chitnis and Henry Perry/ Paul Freeman.
 
Sarah’s discussion focused on purposes and activities of the People’s Health Movement (PHM). Key themes covered included the role of the PHM as an advocacy organization at all levels locally, nationally and internationally for:-- Health for All Now; a comprehensive approach to PHC consistent with CBPHC; and justice and equity especially for poor and deprived populations both in the US and internationally.
 
Ketan discussed his recent thesis focusing on empowerment and communication for social change as evident at Jamkhed CRHP. His research focused on village health workers as the core group and the communication between them, “experts”, and government instrumentalities. He examined communication and other activities as they were used for empowerment. He found that dialogue was important to stimulate critical thinking and peer learning at the village level with VHWs serving as change agents. The VHWs were trained by the Areole’s and their nursing and other staff. Key activities were local training, village meetings, and participative rural appraisal. Together these activities strengthened local self-reliance. Challenging local harmful cultural practices, such as leprosy stigma/discrimination, mistreatment of women and caste discrimination, were identified and practically overcome by the local communities with the facilitation of the Areoles. These processes of gradual change that led to the empowerment of many groups of people within the community required collective action over a sustained period of time.
 
The discussion led by Henry and Paul outlined the evidence-base for CBPHC study which they are working on. They are to be guided by a committee of international experts led by Carl Taylor. The focus is on Child Survival programs and activities at the community level looking at selective, integrated and comprehensive approaches. The study should run over 18 months. More manpower is needed to collect and review articles. A widely distributed broadcast has been sent out to solicit papers dealing with the broad range of topics coming under Child Survival. Documents dealing with community-based research, program and project evaluation and reviews are being sought. Both qualitative and quantitative evidence is to be examined. The purpose of the review is to identify current evidence for CBPHC and community involvement and gaps in current research towards strengthening CBPHC. Interested persons and groups who would like to participate or contribute documents should contact

• Careful planning to establish management and resources for community health(MARCH);
• Identification and addressing of the specific needs of HIV-infected pregnant women;
• Provision of ART consistent with country guidelines;
• Provision of DOTS, comprehensive PMTCT services (based on Partners in Health);
• Food distribution per mobile clinics for malnourished pregnant and lactating women and their malnourished children up to at least two years of age;
• Provision of mobile clinics with  routine and rapid lab testing in the field for such as HIV, syphilis, and anemia and quick referral for education, further diagnosis and treatment;
• Education of mothers about safe infant feeding;
• Development of a system of “accompagnateurs”. 

These “accompagnateurs” were selected by the local women according to basic selection criteria to perform clear responsibilities. They received a monthly honorarium of $40, and monthly training and were guided by a local supervisor. These community workers were each responsible for educating and supporting a particular group of local women including support for safe infant feeding and provision of Retrovir treatment to HIV positive mothers and their babies at birth. They visited their patients daily and ensured that infants are brought to hospital in good time for treatment of acute illness and follow up. They also support the provision of HAART to those living with AIDS, as directed by health personnel, as indicated by CD4 counts.

The results of their program demonstrated that it is feasible to greatly reduce the transmission of HIV from mothers to their children. However, for long term improvement there is a need for much investment in social services. Careful monitoring of the program is necessary to ensure mothers and the most malnourished children receive the food provided. Otherwise malnourished mothers (many of whom lose weight in their third trimester without intervention) may hand on the food they receive to other family members to their own detriment. Also without education and monitoring, although about two thirds of children aged less than five years are malnourished, much of the food meant for them was given to older aged children.
 
For sustainability of programs he recommended that there is a need for a government/private mix, or as appropriate, adequately funded private programs. There was no evidence that, in Haiti, programs run only by the government work due to such issues as a lack of resources. For example, the average government “agent de sante” covers too large a population to have any meaningful impact. Traditional hospital-based approaches do not work as hospitals are geographically based and many do not reach out into the population. Community-based approaches oriented to the local culture with child multiplier effects are needed to reach members of the community on their terms. However, the community also needs the district level technical, referral and resource support, that well organized and community oriented (usually) government services should provide. A partnership between community members, experts and government services is what works best. The emphasis on the roles of these groups should be on “partnerships” rather than “participation”.
    
Gretchen described some methods that were used to overcome barriers to success in CBPHC programs in Haiti. A positive deviance approach was used to improve the focus of education to counteract child malnutrition as described in more detail below in the Mozambique section. Persistence in education is also important. It is knowN that most people need to hear new information 7 times before they try it and a new approach needs to be performed 21 times before it becomes a habit. The CBIO (Curamericas) manual is a good guide to follow. The use of Care Groups is also very helpful.
 
Both maternal and neonatal tetanus are still prevalent in Haiti. A vertical program approach –with money coming from GAVI- was used to open the door for a community-based approach. Given local habits, it was realized that one of the best ways to reach most women was through the local markets. The medical community was not supportive of this approach at first since they required that all activities should be documented in facility based medical records. However, it was found that mothers looked after individual record books given to them for themselves and their children. Consequently the markets were visited early in the morning when women are present, local women volunteers were mobilized and women reached for tetanus immunization through the local markets.
 
Local “gossip” and communication systems were used to get out locally appropriate messages. For example, that it was bad to be pregnant and not immunized, and that just as a cooking pot needed to rest on three stones to work properly so also three immunizations were necessary to protect from tetanus. Each new case of tetanus was investigated and communities were educated along the way to identify those that needed tetanus immunization. A positive investigative rather than punitive approach was followed such that the message communicated was: what happened that this woman did not get her immunizations, what can we do better so that this does not happen again. Once good immunization coverage in women was achieved in this way and a locally well known disease was greatly decreased, - an overall decline in neonatal tetanus of 86% was documented - it was possible to get women interested in further aspects of their health and that of their children.
 
In Haiti, one woman per month was dying from preventable causes. Verbal autopsies were carried out on as many of these as possible. It was found that among these women there were many deaths that could be prevented by good prenatal care, management of pre-eclampsia or adequate transport. Discussions and observation of the behavior of pregnant women identified the need to develop a system so that babysitters would be provided to look after mothers’ other children. With this in place plus adequate transport, mothers could attend for antenatal care and present to health professionals earlier when in complicated labor. A waiting area was also created for mothers near health facilities. Now each mother develops a birth plan to deal satisfactorily with her confinement.
 
Care Groups in Mozambique
 
The Berggrens then discussed the success of Care groups in Mozambique. The details of the Care Group methodology are presented in the Care Group Manual that can be downloaded from our report of our 2004 annual workshop accessible from our home page. The systematized Care Group approach was initially established in Mozambique and subsequentially extended to Cambodia and Rwanda. The practical points that the leaders discussed in relationship to their experience of CBPHC especially in relation to Care Groups were:

• In Care Groups, one carer chosen by the local community is trained to look after and care for each group of 15 families;
• These carers follow up the health needs of each of their families and collect the information necessary for the recording of all vital events;
• These carers support one another and receive technical and expert support through their regular training;
• Positive deviance as applied through the “hearth method” (see