Zimbabwe

Zim AHEAD teams up with Mercy Corps

Summary

In March 2007, Zimbabwe AHEAD joined forces with Mercy Corps, one of the few International NGOs which continues to operate in Zimbabwe, despite the severe operational problems of working in a country where the inflation rate is over 4000% and vital commodities such as fuel and cement are in short supply. Zim AHEAD was contracted to introduce the Community Health Club approach into the two districts where Mercy Corps had started a water and sanitation programme, namely Chipinge and Busia Districts in Manicaland Province, in the south east of Zimbabwe. Training to start up health clubs in Chipinge was completed in October, 2007, with a one week workshop run by Zimbabwe AHEAD. Twelve Village Health Workers were selected for training in four wards and each undertook to start at least two clubs with a target of 70 members per health club. In fact the community response was overwhelming and within four months there were over 33 health clubs with over 3000 active members, with a demand to start up clubs in adjoining areas. The Rural District Council is delighted with the response and the assistant District Administrator has vowed to make the Community Health Club methodology the standard modus operandi for the whole district. With only four out of 25 wards currently covered by the existing project, funds are bing sought to expand this project district wide.

Background

Mercy Corps was introduced to Zimbabwe AHEAD in November 2006, during an evaluation of the Water and Sanitation programme in Buhera and Chipinge Districts, funded by British Lottery fund (BLF). Looking for a feasible health promotion component in the programme, the Mercy Corps team visited the Makoni Community Health Club Programme and were impressed by the ability of Community Health Clubs to achieve sustainable development. On the strength of this empirical evidence of sucessful development over the past decade, Zimbabwe AHEAD, was invited to join Mercy Corps as an implementing partner to take over the health promotion component of the BLF Programme, anda rapid start up was achieved within two weeks of the funding being received.

2 Training

The health promotionprogramme started with a one week training workshop between23^rd – 27^th April, 2007, in Chipinge District, with a total of 34 participants trained. Facilitators from Zimbabwe AHEAD were the Director, two Project Officers and District Coordinator from Makoni. A second workshop was due to be held the following week in Buhera. However, in a country grounded by political control, this training was cancelled at the last minute – a political directive based on suspicions as to why an American NGO was choosing to work in Buhera, the opposition leader, Morgan Tsvangirai’s own constituency. To-date, Mercy Corps and Zim AHEAD have had to cancel all activities in Buhera, until after the election due in March 2008, after which it is expected that the political paranoia should decrease. This fear by the authorities of community organisation through health clubs and the benefits from such a project, that may swing votes, is interesting as it illustrates the power of community health clubs to be an instrument of political change, well recognised by those who fear change.

2. Chipinge Community Health Clubs

In Chipinge, where the project has been allowed to continue, the response from the community in joining and attending health sessions has been overwhelming and far beyond expectations.The initial target of 12 clubs, one per facilitator, has been long forgotten, as facilitators take on far more than was planned, despite having had no transport allowance nor per diems in the first months. Mobilisation began in May, and each month since then has seen a steady increase in registration.

By September, some clubs of 100-180 members had to be divided into two clubs to enable participatory training to be more effective. By Nove 2007, there were 33 health clubs with 2,506, with an average of 76 per club. Clubs were still being formed and a ceiling of 4 clubs per facilitator had to be instigated to ensure facilitators could effectively manage their duties.Facilitators were being given US$1 per session from October, which has, of course, provided a strong incentive for more health clubs to be started. There is also a strong demand for knowledge from other areas where no health clubs has been started, which indicates not only the need for health promotion in the area, but also the acceptability of the AHEAD methodology and the ability of the community facilitators to mobilise their communities effectively.

3. Achievements of Project

Looking at Fig 1, below we can draw the following conclusions on the achievements of the project to-date:

·29 clubs are being operated by 12 facilitators, monitored by 4 EHTs

·There are 2,506 registered members with an average of 97 members per club (excluding the 3 new clubs)

·Average attendance at sessions for all facilitators is 57 members

·9 facilitators have an attendance rate above the average of 57

·3 facilitators are below average and need an EHT should assist them.

·67 health sessions have been done by 12 facilitators in the past 4 months

· With an average of 6 sessions completed by each facilitator, four are above average

Fig 1. Facilitators relative outputs, with EHT comments and recommendations.

Shaded area indicates facilitators monitored by JW at Mid Term assessment (Oct.07)

3.2 Health Club Facilitators

Whilst Zim AHEAD has always used the government health workers, called Environmental Health Techinicians (EHTs) who have had a strong 2 year training in Public Health, Mercy Corps determined that, due to the shortage of EHTs in Chipinge, we would have to rely on Community Health Workers from the villages, despite the fact that they often have little background in health education. Whilst the community facilitators have achieved high levels of mobilisation in the village with impressive community response, the quality of the health training given by them is fairly low,compared to the EHT’s ability to facilitate. Whilst they can handle the hygiene sessions related to diarrhoea on their own, they do not have the confidence to run the more complicated sessions relating to diseases such as Malaria, Bilharzia, worms and skin disease, without assistance from the EHT. By contrast, the qualified EHTs are well used to training community. they are also recognised by villagers as having mandate to train, whilst their neighbours, the newly ‘qualified’ health workers are only one weeks training ahead of their peers, who understandably often deride their efforts at training.

The CHC facilitators who have been village Health workers for some time are clearly more effective than those who have been nominated by local leadership for other reasons, and have no understanding of health issues. In none of the sessions that were reviewed in this Mid Term Assessment (see shaded areas in Fig 1.above), did the facilitators conduct the training alone. Instead they played a support role to either the EHT or PO, as they were not confident to train on their own. As such they can be considered to be still in training, particularly in the more difficult sessions on nutrition, malaria, bilharzia, skin diseases, and worms.

However, it is expected that with time they will learn the issues and next year, on their second intake, they should be able to cope on their own, with less support from our staff. EHTs will still needed to monitor and ensure standards are maintained. However the sustainability of continued health promotion in the area, even if the NGO and MoH are not active is the main advantage of this model as each club now has a community facilitator in their own area.

En Environmental Health Technicians (EHTs)

There are three EHTs, two men and one woman, who were all trained in the initial workshop, who are res0ponsible for monitoring the Community Health Workers. To begin with these EHTs did not have any transport to do this monitoring, and it is only in the last two months that the two men have received motor bikes and fuel for monitoring, whilst the woman continues to use public transport, frequently having to sleep in villages due to lack of buses.

The response from the EHTs to the Community Health club approach is encouraging and some of the benefits they mentioned are as follows:

·The CHCs help to motivate communities

·Members teach each other

·The EHT ‘workload is being eased’

Some interest has been raised by a preliminary look at the household inventories that appear to indicate that some people are voluntarily building latrines without any external assistance. For example the records of Rujeko club (ward ) show that in June there were 39 latrines in the area, and by October there were another 39 new latrines, leaving only 13 members without facilities. If this is true it may be a startling response to the training. These records need to be verified by the EHT whose duty it is to record the number of latrines and new constructions within their ward.The EHTs have agreed to do this in the next few months and PO’s should follow up and raise this issue in the EHT meetings each month, to ensure CHC activities are fully integrated in MoH report.

Community Health Clubs useful for other NGO programmes

It was also noted that other activities in the area will affect the project. PLAN is to distribute ITNs (Insecticide Treated Nets) to the entire districtbefore the rains in November. Last year there were 3,000 distributed in ward 28, and 388 ITNs distributed in ward 29 and 30 for under 5’s and pregnant mothers. There will also be straying of breeding areas, and training for choloquine holders. This will involve all households but it would be better to involve the health clubs in this monitoring usage of nets to ensure these ‘hand outs’ are properly used. The idea of having community health clubs is to help mange health within the community. It is essential that PLAN is fully appraised of the activities and whereabouts of each CHC so that they can tap into this community structure as a resource to ensure sustainability.

Co Conclusion

The first six months of this project has gone exceptionally well despite the many potential difficulties of new personnel and unreliable transport. Mercy Corps has been supportive and Zimbabwe AHEAD has played its part, and there are no major problems from either of the partners. The output in the field has been remarkable with all targets exceeded. There are now over 3,000 Community Health Club members in 33 clubs within a short period of four months, with an ever increasing demand. The only drawback was the enforced withdrawal from Buhera but this has enabled Chipinge to speed up its project. When Buhera starts next year it will also be ‘fast tracked’ with two project officersstationed there. The EC programme will allow the AHEAD methodology, with its long term holistic development process to be taken to the full extent, and preparations are underway to start in December 2007 in the two existing districts as well as Chiredzi. ZimAHEAD looks forward to the next half year, and the final report for the BLF funding will be submitted in May 2008.The MoU between EC and Mercy Corps was signed and funding began in December 2007.

[i] Anthony Waterkeyn. Evaluation Report on Water and Sanitation Programme for Mercy Corps, Nov. 2006

[ii] Zimbabwe AHEAD Proposal to Mercy Corps; ‘Health Promotion through Community Health Clubs’,Feb 2007

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