Zimbabwe

Public Health Promotion Programme for Urban Humanitarian Crises in Sakubva, Mutare.

Zimbabwe AHEAD in Partnership with Oxfam

Reported by: Regis Matimati, Zim AHEAD, Project Manager, March 2009.

UN says Zimbabwe cholera cases rise above 80,000 : 20^th February 2009

Geneva – The UN health agency says the number of cholera cases in Zimbabwe has soared above 80,000. The World Health Organization said Friday that the death toll is now 3,759 out of 80,250 cases. Spokeswoman Fadela Chaib said those figures include all reported cases and deaths since the outbreak began in August through Thursday. Cholera has spread rapidly in the African nation because of Zimbabwe’s poorly maintained infrastructure and crumbling health care system.

Zimbabwe AHEAD is playing its part in the national cholera emergency, which is now an everyday reality for most citizens in Zimbabwe who live in the many high-density suburbs where the water supply is now often contaminated with e-coli. Cholera can be prevented but it requires well disciplined communities to coordinate public hygiene behaviour to limit the spread of the disease, by protection of water sources, hand-washing with soap and safe faecal disposal. We are galvanising communities to protect themselves from killer diseases such as cholera through the training we have been providing for Community Health Clubs (CHCs) since 1997. Whist in normal circumstances, Community Health Clubs in Zimbabwe have a six month course of 24 health sessions, the panic caused by the ravages of cholera means that emergency measures have to be put in place and (like the farm invasions) the training has to be fast tracked.

Oxfam, which has been at the forefront of emergency programmes in the SADC regions for years has subcontracted some of this relief efforts to Zimbabwe AHEAD. In Mutare, the selected project area has seen 126 Cholera cases since the out-break, with 5% Case Fatality Rate (6 deaths). Our project started in Mutare in October 2009, targeting the sprawling high density suburb of Dangamvura in an effort to contain the outbreak. A few months later there are now 10 health clubs, varying from 61 – 496 members, with the average club size of 182 active members. Club attendance rose over the past few weeks to a total of 3,320 people but regular registered members are 1,400 of which 84 (6%) are male while 1,316 (94%) are female. The reason for this sudden upsurge in attendance is attributed to the fact that CHCs are a new phenomenon and many people hoped this was a way of getting onto the Non Food Item (NFI) register, a package given to the most vulnerable. Instead by joining CHCs they are provided with the means, by health knowledge, to defend themselves against cholera by their own efforts. So far club members have had 4 health sessions each; one on club membership ground rules, norms and values, cholera awareness, community diseases burden and setting up club interim committees. One CHC is so already enthusiastic the members are already all geared up to hold a clean-up campaign in their catchment area.

CHC members household Baseline Data

Because it is important to be able to measure all achievements in hygiene behaviour change, a a household inventory was done by CHC members themselves. Already 2,629 visits to all CHC members households have been done in groups and a picture of the health and hygiene enabling facilities was constructed for the Sakubva community. This information will form a base upon which our CHC activities will be measured as we aim to raise the percentage coverage by at least 30%, especially in those areas with such a low percentages. For example, only 15% currently have rubbish pits, and although 86% have a safe water source this is likely to become contaminated by dirty handling as only 16% are using a ladle to take drinking water from water stored at home and only 41% have safe closed water storage containers. Some positive findings are that 89% have a toilet although the cleanliness of the toilet is important as may if exposed to flies, the health risk of open defecation is not averted. Important for other diseases than cholera and diarrhoea, we found that 91% of the household have a bathroom (important to prevent water washed diseases such as scabies and ringworm); 75% have well ventilated bedrooms (known to affect rate of respiratory infection), although only 20% have mosquito nets to prevent malaria which is on the rise in Zimbabwe in recent years.

Non Food Item emergency packages

The 2,375 NFIs beneficiaries who receive the emergency package have been given Cholera awareness and response sessions by Zim AHEAD with their accompanying relatives and family members,at the distribution site. 2,375 beneficiaries received double issue of soap and cotton wool from the NFI handouts, and the remainder 625 will receive during a mop up exercise as distribution was hindered by incessant rains that fell during the distribution period.

Trainer of Trainers for School Health Clubs

A five day training for school health masters / School Based Facilitators (SBFs) was held in Mutare from 09 to 13 February 2009 and was attended by 24 school health masters, as well as the Mutare City Chief Nursing Officer, one Environmental Health officer, four District Education Officers and two officers from the Min. of Education ‘Better Schools Program’. The aim of the training was to equip the SBFs to run the school health clubs. The workshop was successful and the Min officials spoke highly of the course content and where sure this had capacitated the teachers to successfully run the school health clubs. However the only drawback is the fact that to date most of the school children have not yet gone back to schools, but hopefully things will normalise soon. The school health masters are ready to roll out the school health program as soon as schools get back on track. We will closely support them on this endeavour.

Scaling Up Cholera Response

Based on the success of the community mobilisation through Health Clubs, Zim AHEAD was asked to scale up activities into six more wards in the Mutare area (Wards 15,6, 18, 9,7,8) training volunteers to help prevent the spread of Cholera. A training was held for 40 Public Health Promotion (PHP) volunteers on 11^th/12^th Feb, 2009, to ensure they understand cholera (disease picture, germ theory, prevention and control, management of a cholera case in the home and on the way to a CHC) and they were taught to use the Zim AHEAD tool kits on Germ Theory, General Hygiene, Water Storage, Water Sources, and Sanitation Ladder. In addition they learnt of other participatory activities such as Focus Group Discussions, picture cords, drama, song and dance etc). Volunteers were drawn from various youth groups, middle-aged and elderly, socially responsive residents of Dangamvura. One of these is a Pastor’ swife from one of the churches. We also got representation from a local community based organisation; the Community Working Group on Health.

Public Health Promotion

After the training volunteers were returned to their suburb, to do their duties which are going well. Cholera awareness and response sessions were conducted in some sections of all the 6 wards with volunteers going in groups of six. Door to door campaigns were also done as well as public meetings and attendances to public gatherings were discussions were facilitated. During the Non Food Item (NFI ) distribution, daily a pre-distribution public health promotion was held with all prospective beneficiaries and their accompanying relatives In total, an estimated 10,896 people reached during the month in this exercise. In one of the wards people have been mobilised and are holding clean up campaigns on their own. Schools were also approached and an estimated total of 1,250 pupils were reached.

NFI Registration distribution

With the support of the volunteers, about 4000 NFI beneficiaries have been registered targeting the most vulnerable members of the community. NFIs were collected from Blue Ribbon Foods and ferried by a hired ZimAHEAD Lorry to the 5 distribution sites in Dangamvura daily as needed. A total of 2,688 beneficiaries got 2 bars of soap each – of these, only 2000 got Aqua tabs, but the remaining 1,312 who did not turn up to receive their issues, will be given them in the first week of March.

Other Efforts in Catchment area

Mercy Corps (MC) with funding from UNICEF have embarked on a blanket NFI distribution in the cholera hot spots in Mutare city. ZimAHEAD was involved in setting up the Mercy Corps distribution plan where we highlighted the hot spots. We have seconded our trained volunteers to the MC project for public health promotion sessions in the spirit of collaboration. The MC Project Officer responsible for NFIs spent a morning at one of our NFIs distribution site on a look and learns visit aimed at helping MC design their distribution plan. We are working in close cooperation on this aspect.

Challenges

Almost everyone encountered during PHP is asking for Aquatabs as they know that even though they do not qualify for our NFI, they are still vulnerable given the scarcity of water in Dangamvura. They are requesting to provide these since they are not available anywhere else. We however encourage other water purification means like boiling and chlorination as a stop-gap measure for non beneficiaries.

There were some incidences of political meddling where a couple of councillors feel they should be involved on the beneficiary selection for NFIs. We have managed to deal with such situations by explaining our position and it has helped reduce tensions.

The PHP walk on foot to support the community volunteers and this is quite a mammoth task given the vast distances that need to be covered in the operation area.

Opportunities

Now the training has been done and the CHCs started, we realise that we need a capacity building initiative to prepare management committees that will run the project after we have gone. The committees will sustain the CHC when the program winds up and we use them as an exit strategy. We are in the process of putting together a training module for such trainings and are proposing to run these trainings as soon as funds are available.

Conclusion

We would like to highlight the continued strategic relationships and partnership that we have with the Mutare City Council and other NGOs working in Mutare. We also value the support and cooperation that we are getting from the Sakubva and Dangamvura residents and as a result we will do our best to keep cholera under control.

CONTACT: Zimbabwe AHEAD: Sakubva District Hospital, MUTARE: 0913 038 700 / 011 442 219 regismati@yahoo.com

Zim AHEAD in partnership with Mercy Corps

Project Report. Dr. Juliet Waterkeyn, March 2007

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, and a rapid start up was achieved within two weeks of the funding being received.

Training

The health promotion programme started with a one week training workshop between 23rd – 27th 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.

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.

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

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.

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 district before 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.

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 officers stationed 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.