Effective Intervention is a UK based foundation dedicated to reducing infant mortality rate in developing countries. It has selected Guinea Bissau as it is one of the poorest nations in Africa. It was found that some districts, as many as 300 in every 1000 infants die before they are one year old, from lack of care and medical resources. With such an appalling low survival rate the research programme is hoping that the intervention will make a real difference to the lives of women and children who currently have so little support. Africa AHEAD has been asked to help with the community mobilisation to enable health promotion to be effectively undertaken. The Health Club idea is being enthusiastically endorsed in this ambitious research programme that seeks to lower infant mortality rate by 30% in 3 years. Currently training material is being prepared to enable participatory training to start in October 2007.
Reduction of Infant mortality in the poorest country in Africa: Guinea Bissau, West Africa, August, 2007
Effective Intervention in Africa
Effective Intervention is a new foundation established in 2006, to pilot sound development programmes that can demonstrate scientifically, the most effective means of decreasing infant and child mortality in developing countries. The founding Directors, Peter and Amy Boone, are a philanthropic husband and wife team with a strong commitment to providing rigorous studies that will enable the sector to learn from successful approaches. Their aim in starting Effective Intervention is to target the worst case scenarios in terms of infant mortality rate, and set up two programmes, one in India and the other in Africa as pilot projects from which rigorous studies can be published.
Criteria for intervention
Guinea Bissau in West Africa, was selected by virtue of having one of the highest infant mortality rates in Africa (30% of children dying before they are two). Ministry of Health directed Effective Intervention to pilot the programme in the two most neglected areas: Tombali and Quinara Districts in the low lying estuaries of the south east of the country.
Looking for best practices
When Africa AHEAD Association was selected as one of the finalists in the 2006 Development Marketplace Competition for innovative projects (World Bank, Washington), the Director of Effective Intervention was scouting for best practice in development initiatives. Peter Boone was quick to see the potential of the Community Health Club Methodology for maternal and child health and had the insight to see how it could be used to mobilise communities within the Guinea Bissau context.
The Zimbabwe Experience
After a visit to Zimbabwe in October 2006, to verify the claims made by the Director of Africa AHEAD (Waterkeyn & Cairncross, 2006) on the popularity and cost-effectiveness of this approach, Peter and Amy were convinced. They invited Africa AHEAD to partner with Effective Intervention to advise the Guinea Bissau programme on how to replicate the methodology, and adapt it to West Africa conditions. With the positive experience of Sierra Leone, a West African country where health clubs had thrived in resettlement Muslim villages in the rural areas since 2002, there was good reason to believe the health clubs would be equally popular in the largely Muslim villages of Guinea Bissau. Two lean organisations; Africa AHEAD and Effective Intervention are two small organisation with a lot in common.
- Firstly it is worth noting that both are founded by a dedicated husband and wife team, and that this is a cost effective domestic partnership in both cases!
- Both are small, lean and informal organisations with a strong development ethos with the driving force being the founders’ personal commitment to making a difference.
- Both organisations are interested in the need for rigorous scientific studies to quantify health and hygiene behaviour change in order to demonstrate cost-effectiveness.
- Both have roots in Commonwealth countries: Africa AHEAD is founded by a Zimbabwean/Southern African partnership, and Effective Intervention by Canadians.
- Both continue to have strong links to the mother country through the University of London. The Director of Africa AHEAD studied through the London School of Hygiene and Tropical (LSHTM) where the original PhD research was conducted on the Community Health Club Methodology and the Director of Effective Intervention is based at the London School of Economics, while the statistical analysis for this programme will be done in conjunction with LSHTM.
- Most importantly, both organisations have a vision of holistic and long term development in order to build capacity of the functional communities to sustain their own livelihoods more effectively, particularly in terms of child survival and the prevention of communicable diseases.
Research in Guinea Bissau
The programme in Guinea Bissau is ambitious and if it succeeds, the study will become a seminal work in this field, and will hopefully become known as a model of sound development practice internationally. The research component led by Dr. Ila Fazio aims to monitor for two years the outcomes of the intervention amongst a population of 7,000 women, from approximately 4,500 households, in 300 villages, grouped into 146 clusters. The base line survey was completed this month, and the comprehensive data is now being processed. A post intervention study will be carried out amongst the same population in two years, whilst continuous monitoring will provide longitudinal data. Once the existing picture has been captured the random selection of intervention villages will be done and the implementation of the programme will begin. This consists of two main thrusts; one clinical and one preventative.
High rates of Infant Mortality in the villages of Guinea Bissau
Child rearing in Guinea Bissau is high risk. The mother of twins (above left) battles to breast feed both babies, and relies on milk powder which is often too diluted to provide adequate nutrition. Lack of clinical resources, poverty and ignorance of good child rearing underlies the high death rate in under 5’s.
The tiny one month old weighing less than one kilo, (above right) died shortly after we met her 16 yr old mother desperately trying to nurse her baby, who was chronically malnourished and dehydrated. Having contracted neo-natal tetanus from the use of dirty blades in delivery, the new born was treated traditionally in the village and had continuous diarrhoea. If her mother had been a health club member she would have had the correct information on how to treat tetanus and diarrhoea and her child would have survived. With support from fellow members the young mother would know that she needed to go to the clinic. Effective Interventions will enable this basic knowledge of child rearing to be available as well as free access to clinical care for mothers with children under 5 years.
The Clinical Intervention
The clinical programme will provide training for village health workers and traditional birth attendants, as well as free medical treatment and essential drugs for children under 5, who have been registered. A team of eight nurses will be provided with training material and equipment, as well as quad bikes to provide weekly check-ups for all pregnant mother who are being monitored in intervention villages. As existing health facilities in this region are practically non-existent at present, two mobile clinics will be set up and local hospital and seven Clinics in strategic centres will be supported to enable safe delivery for mothers with complications.
Clube de Saude Communidade
On the preventative health side, all mothers will be encouraged to register with a Community Health Club (Clube de Saude Communidade) that will be set up in each village, and the completion of all 20 health sessions over the next six months will be a prerequisite for free treatment, although paid treatment is available for all and no cases will be refused on compassionate grounds.
Scale of the Programme
The health club will target women in particular, and hopes to attract at least one women from every household within each village. Men, being equally important in decision making on health issues, will also be encouraged to join, in order to ensure that no one fails to benefit from the programme, due to their husbands forbidding recommended practices. This will entail setting up approximately health clubs in 75 clusters, with one to three clubs per cluster. Each of the 225 health clubs should average at least 75 (female) members, giving a target of nearly 17,000 women in the first year alone, with as many again in the following twelve months. Whilst health clubs are free for men and women of all ages and educational levels, a subsidiary of each health club will be the Mother’s group, which is a weekly training for all pregnant and mothers with young babies who will be monitored more closely by the clinical side of the programme. Health Promoters, will be fully mobile with motorbikes and facilitate at around 7-9 health clubs each weekly, depending on the size of their clusters.
The Health Promotion Intervention
The training of 28 health promoters began in August 2007 with one week of training in the introduction to the Community Health Club Methodology, provided by Africa AHEAD. New recruits were then trained in the use of newly developed visual aids, and have become proficient in the use of participatory activities to motivate the community in each session of the village training.
Over 150 illustrations, drawn by the two famous twin artists of Guinea Bissau, Manual and Julio Fernando, have been developed each with key messages in the prevention, transmission and treatment of diarrhoeal disease, malaria and respiratory infections, as well as hygiene sets on safe water and sanitation, immunisation, HIV/AIDS, reproductive health and child care. These card sets, developed using principles of ‘ethnographic illustration’ pioneered by Africa AHEAD (Waterkeyn, 1985), were modelled to some extent on the PHAST Tool kit that became the essential equipment for Environmental Health Technicians in Zimbabwe. With thorough pretesting over the past few months, Effective Intervention has been careful to ensure full comprehension and the cultural appropriateness of each illustration.
New Portuguese PHAST Training Manual
Dr Rebecca King, (Programme Designer), and Albino dos Santos, (Programme Manager), have produced a carefully edited manual that will accompany the visual aids, ensuring a training package that should provide a much needed PHAST Tool Kit for the country and enable the participatory methodology to be easy scaled up to national level. As the manual is in Portuguese, this will doubtless be a valuable addition to the whole continent where English and French publications tend to dominate. Ministry of Health in Guinea Bissau is firmly behind this programme and are providing trainers to be seconded to the field wherever possible. Whilst shortage of MoH environmental health staff has necessitated the 28 health promoters to be employed by Effective Intervention, eight nurses are being seconded to the organisation for the clinical programme. With the base line survey complete and the training materials developed and printed, the intervention is due to start when the rains end in October 2007. Africa AHEAD is proud to have Effective Intervention as a partner in a programme which is set to be a very effective intervention, and will certainly move Africa ahead in a small but we feel, an important way!.