Interview: Evalyne Ngise, Nurse at Arjijo Dispensary

Evalyne Ngise works at the Arjijo Dispensary, she was deployed there in 2010. Sarah Manyeki (M&E Officer for the project in Kenya) had a short interview with her on the 26 June 2014

How many CHWs were trained and of those how many are active?

“The only person who can answer that question precisely is the CHEW, but I think 25 CHWs were trained. Out of this number, I have only noted 1 CHW who is outstandingly active and her name is Mama Faith (Rosemary)”

Asked why she said that the CHW is outstandingly active, she based it on the number of referrals by the CHW and the follow up calls that she makes.

What changes have you noted since the CHWs were trained?

“Since the CHWs were trained, there has been a big improvement. The number of outpatients seeking services has increased from 40 people per month to a minimum of 98 people and an average of over 100. Number of women seeking antenatal services has increased from 1-2 per month to 9-10 per month. The CHWs have also been trained on assessing malnutrition (using the MUAC provided by the MoH) and are therefore referring the children to the facility. They are also following up on immunization and once they identify that a child does not have a scar, then they refer them to the clinic, so far we have received 2 from Katunga village this month and another one who is scheduled to come next week from Sepeyo village (they can not immunize all the time, have scheduled immunization days to avoid wastage)”

“It is now more common to see men coming to the clinic to request for a HIV test. In the last month, we witnessed an upsurge in the number of women seeking Family Planning services. Very many women had a Norplant implanted on them. In the past, there were misconceptions on Family Planning. Many women however prefer depo because it has privacy and not many husbands will allow their wives to practice Family Planning in this community although some men have embraced the change.”

On skilled birth deliveries she said “from 2010 when I was deployed here to late last year, only 2 deliveries had been conducted at the dispensary. Currently, I conduct between 2-3 deliveries per month” She however said that she does not encourage women to give birth at the dispensary. “I prefer visiting the women at the comfort of their homes to assist them from there because the facility’s maternity is not well equipped, there is no delivery bed, beddings and the beds there are not in good shape” She was however quick to note that the County Government of Laikipia has pledged to assist the dispensary with Kshs. 240,000 from their development kitty and this money will be used to equip maternity. “I have ordered for a delivery bed, 4 beds, blankets and pipes for installing piped water system inside the dispensary”. This will be a great relieve for her and for the women. I came to learn later that she had been called to assist 4 more women during the month but could not attend them due to distance and lack of transportation.

According to Evalyne, the community is now more aware of the health issues, “it is now a common occurrence for community members to walk in to the clinic and request for water treatment tablets” she noted. This she attributed to the sessions being offered by CHWs.

What are the challenges experienced?

Despite all these there are a few challenges and the major one is staffing. “As you must have noted, I work alone at this dispensary. Sometimes I am invited for workshops or I have to go out for training which can be as long as fourteen days and there is none to relieve me. This is very disappointed for those community members seeking services during my absence, some walk as far as from Lariokorok Village only to find there is no one and then walk back. I am forced to work through out without having off days and this is very tedious.” She said. Lariokorok after enquiry, I learnt that its 24 kilometers to and fro.

“Another challenge is that the CHWs have no kits. This means that even for the simple cases like headaches, they (CHWs) have to refer” Evalyne added. She felt that if the CHWs are provided with kits, then her workload could be reduced. She also said that the facility is not well equipped. “we have no laboratory and this means that even the simplest cases like the ANC test profiles have to be referred to Doldol Hospital, most of the clients end up not going (to Doldol for tests) because they do not find it as an emergency”, she said.

Referrals are another headache because of the transportation issues. Asked about the sub county ambulance, “Most of the time the ambulance is not available. Most of the time we are forced to transport the referral cases using motorbikes which is very uncomfortable for me and for the patients,” she said.

Recommendations and closing remarks

Asked on what she would recommend, she was fast to point out that there is need for more staff, equip the maternity which is on the pipeline and provide the CHWs with kits. She also highlighted the issue of a gas cylinder used to refrigerates the immunization drugs. “We only have one cylinder in this facility. We are therefore forced to skip immunizations sometimes when the gas is finished and have to wait for an extra cylinder from the Doldol sub county Hospital” She said that a second cylinder would be of great help.

On her closing remarks, she said that “the CHWs are doing a commendable job in referring cases and making up follow up calls, enquiring whether the nurse is available before referring and consulting on what to do for the simple cases as well as finding out the clinic and immunization days on behalf of the community” She however said that the CHWs need to do the household visits more often especially to the women with small children to identify cases of malnutrition.

Understanding links between Traditional and Skilled Birth Attendants

Image

By Pamela Onyo, Anglican Overseas Aid

AACES TBA

The Road Less Travelled (TRLT) is a project supported within the Australia Africa Community Engagement Strategy (AACES). AACES is a partnership comprising the Australia government with ten Australian NGOs and their partners working across eleven African countries. Each year AACES releases an annual report and this year the Kenya partners decided that the theme should be the outcomes of research conducted under the auspices of TRLT.

The research sought to enable better understanding of the current care seeking behaviour of childbearing women in pastoralist communities of Laikipia and Samburu Counties. The two-year study has been conducted by TRLT partners Nossal Institute for Global Health at the University of Melbourne and the Mother’s Union of the Anglican Church Mt Kenya Diocese, in collaboration with Amref Health Africa. It has been funded through the Australian Development Research Awards.

What is the issue?
Kenya has an unacceptably high numbers of mothers and babies dying at the time of birth. This is particularly and especially true for the semi-nomadic pastoralist communities who are living in remote parts of the country where many women deliver their babies at home attended by a traditional birth attendant (TBA). These TBAs are generally highly respected and trusted members of their communities who have a personal relationship with the women they are caring for. However, they are not trained nor equipped to manage complications of pregnancy and childbirth, which occur in about 15% of cases, and contribute to the preventable deaths of mothers and babies.

The government of Kenya wants all women to deliver their babies attended by skilled birth attendants (SBAs) in health facilities such as dispensaries and hospitals and has put a target of 90% skilled birth deliveries by 2015. SBAs are doctors and nurses who are trained and equipped to respond in the event of complications. However, for a range of reasons, women from pastoralist communities are often reluctant or unable to attend these services.

Launching the AACES Annual Report
With the research now complete the findings were disseminated to local stakeholders from Laikipia and Samburu County’s, and also at the national launch of the Australian Africa Community Engagement Scheme (AACES) annual report. Over 200 people attended the national annual report launch including government representatives, community members, and NGO CEO’s.

The report was launched by the Australian High Commissioner, HE John Feakes, while the Archbishop of the Anglican Church of Kenya, HE Eliud Wabukala, was invited to deliver an address on the research report where he said: “If we are to reduce the incidence of maternal and neonatal mortality then we need to understand what the factors are that attracts or inhibits a woman from seeking professional support when giving birth … The report provides illuminating information on the situation for pregnant women in Laikipia and Samburu. This information gives a detailed picture about what it is like for a pregnant woman, the difficulties and challenges that she faces in bringing new life into the world.”

The Research Findings
The main findings from the study are that:

  • The pastoralist women knew about the free delivery care provided by the government, but for many, the distance to the health facility was too far to walk, and transport costs were a problem.
  • Both women and men acknowledged that delivery with an SBA in a health facility is more hygienic and safer because they can manage complications if they occur.
  • The women said that they were frightened of some medical procedures in hospitals, were concerned that their modesty would not be protected, found hospitals to be very cold places, and did not want to be separated from their families during the delivery period. Additionally, SBAs have a reputation for being unfriendly to pastoralist women. Some women thought that having a baby in a health facility was a sign of weakness.
  • According to pastoralist women, TBAs provide comfort and care in a warm and familiar place, and are locally available and affordable.
  • TBAs remain with the women for days to weeks after delivery to care for them and to take responsibility for household duties so they can rest.
  • The role of TBAs includes helping to mediate between the husband and wife, giving dietary advice (sometimes not very good advice), receiving the baby, massaging the woman, promoting breastfeeding, and if necessary, referring and accompanying the woman to the health facility.
  • TBAs are able to recognise the important complications of delivery, but refer rather late in the event of an obstructed labour. They do not really know how to manage a baby that is having difficulty breathing.
  • Actively including TBAs in programmes designed to improve better utilisation of SBAs in pastoralist communities will help to increase the number of SBA deliveries, and reduce the number of TBA deliveries, some of which are unhygienic and unsafe.

Conclusion and Way Forward

  • There is potential complementarity in the perceived strengths of SBAs and TBAs. TBAs are highly acceptable and accessible to women, and are valued for their supportive role and emotional and socio-cultural sensitivity, but are not trained or able to diagnose or manage most obstetric and neonatal risks and complications. SBAs are skilled in diagnosis and management of these risks and complications, but are not seen as very accessible, or acceptable, in their service delivery. This complementarily, and the strong support from all stakeholders for greater integration of the work of TBAs and SBAs, will lead to further consideration of potential models for collaboration and cross-learning.
  • When combined with results from the quantitative arm of the study, they informed options for collaborative models of care involving both TBAs and SBAs for more effective, efficient and contextually appropriate care, which will be developed in partnership with participants and other stakeholders. These models will consider the potential for collaboration across all stages of pregnancy, labour and delivery, and the neonatal period.

As a result of the research the TRLT project and research partners, in conjunction with the Ministry of Health, are investigating the possibility of piloting a ‘pastoralist friendly health facility’.

A pastoralist health facility would support shared care by traditional birth attendants (who are preferred by women to be their service providers) with skilled birth attendants (who are the providers with the skills to save maternal and newborn lives). Such a facility would be structured specifically to suit the requirements of pastoralist women and ameliorate the issues that inhibit them for attending. For example, it may have a traditional house with fireplace on clinic grounds where a woman may weight prior to going into labour, and her close friends and family can be in attendance. A TBA may accompany the expect mother and comfort her during the birthing process, while clinic staff are especially trained to respect the woman’s modesty and accommodate her cultural requirements. The clinic would build close links to the community so that they feel ownership and responsibility for it. The objective is to significantly increase the number of women who attend ante- and post- natal care, and deliver in a safe environment, therefore reducing maternal and neo-natal mortality.

You can watch a video on the AACES 2013-14 Annual Report at: https://www.youtube.com/watch?feature=player_embedded&v=UQJePZcIaKI

You can access the AACES 2013-14 Annual Report at: http://dfat.gov.au/about-us/publications/Pages/aaces-annual-report-2013-14.aspx

You can download a booklet where TBAs and SBAs who took part in the research tell their stories:Walking together book viewing version

Below is a video about TBAs and SBAs, and how they are working together to benefit communities.

Credits for the photo are: From Left – Mary, AACES program beneficiary, John Feakes, Australia’s High Commissioner designate to Kenya (left), Anna Dorney from DFAT, Eliud Wabukala, Kenyan Anglican Archbishop, and Patrick Amoth, Ministry of Health. Photo by Douglas Waudo, ACBF.

Small steps generate bigger changes

By Loretta Pilla, Anglican Overseas Aid

The Road Less Travelled (TRLT) is an integrated maternal and child health and community development project working with nomadic pastoralist communities in Kenya and Ethiopia. The project is led by Anglican Overseas Aid in Kenya, partnering with the Mother’s Union of the Anglican Church of Kenya and the Maasai and Samburu nomadic pastoralist communities in Laikipia and Samburu counties. TRLT’s holistic approach focuses on improving core maternal and child health (MCH) outcomes, and applies methods to address education and literacy, as well as improve access to water, food security, and sustainable livelihoods. The desire to achieve health equity through the empowerment of women underpins all activity. Three years on it’s exciting to see people’s lives changing for the better in Longewan Ranch in Samburu County, especially for women.

Longewan Dispensary, Samburu county.  Image: Loretta Pilla/AOA, 2014

Longewan Dispensary, Samburu county.
Image: Loretta Pilla/AOA, 2014

Understanding women’s empowerment

Transforming women’s lives in a patriarchal environment is a difficult but essential challenge for TRLT. Empowerment is not a simple task; it is a multi-faceted process. Adequate support needs to be in place before starting the process. A sense of belonging and increased self-esteem are factors that contribute to a woman’s status in community. Her respect subsequently grows within families, communities and the broader society. TRLT, through its partnerships, provides the necessary support, information, resources, and creativity to allow women to find solutions to their own problems.

Challenges for women’s health

Initiating the process to improve women’s authority, one cannot ignore the cultural, social and environmental milieu which can inhibit progress. In Samburu, women traditionally birth at home away from qualified nurses. There are many constraints to attending clinics, including lack of nurses, distance, refusal by husbands, and women’s own beliefs that delivering at a clinic is a sign of cowardice.

Antonella Leakono has been the only nursing officer in charge of Longewan Dispensary for five years. As a Samburu woman, she recognises the need to invest in community health programs to achieve better health over the long haul for the people of her community.

“The biggest child health issues in this area are malnutrition, pneumonia, and diarrhea,” Antonella explains. “For women of reproductive age, it is anemia and infections related to giving birth at home.”

Causes of infections can include the use of unsterilised instruments during the delivery such as a knife for cutting the umbilical cord. Raising awareness on MCH remains a challenge, an almost impossible task for one Ministry of Health staff member, like Antonella, to tackle on her own.

Providing support: Instigating change

Longwean Link Person, Carolin, proudly displays her medical supply bag that she carries to every household visit. Image: Loretta Pilla/AOA, 2014

Longwean Link Person, Carolin, proudly displays her medical supply bag that she carries to every household visit. Image: Loretta Pilla/AOA, 2014

At the frontline of change are community health workers (CHWs) who have been trained collaboratively by TRLT and the Ministry of Health to provide frontline health services. Although the 18 Longewan CHWs do not have the same qualifications of a community health nurse, these volunteers spend approximately six hours per day, three days per week, visiting and caring for families, whilst also looking after their own. In one month, the 18 CHWs visit up to 248 households, and provided community members with pain killers, vitamins such as zinc, and oral rehydration solutions.

Carolin, the TRLT link person who has been trained as a CHW, explains that: “We educate women on importance of visiting clinics and on immunisations. Through trainings in the area of maternal neonatal child health, nutrition and first aid, we have the skills to identify danger signs such as bleeding during pregnancies, if a child is malnourished or if a child is not breastfeeding properly”. The work of the CHWs make significant contributions across many of TRLT’s goals in improving women’s health through women’s empowerment in the region. Yet their impact is far greater than just basic health services. They have an effect on community socio-economic standards generally, along with influencing the esteem with which women are regarded.

Empowerment through education and training

In Samburu, only 15% of women can read and write in Maa and/or Swahili.  Hosea and Cecilia are two CHWs in Longewan who have started to facilitate free adult literacy and numeracy classes for men and women. Currently, 24 women and three men attend the classes. Literacy plays an important role in determining women’s health, and their ability to seek healthcare. Improved literacy levels expand women’s access to knowledge, economic resources, and political power.

Painting on the Longewan Dispensary wall encourages pregnant women to visit the clinic.  Image: Loretta Pilla/AOA, 2014

Painting on the Longewan Dispensary wall encourages pregnant women to visit the clinic.
Image: Loretta Pilla/AOA, 2014

TRLT, in partnership with Equity Bank, have organised business training and financial management classes to improve men and women’s ability to save and better manage their assets. Poverty is intrinsically linked with poor health as it forces people to live in inadequate environments. By empowering women with the skills to manage their finances, it makes them less dependent on their husbands, and more likely to financially invest in their family’s health.

Identifying child malnutrition and anemia in pregnant women as a need, CHWs have also been involved in broadening the diet of community members through kitchen garden awareness training conducted in partnership with the Department of Agriculture. TRLT’s seed bank initiative encourages community members to produce their own food, whilst supporting others in their community. TRLT provides start up seeds from which community members grow their own crops. Once the crop has gone to seed, they are expected to keep a proportion for their next harvest, whilst distributing the remaining to others who can then start their own garden.

Saving Lives, Healthy Children, Improved Economy

In combination the CHW activities have an impact far greater than each individual task. Encouraging women to go to clinics for checks and to birth reduces risk of infection and even mortality. Improving diet, and working with the Ministry of Health on vaccination campaigns, leads to healthier children more resistant to debilitating diseases. Literacy education increases confidence and the ability to make and apply decisions that affect mothers’ lives. Starting-up small-scale economic activities generates disposable income to be spent on improving family well being. Along with reducing demand, and associated costs, on curative health services, the total effect contributes to the social health and well being, improves productivity adding to societal wealth, and accordingly strengthen the entire community.

The road ahead: Working together with the community health workers

The cohesion and commitment of these CHWs is palpable. They are being seen as community leaders, and regarded by their peers, both male and female, as equals because of the competencies and authority they provide. Moreover, the carry on effects of their work – empowering women and their communities through an integrated maternal and child health approach – is invaluable.

“People want to live a good life, so they see the value of our work in the community,” Cecilia explains. “The level of knowledge in the community is slowly increasing. People are beginning to change.”

 

Improving access to healthcare

NTV Kenya has recently posted the following video from their Health Assignment program on Youtube.

The program looked at the impact of The Road Less Travelled project in the northern parts of Kenya.

In forthcoming weeks, we will also be sharing three more videos from NTV Kenya. They are providing stories covering toilets, access to water and its links to maternal health, and the role of traditional maternal shelter alongside a modern maternity clinic.

Keeping track of The Road Less Travelled

We are pleased to announce the publication of The Road Less Travelled Annual Report for 2013-14.

Cover of Annual Report

The report provides detailed feedback about the impact of the project in Ethiopia and Kenya, as well as narrative stories of transformation and life-change. Of paramount importance is the engagement with, and benefit for, the most marginalised people within the project communities, especially women.

This is done through a strengths-based approach to community development, in which communities are at the centre of their own development vision and recognise and draw on their existing assets to achieve their development aims.

“People want to live a good life, so they see the value of our work in the community.
The level of knowledge in the community is slowly increasing.
People are beginning to change.”

Cecilia, a Community Health Worker in Longewan, Samburu County, Kenya

Significant progress has been made, with:

  • 2584 additional people having access to sustainable, safe water.
  • 3283 additional people having access to appropriate sanitation.
  • 506 additional people accessing a modern family planning method.
  • 1278 additional children receiving vaccines within the first 12 months of life.
  • 379 child deliveries occurred with a skilled birth attendant present.
  • 317,150 people received vital health education messages around measles, malaria, diarrhea, pneumonia and nutrition.

“Mille hospital has changed the lives of mothers. There is less threat of abnormal presentations and good food is supplied to expectant mothers.”
(Response from a men’s Focus Group Discussion)

You can read the report here: The Road Less Travelled Annual Report 2013-14

The Road Less Travelled: Update

As you are likely aware, this blog has been somewhat dormant over the past few months as we have transitioned its management from Australian Volunteers International (AVI) to the lead project partner, Anglican Overseas Aid.

Changes in Federal Government funding meant that AVI could no longer undertake the communications component of the project. We offer our deep gratitude to AVI, and particularly to Hannah Ford, for the amazing work they have done to run this blog. We highly recommend reading Hannah’s powerful final blog post ‘If these hands could talk’.

We regret that the transition has taken longer than expected, but we are looking forward to sharing a range of new stories over the coming weeks and months.

Of particular note, we recently completed our Annual Report for 2013-14, which outlines the progress made through the project. We will make it available here soon.

Over the coming weeks and months we will be sharing:

  • interviews with voluntary and professional health workers in Kenya
  • an article about cultural shifts among the pastoralists of Ethiopia and Kenya
  • video news stories about our work from National TV in Kenya
  • an article about small steps creating big changes through women’s empowerment
We hope you will continue the journey with us along The Road Less Travelled.

If these hands could talk

I remember gazing at the hands of a traditional birth attendant in pastoralist Laikipia, Kenya, and wondering about the stories they might hold. How many newborns had these hands supported into the world? What challenges had been faced by the women they helped through childbirth, in their remote rural homes far from any health clinic? Beneath the rough and wrinkled surface, how much loss had they absorbed through these experiences?

The hands of a traditional birth attendant in Laikipia County, Kenya.  Image: Hannah Ford / AVI

The hands of a traditional birth attendant in Laikipia County, Kenya. Image: Hannah Ford / AVI

Sub-Saharan Africa has the highest maternal mortality rate, bearing the burden of more than 50 per cent of the world’s maternal deaths. One in 39 women in this region faces the risk of dying in childbirth in their lifetime.

Yet less than half of all mothers in sub-Saharan Africa have the support of a trained midwife, nurse or doctor during childbirth. Even fewer mothers from the marginalised nomadic pastoralist communities of Kenya and Ethiopia have access to skilled birth attendants. While evidence has shown that access to skilled care during pregnancy, birth and post-delivery, is key to saving lives, many women don’t have an option.

For the past two years, I’ve had the privilege of working on The Road Less Travelled project and coordinating this blog. I have learnt so much during this time. As I reflect on my experiences, what stands out to me most is the strength and resilience of the pastoralist communities at the heart of the project – and especially that of the mothers. They want what all women want for their children: the chance to survive and thrive.

Continue reading

Overcoming the obstacles to basic healthcare access

This post was written by Chris McKeon, Writer and Production Assistant at Arete Stories.

When The Road Less Travelled project began, the newly-built Morupusi dispensary sat alone on an empty hill. Its metal roof shone but the dust that covers the region had already begun to settle on its walls. Mounds of rubble surrounded it, instead of the people who normally wait outside health centres. Inside, there was nobody. Its walls and rooms were bare. There were neither drugs, nor places to store them nor people to administer them. The dispensary looked abandoned, but it wasn’t – it had never been occupied.

It was built with funds from the local Constituency Development Fund to serve the 4000 Maasai pastoralists who live in the Morupusi Group Ranch, in northern Laikipia, Kenya. They were walking 10 kilometres to the nearest hospital at Doldol, where they would wait for hours to be seen; a return journey that would take up to a day.

Before the clinic opened, women from Morupusi would have to walk to Doldol carrying their children on their backs if they needed medicine.  Image: Matthew Willman / Anglican Overseas Aid

Before the clinic opened, women from Morupusi would have to walk to Doldol carrying their children on their backs if they needed medicine.
Image: Matthew Willman / Anglican Overseas Aid

“We wanted a dispensary here because of the distance,” explains Elizabeth Kaparo, a local Community Health Worker and Treasurer of the dispensary committee. “Women have to walk to Doldol carrying their children on their backs if they want medicine. So we applied to the Constituency Development Fund (CDF) for money.”

Attaining funding to build the clinic was only the first step on a long road to improving access to health services for the Morupusi community. Once it was built, because the Ministry of Health had not been notified about the clinic, there was no budget allocated for staff, and no medical supplies. The building stood empty, and the Maasai continued their long walk to Doldol.

When the Community Development Committee reached out to Anglican Overseas Aid and The Road Less Travelled for help, project staff saw immediate potential in the clinic to become a central hub for community health and education. They formed a three-way partnership with the community and the Ministry of Health.

Continue reading

Let our sisters learn

For pastoralist children in the isolated Afar region of Ethiopia, access to education has always been extremely limited. For girls, there is even less opportunity. The Afar Pastoralist Development Association (APDA), which began its first literacy program in 1996, is responding to the situation.

Since APDA started the literacy program, it has evolved to improve the coverage and quality of education in the Afar region, with an emphasis on education options that are appropriate for pastoralist children. While primary level education was being achieved in many areas through a combination of mobile and static education, the next challenge was to come up with a solution for how the children would continue their learning.

As an extension of the literacy program, APDA has been piloting a strategy that will ensure more girls gain access to education on an ongoing basis.

In the first year it was difficult to get girls into the student hostel, but over time pastoralist families have come to realise the benefits of giving their daughters the opportunity to learn. Image: Kate Holt / Anglican Overseas Aid

The Road Less Travelled project partner APDA is working with remote pastoralist communities in the Afar Region of Ethiopia to increase girls participation in education.
Image: Kate Holt / Anglican Overseas Aid

Through The Road Less Travelled, a partnership project led by Anglican Overseas Aid, APDA has established a student hostel in the town of Asayita. Pastoralist children from remote rural areas move to the town to live in the student hostel accommodation during the school term, so they have the opportunity to continue learning. The project supports the students to live while they attend the local government school from grade five onwards.

A key priority of the hostel is to increase girls’ participation in education – a challenge that has been met with some resistance from pastoralist communities. One factor that has helped to pave the way for Afar girls is the presence of the hostel house mother, Lako.

Lako is a mother from the same remote community as the students, and responded to APDA’s search for a volunteer house mother.

“They needed someone, so I said I’d go,” she says. “The best thing I can do is look after children. If our children learn, we can have a great future.”

Continue reading