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.

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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.

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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.”

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The changing role of Maasai men in maternal health

James Senjura works closely with the Maasai pastoralist community of Laikipia, Kenya, to improve maternal and child health. He is a Project Officer for Mothers’ Union, Anglican Overseas Aid’s partner in The Road Less Travelled project, and also a father and positive role model for other men in his community. The project works with the community to identify key development challenges, and helps to develop locally-appropriate solutions to deliver basic health care and education where access to formal services is limited. James answers some questions about traditions and gender norms relating to maternal and child health within his culture.

In the Maasai community of Laikipia, how would you describe the traditional role of men in maternal and child health?

Traditionally, men’s role in maternal and child care has been passive. Maternal and child health care was in the hands of traditional birth attendants and old women.

Mostly men provide financial support and organise for transportation, and sometimes in consultation with the traditional birth attendant they decide for further action in case of complications or disease occurring. The father would advise on the estimated date of delivery, so that the woman would be prepared.

Image: Matthew Willman / Anglican Overseas Aid

Traditionally, the role of Maasai men in maternal health and child care has been a passive one. Image: Matthew Willman / Anglican Overseas Aid

It was also the role of man to source food (slaughter animals, draw blood) for the mother during and after pregnancy. When a woman was in the last trimester, the man would ready some rams for slaughter after delivery.

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Improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia

This guest post is written by Dr Ruth Jackson of the Alfred Deakin Research Institute. Dr Jackson is working on a project focused on improving the use of maternal, neonatal and child health services in rural and pastoralist Ethiopia. The project is funded by the Australian Development Research Awards Scheme. Dr Jackson has been learning from the experiences of Women’s Extension Workers who work with the Afar Pastoralist Development Association, a partner in The Road Less Travelled project.

“You won’t believe us – we start walking in the morning up til night time to collect water. Then we grind the wheat, collect sticks for firewood and take water to the animals. Sometimes if we have to sleep where we collect water, we take our baby with us, otherwise we leave the baby in the house.”

- Women’s Extension Worker, Logya, Afar Region, Ethiopia, 25 March 2014

We are sitting in the shade at the Afar Pastoralist Development Association (APDA) training facility with 19 Women’s Extension Workers. The women, many with young children and babies, are attending their annual refresher training. It’s too hot to sit inside the training centre but relatively cool in the shade of the building.

Along the fence line are the rooms in which the women stay for the month. Although they are square and joined together they are built of the same materials as the Afar huts or aris. Aris are normally hemispherical and made of palm ribs covered with matting. They are light and portable and easily dismantled – a job usually done by women.

While the Women’s Extension Workers are away from home attending training their husband or mother has to collect water. Men don’t like collecting water as it’s “women’s work”. But one Women’s Extension Worker explained that they had to help their husbands understand that “helping each other is good. Some men joke about doing it while others don’t like doing it … in the past, some men even refused to allow their wives to come to training.”

Fatuma is a Women’s Extension Worker Coordinator for the Afar Pastoralist Development Association, with a total of 12 WEWs in her team. Image: Kate Holt / Anglican Overseas Aid

Fatuma is a Women’s Extension Worker (WEW) for the Afar Pastoralist Development Association, and coordinates a team of 12 WEWs in her area.
Image: Kate Holt / Anglican Overseas Aid

Afar Region in north-eastern Ethiopia is dominated by the Danakil depression in the north, which is largely desert scrubland with shallow salty lakes and long chains of volcanoes. In the south, the Awash River flows into the northern lakes rather than to the sea. Much of Afar is below sea level and it is one of the hottest places on earth, with temperatures higher than 50°C in the summer. About 90 per cent of the regional population base their livelihood on livestock rearing – cattle, camels, goats, sheep and donkeys – with limited agriculture along the river basins and low-lying riverine areas.

The Ethiopian Ministry of Health acknowledged in Health Sector Development Program IV (2010/11-2014/15) that there was a lack of appropriate health service delivery packages to address nomadic and semi-nomadic communities in Afar Region.

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