Community engagement to tackle maternal mortality in South Sudan

By Sally Theobald

With 2,054 maternal deaths per 100,000 live births, South Sudan has the highest maternal mortality in the world.

South Sudan is in transition. With years of conflict and the construction of a new nation, existing gender norms which mandate women bear many children have been intensified in order ‘to replace the ones that were lost’. Gender and societal norms are in transition. Elders complain that the young no longer listen to and respect their elders, couples do not keep to the traditional three years birth spacing, and marry younger and younger. Parents worry that their girl may get pregnant before marriage so they marry her off early, especially if she is not in school. Girls and boys have very limited access to sex education or contraceptives. These factors can lead to early pregnancy.

The SHARP Programme: community engagement for change

Korrie de Koning (Royal Tropical Institute) and Kingsley Chikaphupha (REACH Trust) have been working on the community participation component of the ‘SHARP’ programme in South Sudan. They provided some insights into how it is altering community norms around maternal health.

The SHARP programme aims to improve maternal health and is funded by the Dutch Government and is a collaboration of the South Sudanese Ministry of Health, Royal Tropical Institute, IMC, Healthnet TPO and Cordaid.  .

As part of the programme the Royal Tropical Institute developed a curriculum for the training of community facilitators to support dialogue and reflection on norms and values shaping maternal mortality and health service access and use. The curriculum was shaped by various sources, but drew substantially on the GTZ developed generational dialogue The curriculum was further adapted with input from the Community District Health Department in Wau, WBeG and Aweil North in Northern Bahr el Ghazal, REACH Trust, Malawi, International Medical Corps, and Healthnet TPO . Training of facilitators focussed on dialogue between older and younger women and men, comparing social and gender norms and practices between present and past, sharing knowledge on maternal health and discussing what needs to be changed for maternal health to improve.

How does it work?

Groups used drawings, statements and proverbs to explore the relationships between communities by gender and generation. For some women, this was their first experience of holding a pen or pencil but they were skilled in drawing images of maternal health decisions, dilemmas and outcomes throughout their life cycle. The ‘but why’ technique was used to probe and understand the rationale behind different cultural norms, their meanings and whether they were seen as fair.

Kingsley facilitated the men’s groups and explained at first there was complete refusal to even entertain the possibility of a discussion on contraception but use of the “but why” technique enabled discussion on the impact of multiple births on (especially young) women and child survival rates. This led to some shifts in viewpoints. Drama was also used, and women acted out what it is like to have obstetric fistula, and how women with urinary or faecal incontinence were treated within their communities. Following work in women and men only groups, the community fed back their ideas and experiences to each other, and for many women (who are very powerful within their own domains) this was their first experience of speaking publicly in front of men.

What changed?

Through the facilitated discussions between genders and generations statements for change were negotiated and agreed. Here are some examples:

  • “If a man with more than one wife is not looking after one of his wives and their children, the wife has the possibility to refuse to produce any more children without having to pay back the cows/bride price and also has the right to not be beaten.”
  •  “We don’t want daughters to marry or be pregnant before 18 years old and we in our family will do all we can –  we want to pledge this to our family and community.”
  •  “Married women should be allowed to use contraception and have three year birth spacing.”

This is an inspiring example of how community engagement can shift gender and societal norms and shows great facilitation skills from Korrie and Kingsley. Facilitators are being trained at local level and the approach will be rolled out and hopefully continue to challenge and change views and practices that undermine women’s maternal health.

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The Conversation: We are happy to be part of it

By Kate Hawkins

The Conversation is a website that was established in 2011 in Australia. Its purpose is to enable experts to comment on current affairs and to uphold high standards of journalistic integrity. Their charter expands outlines the principles that underpin their work, they aim to:

  • Inform public debate with knowledge-based journalism that is responsible, ethical and supported by evidence.
  • Unlock the knowledge of researchers and academics to provide the public with clarity and insight into society’s biggest problems.
  • Create an open site for people around the world to share best practices and collaborate on developing smart, sustainable solutions.
  • Provide a fact-based and editorially independent forum, free of commercial or political bias.
  • Support and foster academic freedom to conduct research, teach, write and publish.

Last week our colleague Barbara McPake had a piece published by the Conversation on “Fixing broken health systems in the aftermath of conflict.” We would like to extend our thanks to the site for featuring us and hope that you will visit their pages, have a browse, and support this important news portal.

Seven things we can learn from the Ebola epidemic in Uganda in 2000 – 2001

By Sarah Ssali, Senior Lecturer, School of Women and Gender Studies, Makerere University

Diseases such as Ebola highlight the importance of a holistic focus on health systems, as opposed to assuming that health is the preserve and concern of health professionals alone. This was the lesson Uganda learnt very quickly in managing the Ebola outbreak in 2001. Until the current epidemic in West Africa, Uganda held the unfortunate record for the greatest number of infections, with 425 recorded cases of Ebola, of which 224 people sadly died (Omaswa 2014, Kinsman 2012).

Gulu district, in the north of the country, bore the greatest brunt of the epidemic, with 393 people falling ill and 203 deaths (Kinsman 2012). But it was not the only affected district. Mbarara district in the south west, recorded five cases of people contracting Ebola of whom four died and Masindi district in the west recorded 17 deaths.

Ebola causes community panic and mistrust in the health system

Initially, the epidemic caused a lot of fear, panic, and anger within communities. As is the case in West Africa now, communities: stigmatized the sick; stormed Ebola isolation units (in Masindi) causing the unit to seek another site; and scared off relief burial teams, forcing them to abandon work (Kinsman 2012). Elsewhere in the country, fear and stigmatization grew, causing those who suspected that they had Ebola to hide and patients to flee hospitals once they knew Ebola treatment was being carried out there. In Kampala, religious leaders held prayer rallies against the epidemic, while in nomadic Karamoja anti-Ebola rituals were carried out.

Very quickly, the Uganda Directorate of Health Services learnt that they needed to do something to restore community trust if they were going to tackle the epidemic. Treatment alone was not enough. They needed the community to understand that those treating Ebola patients and burying the dead meant well and needed the community’s support.

Seven measures taken to tackle Ebola in Uganda

Measures were undertaken to gain the trust of the community and help them fight the epidemic. Okware et al (2002) and Omaswa (2014) provide a list of the interventions undertaken by Uganda’s Ministry of Health, which included the following:

1. Partnerships with communities

Upon realizing that they could not do everything by themselves, the Ministry of Health decided to build partnerships with other actors within the community, such as non-governmental organisations like the Red Cross and World Vision. These partnerships were crucial for mobilizing communities, information dissemination, and early case detection. Okware et al (2002) even state that anti government rebels stopped fighting and supported the anti-Ebola efforts

2. Community-based disease surveillance

The Ministry of Health trained community members to provide a network for surveillance and public information. These community members rapidly reported suspected cases from households, who were rapidly assessed using history of contact and clinical assessment. This strategy was important in that it was not very costly to manage.

3. Work with the Media

Realising the role of the media in informing and misinforming the masses, given their previous role in propagating myths and rumours about Ebola, the Ministry of Health learnt very quickly that they needed to partner with the media to provide prompt and factual public information. Information dissemination could no longer be the preserve of health workers. The media was trained in Ebola and barrier nursing to protect themselves, after which they were charged with providing factual updates about the disease on a daily basis. This way, the media helped curb rumours, myths and risks associated with the disease.

4. Technology for quick field diagnosis of new infections

Because there was no special laboratory for testing Ebola in the country, a field laboratory for spot screening was provided with help from the Centre for Disease Control (CDC) and the World Health Organization. The South African Institute of Virus Research helped customize certain procedures to make them simpler and less costly. This helped with early detection, while those suspected but found to be negative were able to return to their normal lives. This helped reduce stigma and re-build trust between the communities and the health facilities managing Ebola.

5. Infection control and hospital waste management

While health facilities should routinely manage waste professionally, this is not the case, especially in rural communities. Moreover, no one had been prepared for the kind of waste management that accompanied an Ebola epidemic. Sometimes, health workers thought that ensuring that isolating people with Ebola was all they needed to do. In addition, there was need to protect non-health workers in the Ebola response, such as drivers. The Ministry of Health developed a programme to promote infection control in hospital and health facility settings. However, this training was not restricted to health workers, but to others such as drivers who transported people to referral centres.

6. Work on the legal, ethical and social issues

One of the biggest challenges in combating infectious diseases arises from people’s traditions and cultural norms. Such traditions, with respect to the Ebola epidemic, relate to burials in ancestral grounds, funeral ceremonies, and the handling of the dead. People were provided with information about the dangers of touching those who had died of Ebola and encouraged to leave burials to the specially trained burial committees.

In addition, there were issues of disclosure and confidentiality, which posed ethical challenges to medical workers, and the several children (about 500) orphaned by Ebola. To address these, the government enacted the Workman Compensation Act which entitled infected health workers and their close kin some form of compensation. Individual confidentiality was suspended for public information sharing and counseling services provided to the orphans. In addition, a Post-Ebola Association and a special clinic opened to provide services to survivors.

7. National and international collaborations

One thing that has been associated with Uganda’s success in combating epidemics such as HIV and Ebola is the leadership and commitment from government. With the suspicion of Ebola in Uganda, despite meager finances, the government embarked on a process of providing essential resources to help combat the epidemic. These essentials included but were not limited to; supplies, funding, expertise, communication, and information. Where resources became a challenge, the government called on the international community to help. Some of these, such as CDC, provided the expertise in field testing. All external actors were coordinated by the National Task Force. In addition, other tasks forces were established at the district (DTF) and between ministries (IMTF). These task forces included policy makers, such as district leaders, Members of Parliament, religious leaders, and the police along with people from the health sector.

References:

Kinsman John (2012), “A Time of Fear”: Local, National, and International Responses to a Large Ebola Outbreak in Uganda, in Biomed Central 8 (15), Pgs 1-12

Okware S. I et al (2002), An Outbreak if Ebola in Uganda, Tropical Medicine and International Health, 7(12), Pgs. 1068-1075

Omaswa Francis (2014), Regaining Trust: An Essential Prerequisite for Controlling the Ebola Outbreak, The Lancet Global Health Blog, 11th August 2014

Photo courtesy of Josh Zakary https://www.flickr.com/photos/joshzakary/6864103297

Ebola emerges in fragile states: another ‘wake- up’ call?

By Kate Hawkins

Many ReBUILD researchers are also members of the Thematic Working Group on Health Systems in Fragile and Conflict-Affected States. Suzanne Fustukian (pictured), of the Institute for International Health and Development, Queen Margaret University, Edinburgh, is on the Steering Committee.

Along with Karen Cavanaugh who works at USAID she has just published a blog on Ebola for the Health Systems Global website. In it she argues:

In 2013 World Bank President Jim Kim stated that the lack of progress for many fragile states: “should be a wake-up call to the global community not to dismiss these countries as lost causes,” and that “timely and critical support [is needed] to improve the lives of people living in these fragile countries.”

If the global community has been sleeping on the job of supporting fragile and post-conflict settings, then the Ebola outbreak is certainly something to wake us up.

Read more…

What can we learn from health policy making patterns in post-conflict Sierra Leone for post-Ebola times?

By Kate Hawkins

I am a big fan of the IHP newsletter. It lands in the email every Friday and never fails to provide something to make you think, laugh, or get irritated. The editorials by Kristof Decoster are a must read and you can follow him on Twitter. What more could you ask for?

So a huge thanks to the IHP newsletter team for highlighting a blog by our colleague  last week. She argues that:

One of the unresolved challenges in post-crisis settings is the balance between humanitarian aid and the longer-term development approach to rebuilding the health system. We agree that decisions made in the early recovery phase could determine the long term development of the health system. But how, when, why and by whom are those decisions made? We know surprisingly little about that.

Drawing on evidence from a recent paper in Conflict and Health she outlines what happened with human resources for health reforms in Sierra Leone, from the end of the conflict in 2002 until 2012, and suggests some lessons that other countries can learn.

You can read all about it on the IHP website…

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