Trusting the people to solve their health problems
"My neighbor was pregnant, and last month she was going to the well to draw water and fell down.
"There was not a road to the hospital. We put her in a wheelbarrow. It was raining very hard. We had to wait three to four hours for the rain to pass. It was midnight, and we were very far away.
"Before we got to the hospital, she died."
Alice Daniel sits in a teal blue room of the small clinic in Mpape, Nigeria, an impoverished community of tin shacks just outside the capital city of Abuja. Indignation simmers beneath the words of her story. Daniel knows that for many Nigerian women, pregnancy is a roll of the dice. Joy or death. In Nigeria, a woman's lifetime risk of death during pregnancy or childbirth is 1 in 18. For women in industrialized countries, the risk is 1 in 8,000.
Her neighbor's death encouraged Daniel to help pregnant women in her community get antenatal care at the clinic as well as reliable emergency transportation. "I want to save my women," Daniel says.
Sitting near Daniel on a wooden bench, businessman Abdullah Abubakar joins the conversation. When his wife went into labor in 2002, Abubakar rushed her to the hospital on a motorcycle. "Before we could get to the hospital, the baby died. It nearly claimed my wife, too," he says. "Since then, I feel pain when I see women in labor without help. I must support them."
The barriers to safe births for mothers and babies in Nigeria—Africa's most populous country—are considerable: The nearest clinic is likely far away and has paltry stocks of medications. Health providers are not always well trained or particularly trusted by the community. In some parts of the country, a woman must have her husband's permission to leave the house (which creates a serious risk if she goes into labor while her husband is away). Many women are not educated about pregnancy's danger signs such as headaches, swelling feet, bleeding and so on. Transport to a clinic or hospital is often prohibitively expensive or nonexistent. Such obstacles often prove insurmountable for Nigeria's poor, so they resort to what they have always done: giving birth at home and praying.
Today, even the most basic tools of medicine and public health—immunizations, antibiotics, safe drinking water, antenatal care and so on—still elude many of Nigeria's 140 million citizens. And it is not just mothers who are dying but babies, children, adolescent girls and boys, and men. Traditional indicators of population health are a compendium of misery: More than 1 million Nigerian children younger than 5 years of age die every year, according to UNICEF. Seventy percent of these deaths are due to preventable or treatable infectious diseases such as malaria, measles, HIV/AIDS and pneumonia. Life expectancy for a child born today is just 47 years.
Indignation simmers beneath her words as Alice Daniel recounts the death of a pregnant neighbor. "I just want to save my women," Daniel says today.
The country is rich in petroleum reserves, but it has failed to secure good health for its people. The health system lacks clearly defined roles for the federal, state and local governments, hobbling efforts to improve health, says Susan Krenn, program director for the Bloomberg School's Center for Communication Programs (CCP). Politicians prefer to construct hospitals and other buildings than to invest in less flashy public health prevention programs. "To me, Nigeria has always been a country of contradictions," says Krenn, who has worked in Nigeria for more than 20 years and lived there in the early 1990s. "You've got some of the brightest, most hardworking, compassionate people in the world, and you've got lots of resources, but somehow it doesn't all connect in a way that works."
EXPERTS IN NIGERIA and other countries increasingly are turning to the communities themselves and to people like Alice Daniel and Abdullah Abubakar. Rather than parachuting in high-cost, ready-made solutions to be imposed on locals, experts are designing efforts to help people in communities solve their own problems. USAID's Community Participation for Action in the Social Sector (COMPASS) is one example. The five-year program began in 2004 and works to improve health care and education for 23 million Nigerians. Another major USAID program called ACCESS aims to save the lives of mothers and their newborns. As a partner organization to these and other efforts, CCP is helping communities to find ways to reduce maternal mortality, improve primary care facilities and increase childhood vaccinations.
It's no small challenge. Solutions directly imported from the West have often met resistance in Nigeria, especially in the country's Muslim north, says Nasiru Ilallah, child survival program coordinator for COMPASS.
"Even when Western education came, people resented it. They thought, the white man is trying to make them Christians, take away from them their religion," he says. "The refusal of mothers to give the polio vaccine to their children is this issue."
Five years ago, Muslim clerics in Kano state (which has a population of 9 million) began railing against the polio vaccine, claiming it was part of an American plot to make Nigerian girls infertile. The Kano government halted the campaign, and the poliovirus resurged, spilling over into Chad, Sudan and 10 other African countries and setting back the global eradication effort.
Ma Umba Mabiala saw firsthand how a campaign's top-down approach can fail. The senior program officer with CCP's Africa division remembers telling other people involved with the campaign, "I don't feel quite comfortable with the methodology used to address the polio issue. We need to make sure people feel polio is their own issue." One person replied, "We don't have time to involve the people."
That mentality doesn't lead to success, argues Mabiala who believes it is crucial to first get to know the people and let them get to know you. "You need three to four weeks to build a community coalition," he says. "Some people say you're wasting time, but it's part of the process of building trust. If people don't understand you and don't know you, then they don't feel what you want is in line with their own goals.
Even the most basic tools of medicine and public health—immunizations, antibiotics, safe drinking water, antenatal care and so on—still elude many of Nigeria's 140 million citizens. Mothers, babies, children, adolescent girls and boys, and men are dying.
"We as program officers need to admit we don't have all the solutions, especially in a very complex environment like northern Nigeria," Mabiala continues. "Culturally speaking we may not know how to deal with some behavioral issues. We need to listen to people. How they speak to each other is important. How they share information is important. When we listen to them, we learn things. Those things help us to start to move forward."
A PROCESSION OF women and men wind their way along a path curving through a barren field. It is early May, the end of the dry season in northern Nigeria. The land is chessboard flat, and the dirt is baked to a powder. They walk to a freshly painted, cream-yellow building in their small community of Dawanau, on the outskirts of the city of Kano.
They are here to show off the building being renovated. New bars are on the windows, new glass is in. Outside, a painter is touching up green paint on a window's bars. The men and women shuffle inside. The rooms are clean, but empty. Voices bounce off the bare walls and concrete floors. The people are beaming.
They did this themselves.
The house, previously unused and water-damaged, has been transformed as a temporary home for midwives. The renovation was one of their solutions for Dawanau's health problems. The people knew how important skilled birth attendants are for reducing the high rate of maternal mortality, but they also knew that trained midwives were reluctant to come to Dawanau because there was nowhere for them to stay before or after delivery. So the community decided to make an apartment for them.
Dawanau's efforts to improve the health of its people are a textbook case of the community involvement that CCP tries to promote. CCP staff begin the process by meeting with community leaders and organizations, says Mohammed Yusuf Gama, a community mobilization coordinator in Kano state. Those who want to participate are trained in how to mobilize a community around specific issues and make plans that result in change.
"We don't give them money because we want them to look at problems as their own problems," says Gama.
Before strolling to the midwives' house, Dawanau's community volunteers met with an ACCESS team at the community's health clinic. Seventy people gathered on the clinic's concrete porch, a blocky structure the color of faded mustard. An Arabic music ringtone burst from someone's mobile phone, momentarily drowning out the creaking of benches and scraping of sandals on concrete. A man handed out bottles of Coke, Sprite and orange Fanta. Palms to the sky, the imam opened the meeting with a prayer.
A community group leader named Ahmad Adamu stood and recounted his team's efforts in Dawanau. He recalled how things were before their work started. Antenatal care available at the local clinic was largely ignored, maternal mortality was high, and few people visited the community's clinic, which was in disrepair. His team first tackled the antenatal care issue, deciding that husbands would be key in getting their pregnant wives go to the clinic. So his team set out to persuade men of Dawanau how important antenatal care is, how the clinic visits prior to delivery allow health workers to examine the woman, test for anemia and other conditions, describe warning signs, and so on. The meetings changed the men's perceptions, and antenatal visits increased. Before the community teams visited 22 nearby villages starting in July 2007, only 30 women came to the Dawanau clinic per week for antenatal care; by March 2008 there were 120 such visits. The average number of births in the clinic during that time jumped from 5 per week to 17.
ACCESS, COMPASS and similar programs are also helping reduce maternal mortality by encouraging men and women to prepare in advance for the delivery by saving money and making contingency plans that empower the woman to go to the hospital should her husband be away. They persuade men to stop demanding that their pregnant wives fetch water or firewood for the family. (One recent victory: A religious leader in one district banned pregnant women from doing such work.) To avoid tragic deaths like that of Alice Daniel's neighbor, communities have also arranged with the transport workers union to drive women to the hospital in emergencies. The people take up a collection to pay the driver.
With COMPASS's support, health workers in Mpape (the destitute community near Abuja) canvass the sprawling community for pregnant women and encourage them to come to the clinic for antenatal care and delivery. The outreach work has yielded significant results, says Sani Adanu, the clinic's officer-in-charge. Each month, hundreds of women come for antenatal care, and 15 or so deliveries take place. Previously, such visits were infrequent at best, he says. Expanding the clinic hours and improving access to medications (through another USAID-supported fund) are also part of the reason that more people are coming to the clinic. "Truly, there has been 100 percent change," Adanu says.
A midterm assessment of the COMPASS project backs up Adanu's experience. There were 1,872 deliveries in facilities connected with COMPASS-sponsored community groups in Kano state, while just 70 were recorded in facilities without the groups. In Bauchi state, the numbers were not as dramatic but still significant: There were 920 births in facilities connected with COMPASS groups and 396 in facilities without the groups. The number of visits for family planning or antenatal care among facilities connected with community groups was twice that of facilities without them.
Mabiala, the CCP senior program officer, has personally witnessed the power of community mobilization. During his initial visit to a community in Bauchi state, local leaders were clearly disappointed that COMPASS would not pay for new buildings and lavish programs. "I told them we did not have anything to give them, but we were willing to share our expertise," Mabiala says. "They were like, 'It looks like COMPASS is different from others—it's a waste of time.'" But Mabiala persisted, ultimately persuading them that there were many things they could do to protect their wives and children that didn't cost money. Taking their children to the clinic to get them immunized, for instance. On subsequent visits, his field staff was warmly received. He returned four months later to find the community had expanded their health facility and paid for some equipment themselves. Dissatisfied with the local government's irregular shipments of vaccines, they send a community member weekly to pick up their supply. "For me it was a big achievement because they understood it was something they can do themselves, and it doesn't cost a lot to make sure their children don't get these diseases," Mabiala says.
Programs like ACCESS and COMPASS serve as a catalyst for change by "opening up" people's thinking, says Krenn. "Sometimes people just need exposure to different ways of thinking," she says. "If you're situated in an environment and this is the way it's always been done, and this is all you've ever known and you've never seen anything different, why would you change?"
Awakening people in Nigeria and other developing countries to their health problems and suggesting ways to solve them is one of CCP's key missions, according to Jane Bertrand, PhD, MBA, technical director of CCP. "Over 90 percent of what we do is demand creation," says Bertrand. "We are trying to create demand for better services [such as] family planning, primary care, AIDS services, immunizations, malaria nets...."
THE PEOPLE SEEK the shade of the mango tree.
Two dozen women in teal, black, maroon and pea-green hijabs sit on carpets spread beneath the tree. Children squirm on their laps or cavort on the fringes of the group. A few white goats with black ears pick at invisible scraps on the parched ground.
More people arrive, claiming spaces in the shade and spilling out into the bright morning sunlight. Most women sit on the carpets; a few sit on plastic chairs. The male leaders and guests sit on cushy velvet chairs hauled out from rooms of squat brick homes nearby.
The tree—one of the few green things in sight—serves as the town center and natural gathering place for the Hotoro community outside Kano city. The crowd soon swells to more than 200.
COMPASS workers hand out blue lanyards with laminated green cards written in the Hausa language that spell out the immunizations children should get at specific ages. (A headshot of a pudgy baby with open mouth is labeled Daga Haihuwa [birth] and specifies the BCG, OPV0 and hepatitis B1 vaccinations.) The women loop the cards over their necks.
Over the next hour, COMPASS program coordinators—both Nigerians on staff and volunteers from the community—extol the benefits of childhood immunizations, longer periods between births for the women and good nutrition for children.
Nasiru Ilallah, the child survival program coordinator, asks the people assembled, "Has anyone lost a child to measles?" A half dozen women say, "Yes, yes." Ilallah says his own grandfather was blinded by measles. He then recounts how smallpox was eradicated thanks to vaccines. People nod their heads. The older ones remember smallpox. He uses the smallpox example to persuade the crowd of the need for children to get their basic immunizations. "I believe no woman wants her child to die, so it is good for every mother to take her children to the clinic," he says.
Fatima Inuwa, a COMPASS reproductive health and family planning officer, tells women they are the "backbone" of the household. "Women must be healthy because without healthy women, no children will be healthy," she says. Then she coyly adds, "We are looking beautiful when we are healthy. Our husbands will love us more." The women laugh out loud and shout their approval.
After the presentations, the temperature nears 100 degrees. People begin lugging chairs back into their homes. Some women pause to share their stories. The mother of 11 children confides that all but two were born at home, though she has made sure to get basic immunizations for all of them. Another tells about her friend Rakya, who refused to let her son be vaccinated, only to see him get measles three years ago and then to lose the use of a leg to polio.
Zuwaira Mohammed, a female community coalition leader from a nearby community called Kawaji, has come to lend her support to the campaign in Hotoro. In Kawaji, she cajoles mothers to get their children vaccinated. "Now there is not much measles in our children. Before, the children were in bad condition because [the community] had no awareness," she says. "I am confident we are going to mobilize people in the whole state."
In a nation like Nigeria with so many people spread over a large country that lacks a robust public health and primary care infrastructure, the community-up approach may be the best means of making progress.
William Brieger, a professor of International Health who lived in Nigeria for 26 years, is an advocate of the approach. Brieger, DrPH '92, MPH, helped design the COMPASS project, drawing on a previous program's community mobilization approach. He's recently completed an unrelated project in Nigeria and three other countries that relied on communities themselves to distribute bednets and vitamin A supplements, treat people sick with malaria and detect cases of tuberculosis. Early indications are that the three-year project has been a success. "These things would not reach the communities by and large, if the communities did not have a role in the planning and delivery process," Brieger says.
The results of these types of community programs are not limited to public health, says Mabiala, the CCP program officer. He notes that a recent USAID evaluation of the COMPASS project uncovered a surprising trend. "They found those community coalitions are now a big part of the movement of democratization," he says. "They are playing a key role now that they know their rights. The local governments cannot do anything without them. People are saying, 'We need to make sure that [tax] money is used efficiently to address our needs.'"
"This was not our goal," Mabiala says. "Our goal was to address the basic needs in health and education."