This is the second (first) in a series of posts about implementing health projects in a developing country. It is meant to introduce a reader to the inner workings of public health training and action, especially the collection of baseline information, and share with the world data, stories, and personal thoughts about the ongoing challenges of global health in Mozambique.
Public health is all about knowing who matters most.
We want to believe that all information that we need to be successful in any area or field is advice, input, and research from those who we deem as “experts.” While these voices are crucial in public health to develop a robust assessment, there are lesser-heard voices that act to compliment the information gained from national health statistics and evidence-based research and provide a more personal insight and tailored focus of the CNA.
The lesser-heard voices belong to those in the community who are living with and seeing the daily effects of any given disease or health issue: the mother of two who is HIV-positive along with her children, the community leaders who have daily discussions with their neighborhoods about issues, the volunteers in the health system that work to seek out the patients who have abandoned their treatment. They all have voices and deserve to be heard. The simplicity of public health: Listen to these people and, often, solutions will reveal themselves.
Public health is all about understanding those who matter most.
Before we can collect personal information from those in the community, we need to first better understand the community itself. Sure, we have national statistics, photographs of key places in the town, a history of the community, and an overall opinion about the health issues that matter most to people, but we need to round out our understanding with a current snapshot of the community and its resources to better understand the people.
Everyone shook their heads in confusion when I first asked about a map of my community. From the local health leaders to those who work in the local government, nobody was able to provide a detailed map of the neighborhoods and main streets. Having an overall view of the layout of the community is crucial in understanding proximity, abundance, and availability of local resources for those living in the neighborhoods. Good place to start.
Instead of walking the entirety of the community and sketching out a rough map, I thought about who would already have this information through experience and knowledge of the community. The answer was simple. Located in each hospital in Mozambique are activistas, or volunteers from the community who search out patients who have either abandoned treatment or are in need of crucial medication. Each day, these volunteers are given stacks of cards with patient information. Their task sounds simple: search the neighborhoods, find the patients, give them treatment or bring them back to the hospital. The reality is much more difficult, but we will discuss that more later.
Working with the activistas, we created a detailed community map (below) with the district hospital as the central point, names and borders of neighborhoods, and the locations of key resources, including the markets, the police station, and churches.
Now that we have a better understanding of the locations of key points in the community, we also need to better understand specifics about some of these points, mainly the abundance of food in the markets. Since nutrition and availability of food is firmly linked to the overall health of the community, we need to know which foods are available during which parts of the year, thus knowing which foods we are able to use in future interventions and health programs.
Working with the chefe (boss) of the market located to the east of the hospital as well as vendors who work daily in the market, we together created a seasonal calendar complete with the name of the product, the months along the top of the calendar, the time in which the crop is planted (plantar), harvested (colher), and sold/eaten (consumir). The yellow bars are the crops that are available all year. It is clear that Namapa has a high abundance of available food items. While the issue is usually cost, we now know that food is available.
In addition to an abundance of food from the markets, other resources in the community include: a community radio station that airs health messages in both Portuguese and the local language; water pumps around the community that provide a constant (with energy) supply of water for the neighborhoods; access to the national highway for travel and import of crucial supplies; cellular networks for both phone calls and internet access; and Namapa is home to the district government offices.
Public health is all about listening to those who matter most.
Now that we have a detailed profile of our community, a general opinion from the public and patients regarding health problems, a precise community map, and more information regarding the availability of food items, we are able to start collecting qualitative information from the community to best identify our direction for future health programs.
Who better to understand both the inner-workings of the hospital system as well as the health issues in the community than those who are volunteering their time to locate lost patients and reduce the burden of diseases in the community? The activistas not only have detailed information on the best direction to take future activities, but since they are volunteer workers they also have an unbiased view to provide honest answers and a personal motivation that will help us to better understand Mozambican’s values.
At the time of this assessment, my hospital had six activistas (now seven). Using a sign-up sheet, I scheduled interview times with each activista. During each interview, I first collected demographic information (below) regarding the activistas, including age, where they are from, time as an activista, the reason for becoming an activista, daily hours in the hospital, daily hours out in the field, with how many patients they speak in the hospital, and with how many patients they speak out in the field.
Following the collection of demographics, I asked each activista a series of questions about logistics, strengths, and challenges of improving health in Namapa. Below I will share a couple insights from each category, but all are located in my assessment that will be available once it has been reviewed and corrected for grammar by Peace Corps staff.
Besides some of the demographic questions asked above, I asked the activistas, “What do the members of the community think about activistas?” All of the activistas agreed that the people of Namapa, especially those patients who abandon treatment early, believe that the activistas are improving the health of the community. People know that the activistas are linked to the hospital and, therefore, are able to provide information regarding health, illnesses, and prevention.
All of the activistas discussed the importance of the palestras (health talks) that they both create and complete out in the neighborhoods. Community health workers and Peace Corps Volunteers (PCVs) complete palestras in the community because of the lack of information regarding prevention and limited resources. The activistas discussed the fact that since they are seen daily in the community with important health information, they are trusted. It is more difficult for a PCV to enter the community with information since they are new.
Strengths & Motivations
I asked the activistas, “What motivates you to work as an activista?” Since the activistas don’t earn any money for their work (besides the occasional money given by one of our team members), they all agreed that helping to diminish the burden of disease in the community was their main motivation. The demographics show that five out of six of the volunteers are from Namapa, so they have a strong connection to the community.
One of the female activistas described how her son is living with HIV. Looking down as she describes the disease, it’s clear that the issue is close to her heart and family. Also, another volunteer said that he himself is living with a disease, and by working in the community, he knows he is helping others and decreasing the likelihood that they’ll acquire the disease.
I asked the activistas, “What are the challenges of the job?” While they are all motivated by improving the health of the community, they all agreed that one challenge is actually diminishing the burden. They are out in the community each day searching for patients or giving health talks, yet the diseases continue to tear through the neighborhoods. They discussed how it is difficult for six people to reach so many people. With a population of more than 60,000 people, Namapa is too large of a town for such a small group.
Another challenge that is seen throughout the health system in Mozambique is the organization of the patient cards in the hospital. All patients are registered when entering the hospital, but because the system is not (yet) electronic, the paper forms are put into filing cases that are disorganized, dirty, and confusing to understand. The activistas spend crucial time in the morning simply searching for the patient’s information before heading out into the community. A faster system could help them reach more patients.
Finally, a problem that is also seen nationwide is transportation for the activistas. Since they are volunteers and there is limited funding for the hospitals, the activistas have to search the community by foot. With so many neighborhoods and limited time, not as many patients are reached. In the past, the volunteers had bicycles, but because of thieves, poor quality of the bikes, and poor maintenance, the bikes don’t last very long. Additionally, a motorcycle or car is out of the question because of cost.
I asked the activistas, “If you could change one thing about your position, what would it be?” While all of the volunteers said they were content with the job, they mentioned the need for a little bit of money for their families, transportation to get around the community, and the need for more material. The activistas enter the community without any physical pamphlets or information. Their palestras are just through speaking. However, there is the issue of literacy in the community as well as those who only speak the local language.
Public health is all about continuing the conversation.
The conversations with the activistas were crucial in developing a focused assessment. However, the conversation needs to continue into the implementation of the interventions or health programs. Additionally, we need to continue to speak with as many members of the community as possible to make sure all voices are heard and all voices are included.
Next, we need to better understand our organization’s reach in the community, speak with those directly affected by our organization, and identify any areas of improvement.
Questions? Concerns? Contact me!