Feature

Give us the tools…

Imagine earning £25 a month 14 years after qualifying as a health worker, being the only trained member of staff for a population of 4,741 people, with a budget of £50 a month in an area with no vehicles or roads.
This is the situation of Boniface Kaira. Despite a lack of books, educational opportunities, or other professionals nearby he has a clear vision of what needs to be done.
He challenges his government, international aid agencies and the public health movement to enable Tapo, the community he serves, to be given the power and capacity to meet its own needs.

I graduated with a diploma in environmental health technology in 1989. I had worked in four other rural health centres (RHCs) before coming to Tapo. I head a team of three health workers, two of whom are untrained. We offer a limited number of basic services, including immunisation, growth monitoring, antenatal care, family planning, and extension services in areas of water and sanitation. We hold clinics, have a delivery ward, inpatient facilities and offer outreach services.

We support local health committees and a team of volunteer community health workers based throughout the area who have a clinical and health promotion role.

Some villages are three hours walk from the clinic. The gas fridge (there is no electricity) is not able to make ice blocks so we are unable to offer immunisation clinics in the furthest villages. As an RHC we lack facilities such as a laboratory or an ambulance for effective referral and transport.

My prime role in the community is to help people understand their problems, what they can do to try to alleviate them and how they can access external resources. People expect me to be not only a frontline health worker but also a development facilitator.

Problems such as access to safe drinking water and sewage disposal, food scarcity, the need to improve domestic income and diseases such as malaria and HIV/AIDS are challenging.

Some obstacles arise from a lack of resources: health services, for example, need skilled workers, and good transport and communication systems to maintain regular contact with the community.

The Tapo community cannot meet all these needs from its own resources and needs external support with user-friendly conditions. This is where my role comes in, explaining government policies and/or programmes to people in the community.

People are aware that external support can be accessed through donor countries, aid agencies, aid projects and so on, and that these are motivated by good intentions such as raising our standard of living and alleviating poverty.

But as a grassroots development facilitator, I sometimes wonder whether the aid is achieving its objectives. Some of the conditions attached to aid have done more harm than good. The Zambian Structural Adjustment Programme (SAP) in the early 1990s, for example, was a condition of donor funding. The effects of SAP have been devastating. The Zambian government was told to come up with poverty reduction strategies for it to be considered for ‘Highly Indebted Poor Country funding’ and it came up with a poverty reduction strategy paper. But how many people at grassroots level understand this paper? It takes no account of the effect on an average Zambian community like Tapo. Regardless of the conditions attached to aid, communities need programmes that will give them the power, capacity, voice and opportunity to deal with their own problems.

Donor and aid agencies projects with specific targets have worked and achieved results. But this requires a system that recognises the way people manage resources and interact with one another, and that what they do about their problems, is different from community to community.

The Dutch-sponsored primary healthcare project in Western province is a successful example of community empowerment. It began by looking at issues of health rather than infrastructure, and was proactive in enabling communities to identify their needs and helping them to do what they wanted, rather than the things aid workers promoted.

So if they decided they wanted pit latrines, they were helped to build them. The health workers moved from being teachers to being facilitators. Previously communities were often told ‘if you don’t build the pit latrines, we won’t give you painkillers’. The result was that latrines were built to impress health workers but not used by the communities.

Donor programmes can also achieve a lot if programme facilitation is done well. If left to facilitate projects, some politicians manipulate them towards outcomes they can use as campaign objectives. If K2bn (approximately £250,000) is released for poverty alleviation in a small district like Kalabo, politicians will use the funds for feeder roads.

But in communities like Tapo, development is not about infrastructure but about shifts from negative images – ‘we are illiterate, helpless, poor’ – to positive ones – ‘we are competent human beings, we can improve the situation, we know ourselves better than anyone outside, people can learn a lot from us’.

This leads to a change in behaviour, which in turn leads to the community being better able to deal with its own problems. High-quality community development facilitation is about achieving outcomes, not outputs.

Government policies and donor funding are the same throughout the country but communities are different in terms of what they do and how they do it. Communities like Tapo have been under-estimated, to say the least. People in Tapo feel that global public health concerns are professionally driven thus denying them a much-needed ‘voice’ on issues that affect them. They do not want to be seen as recipients but as equal partners. They understand their situation and can make timely and meaningful decisions on issues that affect their lives. They should be given the opportunity to make decisions regarding their own needs.

Boniface Kaira would welcome contact from readers and can be reached at the following address:

Mr Kaira, Boniface Gimda, Tapo RHC, Kalabo DHMT, PO Box 930005, Kalabo, Zambia