How the ITN and bicycles came to this community in Zambia’s Kapululwe area – about an hour and a half east of Lusaka – represent a slice of what one of the largest Zambian and U.S.-supported programs, RAPIDS, has learned during the course of its six-year grant.
RAPIDS – or Reaching HIV and AIDS Affected People with Integrated Development and Support – is nearing the end of its six-year, $57.4 million grant from the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and USAID. It is implemented by six major NGO partners (Catholic Relief Services, CARE, Africare, Expanded Church Response, Salvation Army and World Vision) and 181 community- and faith-based organizations. World Vision is one of the lead implementers in the program – working very closely with RAPIDS in the Kapululwe area.
The program certainly has had a wide reach, training more than 18,000 community caregivers in 52 of Zambia’s 72 districts and hoping to reach 20,000 by the project’s end, said Batuke Walusiku, RAPIDS’ deputy chief of party for program implementation. But what impact has it had on health and quality of life outcomes and what lessons can we learn from such a large community-based program?
The initial focus of RAPIDS was training community-based caregivers in prevention, care and treatment for HIV/AIDS. HIV prevalence from 2001 to 2007 seemed to have leveled out at about 15 percent of the adult population, after rising from about 9 percent to 16 percent during the 1990s, according to a UNAIDS/World Health Organization 2008 report. About 1.1 million people were estimated to be living with HIV at the end of 2007.
The flattening of HIV prevalence could be attributed in part to RAPIDS – it is difficult to quantify one program’s effect. What can be said is that the caregivers I talked to today felt empowered, and the community members they worked with in Kapululwe indicated an increased knowledge of HIV/AIDS.
Wildy Susu, 39, a RAPIDS-trained caregiver since 2004, told me that a major benefit of the program has been to allow the caregivers to meet regularly and organize so that they can continue some form of service if World Vision and RAPIDS were phased out. Loveness Mukatela, 46, another RAPIDS caregiver since 2004, said she hopes RAPIDS and World Vision stick around, but added, “We have been trained, we have been exposed, so nothing can stop us.”
The successes of the community caregiver training in HIV/AIDS led the program to add ITN distribution and malaria messaging. Integrating another major health issue might not make sense if the program looses its focus on a targeted outcome. But in this case, if these caregivers were in homes talking with their neighbors on a regular basis, it seems to make sense that bed nets and malaria prevention and treatment messages could be added on.
A couple of the caregivers I talked to said they did not have major problems adding malaria to their docket. Walusiku said RAPIDS had an initial learning curve because they had not worked in malaria before, but she believes they are much better prepared for their next major ITN distribution of nets provided by the Against Malaria Foundation in about one month.
Early on, RAPIDS also realized a community-based undertaking such as theirs cannot be about health alone. The program provides people who take care of orphans and vulnerable children livestock to improve their economic and food security situation (I saw one woman who had been given goats and another a cow). RAPIDS also teamed up with World Bicycle Relief, who donated bikes to give to caregivers. The bikes allow the caregivers to cover greater distances, use it for personal or economic reasons and transport community members to local clinics.
And therein lies what Walusiku considers a major gap. She said it is absolutely vital that the Ministry of Health create a system to track the contributions of community health workers with defined consequences for districts who do not do the tracking so that their contributions could be more easily quantified and integrated into the overall health system.
Another issue involving tracking is that of referrals. Caregivers are trained to refer beneficiaries to the proper clinic for the services they need – which often results in a lift on their bike. However, Walusiku said follow-through on the referrals is difficult because overstretched staff at the clinics cannot be expected to fill out paperwork on if a referral was actually utilized.
Tomorrow I am sitting in on a dissemination of workers from all around the country who take part in Johns Hopkins’ Heath Communications Partnership program, as well as making a visit on a new partnership on training vaccination managers. I look forward to your comments and questions.