Posted by: afedorova | 09/03/2009

Challenges of reaching the rural population

GHC Policy Communications Coordinator Vince Blaser is traveling in Zambia and Tanzania to visit member programs and report on policy connections. This is the fourth of his reports.

LUSAKA, Zambia – Euphrasiah Monze, Danford Makayi, Deborah Mubashi, Mutale Masenga and Dr. Mary Ngoma work at different programs, in different health sectors, from different funders and with different populations. But they all sounded a similar chord when asked about some of the largest challenges and/or gaps in improving the health of people in their country: delivering information, resources and commodities to rural and remote populations.

Zambia certainly is not unique in that rural residents have worse outcomes on many of the health indicators – this disparity holds true in the world’s richest to poorest countries. However, Zambia’s vast size (752,614 sq km), varying climate (some roads are often impassable during the wet season), and increasingly difficult economic situation all lead to a tricky set of issues in trying to reach the country’s rural population with the health services they need. And that is where the perspectives of Monze, Makayi, Mubashi, Masenga and Ngoma can help shine a light on how the disparities in Zambia might be reduced.

Childhood Vaccinations

Ngoma, an associate professor of pediatrics and child health at the University of Zambia, first attempted to address the disparity in childhood immunizations about 10 years ago when she applied for grant funding from an organization called NESI to train mid-level health managers in childhood immunizations. According to the 2007 Zambia Demographic and Health Survey, about 68 percent of children from 12 to 23 months old were considered fully vaccinated – which includes one dose of BCG vaccine, three does of DPT or combination of DPT-HepB-Hib vaccine, three doses of polo vaccine, and one dose of measles vaccine. However, the percentage of fully vaccinated 12- to 23-month-old children was lower in some rural provinces – including 51.5 percent in Northwest province.

Ngoma’s NESI request was not granted, but her plan was in hand when the Merck Vaccine Network Africa (MVN-A) and Merck Company Foundation came calling about three years ago with a request for proposal. Merck was already supporting similar training programs between universities in Kenya and Mali and universities in the United States. After the RFA process, MVN-A decided to fund collaborations in Uganda and Ngoma’s Zambian proposal.

The four-year Zambian program – a collaboration between the University Teaching Hospital of the University of Zambia School of Medicine and the United Kingdom’s Brighton and Sussex University Hospitals NHS Trust – trained 25 “national trainers” at its newly refurbished facilities in Lusaka two months ago. Next week some of these trainees will become trainers when the program brings in its first crop of mid-level managers from the Northwestern and Western provinces for an intensive-six day training on issues such as vaccine management, cold chain management, supervision, and communication between service providers and clients.

Ngoma told me that it had been about eight years since the Zambian Ministry of Health held a childhood vaccination training, adding that the program will work with the ministry to help fill the gap in childhood vaccine uptake in the rural areas. Merck is providing $200,000 this year for the program.


Cross-Sector Health Communications

As Ngoma and the MVN-A program prepared for their official launch, Monze, Makayi and staff at Health Communications Partnership (HCP) disseminated the five-year project’s findings at a major gathering here in Lusaka – and a different set or rural successes and challenges emerged from its findings.

Funded by USAID, HCP is a partnership between GHC members the Johns Hopkins University Center for Communication Programs, Save the Children, and the International HIV/AIDS Alliance. The program aimed to mobilize and empower communities in 22 of the country’s 72 districts, engage local leaders, empower youth and harmonize health communications through increasing community capacity, and increase exposure to health messages through drama, TV/video and print materials. The messaging was cross-sector, including family planning use, birth planning, delivery at a health facility, exclusive breastfeeding, insecticide-treated bed net (ITN) use, and HIV prevention.

Monze, 35, who worked for HCP in the Luangwa District, and Monze, 41, who worked in the Solwezi District, told me that the challenges HCP faced in getting these important messages to the rural districts were in logistics (transport, access to radios, etc.), as well as the differing levels of leadership quality in the communities they worked in. A communications program is only as good as the people doing the communicating – and HCP was able to facilitate the development of some excellent successes, such as one of the first men’s clubs to discuss safe motherhood in Mansa, Zambia, according to Lynn Lederer, HCP’s chief of party.

HCP, near the end of the project, found some major successes when it conducted a survey in 21 of the 22 districts (researchers couldn’t reach one because of impassable roads) and 13 districts who might have received the mass media messages but were not targeted by the project. The program was able to reach a high percentage of people surveyed in the 21 districts, and there were greater increases from 2005 to 2009 in several indicators compared with the non-intervention districts – such as in the percentage of people who had a positive attitude of people living with HIV/AIDS and percentage of pregnant women with plans to deliver at a health facility.

However, two statistics not necessarily attributable to HCP alarmed people at the dissemination – from 2005 to 2009 there was about a 14 percent drop in the percentage of males ages 15 to 24 who used a condom the last time they had sex, and similar drop in the percentage of married women using a modern contraceptive.

Dr. Reuben Mbewe, who spoke at the meeting for the Ministry of Health, said that the ministry is launching a condom promotion campaign and that “innovative ideas” were needed. But a drop in family planning use has been documented in other reports, so why is this the case? The experience of the group I visited Thursday afternoon might help tell the story.

Reproductive Health Services

Planned Parenthood Association of Zambia (PPAZ) has been around in Zambia since 1972. Hilda Wina, 52, program manager for clinical services, has not been at PPAZ that long, but when she started working at the program in the 1990s, the program had a sizeable presence in the country’s rural areas, including the Eastern and Northern provinces. Then in 2001 in came the Bush Administration, which reinstituted the global gag rule – cutting off all funding to groups such as the International Planned Parenthood Federation (IPPF) that speak about and/or provide abortion services, even if they do so with their own funding.

PPAZ – which now provides a range of services including family planning, voluntary counseling and testing for HIV, treatment of sexually transmitted infections, prenatal and postnatal care, emergency contraceptives, lab tests, ultrasound services and Pap tests – lost about half its funding as a result of the gag rule, Wina said. Some of the rural centers were closed and staff was laid off.

It is of little wonder then why Mubashi, 23, and Masenga, 22, told me they believe the biggest needs for sexual and reproductive health lie in the rural areas. Mubashi and Masenga are both second year social work students at Evelyn Hon College, and this year they have been working long hours as part of their assessment requirements at PPAZ’s nearby clinic in Lusaka. They said that young people at their college and other places they have done outreach in the city are very receptive to condom promotion and family planning messages but rural areas needed more outreach.

Wina said that the organization is training people in rural areas in family planning messaging, adding that they are hopeful that the Obama Administration will be much more supportive of this critical issue. At the HCP dissemination, USAID Mission Director Melissa Williams seemed to give positive indications, stating support for a “revitalized national family planning campaign” in Zambia. Seems pretty clear that accessing the rural areas needs to be central to this campaign.

Tomorrow I will head out of Zambia and will reflect on some lessons learned during my week here. Please feel free to contribute to the discussion, and I look forward to reporting next week from Tanzania.

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  1. Transportation has been identified as a missing link in getting health interventions to those who need it most. However, the solution to this does not lie in merely providing vehicle and motorcycle fleets but in ensuring that adequate maintenance is put in place so that there is a zero break down of these vehicles. This in essence will ensure that health interventions are not delayed, interrupted or completely unavailable to those in remote communities in order to reduce the ever increasing inequities in health.

  2. I concur with Babatunji and would add that information and communications technologies are also increasingly relevant. For instance, power-efficient computers and forward caching of relevant content over GPRS or “sneakernet” can go a long way toward overcoming the “last mile” challenge posed by lack of power and bandwidth in rural settings.

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