Focusing on hygiene and vaccination, a health project serving isolated Kumi and Soroti Districts has used overseas funding from Canada to help build a sustainable cadre of grassroots-level volunteers.
TILLING, Kumi District, Uganda - For most people in this remote village some 360 kilometers northeast of Kampala, the long days and nights when their children easily grew sick and frequently died - all without a clear explanation - are not difficult to recall.
"When a child became sick, the community felt the child had been bewitched," said William, a 61-year-old farmer, discussing how only a few years ago the village's children were easy prey for common diarrhea and other killer diseases of childhood, such as whooping cough, measles, tetanus, polio, tuberculosis and diphtheria.
But much has changed since many families here have adopted basic health and sanitation practices. Volunteer community health workers, trained and supported by the Uganda Bahá'í Institute for Development (UBID), have helped significantly to raise immunization rates and increase the awareness of basic hygiene in some 30 villages in Kumi and Soroti Districts in eastern Uganda.
Although preprogram health data for these villages is scant - there were virtually no similar rural health projects serving them before the UBID program - regional health officials, UBID-trained health workers, and the local people themselves say that childhood death rates have fallen greatly and the overall quality of health has improved.
"The Bahá'í project changed the behavior of the community," said Nelson Omudu, coordinator of the Uganda National Expanded Program for Immunization (UNEPI) at Ngora Hospital in Ngora, Kumi District. "It did this several ways. Through the use of the latrine - now many people know the importance of the latrine. Immunization used to have a poor turn-up, but now many people bring their children. With malaria, now people know about the use of nets and the number of cases is reducing. And before, water sources were neglected. Now people know the importance of clean water."
More than a health education success story, perhaps the real lesson of the Bahá'í project lies in its record of sustainability. Started in 1986 by the Bahá'í community of Uganda on a very small scale, the program received a huge boost in 1993 when the Canadian Public Health Association helped to fund a three-year project to expand the training of community health volunteers and establish village health committees.
By the time the Canadian-sponsored funding ended in 1996, some 71 community health workers had been trained and about 65 were actively operating in their home communities. The project has continued its training process, offering courses to 20 more volunteers over the last three years, and managed to support sustained activity by some 53 community workers - despite a two-thirds reduction in its budget since the end of Canadian funding.
Further, a relatively high percentage of those trained have been women, reflecting hard-fought success at overcoming the traditional reluctance to allow women to work at such tasks.
Encouraging sustainability was the aim of the Canadian Public Health Association - and remains a major goal for UBID.
"I'm delighted to hear what has been going on," said Dr. Edward Ragan, who directed the CPHA International Immunization Program during the mid-1990s, discussing the ongoing activity in the UBID health project. "It is in keeping with what we tried to do [with our funding], which was not necessarily just immunize children nor simply train people medically, but to create a context for sustainability, which is the way development will be done in the future."
"A lot that happens within the Bahá'í community is because it has a strong spiritual base to it, and you don't find the same strong degree of fervor in other groups, and that is a plus point," Dr. Ragan added.
Reaching the underserved
The UBID health program operates in isolated rural areas of two districts in eastern Uganda. In both Kumi and Soroti Districts, the terrain is mostly flat grassland interrupted sporadically by forests and isolated swamps and served by few paved roads.
The people in the area are Itesos. They are mostly farmers growing cassava, groundnuts, millet and cotton on small plots ploughed by oxen and weeded by hand. They raise chickens, turkeys and cows. Homes, made mainly from mud bricks with thatch roofs, are scattered over a wide area.
"The strength of the Bahá'í project in Kumi and Soroti was that it was willing to go down to the most underserved areas of the districts and try to make the much needed health services available," said Fred Ssengooba, a lecturer at Makerere University's Institute of Public Health, who has examined the project. "There is a serious shortage of trained health providers … in distant rural areas."
The project's approach has been simple: to train local volunteers to be community health workers (CHWs) and community vaccinators (CVs) who could teach their fellow villagers the basics of home hygiene and sanitation and administer vaccinations against major childhood diseases.
Since 1993, the program has trained 76 community health workers and another 14 higher-level local health education specialists, known as trainers, who work with the community health workers. It has done this for less than US $100,000 in overseas assistance, a bargain price for international development programs.
Along the way, the program has struggled with a number of obstacles, from the distrust of villagers over the safety of vaccination to the traditional reluctance of women to "work" outside their homes. There have been internal challenges, as well, as the Ugandan Bahá'í community sought to improve its own administrative capacity to operate such a program.
But the results were a "tremendous success" when measured against the project's initial goals, according to an evaluation done in 1996 by Narathius Asingwire, acting head of the Social Work and Social Administration Department of Makerere University of Kampala. According to Mr. Asingwire's report, written in collaboration with Dr. Ssengooba, the UBID health program:
-- More than met its goal of increasing immunization coverage by six percent among children under the age of five, achieving instead an increase of 28 percent.
-- Registered "good success" in promoting community health care practices "as evidenced by high latrine coverage, plate racks, garbage pits and sanitation practices."
-- Achieved a retention rate for its volunteers of more than 90 percent, offering a "clear testimony that manpower trained can make the project survive for a long time."
"What I found unique with the Bahá'í health project was the element of keeping the volunteer staff on board without burning-out," said Mr. Asingwire in a recent interview. "In most projects, volunteers with time tend to burn-out due to lack of incentives, such as remuneration.
"This, however, needs to be appreciated in the context of the Bahá'í principles and values which in a way greatly promote that sense of unselfishness, where the followers can work voluntarily for the common good of the community," added Mr. Asingwire.
Indeed, program managers agree that the project's record of success, both in relation to short term health improvements and longer term sustainability, stems largely from the project's distinctive emphasis on volunteerism and community service, which emerges from the spiritual ideals that underlie the project's conception.
"The principle of service to others as the highest good and the concept of 'work as worship,' along with the equality of women and men, which are all Bahá'í principles, are incorporated completely in our training and our field work," said Vinita Walkup-Gilbert, who was coordinator of the UBID health project from 1993 through 1997 and who still serves as a consultant. "We feel the emphasis on these principles makes a significant difference in what happens on the ground. It is reflected in the time our people volunteer and in the way they treat the people they serve."
Connecting with the community
Community members say the project has indeed saved many young lives. "Communities were not aware of why their children were dying," said Ketula Arinyi, a 45-year-old mother of 10 who is now a community health worker in Tilling.
And there was reluctance, at first, to the measures proposed by the UBID-trained workers. Some mothers, for example, believed that vaccinations would harm, not help, their children and they hid them during immunization campaigns. The key to stemming those fears lay in the selection and use of volunteers from each community.
"When the program started, an anti-government politician said this was a program of the government to reduce the population," said Mr. Ebetu, the 61-year-old Tilling farmer quoted earlier. He noted that although he had a child who died of measles long before the project, he was still wary. "Because if the program was free, we questioned it. It may be to kill our children."
But, said Mr. Ebetu, once it became clear that the program was community-based and was drawing its volunteers from each village, the attitudes changed. "The condition for the selection of the community health workers was that they had to be living in the place where they would work, be married and be accepted by the community. When we heard this, the right thing, we said 'yes.'"
Patrick Okanya, a community health worker in Kalapata added: "We would show the difference between our children, who were immunized, and their children who were not. We used ourselves as an example."
Explained Alfred Okello, who is currently coordinator of the project: "Each community health worker has the goal to raise awareness of the people about the prevention of diseases. We use charts on basic health messages with different problems facing the community such as the effects of drinking unclean water."
Encouraging women volunteers
The Ugandan Bahá'í community, as well as its Canadian funding partners, felt it was very important that there be a balance between women and men in the program. Of the total volunteers trained so far, 50 are men and 41 are women.
Much effort was put into recruiting women volunteers into the program and keeping them active in the communities.
"One of the things we did was to encourage women to come to the training with their babies and with baby sitters," said Ms. Gilbert. "This made it possible for many women to take part who otherwise would not have been able to. It made a lot more problems for us - such as having ten babies crying at once - but it was the only way we could ensure more women were involved."
Another issue was the objection of husbands. "At the beginning, my husband was doubting, thinking 'maybe they want to grab my wife away,'" said Margaret Okoboi, a UBID-trained community health worker from Kalapata. "But now the changes made in the family have made him very happy," she added, referring to their use of latrines and drying racks, and access to clean water.
To help overcome such worries, project managers visited husbands early on in the project. "We tried to sensitize the whole community when we went in to select a volunteer worker," said Ms. Gilbert. "We talked about the whole concept of the equality of women and the great value of women as community health workers."
The training given to each volunteer included information on immunization, the prevention and treatment of diarrhea and worms, rehydration therapy, malaria prevention, nutrition, child health care, pregnancy health, child spacing, first aid and household sanitation. The training is distinctive for its follow-up, with refresher courses offered after three to four months of monitoring in the field.
The project also exemplifies the importance of partnership in international development efforts. The partnership underlying the Uganda project is multilayered: the Canadian Bahá'í community played a key role as a liaison between the CPHA and the Bahá'í community of Uganda, through its Canadian Bahá'í International Development Service (CBIDS). Money was also contributed by the Bahá'í International Community.
"Strengthening institutional capacity was a background theme throughout the entire endeavor," said Andy Tamas, secretary of CBIDS executive committee. "All parties, including ourselves, experienced that as the years and activities went by." Canada's funding for the Uganda project, which was part of a CAN$30 million campaign to strengthen primary health care and immunization, originated with the Canadian International Development Agency (CIDA). CIDA contracted the Canadian Public Health Association to design and manage the campaign, which worked with 29 partner agencies to support 60 projects in 28 countries.
Certainly, the overseas partnership did much to strengthen the capacity of the Ugandan Bahá'í community to carry on. "When the project began there was no full-time person to look after it," said Brian Burriston, the current director. "There was no reliable administrator or management available. And now since UBID exists it allows other opportunities to be explored."
According to Mr. Burriston of UBID, the majority of the volunteer workers trained during the last six years remain actively involved in health education and care in their communities. "In 1998, 53 were filing reports at least every other month," said Mr. Burriston. "And community health workers are notorious for not sending in reports even when they are working. And what is significant, I think, is that at least one-third of that number have been working for five years without pay."
Such activity is in evidence in many of the villages where the program has operated. In Kalapata, for example, every household has a latrine except where the household is built on hard rock. Almost all houses have drying racks for dishes. No one uses water from shallow wells for anything but brick making. Most use water from deeper drilled "boreholes"; others use home wells which have been cleaned of debris and fenced. Most of the children are now vaccinated against basic diseases.
Likewise in Tilling. "Most households now have a proper pit latrine, a drying rack for dishes and eating utensils, a clean source of drinking and cooking water, and swept grounds around their houses," said Stephen Opedun, secretary of the local council which serves Tilling. "Perhaps most significantly, nearly 100% of the children in Tilling are fully immunized against the six killer diseases."
Referring to the moral education component of the training given to CHWs, Mr. Opedun added: "People are realizing that the moral values promoted by the program are a good thing."
Mr. Burriston says that much credit for the improvements in hygiene should be shared with the Government, which has recently been making an effort to increase the use of pit latrines. "A cholera epidemic in the country has focused attention on sanitation and produced a positive result in terms of improved sanitation in schools and homes," he said.
But the people here openly attribute such improvements to the adoption of the hygiene and health messages presented by the local community health workers trained by UBID. Said Ginatio Tukei, a farmer in Kalapata: "Now people in other places are demanding for the project to be extended into their villages."
-- With reporting by Steve Worth