| SAPLER Population Trust | |
| Splendidly Alive People Within Limited Environmental Resources | |
Part V: Combining Family Planning and Prevention
South Africa cannot get full primary curative medicine to all her citizens unless maximum attention is given to preventing illness.
This section looks at three ways of doing this:
1. The TPA health promotion team motivates people to use family planning, brings them to the clinic and visits defaulters to see what the problem is. They also arrange for transport for sterilisations. This team now tackles every other sort of urban problem as well, from drug abuse to paraffin burns.
2. Marina Clarke's original "nompilo" scheme has been taken over by The Rural Foundation. The nompilos live in the area they work in and are trained in very basic prevention skills. Marina says, "They may not be generally educated, but they are certainly primary health care educated."
3. The Bekimpilo Trust takes trained nurses into informal settlement areas. These teams can diagnose illness and also help in handing out medicines, but they leave the main curative work to the clinic services.
A similar scheme operates in the Cape.
Advisers, Nompilos and Community Health Workers
A "family planning adviser" is someone who explains what fp is and what its advantages are. He or she then sees that the client gets to and from the services, and also follows up on any defaulters.
Part of the original government family planning scheme set up in 1975 was the training of family planning advisers who formed teams under family planning liaison officers.
When fp was integrated into phc these advisers were given all sorts of different jobs, including community health work for which they were not trained, and filing and general helping out which made no use of their training.
In our survey we particularly came across this in Natal. In the Transvaal the entire operation simply refused to be integrated. They have continued operating as fp specialists, although with less money. The advisers now do 50% of other community health work.
Rural schemes are difficult to assess because they are all different. The original nompilo scheme in Middelburg started by Marina Clark included family planning advice among its 10 preventive primary health skills. This was well supervised by Marina herself and in time that local operation under the enthusiastic Sarah Mhlango had a team of unpaid mini-specialists in each of the areas.
When we went to Middelburg we were unable to assess whether families were getting smaller because the cards did not distinguish between genetic children and adopted children - whether permanently or temporarily staying there.
The Rural Foundation took over Marina's scheme and reports that 53 Community Development Associations are operating countrywide. However, we have no figures from them as to how well the fp side of things is going, and we do know of a farm in the Northern Transvaal where the nompilo does not do fp education.
Peter Dodds visited Rural Foundation nompilo schemes in the Cape and felt that once these women had been trained and had proved themselves they could very easily be taught to do injections.
Marina Clarke is now working for the Get Ahead Foundation. She has had to spend most of the first year fundraising, but has also managed to train a few nompilos.
How well community health worker schemes work elsewhere seems to depend on how well they are organised and motivated. They cannot be assessed in an abstract way.
Remuneration varies between no payment at all to R800 a month (Natal).
Training is varied, emphasis is varied. Women doing this work would like more clarification on their job status.
When Natalie Stockton's fp liaison officers and advisers were told to be incorporated into the health clinics, three provinces obeyed: one did not.
In Natal these trained workers have faded away into other jobs or have become clinic "helpers". They fill out forms in the clinics.
The Transvaal simply refused to go along with this colossal waste of a trained workforce. What they have done is to become health education workers who still spend half their time doing family planning motivation and support.
in the Annual Report on Health Education for the old PWV area the words "Primary Health Care" are used in the preventive sense. Everything this team of workers is doing is aimed at preventing ill-health.
From the Annual Report 1993/94. TPA Community Health Services, Region PWV:
Preface: "We are committed to the RDP and to the new National Health Plan in order to serve our communities by giving them, to the best of our ability, a comprehensive primary health care education programme which will contribute to the upliftment of the society as a whole, especially that of the mother and child.
"This programme was established 20 years ago. As a result of the needs of the communities health education was extended from family planning to primary health care. This section believes that health education through small group discussion projects, exhibitions, health days, training of community leaders (for example, traditional healers), is the most effective way to spread information and knowledge to people.
"Our section's main focus is health promotion. The section consists of 331 well trained, motivated and skilled Health Advisers who live in the communities they serve ... There are 22 Community Liaison Officers who are responsible for organising health education opportunities. They also direct and develop the health advisers..."
"Because of financial restrictions no expansion of services has taken place since 1988. This means that almost all the new developing areas within the PWV, especially the informal settlement areas, do not get the health education they deserve..."
Introduction: "Primary Health Care (PHC) includes education concerning prevailing health problems and the methods of preventing and controlling them. Educating people on health care is the best way of empowering them to deal with their basic health problems. Knowledge can prevent or alleviate many common ailments encountered within communities." They go on to explain how they aim to change habits and attitudes and their attempts to evaluate what they do. They say that mass media is not as effective as one-to-one communication. Their topics include breastfeeding, immunisation, substance abuse, safety in the home, TB, etc. On the following pages I shall focus mainly on their work to do with STDs, teenage pregnancy and fp. Youth Sexuality Education Programme:"The girl who has an illegitimate child at the age of 16 suddenly has 90% of her life's script written for her. Her life's choices are few and most of them are bad." (Rill)
"The Sexuality Education Programme is a life skills programme aimed at preventing irresponsible sexual behaviour and its unfortunate consequences.
The availability of contraception is not effective in decreasing teenage pregnancies. Research has shown that teenagers visit a clinic only about a year after their first sexual experience. There is also an inadequate use of reliable contraceptive methods.
The programme aims at informing adolescents about reproductive health, sexual responsibility and adult roles without being patronising. Decision making and value clarification form an integral part of the programme offered to teenagers ...
"We provide the adolescent with strategies to cope with difficult situations - (saying "NO"). This is done by role-playing, drama and theatre ...
In the past year 312 599 teenagers were reached through the programme.
"In Sharpeville, at the Roman Catholic Church, a teenage sexuality project reached approximately 57 youths on a monthly basis."
Special protects on sexual abuse: "...the alarming incidence of sexual abuse..."
Strategies to cope ... hints on self-assertiveness ...
The Male ProgrammeThere are 38 male advisers in this province whose main task it is to educate male and female adults in industry on phc. They are also involved in education at hostels, taxi associations, prisons and at labour offices. They reach unemployed males during house visits in informal settlements and assist with youth education in schools.
The primary objective of the male programme is to educate males on all important health issues and to bring phc education into their work place.
Success is shown by the decrease in STDs of 75% to 15% at the clinic serving the Ekandustria industrial area near Bronkhorstspruit. This drop was reported within six months after the implementation of information sessions.
There is always a demand for condoms once males have attended sessions. The demand cannot be met and some industries are requested to purchase condoms for their workers.
Unemployed males are reached at Labour Centres.
The Female Programme
Information and guidance to women of all ages whenever the time and place are suitable.
"It often happens that contraceptive users do not return to the clinic for their contraceptive method on a regular basis. The female adviser compiles a list of these clients and does personal follow-up visits to these people at their homes. She remotivates them to visit the clinic on a regular basis.
This section supports the idea of papsmears being taken on demand, at ALL fp and phc clinics.
NON-DEPARTMENTAL ADVISERS (Covered in Julian's steri survey) People within firms. Spend at least two hours per week on active education.
Community Health Workers
53 CHWs have been trained at Boskop or by advisers and nurses.
Some are voluntary and some are paid by local authorities.
They assist in day care centres, food gardens, feeding schemes and basic health education.
Youth WorkersYouth workers are mostly the leaders of youth groups and are identified and chosen by the group. Aged between 12 and 21.
Given a course in sexuality and health education. Work with a Youth Adviser.
At Vista University 15 youth counsellors provide info on phc and sexuality education to the students. They also distribute condoms and literature.
Supporting Other Health Services
There is currently a shortage of clinical staff in most of the clinics, creating the need for an additional trained person to counsel, give guidance and information to the public.
In the Germiston local authority area, the Medical Officer of Health, Dr Cora Erasmus, wrote a letter in which she stated that the nurses could not do without the services of the advisers.
Successes with Steris
There is always a need for proper motivation and counselling of patients who are considering sterilisation. The role of the female adviser concerning the steri-patient is vital and indispensable. It is mostly the adviser who identifies the possible steri-patient on a house-to-house visit, at the mobile clinic, the fixed clinic or the hospital clinic while giving education on contraceptive methods.
The adviser books the patient into the clinic, makes sure that the male adviser in the area will be able to take the patient home after the operation and sometimes even assists in the theatre and afterwards in the wards.
The female adviser always does a follow-up visit on each steri-patient and makes sure that each one of them turns up for the check-up at the clinic.
During the past year, in the Vaal Triangle, 528 female and 65 male clients were sterilised.
The female adviser is an indispensable part of the team: We received a letter from Dr Christo Papavarnavas regarding an adviser: "She is kind, tolerant and compassionate with the patients and I believe that she is an integral part in the functioning of the sterilisation team at the Northcliff Day Clinic."
Informal Settlements
Most of the residents originate from the backyards in townships, other squatter camps, rural areas and other African countries. They have very little knowledge of phc services. No advisers are stationed in the informal settlement areas. A total lack of infrastructure.
In Soweto, advisers visited and presented projects in 8 informal settlements, where 43 000 residents have been reached during the past year. After the presentation a marked increase in the attendance of nearby clinics were reported.
At the informal settlement in Duduza, Nigel, the following topics were identified as needs and addressed through health projects:
ConclusionParaffin poisoning
Child accident prevention
Breastfeeding
Nutrition
Cholera
AIDS
The education section plays an important role in the steady growth of clinic statistics and is instrumental in improving the health of the people. Projects mentioned in this report are only examples of the vast number of projects launched, and individuals and groups educated during the year under review.
A total of more than 12 million people were reached during this financial year through projects, individual counselling and group education.
Envirofeature
'I give you love, health and cares
Anne Cluver Weinberg, SAPLER, P 0 Box 51446, Raedene 2124
"I was sitting there with the women and saying: well you are not really nurses or doctors - you are something more than nurses or doctors. Now here is R50 on the table. I want you each to choose a word by yourself, and the one who chooses the word we all like will get the R50, " (Maryna Clarke). Thus, the Nompilos were christened, meaning 'I give you love, health and care'.
Maryna Clarke started the Nompilos and Sarah Mahlango now runs the Middelburg scheme on Mr van der Merwe's farm. Near the farmer's house is a small enclosed area which is a crèche for the children of the local labourers. The children sit on chairs of paper mache and sing songs about washing hands and planting vegetables.
Next to the crèche garden is a very tiny room in which there are bed and a table. On the table are two boxes-one red and the other green. In the green box are the names of all the labourers who are parcitipating in the Nompilo scheme. In the red box are the names of those who have so far not been willing to parcitipate.
Nompilos are illiterate women who are elected by farm labourers to learn the skills of the Nompilos Scheme. These are:
The Nompilos visit every parcitipating family at least once a week. If a woman decides on the injection method of contraception then the Nompilo ensures that she is present on the day when the TPA Mobile Clinic comes around.
At the end of 1992 there was a long ceremony in Middelburg for the people who had gained their Nompilo certificates.
There were songs about 'breast feeding being best'; there were plays about teenagers becoming pregnant and not knowing who the father was; and there were speeches and Bible readings. In between the speaches and plays Sarah inspired the Nompilos; Sarah raged at them that they must live up to Maryna's high standards.
At the end of the ceremony all the new Nompilos recieved Gideon Bibles.
The Middelburg Nompilo Scheme grows from strength to strength, and Maryna Clarke now works for the Rural Foundation in Stellenbosch trying to raise schemes all over the country.
Good luck Maryna, and keep up the good work Nompilos!
(refference: SAPLER Newsletter, Number 1, April 1993, page3.)
Bekimpilo works in the informal areas around Durban. The trust is an example of SAPLER's basic philosophy of "Let's do what works".
What impressed SAPLER was:
1. The emphasis on preventive medicine.
2. The fact that Bekimpilo never advertises for nurses, and has a filing cabinet of nurses wanting to work for them, in spite of paying less than is paid to nurses in Durban.
3. Their high community acceptance, especially among the young.
To look at this last point first: Dr Liz Standing, who started Bekimpilo, found that doing initial surveys before moving into an area did not work. People were suspicious and did not like the questioning.
So the trust simply moves one of its Neighbourhood Health Units into an area - into a school yard for example - and starts operating. Very soon they have won the trust of the community - and from then on no one wants them to go.
There are now 15 three-member teams working in 10 peri-urban venues in KwaZulu/Natal, directing high-quality services for the young and those who care for them. The small service centres cost in the region of R25 000, but come up to WHO standards.
They offer: Immunisation, well-baby and preschool services, family planning services, and STD diagnosis and prevention.
Bekimpilo started in 1990. The family planning clinic recorded 5 676 attendances in the first year, 10 551 in the second year and 16 034 in the 1993/4 year.
Dr Standing comments:
"A high quality, easily accessible, user friendly family planning service is the objective. This is all important, particularly for ongoing compliance. It is interesting to note that the numbers of those who attend our fp service for consultations only has steadily increased.
"A number of these consultations are by clients who have been started on contraceptives in other clinics where professional follow-up consultation is not readily available to deal with the problems that the client later perceives. In this part of the country it appears that very few State or Provincial nursing staff are specially trained in fp techniques.
"The standard of service in most clinics is of poor quality and counselling virtually non-existent. Often they are out of stock on certain items. This can result in clients being changed from Depo to Pills, and vice versa, which makes a nonsense of 'informed choice of method'.
"In contrast we have our own qualified fp sister tutor who monitors the service and ensures it is up to scratch in all our units.
"We also do battle with Hospital Dispensers who try to only part fill our orders in an attempt to reduce costs."
Dr Standing continues:
"Our fp service is only a part of the Health and Development package we offer to the high-density mostly informal areas where we work which are often subjected to gross physical and social deprivation. Our total package is directed towards enhancing the quality of life and improving and maintaining a healthy lifestyle.
" Our service is only acceptable in sites where there is a reasonably accessible curative facility, and is only economically viable where there are sufficient people living within walking distance of a unit to justify our staff costs (Not less than 10 000 people served by one Neighbourhood Health Team)."
Working with Existing Structures and Self - Reliance
In the Bekimpilo areas there are no "existing structures". However, as soon as a school starts, the Bekimpilo people can work from there.
Bekimpilo uses school pupils to take health messages back to their parents. It also encourages all sorts of community activities like food gardens. It thus gets self-reliance going in areas where people have often become too discouraged to start.
Bekimpilo workers (45 black - a few of them men) do not live in the areas they work in. Dr Standing feels that they would not be able to maintain their high standard of work unless they could escape from the violence and depression of these areas when the day's work is done.
This is not based on any theory, but simply on what has been found to work.
How does this scheme compare with a nompilo scheme?
Nompilo schemes probably work best in areas which are less mobile - on farms, and in "resettlement areas" such as Winterveldt, where the same people have lived for a long time. Time and experience are required for a nompilo to become fully useful.
"Prevention" by Donald Henderson
A Different Drum?
"Integration (of health care services) is one of the most controversial issues today, but thinking about it has been hopelessly confused. Many speak of primary health care as though it were comprised of a similar set of activities which are all delivered in a similar manner by a common health staff. Many programs have been organised based on this belief.
"in fact, primary health care comprises quite disparate activities, requiring different strategies. Curative care, for example, is actively sought by those who are ill and can be dispensed in clinics and health centres as has been traditionally the case. However, experience has shown that in such health centres curative medicine invariably takes precedence over preventive care despite the fact that it is less cost-effective.
A vivid example from the smallpox program was the fact that health centres seldom vaccinated anyone, they had too many sick people to treat - including many with smallpox - to devote time to the prevention of the disease. In contrast, preventive interventions, such as immunisation, are seldom sought by people. They have to be brought to the people and actively promoted. They require marketing and merchandising. Even when such programs are actively promoted, comparatively few people will seek immunisation if, for example, they have to make a special trip to the health centre.
"this suggests that preventive programs - including immunisation, ort, family planning, vitamin a administration and malaria prophylaxis - will be more effective if organised differently from curative programs.
They require community involvement through aggressive communication campaigns, including social marketing programs, and developing delivery strategies that make vaccines and other needed commodities readily available in villages throughout a country."
Donald A Henderson
Formerly: Chief Medical Officer of WHO's Smallpox Eradication campaign
Presently: Dean of the John Hopkins School of Hygiene and Public Health