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Part II: Peter Dodds and the Rural Zimbabwe Scheme
Peter Dodds ran the very successful Zimbabwe rural family planning scheme in the 1970s. He has always maintained that it is useless to advocate population limitation without having all aspects of family planning in place. His scheme makes infinite sense in terms of the RDP and grassroots self-help.
Peter Dodds ran the first serious attempt to reach grassroots, illiterate women with family planning. This was in Zimbabwe in the 1970s.
He would go into a rural village, chat about fp, and almost invariably find one woman who was interested in the idea. He would teach her not only all about fp methods but also how to give the Depo Provero injection.
The Rhodesian Medical Council gave him permission to do this on the grounds that "family planning" is not a "medical" matter - does not have anything to do with disease and its cure and therefore its implementation does not have to be carried out by trained nursing staff.
Unfortunately, politically-motivated people saw the Depo Provero injection as a deep plot against black Africa, and the whole scheme had to be abandoned.
Zimbabwe's population has risen from 7 million to 10,5 million in the 13 years since Peter Dodds left.
I have copies of letters to Peter Dodds from Dr Ushewokunze, Minister of Health, and from international organizations, attesting both to the efficiency and the humanity of the scheme.
What happened was that an evil, fanatic, superstitious wind blew in from America - apparently from one white man.
The wish to use Depo had come from the people. It was not imposed on them. No one had ever died from Depo, and those who suffered side effects could change after three months.
But the voice from America said that Depo was carcinogenic, racist, anti-women and a weapon of the capitalist establishment to bring about global population control.
The entire medical establishment of Zimbabwe, black and white, and including the Medical School, supported Peter Dodds.
But the fanatics won. When the ban on Depo was made public, 100 000 regular Depo users demonstrated outside Mugabe's office. But this made no difference. Peter's office was closed down in 1982 and the scheme collapsed.
The ban on Depo was lifted in 1992. But how much suffering had been caused in those years between?
Peter Dodds was to have led the SAPLER inquiry into the unmet need for fp in SA, but was forced to withdraw. However, I am able to draw on his experiences by quoting from his correspondence with me.
I will start by quoting from the letter he wrote to the Star in 1990. It was as a result of the correspondence in the Star that SAPLER was started, as I wrote a letter suggesting such an organization, and Mary Rose of the Institute of Natural Resources came to see me about it.
Peter Dodds is retired and living in Simonstown. He is available to help us as soon as the government gives its go-ahead to a grassroots scheme and as soon as trained lay people are allowed to give injections.
Intense social unrest is not anathema to family planning
(From a letter to the Star 28 Aug 28, 1990)
It is unfortunate that Operation Hunger executive director Ina Perlman should, in her response to "Stop hunger: start birth control" give further currency to the myth that social unrest is anathema to family planning.
Statistics, analyzed by the Population Reference Bureau (which is the demographic authority), revealed that the incidence of family planning had grown throughout the Rhodesian bush war and that the population growth rate had been reduced.
Subsequent reports by the World Bank confirm these findings. The movement of rural communities into the protected villages did not divert the family planners. The essence of the exercise is the manner in which the family planning is offered and serviced.
Family planning from within a community, through the medium of a member of that community, becomes a natural part of the social fabric.
Peter Dodds
Mbabane
EnviroFeatureFamily Planning: Rural education and distribution
Peter Dodds. P 0 Box 318, Simon's Town 7995
(Photographs: David Dodds)
The successful development during the 1970s of the rural family planning programme in Rhodesia (which became Zimbabwe) was based on lessons learned through pioneer work with lay personnel and, on growing appreciation that education in family planning is contraceptive service.
Initially education was given the primary role and it was assumed that a person who had been motivated towards planned parenthood would somehow find their way to a clinic where contraceptive services were available.
The approach proved counter-productive as potential family planners encountered numerous problems which frustrated them and before long robbed them of their motivation.
The primary difficulty was access to contraceptives and contraceptive services on a regular basis. Obtaining contraceptives in a rural situation meant going somewhere, which took time and possibly a bus fare.
Walking meant an even longer time away from the daily work of child care, wood and water collection, maize weeding, livestock supervision and cooking. A bus fare often did not fit into the family budget or the request came up against a reluctant husband.
The determined woman able to overcome these difficulties found herself at a clinic standing in a queue of sick people or people with sick children.
There was nothing wrong with her - she was simply a healthy woman wanting to find out about contraception and to obtain whatever was suitable for her. In that queue she had no priority; sick people came first. She also wanted time for a quiet talk.
The longer the queue became the shorter her chances became. When her turn did come she was usually confronted by a nurse (most likely a stranger) whose professional training did not include contraception and family planning and who was anxious to get on with her primary role of helping to heal the sick and mend the injured. Not infrequently contraceptive supplies were inadequate or non-existent.
From these experiences emerged several important lessons: an effective family planning programme must relate information, education and motivation to the actual service The service must be close at hand. it must be familiar, competent and sympathetic.
Those lessons dictated the first change in the job title from 'Field Educator' to 'Educator/Distributor', quickly shortened to 'ED' and the change in job content to include the supply of oral hormonal contraceptives alongside condoms, foams and jellies.
The new responsibility called for retraining and the field force was systematically brought into the Family Planning Association's (FPA) Headquarters to undergo the newly devised course.
New entrants to the field force strength underwent this training before returning to their place of work - the area in the vicinity of their home whether it was with the husband on a farm or estate, in a village, or a squatter settlement on the fringe of a town.
The essential feature of her appointment was her acceptability in that community - an identifiable face, preferably with a small family of her own and a husband with a common-sense view of planned parenthood.
Nothing was done in secret. The ED wore a beige dress with a green jersey and carried a green canvas shoulder-bag with all her papers and equipment. She was by common acknowledgement 'Mrs. Family Planning' - a good woman; she could read and write and was the source for that community of information, support and contraceptive supplies.
Women were the backbone of the field force but men played an important role, mainly in the urban industrial situation, handling the education and motivation of men, supplying condoms and providing information on vasectomy.
Men also supplied the first line of supervision for the rural field force. Where geographically possible EDs were grouped in tens, and. a group leader visited them at their places of work, lending support by educating the men and elders and ensuring continuity of contraceptive supplies.
Hovering in the background in each of the Provinces was a professional nurse, the Nursing Officer, who in addition to traditional nursing qualifications had successfully undergone the Association's rigorous course of family planning training.
The Nursing Officer ensured that a competent level of advice and service was maintained, handled problems which might arise, liaised with the normal health services of the Province and ensured that each clinic or hospital carried effective contraceptive stocks. Nursing Officers and Nurses in the Association's State Clinics could also obtain a qualification for the insertion of intra-uterine devices (IUDs).
The Association did not carry out its pioneer work in isolation. Its own highly qualified medical staff worked in close collaboration with the Department of Obstetrics and Gynaecology at the University, principal officers of the Ministry of Health and local Government and gynaecologists in private practice.
This highly professional back-up (provided without cost to the Association) was vital, as one of the important obstacles to be overcome (and it was overcome) with the deployment of EDs was the prejudice (largely medical) against lay people supplying hormonal drugs (the 'pin') to the public.
Those professionals had a hand in the training devised for the field force and its updating. The continuous process of updating led inevitably to the next question to be confronted - and that was how to satisfy the popular demand for the injectable contraceptive.
The 12-weekly injection had so many practical advantages, particularly for the rural woman, freeing her from the regime of the daily pill - forgotten, misplaced, eaten by the children! This had an additional medical complication administration by means of an injection with a syringe..
The Association submitted a paper to the Medical Council, seeking their approval for this new step. In the Council, the request received strong support from the Secretary of Health (the late Dr Eric Burnett-Smith).
The point was made that the Association's personnel were not diagnosing sickness and were not prescribing and administering a treatment: they were simply proposing to provide a social service for healthy people. The Association had already overcome prejudice against its use of lay people to distribute the pill and established a reputation for responsibility and competence in that field.
There were no objections to the Association embarking on a process of selectively retraining EDs to add the injectable contraceptive to their range. A new title emerged - the EDI. A new training course was devised and a select few EDs were brought to Headquarters for the new course.
They themselves were overjoyed to be able to offer their parishioners a complete service by the introduction of the injectable contraceptive. The EDIs soon demonstrated their competence and responsibility with the injection and systematically all EDs were retrained, In a comparatively short time there were over 100 000 regular users of the injectable method of contraception.
The deployment of the Association's personnel would not have been possible without the vigorous support of the community at large. Major agricultural estates and individual farmers provided accommodation for Association nurses and ED1s, progressively taking over the cost of their employment, supplies and equipment. Farmers provided transport to enable an EDI to cover a large number of farms in one case a motor cycle was purchased. Staff based in Kariba were taken to work in
the tribal trust lands on the lake's southern shores in the power boats of the administration. All EDIs had personal bicycles which also served to maintain their acceptability and visibility. On their rounds they could stop for a chat bringing or hearing the latest local gossip.
As the field force grew the Association's substantial reliance on mobile clinics diminished and these were progressively withdrawn from service. By the time Rhodesia became Zimbabwe there were over 400 EDs and EDIs deployed throughout the country.
Among the many important sociological lessons this pioneering work taught was the resilience of the ED approach to family planning.
It had long been believed that family planning would not prosper in times of stress, yet it is clearly documented that in a war situation the ED remained a natural feature of the social fabric. In the later stages of the war whole communities were moved into protected villages and their EDIs were sent with them, carrying on their daily round.
EDs also underwent regular in-service courses of training. These courses and pay day of course served the important purpose of keeping the administration in touch with developments and problems in a particular area and even with particular people.
At one stage EDs in an area were harassed by youths who considered that their skirts were too short. The problem, simply a passing phase, was solved by providing the EDs with a flowery wrap-around to cover them down to their ankles.
The communications system established with the ED and with the clinic in the field meant that headquarters administration was never remote from events on the ground and could act and react to respond to situations and circumstances as they emerged, lending support or securing support for the staff to enable them to continue their work without interruption.
The unique success of the ED approach to family planning in Zimbabwe attracted wide international acknowledgement and financial support and the field force was substantially expanded. Officials
from programmes from other African countries were sent to study the Zimbabwe approach. The ED approach has another and most beneficial side effect - it serves to release professional medical personnel, both doctors and nurses who in Africa are in very short supply, to get on with the care of health and life. It also serves to put family planning back in the hands of those whose concern it really is.
Author's Note:
Editor's Footnote:This article is concerned only with the Rhodesian (Zimbabwe) Family Planning Association's use of lay personnel in its rural operations. The Association, in fact, served all sectors of the community, operated two major training centres in Harare and Bulawayo and provided clinic services in all urban centres. Sterilisation (Male and Female) was offered free of charge at the Association's own theatre in Harare, along with sub-fertility examination and treatment.
The Association was responsible for purchasing the national contraceptive supply and ensuring all sociation and health service outlets were adequately stocked with the correct range of contraception.
The Association was an independent non-Government organisation relying on financial support from all those concerned with the provision of an effective national family planning service. By 1981 the Association was responsible for the bulk of the country's family planning.
Zimbabwe's population has risen from 7 million to 10,5 million in the 12 years since Peter Dodds left! (Ref: SAPLER Newsletter, No 1, April 1993, p.3).
Quotes from Peter Dodds's Letters to Ann Weinberg
Simon's Town, 4 Sept 1992.
Dear Mrs Weinberg,
Thank you for the various papers you have sent me which I have enjoyed reading.
On page 152 of Jordaan's book is a list of organisations involved with population and, so far, I have encountered no evidence which leads me to believe they share a common goal and act jointly to secure their objective.
In discussions I have had with various bodies the impression I am given is of autonomous organisations pursuing parallel paths. I sincerely believe this cannot go on and, from my own experience, I am satisfied that SA's population fate will only be resolved successfully if energy and resources are welded into one unit.
It goes without saying that a fairly radical change must take place as Government is the primary family planning source and that is wrong, from the outset. SA's family planning services must be privatised and, once that is done, I do not believe there will be a shortage of population aid.
Yours sincerely
Peter Dodds
11 Sept 1992.
Dear Ann Weinberg,
Sadly, Jordaan is pursing a goal which (as history has established.) was abandoned a considerable time ago. 'Summits' are not the answer, nor is there any need to place reliance on political and social leaders. They, if they have any common sense at all, will be only too happy to deliver 'key note' speeches, make suitable public exhortations from time to time, and keep the coffers open. That is the sum total of their contribution. All we require is that the general public be aware that they are supportive.
Public figures (social and political) do not wish to be actually involved. McNamara, during his time with the World Bank, was the most supportive leader available and we use his many and famous words - but he was not physically involved.
Our objective, I believe, is to identify an agency with the basic framework in place which has public credibility, right down to the dust of the village, which can be made into the national family planning agency. A definitive agency, not an organisation which includes family planning alongside all the other trappings of child and maternal health services.
Traditionally the health services have not included family planning and contemporary contraception in their training programmes which is why they cannot be relied upon to provide the care and devotion that a potential family planner requires. They have neither the time nor the motivation. In time the national health services merely become a collaborating agency.
We also have the task of ensuring that the medical fraternity accord recognition to the fact that family planners are not sick people and family planning agencies do not engage in diagnostics and prescription.
A trained lay family planner is perfectly competent to interview, counsel, make a simple health check, decide what contraceptive method is appropriate, supply it, and keep up the planners' motivation and supply.
There are no contraceptive methods, apart from IUDs (and even that is no longer sacrosanct), sterilisation and abortion which call for professional medical involvement.
Another major hazard is encouraging people, who currently have their little empires, to allow them to be absorbed into a national movement.
Lastly (for the moment) there is a need to encourage those who conduct forums, of one form or another, to accept that scattering demographic erudition around the countryside is not the way to get people to take the necessary practical steps to plan their families.
By and large those likely to absorb the erudition are part of the educated and economically active sector and they do not need much motivation anyway.
Educational and motivational forums must be related to the services on the ground. There really is no purpose in holding meetings to promote family planning unless there is ready access to data on who is doing the family planning, where, under what circumstances and how successfully.
Once that information is available then the education and motivation can be applied in support, at the roots.
Yours sincerely
Peter Dodds
From Peter Dodds's protect proposal on family planning in SA (Jan 1993)There is a common appreciation that the rate of population growth in SA is of such a magnitude that it will defeat the ability of govt. to provide effective health and education services for the populace and the economy to provide employment opportunities.
Other institutions and organisations have set out in authoritative detail the harmful impact this development will have on environmental and ecological features and, ultimately, on the quality of life.
It is also a common appreciation that a reduction in the current rate of population growth can be influenced by educational and developmental progress and urbanisation.
There is general acceptance, at the same time, that the personal ability of people to impose restraint on their own fertility is governed by the access they have to effective family planning services.
It is relevant, also, that the presence, in an area, of a sympathetic and efficient family planning delivery service serves an important motivational function.
Currently there is no clear appreciation of the extent to which the entire at risk (15-49) population has access to family planning services.
The Department of Health produces its own data on contraceptive consumption at its own clinic unit (3138 fixed units and 1085 mobile clinics) but no similar information is available in respect of the TVBC and self-governing states where the majority of at-risk women can be found.
No information is available to determine whether or not the services that are provided are optimal for the purpose of persuading people to adopt planned parenthood as a way of life. 19 Jan 1993
Dear Ann,
Giving consideration to the question of cost gave me additional food for thought. Firstly, is it appropriate to conduct this exercise in two parts? It would be difficult to isolate fact from assessment and critical comment. Logic points one in the direction of a single document containing a progressive commentary on what is found, what is good or bad about it and what needs to be done by way of rectification.
... donors are, in my opinion, more likely to respond to a 'plan for the future' than a simple factual report on what goes on.
Yours,
Peter
24 Sept 1993. Large sums of money are available, with various agencies, but cannot be allocated until persons and organisations of competence and integrity can execute projects and have either the backing of a Government or at least a guarantee of noninterference.
lst Oct 1993. In so far as our hypothetical 5m rand programme is concerned, how much time do I have to prepare it? It does not matter if the Ministry continues to provide its service (which is all it is) so long as there is no exclusivity.
That may be the bureaucratic problem, an unwillingness to let anyone else get into the act, which is already part of the present shortcoming. If there is to be an independent NGO in the field it must be free to operate in the field of hormonal contraception using lay people, paramedics and professional nursing staff. It would also be part of the Ministry's obligation to complement the work of such an organisation and not behave like a dog in the manger.
8 Oct 1993. A visit was made to Paarl Hospital. Dr de Villiers is a protagonist of sterilisation after family completion and pursues a vigorous and successful path in his area of jurisdiction. His promotional efforts are supported by Department 'motivators' under his control. Dr de Villiers is an isolated case, but the degree of his success demonstrates what can be achieved if the motivation, the opportunity and the means are present at one and the same time.
11 Jan 1994. To my mind the only worthwhile project remaining is to secure a mandate from 'those in authority' to redesign the country's approach to family planning: not as an abstraction but with the clout necessary to bring it into being. Work along those lines would call for an entirely different approach and for formal remuneration at a suitably attractive level.
28 June 1994
Dear Ann,
Good luck on your wandering through the wilderness of Lebowa and Gazankulu.
A Minister of Population has its attractions but I am not sure that is the route. One could not wish to create a bureaucrat who becomes simply a demographic cipher.
We have to tackle the task in two bites. The first is best summed up in your own acronym - RESA. (Reach Every South African).
We found it counterproductive to exhort people to plan their parenthood in a contraceptive desert. You can motivate people if, close at hand, is an identifiable, socially acceptable and effective source - a source sufficiently flexible to cope with the vagaries of life.
Dwellers on the Cape flats who are currently under water could not be blamed for forgetting their dates, but that position would change if the 'source' is a neighbour who is in the same straits.
To bring about that situation calls for action to deregulate contraceptives and make them available through community sources. (CBD). That calls for someone with the authority to REQUIRE, INSTRUCT, COMMAND the Minister of Health to relinquish her exclusive control and to recognise that the Ministry's role as the contraceptive delivery service will diminish.
In future, each static or mobile health outlet would have, as part of the service, a lay person/paramedic devoted to fp. The door would be open to mobilisation of nompilos etc. as an opening gambit. (It goes without saying that the Rural Foundation cannot be permitted, any longer, to train their personnel over a period of years. A more sophisticated selection procedure is required accompanied by formal courses of residential training of four to eight weeks.)
The Dept of Population Development can stand down and their expenditure utilised for other more useful contemporary purposes. As the RESA programme progresses it will develop its own momentum and once it is in place, nationwide, formal exhortation towards the two-child family will become socially and politically digestible.
There would need to be a measure of direction for the various voluntary agencies, and their license to function would ensure that resources/services are not dissipated and develop along complementary lines.
About the men - You will find that as the fp presence grows men will become party to the programme.
There, you need not retire after all: you can be Minister for Population.
Regards,
Peter
lst April 1995
Dear Ann,
I find it hard to believe that a medical man could seriously suggest that a year's training is required before a sensible woman can undertake the provision of injectable contraception. It suggests a profound reluctance to recognise (and accept) the ability of lay people to undertake simple tasks which, until now, have been in the exclusive preserve of the medical profession. I found the same deep conservatism when I discussed lay personnel with doctors here.
We had a clientele of 100 000 depo users and we did not lose one of them
Regards,
Peter