Our third case study from the Democratic Republic of Congo comes from Marabo, a village of 5,000 people. Though near Nyankunde Christian Centre – a 250 bed hospital – health activities were limited to a poorly attended private health post. There was little support for primary healthcare and only 23% of children were fully immunised.
Often the people of Marabo were described as ‘difficult.’ (This could mean health professionals have failed to understand the population’s difficulties!) Even with patients paying full costs, there was no way in which the health post could be self-financing.
In July 1997, following the war and a long dry season, students from the Institut Panafricain de Santé Communautaire (IPASC) did a health survey of Marabo. They found that over half the children under five were malnourished, and that many people were tired and demotivated.
Puzzling attention
IPASC’s principle is to listen to a community and then facilitate their response to key problems. So IPASC staff and students visited the village several times a week to meet the people and hear their problems. The community was puzzled by this attention since they had felt abandoned for many years – but within ten days they formed a committee to consider their problems logically. The urgent need was that of the malnourished children. The villagers asked for work, so that earnings would provide a communal meal for the children. A few weeks later, with full stomachs, many of the pathetic children had turned into cheerful toddlers. Now the villagers asked for spades for digging. The IPASC agriculturalist went out with students to give advice on what could be effectively and economically grown. Soon, gardens started to sprout soya beans and other nutritious foods.
The next need expressed was for a protected water source. A student spent several weeks working with the community to clear vegetation from a spring site and to put in a pipe and cement surround to protect the spring. This protected water source later meant Marabo was one of the few local villages spared from a serious cholera epidemic.
Only when improvements in nutrition, agriculture and water had been achieved did the community turn its attention to the health centre. A dilapidated hut which previously served as a health post could be rebuilt – but they needed a nurse and an initial stock of essential drugs. They purchased a few important drugs, and sent a male student community nurse, Jean, from Burundi. Another nurse looked after the curative care, while Jean was responsible for working closely with the community. His caring attitude quickly won a warm response. As a result, the primary healthcare activities came alive. In six months the immunisation coverage of under-fives had risen from 23% to 90%. Around ten patients attended the health centre each day.
The newest initiative is to upgrade the health post to a centre with a maternity ward. A community member gave 8,000 bricks towards this, while others dug up large rocks for the foundations. IPASC helped with their transport.
Conclusions
- Establishing a health post without first defining the target community may mean there are too few people to make the post self-financing. In this area a population of 4,000–5,000 is needed for a health post and 8,500–12,000 for a health centre.
- A health post may not be a priority need. In Marabo, nutrition, agriculture and water were thought to be far more important to the community than medicines. Until these needs were met, it was unlikely that patients would attend the health post. No patients means no income.
- We found that a nurse who places curative care before community involvement will seldom have sufficient patients to be self-financing. Nurses are much more likely to win people’s confidence if they…
- mix with the community
- visit handicapped, chronic and high risk patients
- associate themselves with daily concerns
- are available to all sectors of the community.
- If people have confidence in their community nurse, that’s who they will turn to when they fall sick. This automatically increases the number of patients, and thus the income of the health post.
- Marabo health post is run by a committee which examines activities, income and expenditure. This ensures the community’s involvement and enables them to understand and control the level of self-financing. A partner programme (in this case, IPASC) should facilitate, rather than impose development and encourage dependency.
Self-financing has more to do with an approach to a community than with the financial management of a health post.
Compiled by Pat Nickson, who is the Director of IPASC, c/o PO Box 21285, Nairobi, Kenya.
