Tuesday 17 December 2013

For reference: EMBRACE - 20th November version

15. EMBRACE - 20th November version

For the purposes of telling the story to posterity, I think it will be good to publish each major update of the Grand Plan as it emerges, without taking down the previous version.

In this way we can have shown how our thinking developed.

I imagine that there will be many more versions. In the end, when the ship founders on the rocky shores of a much better place, we can take the timbers and build a house. 


EMBRACE
(Empowering Mothers & Babies to Receive Adequate Care & Equality)
Berega Hospital & Communities of Mnafu & Tunguli

Development Plan for Maternal, Child & Reproductive Health

The inter-connected problems
Berega Hospital serves a vast and inaccessible territory of rural Tanzania with a population of 217,000. There are 8,500 births/year, of which only 1000 occur in a health facility. Nearly 1 in 100 women die in each childbirth. Many more suffer drastic chronic disability, such as vesico-vaginal fistula, (VVF).

Rural areas have a particular problem, made worse by the lack of education, lack of empowerment, and lack of access to birth control. More than 80% of the population live on less than £500/year. (In Europe, the figure is less than 2%). As a result of poverty, severe under-nutrition is common. Up to 10% of children do not reach their fifth birthday. Malnutrition is a vital component of the mortality, because of its effect on reducing the capacity to resist illnesses such as diarrhoea, meningitis and pneumonia.

Berega provides the only Comprehensive Emergency Obstetric Care (CEmOC) facility – ie capacity for caesarean section – for 7,000 sq km of territory. There are only two tar roads. Most other roads are impassable in the rainy months, and in the dry are only negotiable by expensive and dangerous three-person motor-bike rides, (comprising for instance a driver, a labouring woman, and a carer/blood donor). Even for those few who live near the main roads, travelling to any other CeMOC facility is both unaffordable and impractical, (70km to Kilosa; 110km to Morogoro; 180km to Dodoma).


The Vision    
The vision is for trained Community Health Workers (CHWs) to reach out, initially to the isolated communities of Tunguli and Mnafu, working with the Traditional Birth Attendants, (TBAs), Village health Workers (VHWs) and village leaders, to develop a systems for managing  childbirth, family planning, immunisation, child nutrition, and chronic conditions (eg malaria, anaemia, diarrhoea, TB, infestations, & HIV). CHWs will also help improve collection of information – eg demography, birth rate, etc.

In the process, we hope to influence the social order, by empowering women at the centre of the community development process.


Partnership – the interconnected solutions
The project is a collaboration between Berega Mission Hospital; a community development charity, (Hands4Africa); a Berega development charity, (BREAD); a Berega charity with a special interest in Tunguli, (Mission Morogoro); and a high-profile international women’s charity, (Ammalife), which has led key research. EMBRACE is a ‘sister-project’ within Ammalife.

Many recent visits to Tanzania have been made by UK and USA stakeholders, with several two-month stays at Berega.


Principles of the approach
Key features of EMBRACE, based on high-quality research, are:
·         collaboration between agencies
·         community participatory learning and action
·         training of CHWs, local women, VHWs and TBAs to take lead roles in community health and development
·         improved: maternal and child health; transport; primary care; data; family planning; and education of women; and
·         recurrent evaluation to learn lessons, to build on success, and to limit undesired outcomes

The proposal is based on local need and perception. EMBRACE will initially concentrate on building relationships by and through education of local women leaders: Community Health Workers, Village Health Workers and Traditional Birth Attendants, (CHWs, VHWs & TBAs).

Meanwhile, H4A will address transport and community meeting facilities.

The main deliverables at the first year are consensus and access to safe birth care. Thereafter, women & children’s health and community development will progress hand-in-hand.

In the hospital, a new set of agreed standards for maternity care will be bedded in, so as to ensure that those women arriving will be dealt with appropriately. Meanwhile, expanding the capacity of care-giving will be addressed by getting ready for the training of front-line ‘medical’ staff, the Clinical Officers, (COs). COs will meet the primary care needs of women and children both in the hospital and in the community – education, family planning, antenatal care, chronic ill-health & nutrition.


What will actually happen:
Phase 1. Establish a foundation    Phase 2. Build on it

Phase 1: Foundation Project: Build Relationships, Information and Infrastructure
Mnafu: learning from Tunguli:
There will be a lag phase in Mnafu before CHWs can begin the process of engaging TBAs and VHWs, for four reasons:
·         The hospital will need six months to bed in its standards and to increase capacity before it is ready to accept the extra influx of mothers
·         A purpose-built facility in the community would enhance the possibility of putting women at the centre of community development
·         This will also allow overnight accommodation – an important facility for visiting staff, particularly in the rainy season
·         Transport solutions are expensive and organisationally difficult to set up, but need to be active as soon as women are being offered emergency transfer to hospital

For this reason, the CHWs will sharpen up their community engagement process by first approaching the village of Tunguli. Tunguli already has a clinic – the only peripheral clinic in Berega’s territory – and already provides comprehensive primary care and basic childbirth facilities. Despite this, the large majority of mothers consult TBAs rather than the clinic. Furthermore, it is far from clear that the presence of a clinic translates into reduction in maternal and child mortality. We need to know the data on this, as well as understanding the possible reasons.

CHWs can therefore be trained to engage with TBAs, VHWs, the women themselves, and community leaders, to explore the possibilities of improving the system. Once EMBRACE Mnafu is ready to begin, the CHWs can transfer the learning from Tunguli to Mnafu.
Phase 1 in Mnafu:

Based on evidence of simple, workable solutions, the charity Hands4Africa will develop the transport system, including drivers, fuel, and vehicle maintenance, for adequate emergency transport in labour.

Additionally, they will build a health / community facility (using their high-quality compressed-earth technology.

At the same time, they will begin building the partnerships for Phase 2, which will include development of agronomy and education.

When the transport and building are sufficiently advanced in being delivered, CHWs will begin to engage with the community, building on lessons learnt at Tunguli.


Phase 1 in Tunguli:

Led by Berega’s maternity lead, Dr Abdallah MPH, the EMBRACE Foundation Project centres on community mobilisation and participation. Trained CHWs will engage with community leaders, VHWs, TBAs, and mothers, to examine their problems, ideas, potential solutions, and priorities in relation to pregnancy and childbirth; nutrition; family planning; immunisation; and chronic disease.

Their role in the six months will principally be the gathering of information, and the establishment of partnership. Amongst other duties, they will need to:

·         Meet village and school leaders and establish credibility and shared purpose;
·         Meet mothers and hear their story, and learn about their perceived needs;
·         Meet TBAs and learn of their practices, their concerns, and their ideas;
·         Meet Village Health Workers (VHWs) and discover what records and registers they           keep, what the problems are, and what their thoughts are on solutions and priorities. Where there are no VHWs, the CHWs could help in establishing them.
·         Discover what currently happens when there are problems in childbirth;
·         Assess other health issues relevant to health and well-being of mothers and children, such as malnutrition; family planning; HIV; STDs; TB; & Malaria
·         Discuss with the appropriate people about systems for ‘Road to Health’ charts, in particular for monitoring growth and immunisations in pre-school children. This would, in the fullness of time, work alongside a mature schools health programme for children of school age.
·         Attempt to obtain raw data on rates of death and serious complications, and try to enhance future collection of such data;
·         Assess the current frequency of attendance of women from Mnafu (and environs) to Berega, and determine what problems they come with, and what outcomes currently occur.

At the same time, as this is occurring, the charity Mission Morogoro will provide transport solutions for the established clinic at Tunguli, including the provision of an adequate vehicle for emergency transport in labour. This solution will include drivers, fuel, and vehicle maintenance.

This transport upgrade will not significantly increase the burden on Berega, as women already are transferred from Tunguli. The quality and reliability of transport will however be significantly improved, and this can be used by EMBRACE to mark a new era of engagement, and therefore to enhance the CHW work.


Phase 1 in Berega:

At the same time, the hospital will be working to implement a new Charter of Standards, to prepare it for the future influx of patients. This will include a two-month visit of a consultant obstetrician, with planning for follow-up visits; plus a programme of on-site training and inspection which will particularly include:
·         recognition of sick patients
·         emergency kits, and
·         reflective learning.

With regard to children, Phase I needs to concentrate on:
·         Emergency Triage Assessment and Treatment, (ETAT), which involves the recognition of sick children, and appropriate management, especially in the first 48 hours;
·         ward protocols for the Children’s ward and the Premature Baby Room, to include screening for and treatment of malnutrition (and any underlying causes), as well as routine daily feeding of children;
·         the initiation of Road to Health charts for those under-5s that do not have them.


Phase 2: Building on the foundation:

Phase 2 in Mnafu: Primary care; Access to CEmOC; Education, Agronomy
Having established the relationships, and understood the community perspective, CHWs will work with and train TBAs and VHWs, to bed in safe childbirth solutions, including bringing selected women into Berega for birth.

After successful childbirth within the scheme, and return of the woman and child to the community, CHWs would try to enhance breast feeding, family planning, immunisation, growth charting, under-5s nutrition, and prevention and treatment of diarrhoea, malaria, worms, and other chronic conditions. This would be centred at a purpose-built health and community facility. Healthy mothers and babies would encourage other women to follow the same path.

Once the purpose-built community facility is functional, and indeed whilst building is happening, H4A will be negotiating with the community to develop its agronomy. This will have the dual effect of creating income, and providing food.

They will develop transport solutions, based on experience and evaluation.

As these developments are settling in, the ultimate goal for H4A is to help the community to build and staff a school. Not only will this provide health through education, but also it will eventually provide educated school-leavers who can come back to the community after training as, for instance, health and development professionals.

Phase 2 in Berega: Expanding hospital capacity

In Phase 2, Berega will expand its School of Nursing to train both Clinical Officers and nurses/midwives. COs can deal with childbirth, family planning, and treatment of disease.

This will involve a significant building programme, to include classrooms, accommodation, offices, and outpatient department expansion. This is made cheaper and higher quality by H4A’s compressed earth building materials technology, which is already in situ.

CEmOC facilities at Berega will be brought up to standard, in particular in relation to caesarean section. The hospital standard of a decision-to-readiness time of 30 minutes maximum for urgent CS will be monitored and the findings discussed, with ongoing modifications made in the light of experience.

Both for the development of CO training faculty, and for the oversight of the clinical work, there will be regular visits of senior staff from the UK and elsewhere. In particular, the maternity services will be overseen by a consultant obstetrician on site for at least two months every year.


SMART Objectives for The EMBRACE Project

Summary objectives for the end of three years

In the community:
1.    Women in key roles – Mothers, CHWs, VHWs, TBAs – will be influential in driving social, health, educational and economic development

2.    There will be good local access to antenatal & primary care, and systems for referral of women and children with serious and/or chronic disease

At the hospital:
3.    Clinical Officer training will be have begun, with adequate recruitment, accommodation, curriculum, faculty and supervised placements

4.    Data systems will be strong, and the impact of this project on the community of Mnafu will have been measured and evaluated, learning lessons

5.    Hospital standards will be regularly measured and reinforced, which will show that maternal and perinatal mortality will be acceptable and falling

Expanded objectives, looking forward to five years

At 6/12:
Two trained female CHWs will have forged links with all key community leaders, key individuals, TBAs, VHWs, and any other significant players the Mnafu community.

A report will be written on the findings from the experience gained by the Team at Tunguli. Lessons will be learned that can be transferred to Mnafu. A pathway will be agreed with TBA's and VHW's for bringing to hospital those mothers who are likely to experience difficult births.

A transport solution for this will be in place.

At 12/12:
In the community, plans will have been agreed which include:
·         acceptance of key roles of women – especially VHWs, TBAs, mothers and teachers – within the body which determines the development of the community
·         training of TBAs as part of triaging pregnant women
·         referral pathway, transport and economics of pregnant women needing hospital
·         training of VHWs, including in establishing accurate demographics and records
·         systems for improving health of mothers and children by access to primary care and antenatal care
·         provisional long-term plans for transport, education, and a maternal /child / family planning health facility
At the hospital:
·         the plan for CO training will have Government approval and a start date
·         inspecting the implementation of the Charter of Standards for care of mothers and under-fives will be happening at least weekly
·         systems for measuring the impact of the project on the Mnafu community, and their uptake of services at the hospital will be in place


At 2 years
In the community:
·         empowered and trained women will be involved in normal decision-making in the development of the community
·         trained TBAs will be following agreed pathways of care for pregnant women
·         pregnant women needing hospital will be arriving there readily, reliably and affordably in sustainable transport systems
·         there will be appropriate action towards the goal of local access to antenatal care, family planning, immunisation, & growth charting; and systems for dealing with malaria, infestations, diarrhoea, and malnutrition, and for referral of women and children with serious and/or chronic disease
·         trained VHWs will be directly and deeply involved in maintaining the health of mothers and under-fives, including in the complete and accurate recording of key data and demographics
·         long-term plans will be in an advanced state of readiness for transport, education, enhanced prosperity and a maternal /child / family planning health facility
·         At the hospital:
·         CO training will have begun
·         Monthly reports on maternal and under-fives health will be produced, based on accurate and complete data, as well as regular inspection against the Charter of Standards
·         These will demonstrate acceptable levels of care
·         Three-monthly reports on the access of the Mnafu community to hospital-based care will be produced, based on accurate and complete data
·         These will demonstrate an appropriate uptake of primary and secondary care, with follow-up of healthy women and children in the community
·         Transferrable lessons will have been learned for similar development of other isolated and /or needy communities

At 3 years
In the community:
·         The two-year goals will have been revisited and implementation will have been strengthened where needed
·         there will be local access to antenatal care, family planning, immunisation, & growth charting; and systems for dealing with malaria, infestations, diarrhoea, and malnutrition, and for referral of women and children with serious and/or chronic disease
·         long-term plans for transport, education, and a maternal /child / family planning health facility will have begun implementation, including at least the commencement of the building needs

At the hospital:
·         CO training will be have completed its first year, with adequate recruitment, accommodation, curriculum, faculty and supervised placements
·         Data systems will be strengthened
·         Maternal and perinatal mortality will be at acceptable levels, and falling
·         Transferrable lessons will have begun to be implemented for development of other isolated and /or needy communities


At 5 years
In the community:
·         Women in key roles will be influential in maintaining the drive for social, health, educational and economic development
·         There will be good local access to antenatal care, family planning, immunisation, & growth charting; and systems for dealing with malaria, infestations, diarrhoea, and malnutrition, and for referral of women and children with serious and/or chronic disease
·         A maternal /child / family planning health facility will be built and operational
·         Systems for local education will be implemented

At the hospital:
·         CO training will be have completed its third year, (with its first graduates), with adequate recruitment, accommodation, curriculum, faculty and supervised placements
·         Data systems will be strong
·         The impact of this project on the community of Mnafu will have been measured and evaluated, and will demonstrate that the project has brought about substantial reduction in mortality and severe morbidity of mothers and under-fives
·         Hospital maternal and perinatal mortality will be at acceptable levels, and falling
·         Transferrable lessons will be being learnt from the development of other isolated and /or needy communities

Management and accountability of funding

The funding of this project will be separate from the hospital funds, and ring-fenced such that it can only be used for the designated purpose. The health aspects of the project will be housed in the UK maternal health charity Ammalife11, who will hold the funds, (without charge), and who will expect accountability for their deployment.

Deployment of health and health education aspects of the project will be managed through a cooperation between Berega Hospital12 Management Team, and their charity partners BREAD13. The BREAD project management team visit Berega at least once a year, to oversee the implementation of charitable works.

The community development and transport aspects of the project will be under the aegis of the American charity, Hands4Africa14, who have a long history of extraordinary success in the development of education, transport, building and agronomy in Berega. They are self-funding.

Collaborators

All partners are in agreement, and fully on board with this project plan:

Rev Isaac Y Mgego
Director, Berega Hospital

Prof Arri Coomarasamy
Trustee and Founder, Ammalife

Dr. Brad Logan
Founder and Chief Executive, Hands4Africa

Gary Mann
Chair, BREAD

Dr. Laurence Wood
Obstetrician & Project Activator

Tony Mortimer
Chair, Mission Morogoro



Key evidence for the strategy includes:

(* = evidence contributed to by Ammalife)
·         The recent census quantifies the problems3.
·         Local, trained CHWs (& VHWs) are central to the solution6.
·         The model of VHW training is critical10.
·         *Women’s participatory learning and action is highly effective15.
·         *Training of TBAs really really helps16.
·         *Clinical Officers are a vital part of the solution. Not only are they effective in primary care but even in complex maternity interventions17.
·         *Transport solutions are both vital and deliverable18
·         Christine MacArthur is currently trying to ‘manualise’ engagement with TBAs

References
15.  *http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)606856/fulltext
16.  *http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(13)606856/abstract
17.  *http://www.ammalife.org/wp-content/uploads/2013/06/BMJ-ClinicalOfficers.pdf
18.  *http://www.ijgo.org/article/S0020-7292(13)00256-7/abstract


15. Grandma’s Juice

15. Grandma’s Juice
16th December 2013

Words. In this blog, I use them to depict the dire reality of life in a remote part of Africa. But the tragedy unfolds there, whether or not I describe it. (Just like when I am sent to do the shopping: what I buy is going to be wrong, whether or not my wife gets the chance later to give me personal feedback. What’s the difference anyway between fresh crème and crème fraiche? A trifle, surely?)

Anyway, it is the reality that matters. The words can get in the way. The situation in Berega, (as in many other parts of the world), is bursting with meaning and import and consequence, but all you get are words. My words, in the case of Berega. Can they be enough?

My 21-month grandson, already a master of the inadequacy of words, illustrates the point: “Man-ma’s juice is hot!” ‘Man-ma’s juice’ was my cup of tea. This was Freddie’s first full sentence, at the start of that wonderful decade between not being able to speak, and not wanting to. It was so cute that we have not had the heart yet to begin the rigid programming of mind which The World demands of its inmates.

The sentence was nevertheless wrong in every way: He calls both my wife and I ‘Man-ma’, a corruption of ‘Grandma’, but I am in fact ‘Dandad’. It was not juice, it was tea. And although he was correct to infer that beverages made with boiling water can indeed be hot, this particular cupful was at best tepid. The nub is this: Did we pull him up on the inadequacy of his descriptive powers? (“You foolish child! I am your male antecedent; a beverage by definition cannot be a vegetal extract; and this specific cup was barely above the melting point of caesium at atmospheric pressure!) Yes, we did.

No, not really. Instead we boasted about the cleverness and cuteness of little Freddie to all those who have not yet got into the habit of crossing to the other side of the road when they see us coming with a smug look on our faces, and a finger fumbling for the photo album on the phone.

Freddie also deploys many other teddy-cuddling cutenesses. My favourite is his tendency to use ‘No’ to mean both ‘no’ and ‘yes’:
(“You poor little baby, you are so hungry. Do you want some food?”
“Nooo-oooo-sob sob sob-ooooo”
“Here it is then…”)

(By the way, these verbal faux pas are presumably designed by Nature to endear us to what are otherwise machines for turning anything edible into poo. “I’m weally weally hungwy” is far more likely to induce a beleaguered parent to stump up a sausage than: “Mother, the hour of my repast has surely slipped into the abyss of forgotten dreams. Ah! The sweet sound of sausages, that breathes upon a bank of bacon, stealing, and giving odour!” Without the endearing mistakes, they weally would be hungwy. Perhaps the highly intelligent Cro-Magnon man died out because their children’s first sentences were particularly annoying – “Oi! Pig-face! Get me grub! Now!!!”)

The nub is this: words are important, but alone are not enough. Freddie, like rural Tanzania, is bursting with meaning and import and consequence, for instance about the potential danger of Grandma’s Juice or Bad Roads or High Blood Pressure. The expression of this does not do justice to the reality or the understanding.

This last month has been full of similar inadequacy of expression. My time has been split between getting harmony and getting money. The various charities working for Berega’s future need to harmonise, and that means having a collective plan that says clearly what we are all trying to do; how; and by when. Meanwhile, grant applications demand a certain practised style in the use of words: ‘The evidence-based intervention propounds a setting-specific self-sufficient synergy between the inter-agency evaluative action objectives and the … er … chickens’. (Often I run out of steam towards the end of these sentences, which is why I am not a very successful grant-raker.)

Words, words, words, but what of the mum who does not return home to her children? Does ‘1% maternal mortality per childbirth’ convey enough of the sadness? Does it capture the empty, desolate weariness of the 6 and 8 year old sisters as they struggle next day to find water and carry it home? All hope of schooling now lost, how will they themselves survive?

I feel the inadequacy, then, as well as the usefulness, of having adopted a catchy title for what we are trying to do: ‘EMBRACE’ – Empowering Women to Receive Adequate Care & Equality’. Thanks to Howard and Paul, we now also have a logo, a flyer and a standing order form. A facebook page is being set up. Twitter will follow. Thanks to Ammalife we have a Mother charity, and thanks to Debbie and Blanché, a global following amongst the world’s pearly queens. Thanks to lots of you (but not enough!), we have some money. Thanks to BREAD, Hands4Africa, Mission Morogoro, Isaac, Abdallah, the Diocese of Worcester and others, we have a plan.


What is needed now is somehow to convey what is really happening there, and how it is changing. What goes right, what goes wrong. What helps, what hinders. Which sentiment, softly spoken by the right person to the right person, will have the power to stimulate a new understanding and a new expectation in this beautiful and untouched part of Africa.


Words will not be enough. Let me think, over Christmas, how the story of this next year can best be told. Meanwhile, I hope that the story of a very successful Childbirth brings joy to your world, and to those you share it with.

Laurence
xxxxxxx



By the way, apologies for the very late arrival of this blog. Life has been full, in many ways. If in future you would like to know when a blog is being posted, please email me, and I will set up a Wandering Nib Club.