EMBRACE –
Tushikamane:
Reducing
death through community mobilisation and women’s groups
Tushikamane attempts ‘Kupunguza vifo vya
wajawazito na watoto’:
That is, to reduce deaths in pregnancy and
childhood.
EMBRACE is the English name:
Empowering Mothers and Babies to Receive
Adequate Care & Equality
The mission is this:
Through empowerment and education of women,
it hopes to reduce tragic deaths,
and to bring sustainable, multi-faceted
enrichment
to the lives of impoverished Tanzanian
villages.
The Problem:
Tragic death of mothers and babies in rural Tanzania
In 2013, in the world, a total of 289,000 women died of
complications of pregnancy and childbirth.
For every women who dies, approximately 20 others suffer serious
injuries, infections or disabilities.
Rural Tanzania has far, far more of these tragedies than
it should: Every day, 35 mothers die in
relation to childbirth. In rural areas, I in 10 children do not reach their
fifth birthday. An unknown known suffer consequences such as brain damage.
In isolated rural areas such as Tunguli, in fact, nearly
1 in every 100 women dies in childbirth. The five main causes are eminently
addressable: bleeding, sepsis, obstructed labour, eclampsia, and unsafe
abortion. Each maternal death
deals a disproportionate blow to the village from which the woman comes – who
will look after the other children, and perform the relentless tasks of daily
living?
There are many interconnected reasons why these things
are not dealt with well, eg: lack of access to health care; social inequality;
lack of education; chronic disease; malnutrition; long distances to travel when
sick; poor family planning; and poor transport. Underlying it all, 90% of the
population live on $2/day or less.
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 1,000 occur in a health facility. Tunguli clinic serves an area of perhaps
625 sq km, and according to the latest census this might represent as many as 20,000
people, (although by no means all of these use Tunguli Health Centre).
Why use
community mobilisation & women’s groups? Why not just fix things?!
It is tempting, when working with such abject need, simply to move in
and try to fix things – build a clinic, set up family planning, built infrastructure,
etc. Fixing things is exactly the right thing to do, as long as you take the
community with you, and as long as there is a long-term drive for improvement. The
sad reality, however, is that commonly in Africa these interventions are ‘done’
without full community buy-in, and often the long term follow-up is lacking. Such
efforts often eventually founder, and commonly fail to reduce mortality:
equipment breaks; new ways are not adopted, people do not attend; things are
not maintained; etc.
Especially in relation to externally-donated solutions, if they are not
owned, then they do not necessarily address the right priorities. Indeed, those
things which really influence maternal and child mortality are predominantly
defined by the behaviour of those whose voice is under-represented: the women –
eg seeking family planning, hospital birth care, or immunisation; using clean
water and mosquito nets; persisting with breast feeding; understanding child
nutrition; recognising serious illness; etc. Indeed, in the typical male-dominated
hamlet, the real life-saving priorities may well not be fully understood by the
men.
If what needs to be influenced is the behaviour of women of
child-bearing age, then outsiders coming in and telling them what to do is not
the answer. The way ahead does indeed begin with education and understanding, but
in such a way as to develop internal role models, so that women begin to copy
successful behaviour. Women must develop a stronger voice.
This voice of the women, in turn, leads to identification of core
infra-structural needs such as transport, crops, employment, water, food,
primary care access, etc. Addressing these needs once they have already been
owned and prioritised makes it much more likely for them to work.
It is now clear from evidence in a number of countries, that the way to
engage women of child-bearing age is to begin with women’s groups in the
hamlets. Although they begin with bringing younger women together, they
eventually bring in all of those whose voice should be heard, including older
women, men, and those whose existing role impinges on maternal and child
health. The resulting group is called a ‘PLA Group’ – Participatory Learning
& Action Group.
PLA Groups
(Tushikamane Groups)
PLA groups will try to reduce death of mothers and
babies by creating a space for discussion where community members, and women in
particular, are given an equal voice, and are able to identify prioritise
problems that cause death.
This in turn will result in identification of needs and
locally-developed solutions, which will go beyond health; including tackling
education, transport, water, sanitation, food, agronomy, family planning and
poverty, (as successful programmes such as those run by Hands4Africa have already
shown!).
The extended Tushikamane support network can then help
the community to develop, implement and evaluate their own locally feasible
solutions. Working each to their own strength, but in harmony with the whole, partners,
charities and initiatives both within and outside the Tunguli community can
seek to turn solutions into reality, using well-judged, well-executed and
sustainable methodologies, eg breast feeding promotion, growth charts;
sanitation systems; immunisations; protected wells; affordable emergency
transport; family planning; food and cash-crop plantations; malaria prevention;
anaemia prevention; TBA education; female education groups; etc.
PLA Groups
begin with women of reproductive age, (16-49). Pregnant women, new mothers and
adolescent girls will particularly be encouraged to attend. As time goes on, all those other community
members concerned about maternal and newborn health issues, including men,
older women and local leaders, will also be eligible to attend and will be made
aware of the women-centred nature of the groups.
PLA groups are not health education groups where a
facilitator gives messages to group members like a teacher. Instead, PLA groups are a space for discussion
where women and other community members identify and prioritise problems, then
and develop and implement their own locally feasible solutions to these.
This discussion takes place through a closely
directed cycle of 14 meetings of the group, and at each meeting there is a
specific agenda, and a specific purpose. This takes place through four distinct
phases. Groups will be guided through this four-phase PLA cycle of meetings by
either Ester Paul or Rehema Semwali, (the ‘Facilitators’).
As an important follow-up to the process, the Tushikamane
Project will also attempt to measure the effects of the programme, to learn
lessons for possible future expansion. This will be facilitated by the recent
road mapping exercise, and standardised place-names of the villages and
hamlets.
OVERVIEW OF
THE TUSHIKAMANE GROUP CYCLE
TUSHIKAMANE
groups will be guided by
Facilitators
through a
‘participatory learning and action cycle’
with four
phases and a total of 14 meetings.
How
long will the Tushikamane Group approach take?
The design and teambuilding process should take
approximately two months. Groups should meet roughly every
fortnight, and no less than every month, depending on what is most acceptable
to them. Implementation of the
strategies identified should be undertaken for between three to six
months. As a result, you can expect the
following timescale for implementing the Tushikamane group approach:
Design,
set-up and teambuilding
|
2
– 4 months
|
|
Phase
1: Identifying problems together
|
Five
meetings
|
2.5
– 5 months
|
Phase
2: Identifying solutions together
|
Three
meetings
|
1.5
– 3 months
|
Phase
3: Implementing solutions together
|
Three
meetings
|
1.5
– 3 months
|
Implementation of solutions
|
3
– 6 months
|
|
Phase
4: Evaluating together
|
Three
meetings
|
1.5
– 3 months
|
Total
|
12 – 24 months
|
|
What
has been said so far?:
Overview
of Tushikamane:
We
will engage communities effectively.
We will do
this by creating a group in each selected hamlet.
Elsewhere,
each group is called a ‘PLA’ group:
‘Participatory
Learning & Action Group For Maternal & Newborn Health’
In the
Tunguli Project, it will be called a ‘Tushikamane Group’
(‘Working
Together Conference’ or ‘Empowerment Assembly’)
Each group
will be taken through a cycle of 14 meetings designed to lead to community
prioritisation of actions to reduce death of mothers and babies
IN SUMMARY: HOW WILL TUSHIKAMANE
BE IMPLEMENTED?
•
WM and AG will visit Malawi in mid-November,
at the kind invitation of MaiMwana – the Malawian predecessor of Tushikamane,
which has had enormous success in reducing death of mothers and babies using ‘participatory
learning & action cycles’.
•
At the end of November, the entire
team will spend a week in training and preparation for implementation: Laurence
Wood, Coordinator; Rev Isaac Mgego, Project Chair; Wilbard Mrase, Project Director;
Alex Gongwe, Project Supervisor; and the two Project Facilitators, Esther Paul
and Rehema Semwali.
•
The Facilitators (EP & RS) will then go into the community,
each in her own part of the territory, and will set up 3 Tushikamane groups each.
•
This will be done under the close
management, guidance and supervision of AG, the Supervisor.
•
WM & IM will provide oversight,
and will meet weekly with the team members, and monthly with the entire team.
This monthly meeting will not only help shape direction and help clarify how to
take the next steps, but will also give the Project Director and Project Chair challenges
of obstacles to overcome, doors to be opened, etc.
•
With this as the back-drop, EP & RS
will then guide their groups through the entire Tushikamane cycle of meetings,
using a detailed manual to guide them, and picture cards to stimulate
discussion
•
Alex Gongwe will continually
supervise & support the facilitators and groups
•
In the last phase of the cycle, an
evaluation is made of impact, and of lessons learnt.
•
The cycle can then begin again, both
in that hamlet, and others nearby.
•
This might lead to a large-scale
collaborative bid to set up a widespread expansion of the Tushikamane process,
based on the experience of the Tunguli pilot.
Setting up
Tushikamane Groups – getting ready to begin
Encouraging potential community
members to attend
The people most affected by a problem should be actively
involved in assessing their situation and deciding what to do about it. RS & EP will therefore encourage women of
reproductive age to join the groups as a priority. These women themselves will
determine the membership of the group.
RS & EP will encourage them to prioritise pregnant
women and new mothers, as well as newly married women and adolescent girls, especially mothers and adolescents from the poorest
families.
We will want them to include any community members who
are concerned about death of mothers and babies. We want the group membership eventually to
include all those who are involved in care of women and babies through
pregnancy, childbirth and postnatal care. This might include, for example,
birth attendants; Village Health Workers; local leaders; local workers for NGOs
or Government projects; etc.
Ester & Rehema will
encourage all of these to attend the groups they are establishing. They will
ensure that all group members realise that their role in the group will be to
listen to, and respect the views and opinions of female members, then provide
advice and support where necessary to achieve the objective of improving the
health of mothers and babies.
Group Chairwoman and Committee
Each group may choose to elect a committee and/or to
assign specific responsibilities to specific group members. The committee should be mainly of women – eg
only one-quarter male. The committee should elect a chairperson, and a secretary
in the first instance.
The Chairperson of each group should be a woman. The role
of the Chairperson is to lead the group.
This includes providing leadership and direction, managing the committee
members and group members and representing the group at local, district and
national forums.
The role of the Secretary is to record group activities. This
includes filling the group register and meeting report after every meeting.
As the group develops the need, there should be a treasurer,
whose role would be to monitor group funds and other group resources.
All Group committee members have the role to encourage
community members to join the Group, and participate in meetings, and to
provide co-facilitation support to the Facilitator, (Rehema or Ester).
How many Group members should be recruited?
The total number of group members registered per group
should be approximately 50. Group
membership is open and thus it is likely that the total number of registered
group members will increase over the lifetime of a group.
However, not all registered members will attend every
group meeting. To ensure maximum
participation, the optimum attendance of registered members at each group
meeting should be 25-30. With more than
this it is difficult for everyone to participate and for the facilitator to
manage the group. Meetings should be attended by at least 10 group members to
make them worthwhile. If not enough
members come to a meeting, the facilitator and the members who have come can go
around the village to fetch the other attendees. If attendance is very low, it
is better to cancel the meeting and rearrange it on another date.
Some Rural Tanzanian facts and
figures relating to group size
Evidence suggests that groups are most effective where at
least 30% of pregnant women are members of groups. Given the detailed information in the
Tanzanian Census, we are able to do some calculations and estimations about
group size:
This
detail comes from: http://www.nbs.go.tz/nbs/takwimu/references/Tanzania_in_figures2012.pdf:
Tanzania has an official village and hamlet structure. A
'hamlet' is 100 households. A 'village' is 3-4 hamlets. If one group
should could cover (say) 700 population, then in rural Tanzania this would
mean:
·
one hamlet contains around 700 people,
(if 7 people per household);
·
this covers about 6 x 4km of
territory, (if the population density is 31people/sq km);
·
(of which mothers at least a third should be
in the group);
·
there may be 175 women of reproductive
age, (because they form about a quarter of the population)
·
the healthy of whom would go on to
have more than six children, (fertility rate 6.3)
·
With a maternal death rate of 1
in 200 births in Tanzania as a whole, and perhaps 1 per 100-150 births in
rural areas, there would be one
maternal death every 5 years for each hamlet /women's group;
·
each hamlet of 700 people might have
28 births/year, (Crude birth rate 39);
·
of these, perhaps 2 neonates and
one further under-5 will die each year per hamlet.
With one Facilitator covering three hamlets this would be a
population of around 2,000. That would mean that each Facilitator would
start off with one maternal death every two years or so, and around 7
baby/child deaths per year on her patch - huge scope for any intervention to
show benefit.
Ensuring to include existing groups
RS & EP will need to find out what activities other
organisations and the community are carrying
out or planning. This is important to ensure that they do not duplicate efforts and that plans complement or
support existing activities. If there are already any active groups in the community that you can work with,
then they should be invited, at the right time, to send representation to the
group.
Ester and Rehena should meet with
·
Village Chairmen;
·
with district-level organisations, such as
charities and Non-Governmental Organisations, (NGOs);
·
with Governmental officers and initiatives;
·
and with any other possible partners, to find
out about existing groups.
The Tushikamane group will have a life of its own, but it
must work in harmony and cooperation with existing activities and groups.
Once Groups are formed …
As soon as Tushikamane groups are fully formed, they need
to begin the process of discussing and prioritising the issues which cause
death of mothers and babies. This discussion is carefully orchestrated over a
series of 14 meetings by Rehena and Ester, under the management and supervision
of Alex Gongwe; and under the direction and facilitation of Wilbard Mrase and
Rev Isaac Mgego.
At the end of the fourteen meetings, there is a formal
evaluation which tries to measure the impact of the whole process. If it has
gone well, then the fourteen-meeting process is begun again, to search for new
priorities. For this reason, the process is called the ‘PLA Group Cycle’.
The following is an overview of the 14 meetings
for details see the post: Tushikamane 'Methodology in detail'.
THE TUSHIKAMANE
GROUP CYCLE
Phase 1:
Identifying problems together
The
focus of Phase 1 of the meeting cycle is for the Group to identify and
prioritise
problems
relating to health of mothers and babies
Meeting
1: The hamlet gets together to form a group
The objectives of the meeting are to:
·
To introduce the programme into the local
context
·
To introduce the ideas of ‘Participatory
Learning and Action’
·
To establish a group committee and ground rules
Meeting
2: Young women identify maternal health problems.
The objective of the meeting is to:
·
To discuss current maternal care home care and
service care-seeking practices
·
To identify health problems affecting women
during pregnancy, delivery and after birth
Discussions in the Group meetings will be stimulated by Rehena
and Ester using some tools designed for the purpose – eg picture cards illustrating common maternal and
neonatal problems, contributing factors, and actions to prevent and/or manage
these common problems.
There are 60 cards in all:
·
Problem cards (21 cards): covering the main
health problems affecting mothers and newborns
·
Contributing factor cards (17 cards): covering
the main contributing factors to these problems.
·
Preventative activity cards (13 cards): covering
the main activities people can perform to prevent problems affecting mothers
and babies from arising.
·
Management activity cards (9 cards): covering
the main activities people can perform to manage problems affecting mothers and
newborns once they have already arisen
Example of Problem card - Prolonged labour:
Example of Contributing Factor card - gender-based violence:
Example of Preventative Activity card: Training Traditional Birth Attendants:
Example of Management Activity card: Giving baby the medicine:
Meeting
3: Young women identify neonatal problems
The objectives
of the meeting are to identify health problems
affecting babies during pregnancy, delivery and after birth; to
discuss current neonatal care at home; and to discuss why, when and how women
seek help.
Meeting
4: Prioritising problems
The
objective of the meeting is to prioritise the three most important maternal and
neonatal health problems that will be addressed in this cycle
Meeting
5: Identifying contributing factors
The
objective of the meeting is to identify the causes of the priority problems
identified
THE TUSHIKAMANE GROUP CYCLE
Phase 2: Identifying
solutions together
The
focus of Phase 2 of the meeting cycle is for the Group to plan solutions
to
address the problems relating to health of mothers and babies
Meeting 6: Identifying prevention
and management activities
The
objectives of the meeting are to:
·
To
identify the activities that can prevent the priority maternal & neonatal
health problems from arising
·
To
identify the activities to manage the priority maternal & neonatal health
problems if they already exist
Meeting
7: Making plans
The objectives of the meeting are
to:
·
To
identify solutions to prevent
and manage the priority problems
·
To
identify resources that might help and the barriers that might hinder
implementation of these solutions. (eg both VHWs and
Birth Attendants might help to deliver on issues such as breast feeding; Family
Planning; immunisation; hygiene; malaria prevention; & recognising signs of
severe illness.)
From
experience the most common types of solutions
identified by groups include:
·
Health
education
·
Transport
·
Group
fund
·
Clean
delivery kits
·
Income
generating
·
TBA
training
·
Liaising
and lobbying with health facilities
·
Vegetable
gardens
After
Meeting 7 the group members should meet to prepare and practice for the
presentation to the community in the next meeting.
Meeting
8: Presenting progress to the community
The
objectives of the meeting are to:
·
To
feedback discussions, including prioritised problems and solutions, to all
community members
·
To
gather the ideas and opinions of all community members on the issues discussed
by the group
·
To
get encouragement and support from all community members for the implementation
of solutions
THE
TUSHIKAMANE GROUP CYCLE
Phase 3:
Implementing solutions together
The
focus of Phase 3 of the meeting cycle is for the Group to implement the
solutions identified to address problems relating to health of mothers and
babies
Meeting 9: Planning the solutions
The objectives of the meeting are to:
·
To get cooperation and understanding from all
stakeholders in relation to the proposed solutions
·
To finalise and agree an action plan for the solutions
Meeting 10: Gathering resources
The objective of the meeting is to plan how to gather the
resources necessary for the solutions
to be implemented.
Resource mobilisation
After Meeting 10 the group members should mobilise the
resources they need to implement the solutions.
Meeting 11: Developing monitoring tools
The objective of the meeting is to plan how to monitor
the progress of implementation of the solutions
Implementing and monitoring the solutions
After Meeting 11 the group members should implement and
monitor their solutions. They should do this for three to six
months. Groups and taskforces should
meet regularly with their Facilitator during this period, to review the
progress of implementation, celebrate achievements and identify and address any
challenges. The frequency of meetings is
determined by the group members themselves.
THE
TUSHIKAMANE GROUP CYCLE
Phase 4:
Evaluating together
The
focus of Phase 4 of the meeting cycle is to evaluate the impact of the
solutions implemented on the priority problems identified relating to health of
mothers and babies
Meeting 12: Progress in evaluation
The objectives of the meeting are to:
·
To explore why evaluating the group and the solutions together is important
·
To prepare and plan for the evaluation
Collecting evaluation data
After Meeting 12 the group members should gather the
evaluation data they need.
Meeting 13: Evaluating the success
of projects and of Tushikamane
The objectives of the meeting are to:
·
To evaluate how well the priority problems have
been addressed
·
To evaluate the functioning of the group
·
To plan for the future
Meeting 14: Planning for the future
The objective of the meeting is to decide what to do next
with the Group.
Restart the cycle
After Meeting 14 the Group should be supported to restart
the cycle in Phase 1, 2 or 3 depending on what was discussed and agreed during
the meeting.
After one cycle of group meetings, the group should feel
ownership of the programme and should have the capacities to continue
meeting. The role of the supervisors and
managers is to be available to continue providing technical advice, but the
direction and focus of the group is the decision of the group members
themselves.
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