Social & Cultural Basis for Community and Primary Health Programs

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COMMUNITY CHANGE CASE STUDIES

This document contains case studies on community change processes. If you are working alone on this, chose two case studies for analysis and comparison. If you are working in a group, chose three. You are also welcome to make up your own case study to use as one for comparison. If you do develop your own case study, please write it out in a similar way as those found here and included it at the end of your worksheet. Base your own case study on an actual community experience, but change names and places to maintain confidentiality. Community Case Study 1: The Transition to Western Medicine in Agatu

Agatu community in Benue State Nigeria is located 90 kilometers off the major road connecting the two largest cities in the region. The community has a major market that is held every fifth day. The inhabitants are mainly farmers. They lacked most of the modern amenities, such as potable water. Their major source of water was the Ado River. Although there was no clinic in the community, the people had access to a variety of indigenous practitioners including those specializing in bone setting, children’s illnesses, general herbal medicine, and divining and counteracting curses and poisoning. There were also traditional birth attendants.

Few members of the community received formal schooling. One fortunate youngster was Herbert Ada. When Herbert’s father died in 1955, his mother sent him to work as a houseboy for a prominent businessman. The businessman later moved to the state capital, where, in 1958, he enrolled Herbert in primary school. Herbert finished first in his class in 1963 and was awarded a scholarship by the state to attend secondary school. His performance there made it possible for him to win a scholarship to study medicine in Britain.

When Dr. Ada returned to Nigeria, he set up his practice in the (former) national capital and business center, Lagos, located nearly 1000 kilometers from home. Dr. Ada would visit Agatu once in two years and made sure that a bank account was set up to support his mother and immediate relatives, but his involvement in hometown affairs was minimal.

Then, in 1983, on a visit home, he learned that his favorite uncle had died of severe stomach pain only a few hours before his arrival. The condition had persisted for about four days, and the uncle had been attended by an herbalist. Dr. Ada insisted on a postmortem, something quite unusual in a culture that accepted death as something unquestionable. At the hospital in the state capital, it was found that the uncle had died of appendicitis. This event challenged Dr. Ada to consider how he might use his good fortune and skills to help the development of his hometown.

After the funeral, Dr. Ada met with the village chiefs and offered to help build a health clinic for the community. The chiefs later summoned members of their council, but much opposition to the idea was voiced by the local healers and their relatives. The council became deadlocked, so Dr. Ada returned to Lagos.

Three months later, one of the most influential of the local leaders sustained a deep cut while working on his farm. He was taken to one of the herbalists, who tried to control the bleeding. Because a major artery was involved, the man bled to death. This tragedy generated much heated discussion among the townspeople. Even people from neighboring communities heard the news, and when they confirmed that the rumors of Dr. Ada’s offer to build a clinic had been rejected, they blamed the people of Agatu for their own suffering.

The chief of the community therefore summoned another meeting of his council. At this point a

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majority of those present decided that Dr. Ada should be invited back home to build a clinic.

Dr. Ada returned in late 1984 and began consultations with the villagers about the site for the clinic. His own family members began pressuring him to locate the clinic on their family land so that they could set up shops and canteens that would cater to the patients and relatives who would attend the clinic. Dr. Ada remembered that the scholarships he had enjoyed had come from public funds, and therefore he decided in this case to listen to the will of the majority of the community members and accept a site that was centrally located.

The first step in the project was the sinking of a borehole well to provide water for construction and later for use at the clinic. Because of the skills involved, the community decided to hire a contractor to do the work. The contractor hired community workers as laborers, and they were happy to earn this extra daily wage. Some of the community leaders also served as supervisors and thereby also earned some wages. After completion of the well, the clinic itself was constructed in the same way. Trained staff were sent in from the state Ministry of Health to work in the clinic, and the non-professional and maintenance staff were hired, as decided by the council, on a quota basis from each section of the community. A generator was obtained so that there would be light in the clinic at night, and the state placed an ambulance and a bus at the clinic.

A local social club took responsibility for recruiting and sending for training two local people to serve as water treatment attendants. At a council meeting, community leaders decided that each social organization would contribute regularly to buy chemicals to treat the well water and parts to maintain it.

Now it remained for the community members to begin patronizing the clinic. For the first year, utilization was low. Several factors contributed to the problem. Villagers felt awkward seeking health care from “strangers.” The indigenous healers, in contrast, were long-standing neighbors. The various techniques for diagnosis and treatment at the clinic were unfamiliar. In particular, clinic diagnosis lacked consultation with oracles and inquiry into the social circumstance s of the patient. “Red tape,” such as registration procedures, were confusing. Notions of causation offered by clinic staff for illnesses contrasted with the naturalistic and supernatural explanations given by the local healers. Although villagers were anxious to try the “modern” drugs prescribed by clinic staff, supplies were often short, necessitating long rides to neighboring towns.

Referrals to distant hospitals were seen as admission on the part of the clinic staff that they were not fully competent. Not only did utilization of the new clinic drop, but the indigenous healers began organizing meetings to plan a campaign against the clinic and all its perceived shortcomings.

Fortunately, the clinic workers’ salaries continued to be paid. The staff had their own meetings to analyze the problems and realized that public relations was at the core of community resistance. Subsequently, staff were trained to make home visits. Such personal contact created mutual trust and reignited interest in attending the clinic. Previously, most treatment had been provided free of charge. This policy was changed, and token fees were introduced. This increased community perceptions of efficacy of the medicines and also provided a source of income so that a regular supply of medicines could be maintained.

Attendance increased steadily until the clinic actually became overcrowded by 1988. This led community leaders to approach the state government to lobby for an enlargement of the clinic into a comprehensive health center. Although the government did not come up with the money, the project went ahead. Dr. Ada plowed back earnings from the clinic into the building fund, and this was supplemented with community contributions. Community members also provided labor for the construction.

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Community Case Study 2: Hygiene and Sanitation in Karimu Village

Karimu is an old village in the central savannah area of Nigeria located not far from the new capital, Abuja. Its 20,000 people live in scattered clusters of huts but do have a king and a council of 20 traditional chiefs. Agriculture is the major occupation, with residents growing yams, rice, cassava, and maize. Village women are responsible for domestic work as well as for helping their husbands on the farms. There are two primary and one secondary schools. The government has built a new health center, but this has not yet been commissioned.

It was observed by the regional health department staff that the villagers lacked toilets, refuse disposal systems, potable water, and good roads. As one of the health staff commented in 1993, “They lived in thatched huts, defecated in nearby bushes, drank water from ponds, streams and rivers, and dumped their refuse anywhere around their homes. Their attitude toward personal and environmental hygiene was very poor, and most of them looked extremely dirty.” Because of the poor situation, there had been frequent occurrences of cholera, dysentery, and meningitis.

The Health Department had always responded during any outbreak of diseases by giving immunizations and health talks about the cause and prevention of disease. Finally the health workers felt that the situation in Karimu village was becoming “unbearable.” They set out a goal of intervening to solve these observed problems.

First, the health staff went to the village and visited the chiefs, seeking “their full participation, cooperation, and support for our program.” They then formed a Village Health Committee (VHC) consisting of 20 members, including most of the chiefs. The health workers next proceeded on their own community diagnosis, which identified the problems noted above as well as “low level of education, overcrowding in the huts, no electricity, and lack of immunization services.” The VHC was guided to identify its own concerns and mentioned cholera, dysentery, measles, scabies, anemia, and malnutrition.

Although the health workers’ assessment of the human behaviors that contributed to the many of the problems (eating raw, unwashed fruits, not washing hands after defecation) pointed to the ba sic need for an adequate supply of potable water, the team noted that, “We did not have the resources to provide a borehole well.”

Further investigations led the health team to learn that the villagers lacked knowledge about “the side effects of a dirty and filthy environment. In fact, they did not perceive that their environment was dirty. They had a poor attitude toward keeping their environment clean. They misprioritized their values, attaching more importance to other areas of their lives and not to their personal health and hygiene.”

The VHC was the foundation for intervention as planned by the health team. They “joined the leaders of the VHC to mobilize community awareness.” Selected groups of women, students, and the VHC were trained on personal health and environmental hygiene. These trainees in turn delivered health talks to different segments of the target population: at schools, markets, and from house to house. As a result, the young men in the village divided themselves into workgroups to maintain the sanitation of different sections of the village. The women were observed to be more active in sweeping surroundings of their homes. Follow-up surveys and discussion groups revealed that, “There was a tremendous change in the attitudes of residents towards personal and environmental hygiene. They were now taking their bath two times daily, washing their clothes and taking care of their hair and nails.”

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Community Case Study 3: Alawo Bridge

The Inalende and Abebi communities in Ibadan City are two of the communities in the Ibadan North-West Local Government. Trading and commerce are the main occupations of the inhabitants. Some of the men combine trading with farming on the outskirts of the city. Community Development Associations (CDAs) are common in the area, and the two communities have a joint CDA to which public service agency staff also belong, including those of the Health Department. The people in this congested urban area have expressed a number of health and development needs and problems over the years including high levels of fevers, high blood pressure, lack of potable water, and inadequate facilities for disposing of human waste. There is a small health center that serves the area, but people tend to patronize patent medicine shops more often because they can buy drugs on credit from the owners who are also their neighbors in the community.

Another concern of the two communities is a very large erosion gully that separates them. It is possible to cross the ravine using rough steps carved into the sides during the dry season, but during the rains, it is impassible. Even in the dry season, the ravine is not a pleasant place to cross because people use it for feces and refuse disposal.

Several years ago, the issue was raised in the two communities about constructing a bridge. This would enhance trade generally and make it possible for the Abebi farmers to get to the road out of town more easily and the Inalende women to reach the health center/maternity center more easily.

After much conversation among both community leaders and the average citizens, consensus developed about the need for a bridge. At the time, no CDAs had formed, and initiative was taken by the Landlords Association (LLA) in the two communities. A meeting was held with representatives of the associations from both communities. Each extended family compound in the community was represented in the LLA, and as many compound leaders as possible attended the first meeting. Also, the chief of each community was present. Several meetings were held over the next few months, and after each, the compound heads passed information about the deliberations back to community members.

Although they were not represented at the meeting, the women of the community were very interested because they suffered more — carrying heavy loads to and from market on their heads and dealing with difficulties climbing in and out of the ravine. A delegation from the market women’s association visited both community chiefs to express its concerns and lend its support to the effort. These thoughts were tabled at subsequent meetings.

During the meetings, skilled artisans (such as carpenters, plumbers, and masons) within the two communities were identified as to who could help with bridge construction. The aspect of manual labor was debated, and a schedule was worked out wherein each compound in the area would provide people to carry blocks and loads of sand and fetch water.

At one point, work stopped. A meeting was called and the representatives from Abebi Community complained that they were contributing more time and funds than those from Inalende. The two chiefs sat the participants down and did a mental accounting on the spot. When the allegations proved to be true but not grossly out of proportion, everyone was satisfied and work continued.

At a point when the economic condition of the country became worse, work on the project stopped completely. Several pillars to support the bridge had been built, and a good store of sand,

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cement, and blocks had been amassed, but the compound leaders could not convince their members to increase their level of donations to match inflation.

About two years later, a new government encouraged communities to form the CDAs. Abebi and Inalende formed their own. Both groups independently began discussing the issue of the bridge but did not want to take the initiative alone to finish it. As noted, the CDAs included staff from local government health, works, and community development departments. Most of these staff took part in more than one CDA and shared with the Abebi and Inalende CDAs that both were talking about the same issue. An informal meeting was held with representatives of the two groups, with the final result that they decided to merge to form one CDA, the Abebi -Inalende CDA. This set the foundation for resumption of work on the bridge.

Because local government agencies promoted and were involved in the CDA movement, the local government also provided matching grant money to communities for development projects. All compound heads were encouraged to attend the first joint CDA meeting where they resolved to resume the regular donations for the project. Now with the availability of a matching grant, there was enough money to finish the project. In addition to the contribution of skills by the local artisans, the community, through the CDA structure, also benefited from technical advice from the local government engineers. Some modifications were made in the design, and the bridge was finished within six months. Now there is active commerce and social interaction between the two communities, and their joint CDA is planning a new project — building a community high school.

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Community Case Study 4: Ajara Community Coalition

Ajara is a community of about 10 small villages with 5000 residents spread our along a lagoon and connecting waterways in southern Nigeria. Most residents are farmers, fishermen or processors and traders of farm and fish products. Transportation in the area is usually by motorcycle or canoe.

Ajara is served by one local government primary health clinic (PHC) with 4 beds for admission/observation and/or delivery. Staff consist of a nurse, two community health extension workers, a dispensary attendant and a ward attendant. The nurse commutes from the city daily, about one hour journey each way. She usually does not come to work on Fridays. The other staff live in the surrounding villages. They run a weekly child health clinic and a weekly antenatal clinic. Other days are used for general outpatient care, administration and cleaning/maintenance.

About 20% of the approximately 250 pregnant women annually register for ANC, but less than half of these deliver their babies at the clinic. There are three indigenous healing centers with inpatient care in the area, several dozen individual indigenous healers, two private nursing centers and seven patent medicine shops. Five churches encourage their pregnant members to come to the church to deliver where they are supervised by elderly female members.

There are three primary schools in the village, but secondary school students must trek to the district headquarters to further their education. Primary school attendance is over 80%, and actually more girls go to school as boys are often accompany their fathers to farm or for fishing. Although each school has six grades, only one has enough teachers to cover two arms/classes for each grade. One school has only 5 teachers, one of whom manages a combined first and second grade class. If they want a proper place to sit, students are expected to bring benches from home.

Ajara has a chief and a council of elders, one of whom is a women=s leader. There are several Muslim and Christian congregations in the area with various men=s, women=s and youth associations. There is a town progress union, a credit and savings cooperative among teachers and other civil servants, two farmers= unions, a fishermen=s union, a market women=s association and a transport workers union.

In late 2004 an NGO known as COMPAP (Community Participation to Attack Poverty) established an office in the state. Working with the State Ministries of Health and Education COMPAP identified 10 districts that were considered most underserved in the state. In August 2005 COMPAP visited the district in which Ajara was located, and the district council president and Directors of the Health, Education and Community Development Departments identified 10 communities where health and education services were least well utilized. Ajara was among these.

A community organizer from COMPAP visited the Ajara along with the local government health department’s health educator. They met the village chief and his council of elders and began an informal discussion about the status of health and education services in the community. They also asked the chiefs about local community based organizations (CBOs) that had shown interest in health and education issues. Through this process they heard a number of complaints about the quality of services, the attitudes of the staff and the availability of materials and supplies at the local health center and schools.

Later the community organizer and the health educator contacted the leaders of the local CBOs and stopped by the PHC and the schools. They asked if people were interested in coming together to form a community coalition of all interested CBOs to address some of the concerns the chiefs had outlined. Most were enthusiastic, but a few were skeptical, “The health workers tried to organize us into a health committee about ten years ago. They would set meeting dates, and then fail to show. When we discussed improvements needed in the health center, the staff accused us of being

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ungrateful. Eventually we stopped attending.” People were told that a coalition would be unlike the former health committee in that community members would run the coalition themselves. People asked, “Is the government going to give us money to run a coalition?” and the organizers explained that it was up to the community, if it thought a coalition was useful, to manage it for themselves.

After finding an agreeable date and venue, the organizers asked one of the elders if he would serve as convener so that the community could take charge from the beginning. Representatives of the mosques, churches, trade associations, social clubs, health services and schools attended. In all 55 people were present, 5 health staff, 12 teachers and the rest representing 17 CBOs. After hearing an explanation that a community coalition could be a problem solving tool, a way to mobilize resources and an advocacy voice for community needs, the attendees were divided into four groups to brainstorm and discuss ways to improve the health and education services in the town. The teachers formed one group and the health workers a second. Community members were divided in two, with some choosing to discuss health issues while the other focused on education. Each group selected its own moderator and recorder. The groups were asked to come up with a list of the top 5 priority problems.

After lunch each group reported and answered questions from the whole assembly. They then moved into two groups – one on education, the other on health. In these two groups the organizers facilitated discussion and encouraged the providers and the community members to come to a common view on one or two top priorities. They worked to analyze the reasons for the problems and possible solutions. The facilitators worked hard to keep people calm and look objectively at the problems without blaming each other.

The health group talked about the low attendance at antenatal and delivery services. They found common ground on the issue of privacy and security at the clinic. Community members observed that at the clinic was too open and no woman would want to be examined or deliver if people could just walk by and see her on the examination table or in labor. The health staff were concerned that there were frequent thefts of equipment and that people would barge into the examining room at any time asking for treatment interrupting the care. They all agreed that a proper wall around the clinic and doors with locks would help solve this problem.

The education group did not take long to see together that many of the classrooms were in poor condition. Teachers were worried about the many broken and missing windows, which was a main reason they did not keep any books or supplies in the classroom. Parents complained that when it rained wind blew water in through those broken windows and drenched their children. They also observed that most of the roofs leaked. People asked PTA members, one of the CBOs attending the meeting, why they had not addressed these issues, and they explained that they were a small group and needed the support of the entire community.

When the groups reported back in the evening, the organizers explained that they could form a coalition of CBOs and service providers to follow up on these issues. They would have to set their own by-laws and structure and make a commitment to find solutions using whatever resources were available. One elder asked, “What about roads; what about our market? You have only talked about schools and health clinics. We have many problems.” The organizers explained that it was useful for a coalition to start with one or two issues and solve those first. After gaining experience and success they could decide on any other problems they wanted to address. The man was happy and suggested that the people assembled go back to their CBOs and tell the story of what happened today and encourage them to follow through. The organizers suggested that before they depart, that they set a date to form the coalition and develop work plans to address the two priority issues discussed at this meeting. A PTA member spoke up in favor saying that as just one small CBO they had not been able to accomplish much, but the idea of a coalition involving all groups in the community gave them hope.

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Before departing, the group sought five volunteers to form an organizing committee. The committee would make arrangements for the next meeting and draw up a draft set of by-laws for consideration. One teacher, one nurse, one women leader, one male leader and one youth leader were agreed upon as the committee members.

When the group reconvened there were 76 people present. The organizing committee presented its ideas for by-laws, and with some modification these were accepted. They skirted around the issue of dues, but did mention something about contributions from the CBOs. They proposed initially that four committees be formed. An obvious one was an executive committee of officers. They also suggested a finance committee. Two program committees included education and health with a proviso for adding other committees as issues arose. The group then divided in two and started working on developing action plans for the two priority issues selected last week.

The community organizer from COMPAP was present for the deliberations, but sat in the back quietly. When asked about the issue of dues and finance, he replied simply that the community had to plan according to its means.

The education group came up with a plan that built on PTA efforts since that group had raised some money. They also involved the carpenters’ guild, another CBO member, but also said they would talk with the chiefs about asking each household, whether they had children in primary school or not, to make a contribution since educated children benefit the whole community. With members of the local churches and mosques present they asked that announcements be made at services to gain support for this project and maybe even for a special collection. They agreed that for now the cost of new roofing sheets was beyond their capacity, but formed an advocacy delegation to visit the district council and school board to press the case for repairs. A strong and articulate member of the market women’s association was chosen to lead the delegation. A person was also put in charge of each of the other components of the plan – the fundraising, the actual construction.

The wall around the clinic project appeared to be more challenging that originally thought. A temporary solution was found when the local safety/vigilante group volunteered to post a guard at the clinic 24 hours. One of the women’s church societies agreed to help keep order inside the clinic on antenatal days so that people would not barge into consulting rooms, but take their turn in the waiting room. On their part, the health staff agreed to come to work on time so that they could register people in a timely and orderly fashion and avoid rushing. This group too, agreed to form an advocacy delegation. One member said her senior sister was actually a district council member, elected from a nearby village, and that they could approach the council through her. A couple of the social clubs agreed that if the local council provided money for cement, they could mobilize the youth to dig and carry sand to the clinic to help build the wall.

A year later there is still no clinic wall, but ANC attendance and delivery have increased because people saw that the guards and the women volunteers at the clinic were serious in their efforts and now trusted the clinic. Several large piles of sand were seen at the back of the clinic. All the schools have proper windows now, and one classroom per school has a new roof. Coalition members are happy with the progress and seem a bit surprised how much they could do with their own efforts. Another committee has been formed for making road repairs within the town through volunteer effort, and advocacy visits to the local council to get the road into town paved have started.

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Community Case Study 5: HIV Support Group in South Africa

OXFAM PARTNER PROFILE: Itumeleng Modimola, Welgeval, South Africa Itumeleng Modimola, manager of Pholo Modi Wa Sechaba, is a caregiver, community worker, HIV/AIDS counselor, fund raiser, mentor, and role model who has nurtured a commitment to care for others into a sanctuary of support for families infected and affected by HIV/AIDS in South Africa’s North West Province. Writer: Charles Scott, South Africa The tree is a powerful symbol of stability and resilience across much of Africa. Trees provide shelter from the blazing sun, traditional medicines, building materials, firewood, and food. So, it was fitting that a group of 30 women chose to gather beneath a tree in Welgeval village in 2002 and decided they had to take action. “When we became aware of the deadly effect of HIV and AIDS in our community, we realized we had to do something,” says Itumeleng Modimola. “It was not easy when we started; people were not used to the idea of caregivers and because of the stigma around HIV and AIDS, people would pretend they were not at home when we came to visit.”

But the women persevered, and in 2006 their efforts were rewarded when the local traditional council offered them land and a building as a base for their organization. Today Modimola is the manager of Pholo Modi Wa Sechaba, a thriving community-based HIV/AIDS project in Welgeval in South Africa’s North West Province. The organization— whose name means “health is the root of the nation” in the local language, Setswana—is dedicated to overcoming the devastating impact of HIV/AIDS in the local

community. Every day the Pholo Modi Wa Sechaba site is alive with activity as children from AIDS-affected families crowd into the small day care room and spill out onto the dusty playground. In the afternoon, they are joined by their elder siblings and other schoolchildren for a healthy meal and supervised afterschool activities where they learn life skills—such as how to prevent HIV/AIDS. The once-barren garden is now green with tidy rows of vegetables. The foundation and walls of a new community center are taking shape nearby, the material and labor provided by members of the organization. Pholo Modi Wa Sechaba runs a support group for people living with HIV/AIDS and has 20 caregivers who provide home-based care services to almost 300 families in four villages. It is a member of the AIDS Consortium, a South African national umbrella organization that helps community groups struggling to provide services for people living with HIV/AIDS. A grant from Oxfam America is helping

South Africa has the world’s largest number of HIV infections—an estimated 5.5 million of the country’s 48 million people live with HIV. Women are hardest hit. In 2005, one in three women in South Africa aged 30– 34 were living with HIV.

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the AIDS Consortium extend its reach to the North West Province, where Pholo Modi Wa Sechaba and some 100 other community organizations will get additional training to raise and manage money, design and carry out better community programs, and train their staff. With the AIDS Consortium’s help and growing awareness about HIV/AIDS in the community, Modimola says her organization is making progress. “The situation has changed for the better; people are more aware of HIV and take informed decisions to protect themselves and their families. But we still have a long way to go. Government and other partners need to increase access to anti-retroviral [ARV] treatment and health services in our area,” says Modimola. “While we are doing the best we can with limited resources,” she admits, “training and retaining caregivers … is an ongoing challenge.” Modimola has built strong partnerships with the local clinic, tribal authorities, and government departments. Pholo Modi Wa Sechaba receives an annual grant from the provincial government to provide food to 60 families and a monthly stipend for the caregivers. Once this grant is depleted, however, Modimola predicts many caregivers will be forced to quit; they cannot afford to work without pay. Local caregivers provide a vital service to the community and fill the gaps in the national health care system. Often they are the first to identify members of the community who may have become infected with the HIV virus and the last line of care for those with AIDS. While ARV treatment and hospital care is the responsibility of the state, there are not enough doctors, nurses, and hospitals to cope with the spread of the disease. Like the tree beneath which Pholo Modi Wa Sechaba was founded, Modimola and local caregivers serve as symbols in their community. Their steady commitment in the face of challenges has given strength to many.

Read | Learn | Change the world For stories and more information on Oxfam’s work on HIV and AIDS in South Africa, go to www.oxfamamerica.org/hivaids.

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Community Case Study 6: Building a Bridge to Fight Malaria

humanitarian news and analysis UN Office for the Coordination of Humanitarian Affairs INDONESIA: Building a bridge to eliminate malaria NGRECO, 8 February 2009 (IRIN) - Like most remote villages in Indonesia, Ngreco, tucked away in the mountains of Pacitan District in East Java Province, suffers from a high incidence of malaria. The village's remote location means residents are inaccessible to district health workers, and have little access to health care services. In eastern Indonesia, where malaria is endemic, malaria rates are usually 20-30 percent, but at one point in Ngreco it reached 80 percent.

In 2006, a US$25,000 grant from the local government allowed the 5,400 inhabitants to build a much-needed concrete bridge to replace the precarious, hanging bridge that they had been forced to use until then. The money was not enough, but the villagers knew they needed the bridge, and so they decided to contribute their time and resources to make up the difference. "Villagers worked in shifts," said Wasi Prayitno, head of the task force that carried out the project in Pacitan. "Thirty people worked each day for three months until the bridge was completed." They were paid 50-70 percent of their normal wages. Bridge allows access by health workers

Haryono, the village head, enumerated the benefits they have reaped from the bridge: cheaper prices for the goods they purchase, higher selling prices for their produce, easier access to schools and hospitals, and, he emphasised, a drastically reduced malaria incidence of just 20 percent. "Before, health extension workers could not get in. The sick had to be carried out by villagers on stretchers," he told IRIN. "Now, health workers come and conduct spraying and distribute medicine. We also now have a clinic in the upper side of the village." In a country where, according to the World Health Organization, nearly half the population or more than 90 million people live in malaria endemic areas, Ngreco's experience shows that the government's goal of eliminating the mosquito-borne disease by 2030 is not impossible. Both government and private malaria experts told IRIN that reducing isolation is a critical factor in achieving this goal.

Photo: IRIN

A new bridge in Ngreco village, East Java Province, has helped reduce incidences of malaria

Before, health

extension workers could not get in. The sick had to be carried out by villagers on stretchers.

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Dave Jenkins, director of SurfAid International in Indonesia, which runs an anti-malaria programme covering more than 200 villages in Mentawai Islands, eastern Indonesia, said that while incidents of malaria fluctuate based on a number of variables, such as weather, "access [by health workers] is one of the critical success factors". "Isolation is a huge issue," he told IRIN. "It's the reason there's a high incidence in remote areas." The Ministry of Health agrees. "Indonesia has a strong health infrastructure. We have specific malaria control units in districts. We recruit women volunteers and train them in malaria control," said Rita Kusriastuti, the ministry's director of vector-borne diseases. "But our volunteers can't conduct spraying and distribute bed nets if they can't access the villages." "Behaviour change is key" She added that Indonesia was currently on track to meet the Millennium Development Goals of halting and beginning to reverse the incidence of malaria by 2015. "In Java and Bali, the incidence is now just 0.2 percent," she said. Jenkins warns, though, that not too much credit should be given to any single factor, and that an effective malaria control programme should have a mix of interventions. "In Mentawai, we have seen very significant reductions and very strong downward trends, but not all this is due to our interventions. There are natural fluctuations in malaria incidence. Behavior change is key," he said. "You can't just go into a village and dump bed nets. You have to educate people in using them." WHO said that in 2000, only about 0.2 percent of children slept under an insecticide-treated bed net. "Once people use bed nets, that's definitely an indicator of success," Jenkins said. jd/bj/cb