Message-ID: <3256E24B.1869@m.cc.utah.edu> Date: Sat, 5 Oct 1996 16:33:47 -0600 From: "James B. Mayfield" <mailto:james.mayfield@M.CC.UTAH.EDU> Subject: CHOICE Village Health Program To: Multiple recipients of list DEVEL-L <mailto:DEVEL-L@AMERICAN.EDU>
I have been a member of this list for two years and have been amazed at the variety of people participating on this list. I wish to take this opportunity to let you all know about a Village Health Program presently being implemented by the CHOICE organization. We are especially looking for people with medical background who would like to spend 1-2 weeks in a village in Africa, Asia, or Latin America helping to set up a long-term village health care program. If you know of other lists that might include people interested in this program please send this message on.
The CHOICE Village Health Program
An Invitation for Volunteer Service in an Overseas Health Programs
by James B. Mayfield, PhD
"Recall the face of the poorest and the weakest man whom you may have seen and ask yourself if the step you contemplate is going to be of any use to him. Will he gain anything by it? Will it restore him a control over his own life and destiny? In other words will it lead to self-reliance for the hungry and spiritually starving millions? Then you will find your doubts and your self melting away." Mahatma Gandhi
CHOICE Village Health Program
What is the Problem? Looking at the data provided by Lester Brown in the State of the World 1995, one finds that in 1960, the richest 20 percent of the world's people absorbed 70 percent of global income; by 1989, the wealthy's share had climbed to nearly 83 percent. The poorest 20 percent, meanwhile, saw their share of global income drop from an already meager 2.3 percent to just 1.4 percent. The more developed countries (MDCs) with roughly 22 percent of the world's population have access to nearly 70 percent of world's goods and services. The bottom 40 percent of the world's population has access to less than 15 percent of world's wealth and even worse, the bottom twenty percent (roughly one billion people) has access to less than 3 percent of the world's wealth, measured in Gross National Product (GNP) terms. Such people have never attended a school, have never been cared for by a doctor, have never been vaccinated, nor taught the value of boiling their water or giving oral rehydration therapy to their sick children. Among such people, 2 billion adults are for most purposes functionally illiterate, over 1.5 billion people are without safe drinking water, 1 billion people suffer from hunger, 150 million children under age of five (one in three) are malnourished, about 100 million people are completely homeless, and 12.9 million children each year die before their fifth birthday from easily preventable diseases. They are the most vulnerable, have the lowest status in their societies, are generally located in isolated rural areas, and too often are ignored if not forgotten by their own governments and even the international community supposedly concerned with the plight of the poor. In fact, most resources available for the poor tend to go to people living in towns and villages that are closest to the big cities and thus are most accessible to roads, marketplaces, and government services. The poorest of the poor live in villages and rural areas that lack electricity, potable water, and the basic social services related to health and education. Given the limited resource-base found in most of the Less Developed Countries (LDCs), these rural areas will be the last to receive the help that is needed.
What is Needed? The CHOICE organization is looking for physicians, dentists, nurses, public health workers and others with basic health care skills who are willing to work for one or two weeks in a rural village to help establish a long-term health care program in the more disadvantaged rural communities in Africa, Asia, or Latin America. Over the past 14 years over 50 medical professionals have experienced the thrill and adventure, the satisfaction and the tremendous learning opportunity from a CHOICE expedition into these less developed areas. Many medical professionals bring members of their own families to share in this life-changing experience. The medical personnel selected to participate in the CHOICE Village Health Program are expected to spend a minimum of five days in the village, with the mornings devoted to training village health workers on the concepts and procedures outlined in the book by David Werner Where There Is No Doctor or the book by Murray Dickson, Where There Is No Dentist. In the afternoons of these five days in the village the participating medical personnel are expected to conduct a public open clinic, to provide basic health care for the local villagers as well as supervise and support local village health workers to develop skills on concepts and procedures presented during the morning training sessions. Such medical personnel must be willing to bring some of their own basic medical supplies and equipment, provide some basic medical care and training for local village people, and be willing to pay their own living and travel expenses, which if tied specifically to the medical project, can be considered a tax deductible charitable donation. Participants in the CHOICE Village Program must be willing to fly into these areas for a week or two period of time. Each participant is free to select the time of the year when they would serve, whether it be Spring, Summer, Autumn or Winter. Some times are better than others both for the participants (their work schedule, family commitments, etc.) and the villagers (their planting and harvest times, the rainy vs dry season, etc.). We will be happy to give you the times of the year when it is most appropriate to be in specific countries where these projects are being implemented.
The Program The CHOICE program has several advantages over other humanitarian medical programs developing countries. 1. Many doctors have participated in humanitarian medical programs but have felt some frustration in knowing that what they did, while it was helpful to the individuals receiving medical treatment, probably had very little long-term impact on the community as a whole. By combining short- term professional health care and training of local health care workers, the long-term, broader impact on these communities can be much greater. 2. Field research conducted by a number of donor agencies has determined that nearly 75 percent of all health-related deaths in rural villages can be prevented by individuals with less than four weeks of intensive training in: oral rehydration, basic awareness of communicable diseases, proper nutrition, the do's and don'ts of modern medicine in a village environment, care of simple respiratory problems, simple first aid practices, concepts of sanitation and basic public health, oral hygiene, etc. The major focus of this program is to establish a long-term training program to support paraprofessional village health workers in their efforts to provide health care to the poorest of the poor in the less developed countries of the world. 3. In each village there will be translators provided to work directly with the medical professionals participating in this village health program. Most of these villages can be quite isolated and CHOICE has had 14 years experience orienting participating medical personnel to survive in these rural settings. In most areas, the medical professionals will be staying in rather primitive accommodations (sometimes staying in the limited facilities of the rural hospital or clinic, or in a smaller third or fourth class hotel, sometimes staying in local housing and in some situations even living in tents). The rural areas are generally very primitive and participants will need to bring basic camping equipment, sleeping bags/mosquito netting, etc. CHOICE has learned what it takes to keep Westerners healthy in these isolated areas. CHOICE, through its local representatives, will ensure that bottled water is available for drinking and that necessary food will be prepared in a sanitary, proper way while the participants are in the rural areas for the five days. Generally participants stay in modern hotels in major cities at the beginning and at the end of the five day experience. Some arrangements can be made for a participant to go into the same village area over an extended period of time if they so desire. Other participants have found it more enjoyable to work in a different country each time they participate in the CHOICE Village Health Program. In order to ensure that adequate time is available to make all the needed arrangements, we encourage potential participants to give us 3-6 months notice concerning their availability. The CHOICE office will: (a) provide a packet of training materials and/or a one-two day orientation workshop prior to departing for the village area. (b) plan and organize all travel and living arrangements while outside the United States. (c) prepare the local village for your arrival. Travel and living costs for such one-week experiences generally range from $1000 to $3000 per person depending on the international and local travel costs to the village and the costs of hotels at the beginning and end of the one-week visit to the village. 4. The CHOICE Village Health Program has designed a eight stage training program where village health workers receive intensive training for forty days: five days a week over four separate weeks scattered over a two year period. All medical personnel who participate in the program are free to choose which stage of training they want to give. A carefully designed curriculum outline has been developed for each week with a set of training materials and field-tested training interventions prepared for the medical professionals giving the training.
CHOICE has projects in Mexico, Guatemala, Bolivia, Kenya, India, Indonesia, Samoa, and Vietnam. Most of these areas have full time Rural Development Facilitators (RDFs) paid by CHOICE and assigned full time in the village area to provide follow-up training and support after the medical professionals have left and until the next level of training can be given. Each participant will be told what level of training the village health workers need in a given village. Potential participants who have an interest in working in a disadvantaged area and desire more information may write to the CHOICE headquarters: 643 East 400 South, Salt Lake City, Utah, 84102 or call at (801) 363-7970, or Fax (801) 363-7980 or e-mail mailto:CHOICE@Burgoyne.com
CHOICE (Center for Humanitarian Outreach and InterCultural Exchange) is a nonprofit, non- denominational, organization established to provide humanitarian service opportunities in some of the poorest and most disadvantages areas in the world. Those wishing to contact medical personnel who have participated in a CHOICE overseas program may request a list of such people from the CHOICE office.
Eight Basic Principles in the CHOICE Village Health Program 1. A Long Term Commitment Is Needed: Sustainable Village Health programs require at least two years of support and encouragement if they are to survive after the outsiders leave. Many outside organizations will provide a one-time program of aid and support, but such efforts are almost never sustained over time. Solution: Establish a two year program through which eight levels of training are provided by health care professionals (physicians, dentists, nurses and technicians) who are prepared to work with mostly illiterate village health workers. If most countries of Africa, Asia, and Latin America were to wait until they had enough resources to provide adequate health care for their thousands of villages, it could take several hundred years. The World Health Organization has determined through field research that 75 percent of the deaths in village communities could be prevented by the interventions of para-professionals who have had less than 4-8 weeks of training. 2. Long-Term Training More Effective Than Short-term Training Too many village health workers receive a one-time intensive course of several weeks and then are expected to function basically on their own. While such training in a concentrated period of time is quite common, without costly programs of follow-up, the impact will be limited. Solution: The CHOICE Village Health Program has found that having shorter periods of training (five days) scheduled over a longer period of time (usually every three months) will have much more long-term impact in ensuring that the training is understood, practiced and internalized. The training program established by the CHOICE Village Health Program seeks to provide eight weeks of training but scatters the training out over a two year period at an interval of every three months Each health worker is given specific assignments, is prepared in specific skills and interventions, and is provided with specific supplies that they are to practice and use over the three months between each training session. 3. Focus on Very Basic Medicine with an Emphasis on Preventive Medicine: Most professional medical personnel are generally trained in curative medicine which works well in an environment where medical resources and facilities are readily available. Medical personnel who participate in the CHOICE Village Health Corps will often need to have their orientation to medicine modified. All trainers are expected to become completely familiar with the material found in David Werner's two books: Where There Is No Doctor and Helping Health Workers Learn. Solution: Effective village health programs must combine both curative and preventive medicine, but emphasis should be placed on preventive strategies: sanitation, education, and nutrition. Effective trainers will seek to provide information, skills, knowledge and interventions that are readily understood by people with little education, easily introduced and incorporated into the local culture, and can be practiced by people with little training. CHOICE provides experienced interpreters who are prepared to work with the medical professional in training village health workers. 4. Training Must Include Hands-on Practical Emphasis: Too many health care programs emphasis class room study, with a strong dose of reading and listening. Most para-professional health workers have had little schooling, are not able to take notes in a class room setting and will not retain much of what they hear in the training. Solution: The five day training program is scheduled as follows: In the mornings (8-12 a. m.), the trainer introduces the basic concepts of the program to the village health workers. Much of the training must emphasis a "learn by doing orientation." During each afternoon, (1-5 p.m.), an open public clinic will be set up. During the first two or three sessions of training the professional trainer will obviously take the lead, but is encouraged to involve the village health workers in the diagnosis, suggested interventions, and possible follow-up as much as possible. In the later sessions of the training, especially during the training of the second year, the medical professional is encouraged to take a back-seat to the village health workers. This is important as a crucial part of building the health workers status with villagers, confidence in his/her ability to provide health care service and skill in implementing preventive and curative interventions. Equally, important is the way in which the professional demonstrates to the villagers that what the village health worker is doing is good, should be listened to, and that the professional has confidence in the village health worker. Villagers often believe that the only person who can help them is someone in a white coat who dispenses pills. The professional plays an important role in legitimizing the role and status of the village health worker among their fellow villagers. 5. Pay for Services Program Must Be Instituted: Many rural health care programs provide medical care and medicine at no charge. When such medical supplies are no longer available, and this is most of the time, the rural health program quickly dies. Solution: CHOICE will provide each village health worker with a medical kit, made up of basic medicines, supplies and instruments needed. The village health workers are strongly encouraged to charge some fee for their services and to charge for the medicine dispensed. There will be times when some of the poorest of the poor may need to have these services and medicines somewhat subsidized. However, as a principle, it is hoped that the villagers are gradually prepared to see that medicine does cost money, that if the village health worker is to replenish his meager supply of medicine, he will need to receive some payment. CHOICE is committed to re supply the village health workers' medical kit every three months during the two years of the program, but the village health workers are encouraged to charge the villagers when they dispense supplies, to purchase local equivalents of the medicine given, and over the two year period of the program to establish their own medicine fund large enough to purchase the supplies they need independent of outside support. Implicit in this principle is the notion that antibiotics are to be used sparingly, that many highly sophisticated drugs are inappropriate in a village setting, and that when a villager has a serious medical problem, they should go to a professional medical person. 6. Full-Time RDFs are Needed to Support and Encourage the VHWs: In many village health care programs, the village workers receive very little supervision, support or monitoring. Even though they have been give several weeks of training, within a few months without outside support, they soon become discouraged, apathetic and ineffective. Solution: In each area where the CHOICE Village Health Program is established, a full-time rural development facilitator (RDF) will be assigned. This will generally be a local person, trained in community development and general rural development program implementation. He or she will generally be responsible to cover 10-20 villages and thus will be visiting on a fairly regular basis with the village health workers, assessing their effectiveness, determining what problems they are having, reinforcing the previous training that they had received, and perhaps even bringing them together periodically to share problems, successes, concerns and interventions that have worked or not worked. 7. Specific Strategy to Integrate the VHWs into the Formal Health System: Many outside organizations have sent medical personnel into rural communities to provide modern medical care. Such humanitarian work is greatly appreciated, but unfortunately, such efforts seldom have any long-impact on the community. Even when the village health care workers receive adequate training and support, the program quickly dies when the outsiders are no longer funding the program in a given area. Solution: As soon as CHOICE moves into a new area and sets up a CHOICE Village Health program, a set of activities must be set up by which the village health workers are gradually integrated into the formal health system of their respective countries. Contact with local clinics, rural hospitals must be established, and specific personal in these facilities must be encouraged to see the value and competency of the village health workers. One way CHOICE seeks to build these kinds of relationships is to obtain donations from US hospitals, clinics, pharmaceutical houses, etc., to provide needed supplies to these formal health systems. Also, district health officials and hospital personnel can be invited to visit some of the training sessions, to see the quality of services being provided and the way that these village health workers can be an important component of the formal health service. CHOICE is committed to work in a rural area for two years and then seeks to move into another rural area and to start the whole process over again. This principle of integrating village health workers into the formal system is crucial to this process. 8. Localize the CHOICE Health Corps Program: Many health care programs are implemented by Americans and other foreigners, based upon the belief that we of the developed countries have the training, the funds and the skill to help the less fortunate people of this world. While this kind of thinking is appropriate in the short-run, the long-term consequences may not always be positive. In our attempt to help the disadvantaged of the world, we may be denying local people from developing the skills and commitments needed to learn how to care for their own people. Solution: The long-term goal of the CHOICE Village Health Program in a given country would be to recruit local health professionals to initiate the principles of a sustainable village health care program themselves. From among the many VHWs trained under the CHOICE health program, 3-4 of the very best could be trained and supported by local sources of funding to duplicate this program independent of American professionals. This would be the long-term goal of this program.
Implementation of the CHOICE Village Health Program As a way of ensuring that the CHOICE Village Health program is implemented in ways that are consistent with the above mentioned eight principles, the following sets of responsibilities must be fulfilled by the CHOICE headquarters, by the RDFs assigned in the rural hospital outreach areas, and by the staff of the rural hospitals participating in the program. Each RDF is encouraged to identify a rural hospital or large clinic that is willing to participate with CHOICE in a Two year Rural Hospital/Clinic Outreach Program. This Outreach Program will be organized to be flexible, to reflect the different situations where our RDFs presently work. It will be our goal to work with a select group of hospitals/clinics for a two year period, following the procedures outlined below. At the end of the two year period, we would hope that the RDF in each area would then help us identify another hospital/clinic where the two year process would be replicated.
A. What the CHOICE Office will be expected to do: (Please remember, at this point, we are still in the planning stage and many of the details will have to be worked out over the next 6-12 months
1. Prepare Training Materials for Eight Weeks of Training CHOICE will prepare a detailed training program to help train village health workers. We will prepare all the training materials (plus any training materials that you or your contacts may recommend that we use). We hope to prepare eight weeks of training that will be scheduled over a two year period. If we schedule a week of training every three months, it will take two years to complete the eight weeks of training that we have prepared. We have learned that it is better to give a little bit of training, give the village health workers an opportunity to practice what they have learned, and then three months later give them another week of training, review what they learned in the first week and answer any questions that they have. (See the attached possible training schedule) 2. Supplies for the Hospital/Clinic CHOICE will arrange to make a shipment of equipment and medicine to the hospital that is participating with CHOICE in the Outreach Program. While we are still working out the details, it is our hope that approximately $5,000 worth of medical equipment and supplies would be sent to the hospital each time that we have one of our weeks of training. Thus during the first year, there would be four weeks of training and we would hopefully be shipping four shipments of medical equipment and supplies. Obviously we cannot provide large expensive medical equipment, but we should be able to send many basic types of equipment that a hospital could use. While we encourage the participating hospital to let us know what kind of equipment and medicines would be helpful, obviously we cannot guarantee that everything that they need will be available. It is important that the hospital staff understand that nothing can be guaranteed, that our resources are limited and we rely on donations from hospitals and companies here in the United States.
3. Supplies for the Village Health Worker CHOICE will be providing each village health worker with a village medicine kit, of some of the basic kinds of things that they might need. During each week of training we would bring additional supplies to ensure the village health workers have some of the supplies they need. 4. Prepare a Team of Medical Trainers CHOICE will recruit and train four teams of medical professions for each area participating in the Outreach Program. (American physicians, nurses, practitioners of various kinds). Each team will agree to spend at least one week each year to work with the staff of the hospital/clinic. These medical teams will pay their own expenses and will be willing to participate in the village health worker training program in your country. In the team's orientation training, CHOICE will provide background material on the culture and the traditional forms of medicine presently existing in your areas, also they will be given specific information on the major kinds of medical problems that exist in your area. Once the team arrives in your country, they will be provided translators when needed. We would hope that some medical staff from the hospital/clinic or other medical people in your country would also be willing to donate one week of their time to participate in the village health worker training. While their major focus would be on training the village health workers, the American team would also be available to conduct some public clinics and perhaps even provide some training for the hospital/clinic staff if that is needed and requested.
Note the following possible schedule of training weeks
First Week of Training Sometime between 1 May 1997 and 30 July 1997. The RDF working with the hospital staff and the village health workers to be trained would be expected to identify the best week for the training. We are asking you please to identify 2-3 weeks as possible options during this three month period that would be best for the hospital staff and best for the village health workers. The more options that we have the better chance we will have of recruiting American medical personnel to come and work in your country. We want to be able to give a specific week so that the Americans can plan their own schedules to meet your needs. Second Week of Training Sometime between 1 August 1997 to 30 October 1997. Again it will be helpful if a specific week can be selected, but with some flexibility giving us one or two other weeks as alternative times to provide the one week training. Third Week of Training Sometime between 1 November 1997 and 30 January 1998 Fourth Week of Training Sometime between 1 February 1998 and 30 April 1998. ******The 5th through the 8th week of training then would be scheduled on the same basis through 1998-99.
B. What the Rural Development Facilitator (RDF), will be expected to do
1. Help Establish Village Health Committees The RDF would be encouraged to visit the villages that wish to participate in this program. The RDF will explain the purpose of the program and seek to establish a village health committee, made up of both formal and informal leaders in the village who have some commitment to improving the health and sanitation of their village. We have found that sustainable village health programs require the active participation and commitment of a village health committee who are responsible to help recruit 1-2 villagers to become village health workers. The village health committee is also responsible to establish a village Health Fund which helps pay for the medicines that the village health worker will need after the two year training program is over. This can be done either by the committee organizing its own income generating project, or encouraging the villagers to pay some small fee for the medicine that they receive, or by establishing a small pharmacy which sells the medicine at a price high enough to be able to make a little profit. 2. Recruit and Motivate the new Village Health Workers The RDF is expected to be involved with the village health committees in selecting the village health workers to be trained. We have found that generally older men or women (over 30 years of age), better if they are married, who are committed to staying in the village, who have some background in medicine, or who have a great interest in being a village health worker, and who have the support of the village community, make the best village health workers. Younger, single people are often willing to trained but they often move to the town or get married and move to another village. Also, it is very helpful if these village health
--Jim Mayfield ÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿÿmailto:james.mayfield@m.cc.utah.edu CHOICE Homepage: http://burgoyne.com/pages/choice