A Life-line for Rural Communities: Training Community Health Workers in Somaliland

In this blog, THET's Communications Officer, Timur Bekir, describes his visit to a rural village in Somaliland to see how a newly trained group of Community Health Workers are improving healthcare for the local population.

We’re driving along one of Somaliland’s main roads, an artery that cuts across the Sahil Region linking the capital Hargeisa with the coastal city of Berbera, when our driver, Abdi, makes a sharp right turn, leaving the relative comfort of the pot holed tarmac and embracing the undulating and unforgiving terra incognita of the Somaliland desert. As we hit the earth, we’re thrown about in all directions and I make use of any and all handles to support myself. A couple of minutes in and I’m starting to feel nauseous. ‘How long till we’re there?’ I enquire. ‘Two hours,’ comes the reply, ‘maybe three.’ It’s at this point that I realise the herculean task of getting an ambulance to a remote village like the one we’re visiting today, and how truly awful it must be for any sick patient taking that journey.

60% of the population in Somaliland is nomadic and many settlements and villages sit in isolated rural parts of the country. These remote communities have little or no access to healthcare and often only seek treatment when conditions take a turn for the worse. I’m visiting one such village today, Hulqaboobe, to see how THET’s Community Health Worker (CHW) programme is bringing essential healthcare to the local population.

I’m traveling with Amina Abdi, the lead tutor for the Community Health Worker programme. The programme has been developed by THET in collaboration with the Somaliland Ministry of Health and the UK Department for International Development, and takes a three tired approach: train CHWs, update the existing CHW curriculum and training manual, and deliver training to trainers who can continue to deliver the course in the future.

CHW lead tutor Amina Abdi. Photo: Timur Bekir

One of the fundamentals of the CHW programme is that students must be selected by their local community and then return back to that same community to work and provide healthcare, as Amina explains:

One of the criteria was that trainees should be selected by the health committees in their village. The person living there knows the rules and what the situation is in the community. We wanted to make sure the candidate can help their own community.

Hulqaboobe Village. Photo: Timur Bekir

The car slows and Abdi tells me we’re in Hulqaboobe. The village is flanked by mountains on two sides and looks about as remote as you can get.  Up ahead sits a large tree surrounded by huts and a Primary Healthcare Unit, built recently by one of THET’s partners Health Poverty Action. The village elders greet us and I’m introduced to the three CHWs who will be serving the local population. I speak to one, Asiya Awiye Muhumed, about her experience on the course:

When I was selected by my society that was the first time they trusted me, and during my first visit to the village after initial training we organised a community gathering and explained about our objectives. We told them that with the knowledge we are gaining from the training we want to serve them better.

Newly trained CHW, Asiya Awiye Muhumed. Photo: Timur Bekir

Health indicators in Somaliland are extremely poor. According to UNICEF one in every 14 children die before reaching age one while one in every 11 children does not survive to their fifth birthday; the maternal mortality ratio is 1044/100,000; and less than 50% of births are attended by a skilled attendant.*

CHWs embark on a nine month course that is broken down into six week blocks. This includes three weeks of class based study, a week working in their local health facility, and a community placement for a week, which is followed by a week of leave. Amina highlights the scope of the training:

The topics they are learning are really a lot. I can say some of the things they are learning are how to take care of pregnant mothers, how to take care of sick children, how to recognise the danger signs during pregnancy, after pregnancy, or during delivery. The healthy environment is also one of the things we are teaching them so they understand what health means and why we need to have a healthy environment, a simple example being handwashing.

The rugged beauty of Hulqaboobe village is quite stunning. The unexpectedly green landscape is broken up by orange rock and dusty earth, punctuated by the bright, vibrant colours of the Hijabs worn by local women. There is a huge crowd in Hulqaboobe today and Hersi Ahmed, one of the other CHWs selected from the village, explains that this is usual. People come from all around the area to be seen by the health workers:

Every day is like this and there are lots of sick people who need help, that is why I wanted to work for my people.

Hersi describes the impact of the training so far:

The training is going very well. We’re learning a lot of good things and Amina is supporting us to learn many things which we did not know before. We did not know how to measure BP and first aid, we knew none of these! But now we know many things.

CHW Hersi Ahmed. Photo: Timur Bekir

As our time in Hulqaboobe draws to an end I grab a quick word with the village elder. I ask him what impact the CHWs will have on the community:

Before this health facility was built we used to hire a lorry to take pregnant mothers to hospital, but now we get access to ambulances, and when someone gets ill in the village we get medicine from the health centre. Initially, there was only one health worker in the facility, but now we are expecting it to be more efficient because we are going to have the Community Health Workers who are very active in the health centre. So that is huge benefit to the village people, and we are very grateful to those whose support has made this happen and all those who participated in their training. We want to continue from there and improve upon it, I hope that we continue receiving support.

Village elder, Muse Hussein. Photo: Timur Bekir

The engine of our car rumbles into life behind me, signalling that it really is time to go. It’s clear from the people I’ve met today that the appetite for healthcare development is strong in Hulqaboobe. The CHWs are providing a much needed life-line to neglected communities and I look forward to returning again when the CHWs have graduated and are in their posts to see the impact they are having on patient’s lives.

*Summary Preliminary Results Multiple Indicator Cluster Survey, 2011, UNICEF.  

Developing village-based community mental health care in southern Malawi

In the blog, project Co-ordinator, Jerome Wright, charts the development of partnership project work between  the Department of Health Sciences at the University of York in the UK and Zomba Mental Health Services in Zomba, southern Malawi. 

The origin of the Mental Health in Zomba (MHiZ) Project stems from work on a 2005-6 British Medical Association (BMA) Humanitarian grant funded project to pilot the teaching of mental health care to staff posted at health centres around Zomba in southern Malawi.  These health professionals – nurses, clinical officers, medical assistants - were updating their mental healthcare skills, skills they rarely utilised in the midst of challenges besetting the low resourced and overstretched health centres, compounded by the priority afforded to physical health problems of communicable disease and mother and infant health.  The evidence of mental health problems contributing to the global burden of disability, and how the physically unwell and their carers are among the most vulnerable to mental health problems, was only beginning to emerge.  Two things were challenging – HOW to design and deliver mental health training that would be effective and accommodate the social and cultural context of rural Malawi and secondly, WHERE best to target these efforts.

Health Surveillance Assistants (HSAs) are a group of Malawian health workers closest to the communities they serve.  While based at a health centre, they attend there only once or twice a week but spend most of their time promoting health in the villages – directing efforts to providing vaccinations, monitoring children and mothers’ health, supporting the treatment of malaria, TB and HIV, monitoring and promoting community efforts at water and sanitation facilities and tracing outbreaks of infectious disease. Mental health was not included in their training to become an HSA and yet at the teachings HSAs would describe ‘people experiencing madness’ (“anthu a misala”) and other mental health and development difficulties such as learning disability, epilepsy, low mood and suicide.  Though previously untested, the accessibility of HSAs within the communities made them the ideal staff group to be supported to promote mental healthcare for people closest to their homes.   

HSAs from Matiya health centre. 

However, what type of assessment and intervention should be promoted? In the past, initiatives in low income countries have tended to focus on enhancing the often sparse psychiatric service, with the intention that the ‘expert’ knowledge of mental illness from institutions filtering through the interventions and provision of effective care to the public.  The knowledge espoused too would be based upon that evidenced from other (usually high resourced) countries – with the assumption of universal applicability and appropriateness.  While there appears to be an agreement that throughout the world people experience mental distress, the way that these experiences are understood, lived, and ‘treated’ differ according to cultural context.  A decade of experience working with colleagues in rural Malawi – where there are rich traditional African and other religious responses to what might be described as mental health problems, together with its mixed picture of effectiveness and an absence of western psychiatric thought – meant we wanted to tread carefully by introducing a determinedly ‘healthcare’ response to people suffering distress that was also conducive to Malawian social and cultural mores. 

MHiZ Project manager Chikayiko Chiwandira and Nurse Jane Mlumbe providing supervision to HSAs.

To develop such a mental health curriculum that would assist HSAs in recognising and responding to the range of mental health problems they witness in their communities, a mixed group of Malawian and UK health professionals, academics, users of mental health services and HSAs themselves was convened.  Through a series of workshops and deliberations a three day training programme was designed and prepared. The curriculum acknowledged multi-factorial pathways to experiencing mental health problems, accepting the personal value and significance of people’s own attribution beliefs (stress, the use of drugs, bewitchment, the ‘will’ of God etc.) and offering a ‘health model’ as a way of responding to the distress.  Although, within the community, ‘bewitchment’ was the most common attribution for a person experiencing what may be termed a mental health problem, so too was ‘stress’ which provided HSAs with an ideal opportunity to pose a ‘stress-vulnerability’ model to understand the psychological ‘distress’ as a health problem.   Instead of identifying psychiatric diagnoses, a client- and HSA-assessed adjudication of ‘psychological distress’ and ‘risk to self or others’ was sought, together with a  Human Rights framework utilised to determine prioritisation and acceptability of an intervention against a person’s consent.  The response and interventions from HSAs too emphasised the mobilisation of support locally from within the family or wider community, with the health centre available for the most severely disturbed people.

The curriculum was successfully piloted in 12 health centres between 2010 and 2012 and involved training 271 HSAs and the current MHiZ Project is now scaling–up that programme to the whole of Zomba District which includes 32 health centres and serves a population of 550,000.  In a development from the pilot project, to support the integration and sustainability of mental health within the role of HSAs further, a one day training course on mental health using the same model was also provided to 240 health professionals based at the 32 health centres in order to acquaint them with the HSAs new role and enlist their support managing mental health problems at health centres. 

In 2013, once a ‘training of trainers’ programme was completed, nine Malawian trainers delivered ten three day training programmes to more than 450 HSAs.  The third day was delivered six to nine months following the first 2 days to incorporate an opportunity for HSAs to review and discuss their new mental health roles.  A pre- and post-training assessment of each individual HSA’s knowledge and confidence in tackling mental health issues was also undertaken, with increases in both recorded on follow-up. 

In the 18 months since the trainings, the small MHiZ team have provided monthly supervision to HSAs at their health centres, reviewing their interventions with individuals and families and also the huge number of mental health promotion activities the HSAs have facilitated.  A record of both HSAs’ mental health care activity with individuals and their families and their mental health promotion activity is being collated.  Records show people are presenting to HSAs with a range of life-problems: bereavement, abuse, marital problems, epilepsy. Carers attend to see the HSA describing clients ‘abnormal’ behaviours such as ‘wandering’, not eating, not sleeping, dizzy, talking to self and smoking ‘chamba’ (marijuana).  The HSAs describe people challenged by difficult social contexts including death of loved ones, abuse, physical illness and relationship problems, with more than 1 in 10 people feeling suicidal.  HSA interventions range from providing information, emotional support and reassurance, communicating with extended family or community to mobilise support, advice on medication or referral onto the health centre.

To date, records of over 800 mental health promotion activities have been collected, with over 40,000 persons attending these events – including public meetings, meetings of village health committees, consultations and support groups for patients and carers.   This demonstrates the huge reach HSAs have within their communities and the potential this has for public mental health promotion and sensitization.

As the project nears its end in March 2015, we look towards sustainability and summative evaluation.  In September last year the Project financed and hosted an Award Ceremony at Matiya Health Centre, Zomba District, to celebrate their efforts as the top performing health centre and the mental health work of individual HSAs.  The event, attended by local stakeholders and national press, has helped to draw attention to the potential of HSAs and to generate interest within the Malawi Ministry of Health and more widely in developing this or similar initiatives. To inform this too, the MHiZ Project team is currently analysing data to determine both successes and ongoing challenges in developing this innovative approach to community mental health care. 

MHiZ Project manager Chikayiko Chiwandira and Assistant DHO Mr Mlotha presenting HSA Shadreck Chinsima with his award of bicycle for his excellent and sustained contribution to mental health promotion and care.

In the coming weeks, we are looking forward to testing the degree to which the MHiZ Project has developed a way of increasing primary mental healthcare that is responsive to local understandings and experiences of distress and provides humane and effective care for some of the most vulnerable people in society.

MHiZ Project Lead Jerome Wright congratulating top HSA Shadreck Chinsima on his award.