LESSONS IN COLLABORATION FROM SHINYANGA
By:
Opia Mensah Kumah, Jason Onsembe, and Mere Kisekka

October is the peak of the dry season in Shinyanga. During this period Shinyanga town, the capital of the region of the same name in western Tanzania, sits in the middle of a dust bowl where only cactuses and the hardiest drought-resistant plants survive. Water is scarce. So is fuelwood. Women and children bearing pots and pans roam the countryside in search of water. Herdsmen and their cattle range far afield in search of grass - and water. In October Shinyanga looks and feels poor and deprived.

And yet Shinyanga is a treasure trove. The region reputedly sits on the largest deposits of gold in Tanzania. Rubies and other precious stones can also be found there. The two million Sukuma people who inhabit the region own the largest herd of cattle in the country - as many as three for every inhabitant. During the rainy season, the land becomes kinder and yields a bountiful cotton crop.

UNFPA Dar es Salaam and CSTAA have unearthed another treasure in Shinyanga. It is the Family Life and Health Education Project. The project, implemented by the Shinyanga Regional Development Authority (RDA) with technical and financial support from UNFPA, is a storehouse of experiences and novel approaches from which many lessons in programme design and implementation may be derived.

The project was started in 1989 as part of a coordinated Joint Coordination Group on Policy (JCGP) response to a severe drought that affected the region in the early to mid-1980's. The drought dried up wells and streams, killed the trees that provide fuelwood, and deprived cattle of grass and water. Food shortages resulted, malnutrition and water-borne diseases increased, particularly among children. Women, who traditionally gather fuel wood and fetch water for domestic purposes, had to travel ever increasing distances daily.

The JCGP partners - UNDP, UNFPA, UNICEF and WFP - focussed their efforts, in a pilot phase, on three critical issues inter-connected by the drought: water, women and health. During this phase UNFPA supported family planning and family health education activities in two divisions in Shinyanga Rural District; UNICEF implemented a child survival component; UNDP supported water and sanitation and afforestation activities; while WFP initiated A series of evaluations conducted 1994 found that contraceptive prevalence had increased from one to 10 percent in the pilot zone. Infant and maternal mortality also increased significantly compared to the rest of the region.

The RDA was so impressed with the results of the pilot phase that it decided to continue the activities initiated. However two of the original JCGP partners - UNDP and WFP - for various reasons decided to discontinue their assistance. UNICEF continued - and indeed expanded - its activities under its Child Survival Promotion and Development (CSPD). Based on the evaluations and fervent appeals from the Regional Development Authority, UNFPA decided to extend the project. It was re-designed in October 1994 with CSTAA assistance and was launched in September 1995 as URT/95/P08.

The new project introduced some significant changes. The coverage of project activities was extended to the entire region; a project management structure was established that integrated activities into existing district and division level administrative and health structures; the MCH focus of the project was expanded to include HIV/AIDS; a multi-media communication approach was instituted to replace the costly and labour intensive face-to-face interaction which was the only channel of communication in the pilot phase. Two media Innovations were introduced. Community-based traditional drama troupes known as manjus were recruited. Secondly, the project capitalised on the popularity of the award-winning UNFPA-supported radio drama serial Twende na Wakati by re-writing 26 episodes, or three months' worth of the series, to focus on issues covered by the project.

Two aspects of the project from which important lessons may be drawn are: (i) the use of IEC to maintain the linkage among the water, women and health themes established in the original JCGP project; and (ii) the collaboration among the CSTAA Advisors responsible for IEC, Data and Socio-cultural Research in implementing the project.

Water, Women and Health

Following the withdrawal of UNDP, the Dutch technical cooperation agency, HMV, which supported a water supply scheme in parts of the region, and HASH, a locally-based NGO involved in afforestation, were encouraged to expand their programmes to include the water sanitation, and afforestation activities supported by UNDP in the pilot phase. In response to the RDA's concern to maintain the integrity of the original JCGP project concept , the URT/95/P01 project was conceived to encompass two new themes in addition to reproductive health, namely: (i) gender, focusing in particular on the alleviation of women's chores related to collection, transportation and storage of water and fuelwood and the promotion of male involvement in these activities; (ii) and mobilisation of the community to participate in water, sanitation and afforestation activities. During a message design workshop conducted in April 1996 messages on the three key themes were developed.

IEC Collaboration with Data and Socio-Cultural Research

Research and evaluation were integral to the design of URT/95/P08. Three types of research and evaluation are envisaged to guide the implementation of activities and to measure the effectiveness and impact of interventions. These are:

  • Formative research, to guide message development and dissemination;

  • Monitoring, to assess the impact and effectiveness of interventions on a continuing basis; and

  • impact evaluation, to measure the overall impact of interventions at the end of the project.

    During an IEC strategy and project implementation workshop organised in November 1995 to launch the project, Messrs. Jason Onsembe and Opia Mensah Kumah, the CSTAA Advisors for Survey Method and Sampling and IEC Organisation and Management respectively guided local consultants from the Demographic Training Unit (DTU) of the University of Dar es Salaam and project management staff to design a research and evaluation plan that spelt out methodologies, data processing and analysis procedures and a format for reporting the results. An important aspect of the research and evaluation plan was the development of key indicators for each of the three main themes - water, women and health. Questionnaire design, data analysis and report writing were all conceived to be derived from the indicators. CSTAA adopted a multi-sectoral, multi-disciplinary approach to executing this comprehensive research and evaluation plan.

    The research and evaluation plan called for a variety of methodologies to carry out each type of research.

    For formative research, three studies - a literature review, focus group discussions and selected data from the baseline KAP survey - were conceived to provide the socio-cultural and media information necessary for message design and media strategy development.

    For monitoring, two studies were set up: (i) periodic analysis of service statistics and administrative records, and (ii) a panel study using "satellite families" to monitor the effectiveness and impact of mass media messages, particularly through the radio soap opera, "Twende Na Wakati".

    For impact evaluation, a baseline and post-intervention KAP survey was designed to provide a quantitative measure of the impact of project interventions.

    From the CSTAA end, a three-person research and evaluation team comprising Messrs Kumah, Onsembe, and Ms. Mere Kisekka, Advisor in Socio-Cultural Research, was constituted to backstop the research and evaluation activities of the project. The IEC Advisor, who designed the project and oversees its overall technical backstopping, coordinated the design and implementation of the research plan. Mr. Onsembe assisted in designing the sampling frame, data collection and analysis for the baseline KAP survey, while Ms. Kisekka reviewed all data collection instruments to ensure that they were sensitive to socio-cultural and gender considerations. Ms. Mie Baek, National Programme Officer at UNFPA/Dar es Salaam, and Mr. John Millinga, Project Manager, coordinated all logistics and field support in Dar es Salaam and Shinyanga.

    Conclusions and key lessons

    Although the project is still ongoing and a formal evaluation has not yet been conducted, two key lessons may be derived from its design and implementation. The first is that, within a rural community where development activities are conceived holistically, reproductive health IEC programme can be so designed as to address gender concerns as well as related development issues, in this case water and sanitation and afforestation. Such a linkage need not necessarily compromise the reproductive health component; indeed it may enhance it by making the entire project more acceptable to community members.

    The second lesson is that the implementation of the research and evaluation component of an IEC programme can benefit from specialist technical input by data and socio-cultural Advisors. In the past, too many IEC projects carried out research activities whose outputs were of questionable value because research professionals and specialists were not involved in design and implementation.

    TWO APPROACHES TO MEETING THE NEEDS OF YOUTH
    By :
    Adjoa Amana

    For purposes of programming youth are typically divided into in-school and out-of-school. Reproductive health programmes for youth are usually designed one or other of these two categories. Addressing youth in either situation presents peculiar challenges in sub-Saharan Africa. We present below two approaches employed in Eritrea and Kenya to reach out-of-school and in-school youth respectively.

    Youth Centre in Eritrea

    A major challenge to addressing the reproductive health needs of out-of-school adolescent is that, unlike their counterparts in schools, they are hard to reach unless they belong to certain organizational structures. The problems facing many of these young people include early and unprotected sexual relationships, unplanned and unwanted pregnancy, school drop-out, induced abortions, sexually transmitted diseases, prostitution, early marriages, early child bearing among unmarried adolescents, sexual harassment and abuse, drug and alcohol abuse.

    In Eritrea, UNFPA and the National Union of Eritrean Youths (NUEYS) have responded to this problem through a three-year project entitled Reproductive Health Education and Counselling Services for Youth (ERI/96/PO1). NUEYS is a national NGO with 100,000 members throughout the country. The goal of the project is to promote awareness of reproductive health and responsible parenthood among the youth, and to assist in developing and strengthening national capacity for providing adolescent health services. The immediate objectives include:

    As part of its contribution NUEYS converted one of its buildings which used to be a night club in Asmara into a youth centre for young people. This centre is the first of its kind in Eritrea. It has a training hall, a library, a consulting room for adolescent health services, including reproductive and sexual health and family planning services, two counselling rooms, and a room for routine laboratory work.

    A NUEYS member who is a trained physician has been designated as the project manager and clinician. He works closely with Planned Parenthood Association of Eritrea (PPAE) and the Ministry of Health to ensure that the provision of services is in line with the Ministry's procedures and guidelines. A system for efficient referrals is being worked out. The counselling section has a trained counsellor and sessional clinical psychologist who visits the centre weekly. Medical and audio-visual equipment, computers, videos, books and games have been purchased.

    In May 1996 a training of trainers workshop on adolescent sexual and reproductive health and counselling skills was held in the training hall of the youth centre. Participants included health workers from MOH, the Eritrean Red Cross, St. Mary's Psychiatric Hospital as well as NUEYS youth leaders from the regions. The main objective of the workshop was to train trainers who will conduct training in the regions. The two-week workshop, conducted with the technical guidance of CSTAA Adolescent Reproductive Health Adviser, was facilitated by experts from the Ministry of Health and the University of Asmara. Based on the WHO Adolescent Counselling Skills Manual, the training was divided into three sections. The first section covered the reproductive and general health issues related to the needs of adolescents in Eritrea, the second section covered the basic psychodynamics of counselling especially listening skills and the third section combined the reproductive health issues and the couselling skills in role play exercises to practice the skills taught. Video films on AIDS counselling and teenage pregnancy were shown.

    Training materials are being translated into Tigrigna and other major languages for training in the regions. NUEYS hopes to establish similar youth centers in all the regions to meet the sexual and reproductive needs of youths.

    Adolescent Counselling Training in Kenya

    In Kenya, efforts to introduce population/family life education schools have been hampered by opposition from religious groups and other powerful social forces opposed to offering reproductive and sexuality education to students. To get around this barrier, UNFPA and the Ministry of Education have decided to try a new approach: introducing counselling skills using the issues of an adolescent reproductive health information and education through school teachers as focal persons for counselling services in the schools. For this purpose 30 primary school teachers were selected from all provinces to participate in a six-week course in guidance and counselling organized by the AMANI. Technical support was provided by the CSTAA Adolescent Reproductive Health Advisor.

    A remarkable feature of the workshop was the methodology it employed. The workshop had three components; class work, field placement and assigned reading.

    The class work

    Four days of the first week were devoted to class work to ensure a good knowledge base before embarking on the field assignment. Thereafter, the first two days of each week were devoted to class work, followed by three days of supervised field work. The class work which was very participatory was based on the WHO counselling module which breaks each day's class work into three parts.

    The mornings were devoted to issues such as child development, maturation, adolescent reproductive and sexual health with specific reference to the Kenya situation, drug and alcohol abuse, gender, sexual abuse and harassment, teenage prostitution, female genital mutilation (FGM), generational gap, helping parents understand adolescent development issues, school discipline, how to use alternative forms of discipline, stress management, etc. The presentations were enhanced by discussions and roleplay exercises.

    The first half of the afternoons was devoted to the basic psychodynamics of counselling including the initial interview, micro-skills of listening and observing, counsellor's responsibility, confidentiality, privacy, duration and frequency of session, difficult moments in counseling, bringing counselling to a close, communication skills needed by parents, counselling adolescent with the family, conflict resolution, etc. Again presentations were very interactive and included modeling and a play by a psychodrama group.

    The second half of the afternoon was devoted to roleplay exercises in triads. The case studies for the role play exercises comprised of issues that had been presented in the morning combined with the skills taught in the first half of the afternoon. In the roleplays, the three participants in each triad took turns to act as a counselor, counselee and an observer. Each day ended with a wrap-up, reading and field assignments.

    Fieldwork

    Before the commencement of the training, the Ministry of Education prepared fifteen schools in the Nairobi metropolis to be used for the field placement segment of the training. Arrangements were made for each school to accommodate two participants. The headmasters of the placement schools met with the participants before the fieldwork began to discuss the programme and expectations. The field assignments varied from week to week. These included :

    a. Creating a resource file for the school, e.g resources in the neighborhood such as churches, clinics, hospitals, youth programmes, parents support, etc.
    b. Identifying services available for referral of students,
    c. Establishing what services are missing
    d. Interviewing teachers, administrative team, students, parents
    e. Establishing the level of parental involvement in school activities
    f. Gathering newspaper clippings on children and adolescent issues and attitudes
    g. Identifying problems in the school, e.g. drugs, sexual and other behavioural issues
    h. Assessing programmes provided by the school to deal with the identified problems
    i. Reviewing mechanisms for resolving conflicts, enforcing discipline, etc.

    Eleven professional counsellors from the AMANI Institute supervised the field placement exercise. A supervisor was assigned to the two participants in each school and each participant received individual clinical supervision.

    Reading Assignments

    The trainees hed to read a large number of reading materials, handouts of presentations and copies of relevant materials from the AMANI library, including the following: Counselling Skills Training in Adolescent Sexuality and Reproductive Health; The Skilled Helper; The Barefoot Counsellor; Personal Counselling; Encouraging Growth & Development in the African Child; Social Work with Children; Effective Helping; and Interview Strategies for Helpers.


    LESSONS LEARNT

    i. Teachers are aware of many of the problems being faced by adolescent and some are capable of providing counselling services for the students in their schools.
    ii. Many school teachers know very little about the adolescent's physical and emotional development and the communication skills needed to help them cope during this transitional phase of their lives.

    iii. The required institutional arrangements should be put in place before the participants complete the training to ensure there is a support system within which what they have learnt will be implemented as planned.

    iv. The utilization of a reputable local institution such as AMANI and the careful packaging of sensitive issues in adolescent sexual and reproductive health, enhance its importance and acceptability to all concerned.

    v.The experience has shown that there is a critical need for such a service in the schools, hence the training should be extended to other schools.

    CSTAA ADVISORS ASSIST UNFPA REGIONAL TRAINING PROGRAMMES

    From March to June 1996 CSTAA IEC Advisors Opia Mensah Kumah and Barnabas Yisa were involved in developing training modules and curricula for three UNFPA-supported regional training programmes.

    In March, Mr. Yisa co-facilitated a workshop organised by the Nairobi-based Regional IEC Training Programme for Anglophone Africa to revise two draft training curricula in Population/Family Life Education and review draft outlines of training modules. A total of 16 participants attended the workshop.

    The outputs of the mission included curricula on "Strategy Development and Management of Population/Family Life Education" and "Population and Family Life Education Skills Development for Teacher Trainers". In addition, draft training modules and units of modules were developed and reviewed during the workshop. Selected readings were identified for inclusion in the curricula and modules.

    From 21 to 28 April Messrs. Kumah and Yisa joined a group of some 30 IEC specialists from CST/Dakar, FAO (TSS-Rome), UNESCO/BREDA-Dakar and various institutions in Cote d'Ivoire to finalise training modules for the Regional IEC Training Programme for Francophone Africa based in Abidjan. Prior to the meeting, the Training Programme had commissioned a number of experts draft the modules to be discussed during the workshop. Mr. Kumah prepared two modules on: "IEC Strategy Development", and "Organisation and Marketing of Reproductive Health Services".

    The workshop reviewed all the modules and agreed on the objectives, duration and module composition of five training courses. These were: (i) Organisation and Management of IEC Programmes; (ii) Inter-personal Communication and Counselling; (iii) Strategy Development, Message Design and Materials Development; (iv) Training of Trainers for POP/FLE; and (v) Development of Curriculum and Training Materials for POP/FLE Programmes. It should be noted that the IEC Organisation and Management Course was designed as a common course for managers of both formal (in-school) and informal IEC programmes.

    From June 10 to 15, Mr. Kumah undertook a mission to Mauritius as a member of a team of specialists in Reproductive Health and Education Methodology to review the curriculum of the Regional Family Planning Training Course based at the Institute of Public Health in Pamplemousses, Mauritius. The team was led by a consultant, Prof. Raja Bandaranayake of the University of New South Wales in Sydney, Australia. Other members, in addition to Mr. Kumah, were: Ms. Wariara Mbugua, Gender Advisor, CST/Harare; Dr. Mamadou Diallo, RH Advisor, CST/Dakar; Dr. Alexis Ntabona, Regional Advisor WHO/AFRO, Brazzaville; and Mr Isaac Obeng Quaidoo, Coordinator of the Regional IEC Training Programme based in Nairobi. Staff of the Project, led by Dr. Lindsay Edouard, the Project Director, took part in the exercise.

    Based on a background paper prepared by the Project staff, the team reviewed five aspects of the training programme and curriculum: (i) course structure; (ii) technical content; (iii) educational methodologies, (iv) target participants; and (iv) trainers.

    On structure, the team decided to maintain a six-week course, with approximately two weeks devoted to RH content and four weeks devoted to educational methodology. Content and methodology will be integrated by using instruction on content to demonstrate various educational methodologies taught in the course. The technical content will continue to focus on family planning, but other issues in RH, as defined by ICPD, will be included. Educational methodologies will emphasise participatory and discovery approaches.

    The team identified two categories of primary target participants, (i) trainers and teachers (TOT's) in RH training institutions, and (ii) RH programme supervisors whose activities converge with those of TOT's in the field. Potential trainers will be drawn mainly from the TSS/CST system, as well as selected high-level RH academic, research and training institutions.

    THE GREAT PRSD "EPIDEMIC" OF 1996:
    THE FIRST WAVE

    In June, CSTAA Advisors were involved in two Programme Review and Strategy Development ( PRSD) exercises in Kenya and Tanzania. These were the first two of a round of six PRSD's scheduled to be held in the CSTAA sub-region before the end of the year that came to be known at CSTAA as "the great PRSD epidemic of 1996".

    The Kenya and Tanzania PRSD were both exciting and challenging, and provided some useful hints for the remaining four. They were exciting for two reasons. First, the PRSD's proved to be the ultimate joint missions. Advisors from various sectors representing a broad range of disciplines were involved. This composition was further enriched by the inclusion of an Advisor and international consultants handpicked by New York.

    In Kenya, the team comprised: Prof. O. O. Arowolo, a population and development specialist based in Namibia, as team leader; Messrs. Jean Marc Hie (Data) and Opia Mensah Kumah (Advocacy and IEC) from CSTAA; Ms. Wariara Mbugua (Gender) of CST/Harare; and Dr. Ogbaselassie (Reproductive Health) from TSS-WHO/Geneva. (Dr. Ogbaselassie was scheduled to join CSTAA in July.)

    The Tanzania team was led by Prof. John Oucho, a population and development specialist from Kenya. The other members of the team were all from CSTAA: Ms. Adjoa Amana (Adolescent Reproductive Health), Mr. John Herzog, (Population and Development Strategies), Dr. Luca Monoja (Reproductive Health) and Mr. Jason Onsembe (Data)

    Mr. Fidelis Zama Chi, Programme Officer in the Africa Division of UNFPA/New York and focal person for CST's, participated in both the Kenya and Tanzania PRSD's. A select group of national consultants took part in the exercise in both countries.

    The two PRSD's were also exciting because they were the first to be conducted in the CSTAA sub-region after the ICPD. For CSTAA, therefore, they represented the first opportunity to conceive a national population and development strategy following UNFPA's post-ICPD programme implementation framework, that identifies three thematic areas, namely reproductive health, population and development strategies and advocacy.

    This novelty had its downside. Since new PRSD guidelines based on the new framework were not yet developed, it became necessary for team members, the UNFPA field office and national counterparts to to "negotiate" on key concepts such as advocacy and gender and how to operationalise them. Fortunately, both CSTAA and CR's had anticipated this problem. In both Kenya and Tanzania, the UNFPA Field Offices organised meetings at the national level to reach consensus on strategic approaches and operational mechanisms. CSTAA Advisors participated in these meetings.

    Another challenge faced in Kenya and Tanzania was determining the optimal duration of the mission. In Tanzania, the mission lasted three weeks. In Kenya, however, it lasted barely two weeks. This turned out not to be sufficient time although the team leader stayed behind and extra week to finalise the Aide-Memoire and draft PRSD document.

    The lessons learned from these two PRSD missions were shared with other Advisors as well as UNFPA/New York.

    TANZANIA EMBARKS ON HEALTH SECTOR REFORM
    By
    Dr. L.T. Monoja

    The Government of the United Republic of Tanzania officially launched a health sector reform programme in October 1995. The reform vision is a well-functioning universally accessible and quality health care. The Government hopes to achieve this by focusing its role on policy, legislation, regulation, monitoring & evaluation and coordination functions; by increasing private sector participation in the provision of health care; by empowering communities to take active part in the provision and management of health services and by decentralizing health services management. However, Government will ensure the provision of an essential package of primary health care services especially at the community, dispensary, health centre and district hospital levels. These levels will be linked by functional referral and supervisory mechanisms. The essential package at all levels includes reproductive health services: namely safe motherhood, family planning, prevention and management of STDs, IEC among others. The initial reaction of donors, including UNFPA, to the reform programme has been positive and supportive. All donors were actively involved in the planning of the reform process. The last joint Government/Donors Consultation was in April 1996, during which the Government presented the global workplan for 1996 - 1999. The joint consultation was lead by the Government as the whole reform process is.

    CST/BANGKOK ADVISOR VISITS CSTAA

    Ms. Carmelita Villanueva, Regional Advisor for Population Documentation and Information, of UNFPA/CST for East and South-East Asia undertook a mission to CST/AA from 6 to 11 February 1996. The purpose of the mission was to assist in reorganising and computerising the CSTAA documentation unit.

    During the five days of her mission, the visiting Advisor reviewed the existing documentation system, identified areas for improvement and recommended the following activities for immediate implementation:

  • introducing a more practical and effective classification system;

  • reorganizing the documents collection to facilitate a more efficient access and retrieval of information;

  • training the Documentation unit staff; and

  • preparing a framework and plan to guide operations of the documentation unit.

    In addition, Ms. Villanueva recommended requisite office equipment and supplies. These included 150 box files, 12 bookshelves, 5,000 pieces of gummed book labels, 2 steel filing cabinets. Others are tables and chairs for librarians and readers, borrowers' cards for readers, folder hangers; and curtains to protect materials from the sun.

    Apart from technical restructuring the Advisor recommended a physical reorganisation of the unit- expanding the space, filing of mission reports and administrative materials separate from the other collections. On completing her assignment Ms. Villanueva shared with the CSTAA Advisors some of her ideas on documentation and the role of population information through various papers she has written on the subject. The papers will complement the guidelines for setting up and implementing documentation units in countries covered by CSTAA. In this regard she made special reference to the Library and IEC Materials Centre established in Shinyanga in Tanzania. She commended the guidelines for setting up and operating the centre prepared by the CSTAA IEC Advisor.

    DECENTRALIZATION EMPOWERS
    By
    Dr. L.T. Monoja

    In June 1994, Nigeria and UNFPA embarked on a decentralized implementation of the Reproductive Health Programme. As a result, RH programmes were established in 10 States. Ogun State is one of the programme implementation sites. Unlike previous programmes when state authorities depended on initiative from the Federal Ministry of Health in Lagos, the decentralized implementation placed state authorities in the driver's seat. Ogun State health authorities grabbed the challenge and a team of policy and decision makers embarked on sensitization of local government areas and communities (see photograph below). Aware of the demand being created by the sensitization campaign, the State Health Authorities have created a budget line in the regular budget for the procurement of contraceptives. Furthermore, tuition fees have been instituted for training at the State RH School which is now open to public sectors as well as private individuals wishing to acquire RH skills. The interest and motivation to direct programme implementation in the other 9 States is as high as in Ogun.