Project Formulation Study on Community Health Sector In the Republic of Angola (Summary) January 2009 Non-profit Organization HANDS(Health And Development Service)
Table of Contents 1 Summary of the Project 1 2 Overview of the Society and Health Situation in Angola 2 3 The Situation of Society and Health Status in Luanda 5 4 Community Health Agent Program 10 5 The Possibility of Japanese Cooperation 13
2. Overview of the Society and Health Situation in Angola 2.1 General Information Being located in the south-west Africa, Angola has the area of 1,250,000 square km (around 3.3 times of Japan) and the population of 12,530,000 1 as of July 2008. In April 2002, Angola put an end to the conflict which had continued for 27 years and is now faced with various social problems such as damaged infrastructure and lowered productivity by the war, landmines scattered across the country, and drastic increase of the population due to the returning refugees and the worsening urban problems. In addition, rural areas hold an issue of resettlement of returning refugees, and handling of Angolan refugees who have not returned to the country by 2007 (190,000 people: 125,000 in Democratic Republic of the Congo, and 42,000 in Zambia) lies in the months ahead. The economy of Angola continues to grow, due to the steady growth of export of abundant natural resources such as petroleum and diamonds. The gross domestic product per person(gdp)is US$5,595 2, which is higher than the average of Sub-Sahara Africa(US$1,998) 3. However, Angola is still dependant on food supply from abroad, as over 50% of the food is imported. 70% of the population live below US$2 a day, especially in the rural areas. The gap between the rich and the poor is great, and there are various economic issues at hand. 4 2.2 Community Angola consists of 18 provinces and 164 districts, and the administration below the district level is constructed as shown in Figure 2-1. The population below 15 year-olds accounts for 43.6% of the total population. It is estimated that on average a women gives birth to 6.2 children. There are 6 ethnic groups and climate, economy, food culture, traditions, customs, languages, and community structure vary from province to province. 5 Province(Província) District (Municipio) Division (Comuna) Bairro Sector Figure 2-1 Divisions of Local Administration in Angola 1 https://www.cia.gov/library/publications/the-world-factbook/geos/ao.htm CIA The World Fact Book, Angola 2 Estimation of IMF 4 UNDP Human Development Report 2008 4 www.irinnews.org IRIN - Integrated Regional Information Network (1 October 2008) 5 https://www.cia.gov/library/publications/the-world-factbook/geos/ao.htm CIA The World Fact Book, Angola 2
2.3 Health Status Health indicators of Angola are among the worst in the world. The average life expectancy is 41.7 years, infant mortality rate is 154 (per 1,000 live births), under 5 mortality rate is 260 (per 1,000 live births), and all of these indicators are ranked as the second worst in the world, just above Sierre Leone. Maternal mortality rate is 1,400 (per 100,000 live births), the fourth worst in the world. 6 2.4 Health Administration System The Ministry of Health exercises jurisdiction over policy making, long-term development strategy planning, assistance to research, and technical and human resource development, and management of national institutions and organizations. The Ministry of Health consists of Minister, two Vice Ministers (one in charge of medical services and the other public health services), and five Directions. Public health services are provided by the National Directorate of Public Health(DNSP), one of the five Directions in the ministry Central Executive Office 7. Health and medical services in Angola are provided through the public health and medical facilities and its system is divided into 3 levels, from level 1 to level 3, as shown below in Figure 2-2. The Ministry of Health is responsible fors Level 3, the Provincial Health Department for Level 2 under the supervision of the Ministry of Health, and the the District Health Department for Level 1 under the supervision of the Provincial Health Department. Level 3 Level 2 National Hospital Provincial Hospital District Hospital Level 1 Health Center(public/private) Health Post (public/private) Community Community Health Agent Figure 2-2 The National Health System of Angola 1 6 http://unicef.org/infobycountry/angola_statistics.html. Under 5 Mortality Rate and average life expectancy is data from 2006, maternal mortality rate is data from 2005. 7 Direcção Nacioanl de Saúde Pública:Relatório de Actividades 2007 3
2.5 Health Policy and System / Finance System The government of Angola gives instructions on health policies and their operation to the Provincial Health Department through National Directorate of Public Health( (DNSP), the Ministry of Health. The Division of Public Health and Endemic Control (Departamento de Saúde Pública e Controlo de Endemias) manages and supervises community health policies. The District Health Department implements health policies and disease control. Regarding financial administration, the salary of the staff working for the Ministry of Health is provided to the finance division (OGE: Orçamento Geral do Estado) of the Provincial Health Department by the Ministry of Finance (Ministéiro das Finanças). Other expenses are allocated from the Provincial government according to the monthly reports made by the Health Department 8. 2.6 Health Plan / Program 9 The Ministry of Health considers the following health issues as most important 10. 1) Improvement of maternal and child health services(with the objective of decreasing maternal and infant mortality rate) 2) Polio eradication 3) Leprosy eradication, malaria/tuberculosis/cholera control 4) Other infectious diseases control (HIV/AIDS, sexually transmitted infection (STI), sleeping sickness etc.) 5) Health and medical services for non-communicable diseases(hypertension, diabetes, heart disease) The government of Angola has begun to introduce the Community Health Agent Program (Programa de Agentes Comunitários de Saúde: PACS 11 ) nationally to strengthen coordination among different levels in the health system, especially the linkage between community and Level 1, as well as that between Level 1 and Level 2. 8 Gabinete de Estudos, Planeamento e Estatística:Plano de Desenvolvimento Sanitário da Provincia de Luanda 2008-2018 9 See DNSP Plan and the report of 2007 10 Direvção Nacional de Saúde Públlica:2007 11 For details of the community health agent program, see Chapter 4. 4
3. The Situation of Society and Health Status of Luanda 3.1 General Information of Luanda Province Luanda Province consists of 9 districts. District is divided into communas, communa into bairros, and bairro into sectors. The population of Luanda Province is drastically increasing after the end of the conflict, from 5 million in 2005 to 7 million in 2008. 3.2 Health Information and Community Health Policy in Luanda Province According to the activity report of the Health Department of Luanda Province 2007 (Relatório de Actividades 2007), the five major diseases are malaria, acute respiratory infection, acute diarrhea, typhoid, and sexually transmitted infections (STI). Diseases which cause the most deaths are malaria, acute diarrhea, meningitis, acute respiratory infection, and acute malnourishment. The Department of Public Health and Endemic Control is in charge of public health. 3.3 Health System of Luanda Province In Luanda Province, health and medical services are provided by public medical facilities from Level 1 to Level 3 (96 facilities), clinics in private companies, and private medical facilities. The public health system is shown in Figure 3-1. Level 1 Level 2 Level 3 National Hospital (general hospital included) General Hospital Specialist Hospital(Obstetrics)Provincial/District Hospital Health Center: High Function Type (function similar to a district hospital) Health Center: Special Type(Pediatric and Orthopedic) Health Center: General Type(a typical health center) Health Post Type II(examination available) Health Post Type I(examination unavailable, clinical examination only) Clinic(examination only) Vaccination Post(Postos de Vacinas) Community Community Health Agent Figure 3-1 Public Health System of Luanda Province 3.4 Public Health Finance in Luanda Province The current expenditure of the Provincial Health Department is shown in Table 3-1. There are three expense items, personnel costs(salary), pharmaceutical costs, costs of equipment and goods of health facilities. Divided the total expenditure of community health in Luanda (96,356,878Kz) by the population of 7,395,976, the expenditure per person is 13 Kz (=0.17 USD). Expenditure of the community health agents are not included in the personnel costs of the current expenditure, and therefore it is assumed that there is a separate budget allocated for the community health agent program. In this study, however, it was impossible to obtain related data due to various constraints. 5
Table 3-1 Current Expenditure for Community Health of Luanda Province 2008 12 (1 USD = 75.16 Kz : Jan, 2009) Item Annual Expenditure (Kz) % Personnel Costs(Salary) 49,856,053 52% Pharmaceutical Costs 33,190,825 34% Costs of Equipment and Goods of Health Facilities 13,310,000 14% Total 96,356,878 100% 3.5 Situation of Public Health and Medical Services According to the Provincial Health Department, the survey conducted in 2008 revealed the rates of health facility/staff against the population were 1 public medical facility per 81,274 residents, 1 doctor per 21,882 residents, 1 nurse (tecnico) per 1,298 residents, showing a lack of health facilities and personnel. Furthermore, the number of beds available at the time of delivery was 0.3 per 1,000 women of reproductive age (15-45 years old), general inpatient beds were 0.15 per 1,000 people, which indicates that delivery and inpatient holding capacity is insufficient. 13 In principle, medical services at public health facilities are free of charge. However, depending on the type of service clients received, there are some cases that a medical personnel or a facility ask a patient to pay. In order to deal with the growing population in Luanda Province, the Provincial Health Department is challenged with the issues of strengthening of the health system, and improving medical facilities and services. In order to collect the basic data necessary for planning til the year 2018, the Provincial Health Department conduted a survey on public health and medical facilities, and clarified the precise number of facilities and classification, followed by revisions. Name of District Table 3-2 Public Health and Medical Facilities in Luanda Province(July 2008) 14 General Hospital District Hospital/ Health Center (High Funtion Type) Health Center Health Center (Special Type) (General Type) Health Post (Type I II) Ingombota 0 2 1 1 0 4 Ingombota 0 2 1 2 3 8 Rangel 0 1 0 1 3 5 Sambizanga 0 1 0 4 0 5 Cazenga 1 5 0 3 1 10 Kilamba Kiaxe 2 3 2 4 5 16 Samba 0 1 0 2 4 7 Cacuaco 0 2 0 3 13 18 Viana 0 2 0 4 12 18 Total 3 19 4 24 41 91 (Source:Gabinete de Estudos, Planeamento e Estatística:Plano de Desenvolvimento Sanitário da Provincia de Luanda 2008-2018) Total 12 Gabinete de Estudos, Planeamento e Estatística: Plano de Desenvolvimento Sanitário da Provincia de Luanda 13 Gabinete de Estudos, Planeamento e Estatística:Plano de Desenvolvimento Sanitário da Provincia de Luanda 2008-2018) 14 Gabinete de Estudos, Planeamento e Estatística:Plano de Desenvolvimento Sanitário da Provincia de Luanda 2008-2018) 6
According to Director of the Luanda Province Department of Health, in order to overcome the problem of lack of medical doctors, Luanda Province has invited doctors from Cuba since 2006 and now around 60 doctors are working at the health center of each district. However, there are not yet enough doctors to cover all the health centers. Regarding the Community Health Agent Program, there is a plan to expand the program to all areas of Luanda province. According to the interview with Director of the Luanda Province Department of Health, there is plan to include prevention education and information dessemination regarding dental hygiene and chronic diseases (such as hypertension and diabetes) into the activities of the community health agents. The study team visited three public health facilities: two in Viana District (a health post type II and a health center general type) and one in Cacuaco District (a Health Center High Function Type). At health centers, out-patient medical care, examination, vaccination, hospitalization (especially children), and facilities for delivery are available. However, since there is no operation room, it is not possible to perform a Caesarean section. It is usually difficult for transport emergency cases, because of bad road conditions and congestion. There is no emergency system and it is a problem if a medical facility does not have an ambulance. The emergency referral system between health post/health center and the secondary level hospitals is not in place, and reportedly there are some cases where people passed away while being transfered. 3.6 The Present State of Private/Informal Health Services Private health facilities include clinics in private companies, and facilities established by private organizations such as church. The services offered by them are charged. However, because the private facilities are better than the public ones in terms of infrastructure and personnel, as well as waiting time, many people use their services. At the community level, there are quite a few people use the informal health services such as treatment by a witch or a traditional healer, and delivery assisted by a Traditional Birth Attendant (TBA), all of which are not authenticated by the Provincial and District Health Department. 3.7 Stakeholders in the Health Sector Luanda Province is divided into administrative divisions(municipio), comuna, bairro, and sector in the descending order. There are local leaders, president in bairro and coordinator in sector. They work on a voluntary basis without payment. At the time of health campaigns, they mobilize students and youth as volunteers. and are also is in charge of selecting Community Health Agents. Through these activities the local leaders help the District Health Department, and when there is a health-related problem in community, they report it to the District Health Department. Regarding the community, in some cases there was a psychological distance between the public health facility and the residents. Some residents carried a feeling of distrust to the government including the public health sector or did not know what kind of services was available at health centers and health posts. However, through the work of community health agents, the role of the public sector became known to many people and the feeling of distrust began to lessen. 7
On the other hand, because treatment given by private facilities is very expensive, expectations for the public facilities were quite high. In the Cacuaco health center, there were so many patients that the corridors were packed with people. In Viana District, the majority of people interviewed wished to have a new hospital or a health center in the area. 3.7 Approaches of Development Partners 1) UNICEF Through the Programme for Acceleration of Child Survival and Development for the Achievement of the Health-Related Millennium Development Goals 2007-2009(Phase 2)UNICEF is supporting in a total of 5 provinces and 16 district which includes Luanda Province. In this program, UNICEF is supporting not only public health and medical facilities, but also local NGOs and churches. From 2007, UNICEF is providing technical cooperation for the community health agent program. (Details in Chapter 4) 2) UNDP Under the funding of Global Fund for Malaria, Tuberculosis and HIV/AIDS, UNDP is undertaking control of malaria, Tuberculosis, and HIV/AIDS, and capacity building of the Ministry of Health, mainly targeting Luanda Province. 3) USAID USAID allocates 87% of its budget to the health sector. The main areas of cooperation are 1) Basic Health Service Program (Angola Essential Health Service Program: SES), 2) malaria control, 3) HIV/AIDS. There is no program specializing in community health, however the concept of civil society strengthening is incorporated in all the programs areas and trying to revitalize community organizations. 4) EC Until 2006, EC s health sector cooperation mainly focused on strengthening of NGO capacity in the rural areas and emergency relief such as rehabilitations of facilities. At the same time, EC has been involved in capacity development of the Ministry of Health (especially human resource development) and in formulation of health policies (including the national essential drug and blood transfusion). 5) NGO Major NGO implementing health and hygiene-related programs include the four organizations below. Medicos del Mundo(MDM):Reproductive Health and community health Rede Esperança:Infectious diseases, hygiyne, HIV/AIDS 8
APACP(Associação de Profissionais e Amigos de Combate à Pobreza):Sanitation and living environments Africare: Polio eradication, water and sanitation 9
4. Community Health Agent Program 4.1 Summary of Community Health Agent Program In February 2007, with the purpose of improving the health status of community people, Angola launched the Community Health Agent Program (Community Health Agent Program/Programa de Agentes Comunitários de Saúde: PACS) in 70 districts out of the total 164 districts in the country. The 70 districts are distributed across the country and make up 70% of the total population. In Luanda Province, out of the total 9 districts, 6 districts were selected as the program target areas on the conditions of absence of a hospital and bad health status. In each district, the most populous comuna was selected. The three districts where the program has not yet started have a hospital and the health status of residents is relatively good compared to others. Each target area carries out the Community Health Agent Program and gradually follows own schedule. 4.2 The Situation of Community Health Agent Program in Luanda Province 4.2.1 Target Areas In Luanda Province, the Community Health Agent Program has been launched in the following divisions or in parts of the divisions of the 6 districts. Table 4-1 Districts/Divisions of the Community Health Agent Program in Luanda Province District Division Cazenga Cazenga 18 Zone Cacuaco Kicolo Sambizanga Ngola Kilange Viana Km9 Km12 Kilamba Kiaxe Avemos de Voltar Samba Benfica 4.2.2 Objective of the Community Health Agent Program The objective of the Community Health Agent Program is to provide the following services to the community in order to improve the health status of the people. 1) Provision of continuous health education to the community 2) Strengthening the relationship between health center staff and community 4.2.3 The Selection of the Community Health Agent Community Health Agents are selected according to the following process and criteria. 1) One Community Health Agent is assigned to 100 households.(in thinly populated areas, one Community Health Agent Program is assigned to 20-30 households.) 2) The selection criteria are Men and women over 18 years old who reside in the community, literacy (completion of primary school), and motivation. 3) With the help of the community leader, personality and behavior observation of a candidate is conducted. 10
4.2.4 Profile of the Community Health Agents As of July 1, 2008, 1,800 community health agents have been trained. Women have more opportunities to earn income as a food seller, and therefore most of the community health agents are men. Community Health Agent does not work full time, and it is possible to adjust working hours for his/her convenience, some have another job. Common professions of community health agents are students, teachers, and retired nurses. Many of them have experience of serving as NGO health volunteers called an activist. 4.2.5 Community Health Agent Program Management System The implementing organization of the Community Health Agent Program is the Public Health Division of the Provincial Health Department. In Luanda Province there is one community health agent per 100 households, and one supervisor per 20-25 community health agents. The supervisor is selected from community health agents and is in charge of both supervision and tasks of a community health agent. Inside the health administration, coordinators who are selected from district staff is in charge of management and supervision of community health agents at the district level. At the province level, under the supervision of the provincial coordinator responsible for the whole program, a coordinator manages and supervises a district he/she is in charge. 4.2.6 Training of the Community Health Agents Community Health Agents receive training for 30-35 days, after they are assigned to their position. The Introductory training consists of theories and skills. As the first step, Provincial Health Department (DPS), UNICEF, 2 Brazilian doctors who have been invited to work in Angola, professors of Medical University, and a team of provincial doctors conduct Training of Trainers (TOT) to coordinators, and then the coordinators conduct training to the community health agents. 4.2.7 The Role of Community Health Agents Working for 2 hours per day/ 8 hours per week, mainly through home-visits (at least once a month), Community Health Agents conduct the following tasks: Registration and monitoring of the community households Recording of the number of pregnant women and children under five years old Promotion of antenatal checks and use of a mosquito net to pregnant women Measurement of body weight, vaccination, nutrition intake, parasite control, vitamin A supplement for children under 5 years old Water management (distribution of chlorine), use of toilet, teaching of individual and group sanitation management for all household members Referral of patients Reporting of notifiable diseases such as measles and polio Participation in health campaigns(vaccination, HIV voluntary testing, etc) 11
4.2.8 Working conditions of Community Health Agents Community health agent is not a volunteer work, but a paid job. The Luanda provincial government bears all the expenses for the monthly salaries as below. In addition, as a physical incentive, the community health agents receive bicycle, boots, raincoat and so on from UNICEF. In Vienna District distributes them a hat and a vest as a uniform. Community health agent 4,000 kwanza(around 53 dollars) Supervisor 6,000 kwanza(around 80dollars) Coordinator 8,000 kwanza(around 107dollars) 4.2.9 Community Health Agents The Luanda Provincial Health Department adopted the reporting system of Community Health Agent Program in July 2008. Under this system, every month, the community health agents fill in a report form with information such as the number of households he/she is in charge of, number of pregnant women, neonatal infants, and infants and the number of deaths, number of clients and coverage rate of antenatal checks and vaccination, and then hand in the report to the supervisor. Then the supervisor submits the report to the coordinator at district level. The coordinator compiles all the data of the district and submits it to the provincial coordinator. The supervisor and the Community Health Agents hold regular meetings and the activities. At times the supervisor accompanies Community Health Agent s home visits and the community health agents attend a monthly meeting with the district coordinators. 4.2.10 Future Plans for Community Health Agents in Luanda Province The Provincial Health Department is planning to train 3,000 Community Health Agents in 2009. 4.3 Issues for Community Health Agents Program One year has passed since the launch of the community health agent program and the area expansion and full-scale implementation are scheduled. Provided the inevitable drastic increase of community health agents, in order to ensure the program s good performance, it is assumed that the following issues require consideration. Training of the Community Health Agents Management and support of the Community Health Agents Increase of number and training of coordinators for the speeding up of the training of Community Health Agents Development of working manual for Community Health Agents Improvement of the quality of health education for community and communication by the Community Health Agents Strategy for health education, planning (message, communication method, development of education materials etc.) Continuous budget allocation 12
5. The Possibility of Japanese Cooperation 5.1 Successful Cases of Participatory Community Health and its Factors A factor analysis was conducted on successful cases of Participatory Community Health projects, including JICA Zambia Lusaka District Primary Health Care Project (Phase 2), and three projects implemented by HANDS Project for Strengthening Community Health Services in Amazon, Brazil (Grassroots Technical Cooperation Project), Project for Improving Health Services with a focus on Safe Motherhood in Western Kenya (Proposed-Type Technical Cooperation Project: PROTECO), and Project for Improvement of District Health Management Capacity in South Sulawesi Province in the Republic of Indonesia 15 (Technical Cooperation Project). Factors which contributed to building the voluntary and sustainable participatory community health system were analized. As a result, three major factors were identified: 1)a two-way approach towards service providers and recipients (community), 2) fostering of community ownership and motivation, and 3) utilization of community human resource to bridge the community and the health facility. 5.2 Incorporation of the Successful Cases of Community to the Angola Case The three factors identified contributed to the establishment of the voluntary and sustainable participatory community health system were examined against the capacity of the health administration (Ministry of Health, Province, and District Health Department) and the applicability of the factors is shown in Table 5-2. The community health agents corresponds to the community human resource to bridge the community and the health facility and through the activities of this proposed project, this factor becomes a key element in realizing the bottom-up approach from the community. With the expansion of the program, there is a possibility extending the program to community participation in the health sector and voluntary activities aiming for health improvements. In order to make this happen, it is necessary for the Ministry of Health to lay out a policy for community participation and actively promote it. 15 Joint implementation with International Development Center of Japan (IDCJ). 13
Table 5-2 Capacity Development Elements of the Community Health Organizations Capacity Factor 1. A two-way approach of bottom-up and top-down 2. Fostering of community ownership and motivation of the community 3. Utilization of community human resource who is able to bridge the community and the health facility Human Resource Possibility of collecting the needs of the community by the community health agents There is none at the moment, but there is a possibility through the activities of community health agents. Community health agents play a role of bridging the community and the health center Other Resource Increase in the budget of the health sector Improvement of health facilities both in quality and quantity Budget allocation for the community health agent There is none at the moment Increase in the budget of the health sector Improvement of health facilities both in quality and quantity Budget allocation for the community health agents Management Internal environment In principle, it is top-down, however, there is a possibility of change as a result of the launch of the program There is a commitment towards community health agent programs None at the moment None at the moment Establishment of the supporting system establishment of the community health agent remains an issue for the future. There is a commitment towards community health agent program. 5.3 Proposal of a Community Health Project The Community Health Agent Program of Angola is efficient for realizing two of the three factors of the successful community health as mentioned in the previous section, and the two factors have the possibility of leading to the third factor. Therefore, it is considered appropriate to promote community health putting the establishment of the community health agent program as the core element. However, in order to make a comprehensive improvement of the community health situation, health promotion to the community alone is not enough. It becomes necessary to improve the primary health and medical services. Keeping this precondition in mind, the two projects proposed below are based on a community health improvement approach. 5.3.1 Approach 1 : Supporting the Operation of Community Health Agent Program In Luanda Province, the Community Health Agent Program (PACS) will be fully in progress. However, in order to implement the program effectively, there remains various problems in the area of operation and management. Therefore, we would like to propose an approach which will support the operation of the Community Health Agent Program in the Luanda Province. In this approach, we focus on strengthening the Community Health Agent Program (PACS). This approach aims to strengthen management of the four types of stakeholders: community health agent, District Health Department to manage the community health agents, public health and medical facilities (health center and health post), and residents. Consequently, the foundation which facilitates cooperation among the stakeholders is laid. The specific targets and contents of the cooperation are shown in the Table 5-3. Based on this, the details are decided according to the budget. 14
Table 5-3 Approach 1: Supporting the Operation of Community Health Agent Program Target Activities Details Ministry of Health Ministry of Health, Provincial /District Health Department (South-south cooperation with Brazil) Provincial/District Health Department Health Center Health Post Community Health Agents Community Community Health Agents Strengthening of Operations and Management of the Community Health Agents Training in Brazil for the coordinators of community health agent program, invitation of lecturers from Brazil. Training in Brazil Operational support to the Community Health Agent Program Capacity building of community health agents Health and sanitation improvement by the community Promotion of health education Planning of health education on Community Health/Design of methods Development and extension of health education materials on community health Development and extension of a community participatory method. Development of in-service education system for community health agents. Development of educational material for in-service training for community health agents Development of a system for monitoring and evaluation of the community health agent program Operation of community health agent program Manuals for community health agents Methods for health education/materials Selection Process of Community Health Agents Monitoring and Evaluation of Community Health Agents Data analysis, management, usage of community health agent reports Continuous education and support to the community health agents Cooperation to the district health office Information sharing with the community health agents Capacity building of community health agents communication health education data collection, reporting supporting health and sanitation improvement activities of community people Health/sanitation improvement activities by the community Health and sanitation behavior Living environments Community Environments Planning of health education Message, media design Development of education materials Awareness raising events To the District Health Department(Provincial Health Department partially included)support is provided for management capacity development to enable functions the community health agent system. The areas covered are the monitoring and evaluation of the performance of community health agents, analysis, management, and usage of reported data, and the continuous support and training of 15
the community health agents. The utilization of the JICA Third Country Training Program in Brazil which is experienced with its community health agent system is assumed to be effective for the management capacity development. As the health service providers, health centers and health posts should be encouraged to cooperate with the District Health Department in sharing information with the community health agents as well as in supporting them. The capacity development and the continuous motivation of community health agents hold the key to the success of the program. The areas of capacity development which need strengthening are: communication and health education skills, data gathering/processing/ recording, and supporting the community health and sanitation improvement activities. Also, in order to maintain the motivation, a democratic personnel selection process, regularly held trainings, careful supervision, provision of awareness goods, and information sharing and cooperation among the community health agents are thought to be effective. For the improvement in the quality of health education by the community health agents, communication methods, health education planning (message, media), and the development of educational materials are important. For health education, it shall be effective to utilize the Brazilian community health agents experience and their materials, or adjust them to be suitable for the Angolan context. At the same time, inviting lecturers from Brazil for the training of Angolan lecturers and then training community health agents in a cascade manner is also regarded as an effective method. Regarding the fostering of ownership of the community, it is important for the community health agents to build a system to support planning and implementation of the planned activities by the people. As shown in the experiences from the past projects, the guarantee of the right of people s self decision based upon the supporting system highly promotes the people s motivation to make a change. As a result of the encouragement of the community by the community health agents, it is expected that the people take an action for their own health improvement (for example, processing of the garbage in the community). With regards to the target districts, there are two options: either choosing from the six districts where the community health agent program has already begun, or from the three districts where the program has not yet been launched. Regarding the Community Health Agent Program Operational Support pilot project, given that UNICEF assistance is difficult to reach provinces other than Luanda, it is worthwhile to consider selecting a province with the great needs from the western provinces where the health condition is not acceptable(lunda Norte, Lunda Sul, Uige, Zaire, Moxico) 16. 16 From the interview to the Ministry of Health Public Health Department Officer 16
5.3.2 Approach 2 : Improvement of Services of Primary Health and Medical Facilities As mentioned in 5.3.1, Approach 1 Supporting the Operation of Community Health Agent Program focuses on the disease prevention and health service access of the community through attitude and behavior change of the people as well as through establishment of the relationship between the community and public health and medical facilities. In order to achieve this, service improvement is necessary at the primary health and medical facilities (health centers and health posts) where the people referred to by the community health agents have access. Therefore, we would like to propose another approach called Improvement of Services of Primary Health and Medical Facilities. In this approach, it is effective to focus on maternal and child health which is particularly in a critical condition. Areas of intervention include malaria control, diarrhea and acute respiratory infection control, antenatal check promotion of facility delivery, vaccination, improvement of nutrition intake and growth monitoring targeting the expected mothers and children under 5 years old. A user-friendly service provision needs to be pursued, by the community health agents conveying the people s needs to the health facilities, and through the community participation in the management of the health facilities. Regarding this approach, the targets and contents of the cooperation are shown in Table 5-4 below. Based on these, the details of the project are decided according to conditions such as the project budget. Table 5-4 Approach 2: Improvement of Services of Primary Health and Medical Facilities Target Activities Details District Health Office Health Center/ Health Post Management Support Service Improvement Community Participatory Management Work planning Activity Procurement, management and distribution of goods (drugs, mosquito nets etc.), Monitoring and evaluation Strengthening of maternal and child health service Malaria, diarrhea, acute respiratory infection control Antenatal check Facility delivery Vaccination Nutrition Intake Growth monitoring Management support(planning, monitoring) Feedback of people s voice by the community health agent Participation of community representatives in the facility management 17
1. Summary of the Project 1.1 Background and Purpose of the Project In April 2002, Angola put an end to the conflict which had continued for 27 years and is faced with various social and economical problems caused by the calamity of war. The health indicators of Angola compared with the other countries in Sub-Saharan Africa are quite severe, and from the standpoint of human security, it is in an unacceptable situation. On the basis of National Health Sector Five Year Plan (2005-2009) laid down in 2005, the government of Angola is tackling the maintenance of medical and health institutions, enhancement of maternal and child health services, infectious diseases control, and training of personnel in the health sector. As a result of the Project Formulation Study of the Health Sector conducted in March 2007, JICA established the policy to support health equity instead of advanced medical servicesfrom the viewpoint of human security. JICA decided to make improvements in the health and medical services of Luanda province through the top-down approach putting Joshina Machel Hospital, which has shown actual performance in Grant Aid Cooperation at the focal point. In October the same year, technical cooperation Project for Improvement of Capacity of the Joshina Machel Hospital was launched and the training of the health personnel has begun. On the other hand, in order to improve the health status of the populations, community based approach is also important. This study aims at proposing community health programs to strengthen the health sector of Luanda Province. These community programs are expected to complement the top down approach in order to improve the health sector of the Luanda province. The study is conducted on the basis of collection and analysis of information on community health in the province and through discussions with concerned parties such as the national and local governments of Angola, development partners, NGOs, and communities. 1.2 Study Team Members Leader/Community Health Administration:Akiko Hayashi(Non Profit Organization HANDS) Community Health Activities: Akiko Matsumoto (Non Profit Organization HANDS) Interpreter: Kyoko Tamai(Japan International Cooperation Center) 1.3 Work Schedule The field work of the project formulation study was conducted during the period of Nov. 19th - Dec 17th, 2008. 1
5.4 Points to be Considered in Planning and Operation of the Community Health Program 5.4.1 The Latest Information Related to the Angolan Policy and System In Angola, the president election is scheduled in 2009, and the provincial election in 2010. Also, there is a plan to further expand decentralization. In accordance with these movements, the health and medical policy is expected to change. So as to plan cooperation in the area of community health, it is important to know about the latest trend regarding the health and medical administration and decentralization. 5.4.2 Demarcation with UNICEF in Supporting the Community Health Agents Program In supporting the community health agents program, UNICEF has undertaken establishing the system of the program, and therefore, Japanese government needs to discuss with the government of Angola and UNICEF in articulating demarcation to support the program. It is necessary to design monitoring, data management, and health education in a manner to maintain consistent with the reporting and training systems of the Community Health Agents that have been already introduced with cooperation of UNICEF. 5.4.3 Issues Relating to the Activities of Community Health Cooperation in Luanda Province There are many problems associated with implementation of community health activities in Luanda Province. The most significant one is the high prices. UN organizations apply the same standards of accommodation and daily allowance in large cities in developed countries such as New York. There is also a problem of constant congestion. The community carries a problem which makes it difficult to provide cooperation. In areas with relatively high living standards, the people s demands tend to be costly (water pipeline and electricity lines). On the other hand, in the slum areas where the population is growing continuously, the living environment and infrastructure (toilet and water system) remain in a poor condition. Unless they are improved, it is difficult to enhance the health status of the community and requires huge investment. The issues raised above in consideration, it is extremely difficult to implement a grass-roots type community health project with a limited budget in Luanda Province. There is another problem that it requires great efforts to coordinate many development partners and NGOs already working in Luanda Province. 5.4.4 The Possibility of Community Health Cooperation in areas besides Luanda Province As mentioned above, it is expected that the cooperation in the field of community health in Luanda Province is faced with a variety of difficulties. Whereas in rural areas other than Luanda Province, despite the harsh health and medical situations compared to the capitol city, there are areas where development partners have not yet reached, and the needs for assistance is relatively high. It deserves considering supporting rural areas after studying the situations of provinces other than Luanda.. 18