MALAWI, ZAMBIA, AND THE UNITED STATES: CREATING SYNERGY AND PUBLIC HEALTH CAPACITY BUIDLING TO ADDRESS HEALTH AND SOCIAL PROBLEMS Kerry J. Redican Virginia Tech, USA [email protected] Patricia Kelly Virginia Tech, USA [email protected] Kaja M. Abbas Virginia Tech, USA [email protected] Francois Elvinger Virginia Tech, USA [email protected] Madison Gates Virginia Tech, USA [email protected] Kathy Hosig Virginia Tech, USA [email protected] Susan West Marmagas Virginia Tech, USA [email protected] Sheila Carter-Tod Virginia Tech, USA [email protected] ABSTRACT Malawi and Zambia share not only a common border but also many of the same health problems. Both countries have adopted the Millennium Development Goals (MDGs) of the United Nations as targets for development including reducing the maternal mortality ratio; reducing the mortality rate among children under the age of five years; improving hygiene and access to safe water, and improving nutrition. In 2010–2012, the Department of Population Health Science and the School of Education at Virginia Tech, through a Department of State (Bureau of Educational and Cultural Affairs) grant partnered with NGOs in Malawi and Zambia and sponsored twenty eight (n=28) health professionals (Global Health Fellows) from both countries to participate in a four week exchange program. The Fellows spent three weeks at Virginia Tech and one week in Washington, DC. The purpose of this project was twofold: first, to engage professionals at the grassroots level who are actively involved in health care for marginalized populations in Malawi and Zambia, and second, to

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develop synergy among community health and media professionals from Malawi, Zambia, and the United States that focused on health strategies to educate women and children in reproductive health, nutrition, hygiene, and sanitation. While in the United States participants learned American public health best practices used to address similar health problems. In addition they spent one week working with a public health professional in an immersion experience. This culminated in 28 different action plans that were implemented when they returned to their country. Action plans included addressing issues associated with women’s health, community capacity, reducing the spread of HIV, and health literacy. An American team of public health professionals visited each participant 4 months after implementation of their action plan. Partnering with in country NGOs to select Global Health Fellows, learning American public health best practices, immersion experiences, action plans and follow-up were all successfully planned and implemented. This project represents a successful international partnership that led to important sustainable projects with the potential to impact public health capacity. Keywords: Best Practices, Global Health Fellows, International Partnerships, Millennium Development Goals, Public Health Capacity Building 1 INTRODUCTION Malawi and Zambia have many things in common. They have a common border, and they once were one country under the Federation of Rhodesia and Nyasaland from 1953 to 1963. The people near their borders share cultural norms and language. During the colonial period under the British rule, the development strategies were very similar, with the exception of the development of industry: in Zambia, the colonial power emphasized mining while in Malawi farming was the mainstay. Both countries have similar challenges regarding development. The majority of their people live in rural areas. Both countries face high levels of poverty with more than sixty percent of the population living on less than $2 per day (World Vision, 2010). In Zambia, one in five children is underweight and 46% of the population is undernourished. In Malawi, 53% of the people live below the poverty threshold, and 75% of secondary school aged children are either working or staying at home to care for their siblings instead of going to school. A chronic food crisis is a major cause of malnutrition and has increased the risk of diseases. Both countries have adopted the Millennium Development Goals (MDGs) of the United Nations and targets for development. These goals are an embodiment of wider human concerns and issues which are intended to provide “people centered” measures of human progress. These goals are also intended to encourage and challenge national initiatives and strategies geared towards alleviating poverty and improving living standards of the “poorest of the poor” across many nations. At the United Nations forum in New York, heads of state and governments decided to focus on eight goals that touch upon the following: available income and food; education; gender equality; child mortality; maternal health; HIV/AIDS and major diseases; environmental sustainability; and global partnership (UNDP/Malawi, 2009). Both countries are committed to achieving the MDGs but have been constrained by insufficient resources and limited public health capacity. However, with regard to the MDGs relating to health, both Malawi and Zambia have been working on the following priorities: a) Reducing the maternal mortality ratio; b) Reducing the mortality rate among children under the age of five years; c) Improving hygiene and access to safe water; and d) Improving nutrition.

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Many communities, particularly in rural areas, do not have easy access to public health information because of the severe shortage of professional staff in the health sectors of both countries as summarized in table 1. Table 1: Statistics of physicians and nurses (World Health Organization, 2010) Country United Kingdom United States Malawi Zambia

Number of physicians per 10,000 people 23 26 <1 1

Number of nurses per 10,000 people 128 94 6 7

According to World Health Organization, the recommended minimum number of health care professionals (physicians, nurses and mid-wives) required to provide key health care services that can meet the MDGs is 23 per population of 10,000. With an average density of seven professionals to 10,000 people, Malawi and Zambia are, therefore, far below the optimum number of health professionals. This human resource constraint has a serious impact on the two countries’ capacities to implement effective and efficient strategies for reducing child mortality and improving maternal health in line with the MDGs, through for example, educating women in reproductive health, nutrition, hygiene and sanitation. Faced with the overwhelming workloads and other constraints such as poor communication and transport infrastructure, limited health kits and inadequate supplies of electricity and safe water the health and social problems in Malawi and Zambia are exacerbated. The purpose of this project was twofold: first, to engage professionals at the grassroots level who are actively involved in health care for marginalized populations in Malawi and Zambia, and second to develop synergy among community health and media professionals from Malawi , Zambia, and the United States that focused on health strategies to educate women and children in reproductive health, nutrition, hygiene, and sanitation In February, 2010, funding was received from the United States Department of State (Bureau of Educational and Cultural Affairs) to develop an educational experience for professionals who are actively involved in health care for marginalized populations at the grassroots level such as public health officials, midwives, community leaders, activists, educators, NGO workers, and media specialists to: 1. Evaluate community health policies, practices, and processes focused on reproductive health, nutrition, hygiene and sanitation and identify those practices, policies, and process appropriate for their respective communities; 2. Develop sound, comprehensive community health strategies focused on improving health and wellness of women and children in disadvantaged urban and rural communities; 3. Gain an understanding of community health strategies, policies, practices, and processes that address the health and wellness of women and children in disadvantaged urban and rural communities in Zambia and Malawi.

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The impact of this project was the creation of international networking among professionals participating in the cultural exchange visited. Professionals from Malawi, Zambia, and the US, through this project, developed sustainable networks that facilitated exchange of challenges and best practices in the provision of public health services to the underserved communities. Accomplishing the objectives of this project required partnering with in country NGOs, recruiting health and media professions in Malawi and Zambia, developing a four week educational experience based in the United States, and evaluating the project. Figure 1 highlights the relationship of the major activities involved in this program. 2

METHODS

2.1 Global Partnerships The Department of Population Health Sciences and the School of Education at Virginia Tech partnered with the Malawi Health Equity Network in Lilongwe, Malawi and World Vision in Lusaka, Zambia. These NGOs assisted both in the recruitment of health and media professionals from Zambia and Malawi and coordinated experiences for the US teams follow up visits to projects in Zambia and Malawi.

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Figure 1: Activites Involved in the Global Exchange 2.2 Recruiting Zambian and Malawian Health Professionals Through a competitive process, 28 Zambians and Malawians from the health, education, and journalism sectors were selected for US exchanges (seven from each country in year one and year two). They were referred to as Global Health Fellows. The Malawi Health Equity Network and World Vision Zambia were instrumental in identifying in country applicants for

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the program and conducting several rounds of interviews to yield a smaller group of candidates. Given that at least a portion of the projects centered on using radio and print media to disseminate information, the messages had the potential to reach millions of people. Participants provided a project report and project sites were evaluated by both the project directors and site visit teams. 2.3 Program Logistics A program such as this one has many moving parts. The US Exchange involved seminars, discussions, on-site visits, internships, home stays, and cultural experiences. Each participant developed a project designed to increase the health literacy of women and children in urban and rural settings in Zambia and Malawi. After the interviewing and recruitment of health professionals, project directors worked with the United States Embassies in Malawi and Zambia to get immigration approval for participants. For the most part this went smoothly with much Embassy cooperation. Round trip airline flights and hotel accommodations were confirmed. American families who would host the participant for the third week were identified and recruited. The intention was to provide an opportunity for the participant to live with an American family and see how the family functions on a day-to-day basis. Project directors also needed to critically reviewed the participants’ background and interests so that a matching education program and immersion experience could be developed. Developing the educational and immersion experience was done in cooperation with faculty from Virginia Tech and community based health professionals. Draft copies of the program were shared with participants two months before their arrival to procure feedback to update and match their needs and interests with program content. 2.4

Educational Experience

Weeks 1 and 2: Seminars at Virginia Tech Topics Environmental Health Epidemiology Health Education/Promotion Health Communication Health Care Systems Public Health Programming Public Health Program Evaluation Grant Writing Program Sustainability Week 3 – Immersion Experience 40 Hour Placement (immersion experience) in New River Valley Health District Free Clinic of the New River Valley Child Health Investment Partnership

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Community Services Boards Roanoke County Prevention Council Television and Radio Stations Week 4 – Washington, D.C. United States Department of State Conference Networking with Respective Embassies Action Plans Each participant developed an action plan for a health problem they wanted to address, mostly work related. Action plans were developed in consultation with content specialists from Weeks 1 and 2, the immersion experience preceptor, and faculty from the Department of Population Health Sciences. The format of the action plan consisted of a documentation of the health problem/issue, measurable objectives, intervention, resources needed to implement the intervention, evaluation plan and sustainability plan. Each participant developed a budget to implement their action plan and after the budget review they received $300 to implement the plan after budget review. Examples of action plans can be seen in Table 2 Table 2: Examples of Action Plans Action Plan Title

Country

Brief Description

Estimated Impact

Income Generating Activities by HIV Positive Mothers to Improve Nutrition

Zambia

Ten village groups of women and orphans planted gardens where none had existed before to provide for better nutrition and market for money

300 (10 women per village group and 30 orphans per group)

Health Literacy Programs in 40 Churches

Zambia

Volunteers trained in 40 churches who then serve as group facilitators to communicate messages on reproductive health

1,280 (80 volunteers trained; 3 workshops per church and average attendance of 20)

Community-Based Food Supplement Sustainability Program

Malawi

Building a goat house and purchasing goats to provide nourishment for children under 5.

100 children under 5 are receiving daily milk

Contraceptive Clinic

Malawi

Health communication messages focused on contraception

3,000 women

Promoting Behavior Change for Better Nutrition Using Radio

Malawi

Radio messages focused on health behaviors

10,000 Malawians

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Primary School Sanitation Project

Zambia

Training and sensitization on hygiene through skits and discussion including hand washing techniques

1,000 youth

Youth Sensitization on Malaria through Soccer Tournaments

Zambia

Young men are using malaria nets to fish with. To garner their support and understanding of the problem, soccer tournaments were organized which drew them to hear the messages and participate

100 young men and 10,000 spectators

Community Health Scorecard

Malawi

Comprehensive set of needs assessment activities to determine factors related to health status, community engagement, resources and responsiveness. Strategies are then developed to address the findings

500 villagers

Community Bicycle Ambulance

Malawi

Provides transport to health care (15 km away from village) for pregnant women and critically ill children. Access encourages women to deliver their baby in clinics where they can be HIV tested and treated.

3,000 villagers

Improving OVC Households Resilience Through Economic Strengthening in Lusaka

Zambia

Empowering village women who have been impacted by HIV/AIDS to economically strengthen their community through the building of a goat shelter and selling goat milk

5 village women and 25 children

2.5 Follow up Visits Four months after the Global Health Fellows returned home two teams of American college faculty and medical professionals, most of whom had been involved in the educational program visited each project in Malawi and Zambia. Over a two week period one team visited Malawi and one team visited Zambia. Each team was prepared to both assist the Global Health Fellow with project related issues and evaluate the implementation and impact. 2.6 Project Evaluation Each project was evaluated based on the evaluation framework in the individual action plan. In addition, the entire program was evaluated by each participant. In all cases the Global Health Fellows were successful in achieving the objectives in their action plans and the projects were felt to be sustainable.

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3 PROGRAM EVALUATION Participants were provided an opportunity to evaluate the overall program. An open ended survey was created and distributed toward the end of Week 4. Results of the evaluation were overwhelmingly positive. Examples of comments from participants concerning what they thought the US would be and what they found from their experience included: Everything in America is big – large portions of food, sodas, cars I thought all white people were not good to black people, but see that’s not true People not being friendly, but I found out that people are very friendly I was surprised with the way people are concerned with life. Life is very fast as compared to Malawi, especially about time What surprised me? Non-profit fundraising; more Christians than I thought; Virginia Tech is a big university (thought it would be small); thought people would be too reserved to speak but they are cheerful; thought students would be wild (less concerned for each other) but found they were courteous and humorous. Unsafe, noisy, violent environment as portrayed in Hollywood movies, but we had a safe, violent free setup and no guards. American people could not have any interest in visitors from Malawi, but many showed interest and wanted to know more of Malawi. Thought there were no individuals who struggle to get health services, but I noted that there are people who are earning below federal poverty levels and cannot have insurance My general perception about Americans was that they were arrogant, forceful, unkind as opposed to what we saw. People are a lot more kind and warm hearted. 4 CONCLUSION The global exchange is a very meaningful way to promote learning about how to deal with health challenges involving social development. The learning was bi-directional. Malawian/Zambian professionals learned about United States public health best practices. More specifically, they (1) learned how community health efforts work together to protect, promote, and improve the health of the community; (2) observed medical technologies that improve patient/client health; (3) applied networking and skills transfer opportunities to build problem-based community health teams that will continue in country; and (4) observed colleagues’ attitudes towards “clients” and noting the impact of culture on the concept of care. United States professionals who participated in the classroom/community based educational experience and/or supervised the immersion experience: learned how public health professionals work with limited resources in situations of great demand for health services; how others work in environments characterized by limited or lack of communication infrastructure, inadequate health facilities, and poor supply of water and electricity; encourage

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networking and skills transfer opportunities; and observe colleagues’ attitudes towards “clients” and noting the impact of culture on the concept of care Exposure to different cultural settings helped US participants appreciate cultural diversity and enhance their openness to different colleagues and clients in today’s global village in which they practice their community health based professions. 5 1. 2. 3.

BIBLIOGRAPHY United Nations (UNDP). (2010). We Can End Poverty: 2015 Millennium Development Goals. Retrieved from http://www.un.org/millenniumgoals/. World Health Organization. (2010). World Health Statistics. Retrieved from http://www.who.int/gho/publications/world_health_statistics/en/index.html. World Vision. (2010). Zambia. Retrieved from http://www.worldvision.org/ourwork/international-work/zambia.

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