Working with Communities to Strengthen Their Resilience

This year’s food crisis in the Sahel, a thin strip of land below the Sahara, marks the third time this decade that the region has suffered a food shortage. Chad and Niger, the two countries that traditionally have food shortages, were joined this year by Mali, Mauritania, Burkina Faso, Senegal, Gambia, Cameroon and northern Nigeria. According to Save the Children and OxFam, over 18 million people in the Sahel are affected by hunger, and upwards of one million children are at risk of severe malnutrition.

The shortage did not come as a surprise; forecasting technology allows aid organizations to predict and plan for famines in advance. Therefore, the fact that famines happened in both 2005 and 2010 is rightfully frustrating to aid organizations, and leaves them wondering what can be done to better prevent or mitigate the cyclical food crises in the Sahel.

Map of countries and their food vulnerability

It is out of this frustration that aid agencies are recognizing the need to provide humanitarian aid with the intent of helping the long-term prospects of a community or state. The idea that programming should help people overcome shocks is referred to as resilience.

Resilience programming has been recognized as a step towards helping communities reduce their vulnerabilities so that when a major shock, such as a food crisis, political upheaval, or natural disaster occurs, there is less of an impact on the community. Or, if there is an impact, the community is able to return to their baseline level more quickly than without the aid programs. For example, negative coping skills, such as selling assets, would be less prevalent in a family that is resilient versus a family that is not. Moreover, systems should be resilient, meaning that a health center’s resources and staff should not be debilitated during a crisis. A resilient health center would be prepared for an increased patient load by training staff or having a supply chain that can react quickly to fluctuations in times of crisis.

As an intern at UNICEF’s West/Central Africa Regional Office this summer, I helped UNICEF gather information and plan for resilience-focused programs. Because the level of resilience of a community is determined by a number of factors, UNICEF is approaching resilience by looking at how their sectors are interacting and the best way to link their humanitarian aid with their development work.

In order to support this goal, I met with Section heads to gather information about how they see resilience fitting into their programs. I spoke with Country Offices to find out what they knew about the concept and whether or not the office had begun considering resilience as a framework when planning programs. I met with other UN agencies in order to learn about the coordinated approach to resilience, and met with other organizations to find out about their work. I helped create two monitoring tools to assess the progress towards implementation of resilience programming. Most important, I identified programming that was already promoting resilience, and identified areas where resilience-based programming could be increased in the Sahel.

Measuring the impact of resilience programming is difficult since so many factors can influence a person or community’s level of resilience, but I hope some operational research will take place to assess the impact of resilience programming. Research in both Palestine and Kenya by Alinovi et al. provides a comprehensive look at how to measure resilience to specific shocks. Columbia’s Sandro Galea used census data in the Gulf region to measure expected levels of resilience in communities impacted by Katrina.

Although the Sahel faces many challenges, I am hopeful about the future of the region. As a Peace Corps volunteer in Cameroon, I saw the daily challenges the population faces, but also saw populations that had inherent safety networks that provided resilience. Therefore, I believe that the combination of the natural evolution of existing safety nets coupled with smarter, more strategic aid from the international community will result in disasters that are less debilitating to communities in the Sahel.

Abigail Greenleaf
MPH Candidate, Mailman School of Public Health

Allowing female CHEWs to ride gender-friendly motorbikes in Jigawa State, Northern Nigeria: a critical step towards better maternal and child health

A gender-friendly motorbike

Nigeria has a disproportionate burden of global maternal mortality burden. About 342,900 women worldwide died from causes related to pregnancy and childbirth in 2008. Three out of five of these deaths occurred in sub-Saharan Africa, and Nigeria alone had an estimated 50,000 maternal deaths thus constituting one of the highest maternal mortality ratios (MMR) in the world. The situation is dire in northern Nigeria, where MMR is estimated to be significantly higher than the national average with recent estimates for the north exceeding 1,000 per, 100,000 live births compared to MMR estimates for the southern region below 300 per 100,000 live births.

Between 2007 and 2008, a Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN); and the Maternal, Newborn and Child Health (MNCH) Program targeting four states in northern Nigeria (Jigawa, Katsina, Yobe, and Zamfara), was established with co-funding from the Department for International Development of the United Kingdom and the Government of Norway in response to dire health status of women and children.

With the support of the operations research unit for PRRINN-MNCH Program, Jigawa state consequently decided to pilot an adaptation of the Navrongo Community-Based Health Planning Service strategy in Ghana to bring services to especially remote communities. This decision is convergent with the position of the Nigerian Association of Health Workers. The association has recognized the need to ensure that the health system focuses on deploying community health workers to provide basic health services in the communities.

A study was designed to explore the feasibility and outcome of community-based health extension workers (CHEWs) providing essential MNCH services within remote communities in Jigawa State. If the pilot in one Local Government Area in Jigawa showed the feasibility and effectiveness of this model, it can be expanded to other areas in Jigawa, if not to other states facing the same constraints on effective access and utilization of primary health care services. In this way, Jigawa will answer the call by the Nigerian Association of Health Workers, and be able to provide national leadership in systematically introducing innovations to the primary health care system and its effective and efficient use of available resources that appear to be key to making substantive progress towards the attainment of MDGs 4 and 5.

The pilot was conducted in the rural and remote communities of Kadawawa and Takalafiya, with a population of 20-25,000 people each. In each community the CHEWs sought to engage 5,000 women of childbearing age, with a focus on the 1,000 pregnant women and the 1,000 who had children under age 1.

Deploying a CHEW to work and live in a community is one of the interventions that have generally been known to work effectively in many settings. However, deploying such an intervention in a rural setting of Jigawa State and assessing the health system challenges and the capacity to respond to them was one of the key objectives of the pilot study.

While the study generally demonstrated an increase in the uptake of MNCH due to the availability of CHEWs, transport for making home visits especially during the rainy season was one of the challenges experienced during the study. A number of home visits could not be made due to the difficult terrain. Most of these problems were reported to the health administration and efforts to resolve these were made within the limits of the health administration.

Successes and challenges from the pilot study were shared with stakeholders in order to plan effectively for the scale-up. One critical action was the support of the operations research team for the study which made intensive advocacy visits to senior health officials on some of the challenges encountered. The Gunduma Health System Board in Jigawa State, inter alia, obtained approval from the State Assembly to employ more female CHEWs towards the end of 2011. At the time of the study, the Gunduma Health Systems Board had budgeted for more CHEWs recruitment for 2012 and apparently recruitment of female CHEWs will become regular and stabilize.

With respect to transportation, an advocacy visit was made to the traditional ruler, the Emir of Dutse in August 2011, who gave consent to allow female CHEWs to ride motorbikes to implement home visits. The Emir consented to the purchase and deployment of gender-friendly motorbikes in order to address this challenge. Such consent was critical since women riding motorbikes is considered by others within the community and northern Nigeria in general as contrary to sociocultural and religious beliefs. By the first quarter of 2012, 20 motorbikes were purchased and female CHEWs will be trained to ride the motorbikes and use them during the scale-up phase of the intervention. While addressing the MNCH challenges in northern Nigeria is not a here and now matter, allowing female CHEWs to ride motorbikes is a milestone in efforts to provide integrated MNCH services at the doorsteps of the community and this will increase access and utilization of MNCH services in rural areas.

Gender-friendly motorcycles have a step-through space which makes it easier for them to mount the motorcycle than the 'male' motorcycles which have a gas/fuel tank in the middle. Gender friendly motorcycles have a gas/fuel tank under the seat.


Henry V. Doctor
Associate Research Scientist, Population & Family Health
Operations Research Advisor, PRRINN-MNCH Program, Nigeria

Losing sight of invisible women: Behind the maternal mortality statistic

Transport for women with obstetric complications
in the Democratic Republic of Congo

Observers of global public health are rightly encouraged by new figures on the extent of maternal mortality in the world.  Both the data of the University of Washington’s Institute of Health Metrics and Evaluation and new data from the United Nations show that the stubborn figure of over 500,000 maternal deaths per year that had been cited for so long may finally be replaced by the still alarming but encouraging figure of about 350,000 annual deaths.  The new data arrived in time to generate encouragement at the September 2011 session on the Millennium Development Goals.

While the new data represent an achievement that should be both celebrated and studied in more detail, optimism around these figures must continue to be tempered by the reality that women in most of sub-Saharan Africa and probably the poorest women in most countries did not enjoy the gains represented by the new data.  As an obstetrician from Chad, one of the poorest countries in the world, I see these new figures with a mixture of optimism and continued concern about how the world understands the phenomenon of maternal death and injury.

I have been privileged to observe maternal health services in a number of African countries for over three decades.  When I graduated from secondary school in 1970, there were two Chadian medical doctors in the country, neither of them focused on maternal health.  The common saying “a pregnant women is a woman who has one foot in the tomb” was illustrated only too graphically for all Chadians, including myself, as I watched relatives and other women of my acquaintance die from complications of childbirth.

I wish that I could say the situation has greatly improved in Chad and many African countries.  As the new data show, maternal death is entrenched at high levels in a number of countries.  As WHO has noted, in some countries HIV is a barrier to reducing maternal death, but in other countries the intransigence of maternal mortality reflects the difficulty of women’s struggles against many kinds of subordination.

I wonder whether the global policy-makers who will be poring over the new statistics understand the circumstances that add up to maternal death in my country and too many others.  When I worked briefly in Ethiopia, for example, I was struck to find there what we also see in Chad – that there are remote areas where it is well known to everyone that rural women die waiting alongside roads, hoping to find a car that can bring them to a maternity hospital.  Too often, their active labor does not come on the market days that may be the only time when a vehicle may come by.  Naturally, it is not the better-off women who have this problem.  Somehow the many women, especially rural women, who do have it, are practically invisible.

But women are so subjugated that in some places, even the better-off ones are constrained by gender-based subordination as they struggle to save their own lives.  As a practicing obstetrician in one of Chad’s main hospitals, I remember dealing with a woman who was related to a high-level official, so not among the most marginalized of my patients in social terms.  She was suffering in obstructed labor from a breech presentation of the fetus, indicating the urgent need for delivery by caesarean section.

But in her ethnic group, it was a strongly held view that “real women” should not deliver babies by caesarean section.  She feared that a caesarean would cause her husband to reject her and take other women as wives.  In the hours that I had to spend talking to her and her husband, we came close to seeing her add to the mortality statistics.  This is the situation of even the better connected women in my country.

In my current position in RAISE, a program affiliated with Columbia University that works to bring reproductive health services to war zones and other emergency settings, I have seen how women are once again the most vulnerable to the worst effects of political instability and insecurity.  Though I had witnessed the subordination of women in so many communities in Africa, it has been deeply shocking to me to see the health effects of the use of rape as a weapon of war in Congo.

When communities are threatened by violent soldiers or rebels, somehow society tolerates a situation where men stay at home to avoid insecurity, but women are sent to work on the crops or fetch water or fuel.  I have met so many women in that situation – women who were raped and gang-raped with horrible life-long injuries simply because only women do the chores that sustain the household.

I was honored to be invited to observe the activities of the health system in Honduras that have led to improvements in maternal health outcomes in that small country.  Honduras is better off than Chad in per-capita income, but it still faces very severe resource constraints for health services.  With the limited resources at their disposal, health officials and service-providers in Honduras assessed the maternal death situation and realized that the risk of death was highest among low-income rural women, including those in remote mountain areas.

Making it a political priority to solve this problem led officials and communities to work together to ensure that women could find transportation to get to health facilities and that those facilities would have the basic services needed to prevent the vast majority of maternal deaths.  This experience for me was both moving and maddening.  Making a difference in the statistics should not be so hard for Africa, but women just don’t count for much.

A lifetime of advocacy for government attention to the relatively simple measures that need to be taken to reduce needless deaths and disability linked to childbirth among Chadian women makes me concerned that the message of the new maternal mortality data will be that the victory is won and we can rest on our laurels.  Rather, in my country and many of its neighbors, we must urgently seek ways to re-energize a focus on maternal death that is based on women’s right not to die as well as the right of all women to comprehensive reproductive health services.

In the aftermath of the Millennium Development Goals discussions, every leader who praises the countries that have reduced maternal mortality must also be concerned about places where the lack of progress is link to the continued atrocity of treating women as less than human.  Maternal mortality should always be spoken of as a symptom of the more pernicious pathology of failing to give political priority to women’s rights, humanity and dignity.  

- Grace Kodindo, MD, Assistant Clinical Professor of Population and Family Health