In 2016, Zambia’s Ministry of Health named MATHEWS MONDE one of its most innovative health workers. In this interview, he tells us why he wants policy makers to rethink what community health work means, and how his role in the Chabbs Cluster provides a template for the future.
You’ve said before that we need a paradigm shift in how we understand ‘community health work’. Why?
So many times I’ve seen government and NGOs go into a rural community to implement a community health programme, but it’s been designed by a technocrat in a city, with no real input from the community. And even though these programmes are evidence-based, and born of a lot of expertise, they fail. And they fail because they don’t consider the culture of the rural community they are intended for. The community voice is absent from the start, and so the programme takes no account of what communities want or need. And I’ve been studying Community Health at the University of Lusaka, and it’s a similar story there. “What can you do for the community?”. That’s the question we get asked at the start: it’s this idea that we have solutions for people who have no solutions, and so we need to go and tell them what to do.
Can you give an example?
I can give you a few, yes. I was involved in a Malaria Control Programme, and I was with a team who were going into a district with an insecticide for people’s homes, one which would kill and repel mosquitoes. We trained people in the town to do this – to visit rural communities, and to offer to go into people’s homes and to spray their walls. But many villagers would say “we can’t allow you to enter our home, because we don’t know you and we don’t know what you’re spraying”. I was shocked at the number of refusals – we clearly had a problem with trust. And the community feedback was that “you never consult us, you just bring things to us”.
I think if we were to consult with them, we would all benefit. I know a lot of people in rural areas burn cow dung to keep mosquitoes away – this has been a common practice for a long time. So what if the Ministry of Health could explore how this works: if they could study what is discharged in the smoke, find the active ingredient, and work with that. There are community practices like this that have been used for a long time, which people believe can keep them healthy. Rather than dismissing them, what if the health system worked alongside communities and studied these solutions with them? If we started by listening to local people, and what they were saying, then it could be a different story.
Do you have other examples?
We’ve seen a similar thing with sanitation. Some years ago, the Ministry of Health built sanitation platforms to be used to make latrines in rural areas. The platform was a piece of concrete with a hole to be used as a toilet. So we had a lot of them packed and taken to a community centre in one district, to then be distributed from there. And then some time later – in 2006 – there was a Cholera outbreak. We returned to the community centre, only to discover the platforms were still there. They hadn’t been used! And again, it was because we hadn’t thought to ask if people actually wanted these platforms, or if they knew how to properly use them. I know from the Cluster and our community visits that there are alternative methods of building effective and safe latrines that the community use, ones that use local available resources, in a sustainable way. There is one that uses local wood, which is fashioned into a honeycomb structure, and it’s very durable and strong.
So what I’m saying is that if we combine local wisdom and methods from the community, with the technology and science of the Ministry of Health, then we could really do great things. Let me just give you another example. We have fruits and herbs that grow naturally in our rural communities, which can be used to help with different medical complaints, like diarrhoea. Culturally – if not scientifically – these methods have been proven and accepted. So why can’t the science catch up?
How are you working to make this kind of change happen?
Over the last twelve years I’ve been involved in Malaria control, and I’ve tried to make sure that consultation and listening become key parts of our contact with the community. I also make sure we invite community members to volunteer to participate in the programme. But more needs to be done. For example, the government has an initiative of training Community Health Assistants. The idea is that these people work in their community 80% of the time, and at government offices the other 20%. It’s a great idea, but we’ve discovered that they really spend most of their time at their office and not in the community. I think that when they get on the government payroll, they become like civil servants – a way of working that can become quite contagious.
Community work can take time. Do you think these people see the top down approach as quicker and easier sometimes?
Yes, I think so. But this approach doesn’t work. You see, very often local people have the solutions to their problems. And I know this from my experience with the Cluster: as Cluster members we often visit people’s houses in the community, to find what people do to keep themselves healthy, and the challenges they face in doing that. And through this we discover local solutions that make sustainable use of local resources that are all around us. This is how we came across the honeycomb structure for latrines. All the government needs to do is listen to the community and work with them.
And this is why you believe so much in the Cluster model?
Yes, Arukah Network is real community health work. We know from visiting and talking with local people that they can take a lead on a lot of important health issues. And these solutions save money too! Government interventions tend to be much more expensive than what communities are able to do. The Ministry of Health spends a lot of dollars buying drugs and all these things, and I think we will find better, cheaper solutions if community consultation becomes a foundation of what we do. We would save money, and people would be healthier.
The three examples we’ve discussed certainly seem to back that up: a chemical spray that costs money verses cow dung that’s free; heavy, concrete pit latrines compared with the local wood structures; and then local herbs and fruit that compliment medicine.
Yes exactly – we just need to start listening to the community more, and I believe we can have a much greater impact.
Learn more about Mathews and his Cluster here.