by Stan Rowland
Successful projects in Uganda point the way for others.
Medical missions have always been committed to caring for physical and spiritual needs. Often, however, in day-to-day practice, a medical missionary is faced with an incredible case load. That can produce tension as demanding physical concern conflicts with spiritual needs. But Christian doctors and nurses can multiply themselves through training thousands of local people to handle simple medical problems and to share the truth about Jesus Christ. The solution lies in Christian community-based health care.
Evangelism may be central in a hospital-based program, but there is little opportunity for discipleship: patients are far from home and at the hospital for only a short time. In contrast, discipleship is central in a community-based program, and both spiritual and vocational multiplication take place through community health evangelists.
Since 1981, four pilot community health evangelism (CHE) projects have been established in Africa; three are still functioning.
A CHE training project began in May 1982 in Buhugu, Uganda (25 km northeast of Mbale). This is a joint project of the Church of Uganda, Mission Moving Mountains, Life Ministry, and the local government. Twelve CHE volunteers from 10 villages within an eight-kilometer radius of Buhugu were trained for three days a week for 10 weeks. Since they have been working in the community, they have seen more than 400 accept Christ, and each one has up to three follow-up groups of 10 to 15 people. A second group began training in May, 1983, and trainees in an adjacent area started their program early in 1984.
Community health, besides seeking to prevent common illnesses, takes health services to the community instead of asking the people to come to a central institution. As you climb the pyramid, more sophistication is required, greater resources are used, care is more expensive, and fewer people are reached. By training local villagers, CHE emphasizes the broad-based tier of community health. It takes time at the outset to establish a project-possibly up to six months. The better the job is done at the beginning, however, the fewer problems will be found in implementation. Local people must be fully involved and understand the objectives, and they must see the project as their own; they are the ones who will make the project successful. It is important to find a local influential person with the vision to champion the project-and who has the necessary time available to concentrate on its success.
From the start, the key to an ongoing community health evangelism program is local community involvement. Commitment is established by and through a local community health committee, whose members must view all work done as their responsibility and not that of an outside agency. The project must focus on the community, not on outside partners, and must be viewed by both insiders and outsiders as the community’s property. The outside agency’s identity must be subordinated to the local project.
The community health committee is chosen primarily from Christians, but it also includes community and opinion leaders. The committee is responsible to: (1) participate in assessing village health needs, plan budgeting, and rank the needs; (2) participate in committee training; (3) choose people to be trained as CHE volunteers; (4) supervise day-to-day work of the volunteers in the community; and (5) evaluate and modify the program to make sure it meets community needs.
Preferably, the committee should be church based, with mature and well-respected members who represent different segments of the community-education, government, business, agriculture, community development. A good-sized committee consists of five to nine members. Prior to choosing CHE, the preliminary community committee should undertake training and should not finalize membership until after the training has been completed. This should include instruction in the basic message, home modeling, planning, problem solving, defining of their role and responsibility, follow-up, and evaluation.
CHE volunteers should be at least 25 years old, married (generally), mature, in good health, well respected; they should show respect for others, be stable, knowledgeable of the community, highly tolerant of frustration, display a sense of humor, and be able to listen with patience. Though it is preferable to train Christians as CHE volunteers, it is not a requirement. The spiritual content is strongly emphasized during program initiation discussions. Volunteers should be individuals who have already set an example through community activities, and they; must be willing to work both spiritually and medically.
It is not preferable to select CHE workers who have had; too much education, or they in turn may teach at a level too high for the people in their villages. A local village education of seven years or less is suggested; these people are less mobile and more likely to remain in their villages. Those who are more highly educated look for pay ad prestige rather than an opportunity to serve people, Often older, less educated people have a greater desire to serve their community. (We have successfully taught illiterates, though this requires a simplified approach.)
Mature, respected women are desirable since most of the health problems are found in women or in children under five years of age. Older women with children have much better access to other women. A program should have fewer men than women.
Experience has shown that it is best if CHE workers are part-time volunteers. If paid, people often desire the monetary remuneration and are not as interested in seeing lives changed. A number of other factors also must be considered:
1. If the pay for health workers comes from an outside organization, that organization, not the community, then controls the program.
2. It will be seen as foreign to the community even if the remuneration comes from the government.
3. The amount of money needed to pay a nation’s CHEs is far beyond an organization’s ability to provide.
4. If the remuneration comes from the community, the tendency of the community is to look for the sale of drugs as a means of paying salaries.
The village can provide remuneration in kind for the time the CHE volunteers spend working. For example, another person can dig in the worker’s shamba for him, or provide food. A scheme whereby each family pays a month’s subscription fee (set at 1/2 percent of the average monthly income in the area) has also been successful. This is similar to prepaid health insurance in the United States. Some have paid a small percentage from crop sales into a fund to provide income for the program or had special fund-raising programs.
The CHE volunteer’s primary role is as a health promoter emphasizing preventive medicine and having a spiritual ministry. By the end of their training, we hope that CHE workers will have a burning desire to reach their area for Christ and to see changed physical and spiritual lives and conditions among the people in their villages.
Most of the workers’ time will be spent in home visitation, not at an aid post. They will be expected to model what they have learned in their personal and family lives. Medical care should be viewed as a servant to the spiritual ministry. Evangelism and discipleship must be interwoven with the health work. The intent is for them to become multipliers in light of health and spiritual truths. They should make appropriate regular reports to the community health and executive committees.
No more than 12 to 20 CHE workers should be trained at a time. Training should take place in a central location that is within walking distance of the villages sending trainees. Ideally, one part-time CHE volunteer per 350 population, or one full-time per 750 to 1,000 population, should be trained. Training involves the trainee’s active participation in home visiting, role playing, story telling, singing, demonstrating, and discussing. It is critical that the trainers work with the trainees in home visitation two to three days a week to enhance chances for success. The initial training of two or three days per week can extend over 24 to 30 training days. One physical and one spiritual subject is taught each day, and the two are integrated. Time is also allowed for recreation, fellowship, and group interaction. Following initial training, teaching continues on additional topics, one day every two weeks or two days per month.
There is some advantage in focusing on one or two critical problems that are found in the area. A simple before and after training survey should focus on the problems being taught so that trainees can see results and gain positive reinforcement for their work. They can be encouraged to be successful in specific development projects in which they have an interest, including fish ponds, forestry, and so on. Exceptionally bright and gifted people are sought from among the trainees to assume the teaching and monitoring functions. This allows the training programs to move into new geographical areas.
Upon completion of the initial training, trainees are awarded certificates designating them as community health evangelists. They should serve an internship of one year while they practice what they have learned and gain more knowledge. If they have performed to the satisfaction of their committee they may then be made a senior community health evangelist.
We use the term "evangelist" to keep before the volunteers that a major part of their role is in evangelism. Though we may start with some non-Christians, it is our desire that each one comes to a personal relationship with Christ. Much of our initial spiritual teaching is aimed ; toward this end. The term "evangelist" is as much psychological as anything else, in that we want the volunteers to be sharing the truths of Christ as much as they share; physical truths. The vast majority of people who go; through the training come to this personal relationship’. with Christ; those who don’t, in many cases, drop out of; the program those who don’t in many cases drop out of the program.
Trainers for the initial model would include two to four people who have skills in a combination of teaching, nursing, nutrition, community development, agriculture, sanitation, or literacy. Because it is important for these trainers to have a common basis, each team undergoes three two-week orientations spread over a period of three to six months. The intent is to train them in spiritual content, community development principles, and the basis of a CHE program.
While local and government people with experience can be used as supplementary teachers, care should be taken that they do not usurp leadership or modify the program’s direction.
Expatriates, when used, should immediately spend two to four weeks in a rural home to establish bonding with the culture. In their first six months they should concentrate on culturalization, language, and in work with the community in developing community participation and goals. They should also help the community identify priority needs and the resources already available.
In CHE programs, curative medicine should be downplayed whenever possible. For community health to function properly, there must be a referral chain for those too sick for the community program, expressed earlier in the three-tier pyramid approach.
The whole health scheme must be based on a spiritual platform that balances prevention and cure. An organization may have to become involved in the second tier of the pyramid, the health center (if none is available), but this should only be done as a last resort. The program may then become more curative-and evangelism-oriented, as opposed to preventive-and multiplication-oriented.
The program may be an integral part of the church, as in Uganda, where most dioceses run curative clinics. Mobile clinics could be provided by the base clinic team into the areas where volunteers are working, also starting a CHE program in an area where a clinic is already available.
The workers should dispense no drugs. This will prevent the program from developing a curative orientation and keep money from the sale of drugs from becoming the reason for the program’s existence. If drugs must be given for any reason, only the following should be dispensed: aspirin, chloroquine, worm medicine, iron tablets, eyeointment, and tincture of iodine. These drugs should be obtained within the country, either from government, church, or private industry sources, and not be imported.
If a clinic must be set up, the community should supply as many resources as possible: the clinic building and housing, or where construction is necessary, the land, labor, and locally available building materials. The salaries of the clinic staff (national nurses, midwives, and additional helpers) should be the community’s responsibility. Charges for the curative services and drugs should cover the costs of operating the center and provide operating funds for the CHE work.
1. The primary goal is to reproduce Spirit-filled CHE volunteers who are capable of reproducing themselves in others, both in physical and spiritual terms. Ideally, that reproducibility will move down to at least the fourth generation from the initial training team.
2. The program should be integrated into the church infrastructure with the church leaders taking responsibility for it.
3. By the second generation, the program should be totally taught and led by nationals.
4. The program should continue on and expand to adjacent areas from the starting area through local training teams after the initial training team leaves an area.
5. The program should be self-funded locally.
6. The villagers should see the program as their own and not as an outside agency’s.
7. There should be an improvement of at least 50 percent in the health indexes.
8. Drugs and supplies should be obtained within the country and paid for from a local revolving account.
9. There should be an appropriate ratio of CHE workers to population, probably one part-time volunteer to 350 people.
We have begun the multiplication of this program throughout Uganda, based on the foregoing principles. We have started three joint programs with the Church of Uganda in different areas of the country where we jointly supply staff. We expect to begin three or four more programs within 12 to 15 months. In addition, we have become consultants and enablers to three all-church projects to help with their programs. We expect to be involved in another five to seven at the same time. We are praying for 50,000 CHEs eventually throughout Africa.
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