Mixed service of human and animal health in pastoral zones:                           An innovative and promising experien...
SUMMARY1.   PASTORAL VASTNESSES WHERE HEALTH IS OUT-OF REACH            32. AN INNOVATIVE EXPERIENCE OF HEALTH MOBILE SERV...
This document presents briefly an experience lesson learnt from two projects carried out by AVSF:         The PSSP1 NT, P...
Infant and maternal mortalities3 are the highest in West Africa; populations are not much vaccinated.Cattle is not vaccina...
2.1.    A local mixed health serviceBoth projects are funded on intermediaries that guarantee a basic health service meanw...
2.3.     Involvement of local authoritiesIn Mali, local authorities and decentralized technical services (veterinary servi...
3. Results, costs and economies of scaleThe organization of mixed health mobile teams has brought closer the basic health ...
facilitating access to health and introducing the habit of medical consultations and animal healthcare.Besides, the manage...
have elaborated a framework document which defines the main guidelines to carry out coupling inpastoral zones; this framew...
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Mixed Service of Human and Animal Health in Pastoral Zones: An Innovative and Promising Experience

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This document presents briefly an experience lesson learnt from two projects carried out by AVSF:

- The Project of Securization of Pastoral Systems N’Gourti-Termit, implemented by AVSF in partnership with the NGO KARKARA up North of Zinder region in the districts of N’gourti and Tesker, North-East of Niger.

- The Programme for food security for populations and livestock living in a nomadic environment, implemented by AVSF in partnership with the NGO ADESAH in the districts of Ber and Salam, circle of Tombouctou, North Mali.

The particularity of these two projects has consisted in implementing a mixed health service (animal and human) in pastoral zones.

[ Originally posted on http://www.cop-ppld.net/cop_knowledge_base ]

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Mixed Service of Human and Animal Health in Pastoral Zones: An Innovative and Promising Experience

  1. 1. Mixed service of human and animal health in pastoral zones: An innovative and promising experienceMeeting for the organization and welcoming of the mobile health Veterinary care on livestock next to a wellteamInformation and awareness-raising meeting with women on pre- Taking care of a patient on sitedelivery consultation, vaccination and hygieneAgronomes et Vétérinaires sans frontières – September 2010 Page 1
  2. 2. SUMMARY1. PASTORAL VASTNESSES WHERE HEALTH IS OUT-OF REACH 32. AN INNOVATIVE EXPERIENCE OF HEALTH MOBILE SERVICE 42.1. A LOCAL MIXED HEALTH SERVICE 52.2. A MIXED HEALTH MOBILE SERVICE 52.3. INVOLVEMENT OF LOCAL AUTHORITIES 62.4. AWARENESS-RAISING ACTION 63. RESULTS, COSTS AND ECONOMIES OF SCALE 73.1. ADVANTAGES OF A MIXED HEALTH MOBILE SERVICE 73.2. LIMITS OF A MIXED HEALTH MOBILE SERVICE 83.3. DURABILITY 8CONCLUSION 9Agronomes et Vétérinaires sans frontières – September 2010 Page 2
  3. 3. This document presents briefly an experience lesson learnt from two projects carried out by AVSF:  The PSSP1 NT, Project of Securization of Pastoral Systems N’Gourti-Termit, implemented by AVSF in partnership with the NGO KARKARA up North of Zinder region in the districts of N’gourti and Tesker, North-East of Niger. The P.S.S.P. NT started on December 31, 2003, for three years. Its global cost is of 1 446 404 €, financed by the EU.  The PNT2, Programme for food security for populations and livestock living in a nomadic environment, implemented by AVSF in partnership with the NGO ADESAH in the districts of Ber and Salam, circle of Tombouctou, North Mali. The PNT has duration of 3 years, from 2008 to 2010. It is financed for an amount of 960 000 € by the EU, the RRA (French Region of Rhône-Alpes) and the Swiss cooperation.The particularity of these two projects has consisted in implementing a mixed health service (animaland human) in pastoral zones. 1. Pastoral vastnesses where health is out-of reachThe zones of these two projects are pastoral zones, characterized by:  A major difficulty in physical access (tracks) and deficient communication means for vast zones (for example, the zone covered in the region of Tombouctou is 40 000 km2, ie. area of Switzerland)  The near absence of the basic services : animal health, human health, education; and few state services, due to a lack of means  The absence of private operators : the veterinarians who could settle down in these zones did not stay, because the activity is extremely difficult and non-profit making due to long distances  A mobile and very-spread population (0.5 to 2 inhabitants / km2) of Fulani, Tuaregs and Moorish people, whose principal activity is the pastoral transhumant breeding of cattle, sheeps, goats and camels.  A difficult access to water (families travel up to 10 km to find water in pastoral wells or temporary ponds; during the dry season priority is given to animals)  Strong socio-cultural traditions  A great proximity between humans and animals that increase the risk for zoonotic diseasesSanitary problems faced in these pastoral zones are linked (a) to the absence of basic services thatcould raise awareness on hygiene, help fighting against malnutrition and making prevention againstpre- and post-delivery pathologies and (b) to the proximity human/animal that encourages theincidence of zoonosis (anthrax, parasitic diseases, tuberculosis, and brucellosis).1 French acronym.2 French acronym.Agronomes et Vétérinaires sans frontières – September 2010 Page 3
  4. 4. Infant and maternal mortalities3 are the highest in West Africa; populations are not much vaccinated.Cattle is not vaccinated or too lightly for an efficient protection. Moreover, extremely contagiousdiseases are listed as Contagious Bovine Pleuropneumonia, Contagious Nodular Dermatitis and cattlepox for animals; measles, tuberculosis, meningitis for humans.With the physical and social characteristics of these pastoral zones, a saving on structure costs can bemade thanks to a mixed service of mobile health. Moreover, with the strong interdependencebetween humans and animals, it is difficult to bring care to humans without taking care of herds, andvice versa.Testimony of M. Zeini Ould Jalalah, traditional chief in the region of Tombouctou and president ofASACO monitoring committee.« I really want to thank ADESAH and AVSF for their actions in our zones and I recall that we do nothave and do not know any NGO that intervenes in our zones except both of them. That is why it isnever talking too much when showing our gratefulness.In terms of mobile health, I personally think that the system must be maintained but also improvedthanks to the implementation of health huts in identified sites with local staff previously trained bythe team and that can guarantee the continuity of mobile service (advice for drug treatments,patients follow up, basic cares, etc.) but also support the mobile team in its work. The team hasalready trained birth attendants and knows what it brings in terms of work support and agility.Nowadays, we need to think about it in order to guarantee the permanence of cares in our zones andit can only be done if the mobile team still has a financing. Some sites have become real villages,thanks to the support of these NGOs (AVSF/ADESAH). We were looking like dusty luggage, but todayour awakening is accelerating and we need to think about these activities to become viable. »In this context, how to support health services? How to implement an operating animal and humanhealth service? 2. An innovative experience of health mobile serviceIt is a mixed service for animal and human health. On one part, the service is provided by breedingassistants and birth attendants4, who are settled local actors trained by the projects. And on anotherpart, the service is mobile via visit tours in the camps5 offering preventive and curative care andawareness-raising activities. It can be considered as an innovative approach that involves a reflectionon “coupling” animal health and human health. The aims are to facilitate access to health care fornomadic populations, in particular prophylaxis, and for their livestock, as well as to improve theirsanitary practices by awareness-raising actions.3 In North Mali, 55 children out of 1 000 die during the pre- or post-delivery period and 6 women out of 1 000die in childbirth due to complications4 A birth attendant is a person who comes from the community and who has been trained to follow up of pre-and post-delivery basics.5 A camp is a group of 4 to 10 families managed by a camp chiefAgronomes et Vétérinaires sans frontières – September 2010 Page 4
  5. 5. 2.1. A local mixed health serviceBoth projects are funded on intermediaries that guarantee a basic health service meanwhile thevisits of the mobile teams. These intermediaries, depending on their level of qualifications, make theearly screening for malnutrition, identify and follow up pregnant women, identify non vaccinatedpopulations (who will be targeted to be vaccinated) and, for the livestock, guarantee external andinternal deworming. The intermediaries come from the communities and provide a paying service.Their geographical division follows a participative process and strives to cover a vast pastoral zone. Inthe Nigerien case, breeding assistants are breeders trained and equipped to provide health care toanimals and to raise awareness on the importance of animal health. First-aid birth attendants aretrained by midwives; they take care of pregnant women’s and children’s health.It allows offering a real local health service with a multiplier effect (training for other breeders,awareness-raising, advice on health and hygiene practices). The activity of birth attendants andbreeding assistants helps improving the sanitary situation and facilitates the access to health care forrecurrent diseases; the most difficult cases are orientated towards the nearest health structures.Involved in training and following up, these structures recognize the functionality of this local mobileservice, underline the positive role played by birth attendants and note the increasing number of pre-delivery consultations in nomadic populations who were before reluctant.To conclude, birth attendants and breeding assistants are intermediaries for the mobile caravans ofmixed health. 2.2. A mixed health mobile serviceThe organization of the mobile service is different for each project.For the Malian project, the mobile team has different meeting points defined on a participativedivision with traditional chiefs and visits each site on the same day each month (for example fromthe 14th to the 19th in Hassi Kayar). The meeting points are designed to cover the zone withoutcompeting with existing health structures. Each quarter, the Association of Community Health(ASACO6), composed of community leaders, defines the meeting points for the following quarters: itallows taking into account the mobility of the camps.The visit round of the mobile team lasts 1 month for 21 days working on-the-ground in 7 sites.For the Nigerien project, only two mobile campaigns were organized in the context of the 2005drought and in 2006. Teams were composed of civil servants of health technical services and for theveterinary part, of private veterinarians. For animal health care, the trained breeders assisted theveterinarians for contention and animal care. The meeting points were defined by the communityleaders of the intervention zone. In order to implement this action, a framework document “couplinghuman health and animal health” was signed by the Nigerien Department for Human Health and theNigerien Department for Animal Health.6 French acronym.Agronomes et Vétérinaires sans frontières – September 2010 Page 5
  6. 6. 2.3. Involvement of local authoritiesIn Mali, local authorities and decentralized technical services (veterinary services, health centers) aredeeply involved in the brainstorming and the implementation of the health mixed service. A steeringcommittee composed of these structures with ASACO representatives7 assesses the results of themobile team on technical as well as socioeconomic aspects.The ASACO: - guarantees a community management and the follow up of the mobile service: ASACO hires the mobile team and supervises it. - involves and gives responsibilities to the population on health care issues : definition of the consultation price, control of the activity, of the cash flows and of human and veterinary pharmacies - involves procedures to maintain this innovative system of health access; it negotiates in particular the registration of the mobile team in the annual operating health plan on a regional level, which allows to accede to free allowances of national programmes (mosquito net, iron and vitamin A for women).The project only has a catalyst role when facilitating to teams the necessary means, allowingtechnical services to appropriate their actions. Local authorities coordinate the activities.Pharmaceutical and veterinary drugs are provided by private suppliers (animal health) or byprogrammes (human health).In Niger, local authorities have participated in the preparation of the visit calendars with thetechnical services (health service deeply involved because its officers were part of the visit rounds)and community leaders. 2.4. Awareness-raising actionAwareness-raising is an essential compound of the mobile service activity; it allows increasing theimpact by approaching populations who are reluctant at first. It is a major aspect for the success ofthe service. The aim of the awareness-raising sessions is to improve the practices and the behaviorsof the populations, in particular for human and animal health, and children education. They arecarried out by the mobile team during the visits. It can also be done by community leaders. Forexample, in Mali, some families reluctant to vaccination and pre-delivery consultations wereconvinced by community leaders. The technical services train regularly the mobile team on modulesto be spread on-the-ground.7 ASACO : Association de Santé Communautaire (the Association for Community Health), managing basic healthstructures in Mali for institutional aspects.Agronomes et Vétérinaires sans frontières – September 2010 Page 6
  7. 7. 3. Results, costs and economies of scaleThe organization of mixed health mobile teams has brought closer the basic health services and thenomadic populations who were difficult to approach. It allows increasing deeply the vaccination ratesof human populations (factor 1 to 6 in comparison with pre-existing structures when they alreadyexisted). The sanitary system that has been carried out allows accessing the most isolatedpopulations of the zone.In the region of Tombouctou in Mali, the annual cost for a mobile team (1 driver, 1 guide from thecommunities, 1 nurse, 1 care assistant, 1 breeding technician + depreciation of the vehicle,maintenance and fuel + technical equipment) is of 29 000 Euros approximately. A human healthconsultation is charged 500 FCFA, i.e. 2 times more than in a permanent structure. This amount hasbeen decided by the communities themselves in order to increase the flow of cash in ASACO. Thepre-delivery consultations are free, in compliance with the national policy of Mali. Medicines areproposed at the same price as the regional pharmacy.In terms of animal health, costs are entirely charged on the populations (consultation charged 50FCFA per head; price of veterinary products slightly uprated to anticipate losses and shipment toTombouctou when supply is done directly by ASACO).Products and services that are at the disposal of the populations are at an affordable price (genericdrugs); beneficiaries have the financial means to pay for health service as well as for animals (thanksto social assistance: a notable can pay for a person who does not have the financial means to receivemedical care). For example, in the intervention zone in Tombouctou, in case of health problems forhumans or for animals, a minimum amount of 200 000 FCFA (305 €) is necessary for the visit of atechnical agent (vehicle renting + fuel + services) when it is a 500 CFA-cost with the mobile team (lessthan 1 euro). Intervention costs remain prohibitive for emergency cases and out of the team visits.And, it is important to note that before the intervention of the mobile teams, the service was notmuch existing in these zones in particular in terms of prophylaxis (vaccination and pre-deliveryconsultations) for human and veterinary health.Coupling allows decreasing intervention costs 45% in comparison with sector strategies. It meansthat in case the same service is taken in charge by two different teams for human and animal health,the cost is increased a 45%. Saving is made on the visit and the vehicle depreciation which are thehighest costs in pastoral zones. 3.1. Advantages of a mixed health mobile serviceFor the population, coupling is a beneficial action to implement a local system (breeding assistantand midwives) and to organize the mobile service, what allow them to access health services. Indeed,the intervention of a doctor or a veterinarian is a high cost in these zones.For health services, the advantages of coupling are diverse: exchanging experiences, sharing means,increasing knowledge, improving sanitary coverage, facilitating access to difficult zones,strengthening service activities, raising awareness, etc. Local service and mobile service allowAgronomes et Vétérinaires sans frontières – September 2010 Page 7
  8. 8. facilitating access to health and introducing the habit of medical consultations and animal healthcare.Besides, the management of this service brings closer the different parties (technical services, localauthorities, communities) on a federative action. When starting this action, there have been a lots ofcomplaints (ones’ inefficiency, others’ hesitations, etc.), but each one has been able to know betterand to understand the constraints of the different actors.From an institutional point of view, these operations have allowed significant advances: - In Niger, a framework document on coupling human health and animal health has been approved. - In Mali, only ASACO in Tombouctou specifies in its articles the management of a mixed service and the districts of Ber and Salam have constituted an intercommunity association to manage this service.The interest beard by the populations of North Mali to this service has allowed to send 10supplementary mobile teams in 3 months to cover a contextual need, with the 2010 drought in NorthMali (with the support of technical services, the European Union / ECHO and the French Embassy inMali). 3.2. Limits of a mixed health mobile serviceThe monthly frequency for visits on each site allows in theory realizing vaccination boosters in humanhealth. But, in case of drought, vaccination boosters can not be done on time due to very significantand scattered populations’ movements.The mobile team can not realize medical surgery and must, in case of emergency, bring the patient tohospital, what brings again the problem of travelling cost. 3.3. DurabilityThe durability of such service is the defective part of these experiences! For human health, anddespite the population’s enthusiasm, it remains difficult to collect membership funds dedicated toguarantee the renewal of drugs stocks and to register the salaried doctors and nurses on the statebudget. The national health policy does not take into account mobility.For animal health, a private supplier could only offer that service in case its fuel and depreciationcosts are taken in charge …At a ministry level, this action of merging human and animal health needs a long-term-follow up anda strong institutional approach.Durability of coupling goes necessarily through the strengthening of the collaboration between bothservices (human and veterinary health), the follow up of steering committees composed of differentactors and the creation of a sufficient fund to support this service. In Niger, 2 health departmentsAgronomes et Vétérinaires sans frontières – September 2010 Page 8
  9. 9. have elaborated a framework document which defines the main guidelines to carry out coupling inpastoral zones; this framework document has not been approved yet.Constraints in human and animal health are not always the same. In terms of human health, civilservants depend on 2 different services. In terms of veterinary health, drugs supply still needs someadjustments.From Tombouctou experience, steering committees are essential to create a synergy. Even if thetopic is federative, synergy is far from being achieved due to concerns and paths of the differentactors; and in case one actor blocks the situation, all the service is questioned.To conclude, the populations generally cannot take in charge the mobile teams’ costs for visits andsalaries. If we want a facilitated health access for every one, the State must find the necessaryfinancial means. But the general context underlines regularly a lack of human and logistics means,even to guarantee the basic services in secondary urban centers! In this case, a pro-active policy fromthe States and their financial partners is essential to cover health needs in Sahel-Saharan pastoralzones.ConclusionIn these experiences, coupling animal health and human health allows reducing significantly theservice costs and making it available in isolated zones with an important mobility of populations.The State must provide a basic health service to its populations. It is taken into account in strategyframeworks to fight against poverty in many countries and is a whole specified paragraph in theMDGs (Millenium Development Goals). But, West African States and their local authorities do nothave the necessary financial means. The financial durability and the spread of this health system tothe whole Sahel-Saharan strip can only be realized by a national institutional decision (or sub-regional) with the mobilization of the financial partners.Furthemore, this issue overtakes the concern of the sub-regional States. The Sahel-Saharan vastnessshelters important human and animal populations that are not vaccinated and do not beneficiatefrom epidemic supervision activities. It represents a mayor risk in the diseases incidence and theirexpansion through the frontiers.Lastly, the awareness-raising actions should allow decreasing the incidence of human and animaldiseases. Consumption practices of animal products (in particular raw milk) and water (traditionalwells with low depth, soil, etc.) are lines of enquiry to find simple solutions in order to improvepopulation health by changing behaviors and by reducing mortality and morbidity rates.This experience, very much appreciated by the population and with a lower cost compared to thesector-based classical system, deserves to be improved and integrated in sanitary development plansfor pastoral zones because it is full of promises and it adapts to the reality on-the-ground.Agronomes et Vétérinaires sans frontières – September 2010 Page 9

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