1COMMUNITY CHANGE CASE STUDIES This document contai.docx

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COMMUNITY CHANGE CASE STUDIES
This document contains case studies on community change
processes. If you are working alone on this,
chose two case studies for analysis and comparison. If you are
working in a group, chose three. You
are also welcome to make up your own case study to use as one
for comparison. If you do develop
your own case study, please write it out in a similar way as
those found here and included it at the end
of your worksheet. Base your own case study on an actual
community experience, but change names
and places to maintain confidentiality.
Community Case Study 1: The Transition to Western Medicine
in Agatu
Agatu community in Benue State Nigeria is located 90
kilometers off the major road connecting
the two largest cities in the region. The community has a major
market that is held every fifth day.
The inhabitants are mainly farmers. They lacked most of the
modern amenities, such as potable
water. Their major source of water was the Ado River. Although
there was no clinic in the
community, the people had access to a variety of indigenous
practitioners including those specializing
in bone setting, children’s illnesses, general herbal medicine,
and divining and counteracting curses

and poisoning. There were also traditional birth attendants.
Few members of the community received formal schooling. One
fortunate youngster was Herbert
Ada. When Herbert’s father died in 1955, his mother sent him to
work as a houseboy for a prominent
businessman. The businessman later moved to the state capital,
where, in 1958, he enrolled Herbert in
primary school. Herbert finished first in his class in 1963 and
was awarded a scholarship by the state to
attend secondary school. His performance there made it possible
for him to win a scholarship to study
medicine in Britain.
When Dr. Ada returned to Nigeria, he set up his practice in the
(former) national capital and
business center, Lagos, located nearly 1000 kilometers from
home. Dr. Ada would visit Agatu once in
two years and made sure that a bank account was set up to
support his mother and immediate
relatives, but his involvement in hometown affairs was minimal.
Then, in 1983, on a visit home, he learned that his favorite
uncle had died of severe stomach pain
only a few hours before his arrival. The condition had persisted
for about four days, and the uncle
had been attended by an herbalist. Dr. Ada insisted on a
postmortem, something quite unusual in a
culture that accepted death as something unquestionable. At the
hospital in the state capital, it was
found that the uncle had died of appendicitis. This event
challenged Dr. Ada to consider how he
might use his good fortune and skills to help the development of
his hometown.
After the funeral, Dr. Ada met with the village chiefs and

offered to help build a health clinic for the
community. The chiefs later summoned members of their
council, but much opposition to the idea was
voiced by the local healers and their relatives. The council
became deadlocked, so Dr. Ada returned to
Lagos.
Three months later, one of the most influential of the local
leaders sustained a deep cut while
working on his farm. He was taken to one of the herbalists, who
tried to control the bleeding. Because
a major artery was involved, the man bled to death. This tragedy
generated much heated discussion
among the townspeople. Even people from neighboring
communities heard the news, and when they
confirmed that the rumors of Dr. Ada’s offer to build a clinic
had been rejected, they blamed the
people of Agatu for their own suffering.
The chief of the community therefore summoned another
meeting of his council. At this point a
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majority of those present decided that Dr. Ada should be invited
back home to build a clinic.
Dr. Ada returned in late 1984 and began consultations with the
villagers about the site for the clinic.
His own family members began pressuring him to locate the
clinic on their family land so that they
could set up shops and canteens that would cater to the patients
and relatives who would attend the

clinic. Dr. Ada remembered that the scholarships he had
enjoyed had come from public funds, and
therefore he decided in this case to listen to the will of the
majority of the community members and
accept a site that was centrally located.
The first step in the project was the sinking of a borehole well
to provide water for construction and
later for use at the clinic. Because of the skills involved, the
community decided to hire a contractor to
do the work. The contractor hired community workers as
laborers, and they were happy to earn this
extra daily wage. Some of the community leaders also served as
supervisors and thereby also earned
some wages. After completion of the well, the clinic itself was
constructed in the same way. Trained
staff were sent in from the state Ministry of Health to work in
the clinic, and the non-professional and
maintenance staff were hired, as decided by the council, on a
quota basis from each section of the
community. A generator was obtained so that there would be
light in the clinic at night, and the state
placed an ambulance and a bus at the clinic.
A local social club took responsibility for recruiting and
sending for training two local people to serve
as water treatment attendants. At a council meeting, community
leaders decided that each social
organization would contribute regularly to buy chemicals to
treat the well water and parts to maintain
it.
Now it remained for the community members to begin
patronizing the clinic. For the first year,
utilization was low. Several factors contributed to the problem.
Villagers felt awkward seeking health

care from “strangers.” The indigenous healers, in contrast, were
long-standing neighbors. The various
techniques for diagnosis and treatment at the clinic were
unfamiliar. In particular, clinic diagnosis
lacked consultation with oracles and inquiry into the social
circumstance s of the patient. “Red tape,”
such as registration procedures, were confusing. Notions of
causation offered by clinic staff for illnesses
contrasted with the naturalistic and supernatural explanations
given by the local healers. Although
villagers were anxious to try the “modern” drugs prescribed by
clinic staff, supplies were often short,
necessitating long rides to neighboring towns.
Referrals to distant hospitals were seen as admission on the part
of the clinic staff that they
were not fully competent. Not only did utilization of the new
clinic drop, but the indigenous healers
began organizing meetings to plan a campaign against the clinic
and all its perceived shortcomings.
Fortunately, the clinic workers’ salaries continued to be paid.
The staff had their own meetings to
analyze the problems and realized that public relations was at
the core of community resistance.
Subsequently, staff were trained to make home visits. Such
personal contact created mutual trust and
reignited interest in attending the clinic. Previously, most
treatment had been provided free of charge.
This policy was changed, and token fees were introduced. This
increased community perceptions of
efficacy of the medicines and also provided a source of income
so that a regular supply of medicines
could be maintained.
Attendance increased steadily until the clinic actually became

overcrowded by 1988. This led
community leaders to approach the state government to lobby
for an enlargement of the clinic into a
comprehensive health center. Although the government did not
come up with the money, the project
went ahead. Dr. Ada plowed back earnings from the clinic into
the building fund, and this was
supplemented with community contributions. Community
members also provided labor for the
construction.
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Community Case Study 2: Hygiene and Sanitation in Karimu
Village
Karimu is an old village in the central savannah area of Nigeria
located not far from the new capital,
Abuja. Its 20,000 people live in scattered clusters of huts but do
have a king and a council of 20
traditional chiefs. Agriculture is the major occupation, with
residents growing yams, rice, cassava, and
maize. Village women are responsible for domestic work as well
as for helping their husbands on the
farms. There are two primary and one secondary schools. The
government has built a new health
center, but this has not yet been commissioned.
It was observed by the regional health department staff that the
villagers lacked toilets, refuse
disposal systems, potable water, and good roads. As one of the
health staff commented in 1993, “They
lived in thatched huts, defecated in nearby bushes, drank water

from ponds, streams and rivers, and
dumped their refuse anywhere around their homes. Their
attitude toward personal and environmental
hygiene was very poor, and most of them looked extremely
dirty.” Because of the poor situation, there
had been frequent occurrences of cholera, dysentery, and
meningitis.
The Health Department had always responded during any
outbreak of diseases by giving
immunizations and health talks about the cause and prevention
of disease. Finally the health workers
felt that the situation in Karimu village was becoming
“unbearable.” They set out a goal of intervening
to solve these observed problems.
First, the health staff went to the village and visited the chiefs,
seeking “their full participation,
cooperation, and support for our program.” They then formed a
Village Health Committee (VHC)
consisting of 20 members, including most of the chiefs. The
health workers next proceeded on their
own community diagnosis, which identified the problems noted
above as well as “low level of
education, overcrowding in the huts, no electricity, and lack of
immunization services.” The VHC was
guided to identify its own concerns and mentioned cholera,
dysentery, measles, scabies, anemia, and
malnutrition.
Although the health workers’ assessment of the human
behaviors that contributed to the many of
the problems (eating raw, unwashed fruits, not washing hands
after defecation) pointed to the ba sic
need for an adequate supply of potable water, the team noted
that, “We did not have the resources

to provide a borehole well.”
Further investigations led the health team to learn that the
villagers lacked knowledge about “the
side effects of a dirty and filthy environment. In fact, they did
not perceive that their environment was
dirty. They had a poor attitude toward keeping their
environment clean. They misprioritized their
values, attaching more importance to other areas of their lives
and not to their personal health and
hygiene.”
The VHC was the foundation for intervention as planned by the
health team. They “joined the
leaders of the VHC to mobilize community awareness.” Selected
groups of women, students, and the
VHC were trained on personal health and environmental
hygiene. These trainees in turn delivered
health talks to different segments of the target population: at
schools, markets, and from house to
house. As a result, the young men in the village divided
themselves into workgroups to maintain the
sanitation of different sections of the village. The women were
observed to be more active in sweeping
surroundings of their homes. Follow-up surveys and discussion
groups revealed that, “There was a
tremendous change in the attitudes of residents towards
personal and environmental hygiene. They
were now taking their bath two times daily, washing their
clothes and taking care of their hair and
nails.”
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Community Case Study 3: Alawo Bridge
The Inalende and Abebi communities in Ibadan City are two of
the communities in the Ibadan
North-West Local Government. Trading and commerce are the
main occupations of the inhabitants.
Some of the men combine trading with farming on the outskirts
of the city. Community Development
Associations (CDAs) are common in the area, and the two
communities have a joint CDA to which
public service agency staff also belong, including those of the
Health Department. The people in this
congested urban area have expressed a number of health and
development needs and problems over
the years including high levels of fevers, high blood pressure,
lack of potable water, and inadequate
facilities for disposing of human waste. There is a small health
center that serves the area, but people
tend to patronize patent medicine shops more often because they
can buy drugs on credit from the
owners who are also their neighbors in the community.
Another concern of the two communities is a very large erosion
gully that separates them. It is
possible to cross the ravine using rough steps carved into the
sides during the dry season, but during
the rains, it is impassible. Even in the dry season, the ravine is
not a pleasant place to cross because
people use it for feces and refuse disposal.
Several years ago, the issue was raised in the two communities
about constructing a bridge. This
would enhance trade generally and make it possible for the
Abebi farmers to get to the road
out of town more easily and the Inalende women to reach the

health center/maternity center more
easily.
After much conversation among both community leaders and the
average citizens, consensus
developed about the need for a bridge. At the time, no CDAs
had formed, and initiative was taken by
the Landlords Association (LLA) in the two communities. A
meeting was held with representatives of
the associations from both communities. Each extended family
compound in the community was
represented in the LLA, and as many compound leaders as
possible attended the first meeting. Also,
the chief of each community was present. Several meetings were
held over the next few months, and
after each, the compound heads passed information about the
deliberations back to community
members.
Although they were not represented at the meeting, the women
of the community were very
interested because they suffered more — carrying heavy loads
to and from market on their heads and
dealing with difficulties climbing in and out of the ravine. A
delegation from the market women’s
association visited both community chiefs to express its
concerns and lend its support to the effort.
These thoughts were tabled at subsequent meetings.
During the meetings, skilled artisans (such as carpenters,
plumbers, and masons) within the two
communities were identified as to who could help with bridge
construction. The aspect of manual
labor was debated, and a schedule was worked out wherein each
compound in the area would
provide people to carry blocks and loads of sand and fetch

water.
At one point, work stopped. A meeting was called and the
representatives from Abebi
Community complained that they were contributing more time
and funds than those from Inalende.
The two chiefs sat the participants down and did a mental
accounting on the spot. When the
allegations proved to be true but not grossly out of proportion,
everyone was satisfied and work
continued.
At a point when the economic condition of the country became
worse, work on the project
stopped completely. Several pillars to support the bridge had
been built, and a good store of sand,
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cement, and blocks had been amassed, but the compound leaders
could not convince their members
to increase their level of donations to match inflation.
About two years later, a new government encouraged
communities to form the CDAs. Abebi and
Inalende formed their own. Both groups independently began
discussing the issue of the bridge but did
not want to take the initiative alone to finish it. As noted, the
CDAs included staff from local
government health, works, and community development
departments. Most of these staff took part in
more than one CDA and shared with the Abebi and Inalende
CDAs that both were talking about the

same issue. An informal meeting was held with representatives
of the two groups, with the final result
that they decided to merge to form one CDA, the Abebi -
Inalende CDA. This set the foundation for
resumption of work on the bridge.
Because local government agencies promoted and were involved
in the CDA movement, the local
government also provided matching grant money to
communities for development projects. All
compound heads were encouraged to attend the first joint CDA
meeting where they resolved to
resume the regular donations for the project. Now with the
availability of a matching grant, there was
enough money to finish the project. In addition to the
contribution of skills by the local artisans, the
community, through the CDA structure, also benefited from
technical advice from the local
government engineers. Some modifications were made in the
design, and the bridge was finished
within six months. Now there is active commerce and social
interaction between the two
communities, and their joint CDA is planning a new project —
building a community high school.
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Community Case Study 4: Ajara Community Coalition
Ajara is a community of about 10 small villages with 5000

residents spread our along a lagoon
and connecting waterways in southern Nigeria. Most residents
are farmers, fishermen or processors
and traders of farm and fish products. Transportation in the area
is usually by motorcycle or canoe.
Ajara is served by one local government primary health clinic
(PHC) with 4 beds for
admission/observation and/or delivery. Staff consist of a nurse,
two community health extension
workers, a dispensary attendant and a ward attendant. The nurse
commutes from the city daily, about
one hour journey each way. She usually does not come to work
on Fridays. The other staff live in the
surrounding villages. They run a weekly child health clinic and
a weekly antenatal clinic. Other days
are used for general outpatient care, administration and
cleaning/maintenance.
About 20% of the approximately 250 pregnant women annually
register for ANC, but less than
half of these deliver their babies at the clinic. There are three
indigenous healing centers with
inpatient care in the area, several dozen individual indigenous
healers, two private nursing centers and
seven patent medicine shops. Five churches encourage their
pregnant members to come to the church
to deliver where they are supervised by elderly female members.
There are three primary schools in the village, but secondary
school students must trek to the
district headquarters to further their education. Primary school
attendance is over 80%, and actually
more girls go to school as boys are often accompany their
fathers to farm or for fishing. Although each
school has six grades, only one has enough teachers to cover

two arms/classes for each grade. One
school has only 5 teachers, one of whom manages a combined
first and second grade class. If they
want a proper place to sit, students are expected to bring
benches from home.
Ajara has a chief and a council of elders, one of whom is a
women=s leader. There are several
Muslim and Christian congregations in the area with various
men=s, women=s and youth associations.
There is a town progress union, a credit and savings cooperative
among teachers and other civil
servants, two farmers= unions, a fishermen=s union, a market
women=s association and a transport
workers union.
In late 2004 an NGO known as COMPAP (Community
Participation to Attack Poverty)
established an office in the state. Working with the State
Ministries of Health and Education COMPAP
identified 10 districts that were considered most underserved in
the state. In August 2005 COMPAP
visited the district in which Ajara was located, and the district
council president and Directors of the
Health, Education and Community Development Departments
identified 10 communities where health
and education services were least well utilized. Ajara was
among these.
A community organizer from COMPAP visited the Ajara along
with the local government health
department’s health educator. They met the village chief and his
council of elders and began an
informal discussion about the status of health and education
services in the community. They also
asked the chiefs about local community based organizations

(CBOs) that had shown interest in health
and education issues. Through this process they heard a number
of complaints about the quality of
services, the attitudes of the staff and the availability of
materials and supplies at the local health
center and schools.
Later the community organizer and the health educator
contacted the leaders of the local CBOs
and stopped by the PHC and the schools. They asked if people
were interested in coming together to
form a community coalition of all interested CBOs to address
some of the concerns the chiefs had
outlined. Most were enthusiastic, but a few were skeptical, “The
health workers tried to organize us
into a health committee about ten years ago. They would set
meeting dates, and then fail to show.
When we discussed improvements needed in the health center,
the staff accused us of being
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ungrateful. Eventually we stopped attending.” People were told
that a coalition would be unlike the
former health committee in that community members would run
the coalition themselves. People
asked, “Is the government going to give us money to run a
coalition?” and the organizers explained
that it was up to the community, if it thought a coalition was
useful, to manage it for themselves.
After finding an agreeable date and venue, the organizers asked
one of the elders if he would

serve as convener so that the community could take charge from
the beginning. Representatives of the
mosques, churches, trade associations, social clubs, health
services and schools attended. In all 55
people were present, 5 health staff, 12 teachers and the rest
representing 17 CBOs. After hearing an
explanation that a community coalition could be a problem
solving tool, a way to mobilize resources
and an advocacy voice for community needs, the attendees were
divided into four groups to
brainstorm and discuss ways to improve the health and
education services in the town. The teachers
formed one group and the health workers a second. Community
members were divided in two, with
some choosing to discuss health issues while the other focused
on education. Each group selected its
own moderator and recorder. The groups were asked to come up
with a list of the top 5 priority
problems.
After lunch each group reported and answered questions from
the whole assembly. They then
moved into two groups – one on education, the other on health.
In these two groups the organizers
facilitated discussion and encouraged the providers and the
community members to come to a
common view on one or two top priorities. They worked to
analyze the reasons for the problems and
possible solutions. The facilitators worked hard to keep people
calm and look objectively at the
problems without blaming each other.
The health group talked about the low attendance at antenatal
and delivery services. They
found common ground on the issue of privacy and security at
the clinic. Community members observed

that at the clinic was too open and no woman would want to be
examined or deliver if people could
just walk by and see her on the examination table or in labor.
The health staff were concerned that
there were frequent thefts of equipment and that people would
barge into the examining room at any
time asking for treatment interrupting the care. They all agreed
that a proper wall around the clinic
and doors with locks would help solve this problem.
The education group did not take long to see together that many
of the classrooms were in
poor condition. Teachers were worried about the many broken
and missing windows, which was a
main reason they did not keep any books or supplies in the
classroom. Parents complained that when it
rained wind blew water in through those broken windows and
drenched their children. They also
observed that most of the roofs leaked. People asked PTA
members, one of the CBOs attending the
meeting, why they had not addressed these issues, and they
explained that they were a small group
and needed the support of the entire community.
When the groups reported back in the evening, the organizers
explained that they could form a
coalition of CBOs and service providers to follow up on these
issues. They would have to set their own
by-laws and structure and make a commitment to find solutions
using whatever resources were
available. One elder asked, “What about roads; what about our
market? You have only talked about
schools and health clinics. We have many problems.” The
organizers explained that it was useful for a
coalition to start with one or two issues and solve those first.
After gaining experience and success they

could decide on any other problems they wanted to address. The
man was happy and suggested that
the people assembled go back to their CBOs and tell the story of
what happened today and encourage
them to follow through. The organizers suggested that before
they depart, that they set a date to form
the coalition and develop work plans to address the two priority
issues discussed at this meeting. A
PTA member spoke up in favor saying that as just one small
CBO they had not been able to accomplish
much, but the idea of a coalition involving all groups in the
community gave them hope.
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Before departing, the group sought five volunteers to form an
organizing committee. The
committee would make arrangements for the next meeting and
draw up a draft set of by-laws for
consideration. One teacher, one nurse, one women leader, one
male leader and one youth leader
were agreed upon as the committee members.
When the group reconvened there were 76 people present. The
organizing committee
presented its ideas for by-laws, and with some modification
these were accepted. They skirted around
the issue of dues, but did mention something about
contributions from the CBOs. They proposed
initially that four committees be formed. An obvious one was an
executive committee of officers. They
also suggested a finance committee. Two program committees
included education and health with a

proviso for adding other committees as issues arose. The group
then divided in two and started
working on developing action plans for the two priority issues
selected last week.
The community organizer from COMPAP was present for the
deliberations, but sat in the back
quietly. When asked about the issue of dues and finance, he
replied simply that the community had to
plan according to its means.
The education group came up with a plan that built on PTA
efforts since that group had raised
some money. They also involved the carpenters’ guild, another
CBO member, but also said they would
talk with the chiefs about asking each household, whether they
had children in primary school or not,
to make a contribution since educated children benefit the
whole community. With members of the
local churches and mosques present they asked that
announcements be made at services to gain
support for this project and maybe even for a special collection.
They agreed that for now the cost of
new roofing sheets was beyond their capacity, but formed an
advocacy delegation to visit the district
council and school board to press the case for repairs. A strong
and articulate member of the market
women’s association was chosen to lead the delegation. A
person was also put in charge of each of
the other components of the plan – the fundraising, the actual
construction.
The wall around the clinic project appeared to be more
challenging that originally thought. A
temporary solution was found when the local safety/vigilante
group volunteered to post a guard at the

clinic 24 hours. One of the women’s church societies agreed to
help keep order inside the clinic on
antenatal days so that people would not barge into consulting
rooms, but take their turn in the waiting
room. On their part, the health staff agreed to come to work on
time so that they could register people
in a timely and orderly fashion and avoid rushing. This group
too, agreed to form an advocacy
delegation. One member said her senior sister was actually a
district council member, elected from a
nearby village, and that they could approach the council through
her. A couple of the social clubs
agreed that if the local council provided money for cement, they
could mobilize the youth to dig and
carry sand to the clinic to help build the wall.
A year later there is still no clinic wall, but ANC attendance and
delivery have increased because
people saw that the guards and the women volunteers at the
clinic were serious in their efforts and
now trusted the clinic. Several large piles of sand were seen at
the back of the clinic. All the schools
have proper windows now, and one classroom per school has a
new roof. Coalition members are
happy with the progress and seem a bit surprised how much they
could do with their own efforts.
Another committee has been formed for making road repairs
within the town through volunteer effort,
and advocacy visits to the local council to get the road into
town paved have started.

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Community Case Study 5: HIV Support Group in South Africa
OXFAM PARTNER PROFILE: Itumeleng
Modimola, Welgeval, South Africa
Itumeleng Modimola, manager of Pholo Modi
Wa Sechaba, is a caregiver, community
worker, HIV/AIDS counselor, fund raiser,
mentor, and role model who has nurtured a
commitment to care for others into a
sanctuary of support for families infected
and affected by HIV/AIDS in South Africa’s
North West Province.
Writer: Charles Scott, South Africa
The tree is a powerful symbol of stability
and resilience across much of Africa.
Trees provide shelter from the blazing sun, traditional
medicines, building materials, firewood, and
food. So, it was fitting that a group of 30 women chose to
gather beneath a tree in Welgeval village in
2002 and decided they had to take action. “When we became
aware of the deadly effect of HIV and
AIDS in our community, we realized we had to do something,”
says Itumeleng Modimola. “It was not
easy when we started; people were not used to the idea of
caregivers and because of the stigma
around HIV and AIDS, people would pretend they were not at
home when we came to visit.”

But the women persevered, and in 2006 their efforts were
rewarded when the local traditional council offered them
land and a building as a base for their organization. Today
Modimola is the manager of Pholo Modi Wa Sechaba, a
thriving community-based HIV/AIDS project in Welgeval in
South Africa’s North West Province. The organization—
whose name means “health is the root of the nation” in
the local language, Setswana—is dedicated to overcoming
the devastating impact of HIV/AIDS in the local
community.
Every day the Pholo Modi Wa Sechaba site is alive with activity
as children from AIDS-affected families
crowd into the small day care room and spill out onto the dusty
playground. In the afternoon, they are
joined by their elder siblings and other schoolchildren for a
healthy meal and supervised afterschool
activities where they learn life skills—such as how to prevent
HIV/AIDS. The once-barren garden is now
green with tidy rows of vegetables. The foundation and walls of
a new community center are taking
shape nearby, the material and labor provided by members of
the organization.
Pholo Modi Wa Sechaba runs a support group for people living
with HIV/AIDS and has 20 caregivers
who provide home-based care services to almost 300 families in
four villages. It is a member of the
AIDS Consortium, a South African national umbrella
organization that helps community groups
struggling to provide services for people living with HIV/AIDS.
A grant from Oxfam America is helping
South Africa has the world’s
largest number of HIV

infections—an estimated 5.5
million of the country’s 48 million
people live with HIV. Women are
hardest hit. In 2005, one in three
women in South Africa aged 30–
34 were living with HIV.
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the AIDS Consortium extend its reach to the North West
Province, where Pholo Modi Wa Sechaba and
some 100 other community organizations will get additional
training to raise and manage money,
design and carry out better community programs, and train their
staff. With the AIDS Consortium’s
help and growing awareness about HIV/AIDS in the community,
Modimola says her organization is
making progress.
“The situation has changed for the better; people are more
aware of HIV and take informed decisions
to protect themselves and their families. But we still have a
long way to go. Government and other
partners need to increase access to anti-retroviral [ARV]
treatment and health services in our area,”
says Modimola. “While we are doing the best we can with
limited resources,” she admits, “training and
retaining caregivers … is an ongoing challenge.” Modimola has
built strong partnerships with the local
clinic, tribal authorities, and government departments. Pholo
Modi Wa Sechaba receives an annual
grant from the provincial government to provide food to 60
families and a monthly stipend for the

caregivers. Once this grant is depleted, however, Modimola
predicts many caregivers will be forced to
quit; they cannot afford to work without pay.
Local caregivers provide a vital service to the community and
fill the gaps in the national health care
system. Often they are the first to identify members of the
community who may have become infected
with the HIV virus and the last line of care for those with AIDS.
While ARV treatment and hospital care
is the responsibility of the state, there are not enough doctors,
nurses, and hospitals to cope with the
spread of the disease.
Like the tree beneath which Pholo Modi Wa Sechaba was
founded, Modimola and local caregivers serve
as symbols in their community. Their steady commitment in the
face of challenges has given strength
to many.
Read | Learn | Change the world
For stories and more information on Oxfam’s
work on HIV and AIDS in South Africa, go to
www.oxfamamerica.org/hivaids.
11
Community Case Study 6: Building a Bridge to Fight Malaria

humanitarian news and analysis
UN Office for the Coordination of Humanitarian Affairs
INDONESIA: Building a bridge to eliminate malaria
NGRECO, 8 February 2009 (IRIN) - Like most remote villages
in Indonesia, Ngreco, tucked away in the
mountains of Pacitan District in East Java Province, suffers
from a high incidence of malaria.
The village's remote location means residents are inaccessible
to district health workers, and have little
access to health care services. In eastern Indonesia, where
malaria is endemic, malaria rates are
usually 20-30 percent, but at one point in Ngreco it reached 80
percent.
In 2006, a US$25,000 grant from the local government allowed
the 5,400 inhabitants to build a much-needed concrete bridge
to replace the precarious, hanging bridge that they had been
forced to use until then. The money was not enough, but the
villagers knew they needed the bridge, and so they decided to
contribute their time and resources to make up the difference.
"Villagers worked in shifts," said Wasi Prayitno, head of the
task force that carried out the project in Pacitan. "Thirty people
worked each day for three months until the bridge was
completed." They were paid 50-70 percent of their normal
wages.
Bridge allows access by health workers

Haryono, the village head, enumerated the benefits they have
reaped from the
bridge: cheaper prices for the goods they purchase, higher
selling prices for their
produce, easier access to schools and hospitals, and, he
emphasised, a drastically
reduced malaria incidence of just 20 percent.
"Before, health extension workers could not get in. The sick had
to be carried out by
villagers on stretchers," he told IRIN. "Now, health workers
come and conduct
spraying and distribute medicine. We also now have a clinic in
the upper side of the
village."
In a country where, according to the World Health
Organization, nearly half the
population or more than 90 million people live in malaria
endemic areas, Ngreco's experience shows
that the government's goal of eliminating the mosquito-borne
disease by 2030 is not impossible. Both
government and private malaria experts told IRIN that reducing
isolation is a critical factor in achieving
this goal.
Photo: IRIN
A new bridge in Ngreco village, East
Java Province, has helped reduce
incidences of malaria
Before,
health

extension
workers
could not get
in. The sick
had to be
carried out
by villagers
on
stretchers.
12
Dave Jenkins, director of SurfAid International in Indonesia,
which runs an anti-malaria programme
covering more than 200 villages in Mentawai Islands, eastern
Indonesia, said that while incidents of
malaria fluctuate based on a number of variables, such as
weather, "access [by health workers] is one
of the critical success factors".
"Isolation is a huge issue," he told IRIN. "It's the reason there's
a high incidence in remote areas."
The Ministry of Health agrees. "Indonesia has a strong health
infrastructure. We have specific malaria
control units in districts. We recruit women volunteers and train
them in malaria control," said Rita
Kusriastuti, the ministry's director of vector-borne diseases.
"But our volunteers can't conduct spraying
and distribute bed nets if they can't access the villages."
"Behaviour change is key"

She added that Indonesia was currently on track to meet the
Millennium Development Goals of halting
and beginning to reverse the incidence of malaria by 2015. "In
Java and Bali, the incidence is now just
0.2 percent," she said.
Jenkins warns, though, that not too much credit should be given
to any single factor, and that an
effective malaria control programme should have a mix of
interventions. "In Mentawai, we have seen
very significant reductions and very strong downward trends,
but not all this is due to our
interventions. There are natural fluctuations in malaria
incidence. Behavior change is key," he said.
"You can't just go into a village and dump bed nets. You have to
educate people in using them."
WHO said that in 2000, only about 0.2 percent of children slept
under an insecticide-treated bed net.
"Once people use bed nets, that's definitely an indicator of
success," Jenkins said.
jd/bj/cb
Please use this proposal form only; submissions not using this
format will not be accepted
604.771.86 – Social & Cultural Basis for Community and
Primary Health Programs
Name(s):
Case Study – Community Change Analysis (Complete Parts A,
B and C)
A. COMMUNITY DIAGNOSIS: Pick one case study and

describe how the following community systems influence the
issue described.*
Name of Case Study -->
Community System
Description of System’s Influence
Social
Cultural
Political
Economic
Geographical
*if any particular system is NOT influential, state so clearly
B. ANALYSIS: Compare two case studies if working alone.
Compare three case studies if working as a group (of no more
than 2 or 3 people). You may write and submit a real-life case
study from your own experience as one of the case studies (if
so, attach to end of this document). Analyze the case studies on
the variables and characteristics in the chart below. Provide
specific examples for each.
Case Study Analysis Sheet
Comment on each of the following factors as best as possible
from information given in the text/case.
Case Study
Name of Case 1
Name of Case 2
Name of Case 3
1. Community typology/characteristics

2. Degree of Collective Efficacy (state low, moderate, high &
explain why)
3. Community Resources – which were available and which
were used to address their concerns?
4. Community capacity changes (what changed? leadership,
participation, behavior, norms, organizational structure,
networks, resources)
5. Which Change Agent approach(es) (see planned change
approaches and Rothman community development models) were
used during the intervention?
6. Level of participation (acceptance, mobilization,
participation, involvement, control) at beginning and at present
point in time
C. DISCUSSION: Compare two case studies if working alone.
Compare three case studies if working as a group (of no more
than 2 or 3 people) and discuss the lessons learned about
community organization and intervention.
Discussion Item

Your Comments
1. This may include attention to possible effects that different
forms of community typology, change agent approach or
collective efficacy had on the success or failure of change and
on promoting participation.
2. Pick one of the case studies you analyzed and describe
possible future interventions to sustain the efforts at change.

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