Providing basic health services in complex humanitarian situations during a pandemic presents significant challenges. Our experience working with internally displaced people (IDPs) in the Cabo Delgado province of Mozambique has taught us that a health intervention can only be successful with effective community engagement strategies. In other words, we either work with the community or we go home.
Engaging with the community is often the only way to guarantee acceptance of an intervention, allowing humanitarian workers to make the most efficient use of limited resources. Without community engagement, the deployment of effective communication strategies to influence perceptions and affect behaviours is almost impossible. In situations where a large inflow of forced migrants intensifies competition over limited resources and upsets the local equilibrium, community engagement is also essential in order to address conflict in a culturally sensitive manner.
The Cabo Delgado province of Mozambique is currently the site of one of the most urgent IDP crises in the world. Violent attacks by non-state armed groups in the north-east of the country and devastation by cyclone Kenneth in 2019 have displaced approximately 732,000 people. This population is now living in precarious conditions with limited access to basic health services. Approximately 36% of the health facilities in the hardest-hit districts have been destroyed and the northern section of the province is an effective ‘no-go zone’, outside the reach of humanitarian actors.[1] The economic effects of the COVID-19 pandemic and limitations on travel and gatherings have also greatly complicated the humanitarian response.
Doctors with Africa CUAMM, an Italian NGO, has been collaborating with local institutions in setting up systems for prevention, identification, referral and follow-up relating to COVID-19, cholera, acute watery diarrhoea, HIV-AIDS and other infectious diseases (as well as in reproductive, maternal and child health issues, and malnutrition). We have learned that providing medical expertise and support to the national health system alone are not enough. Cultural awareness and effective engagement of the local population and institutions are essential to success.
Community advocacy and monitoring
Community activists (CAs) are the core of CUAMM’s work. These people are appointed by the local authorities but are supervised and paid by CUAMM, and can include IDPs. CAs understand the local context and the languages spoken by the forced migrants. They are part of the local health system and serve as a link with the local population. Their training includes early detection and reporting of outbreaks within the community as well as the promotion of preventive behaviours such as social distancing, handwashing and wearing masks. They also undertake advocacy to prevent marginalisation of people suffering from HIV-AIDS, cholera and COVID-19.
CUAMM also works closely with village health committees, community elders, traditional healers, midwives, and formal and informal health practitioners. Village health committees are particularly important; they are composed of medical and non-medical professionals, village elders, religious leaders and other individuals respected within the community, and derive their credibility from the collective authority of their members. With the active participation of the village health committees we have been setting up an epidemiological surveillance system to detect the outbreak of COVID-19 and other communicable diseases, using detection mechanisms (such as private screenings conducted during household visits) that would otherwise be considered too sensitive or intrusive. The engagement of CAs and local health committees is critical to ensuring that the system works, the community is kept informed, and those who abandon their treatment are found and brought back.
We have also learned how essential it is to enlist the participation of village elders, birth attendants, and traditional healers (feticeiros), who, although not formal health-care professionals, are respected in their communities and often accredited by government authorities. These local actors play an important role in raising health awareness and encouraging compliance with preventive measures. In the district of Montepuez, for example, traditional healers were instrumental in convincing reluctant families to adopt handwashing practices in their households and to forgo traditional burial ceremonies. Using more modest alternative rites, where a few selected representatives of the community performed the ceremony, minimised the risk of contagion. Feticeiros also play a key role in discouraging the stigmatisation of people who are infected with COVID-19, thus ensuring that they receive the proper treatment.
Mediating conflict between IDPs and host communities is an integral part of a larger strategy to contain the spread of communicable diseases, as conflict in the community promotes distrust, disrupting the necessary channels of communication for monitoring, referrals and medical attention. To this end, we have found it useful to work with community courts, providing them with medical training and supporting their work; we also complemented their functions by including in our work a) mediating in conflicts over water and other resources and b) advocating on behalf of victims of gender-based violence and accompanying them through the health and court systems.
Integration of displaced health-care practitioners
Among the people displaced by the conflict in northern Mozambique, we identified nearly 600 state-employed health-care workers. While obviously a loss to the populations that stayed behind, these workers presented an opportunity to reinforce the health response in areas where IDPs first arrive. In partnership with the national health authorities, we have begun negotiating the reassignment of these professionals to the fragile state health facilities that have been stretched beyond capacity.
Displaced health-care workers are helping to set up Temporary Advanced Medical Posts in locations where many IDPs are registered and local health authorities are under stress. These posts are accessible to both the migrant and local populations and operate a basic triage system to screen patients and refer them when necessary to government health centres. We have noted that the inclusion of IDP health workers has greatly facilitated communication with the displaced communities and has encouraged trust. Integrating IDP professionals in the health response has also provided them with a source of livelihood and a sense of purpose.
Communication strategy
The engagement of community leaders, including village elders and religious leaders, has been crucial in our attempts to develop an effective communication strategy to disseminate culturally appropriate medical information to remote communities in compliance with the social distancing and travel restrictions imposed by the COVID pandemic. Because of the geographic isolation of many of the IDP resettlement sites and the constraints imposed by the pandemic, many of the methods and mobile technologies traditionally used to raise health awareness are not available. We were able to develop an innovative communication strategy, however, with the engagement of the community.
One approach that proved effective was to enlist a troupe of local actors to help broadcast a series of radionovelas – radio soap operas – in Portuguese and six local languages; these transmitted important COVID-19 mitigation information through storytelling. Radionovelas are very popular in Mozambique, particularly in areas with low literacy rates. In the districts of Montepuez, Balama and Chiure, our radio programmes reach approximately 380,000 people – just over half of the total population of 750,000 people.[2] CUAMM was also able to engage with religious authorities at the national and local level to help disseminate key public health announcements through religious communities.
One of the principle challenges we faced at the onset of the pandemic was how to convey epidemiological risks in a manner that the community would understand and take seriously. During the first months of the pandemic, we needed to dispel several myths about COVID-19 causes and cures that had been proliferating rapidly within the community. To do so, we engaged respected religious leaders to deliver correct information in a manner that was easily understood. The majority Muslim community of Cabo Delgado allowed their mosques’ loudspeaker system to be used to disseminate accurate information, and CUAMM worked with these religious groups both to insert health information into religious services and to devise alternative religious ceremonies that were meaningful yet limited the risk of contagion.
As the migration crisis moves beyond the emergency phase, the community needs to own and be committed to the continuing success of the health programme, for the sake of sustainability. Ultimately, we are merely facilitators. We must either engage with the community or prepare to go home.
Gabriel Cardona-Fox gcardonafox@johnshopkins.it
Associate Fellow, Bologna Institute for Policy Research, Johns Hopkins University; Senior Research Associate, Internal Displacement Research Programme, University of London
Giovanna De Meneghi g.demeneghi@cuamm.org
Country Manager, Mozambique, Doctors with Africa CUAMM
Edoardo Occa e.occa@cuamm.org
Head of Community Health Programmes, Mozambique, Doctors with Africa CUAMM; researcher, University of Milan
Andrea Atzori a.atzori@cuamm.org
Head of International Relations, Doctors with Africa CUAMM, Italy
[1] Humanitarian Response Plan, Mozambique (Abridged Version), December 2020 https://reliefweb.int/sites/reliefweb.int/files/resources/MOZ_2021_HRP_Abridged_Version_20201218.pdf
[2] Source: Radio Comunitaria Mpharama de Balama; Radio Comunitaria Girimba de Montepuez; e Radio e Televisao Comunitaria de Chiure; Instituto de Comunicação Social.