1. 32 nd Global Health Council Conference2005 Mobilizing Underserved Communities around RH: The Nembe Initiative Mike Egboh, MPH Pathfinder International Thursday, June 2 Co-Author: Ebele Udezue

2. 32 nd Global Health Council Conference2005 Introduction  Most hard-to-reach communities have very limited access to health care and social services.  Barriers to services include physical barriers, like the Nembe Creek in the Niger Delta, and religious barriers, like women in Purdah in the north.  These communities have been traditionally ignored over the decades.  Conditions in the Niger Delta have deteriorated due to the crisis engulfing the region since the execution of environmentalist Mr. Ken Saro-Wiwa.  The Nembe Creek initiative is Pathfinder’s attempt to overcome these barriers and draw attention to the plight of these marginalized communities.

3. 32 nd Global Health Council Conference2005 Background  Pathfinder International received a grant from The Ford Foundation to strengthen the delivery of reproductive health and other services in Nigeria.  The project had two components:  Reproductive Health & Community Development (RH/CD) component  The RH component focused on the Hard-to-Reach populations, including Nembe Creek in The Niger Delta, two communities in the Mambilla Plateau, and women in Purdah in Kano State  Institutional Capacity Building (ICB) components.  The ICB component focused on building NGO/CBO institutional capacities.

4. 32 nd Global Health Council Conference2005 Objectives  To create access to high quality, integrated reproductive health information and services for hard-to-reach, under-served and under-privileged populations across the country.  To strengthen the institutional capacity of RH NGOs and CBOs to deliver quality services at the community level.

5. 32 nd Global Health Council Conference2005 The Nembe Initiative Main objective of the project was to enhance the capacity of the community to deal with RH issues

6. 32 nd Global Health Council Conference2005 Why Nembe Creek?  Situated deep in the Niger Delta  Harbors one of the most productive oil ridges for Shell  Lacks access to health care services  Plays host to nomadic sex workers on weekly basis  Very poor health indices  Conflict situation exacerbated poor RH conditions  Lack of support in social services from Shell

7. 32 nd Global Health Council Conference2005 Approach  Needs Assessment:  Used participatory and consultative approaches to conduct community mapping  Focus group discussions (FGD) to identify in-depth community felt needs and set priorities  Structured interviews with key stakeholders

8. 32 nd Global Health Council Conference2005 Findings  Very poor RH indices (High MMR and IMR)  High incidence of malignancies, especially cervical and breast cancer among women  Total lack of modern health care services within the creeks (nearest clinic about 35 minutes boat ride away)  The only primary health center was abandoned.  Lack of trained community health workers (TBAs and VHWs)  High level of ignorance of RH health and services  High levels of sexual abuse, rape and gender-based violence  Erosion of traditional social values as a result of oil exploration and exploitation

9. 32 nd Global Health Council Conference2005 Dissemination of Findings To ensure buy-in and community ownership, key stakeholders were identified and invited to a dissemination workshop, including:  Federal and State Ministries of Health  Donors (UNFPA, UNICEF,USAID,FORD etc)  Community Representatives  Partner organizations (AFRICARE, CEDPA etc)  Media  Shell and other oil companies

10. 32 nd Global Health Council Conference2005 Project Components  Advocacy  Mobilization  Capacity Building

11. 32 nd Global Health Council Conference2005 Using a Participatory Approach  To empower the Nembe community  To involve community members in implementation  To encourage participation among stakeholders for sustainability  To create an enabling environment for collaboration with other partners

12. 32 nd Global Health Council Conference2005 Project Activities  Recognizing a general distrust for outside intervention, initiated advocacy activities with all key stake holders  Worked with community “gatekeepers” to prioritize RH needs  Negotiated other developmental needs with both Shell and the government  Jointly developed project implementation and monitoring plans.  Established inclusive community development committees (CDCs) and Project Advisory Committees (PACs)  Developed training plans for the committees and community health workers

13. 32 nd Global Health Council Conference2005 Activities cont’d  Information, education and communications strategies  Awareness workshop on RH and development for over 500 community members  Pathfinder worked through the existing public and faith-based health facilities  Community-based workers such as the TBAs, VHWs and peer educators were trained, while facility health workers received training in FP service delivery and the syndromic management of STIs

14. 32 nd Global Health Council Conference2005 Achievements  Community response structure developed and operational  Health Center renovated, equipped and LGA staff posted to provide services  Referral linkage with LGA and SMOH established and operational  15 TBAs trained  Project instigated Shell’s participatory community development response  Community development center established and operational for vocational training  Micro-credit established to alleviate poverty and reduce youth unemployment

15. 32 nd Global Health Council Conference2005 Lessons Learned  That communities can be active participants on issues concerning their health, if they are involved in the identification of their own needs, and assisted in setting priorities  More time and attention is required to work with communities to increase access to and use of RH services  That balancing mobilization for RH services with economic empowerment ensures sustainability  Recognition and use of community systems and infrastructures enhances acceptance and use of RH services  It is capital and human resources intensive to work effectively in communities in crisis.

16. 32 nd Global Health Council Conference2005 Recommendations  Community mobilization for underserved populations must be practical and simple  Partnerships must be explored and employed to ensure that community's perceived needs are addressed  Existing community structures must be identified and strengthened for effectiveness.  All key stakeholders including perceived troublemakers must be involved in decision-making.  Each community is different and as such no one model will fit all  Balance awareness creation and demand generation with economic empowerment

17. 32 nd Global Health Council Conference2005 Conclusions  These developments are positive signs that “Hard-to Reach ” communities are not so hard to reach, if appropriate approaches are adopted to meaningfully engage them in activities and inspire their active participation on issues concerning their health and socioeconomic well- being.  Pathfinder’s participatory program development and implementation strategies have enhanced the Nembe communities’ sense of project ownership and involvement.

18. 32 nd Global Health Council Conference2005 Thank you! For more information, please contact Mike Egboh at megboh@pathfind.org Pathfinder International/Nigeria Plot 1456 Justice Sowemimo Street Off T.Y. Danjuma Street Asokoro, Abuja Nigeria