Health Communication, Exchange, resources and links

AfriAfya, the African Network for Health Knowledge Management and Communication, was set up in April 2000 with initial 18-month funding from the Rockefeller Foundation (from January 2001). It emerged from a workshop convened by Kenya-based health development agencies to explore new opportunities for harnessing communication and information technology for community health. The Partner Agencies (PAs) are Aga Khan Health Services, African Medical and Research Foundation (AMREF), CARE International, Christian Health Association of Kenya (CHAK), Ministry of Health, PLAN International, SatelLife Healthnet Kenya, and World Vision International. The project is designed to work through a coordinating hub and seven field centres selected from existing community-based health intervention sites run by each of the partner agencies. HIV/AIDS is being used as the pathfinder topic while the network is being established.

AfriAfya aims to contribute to African health and social development through communicating relevant health information to local change agents. It seeks to establish mechanisms for generating, managing and sharing knowledge at community level through active institutional networking.

AfriAfya’s specific objectives are to:

This paper offers some independent reflections on AfriAfya’s progress towards meeting those objectives from January 2001 until March 2002. It is based upon the participation of the author in two meetings involving representatives from the project’s field centres – one in November 2001, and the second – a mid-term evaluation workshop – in March 2002. The report is based upon a participant observer methodology, supplemented with a review of some key project documents, and informal, unstructured discussions over time with project staff, field centre staff, and members of the project’s steering committee. It is not an exhaustive evaluation review; nonetheless, it does provide some insights into the work of the project – a project which is exciting, innovative and, as the comments below indicate - effective.

The main justification for the project is important to understand. It tackles two processes that are all too often neglected in development projects:

The original project proposal notes that an abundance of health knowledge exists both locally – within the communities in which the field centres work and within the experience of the field centre staff – and globally – in a range of locations and containers. Much of the global knowledge, however, is not accessible locally – due in part to the ‘lack of an appropriate mechanism for harnessing, synthesising and packaging this information in a form that is relevant, appropriate and user friendly’.

The proposal also highlights the problem that much of the local knowledge is not valued externally. In part, this is also due to the lack of an appropriate mechanism for making local knowledge more visible and relevant to the global community.

Underpinning all of this is the lack of a mechanism for regular sharing of knowledge and experience among organisations working on similar concerns. This starts to unfold the communication issues within knowledge generation. Another aspect of the communication process is that the communication tools, methodologies, formats (and perhaps even the processes) used by communities often differ vastly from the modern information and communication technologies favoured in the global system.

AfriAfya set out to explore interactive knowledge generation and management and communication at the community level with a view to strengthening both processes. It is seeking to increase (individual and collective) learning, build better knowledge generation and sharing mechanisms, and improve communication practices.

This paper particularly focus on the work of AfriAfya around these learning and sharing/communicating processes.

Part of AfriAfya’s exploration process was to see whether newer technologies – computers, e-mail, satellite receivers to download selected web content (WorldSpace) – could interact successfully with more traditional technologies – print, storytelling, puppet shows, drama, video, radio – to improve access to health information for community health workers in marginalized Kenyan communities.

Each of the seven field centres was provided with a computer and its operating software, a printer, WorldSpace receiver and PC adaptor, one field centre was additionally provided with a TV and video. The field centres were existing community-based health intervention sites. They are situated throughout the country and in a range of settings: an urban slum community-based health care project, a rural dispensary, a mission hospital, a rural community training centre, a community-based child survival project, a primary school and a District Medical Officer’s office.

Field centre staff involved in the project were given initial training in use of the computer and the WorldSpace receiver during a workshop in June 2001. This workshop also provided some training in how to develop a workplan, and each of the centres also developed a workplan.

Much of the workplan was based around the findings of a baseline assessment of each of the communities. This assessment considered:

It also considered available knowledge, attitudes and practices around HIV and AIDS.

This approach was used to ensure that the idea of the need for a strong two-way communication process was embedded strongly in the project from the very beginning. The information and the technologies were meant to respond to community needs. The idea was to find out what communities already know, be clear about how they communicate and how they prefer to communicate and what further information they want.

This is describing a demand-led system, one that is community-focused.

Two measurements of whether AfriAfya is achieving its objectives relate to the amount and type of vertical communication and of horizontal communication.

Vertical communication can be:

It should be flowing well in both directions.

Horizontal communication can be:

There are signs that both vertical and horizontal communication is on the increase. As a result of the improved access to information in the field centres, more community members are asking questions. Some of those questions are becoming complex and very personal and specific to individual situations. That they are being asked indicates a growing sense of trust being established between the communities and the field centres.

In the case of the field centre at the District Medical Officer’s office in the Ministry of Health (where the community is a set of dispensaries, health centres and hospitals throughout the district), there is a clear improvement in flows in both directions. In 2000, only 49% of the health facilities were regularly filing monthly reports; in 2001, 85% were doing so. Why did the increase happen? Because with the improved technology, the District Medical Officer was able to produce regular and timely syntheses of the individual reports and circulate them back to the health facilities. A further indication of improvement is that the 2001 annual district report was out in March 2002 – much earlier than it ever appeared previously.

The Provincial Medical Officer in whose territory this district is located has noticed the improvement and is now interested in involving other district offices in the project - another indication of vertical communication having impact.

Meanwhile, another layer down, the dispensary in this district that is also a field centre has been noticed by other dispensaries. They, too, would like to get involved, an example of some horizontal communication.

In the primary school setting, children participating in the health club are now increasingly playing a role within their community and families to encourage discussion and dialogue about HIV and AIDS. Other schools in the area have heard about the work being done. The partner agency is interested in involving them in the AfriAfya project. Horizontal and vertical communication are interacting here.

Between the different field centres there is some limited horizontal communication, but it usually needs mediation. Whenever there is a meeting involving the different field centres, the communication is evident. The nurse at the mission hospital, for example, described how she was able to use the WorldSpace radio broadcasts on health topics to start discussions. Other field centres, who had not seen the benefit of the radio, excitedly took down the details of the channels and the times. A new strategy was being adopted. Between meetings, however, there is little exchange among the field centres, something that the hub is planning to work on in the future.

The communication between the partner agencies in AfriAfya is increasing. A quarterly meeting of the chief executive officers (CEOs) of each of the agencies is one way this is happening. Interestingly, the CEOs are so pleased with what is happening in AfriAfya, that they are advocating for closer cooperation in other areas. This type of horizontal communication could have positive benefits for development work throughout the country. And, if a little horizontal communication happens in each of the agencies, the impact could spread to other countries, as most of the partner agencies have country offices elsewhere.

Is all this communication systematic? Is it consistent among all the centres and communities? Is the flow strong in both directions? Does it work more effectively in particular settings? If so, why? These are some of the questions AfriAfya could pursue in future work.

Two weak points in the communication chain that can be (and have been) identified (other than the point made about the flow between field centres) are the flow between the hub and the field centres and the flow between AfriAfya and related organisations in Kenya.

Project staff and field centre staff are critical of the limited nature of the flow from and to the hub. There is flow, but it is not as strong or as consistent as anyone would like. Field centres are aware that they are not sharing lessons enough. The staff at the hub are aware that they are not following through on communications sufficiently to ensure that they have been received and are being acted upon. All parties are increasingly becoming aware that they need to focus more attention on this.

Staff at the hub of AfriAfya have been good at developing and seizing opportunities to share the lessons of the project with external agencies. Talks at a world congress in Argentina, an international workshop in Tanzania, and a meeting of the Health Information Forum and a lunchtime discussion plus a sensitisation tour in the UK are some of the more recent examples. However, AfriAfya has been less effective at ‘spreading the word’ and connecting with related organisations within Kenya itself. There are valid reasons for this – not the least of which is simply the time available. However, this is probably an area that needs some prioritising in any future work.

One of the strategies that AfriAfya is introducing to improve ‘internal’ horizontal and vertical communication is the recruitment of a new staff person who will undertake a series of visits to all of the field centres. This face-to-face opportunity will help to strengthen the horizontal flows between the field centres as well as introducing a mechanism that can strengthen the horizontal communication between the hub and the field centres.

Exchange visits among staff from the field centres is also being discussed. This would be a useful learning approach, and would also strengthen peer monitoring and evaluation activities within the project. It is certainly worth pursuing further.

This improved (and improving) communication flow is a major achievement for AfriAfya. But there are others. At the March 2002 workshop, staff from the field centres were able to point to many achievements they felt were significant, including:

For some of the individual organisations involved in AfriAfya, there have been strong achievements as well. Generally, they see the involvement as something that helps to strengthen and promote their own organisations. But for some, such as the World Vision field centre, the work with AfriAfya has helped ease the introduction of an HIV and AIDS component into the overall programme of the organisation.

Improving the communication flows within the AfriAfya ‘system’ is probably the major challenge facing the project. Some mechanisms for doing this have already been proposed and some have been put in place. More generally, strengthening communication skills and capacity within the staff in the field centres has been identified as a key to better communication.

This also includes looking at ways of adapting information so that it is relevant and appropriate for the audiences and so that it responds to the demands coming from community members. Strengthening the knowledge management system at the hub and looking at ways to develop repackaging skills will be important steps for the future.

AfriAfya has been experimenting with various media and ICTs. But there is more that could be done. Greater use of radio, of video, of traditional media are possibilities that could be explored. Already, there is a strong sense within the project of the benefits of combining different approaches and different media and channels to communicate information. This needs to continue through looking at ways to move beyond the computer.

Many of the lessons that have been learned as a result of AfriAfya are not necessarily new. For many people who are involved, they simply reinforce and strengthen the validity of lessons that have already been learned. The experience of AfriAfya has also served to move some of those lessons from the realm of the theoretical to the realm of the practical. People are learning the lesson of not simply what it would be good to do, but how to do it and – perhaps most importantly – that it can be done in Kenya with limited resources.

Among the lessons identified in the March 2002 workshop are:

There are clear signs that AfriAfya is having impact on the communities in which it is working. People are discussing HIV and AIDS, asking questions they would not have asked before, seeking voluntary counselling and testing services, asking for condoms more than in the past.

There are clear signs that AfriAfya is having impact on the organisations that are involved in the project. The dialogue among the CEOs, the improved performance of particular field centres, the enhanced capacity of staff are only some of the indicators of this.

There are also signs that AfriAfya is having impact internationally. Its findings are being received with interest. For example, from the presentation at the workshop in Tanzania in March 2002, an organisation in Ghana and a major health foundation that supports it, are now considering exploring a similar approach.

But AfriAfya has also had a very powerful impact on the individual people working in the field centres. They talk about the involvement as something that has changed their lives, as something that has improved their own personal development and as something that has made it easier for them to serve their communities.

These are just some of the comments:

The last word goes to Rebecca Amimo, a school teacher in the Plan International field centre in Diemo Primary School in Kombewa:

Reflections on AfriAfya