Still going after all these years .....?!

The Elim Care Group Project is situated in the far north of South Africa. It is an initiative focusing on health promotion and on development in a rural setting, consisting of community-based women’s groups who are doing voluntary and unpaid work in their own localities. The project began in 1975, and its most distinctive feature is the emphasis on group action rather than on individual community health workers. They started with the prevention and control of a single disease, trachoma, and from there progressed to general health promotion and community development. In this process, there was a concerted effort to enhance the ability of individuals and of groups to address their problems, and to support their initiatives. From a modest beginning, the Care Groups have grown into a large movement of approximately 350 groups and over 10.000 women.

Dynamics of the Care Groups relevant to Sustainability

The project was initiated in response to epidemiological research on trachoma which was at that time the most common cause of blindness in the Elim area. Given that improved hygienic practices would prevent transmission of the disease, while its cure required prolonged daily application of antibiotic eye ointment, and the pre-school children, which were the reservoir of infection, were not adequately reached by the health services, it was clear that reliance on the traditional curative health care approach could not possibly be successful. Trachoma was also a suitable entry point for community involvement because the disease was well known and people were concerned about it. It was therefore not difficult to win a number of village women to join the project. The volunteers organised themselves into groups, electing their own leaders. A hospital-based nursing assistant and a social worker, called "Care Group Motivators", visited the groups at regular intervals and provided ongoing training.

Care Group members were no different from the rest of their community and struggled like others to survive under conditions of poverty and lack of infrastructure, water, fuel and jobs. Their health messages were credible and easy to understand because they were down to earth, addressed common community problems, and were delivered in the villagers’ everyday language. This, and the example given by the Care Group members’ own, now improved homesteads, enabled the rapid spread of health messages throughout communities, and led to a positive competition amongst neighbours to do likewise.

In our experience, this sharing between individuals and small groups has been more effective than health lectures to larger audiences because there is a personal commitment. Many villagers began to set new priorities, especially for the proper use of the little water which was available. Even in very poor settlements the standards of hygiene improved. The prevalence of active trachoma dropped rapidly from then on, and by the early 1990's, the disease had almost completely disappeared from the area. With the growth of the movement, the Groups’ interests diversified increasingly, according to the needs of the various localities. Some addressed community problems such as care for the aged or the disabled, or they organised crèches for children of working mothers. Others turned to income-generating co-operatives. It is the strength of the Care Groups and of the Project Team that they can adapt to changing needs. Whenever they see a health or community problem, and they themselves arrive at a solution through discussion and consensus building, they are keen to pursue the issue with perseverance, even when progress is slow at times.

Sustainability

"Sustainability" in the context of health and development projects is used to indicate the ability of a project to continue functioning after withdrawal of support from outside. At the level of the individual, it means "empowerment", enabling individuals to "help themselves" usually after a brief intervention. At the level of projects or programmes, sustainability implies the building of sufficient expertise and organisational structure to allow the project to function independently.

In reality, the concept of sustainability of programmes is driven by donors, and is usually expressed in terms of financial sustainability. Typically, donor agencies require specified time limits for assistance and strategies to ensure that projects become financially independent within this period, often irrespective of the question whether or not it is good or bad for the future of the project or of the communities involved. In view of the experience with the Care Groups, we wonder whether these interpretations of sustainability are applicable to health and developmental projects, or whether, perhaps, sustainability is a myth.

Why are the Care Groups still going, 23 years later ?

The main factors which, in our view, contribute to the long-term success of the Elim Care Group Project are the following:

Issues in leading and learning: All involved were both learners and teachers without having experience in this type of project. All began with directive teaching, changing rapidly to a facilitating style of interaction. As learner, the Project did not adhere to a fixed programme, which had the advantage that it could be flexible and open to the initiatives of Groups and of motivators. In addition, it was essential that the Project could start with two sensitive and innovative people as the first motivators, and that one of them offers continuity as a key person in the Project until today. Throughout the entire 23 years of the Project, a conscious system of continuous learning for all staff has been in place.

Starting and going slowly (as opposed to "fast-tracking"): There was no motive for rapid success, no personal career advancement nor meeting donor time-tables. This allowed the Project to start slowly, at a pace the Care Groups and Care Group Motivators demanded and could follow. A major advantage of this beginning was that Motivators could take ample time to engage in trust building within communities, and to listen to the people, particularly the grandmothers, before defining action. As a result, each group started around a problem identified as a priority both by communities and by the health services.

Empowerment of groups: Training in problem-solving and decision-making when addressing their own needs strengthened the self-reliance and self-esteem of both individual members and Care Groups. The Care Groups slowly became a force and useful platform for development in their communities. Ongoing training in "Group Building" finally led to the establishment of their own Care Group Council and Management Committee with growing independence from the base hospital. Even with a changing membership, most groups maintained a stable core, thus ensuring a greater degree of continuity than individual health workers could have provided. In addition, by encouraging collaboration with trained Community Health Workers, and by emphasising the need to address problems of poverty and under-development as community problems that need community solutions rather than as individual problems requiring individual solutions, a wide coverage of whole communities ensued.

Financial support of the Project and of individual Care Groups: The Elim Care Group Project started without outside funding, relying on the limited measure of flexibility in the governmental hospital budget to cover this new development. Partly because the problems tackled by the Care Groups were also identified as problems for the health services, and partly because the hospital’s director supported community-based health work in its own right, the shifting of staff from clinical duties to Care Group activities could take place relatively easily. However, the flexibility was soon exhausted when demands were made for the financing of activities that are competing with normal hospital budget line items, such as transport, or activities that are not considered to be health budget items at all, such as funds for bulk-buying schemes, garden materials or water pumps, even though such activities had clear health benefits. Fortunately, the Care Groups found (in the Christoffel-Blindenmission) a donor who was committed to long-term funding which maximised the job security of non-government staff, freed Project staff time from fund-raising efforts, and eliminated discontinuity in programme planning. In addition, the donor was willing to change with the organic changes in the life of the Elim Care Group Project. The mixed government / NGO nature of the Care Groups was crucial in its survival and growth until now, although at times the Care Group Motivators were caught between conflicting demands from either side. What future developments will be, we cannot predict.

In summary, in terms of the control of trachoma which was spearheaded by the Care Groups, we believe that the persistent low prevalence of trachoma is based on a lasting increase in health awareness and practices. In this sense, the Project is now sustainable. On the other hand, this sustainability was achieved through empowering individuals and groups to identify and solve health and development problems. This new found capacity is now being applied to the many other problems facing these communities. Each one of these problems justifies further support, specifically as the geographical and social isolation of these communities has changed little. In this sense, sustainability of the project is a myth.

*Erika Sutter, former ophthalmologist at Elim Hospital, South Africa, Founder and Team Leader of the Elim Care Group Project (South Africa Mission - KEM/DM); Carel B. IJsselmuiden, former Team Leader of the Elim Care Group Project, Professor and Head of the Department of Community Health at the Faculty of Medicine, University of Pretoria, South Africa.

The book "Hanyane, a Village Struggles for Eye Health" by E. Sutter, A. Foster and V. Francis, Macmillan Publishers 1989, is based on the experiences with the Care Groups. This and the French translation ("Hanynane - Bien voir et mieux vivre au village") are both available from International Centre for Eye Health, Institute of Ophthalmology, Bath Street, London EC1V 9EL, UK. The English edition can also be obtained through TALC.