Mixed Service of Human and Animal Health in Pastoral Zones: An Innovative and Promising Experience

Agronomes et Vétérinaires sans frontières – September 2010

Mixed service of human and animal health in pastoral zones:

An innovative and promising experience

Meeting for the organization and welcoming of the mobile health

team

Veterinary care on livestock next to a well

Information and awareness-raising meeting with women on pre-delivery consultation, vaccination and hygiene

Taking care of a patient on site


SUMMARY

1. PASTORAL VASTNESSES WHERE HEALTH IS OUT-OF REACH 3

2. AN INNOVATIVE EXPERIENCE OF HEALTH MOBILE SERVICE 4

2.1. A LOCAL MIXED HEALTH SERVICE 5

2.2. A MIXED HEALTH MOBILE SERVICE 5

2.3. INVOLVEMENT OF LOCAL AUTHORITIES 6

2.4. AWARENESS-RAISING ACTION 6

3. RESULTS, COSTS AND ECONOMIES OF SCALE 7

3.1. ADVANTAGES OF A MIXED HEALTH MOBILE SERVICE 7

3.2. LIMITS OF A MIXED HEALTH MOBILE SERVICE 8

3.3. DURABILITY 8

CONCLUSION 9


This document presents briefly an experience lesson learnt from two projects carried out by AVSF:

The PSSP1 NT, Project of Securization of Pastoral Systems N’Gourti-Termit, implemented by

AVSF in partnership with the NGO KARKARA up North of Zinder region in the districts of

N’gourti and Tesker, North-East of Niger. The P.S.S.P. NT started on December 31, 2003, for

three years. Its global cost is of 1 446 404 €, financed by the EU.

The PNT2, Programme for food security for populations and livestock living in a nomadic

environment, implemented by AVSF in partnership with the NGO ADESAH in the districts of

Ber and Salam, circle of Tombouctou, North Mali. The PNT has duration of 3 years, from 2008

to 2010. It is financed for an amount of 960 000 € by the EU, the RRA (French Region of

Rhône-Alpes) and the Swiss cooperation.

The particularity of these two projects has consisted in implementing a mixed health service (animal

and human) in pastoral zones.

1. Pastoral vastnesses where health is out-of reach

The zones of these two projects are pastoral zones, characterized by:

A major difficulty in physical access (tracks) and deficient communication means for vast zones (for example, the zone covered in the region of Tombouctou is 40 000 km2, ie. area of Switzerland)

The near absence of the basic services : animal health, human health, education; and few state services, due to a lack of means

The absence of private operators : the veterinarians who could settle down in these zones did not stay, because the activity is extremely difficult and non-profit making due to long distances

A mobile and very-spread population (0.5 to 2 inhabitants / km2) of Fulani, Tuaregs and Moorish people, whose principal activity is the pastoral transhumant breeding of cattle, sheeps, goats and camels.

A difficult access to water (families travel up to 10 km to find water in pastoral wells or temporary ponds; during the dry season priority is given to animals)

Strong socio-cultural traditions

A great proximity between humans and animals that increase the risk for zoonotic diseases

Sanitary problems faced in these pastoral zones are linked (a) to the absence of basic services that

could raise awareness on hygiene, help fighting against malnutrition and making prevention against

pre- and post-delivery pathologies and (b) to the proximity human/animal that encourages the

incidence of zoonosis (anthrax, parasitic diseases, tuberculosis, and brucellosis).

1 French acronym.

2 French acronym.


Infant and maternal mortalities3 are the highest in West Africa; populations are not much vaccinated.

Cattle is not vaccinated or too lightly for an efficient protection. Moreover, extremely contagious

diseases are listed as Contagious Bovine Pleuropneumonia, Contagious Nodular Dermatitis and cattle

pox for animals; measles, tuberculosis, meningitis for humans.

With the physical and social characteristics of these pastoral zones, a saving on structure costs can be

made thanks to a mixed service of mobile health. Moreover, with the strong interdependence

between humans and animals, it is difficult to bring care to humans without taking care of herds, and

vice versa.

Testimony of M. Zeini Ould Jalalah, traditional chief in the region of Tombouctou and president of

ASACO monitoring committee.

« I really want to thank ADESAH and AVSF for their actions in our zones and I recall that we do not

have and do not know any NGO that intervenes in our zones except both of them. That is why it is

never talking too much when showing our gratefulness.

In terms of mobile health, I personally think that the system must be maintained but also improved

thanks to the implementation of health huts in identified sites with local staff previously trained by

the team and that can guarantee the continuity of mobile service (advice for drug treatments,

patients follow up, basic cares, etc.) but also support the mobile team in its work. The team has

already trained birth attendants and knows what it brings in terms of work support and agility.

Nowadays, we need to think about it in order to guarantee the permanence of cares in our zones and

it can only be done if the mobile team still has a financing. Some sites have become real villages,

thanks to the support of these NGOs (AVSF/ADESAH). We were looking like dusty luggage, but today

our awakening is accelerating and we need to think about these activities to become viable. »

In this context, how to support health services? How to implement an operating animal and human

health service?

2. An innovative experience of health mobile service

It is a mixed service for animal and human health. On one part, the service is provided by breeding

assistants and birth attendants4, who are settled local actors trained by the projects. And on another

part, the service is mobile via visit tours in the camps5 offering preventive and curative care and

awareness-raising activities. It can be considered as an innovative approach that involves a reflection

on “coupling” animal health and human health. The aims are to facilitate access to health care for

nomadic populations, in particular prophylaxis, and for their livestock, as well as to improve their

sanitary practices by awareness-raising actions. 3 In North Mali, 55 children out of 1 000 die during the pre- or post-delivery period and 6 women out of 1 000

die in childbirth due to complications

4 A birth attendant is a person who comes from the community and who has been trained to follow up of pre-

and post-delivery basics.

5 A camp is a group of 4 to 10 families managed by a camp chief


2.1. A local mixed health service

Both projects are funded on intermediaries that guarantee a basic health service meanwhile the

visits of the mobile teams. These intermediaries, depending on their level of qualifications, make the

early screening for malnutrition, identify and follow up pregnant women, identify non vaccinated

populations (who will be targeted to be vaccinated) and, for the livestock, guarantee external and

internal deworming. The intermediaries come from the communities and provide a paying service.

Their geographical division follows a participative process and strives to cover a vast pastoral zone. In

the Nigerien case, breeding assistants are breeders trained and equipped to provide health care to

animals and to raise awareness on the importance of animal health. First-aid birth attendants are

trained by midwives; they take care of pregnant women’s and children’s health.

It allows offering a real local health service with a multiplier effect (training for other breeders,

awareness-raising, advice on health and hygiene practices). The activity of birth attendants and

breeding assistants helps improving the sanitary situation and facilitates the access to health care for

recurrent diseases; the most difficult cases are orientated towards the nearest health structures.

Involved in training and following up, these structures recognize the functionality of this local mobile

service, underline the positive role played by birth attendants and note the increasing number of pre-

delivery consultations in nomadic populations who were before reluctant.

To conclude, birth attendants and breeding assistants are intermediaries for the mobile caravans of

mixed health.

2.2. A mixed health mobile service

The organization of the mobile service is different for each project.

For the Malian project, the mobile team has different meeting points defined on a participative

division with traditional chiefs and visits each site on the same day each month (for example from

the 14th to the 19th in Hassi Kayar). The meeting points are designed to cover the zone without

competing with existing health structures. Each quarter, the Association of Community Health

(ASACO6), composed of community leaders, defines the meeting points for the following quarters: it

allows taking into account the mobility of the camps.

The visit round of the mobile team lasts 1 month for 21 days working on-the-ground in 7 sites.

For the Nigerien project, only two mobile campaigns were organized in the context of the 2005

drought and in 2006. Teams were composed of civil servants of health technical services and for the

veterinary part, of private veterinarians. For animal health care, the trained breeders assisted the

veterinarians for contention and animal care. The meeting points were defined by the community

leaders of the intervention zone. In order to implement this action, a framework document “coupling

human health and animal health” was signed by the Nigerien Department for Human Health and the

Nigerien Department for Animal Health.

6 French acronym.


2.3. Involvement of local authorities

In Mali, local authorities and decentralized technical services (veterinary services, health centers) are

deeply involved in the brainstorming and the implementation of the health mixed service. A steering

committee composed of these structures with ASACO representatives7 assesses the results of the

mobile team on technical as well as socioeconomic aspects.

The ASACO:

- guarantees a community management and the follow up of the mobile service: ASACO hires

the mobile team and supervises it.

- involves and gives responsibilities to the population on health care issues : definition of the

consultation price, control of the activity, of the cash flows and of human and veterinary

pharmacies

- involves procedures to maintain this innovative system of health access; it negotiates in

particular the registration of the mobile team in the annual operating health plan on a

regional level, which allows to accede to free allowances of national programmes (mosquito

net, iron and vitamin A for women).

The project only has a catalyst role when facilitating to teams the necessary means, allowing

technical services to appropriate their actions. Local authorities coordinate the activities.

Pharmaceutical and veterinary drugs are provided by private suppliers (animal health) or by

programmes (human health).

In Niger, local authorities have participated in the preparation of the visit calendars with the

technical services (health service deeply involved because its officers were part of the visit rounds)

and community leaders.

2.4. Awareness-raising action

Awareness-raising is an essential compound of the mobile service activity; it allows increasing the

impact by approaching populations who are reluctant at first. It is a major aspect for the success of

the service. The aim of the awareness-raising sessions is to improve the practices and the behaviors

of the populations, in particular for human and animal health, and children education. They are

carried out by the mobile team during the visits. It can also be done by community leaders. For

example, in Mali, some families reluctant to vaccination and pre-delivery consultations were

convinced by community leaders. The technical services train regularly the mobile team on modules

to be spread on-the-ground.

7 ASACO : Association de Santé Communautaire (the Association for Community Health), managing basic health

structures in Mali for institutional aspects.


3. Results, costs and economies of scale

The organization of mixed health mobile teams has brought closer the basic health services and the

nomadic populations who were difficult to approach. It allows increasing deeply the vaccination rates

of human populations (factor 1 to 6 in comparison with pre-existing structures when they already

existed). The sanitary system that has been carried out allows accessing the most isolated

populations of the zone.

In the region of Tombouctou in Mali, the annual cost for a mobile team (1 driver, 1 guide from the

communities, 1 nurse, 1 care assistant, 1 breeding technician + depreciation of the vehicle,

maintenance and fuel + technical equipment) is of 29 000 Euros approximately. A human health

consultation is charged 500 FCFA, i.e. 2 times more than in a permanent structure. This amount has

been decided by the communities themselves in order to increase the flow of cash in ASACO. The

pre-delivery consultations are free, in compliance with the national policy of Mali. Medicines are

proposed at the same price as the regional pharmacy.

In terms of animal health, costs are entirely charged on the populations (consultation charged 50

FCFA per head; price of veterinary products slightly uprated to anticipate losses and shipment to

Tombouctou when supply is done directly by ASACO).

Products and services that are at the disposal of the populations are at an affordable price (generic

drugs); beneficiaries have the financial means to pay for health service as well as for animals (thanks

to social assistance: a notable can pay for a person who does not have the financial means to receive

medical care). For example, in the intervention zone in Tombouctou, in case of health problems for

humans or for animals, a minimum amount of 200 000 FCFA (305 €) is necessary for the visit of a

technical agent (vehicle renting + fuel + services) when it is a 500 CFA-cost with the mobile team (less

than 1 euro). Intervention costs remain prohibitive for emergency cases and out of the team visits.

And, it is important to note that before the intervention of the mobile teams, the service was not

much existing in these zones in particular in terms of prophylaxis (vaccination and pre-delivery

consultations) for human and veterinary health.

Coupling allows decreasing intervention costs 45% in comparison with sector strategies. It means

that in case the same service is taken in charge by two different teams for human and animal health,

the cost is increased a 45%. Saving is made on the visit and the vehicle depreciation which are the

highest costs in pastoral zones.

3.1. Advantages of a mixed health mobile service

For the population, coupling is a beneficial action to implement a local system (breeding assistant

and midwives) and to organize the mobile service, what allow them to access health services. Indeed,

the intervention of a doctor or a veterinarian is a high cost in these zones.

For health services, the advantages of coupling are diverse: exchanging experiences, sharing means,

increasing knowledge, improving sanitary coverage, facilitating access to difficult zones,

strengthening service activities, raising awareness, etc. Local service and mobile service allow


facilitating access to health and introducing the habit of medical consultations and animal health

care.

Besides, the management of this service brings closer the different parties (technical services, local

authorities, communities) on a federative action. When starting this action, there have been a lots of

complaints (ones’ inefficiency, others’ hesitations, etc.), but each one has been able to know better

and to understand the constraints of the different actors.

From an institutional point of view, these operations have allowed significant advances:

- In Niger, a framework document on coupling human health and animal health has been

approved.

- In Mali, only ASACO in Tombouctou specifies in its articles the management of a mixed

service and the districts of Ber and Salam have constituted an intercommunity association to

manage this service.

The interest beard by the populations of North Mali to this service has allowed to send 10

supplementary mobile teams in 3 months to cover a contextual need, with the 2010 drought in North

Mali (with the support of technical services, the European Union / ECHO and the French Embassy in

Mali).

3.2. Limits of a mixed health mobile service

The monthly frequency for visits on each site allows in theory realizing vaccination boosters in human

health. But, in case of drought, vaccination boosters can not be done on time due to very significant

and scattered populations’ movements.

The mobile team can not realize medical surgery and must, in case of emergency, bring the patient to

hospital, what brings again the problem of travelling cost.

3.3. Durability

The durability of such service is the defective part of these experiences! For human health, and

despite the population’s enthusiasm, it remains difficult to collect membership funds dedicated to

guarantee the renewal of drugs stocks and to register the salaried doctors and nurses on the state

budget. The national health policy does not take into account mobility.

For animal health, a private supplier could only offer that service in case its fuel and depreciation

costs are taken in charge …

At a ministry level, this action of merging human and animal health needs a long-term-follow up and

a strong institutional approach.

Durability of coupling goes necessarily through the strengthening of the collaboration between both

services (human and veterinary health), the follow up of steering committees composed of different

actors and the creation of a sufficient fund to support this service. In Niger, 2 health departments


have elaborated a framework document which defines the main guidelines to carry out coupling in

pastoral zones; this framework document has not been approved yet.

Constraints in human and animal health are not always the same. In terms of human health, civil

servants depend on 2 different services. In terms of veterinary health, drugs supply still needs some

adjustments.

From Tombouctou experience, steering committees are essential to create a synergy. Even if the

topic is federative, synergy is far from being achieved due to concerns and paths of the different

actors; and in case one actor blocks the situation, all the service is questioned.

To conclude, the populations generally cannot take in charge the mobile teams’ costs for visits and

salaries. If we want a facilitated health access for every one, the State must find the necessary

financial means. But the general context underlines regularly a lack of human and logistics means,

even to guarantee the basic services in secondary urban centers! In this case, a pro-active policy from

the States and their financial partners is essential to cover health needs in Sahel-Saharan pastoral

zones.

Conclusion

In these experiences, coupling animal health and human health allows reducing significantly the

service costs and making it available in isolated zones with an important mobility of populations.

The State must provide a basic health service to its populations. It is taken into account in strategy

frameworks to fight against poverty in many countries and is a whole specified paragraph in the

MDGs (Millenium Development Goals). But, West African States and their local authorities do not

have the necessary financial means. The financial durability and the spread of this health system to

the whole Sahel-Saharan strip can only be realized by a national institutional decision (or sub-

regional) with the mobilization of the financial partners.

Furthemore, this issue overtakes the concern of the sub-regional States. The Sahel-Saharan vastness

shelters important human and animal populations that are not vaccinated and do not beneficiate

from epidemic supervision activities. It represents a mayor risk in the diseases incidence and their

expansion through the frontiers.

Lastly, the awareness-raising actions should allow decreasing the incidence of human and animal

diseases. Consumption practices of animal products (in particular raw milk) and water (traditional

wells with low depth, soil, etc.) are lines of enquiry to find simple solutions in order to improve

population health by changing behaviors and by reducing mortality and morbidity rates.

This experience, very much appreciated by the population and with a lower cost compared to the

sector-based classical system, deserves to be improved and integrated in sanitary development plans

for pastoral zones because it is full of promises and it adapts to the reality on-the-ground.

Mixed Service of Human and Animal Health in Pastoral Zones: An Innovative and Promising Experience

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