In October 2007, AMREF launched a groundbreaking three-year development project in the Katine sub- district of northeastern Uganda, one of the country’s most impoverished regions. Created in partnership with the Guardian and Barclays, the project works with the people of Katine to improve their lives while at the same time educating the UK public about international development.

Katine was badly affected by civil war in the first half of this decade. Many residents lost their homes, their belongings, even their lives when rebels from the Lord’s Resistance Army ransacked the area in 2003 and again in 2005. As the people of Katine returned to what was left of their villages, they faced destitution.

Because the needs there are so great, the Katine Community Partnership Project (KCPP) focuses not only on health and water and sanitation but also on education, livelihoods, and governance. The Guardian, meanwhile, brings the story of Katine to as many as 400,000 readers every week through the project website (www.guardian.co.uk/katine) and the newspaper itself.

Bringing Hope — and Talk Radio — to Katine

On Christmas morning, a voice rings out across Abata village in Katine.

“Today is a big day! I know you’ve prepared a lot of food for the festivities. But before you begin, I want to remind you — do not give the food to your children before you heat it.”

It’s the voice of Ruth Emolu, a member of one of the village health teams trained by AMREF. She has risen early this morning to deliver a message of goodwill and healthy eating to the residents of her community. She strides purposefully among the huts, megaphone in hand.

“Even if you are feeling tired or the fire has gone out, you must light it up and warm the food so they do not get sick!”

Ruth takes her role on the village health team very seriously, educating her community with equal part concern and enthusiasm. Every week she visits families to teach them how to keep their homes clean, ensure they use mosquito nets, and protect the water they collect from the new village borehole from contamination.

In nearby Soroti town, Margaret Aniko spreads similar messages across Katine on AMREF’s weekly radio show on Delta FM. Every Friday from six to seven in the evening, volunteers and staff from the Katine project deliver the latest project news and discuss the issues affecting the people of the sub-district.

Speaking in Kumam, a local language, Margaret encourages pregnant women to go to their local health centres for checkups and announces visits by the mobile immunisation teams. Listeners from all over the region call in to ask her questions about health and sanitation, which Margaret, a member of one of 272 AMREF-trained village health teams, answers confidently.

In areas where there are few doctors, village health teams play a vital role. Comprised of trained volunteers like Ruth and Margaret, they provide treatment and advice and make referrals for their patients.

“There are 100 homes in my village,”says Ruth.“People are clean and healthy, and our children are going to school. I have seen a great change since AMREF came to work with us.”

Margaret sees personal as well as communal benefits: “I feel I am more empowered and valued with equal footing with my husband,” she says. Nowadays, she’s a minor celebrity — people approach her for health advice even when she is not on the radio.

Ruth Emolu spreads health messages through her village. Photo: Stevie Mann/AMREF

Goal 1: Train 100 health workers

Goal 2: Reduce malaria prevalence

Goal 3: Improve borehole coverage

Goal 4: Immunize 100% of kids

Project Photos & Video

View the project brief (pdf)

It’s 10 a.m. and the maternity ward at Lui Referral Hospital teems with patients. New and expectant mothers queue patiently in the hallways and waiting rooms. They wait to receive antenatal check-ups, fill prescriptions, even give birth.

In the middle of everything is Alice Taabu. One of only two qualified midwives at the 75-bed hospital, Alice calls her patients into the consultation room, one by one. They come from as far as two, three counties away.

“I attend up to 40 patients every day, another eight inpatients, as well as deliveries. It can be challenging, says Alice. especially when a delivery is due,” Alice says.

Alice handles the pressure well. She takes her patients’ histories, discusses the importance of a hospital delivery, counsels them on family issues, provides advice about nutrition, and performs physical examinations. At intervals she checks on the progress of patients in labour.

“I divide my time between the antenatal clinic and the delivery wards to monitor the mothers. When a delivery is due, I often have to abandon all else to attend to it.”

A few years ago, Alice could not have imagined she would be shouldering such responsibilities. She dropped out of secondary school after only a year because she couldn’t afford the fees. Medical training was a faraway dream.

But with support and encouragement from her family, Alice entered the AMREF-run Lui National Health Training Institute in 2006, where she trained as a community midwife. She graduated with her certificate in 2008.

“The training I received from AMREF has helped me a great deal,” she says, proudly. “I can tell when labour is obstructed; I can identify and deal with cases of post- partum bleeding. I can fix nasal-gastric tubes for feeding, I can even transfuse blood and set up intravenous lines.”

Alice is one of the building blocks of southern Sudan’s fledgling health system. Decades of civil war destroyed most of the region’s hospitals and health clinics. Many of the region’s health professionals fled the country, leaving fewer than 1,000 to serve a population of over 8 million.

Working with the Ministry of Health in southern Sudan, AMREF is helping to rebuild the health system from the ground up. Every year we train thousands of health workers like Alice, graduating midwives, laboratory technicians, nurse’s aides, clinical officers, and more.

“Before I was in darkness, but now I am in the light,” says Alice. “I am grateful to AMREF. Without their help, this would not be possible.”

Southern Sudan still needs health workers. But with talented, enthusiastic people like Alice in place, there is hope.

Our work in Sudan is supported by Direct Relief International.

Sub-chief John Losikiriat educates children about hygiene and sanitation  Photo: Tyler Stiem/AMREF

Goal 1: Train 100 health workers

Goal 2: Reduce malaria prevalence

Goal 3: Improve borehole coverage

Goal 4: Immunize 100% of kids

Project Photos & Video (to be added)

View the project brief (pdf)

For years, Ester Nakamya struggled with stigma. A health assistant at Kasana Health Centre in Luwero, Uganda, her job was to educate people about TB and encourage them to be tested and treated if they were infected.

But TB was not well understood and that made her job difficult.

“Someone with TB was assumed to be promiscuous. People believed that TB was fatal and you would die very quickly,” she says.

Compounding the problem, the links between TB and other diseases, such as HIV/AIDS and malaria — the diseases responsible for the greatest number of deaths in Luwero — were not well delineated. Patients were often tested and treated for one disease but not necessarily all three.

Yet research shows that half of all TB patients in Uganda are also HIV-positive, and nearly a third of AIDS deaths are the result of TB-related complications. Likewise, an HIV-positive person is more likely to die from malaria, and malaria can increase viral loads and the risk of mother-to- child transmission.

When a person is infected with multiple diseases but diagnosed and treated for only one of them, they are much less likely to recover. This in turn reinforces the perception that TB and HIV/AIDS are devastating, terminal illnesses.

“People who were infected [with TB] didn’t want to go to the hospital,” says Ester. “They were ashamed, and they saw no point.”

Yet when treated at the same time, TB and malaria can be cured and HIV/AIDS can be managed effectively. In 2006, with support from AstraZeneca, AMREF launched MAT, an integrated disease management programme in central Uganda.

Designed to tackle all three diseases simultaneously, MAT trains village health volunteers like Ester to collect data using questionnaires translated into local languages and then feed them into the district health management information system.

Health authorities in the Luwero and Kiboga districts now have a more accurate picture of the local disease burden and are thus better able to manage drug supplies and allocate resources.

Through an integrated referral system, the MAT programme also helps government health departments to work more seamlessly together, taking a big-picture approach to disease management.

Two years into the five-year pilot programme, AMREF and Ester have already seen changes, both in the health of patients and in overall attitudes towards TB and HIV.

“People seek treatment more often now,” says Ester. “I was touched to hear one of my patients tell me that ‘Tetukyali babisi ku ndwadde zi namutta ng’edda,’ meaning, we are no longer ignorant about the killer diseases like before.”

Photo: Nell Freeman/Getty Images

Goal 1: Train 100 health workers

Goal 2: Reduce malaria prevalence

Goal 3: Improve borehole coverage

Goal 4: Immunize 100% of kids

Project Photos & Video

View the project brief (pdf)

Amina Abdi is 13 years old and a student at Ushirikia Childrens’ Centre in Kibera, a large informal settlement of over a million people on the outskirts of Nairobi. Her school is one of 30 where AMREF and GSK have launched PHASE, a personal hygiene and sanitation education programme targeted at students, teachers, and their friends and families. Here she describes her life in Kibera and how the programme has benefited her neighbourhood.

Life in Kibera is of hope and despair, happiness and sadness. Last week, a train derailed and some people died. I was very sad. Sometimes houses catch fire because people’s houses are crowded and people lose property. There is also shortage of water and we do not have toilets.

I am a class 5 pupil at Ushirika children centre in Laini Saba neighbourhood of Kibera. I love to study and I love my teachers. I have been in this school ever since nursery school. The only problem was that before PHASE we had just one latrine that we shared with boys.

When we are in our periods it was very difficult. We had no sanitary towels and when we go to the toilet to change the cloth material that we use, there is always a line. So people make noise: “You. . . young girl, what are doing in the toilet for all that time? Come out. This is not a hotel!” For boys, it’s easy because when pressed, they can help themselves anywhere in the slum. They don’t care. For short calls, they just stand against a wall and it’s done. These are some of the things that make life in Kibera challenging.

Ever since AMREF introduced the PHASE programme, I have seen admirable changes in our school. AMREF built for us a four-door latrine and now we have more privacy especially during our menstruation cycle. We also have a water tank and water supply. We use the water to drink, cook and wash our hands after visiting the toilet.

I am a member of the PHASE school health club. There are 28 of us, and we meet every Tuesday and Thursday after school. Club activities include cleaning the school compound, washing school latrines and ensuring that they are properly used. Club members also supervise filling water into our leaky tins [handwashing stations] and advising other pupils to ensure their personal cleanliness is improved. We also share health messages to the entire school, our siblings and our parents.

PHASE project is very important because through it, we can prevent the spread of diseases like cholera, typhoid, dysentery and intestinal worms. We always was our hands and we also get drugs for de-worming and vitamin A which have greatly improved our health. Through PHASE project, we have come to know the importance of personal cleanliness, and of eating clean, properly cooked and balanced foods.

Now we have more time in class without being sick and we are slowly improving our academic performance. We really thank the GSK and AMREF for bringing PHASE to our school.

AMREF’s work in Kibera is supported by GSK.

Amina stands at the PHASE mural in her school. Photo: AMREF

Goal 1: Train 100 health workers

Goal 2: Reduce malaria prevalence

Goal 3: Improve borehole coverage

Goal 4: Immunize 100% of kids

Project Photos & Video

View the project brief (pdf)

It’s the rainy season in eastern Tanzania. The villages of Mtwara are buzzing with excitement — and mosquitoes. Today is Village Health Day, a monthly event organised by AMREF and local leaders that brings people together to eat, socialise, and talk about health. Especially malaria, a leading killer of children under five across sub-Saharan Africa.

In Namkuku Village, a drama group performs a skit about insecticide-treated bednets. The audience has formed a circle around them and watches intently as the actors dramatise the conflict within a family about who should sleep under their net.

“You’re a strong man,” says the actress who plays the wife. Like everyone in the cast, she belongs to the AMREF-trained village health team. “You have some immunity against malaria. Our babies have no immunity yet. If they are bitten by mosquitoes, they will get much sicker than you.”

The actor playing the husband pretends to think about this for awhile. Finally, he agrees. “You’re right. We will get a second one. You and the babies will sleep under this one in the meantime.”

Because of its coastal setting and relative impoverishment, Mtwara District suffers from malaria mortality rates twice the national average. The majority of the deaths are among infants and young children. AMREF’s Mtwara Malaria Control Programme works closely with district authorities and local communities to provide education, training, nets, and medicine so they can overcome the burden of chronic ill-health caused by malaria. Community health worker Amina Nwaya explains why education is important:

“The problem isn’t that people in my village can’t afford nets,” she says.

“Some can, some cannot. The bigger problem is education. People have resigned themselves to getting sick. They think the nets do not make a difference or they even believe that sleeping under a net will cause suffocation.”

Trained by AMREF, Amina regularly visits the families in her village to make sure they are protecting themselves against malaria. Like the 1298 other health workers AMREF has trained in villages across the district, she is especially vigilant when it comes to new mothers and their babies.

“Malaria can progress very, very quickly in infants especially. I teach mothers to identify the symptoms and encourage them to call on me any time. Then I can advise on treatment and make a quick referral to the local health clinic.”

Since 2007, the Mtwara Malaria Control Programme has distributed over 9,000 insecticide-treated bednets since its inception. Over 90% of young children, nearly 80% of mothers, and 50% of fathers now sleep under nets [Bindu to confirm these stats]. Malaria deaths have dropped significantly among mothers and children as a result.

Liyaya Dihone, a mother of three from nearby Mbambakofi Village, has seen firsthand the difference bednets and health education can make: “Before AMREF came, I used to go to the dispensary every week for malaria treatment. I or one of my children was always sick. I worried I would lose them, but like most people, I accepted that malaria was a fact of life. You couldn’t escape it.”

“With AMREF’s help, I have come to realise that I myself have the power to protect my childrens’ future.”

Our work in Mtwara is supported by the European Union.

Mother and child with their insecticide-treated net. Photo: Stevie Mann/AMREF

Goal 1: Train 100 health workers

Goal 2: Reduce malaria prevalence

Goal 3: Improve borehole coverage

Goal 4: Immunize 100% of kids

Project Photos & Video

On the plains of Kenya’s northwestern frontier, a group of nomads march their herds of bony cattle to water. The dry season has begun and the reservoir, constructed by AMREF in 2001, is a vital source of water in this harsh, drought-prone region.

“During the rainy season, we bring our livestock for watering almost every day. When it becomes dry and we must search for pasture, we come here less often because it involves walking very far,” says Lorot Lorimor.

Tall, thin, and armed with a Kalashnikov rifle, Lorimor will spend a week camped near the reservoir with his adakar, a group of 50-100 families that forms the basic social unit of Turkana society. The Turkana are nomadic pastoralists who have for centuries migrated across the region as part of their traditional way of life.

“You can see the men carry guns,” says Peter Ngala, a public health officer who works closely with AMREF here. “This is for protection. Because of the droughts, they must travel long distances to find water and pasture and this brings them into conflict with neighbouring tribes.”

Climate change has made life increasingly difficult for the Turkana. As water becomes scarcer, they struggle with parasitic infections. Kenya’s health care system, already weak, does not reach them because they’re always on the move, travelling from one swath of pastureland to the next. The lack of services, coupled with disease and gun violence, has made them one of the country’s most vulnerable groups.

With input from Ngala and the Ministry of Health, AMREF has developed an innovative programme to bring clean water and health care to the Turkana people. Using maps of the migratory routes, we have begun to establish dispensaries and health clinics along them. Each medical outpost will, upon completion, feature a borehole and/or rain catchments.

“The idea is that the adakars will be able to access health care and clean water as they move. This will help prevent disease and reduce conflict — they will no longer have to cross into enemy territory to water their livestock,” says AMREF programme manager John Kener.

To this end, AMREF is also training community health workers from within the adakars to diagnose and treat common illnesses. They refer serious cases to the hospital in the nearby town of Lokichoggio.

This project is funded by the European Commission and Big Lottery Fund.

Sub-chief John Losikiriat educates children about hygiene and sanitation  Photo: Tyler Stiem/AMREF

Goal 1: Train 00 community health workers

Goal 2: Build 00 mobile health centres

Goal 3: Improve borehole coverage by 00%

Goal 4: Immunize 00% of children

Project Photos & Video

View the project brief (pdf)

Today, Edina Japheth is the happily married mother of a young child. But just a few years ago she was treated as a pariah in her own village, rejected by her neighbours and her family because of an injury she sustained during childbirth that left her incontinent.

“I was fetching water by the river near my home when labour started. I went to see my aunt, who is a traditional birth attendant. At first everything was fine, but the labour went on for many hours. Eventually my aunt sent me to the nearest medical dispensary. They said they couldn’t deliver my baby either, and I was referred to the district hospital.”

Edina was rushed into surgery for an emergency cesaerian section, but by then it was too late. Her baby had died. Discharged from the hospital and still coping with the trauma of her loss, she discovered that she was wetting the bed and dribbling urine throughout the day. She was suffering from fistula, a hole that can develop between the bladder and the vagina during childbirth.

“There was a smell that I couldn’t get rid of. People looked at me as though I was not a human being, and even my family started to keep their distance, refusing to eat with me because I was unclean. My husband rejected me. It was terrible.”

Edina suffered with the injury for three years, until she heard about the Ministry of Health and Social Welfare, Tanzania National Fistula Programme run in collaboration with AMREF and Women’s Dignity, a Tanzanian charity.

“Under this programme we now offer fistula repairs free of charge,” says Dr. Gaudens Konba. A gynecologist and obstetrician, Dr. Konba has received training from AMREF on three separate occasions and now works at a district hospital in southwestern Tanzania, where he performs the surgery on as many as 100 patients per year.

In 2008-09, AMREF and its partners trained seven doctors and eleven nurses and operated on 463 women in Tanzania — more than six thousand since the programme began, seven years ago. Fistula can be repaired with local anaesthetic and patients tend to recover quickly, making it a very effective medical intervention.

Edina was discharged after two weeks and went home to her family. A year later she was married to a young man in a neighbouring village, got pregnant, went straight to the district hospital, and delivered a healthy baby. She has put the years of stigma and discrimination behind her, but cannot forget them.

“When I think about the suffering of those years before, it seems very far away, but I think it is important that people understand that fistula is an injury, not a hygiene problem.”

In addition to our work with surgeons, AMREF is teaching midwives, traditional birth attendants, and other frontline health workers to identify labour complications and make quick referrals. We’re also educating communities about fistula to discourage stigma.

Our work in Tanzania is supported by the Federation of Gynecology and Obstetrics.

Dr. Asrat Mengiste examines some x-rays. Photo: Stevie Mann/AMREF

Goal 1: Train 100 health workers

Goal 2: Reduce malaria prevalence

Goal 3: Improve borehole coverage

Goal 4: Immunize 100% of kids

Project Photos & Video (to be added)

This project was completed and handed over to the government and communities of Soroti District, Uganda, in December 2009.

“This is a very exemplary borehole. You can admire how the community has owned the project. They really feel that it is theirs,” says government health inspector Moses Amolo, indicating one of the boreholes AMREF recently handed over to the people of Soroti District, northeastern Uganda.

“It is a big improvement. You cannot believe how it was before. Everything, all of the health centres were badly destroyed by rebel attacks. There was no clean water, people were sleeping in the open,” says Robert Emwoku, the headteacher at Ojuba Community Primary School and a member of Ojuba Village’s water and sanitation committee.

He smiles proudly: “[My] pupils are benefitting especially. They are the ones who are maintaining the sanitation of the borehole.”

Ojuba is one of the many rural communities that dot the forested plains of Soroti. Badly affected by drought and by a war that displaced thousands of its residents, the region has only just begun to recover.

AMREF was among the first non-governmental organisations to lend a hand to the long-term rebuilding process, and in 2009 we completed our first? major project in the region, the four-year Soroti Integrated Care Programme.

“Because the need in Soroti was so great, we knew we must address the health problems from the ground up,” says programme manager Nico [Lastname]. “There were very few government services, and the communities were very fragile.”

The programme, which has been fully adopted by the people and government of Soroti district, is an example of AMREF’s unique, collaboration-rich approach to health. Bringing together the district government, community leaders, and the people of Soroti, we have repaired health facilities, sunk boreholes (making sure to teach communities how to maintain them), provided basic health education, and improved service delivery by training village health teams (VHTs) how to diagnose and treat simple diseases and refer more serious cases to the newly refurbished clinics.

“AMREF and the village health teams have helped us to run the health centres more smoothly and serve more patients,” says nurse Daphine Akello. Attached to Bugondo Health Centre near Soroti Town, the district capital, many of the patients she sees are referrals from the VHTs. She continues:

“Thanks to the VHTs, the nurses and clinical officers can spend more time with individual patients. We also have more time to manage our supplies, so there are fewer stock-outs.”

Since the project started, AMREF has sunk xx boreholes, distributed 12,000 insecticide-treated bednets, trained 126 water and sanitation committee members, and refurbished xx health centers. We have also established 44 community development committees to help plan and manage the overall development of the region.

“You can see the difference everywhere,” says headteacher Robert Emwoku. “People are healthier, more secure. We feel like we have control of our own future now.”

“Our goal when we started this ambitious project was to see it taken over by the district health authority and the communities. We can now say that our interventions are sustainable, they work, and we have done our job,” says [Nico’s Lastname].

“The next step is to apply the lessons here to other parts of Uganda.”

Our work in the Soroti district of Uganda is supported by the European Union.

Residents of Katine share a laugh. Photo: Dan Chung/The Guardian

Achievement 1: Train 100 health workers

Achievement 2: Reduce malaria prevalence

Achievement 3: Improve borehole coverage

Achievement 4: Immunize 100% of kids

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