Integrated Community Based Child Survival, Reproductive Health and Water and Sanitation Program in Mkuranga District, Tanzania: A Replicable Model of Good Practices in Community Based Health Care

This journal article shares the experience of the African Medical and Research Foundation (AMREF) in using community-based health care (CBHC) approaches to implement integrated water and sanitation, child survival, and reproductive health programmes in the Mkuranga District of Tanzania. According to the article, in order to achieve the Millennium Development Goals (MDGs) and the National Poverty Reduction Strategy goals, building partnerships with communities who are the key beneficiaries is a prerequisite. The study concluded that the model demonstrates that community participation is key to community empowerment, as well as community ownership and sustainability of health interventions.



In four wards in the district, AMREF initiated a 5-year water, hygiene and sanitation (Watsan) project in 2001, developing and testing models and approaches which work effectively in rural and poor income urban areas to increase access to safe water and improve sanitation. AMREF then introduced a reproductive health and child survival programme in response to community demand for further capacity building. It began with piloting a community-integrated management of childhood illnesses (c-IMCI) project.


CBHC was the fundamental implementation approach for this programme. In order to enhance community participation, AMREF used community forums, inter-village competitions, community theatre groups, village health days, and house-to-house visits as broad community mobilisation approaches. Trained community owned resource persons (CORPS) used checklists assessing hygiene and sanitation practices at the household level for community competitions for hygiene and sanitation promotion. Capacity strengthening for village cultural groups focused on behaviour change by delivering health messages through different methods such as songs, role plays, and other types of drama.

Capacity building tools included a training curriculum and different training packages used to train different committees, with the aim of strengthening health management systems for community and district leadership on prevention and control of communicable diseases. Contents of the training included gender-based intervention approaches, resource mobilisation, and life-savings skills for health care providers.

The health and development programme in Mkuranga was implemented through CORPS, the majority of whom were men and women aged between 18-30 years. The CORPS implemented programmes in their respective communities, gathered data, and facilitated bottom-up planning. "In the Mkuranga program, it was learnt that the volunteerism spirit among CORPs was maintained and sustained even without financial incentives through the following: Community involvement and participation at project inception...[and] Capacity building: Training packages were developed based on programme objectives and knowledge needs of the volunteers. Health was addressed as broad community development issue and this motivated the CORPs to deal with a development agenda rather than focusing on diseases alone in a vertical approach." Other retention aids were: supportive supervision, a flexible schedule, community recognition, programme participation certificates, and visual identification materials, such as T-shirts, bags, information, education, and communication (IEC) materials "designed to provoke discussions and dialogue on different issues among community members and sometimes with the professionals", document folders, and bicycles to facilitate transport during their work.

According to the article, the initiative resulted in the following key outcomes:

Community structures and health systems

From the document: "Community structures and health systems were strengthened and linked to each other. The project notes that target villages had functioning village health and water committees which were linked and accountable to the village government council. The committees held monthly meetings and recommendations from these meetings feed into ward and district level meetings. In this way, community voices are heard in district planning processes. A Community Based Health Management Information System (CBHMIS) was well established and functioning at 100% of the target villages. Reports are then channeled through the village leadership to the nearby health facility, AMREF and the District Medical Officer at district level. This data provides the information required for evidence-based district planning.

A total of 96% of the CORPS were retained over the period of five years. Additional CORPs were recruited on request....The district had adopted and scaled up the intervention packages to cover the entire district. The Life Saving Skills and clinical c-IMCI packages were implemented at 100% of the health facilities in the district, including those owned by the private sector."

Child survival

As reported here: "The programme resulted in a 45% increase in utilisation of health services provided at health facilities. A decrease of about 90% in the proportion of children arriving at the health facilities with severe disease conditions (e.g. febrile convulsion, severe dehydration from diarrhea, and severe pneumonia) has also been recorded. Vaccination coverage increased from an average of about 76% to over 98%. The project improved the children's nutritional status. The proportion of children with good nutrition status.... The proportion of children with severe malnutrition did not change.... [However, a] reduction in morbidity was recorded among under-fives [from] 174/1000 live births [2004] compared to 220/1000 live births in 2000 when the project was introduced."

Maternal health

Use of health facilities for maternal health care improved, measured by visits to antenatal clinics. The proportion of women delivering their babies at the health facilities increased, as did the quality of maternity services at the health facilities. The number of households owning at least one bed net has increased. Men became increasingly involved in reproductive health and are increasingly accompanying spouses at antenatal visits.

Water and Sanitation

The project facilitated construction of wells, bore holes, rain water harvesting systems, and protection of springs, increasing households with access to safe water, and the villages had established water funds and opened bank accounts. "All the project villages had at least three trained water artisans to support operation and maintenance of their water points. Basic sanitation improved."

In terms of lessons learned, the article explains that: "Community problems are complex and intertwined in a complex manner such that when people are empowered to solve one problem, their awareness increases and thus the demand to solve other problems increases as well. Community members have the potential to solve their health problems, but lack awareness of their potentials. Community health interventions should aim at creating an enabling environment for the communities to build competencies and realize their potential to bring about change. The decentralization policy renders power and responsibility to the community to plan and manage their own health development programs. However, their capacity is in most cases inadequate. Capacity strengthening for the community structures is therefore a prerequisite for programs which promote participation of the beneficiaries."

The article concludes that partnership in CBHC is an effective approach for implementing community health development. It may be applied elsewhere through scaling up to enhance community participation in other sectors as well.