Community-based animal health worker among Fellata nomads of Sudan/South Sudan Charles Hoots
With 70% of emerging infectious diseases estimated by the World Health Organisation to be zoonotic in nature, livestock and wildlife often fall ill from these pathogens before they spread to people. As a result, veterinarians and other animal health workers (AHWs) can play a crucial role in early detection of emerging zoonotic diseases, especially in remote areas of poorer countries where human health care infrastructure is sparse or absent.
Yet, despite significant numbers of livestock in rural areas of developing countries, AHWs are few and far between, unable to generate sufficient income to make a living. Well-intentioned policies from national and international organizations in some cases end up driving AHWs away, or into more lucrative pursuits. As a result, animal disease outbreaks, many with public health impacts, may run their course for weeks before being detected and addressed by the authorities.
Populations in remote areas of Africa and Asia in particular often inhabit marginal land unsuitable for anything but subsistence livestock rearing of sheep, goats, camels, or cattle. Veterinarians, accustomed to urban life after years of veterinary schooling, rarely want to work in such places. Life is tough there, family is far away, and income potential is lower for them than in urban areas.
Arid region typical of where animal health workers are most needed, but too often absent. Charles Hoots
CAHWs to the Rescue
Partly in response to this shortage, as well as to a general privatization of animal health care services in the face of worsening government finances, the late 1980s and 1990s witnessed the training of community-based animal health workers (CAHWs), notably in East Africa. CAHWs were recruited directly from livestock-keeping communities, trained in basic diagnosis and treatment of common animal diseases, then encouraged to return to their communities to work.
With more modest income aspirations than veterinarians, the trust of their local communities, and a vested interest in the health of their communities’ animals, the CAHW programs proved largely successful, despite some resistance from national veterinary interests.
CAHWs were used heavily in the effort to rid the world of rinderpest during the 1990s and 2000s, sending them to implement cattle vaccination campaigns in war-torn communities of southern Sudan, for example, where outsiders could not easily go. The success of this project (Rinderpest was declared eradicated by the World Organisation for Animal Health in 2011) would likely have been impossible without the work of these people.
Training of community-based animal health workers – Upper Nile State, South Sudan Charles Hoots
Today CAHWs act as the eyes and ears of animal health ministries in many countries, reporting outbreaks or suspicious deaths in herds that allow veterinarians or human health officials to investigate and initiate control measures sooner rather than later.
Unintended Consequences
Because the inhabitants frequently live at subsistence level in the best of times, it is common to find national and international non-profit groups (NGOs) active in these marginal areas, engaged in development or humanitarian (emergency) activities. In my own work in South Sudan with the German branch of the NGO Veterinarians Without Borders, we used a group of 40 CAHWs to treat livestock around the refugee camp where they lived. From May to October, they followed larger herds to their grazing areas up to 100 km away, traveling on foot in hot, extremely humid conditions.
Many NGOs have trained, supplied, and funded CAHWs over the years, facilitating their acceptance by and cooperation with veterinarians and government authorities. But in other ways, policies have inhibited the long-term potential of CAHWs. The most conspicuous is the laudable, but detrimental, provision of free or heavily subsidized medications, vaccines, and animal health services to livestock owners.
Such activities offer employment to animal health workers. However, the resulting distortion of prices eliminates the profit motive for any veterinarian, CAHW, pharmacist, or trader in these products. These projects are often short-term. Once the funding ends and the NGO has packed its bags, the vaccines and medications, which comprise the major source of income for any successful animal health worker, dry up.
For long afterwards, local livestock owners may mistrust anyone charging money for livestock medicines, suspecting they continue to obtain them for free from the NGOs. At best, locals are reluctant to purchase any drugs or services, hopeful that the NGO will return with another project soon.
And this same prospect prevents animal health workers from investing in an inventory of drugs, fearful that the arrival of another NGO project will ruin their business. In the meantime, cheap counterfeit or diluted drugs often fill the gap, further weakening trust in the animal health system.
To Pay or Not to Pay?
Habits are hard to change. For one, it feels good to give things for free.
Another consideration is humanitarian projects vs. development projects. The latter are typically longer term efforts to improve incomes and resources through sustainable mechanisms. The negative impacts of free animal health services in this environment are usually obvious.
Humanitarian projects, on the other hand, respond to natural disasters and wars and involve large numbers of often destitute people who have lost nearly everything. The costs and benefits of charging for animal health services in these circumstances is often less clear cut.
In South Sudan, many of the refugees I worked with had fled their villages in neighboring Sudan with no time to pack anything, taking only the clothes on their backs. Others had time to plan their journey and were able to drive significant herds of cattle, sheep, and goats ahead of them. We found the latter able and willing to pay for veterinary work (sometimes in cash, more often by handing over a sheep or goat for every so many animals vaccinated or treated). But an elderly woman with a chicken she carried with her across the border, for example, obviously cannot pay to treat or vaccinate her bird.
There is no easy answer for how to deal with such situations:
Charge everyone?
Charge no one?
Charge only those who can pay (such as through issuing vouchers to those deemed unable to pay, and with the inevitable abuse this spawns).
Boy in Afghanistan’s Badakhshan Province. Can he afford to vaccinate his sheep? Charles Hoots
Woman in Maban, South Sudan. Can she afford to treat her sheep? Charles Hoots
Fortunately governments, NGOs, and international donors who fund the NGOs are increasingly aware of the distortions that free services and materials cause in such settings. Those with experience in the livestock sector tend to charge something for the materials they provide, if nothing more than simple cost-recovery that reminds beneficiaries of the intrinsic value of the items and services. In many cases, any income is later returned to the CAHWs, who are encouraged to use it to purchase medicines once the NGO is gone.
Short-Sighted Solutions
Aid projects run for set lengths of time and one of the worst outcomes for an NGO is to not spend the money earmarked by a donor for the project. As their activities wind down, NGOs feel pressure to use up any remaining balance of funds. One relatively easy way to achieve this is to provide blanket vaccination or deworming to livestock. Fees are not collected because the objective is to spend the money, not take it in. The tedious paperwork required by donors when money is paid to NGOs by beneficiaries just slows things down.
And who can argue with free animal health services, right? But unless there is a serious parasite problem, blanket deworming of all animals in a herd is not necessary or even recommended. And even a vaccine campaign is not always benign, potentially causing more long-term damage than good if there are no follow-up vaccinations.
Carefully planned agreements on cost-recovery pricing of livestock medicines between NGOs, international, and government agencies can collapse when an outside NGO decides to give medications away free, without discussing with others working in the area. It creates mistrust of the NGOs and even of the local animal health workers, both of whom are then suspected by the community of profiting from the sale of medicines. They reason, quite logically, that the drugs obviously don’t cost anything since the other NGO is giving them away. This adds one more to an already large number of obstacles for any animal health worker hopeful of making a living once the NGOs are gone.
Prerequisites for Success
Creating an environment that allows animal health workers to survive in rural areas of developing countries requires many things. Not least is a stable environment that encourages someone to build an inventory of equipment and medicines to serve the community. In war-torn South Sudan, Somalia, and Afghanistan, this is but a dream for now. CAHWs operating in these countries are still heavily subsidized by international donors, for better or for worse.
Harmonization and enforcement of pricing practices between governments, international donors, and NGOs working in rural areas can complement rather than undermine animal health workers.
Better training and frequent refresher courses will increase trust in animal health workers’ skills and calls for their services. Business management should be an integral part of this training as most CAHWs have little or no prior business experience, a major impediment to their success in the past.
Keeping animal health workers in rural areas is in everyone’s best interest, but it is not an easy task to achieve sustainably. Their ability to recognize outbreaks of emerging diseases of public health and economic concern can be critical in halting their spread to cities, neighboring countries, and even to other continents. We need to encourage, not stifle, their efforts.
Further Reading
Holden S. The economics of the delivery of veterinary services. Rev. sci. tech. Off. Int. Epiz. 1999, 18(2), 425-439.
Koma LM. Can Private Veterinarians Survive in Uganda? UCIAS. 2003; 5.
Mugunieri LG, Omiti JM, Irungu P. Animal Health Service Delivery Systems in Kenya’s Marginal Areas Under Market Liberalization: A Case for Community-Based Animal Health Workers. IPAR and IFPRI. 2002.
Wang LF and Crameri G. Emerging zoonotic viral diseases. Rev. sci. tech. Off. Int. Epiz. 2014, 33(2), 569-581.
Yes, I agree with all that you say with regard to the problems with regard to improving access to medicines and animal health services for farmers living in remote areas, the sustainability of service providers and the services that they provide – BUT from a legal point of view CAHWs, and indeed any other category of veterinary para-professional, always need to be supervised by a qualified veterinarian in order to ensure, in particular, that prescription only medicines and vaccines requiring a cold chain, are being used correctly. This is because of concerns over the development of anti-microbial resistance and the potential for drug or pesticide residues entering the human food chain when prescription only medicines and sometimes pesticides are used inappropriately and when withdrawal periods are not respected according to the manufacturer’s recommendations printed on the leaflet accompanying the medicines. The World Organisation for Animal Health (OIE), the institution mandated by the WTO to set the sanitary standards for international trade in animals, animal products and certain other high risk commodities, requires that veterinary para-professionals should only be authorised to use prescription only medicines and certain vaccines and perform services which are deemed to be acts of veterinary medicine and surgery when working under the “supervision” of a qualified veterinarian. What is difficult is to develop a sustainable model in which an effective level of supervision is included, thus meeting the regulatory requirements and at the same time being sustainable.
Any NGO that decides to train and deploy CAHWs or any other category of para-professional animal health service providers should therefore include an exit strategy right from the beginning to ensure that the support and supervisory role played by its own professional staff during the project is replaced by some form of credible and sustainable support and supervision, once the project ends. Such support mechanisms should, at the very least ensure that the medicine and vaccine supply is properly regulated and that technical difficulties experienced by para-professionals with limited knowledge and skills are resolved through referral to a qualified supervisor. Numerous different models have been attempted in the past but very few, if any, have been been completely successful. It is partly for this reason that many governments have as yet been very reluctant to allow CAHWs to become legally recognised, believing that their presence is only temporary and they they will soon be replaced by a veterinarian who can be trusted to comply with the standards required to control issues such as anti-microbial resistance and drug residues entering the food chain. The resistance to allowing veterinary para-professionals by government authorities stems from a mixture of professional protectionism and a genuine concern over the correct use of anti-microbials and vaccines and possibly over the fear that the para-professionals may start to undertake veterinary activities beyond the level of the knowledge and skills imparted during the relatively short period of training which is often given to them. But here we are in 2016, and the story was the same back in the early 80’s when we first started seeing CAHWs being trained and deployed in remote areas by well-meaning NGOs. It is unlikely that the economics of farming in remote areas is likely to change dramatically in the coming fifty years. CAHWs and other categories of veterinary para-professional service providers will be needed in such areas for the foreseeable future.
The challenge we now face is firstly to convince senior decision makers responsible for setting policies and thus the shape of veterinary legislation that CAHWs are likely to be needed for some time to come, and then accommodate them in their legislation, to ensure that their activities are satisfactorily regulated. The next challenge is to find the right models for ensuring that CAHWs services remain fully functional and at the same time satisfy regulatory requirements with regard to “supervision”.
Many NGOs in the past have been guilty of failing to consider the long-term implications of training and deploying veterinary para-professionals in order to improve access to veterinary service delivery in remote areas. They didn’t have an exit strategy. It is essential that BEFORE any NGO embarks on such an activity that an exit strategy is developed from the beginning of the project. Such an exit strategy should be crafted in such a way that it meets regulatory requirements of professional supervision. Thus, there is a need to engage with all stakeholders, not only to ensure that farmers are able and willing to pay for the services, but also to satisfy the law makers as to how the requirements for professional supervision can be met.
Perhaps the most challenging issue facing us in this respect is how can the presence of a veterinary supervisor be sustained in an area where the turnover in medicines sales is relatively small and thus returns are insufficient to make it interesting for a veterinarian to set up in business. It is essential that whatever mechanism is developed, “supervision” needs to be effective, in order to convince the regulatory authorities that the risks of anti-microbial resistance and drug residues are adequately controlled.
Experience has shown that unless the supervisor is rewarded for his presence with a financial gain, he is unlikely to remain engaged with supervision a veterinary para-professional. From a legal point of view the supervisor would be required to take full responsibility for any outcomes of the activities being undertaken by the CAHW or other category of veterinary para-professional he is supervising, so there is an element of risk. One mechanism that might work is that the supervisor should become the sole source of medicine supply to the veterinary para-professional he has agreed to supervise and that a contractual relationships is drawn up between the two. By so doing, not only is the public interest protected, through less risk of the development of anti-microbial resistance and the introduction of unwanted antibiotic or other residues in animal products destined for the human food chain, but also statutory requirements can be met. Thus the ideal model “veterinary practice” for a remote region might involve the presence of a veterinarian located at a settlement in or at the edge of the remote region, which would have access to markets and services further afield, with a network of several veterinary para-professionals working under his supervision, deployed at the community level. Business models need to be developed to ensure that a profitable business can be established under these conditions, so for instance the minimum number of supervised para-professionals needs to be determined based on the density of human and livestock populations, demand for services and their estimated annual turnover of medicine and vaccine sales. Consideration may be given to build into the model a mechanism whereby the service providers play a role in marketing some of the offtake derived from the animal production system, thus helping farmers to gain access to remote markets and thus be in a better position to pay for the services they are using.
Appreciate the challenges mentioned in the write up and the comment of John Woodford. We in India ( with support from Agriculture Skill Council of India and GALVmed ) are taking some unique initiatives focusing at developing National Occupational Standards (NOS) and Qualification Pack ( QP) for veterinary para-professionals including AHWs. The NOS are designed keeping in mind the job profile vis a vis performance criteria. These are living documents and more improvements are expected. Revenues for private para-professionals/ AHWs may flow from government / private development projects including companies producing and marketing farm inputs / outputs. Our aim is to create a skilled group of certified workers ( essentially with career mobility ! ) who can partner with registered veterinarians ( supervisors ) to provide services. Efforts are now being made to engage with all stakeholder for developing an appropriate supervision, monitoring data sharing framework. Work is also going on to develop nationally certified training manuals as per developed standards. More about the project is available at: http://www.vethelplineindia.co.in/development-of-national-occupational-standard-nos-and-qualification-pack-qp-for-para-veterinarians-in-india/
Looks like a great program, Miftahul Islam, from your website link. I hope you will find it successful and not forget to publish an easily accessible Lessons-learned evaluation afterwards.
Thanks and good luck.
Charlie
Check this link to download a write up on our experiences till date : http://www.vethelplineindia.co.in/wp-content/uploads/2014/11/DetailTalk_UGC-SAPNationalSeminar_SkillingIndia.pdf
You bring up some great points, John.
And I completely agree with you about the importance of veterinary supervision of CAHWs in their work. Perhaps I should have stressed this more in the posting.
This issue is faced constantly in much of Africa. Oftentimes the best that can be done is to insure that CAHWs are supervised by para veterinarians working for their respective Ministry of Animal Resources. This is sometimes achieved by distributing any NGO- or FAO-supplied medications and vaccines to these government para-veterinarians, who then distribute them to the CAHWs working in their area. The CAHWs provide simple written reports of drug/vaccine administration information for accountability to the govt para vet, who also gives the NGO a copy. The reported information can be confirmed as needed (though that is often easier said than done in remote regions).
The problem with this, of course, is that it causes CAHWs to depend on the government for supplies. Your idea of having them depend on private veterinarians for the vaccines and medications would be much more sustainable, if the private veterinarian can be persuaded to live near to, accept, and supervise the CAHWs.
Charlie very interesting and accurate post. Having work in this sector for many years I agree with the points raised by John Woodford. Personally I believe that the issue of the CAHWs long term sustainability is extremely difficult to solve because CAHWs do not have the monopoly on drugs and today veterinary drugs are available virtually everywhere! Even in the most remote (in Africa) areas there are “tea shops” and in such places veterinary drugs are often sold. So in this situation a nomad often buy the medicine himself and after verbal instructions from anybody (shopkeeper, friends and CAHW) treat his animals himself. Obviously under/incorrect-dosing, inadequate drug storage and sterility issues are widespread. This issues could be alleviated by the presence in the areas by CAHWs but it will be hard to expect them to effectively compete with the ubiquitous “tea shop”! However their financial survival could be ensured if they are periodically involved as paid field personnel in government vaccination campaigns or disease surveys. In such way they will have a sure income, reach remote areas (and do business when there) and be known by the population as trusted “field veterinary personnel” .
Excellent points, Maurizio. I appreciate your insights. It will likely be true in the near future that many CAHWs will only make a living if they can link with government projects and agencies, as you say.
One hope is that trained animal health workers (whether veterinarians or CAHWs, and whether government or private) can gain trust by providing better advice and better drugs than the “tea shop” pharmacies whose medications sit in the sun all day and often are diluted with water. It may be far off, but we can hope!
A very interesting discussion. As someone working for an NGO trying for some years to move away from setting up free service provision structures (that run in parallel and compete with local existing services) to building capacity in those existing services, I have been party to the challenges mentioned above. Having an integrated animal health service appropriate to the local context involving private and public services, training institutions and vets, paraprofessionals and CAHWS as relevant is key, as is a functioning, essentials medicines supply chain and regulatory system.
As an NGO that has a wider welfare remit, we also come up against the dilemma that a privatised system (including at CAHW level) sometimes struggles to provide quality outcomes on pain relief and euthanasia. This can be a considerable challenge if donors are providing funds for such interventions to be achieved.
As you are painfully aware, euthanasia and pain relief are complicated issues in NGO work. It is hard enough to get vaccines and antibiotics to many places that need them, let alone these medications that are largely, perhaps arguably, considered only secondary in importance. Some of the more effective pain relievers are opioids and keeping a stock of them around is asking for trouble (that goes for anywhere in the world, not just poor countries). And euthanasia solutions, though able to end so much suffering, pose the risk that scavenging animals or even people trying to salvage the meat from a recently dead animal, will ingest the “poison” and die. It would be nice if some middle ground could be found.
I agree that these could be very welcome additions to NGO pharmacies and not enough thought is given to including them. I hope your promotion of them will meet with success.
Charlie is right. It may be unpleasant to admit but in many pastoral/nomadic areas implementing ideas about livestock pain relief and euthanasia is simply wishful thinking. Euthanasia is already a common practice: once a livestock is seriously sick is eaten !