Community Case Study 1 – Evolving community self‐

monitoring
By: Bright Orji, Jhpiego, Nigeria

Ekpuk Essien is a kin group in a rural Ikot Annang community in Onna Local Government Area
(LGA) of Akwa Ibom State, Nigeria. It is one of those neglected oil prospecting communities.
Ekpuk Essien has no drinking water except a nearby river. The inhabitants are subsistence
farmers, especially the women, men sit at home and women do most of the farm work. Most of
the young men had gone to Uyo the State capital in search of jobs and education. The
community has only one health center that was built in the early 1970’s but due to lack of
maintenance the building is dilapidated, and few health care providers posted to the center are
always not on duty for fear of the building collapsing on them and after being warned by one of
the Agencies working in the region. Another health center closest to Ekpuk Essien is about 190
kilometers away, therefore people in the community seek for treatment from spiritual, traditional
birth attendants, herbal healers and medicine hawkers that infiltrate the occasional market in the
neighboring community. The market comes up once every two weeks, Ekpuk Essien women sell
their farm products at this market.

In early 2008, Jhpiego - An Affiliate of Johns Hopkins University was commissioned by one of
the companies exploring oil in the region to control malaria in pregnancy (MIP). In Nigeria,
malaria in pregnancy is one of the major diseases of public health concern with an annual death
of about 4,800 women. MIP control is a component of Ante natal Care (ANC), but most pregnant
women do not attend ANC and those that register; come very late in pregnancy gestational age,
a period too late for them to receive the available malaria interventions. Therefore, Jhpiego
adopted a two prong approach that include 1) community directed intervention (CDI) which
engaged community volunteers to identify pregnant women, distribute health commodities under
the guidance of the health care workers and refer them to attend ante natal clinic (ANC) to
obtain other available services; and 2) Quality improvement of performance standards by the
health care providers that would ensure the provision of quality care services to make
community referral feasible and attractive to pregnant women. Therefore, Jhpiego in
collaboration with the senior personnel of the State Ministry of Health visited the authorities of
the Onna LGA and various communities that would benefit from the project to advocate for their
support and commitment. Ekpuk Essien was one of the beneficiary communities visited.

One of the points of discussion during the visit was the state of the health center in Ikot Annang
community. The chair-person of the LGA, Lady Ekpo-Attai recounted her experience as a child
with hospitals when she was growing up under an elder sister who was a nurse. In those days,
hospital environments, neatness of the nurses, quality of care provided and attitude of workers
to work were all quite impressive and appealing that she desired to be a health worker.
Therefore, she promised to work with the community to renovate the health centers in the LGA
and restore health to the first position in the LGA. However, given the lean resources of the LGA
and other competing ends, the LGA authority approached the communities as stakeholders to
fashion out strategies to raise funds for the renovation of health centers in the area. The
communities pointed out that they do not have money to contribute but would support the LGA
to identify prominent sons and daughters to visit one of the oil companies in the region for help.
Though it took several meetings for this decision to be arrived at, but the visit to the oil company
was carried out. The oil company requested that at least two health centers be identified and
costs of renovation estimated to make an informed decision. As it would be, one of the health
centers identified was Ikot Annang health center. The Oil Company accepted the renovation of
the health centers but work will begin first with Ikot Annang community health center.
Renovation work started at the health center in early 2009, during which period the health
center relocated to chief’s compound. It was from here that the health workers were
coordinating the services provided by the community-selected volunteers in the MIP project.
During the community selection of the volunteers, Mrs. Enobong Udoh and Ekaette Okon from
Ekpuk Essien kin group volunteered to serve in the project.

The kin group promised to pay stipend to the volunteers to support transportation as well as
motivate the volunteers. However, the kin group reneged on the promise. But Enobong a 55
year old former primary school teacher that retired from in 2006, after putting in more than 35
years in active service and reached the mandatory age of retirement while her colleague
Ekaette Okon was a 40 year old popular local Seamstress in the community continued to serve
their people. Enobong said that ‘she resolved to serve in the project because she has seen
several infants die very early after births, women died in pregnancy and want be involved with
anything that would reduce or stop these deaths’ while to Ekaette it is a continuation of the
services she has been rendering to the community since after her training as a Seamstress.
During the training on malaria they received as volunteers, Enobong and Ekaette made up their
minds to serve whether they were paid or not. They have continued to provide services, leading
to high uptake of malaria in pregnancy interventions at the health facility and community levels.

In mid-2010, the renovation of the health center was completed, and handling over ceremony
was organized. During the ceremony, a little drama but which later transformed the health
center and the lives of the members of the community took place. The chairman was reading
her address prepared for the occasion when she was interrupted by a ‘madman’ in the area
popularly known as Dr. Ino (Ino means ‘nothing’ in the local dialect) shouting from his standing
position in local dialect. At least to the hearing of the guests seated at the high table that
included senior officers and personnel from the LGA and Oil Company “this renovation is
incomplete without water provision” to chagrin of the Chairman who stopped the reading of the
address to inquire of the fellow making the noise.

When no one indicated, the chairman out of annoyance recounted several efforts that brought
the successful execution of the renovation exercise, and ended up indignantly requesting the
fellow shouting to volunteer and dig a borehole. But after about a space of two weeks, the oil
company commissioned a contractor to sink a borehole at the health facility, and this has been
completed and handed over to the community suffice it to say that today, the community drinks
from the borehole, the LGA provided fund for generator and gas to ensure water is pumped
regularly.

In 2011, Jhpiego expanded the malaria interventions in the LGA to include community case
management of malaria (ICCM) using rapid diagnostic test kits as a component of home
management of malaria, dispensing of appropriate antimalarial drugs (Artemisinin-based
combination therapy (ACT), counseling on drug adherence and adverse reaction, treatment of
pneumonia and diarrhea, the commonest diseases killing children in the region. Enobong and
Ekaette were trained as part of the team to provide ICCM services under the guidance of the
health care workers. Given the increased responsibility assigned to the volunteers, project staff
worked with health workers to mobilize communities and seek support and commitment for the
volunteers by their communities.

It was during one of such meetings that Ekpuk Essien community members reiterated their
earlier support and commitment to their volunteers Enobong and Ekaette. They promised to pay
them stipend each month, to augment their transport fare to the facility to carry commodities,
submit data and attend monthly meetings. Shortly after the training, the Ekpuk Essien paid
Enobong and Ekaette the first monthly stipend. However, after receiving the stipend Ekaette
was informed that her daughter that lives with her husband in the city has given birth to her first
grandchild – a baby girl. As custom would demand, Ekaette traveled to spend some time to
nurse her daughter and grandchild. During this period, Enobong could not provide services
because she was waiting for Ekaette to return from the city so that they could work together.
However, luck ran out of the volunteers when members of Ekpuk Essien kin group observed
that neighboring communities has started to enjoy the ICCM services from their volunteers.

Ekpuk Essien elders summoned Enobong to appear before them and explain why they were not
providing services. Enobong’s explanation that she was waiting for Ekaette that traveled to the
city to return so that they could work together was not satisfactory to the elders. The elders
argued that Enobong and Ekaette has been paid their monthly stipend and should therefore
render services, as a result they fined Enobong and Ekaette one goat to compensated for the
period of time lost that services were not rendered. The volunteers promptly reported the case
during the monthly meeting of all volunteers, where it was resolved that a three man delegation
be sent to Ekpuk Essien to appeal on the behalf of Enobong and Ekaette. In the dialogue that
took place between the delegates and elders of Ekpuk Essien Kin group, it was resolved that
Enobong and Ekaette be forgiven but a three man committee set up to oversee the activities of
the volunteers so as to guide against the reoccurrence of similar situation. The committee also
will be providing regular feedback to the elders of Ekpuk Essien.