Lam, Yukyan

Public Health



Bolivia - Factors affecting care-seeking for labor & delivery among GuaranĂ­ women in Bolivia

The Center for Global Health's GHEFP award helped fund Yukyan Lam's work with World Relief in Gaza Province. Following interviews with facility-based health workers, project staff, community health volunteers, and health officials, as well as visits to TB treatment facilities in three of the six project districts in August 2013, Yukyan developed a manual on the process of implementing a community-centered TB detection and treatment program based on the care group model. In addition to detailing the steps undertaken in the Vurhonga Project, the manual openly describes some of the challenges that have affected and continue to affect the project's impact and sustainability. World Relief plans to edit and circulate the manual with Ministry of Health officials, USAID representatives in Mozambique, and other NGOs working in the country. At the same time, Yukyan has also participated in analysis of the baseline and mid-term Knowledge, Practices and Coverage (KPC) surveys, and provided input to World Relief staff on areas for improvement.

Mozambique’s Gaza Province is dusty in August, with dry, cracked roads connecting small towns to even smaller villages. Chokwé, with its 61,000 inhabitants, is one of the province’s most populated areas. The Limpopo River, the source of catastrophic flooding in January 2013, runs past this rural town, carrying greenish-gray water eastward from central southern Africa to the Indian Ocean.

On a quiet street a few blocks from where the town’s two main roads intersect is Carmelo Hospital. Formerly a convent reminiscent of Portuguese colonial architecture, the building was transformed into a hospital in the mid-1990s and now serves as the province’s referral center for TB and HIV patients. Unfortunately, most of Gaza’s TB cases never make it to Carmelo Hospital. In fact, most cases do not make it to the “TB room” of any of the province’s district-level health centers. If the WHO statistics are accepted as accurate, then the principal problem concerning tuberculosis in Mozambique is that half of the country’s TB cases never reach a health facility. The problem is particularly serious in Gaza Province.

When I arrived in Chokwé at the beginning of August 2013, my task was to document the experience of World Relief’s community-based TB project. The project had recruited over 3,500 community health volunteers to cover households in six districts of Gaza Province. In each district, volunteers were jointly selected at the village and neighborhood levels by communities and project personnel. The goal was to reach universal coverage of all households in the project districts. Community health volunteers were trained on TB symptoms and tasked with periodically visiting the ten households closest to their own. They helped those suspected of having TB visit a health facility by providing encouragement and, when possible, logistical assistance. They also followed up with diagnosed TB patients to promote adherence to a DOTS regimen.

Speaking to project personnel (in Portuguese) and two dozen or so volunteers (through English/Portuguese-Shangaan interpreters), I learned their perspectives on the difficulties of community TB case-finding. In this landscape of scattered villages and dirt roads that just as easily crumble in dry season as wash away during wet season, it was no surprise that access to health facilities emerged as the key obstacle to TB testing, diagnosis, and treatment. The primary obstacle was not TB suspects’ willingness to get tested nor “erroneous beliefs” about the etiology of tuberculosis, but rather their lack of money to pay for bus fare and the absence of any other means of transportation. It struck me that even a large dose of creativity and human ingenuity could not fix a problem that required, ‘simply’ and fundamentally, greater investment of resources to improve infrastructure and the health system’s reach. Project staff and health volunteers had transported TB suspects to health facilities on their motorcycles or bicycles, TB suspects’ families had sold animals to raise money for bus fare, and village leaders had made requests to vehicle owners in the community on behalf of TB suspects. But all of these were ad hoc solutions.

I know this story is not unique. Indeed many like it have been witnessed and told countless times before by those with decades more experience in resource-poor settings.  Yet there may be some value in re-telling it. The document I wrote would later be presented to the Ministry of Health, which claimed to be working on various initiatives to improve TB detection and treatment in rural settings, including village “TB days” and better tracking of community-based DOTS. Although it would be naïve to assume that these changes would happen quickly or that they would happen at all, I am nonetheless grateful for the opportunity to make a brief, but hopefully useful, contribution to this effort.


Caitlin Kennedy, PhD MPH,BA

Co-Director, MPH concentration in Social and Behavioral Sciences in Public Health; Associate Director, Center for Qualitative...

Joanne Katz, ScD MS,BSc

Associate Chair, Director of Academic Programs

Stefan Baral, MD MPH,MBA,MSc

Director, Key Populations Program

Robert Bollinger Jr., MD MPH

Director, Johns Hopkins Center for Clinical Global Health Education (CCGHE); Associate Director, Johns Hopkins Center for Global...

Noreen Hynes, MD MPH

Director, Geographic Medicine Center of the Division of Infectious Diseases

Yukari C. Manabe, MD

Associate Director of Global Health Research and Innovation

March 2019




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