VETWORK UK

a Participatory Community-based Vaccination and Animal Health Project (PARC-VAC), OAU, Inter-African Bureau of Animal Resources (IBAR), Box 30786, Nairobi, Kenya [Email parcvac@iconnect.co.ke]

Within the context of restructuring of government veterinary services and the liberalisation of pharmaceutical supplies, various models using participatory techniques are being developed to establish fully privatised pastoral veterinary practices. The paper describes and discusses the various approaches being used to establish such private practices. Major lessons learnt in delivering community-based animal health services (CAHS) and key issues to address in order to make such services sustainable are highlighted. Diagrammatic models of the delivery systems used are described. The paper discusses methods in which these relatively new, privatised and CAHS might best and most rapidly be adopted, by various levels of decision-makers. The paper concludes that private pastoral veterinary practices could be both economically viable and provide needed services if national governments put in place specified policy and legal frameworks that create an enabling environment for them to operate within.

Government animal health services in the Greater Horn of Africa [GHA] have for the last 40 to 50 years had the mandate to carry out both clinical and preventative livestock health care. Such services do function well when sufficiently funded in terms of equipment, transport and staff incentives. There are economies of scale, standardisation of policy, drug use and training. The service can provide for the common good. Unfortunately over the last 10 to 20 years the resources available to run government vet services have either not been maintained or have not kept pace with rising costs within the agricultural sector. The result has been that the government services have in many areas and in many countries been unable to provide the service they would like to have. In recent years this has led to calls for government departments to raise their own funds through cost recovery and the use of revolving funds. It has however been difficult for government departments to adapt to this system. The cost recovery funds are often either not sufficient to function as a true revolving fund or are diverted to other uses within central government. The current trend is for government veterinary services to be decentralised both financially and managerially, for importation of veterinary pharmaceuticals to be liberalised and for clinical and preventative animal health care to be given over to the private sector. Both donors and banks are encouraging these changes. The results are mixed. In many areas of high agricultural potential veterinary privatisation has, despite teething problems, taken off. It is generally viewed as a success, particularly if you have the resources to afford the service.

In Arid and Semi Arid Lands (ASAL) the situation is very different, in these areas the private vets have not been able establish the traditional model of veterinary practice because it is not economically viable. The government vet services have at the same time seen cut backs and in some cases are unable to do little more that pay the salaries of staff without providing them with the resources to work effectively. The government staff in turn lack the capital, the training and the stability (due to duty station transfers) to start viable businesses. They manage by supplementing their government income and benefits package through selling small quantities of pharmaceuticals, in competition with pharmacies and other traders or by providing any other peri-urban services.

In many pastoral areas "black" markets in veterinary drugs arise because the need and willingness to pay for animal health services remains. This "black" market is not a solution for the livestock owners. Pastoralists, though extremely experienced in disease diagnosis and the use of ethno-veterinary medicines, lack the knowledge to determine the ethical use, dosage rates, route of administration, quality or proper price of "modern" allopathic medicines. Livestock production suffers in that major disease problems are not being treated cost effectively, with appropriate drugs. The veterinary profession also suffers because they are losing initiative to untrained traders. They are not carrying out the role they were trained, at high cost, to do. The overall result is that the livestock owners cannot get the animal health advice and service they need to get if they are to significantly improve their productivity.

In order to meet the needs of the livestock owners in ASAL pastoralist areas various groups, particularly non-governmental organisations (NGO) and farmers associations, are developing alternative animal health delivery systems. These are community-based initiatives that tend toward decentralised and privatised animal health delivery systems. This paper describes the development theory upon which these systems are developed, their usual structure, the factors affecting sustainability and the policy issues that have to be addressed in order to encourage their adoption.

Recognition that participation by communities in development programs is required for them to succeed, combined with the lessons learnt from earlier approaches, led to the development of interactive data gathering and planning tools which have become known as Participatory Rural Appraisal (PRA) tools (McCracken et al 1988).

Participatory rural appraisal tools are now used in the majority of successful development projects in pastoralist areas and risk prone areas. PRA tools permit the livestock owners or pastoralists and facilitators to better record, count, measure, problem pose, discuss and analyse their existing situation with the aim of:

• building on what people already know;
• using and developing people's abilities and skills to analyse and evaluate their surroundings;
• reveal whether human and material resources are being used efficiently and effectively;
• help people to analyse their individual situations and see how their activities may be altered in a beneficial manner, thus setting local priority needs;
• enable people to study their own methods of organisation and management;
• provide good information for making decisions about planning and programme direction;
• increase the sense of collective responsibility for programme development, implementation, monitoring and evaluation;
• identify indicators for monitoring and evaluation to be recorded;
• concluding with a community action plan (also sometimes called a social contract).

When working with livestock owning communities certain PRA tools are commonly used. See appendix one for very brief details on each tool.

Community-based animal health service (CAHS) projects are often associated with organisations. There is a wide variation in the level of maturity of CAHS projects around the GHA - some are just starting with very little experience of what to do, some have been running for years but are still not sustainable, some are progressively moving toward sustainability and most are learning as they progress. What should be of primary concern to all these projects is that they eventually become economically free-standing without the crutches of subsidy or outside staff support. Because of this variation organisations are developing ideas, policy initiatives and projects that will lead to privatised community-based veterinary practices. Such veterinary practices are likely to be the most efficient way to bring sustainable, professional and ethical services to livestock owners residing in pastoralist ASAL areas.

It is perfectly valid for a private veterinarian to develop a business plan that includes PRA with local communities or pastoral institutions. It is building upon a successful development methodology that has been evolving over the past 40 years. Veterinarians can build up the client base by making agreements, through PRA, with livestock owning communities and institutions. There are two fundamental driving forces behind these agreements:

1. The livestock owners perceive that one of the major problems they face in life is animal disease. They are therefore willing to pay for animal health services.
2. A veterinary doctor seeks to make a living from providing an animal health service to the people who need and want one.

The agreements consist of the following basic terms.

• The veterinary doctor agrees to remain in regular contact with the livestock owners plus their opinion leaders and / or their pastoral institutions e.g. Livestock Users Associations. S/he agrees to train, monitor (supervise) and supply a group of livestock owners who will provide vaccination and clinical services for their communities. These people are often called Community-based Animal Health Workers (CAHWs). They live with and move with the livestock owners. The veterinarian agrees to use his or her professional training and ethical standards to ensure appropriate and cost effective medicines are supplied to the client. The veterinarian agrees to provide a referral service for difficult cases and to assist in the control of epidemics. The veterinarian may use mid-level veterinary workers (AHA) to act as middlemen in this process or local institutions might select such people to work for them.
  
  The veterinarian makes a living from the profit made on the medicines and vaccines that s/he sells to the livestock owners through the network of CAHWs. In some countries governments have begun to contract such private vets to provide vaccination using CAHWs within their practice area against diseases which threaten the public good e.g. rinderpest, CCPP, goat pox, CBPP.
• The livestock owning community agree to select individuals whom they trust and respect to be trained as CAHWs. They agree to utilise the trained CAHWs' services. They agree to pay for those services. In pastoral situations they advise which diseases are a problem to them and which they are willing to pay for the control of. They agree on how and when to address these diseases. For example the time of year and place for vaccination can be agreed upon and closely co-ordinated. Details such as labour provision can be agreed in advance.
  
  The livestock owners gain through the increased livestock production and reduced mortality that results from regular and appropriate use of veterinary medicines and vaccines and provision of appropriate extension messages. The benefit-cost analysis of provision of such services are proven to be cost effective (Schreuder et al 1995, OLS 1995). Because the pastoralists have participated organisationally in establishing a sustainable delivery system that is based on real economic factors, this organisation input can be further built on in terms of developing other sectors such as marketing of livestock.
• The CAHW agrees to be trained, to provide specified vaccination and clinical services at agreed prices and to work under the professional supervision of the veterinarian or a mid-level veterinary worker. The CAHW gains from having developed a skill and their status. They have a means of making a living or improving their situation from the profit they make from the treatments and vaccinations they provide. They can continue to keep livestock and move with their communities (if they are trans-humant or nomadic pastoralists).

The structure of the resulting animal health delivery system is depicted in figures 1 & 2 over the page.

Pastoralist institutions such as Livestock User's Associations (LUA) are usually delivering some form of non-veterinary supervised animal health service. Establishing sustainable animal health delivery through associations / committees and revolving funds is a lengthier and more difficult process. The association normally requires capacity building. Accountability for funds has to be carefully developed. Private and Government Veterinarians believe that the services they provide should move toward being veterinarian supervised and should not be subsidised. A typical model of an LUA in transition to a more veterinary supervised delivery system is depicted in figure 3.

Some advantages of associations are that they increase levels of local organisation, they are more easily accessible as entry points to outsiders than traditional structures, they can be the link to traditional structures, they may additionally address problems which are for the public good such as livestock marketing facilities, drought management roles and water source development. The authors believe that models depicted in figures 1 and 2, where private vets have close relationships with the livestock owning community, possibly through traditional structures and directly employ mid-level veterinary workers and CAHWs is a more efficient model in terms of delivery animal health.

Just as for private practices established in the high potential areas, government veterinary services gain because epizootic and enzootic diseases are reliably controlled - resulting in increased livestock production. The government services are more able to utilise their finite resources for the public good through, continuing professional education of government staff, quality control monitoring of the provision of privatised clinical and vaccination services, standardisation of training levels, enforcing the laws governing the supply and use of ethical medicines, disease surveillance, livestock movement control, enforcement of meat hygiene regulations and research. The government vet services can utilise the private vet, through both the field level CAHWs and mid-level vet workers, to provide an accurate and rapid disease surveillance and monitoring network. Government veterinary services should be able to utilise private vets and CAHWs networks in the case of disease outbreaks that threaten the public good.

Can CAHWs be relied upon to provide services in a professional manner to the required standard? Initial research carried out by OAU/IBAR/PARC suggests that they can. Pre- and post- rinderpest vaccination serological studies provide an objective measure of CAHWs efficiency in handling and administering a substance that requires precise dilution and measurement prior to administration. In addition, the large amount of serological data which has been generated by PARC following conventional rinderpest campaigns in Africa allows one to directly compare the efficiency of CAHWs vaccinating their own communities cattle with vaccinations carried out by veterinarians and mid level veterinary workers.

Table 1 provides some examples.

In southern Sudan, CAHSs have been established in war torn pastoralist areas. The government veterinary services had broken down in the rural areas through lack of funds and the war. After mobilisation of communities to select CAHWs for training as vaccinators in 1993 the number of clinically diagnosed outbreaks of rinderpest reduced (Jones et al 1998). The number of cattle vaccinated in 1993 by OLS was more than ten times the 1992 figure, increasing to 1.48 million head and remained above one million annually until 1996. The figure is likely to drop in 1997-8 due to acute famine in S. Sudan (Jones et al 1998). These CAHWs also provide clinical services on a cost recovery basis. Operation Lifeline Sudan (OLS) vaccinated over 6.5 million cattle since 1993. serum samples taken from 1995 to 1997 showed a 76% sero-positive rate in vaccinated animals. This compares favourably with the vaccination efficiencies of 50 to 80% achieved by government veterinary services in PARC member states (FAO/IAEA, 1992). There is qualitative and quantitative data from NGO reports and evaluations to show that CAHS are popular, cost effective and efficient (Schreuder et al 1995, Jost, C 1994, OLS 1995, Jones et al 1998).

CAHS projects and how to establish them have been described elsewhere (Mariner et al 1994, Leyland 1996, Leyland 1998). From the experience gained by projects, a few key factors are still worth highlighting:

• When making the community action plan it is important to discuss the difficult policy issues from the very start e.g. charging for services, who holds animals whilst they are being treated! This dialogue process does not stop once the plan is agreed to and services start to be provided. Problems will arise and will need to be regularly addressed.
• Community-based projects often involve a capacity building component for existing social structures. The process is often a learning process for all parties and so the projects need to have flexibility and responsiveness built into them.
• Drug supply mechanisms, cold chain management, coordination of vaccination using non-heat stable vaccines and monitoring activities need to be thought about from the start of projects - just like a business plan.
• CAHWs need to be paid realistic incentives, any records they keep need to be tailored to their literacy level. Provision of bicycles greatly increases the areas that they can cover.
• The time needed and expense in carrying out the community dialogue, using PRA tools, should not be under estimated. It is important to reach the real livestock owners rather than just their official representatives e.g. chiefs.

• Illiterate CAHWs commonly outperform the literate ones because they are closer to the livestock owners and they value their positions and training more highly. The training of such a cadre of CAHWs has to be extremely applied, practical and repetitive. Regular refresher training will need to occur. This requires novel training methodologies to be taught to the trainers (private vets). It is important to incorporate local perceptions of what causes diseases and local disease names into training. The government should start to regulate such training so that CAHWs can be tested, by oral examination, to ensure they meet a required standard.
• CAHS are potentially more gender sensitive than conventional animal health services. It is possible through PRA / dialogue to analyse the role played by women in the care of livestock. It is then relatively easy to work out what training women require and how they fit into a community action plan.
• The preservation and incorporation of ethno-veterinary knowledge (EVK) is another factor that needs to be considered. Local treatments and remedies are often cheap and effective. Such knowledge should be incorporated in CAHW training and traditional healers assisted rather than sidelined. This is not easy to do when commercialising services but this knowledge should be utilised and built upon. EVK may in the future benefit not only those communities but also others.

Private Pastoral Veterinary Practices (PPVP) are still in the process of being developed. There are a number of non-government and government projects in different parts of the GHA pursuing a privatisation approach. They are at various stages of implementation and use different strategies. To support their effective delivery, there are a number of policy issues to take account of. The major ones are detailed below: -

• The legal and policy frameworks of many countries were developed at a time when national veterinary services were provided by the government alone. They need to be re-examined and amended to reflect de-regulation of drug supply and privatisation of veterinary services. Amendments to the law particularly need to take into account the future roles of mid level veterinary workers and CAHWs in pastoral areas.
• If the veterinary profession is to re-take the initiative in provision of cost effective and efficient services in pastoral areas, it needs to begin representing the interests of the mid-level vet workers and CAHWs.
• Remote pastoral areas were often treated as special disease areas by colonial authorities who often controlled the movement of livestock and people in and out of these areas. Some of these laws are still in place and are affecting the development of livestock marketing in these areas (Little 1992). These should be reviewed to encourage cash economies to develop.
• Remote pastoral locations or low potential areas often lack education and medical facilities. They are therefore a harsh environment for a well-educated, entrepreneurial vet with a family to want to live in - unless they are from that place. There is currently a great shortage of indigenous vets from pastoral areas and it could take some national commitment to train more vets from these areas.

• Currently in many regions vaccination against notifiable diseases can only be carried out by government vets and vaccinators. This might be in the very same areas where there are thriving networks of CAHWs - usually being supervised by a vet working for an agency. At vaccination time labour is duplicated. As the government vets can monitor the quality of vaccination, it should be more efficient to contract out the vaccination work to private vets using the local people on the ground with the livestock. Such contracts would provide regular income for private vets. This can only be brought about through policy change and close involvement of district authorities.
• The initial phases of establishing a CAHS project are a feasibility study followed by more in depth community dialogue / confidence building using PRA tools, agreeing a social contract and training of CAHWs. This process can take several months and can be difficult depending on the area and the experience of the person/s undertaking it. It is this phase that poses the biggest financial burden on any PPVP. The burden is basically the time and transportation of the investigator. It does not preclude provision of a relative simple financing scheme to a suitably committed individual. It is the authors' experience that recent veterinary graduates are often willing to establish simple practices with a minimum of investment, particularly if they are no longer guaranteed a government position. New graduates from pastoralist areas are already being headhunted for such schemes. The mechanisms for financing such practices still need to be worked out.
• Many remote pastoral communities are not yet monetised. This is not normally because those communities don't aspire to services which have to be bought with cash. It is caused by lack of markets for their livestock wealth and banks for their cash wealth. Improved marketing and trading in pastoral areas needs to be addressed if cash economies are to start.
• CAHS projects are proving in many areas to be vehicles or "entry points" for exposing isolated communities to other sectoral inputs. The common ones are facilitation of peace initiatives, organisation of community leaders into farmers associations which can then plan and work with other sectors such as water conservation, rain water harvesting, marketing and human health services. Such projects also have a role to play in famine early warning systems. These roles should not be overlooked in the drive toward privatisation in a given area.

• Many organisations implementing CAHS projects do so for altruistic or rehabilitation reasons. They are often subsidised. Such projects need to be encouraged to leave provision of vaccination and clinical services to the private sector. Organisations can then concentrate on sectors, which benefit the public but are less commercially viable. It would be a relatively simple task to phase many NGO projects into full privatisation, once a supportive legal and policy framework is in place. Many of these projects are being prevented from being privatised by current policy and laws.
• Pastoral areas are liable to natural disasters such as flood or drought. One response to such situations is the free or subsidised hand out of veterinary medicines by relief organisations. This is guaranteed to put PPVPs out of business. It is therefore important to have appropriate disaster mitigation plans and policies for areas where PPVPs exist. They might consider including a private practice in the relief effort.

1. A fundamental requirement is demonstration that CAHS are effective in terms of cost, delivery of services, disease surveillance and ability to assist with the government's role of development and protecting the public good. It is the responsibility of all project planners, veterinary associations, privatisation schemes to prepare reports which include cost analysis and impact assessment of their efforts to establish CAHS and PVPPs. Currently this information is not either available or not widely available. Encouragement of networking organisations which specialise in CAHS development to do this, such as Vetwork-UK, is vital.
2. Pilot trials of CAHS, negotiated with national and local government veterinary services provide one mechanism for demonstrating effectiveness whilst avoiding prosecution prior to changes in legislation.
3. Involvement of both pharmaceutical suppliers and developers of new diagnostic tools in the process of developing CAHS is useful because these groups are both knowledgeable and influential in their own right.
   Pharmaceutical companies are interested in opening up new markets. They can sanction the process and be encouraged to develop improved drug supply to remote pastoral areas, assist with initial start up costs of PPVPs (if they see a return on investment) and produce new CAHW friendly products in terms of pack size and route of administration.
   Researchers should continue to develop heat stable, pen-side, diagnostic tests.
4. Personal contact, consensus building and group decision making processes at both international, national and local conferences and workshops are important once CAHS can be shown to be effective or an improvement on existing services.
   Holding meetings in pastoral areas makes a difference.
5. Raising awareness of CAHS / PPVPs and the training needs associated with them amongst university lecturers and veterinary undergraduates will affect future attitudes and curricula.
6. Field visits are often highly effective in demonstrating the effectiveness of CAHS to senior decision makers. Such visits have been and can be across international borders.
7. At the field level farmer and local official exchange visits can be very effective in demonstrating concepts and the potentials
8. Mass communication through radio broadcasts, newspaper articles and video production improve awareness and acceptability of new ideas.

Ensuring that both national and local officials are exposed to the above mechanisms is important if the CAHS are to be more readily adopted.

The principles of how to establish CAHS in pastoralist areas are now well established. They are based on the successful development principle of people's participation and the elementary business principle of willingness to pay. Various different models of CAHS are being implemented by a variety of organisations and the potential structures of PPVPs are becoming clearer. Gathering case studies and data on the cost effectiveness and impact of CAHS is an important priority for those organisations which are trying to improve animal health service delivery in pastoral areas. There is a growing body of information to show that CAHS do work and can be privatised. This information needs to be used to influence policy makers at all levels, not just at national and international level. Governments need to begin reviewing and adopting new legal and policy frameworks which will provide an enabling environment for PPVPs to become established. Some NGOs and international agencies need to reassess their facilitating roles in establishing animal health services in pastoral areas to ensure that they encourage sustainability through privatisation. This may mean a more proactive role in trying to influence government policy toward community-based animal health service delivery.

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