Sekekhuneland, which is in the northern Transvaal in South Africa, has suffered from a 2-year drought which has led to a shortage of basic food in the villages and a 50-60% incidence of kwashiorkor among the village children. The natural resources of the area have been eliminated by over population and its attendant deforestation, land erosion, and wildlife decimation. The situation has been exacerbated by a political climate rife with corruption and incompetence. The most pressing problem is a shortage of water which prevents agricultural development and limits food production. Some dangerous traditional beliefs persist, such as believing that sickness is caused by curses which modern medicine cannot affect. In response to this situation, Hlatlolanang ("we share the burden"), a community-based development program has been put into place. The director of the center, Rose Mazibuko, is a nurse who believes that primary health care in its broadest sense is a human right. This involves not only the health sector but also agriculture, industrial development, education, housing, and public works. The first problem tackled was kwashiorkor. Other groups had failed to reduce the incidence of the condition in the area. Hlatlolanang recognized that mothers of affected children were being stigmatized by hospital personnel. Thus, the mothers would often go to the hospital only as a last resort and would avoid the training necessary to help their children. The community requested that Hlatlolanang become a training center where all members of the community could learn how to combat kwashiorkor and where inappropriate attitudes could undergo the necessary changes. Thus, the Hlatlolanang Health and Education Center was born with funding from the Kaiser Family Foundation, an architect who participated in the development workshop and knew exactly what the community wanted, an elected planning committee, and 4 local builders. People were carefully screened and hired to run the center according to a deliberately slow selection process which gave those employed time to acquire the necessary training for development work. Since the main objective of Hlatlolanang is to instill self-reliance in the communities it intends to serve, its programs are only put in place at community request and with the compliance and understanding of the local chiefs. Hlatlolanang is willing both to help and to work with anyone, a willingness which allows the group to avoid regional and village politics. Development work is slow, but gardens have been planted and hope has started to grow in the people.
To develop an appropriate health policy agenda, the National Progressive Primary Health Care Network (NPPHC) and the South African Health and Social Services Organization (SAHSSO) conducted situational analyses in 4 areas: an informal peri-urban area within the Durban functional region in Natal, a rural area in the Mhala-Mapulaneng district in the North Eastern Transvaal, the informal settlement of Botshabelo in the Orange Free State, and a dense township dwelling in Soweto. The analyses were based on interviews with health workers and community leaders, a national survey, and a questionnaire for health service administrators. All 4 areas were characterized by poverty, unemployment, low educational levels, lack of a clean water supply or refuse removal system, housing shortages or overcrowding, and political violence. Preventable diseases, such as water-borne diarrhea and malnutrition, cause substantial morbidity, yet health services tend to be inaccessible, distributed inequitably, of poor quality, and with unclear administrative structures. Community members interviewed indicated that clinic fees were too high, especially given the low quality of care, and there was a general mistrust of the competency of doctors and nurses. There was a lack of consensus on the meaning of community participation; some viewed it as a vehicle for empowerment, while others felt the strategy would be exploited as a means to deny government assistance. Overall, respondents were supportive of a greater role for community health workers and more involvement on the part of nongovernmental organizations. A priority, at present, is attention to the many socioeconomic factors that are compromising the health of black South Africans and overshadowing the rationalization of health services.
Private and bilateral donors currently place a great deal of emphasis on the potential importance of nongovernmental organizations (NGOs) in delivering services to dispossessed populations and nascent democracies around the world. This is particularly the case in Southern Africa. The expectation that NGOs can utilize resources more effectively than government may ultimately imperil the credibility of NGOs internationally. NGOs are expected to be: agents of development; community organizers and educators; institution builders; social service providers; humanitarian relief providers; political activists; human rights protectors; police watchdogs and advocates; organizational and financial managers; technical experts in agriculture and health; democracy promoters; innovators and testers of new ideas and technologies; fund raisers; employment creators; credit providers; and an alternative to governments. African NGOs must identify creative solutions that work; improve NGO capacity for research and evaluation, including definition of their own criteria for evaluation; test technologies and monitor results; and refine participatory and action research methods. 1) NGOs need to make decisions about whether they want to become mere service providers or whether they are going to make a long-term commitment to institution-building. 2) NGOs need to fend off attempts by donors to buy into agendas that are not their own. 3) Another major challenge is to reduce NGO dependency on donors and to increase their accountability to their own constituencies. 4) It must also be ensured that institutionalization does not lead to a lack of responsiveness within the NGO community. In Zimbabwe, workshops have been held to assist the NGO community in developing skills in coalition building around various issues to influence governments and donors, whether on women's issues, environmental issues, or cooperatives. If donors promote more effective development work both by encouraging linkages among these NGOs and by sharing information among the donors themselves, all development actors will learn from each other.
The effectiveness of puppet theater in communicating information about acquired immunodeficiency syndrome (AIDS) has been demonstrated in a project launched in 1988 by the African Research and Education Puppetry Program (AREPP). Puppetry is a vital part of the Bambara, Bozo, and Yoruba cultures. "Puppets Against AIDS" tells the story of a condom refuser who transmits the AIDS virus to his wife and their infant. An evaluation conducted by social epidemiologists in 1989 found the production to be comprehensive in its educational messages and effective in contributing to the audiences' knowledge and intended behavioral changes. A discussion period follows the production. The show was subsequently incorporated into an existing community-based AIDS education program. Because AIDS touches upon sensitive and often taboo areas of social life, the dissemination of information through puppets is not perceived as threatening as interpersonal interaction.
Community theater is being effectively utilized as a vehicle for acquired immunodeficiency syndrome (AIDS) education by the Johannesburg City Health Department. A drama developed and produced by the Department's AIDS Prevention Program in 1989 has been presented to over 20,000 people, at factories, canteens, clinics, parks, and community events. The drama, which revolves around a group of friends living in an urban South African township, includes scenes at the workplace, a health clinic, and disco. A central theme is negotiation of condom use. The event concludes with a discussion period with the actors, all of whom are health workers. Questions that frequently emerge in these discussions are worked into subsequent presentations of the drama. The drama allows the awkwardness of using a condom for the first time to be demonstrated in a way that is nonthreatening to the audience and does not evoke the intimidation often present in the health worker-client relationship. In addition to overcoming problems of information inaccessibility and unreliability, drama offers a means of conveying AIDS prevention messages in a culturally sensitive manner.
