Lessons learned from the experiences of the Kasserine regional health education team, 1987-1991

Concerning the female village health worker (VHW) program: (1) It is nearly impossible to implement a successful community-based health program in rural areas without a regular, assured form of transportation. The lack of transportation for Regional Health Education Team (RHET) members was frustrating and added to team stress, and also blocked field follow-up visits to VHW's throughout the life of the project. (2) For rural regions with limited health personnel, VHW's seem to be a viable way to reach communities, provided the VHW's are well trained, well supervised, and communicate very specific health messages related to actual existing behaviors and not to merely perceived needs. (3) Any reported changes should be evaluated through household observations to determine the accuracy of the information provided. Concerning the school-based hygiene education program: (1) This program greatly increased the knowledge level of both teachers and students regarding water and sanitation, personal hygiene, and household cleanliness. (2) There is a great need for the active participation of the Ministry of Education in this program. More active participation from the teachers is also necessary. Concerning the small community development programs: (1) An evaluation must be planned and implemented for all community development activities and not left optional. However, given their other responsibilities, RHET members often had difficulty finding adequate time to implement this activity. (2) The lack of strong Regional Water User Association Support Unit (UAG) leadership after the departure of the UAG Director led to a paucity of data collection and systematic monitoring activities. This in turn meant that only project outputs could be assessed. Concerning the women's interest groups (WIG) program: (1) Implementing a novel concept such as WIG's at a community level in Tunisia requires a significant commitment of time and resources. Having an outside party take a lead role in creating these structures without the active participation of a local, permanent counterpart diminishes any chance of sustainability after the outside staff member leaves. (2) The support of community leaders is critical to the success of the WIG. This groundwork must be laid well in advance. In several cases, however, the local officials tried to control the WIG instead of allowing the women to do so. (3) The WIG program should have included an assessment component. This would have permitted an analysis of the effectiveness of these community groups in representing women's points of view to the water user associations. Concerning materials development: (1) Flexibility in project design and budgeting can lead to some good, complementary activities and materials for existing programs. (2) Pretesting and field-testing of educational and training materials is a difficult technique to reinforce. (Even with training in these areas, RHET members actively resisted these steps.) It takes constant technical advising to insure that pretesting will take place. Concerning management and organizational issues: (1) Lack of a formal, administrative arrangement between the various ministries involved in RHET activities sometimes hampered these activities. (2) The services of an outside budget manager were necessary to the smooth functioning of RHET and encouraged more innovation and programmatic diversity. (3) The absence of a formalized structure for RHET led to internal conflicts between RHET members that were impossible to resolve in any satisfactory way. Creating the position of UAG Director for project purposes was necessary, but in the long run it left RHET without management, because it was impossible to recruit someone to replace the original Director given the administrative circumstances of the Ministry of Agriculture position. (Author abstract, modified)