Uganda: Home-based HIV treatment extends lives

By, IRIN Plus News, March 6, 2008

Off the beaten track east of Uganda's capital, Kampala, a four-wheel-drive vehicle is taking a nurse, a community health worker and a cooler full of life-saving medication to Gayaza village, where they will call on homes affected by HIV/AIDS.

Although more Ugandans than ever are on antiretroviral (ARV) therapy, many HIV-positive people in remote areas still struggle to get the life-prolonging drugs: health professionals are scarce (about one doctor per 12,500 people) and community health centres are few and far between. Most villagers, mainly subsistence farmers, cannot afford to travel long distances to reach them.

A study conducted in Uganda and published this month in the UK medical journal, The Lancet, has found that home-based ARV therapy provided by trained lay counsellors could be the best option for HIV-infected people living in remote, rural areas.

Mortality dropped more than 90 percent among HIV-positive participants and their families receiving home-based care. Instead of routine clinic visits, lay counsellors visited patients in their homes to deliver medication, support them in adhering to their drugs, collect blood samples, and refer those with symptoms to the nearest clinic. The home-based ARV programme also eased the burden on over-stretched local health centres.

Mortality among the dependants of HIV-positive participants decreased, as parents who were well cared for by the home-based services were in turn better able to care for their children, and the children were less likely to be orphaned.

Conducted between 2001 and 2005 by the United States Centres for Disease Control (CDC), with funding from the US President's Emergency Plan for AIDS Relief and support from Uganda's government, the study involved 1,373 HIV-infected participants and 4,601 of their uninfected family members referred by a branch of The AIDS Support Organisation (TASO), a local non-governmental organisation, in Tororo district in eastern Uganda.

Dr Frank Kaharuza, a CDC researcher, said Tororo was chosen because of its existing infrastructure, high rate of opportunistic infections and the need to find a distribution method for newly available ARVs.

Although most participants lacked post-primary education and lived in homes without electricity or running water, between 89 and 97 percent of them reported taking at least 95 percent of their ARVs - a better rate than many clinics are able to achieve.

"Adherence was surprisingly good," said Kaharuza, who noted that less than two percent of the patients had to be switched from first-line to second-line ARVs, which was usually necessitated by drug resistance developing due to poor adherence.

Scaling up home-based care

In Gayaza, the TASO team visits Deborah Namuwaya, 52, who has been on tuberculosis treatment for six weeks. The frail woman, feet tucked into her black and yellow gomesi (traditional dress), lies on a foam mattress on the concrete floor of her two-room home, coughing uncontrollably.

"We have fuel and transport, so we must assist them," said Florence Natukunda, the TASO nurse. She provides medical treatment and other small measures that make a significant difference to patients with compromised immune systems, monitors hygiene and use of mosquito nets.

Robert Nakidumba, public relations officer for TASO, said the organisation planned to scale up its home-based care programme after the Tororo study findings.

As of June 2007, 14 percent of the 106,000 Ugandans on ARV therapy were already receiving their medication through home- or community-based care, mostly through monthly home visits by TASO staff. Researchers now plan to test the efficacy and cost-effectiveness of home-based ARV programmes in longer and larger studies in other locations.

There are more than 20 million people infected with HIV in sub-Saharan Africa, and many of them live in remote villages with poor access to health services.

The Lancet article on the Tororo study noted that finding a way to scale up the provision of ARV therapy and care, "irrespective of geographic or socioeconomic background", could significantly reduce mortality among people with HIV, improve the health of their children, and reduce the level of orphanhood.

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Source: http://www.plusnews.org/Report.aspx?ReportId=77161

SWAZILAND: Home-based care system expanding

By, IRIN PlusNews, February 23, 2007

Home-based care in Swaziland is increasingly being relied on to compensate for the inadequacies of a public health system buckling under the weight of the country's HIV/AIDS pandemic.

UNAIDS estimates the national HIV infection rate of people aged 15 to 49 at 33.4 percent, the highest in the world, a demoralising environment that has led to nurses migrating to other countries in search of better salaries and working conditions.

The strain placed on the country's resources by HIV/AIDS has resulted in the public health service failing to care for the elderly, especially in the rural areas, and it is a gap being increasingly filled by volunteers within the home-based care network.

One such initiative, started by the Baphalali Red Cross Society in 1999 and orchestrated from the Sigumbeni Clinic, in rural central Swaziland. It sees community volunteers visiting homestead after homestead to monitor their clients' conditions, ensuring medication regimes are adhered to and, if required, arranging doctors visits to the home and providing transport for the collection of antiretroviral drugs and other prescription drugs. Any medical emergencies are referred to Swaziland's second city, Manzini, a 30km drive on dirt roads.

"Our responsibility is to respond to the health needs of terminally-ill patients. These are people with AIDS, tuberculosis, cancer, people who had strokes, and the bed-ridden elderly. It's all about bringing health services to the home," said Muzi Dhlamini, a male nurse who for the past two and a half years has headed-up Sigumbeni's home-based care programme for the Red Cross.

The majority of their patients are adults in the advanced stages of AIDS-related illnesses, or the elderly, an exception being eight year-old Khanya Dube (not her real name), born HIV-positive and severely weakened by chronic anemia. She has developed multi drug resistant TB, a condition, until recently, that would have been a death sentence, because the costs of taking the child to hospital for medication and hospital checkups would have been unaffordable for the family.

The health care provided by non-governmental organisations, including the Red Cross, has brought Khanya under the wing of the home-based care system, bringing life saving assistance to her and other people in isolated rural areas.

"The test found she had a resistant HIV/AIDS, and on Wednesday we switched her treatment. Generally, she is weak, weak, weak. It's the anemia. She needs transfusions, and we arranged these twice. Once she was unable to get the blood she needed because the hospital didn't have the pints," said Dhlamini, highlighting one of the public health care systems shortcomings. This week, Khanya was taken by ambulance to hospital in Manzini.

Hive of activity

Each day the Sigumbeni Clinic is a hive of activity, with small trucks and ambulances arriving and departing to take volunteer workers to far-flung areas and bringing others to the clinic for prescription drugs. About 88 home-based care patients were assisted this week, Dhlamini said, a sizeable number considering the sparsely-populated area of the widely-dispersed homesteads.

Ncane Kunene, a 26-year-old nurse co-ordinates the Red Cross's food security initiative in the area and was supervising the loading of medical supplies on a truck that will also distribute mattresses and food to patients. "Food is an element of home-based care, especially now when there is little food in this area," Kunene said.

Nomcibelo Dlamini, a 54-year-old Red Cross trained care facilitator, who dispenses aspirin, cough suppressant and similar non-prescription medications, said: "I work from a list of patients, and I must report to the clinic the state of each client. I see that the patient is feeling well. There are some ordinary tasks to perform, like changing the position of a patient in bed who has difficulty moving, to avoid bedsores. Sometimes I will feed patients."

Care facilitators are given about US$15 a month for lunches and bus fare, but their supervisor, Dhlamini, wants the amount raised to US$60 a month. Two-thirds of Swaziland's roughly one million people, ruled by sub-Saharan Africa's last executive monarch, live on US$2 or less per day.

"This will be an appeal to our donors. We face a crisis with care facilitators. They are devoting so much of their time to treating the terminally-ill that they cannot earn income to support themselves and their families. This is becoming a problem, because we need them and we are asking so much of them," he said.

The care facilitators also provide advice to relatives on how to care for the terminally ill, including the use of rubber gloves when bathing and tending AIDS patients and keeping accurate records of medicines taken.

"The families are thankful for this programme. It is scary to have a loved one ill and you don't know what to do. We offer moral support, and that is really an important part of what we do. When this programme started, there were people dying of AIDS without medical assistance. The need for home-based care is not new. But HIV/AIDS has accelerated the response," Dhlamini said.

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Source: http://www.plusnews.org/AIDSReport.ASP?ReportID=6717

Mozambique: HIV/Aids Carers to Be Taught ARV Management

By, UN Integrated Regional Information Networks, January 16, 2007

The Mozambican Red Cross will begin training hundreds of volunteer workers to manage antiretroviral therapy (ART) for the HIV/AIDS sufferers in their care.

"This training is extremely important and will improve the work of our carers," Paula Macava, the Red Cross Mozambique coordinator of the HIV/AIDS programme, told IRIN. "We have now finalised an eight-module training package on antiretroviral therapy management, specifically designed for carers."

The three-week training package for volunteers, who should have at least basic reading and writing skills, includes information on how to judge the preparedness of a client to start antiretroviral (ARV) medication, ensure that those using the drugs stick to their regimen, and the importance of eating nutritious food when taking anti-AIDS medicines.

A handful of NGOs have started ARV management training for carers but their reach is limited, whereas the Red Cross has a nationwide network of 600 carers in its home-based care (HBC) programme, which operates in 9 of the country's 11 provinces.

The national HIV/AIDS prevalence rate for adults is 16.2 percent but rises to 19 percent in Manica and 26 percent in Sofala - the provinces bordering Zimbabwe. According to UNAIDS, Mozambique's HIV prevalence rate is the 10th highest in the world, and nearly 80 percent of the country's about 20 million people live on US$2 or less a day.

According to the health ministry, the government, with the support of partner organisations, provides ARV treatment to 34,000 people and aims to have 50,000 on ARVs by the end of 2007. The ministry estimates that 250,000 people may require ARV treatment.

Managing ARV treatment in Mozambique presents a huge challenge, especially in the sparsely populated rural areas where infrastructure is poor.

Red Cross carer Angela Mondlane conceded she was being overwhelmed by the demands of the HIV/AIDS pandemic in her hometown of Moamba, 60km northeast of the capital, Maputo. The HIV/AIDS prevalence rate for adults in Maputo Province rose from 13.5 percent in 2000 to 20.7 percent in 2004, according to health ministry figures.

Mondlane, 42, a mother of three, walks to visit five chronically sick people at least three times a week because her bicycle is broken. Some of them are on ART, but she admits that her knowledge of ARVs is rudimentary, saying, "I need to understand the ARV drugs better."

Her ignorance of administering ARVs showed during a house call on HIV-positive Bata (not her real name), 21, who lives with her aunt and six other orphaned nieces and nephews.

Bata has apparently just started second-line ARV treatment, but neither she nor Mondlane know what these drugs are, or even if they are ARVs. Her aunt is also not sure exactly what the medication is, but thinks it must be ARVs because "she [Bata] is always hungry".

"I know I must take these tablets twice a day. They are different from the other ones - the first lot of tablets made me very sick," said Bata, who has never received any formal education.

Like all carers, Mondlane participated in the health ministry's two-week training course, which teaches basic medical knowledge such as first aid and counselling, but does not include training in administering ARVs. "I am looking forward to the training on ARVs, so I can care for my clients better," she said.


Source: http://allafrica.com/stories/200701160849.html

RWANDA: Locals taking AIDS orphans, widows under their wing

By, IRIN PlusNews, November 23, 2006

KIGALI - The continued poverty and suffering in Rwanda, 12 years after the genocide, is spurring local people to take responsibility for orphans rather than wait for handouts.

"I survived the genocide but my parents did not. After looking after my brothers and sisters I looked around and saw many more children who needed support, like I received from friends and neighbours when I was a child," said Emmanuel Ngabire, who founded of the Rebero Orphans Centre with Leonce Mpenzi.

The centre, in the suburb of Gikondo, in the capital, Kigali, cares for 70 orphans and 18 widows who contracted the HI virus through sexual violence during the genocide.

An estimated 270,000 Rwandan children have lost one or both parents to AIDS-related illnesses, while 800,000 people are thought to have died in the genocide, leaving the country with the highest number of child-headed households in Africa. Rape was deliberately used to intimidate members of the minority Tutsi community and moderate Hutus.

The Rebero centre, where the children come to play after school each day, is supported largely by a group of Rwandan professionals, who donate an average of US$230 per month to feed the children and widows, and also chip in for medical expenses and other emergencies.

Jacqui Sebageni, one of the centre's benefactors, commented, "When we first met these two young men in April, I was struck by the fact that even though they were themselves on a survival level, they reached out to help people in the same situation."

NGOs and the government provide support in their respective capacities, but orphans also need the guidance and support that people with intact families often take for granted. "Because of our country's history, most Rwandan families that have some means are supporting four or five other families," Sebageni said.

Mpenzi met many of the centre's patrons while working as a waiter at Kigali's Intercontinental Hotel. When he had enough pledges of support, he left his job and became a full-time volunteer at the centre.

Twenty-three of the children are HIV-positive, including Jean-Pierre, 6, (not his real name), a shy football enthusiast. "Both his parents are infected," Mpenzi said. "The whole family is on antiretrovirals and his parents are too poor to pay the small fees ... when he starts primary school next year."

Jean-Pierre's family, like the families of other orphans and widows supported by the centre, receives seven kilos of beans and six kilos of flour every month.

Another beneficiary is Venancia Nyirabuzara, 53, whose husband and much of her extended family were killed during the genocide, leaving her with three children. She contracted HIV after surviving a brutal sexual attack when she was three months pregnant and transmitted it to her son, now 12 years old.

"I wanted to die after the genocide; even when I started falling ill and had a serious skin infection I refused to seek medical treatment," Nyirabuzara said. "I hated everyone around me and my children suffered; we had little food and no money because I didn't work."

Ngabire visited her five months ago and encouraged her to join a support group for women who were HIV-positive as a result of suffering sexual violence during the genocide. He also started bringing her weekly rations of flour and beans, and urged her to be tested and seek treatment.

"He took me to meet these women who showed me that I was not the only one with the same problem. I can be free and talk to them about my illness and my experience," Nyirabuzara said. "My children are also happier now that I am more active and not so depressed; I realised that when I was suffering, they were as well."

Since she began a course of life-prolonging antiretroviral medication five months ago, her CD-4 count [which measures the strength of the immune system] has risen from 210 to 320, but she has not yet told her son that he is HIV-positive, or that she is, but hopes she will have the courage to do so soon.

Ngabire and Mpenzi are trying to build a home where they can focus on caring for underprivileged HIV-positive children. "God protected me during the genocide and I promised that I would protect others," said Mpenzi. "Our community must care for these orphans - if we care for each other we will never see the same kind of killings again."

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Home-Based Care Reduces HIV Prevalence Rate

By, Victoria Muringayi, Zimbabwe Independent (Harare), November 10, 2006

THE National Aids Council (NAC) has attributed the decline in the Aids prevalence rate to various projects such as the home-based care system which deals with people living with the HIV/Aids virus.

NAC board chairman, Reverend Murombedzi Kuchera, said the awareness campaigns being carried out by various stakeholders nationwide were helping reduce the prevalence rate.

The prevalence rate for the HIV virus is now down at 18,1% from the previous 20,1%, while projections point to a reduction to a single digit rate by 2010," he said.

"Home-based care is one of the very important strategies in national efforts to address challenges faced by Aids victims at home."

Zimbabwe has over 300 000 people who require anti-retroviral drugs, but only 42 000 of them are receiving treatment. The remainder have to be catered for through home-based care initiatives.

The NAC said it was receiving US$250 000 for anti-retroviral drugs every month from the central bank to cater for those who cannot survive without the drugs.

"We have anti-retroviral drugs that can cater for 42 000 people who are on treatment and need the drugs constantly," Kuchera said.

"We are currently mobilising our resources so that we can source funds for patients on anti-retrovirals so that everyone infected with the virus receives the drugs."

Kuchera was speaking at a community home-based care certificate award ceremony held in Harare last Friday by a non-governmental organisation Jekesa Pfungwa/Vulingqondo.

Jekesa Pfungwa funnelled at least US$30 000 that it received from Irish Aid through Zimbabwe Aids Network to offer community home-based care to 20 monitors and 10 field officers throughout the country.

The money was used to buy bicycles, home-based care kits for the monitors and the field officers to improve efficiency in the programme.

Jekesa Pfungwa deputy director Mabel Moyo said the community home-based care course is the third that they have offered to the community and the 20 monitor's role is to educate and give information to primary care givers, who are family members taking care for the terminally ill.

"The home-based care monitors and field officers have undergone a refresher training course which is a special programme, that was done according to the national standards as required by the Ministry of Health," said Moyo.


Source: http://allafrica.com/stories/200611100363.html

MALAWI: Home based care eases pressure on public health sector

By, IRIN Africa PlusNews reports, August 5, 2006

MZUZU - Faced with the devastating impact of an HIV/AIDS epidemic compounded by abject poverty, Malawians have eased the pressure on state hospitals by caring for chronically ill family and neighbours at home.

A home based care (HBC) project in Northern Malawi has assembled 225 young volunteers in the region's nine districts to provide community based support to homes and guardians looking after people living with AIDS (PWAs). The aim is to ease their suffering and prolong their lives.

Levi Soko, the acting project coordinator for HBC told PlusNews that the project was also looking after 4,000 orphans - providing them with school fees, school uniforms, learning materials and, where necessary, bedding.

"We are supporting 860 affected families who are hosting chronically ill patients. By the end of the project [our target is] 3,000 guardian families. The goal of the project is to create awareness of HIV and AIDS prevention and transmission messages, and also to support guardians that are looking after the [PWAs]," Soko said

It is hoped that the project, which began in 1996, will be able to support 5,000 orphaned children by 2005.

The HBC concept, which gets village committees to organise volunteers to help families care for people laid low by AIDS, is becoming increasingly popular throughout Malawi. The country's 22 district hospitals, including four referral hospitals, are struggling to cope with the overwhelming number of sick people.

HBC minimises the number of times a person would have to be hospitalised.

In Malawi, AIDS kills 70,000 people every year. It is estimated that between 850,000 and one million people now carry the HI virus that causes AIDS. An indicator of this is that 75 percent of Malawi's recorded 27,000 tuberculosis cases in 2001 were HIV positive, according to hospital sources. It is also estimated that 38 percent of the people who have HIV/AIDS are in the most productive age group.

Jennie Mueller, head of Development Aid from People to People (DAPP), a project that helps communities implement programmes to cope with AIDS, said HBC also helped to educate families about HIV/AIDS.

"It helps families understand the illness and people can die with dignity at home. It provides hope and a way to cope and it helps the grieving process because the community would already be reaching out to that family over the period of illness," she said.

Soko said, when possible, the HBC project also offered vocational training such as embroidery, mat making, welding and carpentry to orphans.

"If one community member has a workshop, we request them to offer internship. We do not have a formal structure to accommodate all of them [orphans]. We're using community resources that are on the ground," he explained.

The HBC project is supported by the Catholic Development Commission of Mzuzu Diocese with funding from Catholic Relief Services and a British-based catholic organisation, CAFOD. Soko said the project also worked with other organisations with related projects such as the District Social Welfare and District AIDS Coordinating Committees.

"They really assist us in implementing our activities. We also interact with all the other churches. As of now, we have nine home based care providers, also known as parish coordinators, and two field officers who monitor the care providers," Soko said.

The volunteers had mobilised their communities who donated items such as used clothes, maize flour and sugar while the HBC project provided other sundries, such as basic drugs and vitamins. With the assistance of the volunteer network, the project aims to enable guardians to better manage and care for HIV/AIDS patients.

"We provide foodstuff and Likuni Phala [a porridge] to boost the patients' nutrition. Sometimes the volunteers provide bedding, depending on the needs of the family. But most of all, counseling is emphasised so that the guardians should not lose hope," Soko explained.

However, Soko noted that the project was being undermined by various factors. Chief among these was that communities still discriminated against PWAs.

"This makes it difficult for people to declare their sero [HIV] status," he said.

Another was that in some instances community members demanded to be paid allowances for attending project meetings. "The problem is escalating and the resources ... are becoming too little," Soko said.

Despite these challenges, he said the project's volunteers were very dedicated.

"What it means is that they are serving their neighbours, they're serving their brothers and relatives," Soko said.


Source: http://www.irinnews.org/AIDSreport.asp?ReportID=1400

Congo-Kinshasa: Solidarity Against Aids

By, UN Integrated Regional Information Networks, October 10, 2006

The NGO ACS/Amocongo provides care and support to thousands of people living with HIV.

After losing her sister to HIV/AIDS two years ago, Kimya, an HIV-positive mother of four, felt she had no choice but to take in her sister's children, saying it was "the obvious thing to do - it is solidarity".

"At first the two children were placed elsewhere [with other family members], but it didn't work out," she said in her single-roomed shack in Lubumbashi, capital of the southeastern province of Katanga in Democratic Republic of Congo (DRC).

Despite her poor health and bleak financial position, Kimya, 55, (not her real name) decided that the best place for her nieces was with her. "I was really obliged to do this. My family had abandoned us - they don't even visit us any more," she said as she cradled her crying three-year-old on her lap.

Kimya discovered she was HIV positive in 2002, just after her husband died. "My husband's family came to see me to suggest that I be tested for HIV. I was tested and the result was positive," she said. "I was very unhappy - I had heard people talking about AIDS at the church and I thought I was going to die immediately."

Community Action Association Against AIDS/A Better Future for Orphans (ACS/Amocongo), a local nongovernmental organisation (NGO) founded in 1993, runs voluntary testing centres in nine of the country's 11 provinces, and provides schooling, feeding and psychological counselling to about 8,000 AIDS orphans. Kimya was tested at a centre near her home.

In 1997 ACS/Amocongo decided to expand its assistance to include the families and caregivers of AIDS orphans, on condition that the orphans were not abandoned.

"We want to prioritise African solidarity by telling these enlarged families to give these children affection and a roof over their heads, and we will do the rest," said Dr Jo Bakualufu Ntumba, in charge of follow-up and evaluation in ACS/Amocongo programmes in Kinshasa, the DRC capital.

The United Nations Children's Fund (UNICEF) estimates that after almost ten years of conflict, the DRC has 120,000 HIV-positive children, and 800,000 have lost one or both parents to the pandemic.

Last year, in an initiative financed by the Global Fund to Fight AIDS, Tuberculosis and Malaria, ACS/Amocongo started providing free antiretroviral (ARV) treatment to 2,100 people living with HIV/AIDS. The NGO has a total of 6,600 HIV-positive people on its books in 20 treatment centres throughout the country.

Kimya is one of the patients whose health has improved since she started treatment, but she is worried about her youngest child, who has become HIV positive - the only one of the six she looks after to be infected. ACS/Amocongo has been providing antibiotics to limit opportunistic infections.

Paediatric ARVs are not available in Lubumbashi but, with the help of the Global Fund, ACS/Amocongo is hoping to receive the first batch before the end of the year.

According to Dr Lucien Kalenga, who heads the programme in Katanga Province, 300 of the 1,500 orphans ACS/Amocongo looks after in the province would be eligible for this life-prolonging treatment. "It is difficult to give ARVs to the mother and not to the child," he said.

While they wait, Kimya's priority is to find a way to feed her family. "They are sad because they are hungry. They haven't eaten today," she said wearily.


Source: http://allafrica.com/stories/200610110007.html

Community-based health volunteers key in fighting HIV/AIDS

A Red Cross volunteer lights candles forming a ribbon, the symbol for solidarity with AIDS patients in Bujumbura, Burundi on 25 March 2006. (AFP/File/Dimitar Dilkoff)Johannesburg, South Africa: On the eve of World Health Day (7 April), the International Federation of Red Cross and Red Crescent Societies highlights the growing importance of its volunteers involved in community health activities, especially activities related to HIV/AIDS.

According to the World Health Organization, there is an estimated shortage of four million health workers worldwide, with severe deficiencies in low-income countries and rural areas. Red Cross/Red Crescent volunteers are playing a key support role and increasing the skills of people living with HIV and families for self care, especially in places where national health systems do not respond adequately to the needs of the local population.

The work of volunteers is being highlighted during a Symposium in Johannesburg on April 6-7 about integrated HIV/AIDS community home-based care. The event is organized by the International Federation in partnership with 10 National Societies in Southern Africa. “The Red Cross Red Crescent has accumulated a great deal of experience in home-based care programmes”, says Bernard Gardiner, manager of the Global HIV/AIDS programme for the International Federation in Geneva. “As a result, there has been a demand from other organizations for the Red Cross Red Crescent to share their experiences and knowledge,” he adds.

The Red Cross Red Crescent comparative advantage in care programming is due to its effective use of the widespread network of trained community-based volunteers who provide care and support services to the chronically ill and family members in their homes, which is also a valuable support to overburdened health facilities. The same community-based volunteers also give advice on HIV/AIDS prevention, hygiene, food and nutrition, water and sanitation, prevention of tuberculosis and malaria and adherence to treatment. They are also involved in anti-stigma campaigns with people living with HIV/AIDS.

At present, home-based care programmes run by National Societies in Southern Africa are reaching 50,000 people and approximately 85,000 orphans and other children made vulnerable by AIDS. The Johannesburg Symposium will see the launch of the new five year HIV/AIDS strategy in the region, further promoting home-based care and treatment support. “It is time to share the knowledge and experience which has been built up in Southern Africa and to champion the work of the committed and devoted Red Cross volunteers,” says Françoise Le Goff, Head of the International Federation’s regional delegation in Harare.


Source: http://www.worldvolunteerweb.org/news-views/news/community-based-health-volunteers-key-1144327542/lang/en.html