Monday, October 17, 2011

BATIBO DISTRICT HOSPITAL SURGICAL COMPLEX




THE BATIBO DISTRICT HOSPITAL SURGICAL COMPLEX,
A COMMUNITY PROJECT, MARCH 1998
Authors:
Dr Eyong Efobi John, District Medical Officer; johnefobi@hotmail.com; Tel: (+237) 677766732,
Mrs Tebong Suzan, TSSI, Acting Chief of Bureau of Health;
Dr Mfonfu Daniel, Provincial Chief of Hospital Medicine, dmfonfu@yahoo.com, Tel: (+237) 677601207

Contributors:
Mr Tebo Richard: Econome and Auditor District Health Committee; Mr Munghey Peter: Chairman District Management Committee; Mr Musi Pius: Chairman District Hospital Management Committee;
Mr Atanjang Godlove: Member Management Committee; Mr Tikum Philip: Member Management Committee

PREFACE
The production of this book is an experimental effort to document an experience in working with the community in Batibo Health District since 1992.
It emphasizes on the so much desired partnership between government (represented by the technical health staff) and the community (represented by their elected committee members). These two groups worked together in co-financing and co-management of their health activities. Emphasis is laid on simple strategies to mobilize manpower and funds from the community, mobilize funds from elites and donor countries and especially on the management of these funds.
The realization of the Batibo Surgical Complex is the 12th and most elaborate project undertaken by the community in the spirit of community participation in addition to other obligations. This is a glaring example of the reorientation of primary health care which is the basis of health for all.
Although written primarily to document their experience in working with the community to raise its health status, many health teams may find this manual a useful practical working companion in finding short and long term solutions to the numerous health problems of their communities.
The authors welcome any comments and suggestions which may help improve their experience.
By Dr GHOGOMU AMIDA: Provincial Delegate of Public Health North West Province, March 1998.
(Picture 1: Batibo Hospital Surgical Complex; pic 2: Batibo in Map of the Republic of Cameroon;
pic 3: Map of Batibo Health District; pic 4: NWP Governor visiting the Batibo Hospital project)

ACKNOWLEDGEMENTS
The completion of the Batibo District Hospital Theatre Complex has brought a lot of joy and satisfaction to the Batibo Health District Community and to the sponsors of the project.
This project would not have been completed the without the effort of many people. We the Batibo Health District Committee shall mention just a few names here.
We wish to acknowledge with gratitude and affection the financial support and/or equipment donated by the following: The British High Commission especially His Excellency McCathy and Mr Hamilton Charles; The Canadian High Commission especially H.E. Pierre Guigere and Mr Maurand; The German Embassy especially the Ambassador and Dr Meloni of GTZ Yaounde; The Japanese Embassy especially H.E. Takeru Sasaguchi, Mr Masato Futaishi, Mr Toyoo Okita and Ronstand Langhang.
We thank the entire Batibo Health District Community for their financial support and human investment.
The constant financial support of elites from Batibo and Widikum residing in and out of the country is not forgotten. We thank them sincerely especially those from Yaounde, Douala, Limbe, Bamenda and Washington D.C. In particular, we appreciate the efforts of Dr Mbah Mathias of Washington D.C, Mr Dinku of Dallas and Mr Nyambi Samuel of New York for their special concern.
We appreciate Mr Njock Obenson, who took off time to draw the final plan of this Surgical Complex.
We thank H.E. Bel Luc Rene who sacrificed his time to come and lay the foundation stone as the then Governor of North West Province. His coming was a great moral booster and helped reveal the importance of this community project.
We acknowledge the constant contributions of the Provincial Delegate of Health NWP, Dr Ghogomu Amida.
We acknowledge the tireless efforts in the mobilisation phase of our community by our local administrators: Mr Ettah Mbokaya, D.O. Batibo; Mr Yosimbon Johon, D.O. Widikum; Mr Taku Mulu Peter, former D.O. Batibo; Mr Mbatifuh Thomas, Mayor Batibo; Our Fons, especially the Fon of Bessi, R.M Fokum who actually launched the fund raising at Bessi.
We thank Dr Mfonfu Daniel, Provincial Chief of Hospital Medicine for his constant advice and contribution towards the realisation of this project and initiating this write up.
We are immensely indebted to the fund-raising committee, the staff and all others who contributed but whose names do not feature here.

CONTENTS
Preface
Acknowledgement
Chapter 1: Introduction
Chapter 2: Situation analysis
Chapter 3: Priority projects for the development of Batibo Health District Hospital
Chapter 4: The Batibo District Hospital Surgical Theatre project
Chapter 5: Strategies for the Construction of the Surgical Theatre
Chapter 6: Plan of action and budget
Chapter 7: Mobilization of resources
Chapter 8: Execution of the Batibo District Hospital Surgical Theatre Project
Chapter 9: Supervision of the project
Chapter 10: Evaluation of the Surgical Theatre Project
Chapter 11: Prospective
References:
Annex I: List of Fund Raising Committee
Annex II: List of realistic Contributors of 5000 FCFA and above.
Annex III: List of Group Contributors of 5000FCFA and above
Annex IV: List of Staff of the Batibo Hospital and the District Health Service
Observations and lessons learnt by Dr Daniel MFONFU, October 2011

CHAPTER 1 – INTRODUCTION
The Cameroon National Declaration on the implementation of the Reorientation of Primary Health Care states that the Reorientation of Primary Health Care is not a program. Rather it is the reorientation of our National Health System towards the social objective of ‘Health for All’. The fundamental principle of the Reorientation of Primary Health Care is community participation with a view of promoting self-reliance solutions vis-à-vis its health problems.

The management of health activities and resources is made in the spirit of partnership with consensus from the two partners, the health services and the community organised in dialogue structures.
‘The achievement of the universal and timeless goal of “Health for all” (HFA) means mobilising all for health. Such mobilisation will lead to the resolution of basic health issues, the adoption of an appropriate organisational framework and the overcoming of any major obstacles to health that may be present in a given community, region, nation or continent. The Reorientation of Primary Health Care (RePHC) approach is the means of achieving HFA. This approach which presupposes the full participation of the community ensures that essential health care is accessible to all individuals and families at an affordable cost. It is based on the principle of self reliance and self determination and is most efficiently implemented at the district level’ (G.L. Monekosso, 1994).

In the implementation of the health policy and principles outlined above, the Batibo Health District Committee, having identified the lack of an appropriate District Hospital as a priority problem, decided in 1992 to transform the then Sub Divisional Hospital which was more or less a health centre to a modern hospital in order to make hospital facilities accessible to the Batibo District Community.
To accomplish this, they came out first with a list of priority projects and classified them in order of urgency. With the support of the community, most of these projects were accomplished.

The “Theatre Project” is the last (12th) but most elaborate of the projects carried out till date. It was an ambitious, and tedious community initiated development project, but with the commitment and enthusiasm of the local and external Batibo and Widikum communities; with the understanding and timely aids from friendly countries through the embassies, high commissions as well as friends and sympathisers, the District Health Committee attained a very important milestone in the development of the hospital.

Having accomplished the several significant and important projects in the hospital, we recommended that a report in a booklet form be produced, the objectives of which are: To document the process of the development of the District Hospital; To state the various priority projects realised; To describe the realisation of the Batibo Surgical Theatre Project; To give an account of the achievements made with the financial and material support offered by embassies, donor agencies, groups, associations, sympathisers and the community; To serve as a reference document for the development of the Batibo District Hospital; To motivate anybody who reads this report to support the on going development process of the Batibo District Hospital; To motivate other health district teams to improve their situation as needed.

CHAPTER 2 - SITUATION ANALYSIS
  1. FEATURES OF BATIBO HEALTH DISTRICT
Batibo health District comprises the Batibo and Widikum Sub Divisions, all in Momo Division, in the North West Province of Cameroon. It has a population of 71000 inhabitants. This area of the North West Province is a transition zone between the South West and North West Provinces, so too are its vegetation, climate and culture. The main economic activities are farming (70%), trading, wine tapping and palm oil production.
The road network is fairly good in Batibo Sub Division. The general weather pattern is dry season from November to March with dust, and rainy season during the rest of the year with mud and bad roads, even the Batibo-Widikum which along the Bamenda-Mamfe high way is very bad. Some areas may be inaccessible during the rainy season to vehicles while others are permanently inaccessible – Olorunti and Menka Health Areas.
The Momo River runs through the Health District with Widikum town being the meeting point of the rivers in the Health District.
In Batibo there is pipe born water, electricity and telephone network, while Widikum has electricity and a community water supply.
The main religion is Christianity with the following Churches dominating in decreasing order: Presbyterian, Catholic, Baptist, Apostolic, Full Gospel etc.
The Health District has a high spirit of community participation.
  1. BATIBO HEALTH DISTRICT SERVICES
The Batibo Health District is made of nine health areas, seven of which are functional with health units and two (Olorunti and Menka) non-functional and inaccessible to vehicles through out the year.
The District has eleven health units: One government hospital, District Hospital Batibo, Three mission health centres, Five government health centres, Two private nursing units. Health Areas, populations, health units are shown in (pic 5)
  1. BATIBO HEALTH DISTRICT DIALOGUE STRUCTURES
The dialogue structures are composed of technical staff and elected community representatives (CR) working in the spirit of partnership between the state and the community.
The District Dialogue Structures are: The District Health Committee with a standing Committee of the General Assembly; The District Management Committee, accountable to the District Health Committee; The District Hospital Management Committee, accountable to the District Management Committee and the District Health Committee (pic 6). 
  1. BATIBO HEALTH DISTRICT HOSPITAL
4.1 Location
The Batibo District Hospital is located on the Bamenda – Mamfe highway. It is 5km from the centre of Batibo Town. It has a bed capacity of 65 and serves a population of 71000 from Health District and an additional population of about 15000 from neighbouring Health Districts. It is 45km from Bamenda also on bad roads.

4.2 History
Batibo Sub Division was created in 1969 and the first D.O. came in 1971. In this same year a health centre was built at the present hospital site and called Guka Health Centre.
It consisted of one solid building (the present Maternity Consultation block) later on, the council built one staff house (the present urban health centre), a kitchen (the present administrative bloc) and an unfinished non solid building (the present children’s ward). In 1981, the government signed a decree transforming the Guka Health Centre to a Sub Divisional Hospital after adding one building (the present medical ward).
The first medical doctor Dr Monono Ekeke M. was posted in 1983 to start this Sub Divisional Hospital. Dr Mono worked for about 4 years and was succeeded by Dr Fomambuh Lawrence in 1987 who in turn worked for 3 years and was succeeded by Dr Eyong Efobi John in April 1992 and he has been serving till date.
With the reorganisation of the health system in the country, the hospital was classified as a medicalised health centre in 1995. In September 1996, it was updated to a District Hospital.
The Batibo District Hospital is the first referral level for satellite health units in the District.

4.3 Situation of the District Hospital in June 1992
The District Medical Officer, Dr Eyong Efobi assumed duty and rapidly made a situation analysis of the District Hospital. The hospital was more of a health Centre which had little to offer to critically ill patients. Attendance and admissions were very low, no surgery was being done.
The structures were made up of four unconnected buildings, one of which was uncompleted: The Maternity and consultation building, The medical and laboratory building, The administrative building, The uncompleted building (now paediatric ward).
The District Medical Officer presented the report of the situation analysis to the General Assembly of the District Health Committee. After studying the report with great concern, taking into consideration the appalling condition of the hospital and the suffering of the population the District health Committee decided to transform the Sub Divisional Hospital into an appropriate and modern hospital. To do this, they came out with a list of priority projects.

CHAPTER 3 - PRIORITY PROJECTS FOR THE DEVELOPMENT OF THE BATIBO DISTRICT HOSPITAL
1 PRIORITY PROJECTS IDENTIFIED
In order to transform the health centre structures into those of the hospital, the District Health Committee in 1992 identified the following priority projects: 1) Install electricity in the hospital, 2) Extern pipe born water to some wards, 3) Create an improved surgical theatre, 4) Open a hospital pharmacy, 5) Improve relations between health services and the community, the coordination of health centres (cannot be evaluated in cash), 6) Convert the incomplete building into a paediatric ward, 7) Construct roofed corridors to link the hospital buildings, 8) Increase the number of beds and beddings, 9) Construct modern pit toilets with shower facilities, 10) Create improved physiotherapy unit, 11) Plant flowers and trees to demarcate the hospital boundaries, 12) Construct a real surgical theatre and surgical wards, 13) Build a nutrition centre, 14) Construct a water storage tank, 15) Build an x-ray department and equip it, 16) Construct a mortuary, 17) Build a real paediatric ward, 18) Fence the hospital.

2 PRIORITY PROJECTS ACHIEVED IN THE DEVELOPMENT OF BATIBO DISTRICT HOSPITAL SINCE 1992
These priority projects are presented in (pic 7). As can be seen from the above (pic 7), a large proportion, 71.3%, of the financing of the completed priority projects came from community participation through fund raising activities.
The make shift theatre installed finally in October 1992 did permit the operation of some major and minor surgical cases (pic 8).
Major surgery: Laparatomy, Tubal Ligation, Caesarean Section, Hernioraphy, Amputation, etc.
Minor surgery: incisions, excisions, stitching big lacerations, curettage (incomplete abortion), etc.
Most serious cases were referred to the Provincial Hospital Bamenda because of lack of appropriate equipment for intervention.
It is important to note that, not all major surgeries cited above were performed from the onset due to the inadequate surgical equipment existing at that time. However, some were bought gradually to supplement.

Other services offered by the Hospital
Consultations and treatment in various fields; obstetrics, gynaecology, paediatrics, internal medicine, surgery, family planning, and other units such as physiotherapy, laboratory, nutrition, health education, preventive medicine, etc.

CHAPTER 4 - THE BATIBO DISTRICT HOSPITAL SURGICAL THEATRE PROJECT

1. RATIONALE
In January 1995, during the General Assembly meeting of the Batibo District Health Committee, a review of the make shift theatre was given in which several problems were presented. The improvised theatre was not sealed, it shared immediate boundaries with the laboratory (a potential source of infection); and it is too small to accommodate eventual basic theatre equipments such as an oxygen tank, anaesthesia equipment, a theatre bed, theatre lamp, etc. Both major and minor operating cases were mixed with other medical patients since there was no special surgical ward. Also there was no accommodation for health education activities.
In order to ameliorate this situation, and considering the excellent relations between the community and health staff, and the enthusiastic community participation in previous health projects, we the Batibo District Health Committee decided then to construct a modern surgical theatre in the Batibo Hospital. This was the 12th project and the most elaborate.

2. GENERAL OBJECTIVES
Provide the Batibo District Hospital with a modern surgical theatre capable of handling most surgical cases.

3. SPECIFIC OBJECTIVES
1) Construct two operating theatres, 2) Provide a reanimation unit, 3) Improve the working conditions of the hospital staff in the domain of the surgery, 4) Reduce the number of referred cases, 5) Facilitate the training of health staff in the domain of surgery, 6) Provide a modern sterilization unit, 7) Provide surgical wards including private rooms, 8) Provide accommodation for a health education unit.

4. PLAN OF THE SURGICAL THEATRE BUILDING
Following the proposal of the District Technical Team and the approval of the sketch by the District Health Committee, the plan of the building was first drawn by Mr Tantoh Takwe and his collaborators of the Divisional Service of Construction, Mbengwi in December 1993. Their plan consisted of 2 sub units and 15 rooms and was estimated at 24 millions FCFA. When construction work was to start in July 1995, the health team modified this plan and gave the rough sketch to Mr Njock Obenson who then drew the present plan and costed it at 57 millions FCFA.
The surgical theatre measures 45m by 18m and consists of 24 rooms and 10 toilets. It is divided into three sub units: a) The surgical theatre sub unit comprising a major theatre, a minor theatre, a changing room, a store for sterilised equipment, a sterilisation room, a reanimation room unit and 2 toilets, b) The hospitalisation sub unit comprising of a nurse’s station, a nurses room. 3 private rooms, 3 general wards and 5 toilets room, c) The Health Education unit comprising a conference hall, a library, a general store, a health office and 3 toilets.

5. COST OF THE BUILDING
Following the final plan, the building was estimated at 57000000 FCFA (fifty seven million FCFA)
The cost of the building was made bearing in mind that the country the community will support the project with a lot of human investment.

CHAPTER 5 - STRATEGIES FOR THE CONSTRUCTION OF THE SURGICAL THEATRE

1) Creation of 2 Fund raising committees
a) Fund raising committee for local campaigns: In order to obtain funds, a fund raising committee was formed. This committee is an enlarged health committee comprising people of all works of life. It was charged with the duty of mobilising the community, organising fund raising activities, collection of monies backed with receipts and keeping of records of donors (see annex for list of members).
b) Fund raising committee for elites out of Batibo, donor organisations, Embassies, High Commissions and sympathisers. This committee was essentially made of the standing and management committees.

2) Institution of a hospital development fee at the district hospital
After one year of intensive sensitisation of the population, a hospital development fee of 500 FCFA was instituted at the district hospital for consulting patients and guardians. This fee was only for those who have never contributed before and exempted children, students, apprentices and desperate patients. This programme worked because all monies donated up to 500 FCFA no matter where, were backed by receipts. Some of the receipts were sold at health centres by health centre staff, community representatives, church leaders and some quarter heads. The receipts were usually stocked onto patients’ hospital books.

3) Creation of a Project Committee
The District Health Committee elected the following members into the Project Committee in March 1995:
Chairman: Mr Mungyeh Peter, Chairman of Batibo Health Management Committee
Secretary: Mrs Tebong Susan, TSSI, Primary Health Care Coordinator
Treasurer: Mr Sama Emmanuel, Chairman of the District Management Committee
Members: Dr Eyong Efobi John, District Medical Officer
Mr Musi Pius, President of the District Health Committee
After the reorganisation and constitution of Dialogue Structures in March 1997, the Project Committee was modified by the District Committee as follows:
Chairman: Dr Eyong Efobi John, District Medical Officer
Secretary: Mrs Tebong Susan, TSSI, Acting Chief of Bureau of Health
Treasurer: Mrs Teboh Esther, President of the District Health Committee
Members: Mr Musi Pius, Chairman of the District Hospital Management Committee
Mr Mungyeh Peter, Chairman of the District Management Committee.
Mr Teboh Richard Mbah, Financial Administrator of the District Hospital
Mr Tikum Philip, Member of the District Hospital Management Committee (DHMC)
Mr Atanjang Godlove, Member DHMC
The Project Committee carried out the following activities: 1) Choosing the site for the building, and start of the construction, 2) Recruitment of various workers, 3) Buying of building materials, 4) Organise community human investment as much as possible, especially in the filling of the huge foundation, 5) Establish appropriate financial records to ensure accountability and transparency, 6) Establish quarterly work plan, 7) Write quarterly updates of the evolution of the project.

CHAPTER 6 - PLAN OF ACTION AND BUDGET

1. Plan of action
The following plan of action to realise the hospital surgical theatre project was elaborated by the Project Committee and approved by the District Health Committee in March 1995:
22 April 1995 - Launching of Fund raising; May to June 1995 - Making of cement blocks and acquisition of stones; 01 July 1995 – Initiation of project foundation; 30 September 1995 – Completion of foundation; 14 October 1995 – Laying of foundation stone; November to December 1995 – Raising of walls; January to February 1996 – Roofing; March to April 1996 – Ceiling and metal works; 13 April 1996 – Fundraising rally; May to June 1996 – Plastering and flooring; July to September 1996 – Glass works; October to December 1996 – Equipment; January to March 1997 – Finishing touches; April 1997 – Inauguration (pic 9)

The achievement of the plan of action was greatly influenced by the availability of finances. Consequently detailed plan of action and work plans were revised quarterly

2. BUDGET
The building was first of all estimated at 24 million FCFA and was to be accomplished in 2 phases. Phase 1 was estimated at 15 million FCFA and phase 2 at 10 million FCFA. Later the building plan was changed (from 15 to 24 rooms) so too the estimated cost increased to 57 million FCFA.
As the money did not arrive in block the building committee could only accomplish the quarterly work plans which were sometimes not successful, but with the belief that little drops of rain make a mighty ocean; we managed to push through the building to completion.
Though the building was estimated at 57 million FCFA we finally completed at 51.332.567 FCFA.

CHAPTER 7 - MOBILISATION OF RESOURCES
The under mentioned strategies were adopted but not all went as smoothly as it appears. We had many disappointments at various levels, i.e some dialogue structures and Fons did not cooperate with us as expected. However, we carried on with our strategies mentioned below and succeeded.

1) Mobilisation of the local Batibo Health District Community by the Fundraising Committee
a) Sensitisation of the Administration
The Sub divisional Officers of Batibo and Widikum were sensitized at their offices during meetings with Fundraising Committee members in March 1995.
The Mayors and Chiefs of Services attended these meetings.
The objectives of the sensitization meetings were: 1) To inform them of the decision of the District Health Committee to undertake the Surgical Theatre project at the Batibo District Hospital, 2) To discuss together the strategies adopted, 3) To request their support and collaboration in carrying out activities for the realisation of the project, 4) To promote inter-sectoral collaboration.
The administration authorised and participated in fun raising, laying of the foundation stone and mobilising of the population.

b) Sensitisation of Chiefs of health Centres
The Chiefs of health centres were sensitised during District Technical Coordination Meeting at the hospital in March 1995 and during supervision. They spearheaded the mobilisation of the population towards financial contributions in their respective health areas.

c) Sensitisation of dialogue structures
The dialogue structure members were sensitised during the General Assembly of the District Health Committee in March 1995. Each health area is represented at the General Assembly by two community representatives and the chief of the health centre. They in turn sensitised the dialogue structures in their respective health areas.
Social tours for social mobilization in all health areas were made by the Fundraising Committee. The dialogue structures collected donations from their respective health areas.

d) Mobilization of the Fons of Batibo
Letters were first sent to all Fons explaining the raison d’être for the surgical theatre project.
The Fundraising Committee members then visited all the Fons in their palaces fore more intimate explanation of the project. Their close collaborators also attended meetings.

e) Mobilisation of the entire community
This was done by announcements through national and provincial radio; interviews; announcements in the churches and schools; letters to cultural associations, posters and banners.
 
2) Mobilization of Batibo Community and Elites resident out of Batibo Health District But in the country.
The Fundraising Committee dispatched letters explaining the raison d’être of the surgical theatre project to cultural associations of Batibo/Widikum Elements in various towns in the country. The Fundraising Committee members attended some cultural association meetings in several towns to intimately convince members to contribute money for the project.
The Fundraising Committee members also attended rallies organised by the Batibo communities and elites in some towns in the country.
Most of the journeys were self sponsored.
 
3) Mobilization of Batibo Community and Elites out of the Country
Letters were also sent to Batibo Communities and elites in several countries to sensitize them on the project. The content of the letters included: The rationale for the theatre project; The description of the theatre project; The cost of the project; The amount raised by the local community; The amount of money donated by external Batibo community and elites; The finances received from embassies and sympathizers; The level of achievement and expenditure; The needs required; An appeal for support; The nominal list of all contributors.
 
4) Appeal for aid from philanthropic groups, NGOs and prominent personalities
The Health Committee also wrote letters to the above people appealing for finances. The contents were the same as those for the elites. The response was very poor. Out of 80 letters only 10 responded favourably.
 
5) Appeal for aid from Embassies, High Commissions and funding agencies
The appeal process for aid from embassies and funding agencies was tedious, requiring a lot of determination and sacrifice by the management committee; involving a lot of write-ups and follow up which did not always yield the desired results.
Firstly, the Management Committee addressed letters of appeal to the various embassies and funding agencies.
A first visit was then made to embassies to personally explain the project. The presentation of the project included: The description of the project; The cost of the project; The financial contribution of the Batibo Community; The total amount of money already obtained and sources; The finances received from embassies and sympathizers; The level of achievement and expenditure; Needs to accomplish project; A plan of action.
The official application forms for project support for each embassy were filled.
Several journeys were made by the Fundraising Committee from Batibo to Yaoundé through Bamenda, 450km to defend the applications; following invitations by embassies which were more often very abrupt and urgent; and this necessitated many nights spent writing up reports urgently needed. Most of the trips to Yaoundé were self sponsored by the Fundraising Committee members. A total of 21 trips were made to Yaounde.
Representatives of embassies and donor organs visited the project to appreciate it and verify the accounting records.
Out of the twelve embassies solicited, eight replied to the letters of the fundraising committee, and only four funded the project.
 
6) Organisation of Fund Raising Rallies in Batibo
The approval for the fund raising rallies was given by the Sub Divisional Officer who also participated in its activities. The population was mobilised through: Letters of invitation to the Fons, social groups, health centres and other institutions; Radio announcements; Posters, banners; Church announcements; Personal contact by the project committee members.
Each rally took place at the Batibo Community Hall and field. It consisted of: Bazaar games: - Wheel of fortune games and Various table games like lodo, blind man and bottle, and many other local games; Rosettes; A raffle game: these are local lottery tickets sold at 100 francs; Traditional dances: dance groups are invited to attract the population the population and animate the occasion. They also donated; Sports:- a) Raises: eggs and spoons; needle and thread; 3 legged race; etc. b) Tug of war: This may be between mechanics and drivers, butchers and wine tappers, teachers; c) Football: This usually was old men and women, Catholic women versus Presbyterian women; francophone women versus a female church group; d) Ball room dance: gate fees are usually 200 francs. And during this occasion, we have cutting of cake and raffle draws. Some income also came from sales of drinks.
During the rallies, the population offered contributions individually or in groups, their names were read publicly, they were acclaimed by the population.
The names of all contributors were recorded in the registers. The report of the total expenditure and proceeds was made in the same register. The cost of organising a rally ranged from 150000 – 200000 francs CFA. Three fund raising rallies were organised:
First fund raising – 22 April 1995; Second fund raising – 13 April 1996; Third fund raising – 09 May 1997.
Towards the end of the gala night, the total amount collected during the day was announced; later this same announcement was made over the radio.
 
7) Appeal for equipment to GTZ
Applications for equipment were written to 5 international organisations since 1995 vis:
Clinicare International (Portsmouth – England), MPDL (Caceres – Spain), Spanish friends (Sevilla – Spain), Direct Relief International (USA), Rally for health (USA), GTZ (Yaoundé)
After meticulous, tedious but very informative and cordial negotiations including the visit of the GTZ representative to the project, and several trips to Yaoundé, GTZ kindly accepted to equip the theatre building for an amount of 8.500.000francs CFA .
Similarly, Clinicare International donated 2 pieces of equipment worth 600.000 francs CFA.
 
8) Methods of monitoring Finances
The money never came in block but at varying intervals and amounts. In order to account for this money, we had the following:
 
8.1) Receipts: A receipt was issued for all contributions of 500 francs and above. The booklets were checked on regular basis (monthly).
 
8.2) Register: A register was opened to record the names of all those who contributed 1000 francs and above.
 
8.1) Thermometer drawing: A large thermometer drawing placed on the notice board of the hospital, was used to show the public the level of the support by increasing the level of its mercury according to the monthly of its mercury according to the monthly cumulative total and finances received.
 
9) Feedback to the community and donors
9.1) Letters of appreciation
The Health Committee always wrote letters of appreciation to contributors and donors: Embassies, High Commissions, Organisations, Associations, Groups, and individuals; stating the amount of finances received, list of donors, the level of achievement of the project, the expenditure; further needs, and an appeal for more financial support. Letters of appreciation were sent to all those who contributed 5000 francs and above. The letters of appreciation were always signed by four members of the Health Committee

9.2) Update report
An update report of the evolution of the surgical theatre project was made quarterly by the health committee. It consisted of: Total finances received; Sources of finances; Level of achievement; The expenditure; Financial support necessary to complete the project; List of contributors; Appeal for more support.
The updates were distributed to embassies, associations, and individuals with important contributions.
They were also displayed on the notice board of the hospital.
 
10) Finances raised as of March 1998
10.1) Financial support from the local Batibo Health District Community:- a) Fundraising rallies in Batibo produced 5.859.450 FCFA (pic 10); b) Contributions from the local community through hospital development funds, health centres, or individually to the health committee: 5.173.690 FCFA. Total finances raised by the local Batibo Community: 11.033.140 FCFA

10.2) Contributions from Batibo, Widikum community and elites out of Batibo Health District but in the Country: 3.075.500 FCFA

10.3) Contributions from Batibo and Widikum elites in the USA (Washington DC, New York and Dallas: 3.340.000 FCFA

10.4) Contributions from friends and sympathizers : 550.000 FCFA

10.5) Financial aid from embassies and funding agencies yielded 31,773,900 FCFA (pic 11)

10.6) Running credits: Running credits were used to keep the project going till completion especially during had times. A total of 1.560.000 FCFA was used as hospital/health service contribution to the project during the 3 years of construction.
Summary of income as of March 1998 was 51.332.567FCFA (pic 12, pic 13) and Equipment donated by GTZ: 8.500.000

11) Custody of finances
The project committee used the following banks: i) CCEI Bamenda, ii) SCB Credit Lyonnais Bamenda, iii) Credit Union Batibo, iv) Post office Batibo
The signatories to the accounts are members of the project Committee. A cheque for the withdrawal of money can only be honoured with the signatures of the chairman and those of two other members.

CHAPTER 8 - EXECUTION OF THE BATIBO DISTRICT HOSPITAL SURGICAL THEATRE PROJECT

1. SITE OF BUILDING
The Theatre Building Complex is situated in the southern part of the hospital premises on the left as one enters into the hospital from the east. The building is connected to the middle of the maternity block by a roofed corridor 35m long by 3m wide and to the laboratory on the west by a roofed corridor of 9m long by 3m wide.

2. RECRUITMENT OF WORKERS
The following categories of workers were recruited by the project committee through competitive selections:- a) Bricklayers – led by Mr James Fongang and Timah Simon, b) Carpenters – led by Mr Victor Ndam and Peter Njiwa, c) Painters – led by Mr Atanjang Godlove and Joseph Ndi, d) Electricians – led by Atud Johnson, e) Plumbers – led by Ernest Ndoh, f) Welders – led by Johnson Teke and Mbanwei Divine, f) Glass work – led by Acha Divine.

3. MANAGEMENT OF FINANCES
3.1 Expenditure records
a) There is a daily expenditure register kept by the project committee, b) There is a monthly expenditure register which permits the calculation of cumulative expenditure from the beginning of the project and comparison of expenditure to income raised.

3.2 Modalities of payment
The buying of materials was made by the project committee. The payment vouchers were approved by the project committee members before payment. On receiving his money the supplier wrote his name and signed in the daily expenditure register; a copy of the payment voucher was kept by the project committee.

4. COSTING OF LABOUR
The cost of labour for the execution of the project was made in phases, according to the section realised as follows: earth work, making of cement blocks and acquisition of stones, foundation, raising of walls, roofing and ceiling, plastering of walls and floors, painting, tiling, metal works, electrifications, louvers and glasses.
The cost for each phase was made by each category of workers and submitted to the project committee for study and approval. Work only started after approval.

5. CONSTRUCTION WORK
It’s important to note that we started construction when only 3 million francs was available. It was carried out in phases:

5.1 Earth work
Earth work started on 01/07/1995. It consisted essentially in the felling of trees, removing of vegetation and preparing of the ground for the building foundation.

5.2 Making of cement blocks
The making of cement blocks and the acquisition of stones started on 05/07/1995. Cement and stones were bought at the local market.

5.3 Building of the foundation
Foundation work effectively started on 08 July 1995, after buying stones, cement, rods; and water and electricity conduits. The was completed in early September 1995, it was built on a slope with the depth running from one meter to 2.5 metres, the length was 45 metres and the with 18 metres. The foundation contained 24 rooms and 10 toilets.

5.4 Filling of the Foundation
This was done through human investment by the community of the Batibo Health Area quarters and villages: Knack, Bengang, Tad, Kokum, Mefah Tembei, Nnen, Ewai, Tichui, Njiyen, Ekan, Kwadi, Ngaku, Atangha, Gowi, Ewo, Korowan and Eben.

The earth used for the filling came from the front and back of the front and back of the foundation. Each quarter came on its own programmed day. They were refreshed with palm wine by the project committee.
The filling of the foundation was done from the second week of September 1995 to the first week of 

October 1995 under torrential rains when the soil was very wet and heavy.
The estimated cost for filling of the foundation was 1.100.000 FCFA, but it was done at a cost of 75.000 FCFA (for refreshments).
The community also transported cement blocks from where they were made to the building site, a distance of 80 metres.

6. LAYING OF THE FOUNDATION STONE
The foundation stone of the Batibo District Hospital Surgical Project was laid on 14 October 1995 by the then Governor of the North West Province, His Excellency Bel Luc Rene, in the Presence of the North West Provincial Delegate of Public Health, Dr Ghogumu Amida, Mr Hamilton Charles, the then head of mission of the British High Commission, and other dignitaries like Honourable S.T. Muna, some provincial chiefs and local administrators. He was cheered by a massive population of the Batibo Health District.
It was another occasion for fundraising, 1.016.000 FCFA was raised on the spot.

7. CONTINUATION OF THE BUILDING
After the laying of the foundation stone, the raising of the walls of the building progressed, and other phases of the building were executed simultaneously as finances came in until the completion of the building in March 1998. It was started on 01 July 1995. It took two years eight months to complete.

8. EQUIPMENT
8.1 The surgical unit: The surgical unit was equipped by GTZ for an amount of 8.5 million FCFA.
8.2 Wards and offices: We are counting on the promises of the Canadian High Commission to furnish the building in April 1998. The furniture is estimated at 5 million FCFA.

CHAPTER 9 - SUPERVISION OF THE PROJECT
The purpose of the supervision of the execution of the project was to ensure that: The workers construct the building according to plan; The finances and other resources donated or collected were used for the surgical theatre project; There was accountability and transparency in the management of resources; The objectives, plan or strategies could be changed or modified according to new adaptable needs.
There were four levels of supervision:

1. Internal supervision by the District Dialogue Structures, following the diagram (pic 14).
The immediate supervisory organ of the execution of the theatre project was the project committee headed by the District Medical Officer Dr Eyong Efobi John. Supervision was done on daily basis. An update report on the execution of the journey was done quarterly stating: The cumulative income; The level of achievement of the project; The cumulative expenditure; The problems encountered and solutions taken; The supplementary requirements to complete the project; The plan of action; A plea for more support: A list of contributors.
The reports were always signed by four members of the health committee:- Two community representatives (president of the BDHC and chairman of the BDHMC), and Two technical health staff (DMO and the Project Secretary)
The reports of the project committee were presented successively to the District Hospital management committee, the District Management Committee, quarterly meetings, and to the General Assembly of the Health Committee twice a year.
Each general meeting of the various dialogue structures was an occasion for all the members to visit and supervise the project.
The supervision reports were also distributed to donor Embassies, High Commissions, Associations and Organisations having funded the project.

2. The Divisional supervision was done by the Divisional Service of Construction at Mbengwi.

3. The Provincial Supervision was done by: The Provincial supervisor of Batibo Health District: Dr Daniel Mfonfu, and The Provincial Chief of Bureau for Health Maps: Mr Njock Obenson

4. The Central level supervision: This was effected by funding Embassies, High Commissions, Organisations and Associations who helped financially and materially. They visited the project regularly to appreciate its progress and the management of financial and material resources by the project committee.

CHAPTER 10 - EVALUATION OF THE SURGICAL THEATRE PROJECT
This is an internal evaluation of the Batibo District Hospital surgical Theatre Project; the objectives being to review and appreciate the following: The execution of the plan of action; The balance sheet of income and expenditure; Community participation; The funding Embassies and Agencies; The partnership between health staff and the community; The intersectoral collaboration; The District Technical Team; Supervision; Total cost; Problems.

1. The execution of the plan of action
The surgical theatre project was started on 01 July 1995 and ended in March 1998. It took two years eight months to be completed. Initially it was planned to be completed in 1997.
This project was sponsored through irregular donations and as such work accelerated when there was money and slowed down as donations only trickled in. Much work was also done on credit and paid later when funds became available.
However the completion of the project in two years eight months can be considered as a success.

a) The balance sheet of income and expenditure overview is income 51 238 540 FCFA, and expenditure 50 832 567 FCA. (pic 15: balance sheet overview : month, income, expenditure; pic 16: Graph of monthly income; (pic 17 Graph of monthly expenditure - July 1995 to march 1998 (Dr Mfonfu Daniel, 21 October 2011)

b) The Balance Sheet – proper is shown in (pic 18) and graph of phases of construction and expenditure (pic 19): total income and expenditure each 51 332 567 FCFA; Equipment of theatre: 8.500.000 FCFA; Equipment of ward: 5.000.000 FCFA (anticipated)

2. Community participation
As indicated in the beginning of this report the Batibo Health District Community both in and out of Batibo/Widikum has once more demonstrated their excellent spirit of community participation by contributing 34% of the total cost of the building, and coming out massively for human investment at the building site. It should be noted that the confidence the community has in the District Technical Health Team, the project committee and Community Representatives of the Dialogue Structures was a very important motivating factor for their active and relentless participation. In summary, the local population gave 11 million FCFA and elites living out of the Health District 6.4 million FCFA .

3. The funding Embassies and Agencies
With the relentless efforts of the Health Committee, 8 out of the 12 applications were acknowledged and only 4 finally responded financially as follows: The British High Commission : 10.5 million FCFA; The Canadian High Commission: 3.6 million FCFA; The Japanese Embassy: 15.6 million FCFA; The GTZ: 2 million FCFA; Total: 31.7 million FCFA
Their contribution to the project was immense: 61% of the total finances for the construction of the complex; and the provision of surgical equipment by GTZ worth 8.5 million.
 
The partnership between health staff and the community
The management and realisation of the Batibo District Hospital surgical theatre project has eloquently portrayed the reality of the Reorientation of Primary Health Care which is partnership between health services (staff) and the community in carrying out health activities and projects for the interest of the population.
The Batibo District Dialogue structures including the project committee always acted as one person, with mutual respect, openness, transparency, and love for one another.
The health staff and community representatives sacrificed and suffered together for the well-being of the Batibo Health District Community.

4. The intersectoral collaboration.
The project also highlighted the reality of intersectoral collaboration in health care delivery to the population. Every body in the Batibo Health District was involved including the Administration; WICO, Council, Social Welfare, Police, Gendarmes, Schools, Churches, etc. Transparency and mutual respect were the motivating factors.

5. The District Technical Team.
The District Technical team was comprised of Dr Eyong Efobi, Mrs Suzan Tebong, Mr Tikum Philip, and Mr Teboh Richard. This team led by Dr Eyong Efobi John, the District Medical Officer, tried as much as possible to behave in union with the same language of confidence, sincerity, politeness, and respect so much so that the whole Batibo Community appreciated them and did whatsoever they requested because the results were evident.
The District Technical Health team has no service vehicle but that did not prevent them from working. The District Medical Officer, Dr Eyong Efobi, and Mrs Tebong sacrificed their cars for all the numerous journeys from Batibo through Bamenda on bad roads to Yaoundé. The same cars were used to mobilize community and carry out other health activities.

6. Supervision
The regular supervision from the Provincial Delegation of Public Health, High Commissions and Embassies helped to instil confidence in the Project Committee and motivated them.

7. Total cost
Building: 51.332.576 FCFA; Theatre equipment: 8.550.000FCFA; Total: 59.832.576 FCFA (Fifty nine million eight hundred and thirty two thousand five hundred and seventy six FCFA).

8. Problems
Having completed the project successfully according to the appreciation of the District Health Committee there were three major problems that are worth mentioning: The absence of a service vehicle for the Health service and an ambulance for the District Hospital; Lack of a second doctor; Lack of investment credit from government.

9. Appraisal
This project has revealed that, developing existing government institutions is cheaper and more effective through a community initiated project, managed by the same community, and supervised by donors, than channelling resources through non Governmental Organisations whose impact is most of the time short lived and not felt at the level of the community. Similarly it exposes contracts given to contractors who often do only 50% of the expected work. The Batibo experience could work in most decaying state health institutions provided the committee is trained to be as respectful, transparent and dynamic.
During the General Assembly meeting of 09 January 1998 of the Batibo District Health Committee, it was unanimously agreed that the building should be named after the doctor who led the team to success since 1992. As such it is called EYONG EFOBI SURGICAL COMPLEX.

10. Special plea
The District Health Committee wishes that after going through this report some friends and sympathizers will offer the District Health Service a service vehicle or help with another doctor or help financially to support our next project. See the list priority projects.

11. Inauguration of the building
The surgical complex shall be inaugurated on Saturday, 25 April 1998 at 10.00am.

CHAPTER 11 - PROSPECTIVE
Following the completion of our 12th project, the theatre complex, we decided to engage on our Nutrition Centre Project. The project consists of two subunits: Sub Unit 1 is for Nutrition proper including 4 food sheds (3x3m), 3 provision stores, 1 general wash room and two toilets. The Sub Unit 2 consists of a demonstration room to pregnant women or mothers with malnourished children identified during Antenatal Care (ANC) or Infant Welfare Clinic (IWC), or patients needing special diets, such as diabetic or hypertensive patients.
The project costs 15 million FCFA and to date we have only 6.2 million from the following sources: 4 million FCFA from the German Embassy; 2.2 million FCFA from the local community of which 1.2 million FCFA was recently obtained from fundraising ceremony on 14 March 1998. The SDO for Momo, Mr Acham Peter Cho, sitting in for the Governor, H.E. Fai Yengo Francis, launched the occasion.
We very much want to realise this project by June 1998 and would like you once more to chip in something. Remember always that little drops of rain make a mighty ocean. All this is done in the spirit of trying to develop our hospital in order to make it a reliable and comfortable health unit for our community. Till date, we have realised the following in this project, accounting for 40% of the total cost: Completed the foundation; Made 5000 blocks; Installed water in the building; Raised the walls; We are currently roofing the building and will complete it by mid April 1998. Once more, we need your help to succeed.

REFERENCES
1) G.L. Monekosso, 1994: District Health Management
2) Ghogomu et al 1994: Guide for Dialogue Structures
Annex I: List of Fund Raising Committee: (pic 20)
Annex II: List of realistic Contributors of 5000 FCFA and above: (a) pic 21; (b) pic 22; (c) pic 23; (d) pic 24.
Annex III: List of Group Contributors of 5000FCFA and above: (pic 25)
Annex IV: List of Staff of the Batibo Hospital and the District Health Service: (pic 26)

OBSERVATIONS – LESSONS TO BE LEARNT
“The Batibo-Bamenda road has already been tarred.
This report was written originally in March 1998. The electronic version was produced by Dr Daniel MFONFU, in June 2010 while at UNHCR Lubumbashi, République Démocratique du Congo.
I wrote this version for my web site in order to share with the whole world our magnificent experience in working with the community in Batibo in North West Province in Cameroon while in Bamenda in October 2011. Some graphs have been drawn in order to facilitate the appreciation of the data in tables.
The format and the steps used to write this report are those developed by us to promote community participation represented in the partnership planning & budgeting cycle in the promotion of participatory approach in management of health care delivery in the community with the active community participation at all levels (pic 27, pic 28). We have tried to show the interaction between the levels of health systems and the role of each level. The role played by external partners has been clearly shown and appreciated. This Batibo Health District experience shows that the District Health System in the implementation of Primary Health Care is a reality and it can be replicated in other Health Districts.

Some lessons learnt are:
1) One should never declare that a community is poor, and having no resources.
2) Ignoring community participation does not encourage ownership of a development project by the community but instils in us the spirit of dependency ‘rich to poor’, ‘donor to receiver’, ‘master to slave’, ‘Western world to the South’, developed countries to underdeveloped countries’, etc
3) Discarding the resources of the local population creates an artificial dependence and addiction of a community to external aide or funding, and kills the initiative to self reliance projects or solutions to community health problems.
4) A sustainable development project can only be obtained through local community participation.
5) Supporting community initiated projects, and executed by the community; supervised locally and by hierarchy is far cheaper than hiring contractors or NGOs.
6) This Batibo Surgical Complex has shown us a lot of spirit of commitment, partnership, friendship, cordiality, enthusiasm and respect for each other that existed in all the partners.
7) The documentation of this experience is very important for posterity in order to share it with others rather than burying such an experience in a drawer of our table in the office to rot.
8) The role of the technical staff as an objective pilot in the initiation and execution of this community project should be emphasised.
9) The spirit of transparency and mutual respect reigned in the Batibo District Health Teams.
10) This is our legacy in the implementation of the Health District System”.
Dr Daniel MFONFU, at Bamenda, on 25 October 2011.
 
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