Michael Forson Case Study for UNICEF/UPenn Social Norm Course Pennsylvania University, USA 1 – 12 July 2013

The challenge - Guinea Worm disease in Ghana World Health Assembly resolution in 1986 to eradicate Guinea worm Disease Ghana started the National programme in 1989 with a nationwide case search – about 180,000 cases were found The Northern Region accounted to over 50% of the cases Northern region was the problem spot – Dagomba tribe Record with the fast decline to zero cases after a decade of stagnation. 85% reduction between 2007 (3,358 cases) and 2008 (501), and a 97% reduction between 2009 (242 cases) and 2010 (8 cases). Last case of the disease was reported in May 2010 from Diare community

Map of Ghana showing the Incidence of GW Cases Northern Region

What is Guinea Worm disease?

The programme implementation strategy Case detection and containment: all cases must be detected within 24 hours of emergence (including the pre-emergence) of the worm Safe water provision and abate application Behavior change towards open water sources: filter all water before drinking don’t enter open source water with a guinea worm disease report all identified cases to the village volunteer or health center

The situation before the innovations False beliefs Hereditary witchcraft Preference to relieve pain Customs (Wading into water) Habitual individual action of wading into water affected the society, but society did not sanction it Society Lack of norms Lack of sanctions No legal norms Social Dilemma

Creation of the social Norm Visibility actions (demystify beliefs) Showing of cyclops in water Induced immersion Video show of patients having the worms removed Collective Norm Nobody goes into the water with a hanging worm Build fetching platform Legal norms and sanctions Institutionalization of fines when caught with worm in water Report anyone with a hanging worm Install dam guards to monitor the water we all agree to report any guinea worm case (empirical) an individual behavior to contaminate the water source will affect the whole community (normative) Schema and Script

Pictures of visibility actions Miss Ghana 2007 (Lamisi Mbila) being assisted by members of the GGWEP to identify Cyclops in the filtered water during a community campaign

Innovations that fostered the creation of social norms Garner political support and the creation of legal norms and rules The Donkey Boys The Dam guards A donkey boy in Savelugu Community at work What did not work The cash reward system

Creating the social network The social movement of the people was used to create a social network Map showing the 4 epicenters *source: Ghana Guinea Worm Eradication Programme Gburimanu Area Diare Area Sang Area Sibi Area

Lessons learnt and recommendations Using visibility to change the beliefs is very powerful “seeing is believing” The creation of legal and Social Norms, was the vehicle that caused the shift Need to put mechanisms in place to ensure and enforce sanctions Social movement of the people is very useful Sustainability of the norms after the end of the programme need to be studied. Social norms is very useful and practical and is being recommended for other eradication programmes such as the Trachoma Control as it is also water borne and depends on people’s behavior to break the cycle.

Ghana is now free from Guinea worm The final fight with the innovations talked about

The last guinea worm case in Ghana