Journal of Social Development in Africa (1996), 11,1,53-78 
The Role of "Theatre for Development" 
in Mobilising Rural Communities for 
Primary Health Care: The Case of 
Liwonde PHC Unit in Southern Malawi * 
EZEKIEL KALIPENI & CHRISTOPHER KAMLONGERA** 
ABSTRACT 
This paper argues that the most important element in health care strategy is 
community participation. If social welfare is to be effectively improved it must 
involve the people in making their own decisions and taking their own actions. 
Using popular theatre as a means of communication and education, the Liwonde 
Primary Health Care Unit in the Southern Region of Malawi has succeeded to 
motivate residents of two rural communities to actively involve themselves in 
primary health care activities. The impact of this innovative approach to communication 
and education for health has been remarkable. Recent data indicates that 
cases of deaths due to preventable diseases such as cholera and severe diarrhoea 
have been dramatically reduced especially in the under-five age group. The 
construction of pit latrines and improved water supplies have been vital to the 
improved health situation. 
Introduction 
The success of development in every country must be reflected in the health and 
socioeconomic well-being of its people. This implies that, as a nation develops, the 
incidence and prevalence of infectious and killer diseases must be eradicated or 
curtailed, resulting in the decline of both infant and adult mortality rates, morbidity 
rates, and in the improvement or increase in life expectancy at birth. Health is both 
a prerequisite to and concomitant of development The provision of Westernstyled 
health facilities may not necessarily result in improved health conditions. Of 
critical importance is the motivation of the local people to help themselves in health 
matters. This can be achieved if health information and education is disseminated 
* Revised version based on comments of anonymous reviewer, resubmitted for 
consideration to the JSDA. 
** Ezekiel Kalipeni (PhD) Assistant Professor of Social Geography, Department of 
Geography, University of Illinois 220 Davenport Hall MC-150, 607 South Mathews 
Street Urbana, Illinois 61801, U.S.A. 
Christopher Kamlongera (PhD) Professor of Fine and Performing Arts, University of 
Malawi, Zomba, Malawi.
54 E Kalipeni & C Kamlongera 
in a culturally acceptable manner at the community level. In Malawi, the provision 
of curative services, which are based on the Western biomedical model, takes a 
large proportion of the total government funds allocated to this sector ( National 
Statistical Office, 1992). The lack of effective outreach capacity in the health care 
system has been long recognised by the Ministry of Health and strategies for 
creating acommunky based distribution system that emphasises the primary health 
care approach are being implemented in various parts of the country despite the 
severe lack of trained medical personnel (National Statistical Office, 1992). 
Figure 1: Southern Malawi and Liwonde PHC Project Areas 
S 20 » 10
"Theatre for Development" in Primary Health Care: Malawi 55 
The aim of this paper is to demonstrate one inexpensive way in which 
information and education about health and sanitation can be innovatively disseminated 
in rural settings. The paper documents an effective strategy that was used in 
three villages in Southern Malawi to inspire the local communities to do something 
on their own about their precarious health status during the latter half of the 1980 
decade. These were the villages of Mbela and Mwima located close to the Shire 
River and Chisi Island located on Lake Chirwa (see Figure 1). First, the paper 
briefly reviews the current strategies used for the dissemination of primary health 
care information in Malawi and notes how these strategies have failed to reach out 
to the majority of the people in the rural countryside. Second the paper examines 
the health situation that existed in Mbela and Mwima areas before the introduction 
of the Liwonde Agricultural Development Division (ADD) Primary Health Care 
programme. Third, a conceptual model of the main approach that has been used to 
motivate the people of these areas to assist themselves in primary health care 
activities is briefly described. Finally, an evaluative discussion of the strategy used 
in these three villages is offered. 
Health Information and Education in Malawi: An Overview 
In Malawi, primary responsibility of the Health Education Services of the Ministry 
of Health is the health education of the public (both rural and urban). This activity 
is accomplished through books or magazines (eg, Moyo, Family Health Newsletter, 
Boma Lathu, Za Chikumbi, posters and child spacing booklets) written in both 
English and Chichewa, the national language. Moyo and Family Health Newsletter 
are published by the Health Education Unit of the Ministry of Health. Za 
Achikumbi (Farmers' Forum) is published by the Ministry of Agriculture and deals 
with matters related to agricultural production while Boma Lathu (which specialises 
in providing general news and information to the literate rural community) is 
published by the Ministry of Information and Broadcasting. These magazines 
contain information on ways to prevent diseases such as malaria, bilharzia, 
diarrhoea, tuberculosis, AIDS, leprosy and many other common ailments. 
Education is also effected through regular radio broadcasts of health messages 
prepared by various ministries and government departments (Cbilivumbo, 1975). 
For example, the radio programme 'OPhiri' is ajoint venture between the Ministry 
of Health and the Ministry of Agriculture and it deals with health and agriculture 
issues. 'Umoyo ndi Chitukuko m'Malawi' (Health and Development in Malawi) 
is another jointly prepared radio programme between the Ministries of Health and 
Community Services and deals largely with issues relating to health and development 
These broadcasts are in both Chichewa, the national language spoken and 
understood by the majority of Malawians and English - the official Government 
language.
56 E KaUpeni & C Kamlongera 
Another channel for information diffusion is the use of visual aids: posters, 
pamphlets/leaflets which carry selected health subjects. Furthermore, prior to 
1990, joint efforts among the Department of Agricultural Communications of the 
Ministry of Agriculture, the Ministry of Community Services and the Department 
of Information included the "yellow van" mobile units equipped with film 
projectors and puppet shows (see for example Kamlongera, 1986). Unfortunately 
the "yellow van" mobile film unit programme has been discontinued due to 
financial difficulties. The mobile film unit used to travel to schools and those 
villages that were readily accessible to present free film shows on health education 
and other development related issues. 
Private agencies such as the Christian Hospital Association of Malawi (CHAM) 
and religious institutions are also active in one way or another in the dissemination 
of health information. For example, the Christian Hospital Association runs 
outreach programmes at its larger hospitals. Functional literacy centres and home 
craft centres also play an important role in disseminating health and nutrition 
information to rural communities. Daily health talks at clinics, health centres and 
hospitals are an additional important source of information. In brief, this constitutes 
the information communication set up in Malawi. 
In spite of the commendable multi-pronged efforts directed at the rural population, 
coverage is limited due to a combination of factors, particularly insufficient 
health extension personnel, high illiteracy rales and low ownership of radios. 
About 88 per cent of the population in Malawi is rural and a large proportion of this 
population is illiterate. The results of the 1987 Population and Housing Census 
reveal that slightly less than half of the population aged 5 years and over had some 
education. About 42 per cent of the population aged 5 years and over had attended 
only primary school education. When this is broken down by gender, about SS per 
cent of male population aged 5 years and over had some education compared with 
abwt36per<xttfor females (NationalStatisticalO 
is concerned, about 42 per cent of the population aged 5 years and over was able 
to read and write Chichewa. English or both languages. However, more males than 
females areaWe to read and wriieChichewa,EngUsh or both languages, ie, 52 per 
cent of males are literate in one or both of the languages compared to only 32 per 
cent of females (National Statistical Office, 1991). These figures are certainly an 
improvement overthoseof the 1977 census in which only 30.6percentof the males 
and 14.5 percentofthe females in Malawi were literate (National Statistical Office, 
1984). However, by African standards, the current literacy rates are lower than the 
average for sub-Saharan Africa which was 60 per cent in 1990 (UNESCO, 1992). 
In terms of rural/urban differentiation, it must be kept in mind that the majority of 
the literate population is concentrated in urban areas. The implication is that the 
bulk of the populatwnbasedmniralan^canrKX read the nealthirtfonM 
various pamphlets and magazines.
"Theatre for Development" in Primary Health Care: Malawi 57 
Secondly, only a small proportion of the total population has access to the radio. 
In 1987 about 19 per cent of the persons living in households had access to a radio 
in working condition. In rural areas about IS per cent of the persons living in 
households had access to a radio as compared to 50 per cent of the urban population 
living in households (National Statistical Office, 1991). Clearly the health information 
broadcast on the radio does not reach the intended target population. Thus, 
there is a clear need to involve the rural people and their leaders; to motivate them 
to help themselves. In other words, the diffusion of health information and 
education should not only come from above but should also include a bottom-up 
grass root level component as documented in this paper through the use of the 
"Chancellor College Theatre for Development" which appears to have been very 
successful in motivating people within the areas of Mwima and Mbela in Liwonde 
ADD PHC programme. 
Primary Health Care in a Rural Setting 
Mwima and Mbela are rural trading centres with basically rural characteristics. 
Each centre has a market that meets once a week. Present at these centres are a few 
grocery shops and tea-rooms. These centres are in a sense central areas surrounded 
by rural villages engaged in subsistence agricultural activities and some cash 
cropping. The main food staples are maize arid sorghum and cotton is the main cash 
crop. Each of the areas has an estimated population of 10,000 people. Mwima is 
located along the main Liwonde-Mangochi road about 16 kilometres from Iiwonde 
Township and Mbela is about 15 kilometres away from this road (see Figure 
2). A secondary road which becomes impassable during the rainy season (November 
to February) passes through Mbela trading centre from Balaka to join the 
Liwonde-Mangochi road. These areas are within 20 kilometres from the Shire 
River, outlet of Lake Malawi located within the Great East African Rift Valley. 
Temperatures range from a minimum of 60°F during the cold season (May to July) 
to well over KX)°F during the hot and rainy seasons. Rainfall is adequate to allow 
the growing of both food and cash crops. 
On the other hand Chisi Island is on Lake Chirwa (a mostly swampy inland basin 
lake with no outlet). An estimated population of 3,500 people live on this island in 
small fishing village communities. The island is about 15 square kilometres in area 
and is reachable by small boats and canoes whose capacity is 2 to 6 persons per trip. 
Twice a day the largest boat (with a capacity of 6) ferries people to and from the 
island to the main land. There is a full primary school on the island which is in a 
dilapidated condition. For the nearest health centre people have to travel over 20 
kilometres to the General Hospital in Zomba.
58 E Kalipeni A C Kamlongera 
Figure 2: Liwonde Agricultural Development Division (ADD) 
and Areas of PHC Activities (Mbela, Mwima and Chisi Island) 
20 40 60 
All three areas (Mbela, Mwima and Chisi Island) are within the boundaries of 
Liwonde Agricultural Development Division (ADD) based at Liwonde Township 
(see Figure 2). The activities of this ADD have been partly funded by a German 
Technical Aid grant Instead of concentrating on agricultural extension services, 
the German team sought permission from the Government of Malawi to set up a 
Primary Health Care Unit at the ADD's headquarters to initially provide essential 
PHC services toanumber of selected areas within the ADD. Clearance was granted 
sometime in 1985 and activities of the PHC programme atLiwonde began in 1985. 
The programme is ran by a medical doctor assisted by a senior clinical officer, a 
public health nurse and a senior health assistant 
The PHC team for Liwonde ADD in collaboration with members of the 
Chancellor College Theatre for Development" has been successful in stimulating
"Theatre for Development" in Primary Health Care: Malawi 59 
the interest of the people of Mwima and Mbela areas to engage in locally 
determined primary health care activities. The principles guiding the introduction 
of primary health care in these areas are as follows: 
i) People's concerns and priorities are the main starting point. 
ii) The motivation and participation of the community in its own health care is 
the only basis on which an enduring and comprehensive programme can 
be built, 
iii) Primary health care must be linked to the overall national programme but 
must not be seen as an imposition from above and should include a strong 
bottom-up grassroots level component in the planning process, 
iv) Health is one factor in the total development of the people. Involvement of 
other development sectors, such as education and agriculture is a must 
The Liwonde ADD PHC Unit has three independent components working handin-
hand to promote community health and social well-being. The first and most 
important is the community itself; the second is the PHC Unit team led by an 
experienced medical doctor; and the third component is the "Chancellor College 
Theatre for Development". There is no rigid hierarchical arrangement in the 
provision of PHC services in this rather unique programme. The components can 
be arranged in a set of three interacting but independent circles (see Figure 3). The 
functions of each of these are described in the following about the conceptual 
strategy of the "Theatre for Development". 
Figure 3: Organisational Structure of Liwonde ADD PHC Unit 
Tha LIWM4« PHC Unit 
Th« ChaacaUor CoUag* T b u l n 
for Davalopmant taam'a primary 
task !• to movttvata tha 
community to Idmttfy tawir owa 
hmJUt *ad othar organic* Uooal 
problam* throwcb opan tad 
participatory play*
60 E Kalipeni & C Kamlongera 
The Conceptual Strategy 
The Community Involvement 
As Bennet and Cole-King (1982) point out, Malawi has a long tradition of 
community involvement in development through "self help" projects. Communities 
are organised according to a combination of traditional and political structures. 
Traditional chiefs, village headmen and elders act as the decision-making authority 
in villages. They deal with social and cultural administrative issues such as land 
distribution and use, land and other disputes and traditional ceremonies. Parallel 
to this structure, are the political party organisations at district and village levels. 
During the Banda regime, both traditional and party authorities were combined in 
what was known as the Area Action Committee, the traditional leader being the 
chairman. The Area Action Committee included some Government field workers 
such as agricultural, community development and health personnel, as well as 
community elected members. The Area Action Committee was supported by the 
District Development Committee and it, in turn, supported and coordinated the 
village or Branch Action Committees. Generally, a Branch Action Committee 
covered one or several smaller villages and, like the Area Action Committees, their 
members were drawn from the party and traditional structures. With the new 
democratically elected government, the political structures may have been modified 
to a lesser or greater extent but the role of the traditional leaders remains 
unaltered. It should also be noted that even during the Banda regime, Action 
Committees largely existed on paper with communities preferring to set up project 
committees as and when the need arose. 
While Action Committees were mainly concerned with specific development 
projects for generating community resources, mobilising labour and materials, etc, 
they also served as a channel of communication on official, political and developmental 
matters. Thus it can be safely concluded that in Malawi there exists a welldefined 
community organisational structure, which links traditional and the 
modern political system and which provides opportunities for communication and 
dialogue with government officials at different levels. How effective this channel 
of communication has been remains to be evaluated. 
The Liwonde PHC Unit utilised this opportunity of an already existing organisational 
structure in the communities. The Unit advised the people to select their 
own village and area health committees in Mwima, Mbela and Chisi Island areas 
at the beginning of the project. The size of each village health committee was to be 
no more than 10 members with a chairman, secretary and treasurer. The members 
of the health committees were elected by a show of hands at meetings of the whole 
community attended by the Liwonde PHC Unit team. In Mbela area there were 12
"Theatre for Development" in Primary Health Care: Malawi 61 
village health committees and one area health committee. In Mwima there was a 
total of 10 village health committees and one area health committee; and on Chisi 
Island there were S village health committees and one area health committee. 
The functions of health committees were to report on infectious diseases, 
organize people for health campaigns and health education meetings, and identify 
health problems in the village. They were also responsible for making sure that the 
community provided itself with and maintained safe water supplies through the 
protection of wells. The committees were further charged with the duty of 
promoting the use of health facilities, especially for maternal and child health care 
and immunisation; and the promotion of latrines and refuse disposal and improved 
housing. 
To ensure the committee effectiveness, two members of each village health 
committee were selected to receive training in health matters. These two volunteers 
attended a very concise training course of one or two days which was held at the 
local primary school in each village. This ensured mat all participating volunteers 
were able to reach the training places on foot Teachers and local leaders were also 
invited to these training sessions. These trained members then took the role of the 
community volunteer health workers (locally known as "community doctors") and 
were able to administer first aid and basic medical care, especially for prevalent 
diseases such as diarrhoea, malaria and conjunctivitis which mostly affect young 
children. Training in sanitation comprised part of the curriculum. 
Role of Popular Theatre 
The most unfortunate thing about primary health care activities is that there is very 
little involvement of communities in the early stages of planning. The tasks and job 
description of primary health care workers are conventionally developed by a 
government appointed committee at the national level without consulting the 
concerned rural communities. The end result is that a diagnosis of needs and 
assessment of the organisational potential to support and manage health activities 
at the community level is most often lacking in most PHC plans. Usually 
communities are "told" about the intended programme, and asked to cooperate 
without any constructive input on their part It is the usual top-down approach. 
The three villages covered by the Liwonde ADD programme (Mwima, Mbela 
and Chisi Island) were selected based on their level of underdevelopment and lack 
of accessibility to modem health care facilities. As noted earlier, there are no 
modem health facilities within the vicinity of these villages. Under these conditions 
intensive preparation of communities for an impending health care programme 
is difficult, requiring good social and communication skills on the part of 
health care providers. Furthermore knowledge about health matters has to be
62 E Kalipeni & C Kamlongera 
carefully combined with sensitivity to local cultural values. Unfortunately, agencies 
involved in health care matters usually do not have the capacity, skills and time 
to learn more about the cultural specificities of the local people. The tendency is 
to "tell" or "order" rather than to probe, stimulate and draw out ideas, and build on 
and learn from existing knowledge and expertise. 
The function of the "Chancellor College Theatre for Development" was to fill 
this vacuum, to probe, stimulate and tease out ideas from the community itself. It 
is on these ideas that the PHC Unit builds its PHC activities in each area. Before 
the PHC team started the implementation of its activities in Mwima and Mbela 
areas, the "Theatre for Development" was called upon to go to these areas and make 
an assessment together with the community about their health problems and needs 
and what they thought should be done to alleviate their plight. After preliminary 
discussions with the people, the "Theatre for Development" team found out that in 
this area especially during the rainy season the rural population is particularly 
susceptible to diseases notably cholera and diarrhoea. The latter is particularly 
serious for the under-fi ve year age group. When the people were first contacted by 
the "Theatre for Development" the major problem was the poor quality of health 
of the population and their main desire or perceived need was the establishment of 
a health facility within the areas. Further discussion, however, revealed that many 
members of the community were reluctant to use the health centres for a whole 
variety of socio-cultural reasons. Among other problems identified they had to 
walk long distances and spend all day in order to get to such facilities, often to find 
the medical superintendent out or to find relatively unhelpful personnel as pressure 
of work often led them to make snap and unhelpful diagnosis. Some of them found 
such centres both imposing and threatening. 
Furthermore, many of the diseases they were suffering from could either be 
prevented or treated much earlier, much more cheaply and much more efficiently 
within the local community. Thus the role of the "Theatre for Development" was 
to provide community awareness, to motivate the people to diagnose their own 
specific problems and to stimulate them to find local solutions to the problems on 
a self-help basis. This was effectively achieved through the medium of loosely 
structured plays and sketches in which local community problems were examined 
and potential local solutions explored. At certain points of the drama the villagers 
were asked to participate in the play by determining in what direction the play 
should develop. Under such conditions it was frequently discovered that traditional 
barriers toward local authority could be broken down and issues freely and openly 
debated democratically. Thus, through local entertainment, local awareness was 
heightened and the villagers motivated to help themselves. The detailed design and 
process of the "Theatre for Development" is given in the following section. 
Unfortunately, the "Theatre for Development" did not carry out these preliminary
"Theatre for Development' in Primary Health Care: Malawi 63 
activities on Chisi Island where the introduction of PHC activities was left to the 
PHC team alone. 
Role of the Uwonde ADD PHC Unit 
The role of the three-man team in Liwonde was to render technical assistance and 
supervision to the volunteer village health workers. The team avoided the temptation 
to exercise authority over the community volunteers and did not want to be 
perceived as superiors. Rather, the central objective of the team was to act as a 
backstop by encouraging the people in the villages to solve their own problems 
(health or health related) through the self-help concept 
The Process of "Theatre for Development" 
The use of theatre for educational purposes is not strange to Malawi. Women in the 
country have been known to employ drama during initiation rites when they wish 
to impart knowledge on matters of sex, motherhood, personal hygiene, etc. to 
novices undergoing initiation upon reaching puberty (Kamlongera, 1984; Helitzer-
Allen, 1994). Use of theatre as a tool for development is becoming widespread 
in Africa as a whole (see Kidd & Gnat, 1980; Eyoh, 1986). The strategy in 
"Theatre for Development" work is to shift emphasis from script as happens in 
conventional "professional" theatre to the process of creating the drama and what 
happens thereafter. The differences are shown in Figure 4 on the following page. 
Whereas the script and the actor dominate in the "professional" theatre, it is the 
creative process - which is dependent on research - that is central to "Theatre for 
Development" This is research carried out by both the theatre practitioners and the 
villagers amongst whom they work; in other words, participatory research. A 
description of the work carried on at Mwima provides a good picture of what 
actually goes on in this work. 
Theatre for Development at Mwima 
The drama team is made up of drama students and lecturers of drama from the 
Department of Fine and Performing Arts at Chancellor College. The team goes out 
fully aware that they know nothing about primary health care and the situation 
regarding this issue in the villages. The understanding between the primary health 
care 'experts' and the theatre team is that the latter are to work as an advance party 
in the villages. They go out to scout on problems that exist in the villages. The 
approach here is to let the villagers participate in the scouting by providing them 
with a forum to analyse and articulate the health problems as they understand them. 
When the team arrives in the village - following advance notice of an impending
64 E Kalipeni & C Kamlongera 
Figure 4: Differences in Approaches Between 
Professional Theatre and Theatre for Development 
PROFESSIONAL 
THEATRE 
Script 
\ 
Auditions 
(actors) 
1 
Interpretation 
of script 
Rehearsal 
Technical Inputs 
(lights, sets etc-) 
Publicity 
r 
Audience 
Rerviei^s 
etc. 
visit - theteam makes it very clear from the outset that they bring nothing to the 
village. What they comefor is to learn from the villagers themselves what and how 
they see as their' problems related to health. Very often these go beyond mere 
health issues tocoveragricultural, economic, social and sometimes even political 
ones. 
this penod theatre' work intermingled with setting up the primary health 
machinery ,n motion. THe effect of this was that the two par* o f 7 e wTrk 
never seen as separated from each other, but as an integrated whole 
THEATRE FOR 
DEVELOPMENT 
1 Catalyst 
i 
Re scare h 
» 
Scenario 
creation 
»
1 
Improvisation 
1— 
Performance 
1 
Evaluation 
Follow-up
"Theatre for Development" in Primary Health Care: Malawi 65 
First Visit: Research 
The Medical Adviser in-charge of the PHC programme in the area explained the 
purpose of the visit. A member of the Theatre for Development team took over 
from the Medical Adviser explaining the "theatre" aspect as the immediate goal, 
not the provision of wanted facilities as the case might be. Here the emphasis was 
to get the villagers to understand that the visiting team was in the village to 'learn' 
about the village from the villagers themselves. During discussions, the villagers 
articulated their grievances and requirements. A few comments on their representatives 
at both local, district and parliamentary levels were raised. Villagers were 
told very clearly that information gathered here was going to provide material for 
dramatisation on issues relevant to health. A list of 'grievances* by the villagers 
was noted which included the following things: 
a) absence of a nurse/clinical officer; 
b) lack of good protected water; 
c) lack of proper market in the place; 
d) existence of various diseases e.g. diarrhoea, measles, scabies, and anaemia; 
e) lack of leadership in matters of health; 
0 hospitals being too far, and 
g) lack of general information. 
After the discussion the team, together with the villagers, went on a tour of the 
village to see instances of health hazards in the area. This tour was led by the 
villagers themselves, who explained what they felt was wrong with what they saw. 
Usually these explanations were defensive and so provided an opportunity for brief 
discussions which led to a balanced and revised understanding of the problems. 
The discussions were not formal, but were carried on an ad hoc basis as people 
walked about. The first visit ended here with the promise of another visit the 
following week. 
The most immediate and obvious health problem recognised by both the visiting 
team and the villagers was the condition of the wells that people were drawing 
water from. The wells were not taken care of by anyone and did not have aprons 
around them. Discussion on this problem led to the agreement that it was one which 
could be remedied quite easily. The villagers agreed that they could have the aprons 
around the wells done if they had cement The Medical Adviser promised to get 
them the cement the following week. This work involved clearing the area 
surrounding the wells and gathering bricks and stones. 
Back to campus the theatre team together with the PHC team held a plenary 
session to discuss the following: 
a) problems identified and worthy of consideration for dramatisation; these 
were availability of water and water hygiene, sanitation, and the formation 
of village health committees and the education of the people on the need for 
such committees; and 
b) action to accompany the theatrical presentation.
66 E Kalipeni &. C Kamlongera 
Following these discussions the theatre team went to improvise around the 
issues raised during the visit and the plenary session back on campus. The idea of 
the improvisation was to prepare a 'demonstration' sketch which would be further 
developed on site together with the villagers as both commentators on and 
participants in the play. 
Group visits to Mwima were supplemented by longer stays by members of the 
theatre team. This was to allow the group to get close as possible to the people, their 
living habits and their problems. Through these stays further information of 
grievances was collected, ie, the relationship between the villagers and health 
personnel at hospital and how the former felt about it was explored to the full; such 
information was gathered informally in chats with individuals. Later on this was 
put to good use in trying to get the people to see the need for establishing village 
health committees. 
The Play 
The play that was presented to the village was a mixture of drama and open 
discussion. The procedure here was as follows: 
Phase 1: 
A mother comes to complain to her chief before his elders that she has lost her son 
in a drowning accident. Further discussion of the accident leads to a decision that 
the villagers should dig a well from which they can draw water instead of using the 
river which is not only dangerous, but infested with all sorts of diseases. 
Having agreed that they should have a well another problem comes up. Where 
do they site it? The chief dictates that it should be close to his house, but the elders 
object and suggest alternative sites which are also objectionable. One is too close 
to a graveyard and therefore culturally unacceptable. The other one is too far away 
although at the centre of the shopping area. The chief then opens the debate to other 
villagers present (the audience that is) to express their views on the subject At this 
point the play becomes a real discussion rather than just entertainment. The 
villagers join in the debate. They point out that a well close to the chief s house will 
inevitably be difficult to approach at will as the chief will expect people to treat it 
as if it was his own personal property. Their choice happens to be somewhere in 
the middle of the village. In real terms this is in feet where the village's well is 
located. The discussion moves on to touch on how the village should actually take 
care of the well once it is dug and what people should not do in order to make it 
clean. This part, although imaginary is built on the villagers* own observation of 
what they themselves do at the well, eg, cleaning baby diapers and washing clothes 
etc close to the well instead of away from i t Most articulate in this part of the
"Theatre for Development" in Primary Health Care: Malawi 67 
discussion/drama are women for they are more knowledgeable about usage of 
wells than men. Several problems related to the question of water are brought out. 
At this point the theatre group opens up the participation in the dramatisation to 
the villagers by encouraging the latter to act in a repeat of the sketch just presented, 
but incorporating ideas and arguments that came along as it was first performed. 
In this way more arguments, discussion on the issues relevant to the question of the 
well and its maintenance evolve. After the village's dramatisation, a summing up 
session is gone into. All this is done by the theatre team and the villagers. The PHC 
team just watches as a passive audience; if ever they participate in this it is either 
as actors or audience, NOT as experts. 
Phase 2: 
Building on complaints about the way hospital personnel treat the sick, a sketch is 
developed whose thrust is to get the villagers to find alternatives to the hospital 
when faced with simple ailments. This leads to a discussion of selecting among 
themselves people who might take care of their immediate health needs (ie, health 
committees). 
Having developed this part of the sketch the whole play is then taken to the 
market square where a larger audience is in attendance. The play here substitutes 
details relevant to the village set-up by those referring to the marketplace. Instead 
of just wells, the question of digging garbage trenches and general cleanliness of 
the market are incorporated into the drama. The performance once again is a 
mixture of acting and discussion of issues raised. By the end of the performances 
sufficient ground has been covered to prepare the people to select their village 
health and market committees. This latter part is left in the hands of the PHC team. 
The "Theatre for Development Approach" may be summed as follows. First, the 
theatre group consults with PHC field workers and discusses rather than simply 
accepts issues raised by health people. The idea here is to acquaint the theatre 
practitioner with PHC needs. Second, out of consultation and discussion with PHC 
workers a sketch is improvised and taken to the village. The purpose of this visit 
is to first of all establish the theatre for development idea and to extend discussion 
of the problems of PHC in order to tease out the villagers' point of view. Third, the 
scenario is prepared using findings of the first meeting in the village and rehearsals. 
Fourth, the play is presented to villagers. The presentation style emphasises an 
open-ended approach to allow for discussion as performance is going on. A result 
of this is frank participation between health workers, villagers and theatre people 
in the discussions that arise out of an on going performance. Finally, the PHC team 
comes in with technical details and assistance as per issues pertinent to the 
occasion.
68 E Kalipeni &. C Kamlongera 
"Theatre for Development" and the Focus Group Approach 
Although this study concentrates on the "Theatre for Development" approach to 
motivating rural people into self-help projects, it must be acknowledged that there 
are other equally effective ways of achieving this same goal. The focus group 
approach, otherwise known as group interviews (ie, interviewing people in groups 
rather than individually) has become a popular approach in highly developed 
societies for marketing research. This approach has its origins shortly after the 
Second World War and was introduced in developed countries such as the United 
States as part of "motivation research" (Wells 1974). As Wells (1974) notes, the 
focus group, in essence, is a small, temporary community, formed for the purpose 
of the collaborativeenterprise of discovery. The assembly is based on some interest 
shared by the panel members, and the effort is reinforced because panelists are paid 
for the work. "Grouping" fosters the kind of interaction that penetrates impression 
management and uncovers more basic motivations, even when the group is 
unaware of impression management or of the need to penetrate i t 
Usually the convener of the focus group is some advertiser or advertising 
agency, or a political entity that is looking for help in selling a product, a service 
or like entity. Like most motivation research this approach has been condemned by 
the conservative research establishment as "unscientific" and therefore untrustworthy 
(Templeton, 1994). In spite of the many criticisms that have been 
levelled against die focus group approach, it has prospered, and today in many 
marketing research organisations, group interviews are nearly as common as 
interviews done by traditional survey questionnaires. The primary advantages of 
the focus group technique include the ease with which it can be carried out, the time 
taken to do so and the relatively inexpensive nature of such a strategy of collecting 
information. Other important but largely subjective advantages include group 
synergism, the snowballing effect and stimulation. 
Although in certain types of research the focus group approach is effective in 
gathering the required data, it may not necessarily be successful in motivating 
people for self-help projects. In a recent study, Yelland and Gifford (1995) 
illustrate theculturalinappiopriateness of the focus group interviews in developing 
countries. However, when this approach is combined with other more conventional 
or novel ways of collecting information or motivating people then its advantages 
become apparent (see for example Egan, et al, 1995). The 'Theatre for Development" 
approach is in manyways akin to the focus group approach, but goes beyond 
the limitations of the focus group. It takes into consideration the cultural context 
of the communities concerned and involves all members of the village throughout 
the process rather than a select group of individuals that are paid money for
"Theatre for Development" in Primary Health Care: Malawi 69 
motivation as is the case in marketing research in developed countries. In 
developing countries, researchers have used the focus group approach to collect 
more detailed qualitative information missed during large scale structured surveys. 
While it may be able to 'tease out' problems in a community setting and generate 
some insights for the researcher, it is lacks the power of theatre in arousing interest 
and motivation in the populace. 
The Relative Success of the 'Theatre for Development" 
Approach 
In Malawi, the most common causes of death in the 0-4 age group include measles, 
pneumonia, nutritional deficiencies, malaria, anaemia, diarrhoeal diseases, tetanus 
and diseases of the nervous system (Kalipeni, 1993). Relatively few diseases are 
responsible for the bulk of infants' and young children'sdeath.Itcanalsobe noted 
that all the important causes of illness and death in Malawi are preventable, or at 
least treatable, by means of the primary health care approach, particularly immunisation 
and early case detection and treatment Consequently, primary health care 
programmes which influence mortality are those which address nutritional problems 
in children who are not brought to child clinics, promote nutrition in the 
homes and ante-natal screening, distribute iron and folate to pregnant mothers, 
strive to immunise infants against tetanus and other maladies such as measles, 
encourages sanitation tocurb diarrhoea in children, and provides prophylactics and 
easily available treatments to the vulnerable age groups and pregnant women. 
Interestingly, the villagers of Mwima and Mbela identified health problems of 
mothers and children as the most critical health problems. As observed by the 
primary health care team, the following were among the most common health 
conditions in these villages: nutritional deficiencies, malaria, measles, diarrhoea, 
cholera, conjunctivitis, hookworm, schistosomiasis (bilharzia), scabies, and other 
common respiratory symptoms. Estimates of infant mortality rates according to 
surveys carried out in the areas at the beginning of the program me ranged from 170 
to 200 deaths per 1,000 live births. Well over 50 per cent of the infants were 
underweight On Chisi Island almost all the children aged 4-13 were infected with 
schistosomiasis. Less than ten per cent of the households had a pit latrine. Wells 
and springs supplying drinking water were generally unprotected and in a deplorable 
condition. Deaths from severe diarrhoea and cholera were a common seasonal 
occurrence, particularly severe during the rainy season. 
While it is hard to make an evaluation of the effectiveness and/or success of a 
newly instituted programme, data gathered from these two villages during the 
1985-1990 period indicate that the "Theatre for Development" approach has been
70 E Kalipeni & C Kamlongera 
substantially effective as a catalyst to self-help and good health. The village health 
committees, have been very active in trying to do something about the villagers' 
precarious health conditions. The immediate impact of the programme can be 
clearly seen in the detailed data that is collected by members of the village health 
committees and forwarded to the PHC Unit office at the Liwonde ADD main office 
as monthly returns (see Table 1 for a copy of the health register for compiling 
monthly returns kept by the chairman of each village health committee). The basic 
pieces of health information collected monthly include the number of deaths 
occurring in young children and adults each month; the number of cases of 
diarrhoea each month, the number of families with latrines and the number of 
families using safe water supplies. In addition, volunteer PHC workers record 
additional information in their registers which includes cases treated and referrals 
and monthly nutritional and weight surveillance for children. In general the 
effectiveness of the programme on the health and living conditions of the people 
within the three areas can be gauged by looking briefly at statistics on sanitation 
and water, maternal care and reported infant deaths, and provision of basic 
medications. We briefly provide some data for two periods, namely, pre-intervention 
(1986 and before) and post-intervention (1987 and after). The data presented 
in the tables that follow was largely compiled from the monthly returns registers 
as shown in Table 1. 
Sanitation 
As far as sanitation is concerned, the number of hand-dug wells and latrines 
increased dramatically within a short period of time. By 1988, three years after the 
onset of the programme, the villagers in Mbela and Mwima areas had over 40 
protected shallow wells of about 4 to 7 feet in depth. Concrete slabs have been 
constructed around the wells so that surface water should flow away instead of 
lying stagnant around the well and potentially polluting the water supply. Mwima 
has a village community workshop for producing concrete slabs for latrines. The 
materials and technical advice are provided by the PHC team from Liwonde using 
a limited amount of resources from a German Technical Aid grant. Before the 
arrival of the PHC team in 1985 only ten per cent of the houses had pit latrines. A 
few months later, in June 1986 49 per cent of the households in Mbela and 51 per 
cent in Mwima had constructed pit latrines to the recommended standards. In 
February 1987, about 71 per cent of the families in Mbela and 81 per cent of 
families in Mwima had decent pit latrines (see Table 2 for data on pit latrines for 
Mbelaarea villages for June 1986 and February 1987). A simple statistical analysis 
of the differences of means test in the increase of pit latrines between June 1986 
and February 1987 turned out to be statistically significant at the 5 per cent level
Table 1. Health Register for Ljwonde PHC Unit 
Area District 
Dzina la mudzi (name of village) Mwezi (Month) Chaka (Year) 
Dzina la kumpando wa zaumoyo (village health committee chairman's name) 
Nambala ya nyumba (number of houses in village) 
Nambala ya zimbudzi (number of latrines) 
Nambala ya ana amene anabadwa mwezi uno (number of children born during this month) 
Odwala amene analandira mankhwala kapena anamwalira (patients treated or died during this month) 
age group 
ana azaka 0-4 
(0-4 age group) 
ana a zaka 
kuposa 4 
(Age>4 years) 
akulu 
(adults) 
KHADI YA BUNGWE LA ZAUMOYO (HEALTH REGISTER) 
! 
kutsegula mimba malungo matenda ena died matenda amaso otumizidwa 
kuchipatala 
other diseases, 
specify below 
& J
omwalira 
<•* 
eye diseases referrals diarrhoea malaria I
tf 
a-
72 E Kalipeni & C Kamlongera 
experienced significant increases in households with latrines a couple years after 
the inception of the programme. A few people we interviewed in Mbela area 
pointed out a number of advantages for building latrines. Among them were selfrespect 
for the individual and family and prevention of diseases to attain or promote 
better health. 
This is in contrast to the experience of Chisi Island where the PHC team went 
in without the assistance of the "Chancellor College Theatre for Development" 
troupe (see Table 3). In June 1986 only 20 per cent of the houses had latrines and 
this increased to 30 per cent by February 1986. A difference of means t-test 
indicated that, on average, the increases latrine construction experienced by 
villages on Chisi Island was not statistically significant at the 5 per cent level of 
significance (see note in Table 2). 
Table 2. Number of Latrines in Mbela Area 
Village Number of 
Houses 
262 
58 
168 
62 
150 
320 
319 
118 
239 
139 
Mtira 
Said-Son 
Chipole 
Kalambo 
Mbela 
Pyoli 
Makuta 
Herbet 
Abudu 
Nsanja 
Kabota 107 
Total 1,906 
Note: Estimated population for Mbela area- 9 530 
Results of paired sample differences of m e L ttst. 
M2U £ £ ***, °f ^ ^ W ^ !atrines "» 19»6: 49145. standard deviation: 14.75 
P a h ^ f f T w* ' a t r m e s >n 1987: 71.36, standard deviation: 18.41 
« 3 M r f t ? l^- I.24- P~"bK- °0°2 <*•«• «"* difference between the means 49.45 and 71.36 is statistically significant at the .05 level of significance. 
Source: data compiled from Liwonde ADD Primary Health Care Unit, Monthly Returns. 
Number of Latrines 
June 1986 
Number % Houses 
with Latrines 
107 41 
32 55 
65 39 
71 
71 
30 
64 
46 
44 
106 
95 
203 
54 
133 56 
50 36 
37 35 
926 49 
February 1987 
Number % Houses 
with Latrines 
47 123 
90 52 
45 75 
77 48 
91 136 
79 253 
82 263 
91 108 
63 
45 
75 
150 
62 
80 
71 1,350
"Theatre for Development" in Primary Health Care: Malawi 73 
Once the PHC programme in Mbela and Mwima areas was introduced using the 
novel approach of "Theatre for Development", there were remarkable strides and 
gains. The village health committees motivated by the "Theatre for Development" 
performances, became very active and membership of the committees remained 
intact with just a couple of drop-outs. In contrast, the people of Chisi Island were 
not exposed to the "Theatre for Development" approach and seemed to lack 
motivation. The village health committees on the island, just like in many rural 
areas, appeared to inactive and unconcerned about the communities' plight in as 
far sanitation was concerned. The lack of motivation in Chisi Island and the 
enthusiastic adoption of PHC in Mwima and Mbela provides more credibility to 
the potency of the "Theatre for Development" approach. 
Table 3. Number of Latrines on Chisi Island 
Village Number of 
Houses 
Maluwa 170 
45 Tchuka 
30 Chilima 
Kotamu 
Mkumbira 
Chigwere 
159 
152 
83 
42 Khumali 
681 Total 
Note: Estimated population for Mbela area: 3,405 
Results of paired sample differences of means test: 
Mean per cent of houses with latrines in 1986: 20.46, standard deviation: 10.64 
Mean per cent of houses with latrines in 1987: 30.00, standard deviation: 8.43 
Paired differences t-value: -2.24, p-value: 0.066 (i.e. the difference between the means 
20.46 and 30.00 is not statistically significant at the .05 level of significance). 
Source: Liwonde ADD Primary Health Care Unit, Monthly Returns. 
Maternal Care 
As far as maternal care is concerned, the programme selected a number of 
traditional birth attendants (TBAs) who commanded respect in the community. 
The TBAs were then trained to provide basic antenatal care including iron 
supplementation, malaria treatment and high risk screening. Furthermore, commuof 
Latrines Number 
June 1986 February 1987 
Number % Houses 
with Latrines 
Number % Houses 
withi Latrines 
34 20 8 
33 
40 
13
8 
10 
18 
33 
27 26 43 
20 23 
31 28 
15 
12 
42 
30 
26 
17 40 4 
15 
33
9 
26 176 19 129
74 E Kalipeni & C Kamlongera 
nity 'doctors' were selected and trained to diagnose common conditions and 
administer basic medications such as chloroquine, aspirin, eye ointment, scabies 
ointment and so on. The community 'doctors', in collaboration with the TB As, take 
up the tasks of nutritional and health surveillance of children (including the 
identification of children that require immunisation for the next mobile PHC team 
visit, or to encourage mothers to go to the under-five clinic on appropriate days), 
the distribution of chloroquine, first aid and treatment of minor ailments, the 
management of diarrhoea in children, and treatment of malaria and selected 
common conditions in children and adults. They also educate families and 
community groups on the prevention of these conditions. The efforts of these 
dedicated, community based (unpaid volunteer) PHC workers have been amply 
rewarded. 
Incidence of Disease 
Statistics from the PHC unit in Liwonde show that the seasonal outbreaks of 
cholera declined considerably between 1985 and 1986 when the PHC project was 
in progress (Table 4). Furthermore, immediate reporting of suspected cholera and 
severe diarrhoea to health institutions by the community and improved water 
supplies by provision of sanitary structures at wells/springs have been vital to the 
improved situation. There has also been a significant reduction in monthly infant 
and child deaths caused by diarrhoeal diseases. The incidence of diarrhoea in both 
children and adults experienced a remarkable reduction during the 1985-1990 
period (see Table 5). However, we must caution that the data in Tables 4 and 5 could 
be on the low side for several reasons including under-counting due to parents not 
taking their sick children to the village health worker. It may also be due to the fact 
that the year 1987 was somewhat drier than the year 1986 in terms of rainfall. 
Diseases such as diarrhoea are most intense during the rainy season and drier than 
normal season may reduce the incidence of diarrhoea and/or cholera. However, the 
trends in the data were obviously encouraging. Similar data for Chisi Island was 
not available due to noncooperation of the village health workers charged with the 
responsibility of collecting such data. 
In addition to the reduction of communicable diseases such as diarrhoea, Mbela 
and Mwima experienced substantial declines in monthly infant mortality figures 
between the 1984/85 and 1987/88 periods as shown in Table 6. The current 
esumatedinfantmortality for MbelaandMwimaareas is 150compared to 180and 
above before the PHC project in this area. These are a few examples which 
illustrate the positive impact of this unique programme as evidenced from the 
health and sanitation data collected by the programme. It is unfortunate that 
comparable data on disease incidence was not readily available for Chisi Island 
wun tne exception of latrines which could be easily counted in surveys by the PHC
Table 4. Reported Cases of Cholera and Severe Diarrhoea Incidence in Liwonde Area 
Total No. 
of Cases 
Total No. 
of Deaths 
Total No. 
Positives 
Source: Liwonde ADD Primary Health Care Unit, Cholera Quarterly Returns, October- 
December 1986. 
Table 5: Incidence of Diarrhoea in Children and Adults in Mbela Area 
Village 
Mtira 
Said-Son 
Chipole 
Kalambo 
Mbela 
Pyoli 
Makuta 
Herbert 
Abudu 
Msanja 
Kabota 
Total 
Note: Number of deaths reported were NOTaue to diarrhoea alone but to any other 
disease. 
Source: Liwonde ADD PHC Unit, Monthly Returns. 
"Theatre for Development" in Primary Health Care: Malawi 75 
1985 
December November October 
116 92 155 
0 1 2 
15 8 16 
June 1986 
No. of Deaths No. of Cases 
Adults Adults 
0
0
0 
76
7
2 
64
1 
16 
34
3 
0
0
1
1
2
0
4
0
0
0
0 
0-5 age 
group 
1
0
1
1
3
0
1
2
4
0
0 
0-5 age 
group 
21
0 
11 
111 
7 
33 
93 
13 
30 
38 
10 
203 13 367 8 
October 
46 
1986 
November 
29 
0 0 
1 0 
December 
15
0
0 
1987 May 
No. of Cases No. of Deaths 
Adults Adults 
1 
0
0
1
0
1
1
0
0
0
0 
0-5 age 
group 
9
7
4 
21
1
6
4
1
6
2
2 
0-5 age 
group 
1
1
1
0
2
0
0
0
0
0
2 
5
1
1
6
5
3
1
0
3
7
5 
4 37 63 7
76 E Kalipeni & C Kamlongera 
By concentrating the PHC activities in a number of selected villages, the 
Liwonde PHC Unit hoped that these villages would serve as centres of information 
diffusion to other nearby villages where the programme had not as yet been 
initiated. The model for diffusion was through village contact Indeed this 
approach appears to have yielded the intended results. At the time we carried out 
this evaluation, surrounding villages were requesting the PHC team to initiate PHC 
activities in their areas. Villagers from surrounding areas were coming to Mwima 
and Mbela to observe and receive basic first aid care and treatment from the 
community 'doctors'. 
Table 6: Number of Deaths Among Children Aged 0-5 in Mbela Area 
for the periods 1984/85 and 1987/88 
45- 
40- 
30- 
n 1 
1 • • • 
(dnorf 
I
I• 
u
6
5
> 
| 
15- 
10- 
5- 1 
0- 
1 
;: I: 1
1 1 
fil mww 
Jun» July Aug ' 3*pt ' Oct ' Nov 
Month 
Notes: 
| l 
1 1 
i 1 1 
H I -1
I 
Tl ! • 1 •1 • • 
I " g Jun 9S4-F*b1985 • I Jun 1M7-F«b.19SS 
Results of paired sample differences of means test- 
Men number of death, 1984/85: 26.88, standard deviation: 4.31 
Mean number of death. 1987/88: 17.89, standard deviation: 4.65 
Paired deference, t-value: 4.53. p-value: 0.002 (this denotes'that the difference between 
«?.iT.""]."1011 r " U m b e r ° f d e i l h 8 f 0 r * e •""fc'-fi"' «ge group, ie 26.88 and 17.89 is 
staus ^y,1gmf,cantatthe.051evelof,ignifi a B 1ce ) . 
Source: auAors. data from Uwonde ADD Primary Hedth Care Unit. Monthly Returns. 
1
F»b Jan
"Theatre for Development" in Primary Health Care: Malawi 77 
Conclusion 
The case study discussed in this paper confirms the assertion that PHC planning 
ought to be socially and community oriented, aimed at improving the well-being 
of rural communities. The communities should be mobilised and motivated to 
diagnose their own problems and find their own solutions. Popular theatre like the 
"Chancellor College Theatre for Development" could be employed creatively for 
this purpose. PHC planning has tended to adopt the rather narrow view of 
accessibility relating it to the maximum distance people are willing to travel to 
obtain a particular health service. Consequently much emphasis has been placed 
on building new facilities at great capital and recurrent cost to the state without 
necessarily improving absolute access to rural inhabitants. In reality accessibility 
to health services is concerned with more than just proximity to these services; it 
involves various social, cultural and community health education issues. Active 
community participation and involvement is vital in the success of any PHC 
programme. As shown by the Liwonde PHC programme's relative success over a 
short period of time, there is a clear need to involve the rural people in the planning 
process. In other words, the planning process should not only come from above but 
should also include a bottom-up grassroots-level component. 
Acknowledgement 
This paper is based on an unpublished larger report that was prepared by myself in 
collaboration with Professor Christopher Kamlongera of Chancellor College, University of 
Malawi. Fieldwork for data collection was funded by a World Health Organisation grant 
We are grateful to the Demographic Unit of the University of Malawi for providing the 
necessary logistical support such as transportation and secretarial facilities. We would also 
like to extend thanks to the Liwonde ADD PHC team and members of the Chancellor 
College Travelling Theatre for their cooperation and assistance during our numerous visits. 
The views expressed in this paper are those of the authors. We are also extremely grateful 
to the comments offered by anonymous reviewers to an earlier draft of this paper. 
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