Making Services Work for with Poor People: A community perspective from Save the Children Federation

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Making Services Work for withPoor PeopleA
community perspective from Save the Children
Federation

• World Development Report Consultation Meeting
• September 26, 2002

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• Brief background on Save the Children Federation
  health programs
• Look at making services work WITH poor people
  using three case study examples
• Summary of lessons learned

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SC Health Programs

• Current portfolio obligations 130,000,000
• (48 private, 52 public)
• In over 40 developing countries with major health
  emphasis in 15 focus countries.
• Programs in child survival (incl. newborn
  health), school health and nutrition, adolescent,
  maternal reproductive health, family planning,
  and HIV/AIDS.
• Work in partnership with and through local
  organizations. Little to no direct service
  delivery.

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Learning from the field3 case studies

• Bolivia Warmi Project
• Peru Building bridges for quality
• Bolivia Community-based health information
  system

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A Community Action Cycle
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Warmi Project, Bolivia

• Participatory approach to working with womens
  groups and the broader community to reduce
  maternal and newborn mortality.
• Although attempts were made to improve formal
  services, little progress was made during project
  period. Nearest true referral point to resolve
  complications was 5-6 hours away.
• And yet..

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Warmi Project Perinatal/Neonatal Mortality
Rates/1000
Died within 28 days of birth
1988-1990
1992-1993
?2 Plt0.001, 1 df.
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Care of the Newborn
Surviving newborns, pre and post)
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Immediate Breastfeeding
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New Users of Family Planning Methods
(Women of reproductive age in 7 communities that
requested FP services, 8 mos. (n1380)
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Puentes Setting

• In 1998 in Peru, the MOH was implementing
  several quality improvement initiatives. They
  had limited success and did not increase
  utilization significantly in many parts of the
  country, especially among the poor.

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• What is quality?
• Who is defining quality?
• Who is improving quality?

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Puentes Activities

• Establish local MOH sub-regional team.
• Select project areas.
• Train local MOH team.
• Select community provider participants.

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Puentes Activities- contd.

• Explore quality and produce participatory
  videos with communities and providers
  (separately).

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Puentes Activities- contd.

• Get to know each other and initiate respectful
  dialogue that results in joint definition of
  quality and action plan.

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Puentes Activities- contd.

• Implement plan
• Monitor progress together
• Evaluate results together (after one year)

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Results

• MOH and community report increasing service
  utilization and more satisfied clients.
• Sites have organized joint committees to
  coordinate, monitor and document activities.
• Communities and service providers continue to
  meet to monitor progress on action plans two
  years after project support ended.
• Examples of improvements Expanded hours of
  service, additional resources (human and
  physical) and community participation in
  improving health centers, health education.

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Community-Based Health Information System
(SECI) Process

• Health promoters collect data on key indicators
  from families monthly.
• Service providers collect service utilization
  data.
• Together they consolidate data at the end of the
  month.

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SECI Process contd.

• The health promoter and service providers use
  simple tools to share the data with the
  community.
• Community members review and analyze the
  information.

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SECI Process contd.

• Participants then set priorities and develop
  plans to improve their priority health
  indicators.
• They monitor their progress every month and
  adjust their strategies.

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SECI Results

• More families in SECI communities (compared with
  control communities) reported
• early post-partum breast-feeding
• (OR2.62, 25.7 versus 11.7, plt.05)
• oil supplementation for young children
• (OR1.95, 67.5 versus 51.6, plt.05).
• use of several child health services
• complete child immunization (OR4.78, 11.2
  versus 2.6, plt.05)
• vitamin A supplementation (OR1.96, 58.6 versus
  41.9, plt0.05)
• possession of a health card (OR2.12, 44.9
  versus 27.7, plt.05).
• Willis, et al. pending publication

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SECI Results

• Community(ies) collectively
• agreed to immunize children (and did)
• demanded more information re immunization, ORT,
  cough management and FP from service providers
• demanded information and discussed rights of
  women and children
• agreed to child growth monitoring
• agreed upon a deadline (and fine) for incomplete
  child vaccination
• agreed to collect small monthly fee from all
  parents who have children in a public
  kindergarten for a better diet

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SECI Results contd.

• Womens groups collectively
• produced herbal cough syrup for common colds
• organized cooking sessions with emphasis in child
  feeding
• mobilized the community (including the men) to
  construct a health post with local materials
  (adobe bricks)

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Conclusions recommendations

• Communities and services are motivated to act by
  data presented in ways that can be understood and
  analyzed by all concerned.
• When poor and other marginalized groups
  participate in defining and improving quality,
  they are more satisfied with, and invested in,
  these services.

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Conclusions recommendations

• Communities will contribute their resources and
  support to services when they see that their
  efforts lead to positive changes in their health
  and their abilities to achieve other common
  goals, even beyond the health sector.

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Conclusions recommendations

• Programs should nurture positive relationships
  between communities and service providers and
  develop commitment and capacity of all
  participants to work together.
• Respectful dialogue and negotiation is critical
  for effective partnerships between services and
  communities.

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Conclusions recommendations

• Resources and supportive policies alone will not
  lead to achievement of the MDGs. Programs must
  address the underlying socio-cultural factors
  that influence utilization of services and
  adoption of healthier behaviors. NGOs are often
  well suited to help facilitate this process.
• If financial incentives are considered, keep in
  mind potential threats to sustainability of the
  program and community participation.

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Conclusions recommendations

• Strengthening services is very important, but
  dont forget about what can be done at the
  household and community levels to save lives and
  promote health and well-being.

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Conclusions recommendations

• Making services work WITH poor people is a
  dynamic, interactive process that produces
  changes in social structures and norms needed for
  longer term improvements in health.

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Thank you.