Save The Children- Making Services Work for with Poor People

A community perspective from Save the Children Federation World Development Report Consultation Meeting Making Services Work for with Poor People: September 26, 2002 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  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. Learning from the field… 3 case studies Bolivia: Warmi Project  Peru: Building bridges for quality  Bolivia: Community-based health information system  A Community Action Cycle Warmi Project, Bolivia    Participatory approach to working with women’s 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….. Warmi Project: Perinatal/Neonatal* Mortality Rates/1000 120 100 80 60 40 20 0 Baseline 1988-1990 Final 1992-1993 *Died within 28 days of birth 2: P<0.001, 1 df. Care of the Newborn 80 60 40 20 0 d s it or tie at e hk az t r it rd b ir sc ed co su d ed Us Re Us cte nfe isi D Surviving newborns, pre and post) Baseline (n=151) Final (n=136) Immediate Breastfeeding 50 40 30 20 10 0 Cases Baseline Controls Final New Users of Family Planning Methods 3 0 2 5 2 0 1 5 1 0 5 0 B a s e lin e F in a l (Women of reproductive age in 7 communities that requested FP services, 8 mos. (n=1380) 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.  What is “quality”?  Who is defining quality? is improving quality?  Who Puentes Activities     Establish local MOH sub-regional team. Select project areas. Train local MOH team. Select community & provider participants. Puentes Activitiescont’d.  Explore “quality” and produce participatory videos with communities and providers (separately). Puentes Activitiescont’d.  Get to know each other and initiate respectful dialogue that results in joint definition of quality and action plan. Puentes Activitiescont’d. plan  Monitor progress together  Evaluate results together (after one year)  Implement 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.  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. SECI Process – cont’d.   The health promoter and service providers use simple tools to share the data with the community. Community members review and analyze the information. SECI Process– cont’d.   Participants then set priorities and develop plans to improve their priority health indicators. They monitor their progress every month and adjust their strategies. SECI Results More families in SECI communities (compared with control communities) reported:   early post-partum breast-feeding (OR=2.62, 25.7% versus 11.7%, p<.05) oil supplementation for young children (OR=1.95, 67.5% versus 51.6%, p<.05).     use of several child health services complete child immunization (OR=4.78, 11.2% versus 2.6%, p<.05) vitamin A supplementation (OR=1.96, 58.6% versus 41.9%, p<0.05) possession of a health card (OR=2.12, 44.9% versus 27.7%, p<.05). Willis, et al. pending publication 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 SECI Results –cont’d. Women’s 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) 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.  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. 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.  Conclusions & recommendations  Resources and supportive policies alone will not lead to achievement of the MDG’s. 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.  Conclusions & recommendations  Strengthening services is very important, but don’t forget about what can be done at the household and community levels to save lives and promote health and well-being. 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. Thank you.