Making Services Work

for for withPoor People:

A community perspective from Save the Children Federation

World Development Report Consultation Meeting

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

2: P<0.001, 1 df.

*Died within 28 days of birth1988-1990 1992-1993

0

20

40

60

80

100

120

Baseline Final

Care of the NewbornCare of the Newborn

Surviving newborns, pre and post)

020406080

Used razor

Disinfected cord ties

Used birth kit

Resuscitated

Baseline(n=151)

Final(n=136)

Immediate BreastfeedingImmediate Breastfeeding

0

10

20

30

40

50

Cases Controls

Baseline Final

New Users of Family New Users of Family Planning MethodsPlanning Methods

(Women of reproductive age in 7 communities that requested FP services, 8 mos. (n=1380)

0

5

1 0

1 5

2 0

2 5

3 0

B a s e l i n e F i n a l

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?

Who is improving quality?

Puentes Activities Establish local MOH

sub-regional team. Select project areas. Train local MOH

team. Select community &

provider participants.

Puentes Activities- cont’d.

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

Puentes Activities- cont’d.

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

Puentes Activities- cont’d.

Implement planMonitor progress together Evaluate results together (after

one year)

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.