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Integrating health promotion to improve maternal and newborn health in El Salvador

Author(s) Janet Perkins1, Nicole Répond2, Cecilia Capello3, Ana Ligia Molina Araniva4, Carlo Santarelli 5.
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Lausanne, Switzerland, 3Health Department, Enfants du Monde, Geneva, Switzerland, 4Health Deparment, Concertación de Educación of El Salvador , San Salvador,El Salvador, 5Enfants du Monde, Enfants du Monde, Geneva, Switzerland.
Country - ies of focus El Salvador
Relevant to the conference tracks Women and Children
Summary Women and newborns in El Salvador continue to face elevated risks related to pregnancy and birth. Historically, the Ministry of Health (MoH) has focused primarily on strengthening the health services while neglecting the critical role that women, men, families and communities play in improving maternal and newborn health (MNH). Our project integrates a Health Promotion component (Ottawa Charter) in the broader MNH strategy in order to empower women and communities to improve MNH, increase access to quality MNH services and incorporate community participation in the health system. As a result of our project, we have seen important changes at both the national and local level towards improving MNH.
What challenges does your project address and why is it of importance? Women and newborns living in El Salvador face among the greatest risks related to pregnancy and childbirth in Central America and the Caribbean. With a maternal mortality rate of 81/100,000, a woman living in El Salvador faces a 1 in 490 lifetime risk of death due to maternal causes, compared to the 1 in 3,900 risk of a woman living in a developed country. In addition, 15 out of every 1,000 infants fail to survive the first year of life, with a high proportion of these deaths occurring before the end of the first month. Risks related to pregnancy and birth are magnified in rural areas where the utilization of health services, and institutional birth in particular, remains low.
Achieving real improvement in MNH requires not only improving and expanding health services but also action with the community to improve care in the home of women and newborns as well as increase demand and utilization of health services. However, historically action aiming to improve MNH in El Salvador has been directed primarily at the health services, with only marginal emphasis accorded to the role of individuals, families and communities within the health system. Our efforts aim to address this gap by empowering women, men, families and communities to improve MNH.
How have you addressed these challenges? Do you see a solution? The World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH is designed to facilitate the inclusion of Health Promotion in national MNH strategies. Its primary aims are to empower women, men, families and communities to improve MNH and increase access to MNH services. The IFC framework was integrated into the Pan-American Health Organization’s (PAHO) regional MNH strategy in 2004 and El Salvador was selected as one of four countries for pilot implementation.
Since 2005, Enfants du Monde (EdM), a Geneva-based NGO, in collaboration with the Concertación de Educación of El Salvador (CEES), a consortium of local NGOs, has been supporting Ministry of Health (MoH) to implement the IFC framework. Initially, a national IFC coordinating body was established to oversee IFC implementation in the country and assure that the framework is integrated in broader health initiatives. This IFC committee includes representatives from MoH and CEES, with technical support by EdM and the PAHO country office. This committee collaborates with and supervises IFC coordinating bodies at sub-national and local levels.
The national committee selected eight municipalities, covering approximately 100,000 women of reproductive age, for initial implementation of the framework at the local level for validation. Participatory community assessments (PCAs) were conducted in each municipality at the outset in order to guide planning. These PCAs consist of a series of roundtable discussions with community members and leaders where they discuss priority MNH needs and participate in designing interventions to tackle identified challenges. Results of these discussions were used to develop IFC action plans which were integrated into broader district action plans and implemented. Interventions vary by municipality, but include in general: birth preparedness; strengthening interpersonal skills of health providers; community oversight of health services; sensitizing men to MNH needs and their roles; and promoting rights to health.
At the national level, efforts have focused on institutionalizing health promotion and community participation in the national health strategy. Notably, due to the success of the program, the IFC committee has been invited to participate in elaborating a number of policies related to reproductive health. In addition, actors at the municipal level were consulted by MoH in the revision of the national birth preparedness strategy.
How do you know whether you have made a difference? The actions undertaken at both national and local levels have been successful at reaching their objectives. At the national level, the IFC committee participated in drafting the Strategic Plan for Reducing Maternal and Neonatal Mortality 2011-2015, the Sexual and Reproductive Health Policy, and the Technical Operational Guidelines for the Birth Preparedness Strategy. Largely as a result of their participation, each of these documents contains lessons from the implementation of the IFC framework, thereby highlighting Health Promotion and community participation in each one. These documents have now been finalized and endorsed by MoH. Furthermore, the IFC committee is now participating in drafting the Technical Guidelines for Promoting the Right to Health.
The PCA has elicited a great deal of enthusiasm by MoH at national and local level. Stakeholders have witnessed the benefit of working with communities using this tool and as a result MoH has adopted it for use beyond MNH for analyzing and planning health action more broadly. A range of actors at national, sub-national and local level are being trained to use it, contributing its institutionalization.
At the local level, IFC action plans have been implemented in the eight selected municipalities. Trust has been built between women and families and healthcare providers. Women have been empowered to demand quality health services which have been defined as their right. For example, women mobilized to obtain the right to be accompanied by a companion of choice when receiving MNH services at health facilities, notably during birth, and were successful in this goal. In addition, MoH responded to the community when they demanded that certain positions which had been vacant (i.e., gynecologist, pediatricians) be filled in rural health facilities.
Women and families report seeking health services to a greater extent and high satisfaction with services received. Women take action to prepare for birth and potential obstetrical and neonatal complications. However, challenges still exist in terms of women following through on their plan. Utilization of both routine and emergency MNH services is increasing. Men are increasingly participating in MNH by accompanying women to health facilities, though not to the extent anticipated. Promisingly, in each of the implementation municipalities maternal, perinatal and neonatal death has decreased and no maternal death has been reported in 7 of 8 municipalities for 3 years.
Have you or the project mobilized others and if so, who, why and how? We recognized from the outset of our project that long term success and real integration of the project in national policies and programs can only occur when a variety of actors across different sectors are mobilized. Notably, each year a team of 10 actors from national and local MoH, NGO’s and members of the IFC committee participate in the PAHO/EdM diploma awarding course on the IFC framework at the University of Antioquia in Colombia. This course helps actors from Latin-American understand the critical nature of working with and empowering individuals, families and communities and how to institutionalize mechanisms allowing them to participate to reach the goals laid out in the national MNH strategy. Following the training, these actors support implementation of the framework at national, sub-national and local level.
The national IFC committee’s participation in the Alliance for Sexual and Reproductive health has also served to mobilize others. This intersectoral alliance operates under MoH and includes a number of organizations such as PAHO, UNFPA, Save the Children, Plan International, and World Vision. This alliance has helped to increase visibility of the IFC component and encourage the interest of other members. For example, as a result of this alliance, Save the Children has become financially engaged to support the implementation of certain interventions of the IFC program.
Moreover, efforts have been undertaken to strengthen the system of community health teams at the national and local levels. At the local level these teams include community health workers as well as trained doctors and nurses. They visit under-served communities providing services. Within our program we are training them to integrate health promotion and community participation into their work and conduct PCAs. As a result, their capacities are reinforced to work with and empower communities.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Links have been created between communities and health facilities allowing for meaningful community participation to be institutionalized in the health system. Mayors and religious groups have become involved in funding the implementation of local interventions. Perhaps most importantly, the community, notably women, their partners and mothers-in-law, have mobilized to improve the care of women and newborns and increase access to health services, for example in facilitating transport.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision and the constant search for alliances. To begin with, a central priority of implementation process has been to institutionalize the IFC framework and community participatory processes into the national MNH strategy as well as in other policies at various levels. As highlighted earlier, we have made a great deal of progress in this domain, as components of the IFC framework have been integrated into some of the most important sexual and reproductive health documents and policies recently elaborated.
In addition, the IFC framework is being implemented by MoH, with the support of outside actors, including NGOs and PAHO. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. MoH is now planning a strategy for scaling up to new municipalities.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in existing offices (of PAHO and MOH). Likewise, CEES is composed of a consortium of local NGOs, based and operating in El Salvador. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other local actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country stakeholders prevents an over reliance on outsiders and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate to identify their needs and design methods of addressing these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is better equipped with the capacity to integrate and promote community participation.

Integrating Community Participation in Maternal and Newborn Health Services: Burkina Faso

Author(s) Janet Perkins1, Cecilia Capello2, Aminata Bargo3
Affiliation(s) 1Health Department, Enfants du Monde, Geneva, Switzerland, 2Health Department, Enfants du Monde, Geneva, Switzerland, 3Health Department, Fondation pour le Développement Communautaire/Burkina Faso , Ouagadougou, Burkina Faso.4
Country - ies of focus Burkina Faso
Relevant to the conference tracks Social Determinants and Human Rights
Summary Improving maternal and newborn health (MNH) in regions where women and newborns suffer most requires a rights-based approach which identifies and addresses the broader social determinants of health. In Burkina Faso, we are implementing a health promotion component within the national MNH strategy. A central feature is the institutionalization of community participation in the identification of priority MNH needs as well as the design of interventions. The result is a system in which data related to social determinants of health are collected and used within the health sector. This allows the health sector to participate in addressing these determinants and promotes the rights of community members.
What challenges does your project address and why is it of importance? Despite progress over the past two decades, women and newborns in Burkina Faso continue to face elevated risks related to pregnancy and childbirth. With a maternal mortality ratio of 300/100,000, a woman in Burkina Faso faces a 1 in 55 lifetime risk of death due to maternal causes. Thirty-eight of every 1,000 newborns fail to survive the first month of life. Effectively addressing MNH demands a rights-based approach to health programming that focuses on rooting out inequities and addressing social determinants of health.
Central to a rights-based approach is the promotion of meaningful participation of individuals and communities in the development and implementation of actions designed for their benefit. Participation is both an ends in and of itself, as participation is defined as a right, as well as a means of contributing to a process of empowerment. One of the aims of our program is to integrate participatory processes into health programming. This contributes to assisting the health services in becoming aware of and designing appropriate and tailored interventions to address challenges in MNH, including social determinants, as well as to give a voice to community members and ensure that they are able to participate and are empowered in the process.
How have you addressed these challenges? Do you see a solution? Since 2006, Enfants du Monde, a Swiss NGO, in collaboration with the local NGO Fondation pour le Développement Communautaire/Burkina Faso (FDC/BF), has been supporting Ministry of Health (MoH) in implementing a programme based on the World Health Organization’s framework for Working with Individuals, Families and Communities (IFC) to improve MNH. The IFC framework is designed to form a health promotion component of a broader MNH strategy, as it does in the Burkina Faso national strategy. One of the principal aims is to empower women, men, families and communities to improve MNH. A central component of the empowerment process is institutionalizing participatory processes in health planning.Notably, participatory community assessments (PCA) are conducted at the outset of district-level implementation. These assessments provide a platform for community members, with an emphasis on marginalized groups, to discuss MNH needs in the community and develop tailored interventions. During the PCAs, participants explore the broad array of factors, including social determinants that contribute to poor MNH. The ensuing results of these assessments are planned interventions which are appropriate and specific to the context as well as the initiation of the empowerment of community members as they assume influence in improving the health of their community.While participatory planning processes are not new in health programming, the IFC framework institutionalizes these processes within the broader health system to make community voices systematically represented and to allow for the systematic collection of information related to social determinants of MNH. With the endorsement of the national MoH, actors from within the sub-national MoH have been trained to conduct PCAs in collaboration with other actors working within MNH at the regional and district level. In this position, they have been able to assume the responsibility of listening to the voices of community members and of taking direct action in response to their participation. This process has created a mechanism by which community participation has been integrated within the health sector. This contributes to promoting participation, and thereby rights, of community members, and increases accountability and transparency in the health services. It allows for health inequities and socioeconomic determinants of health to be identified and addressed within the public health sector.
How do you know whether you have made a difference? To date, PCAs have been conducted in seven districts (Tenkodogo, Zabré, Kongoussi, Ouragaye, Barsalogho, and Sindou) over three regions. These assessments have effectively identified challenges related to MNH, many related to rights and socioeconomic determinants, that did not surface through more traditional, non-participatory situation analyses. These include: lack of knowledge of health behaviors during and following pregnancy; lack of awareness of danger signs during and following pregnancy; lack of planning for birth or potential complications; women’s inability to make the decision to seek health services autonomously or use family resources to pay for services due to low socioeconomic status; financial and transportation barriers to reaching health facilities; and lack of satisfaction in interactions with health care providers.
To address these priority concerns, community members, leaders and the health sector worked together to develop interventions. These interventions vary by district, but include health education activities (theatrical performances, culinary demonstrations, radio game shows, etc.), birth preparedness and complication readiness, mobilization of men and the broader community to increase their awareness of MNH rights and needs and enlist their participation in MNH actions, building maternity waiting homes and training health workers to build their capacities to interact with women.Preliminary results to date suggest the success of the processes and interventions. Notably, the IFC interventions have been directly integrated into the MNH action plans of each district. This mechanism has assured the institutionalization of community members’ participation in the planning of activities designed to benefit them. This has not only contributed to the promotion of their rights, but has also provided a way for the health sector to gather data and become involved in addressing the broader determinants of health, including social determinants. Where interventions have been implemented, health care providers have created links for exchanging information with communities. Male partners are accompanying women when receiving MNH services in greater numbers and health information system data has revealed an increase in utilization of MNH services. A current evaluation is assessing the degree to which the activities have contributed to change in MNH knowledge, attitudes and practices in these initial sites of implementation.
Have you or the project mobilized others and if so, who, why and how? We initiated the project based on the assumption that improving MNH cannot effectively be accomplished in a vacuum and requires the mobilization and action of a myriad of actors. As such we have mobilized a variety of agencies and sectors acting at the national, sub-national and district level. This process began with the introduction of the IFC framework at national level. Workshops were held with MoH, Ministry of Education, international organizations and others working on MNH at this level. These workshops were designed to help these actors understand the critical nature of working with and empowering individuals, families and communities and institutionalising mechanisms that allowed them to participate in reaching the goals laid out in the national MNH strategy and ultimately fulfill women’s maternal health rights. Actors from within MoH to be responsible for the IFC component at the national level were identified and their capacities built to lead these efforts.
At the same time, IFC committees, operating under MNH bodies, at sub-national and district level were formed. This structure of IFC committees has created a mechanism allowing for both horizontal and vertical communication. This has reinforced the institutionalization of community participation in MNH as actors at both the national and sub-national levels become aware of the specific needs expressed by community members as well as the social determinants of maternal and newborn health in play at the local level. They are then able to respond with centralized action when necessary and appropriate.
In addition, community members, leaders and groups have been mobilized to participate in MNH action. Notably, health care providers have created linkages for working with communities and for the exchange of information. They have contacted and begun working with community leaders, male partners, community health workers and village birth attendants. Through these links, actors in the community have become engaged in encouraging women to attend MNH services. They also transmit information from the health services to the community and gather information on an on-going basis in the community and relaying it back to the health services. This contributes to the realization of rights, including promoting community members’ rights to information and education and through ensuring accountability and transparency. It also provides a mechanism for continued community participation within the health sector.
When your donor funding runs out how will your idea continue to live? Sustainability of the program has been a priority since its inception and has therefore been implemented with a long term vision. To begin with, the IFC framework and its related interventions have been directly integrated into the national MNH strategy, as the health promotion component and fifth pillar of the national Plan for Reducing Maternal and Newborn Mortality: A Road Map. This has assured that it has never been implemented as a standalone, vertical program. In addition, the component is being implemented directly by MoH, with the support of outside actors, including NGOs and UNFPA. As a result MoH is directly responsible and accountable for its implementation. It has been institutionalized within the MNH program at all levels, ensuring that participatory processes themselves are integrated as well. Moreover, while the program is still financially supported primarily by exogenous actors (i.e. UNFPA, EdM), MoH understands that this funding will ultimately expire and has identified and begun implementing strategies for resource mobilization internally.
In addition, at its core, our project focuses on building the capacities of in-country actors. Notably EdM has no expatriate staff on the ground. Rather, locals are staffed as coordinators in regional offices. Likewise, FDC/BF is a local NGO, based and operating in Burkina Faso. Moreover, at every phase of IFC implementation, the focus remains on building the capacities of State and other actors to implement the framework and assume primary responsibility for interventions. This focus on capacity building of in-country actors prevents an over-reliance on outside actors and ensures local ownership of initiatives, thereby promoting sustainability.
Finally, the program has also launched processes of empowering women, men, families and communities. This empowerment is considered not only a means to an end, but also an end in and of itself. These exercises of working together have built the capacities of community members to collaborate in identifying their needs and designing methods to address these needs. The capacities of the health services have simultaneously been reinforced to include the participation of community members in health planning and services action. This bodes well for the sustainability of the idea as local actors have the capacity to participate and the health sector is equipped with the capacity to integrate and promote community participation.