Celebrating Mothers: Health in the Hands of Women

To celebrate Mothers´ Day today, and every day, Future Generations Peru happily agreed to share with the Future Generations community some basic information on their project called  “Health in the Hands of Women” (MAM Project).  

The MAM Project was implemented in four rural districts of the Huánuco region in Peru from 2010 to 2014 in a population of 92,000 inhabitants in 180 communities, served by 27 primary health care facilities (HF).  The area is located on the eastern slope of the Andes mountains facing the Amazon basin, nine hours by bus from the capital city, Lima.

The stated project goal was to contribute to improving the health of mothers, newborns, and infants, and to reduce chronic child malnutrition.   We wanted to demonstrate to the Peruvian Ministry of Health that it could effectively and sustainably implement at scale a model of primary health care organization and management in rural areas that could successfully support at scale a community-oriented system of health promotion that would reach mothers in the home to improve their home health knowledge and behaviors and improve maternal and child health status.

The project design centered on two over-arching strategies.  The main strategy was the SEED-SCALE methodology of Future Generations which was used to first develop and then strengthen sustainability and replicability of successful interventions.  As we all know,  SEED-SCALE emphasizes building on successes, three-way partnerships, and using local data to make local action plans.   

The second over-arching strategy for the MAM Project design was the Sectorization Strategy, which guides the reorganization of primary health services to focus on community health.  It was expected that this strategy would be sustained and expanded by the regional Ministry of Health. 

A major component of the MAM Project strategy was the Modular Program for Training Female Community Health Workers (CHW) in Maternal, Neonatal, and Child Health.   This was a behavior change strategy that introduced innovations in the Peruvian health sector for CHW trainers (primary health care personnel), supervisors and supporters of CHW (Community Facilitators who were community members), older community women as CHW, with teaching and training materials (flipcharts and facilitator manuals), and a CHW learning/teaching method (“Sharing Histories”).

The MAM Project team of Future Generations trained the trainers (health personnel) and provided training modules and educational flipcharts for teaching mothers.  We also provided checklist-type tools that we had developed to help guide CHW to conduct home monitoring of mothers and children and to report on their activities.  

In health facilities, health personnel trainers provided monthly training workshops to female CHWs and Community Facilitators.   In communities, Community Facilitators supervised and supported CHWs.    CHWs did home visits to pregnant mothers, newborns, and children under age two to share histories with mothers, teach mothers new information with flipcharts, observe mothers´ practice of new behaviors, and detect any danger signs for referral of mothers, newborns, and infants to the nearest health HF.

A key project activity was the implementation and testing of the innovative teaching method for CHWs, called “Sharing Histories,” that empowers mothers through the sharing their own memories of their childbirth and child rearing experiences, hearing other´s experiences, and learning best practices by analyzing what was done correctly or incorrectly in the past.   Female CHW gained self-confidence to speak in front of others, took ownership of their own experiences, and became more effective in their home visits to other women teach them better health practices.  The MAM project tested the effect of the “Sharing Histories” teaching method as an embedded operations research project using a cluster-randomized controlled trial.

MAM worked to improve the quality of care in health facilities (HFs) by changing health staff attitudes about community health outreach and guided the development of management teams in each HF to work together on community health plans and actions.   We worked with them to do an initial self-evaluation and self-planning exercises for both of those purposes.

The final evaluation studies of the MAM Project in 2014 were compared to baseline studies conducted in 2010, major findings showed major improvements in  knowledge and practices of mothers related to health and nutrition of mothers, newborns, and children.   

Some of the key accomplishments of MAM Project include:

• Significant reduction in chronic malnutrition in children 0-23 months of age whose mothers received one or more visits from a CHW, among mothers who could read.
• Significant increases in knowledge of pregnancy, post-partum and newborn danger signs by an average of 16 to 48 percentage points.
• Significant increase in newborns that were wrapped and dried immediately at birth (76% to 98%)
• Significant increases in good hygiene and sanitation practices, including hand washing, disposal of infant feces, water treatment at the point of use, and reducing in-door breeding in dirt-floor kitchens of small animals (such as guinea pigs which are served for special meals).
• Significant increase in the percentage of HF managed by CLAS Associations (43% to 70%).
• Development of a new cadre of human resources for community health called Community Facilitators.  All 47 of them continue to be paid stipends directly by the municipalities in 2017 for their work to support and supervise female CHW.
• Community Facilitators and female CHWs are recognized by health workers as being  key components for the HF-community health strategy.
• Community Facilitators and CHWs are recognized by community authorities and municipalities as playing a critical role in improving community health.
• The Huánuco Regional Health Directorate officially established a permanent “Center for Development of Competencies in Health Promotion” in the Acomayo Health Center which serves to sustain the new approach to community health promotion by guaranteeing the on-going training of trainers so they can continue the training and support to Community Facilitators and female CHWs on a wider scale.
• Municipalities are increasing support to HFs by continued financing to the Community Facilitator stipends, training costs for monthly workshops, and non-cash incentives for CHW and Community Facilitators.  Municipalities expanded their investment in contracting extra health personnel, constructing and remodeling infrastructure for health posts, providing equipment, implementing services (laboratory, maternity waiting homes), and providing fuel for motorcycles or bus fare for health personnel supervision to communities.

The strategy for reorienting health services to work in communities was presented in our publication, Methodological Guide to Sectorization for Health Promotion in Co-management with the Community, which was approved by the Huánuco Regional Health Directorate (the sub-national office of the Ministry of Health) and published by Future Generations in September 2012.   A Directorate Resolution declared the Sectorization Strategy as an official policy for the Huánuco region, to be scaled up to every primary health HF in the region (about 400).

The MAM project built on the new CLAS law on collaborative management of health facilities with citizen participation to strengthen linkages between community, HFs, and municipalities. This included incorporation of community priorities in a participatory budgeting process and coordination for additional sustainable health financing from both CLAS and municipal governments.

Future Generations Peru continues with this work in a variety of ways, and currently has the signed support of the Minister of Health to significantly expand this work in Peru in support of the National Plan for Reduction of Anemia and Chronic Child Malnutrition 2017-2021.

*CLAS are Local Health Administration Community Associations – private non-profit community organizations that collaboratively administer primary health care facilities under contract with the government.

________________________________________________________________

This week's blog post and accompanying photos are kindly shared by Dr. Laura Altobelli, Future Generations University's Professor of Equity & Empowerment (Health) and Director of Future Generations Peru. She has more than 30 years of experience in research, evaluation, and public policy innovation and advocacy, and uses these skills to bring scalable solutions for strengthening public health systems in developing countries.

For Dr. Altobelli's full biography, please visit: https://www.future.edu/facultyDir/laura-altobelli .html