This blog post is the third in the Transparency for Development series “T4D: Views from the Field,” written to highlight what members of the T4D team have observed in launching a co-designed intervention in Tanzania and Indonesia that seeks to empower citizens to improve maternal and newborn health in their communities.
The previous two posts explored problem-driven design and the importance of people in the T4D intervention. In this post, Lindsey Roots takes us inside a Community Scorecard Meeting in one Tanzanian village. She observes how meetings are facilitated to prompt community members to reflect on their own experiences with Maternal and Newborn Health (MNH), and to empower them to identify barriers and solutions to better MNH.
Read other posts from the T4D project here.
By Lindsey Roots
How do you turn information on women’s and babies’ health into real improvements in health outcomes? This question is at the core of the Transparency for Development (T4D) Project. To explore this question, the T4D team and its partners implemented a transparency and accountability intervention in which Community Scorecard (CSC) and Social Action Planning (SAP) Meetings featured prominently. But what do these meetings look like in practice? I went to one village in Tanga region, Tanzania, to find out.
Fifteen Community Representatives (CRs)—a group that consisted of women of childbearing age, community elders, a teacher, and a traditional birth attendant—gathered together over the course of two days to discuss maternal and newborn health (MNH) in their community.
They identified the most pressing barriers to better health, were presented with information on MNH in their village, and used a community scorecard tool to design actions aimed at improving the health of the mothers and infants in the community. These actions included educating mothers on best practices and putting a suggestion box at their local health facility, amongst others.
Day 1: Identifying the Problem
On day one the group of Community Representatives assembled at the local primary school to discuss the current situation of maternal and newborn health in their village. The facilitators (individuals identified and trained by the local chapter of the Clinton Health Access Initiative, T4D’s partner organization in Tanzania) shared that in Tanzania nearly 7900 women die each year due to pregnancy related complications, and that in 2013 there were 21 neonatal deaths for every 1000 live births.
The facilitator reminded everyone that although these statistics are discouraging, each CR is capable of designing and participating in actions to improve MNH in the village.
Sharing the indicators: what’s in a number?
Although national statistics are important indicators, they can seem impersonal. For this reason, the facilitators went on to share information about access to mother and child healthcare in the village, which was lower than in Tanga region or Tanzania as a whole.
One in ten women received the recommended antenatal care (ANC)—four visits, the first of which occurring within the first twelve weeks of pregnancy—relative to two women in ten regionally and nationally, and a government target of nine in ten. This surprised the CRs, who were able to provide multiple reasons when asked why ANC is important—for mothers to get vaccinations, to get health checks, and to see if the baby is breach.
The village was also underperforming in access to postnatal care (PNC). The CRs seemed to absorb the relative statistics. They were disappointed that their village was behind target, but felt as though they were in a position to improve the situation.
With seven in ten women delivering in a health facility, the village was actually above the regional and national facility birth rates (four in ten and six in ten, respectively). However, the CRs could cite examples of women who had encountered complications during home births—one mother had severe complications after the placenta was delivered incorrectly, and another who had difficulties with properly cutting the baby’s cord. The group expressed interest in trying to help more women to deliver at the facility.
Making a global health problem personal
To make these issues even more urgent and personal, the facilitators tasked the CRs to think about times when they personally experienced an obstacle to MNH, or when those they knew experienced barriers.
They began by asking the group where it is safer for women to deliver, to which the group replied “in hospital.” The facilitator then asked where women in the village deliver, to which the reply was the same “in hospital.” The facilitator probed “so there isn’t anyone who delivers at home.” And the CRs replied, “Yes, there are some who do.” The facilitators proceeded to invite stories from the group.
One experience in particular recurred in the stories told by CRs: these MNH services, which were supposed to be free, were often denied to women who didn’t have money or refused to pay the provider. The CRs brainstormed some of the reasons for this: Women were often required to bring supplies with them to receive services at the health facility. The staff at the local dispensary often had bad attitudes, telling patients to come back later, resulting in more women delivering at home. Staff had also been known to refuse to deliver babies to women in certain risk categories.
After discussion in small groups and as a whole, the CRs concluded that there are many barriers preventing women from getting care, including travel distance from some sub-villages to the facility, poor preparation as a result of hiding pregnancy in its early stages, fear of medical checks, the availability of traditional birth attendants for home deliveries, and a lack of understanding and cooperation from husbands. Others added to the list lack of education, irresponsible attitudes of parents, and the negative attitudes of facility staff.
Lack of education and understanding came out as a prominent issue and some community representatives felt it was the foundation of the other barriers and the essence of the entire problem. However, this perception evolved when the CRs started to enact their action plans after the meetings—they began to interact with a wider range of community members and realized that the community was better informed than expected.
At the end of the discussion, CRs voted on the barriers they perceived to be the most significant in the village: lack of understanding/knowledge of women, fear of medical check-ups, distance to the facility, negative attitude of health workers, lack of preparedness for delivery (such as failing to making transport arrangements or purchasing the necessary supplies), lack of male cooperation (such as refusal to accompany women to ANC appointments), and irresponsibility of parents (for example, carelessness in beginning ANC on time).
The social action plan
Now it was time for the group to start thinking of ways to overcome the barriers identified and to help more women and babies access care. The facilitator shared stories of actions that other communities had taken, such as approaching journalists, highlighting high performing staff and identifying intermediaries to approach the health board.
Each story highlighted a successful outcome of the community’s effort: more reliable opening hours, better availability of medicine, improved facility cleanliness, greater patient satisfaction or increased clinic attendance.
One story in particular caught the group’s attention:
The CRs began making plans to install a suggestion box at their own dispensary. Other stories that resonated with the group included a placenta pit built in Kilindi, school toilets built in Iringa, finding an alternative space for the ANC clinic that had been meeting in the village office, and gathering to demand changes to the factory spilling sewage. After a full 5 hours of hard work, the CA’s concluded the first meeting exhausted, but looking forward to day two.
Day 2: From identifying barriers to generating solutions
The CRs arrived bright and early the next day to develop their initial ideas for social actions into operational plans. The group fleshed out their initial ideas by considering the timeline, resources, and people who would be responsible for each step. They agreed on the following actions:
Action 1: Education on importance of maternal and newborn health, birth preparedness planning, cooperation of men, and the importance of health check-ups.
There was still some work to be done on where and how often the education would be delivered but the group agreed that they could provide education to the community within a month, using resources that they already had access to.
Action 2: Encourage savings groups to help parents with small amounts of money for birth preparedness.
Savings groups are common in Tanzania and require regular contributions by each member. Part of each contribution is assigned to a fund for community purposes (e.g. 2500 weekly per person of which 500 goes to the community fund). The central fund is then accessible to any member or their immediate family in emergencies and as a loan for other things. Someone raised the question of whether the savings groups would cooperate with the idea and whether money might be required of parents in order to join and participate in the groups.
Action 3: Talk to health providers about their attitude and coordinate an educational meeting on maternal and newborn health.
The group laid out plans to go to the village leader to get a letter of support and then to go to the facility to speak with the health staff. The CRs planned to achieve this within two weeks. One of the CRs (the teacher) advocated for a more positive and collaborative approach for speaking with the staff, rather than inciting hatred between the community and the health workers. I wondered if, as a public sector worker herself, she felt some empathy for the nurse. The group agreed to pursue this more friendly approach.
Action 4: Suggestion box at dispensary.
One group member stepped forward to offer to build the box and seek permission from the leaders—tasks that the group agreed should take a month. There was some discussion about how comments should be handled, once received. The facilitator advised that it is important that all comments get read and one CR suggested bringing the village leadership on board in this process.
At the end of the meeting, the CR chair gave a grand speech as a tribute to the facilitators’ excellence in helping the Community Representatives identify MNH barriers and devise plans to overcome them. Speech making is typical in Tanzania, but the mood of this speech was particularly jovial.
With the action planning wrapped up and clear steps laid out, we wait to see where the community will take these actions, and what the impact might be for maternal and newborn health. The facilitators will check-in with the community 30 days from now and then again at the 60 and 90 day marks, but it is now up to the CRs to complete their actions—or not.
As part of the intervention evaluation, the T4D team will measure at scale whether these CR groups start and complete their actions, whether they alter them when they experience challenges, or whether they stop the actions altogether. This should help us better understand whether, why, and under what circumstances transparency and accountability activities can prompt community action to improve health outcomes.
Lindsey Roots was the Tanzania Study Coordinator for the T4D project throughout the Phase I intervention. She was responsible for coordinating with the project’s partner organizations in Tanzania and overseeing day-to-day project activities there. Lindsey is now working as a Consultant for Oxford Policy Management (OPM) in Tanzania.