REPORT REVIEW OF COMMUNITY FACILITATORS TRAINING AND IMPLEMENTATION IN WAU AND AWEIL NORTH Korrie de Koning, KIT February, 2015
Background The SHARP program implemented by the Ministry of Health (MOH) South Sudan, KIT, HEALTHNET TPO,the International Medical Corps (IMC) and Cordaid aims to improve maternal health in South Sudan. This community participation component of the programme concerns the uncovering and transformation of norms that are detrimental to women’s health, particularly maternal health, through the adoption of action learning methodology for knowledge transfer, reflection, generational dialogues and the development of action plans. The community participation component is carried out by KIT with the support of IMC and HEALTHNET TPO as part of the SHARP programme in collaboration with the Country Health Departments (CHDs), Health Development Units, in Wau County (Western Bahr el Ghazal, WBeG) and Aweil North County (Northern Bahr el Ghazal (NBeG). The training was developed by the Royal Tropical Institute (KIT) in Amsterdam, The Netherlands and REACH Trust, Malawi. The implementation is conducted by two community participation officers assisted by four community facilitators in each country supervised by HEALTHNET TPO and IMC and supported by the MOH South Sudan.
The methodology for Sexual and Reproductive Health (SRH) Rights Community activities focuses on four elements: 1. The interaction between the generations in the community to enhance the dialogue between the generations about maternal health. To enable dialogue between generations participants include younger and older men and women, boys and girls, community leaders, and are recruited from the community using existing groups such as women’s groups and youth groups. 2. Participatory learning and action dialogues using participatory methods, such as small group work and plenary discussions, questions for reflection, and discussion of desired changes, are used to address underlying norms and values, and develop action plans for change. 3. Participatory Rural Appraisal visualisation techniques such as social mapping, drawing and matrixes are used to produce and visualise information for further discussion and analysis. 4. A knowledge component will consist of the dissemination of information and knowledge using two way communication techniques to generate knowledge about danger signs, the benefits of using health services, the influence of age and number of children and birth spacing on maternal and children’s health, the right to services, messages about what to do to have a healthy pregnancy, delivery and post natal care, and improving birth preparedness, use of contraceptives and prevention of early pregnancy.
The objectives of the SRH Rights Community activity of SHARP are:
Improved health-seeking behavior of the community with regards to the three delays in accessing maternal health care services, as well as the use of family planning methods. Increased capacity of local officials, health workers and communities to fulfill their roles & responsibilities in achieving SRH rights. Improved collaboration between the community & health workers in identifying issues with SRH service delivery and developing/implementing action plans (both together and independently) to improve quality of care.
Overview community dialogue steps and sessions Stakeholder meetings
An introductory stakeholder meeting is held to present the community participation programme to district, Payam and Boma level decision makers and to ensure their support and prepare for the selection of community facilitators. The implementation sites are selected based on the following criteria: staff availability, availability of health facilities and security situation. Urban/rural considerations are taken into account.
Community facilitators are selected Community facilitators (CFs), who are volunteers with compensation for travel and cost of accommodation and food during the training days, are selected in four communities inWau and four in Aweil North county. The selection consists of: one older and one younger male and one older and one younger female. For criteria and process, and job description, see the programme implementation plan. At the end of the process the community is asked to prepare for the selection of participants. For the code of conduct that is signed by each community facilitator, see the programme implementation plan.
Training of facilitators The Community facilitators are trained during a 7 day training of facilitators conducted by KIT in cooperation with HealthNet TPO and IMC and their Community Participation Officers (CPOs)..
Selection of community participants Community participants are selected by the community: 10 younger, 15-25 years and 10 older, 25-50 years, males and females. The community facilitators will guide the selection of participants after the training of facilitators. For the selection criteria see the implementation plan.
Community consultations The facilitators hold separate group discussions with the participants in the dialogue sessions, selected in the earlier meeting, to learn about their views regarding maternal health and birth spacing.
Community dialogue sessions The facilitator teams in each community consist of two CPOs and the four community facilitators who completed the training of facilitators. The teams hold five consecutive dialogue sessions. The five dialogue sessions cover different topics and are concluded by meeting 6: a public meeting.
Follow up period community For three months, community facilitators and other agents of change identified during the dialogues, hold small group discussions/interviews with families, community groups, health workers and community leaders about implementation of the action plan, that was agreed during the public meeting, that followed the 5 dialogue sessions. Once a month, the CPO facilitators and the community facilitators hold a supervision meeting to discuss achievements and challenges. Follow up meetings with trainers and facilitators to review what went well and what did not go well and possibly make changes to the training and process are implemented as required after three months. Public Meeting 2: CPOs and community facilitators invite the community and the leaders and service providers for a second public meeting at which they present to what extent the action plans and requests have been implemented and what the community wants to do next to further address the challenges it faces after three months.
Community Consultations 2: After six months, the CPO facilitators repeat the baseline consultation held in the beginning of the implementation cycle. This meeting signals the formal end of the involvement of the partner NGO. Further follow up needs to be linked to the tasks of the Home Health Promotors (HHPs). An exit strategy should be developed for this in an early phase by HealthNet TPO and IMC.
Evaluation An evaluation will be held in November/December 2015. Questions and the process for obtaining feedback of the community on what changed and interviews with facilitators and CPOs will be developed after the facilitator training. The most significant change methodology will be used to evaluate the programme.
Preliminary results and lessons learned from the first implementation This section summarises the results of the first implementation cycle based on the review meeting held on 12 to 13 February in Wau, WeBG, attended by all relevant stakeholders form WeBG and the CPOs and RHO of NeBG. In general the programme was implemented according to plan with delays in the implementation in NeBG by two weeks. The experiences and lessons learned for dialogue session 5 and the public meeting is based on the experiences in WeBG only. The report starts with a summary of the achievements, challenges and recommendations for the dialogue sessions. The last part of the report summarises the challenges in the wider context in which the programme is implemented and the actions to be taken to address these that were agreed during the meeting. The achievements and changes suggested show a very successful start of the programme. Preliminary observations of HMIS attendance data (not yet cleaned and compared with trends in the year before) suggest an increase in utilisation for the SHARP facilities and some indication that the community participation programme may assist in an increase of deliveries at health facilities. However, it is far too early to confirm these observations.
Achievements • • • • •
•
•
• •
Implementation took place in eight communities. In NeBG drop out of participants was hardly there. In Wau, up to 10 persons dropped out over the five dialogue sessions, especially older men, because they went hunting. Sessions were well implemented in both states. Pledges were made to improve relationships between youth and elders. In WeBG, the public meeting deicded that condoms are to be made available to young people through the health facilities. However, participants also indicated in three villages that there is no transport to the health facility, making it more difficult for young girls and boys to obtain condoms when they need them. The need to postpone early marriage was mentioned in all villages in WBeG and discussed in NBeG (Yasmin and Teddy can you fill in what happened during the public meeting what decisions were made? Participants in both areas suggested discussionsbetween youth and women’s association to address the high bride price, but differences in bride price between various ethnic groups in Wau were not explored. In both areas, the need for more education for girls was mentioned. It was identified that transactional sex happens because of poverty and parents not providing for their children.
•
• •
Husbands not being able to look after too many children was acknowledged and the use of contraceptives to stop having children was mainly mentioned by women and by some men as personal pledges. Concern about high teenage pregnancy was widespread; the importance of making contraceptives available for youth was agreed in all four communities in WBeG. The use of family planning for spacing up to five years was accepted in all communities.
WBeG Issues and challenges suggested by participants and experienced by staff (learning and action points to be taken from reports once received): Need for saving and credit activities, income generation. Challenge for young girls to discuss in larger groups with elders from same family. Young people were challenged speaking out in public. They shy off in providing their feedback. Youth facilitators (girls) in some communities were too shy. It was suggested to extend the age range for the boys and girls to include youth up to 25 years in the selection of facilitators so that the facilitator and participants. This to enable participants to feel confident to politely but clearly challenge and ask questions of older participants. Translation was sometimes required which extends the session to four hours. Lunch provided for participants will help to overcome this. Problems with logistics hinder early departure and timely arrival.
NBeG Issues and challenges: • Some older men and women were very rigid and held others back in suggesting changes. • Community Facilitators selected for the youth were too old. • Facilitation skills of CPOs needs supervision and a learning beyond the initial training. In both areas reporting of the dialogue sessions is lagging behind and may require a different schedule to allow for report writing in between dialogue sessions. The rainy season may bring more challenges to keep to the implementation schedule. The need for shelters to hold the meetings was discussed. Implications • Discuss at the next dialogue 3 meeting, where an expert is providing information on technical aspects of maternal health: Difference anaemia and eclampsia, reasons for infected yes in newborn babies Panadol and for FP needs to be addressed in next sessions of HHPs and next expert session • Connect to education for girls, as grants are only available in Wau town (Lisa will organize meeting in Juba between Korrie and Girl education for South Sudan, conducted: see separate minutes). • Adapt selection criteria: o Do not select from same family, o Select young girls who are (believed to be) able to speak out in meeting with elders, o Select men and women not older than 50 and emphasize to choose persons who are flexible and willing to change. • Emphasize confidentiality to be kept of what is shared in sessions. Provide feedback in larger groups speaking in general and not identifying personal pledges, statements.
• • •
•
Stick to divisions of generation groups as is in the manual. Explore bride-price in more detail in the baseline consultation that is done at the beginning of implementation of the community dialogue in each village. baseline. During selection of CFs, discuss the need to advance transport money for participants and ask the chief to give an advance to those who are not able to pay up front or arrange for participants to be picked up well in advance. Include more practice for community facilitators in the training and review the duration of the training after the second batch is trained.
General issues discussed during day one and finalised during day 2 with Dr Sasa Gabriel, Director PHC, SMOH and Cecilia Raphael, Director RH, SMOH:
Incentives Provisions dialogue days Work of Traditional Birth Attendants (TBAs) Access to services, fees, staff attitudes CHD support Reporting template
Incentives for Community Facilitators WBeG Discussion centred on two issues. The common policy in IMC and Healthnet TPO and the implications for sustainability. Conclusion: 1. In Wau for batch 3 explore the option to select villages so that a community that is central to the other 3 villages can be used for training of CFs, if feasible and still in line with other criteria. This option is to be considered to avoid conducting the training in Wau wich is more in line with the training of HPs conducted in the villages. 2. A sitting allowance of 50 SSP plus transport one way twice for CFs is IMC policy and cannot be changed without due discussion in IMC. To be reviewed by IMC. 3. Participants dialogue days to be provided with water, soda and food. All will receive tshirt or baseball cap and a certificate. NBeG: CFs: Receive 50 SSP per day, which includes transport. Participants: soda and water, but changed this to 10 SSP (less work in preparing). However, this sets all other meetings up for negotiating money payment and sustainability becomes difficult and sends a wrong message. Healthnet TPO and CHD will address this.
Collaboration with TBAs Some TBAs seem to feel threatened with the programme. In WBeG during dialogue 3, they became defensive and did not recognize the danger signs as happening in the villages. In one case, a TBA threated to refuse all assistance to pregnant mothers. In one village it was suggested to arrest the TBA if she is conducting deliveries. There is a need to strengthen collaboration with TBAs. Worldwide this is being tried out. Fines and policing is not a solution, services are still too far away and skilled staff not 24 hours available, so women need TBAs.
Options for strengthening collaboration to be discussed with SMOH and MOH: Reduce preference for TBAs by making facilities more responsive and address staff attitudes that are sometimes judgmental and unfriendly. Work with TBAs in the facility when they bring a woman for delivery. The community can pay the TBA for their services, using the practices followed (e.g. payment may be in kind rather than money). . Motivation of TBAs: TBAs registered to start a business; talk with communities to pay the TBA by the household. Have a meeting as part of the HHP programme and strengthen birth preparedness/ waiting homes? Work out a system for rewarding TBAs when they bring women for delivery timely. CFs to follow up on action plans from community. Action point: SMOH, IMC and Healthnet TPO initiate meeting in the State with other stakeholders to discuss collaboration of TBAs with health facilities and communities wider.
Access to RH services Staff perceived as judgmental towards unmarried pregnant women, poor women. Suggestions with regard to staff attitudes Train staff in non-judgmental attitudes. Discuss feedback with supervisors who can supervise staff. Need to review the system whereby the culture of work is focused on being proud to be well respected and appreciated by the community. This needs group supervision and meetings, individual meetings is not enough and needs to involve all staff to change the culture. Work with CHD and Villigae Health Committees (VHCs) to improve community staff relationships. Action: State RH director to bring issues on attitude to the midwifery association and health forum. Healthnet TPO Reproductive Health Officer (RHO) to bring issue to State Ministry of Health and follow up in health forum meetings? Note retention of midwives is a problem that needs to be discussed with MOH, SMOH. Is beyond the scope of this review meeting.
Referral system (ambulance):
Ambulance in Wau and Aweil county is used private and not available for emergencies. SMoH has not finalized guidelines for control of the ambulance. This hinders in charges to demand the ambulance for patients in a systematic manner with clear guidelines for who can demand an ambulance for what reasons. There is need for a monitoring system to prevent abuse. Action: Director PHC to feedback on results of guidelines; Healthnet TPO RHO to investigate situation in NBeG
Charging of fees Problem: services are supposed to be for free,but this is not the case. Women pay between 30 and 150 SSPs for a delivery in WBeG and around 50 in various facilities in NBeG.
WBeG: This was discussed in a meeting with midwives and for now it has been decided that they can charge 30 pounds per delivery for charcoal and chlorid. This is not yet discussed and introduced to the community and VHCs so that they can establish a transparent system. In NBeG: this problem is put in the hands of the CHD and payam administrators. It needs follow up. Chlorid is in the kit received from UNFPA and charcoal money is paid for by the community contributing 1 SSP. The VHC ensures that there is charcoal for sterilization, so no need for any fee for services. Action: Director RH SMOH and Director PHC to support, IMC and Healthnet TPO RHOs to follow up. SMoH, IMC and community to be involved on the discussion of best way forward without affecting service delivery link to discussion of attitudes of midwives and conduct meetings to inform VHCs, communities and health facility staff in Wau and Aweil North communities.
CHD support This problem was brought in by HealthNet TPO in NBeG. CHD is not joining in for dialogue meetings. In WBeG the director is very much on top of the team and committed. She assigns staff to go for dialogue sessions and they do come along. Suggestion: discuss with head CHD and see if staff can be assigned to join sessions.
Poverty, food security and girl education To address transactional sex, girl education and food security the programme need to link with other NGOs who address these issues.