Services to the People

This project uses interpersonal communication approaches in an effort to enhance the access of vulnerable people (women in rural areas, and their children) to quality health services. The project's name reflects the rationale that, if women cannot go to quality services (because these services are non-existent, or due to problems of transport and finances), trained providers will bring these services to them. However, NSPOH stresses that "even in case we succeed in that, the availability of quality services will not produce the desired outcome (contribute to the reduction of maternal an infant mortality) where there is no possibility for women, men, families and communities to be healthy, to make healthy decisions and, most important, to be able to act on these healthy decisions." Thus, Services to the People adheres to the World Health Organization (WHO) model for safe motherhood, which recognises the importance of working not only with individuals, but also with families and communities. Advocacy is a key pursuit, as well. Specifically, core components of this strategy include:

1. Developing capacities to stay healthy, make healthy decisions, and respond to obstetric and neonatal emergencies
   
   Rationale: NSPOH stresses that self-care (pursuit of a healthy lifestyle, care-seeking behaviour, and compliance with care recommendations) is closely linked to knowledge and social norms. An initial understanding of the reasons for use and non-use of services in different moments of reproductive health is thought to be fundamental for development of appropriate strategies and multi-channel messages, so research is an important part of this area of action. Birth and emergency preparedness is understood to be closely linked with both increased use of services and with the providers' skills for interpersonal communication and counselling. This preparedness is also linked to actions to develop transport and financing schemes and to increase the role of men.
   
   Interventions: Organisers will provide preparation for birth courses, for women and their partners. To understand care-seeking behaviour, a baseline study will be carried out among pregnant women and their partners, with interventions tailor-made based on the findings.
2. Increasing awareness of the rights, needs, and potential problems related to maternal and newborn health
   
   Rationale: This initiative is premised on a rights-based approach which holds that access to appropriate services is a right that people are entitled to demand from their governments, and that people are thus entitled to advocate for comprehensive maternal and neonatal services and information. Organisers believe that, at the individual level, those users who are more informed about their reproductive rights will have improved interactions with their providers, which will lead to enhancement of the quality of care. Awareness also encompasses the role of men and other influential persons in reproductive health. The project seeks to enlarge male involvement by enabling fathers to attend deliveries to support their wives, by urging providers to encourage women to attend clinics along with their male partners (with convenient hours for men provided). "This is linked to the birth- and emergency preparedness, as there the need for couples to communicate and decide together..." Further, mothers-in-law (who have a strong culturally sanctioned power in terms of safe motherhood) and traditional birth attendants (TBAs) should be addressed to enhance a supportive environment for the mother and the newborn. Finally, organisers feel that surveillance and maternal-perinatal death audits, at the local level, should be recognised as a key source of information that allows families and communities to learn about the conditions which contribute to mortality and then to discuss what actions and or/advocacy efforts can be undertaken.
   
   Interventions: Services to the People is developing advocacy and information programmes and actions that address men, women, communities, and key decision makers. Surveillance/audits of maternal deaths will be carried out. Community groups will be established to engage in dialogue with service providers. Finally, training will be conducted; it will stress mutual feedback among providers and the development of a supervisory mechanism within services.
3. Strengthening linkages for social support between women, men, families, and communities and with the health care system
   
   Rationale: Financing schemes are linked to birth and emergency preparedness. (This component will be addressed in the last stage of the project, to promote incorporation of the project strategies into mainstream policy and the national health insurance system.) Similarly, advocacy will be undertaken to support transportation schemes that support birth and emergency preparedness, as well as enhancement of access to quality services, following a rights-based approach.
   
   Interventions: At the individual level, courses to foster birth preparation will be offered. At the district level, community/advocacy groups will be set up. At national level, organisers will communicate best practices and carry out advocacy for incorporation into mainstream structures.
4. Improving quality of care of providers and of health services and of their interactions with women, men, families and communities
   
   Rationale: First, organisers stress that communities must be involved in fostering high-quality care; regular meetings with community groups can be a step in a formal process of opening a dialogue and creating a feedback mechanism, with the aim of establishing quality as an organisational culture and as a continuous and ongoing process. Second, the project is premised on the significance of social support during childbirth (those attending the delivery pay attention to a woman's wishes, feelings of well-being, need for information, and choices; it also includes the presence of a birth companion selected by the woman, as well as a positive and respectful attitude of professional health workers). Third, organisers feel dynamic client-provider interaction is a key element of service quality, as studies show that improving providers' interpersonal competences can influence compliance with care recommendations, women's knowledge, and enhanced use of services. "Interactions should move away from the sessions where the providers gives information to the women, providers should review their own attitudes and develop skills for listening, work with respect for the clients, promote the participation the males etc. Good counselling and communication is thus a lifesaving skill....Training and supervisory support can serve to help providers discover their own prejudices in their interactions with patients."
   
   Interventions: Community groups will be established for dialogue with services. Obstetricians will be trained in Professional Attitude. To further promote social support during delivery, an advocacy and information programme will be developed. Interpersonal competences of providers will be strengthened through training for providers at prenatal/antenatal facilities and delivery homes, as well as for midwives and nurses/TBAs. Training focused on upgrading technical knowledge will also be provided.

To launch this process, which will take a different shape in each of the project countries based on specific priority needs and resources available, a series of training of trainers (ToT) sessions will take place in November 2006. Standards will be set for the future implementation of project activities and training. Six months later, refreshment training at specific (national) sites will be offered. Additional activities include a study tour to The Netherlands (June 2008), and an international exchange of best practices (September 2008).

Safe Motherhood, Infant Health, Reproductive & Sexual Health & Rights.

According to NSPOH, maternal and newborn mortality rates in the project areas are high - approximately 600 per 100,000 live births and 85 per 1000 live births, respectively, according to official statistics. In reality these figures are 10 times higher, according to the United Nations Children's Fund (UNICEF). In Central Asia most maternal deaths are due to 5 major medical causes: severe bleeding (haemorrhage); infection; unsafe abortion complications; hypertensive disorders of pregnancy; and obstructed labour. Explaining factors, again according to NSPOH, include early pregnancies, short intervals between births, extremely limited knowledge of the population on reproductive health issues, high percentage of unattended births (in some areas in Tajikistan 90% of all deliveries are at home, without the attendance of a well enough skilled midwife) and the absence of a well-functioning health system that provides accessible, high-quality care - from the household to the hospital level. A range of social, economic, and cultural factors also contribute to women's poor health before, during, and after pregnancy. This is particularly the case for women who are living in poverty, uneducated, or who live in rural areas (75% of the total population lives in rural areas; nearly 80% of rural women live more than 5 kilometres from the nearest hospital, and transport is not available). At least 60% of deliveries are with complications, with the Kazakh government conceding that 40% of all maternal deaths might have been prevented by improving access to quality healthcare.