Celebrating Mothers: Health in the Hands of Women

November 22, 2021


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.

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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.

 


Voices of Future Generations: Life in the Isle of Skye

May 29, 2018

By all counts, the Isle of Sky is an isolated and rugged place. In this episode of Voices, we hear about it from someone who grew up there.

“When people aren’t near services, you might tend to make more of an effort to do things together,” she suggests, while describing the community events and pastimes on the island.
 

The Treasured Natural Spring at Mount Moroto

May 29, 2018

Text and photos by Vincent Abura, MA student of class 2017

The Karamoja region of North-eastern Uganda has seen more than violent conflict for 40 years. As part of the Community Based Natural Resource Management Course in the Master of Arts degree program, Vincent looked at how stakeholders in a scarce and treasured water source are working together to protect the resource and share the benefits derived from it.  The spring and its watershed are located in the red shaded area in Uganda below.

The watershed provides protection for the spring water, which feeds an underground storage reservoir supplying fresh water to adjacent communities.  The spring and its watershed is habitat many forms of nature, including trees, grass, birds, and insects. The water and its watershed is used for various human activities including planting tree seedlings, watering animals, construction companies, beekeeping, green housing, and a water for urban and rural population of Moroto. The stakeholders are as below.
The spring has a Water Protection Committee, of which Margaret Lotee is the Chairperson. She manages a Committee of nine members, meeting monthly for the wellbeing of the spring. They monitor the fruit trees planted in the watershed by members. The Committee’s interests in the Spring include, water availability, accessibility, restricting access by big construction companies, sustainable fruit trees to improve on the environment and for human consumption. The Spring Protection Committee conducts monthly monitoring of the spring to ensure sustainability of the flow of water in the watershed. They recently restrained the government from constructing a dam downstream that would have interfered with sustained flow of water. 
Photo caption: Two women are standing right in the protected spring and talking about how they manage it.
At the district level, the District Water Officer, Mr. Musa Lowot, says the Water Department’s interest and responsibility is to ensure human and animal access to clean and safe water, protecting natural resources such as trees and vegetation etc. in the watershed, which ensures sustainability of natural resources and protection. In addition, the District Forest Officer, Mr. John Lotyang, says the Forest Office is mandated to protect and conserve forest natural resources through working in collaboration with Environment Office and police to protect natural resources in the watershed. The interest of the Department is to protect and preserve the natural resources downstream and ensure people with livelihood activities downstream such as beekeeping, vegetables growing, car washers, beer distillers and preserve wildlife, birds and domestic animals that depend on the water shade. The District Forest Department encourages protection of up and downstream for its biodiversity through public media awareness and working with police to apprehend perpetrators of natural resources degradation.

Mr. Joseph Nyimalema, the Area Manager for National Water and Sewage Corporation (NWSC), informed me that NWSC operates under the Ministry of Water and Environment and is mandated to supply water to urban and rural communities. NWSC pumps 15,000 liters of water per hour to supply to the urban-rural populations. NWSC is a strong benefiting stakeholder of the watershed, without which it cannot meet its obligations.  The interests of NWSC towards the watershed is legal ownership of land for its 2 water generators, security and safety of its equipment. NWSC recruited security guards to provide security for the assets and safety of water pumped for public consumption.

Arok Jimmy, the Chairperson of the 20-member Resilience Adaptation Committee (RAC), promotes greenhouse and sack gardening as well as soil and water conservation through terracing. They teach communities to grow vegetables and adapt to dry land cultivation. RAC’s interest in the spring is to access water for the greenhouses and sack gardens in homesteads, also in the availability of land in the watershed to control run-off water through terracing.

A local tree nursery is also interested in the spring. An attendant, Mr. Lokoru Bernard, informed me that they are planting different types of seedlings including: K-apples, Eucalyptus trees, papaws, mangoes, and indigenous species that are adaptable to drought in Karamoja. There are approximately one million seedlings planted this year. When converted to monetary terms (assuming a seedling is sold at UGXs 500) 1 million seedlings would amount to 500 million Uganda shillings, an equivalent of $143,000 US.  The interests of the planters is to raise income for their households, which can only be done sustained spring water, employing as many boys and girls as possible and to seek popularity to attract financial support from various programmes.

Photo caption: The tree-nursery garden where the attendant is weeding the unwanted plants from the nursery.   

Over 2000 livestock drink from this spring on a daily basis. This is the most accessible and available safe water for livestock in the district. Other options include boreholes, which are shared with human populations and are overcrowded. To get the attention of the cattle keepers, I had to walk with them and their herds. According to one, Kotol Patrick, their interest is availability of water for livestock. He strongly asserted that, ‘without this source, there is no life for human beings who depend on animals for survival. We shall do everything possible, including fighting to death to ensure water is sustained for their main livelihood.’

In summary, many stakeholders depend on this spring and its watershed for their livelihoods and wellbeing. Many are actively involved in protecting the water, and each plays a unique and important role in the current use and future availability of this invaluable water source. 

University Launches Multi-Country Peacebuilding Research Study

July 24, 2023
This study is being overseen by Dr. Meike Schleiff; text and map prepared by Meike in collaboration with Firew Kefyalew
 
Rationale for the Everyday Peace Indicators (EPI) study undertaken by the United States Institute of Peace (USIP) and built on by Future Generations University
 
One persistent challenge to peacebuilding is the extent to which communities affected by conflict can transform their circumstances. Many become passive recipients of prescriptive interventions by external actors, or top-imposed conceptualizations and interpretations. The bottom-up role has immediate benefit to day-to-day lives. But how to measure peace (or, more helpfully, change whether it comes nearer or becomes more distant)?
 
Typically, methods used to study peace yield complex, scholarly results that are not directly useful (or sometimes even intended for) community use. Through development of ‘indicators of peace,’ this project through local participation and local ownership, seeks to produce sensitive local understanding of interventions in peacebuilding and conflict transformation. The assertion here is that communities are best-placed to measure and interpret their own peace.
 
What are indicators of peace?
 
These are signals that communities develop through participatory action research on their perceptions of their own circumstances/conflict – what peace actually entails to them.
As Roger Mac Ginty and Pamina Firchow detailed in their recent article,[1]“[Developing indicators of peace] is participatory action research that seeks to find out people’s perceptions of their own conflict rather than impose narratives on them. The research asks local people, through focus groups, to develop their own set of indicators. …[T]he research questions are identified and designed by local people. …The research is designed and administered by local researchers and communities as a way of encouraging the identification of issues that are relevant to communities at the neighborhood or village level.”
 
Examples of indicators identified in USIP’s Everyday Peace Indicators project from multiple countries around the world include: 
  • Children are in school without disruption by rebels
  • Being able to hold social events without police disruption
  • How many dogs are barking at night
  • Roads and other key infrastructure get repaired
  • Women feel safe walking in the streets
  • Able to access primary health care center 
Why is Future Generations University interested in EPI?
 
Peacebuilding is an area that the graduate school has been engaged in for a number of years. There is in-house research and academic work that the graduate school wants to build on. Development of indicators for peace is consistent with the community change ideals that the graduate school has been teaching. Moreover, development of indicators of peace is in line with what is taught and practiced in SEED-SCALE. The graduate school is keen to pursue a research agenda in developing indicators of peace, an effort that will be augmented by the partnership it has with USIP.
 
Photo caption: This map shows the 12 country sites (listed below) that are included in the current study.

What does the Future Generations University adaptation of USIP’s work look like?

This a very exciting project that currently has twelve country sites—Afghanistan, Bangladesh, Ethiopia, Guyana, Namibia, Nepal, Nigeria, Somaliland, South Sudan, Uganda, Vietnam, and Zimbabwe—where study implementers are alumni and current MA students. In addition to USIP’s series of focus group discussions to determine community perspectives on peace indicators, we have added a series of key informant interviews with regional/country experts on peacebuilding in each country in order to triangulate community- and expert-identified indicators with top-down global and regional indices and priorities. The study is in full swing now, and we will complete the first phase of indicator identification, verification, and review of potential uses by the end of June 2017. From there, we are seeking additional funding and avenues to further this work—in the field of peacebuilding as well as across other sectors in our institutional research strategy.

[1]  “Everyday Peace Indicators: Capturing Local Voices Through Surveys” in Shared Space: A research journal on peace, conflict and community relations in Northern Ireland. No date.

Musings of a Naturalist II: Gondwana Gardens

July 24, 2023

Text and photos by Dr. Bob Fleming

On our first day in northeastern Australia, in the Centennial Lakes Park in Cairns, we found an arrow pointing to the Gondwanan Evolution Garden.

A Gondwana Garden? I’d never heard of such a thing.

Gondwana, the southern part of the ancient supercontinent of Pangea, is a name well-known name in geological circles, but a garden? This was a first.

Then, on our last day in Australia, this time on Bruny Island off Tasmania’s east coast, we again came upon the concept of a Gondwana garden. Here on the 600 hectare (1,500 acre) Inala Private Reserve we explored their Jurassic Garden dotted with plants whose ancestors once grew on Gondwana.

Photo caption: This Hoop Pine (Araucaria cunninghamii) grows on the Atherton Tableland in northeastern Australia and is a representative of the southern ‘pines,’ a group that likely originated in wet and cool western Gondwana. Today, Araucarias occur in an arc from southern Chile around to New Guinea, a ‘strange’ distribution pattern attributed to the fracturing of the original supercontinent.

As Australia is a continent isolated from others, it is quite understandable that many Australians are aware of the concept of plate tectonics and that continents move, ideas that were considered rubbish during my university days in the 1950s-1960s.

But how to explain the presence of kangaroos in Australia when they are not seen anywhere else in the world? The answer lies in the history of our planet.

Earth’s geological record shows that some 250 million years ago (mya) most of the world’s landmasses were melded into one supercontinent, now referred to as Pangea. Later, beginning around 185 mya, rifts appeared in Pangea and the huge landmass gradually split into two divisions, the southern section named Gondwana. In the ensuing millions of years Gondwana also fractured into parts and Australia is one of those remnants.

Today, much of the flora and fauna found south of the equator speaks of Gondwana. For example the Southern Beech, Nothofagus, survives today in an arc from southern Chile around to New Zealand, Tasmania and north into the mountains of New Guinea. Another example is the early cone-bearing Araucaria ‘pines,’ the distribution of which traces a similar arc from Chile around to New Guinea. Thus one now encounters the Monkey Puzzle tree in southern Chile (and as a garden ornamental commonly planted round the world), the Hoop Pine in Australia, and the Klinki Pine in New Guinea.

Both Nothofagus and Araucaria likely evolved in what was western Gondwana as an Araucaria fossil dating to 185 mya and Nothofagus fossil dating to about 135 mya have been found in beds from that region. Later, due to favorable conditions they continued to evolve and today survive on far-flung remnants of Gondwana.

Photo caption: This Protea roupelliaea is found in southeastern Africa and this individual was at ~1220m (4000’) in the Drakensbergs mountains of KwaZulu-Natal. Members of the Proteaceae, a plant family that includes over 1600 known species, predominately grow in southern Africa and Australia. A limited number of other species live in india and additional fragments of the original Gondwana supercontinent.

Another Gondwana connection is seen in the Proteaceae family, illustrated by the colorful Banksias in Australia and the related Proteas from southern Africa. The parrot family is yet an additional link as members proliferate primarily in two areas of the world – Australia and South America. And then there are spiders. The closest relatives of the primitive Tasmanian Cave Spider (Hickmania troglodytes) are seen in Chile.

Species that evolved early may be driven extinct by climate change or out-competed by later arrivals but on isolated continents and islands with favorable conditions, protection may allow them to proliferate. As an example, 13 of the 19 recognized Araucaria species grow only on remote New Caledonia Island.

Kangaroos are the pride of Australia, the symbol of the Qantas, the national airline, and pictured on the Australian Coat of Arms. These pouched mammals (marsupials) speak not so much of a Gondwana connection but of continental isolation. Indeed, the flora and fauna we find today on whatever continent is the result of a combination of factors including genetic and geological history as well as both ancient and modern climates.

On our last morning in Australia, while admiring the plantings in the Inala Jurassic Garden, all arranged in family clusters, and thinking about the biological threads that connect these southern lands, we were watched all the while (albeit from a distance) by a Bennet’s Wallaby and a Forty-spotted Pardalote, representatives of families found only in Australia. The natural history of this continent is very special indeed.

Photo caption: Southern Beech (Nothofagus) trees front the Pia Glacier, an ice river that drops down the western side of the Darwin Range on Tierra del Fuego Island in extreme southern Chile. The distribution of Nothofagus is from here east to Tasmania and New Zealand and then north to elevations above 2200m (7,000’) the mountains of New Guinea. Fossils indicate that Nothofagus orginated in western Gondwana and today’s disparate distribution is attributed to the breakup of that southern continent.