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CARE Project Enlists
Community Support
PACARA SULLICANI, Peru -- Seasonal rains make their mark quickly on the highlands in
southeastern Peru. Streams that are usually of little concern to travelers are swollen and
intimidating: their muddy beds and banks suck ferociously at the tires of vehicles fording
them. Even with a four-wheel-drive truck, reaching the remote, farming community of Pacara
Sullicani from Juli -- the nearest town with basic health services -- takes at least two
hours.
When weather conditions are ideal, transportation to or from Pacara Sullicani still is
not easy. Nor do most members of this small community of about 200 people wish to travel.
Few people in the nearest town will speak their language, Aymara. Meanwhile, time and
attention must be devoted to the care of the cattle and sheep grazing in the vast plains
of Pacara Sullicani, and the quinoa, beans and purple-flowering potatoes cultivated here.
Crops are not as abundant as they once were. The land tends to be overworked, and there
is less land for each person due to repeated divisions among family members over many
generations. No longer can it feed many people. Nor are large families now needed to
maintain it.
Peru |
4,000 CBD workers |
- Population: 25 million
- Terrain: coastal, tropical forests and rugged mountains
- Area: 1.28 million sq km
|
"The economy of this area makes it very hard for us to raise large families,"
says Felix Montufa, a farmer and volunteer family planning promoter who lives in the
community.
Standing before the dried brown mud and thatch room that he built to provide family
planning consultations, Montufa explains how he was enlisted to do family planning work,
which occupies about two days each week. "I have been providing other community
services since 1987 and I was chosen by the community leaders to be a reproductive health
promoter," he says. "I do this now because I know that if couples have six or
eight or 10 children, it is not good for my community. I like to know that I'm doing
something good for my people."
Montufa is one of 700 community promoters of contraception working in communities near
Puno through a project of CARE-Peru and the Peruvian Ministry of Health (MINSA). This
eight-year-old project, called the Multisectoral Project of Population and Reproductive
Health (PMP), serves approximately 300,000 families throughout the country. Community
promoters can distribute condoms, vaginal tablets and oral contraceptives. For
longer-acting or permanent methods, they make referrals to a MINSA health post, center or
hospital.
The project in the department of Puno is only three years old, but makes family
planning available to some 9,000 people in the area. In other locations in Peru where PMP
projects began earlier and are more developed, maternal health, adolescent issues and
sexually transmitted disease prevention are offered in addition to family planning.
In the past, the project was exclusively financed by major donor agencies -- the U.S.
Agency for International Development and the United Kingdom's Department for International
Development. But donors and MINSA now share the costs, and MINSA will assume all
logistical and financial responsibility by the year 2001.
"The goal has been to get communities involved," says Dr. Irma Ramos of
CARE-Peru, PMP project coordinator, "and for CARE-Peru to provide technical support
to MINSA to increase access to, and improve, reproductive health services for underserved
people living in extreme poverty. Before we began the program, MINSA had reached out as
far as its health posts with reproductive health services. It could go no further. We
facilitated an expansion of those services into rural communities. And, in turn, MINSA was
very helpful in involving the communities and will hopefully be able to provide the
ongoing stability to make the program sustainable."
In the first years of the program, CARE-Peru initiated contact with community leaders,
and, with MINSA, helped the leaders recruit their own promoters. CARE-Peru also worked to
improve a poor contraceptive supply system; trained and supervised community promoters;
and designed reporting forms to allow for proper accounting of services and supplies.
Reports from promoters provide the health ministry with otherwise unavailable information
about contraceptive use and reproductive health among members of remote communities.
CARE-Peru staff members also have provided clinical reproductive health, communication,
sexuality and gender training for MINSA medical professionals at health centers, and
taught them to form, train, supervise and supply networks of promoters.
With CARE-Peru's logistical support, MINSA personnel also continually evaluate the
performance, knowledge and practices of promoters through meetings and supervisory visits
in the community, refresher courses, and follow-up visits to users. Promoters receive
immediate feedback and are classified according to the level of their performance; those
receiving poor evaluations often are dismissed.
Consulting room
Montufa is a fairly new promoter, with less than a year's experience, but he takes his
volunteer work seriously. Inviting visitors into his tidy consulting room -- painted sky
blue and filled with posters, flip charts, brochures and other materials about family
planning -- Montufa indicates meticulously detailed notes, written in a firm, steady hand,
within a notebook and on individual cards. The notes summarize the use of various
contraceptive methods by his clients: 22 users among 60 couples in the community. They
also include referrals Montufa has made for longer-acting or permanent methods, such as
injectables or intrauterine devices. "At first, I mostly distributed condoms and made
referrals for injectables," he concludes, reviewing his records. "But now
vaginal tablets are more popular."
In his records, Montufa has also noted the dates, subjects and attendance for various
talks that he has delivered in the Aymara language to community members.
"During these community chats," says Dr. Ramos, "promoters generally use
pictures rather than text because their clients may be illiterate. They also talk in one
of the local dialects on a level that people can understand. They are trained not only to
discuss family planning methods, but also self-esteem, responsible parenting, hygiene, how
sexual relations and love are related, the importance of prenatal checks, gender issues,
men's reproductive health needs, and other related matters. Offering information,
education and counseling that takes into account the whole individual is fundamental to
removing misconceptions that clients may have held all of their lives.
"Sometimes, people attending these talks are embarrassed by the pictures or
information. But, in our experience, curiosity and interest soon conquer this timidity.
Although many people do not want others in the community to know how they feel about
family planning, their desire not to have many children is often very strong."
"Such promoters greatly help bridge both a geographic and a cultural gap between
clients, who are generally Quechua or Aymara Indians, and medical professionals,"
says Dr. Luis Tam, CARE-Peru health sector director. "Their involvement helps prevent
misunderstandings and allows clients to obtain information that is truly meaningful to
them."
Two contracepting women from Pacara Sullicani attest to this. Both say they want no
more children. Sosana Huayta, one of eight children and the mother of three, says that she
is glad that Montufa has given her the means to control her fertility. Maria Valezques,
one of six children and the mother of two, says Montufa "has been good for us and our
community."
 Such expressions of gratitude from community members are powerful incentives
for voluntary promoters. In the highlands of Peru, strong traditions and communal bonds
prevail. In recognition of their work, communities often bestow special status upon
promoters and exempt them from communal labor. After training, promoters receive
certificates, identity cards, free uniforms and other materials. CARE-Peru and MINSA are
testing other incentives to encourage quality work by community promoters, including free
health services for the promoters and their immediate family members, as well as
reductions in the cost of medicine.
However, many promoters express indifference to the idea of being paid for their work.
Leonardo Chino Aroquipa of the community of Posoconi, sitting on the roan horse that he
usually rides to make home family planning visits, explains that he has long attended
births in the middle of the night "because I like serving my community. I am 38 and
have four children, more than I would have liked, but I did not know about family planning
before. I want others to know, and I will keep doing this work even though I do not get
paid just because I like it. I now have 18 contraceptive users, all men."
Rosa Quispe Hihuaña, a mother of three and promoter since 1997, proudly says that she
has 31 contraceptive users among 73 couples in her sector of the community of Collina
Pampa. Is her work difficult? "Yes, because sometimes the people do not want to use
contraception and tell me that their personal lives are not my affair. Other people
sometimes ask difficult questions. Also, men did not accept me at one time, but many have
changed their minds. Because I do not receive any pay, people are not so suspicious of my
intentions."
Do older people in the community -- long accustomed to large families -- object to the
idea of family planning? "No, because most have suffered very much to raise so many
children," says Hihuaña. "And, not infrequently, women see my family planning
sign and come to visit with their adolescent daughters."
Although both CARE-Peru and MINSA officials consider this CBD model to be successful,
its success was not achieved easily. Nor is its sustainability assured.
"Because this model required that CARE-Peru train MINSA professionals to provide
reproductive health services independently and train, supervise and supply CBD workers, it
was perhaps slower and more difficult than some other CBD models," says Dr. Ramos,
project coordinator.
Beat Rohr, national director of CARE-Peru, emphasizes the importance of government
leadership. The community program "has largely prospered because the present
government favors health care reform in general, wishes to improve reproductive health,
and offers free contraception to every citizen."
Ultimately, the success and sustainability of such a program depends upon the people
living in the remote communities, says Dr. Ciro Castillo Rojo Salas, director of the MINSA
health unit in San Román. "Family planning is not an unknown concept for them,"
he says. "Many people in the highlands have a long history of trying to control their
fertility, and they may very much welcome better ways to help them do so."
-- Kim Best
City Life Isolates Many
Clients
JULIACA, Peru -- A volunteer family planning promoter carefully negotiates her way
across a puddle covering much of the road on the outskirts of this commercial city.
Because she also lives in this neighborhood, the immense puddles and densely populated
streets are familiar terrain.
Firmly and confidently, she steps on rocks strategically placed from one side of the
puddle to the other. Then, reaching a narrow strip of solid ground, she stops and waits
for an obstetric nurse and nurse's aide whom she is accompanying on family planning home
visits. They stop at the door of a mother of two who had been given oral contraceptives at
a PLANFAMI clinic, but did not return for a scheduled visit.
It is not difficult to understand why. The rainy season has made streets nearly
impassable. Also, the mother tells the visiting team, "I decided not to come to the
clinic because I was not having problems with the pill."
Nevertheless, the team counsels her about her health, makes sure she knows what to do
if she misses a pill, and gives her a new supply of pills for another three months.
Finally, they encourage her to discuss reproductive health concerns with her maturing
daughters (11 and 14 years old). She agrees, although somewhat reluctantly.
"Women tend to be timid and fear criticism from the community, so it is very
important to protect their privacy," says the community promoter, who was selected by
people in her neighborhood to serve in the position. "They fear the promoter will
gossip, so you have to win their trust."
One of her clients, a 33-year-old mother of two, admits "I did not like it when
she approached me at first. But we were neighbors, and she talked to me in my language,
Quechua. I was using the rhythm method for two years after the birth of my last child, but
then she told me about the vaginal tablets and I decided to try them. I like them. Now I'm
thinking about using the condoms she provides in addition to the tablets for extra
security."
 The need for home services during the rainy season is particularly acute.
"People really struggle to get to clinics at this time of year," says Juan de la
Riva, executive director of PLANFAMI. "Women are accustomed to staying home, and are
scared to travel, even across town to a clinic."
The visiting team is one of several PLANFAMI efforts to reach people, he says. Funded
by the U.S. Agency for International Development and receiving technical assistance from
Pathfinder International, PLANFAMI operates four clinics within 90 kilometers of its base
clinic in Puno. Typically, an obstetric nurse and nurse aide from each clinic make home
visits, riding into the countryside on a motorcycle or in a well-equipped van that offers
injectables and intrauterine devices, in addition to other methods. PLANFAMI also holds
reproductive health discussions and makes video presentations in the countryside,
traveling by van with electric generators to supply power.
Volunteer community promoters are given uniforms, backpacks, health materials and
contraceptives, an identification card, and transportation to training sessions.
Otherwise, they receive no compensation.
PLANFAMI has other innovative efforts. The organization works with a local police
station that often feeds impoverished street children to encourage the children's mothers
to attend monthly PLANFAMI reproductive health discussions and video presentations, and to
receive medical examinations and contraceptives.
PLANFAMI also offers reproductive health services to male and female inmates at a
prison, where conjugal visits are allowed. And another effort works with tricycle taxi
drivers in Juliaca.
"Not only do taxi drivers know where prostitution takes place in the town, but
they themselves are very much at risk for sexually transmitted diseases," notes Mary
Vandenbroucke of Pathfinder International, who assists PLANFAMI. "Working directly
with these men can be very important."
-- Kim Best
Bangladesh Refines a
Successful Program
The Bangladesh family planning program, which operates one of the world's largest,
oldest and most successful community-based delivery systems, is beginning to shift its
emphasis toward community clinics. The change is designed to improve efficiency and to
address changing cultural needs.
Rather than focusing on door-to-door visits to all couples eligible for contraception,
a system used for more than 20 years, the program is encouraging many couples to obtain
contraceptives from centralized locations, such as village clinics. In addition, the
government has begun to integrate family planning at clinics into a broader package of
health services that includes antenatal and postnatal care, child immunization and
communicable disease prevention.
"A lot has changed with women in Bangladesh over the last 20 years," says
Nancy Piet-Pelon, who followed the Bangladesh shifts closely in her former position as
Asia regional director for AVSC International. "A major reason this program began was
that women were not allowed to leave their homes alone, and that has changed. Their status
has changed. Now, women want to use family planning and can leave their home to get
supplies."
Small community clinics are beginning to offer both family planning and other health
services. Health assistants and family welfare assistants with more training than
door-to-door village workers will provide most of these needs, explains Dr. Mohammad
Alauddin, country representative for Pathfinder International, a U.S.-based service
delivery organization that works in rural areas of Bangladesh.
Sustainability
Door-to-door distribution throughout Bangladesh, using workers called family welfare
assistants, has been among the factors in rising contraceptive use. Demographic surveys
show about half of all married women of reproductive age are using contraception, up from
7 percent in 1975 when community-based distribution began.
In recent years, however, a series of studies raised concerns about the current system.
With the maturity of the program, the demand for services has increased as more and more
women enter their reproductive years. Meeting the growing demand requires efficient use of
clinical facilities and of home service delivery workers. A 1996 study by the Bangladesh
Ministry of Planning, with assistance from FHI and Associates for Community and Population
Research, found that family welfare assistants typically spent only a few minutes with
each client.1 "Visits that take only about four minutes may not be
adequate. For example, the client may not learn very much about how to handle side
effects," says Dr. Barbara Janowitz, an FHI economist who coauthored the study.
Bangladesh |
30,500 CBD workers |
- Population: 125 million
- Terrain: alluvial plain and hills
- Area: 144,000 sq km
|
Under a long-standing system, family welfare assistants were supposed to visit all
couples eligible for contraception every two months, regardless of whether the couple was
interested in family planning or was already obtaining services elsewhere. Targeting
clients who are more likely to need services is one strategy that can improve
effectiveness.2 An analysis by John Snow, Inc., a U.S.-based organization that
specializes in contraceptive logistics management, questioned an emphasis on methods that
require routine visits and supplies, such as oral contraceptives.3
Lower fees charged at clinics than for services provided in home visits can be used to
encourage clients to visit clinics. Also, long-term methods (intrauterine devices and
sterilization) can be offered free, as a way to promote the use of those methods.4
However, studies also suggest caution about strategies that could weaken or eliminate
door-to-door distribution. Without the household program, contraceptive prevalence in 1993
would have been about 25 percent in Bangladesh, instead of 40 percent, according to a
Population Council study.5 Home visits also reduce travel costs for clients,
and waiting time. "In the case of contraceptive continuation, timely workers' visits
may enable women to manage side effects" by offering counseling or an alternative
method, concludes Dr. Mary Arends-Kuenning of the Population Council.6
-- William R. Finger
References
- Janowitz B, Jamil K, Chowdhury J, et al. Productivity and Costs for
Family Planning Service Delivery in Bangladesh: The Government Program. (Research
Triangle Park, NC: Family Health International, 1996)35.
- Janowitz B, Holtman M, Hubacher D, et al. Can the Bangladeshi family
planning program meet rising needs without raising costs? Int Fam Plann Perspect
1997;23(3):116-21.
- Fiedler JL, Day LM. A cost analysis of family planning in Bangladesh. Int
J Health Plann Mgmt 1997;12:251-77.
- Kane TT, Khuda, B, Levin A, et al. Achieving sustainability of health and
family planning services. In Khuda B, Kane TT, Phillips JF. Improving the Bangladesh
Health and Family Planning Programme: Lessons Learned through Operations Research.
Dhaka, Bangladesh: International Centre for Diarrhoeal Disease Research, Bangladesh, 1997.
- Phillips JF, Hossain MB, Arends-Kuenning M. The long-term demographic
role of community-based family planning in rural Bangladesh. Stud Fam Plann
1996;27(4):212.
- Arends-Kuenning M. How Do Family Planning Workers' Visits Affect
Women's Contraceptive Behavior in Bangladesh? Working Papers No. 99. (New York:
Population Council, 1997)52.
Zimbabwe's "Clinics
under Trees" Increase Access
HARARE, Zimbabwe -- Sibonindaba Moyo rides her bicycle along the red dirt roads,
traveling from village to village in the Goromonzi farming area near Harare. In her
waterproof satchel she carries oral contraceptives and condoms, which she will sell to the
women and men she meets along the way.
Moyo is one of more than 700 community-based distributors of contraceptives employed by
the Zimbabwe National Family Planning Council (ZNFPC). While making her rounds, she will
discuss the benefits of family planning with people who have never used contraception. She
will bring new supplies of pills and condoms to women and men who have already begun
family planning, and will refer clients seeking other methods to health clinics. This is
her routine as she conducts "clinics under the trees."
In Zimbabwe, community-based distribution (CBD) workers are an integral part of their
community, which officials believe has encouraged the use of family planning. "People
feel comfortable with one of their own," says Thandy Nhliziyo, ZNFPC assistant
director of service delivery.
The family planning program in Zimbabwe, considered one of the most successful in
Africa, began nearly a half century ago. Initially, services were clinic-based, but by the
mid-1970s, the first CBD workers, known as "pill agents," began working to
increase access to contraception.
Zimbabwe's fertility rate has fallen from 6.6 births per woman in the late 1970s to 4.3
in 1994, and its contraceptive prevalence rate is one of the highest in Africa -- 48
percent of married women of reproductive age are using a modern method. High levels of
contraceptive use are due in large measure to the CBD program, which serves nearly a
fourth of the country's family planning clients. However, in spite of its successes in
reaching clients, fertility levels are considerably higher in rural areas than in cities
(4.9 versus 3.1 births, respectively). The pill is the most widely used method (33 percent
of all married women).1
Most CBD workers are women. They are selected by community leaders who nominate three
candidates. After initial training in Harare, the finalist continues training under a
supervisor in the community, and eventually must pass a written exam. ZNFPC encourages CBD
workers to participate in local activities, such as club meetings or even simply doing
laundry at the river with other women. Their presence shows they are interested in the
community's welfare and is also a reminder that family planning is readily available,
since workers often attend with their satchel of pills, condoms and family planning
information.
"We tell them your working hours are from 8 a.m. to 4:30 p.m., but if someone
comes at 8 in the evening and needs condoms, or they are going out of town and need more
pills, you cannot say 'I closed at 4:30,'" says Hope Monica Sibindi, a ZNFPC
provincial manager.
Zimbabwe |
800 CBD workers |
- Population: 125 million
- Terrain: alluvial plain and hills
- Area: 144,000 sq km
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Very often, a CBD worker is the first, if not the only link, to any type of health care
for families in her community. In addition to family planning information, CBD workers can
dispense analgesics for headaches. They can provide information on HIV/AIDS -- what it is
and how it is transmitted. They discuss breastfeeding with new mothers, explain the
importance of hand washing as a means of disease prevention, talk about the immunization
schedule for infants, and discuss purification of water.
Zimbabwe's CBD program is highly organized and structured. Supervisors, typically
experienced CBD workers with additional training, are responsible for monitoring the work
of 10 to 12 workers. In turn, nurses manage supervisors.
For three weeks each month, a worker typically travels throughout her territory. The
fourth week of the month is devoted to administrative tasks, including ordering
contraceptive supplies, training and record-keeping. During group training, workers
practice counseling skills by role-playing.
A pilot program funded by the Rockefeller Foundation seeks to expand services to
younger adults. Traditional midwives and teachers serve as CBD workers or "family
friends" and visit young people in their homes to discuss contraception and
reproductive health. Parents were skeptical at first, but "but now they are calling
CBD workers for assistance," says Sithokozile Simba, ZNFPC service delivery manager.
Sibindi says a popular view is that discussing contraception encourages adolescent
sexual activity, although many studies indicate that sexual education delays the
initiation of sexual activity. "We need to consider ways to meet the needs of young
people without offending the community," she says. "Even talking with youth
about sex is discouraged. We need to strengthen CBD workers' skills in how to deal with
this."
-- Barbara Barnett
References
- Zimbabwe Central Statistical Office, Macro International Inc. Zimbabwe
Demographic and Health Survey 1994. Calverton, MD: Zimbabwe Central Statistical Office
and Macro International Inc., 1995; Miller K, Miller R, Askew I, et al., eds.
Clinic-based Family Planning and Reproductive Health Services in Africa: Findings from
Situation Analysis Studies. New York: The Population Council and U.S. Agency for
International Development, 1998.
For more information, visit Family Health International's Website at www.fhi.org
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