Action, Persistence, Sustainability: One T4D Community's Effort to Improve MNH (BLOG)


November 30, 2016

This blog post is the fifth in the series “T4D: Views from the Field,” written to highlight what members of the T4D team have observed in launching the co-designed intervention in Tanzania and Indonesia. In an earlier post in the series, Lindsey Roots took us inside a Community Scorecard Meeting in one Tanzanian village. In this post, Jessica Creighton depicts a follow-up Meeting, this time in a village in Indonesia.

By Jessica Creighton

Courtney and I turn down a dirt road.  We pass by rice paddies and jackfruit trees and houses raised up on stilts—typical architecture in South Sulawesi province.  The road grows increasingly bumpy and we experience difficulty finding our destination; two areas of the village do not connect by a road that is passable by a large car, and we’ve entered on the side opposite of where we’re heading.

Eventually we arrive at the home of the community activist coordinator.  Community activists (CAs) are community members recruited to participate in the Transparency for Development (T4D) intervention – an intervention that seeks to improve health outcomes by supporting citizens to act and advocate for change.  CAs discuss barriers to maternal and neonatal health (MNH) in their village and commit to taking action against these barriers.

The T4D intervention involves several meetings with CAs (for a description of earlier T4D meetings, see this post from Tanzania); in this village, we are observing the third, and final, follow-up meeting associated with the T4D program.  In this meeting, the CAs discuss three topics: accomplishments, obstacles, and how to make their work sustainable.

Typical architecture in South Sulawesi, Indonesia. Photo credit: T4D/Jessica Creighton

Typical architecture in South Sulawesi, Indonesia. Photo credit: T4D/Jessica Creighton



When we arrive, the meeting has started and the CAs are deep in discussion about the progress they’ve made on their latest social actions:

  • a door-to-door campaign aimed at educating pregnant women on the importance of MNH;
  • talking to the village midwife to ensure she (or another staff member) is always available at the pustu, a small public health facility in the village; and
  • identifying the blood type of all pregnant women in the village.

One of the CAs is at the wall, leading the discussion and filling in the steps the group has taken towards the education campaign.  The T4D facilitator (hired by project partner PATTIRO), stands watchful in the corner.  Five other CAs, all women, sit on the floor, as does one of their children.  Another CA is helping fill in the matrix.  There is a palpable energy in the room.

For the education action, the group first convened an internal preparation meeting where they worked out the logistics.  Then they prepared questions—since they would meet women one-on-one they wanted the message to be conversational—and they determined an interview-style conversation would be the best approach.  Finally, the CAs carried out the education campaign, traveling to four of the five village’s dusun (subvillages) by motorbike.  The action is marked as complete.

At this point an 8th CA arrives and joins the conversation.  The group walks through the second action, also marking it as complete.

T4D CAs discuss the progress of their effort to identify the blood type of pregnant women in the village. Photo credit: T4D/Jessica Creighton

T4D CAs discuss the progress of their effort to identify the blood type of pregnant women in the village. Photo credit: T4D/Jessica Creighton


Navigating obstacles

It is with the third action—identifying the blood type of all pregnant women in the village—that the CAs report challenges.

As a first step, the CAs approached the head of the puskesmas, a government health facility located a few kilometers outside of the village, to inquire whether her staff had the skills and availability to identify blood type.  The puskesmas head confirmed capacity, but noted that neither the puskesmas nor the pustu had the necessary supplies.

The CAs reconvened to brainstorm how to procure the supplies and decided to purchase them directly if affordable.  Between that time and the now, additional research has revealed the cost: approximately 12 USD.  This is more money than the CAs are able to contribute from their own personal funds.

The group spends the next several minutes discussing what to do.  One suggestion is to ask the village head for money, but none of the women feel comfortable doing so.  Another idea is to fundraise; this proposal is also dismissed.  Finally, the idea to ask the village head for advice rather than for money—acknowledged as strategic move—is introduced.  The CAs decide take this approach and amend the plan.

The group breaks for lunch and the facilitator steps in to introduce the next portion of the meeting.  She begins by recognizing that all of the actions the group set out to tackle at the start of the program are complete, including planting a medicinal herb garden at the village health facility.  They’ve also completed actions they’ve added along the way.  And of course the blood type identification action is ongoing.  She asks if they’d like to add anything new.

One of the CAs volunteers that the puskesmas is a few kilometers away, in the opposite direction of the hospital.  It is necessary to get a referral from this puskesmas to visit the hospital in the case of a complex medical issue.  Would it be possible to get a referral instead from the pustu, which is located within the village?  The group decides to formulate this into an action.

Community members plan a medicinal herb garden at the local pustu (health facility). Photo credit: T4D/Jessica Creighton

Community members plan a medicinal herb garden at the local pustu (health facility). Photo credit: T4D/Pattiro


Sustainability – what happens next?

Once the referral action is discussed and a plan is codified, the group moves onto the final agenda item—a discussion of sustainability.

Since this is the last formal meeting as part of the T4D program, the facilitator asks the group if they will continue to meet, and if so, how they will coordinate with each other.  The CAs confirm they hope to meet monthly, coordinating by phone.  They express an interest in expanding beyond health to also undertake issues of education and religion.  Finally, they aspire to make the group more visible to the rest of the community.

On the drive back to our hotel, Courtney and I reflect on what we observed.  We’re inspired by the enthusiasm of the group and impressed by the breadth of actions they’ve managed to take on over a period of three months.  They’ve reported many accomplishments, navigated obstacles, and put a sustainability plan in place.  But will these actions ultimately lead to improvements in health?

There is a clear logical link between education on the benefits of key services and the uptake of those services.  And enhancing the referral system between community-based facilities and hospitals is a quality improvement frequently recommended by technical experts as a way to advance health outcomes, such as reducing maternal mortality.

To gain insight on such pathways, the T4D team is tracing actions like these—and their links to service uptake, quality, and health outcomes—in intervention villages in Indonesia and Tanzania.  These villages are also part of a randomized controlled trial (RCT) impact evaluation that will allow us to determine whether, on average, the T4D program leads to improvements in maternal and neonatal health.  Ultimately, this means we’ll be able to say whether promising stories like what we witnessed translate to real change.

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