Improving Family Planning by Creating Community-Service Provider Partnerships in Guatemala

This 8-page report explores the 4-year Maya Salud (Mayan Health) project, which Save the Children launched in 2005 in 95 communities across the 3 municipalities of Guatemala's Ixil Triangle: Nebaj, Cotzal, and Chajul. As the opening sections of the report explain, the Ixil Triangle, deep in the highlands of western Guatemala, is an isolated area with some of the poorest education, economic, and health indicators in Guatemala. To that end, Maya Salud sought to bridge the gap between those who wanted information, counselling, and services in sexual and reproductive health (SRH) in their communities and those charged with providing these services but who often lacked the knowledge, skills, and resources to do so effectively.

The report details Maya Salud's use of the Partnership Defined Quality (PDQ) methodology, which engages community members in improving and monitoring the quality of their health services through partnerships with the health system. In the course of a 4-phase process, each of the 88 participating communities established its own Quality Improvement Team (QIT) composed of a subset of community members and health workers. Through dialogue and analysis, the QITs explored the root causes of inadequate quality of services and identified appropriate, feasible solutions for reaching the desired level of quality. The resulting Quality Improvement Plans delineated actions to fill gaps in knowledge, skills, or attitudes. One such action involved building demand by creating peer networks called Amigas/Amigos (friends) in participating communities. Amigas and Amigos learned the basics of FP, including modern methods, peer counselling, and referral (and sometimes accompaniment) to health facilities. In addition, steps were taken to ensure comfortable, confidential FP services, and to bring these services to particularly isolated areas through mobile health clinics.

Save the Children's final evaluation of Maya Salud (2009) measured a number of indicators and contrasted them to the project's baseline (2006), revealing that PDQ had improved access to and use of FP, and that users appreciated service quality. For example, the percentage of couples who discussed FP over a 3-year period rose from 44% to 46% in Nebaj, from 39% to 56% in Cotzal, and from 36% to 50% in Chajul. In 2009, 56% of women indicated that they had discussed birth spacing and desired family size with their partner in the previous year, whereas only 37% of women reporting having done so at baseline. Knowledge shifts were reported; for instance, 72% of women of reproductive age surveyed could name 3 or more FP methods in 2009, up from 52% in 2006. 21% of women of reproductive age received a home visit by a health care provider who spoke with them about FP in 2009, up from 5% in 2006. And 51% of such women received FP information during their last visit to their local health post in 2009, up from 13% in 2006. Practices also shifted: the number of new FP users rose from 2,087 (in 2006) to 5,638 (in 2008) - a 270% change; the percentage of married/united women using a modern FP method was 28.3% at baseline (2006), and 33.5% at endline (2009).

Lessons learned include:

• Invest first in trust: Save the Children found it vital to invest time in building trust between community members and outsiders, such as Ministry of Health (MoH) service providers. Furthermore, "The Amigas/Amigos networks proved an ideal bridge between the project and the people. The volunteers effectively functioned as extensions of the project staff by promoting information and social acceptance of modern FP in their communities. But they also lent social credibility to the project and its goal of increasing the use of SRH services in ways that project staff alone may not have been able to achieve."
• Tailor your communications and schedules: "It is imperative to consider local literacy and culture when selecting ways to train and present information. In Ixil, Save the Children found that problem trees which map out causes and effects of barriers to improved health service delivery, were excellent tools for helping QITs conceptualize the concept of quality....Standardized training materials for groups with shared cultures and experiences also helped the PDQ process: facilitators used such materials to track their progress through themes and topics, and to structure meeting and workshop content. It is likewise imperative to consider local livelihoods. Save the Children scheduled meetings and other events around work hours and important seasonal activities such as sowing or harvesting crops."
• Engage QITs in monitoring and evaluation (M&E): "Because the underlying goal of PDQ is to empower service users and providers to take collective action for their joint benefit, Save the Children realizes that users must also learn to develop and apply monitoring and evaluation tools, and to analyze and act upon the results. Future PDQ work in Guatemala will take this into account."
• Promote learning and engagement among national stakeholders: "Save the Children cannot overemphasize the importance of keeping MoH officials at all levels informed of activities and results....In Guatemala, this meant periodic meetings with MoH and stakeholder groups; documentation and dissemination of learnings and results; and advocacy for the replication of successful models in other parts of the country."

In short, the report finds that "Save the Children's application of PDQ was very effective in the Ixil Triangle. It fostered an increase in demand for and supply of SRH services by bringing the services closer to clients and engaging community members in the promotion of modern contraception use. Perhaps most importantly, PDQ brought service users and service providers together for the first time to negotiate perceptions of quality in health service delivery, and...provided them [with] the structure and support they needed to improve. Using PDQ, Maya Salud set the stage in 88 communities for dialogue about improved SRH service delivery, and for grass roots mobilization, social change, and collective empowerment."