28th March 2014
Following many months of planning, we have got to the point where the theory and the practicalities need to be reconciled into a practical way ahead for the EMBRACE project. This can only be done on the ground, by those with local knowledge, who intend to be part of the process.
To this end, Drs Sion and Abdallah recently met, and have sketched out exactly how the project is to begin. The longest journey starts with the first step, and many never make it that far. As you see below, however, the boots are on, the door is open, and the map is in hand. Here is Sion's recent email:
"Myself and Dr Abdallah sat
down for an hour this morning to dicuss how he forsees the
practicalities of how EMBRACE may work. We are in agreement with what
most have said so far, with a few specifics on how we go about the
process of outreach. We are also aware that improvement of the hospital
comes first.
We must be cautious also not to get carried away- the immediate concerns of the hospital are a dire finanancial state due to government and NGO cuts, and the collapse of the bridge. It is important for the future survival of the hospital that we increase its utilisation, but do be aware that as much as we want to improve things, with falling revenue and patient numbers we are struggling to maintain the status quo.
Based on local knowlege and wisdom the conclusions were this:
We must first identify areas with problems- so far this includes Berega, Tunguli and Mnafu. This requires the mapping.
Next we meet with four key groups of people- this will be TBAs, village health workers, hamlet leaders and village leaders. The purpose of this will be mainly to identify women of child-bearing age (WCBAs) and also to get these 4 groups of people on board. From Abdallah’s survey he found that often women want to deliver in a health facility, but that the decision makers and main influencers in the village were not the women themselves but the hamlet leaders, the TBAs, and community elders.
We must be cautious also not to get carried away- the immediate concerns of the hospital are a dire finanancial state due to government and NGO cuts, and the collapse of the bridge. It is important for the future survival of the hospital that we increase its utilisation, but do be aware that as much as we want to improve things, with falling revenue and patient numbers we are struggling to maintain the status quo.
Based on local knowlege and wisdom the conclusions were this:
We must first identify areas with problems- so far this includes Berega, Tunguli and Mnafu. This requires the mapping.
Next we meet with four key groups of people- this will be TBAs, village health workers, hamlet leaders and village leaders. The purpose of this will be mainly to identify women of child-bearing age (WCBAs) and also to get these 4 groups of people on board. From Abdallah’s survey he found that often women want to deliver in a health facility, but that the decision makers and main influencers in the village were not the women themselves but the hamlet leaders, the TBAs, and community elders.
We will ask these community leaders to identify appropriate women, even to go as far as asking them to form and become key people in the running of the groups, at hamlet level. The purpose of these groups is to first identify problems, which will then inform the next stage of the project- getting people to deliver in a GOOD SAFE hospital. The point of getting the TBAs/leaders/elders involved at the outset is that without their support it will be very difficult to implement solutions to problems raised by the discussion groups.
Again, a key point raised was
how do we evaluate the efficacy of this? We agreed that the first thing
to do was to establish what is going on now. This can be done in 2 ways:
1.
Going through hospital records to record
locations of where people have been coming from to deliver. Furthermore,
once we have good village level population figures we can then highlight
maternal blackspots in our territory. This is being done as I write.
2.
Another way will be doing surveys (as a parallel
to the mothers groups) in the areas of interest- for example trying to
get an actual snapshot of institutional delivery rate (ie. How many
women are actually delivering in a hospital) and also by estimating
maternal mortality in our territory as it currently stands (see the
sisterhood method for evaluating maternal mortality http://www.who.int/
Thereafter, we must evaluate
whether our interventions have been effective- both for our own
improvement, and to increase thelikelihood of getting grants in the
future. This could be done as a
‘Project Evaluation’ or even more academically as a study- perhaps with cluster randomisation to compare like villages, or before and after ‘survey’ methods in the village of interest (surveys will
probably be easier and more practical- EMBRACE is a pragmatic rather than a purely academic undertaking).
‘Project Evaluation’ or even more academically as a study- perhaps with cluster randomisation to compare like villages, or before and after ‘survey’ methods in the village of interest (surveys will
probably be easier and more practical- EMBRACE is a pragmatic rather than a purely academic undertaking).
It is a long road, but we have begun.
Best wishes
Sion
PS
See this study where they
have done almost exactly what we want to do in southern Tanzania:
http://www.ncbi.nlm.nih.gov/
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