When Communities Take Up Leading Role In Improving Maternal and Child Health

When the world locked down in 2020 at the back of a COVID-19 pandemic, all health services left for COVID-19-related interventions were heavily disrupted.  Maternal and Child Health were among some of the most affected services as health facilities offering services continued to face significant challenges compromising the quality of care

By Michael Gwarisa

Even though data points to an increase in institutional deliveries since the year 2016 in Zimbabwe, a decline was noted during the COVID-19 era. This was largely attributed to the disruption in maternal health services and fear of contracting the diseases by both healthcare workers and pregnant mothers among other factors.

However, to hedge Maternal and Child Health against the impact of future health emergency shocks, Cordaid Zimbabwe, working with the Ministry of Health and Child Care (MoHCC), through financial support from the World Bank (WB) is now piloting a new project, the Community Results Based Financing (CRBF) in 4 rural districts of Zimbabwe since February 2023.

The program empowers Village Health Workers (VHWs) to offer certain health services at the community level. The VHW program started in the early 1980s when the country adopted the Primary Health strategy. In Zimbabwe, it was recognized that the greater part of the population resides in the rural areas and most communities face challenges of access to services because of long distances to facilities and non-existence and costs of transport.

    Village Health Workers at Rowa Clinic in Mutare

The Community RBF project is being piloted in Manicaland- Mutare district, Mashonaland Central- Centenary district, Midlands- Gokwe South district, and Matabeleland South- Mangwe district.

Mrs. Lynnet Makuwaza, a VHW from Tushiga Village in Mutare says the CRBF program has allowed (VHWs) to treat minor conditions, creating demand for health services at the grassroots level ie, the village, channeling communities for services and following up defaulters for all programs as well as providing household support for chronic patients in the continuum of health.

I was trained as a Village Health Worker in 2012. We were trained to conduct pregnancy tests and refer pregnant women to the Antenatal Clinic (ANC),” she said.

“We capture all the details of the women we would have referred in our registers and give them referral slips to use when they get to Rowa Clinic. We also conduct follow-ups to check if the referred pregnant women would have visited the Clinic.”

The Village Health Workers also do post-birth follow-ups in the villages to check for any possible danger signs for both the mother and child.

“We teach mothers basic child care practices, hygiene practices, health education, and others. If we note any danger signs, we refer the mothers back to the clinic. We usually do these referrals during the first three days, seven days, and six weeks.

“As for pregnant mothers, we also keep track of their records and ensure we remind them to move to the Waiting Mothers Shelter at the clinic so that there won’t be a need to travel when the pregnancy is already due. We do this to reduce the rate and complications and also ensure if there are any complications, the women get help as soon as possible,” said Mrs Makuwaza.

The rural or Community RBF being implemented in the 80 rural districts of Zimbabwe, focused on services provided at the primary level of care ie rural health centers. With the expanded role of VHWs, the program seeks to improve coverage of key indicators through the direct contact of VHWs and other community health workers working closely with the local leadership.

Under the program, VHWs are incentivized for identifying certain patients early and channeling them to services. Their statistics are recorded and submitted to the national database. The incentivized indicators include early diagnosis of pregnancy and referral for ANC booking before 12 weeks of gestation, promoting the use of long-acting reversible methods of family planning and referral to the health facility, following up postpartum mother/baby pairs, and referring for postnatal services, working closely with carers and community leaders to identify victims of sexual violence and referring them for post-exposure services within 72 hours, giving under 5s Vitamin A when due, Identifying EPI defaulters and referring to services, screening under 5s for malnutrition using MUAC tapes and referring early for IMAM, Identifying IMAM defaulters and referring to the health center and treatment of under 5s with diarrhea using ORS and Zinc and referring severe forms

Apart from VHWs, the CRBF makes use of Health Centre Committees (HCCs) which play the administrative role of providing oversight of the program. They create links between health facilities and communities. They also oversee the governance of the program, work closely with the community health workers in identifying bottlenecks and jointly plan mitigatory measures and mobilise local resources to support the program and create a conducive environment for the implementation of the project.

The ex officio members of the HCCs (councilors) take up issues with local government as health is not only the absence of disease. Other social determinants of health need local government intervention like the provision of roads, bridges, and safe water. They keep registers and records for the clients seen and referred to the facility.

Councillor, Evans Muradzikwa, who is also the Chairperson of the Health Centre Committee at Rowa Clinic in Mutare District said the presence of the CRBF has improved access to maternal healthcare services in the area.

“The HCC manages the RBF fund. It plans how the RBF funds are used. This includes buying medications for the health facilities, repairing broken-down clinic equipment, renovating the facility, or even boiling new structures. We work with traditional leaders, our Village Heads,” said Councillor Muradzikwa.

He added that there are 10 villages under the Rowa Clinic catchment area and each village has an HCC member and these members act as the intermediary between the village, The HCC, and the Clinic.

Meanwhile, Manicaland Province has over 380 functional health facilities and these include some that are benefiting from the RBF program. Dora Clinic is another rural health facility benefiting from the CRBF in Mutare.

Manicaland Provincial Medical Director, Dr Munyaradzi Mukuzunga said the RBF has led to a great reduction in maternal and child deaths as well as reduced the number of home deliveries.

“The RBF has gone a long way in strengthening the health delivery system in the province. Over the years, there has been a general decline in the number of home deliveries as well as maternal and child deaths. Under the CRBF, every year, each facility comes up with a plan that clearly outlines its priorities. So it’s the health facilities working with communities, represented by the HCCs and they agree and loan on what they will be using the subsidies for each year.

“So facilities use resources depending on their needs. For example, some facilities have built waiting-for-mothers shelters for high-risk women so that f any complications arise they will be attended to.”

He added that the RBF is looking at two components, namely the quality and quality of care. Over time it has evolved. Initially, it was focused on quantity, ie how much people would have benefited from the health services under RBF. The net phase was emphasizing more on the indicators of quality. This is quite key in terms of making sure that there is access to those who deserve it in line with our country’s thrust of leaving no place and no one behind.

Through the subsidies, Dr Mukuzunga said they have ensured first are foremost that facilities can improve the health delivery system in terms of looking through what is the need.

The RBF model is a financing mechanism to finance health services that focuses on maternal and child health services. While there are three main barriers to accessing maternal and child health, namely distance to health facilities, the psychological barrier, and the financial barrier. The RBF focuses on addressing the financial barrier to maternal and child health access.

 

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