Reaching mothers and babies at highest risk—a question of scale

At the monthly SISCa events, babies are weighed using hanging scales provided by UNICEF. Because these scales are imported and relatively costly, numbers are limited. This is one reason why mothers have to trek so far to a central weighing station. And the long trek is a reason why, on the average, less than 60% of pregnant women and mothers attend the monthly check-ups. More worrisome still is the likelihood that the mothers and babies who don’t attend are those at highest risk.

In discussing this low attendance with the SHARE staff, an idea occurred to us. If enough scales were available, growth monitoring could be more decentralized. Mothers wouldn’t have to trek so far, and PSFs could do growth monitoring right in their villages or homes. Big crowds and long waits could be avoided, and the health services could be more personal, adapted to each mother’s and child’s individual needs.

But how, people asked, on a limited budget can so many scales be provided? The obvious answer is: through local production! I showed the health workers photos from Mexico of simple, hand-made “beam balances,” which the Timorese Health Promoters could easily make themselves at virtually no cost. The SHARE staff and the PSFs were excited about this possibility. They could better reach those at highest risk, right in their villages. It would allow more direct interaction between mothers and health workers, and perhaps more effective solutions to the persistent undernutrition and high death rates of children.

Addressing the high drop-out rate of health promoters

The Family Health Promoters (PSFs) help as volunteers in their own villages and aldeas, Typically they receive a token “incentive” of about US$5 per month. Often they start out with lots of enthusiasm, but many soon become “inactive” or drop out. One question I was often asked was: What might be done to prevent the high drop-out rate?

An obvious solution is to provide a greater incentive. But incentives are necessarily monetary. What inspires many of us to keep helping is the sense that the service we provide makes a real difference in people’s well-being, and that our efforts are appreciated and respected.

If the PSFs assistance in relation to the SISCa gatherings makes a visible difference in children’s nutritional health and survival, and if the community appreciates that difference, this could strongly motivate the PSFs to continue. But as it stands, child malnutrition and mortality rates remain high. In the two districts I visited, almost no improvement was recorded in the last two years. Similarly, vaccination rates remain so low that this year there was a major measles epidemic—with a high death rate due to complications of pneumonia in those children already undernourished. In Aileu district this year (2011) only 2.8% of pregnant mothers were immunized against tetanus—an all-time low!

If local health workers are to gain credibility and respect in their communities, they should to be able to respond to the health needs people consider most urgent. In disadvantaged communities, people’s biggest felt need is often for curative care. A mother whose baby is dying from diarrhea has little interest in preventive advice. First she wants to cure the illness! Once her baby’s out of danger, she will take more interest in how to prevent the illness from coming back.

If we want people to get involved in a health program, we need to listen to them and start with what they want … which is likely to be curative care. If a health promoter has the basic knowledge and skills—and authorization—to help diagnosis and treat a few of the most common and dangerous ailments (like diarrhea and pneumonia), he or she will have more credibility. The satisfaction that comes from making a real difference is a big incentive to stay with the job and not drop out.

However the Timorese Health Ministry—in line with the advice of WHO—does not permit its Family Health Promoters (PSFs) to provide even the most basic curative care. At a workshop I facilitated for PSFs in Aileu, the district health officer repeated six times that “Treatment is strictly the job of the doctors, not the PSFs.” He made it clear that PSFs were messengers and information-dispatchers of the health professionals. The PSFs listened glumly and said nothing.

After his opening speech the health officer didn’t stay for the workshop. After he left, I asked the PSFs, “Who is it that treats most of the common illnesses in your villages?” A chorus of PSFs replied, “Mothers in the home!” I asked them, “What would happen if only doctors provided treatment?” One of the PSF’s replied ruefully, “If we waited for the doctors, we’d all be dead!” Everyone nodded and laughed.

Most of the doctors simply are not where there needed when there needed. The long delay and expense in reaching them can indeed be deadly. Even with the 300 Cuban doctors now in Timor, they rarely reach the more isolated villages. In Aileu District, the 4 Cuban doctors and 24 Timorese medical students stationed there all stay in the district capital, from which they take occasional forays into the countryside. When I talked with them, they agreed that the doctor-dominant healthcare model practiced in Cuba is not appropriate for Timor. They thought that local Family Health Promoters should play a much more capable role—including diagnosis and treatment of common health problems, with use of a few essential medicines including antibiotics for pneumonia. I fully agree.

The PSFs were enthused about learning more skills and assuming greater responsibility. On discussing the endemic undernutrition in children, it was evident that the routine “nutrition messages” given to large groups of mothers weren’t giving satisfactory results. The pattern of low weight gain after introduction of weaning foods showed virtually no improvement, And the end result too often was stunting, increased illness and death.

The Need for Grassroots Participatory Epidemiology

In talking with health workers it became apparent that: It doesn’t work to keep on repeating the same old nutritional messages that mothers have heard dozens of times. First we must find out what works! That is to say: What can impoverished mothers can do so their weanling children don’t become too thin? Open-ended, participatory study is needed at the community level, asking: What are the combination of factors (the “Chain of Causes, if you like) that contribute to the prevailing pattern of child malnutrition and high mortality. Such a study should not simply be conducted by qualified nutritionists and experts, but include the active input from village mothers. Data from Growth Charts can to be used, not only to review which babies are too thin, but also to see which babies are *growing well—*to learn from their mothers what they are doing right! Based on the findings, a number of mini community-level experiments can de conducted to determine what approaches to weaning, feeding and use of resources give better results. If PSFs and mothers play a key role in this process, it could be an empowering experience for both—especially if they come up with some worth-while answers.

The situation is complex. An initial problem-posing activity—which we discussed with the SHARE team—would be to thoughtfully construct a “chain” or “network” of causes, including the multiple interrelated factors that contribute to the prevalent “failure to thrive.” What is required is good “detective” work: careful observation of all possible factors, without pre-judgment or preconceived conclusions. It calls for open minds and a degree of humility: readiness to listen to fresh perspectives, and to realize the insights and observations of the villagers may be as valid as those of the outside professionals.

Once a “map,” of the causal chain begins to take shape (an ongoing process that should never be consider complete), everyone can stand back and try to figure out which of the causal links might be broken, with what action, by whom, and at what level (family level, community level, national level, or beyond).