A Report for Willow Spring Foundation
Project Name:
Citizen’s Mobilization for Maternal Health in Honduras
Project Location:
Honduras
Project Duration:
12 months (November 2010 – October 2011)
One- month approved extension (up to November 30, 2011)
Amount Requested:
US $ 90,000.00
CARE Contact:
Katherine Goulette, RDC/Foundations Support Officer
CARE USA
kgoulette@care.org
Carmen Hernández, Health Sector Manager
CARE Honduras
Carmen.hernandez@ca.care.org
CARE-Honduras Health Sector Team:
Roney Díaz, Coordinator, Citizen Mobilization component.
Nery Zelaya, Manager Assistant, HOGASA Project.
Geraldina Chávez, Monitoring and Evaluation Assistant.
Dacia Ramírez, Technical Advisor in Reproductive Health
Karla Alvarado, Administrative Assistant
Introduction
CARE Honduras, in complete agreement and aligned with the commitment, the 2010-2038
Country Vision, the 2010-2022 Nation’s Plan and the strategic approach of the Ministry of Health,
addresses it efforts and resources to develop a series of initiatives which contribute to close the
gaps of access and availability, mainly in those geographic areas in the country that historically
have been marginalized and excluded in three departments of western Honduras: La Paz, Intibucá
and Lempira, which have the major poverty conditions.
Currently, CARE Honduras through HOGASA Project with the technical, policy and financial support
of the Ministry of Health, and with the active participation of municipal governments, organized
community, CARE bases its programming on processes such as community participation for health
care, training of community and institutional human resources, the establishment of links and
strategic partnerships in health and to the strengthening and support to national strategies of
maternal and child programming ( IFC, CCHC, family planning, RAMNI, PAI, Promotion of Health)
Taking into consideration the above-mentioned information, HOGASA receives annual funds under
an agreement signed between CARE and the Honduras Ministry of Health for the period 2010 2014 with the aim of complementing community health interventions in 18 municipalities of
western Honduras.
Willow Springs Foundation funds have been planned to contribute in a significant manner to the:
a) Capacity Building of Municipal Health Volunteers’ Networks in relation to Community Base
Health Care and its managerial, administrative and financial capacity at the first level of health
care, b) a set of activities that will strengthen the surveillance system of maternal mortality in
women of 10 to 49 years and in minors of less than five years in the departmental regions, based
on the compliance of elements defined in the “cycle of epidemiologic surveillance “ c) Increase in
citizen and collective capacity to demand accountability aimed at fighting poverty, is particularly
relevant for the area covered by CARE Health Initiatives for the strengthening of social audit
processes, as well as the improvement of mechanisms and tools for monitoring and evaluation of
health care quality.
General and Specific Objectives
HOGASA main objective stated in its 2010 Annual Operational Plan is: “to facilitate a systematic
process through a set of initiatives that promote citizen participation, linkage and partnership as
core mechanisms for the generation of effective responses to the prevailing problems affecting
and deteriorating community health, by consolidating and strengthening local leadership,
promoting shared investment and promoting transparency and accountability in all health
interventions at community as well as institutional level.”
Specific objectives for the new action proposed by HOGASA are:
1. Promote an ample participation of communities in their needs analysis and improvement of
their health condition through the strengthening of citizen mobilization defined by HOGASA
Project.
2. Strengthen and complement the national surveillance system of maternal and infant mortality
in three departmental health regions through the implementation of a process of qualitative
research that enables to go deeply into cause analysis and in the definition of tools for the
sensitize on mortality decrease.
3. Increase citizen capacity to demand accountability, through social audit processes in health
with the participation of entities of social control in seven municipalities.
Partners in this initiative are:
1. Ministry of Health: Policy-making and Ruling Instance of the National Health Policy, with
organizational structures that facilitate continuity of processes of initiatives at national,
regional and local/community level.
2. Municipalities: Government authorities at local level that facilitate accompaniment of
interventions through the Health Representative, member of the Municipality, sponsor
local health processes and support and complement the investment of funds according to
existing legislation.
3. Transparency Committee: Responsible for the Social Audit of Projects and Public Utilities
at municipal level.
Project Activities and Results
Objective 1: Promote ample participation of communities in the needs analysis and improvement
of their health conditions through the strengthening of the citizen mobilization strategy defined by
HOGASA Project.
Activity 1.2. Conduct sessions for the analysis of health condition at municipal level with the
participation of institutional and community actors.
 In the period of May to October 2011, 5 sessions were conducted on the analysis of health
conditions in the municipalities of Dolores, San Juan, Yamaranguila and San Marcos in the
department of Intibucá, and San Francisco in Lempira, with the participation of 67 men and 54
women for a total of 121 participants.
 In this activity, the municipality health indicators were analyzed, based on the information
produced by the Ministry of Health and other institutions, in which municipalities, health
volunteers and institutions currently in the municipality participated.
Activity 1.3.Support and strengthen the municipal planning process in health.
 Four (4) work plans were prepared together with the Ministry of Health, municipality, health
volunteers’ networks and other institutions in the municipalities of Dolores, Yamaranguila, San
Juan in Intibucá and San Francisco in Lempira with the participation of 56 men and 68 women
with a total of 124 participants.
The “municipal health plan” is aimed at establishing priorities and address main problems in
the municipality on the issues of maternal and infant mortality, malnutrition, access to
services, basic sanitation, infrastructure, among others; this process is developed in a
coordinated manner with community and institutional actors.
Activity 1.4. Support to reinforcement sessions on handling illness in the Community Child Health
Care. (May trough September).
 During the period of May to October, 35 sessions of reinforcement to the module on Handling
Illness of the AIN-C Strategy (Community Child Health Care) in the municipalities of the
project’s intervention area with the participation of 284 men and 389 women (total of 673
volunteers).
 Health volunteer personnel performed and reported a total of 152 health care services due to
respiratory infections and 110 diarrhea illnesses. Also, 106 children with danger signs were
referred.
This reinforcement session is aimed at increase access and availability of services at primary level,
mainly for respiratory and diarrhea infections, as well as strengthening the reference system of
the Departmental Health Regions (MOH).
Activity 1.5. Strengthening the development of instances of citizen participation related to the
health issue.
 Nine (9) open municipal sessions were held in the municipalities of Gualcinse, Piraera, Santa
Cruz and San Francisco in Lempira; San Isidro, Masaguara and Dolores in Intibucá and Opatoro
and Guajiquiro in the Department of La Paz. In these sessions 580 men and 369 women
participated, among them community personnel, representatives of various institutions, MOH
and municipality personnel. During the open municipal sessions, issues such as maternal and
infant mortality, socialization of municipal health plans, malnutrition, municipal network plans
and municipal investment in health were addressed.
 Forty one (41) community meetings were held in order to analyze the condition at local level
of the issues of: malnutrition, AIN-C, family planning, maternal and infant mortality and the
system for emergency transportation. At the meetings, a total participation of 348 men and
690 women was observed.
Open municipal sessions and community meetings are mechanisms of citizen participation and an
instance to inform and consult the population on health-related issues. These sessions and
meetings have a legal framework and they are convened by municipal authorities and their
resolutions are binding according to the municipal law.
Activity 1.6. Technical strengthening sessions to the networks’ board using the administrative and
financial procedures manual (July through September).
 An achievement was the use of accounting books for the administration of financial resources
managed by volunteers’ networks.
11 financial reports were prepared by the networks for the municipalities and volunteers’
meetings.
 The use of this financial system has enabled to register, in an appropriate manner, the
amount, source and destiny of resources promoted and managed by the networks. During the
period November 2010 to October 2011 health volunteers’ networks have managed the
amount of L 78,099.71 equivalent to $4,134.
Activity 1.7. Follow up sessions to health volunteers for the implementation of citizen participation
mechanisms (open municipal sessions, community meetings).
 Seven (7) training sessions for reinforcement on citizen participation mechanisms to health
volunteers’ networks in the municipalities of Guajiquiro, Santa Elena and Yarula in La paz,
Jesús de Otoro, Dolores and Yamaranguila in Intibucá and San Francisco in Lempira with the
participation of 67 men and 72 women.
 Fifty-eight advisory and accompaniment sessions to health volunteers’ networks have been
held for the development of meetings and open municipal sessions.
1.8. Facilitate to the Health Volunteers’ Networks a tool for managing information at primary
health level. (June and July).
 An instrument to be used by volunteers’ networks is pending of being designed in order to
facilitate reporting of progress in volunteer’s activities such as: services rendered,
administrative issues and promotion initiatives.
Objective 2. Strengthen and complement the national surveillance system of maternal and infant
mortality in three department health regions through the implementation of a process for
qualitative research that will enable to go deeper into cause analysis and in the definition of tools
to sensitize on mortality reduction. 1
 It bears mentioning the fact that at the same time that CARE – HOGASA was consulting with
the Ministry of Health (MOH) on progress made on the issue of Maternal and Infant Mortality
that would enable to begin activities funded by CARE USA – Willow Spring Foundation, news
were heard that the MOH was beginning research on “Strengthening the Surveillance System
of Maternal Mortality and Updating the Reason for Maternal Mortality” at national level with
a focus mainly quantitative. Therefore, the MOH was pleasantly surprised to hear the news
that CARE-HOGASA would be conducting, almost simultaneously, a research on the issue of
1
Las actividades 2.1; 2.2 y 2.3 fueron descritas en el reporte anterior de medio término.
maternal and infant mortality from a qualitative approach in 3 of the country’s 18
departments, which would be complementary to the findings.
 The team of field facilitators and HOGASA project coordinators provided accompaniment to
institutional health personnel during collection of field information of quantitative research on
Maternal and Infant Mortality. Additionally, funding support was provided to conduct a
training on the process of “Quantitative Research of Maternal and Infant Mortality” aimed at
institutional health personnel and for hiring full time human resource during one month in
order to process in the computer the information obtained in the field (mainly in the Health
Region of La Paz).
Activity 2.5. Data processing of the research: input, cleaning and
Activity 2.6. Generate the research results: output charts for information analysis.
 During this period a higher number of questionnaires were applied which rescue the
information obtained in the field on maternal and infant death events. Following is the total
of questionnaires applied and their origin:
TOTAL QUESTIONNAIRES APPLIED BY DEPARTMENT
NAME OF THE GUIDE
TOTAL
QUESTIONNAIRES
APPLIED
INTIBUCA
LA PAZ
LEMPIRA
GUIDE 1 MATERNAL DEATH
27
16
8
3
GUIDE 2 INFANT DEATH
121
53
47
21
GUIDE 3 MOH PERSONNEL
15
9
2
4
GUIDE 4 AUTHORITIES
18
11
5
2
GUIDE 5 SURVIVING WOMEN
17
10
3
4
GUIDE 6 VOLUNTEERS AND
MIDWIVES
20
10
4
6
 A total of 218 research instruments were applied to relatives, doctors, nurses’ aides, sector
supervisors, municipal mayors and members of the municipal corporation, surviving mothers,
health volunteers and midwives in 20 municipalities of the three departments covered by
HOGASA project.
It is highlighted that the actual time invested in various phases of the research process: design and
revision of instruments, validation, information collection, data processing (codification, input,
cleaning and generation of output charts, analysis, report preparation) was higher than initially
thought, upon submitting the proposal to CARE USA. In spite of that, a first cycle of research has
been completed where results and analysis are presented of 2 of the 5 research instruments
applied.
The document “Maternal Mortality; A perspective from the Right to Health – Honduras” is being
annexed to this report. This report is the result of findings obtained from the qualitative research
on maternal mortality based on information from questionnaires # 1 (interviews to relatives of
maternal deaths) and # 5 (interview to survivors of cases of obstetric emergency). This report was
prepared using the methodology of factor analysis which allows to grade data obtained which
enables to divide the data on issues of interest.
The above shows that the continuation of the research cycle is still pending which allows us to
enter into the analysis of the information collected and to prepare the report based on the
contents of the following instruments:
1. Individual interview to relatives of infant deaths.
2. Individual interview to municipal authorities.
3. Individual interview to Ministry of Health personnel.
4. Guide for focal groups with health volunteers and midwives.
Activity 2.7. Prepare report and analysis of the results of the research and media plan for
sensitizing.
 With the purpose of promoting a Media Plan for Sensitizing on the issue of maternal and
infant mortality, a banner was designed containing a message that calls for community
reflection. Initial design was in charge of field facilitators of HOGASA Project and it was
validated with institutional health personnel in Region of La Paz. The printing of 50 banners
are pending. We would like to complete this activity by distributing them and strategically
placed at the Health Units and Maternal Clinics in the area of project intervention.
A second strategy within the Media Plan is the design of 8 Case Studies that rescue
experiences lived in the community which ended in maternal death and others that had a
successful ending which avoided maternal death. These 8 case studies will be used as an input
for learning and reflection with various groups of interest (circles of pregnant women, youth
groups, health volunteers, among others) using the methodology of Social Analysis and Action
(SAA). Attached is an example of a Case Study.
 OTHER ACTIVITIES (implemented with CARE USA – Willow Spring funding)
With the purpose of strengthening response capacity of 10 Health Units (US) in the 3 country’s
departments, in which HOGASA Project operates, FETAL DOPPLERS were donated to each one
of them, that will contribute to the fetal monitoring in women that come for their monthly
checkup for pregnancy and, based on it, provide reference and timely care.
Additionally, 200 Maternal Bags were prepared and distributed. The bags included a set of
baby diapers and safety pins as a manner of stimulating those women that have attended
their pregnancy controls and have also participated in the meetings called “pregnant circles”,
mainly to those that have come with their partner, thus encouraging man’s participation in
caring of women’s health.
FETAL DOPPLER DISTRIBUTION
HOGASA Project – Citizen Mobilization in Health Component
Quantity Health Unit
Receiving
Municipality
Department
Person in Charge of
the Equipment
1
Maternal
Clinic
Erandique
Lempira
R.N. Miriam Puerto
1
CESAMO
San Francisco
Lempira
Dr. Jenny Alvarado
1
CESAMO
Santa Cruz
Lempira
Dr. Elvin Rodríguez
1
CESAMO
Yamaranguila
Intibucá
Dr. Gloria Arriaga
1
CESAMO
San Marcos Sierra
Intibucá
Dr. Luis Berrios
1
CESAMO
San Juan
Intibucá
Dr. Allan Bustamante
1
San Isidro
Intibucá
Dra. Leticia Chávez
1
CESAMO
Clínica
Materna
Marcala
La Paz
R.N. Edil Santos
1
CESAMO
Santa Elena
La Paz
Dr. René Cruz
1
CESAMO
Santa Ana
La Paz
Dr. Iris Bonilla
Activity 2.8. Conduct general feedback meetings and socialization of results with health personnel
and communities.
 A general meeting for information feedback and socialization of results on the qualitative
research is pending of being conducted.
Objective 3. Increase citizen capacity to demand accountability, through processes of social
audit in health with the participation of entities of social control in seven municipalities.
HOGASA – CARE Project used in 2007 the methodology of Social Control in Health in 2
municipalities in the department of La Paz obtaining valuable results that became inputs to
strengthen the rendering and quality of services , as well as the integration of the health issue in
the agenda of the municipal corporation. This methodology becomes relevant since it enable the
communities to exercise their right to participate in the life and public issues through municipal
transparency committees and to watch over the use of public resources, request accountability
and provide guidelines for municipal authorities to respond to the demands and needs that
strengthen livelihoods in the community.
In the period June – November 2011, with the funding support of CARE USA – Willow Spring ,it was
possible to replicate the methodology of Social Control in Health to SEVEN municipalities in the
departments of La Paz and Intibucá.
Activity 3.1. Cooperation agreements between CARE and departmental health regions of La Paz
and Intibucá for the implementation of the methodology of community evaluation of health
services from the user’s view to be developed in the municipalities of Yarula, Santa Elena, Opatoro,
Guajiquiro, San José in the department of La Paz and Yamaranguila and San Marcos de la Sierra in
the department of Intibucá.
 Two (2) “cooperation agreements” were established between CARE – HOGASA and
departmental Regions of Intibucá and La Paz for the implementation of the methodology of
community evaluation of health services (ECSS).
 Seven (7) “cooperation agreements” were established between CARE – HOGASA and the
municipalities of San Marcos Sierra and Yamaranguila in Intibucá, Santa Elena, Opatoro,
Yarula, San José and Guajiquiro in La Paz for the implementation of the methodology of
community evaluation of health services (ECSS).
 Seven (7) “cooperation agreements” were established between CARE-HOGASA and 4
transparency committees of San Marcos Sierra in Intibucá and Opatoro, Yarula, San José in La
Paz; and 3 cooperation agreements with health volunteers’ networks in the municipalities of
Yamaranguila in Intibucá, Santa Elena and Guajiquiro in La Paz.
The established agreements with these partners include:
‫ ־‬Implementation of the methodology.
‫ ־‬Involvement of the members.
‫ ־‬Funding transportation and meals costs of participants.
‫ ־‬Follow-up to established agreements.
Activity 3.2. Review and adjust questionnaire of opinion for users of health services, with key
personnel from the Ministry of Health and technicians from HOGASA project.
 The “opinion questionnaire” for users of health services, originally designed with the ECSS
methodology, was reviewed and modifications were included related to: information received
from patients, privacy, delivery of medicines, comfort in the installations, furniture, education
in health and appraisal from users of care received. Modifications were made jointly by
project’s technical personnel and Ministry of Health personnel.
Activity 3.3. Compare the opinion of community evaluation of health services with processes of
quality assurance (in the users’ survey), in order to adjust the questionnaire of social control of
health.
 During the comparison between the opinion of the community evaluation of health services
(ECSS) aimed at providing a dignified treatment to users and the process of Quality Assurance
(QA) of health services geared towards the application of technical procedures in the Health
Units, matches were found around the issues asked.
However, an outstanding difference between ECSS and the QA process is that the first one is
implemented by the committees of municipal transparency and the second is conducted by
Ministry of Health personnel. Another outstanding difference is that in the ECSS process
agreements are established that involve local actors and in the QA process a follow-up is
established of the report submitted to the Health Unit
Activity 3.4. Socialization of the initiative for the evaluation of health services with local Ministry of
Health personnel, municipal corporations, transparency committees, networks and volunteers’
micro-networks and other similar instances, and establishing cooperation agreements.
 Socialization meetings were held on the ECSS methodology with Departmental Health Regions,
Municipal Transparency Committees, Municipal Corporations, Volunteers’ Networks and
Institutional Health Personnel. A product of these meetings was the agreements established
for the implementation of this methodology in 7 municipalities, as detailed in activity 3.1.
Activity 3.5 Adaptation and adjustment to the Community Evaluation of Health Services (ECSS)
manual
 The expansion or replication of the ECSS methodology in 7 municipalities allows the Project to
resume the methodology manual and make adaptations; the most important among them is
the inclusion of health volunteers’ networks as implementers of the methodology and the
inclusion of the rights to health issue.
The manual adaptation was made by Ministry of Health personnel and project’s technical
personnel.
Activity 3.6.Training of participants in the process of the opinion on satisfaction as far as health
services received.
 A training session was provided and the evaluation of health services (ECSS) methodology was
validated with the participation of the Project technical team, the transparency committee,
municipal representatives and the social control committee in the municipality of San Marcos
Sierra in Intibucá.
 Seven (7) transparency committees and health volunteers’ networks were trained from the
municipalities of:
o San Marcos Sierra with the participation of 6 men and 5 women
o Yamaranguila with the participation of 5 men and 7 women
o Santa Elena with the participation of 4 men and 5 women
o San José with the participation of 6 men and 7 women
o Opatoro with the participation of 7 men and 9 women
o Guajiquiro with the participation of 7 men and 4 women
o Yarula, with the participation of 5 men and 6 women
A total of participants: 43 women and 40 men.
Activity 3.7. Survey on the evaluation of health units (US) in each municipality.
 A total of 290 questionnaires were filled as follows: 20 in 2 health units in the municipality of
San Marcos Sierra, 60 in 6 health centers of the municipality of Yamaranguila, 30 in 3 health
centers of the municipality of Yarula, 40 in 4 health center of the municipality of Santa Elena,
70 in 7 health centers of the municipality of Guajiquiro, 30 in 3 health centers of the
municipality of San José and 40 questionnaires in 4 health centers in Opatoro.
All the questionnaires were filled by participants in the training sessions; transparency
committees, health volunteers’ networks and members of the municipal corporations.
The municipalities covered mobilization and meal costs for the people that participated in the
information collection.
Activity 3.8. Preparation of results report by health units (US).
The preparation of results report included: revision of questionnaires, consolidation of satisfactory
results, unsatisfactory results and recommendations.
 A total of 29 results reports (2 in San Marcos Sierra, 6 in Yamaranguila, 3 in Yarula, 4 in
Santa Elena, 7 in Guajiquiro, 3 in San José and 4 in Opatoro).
 Two (2) consolidated departmental reports were prepared and were submitted to the
departmental regions of La Paz and Intibucá.
Among main problems found in the municipalities where the methodology was applied, we found:
o Lack of cleanliness in the health centers,
o Installations and furniture in poor condition
o Lack of educational activities.
Satisfactory results mentioned in the evaluation were:
o Privacy.
o Availability and use of medicines.
o Acceptable waiting time.
o Information about your diagnosis.
o Received dignified treatment.
Activity 3.9. Feedback meetings with municipal authorities, volunteers’ networks and health teams.
 Five (5) feedback meetings were held in the municipalities of San Marcos Sierra in Intibucá;
Santa Elena, Yarula, Guajiquiro and Opatoro in La Paz with the participation of the
transparency committee, municipal corporation, Ministry of Health representatives, social
control committee, ANED (Asesores Nacionales Especializados en Desarrollo), health
volunteers, representatives of grass-root organizations, defense counsel for women and
childhood and representatives of the health regions. In these events, a total of 89 men and 94
women participated.
 Commitments were established between the Ministry of Health, municipality, health
volunteers’ networks, transparency committees, departmental health regions, grass-root
organizations, and CARE in relation to:
o
o
o
o
o
Training to Ministry of Health personnel on the issue of rights to health. Revision of
the profile of women janitors from health centers and municipal budget to improve
this service.
Procurement of permanent jobs for doctors and nurses.
Socialization of the research results at meetings with the networks at the Ministry of
Health.
Promotion of projects to improve the installations and furniture of the health centers.
Implementation of the evaluation (ECSS) within the next 6 months in order to evaluate
progress.
Successes and Challenges (Main results in the period June to November 2011)
1. As a product of the coordination between CARE, municipalities, health volunteers’ networks
and the MOH (Ministry of Health of Honduras), “10 municipal health plans” were prepared as
an strategic action to address and give response to main health problems that are facing these
municipalities.
2. The work of technical strengthening and accompaniment from CARE to health volunteers
aided for the implementation of 18 open municipal meetings and 40 community meetings as
spaces to promote citizen participation in health in municipalities of western Honduras.
3. 18 health volunteers’ networks received reinforcement of knowledge on managing the “illness
module” of the Strategy of Community Child Health Care (AIN-C), which allowed them to
increase community health care, mainly related to respiratory illnesses and diarrhea diseases.
4. A process on “Qualitative Research” of maternal and infant mortality was carried out in 3
departments of western Honduras (La Paz, Intibucá and Lempira). The process began from the
review and adaptation phase of research instruments, validation of instruments, field
information collection, data processing (codification, digitalization and cleaning), sessions for
the analysis of generated information and report preparation. All this process was conducted
by HOGASA project technical team (field facilitators, monitoring unit, coordinating team), thus
becoming a manner of LEARNING for the technical team in the area of “research”. Some
actions required the creation of a task force (to digitalize 2 instruments) or have an advisor for
the analysis/organization of collected information with the purpose of preparing a preliminary
report of research findings.
5. A process of Community Evaluation of Health Services was conducted. In this process, the
municipal transparency committee was trained on the management of the ECSS – Community
Evaluation of Health Services and, by this, they played a key role in the facilitation of the
community opinion process, revision of the information obtained, report preparation and
results feedback to the community. This process led to the establishment of institutional
agreements by the health sector and other authorities looking for better health conditions and
promoting accountability in seven municipalities of western Honduras.
Next Steps (prospects for the future)
1.
2.
3.
4.
5.
Promote the IFC (Individual, Family and Community strategy).
Expansion of the ECSS methodology
Research on infant nutritional conditions.
Strengthening health volunteers’ networks.
Advocacy with Ministry of Health personnel and community personnel on issues such as rights
and dignified treatment.
Human Interest Stories
In process of being developed…
Photos
Annexes
I.
II.
III.
(Plan de Trabajo) WORK PLAN
Document “Maternal Mortality; A prospect
Honduras”(Executive Summary).
Sample of Case Study in Maternal Health.
from
the
Right
to
Health
–