Ask. Listen. Act. Repeat.

Julia Monaghan

Pathfinder International | Technical Advisor for Capacity Building
Younger women having their first or second child may not recognize access to health services as a right and as something that could improve their lives.

Younger women having their first or second child may not recognize access to health services as a right and as something that could improve their lives. Photo: Pathfinder.

Evidence-based interventions. High-impact practices. Using data for decision-making.

As program implementers, we (rightly) spend a lot of time focusing on these concepts. But, sometimes, we get so caught up in trying to implement development strategies and interventions “correctly” that we lose sight of the perspectives of the people that our projects are intended to support—local partners, service clients, and community members. Evidence across sectors shows that the people best able to solve problems are often those closest to the situation itself. Thus, effectively removing barriers to sexual and reproductive health services use means taking a step back from our checklists and our data and actually talking to community members to understand what is getting in their way.

Recently, we did just that. And the results reinforce how important it is to build these opportunities for listening into our program designs. Since 2014, Pathfinder has led the “Before, During, and After Pregnancy: Always Women” project in four districts of Mozambique’s Gaza province. Funded by the Positive Action for Children Fund/ViiV, this project was designed to increase utilization of PMTCT services by empowering women with reproductive health information and connecting them through shared experiences.

From November to December 2016, we conducted an end-of project exercise to learn how community members felt about the project. Over the course of two weeks, we surveyed and spoke with 146 young women (both HIV-negative women and those living with HIV), 18 of their family members and partners, seven health providers from facilities within the project’s implementation areas, and 25 community leaders. We asked about their participation in project-implemented community group sessions, their overall experiences, what they felt they gained from participating in the project, and what they would want to see us do differently.

According to the majority of the people we interviewed, the most valuable benefit of the project was an increase in people’s knowledge of how to access health services—in particular, antenatal care and family planning services. These communities are small and people generally know where the health facility is located, so we were somewhat surprised by this finding. But after digging deeper and discussing with community health workers and project partners, it became apparent that this was about more than just the geographic location of health facilities.

Our experience, and what we heard from our partners, is that community members—especially younger women having their first or second child—didn’t recognize access to health services as a right and didn’t consider the health system as something that could offer services to improve their lives. People primarily frequented the health facility only when they were ill. However, after attending the project-sponsored group sessions with community health workers, this perception changed. People felt more empowered to proactively seek preventative services, like antenatal care, and services that gave them more power over their lives, like family planning.

A community health worker shares reproductive health information with a group of young women.

A community health worker shares reproductive health information with a group of young women. Photo: Pathfinder.

This increase in health literacy and individual agency within a population that is vulnerable to HIV infection and/or vertical transmission of HIV to their infants was quite telling for us. Clearly, the messaging that connected with community members in this project went deeper than our original understanding of community needs and the initial project focus on PMTCT. Had we and the project donor understood this earlier on, it would have given us an opportunity to broaden the project scope from the beginning, in a way that also addressed donor priorities. When, as a programmatic implementer, you enter a community with a goal in mind—in this case, the goal of preventing new HIV infections and preventing mother-to-child-transmission of HIV—it’s important to recognize the context and that, in some cases, people’s basic understanding and perception of the health system and its role in their lives need to be addressed first.

What this project has reinforced for us is that as uncomfortable as it may be, when community members speak up and ask for what they need, it’s okay to deviate from the initial project focus to meet those needs. True community engagement demands responsiveness.

With this in mind, going forward, we will prioritize these kinds of interactions: direct engagement with communities to ask what is working and what we can do better. Doing so mid-project, for example, would have helped us scale up the organic feedback loop the community health workers had established with community members on a macro project level.

And this is something that we think all of us working in this space can do more and better. As we, the global sexual and reproductive health community, move forward with defining high-impact, evidence-based practices (certainly a useful, worthwhile effort), we would be equally well-served by reminding ourselves to build in regular and intentional engagement—be it through qualitative surveys or simple conversations—to ensure that we are checking our assumptions and therefore best serving the needs of the communities we work with. At Pathfinder, we’re making our best effort to ask, listen, act, and repeat.