Digital synergies to improve maternal-and-child health

Reducing maternal and perinatal mortality and improving the health and well-being of pregnant women and newborns remain global priorities. The SDGs include the need to ensure healthy lives and promote well-being for all people at all ages; specifically, the goal was set to reduce the global maternal mortality ratio and end preventable deaths of newborns and children under 5 years of age. These international commitments were undertaken by Colombia and included in its public policy. However, although Colombia has improved its indicators in relation to these global goals, progress is not homogeneous at the territorial level. In most rural areas of Colombia health personnel lack capacities to work in cross-cultural settings and there is a very high personnel turnover, therefore many efforts to improve capacites are not sustainable and don´t impact health indicators in the population. In addition, according to Colombian authorities, as a result of the pandemic, the number of maternal deaths increased by 36.3% between 2019 and 2020, bringing the maternal mortality ratio to 65.6 deaths per 100,000 live births, levels not seen since 2012. 

In the department of Cauca, some of the determinants are more critical and the negative outcomes of pregnancy and childbirth show worrying figures, which proves the need for effective intervention to improve the situation of pregnant women and newborns. According to the Ministry of Health, Cauca is the 7th out of 32 departments  with the highest number of home births, with 10.9%, although the national figure does not exceed 3%. It should be noted that home births are more prevalent among women in the lowest wealth quintile (9.9%) and without education (9.9%). The extreme maternal morbidity rate in the department of Cauca was 51.0 per 1,000 live births in 2018, while the national figure was 30.6. And The ratio of perinatal and late neonatal deaths in the department of Cauca was 17.1 per 1,000 live births in 2018, while the national figure was 12.2.

Using a participatory methodology with community leaders and local health institutions, we plan to improve maternal and child healthcare services for women having deliveries and their newborns and women with childbearing potential in Cauca, Colombia, by creating a digital learning platform which aims to offer methodologies, tools, trainings and key data to healthcare providers, families and women. It will include recommendations to adapt them to other territories. To achieve this, we are going to 1. consolidate Sinergias' previous successful experiences, best practices, lessons learned, methodologies, tools and training for healthcare providers into a simple and dynamic digital platform. 2. Using the platform, strengthen the abilities of 150 health workers to provide cross-intercultural and quality maternal and child healthcare services including, enhancing territorial evaluation and planning capacities, improving workers skills and capacities; improving MNCH service evaluations and quality; and exercises to assess the accessibility to culturally competent health services in each region. 3. Increase community participation to generate awareness on sexual and reproductive health rights, availability and use of health services, and promotion of quality and cross-cultural care by empowering women leaders and community health workers.

The project intends to create a digital learning platform and toolbox for health care providers, decision makers and communities mainly directed to rural indigenous peasant and afro Colombian women, in Cauca, which are composed by different populations in terms of ethnic identity, territorial conditions, cultural values and traditional practices. 

First, the women from Cauca who will participate in the project, who have the local knowledge of the context and traditional practices that understand and reproduce the culture according to their heritage. They will be key agents on designing and adapting methodologies, tools, best practices, among others, that will be available in the platform for healthcare workers and other women. The process will use formative investigation and direct education as guiding methodologies.

Second, the healthcare workers who will participate in training programs (community health workers, health professionals, health facilities and directorates). Initially, at least 150 health care workers at a municipal level and 10 at a departmental level will participate in workshops related to strengthening territorial evaluation and planning capacities, improving workers skills and capacities; improving Maternal, newborn and child health (MNCH) service evaluations and quality, patients medical record keeping; and exercises to assess the accessibility to culturally competent health services in each context.  

Third, a broader number of people -families, women and health professionals- that will be able to access and use the resources available in the platform. Furthermore, all the women and children that will benefit from quality and cross-cultural care in the region; this will include: approximately 16,000 pregnant women and 14,500 newborns.

Throughout the 10 years of Sinergias' work, we have woven ties throughout the national territory and, hand in hand with the communities and local institutions, we have generated processes that allowed us to strengthen capacities to improve access to quality health services, appropriate to local conditions and culture. We work with local leaders to map and seize the resources and knowledge of the communities and institutions, and use them as cornerstone in echr project. In particular, in Cauca we worked for 7 years where healthcare services have been historically lacking and MMR are among the highest in Colombia. We aimed to guarantee women’s access to key health services in 32 municipalities (450.000 women and 115.000 newborns). We mapped the health situation with stakeholders and co-defined a roadmap to improve maternal-perinatal care quality with communities and public servants. We trained nearly 15.000 professionals and women, monitored health indicators, co-constructed health promotion strategies, among others. We plan to continue these efforts aimed at local communities and women and health institutions. As happened during the first stage, these two stakeholders will be the ones guiding the specific objectives and activities of the project.

Consultation processes have and will be carried out with local institutions and community leaders. For Sinergias, it is fundamental that the communities themselves identify their needs, participate in the construction of the methodologies and lead the development of solutions. We are convinced  that the impact of any project depends on local ownership insofar as the intention is to strengthen capacities, not to generate dependence on an external agent. Thus, the relationship between the community and local institutions with the project is constant, permanent and above all participatory, throughout the different stages of design, implementation and monitoring. Under the differential approach characteristic of our work, the participation of indigenous women, people with diverse sexual orientation or gender identity, people with disabilities, young people, among others, will be promoted. 

The methodology to be implemented has been tested in three previous projects, and was the winner of the Recognition for Excellence in Comprehensive Early Childhood Care in 2014, a competition led by the led by the Organization for Excellence in Health -OES- and the Ministry of Health and Social Protection, as well as the Kenneth C. Frazer and Social Protection, as well as the Kenneth C. Frazier Award for Equity in Maternal Health, awarded by Merck for Mothers in 2021

We are facing technical and cultural challenges. First, we have already developed a successful methodology that has been scaled up to several municipalities, best practices and tools that can be used to strengthen local capacities of healthcare providers and empower communities. However, reaching all territories and providing constant support in the long term has been a challenge and a limitation to increase coverage. Additionally, the organizational culture in the public sector is not stable. Due to the legal framework and low salaries, there is a high rotation of personnel in hospitals and health centers; therefore the training efforts have to be constant and simple.  We want to create an interactive platform that has free tools for the community and the health personnel and courses where they can deepen their knowledge in locally prioritized topics. The platform will connect both groups with professionals, information and among each other. 

This project represents the coordinated application of an innovation that involves educational digital learning technologies, either synchronous or asynchronous, in fields where there is still a gap, such as training and technical support of new healthcare providers in remote regions of the country. In addition, as the platform offers methodologies and tools designed and tested with the community, health service providers and authorities, we ensure that they have a different approach to those already in existence and that they respond effectively to the needs of the sectors involved. An additional purpose of our methodology, which will be incorporated into the platform, is to guarantee interaction and common problem solving among local key stakeholders through territorial maternal, newborn and child health improvement plans. This gives it a social character that aims to address a national problem that still afflicts the most vulnerable populations. There will also be economic innovation by facilitating induction processes, improving the quality of health services and reducing the risks faced by women and health personnel. Furthermore, the platform will provide tools to analyze maternal and child health program data already collected but underused to guide the decision-making process of health authorities

In addition, this sum of benefits in the areas explained has the potential to be scaled up nationally and regionally; by testing the effectiveness of teaching the already globally known methodologies of Sinergias through virtuality with face-to-face support, it will be possible to scale up and apply this innovation with other departments, communities and health authorities. 

Our long term goal is to ensure that women and children receive comprehensive and quality care during their pregnancies, childbirth, postpartum and children during their early childhood, in accordance with evidence-based national guidelines and local cultural practices. By doing so we will advance in the process of guaranteeing the enjoyment of their rights, reducing maternal and infant morbidity and mortality in rural regions within Colombia.

The main expected outcome is to successfully scale-up the strategy we propose to at least 20 municipalities and to improve quality of MNCH programs as measured by the antenatal care, and the delivery postpartum and newborn care indexes (composed indicators developed in our previous experience that include key evidence based interventions that all women and newborns should have access to according to national guidelines and Colombia’s current legislation). 

An additional key outcome is a digital platform -which includes a toolkit- that aims to offer best practices, lessons learned, methodologies, tools, training and key data to healthcare providers, families and women with recommendations to adapt them to other territories. It seeks to provide rural communities in Cauca, Vaupés and, in the future, other regions in the country, with tools to provide or demand culturally adequate maternal health services.

In five years the platform will be a main source of consultation for public officials and decision makers throughout the country, offering key information and data analysis tools to back their decisions; the platform will offer free resources for community members, mothers and activists on quality health and rights; and, it will offer constant online and blended courses for health institutions and personnel. 

The collective and participatory nature of this project will allow for constant monitoring and evaluation of the impact it is having on the population we will work with. We will use formative evaluation, interim evaluation and a summative evaluation at the final stage. 

The indicators that will be measured are: 

# of municipalities participating and implementing systemic MNCH improvement plans

# of health facilities participating

# of mother-baby pairs attended in municipalities involved in this initiative

Accessibility of the digital platform to the participants and other relevant actors. 

# of resources available in the platform for healthcare workers

# of resources available in the platform for women and community members

Amount of data analysis tools and key information available for relevant decision makers. 

# of healthcare workers who received training 

# of women and community members who participated in the trainings and workshops.

Our long term outcome is to ensure that women and children in Cauca, Vaupés and Colombia in general receive comprehensive and quality care during their pregnancy, childbirth, postpartum and early childhood.  To achieve this we aim in the short term to consolidate Sinergias’ previous successful experiences, best practices, lessons learned, methodologies, tools and training for healthcare providers into a digital platform, that will be one of our main outputs. When the platform is established, as second output Sinergias will strengthen the abilities of over 150 health workers (health professionals from health facilities and health directorates) to provide intercultural and quality maternal health services including, strengthening territorial evaluation and planning capacities, improving workers skills and capacities; improving MNCH service evaluations and quality, improving and skills to tailor programs to different cultures, and enhance data analysis for decision making processes. In parallel, the team will implement actions to increase community participation to generate awareness on sexual and reproductive health rights, availability and use of health services, and promotion of quality care by empowering women leaders and community health workers.

By having skilled workers, tools to train new health care providers and an empowered community Sinergias will be able to advance in the improvement of maternal and child health and wellbeing. In the midterm there will be a change in behavior and the methods in the platform will be widely known in the public and health sector, positively affecting the procedures and the quality of the services. 

The activities to achieve these goals are:

Activities

1. Preparation (team conformation, workplan, fieldwork logistics)

2. Review and selection of the existing experiences, best practices, lessons learned, methodologies, tools and training to determine. As part of the process we will identify which resources have been validated in the past and can be used as they are and which ones need to be validated in the pilot program.  

3. Concertation process with local communities, leaders and health authorities at a national and local level to determine a collaborative plan for the implementation of the pilot and the scale-up. This will include the prioritization of the municipalities that will participate in the pilot and methodologies for the cultural adaptation process. 

4. Designing the platform according to the needs of the local key agents and in collaboration with them. 

5. Validation of the platform with communities and key agents and implementation of recommendation accordingly. 

6. Pilot the platform in prioritized municipalities, including an accompaniment process by Sinergias while training key agents.

7. Final evaluation of the pilot process and implementation of recommendation according to the results to the platform and its contents. 

8. Scale-up within the Department. 

   1. Design of the working plan with local, national and community actors and baseline measurement. 

   2. Constant support from Sinergias to the local authorities on the implementation of the platform using a blended modality. 

   3. Constant monitoring and evaluation of the process and its results. 

   4. Transferring the knowledge of the process to decision makers for inclusion in public policy.

9. Parallel: multilevel advocacy and communication plan to publicize and promote the use of the platform at various levels.  

The core technology is a digital learning platform that will allow us to store a toolkit with key methodologies and information for healthcare providers and community members. As well, the platform will allow us to conduct online and blended training for healthcare providers and administrative staff of health institutions. Furthermore, it will be linked with data analysis tools that will allow the health personnel to analyze existing data to make informed decisions. It will also integrate the tools required to do the quality improvement territorial plans. The platform will have a simple design, accessible and friendly for all types of users. Our biggest challenge is to adapt it to municipalities with low connectivity and to ensure that the platform will be widely used. 

Sinergias has developed a work culture with customs and practices that do not discriminate against any worker on any ground. Our Code of Ethics is built on the principles of diversity, coherence, transparency, inclusivity, flexibility, commitment and expertise. Because our work revolves around human rights, social justice and human dignity for all genders, races, religions, nationalities, ethnicities, ages, disabilities, socioeconomic and political perspectives, we advocate for and ensure that our own team is the first one to commit and put into practice these principles. Our main team is composed 80% by women and 30% by indigenous and rural leaders. Likewise, we assign most of our resources to projects located in territories where the population is mainly indigenous, understanding that these are the most marginalized regions where government resource allocation is the most scarce. 

 Regarding our alliances and field work, we firmly believe that the bases for all ethical and responsible work are found in the constant collaboration with different institutions and ethnic and rural communities, joining efforts to articulate effective solutions to specific health problems. For this reason, our projects avoid top-down approaches. Instead, our field work is based in participatory methodologies that allow the local voices to communicate both their concerns and interests and be actively involved in the development of solutions. In order to achieve this, we have ensured since 2012 that around 70% of our hired team consists of local workers that are from the communities where the project will take place. Most of these are indigenous nurses and public health workers that have the knowledge and experience of the health situation in the setting and that, due to their background as health professionals, allow for effective articulations between Sinergias’ work and the public healthcare system’s services.  

Finally, our decade-long work revolves around the empowerment of the silenced voice of indigenous and rural minorities and the strengthening of their local capacities. We constantly seek to include the diversity of voices within each indigenous and rural communities as well, ensuring that underrepresented groups such as women or people from the LGBTI community are heard and taken into account equally. For this, we established alliances during our founding years with indigenous and rural women who are community leaders, and have continued collaborating with them in our projects up until today.    

The content of the platform has 3 key target groups and the information available will be different for each one. The community and women will have free access to the tools and information needed for them to receive health services for them and their children and to provide useful context adapted recommendations, acknowledging their disadvantage and historical marginalization. The value will rely on contents that are adapted to their needs, languages and cosmovisions, developed with community leaders. 

On the other hand, decision makers and health institutions -public and private- will have a certain level of access to free contents, however, in order to develop the complete methodological healthcare quality improvement process they have to register and pay a fee to receive full support form Sinergias. As such, the platform will offer courses and selected tools that will generate revenue that will be re-invested in the work of the organization and the sustainability of the platform. The courses have been and will be designed to help health institutions to fulfill the requirements established in Colombian law to acquire certifications and upgrade their qualifications; focusing on the existing knowledge and training gaps, starting with basic antenatal, delivery, newborn and obstetric emergency care and breast-feeding counseling. The methodologies and contents have been designed using participatory strategies and including key stakeholders, such as community members, health practitioners, and administrative staff. External partnerships with universities, health directorates, hospitals and other civil society organizations have been established and additional ones will be included. The courses will have tutors and professors from recognized hospitals and academic institutions; allowing us to produce quality content and generate economic value. 

This strategy intends to create a social impact by reaching marginalized communities in an accessible way and strengthening the abilities of those who serve them. The revenue of the platform will be a funding mechanism to expand the mission of the organization using a combined model of service subsidization and organizational support. 

Scaling up and expanding coverage in territories and populations is not an easy task for an NGO. Even less so is it to endure over time and to ensure that people identify the achievements made with each step and remember them as the result of joint planning and effort. To achieve this, the main strategies Sinergias has used are framed in cyclical exercises of joint planning, reflection/evaluation of results and, based on these, new planning cycles. This requires a rigorous analysis of qualitative and quantitative data - for which Sinergias has the best human talent in the social and public health fields - as well as constant dialogue between institutions and communities to build bridges and strengthen alliances. This mix of rigorous studies, continuous socialization of results and joint reflection on progress/retreats has opened doors for us to obtain resources and to position ourselves in the academic world and in the local sphere.

Specifically for the platform, we will create an academic and training offer for professionals that responds to their personal needs and those of the institutions they work for. We have already offered courses that have been requested by the Ministry of Health and regional secretariats of health. Private and public health institutions have a gap in their training, a gap that Sinergias plans to remedy and in parallel generate funds that will come into play with the mentioned sustainability strategies. We are and will be working on public-private partnerships for its financing through contracts with territorial entities, health institutions and projects that finance these processes; in addition to some individual contributions from people who want to be trained in specific topics that we can offer on the platform.

The quality of our work has been recognized at a national and international level by organizations such as  GSK, Save the Children and Merck for Mothers. Our work in alliance with grassroots communities, public and private actors, in areas of knowledge little explored, has made us a point of reference for organizations such as the IOM, UNICEF, PAHO and the Colombian Ministry of Health, which have sought us out directly to work on projects in favor of the health and development of the country's rural and indigenous populations. In addition, Sinergias has built alliances with academia, civil society organizations, and the institutional sector, ensuring that the work can be replicated and is of benefit to key actors. 

An example of this success is the work done in maternal and child health care where Sinergias has worked on strengthening local capacities to improve access to quality and culturally adapted maternal healthcare services, challenging social dynamics and positioning women as key actors in communities’ health. With international funding, we implemented projects to improve the follow-up of mothers living with HIV and their exposed children, as well as to improve the PMTCT and congenital syphilis prevention programs in all departments of Colombia. This work continued, with MSD, in Bolívar and Cauca, where healthcare services have been historically lacking and MMR rates are among the highest in Colombia.  We mapped the health situation with stakeholders and co-defined a roadmap to improve maternal-perinatal care quality. We trained nearly 15.000 professionals and women, monitored health indicators, co-constructed health promotion strategies, among others. ANC, delivery, postpartum and newborn care indicators notably improved; and MMR notably decreased. 

This quality of this work made a sustainable impact on the public institutions that still implement some of the best practices learnt. And, it was recognized with the  Kenneth C. Frazier Award for Maternal Health Equity, which was accompanied by resources that are permitting us to continue with the work. The outputs of this work, such a course on breastfeeding and newborn care have been sought by secretariats and hospitals, resulting in contracts and alliances. These last will help us improve the sustainability strategies that have been working for over 10 years.