Long before I became a physician or heard the phrase “health systems,” I found myself in a situation where I had to understand and improve one.
The importance of client-centered care in the context of health systems strengthening was an early and important global health lesson that I learned in the mid-1980s while volunteering abroad. I had just graduated from college and was contemplating medical school when I spent a year in the small village of Nepeña on the desert coast of Peru. In this village with no running water and limited resources, I saw firsthand why clients needed to be at the center of the health system conversation.
Every week or so, a doctor would travel 40 kilometers from the nearest city, Chimbote, to our village clinic to see patients. People would walk out with prescriptions for basic medicines from the doctor, but they would never actually get those medicines: There was nowhere nearby to buy aspirin—much less penicillin or blood pressure pills. The prescriptions had no value.
One evening in the plaza, I was talking to Rita, the woman who had helped to establish the village library. We began talking about what we could do to make medicines available to the people of Nepeña. She said, “We need a botiquín popular – a community dispensary.” With that, my volunteer project was launched. After consulting with the doctor to compile a list of important medicines, we built a locked cabinet, bought our first stock of medicines and established a plan for sustainable funding through clients’ purchases.
Decades later, I’m even more convinced of the importance of putting people at the center of health systems, and particularly quality improvement initiatives.
It is important to overcome the misperception that client-centered care is not a realistic goal in low-resource settings where there might be complicated structural and sociocultural barriers. In recent years, care has evolved from a traditional top-down model of care for clients to a more collaborative model of care with clients, and now toward a new model of care by clients—where clients are the drivers, and providers are the facilitators. Not surprisingly, clients assign greater value to care when they are direct participants. It’s all about perceived value.
With that enhanced perspective on increasing women’s perception of the value of care, Jhpiego has begun implementing a group-based model of antenatal care (ANC) in response to the problems of low attendance and poor quality that plague traditional ANC. Globally, only 58% of women attend at least four ANC visits. For too many women, traditional ANC doesn’t provide enough return on their investment, so it’s a real opportunity cost for them. Group ANC, however, vastly increases that return on their investment. Women clearly see its value.
In Nigeria and Kenya, where Jhpiego is leading a group-based ANC research study, pregnant women are active participants, providers and leaders throughout the care process. Upon arriving at the clinic for a group ANC session, the pregnant women take each others’ blood pressure, weigh each other and ask about the baby’s movements. This model reinforces the idea that each woman plays a critical role in the success of her own pregnancy – and in that of her fellow group members. A midwife or other clinical provider is still part of the model, offering one-on-one private appointments to each woman, but the clients are at the center of their own care.
Preliminary results of this group ANC model indicate important improvements in the quality of care, the number of ANC visits and in the relationships between clients and their midwives. We hope this new model will result in increased retention throughout the ANC continuum, more facility-based deliveries and better outcomes for mothers and babies.
Health system transformation happens when a pregnant woman—or any patient for that matter— believes that her health care is of great value, and is put at the center of care. That is where she has belonged all along.
Read more about group ANC on the MHTF blog.