Cotopaxi EONC Project

USAID/CSHGP - CHS/Ecuador

Presenter:Mr. Andrew J GallContributorsDr. Kathleen HillDr. Jorge Hermida

Brief Introduction to CHS-Ecuador Child Survival Project

Process of addressing equity issues: ◦ Step 1: Understanding equity issues in project area◦ Step 2: Identify disadvantaged group to focus on◦ Step 3: Decide what is in project’s manageable

interest to change

Concluding thoughts about steps 4-6 for the CHS-Ecuador Child Survival Project

Cotopaxi Province Figures

Population 384,499

Project Target Population

(Women, Children,Infants)

72,437

Poverty Level 90.47%

Rural Population 67%

Indigenous Population 28%

Maternal Mortality 102 Deaths per 100,000 Live Births

Newborn Mortality 7.8 Deaths per 100,000 Live Births

ProvincialHospital (Surgery & Blood 4 hours)

CountyHospitals

AmbulatoryHealth Centers

(Parish Level)

TBAs(Community Level)(3,000 deliveries)

1,500 deliveries

Ministry of Health(3,000 deliveries)

Social Security NGOsPrivateproviders

Cotopaxi Provincial Health System: Fragmented; no continuum of care; inequitable access; poor quality of care

To reduce maternal and newborn mortality and morbidity in Cotopaxi province

Improved household health promotion practices and utilization of a continuum of high-impact community- and facility-based maternal newborn services provided as part of a coordinated network of CHW’s, health facilities

and social organizations.

Increased availability/ access to a coordinated

continuum of high-impact maternal

newborn care provided as part of a network of community and facility

services.

Improved knowledge / demand for evidence-based community and facility MNC services, including improved household health

promotion practices.

Improved quality of MNC services provided as part of a coordinated network

of CHWs and facilities

Improved policy environment for

coordination among community health

workers, health care institutions, and

community /social organizations

Goal/Impact

Strategic Objective

Results/Outcomes

1 2 3 4

Baseline Assessment addressed Steps 1a. and1b.

Methods:

Random selection 462 households rural parishes Cotopaxi Province (using census data)

Household Survey Questionnaire focused on: Project, OR and Rapid Catch Indicators

TBA assessment (qualitative and quantitative)

Reported

Service

Coverage

Reported Site of

Service Delivery

Total Sample

N=462

Indigenous

Indian

(28%)

Non-

indigenous

(72%)

Antenatal Care (4

sessions)

Health Center 88%

TBA/CHW 1%

Other 11%

69% 49% 77%

Skilled Delivery Care

Hospital: 51%

Health Center 9.5%

Private Clinic 13%

74% 36% 89%

Early Post-Partum Care

Home: 10%

Clinic/hospital 50%

Private clinic: 8.4%

5.4% -- --

HH Survey: Main reasons given by women for delivery at home included:

Traditional Practices: 37%

Geographical barriers: 18%

Not enough time: 23%

Lack of money: 6%

TBA focus groups highlighted TBA perceived lack of recognition by MOH facility providers

Lack of functional referral processes between TBAs and MOH institutions. For example, MOH facility health personnel do not respect TBA referral forms recommended by MOH provincial cross-cultural health (“Salud intercultural”) guidelines.

Baseline assessment results confirm lower coverage of high impact maternal newborn services for indigenous women as compared with non-indigenous women.

Based on baseline assessment results and cost considerations, final project strategy:

Prioritize parishes that meet one or both of 2 criteria:

◦ A. > 50% poverty level (national survey data)◦ B. > 50% indigenous Indian population (national survey

data)

Geographic Scope:

21/40 (52.5%) Cotopaxi parishes targeted

Step 4: Define equity goals, objectives and operational definition:

Step 5: Determine Equity Strategy◦ Increase coverage and quality of high impact home-based

MNH services (provided by TBAs & parish micronetwork health teams)

◦ Improve cultural responsiveness of institutional childbirth services

◦ Improve referral systems

Step 6: Develop Equity Focused M&E◦ Our project prioritizes parishes with high proportions of poor

and indigenous women◦ Could stratify selected indicators at baseline/endline for

advantaged vs. disadvantaged groups