Can communities become too engaged in global health initiatives? And how to measure their existence?

By Dana Greeson (Columbia University) and Karen Grépin (Wilfrid Laurier University)

The success of health initiatives depends on how they are accepted by target communities. Do community members perceive the initiative as addressing a priority issue? Is the intervention culturally sensitive? Is there buy-in from community influencers? We look at what happened when communities in Zambia accepted a package of health interventions and augmented it with a punitive measure.

In 2012-13, we conducted an external evaluation of the Saving Mothers, Giving Life (SMGL) program – a public-private global health initiative (GHI) that aimed to dramatically reduce maternal and newborn mortality in Zambia and Uganda.  The ambitious SMGL program targeted both supply and demand interventions, aimed to change health behaviours, and promoted community engagement to increase facility delivery rates.

As part of this evaluation, we collected large amounts of quantitative data on program implementation, including the number of health workers trained and the number of facilities upgraded.  We also conducted focus group discussions alongside quantitative data collection to assess community experiences of SMGL at the conclusion of its first year.  Participants included women who recently delivered at home, women who recently delivered in a health facility, community health workers and local leaders.

In nearly all of the focus groups in Zambia, interviewers reported hearing about an unanticipated local adaptation to the SMGL program: some traditional leaders had imposed penalties – most commonly fines of cash or livestock – on women who gave birth at home after the introduction of the SMGL program.  These penalties were not part of any formal directive of the SMGL program and were not included on any of our quantitative survey instruments as they were not intended component of the program.

This unanticipated finding prompted us to follow up our external evaluation with a paper in Health Policy and Planning called ‘Local adaptations to a global health initiative: penalties for home births in Zambia’.

We learned that traditional leaders had introduced the penalties as a means to rapidly increase rates of facility delivery and thus comply with the aims of SMGL and national health goals. While many women reported that the use of these penalties might increase their likelihood to deliver in a facility, or that it influenced their decision on their last delivery location, there were also reports that penalties might be reducing utilization of postnatal and child health services. Perhaps motivated by the penalties imposed by traditional leaders, some providers began charging women who delivered at home for child health cards provided for free by the Ministry of Health.  After analyzing our data, we notified SMGL implementers, including Ministry of Health officials, about the practice.  Program implementers emphasized that charging families for not delivering in a facility is illegal and unethical and they communicated this message to communities and facilities across the country in order to mitigate the potential negative effects of these unintended penalties.

The existence of these penalties raises the questions of whether it is possible for communities to become too engaged and the roles and responsibilities of international and local partners in the implementation of global health initiatives.  Engaging communities is necessary to ensure program success and local adaptions are likely to enhance program implementation, but what happens when the measures taken go against the intention of program implementers?

In this case, there are no easy answers.  But our unexpected findings underscore the importance of including qualitative methods alongside other more quantitative evaluation study designs. Focus group discussions gave participants a platform to expand on their experiences and facilitators were able to probe when unexpected consequences, such as penalties, surfaced.   Unexpected program effects may be unintended, but they are not unusual, and therefore evaluation studies should be designed to anticipate and monitor for both intended and unintended effects.  Qualitative research methods, such as focus group discussions, may be one such way to help monitor the unexpected effects of programs.

Local adaptations to a global health initiative: penalties for home births in Zambia paper in HPP: 

Image credit: Dylan Walters