“We recognize that what we’re talking about is a journey, but we also recognize that people have dreams for themselves and what this is about is helping them achieve those dreams,” said Ellen Starbird, Director of the Office of Population and Reproductive Health at USAID, at a recent Wilson Center event about the importance of community health systems, with a particular focus on voluntary family planning and infectious disease prevention. This two-panel event focused on how USAID’s Advancing Partners & Communities (APC) project worked together with communities and partners to strengthen health systems and to support countries on the journey to self-reliance said Starbird.

Strengthening Family Planning

Family planning, or the notion that people can and should attain their desired number of children and spacing of pregnancies through the use of contraceptive methods, is crucial in global development. If the need for family planning were met, an estimated one-third of all maternal deaths could be prevented. A. Jean Affo, Chief of Party for APC Benin at JSI Research & Training Institute, Inc., told the story of his little sister who married at 15 and had 8 children. Complications during the birth of her seventh child almost killed her at age 30. After the birth of her eighth child, Affo and his wife, who is a midwife, helped his sister get family planning. She managed to avoid another pregnancy for the rest of her life.  

Like Affo’s sister, women suffer every day because they lack access to information about family planning. In addition, other barriers to implementing effective family planning programs include inadequate supply of contraception and family or community disapproval. “Traditional attitudes still prevent women from learning how to space their births,” he said.

To address the opposition to family planning, it is crucial to operate at the community level, particularly with religious leaders who tend to be men, said Susan Otchere, Project Director of Mobilizing for Maternal and Neonatal Health through Birth Spacing and Advocacy (MOMENT) at World Vision U.S. The key was to focus on birth spacing in the beginning, and not family planning. “Birth spacing” was appropriate to discuss with Muslim religious leaders, because it fit in with the teachings of the Quran, she said. Eventually, “the road did lead to voluntary use of family planning because you can only obtain birth spacing through the use of a family planning method,” said Otchere. “I think having the faith voice in our work will help us move the needle,” she said, especially when talking about family planning.

In 2014, the APC project was launched in Agago, a district in northern Uganda that was particularly conflict ridden at that time. After 3 years of trying to promote family planning in this area, Frederick Mubiru, Chief of Party for APC Uganda at FHI 360 said, USAID asked them to shift gears to address the sociocultural factors that affect the uptake of family planning. The first step they took was implementing fertility hotspot mapping to identify areas with high-fertility and high adolescent pregnancy. Then they worked with stakeholders in the area to create tailored interventions. Mubiru said one of the largest forces of opposition in Agago was the lack of male spousal support, which they addressed through a program called Emanzi, which translates to ‘male role model’ in the local language. Emanzi is a nine-week curriculum on gender issues that includes couple communication and joint decision-making. The success of the program in Uganda was largely due to working in partnerships with the local and national governments, and using evidence to create tailored and adaptive interventions that address the deep-rooted barriers and social norms said Mubiru.

Tackling Infectious Disease

Increasing community capacity to better prevent infectious diseases is an important facet of APC. Infectious diseases run rampant in developing countries, causing around 30 percent of deaths in low-income countries. Most recently, the 2014 Ebola crisis in West Africa was the largest, most severe Ebola epidemic in history. Although Liberia, one of the countries most affected by the epidemic, has been Ebola-free since January 2016, “the crisis did not end with the last patient being discharged from the Ebola treatment unit. The post-Ebola period came with its own challenges and issues,” said Dr. Rose Macauley, Chief of Party for APC Liberia and Country Representative for JSI Liberia.

Some of the issues they tackled included stigmatization of survivors, who were asked to leave their communities, she said. With APC’s help, Macauley and her team met with community leaders to assure them that the survivors were no longer contagious and to get them health services, as needed. APC focused on survivors and their needs, to include access to mental health services. In a country with only one psychiatrist for 4.5 million people, capacity building, to include training of mental health clinicians, was also important. With APC funding, Liberia was able to implement the APC Ebola Transmission Prevention and Survivor Services Program, further building community capacity through direct assistance and technical support.

After the 2010 earthquake in Haiti, there was a dire need to address the infectious disease crisis. Cholera outbreaks claimed the lives of thousands of Haitians, but with funding from APC, Haiti was able to strengthen an existing successful sanitation program. “With the community-led total sanitation strategy, one of our successes was that the percentage of children with diarrhea dropped from 40 percent at the baseline to 4 percent after the intervention,” said Dr. Florence Jean-Louis, Director of Human Development at Fonkoze in Haiti.

The Power of Partnerships

As the name suggests, a core aspect of the Advancing Partners & Communities project is partnership. For APC, it was important to build strong partnerships on the community level, as “local organizations should be key actors in the work for sustainable development, since they are the ones who stay, who strive, who sustain effort with no termination date,” said Dr. Jean-Louis.

Local partners benefit from working with APC, as well. By partnering with local organizations, APC is able to help them both enhance their organizational capacity and systematize their delivery, said James MacNeil, Vice President of World Education. Sometimes, he noted, just asking people in the local community how they are doing and what an organization can do to help them can catalyze action. APC recognized early on that “you need to build the capacities of the partners to be able to collect, analyze, monitor, report, and use the data that they have,” said Chamberlain Diala, Senior Technical Director of APC at FHI360. They also helped partners identify areas of high need and low capacity, he said.

During the past seven years, APC has strengthened health services in more than 40 countries through multisectoral approaches involving diverse partnerships. These partnerships and the “power of communities” were noted by Liz Creel, Project Director of APC at JSI as central to APC’s success in advancing community health and aiding communities along the path to self-reliance.