Maternal mortality and “citizen surveillance”: a Peruvian case study

1. Maternal mortality and “citizen surveillance”: a Peruvian case study Ariel Frisancho National Co-ordinator Health Rights Program CARE Peru afrisancho@care.org.pe afrisanchoarroyo@yahoo.es International Roundtable on Maternal Mortality Human Rights and Accountability Clemens Nathan Research Centre, IIMMHR, SAHAYOG, CARE Peru, Health Equity Group (East Africa) and the Essex University Human Rights Centre Geneva, September 2nd, 2010

2. Background Peru: middle high income country Deep inequities, discrimination, and poverty High incidence of morbidity, mortality and prevalence of avoidable illnesses and deaths in poorer and indigenous communities Poor health system management / monitoring Little respect on HRs; non judicial resources Participatory Voices/No Woman Behind Projects Builds alliances with civil society networks, grass-roots organizations and Ombudsman office to improve quality of maternal health services of poor, rural Andean women through the development of social monitoring mechanisms

3. Actor- Oriented Approach to Promote Accountability Since 2008, citizen surveillance mechanisms are spearheaded by women monitors (“vigilantes”), working on a voluntary basis within local areas (i.e. Puno Region: 40 vigilantes for two provinces, 3 health posts, 3 health centers and one local hospital in each) After attending a series of capacity-building workshops, each vigilante receives accreditation and they plan their visits to health facilities They visit health centers’ officers and explain the mechanism to health providers

4. Women surveillance for accountable health services The vigilantes visit the health facilities 2-3 / week, stay 6 hours. They make direct observations and conversations with female patients in their native language On the basis of their findings, they produce regular reports and analyze them monthly with the regional Ombudsman's office, CARE Peru and ForoSalud members They prioritize the findings, both the good and the bad, and construct a “dialogue agenda” which is presented to the health care networks / hospital directors and health team, to agree commitments of improvement

6. Results • Identification of practices that were deterring women from utilizing services, such as unavailability of services at times of day most needed and charging for medicines and services that were meant to be free • Space for a sustained, systematic dialogue on what women expect from the health care system and the achievements and pitfalls of health care delivery • Commitments to improve health care (opportunity, treat, information, language, culture appropriateness)

7. “When I introduced myself with the hospital doctor he asked me: ‘What is all this ‘Quality surveillance’ thing about? Here we are working hard, you should be doing the same instead of losing your time…or would you like me going into your home and watching all what you make there?’ I told him ‘Doctor, we are vigilantes and we have been trained for this activity. We know the laws. You can not go to my home because my house is private, but I can come to the hospital because this is a public service, and here are my credentials…” Nilda Chambi, Azangaro women leader

8. Empowerment of women community leaders • Medical practitioners and health authorities more accountable to people’s needs • Improvement in obstetric care, child care • Increased demand of maternal health services and institutional birth deliver • Increased general awareness of rights among health authorities and within patients and local communities

9. Lessons Learned • Improving the health of the poor and marginalized in countries with deep, unjust inequalities can not be achieved solely through technical interventions and funding: significant, sustainable change will only happen if the poor and their leaders have a much greater involvement in shaping policies, practices and programs and ensuring what is agreed actually happens • Key Partnership and alliances with public and private actors to increase women’s agency and to address unequal power relations

10. Lessons Learned • International human rights framework/principles used at a local level in an effort to strengthen the quality of attention given in health service delivery • Accountability based on dialogue and governance strengthening, not “name and shame”: building mutual understanding, confidence and credibility • Challenges: poor quality and performance standards, weak local management of health services, discrimination • High officers turn-over

11. Advocating and Promoting Political will Visit of Peruvian Minister of Health to Ayaviri and Azangaro (Puno):national norm for institutional recognition of citizen surveillance initiatives (2008) Advocacy and technical assistance: Peruvian MoH has taken into account for the design of the current Health Sector Reform Policy (promotion of social surveillance of its implementation and development) National Health Quality Guidelines include as the 12th National Health Quality Policy the promotion of citizen surveillance

12. “Changes are not from night to day. It seems to me that some doctors and mid-wives have begun to understand why we are doing this voluntary work….little by little they will realize their work also gets improved” Eusebia Atayupanqui, Leader from Ayaviri