- Nairobi
- Mumbai
- Jakarta
- Mexico City
- Rio de Janeiro
Katy Fentress, Nairobi Community Manager
Getting medical information can be a challenging process for impoverished people who lack both computer access and efficient national health care systems.
When clinics are far away or difficult to reach and outreach programs go widely unpublicized, it can be painfully difficult for a woman living in an informal settlement to keep track of what immunizations her children have had and what needs to be done to ensure they receive the medical examinations they need to grow up healthy.
Although there are actually many clinics that operate within Nairobi’s slums — many of which have now been mapped through community mapping projects like Map Kibera — it remains a challenge for health practitioners to maintain communication with patients who do not have a postal address and can be difficult to track down.
Without the ability to maintain regular contact with their clinics, young mothers — who already lack adequate information about the best choices to make for their children — easily slip through the medical net. As a result, their children are at severe risk of falling sick and possibly not surviving a disease from which they should, in theory, have received immunization.
According to the Kenyan constitution: “Every person has the right to a clean and healthy environment.” The constitution further stipulates that everyone should have the right to have access to good, affordable health care.
Although there is no such thing as universal health care in Kenya, children under five years of age do, in fact, receive all their immunizations free of charge. In view of the fact that most of the important vaccinations are made before a child is five years old — think diphtheria, tetanus, meningitis, measles, and mumps, to name a few — it has become a matter of paramount importance to find a system which will ensure that children living in marginalized communities are guaranteed the same health care as ones living in more affluent areas.
As part of a quest to solve this puzzle, different clinics are trying to harness their limited resources to build up a technology that could be used to tackle the problem. In Nairobi, a pilot project was launched, first in an informal settlement in Dagoretti constituency, and more recently in Kibera.
The project’s name is M-chanjo, and its aim is to harness the power of mobile phones — ownership of which has increased tenfold over the last ten years in Kenya — to keep patients up to date on their upcoming inoculations and on any outreach programs that are due to take place in the area.
M-chanjo
The word m-chanjo comes from Swahili, with the “M” standing for “mobile” and the suffix “chanjo” meaning “immunization.”
The M-chanjo idea is pretty straightforward: by taking advantage of the low SMS sending costs that are now widely available to the public, clinics can draw up a large database of parents, to which they send automated messages on a regular basis.
The idea behind the text messages is to go beyond a simple reminder service and try to include a wider array of tips and suggestions to help parents both prevent and cure their children’s everyday medical problems.
The clinic currently spearheading the project in Kibera is called Ushirika and has been active in the slum for a number of years. In an effort to include as many people as possible in the trial program, clinic staff spent time in the field carrying a mobile device of their own with which they could register children into the database.
Ushirika medical clinic, which serves several thousands of people monthly, aims to provide quality and affordable health care to the community members. In addition to the clinic’s emphasis on curing illness, its staff also is deeply involved in disease prevention.
“You have no idea how much time this system saves us,” says Dr. Fidelis Mutinda, the GP who runs the clinic. “So far we feel so positive about the outcomes of the pilot project that we are thinking of extending the service to patients suffering from HIV.”
Dr. Mutinda goes on to explain that although the technological aspect is essential to ensuring the effective delivery of information, at Ushirika clinic they do not want to undervalue the importance of direct personal support and that they strive to provide a human touch and quality health care to their patients.
The concept behind M-chanjo is practical and there are not many obvious limitations that would keep it from being successful. So far, the Kenyan government appears not to have pulled its weight with respect to the project, leaving the trial phase to private clinics that have limited resources and are not able to expand their reach in a significant way.
It seems clear, nevertheless, that if Kenya as a country is to achieve the fourth of the Millennium Development Goals (MDGs), the government should take advantage of health applications such as the one offered by M-chanjo. If operations like this one were scaled up, it could save many human lives that would otherwise be unnecessarily lost.
Submitted by Katy Fentress — Mon, 07/30/2012 – 00:00
In the foreword for the Mumbai Human Development Report (MHDR) in 2009, Kumari Selja, the Minister for Housing and Poverty Alleviation, states: “…Mumbai contributes 33 percent of income tax collection, 60 percent of India’s customs duty collection, 20 percent of India’s central excise collection and 40 percent of India’s foreign trade … yet the city’s slums get less than 90 liters per capita of water daily. Studies have indicated that in certain slums of Mumbai there is an average of 81 people to each toilet seat available. And only 31 percent of Mumbai’s slum dwellers are likely to complete 10 years of schooling.”
Given the state of the city, Innovation Alchemy recently hosted an Alchemix discussion on urban issues at Bombay Connect, an incubator and co-working space for social entrepreneurs in Mumbai. The session focused on the need and opportunity for breakthrough innovation designed for, and implemented with, the urban poor — a rapidly growing challenge in urban centers such as Mumbai, where 54 percent of the population (more than 10 million people) lives in slums.
The discussion featured two social enterprises: Swasth India and WaterWalla. Swasth, represented by founders Ankur Pegu and Sundeep Kapil, provides low-cost and discounted health care services to slum dwellers in Mumbai and has set up one-stop, integrated health centers that provide low-cost diagnostics, consultation, testing facilities, and pharmacy services. WaterWalla, represented by Soaib Grewal and Jennifer O’Brien, sources and introduces clean water technologies into slums, with a strong emphasis on research and data collection to better understand the problem of water contamination and how to solve it.
Presentations by the social entrepreneurs were followed by questions focused around the following key areas:
- What are the most critical need areas for social and development impact in the urban context?
- What does it take to succeed with a market-based model in urban slums?
- What are the funding challenges for urban-focused social enterprises?
Highlights from the discussion included the following:
- Urban poverty is a poverty of infrastructure and access to resources. As the Mumbai MHDR study highlighted, slums are intensely populated, creating huge pressures on limited resources. Even though people can pay, infrastructure and resources are just not within reach. Waterwalla found that individuals living in unregistered slums in Mumbai were paying twice as much for water as five-star hotels in the city were paying. The water mafia in the region have absolute control over the supply of water, giving them full power to choose when, where, and how much to charge for the water they dispense. Swasth India shared similar insights. Doctors prescribe expensive drugs since they are given incentives to do so — while a large number of equally effective, lower-cost drugs are available in the market which have completed their patent lock-in periods, but these are not on the prescription list of any of the local doctors. Slum communities are paying for these services, but they are paying a lot more and getting a lot less in return.
- Products and solutions exist; however, the supply chain is fragmented, expensive, ineffective, and exploitative. Both Soaib Grewal and Sundeep Kapila highlighted the availability of solutions that can be used effectively in the slum context: over 3,000 different low-cost water filters and a large set of low-cost, high quality drugs that could be used effectively. The gap — and the opportunity — is in the absence of an effective, intelligent, socially relevant supply chain. And this gap is where many social entrepreneurs can come in, bring down costs, introduce more cost effective solutions and find ways to build market-based models. Both Waterwalla and Swasth India are in this space — integrating the value chain, lowering costs, and improving access.
- Slums are “data-poor” regions, and therefore the challenge is one of visibility, transparency, and measurement of social and economic impact. In addition to providing access to products and services, a social entrepreneur who chooses to work in slum communities has to adopt data collection techniques, build deep networks within the local communities, find ways to track and monitor data, and slowly build a repository of community information which can be used to build insights and intelligence for scale. All patients who come to Swasth Centers become members of Swasth India, their medical records are tracked, and every transaction is recorded and maintained. Similarly, Waterwalla has invested time in measuring the quality of water over periods of time and across usage patterns to determine insights that can help it to scale.
- Prototype, prototype, prototype: Both teams who shared insights are at an early stage of development, spending time prototyping, piloting, and building insights on the ground. No silver bullets exist, and given the immensely challenging conditions within slums, this is not quick development. Trust is a huge factor in the adoption of these services, and both teams have learned that they have to spend time in winning that trust by demonstrating that their ideas have a value. The Swasth team set up three centers in different areas of a particular slum before realizing how to cover their operational costs and run a successful health center. The first center is at the corner of a slum, the second near a bus stop with more foot traffic, and the third in a busy market area adjoining slums.
Experimenting with new ideas and products seems to be an essential aspect of developing a strong, high impact, social business model. In the first few years, social entrepreneurs are probably very much a combination of entrepreneurs and social scientists, constantly prototyping and collecting data to develop deeper insights, building, and tweaking their models accordingly.
But being a social scientist does not guarantee cash flows, and many social entrepreneurs find funding and working capital to be inadequate. The need for patient capital was a big discussion point at the Alchemix session, also highlighting the need for grant funding and philanthropic capital which can be more innovative, more risky, and more empowering in these early stages while the social scientist/entrepreneur finds ways to sustain his or her enterprise model. A recent report by the Monitor group and Acumen reveals that “..the MFI sector received $20 billion in subsidies from philanthropists and aid donors to refine its model over two decades,” highlighting the critical role of grant capital in filling a void before impact capital can really play a part.
Alchemix is a curated, open forum discussion among entrepreneurs, innovators, investors, creative minds and engaged citizens. The series was launched by Innovation Alchemy, a collaboration-consulting firm based in Bangalore, India, applying innovation thinking to problems of business growth, scalable social impact and sustainable profitability. Alchemix takes a deep, insightful look at high-impact social models from an innovation lens.
Submitted by Carlin Carr — Mon, 07/30/2012 – 00:00
Julisa Tambunan, Jakarta Community Manager
Sakit bukan pilihan bagi warga miskin Jakarta yang tinggal di perkampungan karena mahalnya biaya pengobatan yang harus ditanggung jika mereka jatuh sakit. Di sisi lain, menjaga kesehatan pun tak mudah, dengan seringnya terjadi epidemi akibat kondisi pemukiman yang buruk seperti demam berdarah, diare, dan tifus. Apakah asuransi mikro bisa menjadi jawabannya?
Dilarang sakit, dilarang sehat
Dengan jumlah penduduk kasar mencapai 10 juta orang dan setengahnya tinggal di perkampungan kumuh, layanan kesehatan yang merata menjadi tantangan besar bagi kota Jakarta. Rata-rata tiap rumah sakit mampu menampung sekitar 100 ribu warga saja. Sementara satu Puskesmas (Pusat Kesehatan Masyarakat) yang jumlahnya lebih banyak namun dengan fasilitas yang jauh lebih terbatas mampu melayani sekitar 25 ribu warga. Dengan jumlah dokter umum saat ini, maka hanya ada satu orang dokter untuk lebih dari seribu warga. Jumlah dokter pun tak merata. Data tahun 2009 menunjukkan jika Jakarta Timur hanya memiliki 372 dokter, sementara Jakarta Selatan yang didominasi penduduk kelas menengah memiliki hampir tiga ribu orang dokter. Bicara jumlah, kapasitas pelayanan kesehatan tersebut jelas tak mampu memenuhi kebutuhan warga Jakarta. Apalagi jika ditilik dari segi biaya dan kualitas pelayanan. Berdasarkan hasil survey yang dilakukan oleh Yayasan Tifa pada tahun 2011 di Jakarta Pusat, 75% warga miskin yang menjadi responden mengaku mendapatkan pelayanan sangat buruk.
Karenanya, warga miskin Jakarta tampak tak punya banyak pilihan. “Kalau sakit mendingan obati sendiri saja, kalau ke rumah sakit malah makin sakit gara-gara lihat biayanya,” ungkap Irwan, warga kampung Kapuk Muara yang berprofesi sebagai tukang ojek. Padahal, kondisi perkampungan kumuh menyebabkan warga miskin sangat rentan terhadap penyakit. Buruknya kondisi air dan sanitasi, serta pola hidup yang tidak sehat, menyebabkan warga sulit unutk tetap sehat sepanjang tahun.
Sejumlah lembaga swadaya masyarakat, seperti PKPU yang sebagian besar sumber dananya berasal dari zakat masyarakat, berusaha untuk meningkatkan akses terhadap layanan kesehatan dengan meluncurkan program seperti Prosmiling (Program Kesehatan Masyarakat Keliling) Terpadu di kampung-kampung kumuh Jakarta. Program ini merupakan klinik berjalan yang “menjajakan” berbagai fasilitas kesehatan seperti pemeriksaan dan pengobatan gratis. Dengan jumlah penerima manfaat mencapai puluhan ribu, sistem ini seharusnya bisa berjalan baik. Sayangnya, implementasi program tidak dilakukan secara berkesinambungan di satu daerah, melainkan berpindah-pindah. Jarang ada satu daerah kedatangan klinik berjalan ini lebih dari sekali.
Skema jaminan layanan kesehatan pemerintah?
Pemerintah Provinsi DKI Jakarta, dalam berbagai kesempatan, menyatakan bahwa pelayanan kesehatan untuk warga miskin di Jakarta sudah semakin baik. Namun pada kenyataannya, pemberian pelayanan kesehatan secara gratis bagi warga miskin di Jakarta, belum sepenuhnya berjalan.
Tahun 2002, Pemda Jakarta meluncurkan program Jaminan Pemeliharaan Kesehatan Keluarga Miskin / JPK Gakin (Healthy Safety Net for Poor Families), yang merupakan sistem asuransi untuk layanan kesehatan bagi keluarga miskin di seluruh cakupan wilayah DKI Jakarta. Pada prinsipnya, program JPK Gakin bertujuan untuk membantu warga miskin dalam mendapatkan layanan kesehatan di rumah sakit yang ditunjuk pemerintah (totalnya ada sekitar 85 rumah sakit). Warga yang berhak mendapatkan asuransi ini adalah mereka yang memenuhi sejumlah kriteria “miskin” yang ditetapkan oleh Badan Pusat Statistik, di mana seluruh premi asuransi dibayarkan oleh Pemda Jakarta.
Adapun kriteria “miskin” tersebut terdiri dari: luas rumah tak lebih dari 4 meter persegi, tak mampu bayar pengobatan, tak mampu melakukan perencanaan keuangan, berpendapatan kurang dari Rp 600,000,-, ada anggota keluarga berusia 15 tahun yang buta huruf, serta ada anggota keluarga yang putus sekolah. Warga yang memenuhi kriteria tersebut berhak mendapatkan kartu JPK Gakin yang berarti mereka memiliki hak juga untuk mendapatkan fasilitas kesehatan gratis.
Sayangnya, memiliki kartu JPK Gakin ternyata tak menjadi jaminan mudahnya akses terhadap layanan kesehatan. Berdasarkan publikasi yang dilansir oleh Forum Warga Kota Jakarta (FAKTA), jaminan atau perlindungan hak atas kesehatan yang sudah diberikan Pemda Jakarta melalui JPK Gakin ternyata membuat pihak petugas rumah sakit memandang rendah para pasiennya. Padahal, fasilitas JPK Gakin termasuk besar. Tahun 2011 lalu APBD Jakarta memberikan anggaran sebesar Rp 513 milyar dan ditambah JPK Gakin PNS Pemda DKI Jakarta sebesar Rp 75 milyar. Yang sering terjadi adalah, pasien ditolak untuk dirawat, atau diberi tambahan perlakuan (treatment) yang menyebabkan mereka harus tetap membayar dengan jumlah biaya besar.
Skema asuransi mikro dari sektor swasta
Perlu digarisbawahi bahwa sebagian besar penduduk Indonesia, terutama mereka yang miskin, belum dilindungi oleh asuransi. Menurut penelitian yang dilakukan oleh Recapital Life, dari 220 juta penduduk Indonesia, hanya sekitar 12% saja yang dilindungi asuransi, tentunya dari kalangan menengah ke atas. Agaknya, ini yang membuat berbagai perusahaan asuransi mulai melihat pasar tersebut sehingga produk asuransi mikro pun mulai makin banyak bermunculan. Allianz serta ACA merupakan dua perusahaan yang bisa dibilang cukup inovatif dalam menggarap asuransi mikro.
Melihat kondisi Jakarta yang sangat rentan terhadap wabah penyakit Demam Berdarah, ACA pun mengeluarkan skema asuransi yang cukup menarik di bawah program Dengue Fever Insurance Card. Sesuai namanya, mereka menjual kartu asuransi murah yang bisa dipakai untuk biaya pengobatan Demam Berdarah. Kartu ini dijual di jaringan minimarket yang sering didatangi warga kelas menengah ke bawah, seperti Alfa Mart dan Indomaret. Jika terjangkit penyakit mematikan Demam Berdarah, rata-rata pasien harus menghabiskan lima hari di rumah sakit dengan biaya mencapai Rp 3.5 juta. Ada dua pilihan kartu yang dijual oleh ACA. Yang pertama, kartu seharga Rp. 10 ribu saja (sama seperti harga satu pak rokok), yang bisa digunakan dalam jangka waktu 3 bulan dan menutup biaya sebesar Rp. 1 juta. Kartu kedua seharga Rp. 50 ribu yang bisa dipakai selama setahun dan menutup biaya sebesar Rp. 2 juta. Kedua kartu dapat efektif digunakan 15 hari setelah dibeli, dan tiap pasien dapat memakai lebih dari satu kartu untuk menutup biaya sampai Rp. 10 juta. Untuk mengaktifkannya, cukup kirim SMS saja. Nasabah tetap mendapatkan klaim meski tak pergi ke rumah sakit, selama ada bukti tertulis bahwa ia benar positif terjangkit Demam Berdarah.
Allianz sendiri menawarkan dua skema asuransi. Yang pertama dan khusus disasarkan bagi perempuan dari kalangan miskin di Jakarta, adalah TAMADERA yang menggabungkan asuransi jiwa dan tabungan. Nasabah membayar sekitar Rp. 10 ribu/minggu selama lima tahun, dan mereka mendapat jaminan terhadap penyakit berat seperti kanker, stroke, serangan jantung, gagal ginjal, luka bakar, dll. Jika setelah lima tahun tetap tak ada klaim, seluruh premi akan dikembalikan pada nasabah. Utamanya, Allianz mengungkapkan bahwa tabungan tersebut bisa digunakan untuk pendidikan anak. Produk kedua adalah Payung Keluarga, yang menyediakan pilihan perlindungan mulai dari perlindungan dasar asuransi jiwa kredit bagi nasabah peminjam kredit mikro dan pasangannya, sampai kepada manfaat tambahan yang dibayarkan kepada keluarga nasabah untuk membantu meringankan tantangan keuangan yang dihadapi keluarga setelah wafatnya sang pencari nafkah. Premi terendah mulai dari hanya Rp. 6.000.
Berhasilkah skema asuransi mikro ini? Terlalu dini untuk dapat menyimpulkan saat ini, karena rata-rata baru diluncurkan dalam satu atau dua tahun terakhir. Tantangannya pun ternyata cukup banyak. Seorang sumber di Allianz mengungkapkan keragu-raguannya, “Banyak warga miskin yang tertarik beli TAMADERA karena promosi kami yang gencar, tapi mereka tidak sanggup bayar premi per minggunya, padahal sudah murah, sehingga akhirnya asuransi pun batal. Kami harus ganti strategi.”
Submitted by Julisa Tambunan — Mon, 07/30/2012 – 00:00
María Fernanda Carvallo, Mexico City Community Manager
El diseño de la protección a la salud en México ha evolucionado de un sistema limitado de protección social por parte del trabajador asalariado hacia un sistema universal. En México a partir de la Reforma a la Ley General de Salud en 2003 se busca el tutelaje del derecho a la salud de toda la población mexicana como portadores de derechos sociales y humanos, sin embargo, existen grandes deficiencias en el sistema de salud con respecto a la calidad y la provisión de servicios adecuados. De acuerdo al Consejo Nacional de Evaluación (CONEVAL), en el Distrito Federal en el 2010 se registró el 35.7 por ciento de la población, es decir más de 3 millones de personas, sin acceso a los servicios de salud provistos por el Estado.
En este sentido, el Proyecto Urbano de Salud de la UAM Xochimilco contempla un acercamiento integral a las zonas marginadas para la promoción y atención de la salud basado en un modelo cooperativista entre la sociedad civil y la población.
Contexto
La salud es un capital fundamental para permitir el desarrollo de diversas estrategias de vida para las personas. Es un elemento que puede condicionar o romper con el ciclo de la pobreza multidimensional, ya que habilita a la persona a trabajar, estudiar y aportar a su sociedad. Cuando la demanda de la población no se puede cubrir por medio del sistema de salud del estado, los pobres y personas vulnerables no tienen acceso a diversas alternativas para cuidar su salud, en este sentido, se genera un círculo vicioso en donde las personas tienen que comprometer sus recursos económicos, familiares y sociales para poder hacer frente a una enfermedad, lo cual los imposibilita para generar otras actividades, destinar recursos para otras necesidades y poner en riesgo su patrimonio, además de traer nuevas dinámicas en el hogar para el cuidado de los hijos y el desarrollo de estrategias de ingreso.
La pobreza y la salud son dos conceptos íntimamente ligados, esta población es la que más reciente la deficiencia en el sistema de salud. Por un lado, deben de realizar gastos de bolsillo para cubrir atender sus necesidades de salud y por el otro, las personas invierten el tiempo en d impactando en la salud de la familia por las actividades que desarrollan.
La provisión de servicios de salud en el contexto de familias marginadas y pobres debe de responder a las necesidades de la población a través de un modelo de cooperativismo entre diversos actores.
Enfoque: sistemas de salud equitativos bajo el rol de la sociedad civil
De acuerdo a Vega Romero, Profesor de la Pontificia Universidad Javeriana, “la Sociedad Civil ha podido contribuir a constituir sistemas de salud equitativos por su enfoque centrado en las personas y en la población, porque propician su participación y movilización y en particular la de los grupos sociales en desventaja; contribuyen además a desarrollar la acción intersectorial en salud y a reducir tanto las inequidades en salud como la atención en salud”. Cuando no existe un suministro consolidado de los servicios de salud por parte del gobierno o del mercado a un costo accesible, las organizaciones de la Sociedad Civil han complementado la responsabilidad del estado, como resultado de acuerdos para desarrollar acciones conjuntas a fin de a desarrollar políticas y programas orientados a ampliar la cobertura de comunidades de difícil acceso.
En el enfoque analizado por el Dr. Romero, concluye que la participación de la Sociedad Civil contribuye a proveer recursos, personal, experiencia técnica y vínculos comunitarios para la acción por la salud. Además, de dar cabida a metodologías participativas innovadoras.
Caso de implementación
El Proyecto Urbano de Salud es una estrategia que combina la investigación y docencia de la academia con las necesidades y prioridades actuales de salud de la población, basada en la participación social para la solución de problemas de salud. El proyecto se implementa a través de los profesionales de salud de la Universidad Autónoma Metropolitana Unidad Xochimilco, en alianza con la Asamblea de Barrios, el Movimiento Popular de Pueblos y Colonias de Sur, y los gobiernos locales de las Delegaciones Tlalpan y Coyoacán.
Para la implementación, la Universidad se acerca a zonas marginadas y de escasos recursos por medio de las organizaciones comunitarias para la realización de convenios de colaboración. Por medio de la alianza, los vecinos organizados obtuvieron la infraestructura y espacios para casas de salud y consultorios, de manera que los profesionales de la salud puedan ofrecer la atención de primer nivel. El Programa está organizado en tres subprogramas:
- Prestación de servicios: Atención Clínica, estudios de laboratorio, medicina general, inmunizaciones, prevención de enfermedades, detección temprana de cáncer cérvico-uterino, y estomatología, entre otros;
- Promoción de la salud, con base en un diseño metodológico de investigación participativa y de estrategias de educación popular en salud, que se materializa en un proceso de organización de grupos específicos de salud, realización de diagnósticos locales de salud, ponderación de problemas prioritarios, capacitación y educación en salud de los grupos organizados, intervención y evaluación para reiniciar el proceso; e
- Investigación en salud, permite a los grupos de población y a los propios prestadores de servicio la generación de conocimientos como base para la acción.
Los grupos de atención versa sobre grupos vulnerables, mujeres, niños y adultos mayores de escasos recursos, a los cuáles se les desarrollan capacidades en torno a su salud, de manera que trabajan con la gente en grupos de trabajo que implementan acciones de cuidado y promoción de la salud en la comunidad.
Impacto
El modelo de intervención comunitaria en el cuidado de la salud ha acercado los servicios a la población marginada y sin acceso, además de contemplar las necesidades y prioridades bajo un diagnóstico de salud que ha permitido canalizar los esfuerzos para la protección de la salud. A través de esta sinergia de actores, la población cuenta con la protección de salud de primer nivel y con apoyo institucional para poder escalar en la pirámide de los servicios de salud públicos.
Entre los resultados de intervención se encuentran:
- Bajo costo en la provisión de servicios de salud por disponibilidad de recursos humanos de la Universidad.
- Atención de la salud bajo un diagnóstico comunitario y priorizado de la salud en las localidades.
- Como consecuencia del diagnóstico, se referencia a la población marginada a hospitales de segundo nivel para la obtención de servicios de salud más especializados.
- En la Delegación Venustiano Carranza se han formado más de 100 promotoras de salud (mujeres de la comunidad) que realizaron talles de “Escuela para padres” en por lo menos 15 vecindades de la Delegación.
- Empoderamiento de la comunidad para el cuidado de la salud.
- Apropiación del proyecto por parte de la comunidad para su sostenibilidad en el tiempo.
- El trabajo del Proyecto Urbano de Salud ha sido difundido entre otras organizaciones locales y comunitarias, de manera que se está expandiendo a otras zonas urbanas de la Ciudad de México.
Para que el proyecto escale con respecto a los servicios que pueden ofrecer a la población, la Dra. Gasca comenta que el financiamiento ha sido un problema, ya que los recursos no son suficientes para el equipamiento, particularmente para detección de enfermedades crónicas; por lo que están sujetos a las donaciones de particulares. A pesar de que la comunidad adoptó el proyecto, la falta de recursos para la prestación de los servicios representa una amenaza para brindar una atención integral, ¿de qué manera se puede asegurar los recursos para que el modelo sea sustentable y cuente con la infraestructura necesaria para brindar servicios de salud integrales?
Submitted by Maria Fernanda Carvallo — Mon, 07/30/2012 – 00:00
Catalina Gomez, Rio de Janeiro Community Manager
In March 2012, Brazil’s Health Ministry launched the Unified Health System Performance Index, which is intended to monitor the quality of health service delivery in the country’s 5,554 municipalities and the federal district. This Index, known as IDSUS, incorporates a total of 24 indicators, 14 of which are related to access to different services and 10 of which are related to the quality of these services. These indicators will be monitored on a yearly basis, with results to be published every three years.
According to this year’s IDSUS, Rio de Janeiro ranked last among Brazil’s capital cities and municipalities in terms of adequate health infrastructure. The local government has publicly expressed its concern, arguing that this score reflects the historic low investment in health services in the city. Although local government investment for health has been increased under the present municipal administration, public service provision currently covers 30 percent of Rio’s population (about 1.8 million people); clearly, greater efforts are needed to reach those who are not covered and to improve the quality of services they receive. But who can actually improve access and quality of health care services? Who can partner with the local government to reach poor communities that are not covered by these services?
Enabling access in low-income neighborhoods in Rio de Janeiro is not an easy task. Violence, lack of infrastructure, and lack of trained personnel willing to work in these areas are just some of the obstacles to the improvement of health services for people living in this city’s poor communities. To respond to these concerns, some non-governmental organizations have begun to partner with the local government in order to improve coverage and quality of health services in the favelas. One organization that stands out is VIVA RIO (VR), a part-research, part-service-delivery institution that has been operating as a service provider with the local government since 2008 and has successfully contributed to improvement of basic health service coverage in Rio’s southern and northern zones. Currently, VR operates 57 basic health units and 2 psychosocial units, benefiting 950,000 people in 35 of the city’s neighborhoods.
Several aspects of VR’s work are worth highlighting as key factors in its success. First, VR works together with the local government, planning interventions and designing joint training courses, an approach that guarantees coordination of efforts, reduction of overlaps, and homogeneity in service provision — and while VR began by piloting initiatives, currently it is scaling up its efforts, another factor that really matters to the local government. Second, VR invests in its personnel — emphasizing the added value of well-trained staff, providing incentives to good performers, and promoting a culture of results and accountability. Third, VR’s technical work focuses on prevention practices rather than just reacting to emergencies. The institution emphasizes the importance of creating a culture of prevention and works together with families as the core unit for its prevention campaigns.
VR follows the national guidelines of the Health Strategy for Families, a strategy that adds value through the presence of multidisciplinary teams known as Family Health Teams that provide health services at the local level. Such teams report back to basic health units and are usually composed of a doctor, a nurse, one or two nurse assistants, and five to ten Agentes Comunitarios (Community Agents). These groups, especially the Community Agents, play a key role in engaging communities with activities and raising awareness on different health issues, such as reproductive health, prenatal and neonatal care, and oral health. Currently, VR operates a total of 240 Family Health Teams, plus 60 Oral Health Teams. VR emphasizes that the real value of its approach comes when its Health Teams come to know the communities they serve and act to mobilize them — engaging people who are typically excluded from debates and information-sharing initiatives.
VR’s health work wouldn’t be complete without a comprehensive approach to the drug problem, which affects many vulnerable communities afflicted with high levels of drug and alcohol consumption. VR approaches this situation at various levels. First, VR operates two psychosocial care centers serving low-income, drug-dependent patients, and conducts a number of activities with adolescents with the aim of preventing their initial contact with drugs and promoting responsible drinking habits among young adults. Second, VR has been taking a stand by raising questions at the policy and legislative levels about the control of drugs and punishment of drug offenders — especially with respect to young drug dealers, who are sent to correctional facilities with little attention given to their mental health and their process of social reintegration once their incarceration is over.
These efforts may buy Rio some time to improve its current poor performance before the next publication of the IDSUS in 2015. To be sure, not all these improvements will be measurable in a period of three years, but there can be no doubt that consistent efforts — especially in the scaling of initiatives and the implementation of new methodologies for engaging communities at the local level — will contribute to an improvement in the city’s ranking. Most importantly, though, the work of non-state actors like VIVA RIO will contribute to enabling a leap in the quality of services provided to families living in poor and violent communities in Rio de Janeiro.
Submitted by Catalina Gomez — Mon, 07/30/2012 – 00:00