How Things Really Work: Lesson 2

February 7, 2012 – What an eye-opening day I had today. I spent the day at the two Centros Focales in Puno. It was fascinating to observe the work of the obstetrices and talk with them about the challenges they face.

I began my day at Laykokota with Rosmery, a bubbly, charismatic woman who may be more excited about healthy breasts and uteri than anyone I’ve ever met! She is resilient despite facing the daily challenge of trying to get the women who come to repay their loans to also come see her in the Consultorio for whatever health problem they may have or to get diagnostic tests done including PAP smears, breast exams, blood pressure measures, glucose measures, and BMI measures. It seems to me she is driven by two things – her genuine desire for the women to be healthy and the metrics she must meet each month. However, her job is more challenging than I ever imagined.

The women come to pay their loans once a month and this process is incredibly hectic. There are several groups in the office at a time and all the women want to get in and out as quickly as possible. Which is understandable, in many cases they have traveled quite a ways to get here, and they have businesses and families to run. So getting them to even listen to you for a few minutes is a challenge.

Another challenge is the pressure they face during this repayment meeting. For example, in the first meeting I sat in on five women didn’t show up, so all the group members were frantically calling to remind them and had to wait for several hours until nearly all arrived. If not, they would have had to make up the difference and pay for their group members who were missing. You might think this would give you plenty of time with a captive audience to talk health, but not so much. The women are counting and recounting money and herding their small children who are running around. Not to mention they are likely worried about the fact that they may have to pay extra this month, and the repercussions that may have on their families and businesses, and the reaction from their husbands. That immediate threat likely outweighs any concern they might have of their long-term health.

Despite these challenges, Rosmery does her best, enthusiastically explaining the importance of these diagnostic tests and taking care of their health. Unfortunately, likely because of the goals, much of her promotion efforts are more about testing than actual preventative health information. At the end of each short session, she tries to get women to make an appointment. Not many do. They are afraid, can’t afford it (despite steeply discounted prices), or simply don’t believe they need these tests. When women do come for their tests, and in some cases get positive results, they rarely do anything about it. The obstetrices recommend follow up tests, oncologist visits, and diet changes, but very few women take these next steps.

In the afternoon I went to Bellavista and talked with Zelmira, a very different personality. She is quieter, more serious, but still very nice and obviously committed. She vocalized many of these same challenges as Rosmery. She has a half dozen flipcharts for sessions on various topics but said she rarely has time to use them with the women. She explained that the “mass” education sessions (which I had read about in the official Pro Mujer manual) rarely actually happen and really boil down to these frantic sessions squeezed into payment meetings like I observed with Rosmery.

So an eye-opening day indeed. I closed the day feeling a mixture of frustration and inspiration to help. I have some ideas about referral programs and incentives, but would love ideas from all of you, especially my fellow MPHers who may have seen similar situations around the world. How do you incentivize women to seek health services? How do you reach them with preventative health messages when formal health education seminars and training sessions aren’t really an option? Please comment here or email me with ideas. Thanks!