Dro Cares

Although the world’s maternal and infant health outcomes have improved over past decades, communities affected by conflict or fragility have been left behind. Globally, nearly two-thirds of preventable deaths of mothers and almost half those of newborns occur in these countries. South Sudan–caught in protracted conflict with interspersed stability—has the world’s second-highest maternal mortality rate, at 1,150 per 100,000 live births, and among the worst for newborn deaths, at 39.3 per 1,000 live births. In Uganda— where conflict continues—829 mothers die per 100,000 live births and 39 newborns die per 1,000 live births. In both countries, sexual and gender-based violence (SGBV) is pervasive, with few services for SGBV survivors. Consequently, these and most conflict-affected countries are not on track to achieve health or gender-related SDGs.

Communities in conflict settings face unique challenges and complex barriers to improved maternal and infant health. In addition to poverty, gender inequality and little access to education and health information, women and children in Uganda and South Sudan have experienced forced displacement and destroyed and fragmented health infrastructure. The presence of armed groups has sometimes restricted safe access to health facilities for the lifesaving RMNCAH services women and children need. Even when accessible, health services are underfunded and health care workers often unpaid, ill equipped and poorly trained.

In spite of these obstacles, communities with whom the team has worked in these two countries have incredible resolve to confront these challenges. Community-centered and led solutions that invest in local capacities have ensured that even during crises, communities in South Sudan and Uganda can empower themselves to improve access to and control over health resources for women and children. As these communities simultaneously face conflict, the impacts of climate change, COVID-19 and other disasters, their capacities to confront these challenges

The project will improve the lives of diverse women of childbearing age, infants and children in 18 conflict-affected locations. It will support community capacities to lead in improving the health of this target group by working with them to co-develop participatory needs assessments and co-design comprehensive packages of evidence-based RMNCAH services that address the specific challenges they face. To overcome gender barriers and increase communities’ RMNCAH knowledge, it will be crucial to engage diverse community members, including men, adolescent boys, and influential elders.

Services will be delivered at community and primary healthcare facility levels, according to assessed needs. Interventions will address key gaps, root causes and systemic barriers, including difficult access to services, limited knowledge of proper health practices, negative gender norms, inadequate facility services and few female maternal health professionals. Strengthened capacities at the two levels of care will lead to comprehensive RMNCAH services. 

Recognizing that community leadership and capacities to address women’s and children’s health challenges are an important, unrealized, yet durable solution, the team will, through, proven learning and training methods, support communities to deliver preventive and curative care.

To address knowledge gaps among community members, the team will support women and their families to learn about the importance of maternal, child and infant care at home, such as exclusive breastfeeding, and will raise awareness about the importance of vaccination, antenatal care (ANC), danger signs for pregnant women and newborns, when to seek health services and how health services can help.

To increase community-level access to RMNCAH services the team will train female and male Community Health Workers (CHWs), recruited from the communities to provide key RMNCAH preventive interventions, including education, counseling, and referrals for safe motherhood and infant care. We will also equip CHWs with RMNCAH commodities, including contraceptives, menstrual hygiene and sanitation kits, e.g. and will train CHWs to identify survivors of SGBV, and provide support and referrals wherever feasible. Community-based services in South Sudan will also include those to lower infant and child mortality rates from malaria, diarrhea and pneumonia through integrated community case management of these conditions.

The teams will increase quality and availability of RMNCAH services at the facilities level, working to strengthen capacities by rehabilitating damaged facilities, equipping and restocking consumables, and by training health personnel to better deliver RMNCAH services, including SGBV services. Where possible and needed, the project will support community members to be trained as midwives.

The initiative will strengthen linkages between communities and facilities by reinforcing MoH-community dialogue and strengthening referral systems. These initiatives will support health authorities to transition the health system towards greater functionality, thereby increasing demand for RMNCAH services.

After five years, participating communities will have strong capacities to plan and deliver community-based RMNCAH services and to act as their own advocates with the MoH for quality RMNCAH services. These capacities will lead to reduced mortality and morbidity of women, infants and children in conflict-affected communities and provide a model for conflict settings that can be taken to scale.

Our collective will strengthen maternal and infant health capacities in communities and facilities to sustain access to life saving services during conflict and instability.

Women and children in communities affected by conflict face enormous threats to their survival. At a time when they most need services, healthcare systems are fractured, facilities often destroyed. More than 60% of preventable maternal deaths and 45% of neonatal deaths occur in fragile settings such as South Sudan and the Central African Republic.

Strengthening community skills, knowledge and capacities to influence health outcomes for women and children increases their likelihood of survival, reinforces resiliency when health facilities are inaccessible, and allows for greater control over health services.

Dromedic Health Care partners and communities will merge our collective strengths to reduce barriers to accessing reproductive, maternal, newborn, child and adolescent health (RMNCAH) services in the community and at health facilities. The project takes an intersectional gender equality approach to ensure equal decision-making of diverse women and men and to increase equitable access to life-saving health services for communities affected by conflict.

The initiative’s co-leads are applicant Dromedic Health Care, Canadian Red Cross (CRC) in partnership with governments of South Sudan and Uganda. The two National Societies are trusted and respected by government and civil society, with deep community roots they use to engage and create space for critical local stakeholders to empower themselves for long-lasting, community-led impact.

The team is well-integrated with local health system structures including the Boma Health Initiative (BHI) in South Sudan, and the Uganda Ministry of Health (MoH) Essential Services Package. They will support National Societies in their unique roles as permanent, principled humanitarian actors with exceptional access to conflict-affected communities and understanding of their needs. As appropriate, they will work, consult and engage with local health authorities, community representatives, military authorities and armed groups, and coordinate with civil society organizations to enhance access and prevent duplication.

Strategies to address disparities and reach marginalized populations can be delivered effectively by response agencies working with state and non-state actors [1]. The literature and the team’s experience, including that of working together for two years in a pilot of this initiative, demonstrate clear need and feasibility for community-led approaches to RMNCAH service delivery and in areas experiencing conflict. Community-led approaches are critical to overcoming health access barriers during conflict and rebuilding health systems in times of transition. 

In addition to ICRC’s experience delivering health services in conflict, the CRC, with National Society partners has delivered similar interventions to those proposed here including in South Sudan and other fragile settings, among them Mali, [4] Liberia, [5] Kenya, and Afghanistan. External evaluations in South Sudan and Mali found significant improvement in maternal, infant and child health. In Warrap State, South Sudan, results include: women seeking at least one ANC visit increased from 18.1% to 75.2% and delivery by skilled attendant from 8.5% to 16.7%. Neonatal tetanus protection increased from 14.3% to 69.8% and over 50,000 children under 5, including infants, received malaria, pneumonia, and diarrhea treatment by trained community volunteers.

Elizabeth is a passionate health care entrepreneur and professional, trained as a nurse and midwife in Uganda. She has managed a private midwifery practice in Uganda, has a diploma on women’s decision-making power in family planning, worked in many conflict-affected areas.

Dr. Nsubuga Gavin is a Dromedic health care advisor who is passionate about community health programming in Africa. He is a medical doctor with a master’s degree in public health and nutrition, extensive experience in RMNCAH, emergency preparedness and response, and has been instrumental in the design and delivery of community-based projects to improve health outcomes for women and children in Uganda

Joseph Mulabbi is a strong advocate for health rights. He has worked in several private health facilities in Uganda as an administrator for five years where he noticed specific gaps in health care. This led him to dedicate himself towards community-based approaches that meet specific needs of people living in conflict-affected areas.

We are currently serving 5 refugee-led communities across Uganda impacting directly over 10,000 people altogether.

For funding, Networking, Partnerships and Collaborations to avert health access barriers in fragile and/or conflict affected communities across Africa.

While many actors implement effective community-based programming to improve maternal and infant health outcomes in development contexts, there is sparse evidence of similar success in conflict-affected settings, where the challenges of engaging communities and overcoming barriers are pervasive and complex. The team’s approach is unique in engaging and making space for communities in conflict settings to empower themselves by strengthening their own leadership and capacity to improve health outcomes.

Red Cross Societies work hard to engage with and build trust among conflict-affected communities and thus have unparalleled access. The project will innovate by building a flexible, adaptive, and resilient community-led approach to deliver a comprehensive package of RMNCAH services that can be taken to scale globally in conflict-affected settings. The partnership among CRC, ICRC and the two National Societies enhances the innovation by providing a permanent local capacity at a national scale to provide sustainable results and long-lasting impact.

In order to be effective, solutions need support from the impacted community including funders, local leaders, decision-makers, residents, media, and others. The question we answer here is How does our solution center local communities and prioritize those most proximate to the challenges being addressed? We understand that a strong solution demonstrates deep understanding of the community and key stakeholders, and shares plans to engage and work with them throughout the process to ensure sustainable and durable outcomes. 

THEREFORE, The team’s CEA approach shifts power relations that exacerbate health inequalities by engaging communities to lead design and delivery of culturally-appropriate, durable solutions. Multiple options for communication and feedback with community actors will continuously integrate diverse viewpoints into project activities.

Strengthened community leadership in RMNCAH, centering women and children, will lead to sustainable knowledge and practice change and increase communities’ access to and control over health resources. Investments in health facilities and stronger referral systems and links between communities and facilities will support health authorities to transition the health system towards improved functionality, thus increasing demand for RMNCAH services.

This project is informed by ongoing programming and focus group feedback from both countries (e.g. youth wish to be more engaged community-led health prevention). Key stakeholders ( volunteers, CHWs, midwives) will bring deep understanding of challenges facing their conflict-affected communities. Midwives trained by the project will be from the community and will later be employed at facilities, building institutional capacity and trust. Referral systems linking needs from community to facilities will be designed with community members.

The team will engage influential community actors (see below) to encourage the adoption of gender-positive attitudes to increase equality in RMNCAH decision-making and reduce SGBV.

The project monitoring and evaluation (M&E) platform will allow for intervention adjustments as needed, with routine and annual progress reviews over five years. Among the tracked milestones:

Year 1:

Communities consulted about RMNCAH challenges they face, their solutions, and toles in achieving project objectives through focus group discussion, human rights and protection, gender and inclusion analysis.

Training and mobilizing community members (volunteers, CHWs) aligned with the BHI in South Sudan and MoH Essential Services Package in Uganda

Support women to enroll in formal and community midwifery schools.

Complete first measurement of key performance indicators (KPIs) using baseline study.

Use an M&E system tailored for conflict-affected settings to assess progress.

Year 2:

Provide one-time supply of required equipment to facilities impacted by conflict and restore facilities (e.g., water points, install solar panels for all-day deliveries) to operate effectively.

Community agents initiate first monthly (or quarterly) report describing progress toward project objectives.

Supervisors make first visits to community agents and engage in tailored refresher trainings based on identified challenges from Year one.

Year 3:

Collect sample data from communities and health information systems as part of mid-term review; assess progress toward objectives and impact of the project on community practices.

Year 4:

Continue implementing activities, including refresher trainings as necessary.

Consult with communities to re-evaluate the situation and begin implementation of project exit strategy.

Year 5:

 In addition to ongoing activities, assess KPIs and impact on RMNCAH at endline; complete exit and handover to communities and health facilities; collect lessons learned.

Results will be assessed against KPIs at baseline, during implementation, and at endline using quantitative and qualitative data. Baseline and endline surveys will measure communities’ knowledge, attitudes, and practices, factoring in gender norms. Secondary data from the MoH Health Information System will highlight health service facility usage. The project will use MoH data collection tools for community-based interventions and to calculate people reached. Data will be disaggregated by sex, age and disability, collected in paper form in communities and digitized by project staff for aggregation, analyses and reporting. Community agents (CHWs, volunteers, etc.) will be trained on data collection tools, including pictorial data collection tools when literacy is low. Baseline, studies, and routine monitoring data will inform adjustments. A final independent evaluation will assess results achieved compared to the plan.

The CRC is experienced in M&E of RMNCAH programs in many fragile settings. All approaches above were used on a CRC maternal, infant, and child health project in South Sudan (2014-2019) and in Mali (2016-2021).

Recognizing enormous needs and noting lacking evidence about effective community-centred RMNCAH service delivery in conflict settings, the team collaborated in a two-year research study, integrating learning through progress monitoring including documenting community and other stakeholder feedback.

From the outset, the team committed to integrating learning and improvements, to apply that learning to strengthen National Societies and community capacities, and envision scaling up this applied learning approach globally in conflict-affected settings, where women and children face some of the greatest threats to their health and survival.

Vision: Conflict-affected communities empower themselves to limit mortality and morbidity of mothers, infants and children.

Outcomes: 1) increased knowledge and attitude change about RMNCAH care; 2) increased access to health services by women and infants; and 3) increased ability of health facilities and staff to meet RMNCAH needs.

Theory: 1) increased knowledge and practice of high quality RMNCAH care will improve practices and increase service use, resulting in reduced mother/infant mortality and illness;

• increased access to RMNCAH services by women/infants will improve health status; and
• improved infrastructure, equipment, supplies, and capacity at health facilities will provide higher quality of care. This combination will create durable change for improved health outcomes.

 Methodologies:

Community Engagement and Accountability (CEA), which centres communities and recognizes community members as equal partners whose diverse needs, priorities and preferences guide everything we do.

Knowledge- and capacity-strengthening of community stakeholders at multiple levels and supporting them to deliver RMNCAH services. Trained personnel become agents of change, role models, and permanent community resources.

Awareness-raising about gender equality, harmful gender norms, SGBV, and sexual reproductive health and rights (SRHR) to shift attitudes to support women’s health.

Engaging community leaders, men and adolescent boys to adopt gender-positive attitudes that increase equality in maternal health decision-making and reduce teenage marriage/pregnancy.

Making strategic investments in rehabilitating health facility infrastructure to cover communities’ essential health care needs.

Underlying evidence for our theory comes from a study by the project partners in 2021, as well as external sources cited in Affirmation of Approach.

We deploy a mix of USSD codes for easy access to services in very remote areas of our operations to enable both CHWs and women. We also deploy the element toll free call centers and community help hubs that are easily accessible by the target groups. Our services and contacts can also be easily found via our website should one want to get in touch with us.

In the near future as access to internet and smartphones rises in the communities we serve, we shall be able to comeup a mobile app that can easily make our work much more easily accessed by our beneficiaries.

The team’s ‘do no harm’ protection, gender equality, and inclusion approach recognizes that experiences of crisis-affected people vary according to their identity. It seeks to understand context-specific norms, inequities, and power imbalances to address discrimination and prevent SGBV, including early marriage, which leads to complicated and unsafe pregnancies. Initiatives include diverse women of childbearing age, infants/children at risk, and influential community leaders, elders, men, youth, volunteers, CHWs, midwives, health facility staff and community and facility health committees.

Studies and needs assessments (including human rights and protection, gender, and inclusion analysis) during project inception will allow communities to identify structural barriers to RMNCAH service access for the most marginalized. These could include barriers based on gender, disability, age, distance, conflict, and other factors; under-resourced facilities lacking privacy for women or adequate services for people with disabilities; lack of female health care workers; financial impediments; and lack of consistent community dialogue in decision-making. In consultation with each MoH, the team will support facilities based on identified needs, centering needs in activities through a DEI lens.

Feedback mechanisms will ensure multiple viewpoints are heard, including from the most marginalized. Key stakeholders will be trained (midwives, CHWs and volunteers) to collect data and require volunteers to understand how to properly identify risk cases and make appropriate referrals. Referral systems structures will also be defined by the community. CHWs will encourage active engagement and adoption of gender-sensitive attitudes that encourage equality in sexual and reproductive health decision-making and reducing SGBV.

The African Union called for an additional two million community health workers to be employed on the continent by 2020. The World Health Organization projects Africa will need six million more health workers by 2030.

And this was prior to the COVID-19 pandemic.

Our business model applies five essential ingredients to reach more than one million clients annually. We call it our “secret sauce.”

1.Peer Mentor Model: we employ and trains women in the local community as community health workers called Mentor Mothers. Our solutions all start with one human simply connecting with another over shared realities and common experiences, which then creates trusted relationships leading to lifesaving education and medical care.

2. On-the-Ground Sustainability: Every Mentor Mother is a paid, professional health worker. Their work not only benefits their local communities, but provides critical income for their own families. We’ve employed more than 11,000 women as Mentor Mothers.

3. Sustained Client Relationships: Given their relationships, our Mentor Mothers help clients access prompt healthcare services, lifesaving medications, remain in care, and adhere to medical regimens.

4. Data Collection & Analysis: Our rigorous data collection, measurement, and analysis protocols pinpoint the impact we’re making on lives and in communities, and help identify where public health needs are greatest.

5. Integrated Service Platform: To most effectively support our vision of health and hope, we employ community- and facility-based health workers in order to reach last kilometer clients. Our new eServices project is the next level for amplifying our impact.

From a big picture perspective, our Kampala city-based Business Development team provides global support for reaching our fundraising goals, and raises the majority of our project restricted revenues from bilateral and multilateral public agencies.

This team develops proposals that reflect the needs of the communities where we work, and simultaneously addresses the complex proposals issued by governments, as well as individualized requests from dozens of corporate and foundation funders annually.

We also have fundraising entities in the United States and United Kingdom which focus on creating deep, long-lasting relationships with philanthropic foundations, corporations, individuals, family investment offices, and trusts.

Underlying the fundraising are our finance and operations teams which direct capital flows and expenditures across country programs, and monitor financial compliance and reporting requirements within each grant and donation.

To start, we’re funding the launch of our new eServices projects from existing budgets. However, to scale and deliver our intended impact to millions more people throughout Africa will require additional funding. Our Business Development and global Resource Mobilization teams are actively researching and prospecting fundraising options from a broad spectrum of sources worldwide.

We are also exploring how to best capitalize on the many new funding sources established to assist organizations with health care access solutions like ours. Long term, by demonstrating the impact and cost-effectiveness of our work, we’re strategizing how we can be directly reimbursed by host governments or through health insurance service fees.

Donor

Amount (USD)

Uganda MoH - 50,000

The Tony Elumelu Foundation - 100,000

UNFPA - 100,000

UNICEF 150,000

Global Giving - 75,000