Taking Health to the High Sierra

People and the Planet -- The Millennium Issue

Taking Health
to the High Sierra

By Don Hinrichsen

One of the great challenges for sustainable human development in the new century is the provision of good quality reproductive health services to people living in poor urban settlements and remote rural areas. One successful model is the Jambi Huasi -or Health House- which is flourishing among the Quechua-speaking people of the Ecuadorean Andes.

Blanca Cusin Camreudo is a 23-year-old mother of two small children, from one of the small communities who live around the mountain town of Otavalo. She has been coming to the Jambi Huasi clinic for two years. She is now anxious to space any future children and has asked for contraception in order to better plan her family.

"I like the services here," she explains in accented Spanish. "I get good advice from the doctors, the medicines are inexpensive and I can get all the services I need from under one roof."

Like other clients at the centre, Mrs Camreudo is poor. Her husband is a subsistence farmer and her neighbours mostly live on or below the poverty line. The climate here in the high Sierra has been described as "eternal spring", but many indigenous communities in these remote settlements have been bypassed by development.

Maternal and infant mortality rates are high. In some remote communities: maternal mortality reaches 250 deaths per 100,000 live births, compared to the national average of 170. Similarly, in some rural areas of the Andes one in every 10 infants does not live to see his or her first birthday.

It was as part of the national strategy to address the needs of the poorest, that UNFPA's Ecuador programme financed this ground-breakmg project in Otavalo to improve the scope and quality of reproductive health services for the Quecha-speaking communities.

A modest grant of $340,000 for a period of four years allowed the Jambi Huasi health clinic, established in 1994, to expand and upgrade its services, initiate an outreach programme, provide reproductive health education and information to women, men and adolescents and introduce a referral system for obstetric complications. Jambi Huasi is unique in that it provides both modern and traditional medical treatment, as well as family planning advice and services. Traditional healers use over 3,600 native plants for medicinal purposes.

The unique combination of services has made Jambi Huasi a very popular clinic. Although it was initially set up to service the needs of some 4,000 people in 10 communities around Otavalo, by 1998 close to 10,000 people were using the clinic's services on a yearly basis, some coming from as far away as 50 kms.

The comprehensive approach to reproductive health care, practised here, has attracted a lot of attention from other NGOs and the government. "Not only do we provide a full constellation of reproductive health and family planning services," points out the clinics's petite director, Dr Miryam Conejo, "but we do so in a culturally sensitive fashion, taking into account the special needs and concerns of our clients. Jambi Huasi has a staff of 14, including two indigenous medical doctors and two community volunteers, who help with outreach. About half of Jambi Huasi's clients use the services of traditional healers. "We have delivery rooms here, as well as an examination room, a lab for blood work, a dentist's office, a pharmacy which dispenses both modern and traditional medicines, an information and education programme, and out-reach services, which include an ambulance for bringing emergency cases to the local hospital," explains Dr Conejo.

The other stunning aspect of Jambi Huasi is that it is well on its way to being a self-sufficient operation. "Cost recovery is an important aspect for us," says Dr Conejo. "Right now client fees account for over 50 per cent of our annual income, a percentage that keeps climbing from year to year. We expect to be completely self-sustaining within six years."

"We need to expand our services and outreach to other communities," points our Dr Conejo. " Already we have an outreach service which brings our medical and educational services by van to several poor, remote mountain communities, but the needs in this region are overwhelming."

The other remarkable aspect of Jambi Huasi is that it has a full-time communication and education specialist. Dr Mercedes Muenala, who has a degree in internal medicine from the University of Quito, spends most of her time speaking to women and men in Quechua communities, in an attempt to increase awareness of reproductive health issues and to build up demand for the services provided by the clinic and its satellite operations.

Dr. Muenala teaching Quechua communities in the High Sierra about reproductive health issues and how to take better care of their children and newborns babies.

Husbands too

Dr Muenala is now so popular that her public lectures are packed. And women usually bring along their husbands and children as well, making Mercedes' visits a community event. "We have managed to increase the basic knowledge of women and men regarding their fertility and how they can have safe births with healthier children," comments Dr Muenala. "Because we are not preaching fertility regulation and the use of contraceptives alone, these traditional communities are much more receptive to our messages and services.

Nevertheless, as Quechua communities learn more about reproductive health issues and how to take better care of their children and newborns, the contraceptive prevalence rate has climbed from 10 per cent to 40 per cent in areas serviced by Jambi Huasi. "Though most Quechua women still want 4-6 children each, they now space their children and take steps to make sure they have safe, healthy pregnancies," observes Dr Muenala. As a result, both the infant and maternal mortality rates have fallen in Otavalo.

The lessons learned in Otavalo have not been lost on the government. The Ministry of Health is following the progress made by Jambi Huasi and intends to replicate this model in other underserved communities. "We are particularly interested in the cost recovery mechanisms used by Jambi Huasi," says Dr Virginia Gomez, Director of Health in the Province of Pichincha, which includes the capital of Quito. "If this model works with indigenous populations, some of whom live in remote, mountainous communities, it might also work in poor urban areas, where reproductive health services are weak or non-existent."

UNFPA's Country Representative for Ecuador, Carolyn Benbow-Ross, is following the progress made by Jambi Huasi with heightened interest. "The lessons learned from this experience are very exciting," says Benbow-Ross, sitting in her office with a view of Quito's extraordinary skyline of volcanoes, traditional buildings and quick moving clouds. "If this experience can be replicated in other indigenous communities, Ecuador can take some major steps in bringing quality, affordable reproductive health care to more of its poorer citizens, without waiting for major donor support. "

The key, says Dr Conejo, is to "transform state services into community services, services that better match the needs of your target communities." This, she stresses, is one of the keys to the success of Jambi Huasi. "We transformed the way health services are offered in traditional communities by making them totally community-based. Once people perceive that they are getting the medical care they actually need, not what medical authorities are telling them they need, it is possible to make rapid and lasting improvements in the reproductive health of women and men."