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Harrisburg: a story of sustainability

In our line of work, it’s not often we get to go back to project sites years after our support ended. The need to keep a country programme afloat means we’re caught in a hamster wheel of closing out finishing projects and starting up new ones. The onboarding of fresh recruits to deliver newly secured awards bring lots of enthusiasm, experience and skill, but inevitably gnaws at the institutional memory. Hard-won relationships with communities are difficult to maintain when the pursuit of new opportunities has moved us on to another village, county or state, and when we no longer have much to bring to the table by way of resources, expertise or time.

So, you may legitimately ask, how do we know if a project achieved what is widely seen as the Holy Grail of development: sustainability? There are lots of known recipes to increase the likelihood of an intervention being sustainable: co-designing projects with communities, keeping their affordability in check, making communities aware of their rights and how to claim them, or seeking market-led solutions wherever appropriate, to name a few. Sustainability can be monitored and evaluated through ever more complex ‘sustainability frameworks’ and indicators.

But the real answer is this: we simply don’t know, until we’ve waited long enough to find out. I got a chance to do exactly that last month in rural Liberia. And I am so glad that I did.

A simple idea

Harrisburg is a district of Montserrado county, which includes the capital city Monrovia but stretches deep into Liberia’s rural heartlands. It is one of the many settlements established by Americo-Liberians, former slaves returning to Africa in the middle 19th century as free men and intent on making this land their home. Like the rest of the country, this area was ravaged by 14 years of civil war and was severely hit by the deadly Ebola outbreak in 2014.

It is at the Harrisburg clinic that Save the Children, in partnership with the UK Department for International Development, supported the construction, equipment and operational viability of a maternal waiting home. It is a place for pregnant women to stay under constant medical supervision for up to two weeks around the time of delivery, thereby reducing the risk of women needing an emergency referral to the maternity clinic in a place where ambulances are nowhere to be seen.

Maternal waiting homes are not new, nor are they unique to Liberia. The World Health Organization carried out a study as far back as 1996 on their potential to save lives, and concluded the concept was promising, provided that “it is considered as part of a comprehensive safe motherhood programme”. Since then many more studies have been carried out on the use of maternal waiting homes in Liberia, Zambia, Ethiopia and other African countries, expanding a body of evidence that suggests that, if well-designed, these homes can increase the use of skilled-birth attendants, reduce stillbirths and bridge the distance between communities and healthcare facilities.

The construction work began in 2012 and finished in 2013, months before an Ebola outbreak that brought the entire Liberian health system to its knees. The package of interventions went far beyond the maternal waiting home and included training on obstetric and essential newborn care, supplies of essential drugs and establishing community case management services. The entire project was wrapped up and all activities discontinued in 2016.

Three years later, the maternal waiting home is thriving: of the 136 pregnant women brought to the health centre by community midwives in the last six months, 128 stayed here. Mrs Jowell, head nurse at the facility for the past eight years, explains that those who live in the neighbourhood usually stay for just a few days, but those who live further away stay up to two weeks.

Recipe for success

While no study has been commissioned to rigorously unpack what made this initiative a success, the apparent sustainability of the maternal waiting home seems to rest on two key ingredients, whose combination has been at the heart of policy change and human society since times immemorial: the incentivisation of positive behaviours, and the reprehension of undesirable ones. Less elegantly, the carrot and the stick.

The first crucial ingredient of success was ensuring that the maternal waiting home was genuinely responsive to women’s needs. Great care was given to ensure that patients, staff and community members were not just consulted, but also actively involved in the design and operations of this home. Communities came up with various ways in which they could contribute to its long-term success – for example, by feeding women staying in the home, a service which neither Save the Children nor the health facility were able to provide.

In my experience, a consistent feature of failed development initiatives, particularly those that include a large element of construction, is that they are infrastructure-centred, supply-led and only involve communities as an afterthought. The development of the Harrisburg maternal waiting home was the complete opposite: the community was fully involved.

But it would be false to claim that community participation alone did the trick. The second critical ingredient was far less participatory,

At 725 deaths per 100,000 live births, Liberia’s rate of maternal mortality rate is the seventh highest in the world. It had reached such heights here – still well over 1,200 deaths per 100,000 live births at the turn of the century – that the government had no choice but to make it a national priority. At the local level, this had unexpected consequences.

Community leaders took it upon themselves to introduce a punitive system of fines to promote institutional deliveries. If a pregnant woman gives birth at home because of what is described as “her carelessness” in not seeking care early, she will pay the community midwife 2,500 Liberian dollars (13 US dollars). On the other hand, if the community midwife is the one who was “careless” in not bringing the woman to the clinic at the earliest opportunity and ends up delivering the baby at home for a fee, it is she who must pay a fine of the same amount.

As a rights-based NGO, the concept of fining poor patients – and especially pregnant women – for not adopting the correct health-seeking behaviour isn’t something we would ever promote or endorse. But true community-led development means handing over power to beneficiaries, local authorities and indigenous governance structures to come up with solutions to local problems. For Mrs Jowell and Jacob Tengbeh, Save the Children’s national health coordinator, this policy has certainly been instrumental in persuading pregnant women to give birth at the maternity clinic, and the maternal waiting home has provided a safe, enabling environment for institutional deliveries to become the norm in Harrisburg.

Maternal mortality remains very high in Liberia, and no study has looked into the impact of this approach on institutional deliveries in Liberia more broadly. What is clear however, is that community participation, social accountability and enabling policies make for a powerful combo in the pursuit of sustainable development, as the story of this maternal waiting home can attest. Smart aid works!

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