Voices from the Field – Reflections on 12 Days in Peru

By Josh Cramer-Montes, Director of Communications

Saturday/Sunday – Newark > Lima > Arequipa

It’s 7:30 AM on Saturday and I’m in the back of a taxi speeding down the highway towards Lima following an overnight LAN flight. The sky is a hazy gray, a common occurrence as a result of the subtropical desert climate meeting the cool waters of the Pacific Ocean.

As I approach the neighborhood of Miraflores, I see groups of surfers on my right, bobbing around in the ocean waiting to catch the next big wave. To my left are steep, 100-foot rocky cliffs with modern buildings perched at their summits. It’s a scene reminiscent of Southern California. In the face of the country’s booming economy, a surge in national pride and a culinary tradition taking the world by storm, one can easily forget about those left out and the poverty that lies beyond.

I’m in Peru for a series of site visits, meetings and events that will have me crisscrossing the southern part of the country and visiting more than half a dozen cities over the course of the next 12 days. It’s my first time here and I’m particularly excited to see the fourth of our five country operations in action.

Monday – Arequipa > Pedregal > Arequipa

My watch alarm goes off at 6:00 AM and despite not having my customary first cup of coffee to jolt me awake, I hit the ground running. Naldi Delgado, Director of Pro Mujer in Peru, and I are teaming up to give a short presentation to a group of visitors from one of our partner organizations, Global Partnerships (GP), a non-profit social investor. The group, headed up by Chris Megargee, GP’s Director of Community and Corporate Relations, is in Peru to see our operations first hand and meet some of the 245,000 strong, hardworking women we serve across Latin America.

GP is one of the organizations – along with PATH and Linked Foundation – that partnered with us for our health pilot program in Nicaragua. This pilot seeks to tackle the increasingly-serious issue of chronic disease among our target population (hypertension, diabetes, sexual and reproductive health and cancers, specifically breast and cervical) and one that has broad implications for people worldwide.

After the presentation we board a van for the hour and a half ride that will take us through the desert to the small rural town of Pedregal. Here we will have the opportunity to see our Jornadas de Salud; a series of health campaigns that consist of RVs retrofitted to suit our needs as mobile health clinics.

Complementing these clinics are staging areas where additional services are provided by ophthalmologists, optometrists and obstetricians, among others, at below-market cost or free of charge depending on the service. Pro Mujer in Peru has four of these mobile clinics that travel to different regions each month. Each of these campaigns lasts a few days and we don’t close shop until every last person – clients and the general public alike – gets seen by trained medical personnel.

Children from the local kindergarten take a break from their school day.

Pro Mujer staff provides patients who are waiting to be seen with preventive health education.

The focus of these campaigns is the screening of chronic diseases. Other tests offered include blood pressure, BMI (body mass index) and breast exams.

The PMP team and I – including Country Director Naldi Delgado (center) - in front of one of our mobile health clinics.

For many of our clients, primary health care services are often out of reach. Frequently, the public health care system in their communities is either limited or non-existent, forcing many to travel long distances in order to access them. Once there, they join dozens if not hundreds of people also waiting to access the same services and there is no way of knowing if they will be seen by a doctor or required to come back at another time.

Throughout this process, our clients are forced to grapple with the crucial decision of remaining at their place of business in order to earn much-needed income or forgo a day’s wages and spend money on transportation to a clinic when they are asymptomatic. As a result, preventivemedical attention falls by the wayside until a client is sick, and by then the situation can be debilitating both physically and financially.

A few blocks from the town center where the campaign is taking place, we go to visit a Pro Mujer client at her place of business. Ángela Mamani Sulla is a 29-year old married mother of three who has a big smile and sunny disposition that makes her look years younger.Ángela runs a small convenience store which also houses the family’s living quarters.

She joined Pro Mujer in February of 2010 after being invited to join the “Sacred Family” communal bank. A communal bank is a group of 20-30 women who come together to take out a loan as a group and receive Pro Mujer’s services – finance (small loans, savings, insurance), business training and health care. They select a name for their group, elect a President, Secretary and Treasurer and guarantee one another’s loans as a group. In the event that one member can’t make a payment, the others make the payment for her until she is able to get back on her feet. As a result of this group guarantee, communal bank members only invite friends and neighbors who are credit- and trust-worthy.

Ángela’ s first loan of US$183 allowed her to improve and expand her family’s living quarters, double the size of her business and diversify the products she sells. It is truly inspiring to hear her story and see how far she has come in a relatively short amount of time.

One final picture before saying goodbye to Ángela and her daughters.

As we say goodbye to Ángela and head back to Arequipa, I realize it’s been a long day of traveling and everyone is wiped out. Tomorrow we head to Mollendo, a small port town of about 30,000 people on the Pacific coast in the southwestern part of Peru.

Tuesday – Arequipa > Mollendo > El Fiscal > Arequipa

The next day we board the bus at 7 AM and over the next two and a half hours, we descend more than 6,500 feet on roads carved into the sides of mountains with spectacular, lunar-like landscapes.

The beautiful but barren scenery on the drive from Arequipa to Mollendo.

We get to our Mollendo center in time to watch the members of the San Camilo communal bank organize themselves and run their loan repayment meeting. They are a warm and welcoming group and after their meeting is over, they take time out of their day to answer some of our questions. Every time someone asks the group’s President, Secretary or Treasurer a question, they stand to respond. It’s a simple act, yet one that speaks volumes. When many women first come to Pro Mujer, they are unable to speak in front of a group or even look someone in the eye. One can only imagine the circumstances that cause them to have this reaction.

The members of the Communal Bank San Camilo process loan repayments.

Within the group, we meet women (and a few men) who run businesses such as dance schools, selling AVON products (a common among our clients in a number of countries), convenience stores and restaurants, among others.

By the end of our time with them, we are all laughing and joking. For however brief the exchange, they’ve allowed us into their world and I’m always touched at the close relationships we are fortunate enough to share with our clients. The reason for this is that we provide so much more than a financial transaction; Pro Mujer is a transformative experience. It is an experience of personal growth where a client realizes her rights, her self-worth and begins the process of harnessing that awakening not only for herself, but her family and community. That sense of trust, support and community, that “we’re all in this together,” doesn’t just end with our clients, it extends to our team and beyond.

In a small file room, I come across a touching sight; the folder of a group of women who named their communal bank (#65) in honor of one of our Co-Founders, Lynne Patterson. It’s sandwiched between “Light and Hope” (#64) and ”Useful Hands” (#67).

From Mollendo, we hop back in the van for the next stop on our journey – El Fiscal. El Fiscal is a small town that has the Pan-American Highway running through the middle of it. El Fiscal caters to truckers and travelers through endless side-of-the-road businesses that offer everything from food and drinks to autoparts, among other things, for their long journeys.

The communal bank group Sarita Colonia is waiting for us to arrive. They’ve finished up their meeting but remain together as a group in order to receive us. We take turns asking them questions about their lives, their businesses, and El Fiscal. Dr. Alfonso Medina, our Health Manager for Peru, gives a talk about the importance of taking care of one’s health and making sure all of one’s exams are up to date. At the end of our session, the group brings out a traditional piqueo de camarones (a buffet if you will, of fried river shrimp complete with head, tails and everything in between) served in our honor. Camarones are the lifeblood of the women in El Fiscal. It was particularly touching that they went out of their way to host and feed us.

Dr. Alfonso Medina talks about the importance of monitoring one’s health.

Despite my best attempts to blend in, a client cheekily points out that I’m heads above the rest.

Pro Mujer staffers and visitors from Global Partnerships around the traditional Peruvian piqueo organized for us by the women of Sarita Colonia.

Wednesday – Arequipa > Lima

Wednesday found us celebrating the opening of one of our newest neighborhood centers, Paucarpata. In conjunction with the opening, Pro Mujer staffers held another health campaign for clients and members of the general public who had gathered for the event.

One of our newest centers in Arequipa, Paucarpata

Juan Carlos Torres, our Financial Services Manager, welcomed everyone with some remarks. Toasts were had and I was then given the honor of cutting the ceremonial ribbon while Naldi used a hammer to break the celebratory bottle of champagne christening the center.

The Pro Mujer Peru team and their mascot Julia.

Performing the ceremonial ribbon-cutting next to center manager, Fernando Paca

Naldi Delgado, Peru’s Country Director christens the Paucarpata center with a ceremonial whack of the champagne bottle.

After the ceremony, we tour the center and learn about the services that are provided on site. There is a medical consultation room staffed by a full-time obstetrician and a unique new service for clients, a BCP (Banco de Crédito) teller machine that allows clients to withdrawal loan disbursements from their bank accounts, deposit savings and pay utility bills safely and conveniently.

During the visit we have an opportunity to watch a new solidarity group (similar to a communal bank but with fewer members), receive its very first loan disbursement. The women are all very proud to be part of one of the first groups in the center, and to have us sit in on their meeting.

Fernando Paca and members of the solidarity group perform a pachamama ceremony, blessing their loan disbursement in the hopes that their money will multiply and bring them success.

This client thought that I would somehow bring some good luck to her funds if I handed them to her. After a few words of well-wishing, I handed them over – but I may have held onto them a few seconds more than she expected!

Following the opening of the Paucarpata center, it’s time for Naldi and me to head to the airport to board another LAN flight to Lima for more meetings.

The view of Misti volcano on the outskirts of Arequipa.

Friday – Lima

This morning we have a series of meetings with key people from the Universidad del Pacifico (UDP); Naldi’s alma mater and one of Peru’s top schools. A few months ago, UDP featured Naldi in a fantastic and inspirational video as part of its “Responsible Leaders” campaign highlighting outstanding alumni. Definitely worth checking out.

Later on that evening, Naldi and I participate in a live, sit-down interview with Peruvian journalist Cecilia Valenzuela for her show, “Mira Quien Habla” (“Look Who’s Talking”) on Willax TV. We’re here to discuss Pro Mujer’s work in Peru and throughout the region. To watch the interview (in Spanish), please click here.

Cecilia Valenzuela, Naldi Delgado and myself after the interview.

Saturday through Monday – Lima > Arequipa > Puno >Arequipa > Lima

I’m up early to fly to Puno, a city on the shores of Lake Titicaca, the world’s highest commercially navigable lake at 12,421 feet above sea level. I’m warned that altitude sickness can make one very ill here, but fortunately, the only symptom I experience is insomnia…wide-awake–at-4 AM insomnia.

I’m in Puno for additional site visits for upcoming projects (more on that in Part 2 of this post) and while I’m here, I’m taking advantage of stopping by our national office and meeting the 40-plus member team. It’s here that I run into Dr. Medina and Juan Carlos Torres, among others. Once again, I feel a beautiful sense of camaraderie that says, “Hey, we’re in this together.”

My time in Puno – and Peru – is quickly coming to a close and in less than 24 hours, I’ll begin the long journey back home. Only two weeks have passed, but the non-stop activities make me feel like I’ve been gone a lot longer – so much so that my colleagues joke that if I spent one more day, I just might be eligible for Peruvian citizenship.

Tuesday – Lima > Miami > NYC

As the plane takes off and I gaze out the window over the landscape, I begin to reflect on the past few weeks.

No matter which of our operations I visit, I’m always inspired by my fellow colleagues. Working at Pro Mujer is a commitment to a cause. It is not a 9 to 5 job and it’s not one spent behind a desk. It is a laboratory where one is constantly overcoming challenges (earthquakes, torrential rainstorms that close airports – more on that in my next entry—blackouts, logistical issues, etc.) and trying new things to find solutions. When something doesn’t work, we recalibrate and change course on a dime.

Why? Because the women we serve depend on it. Poverty is a complex issue with no silver bullet. To be a woman, to be poor and to be indigenous in Latin America is triply challenging, and serious barriers are placed in front of you from Day 1.

While relative poverty varies by country, the culture of poverty among the women we serve is the same. Enduring financial struggles and discrimination, doing double duty as both a mother and a father, and wondering what curve-ball tomorrow will bring are universal.

Access to health care (as a mentioned earlier) is limited or non-existent – this is a main factor perpetuating poverty, as poverty and health are inextricably linked. Because of traditional gender roles, many women are expected to take care of children and family members, often on their own because their partner is either physically or emotionally absent. These gender roles also limit their access to education and training, which then limits their opportunities for employment. They are frequently limited to jobs in the informal sector which is why so many open their own small businesses in or near their homes. Maintaining a business in the informal sector limits, or excludes altogether, access to traditional financial services. In the end, it’s a cycle that often passes from one generation to the next.

Despite all the challenges they face, these women are strong, hardworking and perseverant. Women like Janeth, Luisa and countless others march forward, moving themselves and their families ahead. With the essential tools and support that we provide, I’m confident that their road will be a little easier, and that a brighter future for them and their families is just over the horizon.

All photos taken with my trusty iPhone.

Addressing Chronic Disease in Latin America: Pro Mujer’s Health Pilot Program One Year Later

By Jana Smith, Project Manager, Health and Human Development Services with contributions by Dr. Gabriela Salvador, MD, MPH, Director of Health & Human Development

BLOG UPDATE (NOVEMBER 8, 2011) – To listen to Dr. Salvador talk about how Pro Mujer is addressing chronic diseases in Latin America, click here to listen to her on an EarthSky.org podcast.

BACKGROUND ON PUBLIC HEALTH ISSUES IN LATIN AMERICA AND WORLDWIDE
While maternal and child health interventions reach a relatively broad demographic in Latin America through the public health care sector, there are still no solutions to address the increasingly serious problem of chronic diseases such as hypertension, diabetes, sexual and reproductive health problems and breast and cervical cancers, among other illnesses.

Growing urbanization throughout the region has led many to lead a more sedentary lifestyle and greater consumption of fast food resulting in shockingly high figures of obesity, and by extension, chronic disease, especially in poor segments of the population. To combat these conditions, prevention or early detection is vital, since most of these diseases are “silent;” this is complicated by the high opportunity costs associated with access to care for women from impoverished communities who work in the informal sector. These women support themselves and their families with daily sales, and therefore must decide between lost income and preventive healthcare, the value of which may not be fully recognized until an illness has reached an advanced stage.

In addition to health implications, these diseases have tremendous economic implications for both developed and developing countries. According to a report published by the World Health Organization in April of 2011, non-communicable diseases cause 60% of deaths worldwide, killing 36.1 million people annually. “Non-communicable diseases will evolve into a staggering economic burden in the coming years…It’s a huge impediment to the mitigation of poverty” said David E. Bloom, Professor of Economics and Demography at Harvard University’s School of Public Health in a June 2011 Bloomberg interview.

PROJECT HISTORY
Pro Mujer began its operations in Nicaragua in 1996 and was the first replication of the Pro Mujer model after its founding in Bolivia in 1990. In 2005, Pro Mujer in Nicaragua (PMN) began offering health services with great success, particularly in terms of the usage of Pap smears and contraceptive methods. However, its lack of focus on chronic disease, its per service fee structure, and minimal commercial value prevented the program from achieving greater coverage, impact, and long-term financial sustainability and permanence.

In 2009, Pro Mujer decided to begin an ambitious project to rework its health model in Nicaragua. The aim of this innovative health pilot was to provide clients with comprehensive and affordable primary health care services while addressing the increasingly-serious problem of chronic disease. Between October of 2009 and October of 2010, PATH provided technical expertise in analyzing the market and developing key health elements of the program while Global Partnerships provided funding to launch the pilot which officially started in October/November of 2010. In addition, the Linked Foundation provided and continues to provide, invaluable support and funding.

A Pro Mujer neighborhood center and home to the organization's Nicaragua health pilot program.

Together, the team determined that the adjusted model would aim to comply with four key criteria: market responsiveness, potential for health impact, operational viability, and economic sustainability.  Program design was divided in six phases: structured interviews with industry experts, assessment of health-related needs and opportunities, operational assessment of Pro Mujer, market assessment to determine attractiveness of package for clients, pilot design and a financial assessment.

THE PILOT MODEL
After extensive research and analysis, Pro Mujer rolled out the newly-designed model in October of 2010 at one of Pro Mujer’s community centers in León, Nicaragua. Clients were then able to receive a high-quality, low-cost health package for just US$2.40 a month. The preliminary results have been astonishing and the lessons learned have great implications for Pro Mujer’s operations in other countries as well as other regions around the world.

Dr. Martha Garcia runs the health clinic at the Pro Mujer center in León, Nicaragua.

This comprehensive health package includes:

• A focus on prevalent conditions with an emphasis on chronic disease:  Early detection of hypertension, diabetes, obesity, sexual and reproductive health problems, breast and cervical cancer, among other diseases, are critical. These conditions were selected due to their prevalence in the target population and a lack of successful attention in the public sector.
• An upfront fee: The full cost of the package was priced and paid for in two or three annual installments at the time of loan disbursement.  Removing the link between the moment of usage and payment has been shown in many studies to increase access, especially for low-income populations.
• Services and Delivery:
  
• Screening package:  This component includes a systematic delivery of tests (Pap smear, body mass index, blood and urine exam, glucose test, blood pressure, and breast exam) for early detection of key conditions. Screenings are conveniently scheduled during loan disbursement meetings to lower opportunity costs since clients are physically present at Pro Mujer centers at this time.
• General physician consults:  Clients can utilize these consults to receive interpretations of screening results, follow-up on detected conditions, or for preventive or curative primary care at their discretion. These services are delivered in clinics at Pro Mujer centers and visits are scheduled to remote rural areas to ensure access for all clients.
• Referral system: Pro Mujer facilitates access to specialists, laboratories, and other key services by negotiating discounts for its clients through strategic alliances.

A Pro Mujer client in Nicaragua receives a consultation.

• Health education: The health curriculum was redesigned using a new, informal education methodology focused on healthy habits and the importance of early detection.  Its implementation was accompanied by intensive staff training. These health trainings are delivered by trained credit officials during loan repayment meetings to ensure that all clients are reached frequently and to keep down costs for clients.

PRELIMINARY RESULTS

Indicator	Nov 2010 -July 2011	% Positive
Screenings	4,673	29.4%
Consults	4,687	N/A
Pap Smears	2,196	5.5%
Clinical Breast Exams	3,222	3.5%
Glucose Tests	3,587	15%
Blood Pressure Measurement	5,893	6.8%
Body Mass Index	2,830	67%

When market research was conducted to measure client satisfaction, 81% said that they were satisfied with the package and 78.5% believed that the package was better than comparable services available in the market. Financial analysis shows that the pilot is in line to cover both full direct and indirect costs within a year as projected.

KEY LESSONS LEARNED
Despite much initial success as shown, the pilot has taught Pro Mujer a great deal about delivering preventive services through microfinance using a business model that will benefit the pilot and the other Pro Mujer country operations as well as other industry players.

Breaking paradigms. Health care is often thought of as a very specialized field which requires specialized staff. Experience throughout the world has shown that non-health personnel can be very effective at transmitting key health messages. Pro Mujer’s pilot has shown that coverage, efficiency, and in the long-term impact, is greatest when loan officers – who already have close relationships with clients – deliver health training.  On the other hand, health services are often thought of as a social service.  Pro Mujer has learned that the marketing and sales techniques of its front-line staff are key to making a primary care service attractive to clients.

A Pro Mujer credit officer provides a health training session on kidney disease prevention prior to facilitating the financial aspects of a communal bank or lending group meeting.

Listening to clients.  Constant monitoring of customer satisfaction has enabled Pro Mujer to adjust the package and plan for more significant changes. Although clients have expressed their satisfaction, preventive packages only have short-term commercial appeal for people who do not have conditions. It is vital to constantly improve the value of the package and surpass client expectations. Payment mechanisms are also key. Although the shift away from a per service fee structure service greatly increased usage, clients prefer to pay for the package in monthly installments along with loan repayments instead of lower, individual loan disbursement amounts.

A Pro Mujer meets with Dr. Garcia

Training is key. It is important to thoroughly train all staff, including those in both health and financial, in health education, social marketing and strategy. Training programs to clients are crucial to raise awareness of the value of early intervention and provide tools to improve lifestyle choices.

Rural delivery is a challenge. Not only is service delivery naturally a greater challenge in remote areas, but administrative procedures such as appointment scheduling and test delivery are also complicated by decentralized service delivery. It is necessary to “piggyback” when possible, carefully monitor and adjust processes, and look towards technology to facilitate access and improve efficiency in the future.

Benita Montalvan, a Pro Mujer credit officer, endures rough terrain in order to deliver preventive health education and facilitate communal bank meetings.

LOOKING FORWARD
Pro Mujer is currently planning the second phase of the pilot with the lessons learned from the first phase.  Measures are being taken to improve the payment mechanism, as requested by clients, to make the package more accessible. This has been one of the key points of constructive criticism and it is therefore expected that this change will help ensure continued purchase of the package.

In light of the high prevalence of obesity detected through the screening component, Pro Mujer is analyzing how to incorporate nutritional counseling into the service package and investigating ways to reinforce the practical tips delivered in training sessions so that they lead to concrete behavior change.  It is also believed that the services of a nutritionist would add commercial value to the package.

Market research reflects a great demand for medication, specialty consults, and dental care.  Pro Mujer is looking into different options to facilitate access to these services, whether it is by strengthening current alliances or developing new relationships with partner organizations. These high-demand services would increase clients’ willingness to pay and also enable Pro Mujer to incrementally offer a more complete primary care package to its clients. In order for clients to be able to complete specialized treatments that Pro Mujer’s package cannot cover, the organization is evaluating the incorporation of a capped health loan for existing clients.

As we continue to evolve as an organization, this pilot health care program will be instrumental to advancing our mission in support of Latin America women who are living in impoverished communities.

 

Combatiendo las Enfermedades Crónicas en Latinoamérica a Través del Piloto de Salud de Pro Mujer en Nicaragua – Un Año Después

Por Jana Smith, Gerente de Servicios de Salud y Desarrollo Humano con contribuciones de la Dra. Gabriela Salvador, MD, MPH, Directora de Salud y Desarrollo Humano

ACTUALIZACIÓN DEL BLOG (8 DE NOVIEMBRE DEL 2011) – Para escuchar a la Dra. Salvador hablar sobre cómo Pro Mujer combate las enfermedades crónicas en América Latina, haga clic aquí para escuchar el podcast (disponible en inglés) en EarthSky.org.

ANTECEDENTES SOBRE CUESTIONES DE SALUD PÚBLICA EN AMÉRICA LATINA Y EL MUNDO

Si bien las intervenciones de salud materna e infantil llegan a un demografía relativamente amplia en América Latina a través del sector de salud público, todavía no hay soluciones para abordar el problema cada vez más grave de enfermedades crónicas tales como hipertensión, diabetes, problemas de salud sexual y reproductiva, cáncer de mama y cervical, entre otras.

La creciente urbanización en toda la región ha conducido a muchos a llevar una vida más sedentaria y a un mayor consumo de comida rápida que resulta en cifras sorprendentemente altas de obesidad y, por extensión, enfermedades crónicas, especialmente en los sectores pobres de la población. Para combatir estas enfermedades, la prevención o detección temprana es vital, ya que la mayoría de estas enfermedades son “silenciosas”; esto se complica por el elevado costo de oportunidad asociados con el acceso a la atención de las mujeres de las comunidades pobres que trabajan en el sector informal. Estas mujeres tienen que mantenerse a sí mismas y a sus familias con las ventas diarias, y por lo tanto, deben elegir entre la pérdida de ingresos y la atención sanitaria preventiva, cuyo valor no puede ser plenamente reconocido hasta que una enfermedad ha alcanzado una etapa avanzada.

Además de las implicaciones para la salud, estas enfermedades tienen enormes implicaciones económicas para los países desarrollados y en desarrollo. Según un informe publicado por la Organización Mundial de la Salud en abril de 2011, las enfermedades no transmisibles causan el 60% de las muertes en todo el mundo, matando a 36.1 millones de personas anualmente. “Las enfermedades no transmisibles se convertirán en una carga económica significativa en los próximos años … Es un gran impedimento para la mitigación de la pobreza”, dijo David E. Bloom, Profesor de Economía y Demografía de Harvard’s University School of Public Health en una entrevista a Bloomberg en Junio del 2011.

HISTORIA DEL PROYECTO
Pro Mujer inició sus operaciones en Nicaragua en 1996 y fue la primera réplica del modelo de Pro Mujer después de su fundación en Bolivia en 1990. En el 2005, Pro Mujer en Nicaragua (PMN) comenzó a ofrecer servicios de salud con gran éxito, especialmente aquellos relacionados con la utilización de las pruebas de Papanicolaou y los métodos anticonceptivos. Sin embargo, su falta de atención a enfermedades crónicas, su estructura por servicio de pago, y el escaso valor comercial impidió que el programa alcanzara una mayor cobertura, impacto y su sostenibilidad financiera a largo plazo y permanencia.

En 2009, Pro Mujer decidió iniciar un ambicioso proyecto para revisar y mejorar el modelo de salud en Nicaragua. El objetivo de este innovador programa piloto de salud era ofrecer a las clientas servicios de atención primaria de salud completos y accesibles y a su vez enfrentando el problema cada vez más grave de las enfermedades crónicas. Entre octubre del 2009 y octubre del 2010, PATH aportó sus conocimientos técnicos en el análisis del mercado y el desarrollo de los elementos clave de la salud del programa, mientras que Global Partnerships proporcionó fondos para poner en marcha el piloto. Además, Linked Foundation proveyó, y continúa proveyendo, de un valioso apoyo y financiación.

Un centro de Pro Mujer y la casa del piloto de salud en Nicaragua.

En conjunto, el equipo determinó que el modelo ajustado tendría el propósito de cumplir con cuatro criterios fundamentales: respuesta del mercado, potencial de impacto en la salud, viabilidad operativa y sostenibilidad económica. El diseño del programa se dividió en seis fases: entrevistas estructuradas con expertos de la industria, la evaluación de la salud relacionada con las necesidades y oportunidades, evaluación operativa de Pro Mujer, la evaluación del mercado para determinar el atractivo de los paquetes para los clientes, el diseño experimental y una evaluación financiera.

EL MODELO DEL PILOTO
Después de extensas investigaciones y análisis, Pro Mujer lanzó el nuevo modelo en octubre del 2010 en uno de los centros comunitarios de Pro Mujer en León, Nicaragua. Los clientes pudieron recibir un paquete de salud de alta calidad y bajo costo por sólo $2.40 dólares al mes. Los resultados preliminares han sido asombrosos y las lecciones aprendidas tienen grandes implicaciones para las operaciones de Pro Mujer en otros países, así como otras regiones del mundo.

La Dra. Martha García lidera la clínica de salud en el centro Pro Mujer en León, Nicaragua.

Este paquete integral de salud incluye:

• Un enfoque en las condiciones prevalecientes, con énfasis en las enfermedades crónicas: La detección temprana de la hipertensión, diabetes, obesidad, problemas de salud sexual y reproductiva, cáncer de mama y cervical, entre otras enfermedades, es crítica. Estas condiciones fueron seleccionadas debido a su prevalencia en la población seleccionada y la falta de atención por parte del sector público.
• Pago por adelantado: El costo total del paquete fue determinado y pagado en dos o tres cuotas anuales en el momento del pago del préstamo. La eliminación de la conexión entre el momento de uso de los servicios y su pago, ha demostrado en muchos estudios un incremento de la accesibilidad al mismo, especialmente en el caso de las poblaciones de bajos ingresos.

• Servicios y entrega:

• Paquete de exámenes: Este componente incluye una entrega sistemática de pruebas (papanicolaou, índice de masa corporal, examen de sangre y orina, pruebas de glucosa, presión arterial y mamografía) para la detección temprana de las condiciones clave. Los exámenes son convenientemente programadas durante las reuniones de desembolso del préstamo reduciendo así los costos de oportunidad ya que las clientas están físicamente presentes en los centros de Pro Mujer en este momento.
• Consulta médica general: Las clientas pueden utilizar estas consultas para recibir las interpretaciones de los resultados de la evaluación, darle seguimiento a las condiciones detectadas, o para la atención primaria preventiva o curativa. Estos servicios se prestan en las clínicas en los centros de Pro Mujer y visitas están programadas para las zonas rurales remotas para garantizar el acceso para todos los clientes.
• Sistema de referencias: Pro Mujer facilita el acceso a especialistas, laboratorios y otros servicios clave mediante la negociación de descuentos para sus clientes a través de alianzas estratégicas.

Una socia de Pro Mujer recibe una consulta medica.

• Educación para la salud: El plan de estudios de salud se ha rediseñado con una nueva metodología informal, enfocada en los hábitos saludables y la importancia de la detección temprana. Su implementación fue acompañada por una capacitación intensiva del personal. Estos entrenamientos de salud los hacen funcionarios de crédito capacitados durante las reuniones de pago del préstamo para asegurarse de que todas las clientas sean vistas con frecuencia y mantener los costos bajos para ellas.

RESULTADOS PRELIMINARES

Indicador	Nov 2010 -Julio 2011	% Positivo
Evaluaciones	4,673	29.4%
Consultas	4,687	N/A
Papanicolaou	2,196	5.5%
Mamografías	3,222	3.5%
Pruebas de glucosa	3,587	15%
Medición de la presión arterial	5,893	6.8%
Índice de Masa Corporal	2,830	67%

Cuando la investigación de mercado fue realizado para medir la satisfacción del cliente, el 81% dijo que estaban satisfechas con el paquete y el 78.5% cree que el paquete era mejor que los servicios comparables disponibles en el mercado. El análisis financiero muestra que el piloto está en línea para cubrir los costos totales directos e indirectos en un año según lo previsto.

LAS PRINCIPALES LECCIONES APRENDIDAS
A pesar del éxito inicial demostrado, el piloto ha enseñado a Pro Mujer mucho acerca de la prestación de servicios de prevención a través de las microfinanzas mediante un modelo de negocio que beneficiará a este piloto y el otro las operaciones de Pro Mujer país, así como otros agentes del sector.

Rompiendo paradigmas. La atención médica es a menudo considerada como un campo muy especializado que requiere de personal experto. Sin embargo, la experiencia en todo el mundo ha demostrado que el personal no especializado en esta área también puede ser muy eficaz transmitiendo mensajes claves de salud. El piloto de Pro Mujer ha demostrado que la cobertura, eficiencia y el impacto a largo plazo, es mayor cuando los oficiales de crédito – que ya tienen relaciones estrechas con las clientas – ofrecen formación en salud. Por otro lado, los servicios de salud son a menudo considerados como un servicio social. Pro Mujer ha aprendido que las técnicas de marketing y ventas de su personal de línea son clave para hacer un servicio de atención primaria atractivo para las clientas.

Una asesora de crédito de Pro Mujer da un entrenamiento de salud preventiva antes de facilitar una junta del banco comunal.

Escuchando a las clientas. El monitoreo constante de la satisfacción de la clienta ha permitido a Pro Mujer ajustar el paquete y el plan haciendo cambios significativos. Aunque las clientas han expresado su satisfacción, observamos que los paquetes preventivos sólo resultan atractivos en el corto plazo para aquellas personas que no tienen condiciones de salud. Es de vital importancia mejorar constantemente el valor del paquete y superar las expectativas de la clienta. Los mecanismos de pago también son fundamentales. Si bien alejarnos de la estructura de pago por honorarios aumentó considerablemente el uso, las clientas prefieren pagar por el paquete en cuotas mensuales junto con los pagos de los préstamos en lugar de bajar los montos individuales de los préstamos.

Una socia de Pro Mujer en consulta con la Dra. García

La formación es clave. Es importante capacitar a fondo a todo el personal, incluyendo al personal de salud y finanzas, en materia de salud, mercadeo social y estrategia. Los programas de capacitación para las clientas son cruciales para elevar la conciencia sobre el valor de la intervención temprana y proporcionar herramientas para mejorar el estilo de vida.
La entrega de los servicios en las zonas rurales es un reto. No sólo es la prestación de servicios un reto mayor en las zonas remotas, sino que los procedimientos administrativos, tales como la programación de citas y entrega de la prueba, también se complican por la descentralización de los servicios. Es necesario “colgarse” cuando sea posible, vigilar cuidadosamente y ajustar los procesos, y mirar hacia la tecnología para facilitar el acceso y mejorar la eficiencia en el futuro.

Benita Montalvan, una asesora de crédito de Pro Mujer, tiene que resistir un duro trayecto para poder entregar educación preventiva de salud y facilitar una de las juntas del banco comunal

MIRANDO HACIA EL FUTURO
Pro Mujer está planeando la segunda fase del proyecto piloto con las lecciones aprendidas de la primera fase. Se están tomando medidas para mejorar el mecanismo de pago, conforme a lo solicitado por las clientas, para hacer el paquete más accesible. Este ha sido uno de los puntos clave de la insatisfacción por lo que se espera que este cambio ayudará a asegurar la compra del paquete de continuación.

En vista de la elevada prevalencia de la obesidad descubierta a través del componente de detección, Pro Mujer está analizando cómo incorporar la asesoría nutricional dentro del paquete de servicios y la investigación de formas de reforzar los consejos prácticos entregados en las sesiones de capacitación para que los conduzcan a un cambio de comportamiento concreto. También se cree que los servicios de un nutricionista pueden añadir valor comercial al paquete.

La investigación de mercado muestra una gran demanda de medicamentos, consultas especializadas, y cuidado dental. Pro Mujer está estudiando diferentes opciones para facilitar el acceso a estos servicios, ya sea mediante el fortalecimiento de las alianzas actuales o desarrollar nuevas relaciones con otras organizaciones. Estos servicios de alta demanda podrían aumentar la disposición de pago de las clientas y permitir también que Pro Mujer ofrezca un paquete de atención primaria más completa a sus clientes. Con el fin de que las clientas sean capaces de completar los tratamientos especializados que el paquete de Pro Mujer no puede cubrir, la organización está evaluando la incorporación de un préstamo de salud topado para las clientas existentes.

Conforme evolucionamos como organización, este programa piloto de salud será fundamental para avanzar nuestra misión de apoyar a las mujers de Latinoamérica que viven en pobreza.