| 4. In which ways is the initiative creative and innovative?
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According to the Government’s strategy, in March 2007, studies for elaborating the program began. In that phase, maternal and infant mortality rates were analyzed, as was the policy of strengthening primary care. Research was also conducted in other states and countries by a group of government members connected to the theme.
On October 4th, 2007, with the completion of the consolidated document containing the premises, objectives and definitions of the governance structure and actions to be implemented, the “Mãe Coruja” Program was created by the decree nr. 30,859, to guarantee full attention to pregnant women who are beneficiaries of the public health system, as well as their children and families, with emphasis on health, education and social assistance.
Aiming the effectiveness of the program within the first few months of its implementation, its actions were put into practice initially in the 26 municipalities which presented infant mortality rates higher than 25 deaths/1,000 children born alive, with the region known as “Sertão do Araripe” to be contemplated first.
Still in 2007, teams were assembled to create manuals and establish a monitoring methodology. A decree legalizing the adherence of municipalities to the program was published offering details on registration of pregnant women, and stating the roles of the secretariats involved in the program.
In that period, the program was incorporated to the Government’s Strategy Map, with the adherence to the Strategic Objective related to promoting citizenship. This made other ongoing programs in the state have their actions linked to the “Mãe Coruja”. Some of them are “Milk for All,” “No Pernambuco Woman Without Documents,” and others.
At the beginning of 2008, with the objective of consolidating and broadening the strategy of building the solidarity network in conjunction with the municipalities, non-governmental entities, private institution and federal government, several Terms of Cooperation and Partnerships were signed with these entities through the “Mãe Coruja”. And to make the transfer of state resources for fighting infant mortality to municipalities possible, a decree regulated the transfers from the State Health Funds to the Municipalities’ Funds, created for this purpose.
In 2008 systematic regular monitoring of the program started. It involved regional coordinators at meetings conducted in the Mãe Coruja’s Corners. Since then, infant mortality has been analyzed at these meetings in light of its prevention, as well as the actions programmed for each region.
With results becoming more and more consolidated and expanded and with a view to making public policy of care for pregnant women a permanent action in the state, at the end of 2009 it becomes regulated by a State Law, revoking the decree of its creation promulgated in 2007.
In 2011, the specific indicators of the program were established. They focused on the evaluation of results and the ongoing of the processes. The program’s Strategy Map was elaborated.
With the expansion of the territorial coverage of the program, with the increase of the number of beneficiaries, and with methodological improvements implemented with time, it became impossible to monitor the program through spreadsheets and individual registration forms of the pregnant women and children assisted. Thus, still in 2011, a computerized system was especially developed, with access via web, which became operational in 2012. In that year, the program started having its own budget.
Currently present in 103 municipalities of Pernambuco and managing funds of around R$ 8 million a year, the “Mãe Coruja” Program involves 206 professionals working close to pregnant women, their children and family members, interacting in real time, via web, with the regional and state managers and coordinators, who monitor and evaluate the progress of the program and its results.
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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In his electoral campaign, the current State Governor made a commitment with the population to face the maternal and infant morbid-mortality problem in the State. Having been elected and upon taking office, demanded, right at the very beginning of his mandate, that a group of assessors develop a public policy that could articulate, formulate, execute, and monitor actions that promoted a drop in maternal and infant mortality, mainly in the interior of the State, where those indicators were more unfavorable.
As requested, representatives from seven secretariats of state (Health; Education; Social Development; Agriculture and Land Reform; Planning and Management; Children and Youth; Employment; and Women), created the main premises and actively participated in the conception of the “Mãe Coruja” Program, and later of its implementation. Afterwards, with the inclusion of Government’s officials, eight secretariats made up the Program’s team. The General Coordinition of the project was a responsibility of the State’s First Lady, who was a member of the Program’s Advisory Board.
Throughout the process, actors contributed to the implementation of the program, such as sectors of the federal and municipal government, Non-governmental Organizations and society in general, reiterating its character of State and not Government policy. An articulating network of care for the pregnant woman and her family was developed in each region, acting on the implementation of the actions of the “Mãe Coruja”. This way, besides the entities mentioned above, the following are also part of this network: UNICEF - United Nations Children's Fund; Pastoral da Criança – Children’s Ministry; Abrinq Foundation for Children’s and Youth’s Rights; and the Save The Children Organization.
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| 6. How was the strategy implemented and what resources were mobilized?
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With the creation of the Program in 2007, part of the work group initially formed for the development of the studies, servants from participating secretariats with diverse professional backgrounds, some of which being medical doctors, nurses, social assistants, psychologists, nutritionists and administrators, turned into committees and technical teams. These teams, made up of 33 professionals, among them the State’s First Lady, who became the Program’s General Coordinator, started meeting every week, to address the demands of the development of actions and the actors involved. At the end of 2007, with the implementation of the first actions, ten technicians from the Health Secretariat joined the teams.
To act on the Mãe Coruja’s Corners and regional coordination, there was a simplified public selection to hire degree holding professionals in the areas of health, education, and social sciences, capable of articulating and monitoring pregnant women. They should also have IT knowledge. Initially, 52 professionals were hired to cover the 26 priority municipalities.
At present, about 250 State professionals, among which managers and employees, work on the Program, besides servants and managers from the city governments where the actions are taking place. They are Community Health Agents, basic care coordinators, and maternity hospital directors.
As regards technical resources and materials, the Program has its headquarters in the State Health Secretariat. In the municipalities, the Mãe Coruja’s Corner is installed in spaces provided by the City Halls or by the Agronomic Institute of Pernambuco, for which the furniture and equipment were acquired with Program resources. Today, the “Mãe Coruja” operates a specific computerized system for pregnant women registration, monitoring the actions, and assessing results, all done via web and linking all the areas.
As far as financial resources are concerned, between 2007 and 2011, the Program did not have its own budget. These resources needed for the execution of the Program’s specific activities and its maintenance, circa R$ 4mil (US$ 1.6mil) a year, were allocated every year in the State Budget, in the several actions carried out by the other secretariats involved. In 2012, the “Mãe Coruja” started having its own identity in the state budget, and the resources allocated to it added up to R$ 7mil (US$ 3.4mil), having increased to R$ 8mil (US$ 3.9mil) in 2013.
Besides its own resources, the “Mãe Coruja” Program articulated investments from other sources to fight maternal and infant morbid-mortality. A good example were the partnerships between the State Health Secretariat and several City Halls, which, besides making it possible to transfer about R$ 10mil (US$ 4.8mil) from state resources to municipalities’ basic attention programs, also helped with the donation of equipment to municipal maternity hospitals, which improved the quality of assistance during high risk births. Besides that, the “Mãe Coruja” intermediated the resources from international development entities, from the Ministry of Health and from non-governmental organizations, which added, throughout the years, over R$ 80mil (US$ 39mil), used in the improvement of equipment in the obstetrics network, the increase in the number of hospital beds, and other initiatives.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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Among the main results presented by the Pernambuco “Mãe Coruja” Program, the continuous drop in infant mortality rates in the state deserves attention. Specifically, in the 103 municipalities applying the Program, infant deaths were reduced from 25.8/1,000 observed in 2007, to 16/1,000 accounted for in 2012. In fact, the measurements of the Ministry of Health’s Born Alive Information System conducted in 2012 show that Pernambuco has reduced infant mortality rate by 45% since the beginning of the Program. In the same way, maternal mortality rate was reduced, on average, in the same period, by 14% of the municipalities applying the “Mãe Coruja” and by 5% all over the State, according to data collected by the Maternal Mortality State Committee.
As of the implementation of the Program, other measurable gains were observed: according to data from the Pernambuco Food and Nutrition Security Inter-sector Chamber, there was a reduction of 34%, 14%, and 26%, respectively, in the percentage of pregnant women, breast-feeding mothers, and children between six months and one year old, in situations of mild, moderate, and serious eating insecurity. It was also observed that there has been an increase in the percentage of pregnant women covered by the state network of attention to health with 7 or more prenatal visits. That shows a rise by 17 %, achieving 48% of pregnant women assisted by the “Mãe Coruja”, even considering the territorial expansion of the Program.
Another important result is the increase in the number of families included in social policies that are part of the Program, according to their needs, which since 2008 has shown an average growth of 132%, reaching figures of more than 100 thousand women assisted and more than 50 thousand children accompanied by the Program. This result has been achieved through the matrix and inductive work done by the Mãe Coruja’s Corners, which, at the same time, identify and bring families to the Program, diagnose the situation, and point to the appropriate secretariat.
A fifth and important result was the strengthening of the Primary Attention policy, boosted by the integral, inter-sector, co-participative performance of the Program. After the “Mãe Coruja”, a bigger number of partnerships with various entities was made, which made new investments in equipment, physical structure, and hospital beds in the infant-maternal network possible in the regions assisted.
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| 8. What were the most successful outputs and why was the initiative effective?
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Since its implementation, in October 2007, the Mãe Coruja’s actions have been permanently monitored by the Program’s Advisory Council and local municipal servants.
With the inclusion of the Program, at the beginning of 2008, in the State Strategy Map, the “Mãe Coruja” started being monitored by the Government, within the scope of the “Modelo Todos por Pernambuco” (All for Pernambuco). In this process, which culminates in weekly meetings chaired by the Governor and organized around each Strategic Objective, the strategic action, called Priority Goal, is monitored, in its physical and financial realization, though process indicators.
The monitoring methodology used in the “Modelo Todos por Pernambuco” was incorporated at the beginning of 2008 to the Program’s regular systematic monitoring, involving the regional coordinators in monthly monitoring meetings that take place in the Mãe Coruja’s Corners, also involving the Advisory Council, the State and Regional Coordinators, at a state level, and the Mãe Coruja’s Corners servants, Municipal Articulators and Municipal Secretariats, at a regional level.
In 2011, with the regularization of the Program’s specific indicators, the monitoring meetings conducted by the Advisory Council gained a new deliberative dynamic, focusing also on the assessment of results of the actions taken, using the tool called “Sala de Situação” (Situation Room), which keeps record of the indicators in a managerial fashion. A final analysis of the death watch is also done, in light of its prevention.
An important question is about the Program’s beneficiaries data. Initially, the registration process of those assisted by the “Mãe Coruja” and the monitoring of the actions taken with the various partner institutions was done through registration forms, electronic spreadsheets, and the Health Secretariat’s specific systems.
As of 2011, a computerized system, aimed specifically at the Program, started being developed. This system is capable of automating monitoring and control tools. This system starting operating in 2012, integrating data and all areas involved, substituting spreadsheets, registration forms, and several reports produced in paper. Nowadays, the system is in its second version, allowing Managers and Regional and State Coordinators of the Program to monitor and manage the Program. Besides that, eight State Secretariats have personalized access and functionalities, which allows them to monitor the evolution of the Program in real time, having, as the only requirement, passwords and access to the Internet, once the system works on the web, with technology 100% compatible with browsers such as Internet Explorer, Chrome, and Firefox.
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| 9. What were the main obstacles encountered and how were they overcome?
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One of the difficulties for implementing the “Mãe Coruja” Program was the inequality observed in the regions where the Program operates, each with problems and specificities that influenced in a particular way the causes of infant mortality observed, impeding the construction of a single solution, applicable to any region. It was necessary to study those regions individually, and to establish different approaches to fighting mortality, customizing them for each region.
An important obstacle was the differences in basic structures of primary care existing in several municipalities. To overcome this problem, partnership between municipalities promoted sharing available equipment in each region. Partnership with non-governmental organizations and fostering entities was also tried for the allocation of resources set aside for the acquisition of equipment.
Shortage of local qualified professionals with the desired knowledge for municipal job positions was another hurdle. The solution for this case was the development of continued training, with courses orchestrated by the Coordination of the Program.
Because it was the applicability of a program with inter-institutional actions, conducted in an integrated manner by state, municipal, and non-governmental organs, another obstacle encountered was the articulation of several actors involved. In some cases, for difficulties in this articulation, there was a need to change plans so that the program didn’t suffer any impact in its ongoing and achievement of objective. To minimize this problem, the Coordination of the Program promoted meetings, workshops and training sessions with all involved, aiming to define roles, mobilize, sensitize and commit the various actors.
Last, upon implementation of the Computerized System specific for the Program, it was noticed that not all municipalities had satisfactory Internet coverage, which compromised communication between some Mãe Coruja’s Corners and the Coordination of the Program. Investments were needed to expand local internet in the municipalities where this communication was precarious.
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