The Power of Locally Led Co-creation and Capacity Strengthening

Co-creation and capacity strengthening are two concepts at the heart of localization efforts. But what do they mean to local experts, community members, and advocates? How can co-creation and capacity strengthening improve access to and quality of family planning and reproductive health needs?

In this episode, Isaac Ndaya, a private sector and public health expert at the Total Family Health Organization in Ghana, a partner of MOMENTUM Private Healthcare Delivery; and Ragini Bordoloi, a MOMENTUM Country and Global Leadership: India-Yash Youth Fellow and sexual reproductive health and rights (SRHR) youth advocate in India, speak about how locally-driven approaches can create contextual, effective solutions to meet family planning and sexual and reproductive health needs.

We hear about how approaches like peer-to-peer mentoring can strengthen capacity and create private sector partnerships to meet evolving family needs in the community. And we learn how meaningful co-creation, where local community members are not only involved but are leading program design efforts, can increase accessibility of SRHR knowledge and services.

Transcript

{Intro recording} 

Greetings podcast listeners, and welcome back to our returning listeners. Thank you for joining us for this episode of Momentum Presents.

I'm your host, Angela Pereira.

This season we are focusing on localization, how shifting power and resources — and the microphone — to communities can improve maternal, newborn and child health, family planning and reproductive health.

Now, many donors, including USAID, are strengthening their commitment to locally led development. Co-creation and capacity strengthening are two concepts at the heart of localization efforts, and terms we hear frequently. But what do they mean to local experts, community members, and advocates?

On today's podcast, we will hear from Ragini Bordoloi, a youth advocate in India, on how co-creation can improve sexual and reproductive health and rights; and from Isaac Ndaya, a private sector family planning expert in Ghana, on how to rethink models of capacity strengthening.

How can we make both capacity strengthening and co-creation efforts effective, truly locally driven, and responsive to community contexts? Isaac, thanks for joining.

[Isaac]

Thank you, Angela, for having me.Thank you.

[Angela]

And now, Isaac, you have experience in business and public health. You've helped expand access to family planning, maternal health, and WASH products across Ghana. As the Director and founding staff member at Total Family Health Organization, a partner of MOMENTUM Private Health Care Delivery project, and the current Chief of Party of the USAID Social Marketing and Private Sector Activity, I'd love to hear about your perspective on capacity strengthening.

So first, tell us about your work. What is the mission of Total Family Health Organization?

[Isaac]

All right, thank you once again, Angela.

Total Family Health Organization is a local Ghanaian social marketing organization that works to improve the well-being of people living in Ghana.

Our specialized areas, you have family planning, maternal, child health, nutrition, HIV/AIDS prevention, malaria prevention and treatment, and water, sanitation and hygiene. And we are adding on a new area, which is non-communicable diseases.

As a social marketing organization, we focus on sustainability, and so the private sector is really critical and we focus a lot of our energies in that area. In all of the thematic areas I've mentioned, how do we drive that?

The strategy is through social marketing and social behavior integration approaches, and also distribution of commodities to the last mile, to areas that need them the most.

[Angela]

It’s interesting to hear about how the private sector is involved in meeting public health needs in Ghana. How does capacity strengthening help you reach that last mile?  How do you define capacity strengthening? 

[Isaac] 

Alright. So, capacity strengthening will usually focus on developing or strengthening the skill sets, knowledge base, and then resource base of individuals and organizations — it goes beyond just the individuals -– of individuals and organizations, and ensuring that it improves their performance over a long period of time.

But one critical thing about capacity building for us to understand is that it is not an event. It has to be an ongoing process. You need to continue to understand the dynamics of the environment. What are the changes within the space that you are building capacity?

If you are building capacity in family planning, be it individuals, health providers or even the health facilities, what are the changing trends within the environment? And that will inform opportunities for capacity building.

And so it’s going to be an ongoing process that will continue to respond to environmental needs, respond to the needs of clients, because clients over time, their needs will change and you need to be able to continue to build capacity to respond to those needs. Even networking with all other stakeholders that you will share your skills and share your know-how. It could be classroom-based. You could actually have field-based where you do mentoring and all of that. 

So all of these come together to give us an understanding of how broad capacity building is.

[Angela]

Thank you. Yeah, I think that's really helpful, thinking about it as a flexible, ongoing process, really responsive to different ways that people learn, not just in a traditional classroom. I think one other question I have about capacity strengthening broadly is, how is it crucial for sustainability of health service delivery, particularly for family planning and reproductive health?

[Isaac] 

You need to continue to build capacity to be able to respond to these health needs of people.

We're getting to a point that we have clients who want self-service, such as DMPA-SC, and then SI, self-injection. You need to build capacity of providers to be able to train clients to be able to provide such services.

If you want to remain relevant and be sustainable in your business, then you need to continue to build capacity of your providers, build the structures even for data capture to understand your clients, and you need to build the capacity of people to know what data to collect from clients when they come in. How do you give feedback to clients? How do you have a two-way communication with clients?

Even in terms of financial sustainability, we’re looking at what are the other opportunities within a market space for you to be able to expand your services? And if you want to do that, you need to build capacity of your providers.

Because we have new technology in terms of the method mix that are coming up on the pipeline. So as these come on board, if you do not change, you would fail as a business. And so it's really critical for private sector.

[Angela]

Through the MOMENTUM Private Healthcare Delivery project, I understand that your organization has really been leading peer-to-peer models of capacity strengthening. Can you talk a little bit more about that particular model and approach and how you've seen it work well?

[Isaac]

First of all, through the MOMENTUM activity, we had capacity building for even ourselves as an organization and individuals, and I happened to benefit from that capacity building by a consultant firm that the MOMENTUM project funded essentially to build the capacity of TFHO to able to then offer services, technical services, to offer capacity building for other local organizations, such as the Methodist Health Systems of Ghana. So we actually took that on as part of our portfolio to provide capacity building as a consultancy service. 

And so MOMENTUM Private Healthcare Delivery said after having built your capacity, we're going to give you seed capital to start as a pilot and build the capacity of an organization that you would identify in terms of providing SRH services.

And so we identified the Methodists that have a system and a network of about 25…26 now… facilities and in all of these, they provide services. So we engaged them. And what happened was that we had an inception meeting and we agreed on the blueprint.

And here, what we do is we create a model or design family planning outreach models that these facilities would be able to expand access to family planning services and commodities.

So we sat together, and as a local organization — and they are also a local organization — so it is more a peer-to-peer than coming from the top and then pushing down knowledge or capacity building.

So we saw ourselves as peers since we are both local organizations and we went into what we call a co-creation.

So we did an audit of the services that were provided and we agreed with them that indeed they needed an outreach model. So, together we co-created the blueprint of the model, and MOMENTUM was generous to have some funding for us to buy basic equipment that they needed to be able to treat their instruments for IUD  insertion and removal, autoclaves, and all of that. We purchased some quantity and handed that over.

We needed to then train them on a comprehensive family planning, particularly on long acting reversible contraception, using new models such as counseling for choice, which we properly call C for C, counseling with emotional intelligence, and person-centered care. We have a roadmap with them to do supportive supervision and to do quality of care evaluations.

So you had the models, you had capacity building, you had supply, and the fourth one or the fourth deliverable was actually demand generation. So, we also took them through the process of doing demand generation in communities.

We had one that was based on institutions, educational institutions. We had the school model. You had the one that was the community level model. You had the house to house model. Then we had a mobile model.

So each of these would require different, you know , modalities in terms of demand generation because the locations are different and the people you have to deal with are different. So all of these were part of the capacity building and strengthening that we gave to the providers.

It's rare for you to have what we call master trainers, or trainers of trainers, in the private sector. In most cases, they are usually public sector, or government have the master trainers. They have the trainers of trainers, because these are usually sponsored by donor funding, and you don’t have a lot of donor funding in the private sector.

But we took the opportunity to train master trainers for these network of facilities, train trainers, so that they can train new joiners; so they have trainers in each of these facilities and they don't have to wait for another project to come and bring these new staff together to train when they have their own in-house trainers.

[Angela]

I think that sounds like a really comprehensive model and it seems like you're already seeing some of the successes and impact of this partnership and this model. But I think if you could just give me a couple concrete examples of the successes that you and your team have seen through carrying out this peer-to-peer capacity strengthening model.

[Isaac]

We see a better collaboration between us as an organization and the Methodists because they did not see it as a project, just coming to provide capacity building and then going away. But they saw it as a long term relationship that we're building with them.

In terms of service uptake, we continue to take data from them and to be able to show results that for those providers or those of the facilities that were not providing IUDs and implants, after the capacity building now they have the right skill set to provide. We are seeing some numbers in terms of those specific methods of service uptake in those areas. They are now able to go to communities because they have the models handy. They can go to communities, mobilize people in the community and provide services or do education, and those people come to the facilities for the services.

[Angela]

And how do you think this type of capacity strengthening is different from typical models?

[Isaac]

One, there's trust, and two, there's better collaboration once you see both organizations or institutions see each other as peers. And I say trust because, you’re not having some big organization or some international organization come and provide capacity as a project and go away. We are here with them. They can always fall on us if they had challenges. We keep the contact with these people. We actually are going to be integrating them into new projects that are coming up.

And so that continuity is there. As a local organization, we continue to exist and as long as we have projects in line with what they are doing, sexual reproductive health, we would have a way of integrating them so they will continue to benefit. 

[Angela]

Thank you so much, Isaac, for your perspectives and your insights on capacity strengthening.

I think it's clear from your comments that this type of capacity strengthening, peer to peer, responsive, ongoing, flexible can help, particularly private sector, but other sectors also, with improving their health service delivery like increased access to family planning methods.

So, we're going to go to a different sector, to a different location, focus more on the co-creation aspect of things. Ragini, that's where you come in; welcome to the podcast.

[Ragini] 

Thank you for having me here, Angela.

[Angela]

You’re a prorram consultant based out of Assam, India, and you've been an adolescent in Youth sexual and Reproductive health and rights advocate since you were 19 years old. 

To start, what are some of the challenges around sexual and reproductive health and rights where you're from in Assam, India?

[Ragini] 

Thank you for the question, Angela. Where do I begin? It's been almost four years of engaging with young people, women as well as men in my community and beyond. And I can say that this very understanding of sexual and reproductive health and rights is itself missing.

How does one even articulate the problems and demands if they don't have the vocabulary to do the same? How does one know what service to seek, who to reach out to, understand if the state services are reliable or not, if the knowledge and awareness about their bodies and health are missing? These questions I feel set the backdrop of the SRHR landscape in Assam.

Other than this knowledge deficit about one's health, I feel, especially in sexual and reproductive health, the interventions designed to provide these SRH services continue to be limited. There’s an extremely biomedical model that's focused on providing curative services. Awareness generation is also mostly around harm reduction. And while these are absolutely important, I have observed that this further alienates young people from accessing health. The most pervasive barriers for young people in accessing or even talking about sexual health and reproductive rights is stigma. You know, there's a lot of shame and taboo attached to it, so much so that they will do anything in their capacity to hide it from their parents, peers, neighbors, to avoid humiliation and punishment.

But I want to highlight something. These pre-existing barriers to access healthcare are further compounded by the fact that Assam's geoclimatic conditions make the region very disaster prone. Annual floods during the monsoons damage the existing healthcare infrastructure, obstruct health care service delivery, and mostly displace people.

We have done several consultations with young people from communities affected by these climate casualties, and we have observed that vulnerability is related to menstrual health and hygiene, contraception, pregnancies, and childbirth, are significantly heightened during these circumstances.

The existence and prevalence of these problems only suggests that we cannot achieve health equity without simultaneously working on climate justice as well, especially when the context is Assam. So, all in all, focusing on this intersection has to become a priority, both at a policy level and community level.

[Angela]

Thank you, Ragini. I mean, you painted such a clear picture of the challenges around sexual reproductive health and rights in Assam, India, and I want to know, what specifically motivated you to become an advocate for sexual reproductive health and rights?

[Ragini]

So if I look back at my journey, it began with my own discomfort the first time I got my period when I was 11 years old, 

I was made to follow elaborate traditional rituals that involved me sleeping separately on a bed of hay for more than seven days, not allowed to take a shower, brush my hair, and I was strictly supposed to keep myself from touching anything because my touch had apparently become polluted.

Over time, as I struggled to understand the changes my body was going through, I realized that there was a lack of information, and even if there was information somewhere, I couldn't access it.

So at the age of 19, I started a social media platform, named it “My Vagina, My Rights," with the purpose of disseminating evidence-based and stigma-free material on sexual and reproductive health.

Over time, I could collaborate with youth organizations and collectives to spread awareness on young people's access to SRH services. In that process, I understood that young people are not only demanding access to reliable, confidential, affordable, SRH services, but they also want their communities to be youth friendly at the same time

With my conversations with several young people, young activists, what came out is that there can be hundreds of pharmacies or reproductive health services within my immediate vicinity, and yet I would feel more comfortable and safe for seeking services somewhere else, discreetly. So what is exactly compelling a person to give up the convenience of proximity and instinctively seek out the clandestine? It's mostly fear and shame. We need to have, to demand a deeper reflection on how young people's bodies are often sites of control and surveillance.

This is exactly why I became an SRHR advocate, because until we collectively decide to unpack and dismantle the extremely skewed power dynamics in our home, communities and public spaces, most conversations on access are pretty much useless. You know, young people will continue to live their lives in the shadows, concealed from the world. This is what prompted me to continue my advocacy so that I can demand for more meaningful inclusion of young voices in decision making, so that I can advocate for more locally led context appropriate solutions.

The communities already know about their problems. They're ready to work on the solutions that cater to their distinct needs. How do we facilitate and foster this local leadership? How do we invest in building sustainable, resilient communities?

[Angela]

As an SRHR advocate, what does co-creation mean to you? And could you give an example of what that looks like in your work?

[Ragini]

What introduced me to this idea of co-creation in SRHR programming was one of the experiences I had while working with marginalized women working in tea garden communities. This is when we went to the community and asked them, What do you want next? How do you want to proceed? How do you want to solve your problems? And they immediately said that we do not want anyone else to come in and work in our communities; rather, we want us to be given the resources, be it monetary resources, be it information, be it knowledge. And then we work with that knowledge, we work with those resources, and we work with the community. And I think that instantly changed the way I look at development.

A lot of people are demanding for a more bottoms up approach to development and they are saying that we have our own language, we have our own community practices, and we understand our community more than anyone else would. If you are coming in, please come in only with the resources and we are going to create our solutions ourselves. We have been trying to incorporate it more and more.

For example, I recently made a comic book on adolescents’ access to contraception and safe reproductive services, and this was done in consultation with communities and every graphic is based on the community. For example, what the character would be wearing, what the school would be looking like.

So I created a story where this young girl had you know sexual relations with her, with her partner, and now she is very anxious of what to do. And now she's telling her friend that I missed my period and I'm really scared, I don't know where to go. And this friend says, My sister is a doctor. Please come and talk to her. And the entire comic then is an interaction between this person, this young person and the doctor. 

Most of the content that we create as organizations, how can we ensure that these are not just PDFs that lie in some corner of the internet and are being used by people that these resources are meant for? And that is the essence of co-creation, right? Because this demand has come from the community. It is not me who has thought that, okay, this would be the best resource for them and then create and then disseminate it across the community. It's them saying that, okay, this will not work, but this might work. And me just taking in their inputs and trying with the best of my abilities to create something out of it and saying, ‘Is this going to be useful for you’? 

So, they are the decision makers in the process. Even though I am making the comics, they are the decision makers who are leading the decision on what has to be created, how it has to be created. 

[Angela]
And then, what do you see as the link between how you're using co-creation in your work and then ultimately, how it helps to bridge that gap between availability and access that you were talking about?

[Ragini]

You know, most of the communities have always been viewed as passive beneficiaries of a development program. There was never a conversation on local ownership. Am I even able to design my own solutions? Even that conversation is very new.

So within this limited experience, I have seen people feel more comfortable, there is more relatability, there are more personal interconnections within the community, when someone from the community is leading the decision making rather than someone else who has no connection to the community, just designing policies for them.

[Angela]

Thanks, Ragini. And I want to switch gears a little bit.

You are clearly a formidable youth advocate and you are also a MOMENTUM Country and Global Leadership India-Yash Fellow. Could you tell us a little bit about your participation in that fellowship and how it strengthens your role as an advocate?

[Ragini]

I cannot talk about my experience as an SRHR advocate without mentioning the role mentorship has played in this whole journey, because, A.), I didn't even know that there was a platform for me to voice my demands.

And this is when organizations that were working on empowering youth leadership, you know, empowering youth voices came in and helped me to even move out of my very small space and then connect me to other young activists who are working throughout India and beyond. I felt that through mentorship, the focus was more on harnessing my strengths, what is my strength and how I could utilize it, and how do we build this into our youth-led movement. That is what mentorship has taught me.

As a fellow, I was working on understanding policy gaps that restrict men's active involvement in family planning and also the prevailing gender and social norms that influence their lack of engagement in family planning.

While I was trying to build this knowledge product, at every stage there were people who were giving me customized mentorship. I realized this is what young people want, especially in marginalized communities in places like ours, in Assam. There is a need for young leadership to flourish because there are young people who want their voices to be heard. There are young people who have insight on what is wrong, where the policy gaps are, where the implementation bottlenecks are, but then where do they go to? Who will listen to them? Is there any infrastructure available? Is there any platform available so that their insights are taken seriously?

[Angela]

And so you've been both a mentor and a mentee, so you've been on both sides of it. Could you give a little bit more of a description of what is customized mentorship? What does that look like?

[Ragini] 

So I'll just use the example of my experience as a Yash fellow. Within that fellowship, it was not just one person from one common background. Mentorship that is meant for everyone would not work.

This is where the customized mentorship part comes in. Its when someone's unique, distinct problems,very contextual issues, are understood from them, they are leading the discussion, and they are leading the decision.

[Angela]

If advocates are listening to this podcast, particularly youth advocates around the globe, what lessons have you learned that you would want to share with them?

[Ragini]

The first and foremost lesson that I have learned and that I share with everyone is that, please don't question yourself, you know. Because as young people we have been through it, our lived experiences are evidence. If anyone else is disregarding it, it has nothing to do with your problems being illegitimate. One has to believe in their voice. One has to believe in their intuition, and one has to believe in oneself.

In a consultation meeting, in the presence of several doctors and policymakers, I made a case for youth investment and I made a case for why youth leadership is important. And a doctor came up to me and said, Ragini, I understand what you're trying to say, but you're not 25 yet, so your prefrontal cortex hasn't still grown yet. You might not be able to take the right decisions for yourself.

That's a very funny anecdote I share. But then it's also very relevant, because every time I have talked to youth advocates who have tried to engage with stakeholders, their age and their lack of experience is cited as a reason for their concerns to be not taken seriously.

And I know wherever you are in the world, whoever is listening, there will be many a times when somebody will come and dismiss your experience. But you have to be resilient, and we have to look after each other, and we have to exchange knowledge and exchange life skills so that we can take this fight forward. 

[Angela]

Thank you, Ragini, for sharing your wisdom, your personal experience, your insights –  I really, really appreciate you.

So Isaac and Ragini, throughout today's conversation, I've heard a lot of similar themes from you both, from customization, to responsiveness, to the importance of peer-led capacity strengthening and co-creation, despite your unique role in different locations. So, do you have any questions for each other?

[Isaac]

Ragini, how can organizations like mine, which is a local organization, better work with youth advocates? And this came from the background that our current project, we're actually going to be working with youth advocates that will advocate in terms of policy change and also, most importantly, advocate for private sector investments into family planning and sexual reproductive health, and then maternal and child health. What advice do you have for us? Thank you.

[Ragini]

Thank you for your question, Isaac. I believe we have to look at this as a talent acquisition opportunity.

Young people in my community and beyond, and I'm sure in your community as well, are willing and are very passionate to work for their problems. They have the capacity for innovation.

Thus, I think there should be more efforts to adopt and sustain a youth-led, community centric advocacy approach to push for the representation and leadership of young people. Organizations such as yours can come in, inspire these young people, and give them the right platform so that this can become a reality.

[Angela]

That’s great advice, Ragini.  Now, I'd like to conclude by refocusing on our main theme: localization. Isaac: Why is capacity strengthening crucial to localization?

[Isaac]

In one word, it’s sustainability. Sustainability as a business. And I say this because we are talking about the private sector. Sustainability is a guiding principle of, of of every activity that we do, be it donar funding. We need to be making sure that we are building capacity of even our staff, we are building the structures, we are building all the financial and management structures, program management structures, which is part of sustainability.

Because when I spoke about capacity building, I spoke about the fact that it has to do not just individual, but even the structures of organization, the resources and resource mobilization and all of that. So the critical thing is sustainability. Thank you.

[Angela]

Now, thank you so much, Isaac. I think that's a great point to leave off on and to hammer home. 

Ragini, why is localization crucial for co-creation, for improving health,particularly for adolescents?

[Ragini]

You know, I would first like to answer why localization is the need of the hour and then move on to the implications of localization on adolescents’ improved access to health care. I think I can best answer the first part of the question with an anecdote from my field experience of working with women from tea garden communities in Assam.  

In a consultation meeting with community workers, one of them shared how most people in their community preferred going to the local healer for their health problems instead of their local government authorized health dispensary. Now, these local healers are generally unauthorized people who provide treatments for different ailments, mostly using traditional ingredients and methods.

Upon knowing that this has been happening, the administration of that locality sought to restrict the concerned local healer from providing his services. As an immediate reaction to this, some members of the community rose in protest against the decision.

Now, for an outsider with limited knowledge of the underlying context, this might suggest the prevalence of superstition and dogma within the community.

But, upon closer scrutiny, a completely different and clearer picture emerges. The people preferred going the unauthorized provider because they felt that it was more accessible,

they found it more respectful, and they felt like the local healer understood their problems.

This revealed that access doesn't look the same for everyone. When certain sections of people are not treated most respectfully, when people feel unaccommodated, building a large hospital complex means nothing. Whose expertise are we seeking? Whose experiences are we documenting?

Pre-existing marginalization only get magnified when access is severely limited. In order to address this marginalization and how it affects access, we have to be intersectional in our approach and to be intersectional, we have to focus on localization.

All our efforts to uphold bodily autonomy and agency inherent in the principles of reproductive justice will lack teeth until and unless we talk about strengthening local ownership too. Localization cannot simply be about participatory planning or engaging people at a consultative stage. It has to go beyond it and focus on facilitating local leadership. That I feel should be the goal and objective of localization.

[Angela]

Ragini, thank you so much for that insightful response and what a wonderful way to end today's podcast. Ragini and Isaac, thank you so much for sharing your insights and experiences, and unpacking both co-creation and capacity strengthening, and thank you to our listeners for tuning in.

We invite you to take a listen to previous episodes of MOMENTUM Presents and let us know what you think. Please share this episode with your friends and colleagues, and subscribe to the podcast for easy access to future episodes. Stay tuned to MOMENTUM Presents for more stories on ways that localization can accelerate progress globally for maternal, newborn and child health, family planning and reproductive health.

This podcast is produced by MOMENTUM Country and Global Leadership, funded by the U.S. Agency for International Development.

{Extro recording}