From Local Input to Systems-Level Change: Building an Ecosystem for Quality Service Delivery for Moms and Babies

How can we take the concept of locally led development beyond individual organizations and partners – and ultimately build a movement to improve maternal, newborn, and child health? How can a focus on supporting local and regional ecosystems enable engagement, cross-sharing, and accountability for sustained progress in quality service delivery?  

In this last episode of our season focused on localization, Debrah Lewis–a midwife, co-founder of the Caribbean Regional Midwives Association, and consultant with UNFPA–joins us from Trinidad and Tobago, and Dr. Vaibhao Ambhore, Chief of Party of Saksham, a USAID-funded MNCH Accelerator project under the MOMENTUM umbrella, joins us from India. 

They share concrete examples of taking local, community-informed ideas to scale. We hear about interventions that meet the intersectional needs of women and families, such as a program to address wage loss during pregnancy, and discuss the role that policy dialogue plays in creating systems-level progress for mothers and their babies. 

Transcript

[Introduction:] 

MOMENTUM Presents: Bringing in-depth experience and improving maternal, newborn and child health services, family planning, and reproductive health care in countries around the world; providing technical and capacity development assistance to country leaders and governments; and ensuring that mothers and babies have access to essential care in order to reach their full potential. 

We are MOMENTUM Country and Global Leadership, funded by the U.S. Agency for International Development. Welcome to MOMENTUM Presents. 

[ANGELA PEREIRA]

Hello listeners. Welcome to the final episode in the second season of Momentum Presents. I'm your host, Angela Pereira. This year, we focused on how localization can improve maternal, newborn and child health, family planning, and reproductive health. In these episodes, we've explored the importance of locally led development on childhood immunization efforts, on the co-creation of family planning and reproductive health initiatives, and on perinatal mental health outcomes.

Today, we're going to connect the local to the ecosystem. We will discuss how we can take the concept of locally led development beyond individual organizations and partners, and ultimately create ecosystems and build a movement that champions holistic, quality service delivery for women, moms, newborns, children, and their families. What role can community networks play in policy level and system level change?

I'm thrilled to welcome our two guests to the podcast today for this big picture conversation. Debrah Lewis joins us from Trinidad and Tobago. She is a midwife and Founder and Executive Director of Mamatoto Resource and Birth Center, the only midwifery-led birth center in the Caribbean. She is a long time consultant with UNFPA and one of the founders of the Caribbean Regional Midwives Association, where she is still an active member. 

And Dr. Vaibhao Ambhore is the Chief of Party of Saksham, a USAID MNCH Accelerator project, and a program advisor at PATH South Asia. Prior to joining PATH, he worked with the Ministry of Health in the Center for Studies in Ethics and Rights. He has led multi-state projects on maternal, newborn, child health, supply chain, adolescent mental health, and anemia. 

Welcome, Debrah and Dr. Vaibhao, it's wonderful to have you here today.

So, both of you together bring really diverse experiences to today's conversation. So to start off, I'd like to ask each of you to tell me briefly about your work as it relates to maternal, newborn, and child health. So, Debrah, let's start with you. 

[DEBRAH LEWIS]

Okay. Thank you so much, Angela. So, just in a nutshell, the Caribbean Regional Midwifery Association is a professional organization that's made up of national member associations from 13 countries.

And their mission as they stated, is to — and I will, you know, adlib, – it's to promote high standards of midwifery care. But the way they do that is through capacity strengthening, advocacy, education and training, leadership, mentorship and research. So all of those things is … they focus on all related to midwifery to then ultimately contribute to improving maternal and newborn health in the region.

[ANGELA PEREIRA]

And Dr. Vaibhao, over to you. 

[DR. VAIBHAO AMBHORE]

Thank you Angela. Thank you for having me here. We are implementing USAID-funded MNCH project Saksham under the guidance of our AOR Dr. Sachin Gupta and the Director Health Office Michelle Lang Ali. I would like to thank them for their constant guidance and encouragement. 

We are working in three states in India, Assam, Odisha, and Chhattisgarh, where the rates of maternal mortality are high under this project. In Saksham, – saksham means ‘capable’ – we are looking to achieve three broader results. One on access, improving access to MNCH services. Second, on building capacities of institutions. And third, and most importantly, fostering collaborations between MNCH and non-MNCH partners. 

[ANGELA PEREIRA]

Thank you. You know, this season is all about localization, so tell us a little more, Dr. Vaibhao, of the context in which you are working and doing these three interventions. 

[DR. VAIBHAO AMBHORE]

So, I will speak about Assam, and Assam being the one of the largest tea producing regions in the world. So the Assam region has high, high rates of maternal mortality owing to Assam tea gardens where a lot of inaccessible areas are there. The workers there have migrated from other regions of the country to Assam. So they are not local. And they, they come from different, different communities who lack a sense of identity there. And a lot of issues of access to quality health care are persistent there due to different challenges. Amongst many services that government launches, the issue of access is very important, and also the collaboration between different partners. So the context is of migrated people who work in tea garden areas and who need better access to quality care in MNCH services. 

[ANGELA PEREIRA]

And how does that context impact those three interventions that you discussed in your intro of what Saksham does? 

[DR. VAIBHAO AMBHORE]

Yes. So coming to the first result that we are chasing, the access: looking at these areas, they don’t have good connectivity by road or through internet or electricity, owing to the topography of the region being largely a tea cultivation area.

Also, the hospitals that are there have faced a lot of challenges. They are inside the tea gardens. So retaining human resources there is challenging. And third, in terms of collaboration, the health is a result of collaboration between multiple partners. If the institutional mechanisms are weak, then the collaboration is not optimal. It affects the services and quality. So all three results do get affected by this context and leading to poor maternal child health outcomes. 

[ANGELA PEREIRA]

Thank you, Doctor Vaibhao. I mean clearly very important work that you're leading with the tea garden workers of Assam. And let's go back over to the Caribbean as well and discuss that context a little more.

So, Debrah, in, in, you know, your work and the work of CRMA supporting midwives in the region, what is the context there for midwives and how they're able to provide quality care for women in the region?

[DEBRAH LEWIS]

You know, I think globally it's recognized that midwifery care is vital. They're an important part of a multidisciplinary team. But in this region, even more so, we have two parallel health care systems: public health care, private health care. But the public health care system is really the largest. And the 90 something percent of the births and the care provided are through midwifery care. So they really are, you know, a vital part of the team. 

However, there are challenges, you know, in terms of the scope of practice, regulation and so on. So through the Caribbean regional body, we've been able to address many of those things. You know, access to continuing education, for example, to make sure that we're practicing evidence-based care is a challenge. Travel is expensive, access to conferences, etc. So one of the initiatives that CRMA, as we refer to them — the Caribbean Regional Midwives Association – that they took on, it started during the pandemic, but was virtual educational webinars and on a range of topics. So not just clinical but maternal mental health, postpartum hemorrhage, but also things like self-care. 

But these educational webinars have had an average of about 300-400 persons present from about 14 countries. The last one had over 600 people from 16 countries. So, you know, the context of like really creating, yes, that regional presence, but then being able to localize it. Over 16 midwives from those countries were able to access that information and remain updated on their practices.

[ANGELA PEREIRA]

Thank you so much, Debrah. And I think we're going to keep discussing the Caribbean context specifically. It's really helpful and amazing, your description of creating this large regional presence and network and then really localizing it to support the midwives who are really the backbone of providing maternal newborn care in the region.  And through CRMA, what are ways that you are creating broader systems-level change?

[DEBRAH LEWIS]

So, one of the impactful ways is through what is described as policy dialogue, where we bring together national leaders to really have discussions, so dialogue, about what are some of the policies and changes that can be implemented. 

Certainly, that is one of the big areas, but understanding that MOMENTUM really has supported several initiatives in the region. So they have supported family planning initiatives, capacity building, research, but the policy dialogue has really been one of the most impactful. 

First of all, the listeners may be familiar with the document, the State of the World's Midwifery Report. It's been produced three times. The last time was in 2021. It gives you a picture of what midwifery looks like globally. In all of them, but particularly in the last one, we found that the region really was not well represented in terms of the data and so on. With support, we were able to bring together the nursing and midwifery leaders – the chief nursing officers, the heads of the councils, which are the regulatory bodies – we brought them together for a meeting and we gathered data on practice, education, regulation, and legislation. And then we were able to sit and have a discussion about what are the recommendations that they would come up with, because these are the people that are in the local context, in the national sphere, that will be implementing, you know, many of these recommendations.

So they agreed on several recommendations related to education and workforce and policies. And we created a State of the World’s Midwifery Report: A Caribbean Response. So very specific to this region. But it's an amazing publication with the actual recommendations from the persons who will then go back to the local context and implement many of those recommendations. So I think that policy dialogue piece has been really the most impactful work that we've been able to accomplish in the region. 

If I can give one example, I suppose it's a global problem, but in this region: migration and retention of midwifery staff. So that is one of the primary areas. But we now, in that publication, have concrete examples of what countries can do in the local context to retain their care providers, their health care staff, and just avoid the depletion. Because it is global, so there are other countries that are also looking to recruit, but we can't afford to lose them. So, very specific examples to maintain, you know, their presence here within the region. 

[ANGELA PEREIRA]

So, you're bringing the stakeholders together in these larger policy dialogue discussions, creating recommendations that will hopefully create systems-level changes. But then I think also recognizing, I assume, that people are then going back to their local contexts and working to adapt and actually make some of those overarching recommendations work in their local context.

I'm curious, you know, then, what are the next steps there? How are then those more localized efforts brought back together at a bigger level to see what broader change might be happening? 

[DEBRAH LEWIS]

We understand that there will be unique characteristics within individual countries, but generally the similarities are much more so. The broad recommendation is with each country then taking them back and tweaking, as appropriate, to be utilized within those countries.

But because it was the leaders themselves that came together and met and came up with those recommendations, they themselves then go back and have a responsibility for rolling out the recommendations, for implementing them. They remain accountable. We have also included a monitoring and evaluation process. So they go back out into their individual countries to the local context, work on it, and then periodically come back into the larger group to provide feedback. Because they are held accountable. So they come back and say, what has the progress been? What have you been able to implement under these recommendations related to workforce? What have you not been able to accomplish? What are the plans going forward? You know, so yes, in a group, back out to the local as individuals, back into the group to be accountable.

[ANGELA PEREIRA]

Wonderful. Thank you so much. I think that's a really wonderful example. And let's go back over to Dr. Vaibhao. Let's take that thinking around what it takes to really support these local and regional networks and ecosystems, of different stakeholders who are hopefully all working towards the same goals, but in their local contexts. And can you talk about how you've seen an example of that in your work in Saksham?

[DR. VAIBHAO AMBHORE]

Yes. So we are implementing this initiative in collaboration with Piramal Swasthya, Jhpiego and Deloitte. Looking at the complex context and the high rates of mortality, we formed core groups of frontline workers: frontline workers who are in touch with community, who provide services, who counsel the pregnant women for delivering in the institutions. We formed the groups of these frontline workers and told them that you will be advisors to our project, every quarter we will come to you, and we will ask, ‘What are the problems?’, we will understand what you think is the solution, and we’ll help you implement those initiatives. 

So when we understood the challenges from them, one of the challenges was access to wage compensation schemes that Government of Assam has floated, where they compensate for a pregnant women for wage loss during her pregnancy. Without that, a pregnant woman can continue working and not take adequate ANC care. So in that case, we found this is a challenge which we may not have found otherwise. Any health-related survey would not have picked up this challenges, but we were in touch with the frontline workers who told how to do it, and then we understood that this access to wage competition scheme would require multiple parties to work together. That includes the identity card issuing system, the banking system, which will open bank account, the government of Assam, which will ultimately transfer the money, and the tea estate management, because these are the tea estate workers who are availing these benefits. 

We got all these parties together. We formed a multi-stakeholder forum at the district level, chaired by a highest administrative authority in the district. All people discussed how this challenge can be solved and issued relevant guidelines and instructions to the relevant authorities to start this process. And with this catalytic impetus, we were able to, in the first phases, register more than 3,000 pregnant women. More than $110,000 USD were dispersed to this scheme. But ultimately, what it does is it gives identity to people, the people who did not have any identity card, to people who did not have a bank account, in which they could also receive benefits from the other schemes of the government, not just this scheme. It really opened avenues for them to avail various services through this initiative. 

[ANGELA PEREIRA]

Thank you for that, Dr. Vaibhao. And you spoke a lot about how it's intersectional for stakeholders. Can you speak a little bit about how it's intersectional for the woman, for the person experiencing the intervention? 

[DR. VAIBHAO AMBHORE]

So, when a woman tries to access certain services from different departments, for her, there are multiple things that come into play.

One, she does get her identity. Second, she gets her bank account, which usually many women in India don't have in rural areas in inaccessible areas, so having a bank account is a great achievement for someone living in such an inaccessible area. Third thing, the money that comes into the account can get utilized for a better nutrition during the pregnancy, and it does affect because that money comes with guidelines from the government to be used for nutrition. And hence, it can help the mother as well as baby. So when we see the the photos after the campaigns, we can really see a smile of accomplishment on their faces. They have entered a system that is there to take care of them. So for a woman, it's probably her first experience of services coming to her rather than she seeking services and going to services. But all of these departments coming to her, it creates really a positive impression in her mind about the system that is there to serve her. 

[ANGELA PEREIRA]

It's clear from your answer that there's really an intersectional, multisectoral approach that is often necessary for, you know, these really complex challenges at local levels that involve multiple different people to get involved. So can you discuss that a little more? You know, why is it important to bring different stakeholders, different sectors together? 

[DR. VAIBHAO AMBHORE]

Yes. So when we understood that different parties need to work together, different constituencies, different stakeholders need to collaborate in order for pregnant women to avail these services. We can imagine a pregnant woman, trying to get access to identity card through different offices, then going to banks to open an account, then coming to health facilities to register herself. What this initiative did was became sensitive to the needs of this pregnant woman, and it launched a campaign called MAAdol, which means a local music instrument there, a campaign that provided all these facilities in a single window for a pregnant woman. So there is a spot where all these departments converge. They set up their tables and a pregnant woman goes from one table to the other table, goes through the process and ultimately gets her identity and bank account open, which would have taken months or weeks to get done through different places. And we can't expect a pregnant woman to do that.

Continuing with this thinking, it also is important to improve the quality of services in tea garden hospitals. And these hospitals are run by the tea estates, or tea cultivation industries, who cultivate the tea there. It's not a government system. Government has instituted a public-private partnership there, so government provides certain level of funds to these hospitals to be able to provide certain kind of services. However, these hospitals need a lot of support to improve the quality and ensure that a certain level of services are available there. 

So what we did was we collaborated with the Tea Garden Association, Tea Garden Management, and formed Hospital Management Committees, which needs to be formed under the public-private partnership and give them tools to self-assess and then understand what are the things that they're lacking and then address those challenges. And we are seeing lots of actions being taken by these hospital management committees in terms of labor room improvement, in terms of newborn care corner setting up, in terms of improving labor ward privacy, curtains, washrooms. All these things have come out as a concern in these hospital management committees. And because these committees will stay beyond the project period, we can see a sustaining impact of this intervention beyond the project period.

So when we work with the different constituencies and make them understand that all these factors need to come together for them to be able to address the maternal mortality rate. We were able to garner a lot of support from these different stakeholders who came together to make sure that the services improved in these hospitals. 

[ANGELA PEREIRA]

Thank you so much, Doctor Vaibhao. I think both you and Debrah have just painted really concrete and interesting examples of how it really requires a lot of different actors working together to create solutions that make sense in local contexts. So I think really helpful, really insightful examples there about how we can take this concept of locally led development, take it beyond individual organizations and partners, and ultimately try to build bigger movements that will have an impact on women and children and newborns. I'm wondering, what is also the impact on accountability when you bring different stakeholders together in these different movements?

[DEBRAH LEWIS]

It's really important to involve the stakeholders and the leaders at the national level. So for us, it's the Ministry of Health. We engage the Ministry of Health within each country, usually through the chief nursing officer, who represents midwifery and nursing within the Ministry of Health.

And we also engage the professional associations, because that's where the midwives are. The people that are on the ground. And the regulation because they dictate the laws and the legislation. So really important to involve all of them, otherwise, many of the projects that you'd like to implement will go nowhere.

You know, they each have a piece to contribute. So, absolutely vital to engage them. And an example of what we've done with that is we did a big research study on respectful maternity care. It was done in Trinidad through the university, of course, engaging the Ministry of Health and all of the other stakeholders. But it's not possible to do that full research project in every country, you know.

So what we've done is we've brought together the stakeholders, and the intent is to roll it out in other countries, one country at a time. So the next country was Jamaica. So again, we brought together the persons from the Ministry of Health, the ones from regulation, the professional association, and and of course, really importantly, the community organizations, the people who actually use the services, including adolescents, and they give input into the recommendations.

So again, broad recommendations tweaked for specific countries, but with the buy-in from every level, including the community, because we have to get first the feedback from the community about how they feel about, you know, in this specific case, respectful maternity care, but also what would they like to see done about it and how would they like to be included in implementing the changes and so on.

And then when they're all present for giving the feedback and feeding into whatever the implementation plan is, then they go back with a feeling of accountability because they have given in what they think is the best way to address it.  We continue the conversation, the dialogue continues, so that they can then continue to contribute, but also give us feedback on if it's being done.

So are the providers, are the institutions actually implementing the changes that they have said they would? What is the community's, you know, perspective on it? How is it being received? So from everyone that feedback is important, but that comes with accountability. Without accountability, you cannot get the buy in and the feedback going forward to actually implement many of the changes.

[ANGELA PEREIRA]

Thank you so much. And Dr. Vaibhao I'll go over to you as well to also address that accountability question from your perspective. 

[DR. VAIBHAO AMBHORE]

Again, looking at the quality of care and availability of services at tea garden hospitals, we looked at what are the possible levels at which we can set up accountability structures. So one structure I mentioned already is the hospital management committee.

So there is a committee now that looks at the availability of services and non-availability of certain things at the hospital level, which can be corrected. Second level was at the district level. So we integrated review of health, especially MNCH indicators in the district level review. And we called it District Task Force.

So District Task Force now regularly reviews the updates coming from the tea garden hospitals and the community areas and looks at what are the things that need to be taken up to improve these services. After this, the hospitals and, and the service providers are answerable or accountable for presenting the current status, as well as submitting action taken after a certain thing has been pointed out.

So these forums at the highest level of authority, the minutes of the meetings are issued that lists down all the points that need to be addressed after these meetings. And then we as a project, follow that up and then facilitate that process to make sure that the things are delivered. 

Along with that, we also share the feedback and learnings from these local level, district level implementation at the state level. And these state level learnings are then replicated in other districts and other places where such initiatives can be taken up. So really, we are trying to institutionalize certain accountability mechanisms that can continue beyond the intervention.

[ANGELA PEREIRA]

I think the accountability discussion is really fascinating, and I think there's so many parallels between what you both are doing in terms of, you know, facilitating those feedback loops and making sure that at every level, from ministries of health to the impacted communities, that there's accountability and shared understanding of what the goals are and what everybody is working towards. 

We've been talking about locally led development in this season. We've talked about it a lot through the lens of individual organizations and what it takes, you know, in terms of capacity strengthening, continued long term funding for local partners to really support, you know, work going forward, the importance of co-creation. But now that we're looking at it also from this broader lens of these bigger, locally led networks of people working together towards larger aims, what do you think is really important for the long-term sustainability, for supporting and continuing these locally led networks into the future? And maybe, Dr. Vaibhao, I can start with you first.

[DR. VAIBHAO AMBHORE]

We are trying to make sure that in the long run, these things are sustainable. One of the initial aspects that we do is anything that we produce as a guideline or a new learning from these initiatives, we share that at the state level and try and integrate that in the existing government guidelines.

So it becomes part of the message that is disseminated to various districts and levels below to make sure that these learnings keep informing the future implementation. Second thing is the state, when they are convinced about impact or effectiveness of certain interventions, they include them in their annual budgeting cycle. And that's one of the important advocacy agenda. When a line item is adressing budget for that particular activity, it stays in the long run and keeps getting financed.

At the community level, what we were able to do is increase the interest of youth, local youth into health related initiatives. So at the local level, we formed youth clubs who are interested to contribute to community and we also get a lot of exposure working on these health issues. So we orientate them, sensitize them. And what they do is they go into the community and conduct street plays. They write the script and they engage with the community.

They go on the streets and perform that theater. The community really gets together. They see and they engage with these people to understand more about the kind of entitlements and services they can, that they can avail. What it does is it also makes them more aware of the steps that they can do to avail not just these services, but other services also.

[ANGELA PEREIRA]

Thank you. And I'll turn the sustainability question over to you now, Debrah.

[DEBRAH LEWIS]

Okay. Thanks. Because of the regional documents and discussions, we have been able to incorporate many of these suggestions into actual legislation, so into the laws that have been revised and have already been done, and moving forward will continue to be revised. They've also been incorporated into national policy guidelines that are being issued through the Ministry of Health.

So I think that makes them really engraved for sustainability. And the documents themselves even can continue to be used to support advocacy efforts going forward. As an organization, a lot of work has been done on capacity building. CRMA has produced it first strategic plan, a five year strategic plan with very clear outcomes and objectives. They've had leadership workshops, mentorship workshops, particularly targeting the executives, but also identifying younger midwives for succession planning, because in order for the organization to continue to, we must have people coming up to continue to do the work.

So that's where the work with the executive leadership mentorship continues. We've also done a lot of work around financial planning because we cannot continue to be dependent on external funding. You must have some level of self-sustainability financially. So a lot of work has gone into developing programs that will bring in income in order to be able to continue the work of the organization.

[ANGELA PEREIRA]

Wonderful. Thank you so much, Debrah. I think in this conversation, there have just been so many insights and tips and examples that I think will be really interesting and useful for listeners when thinking about this issue of supporting and scaling local networks. And I want to actually turn the microphone over to you both as well, and see if you would like to ask any questions of each other that have struck you.

So, Doctor Vaibhao, please go ahead if you have any questions for Debrah.

[DR. VAIBHAO AMBHORE]

So, Debrah, we are implementing an initiative called ‘Technical Advisory Group’ under our project and one of the important areas that we are discussing is midwifery. Can you tell us more about how we can, you know, make it more effective in terms of collaboration between the doctors association, midwives, and government to make sure that we are able to scale this initiative?

[DEBRA LEWIS]

Thank you for that question. Well, I think you’ve already made a good start in that the technical working group is multi-disciplinary because that is important. And I think it's well recognized, you know, the role that midwives can play. I think you've had success in terms of getting the pregnant women to access care, and now you have to make sure that you have the workforce to be able to provide the care.

And midwives, I maybe have a bias, but midwives are the perfect providers to be able to do that. So how do you work together? That's a global challenge. But bringing them all to the table together with a common goal, then you're halfway there because after all, everyone wants to see improved maternal, newborn, child health care. So bringing them to the table.

But what I found help in our perspective is each person understanding the role of the other. Because a lot of the resistance comes because the role of the midwife is not fully understood. One person thinks this, somebody thinks something else. If we go back to the start, you would have to ensure that the education programs meet a certain standard of competence so that when you say you have a midwife, you understand what that means. So when that is the start point, there then is the common understanding of what the midwife is and what the role is. And you come to the table, the midwife understands clearly because it's: the pediatrician, the obstetrician. You know, there are many stakeholders at that table, but if each understands their role, you have a common goal. Respectfully discuss, what is my role? How can we, within our scopes, really practice to support each other, but in the end have this same outcome? 

Education, understanding the scope, meeting together. Everything is done together. The clinical practice workshops are done together, because in the clinical area, each person must understand the scope and the role of the other to be able to come together and work together.

So halfway there by having the multidisciplinary team, but better understanding what the scope is and making sure that the midwife is educated to practice within her scope. 

[DR. VAIBHAO AMBHORE]

Great, thank you. Thanks. That's useful. 

[DEBRAH LEWIS]

Right. So, Doctor Vaibhao, my question for you. I mean, I'm really quite impressed with the initiative. It has been successful in supporting the pregnant women to gather documents and to access care.

I wondered, can this project be considered a sort of pilot so that the model can be shared to be utilized in other local regions? And if so, how? 

[DR. VAIBHAO AMBHORE]

Yes, I think very, very important question. Not just pregnant women, but also services for newborns and services for lactating mothers. So there, are there are package of interventions that are delivered to, you know, maternal, newborn, child health.

This model can serve as a good guideline for bringing different multiple stakeholders together, and how to provide a single window of services to a pregnant woman or a lactating mother. This can serve as a good example, even if it is not just wage compensation, but there are other benefits that they should receive from the government. So those different ministries giving, offering different benefits.

So Ministry of Tribal Affairs will give certain benefits. The Ministry of Women and Child Development gives nutrition-related benefits, but they are all provided at different platforms. So this particular model that can put together all these components and provide an example of single-window service for a pregnant woman, can really help set up those models so that a woman doesn't have to access multiple departments to get those benefits. Thank you. 

[ANGELA PEREIRA]

Thank you both so much. That was very interesting. And you know, we always end the podcast with one last question for our guests. So we've reached that time now. 

Bringing it back to the overall season's theme on localization: Why does localization matter for building a movement and for creating systems-level change?

[DEBRAH LEWIS]

It brings to mind, there’s one of our documents that had a tagline or something that said ‘small nations, large impact.’ I think as individual countries, we're small. Small in terms of size, but also small in terms of numbers, the numbers of midwives, the number of care providers. So that it's really challenging to be able to do things as individual countries.

However, together, when we come together and create a regional movement, like a regional wave, to create change and to advocate for what we want, then those things that come out of that can then be utilized by all of the countries at the local level. So, you know, small nations not able to do it alone. Big impact: we come together, we create those things, but then we the wave goes back out and the movement goes back out into the local context to make sure that it's ingrained in the system.

[ANGELA PEREIRA]

Thank you. And over to you, Dr. Vaibhao. 

[DR. VAIBHAO AMBHORE]

I'm reminded of the way we started in the project, and we, we conceive certain models of delivery. And when we tapped into the context in all these three states, our models now look very different, informed by the localization. So, the wage composition scheme or hospital management committees or even addressing home deliveries and making sure that they deliver in the institution were not initially part of our design, but it got informed. And now these models are shaped in different ways, in different states. 

So that really gives us, understanding that, while starting on initiatives, we can give broad guidelines about what we want to address, but unless we go and build a local understanding and get inputs from them and then help them solve their challenges, then only we are able to see impact and scale.Otherwise the initiative can happen in that part, but doesn’t get replicated or doesn't get scaled. 

So localization really helps in addressing complex interplay of challenges. 

[ANGELA PEREIRA]

Thank you both so much. I mean, what an interesting and informative conversation. And I just very much appreciate you both taking time. Debrah, you know, our listeners can't see you, but you're in your scrubs, you're in your midwife mode actively providing care to patients. So, you know, we will let you get back to that very important work. And just very much appreciate both of your time and your insights. 

And listeners, thank you for joining us for this important conversation and for this final episode of the season. We invite you to share this conversation with your friends and colleagues. You can also listen to the rest of this season two’s episodes of the Momentum Presents podcast, as well as our previous season. And stay tuned for season three of the podcast, starting soon, where we will continue exploring how to improve maternal, newborn and child health, family planning and reproductive health.

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

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This concludes this edition of Momentum Presents. For more information about our work, please visit www.usaidmomentum.org, and follow us on Twitter at usaid_momentum for additional resources.