Overview
A project in Costa Rica coordinated by the government and the PAHO/WHO country office has applied knowledge gained in the COVID-19 pandemic to encourage a primary health care (PHC)-led equitable recovery, with a focus on underserved communities.
The project was supported by WHO SDG3 GAP catalytic funding, together with funding for Costa Rica’s overall PHC vision from the Swiss Agency for Development and Cooperation in parallel with wider flexible financing.
Building on the successful implementation of community participation approaches in a previous PHC COVID-19 project, communities identified three areas for action through PHC: improving mental health, preventing gender-based violence (GBV) and violence towards children and supporting people with chronic health conditions.
The project quickly trained more than 250 community leaders who worked closely on collaborative action plans and programmes with underserved communities, including empowering indigenous women and girls. The GBV strand of the project took into account previous work by UNFPA and UN interagency groups.
©WHO/PAHO
Towards more equitable, gender-responsive and community-led PHC
“I am very grateful for this opportunity. As a group we learned things about health that we will put into practice and help others,” reflected a participant from Medio Queso, a remote vulnerable community in Los Chiles County, Costa Rica, on participating in an SDG3 GAP-supported community PHC project. As in many countries, the COVID-19 pandemic strained Costa Rica’s health system, with investments initially going to hospitals leaving PHC mostly out of front-line responses. Health inequalities heavily affecting indigenous, migrant and rural communities also affected Costa Rica’s capacity to cope with the emergency, including issues on mental health and violence disproportionally affecting women. A successful 2020 COVID-19 project1 showed that many health challenges and broader determinants of health could be better tackled with stronger and more integrated community participation, in line with an intersectoral, whole-of-society, people- and community-centered PHC approach.2
During this COVID-19 project, communities and local institutions together prioritized health issues to work on, even beyond COVID-19. Wide ranges of people were reached through social media and community sessions. Three areas were selected repeatedly: improving mental health, preventing GBV and violence against children and enhancing self-management of chronic non-communicable diseases. Typically, these issues disproportionately affect underserved and lower-income communities.
WHO SDG3 GAP catalytic funds supported an initiative to build on the previous COVID-19 project, using community engagement for major transformation in these three priority areas by jointly implementing action plans with communities. Community leaders were trained as ‘multipliers’ to share tools with communities specific to each priority area. Training these leaders relied heavily on virtual options, shown to be helpful in the previous COVID-19 project. Teams of PHC and municipal social service workers supported community leaders to ensure sustainable and quality service delivery. High-risk and underserved groups, such as indigenous women and the deaf community, were sought out for their involvement to improve equity, and adapted versions of training materials were made available for these groups.
For GBV, community leaders were trained in sharing tools to recognize how violence against women and children increased because of the pandemic and how to work with communities to devise violence prevention strategies. Media campaigns on GBV prevention and mental health promotion were produced to reach a wider audience. The mental health component of the project was adapted for young women in indigenous communities, intersecting with the GBV work.
“It is important to keep on with the trainings to develop tools and empower women [who] already are willing to improve their conditions and hence… society,” noted one community participant. Following the GBV sessions, an adolescent girl from the Cabecar indigenous group said that “I learned that a woman is worth more than she imagines, and that if she sets her mind to something in life, she can achieve it.”
“The community support networks generated in the awareness and training processes on violence against women have constituted a protective factor for women who are in risk of GBV, both before and during the pandemic. These actions also contribute to addressing women’s mental health, which is severely affected by GBV”, says Evelyn Durán Porras, Officer-in-Charge, UNFPA Costa Rica.
Collaborating with partners for effective community engagement
Pre-existing partnerships allowed funds to be implemented quickly and with impact. The project further developed these relationships, with broad intersectoral and multisectoral collaborations including local government, community development agencies, PHC organizations and government institutions such as the Ministry of Health, Ministry of Human Development (IMAS), the National Emergency Commission and the Costa Rican Social Security Fund, which provides universal public health care services.
The GBV element of the project was developed in the context of previous collaboration with GAP agency UNFPA and the interagency group on gender, which includes GAP agencies UNICEF, UNFPA and UNDP.
“Gender-based violence is one of the greatest challenges for human development. If we want to build back better and redirect the path towards the fulfillment of the 2030 Agenda, we must work together to eradicate exclusion and violence against women in all its forms, for which community participation is essential”, says José Vicente Troya-Rodríguez, Resident Representative, UNDP Costa Rica.
For all three project areas, many outputs contributed to strengthened PHC through community engagement: 255 community leaders trained and supported in 17 counties, tools shared, community action plans jointly implemented, local working groups formed, capacity built through collaborative work and closer partnerships between local and national institutions and communities. Communities responded by creating a wide variety of their own outputs. One community, for example, built a multi-sport court themselves to support and promote mental and physical health.
Lessons from previous community engagement work contributed to ongoing learning and improvement, including integrating evaluation from monitoring surveys by local partner institutions. For example to avoid challenges engaging overwhelmed healthcare workers due to increases in workloads, the team adapted tasks already undertaken and applied virtual solutions to help increase efficiency and effectiveness.
Working with local health care delivery networks for sustainability, future nationwide training of community leaders through the project model is planned. The Costa Rican Social Security Fund, local governments and PAHO/WHO Costa Rica are working together to integrate progress achieved through these projects into institutional initiatives to strengthen PHC, illustrating that this project has galvanized further collaboration. In close collaboration with the UN Resident Coordinator, PAHO/WHO is also seeking opportunities to work with UN agencies that share complementary mandates to support vulnerable groups such as UNICEF and IOM.
Using Costa Rica’s pandemic response as a learning opportunity, this project increased community participation in PHC, building a common vision, trust and partnerships. Costa Rica has developed strong, tested, sustainable and locally suitable approaches to people-centred PHC, with collaboration incentivized between communities and local and national partners. Individuals and communities were empowered to take charge of their own physical, mental and social needs, contributing to an equitable, whole-of-society and PHC-led recovery from the COVID-19 pandemic.
Community engagement and SDG progress
This project furthers Costa Rica’s progress on a number of SDG3 indicators and connects to wider health and socioeconomic pandemic recovery efforts through PHC strengthening, including the WHO Special Initiative for Action on the Social Determinants of Health for Advancing Equity, funded by the Swiss Agency for Development and Cooperation. The UN’s COVID-19 Response and Recovery Multi-Partner Trust Fund supported a project focused on women, migrants and asylum seekers, including a community-based COVID-19 surveillance mechanism to prevent GBV and discrimination.3 PAHO/WHO Costa Rica supports PHC strengthening within Integrated Health Services Delivery Networks (IHSDN) and others, contributing towards SDG3 targets 3.4, 3.5, 3.7, 3.8, 3d through flexible COVID-19 emergency funds.
What is the SDG3 GAP?
The Global Action Plan for Healthy Lives and Wellbeing for All (SDG3 GAP) is a set of commitments by 13 agencies that play significant roles in health, development and humanitarian responses to help countries accelerate progress on the health-related SDG targets.
The added value of the SDG3 GAP lies in strengthening collaboration across the agencies to take joint action and provide more coordinated support aligned to country owned and led national plans and strategies. A “recovery strategy” (Oct 2021) serves as a strategic update on the SDG3 GAP in the context of achieving an equitable and resilient recovery from the COVID-19 pandemic to the health-related SDG targets.
The purpose of GAP case studies is to monitor SDG3 GAP implementation at country level.
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