ChildCountPlus_ConceptNote

7/30/2019 ChildCountPlus_ConceptNote

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MillenniumVillagesProject:ChildCount+:ACommunityHealthEventsReportingandAlerts

SystemAConceptPaper

"Tomakepeoplecount,wefirstneedtobeabletocountpeople."DrLEEJongwook,FormerDirector

GeneralWHO(20042006)

A. Background

Reducingchildandmaternalmortality,by66%and75%respectively,havebeenidentifiedascore

MillenniumDevelopmentGoal(MDG)targets.InmuchofsubSaharanAfrica,10to20percentof

childrendiebeforeturningfive,andthedeathofmothersduringchildbirth,arareeventinindustrialized

countries,occursfartoofrequently.

Thereissubstantialevidencedocumentingthepositiveeffectsofarangeofsimpleandcosteffective

interventionsonmaternalandchildsurvivalincludingvaccinations,oralrehydrationtherapy,

insecticidetreatedbednetsalongsidestrengtheninghealthsystemstoimproveantenatalcare,safe

deliveryandtheintegratedmanagementofsickchildren[14].However,theirwidescaleapplicationin

areasoftheworldthatneeditmostremainsinsufficient.

InthesubSaharanAfricancontext,numerouschallengeshamperprogresstowardsrapidgainsin

maternalchildsurvival.First,weakanddeeplyunderfinancedhealthsystemshavebeenunableto

introduceandsustainthedeliveryofcriticalinterventions[4].Second,factorssuchuserfees,distance,

andtransportcreatesignificantaccessbarriers.Itisestimatedthatovera100millionpeoplefallinto

povertyeachyearduetoofoutofpockethealthexpenses[5].Finally,thelimitedavailabilityof

accurateandtimelyhealthinformationhasmadeitdifficulttotracktheprogressofinterventionsand

identifycoveragegaps[6].

TheMillenniumVillagesProject(MVP)seekstoaddresstheselimitations.MVPinvolvesthecoordinated

deliveryofapackageofprovenhealthanddevelopmentinterventionsatthevillagelevelamong14

diversesitesin10subSaharanAfricancountries[7].Theaimoftheprojectistorapidlyaccelerate

progresstowardstheMDGtargetsovera5to10yearperiod.Inthehealthsector,MVPemphasizes

integrateddeliveryoffreeminimumpackageofmaternalnewbornchildhealthservices,withgoalof

achievinguniversalcoveragethroughinputstoreferralhospitalsandprimarycareclinics,alongside

providingdirectsupporttohouseholdsthroughacadreofpaidprofessionalcommunityhealthworkers.

CHWsareanimportantlinkbetweenthehealthsectorandthecommunity[8],andthereissubstantial

evidencesuggestingtheycanbeeffectivevehiclesforreducingmaternalandchildmortalityand

improvinghealthoutcomes[3,9,10].ArandomizedtrialintheGambiademonstrateda61%reduction


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inneonatalmortalityaftertraditionalbirthattendantsweretrained[11].Othermorerecentcluster

randomizedtrials[2,1214]andcontrolledtrials[1517]havealsodocumentedpronouncedbenefitsof

CHWprogramsonreducingneonatal,perinatalandmaternalmortality.

IntheMVPcontext,CHWsaresalariedsecondaryschoolgraduatesgenerallyfromthelocalcommunity

whoaretrainedinaminimumsetofcorecompetencies.Therearenearly800CHWsacrossthe14MV

sites.Dependingongeographyandpopulationdensity,thereisaratioofapproximately1CHWfor

every100200households,witheachhouseholdisvisitedatleastonaquarterlybasis.Bytakinghealth

carefromtheclinicsdirectlytovulnerablehouseholds,theprojecthopestodemonstrateimprovements

indiseasepreventionaswellasintheearlydetection,treatmentandreferralofsickindividuals.

WhileCHWscanplayacriticalroleinfacilitatingcoveragewithlifesavinginterventions,theyalsohave

thepotentialtoprovidethevitalfeedbackofhouseholdlevelhealthinformation.Aspartoftheir

householdscreeningvisits,CHWshavethepotentialtogenerateahostofprogramrelevantinformation

including:theregistrationofcommunityhealtheventsincludingrecentbirthsanddeaths;theburdenof

illnesssuchasacutemalnutritionormalaria;andlevelsofcoveragewithessentialinterventionssuchas

immunizations,antenatalcareandskilleddelivery.

Thiscollectionofhouseholdlevelinformationcanbegreatlyfacilitatedbynewadvancesinmobile

communicationstechnology.WithineachMVsite,eachCHWisprovidedwithacellphone.Througha

partnershipwithEricsson,nearlyallMillenniumVillageshaveachievedhighlevelsofcellphone

coverage.TheMVPhasbeenpilotingtheuseofelectronicmobilephonebasedsystemsforthe

collectionofhealthrelatedinformationinanumberofsites.Forexample,inSauri,Kenyathe

ChildCountSystemhasallowedover90%ofchildrenunder5yearsofagetobeelectronically

registeredandroutinelymonitoredthroughanSMS(textmessage)basedreportingandmonitoring

systemfornutrition,immunization,malaria,andothersignsofchildhoodillness(Seewww.ChildCount.org).

ThewidespreaduseofCHWstofacilitatingthisrealtimecollectionofhouseholdleveldatainremote

ruralAfricansettingshasnotbeenpreviouslyattempted.Thisproposaloutlinesanovelapplicationof

themobiletechnologytoguidethetargetingofpublichealthinterventions.Thecentralaimofthe

proposedMVPCommunityHealthEventsRegistryandAlert(CHILDCOUNT+)Systemistofacilitate

reductionsinchildandmaternaldeathsaswellasearlydetection,referral,andtreatmentfortargetrisk

signs.

Theobjectivesareasfollows:

1. TodevelopandimplementacommunityhealtheventsreportingandverbalautopsysystemforCHWs

2. Todevelopandimplementtwowaymobilephonebasedcommunityhealtheventsreporting,feedback,andillnessalertsystemtomonitorandmanagefollowupforbirthsanddeaths;

pregnantwomenandnewborns;childrenunder5years;andadultillnessessuchasHIV,TB,

malaria,andotherchronicnoncommunicablediseases.


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3. Todeveloptoolsandreportingformatsandstructurestobetterenabletheuseofdataforactivecasemanagementanddecisionmakingaswellasperformancemonitoringofhealthworkers

Potentialoutputsofthisworkincludeascalablemodelforthedeliveryandmonitoringofhousehold

leveldeliveryofcriticalmaternalnewbornchildhealthinterventionsthatisappropriateandrelevantto

regionsoftheworldwhereeffectivestrategiestoaddresshealthrelatedMDGsareurgentlyrequired.

B. Descriptionofprojectobjectives

1. TodevelopandimplementacommunityhealtheventsreportingandverbalautopsysystemforCHWs

2. Todevelopandimplementtwowaymobilephonebasedcommunityhealtheventsreporting,feedback,andillnessalertsystemtomonitorandmanagefollowupforbirthsanddeaths;

pregnantwomenandnewborns;childrenunder5years;andadultillnessessuchasTB,

malariaandnoncommunicablediseases

Communityhealtheventsmonitoring,whichwouldincludeaVerbalAutopsysystemforallmaternal

childdeaths,hasbeenputforthasakeystrategytoaddresstheinformationinterventionnexuswithin

theMillenniumVillagesProject.Thehypothesisisthattimelyinformationontheburdenofdisease

alongsidebetterunderstandingpatternsofpreventablemortalityandchallengesfacedinaccessingcare

hasthepotentialtocriticallyinformthetargetinganddeliveryofinterventions.Bybuildingupon

existingsitepersonnelandresources,alowcostMVPCHILDCOUNT+Systemisbeingdevelopedtotest

thishypothesis.Theproposedsystemhasanumberofdifferentcomponentswhichwillbeoutlined

brieflybelow.

i) CommunityHealthWorkers(CHWs)andCHWCoordinators:InallMVPsites,CHWshavebeenintroducedtomaximizethedeliveryofhealthinformationandservicestohouseholdsinthe

projectclusters.Therecurrentlyaratioof1CHWtoevery100200households,withhousehold

visitstakingplaceatleastquarterly.CHWsaresupportedbytheCHWCoordinatorwhoisinturn

supportedbyHealthCoordinators(doctorsoralliedhealthprofessionals),andprovidea

spectrumofhealthinterventionstotargethouseholds.

o TheCHWCoordinatorwillberesponsibleforoverallintegrationofthepaperbasedandelectronicsystemintotheCHWProgramineachsiteaswellasusingthedatagenerated

toimproveoutreachactivitiesinthecommunities.

o TheCHWswillberesponsiblefordatacaptureandfollowupatthehouseholdlevel.AspartofitsoverallHealthServicesDeliverySystemsandMonitoringandEvaluation,the

MillenniumVillagesProjectisfurtherdevelopingthefunctionalityandexpanding

ChildCount(seewww.childcount.or)beyondchildrenunder5.ChildCount+:A

CommunityHealthEventsReportingandAlertSystemwillintegratewithexisting


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informationmanagementsystemsandcatalyzeactionaroundthefollowingcommunity

healthevents:

BirthsandDeaths Under5ChildHealthEvents:newbornchecks,nutritionalStatus,presenceof

diarrhea,immunizationsandthepresenceofdangersigns[MDG4]

Pregnancyrelatedeventsincludingantenatalcarevisitsandinstitutionaldeliveries[MDG5]

PresenceofHIV,TB,malaria[MDG6]aswellasotherchronicconditions

ii) Mobilephonebasedhealthinformationsystem:AllCHWsinaclusterwillhaveaccesstoamobilephonebasedcommunicationsystemforthereportingofcommunityhealthevents.This

platformwillallowreportingofeventsthroughSMS(RapidSMS)orstructuredquestionnaire

(JavaRosa)byaCHWtobetransmittedinstantlytoacentralizeddatabase(MGVNet),whichwill

thenthroughanalgorithmdrivensystemprovidefeedbackand/orguidanceonappropriate

actiontobetakenwhethertotreat/monitorinthehome,refertoafacility,and/oractivatethe

emergencytollfreenumber.ThissystemwillbelinkedbyclientIDtothefacilitybased

electronicmedicalrecordsystemnamelyOpenMRS,sothatallcommunityenteredinformation

willbeavailabletocareproviders.Whileallsiteswillinitiallybeginwithpaperbaseddata

collection,itistheintentiontoimplementthiscomponentasquicklyaspossibleacrossallsites.

eHealthSpecialists,DatabaseManagers,andaroamingteamoftechnicalsupportproviderswill

bestrategicallyengagedanddeployedbasedontheneedsandconditionsofeachsite.

iii)

OpenMRSandUniqueIDsystem:ItisimportanttobeabletouniquelyidentifypersonswithintheMillenniumVillagesaswellasthosewhoattendMVPclinicsorotherwiseuseMVPservices.

Uptonow,theonlyuniqueidentifierswerethoseusedbytheresearchvillageswhichwerenot

availableforpublicuse.AspartoftheChildCount+andMGVNetsystems,OpenMRSwill

generateaunique6digitalphanumericIDwhichcanbeusedthroughoutthevillages.Itwas

designedtobeshortenoughtobeenteredusingamobilephone,yetproduceenoughunique

numberstocovertheentireMVPclusterineachsite.OpenMRSwillalsobeusedastheprimary

databaseforcollectingallfacilitybased,personspecificdatainthecluster,allowingfor

continuityofinformationfromthecommunityallthewayuptothedistricthealthofficeandthe

MinistryofHealth.

iv) Verbalautopsyspecialist:WhenadeathisalertedthroughtheChildCount+system,theVAspecialist,anonclinicalhealthworkerspeciallytrainedintheVAmethodology,willbedeployed

toconductaverbalautopsyatthehouseholdleveltocollectinformationonthebasiccauseof

death.Dependingsitecapacity,VAswilleitherbeconductedbyasingleVASpecialistoraby

SeniorCHWs(thereisoneSeniorCHWforevery5juniorCHWs).ItisanticipatedthatVAswill

visithouseholdswithin26weeksafteradeathhastakenplace.StandardizedVAshavebeen


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developedforuseatallMVPsites,withseparateformsforadults/maternaldeathsandfor

children.ThesemodifiedVAs(paperbaseddatacapture)havetwomaincomponents:

o MedicalCauseofdeath:thishasbeenderivedfromVAtoolsthathavebeenpreviouslyvalidatedtoassesssignsandsymptomsexperiencedbythedeceasedinthetime

precedingdeath.Themoduleconsistsofbothcloseandopenendedsectionsasperbestpracticeguidelines.

o Socialautopsy:aspecificmodulehasbeendevelopedfortheMVPsites,andincludeddetailsregardingthesocialcircumstancessurroundingdeath.Itincludesinformationon

healthseekingbehavior,accessbarrierstohealthcare,communication,transport,and

economics.

AllVAformswillbeenteredintoacomputerizeddatabasemonthly,andsubjecttoanalgorithmic

assessmentofthemedicalcauseofdeathaswellassocialcircumstancessurroundingthedeath.The

medialcauseofdeathalgorithmsareestablished,validtechniquesfordeterminingtheprobablecause

ofdeathandcanbeeasilyadaptedorappendedforlocalcontext.Thisinnovationeliminatestheneed

fordualphysicianbasedassessments,whichcanbebothexpensiveandcreatealongtimedelayin

generatingrealtimeinformationforprogrammanagers.

3. Todeveloptoolsandreportingformatsandstructurestobetterenabletheuseofdataforactivecasemanagementanddecisionmakingaswellasperformancemonitoringofhealth

workers

Thebroadaimofthissystemistoimprovethequalityofcare,andoptimizethetargetinganddeliveryof

essentialhealthservices.TheChildCount+systemwillprovidethebasisforlongitudinalinformationtrackingatanindividualandhouseholdlevelwithintheMillenniumVillages.Integratedwithanexisting

platformknownastheMillenniumGlobalVillageNetwork(MGVNet),ChildCount+willtakeadvantage

ofthemultilingual,multinational,opensourceinformationsystembeingimplementedthroughoutMVP.

Capturinginformationviapaper,mobilephonesandcomputerswillbringtogetherinformationfrom

community,clinicandreferralcenterstoprovideanoverarchingviewofhealthwithinthevillages.

Threekeycomponentswillallowthisinformationtobeusedtoinformdecisionmaking.Theseinclude

analertsystemforcriticalevents;thedevelopmentofaplatformforquarterlyreportingofaggregate

indicators,and;aprocessofusingthemtoinformservicedeliveryknownasCommunityMorbidityand

MortalityRounds.

i) Alertsystem:Aseachindividualhasauniqueidentificationnumber,thesystemhasthecapacitytofacilitatealertswhicharetextmessagessenttoCHWstohelptargetservicedelivery.For

example,thesemightsignaltheneedforfollowupofaseverelymalnourishedchild,thataclinic

patienthasalabvaluethatrequiresareturnvisittotheclinic,orthatarecentlydeliveryhas

takenplace andaneonatalcheck isrequired.Thiswillbean additionto logbooks thathave

beendevelopedtofacilitatehouseholdandpatientbasedtracking.


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ii) CommunityBasedReportingandAggregateIndicators:Itiscriticalthatinformationcollectedinthecommunityisavailabletolocaldecisionmakerstofacilitateplanningandservicedelivery.

Toachievethisgoal,reportingandvisualizationtoolswillbeprovidedaspartoftheChildCount+

andMGVNetimplementation.UsingbasicreportingtoolssuchasMSExcelandPivottables,in

additiontostandard reports, the system will allow localuserswith appropriateprivileges to

view important information at the touch of a button. In addition, standard performance

indicators that are reportedtoMVP onaquarterlybasiswill beautomatically calculated for

entryintothewebbasedcentralizeddatasystem.

iii) CommunityMorbidity&MortalityRounds:theprincipleintentoftheVAmodulewithinMVPChildCount+systemistogenerateinformationonthecauseandsocialcircumstances

surroundingtreatmentdelaysanddeathtoinformandimprovethedeliveryofhealthand

developmentinterventionsontheground.Monitoringinformationaswellasdatacollectedon

causeofdeathwillbecompiledandformthebasisofacommunitymorbidityandmortality

roundswhichwillbecoordinatedbetweentheMVPHealthCoordinators,CHWCoordinators,

clinicstaff,VAS,andtheCHWs.Thesemeetingswillprovideaforumforengagingwiththe

medicalandsocialautopsydatawithappropriaterecommendationsbeingmaderegardingthe

introductionsofnewhealthprograms,modificationsinthedeliveryortargetingofexisting

healthprograms,ortheneedtoliaisewithothersectorssuchasinfrastructure,educationor

nutritiontoaddressotherremediableconcerns.

C. References1. Black,R.E.,S.S.Morris,andJ.Bryce,Whereandwhyare10millionchildrendyingeveryyear?

Lancet,2003.361(9376):p.22262234.2. Bhutta,Z.A.,etal.,Interventionstoaddressmaternal,newborn,andchildsurvival:whatdiff

erencecanintegratedprimaryhealthcarestrategiesmake?TheLancet,2008.372:p.972989.

3. Bhutta,Z.A.,etal.,CommunityBasedInterventionsforImprovingPerinatalandNeonatalHealth

OutcomesinDevelopingCountries:AReviewoftheEvidence.Pediatrics,2005.115:p.519617.

4. Ekman,B.,I.Pathmanathan,andJ.Liljestrand,Integratinghealthinterventionsforwomen,

newbornbabies,andchildren:aframeworkforaction.TheLancet,2008.372:p.9901000.

5. Xu,K.,etal.,ProtectinghouseholdsfromCatastrophichealthexpenditures.HealthAffairs,2007.

6:p.972983.

6. Hill,K.,Makingdeathscount.BulletinoftheWorldHealthOrganization,2006.84(3):p.162.

7. Sachs,J.D.andJ.W.McArthur,TheMillenniumProject:aplanformeetingtheMillennium

DevelopmentGoals.TheLancet,2005.365(347353).

8. UNICEF,StateoftheWorld'sChildren:ChildSurvival.2008,UNICEF:NewYork.

9. Haines,A.,etal.,Achievingchildsurvivalgoals:potentialcontributionofcommunityhealth

workers.TheLancet,2007.369:p.21212131.

10. Bhutta,S.Z.andS.Soofi,Communitybasednewborncare:arewethereyet?TheLancet,2008.

372:p.11241126.

11. Greenwood,A.,etal.,EvaluationofaprimaryhealthcareprogrammeinTheGambia.I.The

impactoftrainedtraditionalbirthattendantsontheoutcomeofpregnancy.JournalofTropical

MedicineandHygiene,1990.93:p.5866.


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12. Kumar,V.,etal.,Effectofcommunitybasedbehaviourchangemanagementonneonatal

mortalityinShivgarh,UttarPradesh,India:aclusterrandomisedcontrolledtrial.TheLancet,

2008.372.

13. Baqui,A.H.,etal.,Improvingnewbornsurvivalandchanginghouseholdessentialnewborncare

practicesinruralBangladesh:theProjahnmoexperience.TheLancet,2008.371:p.19361944.

14. Jokhio,A.H.,H.R.Winter,andK.K.Cheng,Aninterventioninvolvingtraditionalbirthattendants

andperinatalandmaternalmortalityinPakistan.NewEnglandJournalofMedicine,2005.352:

p.20912099.

15. Bhutta,Z.A.,etal.,Implementingcommunitybasedperinatalcare:resultsfromapilotstudyin

ruralPakistan.BulletinoftheWorldHealthOrganization,2008.86:p.452459.

16. Bang,A.T.,etal.,Effectofhomebasedneonatalcareandmanagementofsepsisonneonatal

mortality:fieldtrialinruralIndia.TheLancet,1999.354:p.19551961.

17. Kohn,D.,CommunityinvolvementsavesnewbornsinIndia.TheLancet,2008.371:p.12351236.

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