Community partnerships for health related MDGs Conclusions of The State of the Worlds Children 2008...

Community partnerships for health related MDG’s

Conclusions of The State of the World’s Children 2008 and Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health

Macro-Level: Policies and

Financing

Meso-level:Health system &

other sectors

the importance of communities for Health MDG’s

MDGs :U5MRMMR

Malnut.MalariaHIV/TB

MDGoutcomes

Micro-level:Households/ Communities

Family/

Community

level Care

Population

oriented

(outreach)

services

Individual

(Clinical)

Care

Family

behaviors

availability

access

utilisation

compliance

quality

Efficacy

SWAP

Protection of

Household Revenue

Community Support

Budget Support

Medium Term Expenditure Framework

PRSP

National Health- Nutrition Policy

MDG focused + Child friendly:

The Bamako Initiative• Launched by African health Ministers in 1987• Built on 5 years operations research in Benin

(Pahou) and Congo (Kasongo)• Community movement: Community co-managed,

cost shared and monitored revitalization of 10.000 health centers with drug revolving funds

• Community Based National Health Systems in Benin, Guinea, Mali, DR Congo, Guinea Bissau

• Benin Immmization Coverage from 12% in 1986 to 75 % in 1990 and fully sustained since then

• Resiliance demonstrated during Togo, DR Congo, Guinea Bissau and other crisis

• Foundation for success of ACSD (10-20% U5MR reduction for $ 500/life saved)

Lessons Learned from a hundred years

• Scaling-up will not be achieved through facility-based and outreach services alone: Community Partnerships are central to achieving coverage, creating demand and achieving sustainability.

• Ensuring a continuum of care by delivering integrated packages of health, nutrition, HIV, water and sanitation interventions will be critical to achieving maximal impact on maternal, newborn and child survival.

• Strengthening of ‘health-systems for outcomes’ combines the strength of selective/vertical approaches and comprehensive/horizontal approaches to scaling up evidence-based, high-impact intervention packages and practices, while removing system-wide bottlenecks to health care provision and usage.

A Continuum of Care in Time and Place

Source: PMNCH (www.who.int/pmnch/about/continuum_of_care/en/index.htm), accessed 30 September 2007

http://www.who.int/pmnch/about/continuum_of_care/en/index.htm

Community partnerships in PHC: Ways of enhancing success

• Cohesive, inclusive participation; • Support and incentives for workers; • Adequate programme supervision and support; • Effective referral systems to facility-based care; • Intersectoral collaboration; • Secure financing; and • Integration of community partnerships with

district and national health programmes and policies.

Scaling up community partnerships, a continuum of care, health systems for outcomes

• Realign programmes from disease –specific interventions to evidence-based, high-impact, integrated packages to ensure a continuum of care

• Make MNCH a central tenet of integrated results based national planning processes for scaling up

• Improve the quality and consistency of financing for strengthening health systems

• Foster and sustain political commitments, national and international leadership an sustained financing to develop health systems

• Create conditions for greater harmonization of global health programmes and partnerships

88

7067

5654

4140

3634

2825

232221

1714

83

10

38

44

7

23

10

16

6

108

3

10711

0

10

20

30

40

50

60

70

80

90

100

'92, '05'96, '06'92, '04'00, '06'93, '06'92, '03'92, '02'96, '04'93, '05'98, '06'96, '01'95, '06'88, '05'91, '06'90, '03'98, '06

RwandaBeninMadagascarMalawiGhanaTanzaniaZambiaLesothoSenegalTogoMaliCentralAfrican

Republic

ZimbabweCameroonNigeriaNiger

%

Source: UNICEF global database, 2007

Infants exclusively breastfed (< 6 mos.)

Striking increases in exclusive breastfeeding in 16 Sub-Saharan African countries

Seven Sub-Saharan African countries have achieved increases of more than 20 percentage points over the past 15 years.

Pourquoi accélérer pour l’ODM4 permet d’atteindre tous les ODMs relatifs à la santé

ODM 1 ODM 5 ODM 7 ODM 6

Prestation de service

Ante-conception, Prenatal et Naissance

Neonatal et Post NatalImpact potentiel

sur la NNMRSoins Infantiles

Impact potentiel sur la MIJ

MIIAllaitement initial Allaitement exclusif Maternel

PEC petits poids de naissance Allaitement complementaire

Lavage des mains

Hygiene/ assainissementAlimentation thérapeutique pour les enfants sévèrement malnourisTRO

Zinc therapeutique diarrhee

Vitamine A rougeole

PEC communautaire Pneumonie

PEC communautaire Paludisme

Planification familiale Vita mine A post partum PEV

CPN recentree Supplementation Vit AVaccination Tetanos DeparasitageDetection et prevention VIH SIDA, Syphilis, infection bacterienne

Vaccin Hib

Supplementation FAFPTME

Soins cliniques

PEC rupture prematuree des membranes

PEC infection Nne PEC diarrhee

Niveau de Base

PEC Menace accouchement premature

PEC Paludisme

Accouchement propre PEC Pneumonie

ARVs meres sero-positives

Sub Total Impact 28% 50%Accouchement asssiste

SONUBSONUC

48% 60%

Fa

mil

ial/

co

mm

un

au

tair

e

35%

12%8%

2nd niveau 14%

28%

24%

37%

Se

rvic

es

ve

rs l

es

po

pu

lati

on

s

Full Minimum Package at scale: 30% U5MR, 15% MMR, NNMR reduction for $ 800 per life

savedMinimum package

$ 2.25

$ 1.03$ 0.93

$ 0.30

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

1. Familyoriented/community

based services

2. Population orientedschedulable services

3. Clinical individualoriented care (needs to

be continuouslyavailable)

Total Services

Service delivery mode

Imp

act

in m

ort

ali

ty r

ed

ucti

on

$0.00

$0.50

$1.00

$1.50

$2.00

$2.50

Neonatal Mortality Under Five Mortality

Maternal Mortality Incremental Economic Costs per capita/year

ZZ-Africa generic

The Human Resource Challenge in Africa:1. On the job training of 300,000 community health

promoters and health extension workers;2. Pre-service training and (re) deployment of 300,000

additional health professionals;3. Improved productivity of existing health staff resulting in over 700,000 additional Full Time Equivalents (FTE).

new staff FTE new staff FTE new staff FTE new staff FTE

Community Health/Nutrition Promoters 141,163 217228 55,373 58271 62,518 58814 259,054 334,314Outreach/Health Extension Workers 21,577 48,315 8,311 12,654 9,616 12,654 39,503 73,623Health Center Clinical Staff 170 85,849 141,176 95,150 60,899 47,217 202,245 228,216First Referral Hospital Staff 34 17,405 43,384 22,626 19,168 10,443 62,586 50,473

Second Referral Hospital Staff 0 0 0 12,654 31,918 16,450 31,918 29,103

Total 162,945 368,797 248,243 201,355 184,118 145,578 595,306 715,730

Phase 1,2,3

Additional Number of Frontline Health Workers per Phase in a cumulative approach

Phase 1 Phase 2 Phase 3

Systematic Review of the Effectiveness of Community-Based Primary Health

Care in Improving Child HealthKey Questions• How strong is the evidence that CBPHC can

improve child health?• What conditions/program elements must be

in place for CBPHC to be effective?• How important are partnerships between

communities and health systems?• Does CBPHC promote equity and is it cost-

effective?

Definition of CBPHC

• Activities, interventions, programs that take place in the community outside of health facilities

• Includes selective and comprehensive approaches

• Includes non-health interventions (e.g., micro-credit, education, women’s empowerment, societal factors)

Process

• Review of available documentation– Peer-reviewed journal articles– Books– Program evaluations– Unpublished reports

• Data extraction-2 independent reviewers

• Special focus on community context and community partnerships

Technical Interventions

Delivery System

Health Outcomes

Community Empowerment

Community-Based Primary Health Care

Contextual Analysis and Implementation Framework

Contextual factors:

(external resources and support, political factors, social capital, functionality of health system, country laws, cultural issues, intracountry

inequities, mortality setting, disease epidemiology, opportunities for education, women’s status, strength of medical professional lobby, etc.)

Technical InterventionsCriteria for defining priority effective

interventions

• Safety demonstrated

• Shown to have mortality or nutrition improvement efficacy

• Programmatic experience exists

• Feasibility of or experience with reaching high coverage

Technical Interventions Priority child survival interventions for scale up

• Immunizations for mothers and children• Vitamin A supplementation• Iodine fortification and supplementation when necessary• Home-based neonatal care including neonatal sepsis

management• Clean delivery• Hand-washing• Household water treatment and safe storage• Sanitation• ORT and zinc for diarrhea treatment• Childhood pneumonia treatment• Prevention of mother-to-child transmission of HIV• Cotrimoxazole prophylaxis for HIV-infected children

Technical Interventions Priority child survival interventions for scale up

• Insecticide-treated materials and/or indoor residual spraying for malaria

• Malaria treatment• Intermittent preventive therapy for malaria for pregnant

women• Exclusive breastfeeding promotion for first 6 months• Continued breastfeeding promotion until at least 24

months• Ready to use therapeutic foods for severely

malnourished children• Promotion of complementary feeding for children

focused on 6 to 23 months• Supplementary feeding for food-insecure families

focused on 6 to 23 months

Technical Interventions Interventions with more evidence needed for effectiveness, safety or feasibility of scale up

• Congenital syphilis prevention• Prophylactic supplemental zinc• Prenatal calcium• Detection and treatment of asymptomatic

bacteriuria• Umbilical cord topical antiseptic• Newborn antiseptic skin cleansing• Neonatal resuscitation and airway management• Household smoke reduction with improved

cooking stoves

Technical Interventions Interventions with indirect effects on child survival

• Family planning

• Adult HIV treatment

• Maternal mortality reduction

Technical Interventions Messages regarding effective interventions

• Effectiveness and scale up depend on delivery systems, community involvement and local context

• Although community engagement is ideal, interventions’ dependence on this is variable

• Community engagement promotes scale up and sustainability

• Integrated packages not investigated as well as single interventions


Delivery System

Health Outcomes




Contextual factors:



Delivery System Elements• Integration of services at community level • Foundation of values and power shifting• Peer neighborhood volunteer• Multi-purpose community health worker

– Incentives: monetary, material, other– Facility outreach vs. community-based

• Community-based organization for health• Community generation and use of health data • Bi-directional linkage to national health system

– Accountability of health system• Bi-directional information and communication • Respectful, collaborative delivery system culture• Equitable service delivery

Delivery System Elements• Coordination of formal and traditional health sectors• Appropriate service provision intensity

– Workload of community health workers– Number of tasks, number of and distance to homes

• Processes to shift power locus to communities– Work with women, microcredit, conditional cash transfer

• Communication technology – e.g., mobile phones• Training of community health workers• Supportive supervision of CHWs linked to PHC level• Supplies for service delivery• Adequate global and national financing• Monitoring of CBPHC program• Authority for lay persons to perform health tasks


Delivery System

Health Outcomes




Contextual factors:



Community EmpowermentHow community-driven is the strategy?

• Community as a resource vs. target• Community vs. external priority setting• Degree of community involvement

– Ownership– Decision-making power– Management– Consultation– Influence– Buy-in– Passive recipient

Community Empowerment Areas requiring community involvement

• Leadership• Planning and management• Women• Community management of external resources• Monitoring and evaluation_________________________

• Local context• Value system• Delivery of services in community• Bundle of delivery systems and technical

interventions


Delivery System

Health Outcomes




Contextual factors:



Key Contextual Factors

EcologicalEpidemiologicalSocial/CulturalPoliticalEconomicEducationInternational funding

Recommendations for Implementing CBPHC in Africa

1. “There is no universal solution, but there is a universal process to find appropriate local solutions.” Carl Taylor

2. Invest in promising CBPHC approaches and field sites, start small, and be willing to help them go to scale within a framework of rigorous evaluation and operations research that demonstrates effectiveness in reducing under-five mortality

3. Look for and support promising young leaders who have a passion for CBPHC or who have the potential for becoming passionate leaders of CBPHC

4. Support opportunities for program leaders to visit and learn from successful experiences – build on success

5. Plan at the outset for long-term sustainability and for the supportive “human” infrastructure required for CBPHC (supervision, training, M&E)

6. Make under-five mortality in defined geographic areas the key outcome indicator and build it into ongoing program operations

Next Steps

• Forceful statement SOON from the Expert Review Panel to the world (via Lancet?) – building on the review but moving beyond it

• Early completion of the review as originally envisioned

• Incorporation of suggestions and recommendation of the Expert Review Panel and others into final report

• Broad dissemination of findings

ITNs,Immunisation,

New ORS, Vitamin A,

Antibiotics for Pneumonia, Deworming

Access to Safe & Clean Water, Intersectoral Linkages (Education HIV/AIDS), Household Food Security

Health System Support:- Facility-Based IMCI, EPI+, ANC+, EmOC, PMTCT, Paediatric AIDS

CHILD SURVIVAL AND DEVELOPMENT:-ACHIEVING MDG 4

Feeding Practices, Sleeping under ITNs,

ORT, Hygiene & Sanitation, Early care

seeking

Moving Upstream:- Evidence-Based Advocacy, Leverage of Resources, SWAPS/Govt. Budget/PRSPS, Policy Dialogue

Community Capacity Development:- Social Change Communication, CIMCI, Outreach Support

Improving family and Community

Care practices

Scaling up High Impact Population-

Based Interventions

Services à base communautaire et familiale Situation de base

Indisponibilité de kits pour accouchement propre au niveau des villages

Matrones formées dans la majorité des

villages Insuffisant recours à la matrone - habitude socio-culturelle

Sous utilisation des matrones formées. Barrières culturelles,

ignorance, qualité des prestations/accueil/ non

connaissance des soins NNé

Services à base communautaire et familialePhase 1: 2008-2010

53,3%

29,8%

63,9%

85,0%

29,8%

Approvisionnement en kits d’accouchements et distribution gratuite lors de la CPN

Lever les barrières culturelles et d’ignorance : IEC/CCC,

supervision des matrones pour améliorer la qualité/accueil des

prestations à domicile

29,8%


53,3%

29,8%

63,9%

85,0%

37,1%

IEC/CCC, améliorer la qualité accts à domicile, promouvoir la

participation communautaire dans la gestion des services,

promouvoir la référence pour acct assisté au CSI

37,1%


53,3%63,9%

85,0%

37,1%37,1%

44,4% 44,4%

IEC/CCC, améliorer la qualité accts à domicile,

promouvoir la participation

communautaire dans la gestion des services,

promouvoir la référence pour acct assisté au CSI

Services orientés vers les populationsSoins curatifs et préventifs de l’enfant

Situation de baseFaible disponibilité et inégale répartition des RH, refus à la décentralisation

Barrières géographiques financières et culturelles. Insuffisance de la mobilité

sociale, qualité des prestations/accueil

Rupture de stock de vaccins

Service orienté vers les populationsSoins curatifs et préventifs de l’enfant

Échéance 2015

96,0% 96,0%

68,0%

90,1% 90,1%94,7%

Plan d’approvisionnement et gestion des stocks

Atteindre chaque enfant, Améliorer la qualité des prestations/accueil, IEC/CCC, engagement communautés

Formation initiale,Recrutement, Redéploiement, Prime / motivation

Soins cliniques individuelsSoins cliniques individuelsSoins curatifs au niveau des CSI 2Soins curatifs au niveau des CSI 2

Situation de baseSituation de base

Insuffisance et pb répartition RH, Manque de personnels formés

Barrières financières, physiques, ignorance

Coûts élevés prestations, faible qualité des services/ accueil

Soins cliniques individuelsSoins cliniques individuelsSoins curatifs au niveau des CSI 2Soins curatifs au niveau des CSI 2

Échéance 2015Échéance 2015

79%

95%

78%69% 71%

59%

Formation recyclage Redéploiement des agents

Dévpt PCIME ds cursus de formation

Case santé → CSI 1 CSI 1 → CSI 2

Supervision/ formation PCIME → Qualité accueil/prestation

2006: A regional JUMP START: Scaling up of key health nutrition and WASH

evidence based effective interventions

Wo

rld P

ress

Ph

oto

20

05

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

80.0

90.0

100.0

1 2.5 4.5 6.5 8.5 10.5 13.5 17.5 21.5

Age

Per

cen

tag

e

Exclusive Breastfeeding Breastfeeding and only water

6 months

<2 2 to 3 4 to 5 6 to 7 8 to 9 10 to 11 12 to 15 16 to 19 20 to 23

Exclusive BF and BF+ water only in WCAR

0

10

20

30

40

50

60

70

80

90

100

Sao T

ome

and

Princip

e

Ghana

Benin

Guinea

Biss

au

Seneg

al

Gambia M

ali

Democ

ratic

Rep

ublic

of C

ongo

Camer

oon

Wes

t and

Cen

tral A

frica

Mau

ritan

ia

Congo

Burkin

a Fas

oTog

o

Nigeria

Centra

l Afri

can

Repub

licNige

r

Guinea

Cote

d'Ivo

ire

Gabon

Sierra

Leo

neCha

d

Cape

Verde

Equat

orial

Guin

ea

Liber

ia

Pe

rce

nta

ge

of

ch

ild

ren

< 6

mo

nth

s

Exclusive Breatfeeding Breastfeeding+water

Allaitement maternel exclusif

ou Allaitement maternel avec eau (Source: dernières EDS –MICS)

Exclusive breastfeeding for 6 months Early initiation of breastfeeding (<1 hour after birth) No prelactal foods, No water +++ Saves 225.000 children’s lives per year

Vitamin A and Deworming

Management of acute severe undernutrition in children 6-59 mo Treatment and prevention Through facility-based and community-based programs For the same communities and at the same time (including urban)

→ Support countries in the development of national protocols

→ Support regional & national training workshops for capacity building

→ Ensure pipeline of uninterrupted supplies (therapeutic and

supplementary foods and non food items)

Nutrition suggested activities for CS Jump Start

Why water and sanitation matter to the jump start

• Improved household water quality helps prevent endemic diarrhoea: cholera

Latrine ownership potentially reduces diarrhea disease by an average of 36%

• Handwashing with soap can

– Significantly reduce the risk of diarrhea > 46%

– Can save 0.5 – 1.4 million deaths a year

– Impacts on helminth and eye infections, especially trachoma

– Key in the fight against avian flu

What we need to do

• Include hand washing for mothers in the jump start

• BUT• At the same time

make sure WASH in the CO programme is looking at water point and sanitation (latrine) coverage – MGD 7, target 10

• Doing one without the other makes no long term sense: read the WASH strategy

This requires ‘at scale’ communication programmes

Should not necessarily be WASH sector driven but integrated in to our health and nutrition entry points

Work with academic institutions/NGOs to assist with rapid baseline behaviour assessments and conduct surveys for compliance (behaviour change)

RO is working on guidelines for communication strategies

Integrated Immunization: EPI-VitA-ITNs

• Increase routine immunization coverage for all antigens (including TT 2+) in all districts by 10 points

• Ensure the second dose of measles vaccine for all children (routine and SIA)

• Integrate vitamin A supplementation within routine immunization

• Integrate ITNs distribution and promotion of its utilization within routine immunization

• Introduction in EPI of new and underused vaccines in all countries ( YF , HepB , Hib)

Quelle meilleure contribution de l’UNICEF?

Renforcer les politiques, la

législation, plans & budgets + espace

budgétaire

Analyse de situation basée sur l’évidence

Couverture effective des interventions à haut impact

Atteindre l’ODM 4 et contribuer aux autres

ODMs relatifs à la santé

Analyse de la situation, monitoring & Micro-planification

Facilitation de l’approche MBB

Action au niveau communautaire et stratégie avancée

Community partnerships for health related MDGs Conclusions of The State of the Worlds Children 2008...

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