Strengthening Community Health Systems_Henry Perry_5.8.14
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Transcript of Strengthening Community Health Systems_Henry Perry_5.8.14
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Community-based Approaches to Improving Reproductive, Maternal, Neonatal and Child
Health: Current Status of the Evidence
Henry Perry, Department of International Health
Spring CORE Group Meeting, 8 May 2014
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Outline
• Rationale for the review• Components of the review process• Findings• A framework for improving RMNCH through
community-based approaches• The way forward
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Rationale for the Review
• Rapidly expanding evidence base• Increasing interest in CBPHC• Need to begin to develop a more holistic
(integrated) approach to programming• The follow-on to USAID-supported MCHIP
(RMNCH) is now starting up
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Components of the Review
• General review of any (peer-reviewed or grey) literature on community-based approaches to provision of RMNCH services (465 articles)
• Review of projects/programs/field studies that assessed the effectiveness of CBPHC in improving child health (476 assessments) or maternal health (119 assessments)
• Factors related to effective CHW programming and national CHW program case studies
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Review Process
• Evidence-based review of effectiveness of CBPHC in improving child health
• Large-scale CHW program review• Evidence-based review of effectiveness of
CBPHC in improving maternal health• Broad literature review of promising
approaches to RMNCH
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Findings: General Literature Review
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Newly Emerging Interventions for Community-based Delivery
• Chlorhexidene umbilical cord care• Misoprostol for prevention of PPH• Zinc + ORS• iCCM• Participatory women’s groups
(PLA, Care Groups)• Home-based neonatal care (+ PP FP)• HIV/AIDs prevention, detection, treatment
(particularly for PMTCT)
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Mainstay Interventions for Community-based Delivery
• Immunizations• Vitamin A supplementation• Breastfeeding/appropriate
complementary feeding• Maternal health (multiple
micronutrients, nutritional supplementation during pregnancy, ANC, clean delivery, delivery by a skilled attendant, promotion of facility-based delivery)
• CCM of childhood pneumonia
• Prevention and treatment of malaria (ITNs, IPT, CCM)
• CMAM
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Broader Reproductive Health Interventions that Can Be Provided through Community-based
Approaches
• Family planning• Support for women living with AIDS• Cervical cancer screening and treatment• Harm reduction from unsafe abortion• Detection and treatment of syphilis
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Evidence from Integrated Programs
• PVO child survival projects• Care Group projects• Jamkhed/India, Hospital Albert
Schweitzer/Haiti, Matlab/Bangladesh, SEARCH/India
• BRAC/Manoshi/Bangladesh
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Evidence from Country Successes• Bangladesh
• Nepal
Lancet2013
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Ethiopia
Brazil
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Strengthening Community-based Service Delivery
• Community-based facilities
• Informal and traditional providers
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Community Engagement and Community Partnerships
• Examples– Community-Directed Interventions• Initially for neglected tropical diseases but now moving
into RMNCH
• Descriptions of processes– Manoshi
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Practical Findings from Operations Research
• Need to focus on main causes of mortality in order to demonstrate a decline in mortality– Evaluation of UNICEF West Africa programs with evidence of increased
coverage but no mortality impact (Bryce et al., Lancet, 2010)– Evaluation of home-based neonatal care program in Bangladesh
(Darmstadt et al., 2010)• Need to achieve a certain intensity of women’s participatory
groups for PLA – Program intensity in Ethiopia related to program outcomes (Karim et
al., PLOS 2013)– For PLA groups, need to reach 30% of mothers (Fottrell et al., JAMA
Pediatrics 2013)• Lack of supervision and logistical support are pervasive
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Financial Aspects
• Innovative approaches to financing• Cost-effectiveness limited except for some on
a few specific interventions
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Monitoring and Evaluation
• Practical approaches to assessing effectiveness of large-scale programs
• Monitoring coverage• LiST• Mortality assessment (measurement of changes in
mortality rate, verbal medical and social autopsy)• Strengthening M&E of large-scale CHW programs
(with transparent independent assessments every 5 years or so)
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Emerging Issues
• Mental health for WRA• Gender-based violence (including FGM)• Other diseases of WRA (HIV/AIDS, TB, malaria,
chronic diseases)• Injuries
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Cross-cutting Themes
• Urban health• Scaling up programs• Equity• Health systems strengthening• RMNCH in post-disaster relief and settings
with political conflict
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Policy and Philosophical Issues
• The role of NGOs in fostering community engagement, community mobilization, community-based service delivery, training and support of CHWs
• Restoring a better balance between vertical and horizontal programming
• Strengthening the effectiveness of frontline workers and large-scale CHW programs
• Creating a more favorable policy environment
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Conceptual Approaches
• CBIO• Aggressive home visitation with early
treatment of childhood illness
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Findings from Effectiveness Review
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Practical Program Strategies
• Intervention delivery– Home visits– Participatory women’s groups– Community-case management– Provision of services by mobile teams based at
peripheral facilities
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Strategies for Village-wide Community Empowerment/Mobilization/
Demand Creation• Advocacy meetings with community leaders• Promotion and support of village health committees, village
development committees, and sanitation committees• Community-wide meetings• Community-directed interventions• Village health days/malaria awareness days, etc.• Health talks at Friday mosque gatherings, church meetings, etc.• Sharing locally obtained health-related data with the community• Involving men and older family members (e.g., mothers-in-laws)
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Strategies for Community Empowerment/ Mobilization/Demand Creation in Groups
• Formation and training of women’s groups (community health clubs, pregnant women’s support groups, mothers’ centers/mothers’ committees, Care Groups, PLA Groups, self-help groups, women’s action groups, counseling and support groups)
• Formation of parent committees• Formation of adolescent groups• Formation of farmers’ clubs• Conditional cash transfers to eligible mothers• Savings and loan groups (microcredit)
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Health System Strengthening Approaches
• Training of staff – frontline workers, CHWs, TBAs• Develop or upgrade peripheral facilities, strengthen quality of
care• Strengthen drug supply chain• Strengthen linkages between CHWs and peripheral facilities• Strengthen referral system
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Strategies for Program Design, Identification of Target Groups, Surveillance
• Formative research/appreciative inquiry/PLA/stakeholder analysis
• Village registers (pregnancies, pregnancy outcomes, births, deaths, TB patients)
• Verbal autopsies• Client-held cards (maternal health cards, road-to-health cards,
child health cards, immunization cards)• KPC surveys
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Educational Strategies
• Peer-to-peer counseling• Visual aids• mHealth• Skits, stories, games• Targeting grandmothers• Positive deviance inquiry/identifying strong community-level
workers to support others not as strong
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Review of Large-scale Community Health Worker Programs
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• The final version will be available on the MCHIP website next week:
http://www.mchip.net/chwreferenceguide
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Creating a Framework for Sustainable Improvements in RMNCH at Scale through CBPHC
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Community engagement, etc.
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Paradigm Shift
• Approaching the community as a resource and partner, not a target of programs or passive recipient of services
• Investing in CBPHC as the priority for health systems strengthening and improving population-level health
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The Way Forward
• Entry points– Policy (e.g., for task shifting, etc.)– Creation of “friendly” environment for CBPHC, community
engagement and NGOs– Supporting the development and assessment of “model”
integrated RMNCH programs – Supporting literature reviews/analyses of existing data– Continued research on current and new interventions– Operations research/translating policy and research into
action/implementation research/efficacy to effectiveness research/research on CHW programs
– Replication and scaling up of promising approaches
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Acknowledgments
• MCHIP/USAID • Jim Ricca, Nazo Kureshy and others at USAID
and MCHIP who supported this work• Working Group on Community-based Primary
Health Care of the International Section of the American Public Health Association
• USAID, UNICEF, WHO, World Bank and Future Generations for support of the effectiveness review