Improving the Quality and Scale_Waltensperger
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This document summarizes Karen Z. Waltensperger's presentation on Save the Children's experiences supporting government integrated community case management (iCCM) strategies and programs. It discusses early iCCM treatment experiences in Mali and Ethiopia in the 1990s-2000s. It then outlines critical ingredients for successful iCCM programs, including government strategy, viable community health workers, evidence base, and broad consultation. The document also provides examples of signature iCCM programs in Nicaragua and Malawi, partnerships in Mali supporting the national Secrétaire de Santé Communautaire strategy, and ongoing challenges in implementing quality iCCM at scale.
Improving the Quality and Scale_Waltensperger
- 1. Karen Z. Waltensperger, Senior Advisor Community & Child Health Save the Children experiences supporting government iCCM strategies and programs CORE Group Global Health Practitioner Conference - Advancing Community Health across the Continuum of Care 14 April 2015, Alexandria, VA
- 2. Early community-based IMCI treatment experiences • Mali – Sikasso Region, USAID CSHGP early-mid-90s – Relais (volunteers) with drug boxes – Under regional auspices • Ethiopia – Negelle Borana, Oromo Region, USAID CSHGP late 90s – Pre national Health Extension Program (used volunteers) – Under regional auspices – Published study in EMJ contributed evidence to change national policy, leading to authorization for use of antibiotics by HEWs
- 3. “CCM most needed where most difficult to implement.”
- 4. “Easier” where there is… • Government strategy & national level program • MOH leadership • Costed, budgeted, funded or supported by partners • Viable community-based cadre (CHWs) • Support from medical & other professional associations • Technical working group at national level • Partner coordination, especially in contexts of multiple operational platforms • Evidence base/best practices • Community support & mobilization framework • OR resources and engaged academic partners • Broad consultation, inclusion, ownership – Public-private, community-facility, government-civil society
- 5. SC approach: Integrated CCM (iCCM) • Treatment for diarrhea AND pneumonia AND malaria • Can include: – newborn care (especially PNC and management of neonatal sepsis) – Management of severe acute malnutrition – PMTCT/HIV/TB
- 6. SC partnership approach • No “branded” model • Support national programs • Take advantage of multiple operational platforms • Work at greatest scale possible/practical • National-level component with focus on policy dialogue, standardization, partner coordination – Secretariat function – Technical leadership/technical assistance – Technical working groups – Policy, protocols, guidelines, tools
- 8. Nicaragua national context - 2006 • PROCOSAN – Well-developed national preventive, community- based MCH strategy – Brigadista network (2-14 years experience) – Natural “platform” for CCM • MINSA (Ministerio de Salud) – Concern about antibiotic misuse – Policy prevented brigadistas (CHWs) from dispensing prescription drugs – Experience with CHWs treating malaria, leishmaniasis 8
- 9. Hasta el Ultimo Rincón CCM Project (2006-2011) • Setting: (14 to 37) communities in rural León, (total population: ~84,000) – Site of ongoing SC MCH programming; excellent relationship with MINSA – Mountainous; impassable roads in rainy season – Local health posts available only 16-18 h/wk, some communities 12- 24 hrs travel from health center – Causes of child death: neonatal sepsis, pneumonia, diarrhea • CCM Strategy – Age-group: 2-59 months – Drugs: amoxicillin (pneumonia); furazolidona (dysentery); zinc and ORS (diarrhea); acetaminophen (fever) 9 “Baby on Board” 26 mile round-trip in monsoon for pneumonia treatment
- 10. CCM development process • Supported MINSA to convene national task force • Designed materials with MINSA to complement PROCOSAN: – Training guides – Counseling cards – Mother reminder cards • Selected most advanced, literate brigadistas from Category C communities (2+ hours from HP) • Negotiated with MINSA to ensure reliable drug supply, including zinc • Initiated treatment within 4 months of start-up
- 11. Policy change and scale 11 PROCOSAN/CCM now national “norm” for Category C communities Added neonatal sepsis (first dose & referral) MINSA seeking donor and partner support Current scale – 22 municipalities (districts), 4 departments (provinces) – Trained 105 health personnel – Trained 360 brigadistas along with relevant MINSA supervisors
- 12. SC iCCM programs now • ~20 countries (of ~120) ~12 Africa (Ethiopia, Kenya, Liberia, Malawi, Mali, Mozambique, Liberia, Sierra Leone, South Sudan, Uganda, Zambia…) ~7 Asia ~1 Latin America/Caribbean (Nicaragua)
- 13. Primary partners • Ministry of Health or responsible ministry • Regional, district, local health authorities • Communities • UNICEF, WHO • Local/international academic and/or research institutions • iNGOs, national NGOs, CBOs • USAID, DfID, DFATC, BMGF, other donors
- 14. Malawi’s MDG success • 72% reduction in under-5 mortality since 1990 (from 244 to 68/1000 live births)
- 15. Community-based maternal newborn care (CBMNC) package • Saving Newborn Lives I (~2001-06) • SC Malawi Newborn Health Program (~2007-12) – National-level effort (4 pilot districts) – Acted as secretariat for development of CBMNC package – Saving Newborn Lives II (BMGF) – USAID CSHGP (CS-22) • Access – MCHIP (+4 districts)
- 16. iCCM in Malawi • Since 2008 – 3000+ HSAs (Health Surveillance Assistants) – iCCM (malaria, diarrhea, pneumonia) to 10,400+ hard-to-reach areas – HSAs salaried by MOH
- 17. Malawi multiple operational platforms SC supporting iCCM implementation currently • 20 of 28 districts • 5 operational platforms – USAID bilateral project (SSDI-Services) – 15 districts – QuIC – USAID CSHGP (Mwayi wa Moyo, CS-27 cycle) – RAcE (FATDC through WHO) – MICS (funding through SCUS, SC Canada, SC Italy)
- 18. Generating evidence in Malawi - OR • Effectiveness of integrated community-based MNCH+FP package delivered by HSAs (USAID/CSHGP, 2011-2016, Collage of Medicine) • Integration of malaria RDTs and pre-referral treatment of severe malaria using rectal artesunate as part of iCCM (Barr Foundation and WHO/GMP)
- 19. Challenges remain • HSA residence status • Time spent working in health centers • Stock outs • Transport • Supervision/clinical mentoring
- 20. Supporting Mali’s SEC strategy
- 21. Partner engagement • Ministry of Health, Government of Mali • Save the Children • UNICEF, WHO • FENASCOM • AMM • SEC Ad Hoc Group & Focal Point Partners • Service providers and beneficiaries • USAID, MCHIP • SSGI bi-lateral project (SC prime)
- 22. Components of SEC package • iCCM: malaria, diarrhea, pneumonia: 2-59 months • Family Planning: including injectables and referral for LARC • Newborn: post-natal home-visits and referral • Nutrition: screening and referral • SBCC activities: hand washing, care seeking The image cannot be displayed. Your computer may not have enough memory to open the image, or the image may have been corrupted. Restart your computer, and then open the file again. If the red x still appears, you may have to delete the image and then insert it again.
- 23. The Road to Scale in Mali Decision of GoM to use CHWs to expand basic services to remote communities - Strategy initiated GOM approval of initial SEC strategy First Phase Implementation in 5 regions Comprehensive Evaluation of First Phase (Household Survey, Qualitative Studies) Costed SEC Strategic Plan Developed 2009 2010 2011-2012 2014 2013
- 25. Results of 2013 SEC evaluation • ~3 CHWs per 1000 under-5 children in population • Female CHWs (43% of total) more consistently performing to standard • Only 63% of CHWs received supervision visit in preceding 3 months
- 26. LQAS found low utilization of SEC attributed to financial barriers 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% Kita Diema Bougouni Yorosso 46.1% 64.1% 63.2% 50.0% 7.3% 5.1% 12.6% 5.9% Obstacle financier Obstacle socio culturel
- 27. SEC qualitative study (MCHIP) • Low utilization – both financial and socio- cultural factors • Decision-making/care-seeking • “Ownership” & community support • Lack of consultation & community engagement • User preferences • Erratic supervision • Sexual harassment
- 28. iCCM critical challenges • “Hardest skill set asked of CHWs” • Performance/quality • Supervision/mentoring • Drug supply (child-friendly) • Residence status • Compensation/incentives • Motivation/retention • Pull toward work in health facilities • Case load/competing packages • Policy/practice barriers
- 29. Critical ingredients for harmonization • Government strategy & national level program • MOH leadership • Costed, budgeted, funded or supported by partners • Viable community-based cadre (CHWs) • Support from medical & other professional associations • Technical working group at national level • Partner coordination, especially in contexts of multiple operational platforms • Evidence base/best practices • Community support & mobilization framework • OR resources and engaged academic partners • Broad consultation, inclusion, ownership
- 30. Thank you!