From Five Villages to a National Policy: Community Mobilization in Djibouti

Dr. Stanislas Nebie, Chief of Party, PESCE, JSI Dr. Chehem Watta, Senior Advisor, Ministry of Health, Djibouti Dekha Hadi, Social Mobilization Assistant, PESCE Catherine O’Brien, Senior Technical Advisor, The Manoff Group Elaine Rossi, Senior Technical Advisor, JSI

Expanded Coverage of Essential Health Services in Djibouti Project (PECSE)

The authors’ views expressed in this publication do not necessarily reflect the views of the US Agency for International Development or the US Government.

Country Context: 2004

• Population: ~800,000 • Size of US state of Massachusetts • Life expectancy: ~46 yrs • Infant mortality: 103 per 1,000 live births (2002) • Under-5 mortality: 121 per 1,000 live births (2002) • Maternal mortality: 650 per 100,000 live births (2002) • Malnutrition, malaria, TB all pose great risks

Health System Context: 2004 • Weak infrastructure • Unreliable health statistics and poor health knowledge • No community mobilization for health!

• MOH health sector reform strategy aims to

increase access

to health care through decentralization, prevention, and primary care

Poor infrastructure

Poor water source in Gourabouss: 2005 As Eyla clinic beds: 2005

Resource Scarcity

Water struggle in Dorra: April 2005

PECSE Project

• 2004–2008 • Expand access to health services – Rehabilitate health facilities – Train health care providers – Establish health management information system –

Mobilize communities

– Focus on rural areas Sagalou Health committee members, April 2006. The Health Committee President is seated on the left.

Community Mobilization: Challenges • No community mobilization existed before in the health sector • MOH not receptive to idea • Health infrastructure in terrible condition • Nomadic populations; refugees • Difficult physical environment

Laying the Groundwork

• “Back to Basics” • Not ready for BCC • Pilot program in 5 sites in 2005 • Very basic community mobilization PECSE and MOH staff in discussion with Goubetto community chief in 2005, when negotiating the establishment of a health committee

Community Mobilization Pilot Approach • Health Post  Health Committee  community members forging links to improve services • Community health volunteer is the link between community and health post staff Daley Aff Community volunteers: Jan 2006

Involving the MOH

• PECSE cultivated excellent relations with MOH, UNICEF, WHO, NGOs, and others • Study tour to Ethiopia and Madagascar • Consensus on community mobilization emerged after study tour Djibouti health committee members and nurses during the study tour in Madagascar, 2005 • MOH interested in replicating model

Scaling Up

• 5 pilot sites  health posts 23 • Each post linked to health committee • Each committee has men and women • 4 or 5 community volunteers (at least 2 female) per community Gallamo community leader giving working tools to a volunteer: May 2006

Training and Supervision

• Training-of-trainer workshops nationwide for community health volunteers • Health education activities • Joint supervision by MOH and PECSE Dorra female health volunteer receiving a loud speaker for community mobilization: August 2006

Training

Work plan development during the Tadjoura district volunteers training: June 2006 Community trainer during Arta health committee members training: May 2006

Supervision

Randa village volunteers during supervision: Sept 2006 Gourabouss community volunteers during a supervision session: Aug 2006

Mobilization at work

• PECSE carried out MOH priorities • Emergency immunization campaigns – Polio in 2005: Health Committees and Volunteers proved themselves – Cholera in 2006: further validation • Volunteers and committees trained in prevention and symptoms • Volunteers spread messages and identified cases for nurses to treat • Avian influenza preparedness

• MOH requested urban community mobilization work • Flipchart produced covering 9 health themes for nationwide distribution • Mobile caravan performed skits • Radio spots

Additional Activities

Mobile theater group performing a skit

Flip Chart Preparation

Nutrition for a nursing mother When to take a child to the health post Tadjoura district volunteers and community members training in flip chart utilization: Feb 2006

Infrastructure Rehabilitation

Medical waste situation in 2005 Incinerator now available in the 23 project sites for medical waste management Solar pump installation in Assamo Drilled well in 2008

Infrastructure Rehabilitation

Alaili-Dada Clinic 2004 2005 Medeho clinic toilet

National Community Mobilization Strategy • After study tour, MOH formed committee on social mobilization for health policy • • PECSE provided framework for policy

National Policy promulgated in 2006!

– Validated role of Community Health Volunteers and Health Committees – Created new MOH cadre of Health Aides based on Ethiopian model

A major step forward

Ass-Eyla health committee members showing their certificates of recognition with pride: April 2008

Results

• By late 2006 utilization rates rose for prenatal care and immunization • Contributed to positive national results: 2002 2006 Infant Mortality (per 1000 live births) Under-5 Mortality (per 1000 live births) CPR 103 121 12%

67 94 18%

The Project social mobilization assistant with the Gallamo female volunteer ‘s child: 2006

Results: Deliveries

Proportion of Deliveries in PECSE intervention health facilities

30 20 10 0 70 60 50 40 Alisabieh Arta 2004 2005 2006 2007 Dikhil Obock

PECSE district

Tadjourah Average

Results: Antenatal Care

Antenatal Care: at least one visit (2004-2007)

2800 2550 2300 2050 1800 1550 1300 1050 800 550 300 50 JA N FE B M A R A PR M A Y JU N JU LY A U G S EP T

Months

O C T N O V D E C 2004 2005 2006 2007

Thanks to a great team

Minister of Health and Project COP at Knighthood Ceremony for COP, May 2008 Community Mobilization Team: May 2008