Transcript Presentation Outline

Engaging informal providers in Bangladesh
Stakeholders’ consultation on Informal Service Providers
Organized by: CReNIEO
Chennai in India
21-22 March 2014
Dr. Mahfuza Mousumi
Project Manager, Health & Nutrition
Save the Children, Bangladesh
Email: [email protected]
Presentation Outline
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Child health situation in Bangladesh
CCM Project overview
Village Doctors engagement experinaces
Program results
Lessons learned
Trends in under-5 child mortality in Bangladesh
Neonatal Deaths/1,000 LB
1-11 Month Deaths/1,000 LB
Deaths per 1,000 live-births
12-59 Month Deaths/1,000 LB
133
46
35
116
34
34
94
88
28
23
65
24
24
13
15
MDG Target
53
11
10
48
52
48
42
41
37
32
17
10
21
1989-93
1992-6
1995-9
1999-2003
2002-6
2007-11
2015
Source: BDHS 2011
Distribution of under-5 deaths in Bangladesh by
causes of deaths: 2006-2011
Other
2%
Other
neonatal
7%
Undefined
6%
19%
7%
Drowning
Pneumonia
Pneumonia
9%
22%
13%
Possible
Possible
serious
serious
infection
infection
15%
Source: BDHS 2011
Pneumonia Treatment Status (BDHS 2011)
 50% care seeking for Pneumonia from drug
stores and Village Doctors (VDs)
 35% of children with symptoms of pneumonia
were taken to health facility or a medically
trained provider
 79% of the children seeing a provider were
prescribed antibiotics
Presentation Outline
CCM Project overview
Project Information
 Implementation area: 17sub-districts in
southern part of Bangladesh
 Target group : Children under five years of age
(approx. 400,000)
 Duration : February 2012 to April 2014
 Donor : Procter & Gamble
Project strategies
MOH front line
workers’ capacity
strengthening
Public/
formal
Capacity building of
VD & linkages with
formal HS
Private/
informal
Community
engagement and
support mechanism
Community
groups
Improve access
to quality
services
Presentation Outline
 Village Doctors engagement
Rationale for engagement
 Increase coverage of protocol
 Popular & common choice of population esp.
among poor HHs
 Village resident, available 24/7
 Drugs available at the clinic (provide drugs on
easy installment)
 Conduct home visits
Initial considerations for VD engagement
 Process of VDs selection
 Training & skill retention
 Quality Assurance
Selection of Village Doctors
 Service mapping (identify gap areas)
 Consultation with community leaders to identify
popular VDs for children U5, VDs association
 Live /practice in the targeted village
 Willingness to participate in training and treat
children following national protocol
 Not involved in political activities
Who are the selected VDs?
 75% of them completed 10th grade
education
 Majority are between 30-50 years of
age
 Most of them received 3-6 months course from
private institution and also worked as assistant
of a doctor or VD
 Nearly all operate a pharmacy
Capacity building & QA approach
 Revision of basic training manual specially for VDs in
partnership with IMCI unit, MOH
 Adaptation of standard monitoring & supervision tools
 Conduct basic & refresher trainings by MOH sub-district
level MTs; 298 VDs trained on CCM (3-day) and 281
currently active
 Provided essential supplies & job Aids -ARI timer,
thermometer, chart booklet, treatment register,
referral slips & tools.
 Supportive supervision- joint supervision with MOH
supervisors
Presentation Outline
Results
Number of cases treated by trained VDs
N=199
Oct’12 to Dec’13
Percentage
Key findings of Supervision Visit
100
90
80
70
60
50
40
30
20
10
0
N=184
Correct case
management
Treatment Record keeping Availability of Availability of
consistency
drugs
supplies
January to December 2013
Supervision Mechanism
 Post-training follow up visits: each VD supervised
twice a month for initial 3 months followed by
monthly supervisory visits
 Review register
 Direct observation/ case scenario
 Random HH visit of treated cases
 Joint supervision with MOH supervisors (98% of
VDs received supervision visit in the last month)
Supervision Checklist
Presentation Outline
Result: Key findings of Village Doctors assessment
Diagnosis and treatment of pneumonia
Before training
After training
• Only 35% used
• Count respiration rate
equipment
using ARI timer
(stethoscope/watch) • Use simple antibiotic
for pneumonia
(amoxicillin)
diagnosis
• Referral of severe
• Diagnosis made based
pneumonia cases
on symptoms
• Used higher antibiotic
Availability of Supplies
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92% of VDs have functional ARI Timer
All VDs have functional thermometer
IMCI Algorithm/chart is available with 97% VDs
96% of VDs are maintaining service registers
Drugs availability
 98% of trained VDs are selling amoxicillin of
recommended brands
 ORS and Zinc are also available in their
pharmacy
VDs attitude and practices around referral
Before training
After training
• Almost absent among • Giving preference to
VDs
treatment protocol over
• Perceived as unskilled
business motive
and incapable
• Refer sick children
• Financial disincentive
following protocol rather
of people seeking
than doing trial and error
treatment elsewhere
Referral linkage with MOH
 91% of VDs are using referral slips
 97% of VDs referred sick children to near by
appropriate MoH facility
 88% severe/danger sign
 24% diarrhea with severe dehydration
 15% sick newborn
 76% of VDs have mechanisms to ensure quality
services/follow up
Lessons learned
 Low profit margin and slow recovery of treated cases with
amoxicillin is a challenge for following standard treatment
protocol
 Refresher training, review meeting and supportive supervision
are effective ways for ensuring quality and maintain motivation
 Joint supervision with MOH staff supports establishment of
linkage with formal health system; adding VD treated cases in
national HMIS
 CCM projects created scopes for VDs engaging in other child
health interventions by government & non-government
programs.
Next steps
 Preliminary results/experiences are promising. VDs are following
protocol & maintaining guideline and referring severe cases
 SC wants to expand this to additional VDs and conduct research
to identify what is needed to enhance quality of pneumonia
treatment by informal providers at scale
Thank You