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.
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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 the importance of communities for Health MDG’s MDG outcomes Protection of Household Revenue Community level Care Efficacy Population Family oriented behaviors (outreach) Community Support services Individual (Clinical) Care Macro-Level: Policies and Financing MDG focused + Child friendly: Family/ MDGs : U5MR MMR Malnut. Malaria HIV/TB Meso-level: Health system & other sectors Micro-level: Households/ Communities quality compliance utilisation National HealthNutrition Policy PRSP SWAP Budget Support access availability Medium Term Expenditure Framework 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 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 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. % Infants exclusively breastfed (< 6 mos.) 100 90 88 83 80 70 70 67 60 56 54 50 44 40 41 40 30 38 36 34 28 20 22 21 25 23 23 17 16 14 10 10 1 1 7 3 8 10 10 10 7 6 0 '98, '06 Niger '90, '03 '91, '06 '88, '05 '95, '06 Nigeria CameroonZimbabwe Central African Republic Source: UNICEF global database, 2007 '96, '01 '98, '06 Mali Togo '93, '05 '96, '04 Senegal Lesotho '92, '02 '92, '03 '93, '06 Zambia Tanzania Ghana '00, '06 '92, '04 '96, '06 '92, '05 Malawi Madagascar Benin Rwanda 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 Natal Impact potentiel sur la NNMR Soins Infantiles MII Allaitement exclusif Maternel PEC petits poids de naissance Allaitement complementaire Familial/ communautaire Allaitement initial Impact potentiel sur la MIJ Lavage des mains 8% Hygiene/ assainissement Alimentation thérapeutique pour les enfants sévèrement malnouris TRO 12% Zinc therapeutique diarrhee Vitamine A rougeole PEC communautaire Pneumonie Services vers les populations PEC communautaire Paludisme Soins cliniques Niveau de Base Planification familiale CPN recentree Vaccination Tetanos Detection et prevention VIH SIDA, Syphilis, infection bacterienne Supplementation FAF PTME PEC rupture prematuree des membranes PEC Menace accouchement premature Accouchement propre Vita mine A post partum PEV Supplementation Vit A Deparasitage Vaccin Hib 35% 24% PEC infection Nne PEC diarrhee PEC Paludisme 28% PEC Pneumonie ARVs meres sero-positives 2nd niveau Sub Total Impact 28% Accouchement asssiste SONUB SONUC 37% 48% 50% 14% 60% Full Minimum Package at scale: 30% U5MR, 15% MMR, NNMR reduction for $ 800 per life saved ZZ-Africa generic Impact in mortality reduction 35.0% Minimum package $ 2.25 $2.50 30.0% $2.00 25.0% $1.50 20.0% $ 1.03 15.0% $ 0.93 $1.00 10.0% $ 0.30 $0.50 5.0% 0.0% $0.00 1. Family oriented/community based services 2. Population oriented 3. Clinical individual schedulable services oriented care (needs to be continuously available) Total Services Service delivery mode Neonatal Mortality Under Five Mortality Maternal Mortality Incremental Economic Costs per capita/year 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). Additional Number of Frontline Health Workers per Phase in a cumulative approach Phase 1 new staff Phase 2 FTE new staff Phase 3 FTE new staff Phase 1,2,3 FTE new staff FTE Community Health/Nutrition Promoters Outreach/Health Extension Workers Health Center Clinical Staff First Referral Hospital Staff Second Referral Hospital Staff 141,163 21,577 170 34 0 217228 48,315 85,849 17,405 0 55,373 8,311 141,176 43,384 0 58271 12,654 95,150 22,626 12,654 62,518 9,616 60,899 19,168 31,918 58814 12,654 47,217 10,443 16,450 259,054 39,503 202,245 62,586 31,918 334,314 73,623 228,216 50,473 29,103 Total 162,945 368,797 248,243 201,355 184,118 145,578 595,306 715,730 Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health Key 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 costeffective? 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 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.) Delivery System Health Outcomes Technical Interventions Community Empowerment Technical Interventions Criteria 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 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.) Delivery System Health Outcomes Technical Interventions Community Empowerment 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 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.) Delivery System Health Outcomes Technical Interventions Community Empowerment Community Empowerment How 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 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.) Delivery System Health Outcomes Technical Interventions Community Empowerment Key Contextual Factors Ecological Epidemiological Social/Cultural Political Economic Education International funding Recommendations for Implementing CBPHC in Africa 1. 2. 3. 4. 5. 6. “There is no universal solution, but there is a universal process to find appropriate local solutions.” Carl Taylor 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 Look for and support promising young leaders who have a passion for CBPHC or who have the potential for becoming passionate leaders of CBPHC Support opportunities for program leaders to visit and learn from successful experiences – build on success Plan at the outset for long-term sustainability and for the supportive “human” infrastructure required for CBPHC (supervision, training, M&E) 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 CHILD SURVIVAL AND DEVELOPMENT:ACHIEVING MDG 4 Scaling up High Impact PopulationBased Interventions ITNs, Immunisation, New ORS, Vitamin A, Antibiotics for Pneumonia, Deworming Improving family and Community Care practices Feeding Practices, Sleeping under ITNs, ORT, Hygiene & Sanitation, Early care seeking Community Capacity Development:Social Change Communication, CIMCI, Outreach Support Health System Support:- Facility-Based IMCI, EPI+, ANC+, EmOC, PMTCT, Paediatric AIDS Access to Safe & Clean Water, Intersectoral Linkages (Education HIV/AIDS), Household Food Security Moving Upstream:- Evidence-Based Advocacy, Leverage of Resources, SWAPS/Govt. Budget/PRSPS, Policy Dialogue Services à base communautaire et familiale Situation de base Matrones formées dans la majorité des villages 85.0% Indisponibilité de kits pour accouchement propre au niveau des villages Insuffisant recours à la matrone habitude socioculturelle Sous utilisation des matrones formées. Barrières culturelles, 63.9% ignorance, qualité des prestations/accueil/ non connaissance des soins NNé 15.2% 15.0% Dispo intrants village Access des matrones F Acc par matrone Acc par matrones form 15.2% Acc propre + Matrone F + T˚ Services à base communautaire et familiale Situation de base Matrones formées dans la majorité des villages 85.0% Indisponibilité de kits pour accouchement propre au niveau des villages Insuffisant recours à la matrone habitude socioculturelle Sous utilisation des matrones formées. Barrières culturelles, 63.9% ignorance, qualité des prestations/accueil/ non connaissance des soins NNé 15.2% 15.0% Dispo intrants village Access des matrones F Acc par matrone Acc par matrones form 15.2% Acc propre + Matrone F + T˚ Services à base communautaire et familiale Phase 1: 2008-2010 Approvisionnement en kits d’accouchements et distribution gratuite lors de la CPN 53,3% Lever les barrières culturelles et 85.0% 85,0% d’ignorance : IEC/CCC, supervision des matrones pour améliorer la qualité/accueil des 63.9% 63,9% prestations à domicile 29,8% 15.2% 15.0% Dispo intrants village Access des matrones F Acc par matrone Acc par matrones form 29,8% 15.2% Acc propre + Matrone F + T˚ Services à base communautaire et familiale Phase 2: 2011-2012 IEC/CCC, améliorer la qualité accts à domicile, promouvoir la participation communautaire dans la gestion des services, 85.0% 85,0% promouvoir la référence pour acct assisté au CSI 63.9% 63,9% 53,3% 37,1% 37,1% 29,8% 15.2% 15.0% Dispo intrants village Access des matrones F Acc par matrone Acc par matrones form 29,8% 15.2% Acc propre + Matrone F + T˚ Services à base communautaire et familiale Phase 3: 2013-2015 85.0% 85,0% 63.9% 63,9% 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 53,3% 44,4% 37,1% 37,1% 15.2% 15.0% Dispo intrants village 44,4% Access des matrones F Acc par matrone Acc par matrones form 15.2% Acc propre + Matrone F + T˚ Services orientés vers les populations Soins curatifs et préventifs de l’enfant Rupture de stock de vaccins Faible disponibilité et inégale répartition des RH, refus à la décentralisation Situation de base Barrières géographiques financières et culturelles. Insuffisance de la mobilité sociale, qualité des prestations/accueil Service orienté vers les populations Soins curatifs et préventifs de l’enfant Plan d’approvisionnement et gestion des stocks 96,0% Échéance 2015 Formation initiale, Atteindre chaque enfant, Améliorer la Recrutement, qualité des prestations/accueil, Redéploiement, IEC/CCC, engagement communautés 96,0% Prime / 94,7% 90,1% 90,1% motivation 68,0% Soins cliniques individuels Soins curatifs au niveau des CSI 2 Situation de base 95.0% Insuffisance et pb répartition RH, Manque de personnels formés 48.0% Barrières financières, physiques, ignorance 47.1% 37.3% Coûts élevés prestations, faible qualité des services/ accueil 36.0% 21.6% Stocks de ME Infirm. 5km CDS Fievre soignee ext Fievre traite prof Prof forme PCIME Soins cliniques individuels Soins curatifs au niveau des CSI 2 Échéance 2015 Formation recyclage Redéploiement des agents 95.0% 95% Supervision/ formation PCIME → Qualité accueil/prestation Case santé → CSI 1 CSI 1 → CSI 2 79% 78% 71% 69% 48.0% Dévpt PCIME ds cursus de formation 59% 47.1% 37.3% 36.0% 21.6% Stocks de ME Infirm. 5km CDS Fievre soignee ext Fievre traite prof Prof forme PCIME 2006: A regional JUMP START: World Press Photo 2005 Scaling up of key health nutrition and WASH evidence based effective interventions Exclusive BF and BF+ water only in WCAR 100.0 90.0 80.0 6 months Percentage 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 1 <2 2.53 2 to 4.55 4 to 6.57 6 to 8.59 8 to 10.5 10 to 11 13.5 12 to 15 16 to17.5 19 Age Exclusive Breastfeeding Breastfeeding and only water 20 to21.5 23 m e To an d Pr in ci pe G ha na G Be ui ne a nin Bi ss au D S em en oc eg ra a G tic am l R bi ep a ub lic M W a of es C li o ta nd Ca ngo m C en ero tra on lA M fric au a rit an ia Bu Co n rk in go a Fa C so en tra To lA go fri ca Nig e n R ria ep ub lic N ig e G r ui C ne ot e d' a Iv oi re Si Ga b er ra on Le on e C ha Eq Ca d ua pe Ve to ria r l G de ui ne a Li be ria Sa o Percentage of children < 6 months Allaitement maternel exclusif ou Allaitement maternel avec eau 100 90 (Source: dernières EDS –MICS) 80 70 60 50 40 30 20 10 0 Exclusive Breatfeeding Breastfeeding+water Nutrition suggested activities for CS Jump Start 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) 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 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 • 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 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 Facilitation de l’approche MBB Analyse de situation basée sur l’évidence Atteindre l’ODM 4 et contribuer aux autres ODMs relatifs à la santé Action au niveau communautaire et stratégie avancée Couverture effective des interventions à haut impact Analyse de la situation, monitoring & Micro-planification