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

From Five Villages to a National Policy:

Community Mobilization in Djibouti

Dr. Stanislas Nebie, Chief of Party, PESCE, JSIDr. Chehem Watta, Senior Advisor, Ministry of Health,

DjiboutiDekha Hadi, Social Mobilization Assistant, PESCE

Catherine O’Brien, Senior Technical Advisor, The Manoff Group

Elaine Rossi, Senior Technical Advisor, JSI

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 areasSagalou 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

• MOH interested in replicating model

Djibouti health committee members and nurses during the study tour in Madagascar, 2005

Scaling Up• 5 pilot sites 23

health posts• 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

Additional Activities• MOH requested

urban community mobilization work

• Flipchart produced covering 9 health themes for nationwide distribution

• Mobile caravan performed skits

• Radio spots

Mobile theater group performing a skit

Flip Chart Preparation

Tadjoura district volunteers and community members training in flip chart utilization: Feb 2006

Nutrition for a nursing mother

When to take a child to the health post

Incinerator now available in the 23 project sites for medical waste management

Medical waste situation in 2005

Solar pump installation in Assamo

Infrastructure Rehabilitation

Drilled well in 2008

Alaili-Dada Clinic

Medeho clinic toilet

2004 2005

Infrastructure Rehabilitation

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:

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

2002

2006

Infant Mortality(per 1000 live births)

103 67

Under-5 Mortality(per 1000 live births)

121 94

CPR 12% 18%

Results: Deliveries Proportion of Deliveries in PECSE intervention health facilities

0

10

20

30

40

50

60

70

Alisabieh Arta Dikhil Obock Tadjourah Average

PECSE district

Per

cen

tag

e 2004

2005

2006

2007

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

50

300

550

800

1050

1300

1550

1800

2050

2300

2550

2800

Months

Nu

mb

er

2004

2005

2006

2007

Thanks to a great team

Community Mobilization Team: May 2008

Minister of Health and Project COP at Knighthood Ceremony for COP, May 2008