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

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

“CCM most needed where most difficult to implement.”

“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

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

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

7

Signature iCCM Program

Nicaragua

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

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

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

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

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)

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

Malawi’s MDG success

• 72% reduction in under-5 mortality since 1990 (from 244 to 68/1000 live births)

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)

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

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)

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)

Challenges remain

• HSA residence status • Time spent working in health centers • Stock outs • Transport • Supervision/clinical mentoring

Supporting Mali’s SEC strategy

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)

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.

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

Current SEC coverage

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

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

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

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

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

Thank you!