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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
Macro-Level: Policies and
Financing
Meso-level:Health system &
other sectors
the importance of communities for Health MDG’s
MDGs :U5MRMMR
Malnut.MalariaHIV/TB
MDGoutcomes
Micro-level:Households/ Communities
Family/
Community
level Care
Population
oriented
(outreach)
services
Individual
(Clinical)
Care
Family
behaviors
availability
access
utilisation
compliance
quality
Efficacy
SWAP
Protection of
Household Revenue
Community Support
Budget Support
Medium Term Expenditure Framework
PRSP
National Health- Nutrition Policy
MDG focused + Child friendly:
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
88
7067
5654
4140
3634
2825
232221
1714
83
10
38
44
7
23
10
16
6
108
3
10711
0
10
20
30
40
50
60
70
80
90
100
'92, '05'96, '06'92, '04'00, '06'93, '06'92, '03'92, '02'96, '04'93, '05'98, '06'96, '01'95, '06'88, '05'91, '06'90, '03'98, '06
RwandaBeninMadagascarMalawiGhanaTanzaniaZambiaLesothoSenegalTogoMaliCentralAfrican
Republic
ZimbabweCameroonNigeriaNiger
%
Source: UNICEF global database, 2007
Infants exclusively breastfed (< 6 mos.)
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.
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 NatalImpact potentiel
sur la NNMRSoins Infantiles
Impact potentiel sur la MIJ
MIIAllaitement initial Allaitement exclusif Maternel
PEC petits poids de naissance Allaitement complementaire
Lavage des mains
Hygiene/ assainissementAlimentation thérapeutique pour les enfants sévèrement malnourisTRO
Zinc therapeutique diarrhee
Vitamine A rougeole
PEC communautaire Pneumonie
PEC communautaire Paludisme
Planification familiale Vita mine A post partum PEV
CPN recentree Supplementation Vit AVaccination Tetanos DeparasitageDetection et prevention VIH SIDA, Syphilis, infection bacterienne
Vaccin Hib
Supplementation FAFPTME
Soins cliniques
PEC rupture prematuree des membranes
PEC infection Nne PEC diarrhee
Niveau de Base
PEC Menace accouchement premature
PEC Paludisme
Accouchement propre PEC Pneumonie
ARVs meres sero-positives
Sub Total Impact 28% 50%Accouchement asssiste
SONUBSONUC
48% 60%
Fa
mil
ial/
co
mm
un
au
tair
e
35%
12%8%
2nd niveau 14%
28%
24%
37%
Se
rvic
es
ve
rs l
es
po
pu
lati
on
s
Full Minimum Package at scale: 30% U5MR, 15% MMR, NNMR reduction for $ 800 per life
savedMinimum package
$ 2.25
$ 1.03$ 0.93
$ 0.30
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
1. Familyoriented/community
based services
2. Population orientedschedulable services
3. Clinical individualoriented care (needs to
be continuouslyavailable)
Total Services
Service delivery mode
Imp
act
in m
ort
ali
ty r
ed
ucti
on
$0.00
$0.50
$1.00
$1.50
$2.00
$2.50
Neonatal Mortality Under Five Mortality
Maternal Mortality Incremental Economic Costs per capita/year
ZZ-Africa generic
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).
new staff FTE new staff FTE new staff FTE new staff FTE
Community Health/Nutrition Promoters 141,163 217228 55,373 58271 62,518 58814 259,054 334,314Outreach/Health Extension Workers 21,577 48,315 8,311 12,654 9,616 12,654 39,503 73,623Health Center Clinical Staff 170 85,849 141,176 95,150 60,899 47,217 202,245 228,216First Referral Hospital Staff 34 17,405 43,384 22,626 19,168 10,443 62,586 50,473
Second Referral Hospital Staff 0 0 0 12,654 31,918 16,450 31,918 29,103
Total 162,945 368,797 248,243 201,355 184,118 145,578 595,306 715,730
Phase 1,2,3
Additional Number of Frontline Health Workers per Phase in a cumulative approach
Phase 1 Phase 2 Phase 3
Systematic Review of the Effectiveness of Community-Based Primary Health
Care in Improving Child HealthKey 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 cost-
effective?
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
Technical Interventions
Delivery System
Health Outcomes
Community Empowerment
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.)
Technical InterventionsCriteria 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
Technical Interventions
Delivery System
Health Outcomes
Community Empowerment
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 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
Technical Interventions
Delivery System
Health Outcomes
Community Empowerment
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.)
Community EmpowermentHow 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
Technical Interventions
Delivery System
Health Outcomes
Community Empowerment
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.)
Key Contextual Factors
EcologicalEpidemiologicalSocial/CulturalPoliticalEconomicEducationInternational funding
Recommendations for Implementing CBPHC in Africa
1. “There is no universal solution, but there is a universal process to find appropriate local solutions.” Carl Taylor
2. 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
3. Look for and support promising young leaders who have a passion for CBPHC or who have the potential for becoming passionate leaders of CBPHC
4. Support opportunities for program leaders to visit and learn from successful experiences – build on success
5. Plan at the outset for long-term sustainability and for the supportive “human” infrastructure required for CBPHC (supervision, training, M&E)
6. 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
ITNs,Immunisation,
New ORS, Vitamin A,
Antibiotics for Pneumonia, Deworming
Access to Safe & Clean Water, Intersectoral Linkages (Education HIV/AIDS), Household Food Security
Health System Support:- Facility-Based IMCI, EPI+, ANC+, EmOC, PMTCT, Paediatric AIDS
CHILD SURVIVAL AND DEVELOPMENT:-ACHIEVING MDG 4
Feeding Practices, Sleeping under ITNs,
ORT, Hygiene & Sanitation, Early care
seeking
Moving Upstream:- Evidence-Based Advocacy, Leverage of Resources, SWAPS/Govt. Budget/PRSPS, Policy Dialogue
Community Capacity Development:- Social Change Communication, CIMCI, Outreach Support
Improving family and Community
Care practices
Scaling up High Impact Population-
Based Interventions
Services à base communautaire et familiale Situation de base
Indisponibilité de kits pour accouchement propre au niveau des villages
Matrones formées dans la majorité des
villages Insuffisant recours à la matrone - habitude socio-culturelle
Sous utilisation des matrones formées. Barrières culturelles,
ignorance, qualité des prestations/accueil/ non
connaissance des soins NNé
Services à base communautaire et familiale Situation de base
Indisponibilité de kits pour accouchement propre au niveau des villages
Matrones formées dans la majorité des
villages Insuffisant recours à la matrone - habitude socio-culturelle
Sous utilisation des matrones formées. Barrières culturelles,
ignorance, qualité des prestations/accueil/ non
connaissance des soins NNé
Services à base communautaire et familialePhase 1: 2008-2010
53,3%
29,8%
63,9%
85,0%
29,8%
Approvisionnement en kits d’accouchements et distribution gratuite lors de la CPN
Lever les barrières culturelles et d’ignorance : IEC/CCC,
supervision des matrones pour améliorer la qualité/accueil des
prestations à domicile
29,8%
Services à base communautaire et familialePhase 2: 2011-2012
53,3%
29,8%
63,9%
85,0%
37,1%
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
37,1%
Services à base communautaire et familialePhase 3: 2013-2015
53,3%63,9%
85,0%
37,1%37,1%
44,4% 44,4%
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
Services orientés vers les populationsSoins curatifs et préventifs de l’enfant
Situation de baseFaible disponibilité et inégale répartition des RH, refus à la décentralisation
Barrières géographiques financières et culturelles. Insuffisance de la mobilité
sociale, qualité des prestations/accueil
Rupture de stock de vaccins
Service orienté vers les populationsSoins curatifs et préventifs de l’enfant
Échéance 2015
96,0% 96,0%
68,0%
90,1% 90,1%94,7%
Plan d’approvisionnement et gestion des stocks
Atteindre chaque enfant, Améliorer la qualité des prestations/accueil, IEC/CCC, engagement communautés
Formation initiale,Recrutement, Redéploiement, Prime / motivation
Soins cliniques individuelsSoins cliniques individuelsSoins curatifs au niveau des CSI 2Soins curatifs au niveau des CSI 2
Situation de baseSituation de base
Insuffisance et pb répartition RH, Manque de personnels formés
Barrières financières, physiques, ignorance
Coûts élevés prestations, faible qualité des services/ accueil
Soins cliniques individuelsSoins cliniques individuelsSoins curatifs au niveau des CSI 2Soins curatifs au niveau des CSI 2
Échéance 2015Échéance 2015
79%
95%
78%69% 71%
59%
Formation recyclage Redéploiement des agents
Dévpt PCIME ds cursus de formation
Case santé → CSI 1 CSI 1 → CSI 2
Supervision/ formation PCIME → Qualité accueil/prestation
2006: A regional JUMP START: Scaling up of key health nutrition and WASH
evidence based effective interventions
Wo
rld P
ress
Ph
oto
20
05
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1 2.5 4.5 6.5 8.5 10.5 13.5 17.5 21.5
Age
Per
cen
tag
e
Exclusive Breastfeeding Breastfeeding and only water
6 months
<2 2 to 3 4 to 5 6 to 7 8 to 9 10 to 11 12 to 15 16 to 19 20 to 23
Exclusive BF and BF+ water only in WCAR
0
10
20
30
40
50
60
70
80
90
100
Sao T
ome
and
Princip
e
Ghana
Benin
Guinea
Biss
au
Seneg
al
Gambia M
ali
Democ
ratic
Rep
ublic
of C
ongo
Camer
oon
Wes
t and
Cen
tral A
frica
Mau
ritan
ia
Congo
Burkin
a Fas
oTog
o
Nigeria
Centra
l Afri
can
Repub
licNige
r
Guinea
Cote
d'Ivo
ire
Gabon
Sierra
Leo
neCha
d
Cape
Verde
Equat
orial
Guin
ea
Liber
ia
Pe
rce
nta
ge
of
ch
ild
ren
< 6
mo
nth
s
Exclusive Breatfeeding Breastfeeding+water
Allaitement maternel exclusif
ou Allaitement maternel avec eau (Source: dernières EDS –MICS)
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)
Nutrition suggested activities for CS Jump Start
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
• 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
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
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
Analyse de situation basée sur l’évidence
Couverture effective des interventions à haut impact
Atteindre l’ODM 4 et contribuer aux autres
ODMs relatifs à la santé
Analyse de la situation, monitoring & Micro-planification
Facilitation de l’approche MBB
Action au niveau communautaire et stratégie avancée