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Engaging informal providers in Bangladesh
Dr. Mahfuza Mousumi
Project Manager, Health & Nutrition
Save the Children, Bangladesh
Email: [email protected]
Stakeholders’ consultation on Informal Service Providers Organized by: CReNIEO
Chennai in India
21-22 March 2014
Presentation Outline
Child health situation in Bangladesh
CCM Project overview
Village Doctors engagement experinaces
Program results
Lessons learned
Trends in under-5 child mortality in Bangladesh
52 48 42 41 37 32 21
35 34 24 24
15 10
10
46 34
28 23
13 11
17
133
116
94 88
65 53 48
1989-93 1992-6 1995-9 1999-2003 2002-6 2007-11 2015
Neonatal Deaths/1,000 LB
1-11 Month Deaths/1,000 LB
12-59 Month Deaths/1,000 LB
MDG Target
Deat
hs
per
1,0
00 liv
e-b
irth
s
Source: BDHS 2011
Distribution of under-5 deaths in Bangladesh by
causes of deaths: 2006-2011
Source: BDHS 2011
Pneumonia
Possible
serious
infection
19%
22%
15%
13%
9%
7%
2% 7% 6%
Possible
serious
infection
Undefined
Other
neonatal Other
Drowning Pneumonia
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
Capacity building of VD & linkages with
formal HS
Community engagement and
support mechanism
Improve access
to quality
services
Public/
formal
Private/
informal
Community
groups
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
Oct’12 to Dec’13
N=199
Key findings of Supervision Visit
0
10
20
30
40
50
60
70
80
90
100
Correct case
management
Treatment
consistency
Record keeping Availability of
drugs
Availability of
supplies
Perc
en
tage
January to December 2013
N=184
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
Before training After training
• Only 35% used
equipment
(stethoscope/watch)
for pneumonia
diagnosis
• Diagnosis made based
on symptoms
• Used higher antibiotic
• Count respiration rate
using ARI timer
• Use simple antibiotic
(amoxicillin)
• Referral of severe
pneumonia cases
Diagnosis and treatment of pneumonia
Availability of Supplies
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
VDs
• Perceived as unskilled
and incapable
• Financial disincentive
of people seeking
treatment elsewhere
• Giving preference to
treatment protocol over
business motive
• Refer sick children
following protocol rather
than doing trial and error
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
