Your SlideShare is downloading. ×
  • Like
CCH_Nate Miller_5.7.14
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×

Now you can save presentations on your phone or tablet

Available for both IPhone and Android

Text the download link to your phone

Standard text messaging rates apply

CCH_Nate Miller_5.7.14

  • 94 views
Published

 

Published in Health & Medicine , Business
  • Full Name Full Name Comment goes here.
    Are you sure you want to
    Your message goes here
    Be the first to comment
    Be the first to like this
No Downloads

Views

Total Views
94
On SlideShare
0
From Embeds
0
Number of Embeds
0

Actions

Shares
Downloads
4
Comments
0
Likes
0

Embeds 0

No embeds

Report content

Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
    No notes for slide

Transcript

  • 1. Community case management in emergencies | May 7, 20141 | CCM in Emergencies & Fragile Contexts Nate Miller, PhD UNICEF CORE Group Annual Meeting May 7, 2014
  • 2. Community case management in emergencies | May 7, 20142 | iCCM background Source: Liu, et al. Global causes of under 5 death, 2010 Pneumonia, diarrhea, and malaria account for 36% of child deaths globally. In Africa, they account for 44% of deaths. Coverage of effective treatments remains low.
  • 3. Community case management in emergencies | May 7, 20143 | iCCM background Definition of iCCM: Community-based management of childhood pneumonia, diarrhea, and malaria – May also include malnutrition, neonatal sepsis, other interventions
  • 4. Community case management in emergencies | May 7, 20144 | iCCM background Quality of care: – Ethiopia: 64% of children with pneumonia, diarrhea, malaria, or malnutrition received correct treatment – Malawi: 63% of children with pneumonia, diarrhea, or malaria received correct treatment – Zambia: 68% of children with pneumonia received correct treatment – Others studies showed lower quality of care CCM impact has been shown in controlled studies Lack of evidence of impact of large-scale implementation of iCCM
  • 5. Community case management in emergencies | May 7, 20145 | Child health in emergencies  Increased morbidity and mortality, especially among children – Basic services may be destroyed, disrupted, or overwhelmed – Access to services may be reduced due to disrupted transport, insecurity, or population displacement – Emergency response can miss most vulnerable in the community  Mostly the same causes of child death in emergencies
  • 6. Community case management in emergencies | May 7, 20146 | Resilience  Natural disasters expected to increase in frequency and severity  Chronic conflict and insecurity in many areas  Pre-existing programs shut down during acute crisis  Typical emergency response is too slow and fails to reach many vulnerable communities  Communities and health systems need to be better prepared against shocks  Community-level interventions may allow most timely response and highest coverage of interventions
  • 7. Community case management in emergencies | May 7, 20147 | iCCM in emergencies & fragile contexts Reduce demand/reliance on overwhelmed health services Increase access to and coverage of services, including to the most affected and vulnerable Outside help may may be delayed Increase community resilience and reduce underlying vulnerability More cost effective
  • 8. Community case management in emergencies | May 7, 20148 | iCCM in emergencies & fragile contexts 1) iCCM for vulnerability reduction: reduce the burden of top causes of illness and death 2) Adjust/adapt existing iCCM to target at risk communities or during an emergency 3) Implement iCCM during an acute emergency
  • 9. Community case management in emergencies | May 7, 20149 | Way forward CCM Taskforce: Emergencies working group Literature review Case studies Pilot implementation with M&E and operational research Dissemination of results
  • 10. Community case management in emergencies | May 7, 201410 | Literature review Review of published material – PubMed, Google, grey literature – 6 journal articles, 5 reports – Afghanistan, Cote d’Ivoire, DRC, Ethiopia, Malawi, Mali, Myanmar, Pakistan, South Sudan, Sri Lanka 3 interviews from Central African Republic
  • 11. Community case management in emergencies | May 7, 201411 | Key lessons 1. Community-based interventions can achieve greater coverage than facility-based care in crises 2. CHWs can provide a platform for delivery of emergency interventions 3. Need to integrate emergency response and preparedness into regular development programming
  • 12. Community case management in emergencies | May 7, 201412 | Key lessons Examples: – Ethiopia • Policy change to make CMAM a routine service in response to periodic famine • Allowed faster recognition of and response to crisis • Integrating the emergency response into regular development programming ensured available funding
  • 13. Community case management in emergencies | May 7, 201413 | Key lessons Examples: – Mali • Health system was not prepared for emergency response when conflict started • Scaling up relief programs during crisis took too long • Training and deploying CHWs during the crisis strengthened the platform for nutrition and health interventions post-crisis • Flexible funding from donors allowed for shifts in programs to emergency and then transition back to development
  • 14. Community case management in emergencies | May 7, 201414 | Key lessons Examples: – Malawi • During food crisis, most vulnerable children were not reached by services in health facilities • Previously trained cadre of CHWs allowed for rapid rollout of CMAM program (underway in 10 days) • Achieved much higher coverage of care than facility-based programs • Able to scale up program with no health professionals other than trainers – Sri Lanka • Previously trained cadre of CHWs allowed for rapid training on malaria case management during crisis
  • 15. Community case management in emergencies | May 7, 201415 | Key lessons Examples: – Pakistan • CHWs were first to provide care after floods. • Outside emergency response took much longer • CHWs provided a large network through which to deliver relief – Myanmar • CHWs trained in primary care and emergency response prior to cyclone • They were the first to provide care before outside relief arrived • Relief programs delivered through CHW network
  • 16. Community case management in emergencies | May 7, 201416 | Key lessons 4. Funding needs to be longer-term and flexible  Examples – CAR • Short-term funding led to closing of iCCM program after one year – Ethiopia, Mali, Afghanistan • Flexible, longer-term funding allowed programs to transition back and forth between development and emergency response
  • 17. Community case management in emergencies | May 7, 201417 | Key lessons 5. It is possible for CHWs to continue providing care through periods of moderate conflict and insecurity  Example: – CAR • Malaria CCM program has operated with no breaks in services for the last 6 years, including through the current crisis
  • 18. Community case management in emergencies | May 7, 201418 | Key lessons 6. Initiating a new CCM program during acute crisis will be very difficult  Examples: – CAR • NGO trying to expand geographic coverage during current crisis • Several instances of armed robbery, base was looted, can’t transport equipment to field site • Need frequent access to CHWs for training, supervision, etc. – Cote d’Ivoire • Insecurity after elections halted geographic expansion of program
  • 19. Community case management in emergencies | May 7, 201419 | Key lessons 7. Recruiting and training health workers for emergency response is difficult and time-consuming  Examples: – Myanmar • Shortage of qualified medical staff • More effective to use previously trained CHWs – CAR • Health facility staff fled their posts and recruited staff refused to go to insecure areas • CCM was only way to deliver care to many communities
  • 20. Community case management in emergencies | May 7, 201420 | Key lessons 8. Need to adapt standard guidelines to fit local context  Example: – South Sudan • Low literacy of CHWs caused poor understanding of clinical guidelines and inability to correctly complete registers • CHWs weren’t able to correctly count respiratory rate due to poor numeracy • Simplified, more visual, training materials, job aids, and registers improved understanding • Use of beads for counting respiratory rate improved pneumonia diagnosis
  • 21. Community case management in emergencies | May 7, 201421 | Key lessons 9. May need to find alternative ways of contacting CHWs – Drug supplies, supervision, data collection  Examples: – CAR • NGO staff could not leave town due to insecure roads • CHWs were able to travel to town for drug supplies and to bring reports – Cote d’Ivoire • CHWs had difficulty getting drug stocks and submitting reports because of insecurity • NGO provided larger drug stocks to CHWs and extra incentive to supervisors to continue providing services during conflict after elections
  • 22. Community case management in emergencies | May 7, 201422 | Key lessons 10.CHWs need larger stocks of drugs to cover longer period of time to allow for continued care during crisis  Examples: – Cote d’Ivoire • NGO provided larger drug stocks to CHWs continue providing services during conflict after elections – Myanmar • Regular stocks with CHWs were insufficient for needs following cyclone – South Sudan • CHWs given stocks of several months to continue care during rainy season when many areas become inaccessible • Needed larger storage facilities for drugs and supplies
  • 23. Community case management in emergencies | May 7, 201423 | Key lessons 11.CMAM can be integrated into iCCM  Example: – South Sudan • Simplified nutrition screening of MUAC and oedema were feasible CHWs with poor literacy and numeracy • Higher level of training, literacy, numeracy needed for treatment of SAM
  • 24. Community case management in emergencies | May 7, 201424 | Key lessons 12.Continuity of care/referral care is a challenge  Example – CAR • Shortages of drugs and supplies in health facilities before the crisis • Health facilities were looted, health workers abandoned posts • Children with severe illness referred to health facilities by CHWs, but no care available
  • 25. Community case management in emergencies | May 7, 201425 | Key lessons 13.Donor and NGO policies force programs to shut down in an emergency. Need to find more resilient strategies.  Examples – CAR – South Sudan
  • 26. Community case management in emergencies | May 7, 201426 | Key lessons 14.Work with local communities to negotiate access  Example: – Afghanistan • Difficult to access areas due to insecurity and hostile local leaders • Conducted local security analyses • Used local access negotiators and dialogue with local leaders • Discuss priorities for community and try to address their priorities as part of program
  • 27. Community case management in emergencies | May 7, 201427 | Key lessons 15.Experience with nomadic populations may be relevant for mobile IDPs – Fixed facilities and mobile clinics not effective – CHWs were most effective • Should be selected from communities and move with population • Delivery of drugs and supplies is key challenge – Supply through strategic locations known to CHWs along travel route – Allow CHWs to attain drugs through any public facilities • Supervision and monitoring – CHWs can send reports through health facilities, government officials, local leaders, etc. – Supervision at strategic locations along travel route
  • 28. Community case management in emergencies | May 7, 201428 | Emergency CCM programs needing documentation Myanmar Nicaragua Bangladesh Uganda Mozambique Kenya Haiti Pakistan Afghanistan Sri Lanka Somalia Yemen South Sudan Mali Niger DRC Nigeria Nepal
  • 29. Community case management in emergencies | May 7, 201429 |
  • 30. Community case management in emergencies | May 7, 201430 |
  • 31. Community case management in emergencies | May 7, 201431 |
  • 32. Community case management in emergencies | May 7, 201432 | Case scenario: iCCM in CAR  High insecurity, road bandits, towns and villages attacked, NGO bases looted  Peacekeepers in Bangui and some towns  Some people displaced in camps, some displaced in rural areas, many at home, but without access to care, food shortages  Complete breakdown of health system  NGOs providing services in camps and some towns  High child mortality from infectious diseases, especially malaria  Dangerous environment for aid workers  Little experience with CCM  Only few small CHW networks linked to NGOs
  • 33. Community case management in emergencies | May 7, 201433 | Case scenario: iCCM in CAR Is iCCM appropriate in this context? – Does the potential impact outweigh the risk and challenges? At what scale should iCCM be implemented? What is the minimum security level necessary in an area to implement an iCCM program?
  • 34. Community case management in emergencies | May 7, 201434 | Case scenario: iCCM in CAR How to address main challenges? – Supply chain – Supervision – M&E – Quality of care – Security of staff and CHWs
  • 35. Community case management in emergencies | May 7, 201435 | Case scenario: iCCM in CAR What components should be included in the iCCM program? – CMAM – Neonatal sepsis – Essential newborn care – Immunization – HIV – GBV/sexual violence What is the most appropriate policy for management of severely ill children?
  • 36. Community case management in emergencies | May 7, 201436 | Case scenario: iCCM in CAR What are priority research questions regarding CCM in emergencies? What is an appropriate evaluation design? – Are household surveys feasible?