Integrating Community-Based Strategies into Existing Health Systems_Laura Altobelli_5.6.14
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    Integrating Community-Based Strategies into Existing Health Systems_Laura Altobelli_5.6.14 Integrating Community-Based Strategies into Existing Health Systems_Laura Altobelli_5.6.14 Presentation Transcript

    • Strengthening community collaborative management of health services by building a “model” for community-based primary health care in Peru Learning for leverage by demonstrating program effectiveness Presented by Laura Altobelli, DrPH, MPH, Future Generations CORE Group Global Health Practitioner Conference – May 5-9, 2014
    • Hypotheses Ho 1: Effective improvement of PHC requires fundamental changes in management mechanisms (for financing, human resources management and commuity involvement) Ho 2: Political sustainability of management mechanisms (for financing, human resources and community involvement) requires an effective operational model of PHC linking health services with communities to improve impact on health.
    • Why is it necessary? Improve EFFICIENCY of public expenditures Strengthen QUALITY & WARMTH of care Ensure EQUITY to reduce exclusión How does this happen? SOCIAL CONTROL leading to GREATER TRANSPARENCY and ACCOUNTABILITY Assumptions regarding community involvement in health management FutureGenerations
    • Primary Health Care Faciity National Health Programs Health Services Network Center Roles & functions poorly defined COMMUNIITES Regional Health Directorate Traditional public sector primary health care in Peru MUNICIPALITY
    • Primary Health Care Faciity Local Health Plan Original Legal Structure of CLAS in Peru-1994 SHARED ADMINISTRATION CONTRACT Health Services Network Center Roles & functions poorly defined CLAS CLAS Board of Directors Regional Health Directorate CLAS - Local Health Administration Committee : a private non-profit civil association that administers public financing for one or more primary health care faciliites MUNICIPALITY CLAS Manager COMMUNIITES Elected community members
    • Selects, contracts, & supervises personnel Prioritizes, plans, & purchases equipment and supplies Contracts building projects and supervises them CLAS co-manage public resources with transparency and accountability Finances activities and incentives for community-based health promotion FutureGenerations Wishful thinking… CLAS Board of Directors
    • I. Strengthen co-management of primary health care with a model that articulates community involvement in financial and human resources management with:  An operational model of CBPHC linking health services with communities  Health promotion for behavior change – counseling in health facilities and in homes by CHW  Involvement of community leadership in MNCH  Involvement of municipality in co-management of health promotion – leveraging local resources II. Lead and support efforts for legal stability of CLAS in the context of health reform. Objectives in support of CLAS FutureGenerations
    • Overview – Development of PHC Approach in Peru Seen through the lens of a Theory of Change: SEED-SCALE Methodology
    • Overview – Development of PHC Approach in Peru Scale-One – Ideally functioning local system Scale-Squared – Use the Scale One system to teach others Scale Cubed – Policy Environment • SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)
    • Overview – Development of PHC Approach in Peru Scale One – Ideally functioning local system • Establish a SCALE-One Center: create a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities • Build the model on successful strategies from earlier pilot PHC programs during the previous decade Scale-Squared – Use the Scale One system to teach others Scale Cubed – Policy Environment • SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)
    • Overview – Development of PHC Approach in Peru Scale One – Ideally functioning local system • Establish a SCALE-One Center: create a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities • Build the model on successful strategies from earlier pilot PHC programs during the previous decade Scale Squared – Use the Scale One system to teach others • Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change. Scale Cubed – Policy Environment • SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS)
    • Overview – Development of PHC Approach in Peru Scale One – Ideally functioning local system • Establish a SCALE-One Center: créate a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities • Build the model on successful strategies from earlier pilot PHC programs during the previous decade Scale Squared – Use the Scale One system to teach others • Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change. Scale Cubed – Policy Environment • SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS) • Strengthen SCALE-Cubed with a stronger legal instrument – a Law on CLAS
    • Overview – Development of PHC Approach in Peru Scale One – Ideally functioning local system • Establish a SCALE-One Center: créate a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities • Build the model on successful strategies from earlier pilot PHC programs during the previous decade Scale Squared – Use the Scale One system to teach others • Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change. • Continue to innovate • Develop other “Model CLAS” with local adaptations. • Promote visits to Scale- Squared Centers Scale Cubed – Policy Environment • SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS) • Strengthen SCALE-Cubed with a stronger legal instrument – a Law on CLAS
    • Overview – Development of PHC Approach in Peru Scale One – Ideally functioning local system • Establish a SCALE-One Center: créate a “Model CLAS” to demonstrate how CLAS helps to strengthen the quality of PHC with sustainable links to health promotion in communities • Build the model on successful strategies from earlier pilot PHC programs during the previous decade Scale Squared – Use the Scale One system to teach others • Use de “Model CLAS” as an Experimental Observation and Training Center to scale up the new model of enhanced PHC linked to communities with focus on health behavior change. • Continue to innovate • Develop other “Model CLAS” with local adaptations • Promote visits to Scale-Squared Centers Scale Cubed – Policy Environment • SEED-SCALE concepts initially used to develop a national program for primary health care (PHC) with community involvement (Shared Administration with CLAS) • Strengthen SCALE-Cubed with a stronger legal instrument – a Law on CLAS • Disseminate strategies and results, advocate for policy continuation & improvements
    • Regional Health Directorate CLAS Primary Health Care Faciity Local Health Plan SCALE-ONE: Define and improve quality of relationships around CLAS SECTORIZATION STRATEGY COMMUNIITES COMMUNITY WORK PLANS CLAS Board of Directors COMMUNIITES CWP Health Services Network Center Then, SCALE-SQUARED: Observational learning/teaching center CHW ASSOCIATIONS Blue interventions: Change agent (FG) introduces new strategies to improve quality, build ownership & sustainability. MUNICIPALITY
    • Regional Health Directorate CLAS Primary Health Care Faciity Local Health Plan SCALE-CUBED: New CLAS Law in Peru 2007 MUNICIPALITY Regional Government COMUNSA - Club de madres - Vaso de leche -- APAFA -- Promotor COMUNA - Club de madres - Vaso de leche -- APAFA -- Promotor COMUNSA - Club de madres - Vaso de leche -- APAFA -- Promotor COMMUNITY - Community leader - -CHW Health Services Network Center Roles & functions poorly defined Community- based Organizations COMMUNIITES CLAS Board of Directors New national law on CLAS strengthens the range of participation for government and community collaborative management of primary health care services.
    • Posts, 0.41 Posts, 0.16 Posts, 0.63 Posts, 0.74 Centers, 2.63 Centers, 2.8 Centers, 2.4 Centers, 3.62 Rural CLAS Rural Non-CLAS Urban CLAS Urban Non-CLAS TYPE OF PRIMARY CARE FACILITY Averagen°ofphysicians Source: Altobelli L. Data from National Inventory of Infrastructure, Equipment, and Human Resources 2006. Lima, Peru: Future Generations. Average nº of physicians per primary care facility FutureGenerations 2.32 1.32 2.94 1.73 1 1.5 2 2.5 3 Averagenºvisitsperchildperyear Rural CLAS Rural Non-CLAS Urban CLAS Urban Non-CLAS TYPE OF PRIMARY CARE FACILTY Average n° consultations children 0-4 yrs-old – public health insurance (SIS) Source: Altobelli L and A Sovero (2004) Cost-Efficiency of CLAS. Lima: Future Generations. (Data from SIS Plan A, 2002) Results on CLAS versus Non-CLAS: productivity and efficiency
    • 69.8 72.0 64.5 59.2 50.0 55.0 60.0 65.0 70.0 75.0 80.0 2011 2012 Process: Family planning Health facility performance in 28 CLAS (solid line) and 77 Non-CLAS (dotted line) Ucayali Region-Peru. 2011, 2012. % completion of best practices 73.0 79.8 64.3 62.2 50.0 55.0 60.0 65.0 70.0 75.0 80.0 2011 2012 Process: First prenatal visit 72.6 79.9 65.2 60.7 50.0 55.0 60.0 65.0 70.0 75.0 80.0 2011 2012 Process: Prenatal care follow-up 40.2 37.6 35.6 29.3 15.0 20.0 25.0 30.0 35.0 40.0 45.0 2011 2012 Process: Community actions 78.3 77.1 69.8 71.3 50.0 55.0 60.0 65.0 70.0 75.0 80.0 2011 2012 Process: Healthy and sick child care 73.6 77.7 65.7 86.1 60.0 65.0 70.0 75.0 80.0 85.0 90.0 2011 2012 Process: TB care Results on CLAS versus Non-CLAS: performance Source: Project USAID | Quality Health Care, 2013 FutureGenerations
    • 3 Sectorization Strategy • DEFINED TASKS FOR HEALTH SYSTEM STRENGTHENING 2 Modified Care Group Strategy • NEW HUMAN RESOURCES AND MATERIALS FOR TRAINING CHW 1 CHW Strategy • DEFINED TASKS, INSTRUMENTS & HEALTH PROMOTION MATERIALS Three Linked Strategies for Strengthening Primary Health Care
    • 1 CHW strategy for MNCH CHW ROLES TASKS INSTRU- MENTS Train for community monitoring/ education Learn to change health behaviors. 8 Facilitator Manuals for training in MNCH. ng-Learning Methods. Know the community Household census. Mapping. Identify info. desires of family Family census form. Map of households. Three Question Survey. Monitor risk groups (first 1000 days) Monthly home visits. Identify danger signs. Refer cases. Checklists to monitor danger signs. Referral slips. Educate mothers on best health practices Teach mothers. 7 flipcharts. Checklists to monitor behaviors. Birth Plan card. Report community information Report births & deaths. Report activities. Forms to notify births & deaths. CHW report form. Supervision form. Teaching /Learning Methods
    • “Community Facilitator” Roles: Reinforce training, supervision, and support “Women Leader” (CHW) Health staff - “Tutors for Promotion of MNCH” Roles: Training, sup ervision, and support Pregnant women and mothers of children under two 2 Modified Care Group Strategy for MNCH Group of 15-30 households Care Group
    • Level Preparatory Phase Initial Phase Implementation Phase Monitoring Phase Health sector Management -Be trained in Sectorization -Train Tutors for MNCH* Promotion Weekly tasks Primary Care Health Facility -Be trained in sectorization -Self assess PHC organization & management -Assign team responsible for sectorization -Identify sectors -Categorize risk of each sector -Map each sector -Training materials -Monitoring forms -Train personnel -Assign sectorists to sectors -Tutors train CHW -Create situation room -Deliver basic package of integrated health services -Organize admission system -Develop schedule for community visits Monthly tasks: Each Sectorist Quarterly tasks Sectorization leaders Community -Sectorist meets community leaders -Each community elects their CHW -CF and WL implement the community monitoring system -Develop Community Work Plans Monthly tasks: -Community Facilitator -CHW -WomenLeader District Municipality -Finance health promotion Yearly tasks for TDI Technology MNCH = Maternal, Neonatal, and Child Health -CF and WL implement community edu. & monitoring 3 Sectorization Strategy for MNCH - Tutors train CF and CHW - Pay CF stipends
    • Sectorization Strategy organizes health personnel work in communities Interdisciplinary team work: health facility & community2-stage community mapping and monitoring
    • Huánuco adopts Sectorization Strategy Public event on MAM project Pathway to Integration: Learning for Leverage TA, studies, articles on CLAS National policies Regional & district policies FG projects & activities 1994 2002 03 04 05 06 07 08 09 10 11 12 13 14 MOH establishes & scales-up CLAS CLAS law passed CLAS regulations passed MOH stops CLAS expansion Health reform – laws Regulations on new laws Visits to MAM Project by MOH-MEF Cusco región adopts Sectorization Strategy Pilot “Model CLAS” USAID CSHGP - NEXOS Project USAID CSHGP – MAM Project Awards New MOH health promotion strategy builds on “Model CLAS” Municipal ordinances : recognize CF & WL – Pay CF stipend & trng. costs Legislative advocacy for CLAS Advice to MOH on community participation in PHC Evaluations of PHC pilot projects Sharing Histories cRCT Project FG publishes Sectorization Strategy Huánuco printing flipcharts CLAS pays CF & WL training costs Advocacy on CLAS and PHC strategy
    • Regional Health Directorate CLAS Primary Health Care Faciity Local Health Plan GOAL: SCALE-Squared with National Norms to Scale-Up CLAS with Improved Quality of CB-PHC MUNICIPALITY Regional Government COMUNSA - Club de madres - Vaso de leche -- APAFA -- Promotor COMUNA - Club de madres - Vaso de leche -- APAFA -- Promotor COMUNSA - Club de madres - Vaso de leche -- APAFA -- Promotor COMMUNITY - Community leader - -CHW Health Services Network Center Community- based Organizations COMMUNIITES CLAS Board of Directors SECTORIZATION STRATEGY CWP COMMUNITY WORK PLANS CHW ASSOCIATION 853 CLAS committees now co-manage 1/3 of all primary health care facilities in Peru (2139 out of 7000)
    • Decentralization laws: • Confusion in roles and responsibilities for health - each regional government strengthens (or not) CLAS according to its own decision. Health sector financing issues: • Results-Based Budgeting – in reality this re-centralizes management responsability for public funds. • Fewer funds are transferred to CLAS with the justification that CLAS are “private” and have their own resources. • Budget cuts removed CLAS Regional Technical Support Teams with untoward consequences for CLAS. Policy Environment - Challenges FutureGenerations
    • Policy Environment - Challenges Ministry of Health has had weak leadership in role clarification: • Confusion on decision-making authority between regional health offices, subregional health management micro-networks and networks, and CLAS. • Erroneous perception that “CLAS is autonomous”, therefore the network Budget units do not send reimbursements, budgets, or supplies/equipment to CLAS, placing in jeopardy the ability of CLAS to provide quality services. • The MOH has not emitted clear directives (which it is legally obliged to do) to orient regional governments on the procedures to re-structure existing CLAS and expand new CLAS. • Weakening perception of the importance of community participation and social control of primary care services. FutureGenerations
    • Policy Environment - Challenges Opposition of interest groups to CLAS: • Medical Federation was opposed to the non-public payroll options for contracting physicians. • Medical Federation was opposed the idea of physicians having to work with or respond to community members. Regional administrators of government health budgets opposed transfer of funds directly to CLAS for local administration. Health Promotion continues to be underprioritized: • Relegation of CHW to municipal control. • No clear health sector strategy on CHW work and support. FutureGenerations
    • Policy Environment – Ways to influence Involvement of Government Partners at every step of Project - Regional Government and Municipalities Interest Group on CLAS - Advocacy group founded and led by Future Generations National Health Council – Committee on Health Services Future Generations is the representative of Civil Society Organizations on this committee Working on Regulations to new Law on Integrated Health Networks – includes CLAS Initiative Against Child Malnutrition Consortium of 17 NGOs and donor agencies for policy advocacy on chronic malnutrition and anemia Roundtable to Articulate the Fight Against Poverty (quasi-governmental oversight entity) Group on Maternal-Newborn Budgetary Program Group on Articulated Nutrition Budgetary Program FutureGenerations
    • Thank you! For more reading on CLAS in Peru: L. Altobelli and C. Acosta (2011) Local Health Administration Committees (CLAS): opportunity and empowerment for equity in health in Peru. In: Erik Blas, Johannes Sommerfeld & Anand Sivasankara Kurup (Eds.) Social Determinants Approaches to Public Health: from concept to practice. Geneva: World Health Organization. http://bit.ly/jGKRYq FutureGenerations