2. What is PSI
PSI is a leading global health organization - social
marketing is the core of our work
Social marketing is about making it easy for people to
change their behavior
PSI reaches our target audience where they are
– Most people in the developing world get healthcare through
the private sector
– PSI leverages the private sector - providing training, new
tools, and franchised clinics
We focus on measurement, learning and innovation
Operations in 67 countries
3. 2011 PSI Platform Relevance and Impact
70%
Zimbabwe Lesotho
Malawi
BOD Addressed by PSI Platform (Relevance)
Uganda Namibia Botswana
60%
Congo-Kinshasa Zambia
Swaziland
Mozambique
Kenya
50% Tanzania
South Africa Madagascar Cameroon
Rwanda
Benin Cote d'Ivoire Mali
Ethiopia Angola Nigeria Burundi
40%
Togo
Pakistan
Liberia Myanmar
Cambodia
30% Guinea C.A.R. South Sudan
Haiti Cote d'Ivoire (AIMAS)
>= 50% Relevance
Nepal India PSI Global
20% Tajikistan 40% - 49% Relevance
Papua New Guinea
Thailand Laos Burkina Faso 30% to 39% Relevance
Paraguay 20% to 29% Relevance
10% Mexico
< 20% Relevance
Costa Rica
PSI Global
Romania
0%
0% 1% 2% 3% 4% 5% 6% 7% 8% 9% 10% 11% 12% 13% 14%
National BOD Averted
4. 100%
10%
20%
30%
40%
50%
60%
70%
0%
80%
90%
Zimbabwe
Lesotho
Malawi
Botswana
Namibia
% of National BOD
Uganda
Zambia
Swaziland
Congo-Kinshasa
Mozambique
Kenya
Tanzania
South Africa
Cameroon
Madagascar
Rwanda
Benin
Cote d'Ivoire (plus AIMAS)
Mali
Burundi
Nigeria
Ethiopia
Angola
Togo
Myanmar
Pakistan
Liberia
Cambodia
C.A.R.
Guinea
South Sudan
Haiti
PSI Global
Nepal
India
ranked by % relevance
Tajikistan
Dominican Republic
Honduras
Guatemala
Papua New Guinea
Laos
Thailand
Burkina Faso
Belize
Vietnam
Caribbean
Panama
Nicaragua
Kyrgyzstan
Paraguay
El Salvador
Kazakhstan
Mexico
China
Costa Rica
Russia
Romania
PSI
Injuries
PSI Relevance: 2011 Global DALYs Averted Compared to Burden of Disease (WHO 2004)
Expansion
Relevance
Innovation in
% DALYs Averted by
Innovation in NCDs +
communicable burden
7. Program strategies
Operating in 3 public sector clinics and 1 maternity hospital in
urban and per-urban Managua
Train public health care providers on risk factors for GDM; how
to screen for and detect GDM; proper management and care of
GDM
Establish formal referral and feedback systems between clinics
and hospitals for improved detection and management of GDM
Screen 750 pregnant women/month between 24-30 weeks of
gestational age for gestational diabetes
Enroll women with gestational diabetes in a management
program
– Nutritional therapy sessions, individual and group counseling for women
and their families, GDM management guide, follow-up reminders via
mobile SMS
8. Screening protocols in a low-resource setting
Screen for ≥1 risk factor through clinical interview
– Overweight
– Family history of diabetes
– Unfavorable obstetric outcomes including: GDM or pre-diabetes in previous
pregnancies, 2 consecutive miscarriages, fetal death without an apparent
cause, macrosomia
Diagnose GDM: fasting oral glucose tolerance test in the 24th week with
75g of glucose (with 8 hours of fasting prior to the test)
– Fasting glucose ≥92 mg/dl
– 1 h ≥180 mg/dl
– 2 h ≥153 mg/dl
– Nutritional counseling during wait time
9. Lessons learned so far
Leverage existing RH connections with
government, provider networks, and medical
associations
Maximize current capabilities in
– Training health care providers using behavior change
strategies
– Quality assurance
– Behavior change communications for women via mHealth
Key challenges
– Low levels of knowledge about GDM among pregnant
women
– Inconsistent information provided to women with GDM
across internist, gynecologist, nutritionist
11. Piloting VIA + cryotherapy in a social franchise
Build off of existing family planning platform
– Link to provision of IUDs and other contraceptives
Train 47 providers in VIA at 47 franchises
Train 10 providers in cryotherapy
– Hub and spoke approach to direct women from screening to
treatment sites
Aim to
– Screen 20,000 women
– Treat 2,000 women with cryo
– Prevent 300 cases of cervical cancer
PSI Health Impact Model estimates that 10,000
women screened and treated = 1,006 DALYs
12. Lessons learned so far
Social franchise network provides a flexible platform
to integrate a range of services
Need for advocacy with the medical professional
community
– Task-shifting from OB/Gyn to GPs
– Proving sensitivity/specificity of VIA, safety/efficacy of cryo to
local stakeholders
Challenges in procuring equipment
– High costs of cryo guns
– Delays in receiving import licenses
15. Tuberculosis and tobacco
More than 20% of global TB incidence may be attributable to
smoking tobacco
PSI TB programs in 12 countries
– Screening and treatment through social franchises
• 91% treatment completion in Pakistan; 85% completion in
Myanmar
– Screening and referral linked to HIV TC centers
• 91% of HIV testing clients screened for TB in Zimbabwe
Aim for smoke-free facilities
Identify and assess tobacco use status among TB clients
– WHO “5 A’s” algorithm for those willing to quit
– Who “5 R’s” motivational intervention to promote quitting
Integrate tobacco messaging into community outreach to TB
clients and families
17. Cervical cancer service integration
Into reproductive health programs
– Scaling up screen+treat via social franchises
– Establish mobile services
– Introduce HPV vaccination (Nicaragua)
Into HIV testing and counseling (HTC)
– PSI operates HIV testing and counseling in 30 countries
– 1.4 million people tested and counseled in 2011
– Variety of modalities: social franchises, mobile clinics, stand-
alone clinics
– HTC emphasizes integration – with FP, TB. Why not
cervical cancer?
18. An expanded approach to cervical cancer programs
Behavior change communication
– Cervical cancer screening and treatment
– Vaccine uptake
Incentivized care
– For providers and/or participants
Advocacy
– Ministries of Health and Education
– Medical professional organizations
19. Hypertension and diabetes: the next frontier for franchising
100
90
80
70
60
50
40
30 PSI
20
10
0
Range of franchised services provided, 2011
21. Questions?
PSI 1120 19TH STREET, NW | SUITE 600
WASHINGTON, DC 20036
PSI.ORG | T W I T T E R : @ P S I H E A LT H Y L I V E S | B L O G : P S I H E A LT H Y L I V E S . C O M
Editor's Notes
PSI is a global non-profit organization dedicated to improving the health of people in the developing world by focusing on serious challenges like a lack of family planning, HIV/AIDS, barriers to maternal health, and the greatest threats to children under five, including malaria, diarrhea, pneumonia and malnutrition.
PSI uses DALYs (disability-adjusted life-years) to assess our impact, and we calculate DALYs averted for each of the countries we work in, based on their program operations. As part of our new strategic plan, we have a mantra of “following the need”, i.e. responding to the local disease burden, and are asking our countries to ensure that they are “relevant” – working in the health areas that make up the greatest burden of disease locally.This graph plots % of national BOD averted by PSI program operations against national programmatic relevance (defined as health area BOD that PSI works in/national BOD)Our goal is to be above 40% relevant by 2016. We’re at 26% at our baseline in 2011. We also want to be going to scale and increasing % of national BOD averted. The only way to do that is to get relevant first.
This is another way to showing how we assess relevance, based on BOD. Blue shows current PSI relevance (% of national BOD that we are currently operating in based on current program operations). This is from working in HIV prevention, malaria prevention and treatment, integrated case management of childhood illness, reproductive health (mostly contraception, some abortion and maternal health). Green shows the potential impact of taking some current interventions to greater scale. This is mostly from expanding operations in IMCI in order to get a treating pneumonia, diarrhea and malaria and addressing background undernutritionPurple shows potential impact of expanding programmatic operations in communicable disease. Primarily is PSI started doing childhood vaccinationBrown shows the enormous potential of being relevant by expanding operations in NCDs and injuries.You can see that some of the countries we work in will ONLY be sufficiently relevant to meet SP goals by operating in NCDs and injuries, e.g. China, Viet nam, Mexico, the Carribean, Kazahstan. Basically, Central America and the Carribean, Europe, Central Asia, Southeast Asia, East AsiaTO FOLLOW THE NEED AND SERVE OUR TARGET AUDIENCE, PSI MUST EXPAND INTO NCD PROGRAMMING
Diabetes is fourth most common cause of death among Nicaraguan womenMinistry of Health issued protocol in 2000 for diabetes management with recommendations on screening and managing GDMLittle application of protocolLack of training and supplies Over 75% of pregnant women in Nicaragua get at least 4 ANC visits opportunityPSI supports Red Segura, a network of 65 franchised private clinics in Nica providing RH services, especially access to contraceptives (including implants and IUDs). Also does demand creation using social marketing strategies to promote access to contraceptionWorks closely with MOH and other RH stakeholders in Nicaragua to manage these projectsPSI globally approached by Novo Nordisk, and Nicaragua jumped at the chance. Project primarily supported by WDF, with additional support from Novo Nordisk
I just followed up on the OGTT wait period and the project will train providers (doctors, nurses, techs) so that they explain the importance of waiting to the woman and also provide trainings to project nutritionists who will provide counseling during the wait time. Large for gestational age (LGA) is an indication of high prenatal growth rate, often defined as a weight (or length, or head circumference) that lies above the 90th percentile for that gestational age.[1] Macrosomia, also known as big baby syndrome, is sometimes used synonymously with LGA, or is otherwise defined as a fetus or infant that weighs above 4000 grams (8 lb 13 oz) or 4500 grams (9 lb 15 oz) regardless of gestational age.
Audience insight gained during the first months of project roll-out include: There is a low level of knowledge among women with gestational diabetes about the causes and consequences of the diseaseFew women understand that exercise is an important component for controlling gestational diabetesWomen who report a high level of familial support appear to have an easier time adhering to gestational diabetes management strategiesWomen with gestational diabetes hold a number of erroneous beliefs about the disease that cause them unnecessary anxiety during pregnancy, such that gestational diabetes may cause a baby to be born with diabetes, that gestational diabetes can frequently cause birth defects, and that gestational diabetes can cause the baby to “dry out”There is little consistency between the information women receive from their internist, gynecologist, and nutritionist regarding gestational diabetes, resulting in a high level of confusion among pregnant womenWomen who alter their diet to control their gestational diabetes prepare themselves a special meal rather than changing the diet of their entire family
Approximately 2,700 women die of cervical cancer annually, causing the loss of 40,000 DALYs;the most common cause of cancer among women in MyanmarSQH: almost 2,000 franchisees; in ½ of townships in MM, primarily GPs, one of the biggest health care providers in MM, primarily family planning but most providers do other servicesDrop-in-centers: 17 throughout the country, targeted to urban, high-risk populations (CSWs, IDUs)SPH: products and services such as Ocs and nets via community health workers
Since women won’t initially come in just for cervical cancer screening, take the opportunity for an IDU exam to offer the service to themNOTE: As of 2011 PSI/Kenya screened 25,368 women with VIA averting 394 DALYsOur cervical cancer screening program operates as follows:Supply Side· Training of health providers on guidelines and protocols· MOH recognized certification· Supportive supervision of trained providers to ensure services are provided inline with protocols and guidelines· Provision of job aids as reminders of ‘at point of service’ requirementsDemand Side· Our social franchise has a demand creation team that manages Tunzamobilizers (TMs) on the ground (equivalent of CHWs)· The TMs go around the community meeting women groups raising awareness on various health issues and referring women to Tunza facilities for care and treatment and further counselingLessons Learnt· Integration of new services is appreciated by the service provider because they lack access to training and medical updates· The supportive supervision builds provider confidence to provide services· The supportive supervision aspect becomes more complicated once you have a wider service offering by your providers
TOT happened and then further trainings have occurredScreening is on-going and seems to be successfulHas been difficult to sell local stakeholders on the effectiveness of a public health approach using single visit screen+treat approach (not convinced about VIA instead of pap, and prefer LEEP and surgical methods); they want to see Myanmar-specific data on effectivenessHave been able to do cryo in drop-in centers with high risk women, but not in franchise clinics (cryo explicitly excluded in recent MOU)MMA and PSI doing some ad hoc experience building around cryotherapy on a small scale to “build evidence”
http://whqlibdoc.who.int/publications/2007/9789241596220_eng.pdfActive and passive smoking found to be associated with increased TB incidence and mortality5 A’s : Ask, advise, assess, assist, arrange5 R’s: relevance, risks, rewards, roadblocks, repetition Stumbling blocks are: funding (even tho it wouldn’t cost a lot), heavy verticailization of TB, changing mindsets of stakeholdersNote interest in tobacco and RH integration (discuss smoking risks with women who want to contracept or have kids)
PSI, SFH Nigeria, MSI, and IPPF are currently negotiating with the Gates foundation to work in partnership on a $15M cervical cancer screening and preventive therapy project in Uganda, Tanzania, Kenya, and Nigeria over four years. The project aims to train providers in the screening method visual inspection with acetic acid (VIA) and treatment of pre-cancerous cervical lesions with cryotherapy. The target population for screening is women ages 30-39. All partners are to work together to strengthen referral networks, develop comprehensive quality assurance programs, and identify cost savings through collaboration.Re. HPV vaccine: have been pursuing it, but now trying to understand implications of roll-out of GAVI applications, which require countries to have completed demonstration projects. Have had discussions with Merck and local govts
Incentivized care = performance-based financing and vouchers
PSI offers 8 different service delivery packages so far: FP, SRH, HIV, MCH, Malaria, Tb, Diarrheal disease, pneumoniaRange is 1 – 8 (Myanmar has 8)Most still only have 1 (13/22 = 60%)Myanmar is best with 8. Followed by Cambodia with 7. Benin with 5. Mada and Zim with 3. Laos, India, Mali, Cameroon with 2. And the rest just one (all FP except Zambia which is HIV)a broader range of services than MSI and has a higher proportion of franchisees offering most of those services (exception is SRH).
