Photo source: Kieran McConville, Concern Worldwide U.S., Sierra LeoneIntroductionIn the spirit of our theme “capacity strengthening” I am here to share the thinking of a new project we are designing on reinventing traditional birth attendants in the Sierra Leonean context. SL, like many countries, faces a shortage of health workers. 63% of women in SL deliver at home, many with a TBALike many countries SL is grappling with the concept of TBAs: how can TBAs who are highly regarded in their communities and are usually the first point of contact for pregnant women in need of care re reoriented away from assisting births and reincorporated into the health care system to ensure that women and children are receiving essential care?The Innovations initiative is seeking to find solution for TBA’s role in health service delivery.
Innovations as an initiative has been charged with finding and testing ambitious new ideas that have the potential to overcome barriers and significantly improve access to and delivery of maternal, newborn, and child health services. The initiative has gone through several stages:Identify the most serious and widespread barriers to MNCH coverageGenerate creative and untested ideas, from traditional and non-traditional sources and unheard community voices in health planning and decision makingDevelop the best ideas into models for testingImplement & evaluate (document successes/failures)Create enabling environment for scale-up of the successful ideas in each countryDisseminate research results, process and outcome learning, and contribute to policy development on MNCH and social innovation The initiative has a portfolio of 9 project across 2 phases in 5 countries, SL, India, Kenya, Ghana, MalawiPhase 1 projects are coming to a close with final evaluationsPhase 2 projects are still in project design with implementations starting in fall 2013.
The Essential Newborn Care Corps project, implemented in Bo district in SL, is among the phase 2 projects and is entering into an exciting phase of design.Seeks to transform the role of TBAs by reorienting them away from child delivery to support them in building their own businesses with health related products while clarifying their role within the formal health structure. - ENCC is a network of independently-certified frontline health workers addressing an unmet need by Providing careAdviceSpecific products for saleFree health commondities – including basic medicine for children and mothersENCC will recruits TBAs to form an elite corps of health service providers harnessing their potential to help address the shortage of health workers while complying with the ban on their involvement in deliveryTrainingRe-positioningRe-branding T BAs to become part of the bridge to the formal health systemsEngage traditional birth attendants (TBAs) in an unconventional wayLeverage trust Reposition/task shift/rebrand TBAs to support needs in mothers & children during the postnatal periodEmpower TBAs through training, franchising/business developmentAs Sierra Leone is rolling out and developing its policies for free health care and community health workers respectively we are designing and implementing a pilot that will reposition and rebrand the TBAs in the district of Bo. Through creating an exciting new social franchise these women will be trained and mentored to be micro entrepreneurs who are not only able to generate an alternative revenue stream from their own enterprise but who are also able to become health advocates and act as a referral point to health facilities for women in their community.
Where did the idea of come from?InReceptivity among TBAs remains high, more so than PHU staff. This underscores the desire for TBAs to find a new role and place for themselves in the continuum of care, with the FHCI and ceasing of home deliveries.Many of the change ideas developed to date deal with health care system strengthening (ex. Reversing the lack of resources, access to training, incentives for TBAs and volunteers, formal recognition of TBAs and their role in providing care, etc.). It will be interesting to see if QC can find solutions to these prioritized problems independent of further inputs from Concern/CRS.
Photos source: Kieran McConville, Concern Worldwide U.S., Sierra LeoneTimelyEfforts in SL to redefine the roels of TBAs in light of Free Health Care Initiative -2010Basic Package of Essential Health ServicesNew… Community Health Worker Policy TBAs have the potential to become important health resources in addressing non-delivery care needs in the community, shifting TBAs from their traditional roles has had limited success due in part to the lack of substitute sources of revenue for TBAs Approach seeks to find complementary roles for TBAs in line with recent policies in SLOur innovation is we bringing together the components of social franchising, micro enterprise and the formal health system whilst acknowledging the large human resource gap that so many countries still face. Our social franchise will not only be open to illiterate and literate TBAs, it will also be bringing in some of the best thinking from the private sector…something that has not been tried before in such a way with TBAs. Through understanding of community values, our idea is to rebrand TBAs to shifting their roles without losing the prestige and position they hold. Our TBAs will have a health related business that enables them to hold prestige and position in their communities which will allow them to act as more effective influencers of position change. This repositioning will permit TBAs to use their status as a bridge between their communities and the formal health system
“Raw” ideas (community suggestions) require further refinement before implementation.Infuse domain expertise & knowledge of existing efforts & past challenges.Blend ideas into concepts with greater potential for impact & scale.Push beyond best practice, finding the essence of what is truly innovative.“Design thinking encourages you to gather feedback long before an idea, concept or story is finished. A prototype, in the hands of a design thinker, is finished when it can teach them something. The goal of prototyping is to accelerate feedback and failure. Failing indicates that you haven’t quite yet nailed the experience, and suggests what you might try next. Prototyping lets you find problems, but it also teaches you to ‘let go’ of ideas that aren’t fruitful. Failure due to sins of commission as opposed to those of omission) is not a personal indictment, but an incitement to go out and create another prototype.” “The third space of the design thinking process is implementation, when the best ideas generated during ideation are turned into a concrete, fully conceived action plan. At the core of the implementation process is prototyping, turning ideas into actual products and services that are then tested, iterated, and refined. Through prototyping, the design thinking process seeks to uncover unforeseen implementation challenges and unintended consequences in order to have more reliable long-term success. Prototyping is particularly important for products and services destined for the developing world, where the lack of infrastructure, retail chains, communication networks, literacy, and other essential pieces of the system often make it difficult to design new products and services. Prototyping can validate a component of a device, the graphics on a screen, or a detail in the interaction between a blood donor and a Red Cross volunteer. The prototypes at this point may be expensive, complex, and even indistinguishable from the real thing. As the project nears completion and heads toward real-world implementation, prototypes will likely become more complete.” “Once a promising idea has been proposed, it then needs to be tested in practice. Ideas develop through trial and error, and constant refinement. It’s very rare for an idea to emerge fully formed. There are many methods in use for testing ideas out and refining them, ranging from the formal methods of randomized controlled trials to pilots and experiments. Social entrepreneurs often dive into practice and hope to learn quickly without using formal evaluations or tests. One of the common themes of contemporary social innovation is that it often works best by moving quickly into practice, rather than spending too long developing detailed plans and strategies. Prototypes, pilots and trials: As an idea progresses through multiple stages of rapid prototyping, it faces many challenges: the feasibility of making the product, delivering the service, how to deal with particular issues, what the economics look like, and how it could be made cheaper. The driving principles at this stage are speed, keeping costs low, tangibility and feedback loops from users and specialists.”Rodriguez, D. and Jacoby, R., Embracing Risk to Learn, Grow and Innovate. Roman Magazine Spring 2007. Brown, T. & Wyatt, J. (2010). Design Thinking for Social Innovation. Stanford Social Innovation Review, 30-35. Retrieved from: http://tamarackcci.ca/files/design_thinking_for_social_innovation_-_ssir.pdfMurray, R., Caulier-Grice, J., & Mulgan, G. (2010). The Open Book of Social Innovation. NESTA & The Young Foundation. Retrieved from: http://www.nesta.org.uk/library/documents/Social_Innovator_020310.pdf.
TBA head countCensus of all TBAs in the area- understand background, location data, social network analysis to understand how TBAs are networked with each other, communities, and PHUs (peripheral health unit). Direct contact with TBAs through a gathering of TBAs 3-pronged approach for disseminating information on gathering include contacting TBAs through formal directory of all 110 PHUs, radio/PSA and connections and word of mouth of chiefdom authoritiesDatabase registry of all TBAs in Bo, visual map detailing number, location, networksMarket surveyWhat products can communities afford in selected areasHow much are communities willing to pay for productsWhat products are already availableWhat products are needed and not easily accessible Pricing of productsEconomic viability Other sources of income for TBAsHow this will add to revenue of TBAsNumber of TBAs needed to measure the effectiveness of this model during implementation. Does the income generating/status change enough to motivate TBAs to sellMFSE modelAcceptability and desirability – will TBAs buy sell, will communities buy from TBAs, name, tagline, logo, packaging, uniform, accessories, Test incentive schemeReferral strategiesProduct mixWhat products (affordability, desirability, locally produced, pricing)Balance between products for sale and products for freeTrainingTest acceptability of training materials and approaches (duration, delivery format etc) to ensure understanding and application (pre-post workshop)Linkages to health facility- TBA headcount, testing methods to manage reportingSupply ChainSet up and test supply chain for sale products and for free products (designed of information from TBA headcount)Economic viability of ENCC business model Key question we are interested to hear more about is how do we best position this concept with the global conversation about TBAs so that the best solution to this current challenge can be found and how do we achieve economic viability?
Reinventing Traditional Birth Attendants_Katie Waller
www.innovationsformnch.orgReinventing Traditional Birth Attendants(“TBAs”)Katie Waller, Program OfficerInnovations for MNCH, Concern Worldwide U.S.Spring 2013 CORE Group Meeting
www.innovationsformnch.orgInnovations GoalTo find and test ambitious newideas that have the potential toovercome barriers andsignificantly improve access toand delivery of maternal, newbornand child health services
www.innovationsformnch.orgEssential Newborn Care Corps (ENCC)Bo DistrictPhase II Pilot Beginning 2013Seeks to transform the role of TBAs by reorienting themaway from child delivery to support them in building theirown businesses with health related products whileclarifying their role within the formal health structure.
www.innovationsformnch.orgWhat Inspired ThisIndiaModule-basedtraining fortraditional providersin remote areas &equip them with kitsto deal with medicalemergencies. Agroup of healthstudents.IndiaState-NGOpartnership toenable economicempowerment ofrural/tribal women.A mixed group ofindividuals fromNGO, corporate,government, andacademic sectors,and students.MalawiCertify TBAs toperform approvedservices &procedures; form aTBAassociation toensure propertraining &equipment. Agroup of corporate-sector individuals.MalawiFacilitate ruralhealth workers togo into smallbusiness tosupplement theirsalaries. A group ofuniversity students.Set up a poultryenterprise at theTBAs residence. Agroup of SMEowners.Sierra LeoneFormalizeintegration oftraditionalproviders inmodern health carethrough…incentiveschemes for TBAsto bring clients forinstitutionaldelivery. A mixedgroup of localinnovators andglobal domainexperts.Lessons Learned“People say TBAs are just as important asPHU staff. I say no. I say they are moreimportant than PHU staff”-Kailahun DMO
So what is next?Innovation requires Incubation and Iteration.WE ARE HERE
Market Research Rapid PrototypingMicro franchisesocial enterprisemodelProduct MixTrainingLinkages tohealth facilitySupply ChainMarket SurveyRapid Prototyping: Methods to move quickly to test out anew idea either in a real or partially real environment.TBA Headcount