Strengthening Community Health Systems_Henry Perry_5.8.14


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Strengthening Community Health Systems_Henry Perry_5.8.14

  1. 1. Community-based Approaches to Improving Reproductive, Maternal, Neonatal and Child Health: Current Status of the Evidence Henry Perry, Department of International Health Spring CORE Group Meeting, 8 May 2014
  2. 2. Outline • Rationale for the review • Components of the review process • Findings • A framework for improving RMNCH through community-based approaches • The way forward
  3. 3. Rationale for the Review • Rapidly expanding evidence base • Increasing interest in CBPHC • Need to begin to develop a more holistic (integrated) approach to programming • The follow-on to USAID-supported MCHIP (RMNCH) is now starting up
  4. 4. Components of the Review • General review of any (peer-reviewed or grey) literature on community-based approaches to provision of RMNCH services (465 articles) • Review of projects/programs/field studies that assessed the effectiveness of CBPHC in improving child health (476 assessments) or maternal health (119 assessments) • Factors related to effective CHW programming and national CHW program case studies
  5. 5. Review Process • Evidence-based review of effectiveness of CBPHC in improving child health • Large-scale CHW program review • Evidence-based review of effectiveness of CBPHC in improving maternal health • Broad literature review of promising approaches to RMNCH
  6. 6. Findings: General Literature Review
  7. 7. Newly Emerging Interventions for Community-based Delivery • Chlorhexidene umbilical cord care • Misoprostol for prevention of PPH • Zinc + ORS • iCCM • Participatory women’s groups (PLA, Care Groups) • Home-based neonatal care (+ PP FP) • HIV/AIDs prevention, detection, treatment (particularly for PMTCT)
  8. 8. Mainstay Interventions for Community-based Delivery • Immunizations • Vitamin A supplementation • Breastfeeding/appropriate complementary feeding • Maternal health (multiple micronutrients, nutritional supplementation during pregnancy, ANC, clean delivery, delivery by a skilled attendant, promotion of facility-based delivery) • CCM of childhood pneumonia • Prevention and treatment of malaria (ITNs, IPT, CCM) • CMAM
  9. 9. Broader Reproductive Health Interventions that Can Be Provided through Community-based Approaches • Family planning • Support for women living with AIDS • Cervical cancer screening and treatment • Harm reduction from unsafe abortion • Detection and treatment of syphilis
  10. 10. Evidence from Integrated Programs • PVO child survival projects • Care Group projects • Jamkhed/India, Hospital Albert Schweitzer/Haiti, Matlab/Bangladesh, SEARCH/India • BRAC/Manoshi/Bangladesh
  11. 11. Evidence from Country Successes • Bangladesh • Nepal Lancet 2013
  12. 12. Ethiopia Brazil
  13. 13. Strengthening Community-based Service Delivery • Community-based facilities • Informal and traditional providers
  14. 14. Community Engagement and Community Partnerships • Examples – Community-Directed Interventions • Initially for neglected tropical diseases but now moving into RMNCH • Descriptions of processes – Manoshi
  15. 15. Practical Findings from Operations Research • Need to focus on main causes of mortality in order to demonstrate a decline in mortality – Evaluation of UNICEF West Africa programs with evidence of increased coverage but no mortality impact (Bryce et al., Lancet, 2010) – Evaluation of home-based neonatal care program in Bangladesh (Darmstadt et al., 2010) • Need to achieve a certain intensity of women’s participatory groups for PLA – Program intensity in Ethiopia related to program outcomes (Karim et al., PLOS 2013) – For PLA groups, need to reach 30% of mothers (Fottrell et al., JAMA Pediatrics 2013) • Lack of supervision and logistical support are pervasive
  16. 16. Financial Aspects • Innovative approaches to financing • Cost-effectiveness limited except for some on a few specific interventions
  17. 17. Monitoring and Evaluation • Practical approaches to assessing effectiveness of large-scale programs • Monitoring coverage • LiST • Mortality assessment (measurement of changes in mortality rate, verbal medical and social autopsy) • Strengthening M&E of large-scale CHW programs (with transparent independent assessments every 5 years or so)
  18. 18. Emerging Issues • Mental health for WRA • Gender-based violence (including FGM) • Other diseases of WRA (HIV/AIDS, TB, malaria, chronic diseases) • Injuries
  19. 19. Cross-cutting Themes • Urban health • Scaling up programs • Equity • Health systems strengthening • RMNCH in post-disaster relief and settings with political conflict
  20. 20. Policy and Philosophical Issues • The role of NGOs in fostering community engagement, community mobilization, community-based service delivery, training and support of CHWs • Restoring a better balance between vertical and horizontal programming • Strengthening the effectiveness of frontline workers and large-scale CHW programs • Creating a more favorable policy environment
  21. 21. Conceptual Approaches • CBIO • Aggressive home visitation with early treatment of childhood illness
  22. 22. Findings from Effectiveness Review
  23. 23. Practical Program Strategies • Intervention delivery – Home visits – Participatory women’s groups – Community-case management – Provision of services by mobile teams based at peripheral facilities
  24. 24. Strategies for Village-wide Community Empowerment/Mobilization/ Demand Creation • Advocacy meetings with community leaders • Promotion and support of village health committees, village development committees, and sanitation committees • Community-wide meetings • Community-directed interventions • Village health days/malaria awareness days, etc. • Health talks at Friday mosque gatherings, church meetings, etc. • Sharing locally obtained health-related data with the community • Involving men and older family members (e.g., mothers-in-laws)
  25. 25. Strategies for Community Empowerment/ Mobilization/Demand Creation in Groups • Formation and training of women’s groups (community health clubs, pregnant women’s support groups, mothers’ centers/mothers’ committees, Care Groups, PLA Groups, self- help groups, women’s action groups, counseling and support groups) • Formation of parent committees • Formation of adolescent groups • Formation of farmers’ clubs • Conditional cash transfers to eligible mothers • Savings and loan groups (microcredit)
  26. 26. Health System Strengthening Approaches • Training of staff – frontline workers, CHWs, TBAs • Develop or upgrade peripheral facilities, strengthen quality of care • Strengthen drug supply chain • Strengthen linkages between CHWs and peripheral facilities • Strengthen referral system
  27. 27. Strategies for Program Design, Identification of Target Groups, Surveillance • Formative research/appreciative inquiry/PLA/stakeholder analysis • Village registers (pregnancies, pregnancy outcomes, births, deaths, TB patients) • Verbal autopsies • Client-held cards (maternal health cards, road-to-health cards, child health cards, immunization cards) • KPC surveys
  28. 28. Educational Strategies • Peer-to-peer counseling • Visual aids • mHealth • Skits, stories, games • Targeting grandmothers • Positive deviance inquiry/identifying strong community-level workers to support others not as strong
  29. 29. Review of Large-scale Community Health Worker Programs
  30. 30. • The final version will be available on the MCHIP website next week:
  31. 31. Creating a Framework for Sustainable Improvements in RMNCH at Scale through CBPHC
  32. 32. Community engagement, etc.
  33. 33. Paradigm Shift • Approaching the community as a resource and partner, not a target of programs or passive recipient of services • Investing in CBPHC as the priority for health systems strengthening and improving population-level health
  34. 34. The Way Forward • Entry points – Policy (e.g., for task shifting, etc.) – Creation of “friendly” environment for CBPHC, community engagement and NGOs – Supporting the development and assessment of “model” integrated RMNCH programs – Supporting literature reviews/analyses of existing data – Continued research on current and new interventions – Operations research/translating policy and research into action/implementation research/efficacy to effectiveness research/research on CHW programs – Replication and scaling up of promising approaches
  35. 35. Acknowledgments • MCHIP/USAID • Jim Ricca, Nazo Kureshy and others at USAID and MCHIP who supported this work • Working Group on Community-based Primary Health Care of the International Section of the American Public Health Association • USAID, UNICEF, WHO, World Bank and Future Generations for support of the effectiveness review