Improving the Quality and Scale_Waltensperger

1. Karen Z. Waltensperger, Senior Advisor
Community & Child Health
Save the Children experiences
supporting government iCCM
strategies and programs
CORE Group Global Health
Practitioner Conference -
Advancing Community Health
across the Continuum of Care
14 April 2015, Alexandria, VA

2. Early community-based IMCI
treatment experiences
• Mali – Sikasso Region, USAID CSHGP early-mid-90s
– Relais (volunteers) with drug boxes
– Under regional auspices
• Ethiopia – Negelle Borana, Oromo Region, USAID
CSHGP late 90s
– Pre national Health Extension Program (used
volunteers)
– Under regional auspices
– Published study in EMJ contributed evidence to
change national policy, leading to authorization for
use of antibiotics by HEWs

3. “CCM most needed where most difficult
to implement.”

4. “Easier” where there is…
• Government strategy & national level program
• MOH leadership
• Costed, budgeted, funded or supported by partners
• Viable community-based cadre (CHWs)
• Support from medical & other professional associations
• Technical working group at national level
• Partner coordination, especially in contexts of multiple operational
platforms
• Evidence base/best practices
• Community support & mobilization framework
• OR resources and engaged academic partners
• Broad consultation, inclusion, ownership
– Public-private, community-facility, government-civil society

5. SC approach: Integrated CCM (iCCM)
• Treatment for diarrhea AND pneumonia
AND malaria
• Can include:
– newborn care (especially PNC and
management of neonatal sepsis)
– Management of severe acute malnutrition
– PMTCT/HIV/TB

6. SC partnership approach
• No “branded” model
• Support national programs
• Take advantage of multiple operational
platforms
• Work at greatest scale possible/practical
• National-level component with focus on policy
dialogue, standardization, partner coordination
– Secretariat function
– Technical leadership/technical assistance
– Technical working groups
– Policy, protocols, guidelines, tools

7. 7
Signature
iCCM Program
Nicaragua

8. Nicaragua national context -
2006
• PROCOSAN
– Well-developed national preventive, community-
based MCH strategy
– Brigadista network (2-14 years experience)
– Natural “platform” for CCM
• MINSA (Ministerio de Salud)
– Concern about antibiotic misuse
– Policy prevented brigadistas (CHWs) from
dispensing prescription drugs
– Experience with CHWs treating malaria,
leishmaniasis
8

9. Hasta el Ultimo Rincón
CCM Project (2006-2011)
• Setting: (14 to 37) communities in rural
León, (total population: ~84,000)
– Site of ongoing SC MCH
programming; excellent
relationship with MINSA
– Mountainous; impassable roads in
rainy season
– Local health posts available only
16-18 h/wk, some communities 12-
24 hrs travel from health center
– Causes of child death: neonatal
sepsis, pneumonia, diarrhea
• CCM Strategy
– Age-group: 2-59 months
– Drugs: amoxicillin (pneumonia);
furazolidona (dysentery); zinc and
ORS (diarrhea); acetaminophen
(fever)
9
“Baby on Board”
26 mile round-trip
in monsoon for
pneumonia
treatment

10. CCM development process
• Supported MINSA to convene
national task force
• Designed materials with MINSA to
complement PROCOSAN:
– Training guides
– Counseling cards
– Mother reminder cards
• Selected most advanced, literate
brigadistas from Category C
communities (2+ hours from HP)
• Negotiated with MINSA to ensure
reliable drug supply, including zinc
• Initiated treatment within 4 months
of start-up

11. Policy change and scale
11
PROCOSAN/CCM now national
“norm” for Category C
communities
Added neonatal sepsis (first
dose & referral)
MINSA seeking donor and
partner support
Current scale
– 22 municipalities (districts), 4 departments
(provinces)
– Trained 105 health personnel
– Trained 360 brigadistas along with
relevant MINSA supervisors

12. SC iCCM programs now
• ~20 countries (of ~120)
~12 Africa (Ethiopia, Kenya, Liberia,
Malawi, Mali, Mozambique, Liberia, Sierra
Leone, South Sudan, Uganda, Zambia…)
~7 Asia
~1 Latin America/Caribbean (Nicaragua)

13. Primary partners
• Ministry of Health or responsible ministry
• Regional, district, local health authorities
• Communities
• UNICEF, WHO
• Local/international academic and/or
research institutions
• iNGOs, national NGOs, CBOs
• USAID, DfID, DFATC, BMGF, other
donors

14. Malawi’s MDG success
• 72% reduction in under-5 mortality since
1990 (from 244 to 68/1000 live births)

15. Community-based maternal
newborn care (CBMNC)
package
• Saving Newborn Lives I (~2001-06)
• SC Malawi Newborn Health Program
(~2007-12)
– National-level effort (4 pilot districts)
– Acted as secretariat for development of
CBMNC package
– Saving Newborn Lives II (BMGF)
– USAID CSHGP (CS-22)
• Access – MCHIP (+4 districts)

16. iCCM in Malawi
• Since 2008
– 3000+ HSAs (Health Surveillance Assistants)
– iCCM (malaria, diarrhea, pneumonia) to
10,400+ hard-to-reach areas
– HSAs salaried by MOH

17. Malawi multiple operational
platforms
SC supporting iCCM implementation
currently
• 20 of 28 districts
• 5 operational platforms
– USAID bilateral project (SSDI-Services) – 15 districts
– QuIC
– USAID CSHGP (Mwayi wa Moyo, CS-27 cycle)
– RAcE (FATDC through WHO)
– MICS (funding through SCUS, SC Canada, SC
Italy)

18. Generating evidence in
Malawi - OR
• Effectiveness of integrated community-based
MNCH+FP package delivered by HSAs
(USAID/CSHGP, 2011-2016, Collage of
Medicine)
• Integration of malaria RDTs and pre-referral
treatment of severe malaria using rectal
artesunate as part of iCCM (Barr Foundation
and WHO/GMP)

19. Challenges remain
• HSA residence status
• Time spent working in health centers
• Stock outs
• Transport
• Supervision/clinical mentoring

20. Supporting Mali’s SEC strategy

21. Partner engagement
• Ministry of Health, Government of Mali
• Save the Children
• UNICEF, WHO
• FENASCOM
• AMM
• SEC Ad Hoc Group & Focal Point Partners
• Service providers and beneficiaries
• USAID, MCHIP
• SSGI bi-lateral project (SC prime)

22. Components of SEC package
• iCCM: malaria, diarrhea,
pneumonia: 2-59 months
• Family Planning:
including injectables and
referral for LARC
• Newborn: post-natal
home-visits and referral
• Nutrition: screening and
referral
• SBCC activities: hand
washing, care seeking
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23. The Road to Scale in Mali
Decision of GoM to
use CHWs to expand
basic services to
remote communities
- Strategy initiated
GOM approval
of initial SEC
strategy
First Phase
Implementation in
5 regions
Comprehensive
Evaluation of
First Phase
(Household
Survey,
Qualitative
Studies)
Costed SEC
Strategic
Plan
Developed
2009
2010
2011-2012
2014
2013

24. Current SEC coverage

25. Results of 2013 SEC
evaluation
• ~3 CHWs per 1000
under-5 children in
population
• Female CHWs (43% of
total) more consistently
performing to standard
• Only 63% of CHWs
received supervision
visit in preceding 3
months

26. LQAS found low utilization of SEC
attributed to financial barriers
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Kita Diema Bougouni Yorosso
46.1%
64.1% 63.2%
50.0%
7.3%
5.1%
12.6%
5.9%
Obstacle financier
Obstacle socio
culturel

27. SEC qualitative study
(MCHIP)
• Low utilization – both financial and socio-
cultural factors
• Decision-making/care-seeking
• “Ownership” & community support
• Lack of consultation & community
engagement
• User preferences
• Erratic supervision
• Sexual harassment

28. iCCM critical challenges
• “Hardest skill set asked of CHWs”
• Performance/quality
• Supervision/mentoring
• Drug supply (child-friendly)
• Residence status
• Compensation/incentives
• Motivation/retention
• Pull toward work in health facilities
• Case load/competing packages
• Policy/practice barriers

29. Critical ingredients for
harmonization
• Government strategy & national level program
• MOH leadership
• Costed, budgeted, funded or supported by partners
• Viable community-based cadre (CHWs)
• Support from medical & other professional associations
• Technical working group at national level
• Partner coordination, especially in contexts of multiple
operational platforms
• Evidence base/best practices
• Community support & mobilization framework
• OR resources and engaged academic partners
• Broad consultation, inclusion, ownership

30. Thank you!