Laura Altobelli makes a point.

Laura Altobelli’s Presentation 1 CLAS & decentralization
(click to view and/or download).
 
Laura Altobelli’s Presentation 2 Nexos Project (click to view and/or download).
 
Linking Communities and Local Government to Reduce Maternal and Child Mortality in Rajshahi District, Bangladesh (Samim Jahan, Concern World-wide, Bangladesh)
 

This program is conducting an intervention working with city governments. It’s focus is on child survival and is expanding from 2 to 9 cities in Rajshahi District. Local forums facilitate learning and exchange across municipalities. Providing services to the poor is an important focus. Key stakeholders include elected city leaders, governmental and private health facilities, private pharmacists, youth volunteers, teachers, traditional providers, community organizations, and social and religious leaders. These stakeholders are brought together in 75 Ward Committees who meet monthly to create and review progress towards goals set out in an annual plan.

Several cases were presented about the ways the project worked with different politicians. Initially the politicians were not supportive of the program, but became champions as they learned about the community mobilization effort. In one, the program presented critical leaders with results of a community capacity assessment that demonstrated how their area lagged behind other areas. Another politician took the lead in forming a Ward Health Committee.

Key motivating factors for politicians include: considering health to be a priority and a right, becoming aware of the burden of maternal and child disease and mortality, seeing a connection between their active involvement in the Ward Health Committees, mutual trust and relationships with the program staff.  Politicians had more difficulty participating because of the intangible nature of health outcomes, the long time required to achieve health impact, difficulty visualizing the health infrastructure, the inflexibility of planned programs, the time taken away from business, the political conflict between parties, and corruption.

This project has had success in: reviewing and educating elected leaders about their roles and responsibilities in health, systematic comparisons with other municipalities, the joint assessment of the health status in the working areas, the impact of informal discussions leading to an understanding of the politician’s perspective, the assessments of local capacity, and the impact of events build around culture and the arts.

The program has resulted in governmental funding of Ward Health Committee offices, by-laws detailing roles and responsibilities of most of the Ward Health Committees, identification of high-risk individuals by community health workers, and committee involvement in providing of services to the underserved.

This project recommends other localities be patient in seeing the results of actions, active seeking-out of alternative champions if the leader is not ready, consistent messages, use of appreciative inquiry and positive perspectives, development of realistic plans and expectations, and beginning the problem-solving from the local level – only extending to the politicians when the community is ready.

Samim Janan enjoys the coffee Jean Capps had provided.  

Samim Jahan’s Presentation (click to view and/or download).

Taking Aim at High Maternal and Newborn Mortality in Low Resource Settings

Establishing a National Community Health Worker Training Program in Post-Taliban Afghanistan (Ian Aitken, Management Sciences for Health, Boston)

This presentation described a large USAID funded project with multiple collaborators that eventually reached 7.5 million people in 13 provinces (1/3 of the population) costing $138 million over 3 years. It’s challenge was “how to make best use of resources to establish an effective and sustainable health system in 2 ½ years in post-conflict Afghanistan.”

Infant, newborn, and maternal mortality rates are among the highest in the world. Women of child-bearing age have almost a 1 in 7 lifetime risk of death from childbirth. The rural isolated communities of Afghanistan have difficulty accessing care, especially during the 4-6 months of winter. In 2002, only 7% of the populations had access to a health facility, but only 21% of the facilities had female staff.  By the end of the project, approximately 60% of the facilities had female staff.  This also restricts access of children to care because women take the children for care.

The Ministry of Public Health set its policy through the Basic Package of Health Services, first in 2003 and revised in 2005. A Community Health Worker Policy in June 2003 proposed 50% female workers serving 100-150 households each. The CHWs had low literacy. Training was implemented in three phases, 3 weeks of training with 2 months field practice: disease control and home hygiene, family planning and birth spacing, and childhood illness.

CHWs were shown to be effective, with more births attended by skilled attendants, receiving prenatal and postnatal care, and receiving tetanus toxoid injections. Contraceptive knowledge and practice improved (doubling the four-fold increase of the facilities), as did immunization and care-seeking behavior. The CHWs treated more cases of Acute Respiratory Infections and Diarrhea than the health facilities and did appropriate referrals (five-fold).

While shown to be effective in the short run, the sustainability of the CHW was also addressed. Pictorial health records and reference materials were utilized, supplemented by posters. CHWs prepared community maps for monitoring villagers, cases, and risk factors. The maps became a tool for communicating with leaders. CHWs were supported by village health committees which eventually covered 85% of the villages, 25% of the committees had female membership. Education of the health facility staff about the CHW and system was achieved using the “fully functional health service facility” tool which contains 9 performance standards. A system of CHW supervisors was developed utilizing community members with high school education and specialized training.

The overall system was developed as collaboration between the health facility and the community.

 Iain Aitken answers a question or three.

No presentation available at this stage due to multiplicity of organizations involved.

Village-level Operations Research on Causes of Maternal and Newborn Mortality in Rural Afghanistan (Carl Taylor, Future Generations and Johns Hopkins Bloomberg School of Public Health)

Henry Perry, Iain Aitken and Carl Taylor reminiscing 

Carl Taylor’s main message was “a message of hope” for dealing with the most serious problems of the underserved areas. Future Generations recognized that the USAID/BPHS/REACH program as it adapted to the villages would have gaps. Two years of interviewing identified that the women of the villages knew what they wanted. By “listening to the people”, they adapted almost complete coverage of families in the villages. A focus on changes in behavior and social norms were associated with locally adapted efforts to measure women’s empowerments. Key lesson was not just what was done, but how it was done.

Different categories of community workers were involved: the respected mature women who were CHWs, the Women’s Action Groups composed of mothers with young children who are the busiest, and the Community Statisticians who helped with data collection, interpretation, and communication. Five-day “women only workshops” provided training in hygiene, pregnancy, and childhood illness care. Discussions of Pregnancy Histories led to intensive discussions, which covered a high percentage of the topics in the BPHS curriculum. Following the trainings, the CHWs formed Women’s Action Groups who met monthly as forums for discussion and education of village women. The Community Statisticians ensured community ownership of their own statistics, which are also utilized by the governmental health information systems. The best performing villages in a region become learning centers for the areas around them. Action-Learning and Experimentation by local experts enables adaptation and integration of local findings into on-going sustainable programs.

As a result of the interaction between the five interventions described above, there were very high levels of trust and empowerment. CHWs became actively engaged in their learning. They identified local barriers and developed unique solutions. Major changes were seen in six to 9 months of the project, especially in the attitudes and behaviors impacting maternal and child mortality. The intensive, locally empowering methodology achieved similar impacts to the standard USAID/BPHS/REACH program in remote areas, with less funding, and where there is a higher morbidity and mortality.

Carl Taylor in deep thought

Carl Taylor’s Presentation (click to view and/or download).

Increasing Skilled Deliveries through Community-Based Financing in Northern Guinea (Eric Swedberg, Child Health Advisor, Save the Children)

Presentation focused on the transportation to access for appropriate care one of many interventions addressed by the program. To address this problem, a community risk-sharing or health insurance scheme was developed to cover costs. Two hundred and thirteen Village Health Committees were formally organized and officially chartered. They were then trained in community-based life-saving skills. A total of 73 + 60 + 50 mutual funds were established for the system. Agreements were signed between the VHCs and District Hospitals, as well as between the VHCs and the local Transport Union (taxi system).

Each village established funds that collected individual membership cards costing between ten and twenty-five cents, valid for five years, and a monthly fee of 5 to 10 cents per month for each woman of child-bearing age. Five committee members managed the funds and negotiated agreements. To access funds, the health worker or trained traditional birth attendants would decide to refer, with allowances for the uninsured. As the fund demonstrated success and financial viability, the committees shifted from 100% reimbursement of funds paid to 50-95% repayment. In parallel, health centers were equipped with radios, a new maternity block at a district hospital, and training for health workers, traditional birth attendants, and community members.

Village Health Committees were empowered to, and did, investigate over-charging and recaptured funds. By the end of the project 88% were attended by trained personnel, compared with 46% at the beginning. Referrals increased and maternal deaths decreased. Communities tracked their own child and maternal mortality, which progressively decreased.

Success came from the active involvement of community organizations, local leaderships, and making them responsible for the fund disbursement. The project overcame the absence of a bank and the lack of vehicles. Expansion is proposed to other areas, other adult illnesses, and formation of sub-regional associations.

Eric Swedberg’s  Presentation (click to view and/or download).

CBPHC and Orphans and Vulnerable Children Affected by HIV/AIDS in Africa

Nancy Bryant in action

Addressing the Well-Being of Orphans and Vulnerable Children in Africa: New Challenges to CBPHC (Jack and Nancy Bryant, Tropical Institute for Community Health and Development, Kisumu Kenya)

The Bryants presented the disturbing impact of HIV/AIDS on children through loss of one or both parents. Prior gains in life expectancy are being dramatically reversed in Sub-Saharan Africa. Poverty, poor hygiene, and crowding worsen the impact of HIV/AIDS.

The Tropical Institute for Community Health has an integrated training program emphasizing ethical approaches to achieving the Millennium Development Goals. Based on work with UN Habitat, the TICH has developed a “Masters Degree on OVC of Africa.” The Bryants used a Fulbright Fellowship to develop training and interventions on OVC.

The slums have previously been considered illegal, but are now the focus of governmental redevelopment efforts. A UN Habitat team had been doing a quality socio-economic study of slum communities. A health committee was formed in Old Mlolongo, Kenya, with members who had been doing home-based care for HIV/AIDS patients. One (of many challenges) was to address HIV/AIDS and OVC care in areas where there were no systems of health care. Concerns identified and prioritized were: under-nourishment, immunization, micro-nutrient deficiencies, insecticide treated bed nets, and care. Given the lack of resources, the goal was to develop the community’s own resources. The rich cultural traditions emphasizing care of children is being eroded by the HIV/AIDS epidemic.

However, the science of early childhood development has rapidly evolved in the last few decades. How can the findings be applied to interventions with OVC in Sub-Saharan Africa? Research on the child-caregiver interaction was utilized, not to emphasize the caregiver bringing the child to professional services, but the direct impact of the child-caregiver relationship in allowing the child to thrive and survive. These factors were utilized in designing a workshop which included parents and children.

Following formal presentations, workshop participants made recommendations to the health committee. The social and environmental challenges posed by the trucking industry were addressed. The health committee began with growth monitoring on 400 children (30% had malnutrition). A visiting nurse provided immunizations at clinics organized by the health committee. Hand-washing 3-4 times a day is inexpensive, but insecticide treated bed nets and nutritional supplements have associated costs. Education about nurturing, loving, protective, and supportive child-caregiver interactions was given by the health committee in the community. Child neglect was framed as “unseen inequities.” The health committee began scoring the households about the secure or insecure attachments. Collaborative tool development required cultural sensitivity and was led by the community.

The project was funded entirely by $2,500 from the Bryants’ Fulbright Fellowship and the remaining $500 was left to help the committee extend their project to other communities. Collaborative research is now engaging experts, driven by the community’s initial understanding.

Jack Bryant contemplates a question

Jack and Nancy Bryant’s Presentation (click to view and/or download).

Small Group Work

 Half the participants in action.

The other half is also captivated.

The task:

Each group is a special task force that has been requested to use what they have learned from today’s presentations as well as their own experiences to develop a plan to spend several million dollars to make a positive impact on at least one of the health MDGs. (It is presumed that poverty reduction will be addressed with other funding.) The proposed program’s activities impacts should be measurable. The group should list the top three priority actions they would take to implement their plan. The priorities derived by the 6 small groups formed are listed below.

Group 1

To reduce child mortality

Achieved by creating Networks of Community Actors

1.    Learning exchanges (community visits to exemplary 

       centers, incentives for

2.    Incentives / support systems to stimulate these

       networks

3.    Data systems to demonstrate success

Group 2

To decrease maternal mortality

1.    Educate community health workers, TBA’s

2.    Improve accessibility through community cost-

       sharing scheme for transportation to specialized

       services

3.    Improve quality of services at health center (staff,

       infrastructure, continuing education, etc)

Group 3

To reduce child mortality

1.    25% training community health workers who are

       locally supported

2.    15% supplies, equipment, transportation & teaching

       materials

3.    15% district and regional level training support and

       motivation & links with political leaders

4.    10% ministry, national and political level policy

       changes to support CHW

5.    10% universities and schools about who CHWs are,

       what they need, etc so the CHW are not seen as

       rivals

6.    10% monitoring, research and evaluation

7.    15% technical assistance for national and

       international

Group 4

To reduce maternal mortality

1.    Operational Health Care Systems that can manage  

       obstetrical emergencies (ambulance, operating room,

       medical professionals)

2.    Community Infrastructures (CHWs, supplies, prenatal

       care, resource mobilization, family planning,

       education)

3.    Mechanisms for making health services accountable

Group 5

To reduce child mortality, beginning with a resource assessment

1.    Income generation and micro-credit schemes

2.    Train community members in the use of mosquito

       nets, etc

3.    Train community members in child health

Group 6

Allow community to decide the goal. Assumed interventions will be through district management of about 2 million people.

        1.    Community empowerment to identify the community’s

               needs and resources

2.   Support systems for CBPHC and Village Development 

      Committees

3.   Maternal, Neonatal & young child health promotion 

      (home-based care)

Commentary by panelists and participants

The presenters comment on the group presentations.

• Carl Taylor was impressed by the community focus the groups demonstrated. This is progress in our mindset.
• Jim Grant used to say he believed in community work, but the challenge is to “show you can scale it up.”
• Iain Aitken. Maternal mortality remains one of the areas where are seeing the least gains. In the last years, have seen a variety of interventions. But maternal mortality reduction is the result of a system of care.  Training people outside of the community to learn fails because communities change because social norms change. Therefore, groups of women need to engage on the key issues.
• Iain Aitken believes quality of care at health centers is important. The health facilities need to be accountable to the community for the quality of care provided.
• JC pointed out that groups did not put money into technological research, but rather into the operations research where there was real science.
• John Bryant. Jeffery Sacks’ expert committees developed strategies for achieving MDGs and summarized as “Steps for achieving the MDG’s.” Today’s CBPHC groups’ recommendations came from the bottom-up rather then the top-down approach from Sacks’ report.
• Women’s empowerment is essential to the process.
• Donors need visibility and numbers to sustain their funding.
• “How” requires demonstrations in more than a few villages, but in a larger system.
• On the other hand, working with big numbers can hide latent disparities in the data.
• As you empower women and men loose control, sometimes violence worsens. Men need very specific interventions.
• The Global Health Education … has many training modules to share.
• Health outcomes may actually be best achieved by working on non-health risk factors.
• “P, D, & L” are Program Design and Learning has replaced “M & E” Monitoring and Evaluation.
• What are the trade-offs from being perfect in proving impact vs. the empowerment necessary to achieve it?
• Child survival evaluation used Bellagio calculator to estimate number of lives saved. Demonstrated that community interventions had most impact. Community empowerment was the most effective.

Henry Taylor.  Thank you for the notes!

 A joyful group of participants after the workshop’s successful completion.

Next year, the workshop will focus on the findings of our review of the evidence supporting Community-based Primary Health Care. This workshop should also be exciting-see our links on this study and on the recent UNICEF All Africa meeting in Senegal.