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Community partnerships for health related MDG’s. Conclusions of The State of the World’s Children 2008 and Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health. Meso-level: Health system & other sectors. Macro-Level: Policies and Financing.

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Community partnerships for health related MDG’s

Conclusions of The State of the World’s Children 2008 and Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health


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Meso-level:

Health system & other sectors

Macro-Level: Policies and Financing

Micro-level:

Households/ Communities

the importance of communities for Health MDG’s

MDGoutcomes

Family/

Community

level Care

MDG focused + Child friendly:

MDGs :

U5MR

MMR

Malnut.

Malaria

HIV/TB

National Health- Nutrition Policy

Efficacy

Family

behaviors

Population

oriented

(outreach)

services

PRSP

quality

SWAP

compliance

Budget Support

utilisation

Community

Support

Protection of Household Revenue

access

Medium Term Expenditure Framework

Individual

(Clinical)

Care

availability


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The Bamako Initiative

  • Launched by African health Ministers in 1987

  • Built on 5 years operations research in Benin (Pahou) and Congo (Kasongo)

  • Community movement: Community co-managed, cost shared and monitored revitalization of 10.000 health centers with drug revolving funds

  • Community Based National Health Systems in Benin, Guinea, Mali, DR Congo, Guinea Bissau

  • Benin Immmization Coverage from 12% in 1986 to 75 % in 1990 and fully sustained since then

  • Resiliance demonstrated during Togo, DR Congo, Guinea Bissau and other crisis

  • Foundation for success of ACSD (10-20% U5MR reduction for $ 500/life saved)


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Lessons Learned from a hundred years

  • Scaling-up will not be achieved through facility-based and outreach services alone: Community Partnerships are central to achieving coverage, creating demand and achieving sustainability.

  • Ensuring a continuum of care by delivering integrated packages of health, nutrition, HIV, water and sanitation interventions will be critical to achieving maximal impact on maternal, newborn and child survival.

  • Strengthening of ‘health-systems for outcomes’ combines the strength of selective/vertical approaches and comprehensive/horizontal approaches to scaling up evidence-based, high-impact intervention packages and practices, while removing system-wide bottlenecks to health care provision and usage.


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A Continuum of Care in Time and Place

Source: PMNCH (www.who.int/pmnch/about/continuum_of_care/en/index.htm), accessed 30 September 2007


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Community partnerships in PHC: Ways of enhancing success

  • Cohesive, inclusive participation;

  • Support and incentives for workers;

  • Adequate programme supervision and support;

  • Effective referral systems to facility-based care;

  • Intersectoral collaboration;

  • Secure financing; and

  • Integration of community partnerships with district and national health programmes and policies.


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Scaling up community partnerships, a continuum of care, health systems for outcomes

  • Realign programmes from disease –specific interventions to evidence-based, high-impact, integrated packages to ensure a continuum of care

  • Make MNCH a central tenet of integrated results based national planning processes for scaling up

  • Improve the quality and consistency of financing for strengthening health systems

  • Foster and sustain political commitments, national and international leadership an sustained financing to develop health systems

  • Create conditions for greater harmonization of global health programmes and partnerships


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Striking increases in exclusive breastfeeding in 16 Sub-Saharan African countries

Seven Sub-Saharan African countries have achieved increases of more than 20 percentage points over the past 15 years.

Infants exclusively breastfed (< 6 mos.)

Source: UNICEF global database, 2007


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Pourquoi accélérer pour l’ODM4 Sub-Saharan African countries

permet d’atteindre tous les ODMs relatifs à la santé


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Full Minimum Package at scale: 30% U5MR, 15% MMR, NNMR reduction for $ 800 per life saved


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The Human Resource Challenge in Africa: reduction1. On the job training of 300,000 community health promoters and health extension workers;2. Pre-service training and (re) deployment of 300,000 additional health professionals;3. Improved productivity of existing health staff resulting in over 700,000 additional Full Time Equivalents (FTE).


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Systematic Review of the Effectiveness of Community-Based Primary Health Care in Improving Child Health

Key Questions

How strong is the evidence that CBPHC can improve child health?

What conditions/program elements must be in place for CBPHC to be effective?

How important are partnerships between communities and health systems?

Does CBPHC promote equity and is it cost-effective?


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Definition of CBPHC Primary Health Care in Improving Child Health

Activities, interventions, programs that take place in the community outside of health facilities

Includes selective and comprehensive approaches

Includes non-health interventions (e.g., micro-credit, education, women’s empowerment, societal factors)


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Process Primary Health Care in Improving Child Health

Review of available documentation

Peer-reviewed journal articles

Books

Program evaluations

Unpublished reports

Data extraction-2 independent reviewers

Special focus on community context and community partnerships


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Community-Based Primary Health Care Primary Health Care in Improving Child Health

Contextual Analysis and Implementation Framework

Contextual factors:

(external resources and support, political factors, social capital, functionality of health system, country laws, cultural issues, intracountry inequities, mortality setting, disease epidemiology, opportunities for education, women’s status, strength of medical professional lobby, etc.)

Delivery System

Health Outcomes

Technical Interventions

Community Empowerment


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Technical Interventions Primary Health Care in Improving Child HealthCriteria for defining priority effective interventions

  • Safety demonstrated

  • Shown to have mortality or nutrition improvement efficacy

  • Programmatic experience exists

  • Feasibility of or experience with reaching high coverage


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Technical Interventions Primary Health Care in Improving Child HealthPriority child survival interventions for scale up

  • Immunizations for mothers and children

  • Vitamin A supplementation

  • Iodine fortification and supplementation when necessary

  • Home-based neonatal care including neonatal sepsis management

  • Clean delivery

  • Hand-washing

  • Household water treatment and safe storage

  • Sanitation

  • ORT and zinc for diarrhea treatment

  • Childhood pneumonia treatment

  • Prevention of mother-to-child transmission of HIV

  • Cotrimoxazole prophylaxis for HIV-infected children


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Technical Interventions Primary Health Care in Improving Child HealthPriority child survival interventions for scale up

  • Insecticide-treated materials and/or indoor residual spraying for malaria

  • Malaria treatment

  • Intermittent preventive therapy for malaria for pregnant women

  • Exclusive breastfeeding promotion for first 6 months

  • Continued breastfeeding promotion until at least 24 months

  • Ready to use therapeutic foods for severely malnourished children

  • Promotion of complementary feeding for children focused on 6 to 23 months

  • Supplementary feeding for food-insecure families focused on 6 to 23 months


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Technical Interventions Primary Health Care in Improving Child HealthInterventions with more evidence needed for effectiveness, safety or feasibility of scale up

  • Congenital syphilis prevention

  • Prophylactic supplemental zinc

  • Prenatal calcium

  • Detection and treatment of asymptomatic bacteriuria

  • Umbilical cord topical antiseptic

  • Newborn antiseptic skin cleansing

  • Neonatal resuscitation and airway management

  • Household smoke reduction with improved cooking stoves


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Technical Interventions Primary Health Care in Improving Child HealthInterventions with indirect effects on child survival

  • Family planning

  • Adult HIV treatment

  • Maternal mortality reduction


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Technical Interventions Primary Health Care in Improving Child HealthMessages regarding effective interventions

  • Effectiveness and scale up depend on delivery systems, community involvement and local context

  • Although community engagement is ideal, interventions’ dependence on this is variable

  • Community engagement promotes scale up and sustainability

  • Integrated packages not investigated as well as single interventions


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Community-Based Primary Health Care Primary Health Care in Improving Child Health

Contextual Analysis and Implementation Framework

Contextual factors:

(external resources and support, political factors, social capital, functionality of health system, country laws, cultural issues, intracountry inequities, mortality setting, disease epidemiology, opportunities for education, women’s status, strength of medical professional lobby, etc.)

Delivery System

Health Outcomes

Technical Interventions

Community Empowerment


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Delivery System Elements Primary Health Care in Improving Child Health

  • Integration of services at community level

  • Foundation of values and power shifting

  • Peer neighborhood volunteer

  • Multi-purpose community health worker

    • Incentives: monetary, material, other

    • Facility outreach vs. community-based

  • Community-based organization for health

  • Community generation and use of health data

  • Bi-directional linkage to national health system

    • Accountability of health system

  • Bi-directional information and communication

  • Respectful, collaborative delivery system culture

  • Equitable service delivery


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Delivery System Elements Primary Health Care in Improving Child Health

  • Coordination of formal and traditional health sectors

  • Appropriate service provision intensity

    • Workload of community health workers

    • Number of tasks, number of and distance to homes

  • Processes to shift power locus to communities

    • Work with women, microcredit, conditional cash transfer

  • Communication technology – e.g., mobile phones

  • Training of community health workers

  • Supportive supervision of CHWs linked to PHC level

  • Supplies for service delivery

  • Adequate global and national financing

  • Monitoring of CBPHC program

  • Authority for lay persons to perform health tasks


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Community-Based Primary Health Care Primary Health Care in Improving Child Health

Contextual Analysis and Implementation Framework

Contextual factors:

(external resources and support, political factors, social capital, functionality of health system, country laws, cultural issues, intracountry inequities, mortality setting, disease epidemiology, opportunities for education, women’s status, strength of medical professional lobby, etc.)

Delivery System

Health Outcomes

Technical Interventions

Community Empowerment


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Community Empowerment Primary Health Care in Improving Child HealthHow community-driven is the strategy?

  • Community as a resource vs. target

  • Community vs. external priority setting

  • Degree of community involvement

    • Ownership

    • Decision-making power

    • Management

    • Consultation

    • Influence

    • Buy-in

    • Passive recipient


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Community Empowerment Primary Health Care in Improving Child HealthAreas requiring community involvement

  • Leadership

  • Planning and management

  • Women

  • Community management of external resources

  • Monitoring and evaluation

    _________________________

  • Local context

  • Value system

  • Delivery of services in community

  • Bundle of delivery systems and technical interventions


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Community-Based Primary Health Care Primary Health Care in Improving Child Health

Contextual Analysis and Implementation Framework

Contextual factors:

(external resources and support, political factors, social capital, functionality of health system, country laws, cultural issues, intracountry inequities, mortality setting, disease epidemiology, opportunities for education, women’s status, strength of medical professional lobby, etc.)

Delivery System

Health Outcomes

Technical Interventions

Community Empowerment


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Key Contextual Factors Primary Health Care in Improving Child Health

Ecological

Epidemiological

Social/Cultural

Political

Economic

Education

International funding


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Recommendations for Implementing CBPHC in Africa Primary Health Care in Improving Child Health

1. “There is no universal solution, but there is a universal process to find appropriate local solutions.” Carl Taylor

2. Invest in promising CBPHC approaches and field sites, start small, and be willing to help them go to scale within a framework of rigorous evaluation and operations research that demonstrates effectiveness in reducing under-five mortality

3. Look for and support promising young leaders who have a passion for CBPHC or who have the potential for becoming passionate leaders of CBPHC

4. Support opportunities for program leaders to visit and learn from successful experiences – build on success

5. Plan at the outset for long-term sustainability and for the supportive “human” infrastructure required for CBPHC (supervision, training, M&E)

6. Make under-five mortality in defined geographic areas the key outcome indicator and build it into ongoing program operations


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Next Steps Primary Health Care in Improving Child Health

Forceful statement SOON from the Expert Review Panel to the world (via Lancet?) – building on the review but moving beyond it

Early completion of the review as originally envisioned

Incorporation of suggestions and recommendation of the Expert Review Panel and others into final report

Broad dissemination of findings


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CHILD SURVIVAL AND DEVELOPMENT:- Primary Health Care in Improving Child Health

ACHIEVING MDG 4

Scaling up

High Impact

Population-

Based

Interventions

Improving family

and Community

Care practices

Feeding Practices,

Sleeping under ITNs,

ORT, Hygiene &

Sanitation,

Early care

seeking

ITNs,

Immunisation,

New ORS,

Vitamin A,

Antibiotics for

Pneumonia,

Deworming

Community Capacity Development:-

Social Change Communication, CIMCI, Outreach Support

Health System Support:- Facility-Based IMCI, EPI+, ANC+, EmOC, PMTCT, Paediatric AIDS

Access to Safe & Clean Water, Intersectoral Linkages (Education HIV/AIDS), Household Food Security

Moving Upstream:- Evidence-Based Advocacy, Leverage of Resources, SWAPS/Govt. Budget/PRSPS, Policy Dialogue


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Services à base communautaire et familiale Primary Health Care in Improving Child Health Situation de base

Matrones formées dans la majorité des villages

Insuffisant recours à la matrone - habitude socio-culturelle

Sous utilisation des matrones formées. Barrières culturelles, ignorance, qualité des prestations/accueil/ non connaissance des soins NNé

Indisponibilité de kits pour accouchement propre au niveau des villages


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Services à base communautaire et familiale Primary Health Care in Improving Child Health Situation de base

Matrones formées dans la majorité des villages

Insuffisant recours à la matrone - habitude socio-culturelle

Sous utilisation des matrones formées. Barrières culturelles, ignorance, qualité des prestations/accueil/ non connaissance des soins NNé

Indisponibilité de kits pour accouchement propre au niveau des villages


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Services à base communautaire et familiale Primary Health Care in Improving Child HealthPhase 1: 2008-2010

Approvisionnement en kits d’accouchements et distribution gratuite lors de la CPN

Lever les barrières culturelles et d’ignorance : IEC/CCC, supervision des matrones pour améliorer la qualité/accueil des prestations à domicile

85,0%

63,9%

53,3%

29,8%

29,8%


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Services à base communautaire et familiale Primary Health Care in Improving Child HealthPhase 2: 2011-2012

IEC/CCC, améliorer la qualité accts à domicile, promouvoir la participation communautaire dans la gestion des services, promouvoir la référence pour acct assisté au CSI

85,0%

63,9%

53,3%

37,1%

37,1%

29,8%

29,8%


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Services à base communautaire et familiale Primary Health Care in Improving Child HealthPhase 3: 2013-2015

IEC/CCC, améliorer la qualité accts à domicile, promouvoir la participation communautaire dans la gestion des services, promouvoir la référence pour acct assisté au CSI

85,0%

63,9%

53,3%

44,4%

44,4%

37,1%

37,1%


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Services orientés vers les populations Primary Health Care in Improving Child HealthSoins curatifs et préventifs de l’enfantSituation de base

Faible disponibilité et inégale répartition des RH, refus à la décentralisation

Rupture de stock de vaccins

Barrières géographiques financières et culturelles. Insuffisance de la mobilité sociale, qualité des prestations/accueil


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Service orienté vers les populations Primary Health Care in Improving Child HealthSoins curatifs et préventifs de l’enfantÉchéance 2015

Formation initiale,

Recrutement,

Redéploiement,

Prime / motivation

Plan d’approvisionnement et gestion des stocks

Atteindre chaque enfant, Améliorer la qualité des prestations/accueil, IEC/CCC, engagement communautés

96,0%

96,0%

94,7%

90,1%

90,1%

68,0%


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Soins cliniques individuels Primary Health Care in Improving Child HealthSoins curatifs au niveau des CSI 2

Situation de base

Barrières financières, physiques, ignorance

Insuffisance et pb répartition RH, Manque de personnels formés

Coûts élevés prestations, faible qualité des services/ accueil


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Soins cliniques individuels Primary Health Care in Improving Child HealthSoins curatifs au niveau des CSI 2

Échéance 2015

Formation recyclage Redéploiement des agents

Supervision/ formation PCIME → Qualité accueil/prestation

95%

Case santé → CSI 1 CSI 1 → CSI 2

Dévpt PCIME ds cursus de formation

79%

78%

71%

69%

59%


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2006: A regional JUMP START: Primary Health Care in Improving Child HealthScaling up of key health nutrition and WASH evidence based effective interventions

World Press Photo 2005


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Exclusive BF and BF+ water only in WCAR Primary Health Care in Improving Child Health

<2 2 to 3 4 to 5 6 to 7 8 to 9 10 to 11 12 to 15 16 to 19 20 to 23


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Allaitement maternel exclusif Primary Health Care in Improving Child Healthou Allaitement maternel avec eau(Source: dernières EDS –MICS)


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Nutrition suggested activities for CS Jump Start Primary Health Care in Improving Child Health

  • Exclusive breastfeedingfor 6 months

    • Early initiation of breastfeeding (<1 hour after birth)

    • No prelactal foods, No water +++

    • Saves 225.000 children’s lives per year

  • Vitamin A and Deworming

  • Management of acute severe undernutrition in children 6-59 mo

    • Treatment and prevention

    • Through facility-based and community-based programs

    • For the same communities and at the same time (including urban)

      →Support countries in the development of national protocols

      → Support regional & national training workshops for capacity building

      → Ensure pipeline of uninterrupted supplies (therapeutic and

      supplementary foods and non food items)


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Why Primary Health Care in Improving Child Healthwater and sanitation matter to the jump start

  • Improved household water quality helps prevent endemic diarrhoea: cholera

    Latrine ownership potentially reduces diarrhea disease by an average of 36%

  • Handwashing with soap can

    • Significantly reduce the risk of diarrhea > 46%

    • Can save 0.5 – 1.4 million deaths a year

    • Impacts on helminth and eye infections, especially trachoma

    • Key in the fight against avian flu


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What we need to do Primary Health Care in Improving Child Health

Include hand washing for mothers in the jump start

BUT

At the same time make sure WASH in the CO programme is looking at water point and sanitation (latrine) coverage – MGD 7, target 10

Doing one without the other makes no long term sense: read the WASH strategy

This requires ‘at scale’ communication programmes

Should not necessarily be WASH sector driven but integrated in to our health and nutrition entry points

Work with academic institutions/NGOs to assist with rapid baseline behaviour assessments and conduct surveys for compliance (behaviour change)

RO is working on guidelines for communication strategies


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Integrated Immunization: EPI-VitA-ITNs Primary Health Care in Improving Child Health

  • Increase routine immunization coverage for all antigens (including TT 2+) in all districts by 10 points

  • Ensure the second dose of measles vaccine for all children (routine and SIA)

  • Integrate vitamin A supplementation within routine immunization

  • Integrate ITNs distribution and promotion of its utilization within routine immunization

  • Introduction in EPI of new and underused vaccines in all countries ( YF , HepB , Hib)


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Quelle meilleure contribution de l’UNICEF? Primary Health Care in Improving Child Health

Renforcer les politiques, la législation, plans & budgets + espace budgétaire

Facilitation de l’approche MBB

Action au niveau communautaire et stratégie avancée

Atteindre l’ODM 4 et contribuer aux autres ODMs relatifs à la santé

Analyse de situation basée sur l’évidence

Couverture effective des interventions à haut impact

Analyse de la situation, monitoring & Micro-planification


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