Stakeholders’ consultation on Informal Service Providers Engaging informal providers in Bangladesh Stakeholders’ consultation on Informal Service Providers Organized by: CReNIEO Chennai in India 21-22 March 2014 Dr. Mahfuza Mousumi Project Manager, Health & Nutrition Save the Children, Bangladesh Email: mahfuza.mousumi@savethechildren.org

Presentation Outline Child health situation in Bangladesh CCM Project overview Village Doctors engagement experinaces Program results Lessons learned

Trends in under-5 child mortality in Bangladesh Deaths per 1,000 live-births MDG Target Source: BDHS 2011

Distribution of under-5 deaths in Bangladesh by causes of deaths: 2006-2011 Pneumonia Pneumonia Possible serious infection Source: BDHS 2011

Pneumonia Treatment Status (BDHS 2011) 50% care seeking for Pneumonia from drug stores and Village Doctors (VDs) 35% of children with symptoms of pneumonia were taken to health facility or a medically trained provider 79% of the children seeing a provider were prescribed antibiotics

Presentation Outline CCM Project overview

Project Information Implementation area: 17sub-districts in southern part of Bangladesh Target group : Children under five years of age (approx. 400,000) Duration : February 2012 to April 2014 Donor : Procter & Gamble

Improve access to quality services Project strategies MOH front line workers’ capacity strengthening Capacity building of VD & linkages with formal HS Community engagement and support mechanism Improve access to quality services Public/ formal Private/ informal Community groups

Presentation Outline Village Doctors engagement

Rationale for engagement Increase coverage of protocol Popular & common choice of population esp. among poor HHs Village resident, available 24/7 Drugs available at the clinic (provide drugs on easy installment) Conduct home visits

Initial considerations for VD engagement Process of VDs selection Training & skill retention Quality Assurance

Selection of Village Doctors Service mapping (identify gap areas) Consultation with community leaders to identify popular VDs for children U5, VDs association Live /practice in the targeted village Willingness to participate in training and treat children following national protocol Not involved in political activities

Who are the selected VDs? 75% of them completed 10th grade education Majority are between 30-50 years of age Most of them received 3-6 months course from private institution and also worked as assistant of a doctor or VD Nearly all operate a pharmacy

Capacity building & QA approach Revision of basic training manual specially for VDs in partnership with IMCI unit, MOH Adaptation of standard monitoring & supervision tools Conduct basic & refresher trainings by MOH sub-district level MTs; 298 VDs trained on CCM (3-day) and 281 currently active Provided essential supplies & job Aids -ARI timer, thermometer, chart booklet, treatment register, referral slips & tools. Supportive supervision- joint supervision with MOH supervisors

Presentation Outline Results

Number of cases treated by trained VDs Oct’12 to Dec’13

Key findings of Supervision Visit January to December 2013

Supervision Mechanism Post-training follow up visits: each VD supervised twice a month for initial 3 months followed by monthly supervisory visits Review register Direct observation/ case scenario Random HH visit of treated cases Joint supervision with MOH supervisors (98% of VDs received supervision visit in the last month)

Supervision Checklist

Presentation Outline Result: Key findings of Village Doctors assessment

Diagnosis and treatment of pneumonia Before training After training Only 35% used equipment (stethoscope/watch) for pneumonia diagnosis Diagnosis made based on symptoms Used higher antibiotic Count respiration rate using ARI timer Use simple antibiotic (amoxicillin) Referral of severe pneumonia cases

Availability of Supplies 92% of VDs have functional ARI Timer All VDs have functional thermometer IMCI Algorithm/chart is available with 97% VDs 96% of VDs are maintaining service registers

Drugs availability 98% of trained VDs are selling amoxicillin of recommended brands ORS and Zinc are also available in their pharmacy

VDs attitude and practices around referral Before training After training Almost absent among VDs Perceived as unskilled and incapable Financial disincentive of people seeking treatment elsewhere Giving preference to treatment protocol over business motive Refer sick children following protocol rather than doing trial and error

Referral linkage with MOH 91% of VDs are using referral slips 97% of VDs referred sick children to near by appropriate MoH facility 88% severe/danger sign 24% diarrhea with severe dehydration 15% sick newborn 76% of VDs have mechanisms to ensure quality services/follow up

Lessons learned Low profit margin and slow recovery of treated cases with amoxicillin is a challenge for following standard treatment protocol Refresher training, review meeting and supportive supervision are effective ways for ensuring quality and maintain motivation Joint supervision with MOH staff supports establishment of linkage with formal health system; adding VD treated cases in national HMIS CCM projects created scopes for VDs engaging in other child health interventions by government & non-government programs.

Next steps Preliminary results/experiences are promising. VDs are following protocol & maintaining guideline and referring severe cases SC wants to expand this to additional VDs and conduct research to identify what is needed to enhance quality of pneumonia treatment by informal providers at scale

Thank You