1. 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

2. the importance of communities for Health MDG’s
Micro-level:
Households/ Communities
Meso-level:
Health system & other sectors
Macro-Level: Policies and Financing
MDG outcomes
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
This slide shows a version of the “pathways” framework adapted from the HNP chapter for the PRSP Sourcebook.
The blue panel on the left-hand side of the slide has a box for HNP outcomes. As we move through the module, specific examples of HNP outcomes for the poor will be discussed, along with the risk factors associated with them. The examples will focus on outcomes related to maternal and child health and nutrition, for example low birth weight and maternal mortality.
The second (green) panel has boxes for household and community factors, including household behaviors and risk factors, household resources, and community factors. Solid lines link the main pathways through which these factors influence outcomes, and the dashed line adds some of the feedbacks and secondary linkages to be considered.
The brown and orange panels hold the boxes for factors in the health system/other sectors and for government policies and actions.
Community
Support
Protection of Household Revenue
access
Medium Term Expenditure Framework
Individual
(Clinical)
Care
availability

3. 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 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)

4. 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.

5. A Continuum of Care in Time and Place
Source: PMNCH ( accessed 30 September 2007

6. 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.

7. 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

8. 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.)
Note: These are countries with the current rate of at least 10% and an average annual rate of change of > 1% (except Rwanda)
Source: UNICEF global database, 2007

9. Ethiopia: scaling up ITN

10. Pourquoi accélérer pour l’ODM4
permet d’atteindre tous les ODMs relatifs à la santé

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

12. The Human Resource Challenge in Africa: 1
The Human Resource Challenge in Africa: 1. 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).

13. 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? 13

14. Definition of CBPHC
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) 14

15. Process 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 15

16. Community-Based Primary Health Care
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

17. Technical Interventions Criteria 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

18. Technical Interventions Priority 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

19. Technical Interventions Priority 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

20. Technical Interventions Interventions 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

21. Technical Interventions Interventions with indirect effects on child survival
Family planning
Adult HIV treatment
Maternal mortality reduction

22. Technical Interventions Messages 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

23. Community-Based Primary Health Care
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

24. Delivery System Elements
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

25. Delivery System Elements
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

26. Community-Based Primary Health Care
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

27. Community Empowerment How 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

28. Community Empowerment Areas 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

29. Community-Based Primary Health Care
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

30. Key Contextual Factors
Ecological
Epidemiological
Social/Cultural
Political
Economic
Education
International funding

31. Recommendations for Implementing CBPHC in Africa
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 31

32. Next Steps
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 32

33. CHILD SURVIVAL AND DEVELOPMENT:- 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

34. Services à base communautaire et familiale Situation de base
Matrones formées dans la majorité des villages
Insuffisant recours à la matrone - habitude socio-culturelle
Indisponibilité de kits pour accouchement propre au niveau des villages
Sous utilisation des matrones formées. Barrières culturelles, ignorance, qualité des prestations/accueil/ non connaissance des soins NNé
Genevieve

35. Services à base communautaire et familiale Situation de base
Matrones formées dans la majorité des villages
Insuffisant recours à la matrone - habitude socio-culturelle
Indisponibilité de kits pour accouchement propre au niveau des villages
Sous utilisation des matrones formées. Barrières culturelles, ignorance, qualité des prestations/accueil/ non connaissance des soins NNé
Genevieve

36. Services à base communautaire et familiale Phase 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%
Genevieve

37. Services à base communautaire et familiale Phase 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%
Genevieve
29,8%
29,8%

38. Services à base communautaire et familiale Phase 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%
Genevieve

39. Services orientés vers les populations Soins curatifs et préventifs de l’enfant Situation 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
Genevieve

40. Service orienté vers les populations Soins curatifs et préventifs de l’enfant Échéance 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%
Genevieve

41. Soins cliniques individuels Soins 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
Genevieve

42. Soins cliniques individuels Soins 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%
Genevieve

43. 2006: A regional JUMP START: Scaling up of key health nutrition and WASH evidence based effective interventions
World Press Photo 2005

44. Exclusive BF and BF+ water only in WCAR
< to to to to to to to to 23

45. Allaitement maternel exclusif ou Allaitement maternel avec eau (Source: dernières EDS –MICS)

46. Nutrition suggested activities for CS Jump Start
Exclusive breastfeeding for 6 months
Early initiation of breastfeeding (<1 hour after birth)
No prelactal foods, No water +++
Saves 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)

47. Why water 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
References for slide:
Handwashing with soap: Curtis & Cairncross, 2003; Fewtrell et al, 2005
Effectiveness of house-hold based water quality interventions to prevent endemic diarrhea: Clasen, T., Schmidt, W. (forthcoming 2006) – London School of Hygiene and Tropical Medicine
Effect of sanitation against diarrhea and latrine ownership: Esrey SA, Potash JB, Roberts L & Shiff C(1991)
Effect of handwashing on helminth and tracoma infections: Ensink, J., (forthcoming 2006) London School of Hygiene and Tropical Medicine

48. What we need to do
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
Include hand washing for mothers in the jump start
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

49. Integrated Immunization: EPI-VitA-ITNs
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)

50. Quelle meilleure contribution de l’UNICEF?
Renforcer les politiques, la législation, plans & budgets + espace budgétaire
Analyse de situation basée sur l’évidence
Couverture effective des interventions à haut impact
Atteindre l’ODM 4 et contribuer aux autres ODMs relatifs à la santé
Analyse de la situation, monitoring & Micro-planification
Facilitation de l’approche MBB
Action au niveau communautaire et stratégie avancée