Community System Strengthening as a building block of. Health System Strengthening: Experience from Ethiopia and Myanmar. Kerry Bruce, DrPH. Shirley Ko ...
Community System Strengthening as a building block of Health System Strengthening: Experience from Ethiopia and Myanmar Kerry Bruce, DrPH Shirley Ko, MSc
Presenter Disclosures Kerry Bruce, DrPH The following personal financial relaEonships with commercial interests relevant to this presentaEon existed during the past 12 months No relaEonships to disclose
Is the Community Part of Health System Strengthening Approaches? 2010/2014 Community System Strengthening
2007 Everybody’s Business
2008 Primary Health Care – Now more than ever
Community System Strengthening 1. Enabling environments and advocacy 2. Community networks, linkages and coordinaEon 3. Resources and capacity building 4. Community acEviEes and service delivery 5. OrganizaEonal and leadership strengthening 6. M&E
Ethiopia Yekokeb Berhan Program for Highly Vulnerable Children (HVC) Funded by USAID/PEPFAR 2011-‐2016
Ethiopia – Key CSS IntervenEons Enabling environments & advocacy
• •
Community networks, linkages, partnerships & coordinaEon
•
Resources & capacity building
•
• •
• Community acEviEes and service delivery
• • •
OrganizaEonal and leadership strengthening
•
M&E and planning
• •
•
DisseminaEon and orientaEon of NaEonal OVC Standard Service Delivery Guidelines NaEonal child well-‐being data management system to support policy decisions Referral network with follow-‐up and feedback loops between public/private health faciliEes and community actors – formalized via MOUs Mapping, guidelines, protocols and tools for systemaEze referrals Established mechanisms and standards to harmonize coordinaEon of care Support to CSOs and government in supervision, training and support to 20,000+ local community volunteers CSO grants and local resources mobilizaEon Standards-‐based assessment, idenEficaEon, referral and follow-‐up of HVC to care, treatment and support services PromoEon of HCT to idenEfy HIV posiEve children and caregivers Coordinated support in educaEon, economic strengthening, psychosocial support, food and nutriEon, and legal protecEon Capacity assessments of CSO implemenEng partners, government and community structures – e.g., Community Capacity Barometer Coaching, mentoring of CSOs, community structures, volunteers Mechanisms, standard tools, database to collect HVC data at household level Strengthening regular program data review meeEngs at all levels – with community members and volunteers, government partners
COORDINATION BETWEEN COMMUNITY & HEALTH SYSTEMS Expected Outcomes
Children and families get tested and linked to treatment & care
Community Focused Interventions
HEALTH CARE SERVICES: PUBLIC AND PRIVATE
• • • • •
Treatment-ART Treatment-OPI CD4 count monitoring Adherence monitoring HIV Counseling and Testing (HCT)
Referrals for Care, Treatment and other support
• Monitoring/follow-up for additional HIV Counseling & Testing (HCT) • Home-to-home conversation • Support/referral/escort for HCT • Support/referral/escort for other services
Community Case Identification
HIV POSITIVE
+
OTHER CARE REFERRALS
• • • •
HCT
• Home-to-home conversation on HCT • Monitor and assess health • Referral/escort for HCT • Montoring/follow-up • Support/referral/escort for other services
UNKNOWN STATUS
?
Food & nutrition Treatment for monitoring care HCT & adherence monitoring Other services
• Monitoring/follow-up for additional HIV Counseling & Testing (HCT) • Home-to-home conversation • Support/referral/escort for HCT • Support/referral/escort for other services
HIV NEGATIVE
-
Child Support Index (CSI) Assessment and In-home Conversations with Child and Caregiver
Ethiopia – Key results • • •
Since incepEon over 900,000 children and caregivers have benefited from integrated care and support Midterm evaluaEon (July 2014) revealed increased access to health and social services – the result of strong coordinaEon of care Financial stability increased – parEcularly households receiving ES support: income and spending on basic needs increased by 55% and 46%, respecEvely Indicator
Baseline Midterm (2012) (2014)
HVC caregivers tested for HIV
20%
75%
HVC tested for HIV
-‐-‐
46%
HVC had fever and sought treatment in last 2 weeks
48.4%
63.9%
HVC had diarrhea and sought treatment in last 2 weeks
49.7%
86.2%
Under-‐five HVC fully vaccinated
33.9%
57.6%
HVC aged 3+ years ahending school
71.1%
85.7%
Household engaged in economic strengthening program
-‐-‐
38.3%
Ethiopia – ReflecEons on CSS ‘There has never been an organiza0on engaged in building community system and capacity response to children’s problems. Yekobeb Berhan program however introduced a new ini0a0ve build capaci0es and systems at community levels to sustain care and support to HVC and their families.’ Children Affairs Mainstreaming and Partnership Team Leader, Ministry of Women, Children and Youth Affairs, Federal level
Myanmar – Shirley
• Example 2 (Myanmar?)
Shae Thot Funded by USAID 2011-‐2016
Myanmar’s Integrated Community Health Model
Government, Local Leaders
Health Services Health Private Sector Community Strengthening & Governance WASH Livelihoods
Capacity Development, InformaEon and Products
Myanmar – Key CSS IntervenEons Enabling environments & advocacy
• •
Community networks, linkages, partnerships & coordinaEon
• • •
Resources & capacity building
• •
Community acEviEes and service delivery
• •
OrganizaEonal and leadership strengthening
• • •
M&E and planning
• •
IntroducEon of model in community starts with advocacy and relaEonship building with relevant ministries/officials at township and regional levels Trained Change Agents for MCH, TB, malaria become experts/advocates for community’s health needs and parEcipate in Village Development Commihees Close coordinaEon with Midwives and Township Medical Officers ensure model is supported and connected to formal health sector Support to establish/revitalize VDCs + subgroups (e.g. Mother’s Groups, WASH Commihees) for community health planning, implementaEon, monitoring Exchange visits between Change Agents + VDC members for networking and learning Village Development Funds and economic empowerment of women using Pact’s WORTH model -‐ provide grants and lower interest loans for health needs Allows access to mulEple sources of community-‐owned and –managed funds Change agents scale-‐up evidence-‐based health intervenEons and facilitate access formal health care through referrals Change agents are onen Auxiliary Midwives (volunteer staff members of health system) and serve as natural link between model and health system Leadership and management training provided to VDCs and fund managers VDCs structured and trained to conduct parEcipatory decision-‐making and transparent, accountable community planning ApplicaEon of Community OrganizaEon Performance Index (COPI) to assess and monitor VDC performance in 8 domain areas Change agents required to ahend quarterly meeEngs at Regional Health Centers and Sub-‐Centers for joint monitoring M&E data is fed back to VDCs + Change Agents to keep communiEes central to process
Myanmar – Key results • Since incepEon over 500,000 have benefited from integrated health and community system strengthening • Midterm evaluaEon (May 2015) revealed improved access to health services – the result of strong community strengthening • Financial stability increased – parEcularly households receiving ES support: income increased by a significantly higher rate than controls.
Indicator
Baseline (2012)
Mid-‐term (2014)
Knowledge, e.g. on three or more pregnancy danger signs
7.5
26.5
Four ANC visits
21.1
35.2
% of deliveries with skilled birth ahendants
42.3
75.5
% of children with diarrhea treated with ORS and Zinc
2.4
11.8
% of women able to name 3 methods of modern contracepEon
28.5
41.1
% of households with access to safe water sources (drinking water)
65.0
89.3
Myanmar – ReflecEons on CSS “Before this organizaEon come to the village, it was difficult for us to gather people, but now villagers come because they are interested in gaining more health knowledge.” -‐ Myingyan from Sar Taing Village “We had limited health knowledge before, but this has increased a lot. Since this organizaEon came to the village to build health knowledge, the villagers have gained a long-‐term perspecEve abouthealth.” -‐ Yenangyaung from Sar Taing Village
A new model for HSS with CSS SYSTEM BUILDING BLOCKS
OVERALL GOALS/OUTCOMES
SERVICE DELIVERY
IMPROVED HEALTH OUTCOMES AND WELL-BEING
HEALTH WORKFORCE INFORMATION
ACCESS COVERAGE
MEDICAL PRODUCTS, VACCINES AND TECHNOLOGIES
SOCIAL AND FINANCIAL RISK PROTECTION
FINANCING LEADERSHIP/GOVERNANCE
QUALITY SAFETY
COMMUNITY SYSTEM STRENGTHENING
IMPROVED RESPONSIVENESS AND EFFECTIVENESS BY HEALTH, SOCIAL SUPPORT, EDUCATION AND COMMUNITY SERVICES
PARTICIPATION
EFFICIENCY RESPECT FOR PEOPLE, HEALTH AND OTHER RIGHTS
Conclusions • Neither evaluaEon presented here was specifically looking at the role of the community in health system strengthening, so a targeted study would be helpful. • HSS alone is not sufficient to ensure sustainable, comprehensive services – the community must play a role. • These examples and evaluaEons show that making CSS a core building block in the overall HSS framework may lead to improved health outcomes
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