Improving Child Health through Community Involvement. The NGO Service Delivery Program in Bangladesh

Improving Child Health through Community Involvement The NGO Service Delivery Program in Bangladesh

Acknowledgements I want to thank our consultant, Ms. Marcie Rubardt, who assessed and reviewed Community-IMCI implementation at NSDP clinics. I also thank the IMCI section of the Directorate General of Health Services for extending its support to expand the services to all NSDP rural clinics. I thank Save the Children, USA, for its significant contribution, and Dr. Saikhul Islam Helal, Program Manager IMCI & Newborn Health. Without the leadership and support of Dr. Umme Salma Jahan Meena, Director Clinical Services Team, and Dr. Mahbubur Rahman, Child Health Coordinator, this work would not have succeeded. Dr. Mizanur Rahman, formerly NSDP s MIS Advisor, and now Senior Research and Evaluation Advisor, Pathfinder International, assisted in the pilot study and in designing the monitoring of this new intervention. I also thank many other staff at NSDP and at participating NGOs who assisted in implementing Community-IMCI. Last, I thank NSDP s former CTO at USAID, Mr. Moslehuddin Ahmed, current CTO, Mr. Belayet Hossain and Sheri-Nouane Johnson, OPHN Director, who have provided sound advice and support. Any deficiencies in the scheme are the product of NSDP s efforts. Ms. Jennifer Wilder, Senior Technical Communications Advisor of Pathfinder International edited the report. Dr. Robert Timmons Chief of Party

Improving Child Health Through Community Involvement The NGO Service Delivery Program in Bangladesh Technical Report Cooperative Agreement No. 388-A-00-02-00060-00 April 2007 NGO Service Delivery Program House No. NE(N) 5, Road No. 88 Gulshan - 2, Dhaka - 1212 Bangladesh The views expressed in this publication do not necessarily reflect the views of the United States Agency for International Development or the United States Government.

Acronyms and Abbreviations ARI C-IMCI DD DH GOB IMCI NSDP ORS TOT Acute Respiratory Infection Community-Integrated Management of Childhood Illness Diarrheal Disease Depot Holder Government of Bangladesh Integrated Management of Childhood Illness NGO Service Delivery Program Oral Rehydration Solution Training of the Trainer 2

Table of Contents Page Executive Summary Background Community Integrated Management of Childhood Illness The NSDP Model Training Training of Trainers Training of Depot Holders Monitoring and Evaluation Training Results and Impact of Depot Holders in Communities Impact on Burden of Care Depot Holders Supervision NGO Capacity National and District Linkages Recommendations Recommendations for ToT Training Recommendations for Depot Holders Recommendations on Supervision Recommendations for NGO Capacity Building Recommendations for Linkages Conclusions Appendix A: Implementation of C-IMCI Through Depot Holders Tables, Graphs, and Diagrams Table 1: Key family practices for improving child health and nutrition Graph 1: Referrals by depot holders over time Graph 2: Expected and treated depot holder cases of ARI Diagram 1: Depot holder roles before and after introduction of C-IMCI 4 5 5 6 6 8 10 10 11 12 14 15 17 17 17 18 21 21 21 23 24 8 11 12 19 3

Executive Summary Beginning in 2003, the NGO Service Delivery Program (NSDP), funded by USAID, gave support to the Government of Bangladesh s Health and Population Sector Program by joining their strategy to introduce Integrated Management of Childhood Illness (IMCI) in addressing country-wide needs in child health care delivery. NSDP partner Save the Children provided all technical assistance for implementing the Community-IMCI (C-IMCI) strategy. NSDP chose to focus at the community level through their network of community depot holders, addressing the IMCI key components that target improving household and community practices. Bangladesh endures high mortality and morbidity rates for children under five, most of which can be attributed to preventable illnesses such as Acute Respiratory Infections (ARI), diarrhea, measles, and malaria. NSDP s C-IMCI strategy was developed through an existing network of NGO partners, preparing staff to provide cascade training to community health volunteers, called Depot Holders (DH). The DHs were already providing reproductive health information, family planning, and rehydration packets for diarrhea throughout their communities, and they brought the advantage of access to and trust within their communities. Since January, 2007, NSDP has trained 312 master trainers from among NSDP paramedics and service providers. They, in turn, have trained 6,471 DHs connected to 156 clinics in 46 districts in essential knowledge about ARI and diarrheal disease, as well as basics of pre- and postnatal care for women and newborns. Particular emphasis was given to teaching skills in counseling to ensure their ability to help women take basic prevention steps against common childhood illnesses and to make a choice in the use of family planning. Where poverty and poor education continue to reinforce high rates of child mortality, these interventions enable families to better prevent, identify, and respond to dangerous illnesses for their children. Based on project evaluation data, DHs continue to treat more and more ARI cases formerly referred to clinics. Those that went untreated are, of course, undocumented. The DHs broadened skill base has enhanced their community standing, although the association with family planning remains strong and inhibits developing a new reputation for preventive care. NSDP launched a pilot model for an integrated C-IMCI clinic in Shahjadpur, bringing together all medical providers (trained or untrained) with a broader set of training sessions that ensure that everyone in the community understands the basics of C-IMCI. Recommendations include strengthening refresher trainings, enhanced supervision of DHs, and heightened promotion of their roles as preventive caretakers. Without question, NSDP considers this effort a success, recognizing especially that DHs are the only providers that women in many remote areas of Bangladesh will have in the near term, and their capacity to improve health outcomes has been amply demonstrated by this project. 4

Background Photo: NSDP staff Every year more than 11 million 1 children in developing countries die before reaching their fifth birthday. More than 70 percent 2 of these deaths are attributable to Acute Respiratory Infections (ARIs) (primarily pneumonia), Diarrheal Diseases (DD), measles, and malaria, and virtually all are exacerbated by malnutrition. Almost half occur during the neonatal period. In Bangladesh, major progress has been made in recent decades to reduce early childhood mortality rates from 133 per 1,000 live births in 1993 to 65 per 1,000 in 2006 3. Yet these gains remain skewed against the least educated (113 per 1,000) and poorest (121 per 1,000) families 4. Similarly, the neonatal mortality has declined from 75 to 41 per 1,000 live births in that time period, meaning that newborns represent 63 percent of total infant deaths. 5 In response to global child mortality rates, the World Health Organization joined with UNICEF to develop the Integrated Management of Childhood Illness (IMCI) approach to child health care, which focuses on the well-being of the whole child. The strategy combines improved case management of childhood illness in first-level health facilities with aspects of nutrition, immunization, disease prevention, and promotion of growth and development. The three key components of this system include: Improving the skills of health workers, Improving the health system, and Improving household and community practices. Community-Integrated Management of Childhood Illness (C-IMCI) The NSDP Model In Bangladesh, generic IMCI clinical guidelines were completed by the Ministry of Health and Family Welfare in 2001, and in that same year, they were adopted by the NGO Service Delivery Program (NSDP) as their primary strategy for improving child health services. The NSDP project currently partners with over 30 NGOs that oversee 318 Smiling Sun clinics and 8,200 satellite clinics in Bangladesh. This extensive network of care providers gives NSDP exceptional access to families who are not receiving trained medical care. With its current strong community linkages, NSDP focused on the third key component improving 1 Child Health in the Community, Community IMCI, Briefing Package for Facilitators, World Health Organization, 2004, p.1. (At www.who.int/child-adolescenthealth/new_publications/child_health/isbn_92_4_159195_1.pdf). 2 IBID. 3 Population Reference Bureau, 2006 World Population Data Sheet. (At www.prb.org/datafind/prjprbdata/wcprbdata7.asp?dw=dr&sl=&sa=1) 4 Bangladesh Demographic and Health Survey (BDHS) 2004, p. 118. 5 BDHS 2004, p. 117. 5

household and community practices by adopting Community-IMCI (C-IMCI) as a strategy to improve knowledge and access to services at the community level. The new NSDP project took advantage of its existing network of community-based Depot Holders (DHs), who were already providing family planning and Oral Rehydration Solution (ORS) in their local communities and enjoyed access to poor families. Although 49 percent of mothers in the 2004 Bangladesh Demographic and Health Survey (BDHS), who had a live birth, had received antenatal care from a trained provider, only three in ten of those mothers who had no education received such care. 6 The NSDP C-IMCI therefore focused on building services in poor communities, where education is at its lowest. Each of these DHs was already reaching 300-450 households with family planning and oral rehydration solution packets for diarrhea, as well as making referrals to facilities for other contraceptive methods. Most importantly, they were already a primary point of contact around reproductive health for women, who have little experience with formal health care facilities. With the introduction of community components of IMCI, NSDP improved basic household knowledge of early child care and nutrition, household preventive practices, recognition of serious or potentially serious illnesses, home care, and appropriate careseeking for childhood illness. At the same time, the DHs are providing early intervention and access to facility care in cases of pneumonia and diarrhea, which are principal causes of childhood mortality and morbidity. DHs working with rural NGOs introduced a household registration system to enhance the process of C-IMCI implementation and the monitoring of results. Training Training of Trainers A national six-day training of 312 master trainers focused on community case management (ARI and DD) and counseling, drawing on 16 key family practices related to child health, (see Table 1, page 5). Candidates for master training were drawn from among selected NSDP paramedics and service promoters, and the training was provided by well-qualified national trainers. By involving all national stakeholders in the development and ownership of the training materials, the training program achieved a high level of quality. In addition to covering the essential primary health behaviors, it emphasized counseling a crucial skill that is often under-emphasized in community health worker training. In addition to the trainers, other service promoters and paramedics were fully briefed on the project and asked to support the DHs in the satellite clinics and their communities. Master trainers spent a day orienting these colleagues, as well as clinic managers, to promote widespread understanding of this expanded role for DHs and to encourage their support of C-IMCI. 6 BDHS 2004, p. 135. 6

Strengths The fact that service promoter and paramedic Training of the Trainer (TOT) trainees had already had the facility IMCI training increased the efficiency of the C-IMCI training and helped to assure the quality of clinical services and supervision from the health center level. As with any cascade training strategy, it is difficult to assure the quality of training at lower levels. While the service promoter and paramedic trainers lacked initial confidence, the materials and practical/participatory approaches modeled during their TOT training enabled them to go on to provide quality training themselves. By training two trainers for each health center, turnover could be accommodated. Both NGO and regional/national project staff provided additional support, thus reinforcing the training done at the facility level. In some cases, clinic managers and the paramedics who received 11 days of IMCI clinical management training also provided training and supervision, offering confidence to inexperienced staff. DHs trained in C-IMCI are given their own flip-charts with drawings that help to demonstrate procedures and information to their clients. Finally, NGOs already had some experience using refresher and on-the-job training opportunities to orient replacement volunteers, thus using the cascade training structure to address volunteer attrition. Challenges The TOT training did not include community mobilization strategies and was limited on supervision, in spite of the fact that it is a major responsibility of the service promoters. In reality, the TOT needed to provide comprehensive orientation to the task of promoting the DHs in their communities. Similarly, while only one service promoter and one paramedic were given TOT training from each health center, all of the service promoters and paramedics were responsible for supporting the DHs in the satellite clinics and their communities. However, there was no formal strategy or program for orienting these colleagues or for developing their ownership and support for the intervention. Photo: NSDP staff 7

Table 1. Key family practices for improving child health and nutrition For physical growth and mental development: 1. Breastfeed infants exclusively for at least four months, and, if possible, for up to six months. (Counseling about alternatives to breastfeeding should be available for mothers found to be HIVpositive.) 2. Starting at about six months of age, feed children freshly prepared energy- and nutrient-rich complementary foods, while continuing to breastfeed up to two years or longer. 3. Ensure that children receive adequate amounts of micronutrients (vitamin A and iron, in particular), either in their diet or through supplementation. 4. Promote mental and social development by responding to a child s needs for care through talking, playing, and providing a stimulating environment. For disease prevention: 5. Take children as scheduled to complete a full course of immunizations (BCG, DPT, OPV, and measles) before their first birthday. 6. Dispose of feces, including children s feces, safely; and wash hands after defecation, before preparing meals, and before feeding children. 7. Protect children in malaria-endemic areas by ensuring that they sleep under insecticide-treated bednets. 8. Adopt and sustain appropriate behavior regarding prevention and care for HIV/AIDS-affected people, including orphans. For appropriate home care: 9. Continue to feed and offer more fluids, including breast milk, to children when they are sick. 10. Give sick children appropriate home treatment for infections. 11. Take appropriate actions to prevent and manage child injuries and accidents. 12. Prevent child abuse and neglect, and take appropriate action when it has occurred. 13. Ensure that men actively participate in providing childcare and are involved in the reproductive health of the family. For seeking care: 14. Recognize when sick children need treatment outside the home and seek care from appropriate providers. 15. Follow the health worker s advice about treatment, follow-up, and referral. 16. Ensure that every pregnant woman has adequate antenatal care. This includes having at least four antenatal visits with an appropriate health care provider, and receiving the recommended doses of the tetanus toxoid vaccination. The mother also needs support from her family and community in seeking care at the time of delivery and during the postpartum and lactation period. Training of Depot Holders Between May 2004 and January 2007, master trainers trained a total of 6,471 DHs in a series of nine-day trainings. Initially, the DHs were exposed to the same curriculum as the master trainers, but the volume of information contained in the 16 Key Family Practices proved overwhelming for participants unused to schooling (and some of whom were illiterate). The curriculum was streamlined to five key areas, including: 8

Photo: NSDP staff Care seeking: Only 20.3 percent 7 of parents of sick under-five children with ARI seek care from appropriate care providers when they are sick. DHs learn how to provide basic counseling in: o Improved care-seeking for childhood diarrhea, pneumonia, fever, etc. from appropriate providers or facilities; o Necessary immunizations, including TT vaccination of women of childbearing age; o Care during pregnancy, including emergency obstetric care; o Home care for illness or infection; o Home care for a sick child, including extra fluid and food; and o Continuity and compliance with treatment, and follow-up and referral as needed. Nutrition and Feeding: Crucial to child survival, nutrition education focuses on three issues: o Breastfeeding, including exclusive breastfeeding up to six months of age; o Complementary and supplementary feeding after six months of age; and o Supplementation of micronutrients (Vitamin A, Iron, Iodine). Newborn Care: Seventy-five percent of neonatal deaths occur within the first seven days of life, and 90 percent of women deliver at home with a midwife, making quality intervention at this time crucial. Interventions include: o Exclusive breastfeeding, thermal control, appropriate cord care, and early recognition of signs of illness and timely referral to an appropriate provider; and o Recognition of danger signs during pregnancy, birth, and postpartum (for both mother and child). Care for Child Development: This training brings together a parenting program, nutrition and child development program, home-based early learning opportunities, homebased preschool, and guided transition to primary schools. Preventing deaths from drowning: Drowning is the leading cause of death for Bangladeshi children aged one to four. A component on awareness building was therefore added to the training. Follow-up and Monthly Meetings NSDP and its partner NGO clinics continue to provide follow-up on the original trainings through regular monthly meetings with DHs that also include participating service promoters. Initial plans to involve promoters as monitors and mentors have not been fruitful, but the monthly meetings enable trainers to reinforce knowledge and clarify areas of This DH is being instructed in identification of signs of malnutrition this called baggy pants. 7BDHS 2004, p. 157. 9

confusion. DHs benefit from reinforcement in various aspects of counseling skills, as this relationship is completely new to all of them. These meetings encourage lively discussion and exchange of lessons learned between participants. Pursuant to an initial assessment of existing community practices and behavior change communications materials, NSDP and its NGO partners adapted or developed new materials to disseminate messages about the evolving role of DHs. Monitoring and Evaluation Regular evaluation and monitoring of DH skills provide an effective assessment of their knowledge. This screening determines their knowledge and skill level with the following: Basic 12 signs of a sick child younger than two months, Basic 12 signs of a sick child two months to five years, A list of essential Immediate Newborn Care action steps, Counting the respiratory rate, and Appropriate dosage of Tab. Paed Cotrimoxazole. The only tool they are given is a timing device against which they can clock a sick child s respiratory rate to evaluate the severity of ARIs, and they are tested and tutored in the use of this tool. A Mother s Card, Child DHs identify children at severe risk from pneumonia by timing their respiratory rate with a watch. They are also now approved to dispense medication, which can save many lives from this common cause of child mortality. Health Flip Book, and poster accompany them, and they continue to distribute oral rehydration solution packets and to provide counseling in family planning, oral pills and condoms, and referrals for other methods. The Government Department of Health has approved DHs at the community level to dispense cotrimoxazole and treat under-five children suffering from pneumonia. Training Results and Impact of Depot Holders in Communities In contrast with the national TOT, people generally felt the nine-day DH training was too long and covered too many different messages. Information retention from such a long training was challenging for people with limited education; it was difficult for health centers to liberate their trainers from service delivery duties for that long; and all the different messages tended to get jumbled. So far, two-day refresher trainings have been done in seven clinics, but not all NGOs have budgeted for them. In addition, while the project had planned to include refresher training as part of monthly meeting activities, it seems these meetings are largely taken up with administrative issues. Formal materials have not yet been developed for refresher training Photo: NSDP staff 10

either as a separate one- to two-day training, or as an integrated activity for the monthly meetings. Photo: NSDP staff Meherunessa, a DH from Belabo Smiling Sun clinic in Nardindi district, received a Gold Medal from former prime ministers Begun Khaleda Zia and Sk. Hasina for her excellent work in community health. She is shown here with Dr. Sukuruddin Mridha, director of Primary Health Care, Directorate General of Health Services, and Dr. Helal of NSDP. Based on an assessment of the C-IMCI project conducted by a consultant in 2006, community members acknowledge that the DH is the only community worker offering comprehensive care, counseling, and prevention, as well as curative care for ARI and diarrhea. She offers the first line of health service and can promote early treatment, thereby minimizing the number of severe cases. The breadth of DH activities expanded significantly with tasks of community mobilization, organizing group meetings, doing follow-up visits in the home, and seeking out pregnant women for antenatal care. Impact on Burden of Care The impact of the DHs on the overall burden of care within the community can be assessed through examination of the number of service contacts by DHs relative to those in satellite and static clinics. Graphs 1 and 2 below are based on the 64 oldest and most experienced clinics in the study. They are clearly seeing the largest portion of clients for both ARI and DD, thereby reducing the burden for basic care on health facilities. Though not large, there is clearly an upward trend for the number of ARI cases seen by DHs, with noted peaks around the time the majority of them were trained. The increase in the number of DD contacts is relatively flat, despite the training, due to the fact that DHs had acquired some prior knowledge of DD with their training in family planning. Graph 1: Referrals by depot holders over time N=64 Health Centers 400 Referrals by Depot Holder over time 350 300 CDD ARI # of referrals 250 200 150 100 50 0 11

ARI cases treated by DHs continue to increase and referrals to Smiling Sun clinics are decreasing. Yet, given the high incidence of ARI cases in these communities, the growing number of DHs should be expected to see a great many more cases than the one to five monthly cases reported by DHs interviewed for this survey. This implies that a significant number of parents are not seeking the assistance of the DHs, and some might seek treatment elsewhere. Our assumption for this discrepancy is that, despite their significant stature, communities still do not see the DHs as curative care providers and that adequate marketing has not been done at the community level to achieve such an attitude shift. Graph 2: Expected and treated depot holder cases of ARI N=64 Health Center catchment areas 90000 Expected and Treated DH cases ARI # of service-contacts 80000 70000 60000 50000 40000 30000 20000 10000 0 ARI cases treated ARI cases expected Assumptions for expected case calculation: 42% incidence of pneumonia per month, 52% poor people (assuming those are the primary target for the DHs) as in reporting shortage of food at some time during the year, and.5 children under 5 per household. Numbers based on Demographic and Health Survey, 2004. Depot Holders The prized and respected position held by DHs in their communities, and the leadership roles played by many, represent enduring new contributions to their communities. Though most work the equivalent of seven days out of the month, many are called upon to head up other national health projects, including national immunization days and other major public health initiatives. People come to them for advice on every sort of issue, and at least one has become a locally elected public official (see photo page 10). At the community level, the DHs are proud of their work, feel like they are making a contribution to the health of their communities, and appreciate the status associated with being able to provide medicines. The NGOs who are implementing the program also feel the strategy significantly enhances their ability to reach the people who need services, and their experience has been that it is feasible and effective. Finally, the national government, which was involved in developing the strategy in collaboration with NSDP, is appreciative of NSDP s leading role in piloting this effort, recognizing that, while they see the strategy as essential to their provision of services, they do not have the resources to implement it on their own. 12

Photo: Jennifer Wilder, Pathfinder International Based on interviews with participants and stakeholders, the overall success of the DH trainings and their effective impact on child survival is established. Specific strengths and weaknesses documented in that process include: Strengths The DHs have appreciable knowledge of danger signs for chest in-drawing and dehydration, age-specific respiration cut-offs and medicine doses. The DHs have acquired the basic skills to conduct effective counseling, which gives community women access to a large new body of information that has been unavailable to them. Most significantly, they are learning how to take basic preventive steps in monitoring their own reproductive lives and the health care of their children. In all regions, DHs indicated that referrals were feasible, and patient failure to follow through was based more on cost, personal reticence, and shyness, than on distance or geographic location. (Note: While clinic and NGO staff report that DH referrals increased clinic utilization and income, the data, at least for ARI and DD do not corroborate this. They do make a significant number of family planning referrals which may be the cause of the discrepancy.) The DHs maintain registers with census-based information for their targeted families, including the number of eligible couples and children under five, family planning usage, immunization status, and pregnancies. They use this information, as well as their knowledge of the children they have treated or referred, to target their activities in the community. They also keep a daily tally sheet for tracking cases, medicine dispensed, referrals, and utilization of their services. This sheet contributes to the project s management information system. Trained by NSDP s predecessors, these three women have served as depot holders for 6 to 12 years in the village of Savar. They are valued as leaders in their communities, and one is even a locally elected official. Wearing Smiling Sun saris, they are recognized and respected for their knowledge and the help they offer to their neighbors. Their new skills in C-IMCI add a whole new dimension to their community services as family planning providers. This work is so important to the community, said one of the volunteers. Mothers in our community are always very worried when their children become sick, and now we have the skills to help them right away. Weaknesses Because DHs already play prominent roles as family planning providers in their communities, it is necessary to expand their reputations to include child health and curative care. They maintain that they are working in competition with traditional village doctors. Evidence in the referral data indicates that they are not seeing as many ARI cases as the incidence of these infections would predict, which suggests that many families are still not going to them for this problem. 13

Photo: NSDP staff Most DHs and clinic staff report limited involvement of community leaders in DH activities. This lack of leadership involvement, as well as the limited marketing of the DH as a qualified curative care provider for diarrhea and pneumonia, have probably also contributed to their underutilization for these conditions. There is a 20-25 percent drop-out rate among DHs, primarily because NGOs hire them as employees after they are trained and performing well, or family considerations intervene. DHs indicate they are responsible for visiting 250-400 households per month, and that this involves one to two hours per day in addition to being on call for sick children and assisting with satellite clinics. With the expansion of the job well beyond These DHs in Teknet have just completed their C- IMCI training. Each holds a flipchart booklet containing details on specific early childhood illnesses, which they will continue to use as a reference guide in their work. These women already each regularly visit 250 to 400 women monthly, providing them with contraceptives (pills and condoms) and referring them to facilities for long-term methods. Women in their communities trust them and come to them with every kind of problem. They hold an invaluable position of trust which makes them the key point of entry for any trained health care providers. family planning and ORS, a salary of 400 Taka per month was added. While there is some question about whether they actually work as much as reported, there is a sense that they feel pressure to meet expectations as if it were a job. Similarly, some of the NGOs and service providers also had the expectation that the volunteers were accountable to them since they were paying the honorarium implying that it was like a salary even though it is little more than $10 per month. Supervision Strengths DHs have frequent contact with their clinic staff through monthly meetings, collaboration during satellite clinics, and when they accompany referred patients to the clinic. Particularly during the satellite clinic days, public acknowledgement by clinic staff of the DHs provides them significant credibility. Some service promoters have also used the time in the community to meet with local leaders about health activities, again taking the opportunity to promote the DHs. The project developed a supervision checklist, focusing on technical capacity and skills, in response to concerns about whether the DH could appropriately prescribe cotrimoxazole. This was meant to be used once or twice a year to check for continued skill levels. 14

Challenges Many DH have moved into the C-IMCI program from earlier roles as family planning providers, and the great disparity in their knowledge and skills poses one of the biggest challenges in managing the program. In less literate societies, the best community representative may not necessarily be well educated. However, the community representative should be literate. Both satellite clinic and monthly meeting times tend to be busy, making it difficult to find time for supporting the DHs. While the supervision check list is a comprehensive technical review which could be used as a supportive supervision tool, it has not yet been adopted by all the NGOs. In addition, it does not cover any of the programmatic issues (like community relations, managing clients who can t afford medicines or difficulties with village doctors) that should also be covered during a supervisory visit. Pilot Comprehensive Model of C-IMCI In 2006, NSDP launched a pilot model for an integrated C-IMCI clinic in Shahjadpur. Recognizing the need for all participants in health care services medically trained or traditional to collaborate in a unified community response to childhood illnesses, this project brings together the private/ngo sector, village doctors, drug sellers, and DHs and links them with local, regional, and national government structures. This strengthened collaboration ensures buy-in at every level and a consistent voice of support for the value added and roles assumed by DHs, as well as differentiating them from village doctors. The Pilot Comprehensive Model of C-IMCI provided four separate training packages to specific participants in responding to childhood illnesses. These included: Village Doctors: 75 Village doctors in Shahjadpur Upazilla (and later 60 more in other upzillas) were trained in the proper management of under-five illnesses, with a particular focus on the misuse of drugs (especially antibiotics and potently harmful drugs that are currently overprescribed by village doctors, who have access to them but no training in diagnosis or dosage). 40 health assistant and family welfare assistants, who are government basic health workers, received training in the use of the ARI timer, ORS, and the distribution of cotramoxizole for pneumonia. Their training was based on C-IMCI basic health worker package. 37 DHs had already received the same training as those associated with other NSDP Smiling Sun clinics. Doctors, nurses and paramedics of the government Upazilla Health Complex and the Union Health & Family Welfare Centre (UH&FWC) at the Smiling Sun clinics of NSDP received 11 days of IMCI clinical management training and how provide service to sick under-five children following IMCI protocols. NGO Capacity Strengths The development of NGOs as the primary implementers for the NSDP project facilitates the implementation of C-IMCI because these organizations are already established with health activities in the target areas. Systems are in place to manage supplies, the exchange of money, reporting, and supervision. NGO staff at both clinic and headquarters levels can describe how they use the information they collect in their reports. The NGOs are 15

enthusiastic about the C-IMCI intervention and see it as a complement to their other, more facility-oriented, activities. The NSDP technical support team provides assistance with problem-solving and coordination. The national TOT training strategy, along with oversight by the Regional Coordinators helps assure that programs are consistent across regions and across the different NGOs. Challenges Problems remain with ensuring a consistent supply of cotrimoxozole to C-IMCI providers. Definitive logistics management guidelines for recommended buffer stock, as well as lead time and procedures for ordering, have not been developed. This is complicated by the fact that the minimum quantity for a wholesale order is much larger than that for any individual NGO and thus requires compiling orders among all the NGOs. NSDP is currently performing this operation. Photo: NSDP staff Alternative supplies or solutions for cotrimoxozole shortages have also not been actively explored. The Government of Bangladesh program manager for IMCI indicated the government currently has supplies available and might have been able to help bridge the gap for the current shortage. However, this solution raises the issue of whether the project could sell medicines provided by the government. It would not be in the NGOs interest to introduce free medicines, even as an interim measure, because it would confuse the NSDP reinforced the initial trainings with follow-up reviews to strengthen NGO staff understanding of the material and their ability to pass the knowledge on to DHs clearly. Because everyone involved is Bangladeshi, the misconceptions surrounding birthing, childhood illnesses, infant care, and other health issues can be addressed effectively with understanding and sensitivity. customers expectations in the future. Alternatively, introducing pediatric cotrimoxozole syrup is an option, but it is much more expensive. The professor and head of the Neonatology Department of Bangabandhu Sheikh Mujib Medical University discouraged free distribution of the medicine, because it expires quickly and users tend to keep open bottles around too long. With up to 40 DHs for a single Smiling Sun clinic, both the cost and effort to maintain the clinics is significant. NGOs acknowledged that they had targeted areas for DH placement that were under-represented in the health center utilization statistics. However, they did not take into account the availability of alternative services in those areas, and some DHs may actually have been placed where other services were also available. Finally, recognizing the reporting burden and data overload, NSDP has made a significant effort to streamline the management information system. However, some project sectors have instituted special reports, placing a considerable burden on the NGO reporting system. 16

National and District Linkages Strengths At the national level, the networks and linkages developed for the C-IMCI intervention are impressive. NSDP has effectively cultivated significant interest and participation in the C- IMCI intervention on the part of professional bodies, national government policy makers, and the NGOs. Strong government commitment and contribution to community level service provision provide the mandate for such an initiative, and they acknowledge that they see NSDP as leading the way. As piloting of the Comprehensive Model of C-IMCI progresses (see page 12), it can potentially strengthen the linkages between government and NGOs at the district level, as well as clarify the potential contribution of the different service-delivery cadres to the C- IMCI intervention. Challenges The linkages and coordination have been less consistent at the district level. NGOs have not always seen it as their responsibility to coordinate with the district level, although they do take coordination at the upazilla level more seriously. District level coordination might more appropriately be a role for NSDP from the regional level, although regional coordinators have tended to also be more focused at the health facility and upazilla levels, since that is where most of the NSDP interventions occur. While the team only had the opportunity to discuss the C-IMCI approach with one civil surgeon, it was clear that he was not yet completely convinced that DHs are indeed capable of delivering cotrimoxozole for community-level case management of pneumonia. The district could potentially provide significant technical and logistic support to the NGOs if they are convinced of the benefits. Recommendations Recommendations for TOT Training Most of the recommendations for improvements in the TOT training address steps that could be taken to improve trainer support and promotion of the DHs in their new roles as providers of preventive care for young children. Recommended steps include: Provide more orientation on programmatic issues, such as strategies for increasing community ownership for and interest in their DHs, ways to promote utilization of DH services, and supervision and motivation of community volunteers. Invite clinic managers, in addition to service promoters and paramedics, to the full TOT training to further increase the critical mass of interested people at the health facility level and to have the formal authority of the clinic manager behind the C- IMCI activities. Develop plans and materials for refresher trainings both for one-to-two-day formal trainings and for 30 minute modules to be used during the monthly meetings. In both cases, a selection of materials can be developed for the trainers to choose from, depending on specific identified needs. 17

Encourage NGO monitoring officers for quality assurance and program monitors (medical staff only) to be involved with the initial training, as well as with developing and supporting refresher training, and for orientation of new volunteers. Depending on the capacity of the headquarter monitors, it may be necessary to include them in the TOT training. Particularly non-technical monitors and/or those who did not go through the facility IMCI training, should be included to develop them in this training support role. Recommendations for Depot Holders Partnership between community and health care facilities is an essential component of C- IMCI, and effective coordination between health officials at all levels, NSDP, and partner NGOs encourages refinement of the system and continued learning and buy-in. Recommendations regarding the DH role revolve around community mobilization and strengthening their links to the community, clarifying and marketing their unique contribution to health services - particularly in relation to the village doctors -- and more clearly prioritizing their activities, messages, and motivation. The single greatest challenge with respect to the DH s role in C-IMCI is to establish their reputations as viable curative care providers in the community. NGOs need to facilitate this process. The community associates them with family planning, and, due to their inability to give injections, often resists associating them with curative care. This said, the training, availability of medicines and timers, and involvement and support from the service promoters at the clinic in many cases has helped facilitate the shift towards a more comprehensive role. Recommendations include: NGOs need to market specific C-IMCI activities managed by DHs, (see Diagram 1). Strengthen community mobilization and support strategies, starting prior to introducing DHs as C-IMCI providers in the community, to develop community interest in and ownership of their volunteers. Specific suggestions include: o Invite community leaders and influential stakeholders on the last day of basic C- IMCI training for DHs. o Distribute equipment, medicines, and certificates in a transparent way involving community leaders. o Involve religious leaders in promotion of the DHs and their services. o Involve Satellite Clinic Support Groups, as a representative community structure, in selection and oversight of DHs. o Revisit DH selection criteria to make them consistent with people s expectations for qualified service providers (e.g., more literate, married, older). o Promote the DH s total capacity to provide services at the community level and avoid focusing on just the curative component of their services. Inform field service providers (village doctors/drug sellers) of their skills and services. o Develop a leaflet identifying the unique package of DH services and distribute it through home visits, the Satellite Clinic Support Group, and the health center. o Place additional signboards in important community points highlighting the variety of services they offer. o Organize home visits where clinic staff join the DHs, thus reinforcing their credibility. 18

o Consider adding paracetamol to DHs medicines, since it can address fever, can add to their income, is in demand, and is not a high-risk drug. However, this should only be considered if it can be done in a way that will not overly reinforce the curative component of their role. Diagram 1: Depot holder roles before and after introduction of C-IMCI Village Doctor - injections Depot Holder family planning Village Doctor Limited curative care Depot Holder Health education, family planning, mobilization for the Expanded Program on Immunization and satellite clinic, referral and follow up, service tracking Overlap Limited curative care Overlap Treatment of ARI and diarrhea Historic Depot Holder Vision of Herself C-IMCI Vision of Depot Holder Focus the DHs priorities and messages according to those that can have the most impact. This should take into account the potential impact on mortality and morbidity, the potential for synchronicity with other interventions, and national government priorities. o Focus initially on interventions such as DD and ARI, possibly with additional messages for health education on essential newborn care and complementary feeding. Subsequent training opportunities can be used to add additional content and messages. o Particularly in areas where home deliveries with skilled attendants are being emphasized, use DHs to reinforce essential newborn care messages and follow up. The DHs workload should be more focused and limited, to be more in line with reasonable expectations for volunteers. o While it is already happening to some extent through use of the registers, DHs should be given permission to focus on their high-risk clients (definition to be determined) without expecting them to visit every household in their catchment areas monthly. o Some DHs have mobilized helpers for case finding, Expanded Program on Immunization tracking, or even health education. These can be primary school students, women peers, or follow a child-to-child model. 19

20 Photo: Jennifer Wilder, Pathfinder International o DHs with more than one job can be encouraged to integrate the activities of their different jobs. For example, they may be community volunteers for other programs such as Expanded Program on Immunization or tuberculosis, and/or hold a regular job such as teaching school. This approach leads to more efficient work, while also earning more money. Continue to develop a more comprehensive motivation package to encourage DH and community involvement. Options might include: o Market the benefits of being a DH, including the benefits of training, the availability of additional money for the family, and the potential for leveraging the role into other health worker roles that might also provide stipend and training allowance money. o Reinforce the overall incentive package to add emphasis to the recognition, appreciation, and status components of the role. This might entail development of competitions, awards, and/or bonuses. o Stress volunteer accountability to their community. Even though the NGO is paying their honorarium, they do not report to the NGO as a supervisor. Rather, with recognized accountability to their community as local volunteers, they will receive both recognition and status from where it counts and this will contribute to their motivation. o Avoid actions, such as introduction of an annual salary increase that reinforce the sense that the honorarium is a salary. Alternatively, a bonus recognizing each completed year of service might have the same result without the salary implication. Divide up DH training sessions so that the initial training is shorter and focuses more on the priority activities and messages. (See DH recommendation on prioritizing messages.) Specific training suggestions include: o Focus the initial six-day training on diarrhea and ARI case management, including making proper referrals and the possible addition of health education messages as prioritized. o Include a brief orientation on using watches to count respirations and on using adult cotrimoxazole in the absence of timers and pediatric tablets. o Add new topics, either during formal refresher training or through the use of focused 30-minute modules to be used during the monthly meetings. Develop the necessary structure to provide more support for the training of DHs at the facility level. o Involve monitoring officers and clinic managers (once they have received the TOT training) as well as regional coordinators in these activities.

Organize a one-day orientation for monitoring officers on C-IMCI at the central level, with a monitoring work plan with definite time periods and responsibilities. Monitoring officers and clinic managers could be involved as co-trainers, even if they hadn t actually had the TOT training. In this way, they learn the material as they teach it, and provide support to the local trainers at the same time. o Develop more formal plans for orienting and involving the rest of the clinic service promoter and paramedic staff. Recommendations on Supervision As part of their community role, service promoters should address community acceptance of DHs and strengthen their credibility by promoting them and reinforcing their relationships with community leaders. Supervision of C-IMCI could be more structured at each level: With well-oriented paramedics and service promoters (see recommendation under training), supportive supervision should be prioritized as part of satellite clinic activities, using a check list that focuses on both programmatic and technical issues. Weaker DHs should be targeted for extra help during supervision and monthly meeting activities. Stronger DHs can assist with this support. C-IMCI should be included as part of clinic monitoring by the NGOs. It can be included in a regular supervision check list and/or become part of the Quality Monitoring and Supervision system. (This adaptation is already in progress.) The regional coordinators could take a more active role in supporting and supervising the C- IMCI activities, while providing support for more facility-oriented activities. They should continue with the joint supervision visits, which were well appreciated by the NGOs. Recommendations for NGO Capacity Building Reinforce supervision, training, and monitoring skills of monitoring officers and NGO doctors as mentioned in the previous sections. Develop logistics management guidelines for cotrimoxozole including: o Systems for pooled requisition by the NGOs from the national supply company, in order to maintain the wholesale price and remove the not for sale labeling on the package; o Coordination with government as needed to explore ways to mutually assure reliable supplies; and o Consider alternatives such as the use of adult cotrimoxozole in case of stock outs. This needs to be included in training. Identify alternatives, using either stop watches and/or regular watches, for counting respirations in case the ARI timers are non-functioning. Recommendations for Linkages National policy makers and C-IMCI supporters need to be involved in the review, prioritization, and implementation of these recommendations. In particular, they 21

Photo: NSDP staff need to work together to determine how the messages and activities of the DHs should be more focused and prioritized, and to develop the supplementary training materials for refresher training and monthly meeting training. The project should develop a strategy to cultivate district-level involvement and support through a combination of field visits and issuing of guidelines from the top. o NSDP, through regional coordinator involvement, probably needs to take the lead, along with NGOs at the district level. o It might be possible to include C-IMCI concerns in a district child health committee or some other district committee forum. o National government, with assistance from NSDP, should orient districts on C-IMCI, possibly through a memorandum from the Government of Bangladesh s Directorate General of Health Services. o As the linkages at the district level develop, respective roles between NSDP, the NGOs, and the government will need to be clarified. The experience in piloting the Demonstrative DHs spend about one full day a week visiting the women in their catchment areas, making sure that pregnancies go well, checking up on sick children, and providing family planning methods. Comprehensive Model of C-IMCI will hopefully contribute to this clarification. Conclusions While implementation of the C-IMCI intervention is still in progress, several lessons learned stand out. Community-level female health workers can effectively and appropriately deliver cotrimoxozole for early treatment of pneumonia as part of an integrated C-IMCI framework. Their presence in the community increases access and decreases the cost of treatment, particularly for poor people who might otherwise postpone or neglect treatment of children with pneumonia. Their holistic role addressing preventive and curative measures gives them access to families that more curativeoriented village practitioners don t have, and their volunteer role serving their communities reflects significant commitment to the well-being of their fellow community members. The significant level of commitment at the national level is leading to the ownership that will be necessary for replication on a wider scale. By having involved significant national stakeholders in developing the strategy and training materials, and in doing the training, the groundwork has been laid for tapping this commitment in the promotion and replication of this approach. 22

Targeting the facilities where facility IMCI has been implemented strengthened the C-IMCI approach, as it built on training and understanding already in place. To assure high-quality cascade training and implementation, a strong program at the national level needs to be complemented by good mid-level support. The centralized training of trainers helps to assure the quality of cascade training and project implementation as it moves out from the central level. However, active involvement of the mid-level, such as NGO headquarters staff, NSDP regional coordinators, monitoring officers, clinic managers, and even Government of Bangladesh district staff, is needed to help assure the quality of training and implementation at the facility and community levels. Inadequate community involvement in and ownership of the C-IMCI intervention may be contributing to lack of recognition for DHs as curative care providers. While the current intervention takes place at the community level, family decision makers and community leaders/structures have not been particularly involved in its implementation. As a result, their potential has not been tapped for either oversight or promotion of this intervention in their communities. If this participation were combined with more recognition and promotion of the unique contribution of the DHs to the health of their communities, the intervention would likely be more effective and sustainable, with the potential to scale up throughout the country. 23

Appendix A: Implementation of C-IMCI through Depot Holders NSDP is implementing C-IMCI through the involvement of Smiling Sun clinics and the front line worker in the field called a depot holder. DHs received a nine-day training from C-IMCItrained paramedics/service promoters, who had been prepared in a six-day Training of Trainers program. The components of the DH training are: 1) The status of maternal and child health in Bangladesh, 2) Sixteen key messages to save the child, 3) Good counseling techniques, 4) Antenatal and postnatal care, 5) Child nutrition and care, 6) Good weaning practices, 7) Food: iron, iodine, and vitamins, 8) Early childhood development, 9) Child violence/labor, 10) Cleanliness, safe water, and sanitation, 11) Immunization, 12) Malaria, 13) HIV/AIDS, 14) Feeding during illness, 15) Accident and injury, 16) Child illness ARI pneumonia, 17) Child Illness diarrhea, 18) Referrals, 19) Role of men in maternal and child health, 20) Record keeping, and 21) Community involvement. BUT primary emphasis is given to: 1. ARI, 2. Diarrhea, 3. Referrals, and 4. Good counseling techniques. 24

NGO Service Delivery Program (NSDP) NSDP is a USAID-funded consortium of eight international organizations, led by Pathfinder International, which provides technical assistance and support to a network of Bangladeshi health care NGOs. The program focuses on delivery of essential public health services to 20 million people through training, quality assurance, NGO institutional development, management, and financing. NSDP partners with more than 30 NGOs whose 320 Smiling Sun clinics and 8,000 satellite clinics work in both disadvantaged rural areas and urban slums. About 6,000 community volunteers augment services in rural areas. Smiling Sun clinics play a major national role in providing families with high-quality, low-cost family planning, reproductive, maternal, and child health care, treatment for reproductive tract and sexually transmitted infections, tuberculosis diagnosis and treatment, and limited curative care services. There are more than two million visits to NSDP health care providers each month. Health benefit cards offer free services at Smiling Sun clinics to members of very poor families. Over 60 percent of the poorest Bangladeshis who receive health care in NSDP s catchment areas are served by NSDP providers. Performance-based reimbursement is increasing access of the poorest of the poor to services and increasing the number of able-to-pay customers as well. Smiling Sun clinics are expanding services that generate income for the clinics, including safe delivery at clinics and at home by trained paramedics, emergency obstetric care, laboratory and pharmacy services, health care marts, ultrasonograms, and specialized physician care. Mass media and local behavior change communication campaigns include the popular entertainment-education TV drama serial Enechhi Shurjer Hashi (Bringing the Smiling Sun). Billboards and advertisements of clinic services in cinemas and on city buses and rickshaws, promote health and family planning. Branding and the reputation of Smiling Sun clinics have led to corporate sponsorship of clinics and services. NSDP Partners: Bangladesh Center for Communication Programs (BCCP) CARE Bangladesh EMG, (Emerging Market Group) IntraHealth International Inc. Pathfinder International Research Triangle Institute (RTI) International Save the Children University Research Co., LLC. (URC)