CARE-GSK Community Health Worker Initiative An innovative public private partnership Addressing Human Resources for Maternal Health in remote and un-served district of Bangladesh Overseas Development Institute (ODI) 18 September 2015
Presentation Overview Background and context Project design Intervention descriptions: CARE- GSK CHW Initiative Results and achievements Challenges and lessons learned
Health Status and Inequity Indicator Bangladesh Sylhet Division MMR (Maternal Mortality Ratio-100000 live births) NMR (Neonatal Mortality Rate-1000 live births) IMR Non availability of skilled service providers (Infant Mortality Rate -1000 live births) 194* 425** 32 45 43 59 Delivery Inadequate by Medically functioning Trained of the Provider public health (%) system 32 24 At least one skilled ANC (%) 55 47 Remoteness and geographical vulnerability At least one PNC (%) 29 23 lack of supervision and monitoring with poor health system accountability TFR 2.3 3.1 Source: BDHS-2011;*BMMS-2010; **BMMHCS-2010
Shortage of Human Resource for Health in Bangladesh WHO Standard of HRH: 2.3/1,000 Out of pocket expenditure is more than 64 % Availability of HRH: 0.6/1,000 Gap covered by Quack/ Drug Sellers TBA
Project Location and rationale Sunamganj Ranked as the poorest in terms of health indicators. Frequently affected by flush flood with large water bodies leading to poor communication. Population -2.5 million Poor retention and high absenteeism among the public providers. GoB is committed to improve/address this gap. In 2012, GlaxoSmithKline came forward with its 20% reinvestment Initiative to address the health workers issues in remote & un-served communities.
Project Design Participatory design process through extensive situation/gap analysis and discussions with Ministry of Health (MOH) and other stakeholders like UNICEF, WHO, civil society organizations. Roles of MOH, Obs & Gynea Society Bangladesh (OGSB), local governments have been identified and agreed for implementing the project. Recognized as Public-Private-Partnership (PPP) to address community level Human Resource for Health issues Memorandum of Understanding (MOU) was signed between MOHFW and CARE Bangladesh for PPP.
Proposed Solution By Developing Private-CSBA CHWs
Purpose and Targets Purpose: Ensures consistent, high quality and sustainable Maternal & Child health care services to a population of 1.4 million people in a very remote area of Sunamganj district Targets/Coverage: Working 10 sub-districts and 50 remote Unions (local government unit) Capacity building of 2,112 Community Health Workers, 3,100 Community Health Volunteers, 700 local government members, 1050 public & private health providers Development of 168 community based Private CSBA Each P-CSBA serves around 7,500 population on an average
Development of Skilled Private-CSBA Selection of local married women using defined criteria jointly by the community, local government and MOH staff Skilled development training (both in house & practicum) 6 months WHO & MOH accredited Skilled Birth Attendant (SBA) Training followed by 3 months on the job training One week Primary Health Care (PHC) 5 days C-IMCI training Two days training on HMIS and reporting.
Quality Assurance and Coordination Regular quality assurance visit to P-CSBA using defined checklist Bi-monthly refresher training by establishing skilled lab at sub-district hospital. Monthly joint performance review at union and subdistrict level GoB health centers to identify the gaps and improve coordination.
Extensive Community Mobilization Promotes services, identifies pregnant women, Birth Preparedness, and makes referrals Mobilizes local funds to support poor households and timely transport Monitors service quality and uptake by poor women and links with local government reimbursement schemes if needed
Local Government Engagement and Accountability Advocate, capacity development and engage Local Government members to address health issues in their catchment areas. Negotiate and determine the service price of the P-CSBAs in collaboration with community and P-CSBAs Allocation of funds by local government for serving the poor and supporting referral. Facilitate linkages between P-CSBAs and health facilities and ensure accountability by sharing community feedback.
Promote Social Entrepreneurship Receives entrepreneurship training that include analysis & calculation of market size, development of business plan, promotion and monitoring. External supports for extensive market research to identify opportunities, demands and gaps for developing customized individual business plan and showcasing the service & products. Linkages with drugs and health commodity suppliers, and receives regular supply. Collaborates with traditional healers including TBA to minimize the unhealthy competitions.
Technical Advisory Group Technical Advisory Group (TAG): Participated by MoH, WHO, UNICEF, UNFPA, Save The Children, DFID, JICA, GSK, CARE and other relevant stakeholders (15 members) - Review progress, challenges, share lessons learned, review align with country program, advocate for the best practices
Project results and impacts: Until July 2015 34,745 pregnancies identified and registered. (93% of expected pregnancies in the project area) 9,652 deliveries attended. 68 % service recipient were either poor or ultra-poor Ultra Poor 14% Rich 8% 86,144 ANC and 42,673 PNC provided. 35,931 ENC and 14,377 IMCI services provided. Poor 54% Midle 24% 5,871,867 BDT earned (3785 BDT per P-CSBA/month). *Household ranking was conducted based on predefined criteria
Average Service Contacts and Earnings Average Service Contact by P-CSBA by month Total Earnings (Until June, 2015): More than 5.2 million BDT (> 43,000 GBP) 90.6 92.9 93.0 90.3 86.2 87.3 87.9 84.7 80.6 82.8 77.3 78.4 101.8 94.8 100.0 62.5 68.4 48.9 39.0 40.2 31.9 Average earenings by P-CSBA in GBP 30 33 32 33 4 6 7 8 10 10 12 15 10 14 18 20 18 22 21 22 22 Nov'13 Dec'13 Jan '14 Feb '14 Mar '14 Apr '14 May '14 June'14 July'14 Aug'14 Sept'14 Oct'14 Nov'14 Dec'14 Jan '15 Feb '15 Mar '15 Apr '15 May '15 June'15 July'15 Earnings In June 2015 28 % providers earned BDT 5000 or more (benchmark for financial sustainability)
Births Attended by Skilled Health Personnel in 50 Project unions Increased 38 % 50 Millennium Development Goal (MDG): 50% by 2015 12 24 27 P-CSBAs attended 51% of all skilled births in the project area Project Baseline Dec, 2013 1 2 Sylhet Division BDHS 2011 Project area Jan June,2015* Sylhet Division BDHS 2014 *Project MIS and Government MIS
At least one ANC by skilled health personnel in 50 Project unions Increased 47 % 90 HPNSDP Target: 100 % by 2016 43 47 53 P-CSBAs provided 54% of all skilled ANC in the project area Project Baseline Dec, 2013 Sylhet Division BDHS 2011 Jan June,2015* 1 2 Sylhet Division BDHS 2014 *Project MIS and Government MIS
At least one PNC by skilled health personnel in 50 Project unions 50 HPNSDP Target: 50% by 2016 8 Increased 42 % P-CSBAs provided 64% of all skilled ANC in the project area Baseline (December 2013) January -June 2015 Project Baseline Survey *Project MIS and Government MIS
Referral to health facilities Total 2183 women and 859 children referred to different health facilities 1360 women referred during child birth 714 Ante-partum and 108 post-partum women referred 12% of the women P-CSBAs visited for childbirth were referred to secondary or tertiary health facilities. Total referred in cases at EoC facilities in Sunamganj district* 38 22 50 75 100 129 124 Jan -June July-Dec Jan -June July-Dec Jan -June July-Dec Jan -June 2012 2013 2014 2015 *Government MIS
Key challenges Selection of appropriate P-CSBA candidates (only 2.3% women completed SSC) Inadequate functioning of referral EmOC facilities in Sunamganj (UHC, DH) Competition with local traditional services providers like TBAs and VDs Ensure the social accountability of P-CSBA (Balance between social vs commercial commitments) Geographical hardship, road communication and sudden flush flood for seeking care, referral September 30, 2015 21
Key lessons learned Private Skilled MNCH providers successfully replacing the unskilled/traditional providers. Availability of consistent, affordable, accessible skilled MNCH services to the under-served & poor communities. Potentially sustainable alternative service delivery option for the remote community. Exploit community & local government commitments to address financial, social & governance barriers in assessing health services by poor. Innovative PPP model proving to be effective to address both geographical and wealth inequity in accessing health services.
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