Engaging informal providers in Bangladesh
Dr. Mahfuza MousumiProject Manager, Health & NutritionSave the Children, BangladeshEmail: [email protected]
Stakeholders’ consultation on Informal Service ProvidersOrganized by: CReNIEO
Chennai in India21-22 March 2014
Presentation Outline
Child health situation in Bangladesh CCM Project overview Village Doctors engagement
experinaces Program results Lessons learned
Trends in under-5 child mortality in Bangladesh
1989-93 1992-6 1995-9 1999-2003 2002-6 2007-11 2015
52 48 42 41 37 32 21
35 3424 24 15 10
10
4634
28 2313
11 17
133116
94 8865 53 48
Neonatal Deaths/1,000 LB1-11 Month Deaths/1,000 LB12-59 Month Deaths/1,000 LB
MDG Target
Deat
hs p
er 1
,000
live
-bi
rths
Source: BDHS 2011
Distribution of under-5 deaths in Bangladesh by causes of deaths: 2006-2011
Source: BDHS 2011
Pneumonia
Possible serious infection
19%
22%
15%
13%
9%
7%
2% 7% 6%
Possible
serious infectio
n
Undefined
Other neona-
talOther
DrowningPneumonia
Pneumonia Treatment Status (BDHS 2011)
50% care seeking for Pneumonia from drug stores and Village Doctors (VDs)
35% of children with symptoms of pneumonia were taken to health facility or a medically trained provider
79% of the children seeing a provider were prescribed antibiotics
Presentation Outline
CCM Project overview
Project Information
Implementation area: 17sub-districts in southern part of Bangladesh
Target group : Children under five years of age (approx. 400,000)
Duration : February 2012 to April 2014 Donor : Procter & Gamble
Project strategies
MOH front line workers’ capacity
strengthening
Capacity building of VD & linkages with
formal HS
Community engagement and support mechanism
Improve access to quality services
Public/ formal
Private/informal
Community groups
Presentation Outline
Village Doctors engagement
Rationale for engagement Increase coverage of protocol Popular & common choice of
population esp. among poor HHs Village resident, available 24/7 Drugs available at the clinic (provide
drugs on easy installment) Conduct home visits
Initial considerations for VD engagement
Process of VDs selection Training & skill retention Quality Assurance
Selection of Village Doctors Service mapping (identify gap areas) Consultation with community leaders
to identify popular VDs for children U5, VDs association
Live /practice in the targeted village Willingness to participate in training
and treat children following national protocol
Not involved in political activities
Who are the selected VDs?
75% of them completed 10th grade education
Majority are between 30-50 years of age
Most of them received 3-6 months course from private institution and also worked as assistant of a doctor or VD
Nearly all operate a pharmacy
Capacity building & QA approach Revision of basic training manual specially for
VDs in partnership with IMCI unit, MOH Adaptation of standard monitoring &
supervision tools Conduct basic & refresher trainings by MOH
sub-district level MTs; 298 VDs trained on CCM (3-day) and 281 currently active
Provided essential supplies & job Aids -ARI timer, thermometer, chart booklet, treatment register, referral slips & tools.
Supportive supervision- joint supervision with MOH supervisors
Presentation Outline
Results
Number of cases treated by trained VDs
Oct’12 to Dec’13
N=199
Key findings of Supervision Visit
Correct
case
manag
emen
t
Treatm
ent c
onsis
tency
Record
keep
ing
Avail
abilit
y of d
rugs
Avail
abilit
y of s
uppli
es0
306090
Perc
enta
ge
January to December 2013
N=184
Supervision Mechanism
Post-training follow up visits: each VD supervised twice a month for initial 3 months followed by monthly supervisory visits Review register Direct observation/ case scenario Random HH visit of treated cases
Joint supervision with MOH supervisors (98% of VDs received supervision visit in the last month)
Supervision Checklist
Presentation Outline
Result: Key findings of Village Doctors assessment
Before training After training• Only 35% used
equipment (stethoscope/watch) for pneumonia diagnosis
• Diagnosis made based on symptoms
• Used higher antibiotic
• Count respiration rate using ARI timer
• Use simple antibiotic (amoxicillin)
• Referral of severe pneumonia cases
Diagnosis and treatment of pneumonia
Availability of Supplies
92% of VDs have functional ARI Timer All VDs have functional thermometer IMCI Algorithm/chart is available with
97% VDs 96% of VDs are maintaining service
registers
Drugs availability
98% of trained VDs are selling amoxicillin of recommended brands
ORS and Zinc are also available in their pharmacy
VDs attitude and practices around referral
Before training After training• Almost absent
among VDs• Perceived as
unskilled and incapable
• Financial disincentive of people seeking treatment elsewhere
• Giving preference to treatment protocol over business motive
• Refer sick children following protocol rather than doing trial and error
Referral linkage with MOH 91% of VDs are using referral slips 97% of VDs referred sick children to near
by appropriate MoH facility 88% severe/danger sign 24% diarrhea with severe dehydration 15% sick newborn
76% of VDs have mechanisms to ensure quality services/follow up
Lessons learned Low profit margin and slow recovery of treated
cases with amoxicillin is a challenge for following standard treatment protocol Refresher training, review meeting and
supportive supervision are effective ways for ensuring quality and maintain motivation
Joint supervision with MOH staff supports establishment of linkage with formal health system; adding VD treated cases in national HMIS
CCM projects created scopes for VDs engaging in other child health interventions by government & non-government programs.
Next steps
Preliminary results/experiences are promising. VDs are following protocol & maintaining guideline and referring severe cases
SC wants to expand this to additional VDs and conduct research to identify what is needed to enhance quality of pneumonia treatment by informal providers at scale
Thank You