Concurrent Sessions
Pro-poor Health Financing Strategies
Jaime Carrillo, Executive Director, Curamericas Global, Inc.
Ira Stollak, Senior Program Specialist, Curamericas Global, Inc.
The facilitators presented a summary of findings concerning pro-poor strategies implemented in diverse countries at the local and national levels. While many strategies have failed to increase healthcare access and/or to reduce out-of-pocket health expenses for the poor, they may be considered for adaptation to local/regional approaches that actively incorporate beneficiaries in the delivery of services. In general, national health initiatives have focused on availability, and to lesser extent on accessibility and affordability. But if services are to be reached by the poorest, special attention should be given to the adequacy and the acceptability of health care to the users.
The focus of the exchange during this session was on potential approaches to minimize barriers and enhance successes of presented strategies with the intent to incorporate suggestions into an ongoing effort to implement community-based health system strengthening.
Getting Beyond the Physical: Integrating mental health response into local health systems
Session presenters provided concrete examples of how mental health has been integrated into primary healthcare systems. Participants had the opportunity to ask questions of the presenters about their programs and approaches and were encouraged to take part in interactive activities during the session in order to apply the information provided during the session.
The Current Condition of Mental Health in Afghanistan: Integrating mental health into primary healthcare
Nahid Aziz, Associate Professor, Argosy University
Responding to mental health needs of HIV positive pediatric patients in resource-poor communities
Vicki Tepper, Associate Professor of Pediatrics and the Director of the Pediatric AIDS Program at the University of Maryland School of Medicine
Responding to Mental Health Needs of HIV-Positive Pediatric Patients in Resource-Poor Communities
Family Planning and Child Survival Integration: What are the possibilities?
Victoria Graham, Senior Technical Advisor, Bureau of Global Health, USAID
Mia Foreman, Program Associate, ICF Macro
With the creation of the Global Health Initiative, USAID is committed to strengthening and integrating public health programming --including the integration of family planning (FP)-- into maternal and child health programs. Family Planning programs have been shown to lowers rates of newborn, infant, and child mortality; delay next pregnancy and allow more time for mothers to breastfeed and improve overall infant health; and allow more time for women to recover physically from delivery and nutritionally between births (Family Planning Saves Lives, 4th edition, PRB).
During this session, participants learned about the historical perspective of integrating FP into the CSHGP, learned how some MCH programs are integrating birth spacing/family planning into their programs, and identified FP program strategies and activities that may improve FP indicators. Participants had an opportunity to ask questions, and share their experiences and ideas for future collaboration and technical support.
Integrating Family Planning Into CSHGP and MCH Programs
Care Groups: The Essential Ingredients
Carolyn Wetzel, Senior Coordinator for Health Programs, Food for the Hungry USA
Thomas Davis, Senior Director of Health Programs and International Program Quality Improvement, Food for the Hungry USA
Melanie Morrow, Director of MCH Programs, World Relief USA
Care Groups have been proven to reduce malnutrition, decrease child mortality, and save lives. Since 1995, World Relief, Food for the Hungry, and more than 12 others PVOs in more than 14 countries have “adopted the Care Group model,” but the degree to which organizations adhere to the original components of the model varies greatly. There is a danger that the wide variations in what is called a “Care Group” by various agencies will lead to misunderstandings about the model and the use of less effective strategies that do not fit within the model. These variations, in turn, could lead to fewer opportunities to advocate for the Care Group model and its role in child survival since the term “Care Groups” may come to mean many different things to different people and may not be as effective in lowering malnutrition and mortality.
In this session, participants discussed what elements must be found within a program design for it to be considered a “Care Group.” After the impact and basic elements of the Care Group Model were presented, participants divided into small groups and discussed the rational for the requirements and suggested elements of the Care Group method, giving input and experiences related to each criterion.
Care Groups: The Essential Ingredients
Working Group Showcase (and Planning) for IMCI, Malaria, Nutrition and TB Working Groups
IMCI and Malaria Working Groups (joint session)
Philip Wegner, Health Advisor, Concern Worldwide
Yolanda Barbera, Senior Technical Health Coordinator, International Rescue Committee
Melanie Morrow, Director of Maternal & Child Health Programs, World Relief
The IMCI and Malaria Working Groups jointly hosted a Showcase featuring representatives from the three NGOs--Concern Worldwide, IRC, and World Relief--that make up the consortium for the Expanded Impact Project in Rwanda. Together they discussed the latest challenges and lessons learned in their attempt to reduce child mortality by addressing the three leading direct causes of death in children under five—malaria, diarrhea, and pneumonia—through community-based approaches and improved linkages with health facilities. Participants discussed progress towards integrating home-based management of fever and community case management with Community Integrated Management of Childhood Illness (C-IMCI) and into the overall Community Health System of the Ministry of Health, including looking at how the C-IMCI framework could be changed to better address some of the challenges identified.
Expanded Impact Child Survival Program in six underserved districts in Rwanda
Nutrition Working Group
The Nutrition Working Group continued to highlight useful nutrition assessment tools. The presentation showcased Food for the Hungry's Local Determinants of Malnutrition tool and was followed by a discussion of experiences and the implications of using new food products to address undernutrition.
Local Determinants of Malnutrition: An Expanded Positive Deviance Study
TB Working Group
Khrist Roy, Technical Advisor, CARE
Janet Hwang, Program Associate, CARE
Jennie Quick, Governmental Affairs ManagCommunity Mobilization: Indonesia MITRA TB Projecter, PSI
The session provided a snapshot of diverse activities led by CORE members, with specific activity descriptions/results for these organizations and open discussion time for other members/organizations that briefly brought the group up to date on current TB activities. CARE colleagues presented results from the MITRA project in Indonesia, focusing on two key aspects of this activity. First, they described the project’s success with the pagyuban (TB support groups) as the social mobilization and advocacy platform for DOTS TB in Indonesia. This model has been recognized and showcased nationally by the MoH. The MITRA training curriculum and modules for treatment observers and treatment observer supervisors were also be presented during this session. These modules (adapted version) were accepted by the MoH for national replication.
Community Mobilization: Indonesia MITRA TB Project
Jennie Quick provided an overview of PSI's tuberculosis activities, with a significant focus on how PSI uses private-public partnerships to provide DOTS in Myanmar and Pakistan. She will also discuss HIV/TB integration activities in southern Africa, focusing on Zimbabwe. The group also discussed the draft CORE Group initiative focusing integration of disease specific services at the community level.
Working Group Showcase and Planning for HIV, M&E, SMRH, and SBC Working Groups
HIV Working Group
Addressing Adherence in Resource-constrained Settings: Models of community success
Shannon Senefeld (CRS) and Janine Schooley (PCI), Moderators
Martine Etienne, University of Maryland School of Medicine, Institute of Human Virology
Community Adherence within a Multi-country HIV Treatment Program
Martine Etienne, University of Maryland School of Medicine, Institute of Human Virology
The presentation focused on the recently developed adherence curriculum entitled “A Guide to Providing Highly Supportive Antiretroviral Treatment and Maximizing Adherence in Resource-Limited Settings” which is being used in all of the AIDSRelief/PEPFAR programs. The development process included conducting focus group discussions to help target some of the factors associated with adherence of patients on antiretroviral treatment. Through this process, a Patient Adherence Survey, which is currently being used as part of the evaluation of patient adherence in the AIDSRelief/PEPFAR countries, was designed and piloted.
Community Based Treatment Support Services: The Treatment Support Arm of the AIDSRelief Program
The HIV Working Group also discussed its role and ideas for CORE Group’s Integrating Infectious Disease Programming Initiative.
Monitoring and Evaluation Working Group
James Ricca, Senior Sustainability & Tuberculosis Control Advisor, NGO/PVO Support Team, Maternal Child Health Integrated Project, ICF/Macro International
The vision of the M&E Working Group is to develop new and improved tools and trainings to increase child survival and health program performance and quality through the standardization of use of data, analysis and reporting. M&E is a cross-cutting discipline that touches all aspects of child survival and health programming including IMCI, SMH/RH, TB, HIV/AIDS, SBC, and malaria. This year the M&E WG has been focusing on improving the methods of measurement of equity for NGOs, an effort being led by Jennifer Luna, a Senior Advisor of M&E for MCHIP, through ICF Macro which has been working on methods of incorporating equity into program design.The M&E WG has also been working on improving methods of measuring mortality and community capacity.
The WG Showcase featured Jim Ricca from ICF Macro. Through the MCHIP project he has been developing a new “Contact Intensity” population survey that may be included with KPC or other surveys. The purpose of this survey is to show the effects of CARE Groups and other similar methodologies on the frequency of contact with health personnel and/or the frequency of attendance at community meetings in which discussing child health with mothers is the focus. These results may also be correlated with other health outcomes measured in the KPC survey in order to determine the effect that increased contact has on these intervention methodologies. The discussion contained results from a pilot study that was performed in Liberia by Todd Nitkin and Medical Teams International.
In addition, Jim Ricca has been developing a new “toolkit” through the MCHIP project with five tools for health facility assessment for MNC programs. It was originally developed for national MoHs but is very appropriate for CSHGP projects. It has just been field tested it in Kenya and Ethiopia. Presently the paper forms are finalized and a PDA application is now being developed, along with all the supporting materials: a manual, tabulation plan, and a sample report.
Safe Motherhood and Reproductive Health Working Group
Judy Lewis, Haitian Health Foundation; Director, Global Health Education, Professor, Departments of Community Medicine and Pediatrics, University of Connecticut School of Medicine
William Brieger, Professor, Johns Hopkins Bloomberg School of Public Health, Senior Malaria Specialist, JHPIEGO; Certified Health Education Specialist
Lindsey Grenier, Midwifery Advisor, American College of Nurse Midwives
The Safe Motherhood Reproductive Health Working Group showcased programs to save the lives of mothers and newborns. These presentations provided critical information for reaching MDGs 4 and 5.
“Saving Haiti’s Mothers”, a documentary produced by NOW on PBS which aired on January 29 2010, discusses the issue of maternal mortality pre-earthquake. It presents several innovative approaches to improving access to skilled care. The documentary provides an overview of global maternal mortality as well as several programs in Haiti, including CORE’s own Haitian Health Foundation.
Nigeria has very high maternal and neonatal mortality rates. William Brieger presented the outcomes of a final project evaluation in Nigeria which was directed at improving antenatal care access and utilization.
This program incorporates volunteer community outreach workers to increase antenatal care utilization. Training and monitoring of focused antenatal care improved all aspects of service quality.
Community Directed Interventions to Improve Malaria in Pregnancy Control Services in Nigeria
Lindsey Grenier presented materials from the new edition of Home Based Life Saving Skills (HBLSS) which has been developed in collaboration with CORE SMRH Working Group. She also Showcased the ACNM-CORE Maternal/Newborn Health Initiative.
HBLSS: Improving on Innovation
Social and Behavior Change Working Group
The SBC working group shared new information on the following:
1) new results on the power of Partnership Defined Quality in three countries including a case control comparison;
2) an update from the Powerful to Change group on the factors that make successful exclusive breastfeeding programs;
3) the unveiling of the AED Kit for integrating WASH into HIV Programs. The kit includes capacity building materials, job AIDS, monitoring and evaluation indicators and other treats;
4) plus breaking news on the top four reasons to volunteer for a Working Group!
Barrier Analysis Survey: Working Group Participation
Meeting the Water, Sanitation and Hygiene Needs of People Living with HIV/AIDS and their Families
Concurrent Sessions
We've Collected the Data. Now What? A tool for health systems strengthening through entering, cleaning, analyzing and using Infant and Young Child Feeding (IYCF) data
Kirk Dearden, Consultant and Associate Professor, Boston University
Bethann Witcher Cottrell, Director, Child Health and Nutrition, CARE USA
Carlos Rojas, Senior Advisor, Monitoring, Evaluation and Advocacy, CARE (invited)
Worldwide, more than 9 million children under five years of age die each year. Malnutrition underlies a majority of these U5 deaths. Extensive research has contributed to global feeding recommendations to maximize health for infants and young children. Recent WHO work identifies appropriate indicators of optimal infant and young child feeding (IYCF) behaviors but until now, there has been little specific guidance about how to collect and use these data, especially at the field level where implementing agency staff are best situated to make changes to programs.
The Step-by-Step Guide presented in this session provides instruction to help CARE staff and personnel from other agencies adapt WHO operational guidance for use with smaller-scale surveys among children 0-23 months of age. The Guide provides assistance with the selection of indicators, choice of sampling strategy, entering and cleaning IYCF data, and analyzing the data and reporting the results.
The Guide and accompanying tools are designed for staff from implementing agencies who collect data on IYCF behaviors as well as people who collect data on other topics. While the examples used in this Guide focus on IYCF practices, the Guide can be used by staff working in other content areas as well.
Partnership Defined Quality - Act it out!
Bonnie Kittle, Independent Consultant
Beth Outterson, Director, Adolescent Health, Save the Children
Have you heard about Partnership Defined Quality (PDQ) but you're still confused about how it works? Have you thought about using it to improve the quality of care in your health facilities but you weren't exactly sure what it entails? Come to the Acting It Out - Partnership Defined Quality session facilitated by Beth Outterson and Bonnie Kittle where we'll be acting out the steps of PDQ. This entirely participatory session had participants experiencing the PDQ steps for themselves.
Partnership Defined Quality: Acting it Out!
Community Water Supply and Sanitation Solutions
Elynn Walter, Program Director of Global Water, Health and Schools for Water Advocates introduced the session, which included presentations from the Hygiene Improvement Project (HIP) and CORE Group members PSI and PATH.
HIP Community Sanitation and Hygiene Approaches
Sarah Fry, Senior Hygiene Programming Advisor, Hygiene Improvement Project, AED
Traditional responses to the rural sanitation crisis which treat communities as beneficiaries rather than consumers have clearly not worked; providing subsidized, “one-size-fits-all” latrines through development programs has proved unsustainable and ineffective.
Recognition of past failures and growing recognition of the impact of poor sanitation on all sectors has fostered new and innovative approaches to rural hygiene and sanitation improvement such as Community Led Total Sanitation (CLTS) and customer-centered sanitation marketing.
The USAID-funded Hygiene Improvement Project works at scale in Ethiopia and Madagascar and on a smaller scale in Uganda and Peru, where sanitation innovations are being put into practice and are yielding lessons. CLTS builds on participatory approaches implemented by many CORE members and is a process by which communities confront their own defecation practices and launch collective sanitation actions motivated by disgust and shame. In Ethiopia, HIP has found that CLTS is most effective coupled with more intensive behavior change support through outreach workers ‘negotiating’ small doable improvements over time. In Madagascar, Uganda and Peru, HIP creates demand for sanitation through CLTS, community mobilization, household-level BCC and mass media channels, but also stimulates local supply of a range of hygiene and sanitation products through commercial channels such as hardware stores, small cement factories, and local trained masons, for consumers to purchase and enjoy. Creative public private partnerships (PPP) are also extending the availability and affordability of community sanitation facilities. Another aspect of HIPs rural sanitation improvement includes a focus on “WASH friendly” schools and health centers that combine CLTS and WASH improvements. In all program activities, handwashing with soap is integrally linked to sanitation promotion and ensures maximum health impact from improved household and community activities.
Sanitation Innovations - Hygiene Improvement Project
PSI Diarrhea Prevention and Safe Water Approaches
Megan Wilson, Child Survival Program Manager, Population Services International
PSI’s diarrheal disease programs promote healthy behaviors by educating individuals about purifying drinking water in the home, practicing improved hygiene, and offering treatment for diarrheal disease if a child falls ill. PSI and its many partners are working together to promote the Safe Water System, a water quality intervention that employs proven, easy-to-use and inexpensive solutions appropriate for the developing world. The Safe Water System (SWS) was developed by the U.S. Centers for Disease Control and Prevention (CDC) in 1996. The objective of the Safe Water System is to make water safe to drink at the household through chlorine-based household water treatment and safe storage at the point of use.
Household water treatment and safe storage (HWTS) ensures that each sip of water is safe to drink. HWTS can be adopted quickly, inexpensively, at national scale in both development and emergency situations, making an immediate difference on the lives of those who rely on transporting to and storing water in their homes. HWTS works to address water quality issues while complementing water supply, hygiene, and sanitation interventions. This approach was highlighted in the 2003 UN World Water Development Report as the most cost effective water purification solution.
Preventing recontamination of drinking water through the residual protection of chlorine, HWT keeps properly stored water safe for 24 hours after treatment. Through numerous field-based studies, chlorine-based HWT prevents new episodes of diarrhea on average of 50%.
PSI Diarrhea Prevention and Safe Water Approaches
PATH’s Household and Community Water Treatment Approaches Lorelei Goodyear, Senior Program Officer, Safe Water Project Evaluation and Research, PATH
In resource-poor settings, water often comes from unsafe sources and carries deadly pathogens. The World Health Organization estimates that 1.8 million people die each year from diarrheal diseases, many of which are attributed to unsafe water. Safe drinking water is one of the United Nations Millennium Development Goals—by 2015, the United Nations hopes to decrease the proportion of people without sustainable access to safe drinking water by 50 percent. Household water treatment and safe storage (HWTS) systems are among the most simple, acceptable, affordable, and effective methods of getting safe drinking water to people who need it. If they can be provided at a reasonable cost and with education and service to low-income populations, more people will have access to safe water. They will also be more likely to use HWTS systems correctly and consistently, thereby reducing disability, illness, and death related to unsafe water.
Through the Safe Water Project, PATH is exploring the potential for commercial enterprises to sustainably produce, distribute, sell, and maintain HWTS consumer products to low-income populations. During the five-year lifespan of the project, PATH and its collaborators in India, Cambodia, and Vietnam are testing the effectiveness of several commercial strategies for providing HWTS. PATH is also working with companies to develop new, more affordable technologies for low-income households based on its understanding of user needs in developing countries.
As an alternative to household water treatment, PATH is field testing a smart electrochlorinator for small batch production of highly active chlorine. This fosters micro-entrepreneurship within low income communities, and provides a safe water source for the community at large. The organization believes more households will drink safe water if there are more alternatives for treating water.
PATH's Approach to HWTs and Community Water Solutions
Retention, Attrition and Motivation of Voluntary Workers in Community-based Programs
Peter Winch and Anne Palaia, Social and Behavioral Interventions Program, Department of International Health, Johns Hopkins Bloomberg School of Public Health
Implementation of community-based programs frequently depends on unpaid or minimally compensated workers. Data on factors affecting the motivation and attrition of these volunteers were presented from three studies. In an evaluation conducted during the start-up phase of a study on community-based voluntary counseling and testing services in rural Tanzania, the degree of pro-social motivation, programmatic support and expectations of remuneration were found to be important influences on motivation and attrition. The second study was a systematic review of experience with volunteer motivation and attrition in HIV/AIDS programs. The evidence base was found to be thin. Of 2,659 potentially-relevant abstracts identified, only eight provided primary data on HIV/AIDS volunteer attrition in a low- or middle- income country. None of these interventions offered a clear definition for attrition. The third study is an analysis of factors affecting attrition of community health workers in a newborn care intervention study in Sylhet District, Bangladesh. This latter study highlights the interplay between individual, household and community-level factors.
Retention, attrition and motivation of voluntary workers in community-based programs