Child Health Initiatives for Lasting Change in Ethiopia - CHILD-E
Project Description:
This CS Program strategy will focus on three interventions: Nutrition (35%), Acute Respiratory Infections (35%) and Control of Diarrheal Diseases (30%) within the MOH’s national program of Integrated Management of Childhood Illnesses (IMCI). The project objectives, indicators, measurement methods and planned activities are included in the Program Matrix (Logframe) in section 7: Performance Monitoring and Evaluation.3b1. Goal The goal of the CS Project is to improve the health status of children under five and of women of reproductive age in Farta, Ethiopia. Specific Objectives of the CS program include:• Healthy behaviors are practiced and appropriate medical care is sought as needed by caregivers of children under 5 years and women of reproductive age, especially pregnant and lactating mothers.• Increased sustainable access to health education, quality care and essential medicines (from government, private health sectors, private institutions, and partner organizations).• Appropriate case management of diarrhea, pneumonia and malnutrition is practiced by government health personnel, CHAs, CHWs (including CBRHAs and TBAs) and other service providers.• Local and community-based institutions and local partners are strengthened and demonstrate the capacity to support child survival activities on a sustainable basis.3b2. Program StrategyThe CS Program will work in Farta in the following strategic areas: Skill development of health staff, a group of core staff within the partner organizations, community health agents (CHAs), community leaders, CHWs (including TBAs and CBRHAs), school clubs, women’s groups and other community members to improve communities' access to information and health care services. Community mobilization to promote ownership through active involvement and support to religious leaders, traditional healers, women's groups and influential community leaders.Improve access and availability of services and supplies by strengthening formal and private sector health systems. Behavior change communication (BCC) approaches to promote healthy practices at the community, family and individual level. Quality assurance for service delivery by use of COPE, supportive supervision and promotion of facility management committees.Skill DevelopmentCARE is working with the regional and zonal MOH officials to strengthen the skills of MOH health staff in the facilities by providing training in the MOH approved “IMCI refresher course.†This training course and supervisory support will prepare the 135 MOH staff of Farta to provide case management for ARI, CDD and Nutrition in the hospital, health center, health stations and health posts. To strengthen the skills of CS partner institutions, CARE and the MOH will work closely with the partners to form technical “Core Teams.†These partner institution Core Teams include the Health Unit in the Orthodox Church, the School Clubs leadership team within the MOE Schools and the Student-Teacher leadership club in the Nurse Training Center. Each Core Team will train and support other teams/groups within their organization to organize communities, provide health information and to influence behaviors for care seeking, home based care and address harmful health beliefs and taboos. Community mobilization to promote ownershipThe Core teams will train other groups in the community, such as traditional healers, women’s leadership groups, school teachers, TBAs, religious leaders and community leaders who will in turn inform and promote behavior change in the communities. This approach to skills enhancement will require that each partner makes a serious commitment and assumes responsibility to expand training within their institution. CARE will also build on current activities of the partner organizations. For example, the EOC, the MOE and the GTZ/PRHE have recently been trained/oriented and are actively promoting behavior change in HIV/AIDS. They are already organizing communities for immunization campaigns and distribution of Vitamin A. The Core Team within each partner organization will work closely with CARE and the MOH to expand the training capacity among their members. It is expected that three-day orientation and refresher sessions will be provided for religious leaders, schoolteachers, community leaders, women’s leadership groups and other influential groups. This training would improve their skills to provide health information and to influence health behaviors in the community on disease prevention, ARI care seeking behavior and home based care, CDD home based care and nutrition interventions. Improve access and availability of services and suppliesCARE and the MOH will also work to strengthen the health systems to improve availability of services and supplies in health facilities in support of improved case management for ARI and CDD and to support the Nutrition intervention. This will include providing training for improving the logistics, management and the Health Information Systems (HIS). CARE will work with the MOH to conduct health facility assessments to identify procurement, logistics, supplies/equipment, staffing, supervision and other factors needed for support to the CS interventions (e.g. antibiotics for pneumonia case management, ORS and IMCI treatment protocols). CARE anticipates using two innovative approaches to improving availability of supplies. The first is through a revolving drug fund to establish ‘special pharmacies’ to support ongoing access to essential supplies and medications. The revolving fund will initially be established through seed money provided by the CS Project. CARE will also work with community leaders to investigate if the traditional "Idir/funeral " funds can be expanded to include community support for accessing funds to cover the purchase of emergency medications and basic supplies. To improve availability to services, the CS Program will train and support a limited number of CHAs to provide health information and community based case management. The CS program will also strengthen the health system by organizing health facility management committees to support and guide health facilities and improve community surveillance to better serve the communities.Behavior change communication (BCC)To support the CS interventions and complement the technical training of staff and community organization leaders, the CS Program will develop a strong Behavior Change Communications (BCC) approach. This will include reviewing the data from DHS, MOH, CARE's PRA, and other sources on the key intervention behaviors. Additional data will be collected through a KABP, health facility assessments, partner capacity assessments and qualitative research to identify the factors that support and/or present barriers to local beliefs and behavior change. After gathering and analyzing the available data, CARE will work with the MOH and Partner Core Teams to translate the CS objectives into behavioral terms, identify barriers at the community, health facility, partner and policy levels that realistically can be addressed in the CS Program. CARE will provide the technical leadership to develop the BCC approach and the materials for training and for mass media, and media campaigns in schools based on audience segmentation. BCC materials from the ESHE Project, World Vision, Save the Children, GTZ and other PVOs will be reviewed for their appropriateness for training health staff, CHAs and community members as needed for the Farta area. CARE may need to develop some BCC materials for training religious leaders and traditional healers. These materials would support these two groups to provide health information and reinforce behavior changes to their members and clients through their frequent contact in the community. In the schools, the CS Program will be used to strengthen the already existing student and faculty teacher clubs who promote health information, conduct peer-counseling sessions and provide outreach into the community during campaigns. The CS Program will also assess the potential for using the market places in Farta as a channel for BCC. Quality assurance for service deliveryTo provide Quality Assurance (QA) for service delivery strategy, CARE with an external QA consultant, will work with the MOH to assess the status of the quality of service delivery and define the QA approach. The assessment will include the Core Team's review of the current MOH facilities' technical guidelines/algorithms, data collection systems, management and supervision systems used in the Farta facilities. This will promote self-analysis of the problems, identifying realistic priorities and obtaining their commitment to a QA plan. Building on CARE Ethiopia’s work to date, community leaders, representatives and clients will be interviewed to assess their perceptions of the quality, physical environment, customer service orientation of health providers and other indicators of quality. The proposed project will strengthen the capacity for district planning and management and improve referral linkages to deal with problems of pneumonia, diarrhea and nutrition in an integrated manner. The CS program will also strengthen the health system by organizing health facility committees to support and guide health facilities to better serve the communities. The QA assessments will provide the information base to develop the approach and train a core team of key staff in each MOH health facility on the principles and concepts of quality of care and commit them to implementation. Since the number of MOH staff in Farta is very limited, and the participation of partner institution Core Teams is vital, CARE plans to train the MOH staff together with Core Team members. This expanded core team, with the MOH staff as leader will train other MOH staff at all levels (from senior managers to administrative clerks) on specific quality improvement tools such as the COPE (Client-Oriented Provider-Efficient) tool and introduce these tools to each health facility. Close monitoring of improvements in quality is planned involving teams in self-assessment in each facility with their partners and representatives of the community. The QA plan for each facility will be developed with realistic timeframes. CARE plans to encourage public recognition of facilities that make progress in quality improvement to maintain momentum through such activities as cross visit opportunities, continual follow-up and possible accreditation of health facilities based on a certain pre-determined MOH standard.In addition to the health behavior change with the community-based organizations, the CS Program will address needed behavior changes of the health providers at all levels in Farta. This would include addressing behaviors to improve the quality of their interaction with clients as well as providing them health messages and related communications skills to provide health education at the facilities and in community outreach. To develop the baseline for the health provider behaviors, information from the health facility assessment, direct structured observation and client exit interviews will be used. 3b3. Pilot Strategic InitiativesPilot testing for CHAs in ARI and CDD -- The CS project will pilot the training of forty community health agents (CHAs) for one week in ARI and CDD case management and nutrition interventions. They will then receive follow up refresher training and supervision to assure proper case management in their communities. This focused training will follow after CARE has worked with the MOH to train the CHAs in the basic three month training (currently Farta has no trained CHAs). CARE will also seek permission from the MOH to pilot dispensing antibiotics by CHAs. MOH staff will closely monitor this with support from CARE. Currently, the national policy states that CHAs are not permitted to dispense antibiotics. However, some other PVOs in Ethiopia are piloting the use of CHAs for case management. CARE plans that the CHAs will provide ARI and CDD case management and nutrition intervention and promote preventive health activities in Farta. The MOH standard is that CHAs will initially be trained and "supported" by the CS Program/NGOs and later absorbed into the MOH structure with a small stipend. The role of the CHA, therefore, is not as the typical volunteer but will act as a health provider and an extension of the health delivery system in the communities. The CS Program will work to mobilize the community to "support" these volunteers or they may be allowed to maintain a margin of profit from the sale of pharmaceuticals. Although the use of 40 CHAs appears initially low, it effectively doubles the number of health providers outside of the hospital facility. This allows a ratio of 1 CHA to 7,500 population, which is high, but the MOH should be able to absorb them and therefore sustain the CHAs after the NGOs’ initial training and support. If the model is successful, additional CHAs can be added in the final years of the program. There is a history of this type of support in other CARE projects in Ethiopia. 3b4. Local Partners’ Role The local partners in Farta will play a very active role in the CS Program. During extensive collaborative meetings, each partner confirmed their continued interest and intent to participate in the CS project; each partner has provided a letter of support/partnership indicating that they will be working with CARE on the proposed CS project.The MOH leadership at the regional and zonal levels will technically guide the project using MOH norms, standards and protocols. In addition, they will actively participate in the Training of Trainers and work closely with CARE to train and supervise in data collection and analysis of baseline data. They will also play an active role in training, managing, supervising and monitoring health facility staff and community based health providers to improve service delivery and outreach. The EOC through its Health Unit will play a role in curriculum development and training of community volunteers and women in home based care based on trained staff and its experience in HIV/AIDS work. EOC will work to open its large network of religious leaders to incorporate CS messages in their HIV/AIDS health education, and visits to homes and interactions with their church members. Faculty and students from the Nurses Training Center will assist in expanding MOH outreach into the community and help to staff health facilities to provide services. Their established Health Club (of faculty and students) will support community mobilization and provide health education in local schools and in communities. The MOE will provide their already formalized School Clubs to do expand community mobilization to include outreach health services. They have offered to be agents of change and to disseminate health information to families and communities. They will present drama, skits and art projects to spread health information and influence behavior change in the communities. The GTZ/PRHE Health staff will assist in training heath staff and community volunteers. They will also provide technical support to develop BCC and health education materials and radio messages. Using their prior experience with orienting the local press, GTZ/PRHE will work with CARE to expand advocacy efforts for increased health services for the population. In addition to these, CARE will work with the association of traditional healers in the Amhara region. The modalities of this collaboration will be dealt with during the DIP preparation stage. 3b5. Program Relationship with other health-related ProgramsCARE Ethiopia is working on several health-related initiatives/projects throughout Ethiopia including the MICAH project (described below). This project will be introduced in Farta soon and will complement the CS program. (Please refer to Attachment B for a list of pending health related proposals and pending proposals in the program area).The MICAH ProjectCARE has proposed a three-year micronutrient project, MICAH, starting in March 2002, funded by World Vision International that will be implemented in the program area as well as in two other zones of the country. This program will promote vegetable gardening, distribute Vitamin A, Iron and Iodine supplementation, dietary diversification, construct water supply and sanitation facilities, improve treatment of common illnesses (deworming and malaria) and strengthen the CS project area. The CS project will link with the MICAH project to increase the distribution of deworming medication beyond the 10 MICAH Kebeles and into the remaining 30 CS Kebeles. As deworming pills are provided free of charge, CARE will use the supplements to impact child nutrition through the CS project. The MICAH interventions nicely complement the CS interventions and, therefore, project expenses for MICAH will be used as a match for the Child Survival Program. The ESHE (Essential Services in Health in Ethiopia) ProjectThe CS project will link with the MOH’s national ESHE (Essential Services in Health in Ethiopia) Program, with TA from John Snow International (JSI) and program areas in the south. This relationship will allow the CS Program to use and benefit from the technical approaches, training curricula and management materials developed, tested and being used in the one of the largest regions of Ethiopia (SNNPR). CARE and partners will visit and interchange with their peers in the south. In addition, the opportunity exists for partners to participate in a health facilities and services improvement assessment before the CS Project starts. 3b6. Plans for health policy-related advocacy and activities with coalitions of NGOsCARE's CS Program will support policy-related advocacy on issues such as changes in the national guidelines regarding the use of antibiotics and distribution of iron and vitamin A by CHAs. CARE plans to analyze its issues and information working closely with its CS partners to assure a strong analytical basis for their position.Although there are a limited number of NGOs in Farta, the NGO Network at the national level includes World Vision, Save the Children, etc. with information and contributions from projects such as FEMME, the Reproductive Health Project and NGO Networks. CARE Addis can share lessons learned from the CS program and discuss opportunities for informing GOE policy makers. 3b7. Training Approach CARE will work closely with the MOH officials at the regional and zonal level to provide competency-based training to health staff at all levels and for Partner Teams and a number of community groups. Although CARE’s CS project is not specifically IMCI focused (Integrated Management of Childhood Illnesses), CARE will work with partners to review and revise the already developed and adopted MOH/ESHE IMCI refresher course package used in the MOH/JSI effort in the Southern Zone of Ethiopia. The course focuses on a one-week training of staff in an integrated approach to child health interventions. This "IMCI Refresher" course requires that the Trainers have already been trained in the full IMCI course and have had experience and are competent in IMCI case management. Fortunately, the regional and zonal level staff in the CS Program area in Farta have been trained in IMCI and will be a strong part of the CARE/MOH IMCI core training team.
