Geneva Health Forum Archive

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Integrating HIV Commodity Supply Chains to Prevent Mother to Child Transmission Scale Up in Nigeria.

Author(s) Chioma Nwuba1, Sunday Aguora2, Ogubuike Inmpey3, Elvis Okafor4, Okechukwu Agbo5, Vincent Ihaza6.
Affiliation(s) 1HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 2HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Abuja, Nigeria, 3HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 4HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Abuja,Nigeria, 5HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria, 6HIV/AIDS, Supply Chain Management Systems, John Snow Inc., Enugu, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Health Systems
Summary Reduction in the rate of mother to child transmission of HIV in Nigeria depends on the availability of antiretroviral (ARV) drugs and HIV test kits in sufficient quantities at service delivery points.
The challenge of multiple storage and distribution channels for HIV commodities, late submission of reports, coupled with low commodity delivery coverage of rural clinics has led to pregnant women travelling long distances to access ARV treatment at urban hospitals.
Integrating existing supply chain management systems to prevent stockouts of essential commodities is crucial for preventing new HIV infections among children and for improving the lives of HIV positive pregnant women in Nigeria.
What challenges does your project address and why is it of importance? Globally, the gap for pregnant women receiving antiretroviral (ARV) medicines for the prevention of mother to child transmission (PMTCT) of HIV is 80% and Nigeria alone accounts for 32% of this gap. In addition, Nigeria has the largest number of children acquiring HIV infection with nearly 60,000 children infected with HIV in 2012 alone.
Thus, ensuring that all pregnant women receive access to HIV testing services and anti-retroviral treatment if tested positive is a priority for achieving PMTCT targets in Nigeria. The current system for collection and transmission of logistics management information system (LMIS) reports, from service delivery points at rural clinics to the central medical store, are complex and labor intensive. As a result, report submission is often delayed, leading to stockouts of critical HIV/AIDS commodities and a reduction in the number of pregnant women who have access to the much needed life-saving antiretroviral treatment.
In addition, multiple storage and distribution channels are often uncoordinated, and this has resulted in stockouts of commodities at some health facilities when there are excess stocks at other facilities.
How have you addressed these challenges? Do you see a solution? In order to improve access to HIV testing services and antiretroviral drugs for HIV positive pregnant women, at 471 rural clinics in five focus states, the USAID funded SCMS project of John Snow Inc. in Nigeria implemented the following data driven interventions: Integrated existing parallel HIV/AIDS commodity management system in the region to form a unified system for procurement, storage and distribution of commodities.
 Integrated collection and analysis of LMIS reports with already existing data collection systems thus facilitating timely report submission which informs resupply decisions to health facilities offering PMTCT services.
 Established an axial storage location within the region for storage & distribution of HIV/AIDS commodities to health facilities.
 Strengthened capacity and skills of community health workers on logistics management of HIV/AIDS commodities through on-site training and mentoring on the use of logistics management information system (LMIS) tools, standard operating procedures, good storage practices and quality improvement processes for efficient delivery of PMTCT services
 Introduced simplified reporting forms to aid community health workers in the collection and timely submission of accurate consumption and requisition reports.
 Initiated bi-monthly cluster review meetings which provides a forum for community health workers to have access to continuing education on the management of HIV commodities, review logistics management information reports, share best practices and address challenges.
 Increased collaboration with government agencies and implementing partners to support LMIS report collation and to address stock imbalances through timely inter facility transfer and redistribution of commodities to avert stockouts and reduce wastages due to expiration.
 Commenced monitoring and supportive visits to monitor quality of services delivered and strengthen the performance of health workers at service delivery points.
 Challenges and issues identified at service delivery points are shared with health facility management teams and the regional technical working group who proffer and implement solutions to address these challenges.
How do you know whether you have made a difference? At the end of six months, the reporting rate for ARV drugs increased from 28.7% to 60% while that of HIV test kits increased from 30.4% to 63.7%.
Due to improved availability of rapid test kits, the number tested for HIV increased from 39,044 before intervention to 79, 384 after intervention. Subsequently, the quantity of test kits ordered increased by 98.5% post intervention.
Integration of all existing HIV/AIDS commodity management systems in the region has resulted in improved commodity security of HIV test kits and ARV drugs thus ensuring continuous availability of these commodities for HIV positive pregnant women and children. Furthermore, the introduction of a simplified HIV commodity reporting form which harmonizes collection of data on ARV drugs and HIV test kits has made it easier for community health workers in rural clinics offering PMTCT services to report consumption of commodities and to make requisitions for re-supply.
The cluster review meetings have improved quality of logistics data as well as the collection and timely transmission of such data required for resupply decision making, resulting in increased availability of HIV-related commodities and improved quality of care.
Have you or the project mobilized others and if so, who, why and how? The outcome of our interventions and lessons learned were adopted during the implementation of the third phase of the HIV/AIDS Supply Chain Unification Project , which covered seven states in the South Western region of Nigeria. It integrated all existing HIV/AIDS commodity management systems in the region aimed at improving commodity security in the supply of HIV rapid test kits and ARV drugs. We commenced by convening a stakeholders meeting with the state ministry of health, implementing partners and other relevant agencies on the need to harmonize the warehousing and distribution of HIV commodities to all service delivery points. The importance of HIV testing services especially for pregnant women and the outcome of treatment interruptions due to stock-out of essential ARV drugs was discussed.
Health workers at service delivery points were trained on the logistics management of HIV/AIDS commodities, use of standard operating procedures, logistics management information system (LMIS) tools and good storage practices.Bi-monthly reports on consumption and requisition of commodities are reviewed during cluster review meetings thus ensuring that commodity requests sent to the central level more accurately reflect health facility needs and, consequently, decrease the occurrence of stock imbalances (under/over stocking) which could result in stockouts or wastage due to expiration and damage.
When your donor funding runs out how will your idea continue to live? This program was executed in collaboration with the Federal/State Ministry of Health (HIV/AIDS Division), National Agency for the Control of AIDS and relevant stakeholders of each participating state. Government ownership and leadership of the program is facilitated through the Procurement and Supply Management Technical Working Group (PSM TWG) which is government driven and has representatives of each participating state as members.
This group conducts regular on site monitoring and supportive visits to health facilities in the region where they review performance of the supply chain system at various facilities, assess program implementation, identify and addresses challenges relating to the management of health commodities and quality improvement of supply chain processes in the region.
The government driven PSM TWG also advocates for funding support from respective state governments while seeking ways to improve overall program efficiency.Furthermore, to facilitate ownership and sustainability, each state is actively involved in the collection, transmission of LMIS reports and inter facility redistribution of commodities to health facilities within their states through the state logistics management team.
Working closely with relevant key stakeholders, we hope to achieve government’s leadership and ownership of the project in three to five years from now.

Integrating artistic programs in diabetes education and self management in Madagascar.

Author(s) Tojosoa Rajaonarison1, Haja Ramamonjisoa2, Tiziana Assal3, Jean-Philippe Assal4, Georges Ramahandridona5.
Affiliation(s) 1Art-therapy, Madagascar Diabetes Association, Antananarivo, Madagascar, 2Therapeutic Education, Madagascar Diabetes Association, Antananarivo, Madagascar, 3Art-therapy, Foundation for Research and Training in Patient Education, Geneva, Switzerland, 4Therapeutic Education, Foundation for Research and Training in Patient Education, Geneva,Switzerland, 5Medical, Madagascar Diabetes Association, Antananarivo, Madagascar.
Country - ies of focus Madagascar
Relevant to the conference tracks Chronic Diseases
Summary The Malagasy perception of diabetes is negative. Patient with diabetes often do not accept their treatment and their family members reject them. Heath caregivers need to be closer to patients and to promote a good collaboration with them.
Our Diabetic Association has organized up to 12 painting workshops from 2010 to 2013 with 141 patients. They are centered on patients’ problems and needs. Each workshop provides painting exercises associated with specific moments: blood sugar measurements, diet discussion, and hypoglycaemia. Health caregivers provide flashes of therapeutic education during this time. Workshops also provide psychological and social balance enabling patients to be more responsible for their health
What challenges does your project address and why is it of importance? Painting workshops are a tool to promote therapeutic patient education for all types of diabetics. Organized by A.MA.DIA. (Association Malgache contre le Diabète à Antananarivo), they have brought many changes in our participants’ lives: patients are finally able to express themselves more freely, they discover their personal creativity, they are more involved in social activity, they feel less isolated. This process has a strong effect on the coping ability of each patient. Adherence of treatment increases, medical appointments are better respected and the doctor–patient relationship improves. As a consequence, there is a general improvement of patients and care providers’ attitudes. They all feel more empowered in their daily activities. After the workshops patients feel that their family members understand them better.
How have you addressed these challenges? Do you see a solution? The A.MA.DIA has faced many problems over the years including crowded outpatient clinics, lack of enough fully trained personnel, difficulties in continuing education as well as being faced with false copies of medication: diabetic oral agent, antihypertensive drugs, and antibiotics. This situation has forced us to develop specific courses to teach patients to detect the copies of false drugs that patients may have bought cheaply at a local market.
Hypoglymia in children and young adults is another serious problem.
During the workshops with children, the blood sugar is tested and explanations are given about corrective snacks.
Another aspect is the timidity of patients in the presence of the care providers. The consequence is that patients suffer from a lack of psychological support.
Painting workshops reinforce continuing education as well as the self-reliability of patients.
They develop self-confidence and autonomy.
How do you know whether you have made a difference? The various activities we described, linked to therapeutic education, did not exist 4 years ago. Since their creation and development, there is an increasing demand for participation among patients as well as their families.
There is a weekly connection through skype between A.M.A.DIA and the Geneva center, and a monthly video sessions with the participation of experts who are at the disposal of the team of l’AMADIA Hospital. Those meetings allow joint discussions, lectures, supervision, continuing evaluation and support.
The experts have writen some observations about our workshops of Art-Therapy : “The thing that strikes all those who have observed the AMADIA workshops is the extraordinary enthusiasm and commitment of the caregivers and patients. Caregivers experiment continuously new ways of helping patients using art, working with different groups of participants: families, young diabetics, aged people as well as mixed groups."
The example of AMADIA shows that art can be integrated in a global system of care where emotional expression and medical care can be simultaneously present.
Have you or the project mobilized others and if so, who, why and how? Among the various approaches we have developed, we obtained help from the World Diabetes Foundation and the order of St. Jean France and Switzerland. This allowed the improvement of our Hospital AMADIA and the widening of detection campaigns throughout the country. We also have the benefit of monthly Video sessions with Geneva with the help Orange Madagascar and the Foundation for Research and Training for Patient Education in Geneva.
When your donor funding runs out how will your idea continue to live? We think that financial support from donors is of vital importance for the continuity of the painting workshops. Madagascar is a very low income country and so are the majority of our patients. Many people cannot even afford the cost of their daily pills.
However, psychological support is necessary for people living with diabetes. It is fully recognized that painting equipment colors, paper, brushes are expensive. This is why this type of practice should be supported.

Inclusive decision-making and community empowerment for health and well-being: The Health Promotion and System Strengthening Project in Tanzania

Author(s) Kate Molesworth1, Ally-Kebby Abdallah2
Affiliation(s) 1Swiss Centre for International Health (SCIH), Swiss Tropical and Public Health Institute, Zürich, Switzerland, 2Health Promotion and System Strengthening Project (HPSS) Field Office, Swiss Tropical and Public Health Institute, Dodoma, Tanzania.
Country - ies of focus Tanzania
Relevant to the conference tracks Advocacy and Communication
Summary This presentation aims to show how participatory techniques can be effectively embedded within government health and community development structures to successfully support community action for health and well-being and at the same time contribute to broader positive social change and equitable access to health services.
By using participatory techniques and at the same time mainstreaming gender, HIV and social equity, within the project itself, as well as at the community and government levels, the Health Promotion and System Strengthening Project (HPSS) takes a broad human rights, equity and inclusive approach, to improve the health and well-being of all members of the community.
What challenges does your project address and why is it of importance? The HPSS Project aims to improve the health status and well-being of all members of a community through innovative approaches, with a particular emphasis on the support of vulnerable people, such as women, children, elderly and socially disadvantaged. A special focus is to ensure that all aspects of project implementation and information will maximize the potential to include all sectors of society in community health promotion and address existing inequalities. However, most often communities - and in particular vulnerable groups - do not have an arena in which to raise their voice and address their health concerns, while the possibility of involvement is low.
The project therefore aims to empower communities and their members to identify and express their health needs and demand equitable access to appropriate health care and social services. By addressing local needs and supporting community action for health, the projects aims to establish sustainable community mechanisms and strongly link them with government and non-government structures for sustainable results that contribute to improve health and well-being of all people in the region.
How have you addressed these challenges? Do you see a solution? This presentation will demonstrate how the project translates the Ottawa Charter onto the ground in the context of Dodoma Region and report on early operational research outcomes of the Regional pilot for health reform.
In adapting the health and community development systems to strengthen health promotion, the project has negotiated adapted terms of reference and trained-as-trainers Community Health and Development Officers (CHOs and CDOs) as well as School Health Coordinators (SHC) in community participatory techniques and cutting edge health promotion approaches. As master trainers, with support of HPSS District Coordinators, these government cadres have rolled out a tailored training packages to their assistants, Non-Governmental Organizations (NGOs), Faith Based Organisations (FBO), Community Based Organizations (CBOs) and communities themselves. Following consultative workshops, regional governments agreed to expanded health promotion roles of the Region’s 152 CDOs and their assistants. They work together with Health Officers to support communities, through participatory methods, to identify local health concerns, as well as resources and to plan solutions. In this process the trained government CHOs and CDOs and SHCs facilitate communities to identify their health concerns and solutions in a participatory meeting of peer groups - disaggregated by sex and age as well as by concern groups – such as the disabled. After initial community-led discussions, facilitators showed discussion groups how to quantify their priorities and the group subsequently voted for their primary health concerns. The results of the sub-groups were then presented by the facilitators to the whole community in a final meeting, emphasising the very different priorities of men and women, and different age groups in the same community. This usually resulted in a direct community discussion and debate concerning different perceptions on health and well-being issues within the community. Following this, the community as a whole, facilitated by their trained CDO, prepared a community health promotion plan for presentation to local councils for inclusion within and funding with the Council Comprehensive Health Plans.
How do you know whether you have made a difference? In the process Regional authorities have raised the importance and profile of inclusive, participatory approaches by adding these duties to government staff terms of reference. The strengthening of health promotion, gender and social inclusion approaches within community led-processes has not only improved grass-roots level dialogue and action on local health and social concerns but strengthened the capacity and networking of community-based organisations. This has also set in motion means by which communities can not only take action to address issues in the local context, but access existing funding lines for community health activities. The Participatory Rural Appraisal (PRA) process has been rolled-out to all communities in the 7 districts of Dodoma region. Even at this early stage of the project, PRA outcomes resulted in community health action plans, which have been inclusively developed in more than 200 villages. A total of 220 health promotion action plans have been developed by communities in this way, reflecting 16 priority health-related themes.
By taking an inclusive approach that sensitises government and non-government facilitators, the solidarity and empowerment of traditionally marginalised and stigmatised groups including women, the poor, people living with HIV and affected by AIDS and people living with disabilities has also been strengthened.
Have you or the project mobilized others and if so, who, why and how? Approaches chosen within the HPSS Project have mobilized people on several different levels. Primarily, government CHOs, CDOs and SHCs were trained-as-trainers in facilitating community participatory techniques and cutting edge health promotion approaches. This has led to their expanded health promotion roles in accordance with the regional governments. The master-trainers have rolled out these techniques to all government staff and community organisations in the region. Applying a bottom-up approach, government officers facilitate communities to identify their health concerns and solutions in a participatory manner.
When your donor funding runs out how will your idea continue to live? The HPSS Project, implemented by the Swiss Centre for International Health (SCIH)/Swiss Tropical and Public Health Institute (Swiss TPH) on behalf of the Swiss Development Cooperation Agency (SDC), is subdivided into three project phases, namely a pilot implementation phase from the year of 2011-2014, a consolidation and scaling-up phase between 2015 and 2017 and the completion of a nationwide scale-up in the years of 2018-2020.
By training a cadre of master trainers within government and non-government structures in the first phase of the project in Dodoma region, novel inclusive approaches have been rapidly cascaded to the communities for complete geographical coverage. The inclusive, participatory techniques used effectively advocate for the different health priorities of various groups within community’s debates, inclusive action planning and ensure that these actions are funded and realised.
As approaches have been embedded in the skills and responsibilities of government staff, this allows the direct involvement of community members, in particular giving voice to vulnerable groups. These inclusive, participatory techniques are likely to be sustained and replicated as a nationwide scaling-up of the HPSS approaches and activities in subsequent phases. Furthermore, the project has developed and launched a short course (in June 2012) on participatory techniques for inclusive community action for health promotion at the Zonal Training Centre. This will contribute to sustainability by providing focussed training of development and health staff in the coming years and act as regional resource centre for these activities.

Improving governance and local level planning through community mobilisation: lessons learnt from Bangladesh

Author(s) Rumana Huque1
Affiliation(s) 1Department of Economics, University of Dhaka, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Advocacy and Communication
Summary Poor governance in the health sector is negatively influencing service delivery mechanisms in Bangladesh, which in turn results in low utilization of public facilities. Although the principle of strengthening effectiveness and accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups (CG) in rural Bangladesh, reviews to date have shown very slow progress in this area. The current project strengthened capacity of CGs through providing skilled based training. This enhanced the voice of citizens which inturn improved governance at CCs.
What challenges does your project address and why is it of importance? Poor governance in the health sector is negatively influencing service delivery mechanism in Bangladesh, which in turn results in low utilization of public facilities. Non-availability of drugs and commodities, imposition of unofficial fees, lack of trained providers and weak referral, feedback and monitoring systems contribute to low use of public facilities in Bangladesh. A number of other factors also adversely influence the service delivery mechanism. One such challenge is the inadequate participation of civil society in decision making processes. Evidence suggests that closed decision making processes in unequal societies can result in priorities that are biased towards elite interests and not adapted to the needs and priorities of the poor, which may have a negative impact on equity and social justice. Although the principle of strengthening effectiveness and the accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups in rural Bangladesh, reviews to date have shown very slow progress in this area. Out of 13000 Community Groups very few are functional, leading to inadequate participation of the poor in local level planning or initiating accountability.
How have you addressed these challenges? Do you see a solution? The project has strengthened the Community Groups through providing skilled based training to its members in four upazilas in two districts. It provided relevant information and data including potential sources of funding and information on changes in rules and regulations to CG members. The process contributed to developing self confidence among people in discussing and analysing issues, identifying a problem, visualizing disparities, understanding their entitlements, identifying their duty bearers, articulating issues, developing plans as a team to address their problems, and communicating this properly to the appropriate forum/platform. The project has created a better referral linkage of Community Clinics with Upazila Health Complex (UHC). The patients they refer get special attention and preference at UHC. Due to the monitoring of CG, CC remains open from 9 am to 3 pm six days a week. The greatest success the development of coordination between health care providers and clients, people now conceive as public health care facilities as being their property, the reputation of the CG members in the community has gone up and the utilisation of services and respect for providers at CC has also increased.
How do you know whether you have made a difference? Clearly this project created opportunities for capacity strengthening of the local political leaders as well as community representatives so that they become better informed on health issues. It contributed to facilitating the relationships of citizens with health providers and governments. This in turn has given a platform to improve the quality of information available to citizens and to raise their voices. The project has created a sense of ownership among the citizens in functioning CG's. Interaction between service providers and patients became informal which increased access to services. It reduced the ‘illegal’ operations such as absenteeism and misuse of drugs.
Have you or the project mobilized others and if so, who, why and how? The project has created a link between Community Clinics, which is under Ministry of Health and Union Council members, who are under Local government. Union Council Members now attends the monthly meetings of the CG and monitor their functioning.
When your donor funding runs out how will your idea continue to live? The project will be sustainability even if donor funding is withdrawn, as the community group members are adequately trained and have been empowered to conduct the activities without third party facilitation. A mechanism to generate fund through community mobilisation to meet some expenses as also been created.

Improving Global Health by Leveraging Corporate Value Chains.

Author(s) Asher Hasan1
Affiliation(s) 1Executive, NAYA JEEVAN, Karachi, Pakistan.
Country - ies of focus Global
Relevant to the conference tracks Advocacy and Communication
Summary NAYA JEEVAN collaborates with MNCs such as UNILEVER to cascade its "global health plan for the marginalized" up and down their Corporate Value Chain (CVCs), enrolling low-income stakeholders (suppliers, distributors, micro-retailers, informal domestic workers such as maids, drivers, etc) in a market-based retail incentive/loyalty program that can potentially serve the needs of 660 million lives globally.
What challenges does your project address and why is it of importance? In Pakistan and India, at least 800 million earn less than $3 a day. Like other developing nations, South Asian governments spend just 1.7%-3% of GDP on an under-resourced and overwhelmed public health sector. Consequently, 97% of all health care expenditures occur out-of-pocket and ‘catastrophic’ medical expenses (e.g. for heart attacks, pregnancy complications, etc) are a major precipitant of generational poverty. The three priority issues that low-income, marginalized populations have to contend with are: (i) Access, (ii) Affordability and (iii) Quality.
How have you addressed these challenges? Do you see a solution? NAYA JEEVAN’s accessible, affordable, quality healthcare plan for underserved communities has been cascaded by UNILEVER to over 2500 sales distributors nationwide and 400 microretailers (ice-cream wallahs) who lie at the end of UNILEVER's supply chain. UNILEVER has financed the annual health insurance program costs ($30/life/year) of these microretailers and their dependents in a tiered loyalty/incentive program in which the corporation pays a contribution for health insurance that is prorated to the performance of the retailer. This model can be replicated globally with a varying degree of Corporate co-financing/subsidy which is contingent on: (i) the strategic value of these supply chain partnerships (ii) the cost of the health plan in that specific market and (iii) the impact on their bottom line – i.e increased revenue/sales per dollar invested in this loyalty program. NAYA JEEVAN’s accessible, affordable, quality healthcare plan for underserved communities has been cascaded by Kansai Paints (a Japanese industrial/residential paint company) to over 200 small business painters who lie at the end of Kansai’s supply chain. Kansai has financed the annual health insurance program costs ($30/life/year) of these painters and their dependents in a tiered loyalty/incentive program in which the corporation has fully subsidized the health insurance plan of their loyal customers. This model can be replicated globally with a varying degree of Corporate co-financing/subsidy which is contingent on: (i) the strategic value of these supply chain partnerships (ii) the cost of the health plan in that specific market and (iii) the impact on their bottom line – i.e increased revenue/sales per dollar invested in this loyalty programNAYA JEEVAN’s health insurance plan includes:• Annual medical check-up, which promote the early detection of disease
• A 24-hour telemedicine helpline managed by doctors and available to all beneficiaries to handle any concerns or emergencies that may arise.
• A Health Rescue Fund, which assists beneficiaries for uninsurable conditions or when their hospital management/health care exceeds the maximum annual insurance coverage.
• Preventive Health workshops that detail the causes, symptoms, treatments and prevention against most common maladies to allow individuals to be better able to protect themselves and their families. Our workshops include: Healthy Heart – Keep your Heart Happy & Nutrition – How to Eat Right.
How do you know whether you have made a difference? NAYA JEEVAN has successfully enrolled over 23,000 low-income workers across more than 20 corporations into this incentive program. We have already enabled over 200 critical, life-saving interventions and over 5000 urgent medical consultations by mobile phone that would ordinarily have led to hospitalisation (the aversion of hospitalization has a major impact on worker productivity and health system costs that are saved.In addition to the above, we have conducted a baseline health risk assessment and are monitoring our members for the following outcomes:• Poverty alleviation – by reducing the financial impact of catastrophic medical expenses
• Reduction in Maternal/Child Mortality - through timely intervention and 24/7 access to ambulances, medical doctors, ERs, trauma centers, etc.
• Improvement in Primary Health Outcomes - through preventive health education and behavioral change workshops

• Mitigation of Child Labor/Sexual/Physical Abuse

Have you or the project mobilized others and if so, who, why and how? NAYA JEEVAN has engaged more than 5000 volunteers and stakeholders across the Corporate sector to sponsor the healthcare of children from NGO schools. Over 250,000 residents in an urban slum (Sultanabad, Karachi) have been mobilized to take preventive health measures (nutrition, child immunization, antenatal care) by visiting our Community Health Center.Over 200 secondary/tertiary care centers have been integrated into our nationwide provider network on a cashless basis.
When your donor funding runs out how will your idea continue to live? Naya Jeevan negotiates a basic inpatient (hospitalization) group health insurance plan from various underwriters (for example Allianz-EFU, Pak-Qatar Takaful, IGI Insurance, Saudi-Pak Insurance etc.) at below-market, discounted rates of about USD $16/person/year. By expanding access to a previously untapped low income working population, Naya Jeevan is creating significant value for insurance underwriters who are able to save substantial resources in associated sales/marketing/business development expenses while leveraging Naya Jeevan’s service delivery platform to provide value-added services (VAS) uniquely tailored towards this customer segment. Consequently, insurance underwriters are able to offer Naya Jeevan the health insurance plan at highly discounted group health plan rates of USD $16/person/year.2. Naya Jeevan forms partnerships with various clients including both international and local corporations and businesses such as: Unilever, Espresso, Cafe Flo, Sanofi, Philips, Haque Academy Group, Deutsche Bank, Haji Group, PICT, etc. The supply chains of these clients include a large number of low-income employees from the service industry and informal sector who do not have access to health insurance at all. As discussed, the ‘missing middle’ population forms the target market for Naya Jeevan and clients like local companies/MNCs in Pakistan form the most efficient distribution channel to tap into these masses. Naya Jeevan sells the health insurance plans to clients at ~ US$30/person/year, representing 1.28 – 4.26% of the employee’s monthly payroll (of USD $50-150 per month).Naya Jeevan currently has 70+ clients through which health insurance is being distributed to its low-income members.

3. As part of their respective corporate and business programs, clients finance on average $24 (80%) of the annual $30 health plan cost, with the remaining $6 (20%) paid by the low-income workers directly through payroll.

The clients see this program as a channel to encourage worker productivity/loyalty among their employees and as part of their corporate social responsibility.

Naya Jeevan has witnessed steady growth in its business model, validating proof-of-concept of its sustainability.

Improving Elderly Autonomy Through Serious Gaming and Social Networking.

Author(s) Emilie Pasche1, Rolf Wipfli2, Christian Lovis3
Affiliation(s) 1Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland, 2Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland, 3Division of Medical Information Sciences, University Hospitals and University of Geneva, Geneva, Switzerland.
Country - ies of focus Global
Relevant to the conference tracks Innovation and Technologies
Summary In fifteen years, the number of octogenarians will have increased by 80%. With the ageing of the population, chronic diseases are expected to double by 2050. Healthcare systems may collapse under the weight of the demand. In this context, the MobilityMotivator project aims to provide elderly people with a tool to help them age well by improving their mobility and preventing social isolation. This project follows a four-step plan: a specification phase, a prototype development phase, an evaluation phase and a dissemination phase. The conclusion of this project will enable us to determine the impact of such an approach on the mobility of elderly people and the socio-economic impact.
What challenges does your project address and why is it of importance? Only a minority of elderly people perform a sufficient amount of physical exercises. A study performed in England reported that only 17% of men and 13% of women aged 65-74 reach the recommended levels of physical activity. There are many reasons why elderly do not feel they can or should engage in physical activity (e.g. fear of injury, physical limitations, etc.) which leads to a lack of motivation. The consequences of this lack of activity directly results in the decrease of the quality of life of elderly people, with the increased risk of developing chronic diseases (coronary heart diseases, diabetes, etc.) and increased social isolation. Moreover, because of the growing proportion of older adults, this represents an increasing public health problem.
The challenge of this project is to motivate elderly people to remain engaged in physical activities so that they stay connected with their peers. This challenge is of major importance to both the individuals and the society. For the individual, it is essential to age well in order to have a satisfactory quality of life and autonomy. For the society, active ageing will reduce the health costs and also ensure that the healthcare system is able to manage the demand.
How have you addressed these challenges? Do you see a solution? The MobilityMotivator project proposes an approach based on the development of a serious gaming environment to motivate elderly to remain involved in physical activity and social interaction. The approach proposes two modes: a telemonitoring mode and a gaming mode.
The telemonitoring mode is dedicated to the healthcare provider and enables them to supervise and encourage their patients to undergo physical activities, but also to remain active and engaged within the urban environment. The patient performs exercise at home in front of his television and the healthcare provider is provided with monitoring mechanisms to assess cognitive and physical performances of his patient through the Mobility Motivator platform. It also enables the healthcare provider to define the level of challenges for their patient according to the patient's abilities.
The gaming mode is dedicated to elderly people. The game relies on two elderly people playing together: the outdoor player and the indoor player. Initially, both players get in touch through the platform and start a game. The choice of challenges is based on an intelligent engine that customises the game according to the individual’s assessment for mobility and cognitive capacities. The outdoor player, who is provided with a smartphone, faces a mission such as making his way to the museum in the centre of the town. He moves through the game and performs tasks associated with the mission. At some points, the outdoor player interacts with the indoor player, thus receiving feedback and encouragement. During the time, the indoor player is challenged with a cognitive enigma, such as solving simple orientation problems in a given time, or with indoor physical activities such as chair exercises. The end of the game will be achieved when players reach the final destination. The players can repeat the game process at a later date by switching roles. Over time, the game builds a record of progress, which can be analysed by the healthcare providers when evaluating each patient’s mobility and cognitive abilities.
Although health e-games generally provide health literacy, physical fitness, cognitive fitness, skills development and condition management, these are mainly designed for mainstream consumers rather than the over 65 not familiar with technology like the MobilityMotivator. In addition, no other health e-game incorporates telemonitoring functionalities to enable feedback provided by healthcare providers.
How do you know whether you have made a difference? The development of the solution will be based on a rigorous assessment and monitoring of user needs and interests and will be tested through three user representative organisations in three European countries.
The impact evaluation in real living and working environments will aim to assess the usability of the MobilityMotivator environment under real living and working conditions, using key indicators applicable to indoor and outdoor situations. This evaluation will also enable to determine the impact on mobility, autonomy and socio-economic parameters in comparison to a parallel control group experiencing conventional living and working conditions. A number of qualitative and quantitative indicators for success will be identified. Methods for collecting these indicators in an unbiased way will be defined. Data collection will be designed and planned with the support of statistics experts in the design and analysis of clinical trials.
Have you or the project mobilized others and if so, who, why and how? The project is a European research project which is composed of a consortium of nine partners distributed in six countries: Laboratory of Engineering Systems of Versailles (France), Institute für Arbeit & Technik (Germany), Audemat (France), Inventya (England), E-Seniors (France), University Hospitals of Geneva (Switzerland), German Red Cross (Germany), Studio 345 (Luxemburg) and La Mosca (Belgium). The consortium has been designed with careful consideration to the following key requisites. First, the portfolio of complementary skills necessary to ensure project objectives is met. Second, the consortium comprises a balance between industrial SMEs, research community, user involvement and market expertise. Finally, geographical spread aims to facilitate initial establishment in three European countries (Switzerland, France and Germany) as a foundation for future growth and expansion.
When your donor funding runs out how will your idea continue to live? The market for MobilityMotivator has great potential since it is still largely untapped. A study conducted by Empirica found that a mixed market for technologies, which promote active ageing and other telecare related ICT-products, is emerging. Older people from some countries are starting to privately purchase such products and services in order to age well. Healthcare providers may also be interested to improve the quality of care and supervision provided. Moreover, a modest investment in devices that encourage mobility that could improve the ageing process has the potential to save several billions per year in Europe. Dissemination activities need to be focused on all these actors to convince them of the value of having access to the MobilityMotivator environment. There are signs that, with sufficient support, the market for technology for the elderly can be accessed.
European-wide exploitability of the MobilityMotivator is considered from the very start of the project. The consortium partners plan to launch a Joint Venture in order to implement exploitation strategies and business plans following project completion. This is expected to be achieved within the 2 years of project completion. The potential return on investment will be further investigated following the development of the business model in the research phase.

Barriers for Care and Medicines in Diabetes and Hypertension: A pilot study in Lima-Peru.

Author(s) MARIA KATHIA CARDENAS1, Dulce Morán2, Jaime Miranda3, David Beran4
Affiliation(s) 1CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 2CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 3CRONICAS Center of Excellence in Chronic Diseases, Universidad Peruana Cayetano Heredia, Lima, Peru, 4Division of International and Humanitarian Medicine at the Faculty of Medicine, University of Geneva, Geneva, Switzerland.
Country - ies of focus Peru
Relevant to the conference tracks Health Systems
Summary The aim of this study is to pilot test the implementation, for the first time in Peru, of World Health Organization manual to identify barriers to access to medicines and care in patients with non-communicable diseases (NCD). As part of an active stakeholder engagement in the process, this study aims to promote a policy response. Tools were prepared to collect quantitative and qualitative data. In total, 141 interviews and meetings were conducted in four levels . This study identifies existing bottlenecks in the access to care and management of patients with diabetes and hypertension. This system-level analysis elicits current challenges and opportunities to improve care for NCDs in Peru.
What challenges does your project address and why is it of importance? Non-communicable diseases (NCDs) have been recognized by the global community as a major public health challenge. World Health Organization's (WHO) response includes the development of a Global Action Plan for the Prevention and Control of NCDs for years 2013-2020 and a Research Agenda with focus on the prevention and control of NCDs in low- and middle-income countries (LMICs) such as Peru. The importance of the challenge posed by NCDs in the context of Peruvian health system was also highlighted by the Peruvian Ambassador during the 43rd Session of the Commission on Population and Development. For Peru, WHO estimates a NCD burden that represents 60% of mortality in Peru, which highlights the relevance of chronic diseases for our health system. According to Nolte and McKee the management of chronic NCDs is one of the largest challenges that health systems throughout the world currently face and each system needs to find locally-adapted solutions. These solutions require a clear understanding of the barriers within the health system to access to NCDs care and medicines, from higher policy-level to the individual patient-care experience. Our projects precisely address this challenge.
How have you addressed these challenges? Do you see a solution? We have addressed this challenge by contributing to the limited available body of evidence concerning NCDs and health systems in Peru. Specifically, our study determined barriers for the access to medicines and health care for diabetes and hypertension using a novel tool for health system assessment that was adapted for the Peruvian health sector context. The tool applied was based on the Rapid Assessment Protocol for Insulin Access (RAPIA), a tool that has previously been implemented in six countries (representing four WHO Regions) with the support of the International Insulin Federation: Kyrgyzstan, Mali, Mozambique, Zambia, Nicaragua and Vietnam. Previous implementations of the RAPIA have resulted in improvements in access to medicines like insulin (Mali, Mozambique and Zambia), development of NCD policies (Mozambique and Zambia), inclusion of recommendations in government policies and programmes (Kyrgyzstan, Mali, Mozambique, Nicaragua and Viet Nam), improvement and increase in the visibility of Diabetes Associations (Mali, Mozambique, Nicaragua and Zambia), inclusion of recommendations in projects and programmes of national NGOs (Mali and Nicaragua), external funding and support for diabetes programmes (Mozambique, Zambia and Vietnam) and the use of RAPIA for monitoring and evaluation (Mozambique).At the health system level, the introduction of this tool for the assessment of NCDs will also be helpful for developing future research agendas in the field. This tool can also serve as a field guide to assist researchers in collection, analysis and presentation of data to evaluate and inform the development of health-care services and policies for specific NCDs or groups of diseases.Policy makers can also benefit from these assessments as it can inform them about ongoing challenges or bottlenecks in NCDs-related health care provision. It is expected that the engagement in the planning phases of the study will provide windows of opportunity and knowledge translation that will likely directly translate in policy changes aimed to improve NCD care.
How do you know whether you have made a difference? The results from this study will contribute to a better understanding of the current situation of the management of diabetes and hypertension in the context of the Peruvian health system, in order to formulate appropriate recommendations for the policy decision makers. However, we know that it is premature to attribute any change to this study. In the context of almost non-existing systematic assessments of health systems in the Peruvian health sector, in particular around NCDs, we expect this research to set the grounds for future policy recommendations. Our results show that NCDs are not yet a priority for policy-makers in Peru, at least not in the practice. There are some initiatives that have not yet reached the expected results such as the basic regulation to protect patients with diabetes and a policy to promote reduction of anti-diabetic drug prices. Presently there is only a national guideline for hypertension attention at the primary health level but no guideline approved for diabetes as well as a National Strategy for NCDs without a current Strategic Plan. The universal health coverage in Peru includes a list of essential treatments for each disease covered by any insurance, but it is partially implemented due to the lack of clinical guidelines and the lack of awareness on this topic by the health professionals. At an intermediate and local level we found problems facilitating the demand for medication and laboratory consumables.General practitioners in the lower-level of management provide care mostly to those patients with no complications. Patients with complicated disease are referred to Hospitals, where patients must wait long periods to obtain an appointment. Even those patients with public health insurance often buy their medication at private pharmacies, due to the lack of stock in pharmacy facilities of public sectors. The high price of medicine in private pharmacies is one of the main reasons for treatment cessation by the patient.In order to strive towards achieving a difference we will perform a follow-up on the following activities. As part of the implementation study, a list of recommendations will be shared with the stakeholders before the end of year 2013 and a follow-up of activities will be performed starting the year 2014. During year 2014, every 4-6 months, a member of the research team will contact the stakeholders by e-mail, telephone or by person in order to monitor the implementation of the recommendations.
Have you or the project mobilized others and if so, who, why and how? Since the beginning of the project we participated in different meeting with stakeholders from different sectors in order to establish initial contacts. The purpose of the meetings was to provide information about the project, to listen to different perspectives, and finally, a last activity will be developed before the end of the year to jointly discuss potential recommendations and to define an action plan towards policy changes that are pragmatic and feasible in the current local context. We have developed a presentation of the study to stakeholders, in which we invited them to a workshop session in order to receive feedback of the study. At this workshop we explained the past experience with RAPIA as well as the background and methodology of the present study. The stakeholders gave suggestions and confirmed their support and interest. Among the participants was a high officer of Ministry of Health (MoH), as well as members of different areas of Peruvian MoH, social Security, public health insurance, health organizations, acadaemia, among others.Members of our CRONICAS research team also participated in meetings with the Experts Committee in NCDs, a coordination unit of the MoH. We participated in one of the activities of this Committee which was the discussion of the National Strategic Plan for Prevention and Control of NCD 2014-2021, as well as the meeting for discussing the National Guidelines for Diabetes Management, which has not yet been approved. Additionally, regarding to the Social Security, we also contributed to the Health Services Portfolio, which is a technical guideline for the effective interventions for specific chronic diseases during the patient's lifespan. CRONICAS contribution was cited in the technical document.
When your donor funding runs out how will your idea continue to live? CRONICAS Center of Excellence in Chronic Diseases has as part of its goals "to contribute to research development on NCD in Peru (Goal 1)" and "to participate actively with public health policy-makers and study population (Goal 2)". Therefore, when funding runs out we will still remain in communication with stakeholders. Most of policy makers and stakeholders find our evidence-generation group an ally for policy-related interactions and a source of technical expertise in the generation of future health policies. Whilst being a research-based institution, our group strives towards contributing to the transition from research to action for the improvement of health care in patients with diabetes and hypertension. We also plan to obtain funding in order to develop the study in other regions in Peru which are less-urban and poorer, and have different epidemiological profiles and, obviously, different health-system needs.

GRIP’s Pentagonal Framework for a Global Change in Antibiotic Resistance.

Author(s) Sabiha Essack1, GRIP (Global Respiratory Infection Partnership)2, Laura Noonan 3
Affiliation(s) 1Health Sciences, University of KwaZulu-Natal, Durban, South Africa, 2Various, Various, Various, United Kingdom, General Practitioner, Bellview Clinic, Mullingar, Co Westmeath, Edgeworthstown, Ireland.
Country - ies of focus South Africa
Relevant to the conference tracks Advocacy and Communication
Summary Antibiotic resistance has become a critical health issue on a global scale, with much of the problem resulting from inappropriate use of antibiotics in primary care. To change this practice, the Global Respiratory Infection Partnership (GRIP) has formulated a pentagonal (5 P) framework for the non-antibiotic management of upper respiratory tract infections (URTIs) to promote antibiotic stewardship in primary care. The framework focuses on five key areas to bring about change: policy, prevention, prescribers, pharmacy and patients. It is a flexible framework that can be adapted across countries to create a consistent global approach to change behaviour.
What challenges does your project address and why is it of importance? Antibiotic resistance has become a critical health issue on a global scale [1]. Much of the problem results from the inappropriate use of antibiotics in primary care [2]. URTI symptoms are the most common reason patients to seek medical attention in primary care and account for a large proportion of the antibiotics prescribed in primary care [3].
However, the majority of throat infections are of viral origin and resolve without antibiotic treatment. Despite this, antibiotic use for sore throat infections remains high, partly because it is difficult to determine when antibiotics may be useful, on the basis of physical findings alone [4]. Patient expectations and patient pressure are also important drivers of antibiotic use [5]. To address these issues, a behavioural change is required to improve communication between primary healthcare providers and patients.
How have you addressed these challenges? Do you see a solution? To facilitate a change toward prudent use of antibiotics for the treatment of URTIs, members of the GRIP have developed an international pentagonal (5 P) framework for the non-antibiotic management of such infections (Figure 1) [6]. The principles are then applied to the management of sore throat (as an example of a common symptom of URTIs) offering practical advice to primary care teams on how to implement the guidance in their daily practice. Doctors, nurses and pharmacy staff, working in primary care or in the community, will be provided with a structured approach to management, with the aim of educating and empowering patients to self-manage their condition. The first component of this approach involves identifying and addressing patients’ expectations and concerns with regards to their sore throat and eliciting their opinion on antibiotics. The second part is dedicated to a pragmatic assessment of the severity of the condition, with attention to red-flag symptoms and risk factors for serious complications. Rather than just focusing on the cause (bacterial or viral) of the URTIs as a rationale for antibiotic use, healthcare providers should instead consider the severity of the patient’s condition and whether they are at high risk of complications. The third part involves counselling patients on effective self-management options and providing information on the expected clinical course.
Such a structured approach to management, using empathetic, non-paternalistic language, combined with written patient information, will help to drive patient confidence in self-care and encourage them to accept the self-limiting character of the illness—important steps towards improving antibiotic stewardship in URTIs.This framework has been shared with and reviewed by healthcare professionals from Australia, Austria, Brazil, Germany, Hungary, India, Ireland, Israel, Italy, The Netherlands, Romania, Russia, Singapore, South Africa, Spain, Thailand, the United Kingdom, and the United States of America. The global framework is strengthened through a collaborative approach by input from multiple primary healthcare provider specialties and is applicable across countries and continents. It is envisaged as a prototype that can be adapted to other infections in the long term.
How do you know whether you have made a difference? GRIP identified acute URTIs (with the exception of the more severe infections, such as pneumonia) as being appropriate for a pilot for the development of such an integrated approach because the treatment of URTIs is currently characterised by the overuse of antibiotics in the primary care sector. Antibiotics are often an ineffective and unnecessary treatment option for the majority of patients when alternative symptomatic relief options are available. Once a coherent international approach has been developed to promote a change in the prescribing and use of antibiotics for the treatment of URTIs, this could serve as a model for change in other infections. Spending time with the patient and providing information and reassurance are strongly linked to patient satisfaction. At the individual level, a successful intervention may mean that the patient will be able to self-manage sore throat symptoms in the future. Directing patients to effective self-care and providing information on the expected duration of symptoms reduces re-consultation rates. Applying a structured approach to patient consultations will help all healthcare providers to fulfil these roles in a time-efficient manner.
Have you or the project mobilized others and if so, who, why and how? The GRIP project aims to involve all levels of healthcare professionals and institutions, including doctors, nurses, patients, pharmacists, as well as professional bodies/associations, clinical communities of practice and local experts and national and local Ministries of Health. In 2013 the GRIP hosted an educational conference, with international delegates to discuss and validate the elements of their 5 P framework and their Global campaign with other healthcare professionals. The group also shared their 1,2,3 Toolkit for appropriate respiratory infection management in primary care. The multidisciplinary, educational resources in the toolkit include a CPD module, patient leaflets, patient poster, GP tear-off pad, Pharmacy educational booklet and a conversation guide with an infographic to use in discussions with patients about appropriate RTI management. This toolkit is being adapted for use in multiple countries whilst maintaining consistency of GRIP’s approach. Implementation of national policies by primary care providers will be further enhanced by incorporating the principles into clinical decision-making and by gaining support and endorsement from local experts. For example, leading figures in antibiotic resistance from national societies could be actively involved in the development of guidelines. The role of pharmacy staff is important and diverse. They tend to see patients who have already chosen the self-management route. They can thus offer reassurance and advice on appropriate treatment to increase the chances of optimum symptomatic relief and patient satisfaction while having the knowledge for patient-centred advice on when to consult another healthcare provider. Pharmacy staff are ideally placed to provide reassurance to patients by offering more detailed advice on symptomatic treatment options in line with the patient preferences.To move towards a culture where non-antibiotic management of URTIs is the norm, it is important to mobilise the public and the patient as proponents of non-antibiotic treatment for self-limiting conditions. Educating the public is an important step to nurture change, with potential measures including media campaigns and educational projects in schools and universities, to raise awareness early in the education cycle.
When your donor funding runs out how will your idea continue to live? GRIP’s initiative is multifaceted and supports a unified approach to primary care. With the threat to public health posed by antibiotic resistance continuing to increase, the need for robust and consistent antibiotic stewardship initiatives on a global level will continue to grow. GRIP’s framework aims to provide a memorable and immediately actionable campaign to support changes in practice as well as at a policy level by way of a simple pentagonal framework. A globally consistent and locally adaptable campaign will disseminate a unified message to address a global problem. Once the initiative has rolled out across relevant healthcare professions and the public both globally and locally, the level of education achieved will have increased and overuse of antibiotics will be reduced accordingly. Successful results can be used to support the adaptation of the framework to other infections and be integrated into the policies of other countries facing similar challenges.References
1. World Health Organization. The evolving threat of antimicrobial resistance. Options for action, 2012. Available online: http://whqlibdoc.who.int/publications/2012/9789241503181_eng.pdf. (accessed on 12 September 2013).
2. NHS Choices. Available online: http://www.nhs.uk/NHSEngland/ARC/Pages/AboutARC.aspx (accessed on 30 September 2013).
3. Francis NA, Butler CC, Hood K, Simpson S, Wood F, Nuttall J. Effect of using an interactive booklet about childhood respiratory tract infections in primary care consultations on reconsulting and antibiotic prescribing: a cluster randomised controlled trial. BMJ. 2009; 339: b2885.
4. Van der Velden A, Bell J, Sessa A, Duerden M, Altiner A. Sore throat: Effective communication delivers improved diagnosis, enhanced self-care and more rational use of antibiotics. International Journal Clinical Practice, in press.
5. van Driel ML, De Sutter A, Deveugele M, Peersman W, Butler CC, De Meyere M et al. Are sore throat patients who hope for antibiotics actually asking for pain relief? Ann Fam Med. 2006; 4: 494–9.
6. Essack S, Pignatari AC. A framework for the non-antibiotic management of upper respiratory tract infections: towards a global change in antibiotic resistance. International Journal Clinical Practice, in press.

Provider Initiative Approach to Enhance Family Planning Uptake in Women of Reproductive Age in Rural Communities in Osun State, Nigeria.

Author(s) Ademola Adelekan1, Elizabeth Edoni2.
Affiliation(s) Health Promotion and Education, University of Ibadan, Ibadan, Nigeria, Community Health Nursing, Niger Delta University, Bayelsa, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Women and Children
Summary Despite decades of progress in improving the delivery and availability of family planning services, high levels of unmet need for family planning still exist in many countries. This suggests that novel approaches are needed to extend access to family planning services to women and couples who desire to limit or space their childbearing but are not currently using contraceptives. The integration of family planning with other health services may be one such approach. Although integration may seem logical, the results of efforts to integrate child or primary health care services with other services suggest that integration presents many logistic challenges and that caution is advisable.
What challenges does your project address and why is it of importance? Despite decades of progress in improving the delivery and availability of family planning services, high levels of unmet need for family planning still exist in many countries. This suggests that novel approaches are needed to extend access to family planning services to women and couples who desire to limit or space their childbearing but are not currently using contraceptives. The integration of family planning with other health services may be one such approach. Although integration may seem logical, the results of efforts to integrate child or primary health care services with other services suggest that integration presents many logistic challenges and that caution is advisable. Integrating family planning services with other health services may be an effective way to reduce unmet need. However, greater understanding of the evidence regarding integration is needed. The study determined the effectiveness of provider initiated approaches to enhance family planning uptake among women of reproductive age in rural communities in Osun State, Nigeria.
How have you addressed these challenges? Do you see a solution? A total of 10 out of 30 Medical Officer of Health (MOH) in Local Government Areas in Osun State were randomly selected and trained on Provider Initiated Approach to scale up the uptake of FP among women of reproductive age in rural communities in Osun State, Nigeria. The selected MOH were equipped with FP knowledge and skills on how to integrate FP with other health services. The trainees in turn trained lower health workers who are the primary service providers in rural areas in their various local government health facilities. Women within the reproductive age are assessed for FP needs in antenatal care, maternal and child health, Post Natal Clinic, HIV counseling and testing and other reproductive health services. Family Planning messages were discussed with women through micro-teaching, IEC Materials and as well as client provider interaction. This was done from March to August, 2012.
How do you know whether you have made a difference? Utilization of FP services increased from 5.8% to 30.2% within 3 months and 42.9% after 6 months. The prevalent use of Intrauterine device, injectable, implant and emergency contraceptives increased from 12.8%, 10.1%, 0.2% and 4.7% respectively to 30.8%, 29.7%, 3.9% and 12.9% respectively. Identified barriers to use of FP among women included inadequate knowledge of FP, negative perceptions of FP, financial constraints and inadequate spousal approval. Excess workload for health workers was recorded as a major challenge in this approach.
Have you or the project mobilized others and if so, who, why and how? There was an increased in uptake of family planning services due to use of provider initiative family planning. More health care providers should be trained towards using this approach since current evidence suggests that integration of family planning with other health services using provider initiative approach may be beneficial.
When your donor funding runs out how will your idea continue to live? The government, through the Ministry of Health, will take over the project

Decentralized nurse training in rural Zambia – triplicating the output of trained nurses.

Author(s) Martina Weber1, Toddy Sinkamba2, Klaus Thieme3.
Affiliation(s) Zambia, SolidarMed, Chongwe, Zambia, 2 St. Luke's School of Nursing, Mpanshya, Zambia, 3 SolidarMed, Chongwe, Zambia.
Country - ies of focus Zambia
Relevant to the conference tracks Health Workforce
Summary The SolidarMed pilot project decentralized practical nurse training in rural Zambia started in 2012 with St. Luke’s School of Nursing in Mpanshya. The project aims at providing nurses for rural districts of Zambia by triplicating the annual student intake, and by delivering quality theoretical and decentralised practical training to meet quality standards. It is a pilot project presented as a valuable model for nurse training in Zambia to the Ministry of Health and other interested stakeholders. The project is based on the recommendations of WHO Global Policy Recommendations (2010) on Improving access to health workers in remote and rural areas through improved retention.
What challenges does your project address and why is it of importance? Zambia, like many other low income countries in the region, faces considerable challenges in providing sufficient human resources for health. In Zambia only about half of the health facility workforce are trained. Nurses and midwives are crucial in an already struggling health system, and not having enough key staff like nurses weakens the health system. Zambia has a shortfall of 9’000 nurses which is approximately 60% of its requirement. Rural hospitals particularly illustrate a drastic gap between the planned medical staff and the actual staffing situation. Historically, Zambia has not invested enough in its health training institutions. The under-funding of health institutions, poor training and accommodation facilities, inadequate equipment and study materials, as well as inadequate teaching staff have resulted in high attrition rates from pre-service training (like nursing), fewer graduates and an overall deterioration in the quality of outputs.
How have you addressed these challenges? Do you see a solution? The SolidarMed pilot project tries to target all these recommendations in the partnership with St. Luke’s School of Nursing at St. Luke’s Mission Hospital in rural Mpanshya / Zambia. The school had 30 students in 2009. The project target is to double the output of students by decentralisation of practical training. The first external practical training site is Sacred Heart Mission Hospital in Katondwe – a small hospital in a very rural and remote part of the Province. Experiencing clinical practice is essential for the student nurses to understand their professional future. Nurses are likely to find themselves as one of the few health professionals within a rural health institution. If they have never experienced the reality of rural practice and learnt to deal and adapt to its challenges, the outlook for their retention in the rural areas is not good. Given the limitations of a rural posting, where there is likely to be staff and equipment shortages as well as crumbling infrastructure, nurses need to be trained for this. And this kind of training is only possible if you actually train within a rural, peripheral context. The second external practical training site will be Chongwe District Hospital. This Level 1 District hospital is quite close to Lusaka, in the District capital of Chongwe and here nursing students supplement their experience of clinical practice in a remote rural area with practical training in a more urban hospital. Patient numbers are high, which is also valuable preparation for their professional future. In addition, being based in Chongwe allows nursing students easier access to Chainama Hills Hospital where they complete a practical rotation in mental health. Two clinical instructors are placed at all three practical training sites. The combination of learning and experience available at these three quite different hospitals provides a balanced mix of exposures to various professional settings. This allows nursing students to experience as many aspects of their practical work as possible, and thus gives them the best possible training for their future career.
How do you know whether you have made a difference? The project is on-going. The overall goal is to improve the provision of nurses for rural health care in rural districts of Zambia. In order to achieve this goal, SolidarMed invested in infrastructure and equipment at the decentralised training sites by building a student hostel and staff houses for the clinical instructors at Sacred Heart Mission Hospital in Katondwe and at Chongwe District Hospital, as well as staff houses for the clinical instructors at St. Luke’s School of Nursing in Mpanshya. Additionally, teaching and learning equipment is constantly upgraded. Furthermore, SolidarMed is supporting the training of one nurse tutor and six clinical instructors, incentivising the latter and supporting St. Luke’s Nursing School by placing them on the payroll of the individual practical training sites. To ensure cooperation between the Nursing School and the decentralised sites works smoothly, a comprehensive Framework Agreement is drawn up to define roles and responsibilities. The relevant Ministry of Health and Ministry of Community Development, Mother, Child Health are very interested in both the negative and positive outcomes of this pilot project. It is seen as a way of increasing the output of trained nurses in a relatively cost effective way with the additional benefits for the participating decentralised practical hospitals. Since the start of the project the intake of nurse students has been increased to 103 in 2013. This triples the number of students since the Nursing School started.
Have you or the project mobilized others and if so, who, why and how? This project is a pilot project for the Zambian training system for medical personnel. As well as the training institution, St. Luke’s School of Nursing and its Hospital involved other parties at the decentralized training sites at Katondwe Sacred Heart Mission Hospital and Chongwe District Hospital. All lessons learnt are shared with all stakeholders – e.g. the General Nursing Council of Zambia, the Ministry of Health and the Ministry of Community Development and Mother & Child Health and all other training institutes interested in scaling up their output. The involvement of the General Nursing Council is crucial for the success of this pilot project. This professional body registers nurses and midwives and regulates their professional conduct and education while also registering nursing and midwifery schools. It also has an advisory role in the Ministry of Health on matters relating to nurses and midwives. With regard to nursing and midwifery schools, the General Nursing Council sets the monitoring and evaluation standards, decides whether facilities are suitable for training, conducts supportive supervision visits and evaluates the training programmes offered at individual institutions. Furthermore, the General Nursing Council also develops and reviews curricula, teaching and learning materials, evaluates the implementation of these curricula and conducts knowledge and skills updates for teaching and clinical staff. The lessons learnt could be applicable for other job training institutions in Zambia that focus on topics other than health.
When your donor funding runs out how will your idea continue to live? The design of the SolidarMed project is that the decentralized nurse training can continue after funding runs out. The nursing school benefits from investment in its infrastructure and faculty and will be strengthened in the area of quality assurance. SolidarMed experienced that the practical training sites hosting the students benefited from their participation in nursing training. Nurses in training are a form of additional manpower in the context of a human resource crisis. SolidarMed has not created separate cadres of health professionals or designed its own brand of training, but rather supports Zambian training programmes, tailored to Zambian requirements. The project supports local ownership of human resource for health strategies. So it is fully consistent with Zambia’s national health priorities and strategies as defined in the Government of the Republic of Zambia’s Fifth National Development Plan 2006 -2010 as well as the Ministry of Health’s National Health Strategic Plan 2006 -2010, and the Human Resources for Health Strategic Plan 2011-2015. Preliminary drafts of the Sixth National Development Plan 2011-2015 suggest that this project is in line with Zambia’s future national health priorities and strategies. Local ownership is key to sustainability. SolidarMed supports Zambian solutions to Zambian problems, and this project is fully in line with this strategy. In doing so, SolidarMed recognises that a home-grown solution is more likely to be effective in addressing context-specific challenges, and more efficient and affordable. SolidarMed seeks out local knowledge and expertise to achieve its aims and contributes its own experience to build capacities and strengthen its partners.