Engaging informal providers in Bangladesh

1. Engaging informal providers in Bangladesh Stakeholders’ consultation on Informal Service Providers Organized by: CReNIEO Chennai in India 21-22 March 2014 Dr. Mahfuza Mousumi Project Manager, Health & Nutrition Save the Children, Bangladesh Email: mahfuza.mousumi@savethechildren.org

2. Presentation Outline • Child health situation in Bangladesh • CCM Project overview • Village Doctors engagement experinaces • Program results • Lessons learned

3. Trends in under-5 child mortality in Bangladesh Deaths per 1,000 live-births MDG Target Source: BDHS 2011

4. Distribution of under-5 deaths in Bangladesh by causes of deaths: 2006-2011 Pneumonia Pneumonia Possible serious infection Source: BDHS 2011

5. Pneumonia Treatment Status (BDHS 2011) • 50% care seeking for Pneumonia from drug stores and Village Doctors (VDs) • 35% ofchildren with symptoms of pneumonia were taken to health facility or a medically trained provider • 79% of the children seeing a provider were prescribed antibiotics

6. Presentation Outline CCM Project overview

7. Project Information • Implementation area: 17sub-districts in southern part of Bangladesh • Target group : Children under five years of age (approx. 400,000) • Duration : February 2012 to April 2014 • Donor : Procter & Gamble

8. Project strategies Improve access to quality services Public/ formal Private/ informal Community groups

9. Presentation Outline • Village Doctors engagement

10. Rationale for engagement • Increase coverage of protocol • Popular & common choice of population esp. among poor HHs • Village resident, available 24/7 • Drugs available at the clinic (provide drugs on easy installment) • Conduct home visits

11. Initial considerations for VD engagement • Process of VDs selection • Training & skill retention • Quality Assurance

12. Selection of Village Doctors • Service mapping (identify gap areas) • Consultation with community leaders to identify popular VDs for children U5, VDs association • Live /practice in the targeted village • Willingness to participate in training and treat children following national protocol • Not involved in political activities

13. Who are the selected VDs? • 75% of them completed 10th grade education • Majority are between 30-50 years of age • Most of them received 3-6 months course from private institution and also worked as assistant of a doctor or VD • Nearly all operate a pharmacy

14. Capacity building & QA approach • Revision of basic training manual specially for VDs in partnership with IMCI unit, MOH • Adaptation of standard monitoring & supervision tools • Conduct basic & refresher trainings by MOH sub-district level MTs; 298 VDs trained on CCM (3-day) and 281 currently active • Provided essential supplies & job Aids -ARI timer, thermometer, chart booklet, treatment register, referral slips & tools. • Supportive supervision- joint supervision with MOH supervisors

15. Presentation Outline Results

16. Number of cases treated by trained VDs N=199 Oct’12 to Dec’13

17. Key findings of Supervision Visit N=184 January to December 2013

18. Supervision Mechanism • Post-training follow up visits: each VD supervised twice a month for initial 3 months followed by monthly supervisory visits • Review register • Direct observation/ case scenario • Random HH visit of treated cases • Joint supervision with MOH supervisors (98% of VDs received supervision visit in the last month)

19. Supervision Checklist

20. Presentation Outline Result: Key findings of Village Doctors assessment

21. Diagnosis and treatment of pneumonia

22. Availability of Supplies • 92% of VDs have functional ARI Timer • All VDs have functional thermometer • IMCI Algorithm/chart is available with 97% VDs • 96% of VDs are maintaining service registers

23. Drugs availability • 98% of trained VDs are selling amoxicillin of recommended brands • ORS and Zinc are also available in their pharmacy

24. VDs attitude and practices around referral

25. Referral linkage with MOH • 91% of VDs are using referral slips • 97% of VDs referred sick children to near by appropriate MoH facility • 88% severe/danger sign • 24% diarrhea with severe dehydration • 15% sick newborn • 76% of VDs have mechanisms to ensure quality services/follow up

26. Lessons learned • Low profit margin and slow recovery of treated cases with amoxicillin is a challenge for following standard treatment protocol • Refresher training, review meeting and supportive supervision are effective ways for ensuring quality and maintain motivation • Joint supervision with MOH staff supports establishment of linkage with formal health system; adding VD treated cases in national HMIS • CCM projects created scopes for VDs engaging in other child health interventions by government & non-government programs.

27. Next steps • Preliminary results/experiences are promising. VDs are following protocol & maintaining guideline and referring severe cases • SC wants to expand this to additional VDs and conduct research to identify what is needed to enhance quality of pneumonia treatment by informal providers at scale

28. Thank You