Scoping of Integrated Community Case Management (Iccm) in Burma
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Scoping of integrated Community Case Management (iCCM) in Burma Report September 20-October 11, 2015 Dr. Agnes Guyon Dr. Cynthie Tin Oo Ms. Maura Gaughan 1 2 Table of Contents List of Acronyms ........................................................................................................................................ 4 I. Introduction ........................................................................................................................................... 5 II. Background ........................................................................................................................................... 5 III. Methods ............................................................................................................................................... 7 IV. Findings ................................................................................................................................................ 7 V. Summary of Key Findings .................................................................................................................... 14 VI. Recommendations and Proposed Strategies ..................................................................................... 14 VI. Other Technical Areas/Interventions to Reduce Under-Five Mortality ............................................ 15 VII. Appendixes ....................................................................................................................................... 16 3 List of Acronyms ACT Artemisinin-based Combination Therapy AMW Auxiliary Midwife CCM Community Case Management CHLWG Child Health Lead Working Group D&P Diarrhea and Pneumonia EPI Expanded Program on Immunization HMIS Health Management Information System iCCM Integrated Community Case Management IMNCI Integrated Management of Childhood Illness INGO Implementing Non-Governmental Organization LHV Lady Health Visitor LLINs Long Lasting Insecticide Treated Nets MCH Maternal and Child Health MCSP Maternal and Child Survival Program MICS Multiple Indicator Cluster Survey MNCH Maternal, Newborn, and Child Health MOH Ministry of Health ORS Oral Rehydration Solution PHS Public Health Supervisor PMI President’s Malaria Initiative RDT Rapid Diagnostic Testing RHC Rural Health Center RMNCA Reproductive, Maternal, Newborn, Child, Adolescent Health SARA Service Availability and Readiness Assessment SBCC Social Behavior Change Communication TOT Training of Trainers TMO Township Medical Officer UNICEF United Nations Children's Fund 4 I. Introduction Burma/Myanmar has experienced a steady and consistent improvement of under-five mortality, moving from 106 per 1,000 live births in 1990 to 72 per 1,000 live births in 20151. Despite the progress in reducing under- five mortality rates, Burma/Myanmar was unable to meet its MDG 4 target of under-five deaths per 1,000 live births by 2015. Burma/Myanmar has one of the highest under-five child mortality rates in the Mekong Region: Thailand (12)2, Vietnam (23), Cambodia (38), Laos (72) per 1,000 live births; and among neighboring border countries: Bangladesh (41), China (11), India (56) per 1,000 live births3. Next to neonatal deaths which make up 51% of the under-five mortality, disease burdens for children under-five (caused by acute respiratory infection, diarrhea, and malaria with the underlying cause of malnutrition) contribute to 45% of these deaths3,4. Two-thirds of the population is in the rural areas, living more than 5 km away from the nearest sub-center or rural health center. Community case management (CCM) of diarrhea and pneumonia (D&P) and, to some degree, community-based health education, exists in rural and hard-to-reach communities throughout the country. The Ministry of Health (MOH) has adopted CCM D&P as a national strategy for reducing under-five mortality. However, it is unclear where CCM D&P is being implemented, why those sites were selected, why malaria was not included with pneumonia and diarrhea community-based treatment, and which of the various donor groups are assisting. Additionally, the degree to which supportive policies, practices, and infrastructure are in place to successfully implement a national program is unknown. From September 20 - October 11, 2015 the Maternal and Child Survival Program (MCSP) conducted a scoping assessment of integrated Community Case Management (iCCM) implementation as part of Objective 5 in the approved MCSP Workplan 2014-20165. The scoping assessment was conducted to achieve a better understanding of how CCM D&P is implemented, particularly looking at the potential for expanding the scope of existing malaria volunteers to include treatment for diarrhea and pneumonia. The goal was to identify gaps and strategically target technical areas where USAID/Burma could invest in strengthening the national roll-out of CCM D&P or iCCM in the country. Please refer to the debriefing presentation (Appendix A). II. Background Community Case Management of Diarrhea and Pneumonia CCM D&P represents a relatively new strategy for reducing under-five mortality in Burma/Myanmar, despite the fact that community volunteerism has historically been a strong component of village life. In 2004, Save the Children worked with the MOH to implement maternal, newborn and child health (MNCH) programs, which included CCM D&P in 11 townships in 5 region/states. Volunteers were trained to diagnose and treat diarrhea and pneumonia, and refer severe cases. Save the Children has continued to work with the MOH to expand CCM D&P to new sites under 3MDG funding (Appendix B). In 2010, the MOH Child Health Division, with support from Unicef, piloted an implementation of CCM D&P/malaria in Dawei township (Tanintharyi Region). The pilot aimed to document the implementation process and operationalization to inform future CCM D&P/malaria programs. In 2011, an evaluation of the pilot revealed that while CCM was effective, challenges included: payment for transportation costs for supervisory visits; stock-out considerations, especially in areas severely compromised during the rainy season; attrition of volunteers, and incentives for keeping volunteers motivated6. 1 Dept. of Population, Ministry of Immigration and Population. The 2014 Myanmar Population and Housing Census: the Union Report, Vol 2. May 2015. 2 The Inter-agency Group for Child Mortality Estimation (UN IGME).Levels and Trends in Child Mortality Report 2015. http://www.childmortality.org/files_v20/download/IGME%20report%202015%20child%20mortality%20final.pdf 3 Countdown to 2015 Maternal, Newborn, and Child Survival. http://www.countdown2015mnch.org/country-profiles 4 UNICEF and the SITAN Technical Working Group. The Situation Analysis of Children in Myanmar 2012. http://www.unicef.org/eapro/Myanmar_Situation_Analysis.pdf 5 Objective 5: Collaborate with the MOH to provide national technical assistance for malaria in pregnancy and iCCM. Expected Results: Increased understanding of gaps in CCM coverage in Burma. 6 Ministry of Health, Dept. of Women and Child Health. Evaluation of Community Case Management of Pneumonia and Diarrhea in Dawei Township, Myanmar. 2011. 5 Two key outcomes from the pilot in Dawei were: 1) Unicef’s support for the expansion of CCM D&P (not including malaria) to four more townships (Lashio, Kengtung, Taunggyi, Hpa-an) in two states; and 2) the buy- in of the MOH with the development of the Implementation Guide: A Toolkit for Community Case Management of Childhood Illnesses and Technical Supplements in 2012. The expansion of CCM D&P was in line with the MOH’s 2010-2014 Newborn and Child Health Strategic Plan to increase community-based health services to rural areas and hard-to-reach places.7 The guide includes information on and endorses the treatment of diarrhea with oral rehydration solution (ORS) and Zinc, and of pneumonia with Amoxicillin. Malaria and nutrition were not included in this 2012 guide. In 2014, 3MDG8 awarded 10 implementing non-government organizations (INGOs) to support the expansion of CCM D&P in select townships within five states/regions: Shan, Kayah, Magway, Chin, and Ayeyarwady (Appendix B). INGOs work together with township medical officers (TMO) to implement CCM D&P. While the training and supervision of community volunteers are done by government staff, INGOs are responsible for management, supply chain for drugs and commodities, data collection and reporting. Funding under 3MDG spans from 2015-2017. Currently, funding efforts from Unicef and 3MDG have increased the coverage of CCM D&P to 11.5% of all townships (330). The Department of Child Health and Development released a draft of The Newborn and Child Health Strategic Plan 2015-2018 in April 2015. The focus of this strategy is to strengthen interventions along the continuum of care, linking newborn and child health at both facility and community level. Finalization of the plan is pending until the associated budget has been completed and approved (currently being compiled by Unicef-supported consultants). The strategy and budget are targeted for completion by February 2016. According to the Multiple Indicator Cluster Survey (MICS) 2010 data, 33% of children under five are stunted and 8% are wasted, which is the highest rate in the region. Despite this statistic, nutrition counseling is almost non-existent and is not part of the CCM D&P curriculum. Upon visiting both the rural health and sub-center clinics, social behavior change communication (SBCC) materials displayed on the walls were not up-to-date with international/WHO guidelines.