Research Report Boston University OVC‐CARE Project PRELIMINARY EVALUATION: IMPACT ON HEALTH STATUS OF ORPHANS AND VULNERABLE CHILDREN (OVC) IN NAMIBIA OF MOBILE PRIMARY CARE CLINICS PROVIDED BY THE MISTER SISTER PUBLIC PRIVATE PARTNERSHIP Re‐submitted: August 2012 Center for Global Health and Development Boston University Boston, Massachusetts, USA PharmAccess Namibia Windhoek, Namibia The USAID | Project SEARCH, Orphans and Vulnerable Children Comprehensive Action Research (OVC‐CARE) Task Order, is funded by the U.S. Agency for International Development under Contract No. GHH‐I‐00‐07‐00023‐00, beginning August 1, 2008. OVC‐CARE Task Order is implemented by Boston University. IMPACT ON HEALTH STATUS OF ORPHANS AND VULNERABLE CHILDREN (OVC) IN NAMIBIA OF MOBILE PRIMARY CARE CLINICS PROVIDED BY THE MISTER SISTER PUBLIC PRIVATE PARTNERSHIP AUGUST 2012 Funding Source: PEPFAR‐USAID IQC No. GHH‐I‐00‐07‐00023‐00 Principal Investigator: Frank (Rich) Feeley, JD Center for Global Health and Development Co‐Investigators (BU): Ehimen Aneni, MD, MPH Boston University School of Education Alana Brennan, MPH Center for Global Health and Development Co‐Investigators (Namibia): Rina Hough PharmAccess Namibia Pancho Mulongeni PharmAccess Namibia Bas Rijnen, MA PharmAccess Namibia Ingrid DeBeer, MA PharmAccess Namibia Contact Information: Rich Feeley Center for Global Health and Development Boston University 801 Massachusetts Ave, Crosstown Center 3rd Floor Boston, MA 02118, USA [email protected] Acknowledgement : We are grateful for the guidance and funding by the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID Namibia and USAID Office of HIV/AIDS which supported both the intervention and evaluation. We also appreciate the support of Pharmaccess Namibia and the entire Mister Sister team as well as the farmers, workers and residents at the sites visited by Mister Sister. The support of the Namibian Ministry of Health and Social Services, as outlined in this report, was key to this public private partnership. We also thank the Ministry of Gender Equity and Child Welfare for their guidance and support. Table of Contents EXECUTIVE SUMMARY ......................................................................................................................... 1 I. BACKGROUND .................................................................................................................................. 4 1.1 HEALTH STATUS OF OVC ......................................................................................................................... 4 1.2 MOBILE PRIMARY CARE CLINICS IN NAMIBIA ............................................................................................... 4 1.3 USAID SUPPORT .................................................................................................................................... 7 2. RESEARCH QUESTIONS ..................................................................................................................... 7 3. METHODOLOGY ............................................................................................................................... 8 3.1 OVERVIEW ............................................................................................................................................. 8 3.2 DATA SOURCE ........................................................................................................................................ 9 3.3 KEY INDICATORS ..................................................................................................................................... 9 3.4 ANALYSIS ............................................................................................................................................. 11 4. RESULTS ......................................................................................................................................... 11 4.1 VOLUME AND USERS OF SERVICES ........................................................................................................... 11 4.2 DIAGNOSES AND CONDITIONS TREATED .................................................................................................... 12 4.3 LOCATION AND AGE OF OVC .................................................................................................................. 14 4.4 BASELINE CHARACTERISTICS BY OVC STATUS ............................................................................................. 14 4.5 LONGITUDINAL CHANGES IN HEALTH STATUS ............................................................................................ 16 4.6 CONCLUSION: IMPACT OF MISTER SISTER ON HEALTH STATUS ..................................................................... 19 5. UNIT COST OF SERVICES ................................................................................................................. 20 6. CLIENT SATISFACTION .................................................................................................................... 22 7. LIMITATION ................................................................................................................................... 23 8. CONCLUSION ................................................................................................................................. 23 9. POLICY IMPLICATIONS .................................................................................................................... 25 11. RECOMMENDATIONS ................................................................................................................... 26 APPENDIX ONE .................................................................................................................................. 27 OVC Namibia Evaluation Report August 2012 EXECUTIVE SUMMARY In October and November 2010, a mobile primary clinic operated by Pharmaccess Namibia first visited isolated farms, schools and encampments in Otjozondjupa Region of Namibia. From July 2011 to January 2012, the clinic, christened Mister Sister, provided a regular monthly service in the same region. Part of the costs for this pilot program were paid by farmers, who subscribed N$417 per farm per month to have the clinic make monthly stops to treat their farm workers and dependents. For the six month period, USAID provided funding for Mister Sister to serve all orphans and vulnerable children (OVC)1 along this route, including those at Otjozondu primary school, as well as Five Rand Camp and the Ileni Tulikwafeni nutrition program located there. This report presents an evaluation of the impact of mobile primary care services on health utilization and health status of orphans and vulnerable children (OVC) along this route. The report does not address the benefits of the mobile health clinic to employers or adult patients, nor measure the impact on workload of the Ministry of Health and Social Services (MOHSS) clinics. 428 children visited Mister Sister at both the beginning (July/August) and end (December 2011/January 2012) of the trial period. These children are referred to as the “longitudinal cohort” in this analysis. 635 children (including the 428 children in the longitudinal cohort) visited Mister Sister at the end of the period, and results for this larger group are discussed separately as the “general community.” Overall, approximately 7.5% of all children seen in the general community were orphans, 65,5% were otherwise vulnerable, and 26.8% not otherwise vulnerable. OVC were regular users of Mister Sister, with approximately 10% of the children in the longitudinal cohort single or double orphans, and an additional 80% vulnerable. Only 10% of the longitudinal cohort were non‐orphan children not deemed vulnerable. Clinic records show a marked reduction in the presence of worm infections of the skin during the trial. These infections fell from 15.7% of the longitudinal cohort at the beginning to none at the end, and from 14.1% to 0.2% among all the children in the community. Fewer children showed external signs of intestinal worm infestation, but these dropped from 1.4% to 0.2% of the longitudinal cohort over six months, and from 1.1% to 0.2 % in the general community. Recorded cases of anemia also decreased from 1.9% to zero in the longitudinal cohort and 1.8% to 0.7% in the general community. In July 2011, when this trial started, most children seen by Mister Sister were current in their vaccinations. However, at the time of the initial visits in late 2010, 16% of all children, and 32% at Ileni camp, were delinquent in immunizations. Thanks in part to the mobile clinic visits at that time, only 6.5% of the longitudinal cohort and 4.8% of the general community were not current in immunizations at the start of the trial period in July 2011. By the visit at the end of the study period, only 0.7% of the longitudinal cohort and 1.1% of the general community 1 Orphans and vulnerable children (OVC) were defined using standard definitions from the Namibia Ministry of Gender Equality and Child Welfare, and include single and double orphans, children with HIV and economically vulnerable children 1 OVC Namibia Evaluation Report August 2012 children were recorded as delinquent in immunizations. Regular visits by Mister Sister further improved the already high vaccination rates which resulted from the earlier pilot. The data show some elevated risk for malnutrition in orphans at baseline, and we hoped to see a link between Mister Sister visits and improved nutrition status, but the data