Community Health Approaches in Conflict and PostConflict Countries

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Community Health Approaches in Conflict and
Post-Conflict Countries

• Haiti, South Sudan and the Democratic Republic of
  Congo

Charles Franzén May 26, 2008
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• What is Community Health?

Communities are an essential determinant of
health and the indispensable ingredient for
effective public health practice.
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Ensuring that badly needed resources and
services reach their ultimate destination and
fulfill their ultimate purpose of improving
health at the community level. --Global Health
Council, Preliminary Program (2008)
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Reaching people beyond the end of the
road. --Dr. Uche Amazigo, DirectorAfrican
Program for Onchocerciasis Control
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IMA World Health Major Program Areas

• 1) HIV Care Treatment Services (ART)
• AIDSRelief Project (335m, 5-year project) no
  fixed amount for IMA and/or other consortium
  members
• 2) HIV Care Support Services (HBC palliative
  care)
• Tutunzane HBC Project in Tanzania (100k-200k
  p.a.)
• Global Fund HIV/AIDS DRCongo in 25 Health Zones
• 3) Maternal, Newborn and Child Health Services
• ACCESS Project in Tanzania, Uganda, Kenya, etc.
  TBD

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Major Program Areas

• 4) Health Systems Development Strengthening
• SANRU III in DRC (ended 2006) (27M, 5-yr
  project)
• AXxes Project in DRC (40M 3-year project)
• South Sudan Umbrella Program to Provide Basic
  Package of Health Services (MDTF/World Bank)
• PMURR project (3 grants supporting 23 HZs) in DRC
  (14M)
• SANRU Program SANRU NGO (planned)

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Major Program Areas

• 5) Malaria Treatment and Control
• Global Fund - DRC to 16 Health Zones
• Malaria Community Programs
• CSSC MCP/PMI Project in Tanzania -- 1.5 million
  over 5 years
• UPMB MCP/PMI Proposal Submission in Uganda (under
  review)
• IMA World Health provides Technical Assistance

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Major Program Areas

• 6) Neglected Disease Treatment Control (NDTC)
• RTI/USAID funded Haiti NTD Integration Program
  LF STH -- 1 million annually for 3-5 years
• New USAID/World Bank LF-Morbidity Management
  funding for India Togo
• LF project in Haiti (University of Notre Dame)
• National Onchocerciasis Control Programs in
  Tanzania and DRC moving into long-term
  sustainability phase
• Nicaragua Deworming (on-going)
• Burkitts Lymphoma (on-going in Tanzania)
• Long-Term Programs Completed
• The Kilosa Rotary Project (water sanitation,
  Oncho, ITN distribution)
• LF (WB/Gates)- NGO partnerships in India,
  Burkina, Nigeria, and MOH partnerships in Ghana
  and Tanzania Included West Africa LF Morbidity
  Management (hydrocele surgeries)

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Major Program Areas

• 7) Procurement and Logistics Management
• IMA Medicine Box
• Diflucan Partnership Program (coordinators in
  Tanzania, Zambia (thru CHAZ), Haiti (thru
  Association of Christian Health Institutions of
  Haiti (AICSH)
• Pharmaceutical Supply for USAID PEPFAR Program in
  Haiti in partnership with AICSH
• Liberia Revolving Drug Fund Supply Management
  System

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Major Program Areas

• 8) Pharmaceutical Donations Programs
• Pfizer Diflucan Partnership Program (Tanzania,
  Zambia, Haiti, and other countries)
• The Medicine Box
• J J donations
• GSK donations
• Merck donations
• Abbott donations
• Axios International (DRC)
• Becton-Dickinson
• Boehringer Ingelheim
• Bristol-Myers Squibb

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Major Program Areas

• 9) Capacity Building of FBO Networks
• Human Resource Capacity Development (Capacity
  Project/IntraHealth-USAID)
• Mapping with Global Mapping International (GMI)
• Information Systems development
• FBO health network advocacy
• FBO Co-management of health systems
• Improved planning/coordination with MoH

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IMA World Health Program Implementation Mechanisms

• Provides Technical Assistance to partners and
  FBOs through
• IMA staff e.g. AIDSRelief/Tanzania, South Sudan,
  ACCESS, Capacity, etc.
• Consultants, e.g. SANRU, AXxes, AIDSRelief Year 1
  and part of Year 2 in Zambia, Kenya etc.
• Staff of IMA member agencies e.g. In DRC and
  phase I LF in Haiti
• Staff hired through CHAs, e.g. Zambia DPP, Haiti
  PEPFAR, AIDSRelief Year 1 in Kenya (CHAK) and
  Uganda (UPMB)
• Financial Reporting to the donor by HQ staff and
  direct implementation and oversight by Grantees
  e.g. LF
• Direct procurement by HQ staff and in-country
  logistics management by local partners, CHAs,
  Technical Staff

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• Republic of Haiti

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IMAWH Community Health Approach in Haiti

• Work in close collaboration with the Ministry of
  Health and the Christian Health Association of
  Haiti (AICSH)
• Very disease disease-elimination focused
• Work in Lymphatic Filariasis for past 10 years
• In the past year, consortium prime on RTI/USAID
  funded NTD Integration Program focusing on LF and
  soil-transmitted helminths

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• 15 years of Community-Directed Treatment (ComDT)
  in Tanzania provides many lessons for community
  health interventions in Haiti
• Communities own the program as they own the
  diseases themselves
• Treatment and record-keeping done in community by
  community members
• Follow up, supervision and monitoring all
  community-directed
• Close linkages with AICSH and the Ministry of
  Health

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Haiti Challenges and Limitations

• Integration of two Ministry of Health kingdoms
  (LF and STH) a major challenge
• eg. Office Space, equipment, staff, vehicles, per
  diems
• Integration and agreement of two national disease
  control programs using similar strategies
• Esp. challenging in the Community Health
  perspective
• ComDT vs. School Health drug delivery

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• Managing partner/collaborator expectations
• Purchase of DEC as this is not a targeted
  donation from a major pharmaceutical company
• Scale-up to country wide coverage in three years
  is this really possible with high quality
  interventions and high coverage among the
  eligible populations?
• How to balance scale-up with true Community
  Health approach?
• General insecurity and continuing civil unrest in
  PoP and along the major routes upcountry

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• South Sudan

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IMAWH Community Health Approach in South Sudan

• One of the vastly underserved populations on the
  planet (37 doctors for 10 million people!)
• How are State, County, Hospital and facility
  health delivery mechanisms going to reach the
  people in need in rural areas?
• Focus on BPHS program creating community health
  outreach through county/health zone strengthening
• Reestablish community health workers

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• Sub-contract and monitor health NGOs and INGOs in
  Jonglei and Upper Nile states, strengthening
  through capacity-building into county health
  managers
• Deploy diaspora Sudanese doctors to facilities to
  reestablish community linkages
• Reestablishing community health outreach to
  facility catchment areas
• Emphasis on training and building capacity
  through training schools and programs
• Community members selected for basic training in
  health and hygiene

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• Emphasis on womens health, maternal and child
  care issues including addressing conflict and
  post-conflict gender-based abuses
• Important linkages with local Sudanese health
  service providers
• Liaison with transitioning OFDA/USAID
  opportunities and additional MDTF programs
• In the two states, work through our faith-based
  partnership including World Relief, World Vision,
  SIM, SIC, PRDA, CD, CMA, ADRA and the vast
  network of the newly formed Christian Health
  Association of Sudan (CHAS)

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South Sudan Challenges Limitations

• Pre-post-conflict complexities, full
  implementation of the Comprehensive Peace
  Agreement (CPA)
• Insecurity and armed clashes a reality to date
• Extremely weak central government with little or
  no human resources capacity outside the Ministry
  of Health
• Community Health less a priority than basic
  survival
• Many health cadres not refresher-trained in 20
  years
• No experience of decentralization and
  decision-making at health zone/county
  administrative units
• Managing expectations of partners/collaborators
  esp. over use of sub-grants
• Very poor financial and accounting capacity
  across the board

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• As typical in other similar situations, extremely
  high cost of materiel and salaries
• eg. Some Clinical Officers receiving 3,000 p.m.
• Conflict in Unity State over boundary commission
  rulings on ownership of disputed oil-bearing
  lands this also extends into Jonglei and other
  potential oil-bearing states
• Millions of Sudanese are either refugees in other
  countries or IDPs in the North or scattered areas
  of the South
• Flood season (April-November) rendering access
  poor Supply Chain Management requires
  pre-positioning to be workable in every case

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• The Democratic Republic of Congo

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IMAWH Community Health Approach in the DRC

• Communitaire, Health Zone and Appui Global
  systems very well developed from SANRU I, II
  III and are being built on in the AXxes Project
• Community Health linkages through the community
  health worker relay system and centrally placed
  delivery mechanisms
• Emphasis on vaccination and mother and child
  health throughout the program

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• Conflict Resolution including addressing
  gender-based violence and its aftermath
• Protestant, Catholic and MoH linkages within the
  Health Zone system each with an equal role to
  play bringing their added value to all areas
  where they are strong
• In AXxes, proven Community Health experiences of
  IMA World Health, World Vision and CRS throughout
  the DRC creates a synergy of high expectation and
  consequent high achievement

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DRC Challenges and Limitations

• Severe limitations in post-conflict and
  pre-post-conflict areas
• Humanitarianism vs. Community Health
• High expectations from donors after previously
  successful effort Peter Principle in some
  health zones
• Extremely weak central government support
  advantage (humanitarian work) vs. disadvantage
  (development work)
• Capacity-Building in Human Resources Management
  and Continuous Training/In-Service Training
• Reverse Cornucopia trying to take on too much
  under very trying circumstances
• Management of sub-grantees/partners and universal
  health zone administration standards and
  principles

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Advantages to Working with Faith-Centered Health
Service Delivery Networks for Community Health

• Effective Peace and Reconciliation efforts are
  often faith-based and faith-centered
• Members of faith-based indigenous networks
  provide 30-60 of health care in developing
  nations
• Often the most important partner with the
  Ministry of Health in health care service
  delivery
• In some countries, faith-centered organizations
  are known as the founders of Community Health
  programs
• Faith-based training institutions likewise are
  responsible for training a majority of health
  workers
• Much closer to local communities and local
  authority structures act as voice of the very
  poor
• In DRC, Haiti and South Sudan, IMA World Healths
  work could not be done without true partnership
  at the local level with the faith community