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Implementation Approach

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by

Jessica Kerbo

on 9 October 2014

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Transcript of Implementation Approach

COUNTRY
ENGAGEMENT
IMPLEMENTATION
APPROACH

Definition of indicators
Measurement capacity
Data presentation/use
Better Health Outcomes
and Measuremen
t
Clinical governance
Maternal/Perinatal death audits
Quality improvement
ANC
ID Integration
PNC
Maternal

Newborn
Family Planning

Nutrition
WASH

Immunization
HIV/TB/STI

Malaria
Commodities

Task shifting
Patient flow
analysis
Training

Mentorship
Definition of indicators
Measurement capacity
Data presentation/use
PRIORITY AREA:
Use of partograph
Administration of Uterotonic
Essential newborn care
Birth companion
Prevention of stillbirth
MgSO4 for SPE/E
PPFP initiation

Rooming-in

Administer BCG

Nutrition messages

Establish contact for
follow up (mobile)

Vaccination card/
vaccine schedule

Administer OPV
Core Package
PMTCT

Management of
Puerperal Sepsis

Provision of ACS for PTB

Administer of Hep B
birth dose

Alternative birth position
Context-Specific Package
DRAFT/ILLUSTRATIVE CONTENT
PRIORITY AREA:
Use of Chlorohexidine
4 postnatal care visits
PPFP initation/continuation
In hospital stay for 24h
Exclusive breastfeeding
Baby registration in vaccine register
Administration of vaccines

Counseling of parents
on immunization

Iron folic acid supplementation

Nutrition messages

HIV re-testing

Provision of bednets
Core Package
Management of
newborn infection

Management of
Puerperal Sepsis

Counseling on maternal/newborn danger signs

Home assessment of water/sanitation
Context-Specific Package
DRAFT/ILLUSTRATIVE CONTENT
Objective
: Increase coverage and utilization, quality, and equity of RMNCH interventions by mobilizing and integrating multiple assets within the health system, thereby accelerating progress toward eliminating preventable child and maternal deaths within a generation
WHOLE MARKET DISTRICT APPROACH (WMDA)
KEY ACTIVITIES IN WMDA CORE WORK PLAN
Review literature to compile lessons from past initiatives
Develop diagnostic framework, tools, and practical steps
Identify and engage prospective MCSP countries
Assist prospective countries to assess strengths and weaknesses relative to applying a whole market approach
Identify initial subnational units and a process for national monitoring and learning
Conduct a layered situation analysis
Assist country planning for implementation and M&E
Provide technical assistance with implementation
Work with international oversight and advisory organizations
to promote ownership and dissemination of the mechanism
GLOBAL
LEADERSHIP
AND LEARNING

FIRST
IMPLEMENTATION
STEPS
DESIGN
HOW TO WORK WITH THE WHOLE MARKET DISTRICT APPROACH?
MCSP seeks to
partner with countries
to design and apply the
WMDA

MCSP hopes to identify and engage prospective countries and begin
implementation in the first 18 months
of MCSP

MCSP will work with field teams and countries to tailor the WMDA
approach to
local context

National-level dialogue
on opportunities, feasibility, and fit

Sub-national-level situation
analysis, design, introduction, and implementation

MCSP will work with health authorities to mobilize key governmental structures and large civil society and private sector actors to support a process of
monitoring and learning to scale over time

F R E Q U E N T L Y A S K E D Q U E S T I O N S
Do you have to integrate all services and providers?
No – only those that are appropriate to include within the country
local context.

Is this a new initiative?

No. It’s an approach to orchestrating existing initiatives to the benefit of RMNCH services.

Will all the interventions be applied simultaneously?
Not necessarily – They could be layered over time.

In which countries will it be applied?
To be determined. We are interested in learning from field teams
which countries might be best suited to, interested in, and willing to
apply the WMDA. We are offering to help countries and missions think about whether this is something that they want to try and is feasible and how the concept could be tailored to their context.
Does it have to be applied at the district level?
No. It could be applied in a number of districts and then scaled up, or applied at another level.

Is this intended to change countries’ strategies?
No. WMDA should build upon existing strategies. It might eventually lead to strategy refinement, but the WMDA doesn’t inherently require a strategy change.

WMDA sounds expensive. Is scaling really feasible?
Some of the interventions cost money (e.g. conditional cash transfers), but many of those are already in existence. WMDA is not about throwing a lot of resources at a problem; it is about integrating, orchestrating, and taking advantage of assets that exist. The WMDA involves systems-level
changes that may actually increase efficiency

Are you certain that the WMDA will work?
Yes and no. There is ample evidence that many of the components work individually. Our hypothesis is that better integration and orchestration will allow these assets to work better, building on each other and reducing inefficiencies. Applying the WMDA at the country level will allow us to test that hypothesis and learn how to refine the approach.

For additional information, please write to:

Marty Makinen
Managing Director at R4D
‎mmakinen@r4d.org
and
April Williamson
Program Officer at R4D
awilliamson@r4d.org
Better Care
on the
Day of Birth
DAY OF BIRTH
POSTNATAL CARE
Coordinating and orchestrating
policies and programs at the
local level, identifying gaps
and bottlenecks, problem
solving, using data
STRENGTHEN
HEALTH MANAGEMENT
AND MANAGERS
1. Provide care in the community
2. Voice community needs
3. Increase accountability
PROMOTE
COMMUNITY ENGAGEMENT
RMNCH, WASH,
Malaria, Nutrition,
HIV/AIDS, etc.
INTEGRATE
TECHNICAL
INTERVENTIONS
Conditional cash transfers,
Universal Health Coverage,
performance-based
incentives, etc.
TAKE ADVANTAGE
OF HEALTH SYSTEM TOOLS
Providers: Private comercial, private non-for-profit, public, community-based, informal, etc.

Sectors: Education, social
affairs, etc
MOBILIZE VARIOUS
ACTIONS AND SECTORS
For additional information, please write to:

Jeffrey Smith
MCSP Maternal Health Team Leader and Lead for Better Care on the Day of Birth and ANC / PNC Integration
jeffrey.smith@jhpiego.org

OUTCOMES
Increased coverage

Improved quality

Greater equity

Sutainable improvements
1.

2.

3.

4.
Scale-up Outcomes to reach
Sustainable Impact at Scale


MCSP OBJECTIVE 1 (“SUPPORT SCALE-UP”):
Support countries to increase coverage and utilization of
evidence-based, high-quality RMNCH interventions at the
household, community and health facility levels.
One of the main organizing principles for the MCSP learning agenda will be systematic support and
prospective study of scale up
of 3 key high-impact interventions – one each for
maternal, newborn and child health
– each in multiple countries.
Jim Ricca
Senior Learning Advisor

SYSTEMATIC SUPPORT AND STUDY
OF SCALE-UP UNDER THE
MATERNAL AND CHILD SURVIVAL PROGRAM

What is being scaled up? Who is doing it? How are they doing it?

SCALE UP- ELEMENTS AND STRATEGIES
ENVIRONMENT

INTERVENTION

RESOURCE TEAM
IMPLEMENTER(S)
DISSEMINATION AND ADVOCACY
ORG. PROCESSES
/ CAPACITY BUILDING
RESOURCE
MOBILIZATION

MONITORING
& EVALUATION

COMMUNITY
/ CLIENT ENGAGEMENT

Governance / Information System / Financing / Commodities / Svc. Delivery / HR / Client Engagement
WHO BUILDING BLOCKS

POPULATION COVERAGE

Intermediate measures:
% facilities covered, % providers
deployed , % districts covered
Institutionalization

Service expansion

Source: Based on diagram from Institute for Reproductive Health,
Monitoring and Evaluating Scale up (using ExpandNet concepts)

PILOT
INSTITUTIONAlIZED
REACHING MOST OF THOSE WHO
NEED THE INTERVENTION

Sustainable impact at scale

Key MCHIP General Findings about Scale-up
System thinking is critical – results in terms of “impact at scale” will only be as good as the weakest link
Need to work with a “quality end in mind”
Scale-up is likely to be a long-term process and will not happen at a constant pace
Findings from In-depth Studies
Specific Lessons - In-depth Studies
For additional information, please write to:

Jim Ricca
Senior Learning Advisor
jim.ricca@jhpiego.org
MCSP: Systematic Support and Study of Scale-up
A linchpin of the learning agenda will be to undertake systematic support and
prospective study of scale up


This will include three key high-impact interventions – one each in
maternal, newborn and child health
– each in multiple countries
Delivery mechanisms (e.g., Whole Market District Approach, private sector involvement, etc.) will also be objects of study

Not “Traditional Research” Studies
Analysis will take a
systems approach
to the inputs and strategies used, rather than a “linear” approach
There will be
interplay between implementation and study/learning
(“Developmental Evaluation”), involving both implementers and researchers
Interventions will be
dynamic and adapt
based on information reviewed during the implementation period
The learning will involve
mixed methods
, including both quantitative and qualitative methods
Learning on scale up will
generate ideas for additional learning
– e.g., test one supervisory approach versus another if this arises as an issue during scale up

A short description of the
intervention being scaled up
.
Robust but feasible
coverage information
for the intervention being scaled up.
Implementer(s) / Resource Team
– Who is implementing the intervention? Resource Team should have representation from implementers and supporters
Scale-up strategies
under ExpandNet
Key changes in the
environment


Introductory
2 day HQ workshop
on systematic scale up with ExpandNet personnel as facilitators. Third day of work meetings with individual teams.

Form
Core Scale Up Resource Team
(with representation from the field) to meet quarterly and review scale monitoring data from regular project reports on the interventions whose scale up is being supported & studied.

Semi-annual reviews
with ExpandNet facilitators to track progress and involving other MCSP teams.

Community of Practice
on Scale Up with a listserv and dedicated SharePoint area for key materials.

Country workshops
on systematic support and study of scale up in three countries, co-facilitated by MCSP trainers (trained during initial 2 day HQ workshop) and in-country research institution partners.

Form
Country Scale up Resource Teams
, led by MOH, with other key partners, including local research institution. Meet regularly to review information; make management decisions; share lessons.

Expected Products
Better practice
“Real time” lesson sharing
Within country (Resource Team)
Across countries (Community of Practice on Scale Up)
Across all MCSP Technical Teams (Core Scale up Resource Team)
Summary final reports
at end of project for each intervention supported/studied

MCSP Goals and Objectives
Day of Birth in Context of the Community
Integrated Community Health Platform –
Working Definition

A flexible system for integrated RMNCH services including
health promotion, disease prevention, care seeking
and
Tx
in the community, spanning common gaps in the continuum of care from household to health facilities.
CHW strategy

Local governance

Community Capacity &
Engagement
Broader Context for Provision of
Community-Based Primary Health Care & EPCMD

Day of Birth
and
“other days”

Context-specific Package

CORE
PACKAGE

C-HMIS

Coordination

Other
Interventions

Administratively rational (Volunteer to staff vs. work requirements), technically skilled and supported CHW and volunteer workforce, embedded in viable community structures.
CHW Workforce and Community Infrastructure
DOB Synergies:
CHWs supported as part of the health system; SBAs provide home-based services or TBAs accompany women to facilities/maternity waiting homes;
SBC interventions + comm. mobilization support DOB including celebration of birth;
Community referral/transport system;
Civil society support and accountability;
PLA, Care Groups, etc.

Information for Equity,
Learning and Adaptation
Use of information horizontally (in community) and vertically to and from facilities/districts/MOH structures. Learning processes.
DOB Synergies:

Community HMIS with vital events monitoring, including new pregnancies and maternal/newborn death surveillance
Social autopsies for maternal and newborn deaths
Community involvement for equitable reach of MNH services
Monitoring respectful care

Support Services and Functions

(commodities, supervision, information processes....)

For additional information, please write to:


Eric Sarriot
Community Health & Civil Society Engagement Team Lead
Eric.Sarriot@icfi.com
and
Melanie Morrow
Community Health Team Manager
Melanie.Morrow@icfi.com

Not
a one-size-fits-all blueprint
Institutionalization,
Coordination and Partnerships

Use of information horizontally (in community) and vertically to and from facilities/districts/MOH structures. Learning processes.
DOB Synergies:

Supportive policies and financing for community work re: CHWs, SBAs and MNH interventions.
Functional coordinating mechanism covers all DOB actors (across govt. ministries + departments, private sector and civil society).
MOUs and active collaboration between MOH and CSOs.

Linked to each key intervention
Intervention: Use of MgSO4 for PE/E
Based on WHO confirmed indicators (where they exist)
Simple approaches for data collection
Currently collected for required reporting?
Possible to record in register (extra column?)
Part of facility recording?
Development of additional register / log book
Encourage daily or weekly discussion
Use of audit/feedback cycle improves data collection because data is relevant and used.
Using new techniques of data visualization
Simple 1-day workshop on data recording, graphing and use
Dos and Don’ts of data visualization
Use of simple graphs or charts to record data
Provision of preprinted laminated sheets with X and Y axes labeled


Good practice for management
Daily hand over report – not just numbers but rates of use of interventions
Weekly clinical meeting and service management discussion
Monthly review of cases – morbidity and mortality, etc.
Maternal and perinatal death audit
Specifically supporting the WHO process that is in place in numerous countries
Promotion of continuous use of data and tracking of outcomes

Quality improvement and clinical governance are linked processes that help achieve the same goals
Some elements of clinical governance (such as daily report) facilitate
MCSP will put a greater emphasis on measurement of outcomes as markers of quality

Information Needed for Systematic Support and Study of Scale-up
Key Activities: Selected Countries
Key Activities: HQ
Goal of MCSP globally
Accelerate reductions in maternal, newborn, and child mortality, with increased equity to end preventable maternal and child death

Objectives
Obj 1
: Increase coverage and utilization of evidence-based, sustainable, high-quality RMNCH interventions
Obj 2
: Close innovation gaps needed to improve health outcomes among at-risk populations
Obj 3
: Foster effective policy, program learning, and accountability for strengthening RMNCH outcomes

In the context of continuing health professional education
What evidence is there to support educational techniques, Frequency (single vs. repetitive), setting, and media used to deliver instruction?
What evidence exists about the outcomes (knowledge, skills, attitudes, provider behaviors, patient outcomes) of continued health professional education?


Effective In-Service Training Techniques, Frequency, Setting and Media:
Synthesis of an Integrative Review of the Literature
In the context of continuing health professional education
Find the full report online here: http://reprolineplus.org/resources/effective-service-training-techniques-timing-setting-and-media-evidence-integrative-review

What surprised us? (Or didn’t!)
Didactic-”low to no” outcomes
Simulation effective
Practice and feedback ‘dosage’ matters
Shorter, but more often
Workplace-setting better for skills

Such as:
Warming and Drying
Delayed bathing
Skin-to-skin contact
Exclusive Breastfeeding
Essential Care for Every Newborn
Quality improvement
Clinical Governance
Marty Makinen
Managing Director at R4D
WHOLE MARKET DISTRICT APPROACH
Jeffrey Smith
Maternal Health Team Leader and Lead for Better Care on the Day of Birth and ANC / PNC Integration

BETTER CARE ON THE DAY OF BIRTH AND ANC / PNC INTEGRATION
Melanie Morrow
Community Health Team Manager
INTEGRATED COMMUNITY HEALTH PLATFORMS AND THEIR APPLICATION TO DAY OF BIRTH

Intervention Package: Preventive, Promotive & Curative Services
CHW Workforce and Community Infrastructure
Information for Equity, Learning and Adaptation
Institutionalization,
Coordination and Partnerships
Support Services and Functions

(commodities, supervision, information processes....)
National Policy and Support
Innovations and Policy Translations
Intervention Package/
Preventive, Promotive & Curative Services

“Package” of Community-Based Services in the Continuum of Care, linked to Quality Facility Services

DOB Synergies
:
Priority MNH interventions are delivered on a platform allowing flexibility and as much integration as efficient (MNH, PPFP, Nutrition, Immunization, WASH)
Parents are empowered as primary caregivers

Administratively rational (Volunteer to staff vs. work requirements), technically skilled and supported CHW and volunteer workforce, embedded in viable community structures.
CHW Workforce and Community Infrastructure
DOB Synergies:
CHWs supported as part of the health system; SBAs provide home-based services or TBAs accompany women to facilities/maternity waiting homes;
SBC interventions + comm. mobilization support DOB including celebration of birth;
Community referral/transport system;
Civil society support and accountability;
PLA, Care Groups, etc.

Information for Equity,
Learning and Adaptation
Use of information horizontally (in community) and vertically to and from facilities/districts/MOH structures. Learning processes.
DOB Synergies:

Community HMIS with vital events monitoring, including new pregnancies and maternal/newborn death surveillance
Social autopsies for maternal and newborn deaths
Community involvement for equitable reach of MNH services
Monitoring respectful care

Institutionalization,
Coordination and Partnerships

Local health system governance – Coherence with local government and district health systems – civil society and private sector roles - Financial Resources and Incentives
DOB Synergies:

Supportive policies and financing for community work re: CHWs, SBAs and MNH interventions.
Functional coordinating mechanism covers all DOB actors (across govt. ministries + departments, private sector and civil society).
MOUs and active collaboration between MOH and CSOs.

Toward Scalable Integrated Community Health Platforms - A Looking Glass



Promote
Community partnership
Key household behaviors and
Improved access to essential preventive and curative services

According to
Local epidemiology
Other contextual factors
State of the art practice


In the context of continuing health professional education
What evidence is there to support educational techniques, Frequency (single vs. repetitive), setting, and media used to deliver instruction?
What evidence exists about the outcomes (knowledge, skills, attitudes, provider behaviors, patient outcomes) of continued health professional education?

What surprised us? (Or didn’t!)
Didactic-”low to no” outcomes
Simulation effective
Practice and feedback ‘dosage’ matters
Shorter, but more often
Workplace-setting better for skills

MCSP OBJECTIVE 1 (“SUPPORT SCALE-UP”):
Support countries to increase coverage and utilization of
evidence-based, high-quality RMNCH interventions at the
household, community and health facility levels.
One of the main organizing principles for the MCSP learning agenda will be systematic support and
prospective study of scale up
of 3 key high-impact interventions – one each for
maternal, newborn and child health
– each in multiple countries.
MCSP: Systematic Support and Study of Scale-up
A linchpin of the learning agenda will be to undertake systematic support and
prospective study of scale up


This will include three key high-impact interventions – one each in
maternal, newborn and child health
– each in multiple countries
Delivery mechanisms (e.g., Whole Market District Approach, private sector involvement, etc.) will also be objects of study

Key MCHIP General Findings about Scale-up
System thinking is critical – results in terms of “impact at scale” will only be as good as the weakest link
Need to work with a “quality end in mind”
Scale-up is likely to be a long-term process and will not happen at a constant pace
THANK
YOU

DAY OF BIRTH IN CONTEXT OF COMMUNITY
Such as:
Warming and Drying
Delayed bathing
Skin-to-skin contact
Exclusive Breastfeeding
Essential Care for Every Newborn
C-HMIS

Coordination

Other
Interventions




Core Package
CHW Strategy

Local governance

Community Capacity &
Engagement


Broader Context for Provision of
Community-Based Primary Health Care & EPCMD

Day of Birth
and
“other days”
Context-Specific Package

We envision community health platforms that:
“Deliberate efforts to increase the impact of successfully tested health innovations so as to benefit more people and to foster policy and programme development on a lasting basis.”
ExpandNet (2009).
Practical Guidance for Scaling Up Health Service Innovations
. Geneva: World Health Organization.
Scale-up (Definition)
Introductory
2 day HQ workshop
on systematic scale up with ExpandNet personnel as facilitators. Third day of work meetings with individual teams.

Form
Core Scale Up Resource Team
(with representation from the field) to meet quarterly and review scale monitoring data from regular project reports on the interventions whose scale up is being supported & studied.

Semi-annual reviews
with ExpandNet facilitators to track progress and involving other MCSP teams.

Community of Practice
on Scale Up with a listserv and dedicated SharePoint area for key materials.

Key Activities: HQ
Country workshops
on systematic support and study of scale up in three countries, co-facilitated by MCSP trainers (trained during initial 2 day HQ workshop) and in-country research institution partners.

Form
Country Scale up Resource Teams
, led by MOH, with other key partners, including local research institution. Meet regularly to review information; make management decisions; share lessons.

Key Activities: Selected Countries
Full transcript