1. Stakeholders’ consultation on Informal Service Providers
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

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% of children 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. Improve access to quality services
Project strategies
MOH front line workers’ capacity strengthening
Capacity building of VD & linkages with formal HS
Community engagement and support mechanism
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 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
Oct’12 to Dec’13

17. Key findings of Supervision Visit
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
Before training
After training
Only 35% used equipment (stethoscope/watch) for pneumonia diagnosis
Diagnosis made based on symptoms
Used higher antibiotic
Count respiration rate using ARI timer
Use simple antibiotic (amoxicillin)
Referral of severe pneumonia cases

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
Before training
After training
Almost absent among VDs
Perceived as unskilled and incapable
Financial disincentive of people seeking treatment elsewhere
Giving preference to treatment protocol over business motive
Refer sick children following protocol rather than doing trial and error

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