1. Expanded Coverage of Essential Health Services in Djibouti Project (PECSE) From Five Villages to a National Policy: Community Mobilization in Djibouti Dr. Stanislas Nebie, Chief of Party, PESCE, JSI Dr. Chehem Watta, Senior Advisor, Ministry of Health, Djibouti Dekha Hadi, Social Mobilization Assistant, PESCE Catherine O’Brien, Senior Technical Advisor, The Manoff Group Elaine Rossi, Senior Technical Advisor, JSI The authors’ views expressed in this publication do not necessarily reflect the views of the US Agency for International Development or the US Government.

2. Country Context: 2004 Population: ~800,000 Size of US state of Massachusetts Life expectancy: ~46 yrs Infant mortality: 103 per 1,000 live births (2002) Under-5 mortality: 121 per 1,000 live births (2002) Maternal mortality: 650 per 100,000 live births (2002) Malnutrition, malaria, TB all pose great risks

3. Health System Context: 2004 Weak infrastructure Unreliable health statistics and poor health knowledge No community mobilization for health! MOH health sector reform strategy aims to increase access to health care through decentralization, prevention, and primary care

4. Poor infrastructure Poor water source in Gourabouss: 2005As Eyla clinic beds: 2005

5. Resource Scarcity Water struggle in Dorra: April 2005

6. PECSE Project 2004–2008 Expand access to health services –Rehabilitate health facilities –Train health care providers –Establish health management information system –Mobilize communities –Focus on rural areas Sagalou Health committee members, April 2006. The Health Committee President is seated on the left.

7. Community Mobilization: Challenges No community mobilization existed before in the health sector MOH not receptive to idea Health infrastructure in terrible condition Nomadic populations; refugees Difficult physical environment

8. Laying the Groundwork “Back to Basics” Not ready for BCC Pilot program in 5 sites in 2005 Very basic community mobilization PECSE and MOH staff in discussion with Goubetto community chief in 2005, when negotiating the establishment of a health committee

9. Community Mobilization Pilot Approach Health Post  Health Committee  community members forging links to improve services Community health volunteer is the link between community and health post staff Daley Aff Community volunteers: Jan 2006

10. Involving the MOH PECSE cultivated excellent relations with MOH, UNICEF, WHO, NGOs, and others Study tour to Ethiopia and Madagascar Consensus on community mobilization emerged after study tour MOH interested in replicating model Djibouti health committee members and nurses during the study tour in Madagascar, 2005

11. Scaling Up 5 pilot sites  23 health posts Each post linked to health committee Each committee has men and women 4 or 5 community volunteers (at least 2 female) per community Gallamo community leader giving working tools to a volunteer: May 2006

12. Training and Supervision Training-of-trainer workshops nationwide for community health volunteers Health education activities Joint supervision by MOH and PECSE Dorra female health volunteer receiving a loud speaker for community mobilization: August 2006

13. Training Work plan development during the Tadjoura district volunteers training: June 2006 Community trainer during Arta health committee members training: May 2006

14. Supervision Randa village volunteers during supervision: Sept 2006 Gourabouss community volunteers during a supervision session: Aug 2006

15. Mobilization at work PECSE carried out MOH priorities Emergency immunization campaigns –Polio in 2005: Health Committees and Volunteers proved themselves –Cholera in 2006: further validation Volunteers and committees trained in prevention and symptoms Volunteers spread messages and identified cases for nurses to treat Avian influenza preparedness

16. Additional Activities MOH requested urban community mobilization work Flipchart produced covering 9 health themes for nationwide distribution Mobile caravan performed skits Radio spots Mobile theater group performing a skit

17. Flip Chart Preparation Tadjoura district volunteers and community members training in flip chart utilization: Feb 2006 Nutrition for a nursing mother When to take a child to the health post

18. Incinerator now available in the 23 project sites for medical waste management Medical waste situation in 2005 Solar pump installation in Assamo Infrastructure Rehabilitation Drilled well in 2008

19. Alaili-Dada Clinic Medeho clinic toilet 2004 2005 Infrastructure Rehabilitation

20. National Community Mobilization Strategy After study tour, MOH formed committee on social mobilization for health policy PECSE provided framework for policy National Policy promulgated in 2006! –Validated role of Community Health Volunteers and Health Committees –Created new MOH cadre of Health Aides based on Ethiopian model

21. A major step forward Ass-Eyla health committee members showing their certificates of recognition with pride: April 2008

22. Results By late 2006 utilization rates rose for prenatal care and immunization Contributed to positive national results: The Project social mobilization assistant with the Gallamo female volunteer ‘s child: 2006 20022006 Infant Mortality (per 1000 live births) 10367 Under-5 Mortality (per 1000 live births) 12194 CPR 12%18%

23. Results: Deliveries

24. Results: Antenatal Care

25. Thanks to a great team Community Mobilization Team: May 2008 Minister of Health and Project COP at Knighthood Ceremony for COP, May 2008