the evolution of adaptive health & nutrition service delivery systems: disaster resilience...

The Evolution of Adaptive Health & Nutrition Service

Delivery Systems: Disaster Resilience

Strengthening in Ethiopia

dr. bob alexander(funded by UNICEF Eastern & Southern Africa Regional

Office)

• Problem & frameworks: - Joint FSN Resilience

Initiative - Adaptive BSS study

• Context: Ethiopia health & nutrition

• Adaptive health & nutrition services:

- Evolution of the HEP- Special arrangements for

remote areas (iMHNT)

• Conclusions

What are we gonna do differently?

Problem: Parallel Dichotomous System

Stronger to

address ‘everyda

y’ stresses

Less impacts during &

after ‘extensive’ &

‘intensive’ shocks

Risk-based Development

mechanisms for shocks

contiguum

‘Development’: strengthen regular local clinic management

+‘Emergency’: strengthen parallel external shock response

system =

Service access? Resource use? Context appropriate? Do no harm?

+Crowd out mechanisms for local resilience potential

Resilience Capacities

Category Capacity

Absorb Resist stress & shock impacts entirely & respond to quickly recover

AdaptIdentify temporary changes to stresses & shocks in the system & modify activities temporarily

Transform Identify permanent changes to stresses & shocks & change the system permanently

Key: minimize disruptions of accessto food, income, & services

Role of Adaptive BSS

Predictable Safety Net Transfers

Adaptive Basic Social Services

Sustainable Livelihoods

Protection from Shocks

Resilient SystemStrengthening

Activities

SYSTEM LINKAGES

IMPACTS

ETHIOPIA COUNTRY CONTEXT…

ETHIOPIA AT A GLANCE

Population≈90 million (2nd Africa)• Age: 14% < 4; 3% > 65 • Rural: 80% (highland: mixed;

lowland: more pastoralist)

HDI (2013): 173rd (of 187)

1995 decentralization: • 9 regional states• 2 city administrations• Regions & districts (woredas) have

own constitution (executive, legislative, & judiciary)

HEALTH & NUTRITION ISSUES Access to health services: 45%

High child & PLW SAM rates (double in rural areas)

Chronic food insecure 10.4%

Antenatal care from 28% to 34% from skilled provider; postnatal care low (only 7% within recommended 2 days)

Main diseases: Prenatal & maternal conditions, ARI (acute respiratory infection), malaria, undernutrition, AWD, AIDS

Under 5 (33% of deaths): ARI, AWD, undernutrition, malaria

FACTORS AFFECTING HEALTH:Drought (insufficient/ erratic rain) & migration

Other hazardsRemote areas lack access, education & skills (especially women)

Population Poverty, low income Low access: clean water, sanitation & health facilitiesMillions affected by

drought:

KEY CONSIDERATIONS ↓ chronic & acute Health & Nutrition problems:

both preventive & curative procedures Preventive: local = fast identify problems

(woreda health centres too far) BSS Problem: pastoralists migrate –

static facilities can’t help when they move Biggest migration reason: water for livestock Adaptive BSS strategies must be integrated with

sustainable livelihoods strategies (water access: households, service facilities, crops, & livestock):

- Reduce migration out of necessity - Determine strategies for mobile service access for when people choose to migrate

3-Tier Health System

NUTRITION & HEALTH SERVICESHealth Extension Program (HEP): Replace Health

Centre emergency-focused reactive relief & curative paradigm with local Health Post preventive paradigm (15,000 HPs)

Health Extension Workers (35,000): evolving roles under disease prevention/control, family health, hygiene & environmental sanitation, & health education & communication

Health Development Army: Model households (5:1) take on preventive/ sensitization roles so HEW roles can evolve

Evolution: More adaptive through early identification/action

NUTRITION:FEEDING SERVICES

NUTRITION: DEWORMING, Vitamin A, OEDEMA, SCREENING

NUTRITION: DEWORMING, Vitamin A, OEDEMA, SCREENING

SUCCESS?: 2005-11 ↓ kid stunting (52% to 44%) & underweight (35% to 29%)

HEALTH: MNCH

SUCCESS?

HEALTH: DELIVERIES

SUCCESS? = Infant mortality rates ↓ from 121/1000 in 1990 to 47/1000 in 2013

ADAPTABILITY IMPACTS- - integrated in fixed HCs to improve mobile coverage - can replenish supplies, vaccines, fuel, & spare parts to facilities

UNDISRUPTED SERVICE-Mobile teams can move to affected areas for repairs & supplies

KNOWLEDGE ENHANCEMENT-Strengthens training of lower capacity staff in pastoralist HEW program EQUITABILITY -By providing services to people in remote areas

SUSTAINABILITY - ?????????????????????????????????????????????

Key finding: although expensive, iMHNTs can help improve adaptable access for remote and migrating populations

Integrated Mobile Health & Nutrition Teams (iMHNT) Case Study (Remote/Low Capacity)

Conclusions Long-term investment in training of local capacity through evolution steps of

increasing adaptiveness

Local HEWs/HDA coordinate identification, diagnosis, & basic treatment or referral (e.g., CMAM, CBN, ICCM) = adaptive:

- system adapts to local conditions & capacities

- quicker through decision-making & action closer to the problems

Flexibility to determine which services are better done at HC level (e.g., safe deliveries)

Acknowledge that different areas will evolve differently

Some may need special arrangements (e.g., remote, low capacity): innovative & cost-effective/sustainable?

HEWs accountable to HC; HC accountable for HEW training, supervision, & performance

Integration with other sectors key to overall health & nutrition: HEWs & HDA leaders part of intersectoral community development body (e.g., WASH, Education, Social Protection, Livestock, Crops)

[CF] What (are) we gonna do differently in this opportunity?[CG] What (are) we gonna do differently - before & after big events?[CF] What (are) we gonna do differently to help strengthen capacities [CGC] for everyday & extreme resilience?[FC]: (We need) a platform for coordination – for field level implementation to think & act with one mentality [FC]: Resource & target integration – plans to avoid duplication – in partnerships with implementing partners & community [AmG]: We need to find what complements through an approach - that builds on synergies - to address sustainable, adaptable access in joint solution stories

[FC]: (We need to) embrace how things are changing & build systems that are integrated - in a way to minimize both chronic & acute[FC]: (It’s gotta) expand & contract in surge – to resist, adapt, & bounce forward - for both recurrent problems & those shock-induced [AmG]: It’s gotta build on what’s known already & good M&E – & document lessons for upscaling & advocacy

[AmG]: ask why – then where, what - how & who & when – then budget based on how much we can spend

The Ethiopia Joint Resilience Initiative Song