Local Lessons on Sustainability thinking to improve Health Systems Strengthening

Core Fall MeetingSeptember 14, 2010

Plan Kenya

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Map 1

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GOAL Sustainably reduce child mortality and morbidity in Kilifi

BENEFICIARIES

WRA 64,381U5 46,354

INTERVENTIONS & LOE

MALARIA NUTRITION IMMUNIZATION PNEUMONIA DIARRHEA HIV/AIDS

25% 20% 15% 15% 15% 10%

PARTNERS Kilifi Community, MOH, Plan, AKHSK, PSI, AMKENI, KEMRI-Wellcome TRUST

Plan Kenya KIDCARE Project 1

Steps in Design Process

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Fathers as active caretakers of sick children

Health Services availability right where the communities live

Households to be at the forefront of engaging with health benefits and communication

Plan Kenya KIDCARE Vision for Sustainability

PARTNERS

FATH

ER

S

OLDER CHILDREN

Six components of SF Framework

Health Outcomes Health System Organizational Capacity Organizational Viability Community Competence External/Environmental Factors

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Project

Community Organizations

Central MOH/Gov.

Private sector

Traditional health providers

Health facility

District Managemen

t Team

Community Health

Workers

STEP 1: Defining the Local SystemProject thinking: What will the project do?System thinking: A project is only one of many actors that contribute to sustainability of health outcomes in a local system. So, instead we ask “What will the project partners contribute?” And we also ask “What can others contribute?”

Local System

Civil stability

Other development

sectors

Environment

Project

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Problem Tree 1

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Indicators Baseline Coverage %

Endline Coverage %

Target %

% Children (0-23mths) underweight 26.6 14.4 21.6% Children (0-23mths) births attended by SBA 12.9 35.4% Mothers of children (0-23mths)who received 2TT

24.0 66.7 60% Infants (0-5mths) exclusively breastfed in last 24 hrs

21.1 54.9 31% Children (0-23mths) fully vaccinated by 12mnths

62.2 76.5 74% Children (0-23mths) who slept under ITN last night

20.7 76.7 60% Mothers of children (0-23mths) who know 2 ways of preventing HIV

41.4 66.0 70

Results 1

KIDCARE identified that several elements necessary to achieve her vision were outside her direct mandate.

With partners, KIDCARE adopted, measured and tracked a number of indicators for these elements across several levels

KIDCARE used these measurements to initiate stakeholder discussions and identify decisions/decision-makers required to achieve her vision

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Results 2

KIDCARE recognized several factors at several levels e.g. household factors - (involvement of fathers), community factors - (caregroups+CHWs v/s CHWs alone), public health system factors -(staffing), national factors - (CCM policy) and external factors - (security) as vital for achieving vision

KIDCARE recognized importance for inclusive partnership at district level to be custodian for Health Vision/(DHSF was formed and strengthened)

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KIDCARE Sustainability (Trend) Mapping 2005-2009

34.12

62.02

5560

38

44.92

60

30.28

29.5

65

55

37

27

20

32.5

17

19.5

20

0

20

40

60

80Health Outcome index

Health Services index

Organizational Capacity index

Organizational Viability index

Community Capacity index

Enviromental index

2009 2007 2005

SF spider diagram

Lessons learned while applying SF 1

CSSA enabled an informal HS assessment (outside of the traditional HFA) that helped map what needs to happen to strengthen the system.

Further reflection helped the team to define the community at a lower level than the CHW. This is when the need to have care groups was birthed.

DHCs need to grow from just being “administrator of the dispensary” to “actually managers of health in the entire catchment area.”

Identifying key indicators for the various SF components frequently needed reflection on the problem tree. This in turn made the project reflect on project strategies.

With the choice of indicators also came the realization that there was a need to commit to expanding the M/E framework of the KIDCARE project, to work closely with new local partners and to access new sources of information for indicator measures. A good example is the need to work closely with the District Security Council to update on “political stability”.

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Lessons learned while applying SF 2

Some planned activities failed to happen because policy changed e.g. temporary hire of nurses on vacation to fill spots in the dispensaries failed because MOH abolished cost-recovery which was the planned financing method. Also shopkeeper training in home management of malaria failed to happen because new Malaria treatment guidelines using ACT were introduced.

On the flipside some new activities happened because of an enabling environment so created: CHW work was easier through caregroups Clinton Global Initiative and DANIDA stepped in to recruit extra

nurses for dispensaries Devolved funds from CDF and LATF used to construct and

equip 4 new dispensaries and support access road construction Introduction of KEPH by MOH provided official support of level

1 activities at village level

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Conclusions: What do we see at the end of the tunnel?

HS definition in a local context can be competently constructed by a team of local stakeholders pursuing a common health vision

Even if it is outside the mandate of an individual project, HSS efforts can be assisted through targeted work with stakeholders.

The preceding slides were presented at theCORE Group 2010 Fall Meeting

Washington, DC

To see similar presentations, please visit:www.coregroup.org/resources/meetingreports